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Peluso, P. R., & Freund, R. R. (2018). Therapist and client emotional expression and psychotherapy outcomes: A meta-analysis. Psychotherapy, 55(4), 461–472.

Emotions and emotional experiences are key to being human, and therefore are key to psychotherapy processes and outcomes. Emotion-focused therapy, for example, emphasizing helping clients to overcome their avoidance of emotions by exploring emotions in therapy in order to achieve change. Nevertheless, many therapeutic orientations focus on emotional expression, avoidance of emotions, emotional experiences, and understanding emotions as a means of helping clients to change and to have a better existence. Therapists of all stripes tend to work at creating a therapeutic context so that patients can have a corrective emotional experience. Primary emotions are universal and include happiness, sadness, fear, surprise, disgust, and anger. Secondary emotions are influenced by context and include embarrassment, guilt, and pride. All emotions and their experiences are influenced by cultural contexts, attitudes, and rules. A key aspect of psychotherapy includes helping clients to organize or make meaning of their emotions, and such therapeutic work is associated with positive client outcomes. In this meta-analysis, Peluso and colleagues evaluated the research on therapist and client emotional expression in psychotherapy, and its relationship to client outcomes. Thirteen studies found the effects of therapists’ expression of affect during therapy on client outcomes after the end of therapy had a mean effect size of r = .28 (95% CI: .17, .35), which was statistically significant and moderately large. The 42 studies that looked at client expression of affect during therapy and how it related to client outcomes after therapy found an average effect size of r = .40 (95% CI: .32, .48), which was also statistically significant moderately large.

Practice Implications

This meta analysis emphasizes that emotions matter in psychotherapy. The capacity of therapists to judiciously express emotions, and to help clients to experience and make meaning of their emotions is an important therapeutic skill. Therapists need to focus on and validate clients’ emotions, and therapists should encourage clients to understand and process (i.e., make meaning of) their emotions. This work must occur in the context of a safe, trusting therapeutic relationship. Meaning making and emotional resolution should be considered as key therapeutic goals for most therapies.

Janis, R.A., Burlingame, G.M., Svien, H., Jensen, J. & Lundgreen, R. (2020): Group therapy for mood disorders: A meta-analysis, Psychotherapy Research, DOI: 10.1080/10503307.2020.1817603

Mood disorders are common mental health problems, with a 12-month prevalence of 7% in the population for major depressive disorder (MDD). Researchers have tested group therapy as a treatment for MDD and bipolar disorder. Recently, the American Psychological Association added group therapy as a specialty, attesting to the empirical evidence of group therapy’s efficacy and also the need for specialized education and training. Despite this, some treatment guidelines do not list group therapy as a first line therapy for major depression. Over the past 10 years, an international group of researchers have conducted a number of meta-analyses on the efficacy of group therapy for many disorders. In this particular meta-analysis, Janis and colleagues assessed the efficacy of group therapy to treat mood disorders by looking at randomized controlled trials of group therapy compared to waitlist controls, treatment as usual, and anti-depressant medications. They identified 42 randomized controlled trials of group therapy for mood disorders that included almost 3,000 patients. Treatment orientations included CBT, DBT, psychodynamic, and interpersonal therapies. For primary outcome measures of depressive symptoms at post treatment, the effect of group therapy versus waitlist controls was large and significant (g = .86, 95% CI [.66, 1.06], p < .001, k = 9), and those receiving group treatment were 6.81 times more likely to recover compared to those waiting for treatment (95% CI [3.70, 12.55]). Group therapy also resulted in better outcomes than treatment as usual on primary outcome measures of depression at post treatment with a medium sized effect (g = 0.46, 95% CI [0.22, 0.87], p < .001, k = 11), and those receiving group therapy were 2.75 times more likely to recover than those receiving treatment as usual (95% CI [1.59, 4.72]). Finally, there was no significant difference between group therapy and medications on rate of change in depressive symptoms or on rates of recovery.

Practice Implications

Overall, group therapy was more effective than no treatment and treatment as usual for major depression symptoms. Group therapy was as effective as anti-depressant medications. Group therapy is likely more cost effective because it is a multi-person treatment. Many patients do not respond to medications or they struggle with medication adherence because of unpleasant side effects. And most patients prefer psychotherapy to medications if given the choice. And so, group therapy provides a cost-effective alternative and should be considered as a first line treatment for depression. As indicated by the American Psychological Association’s recognition of group therapy as a specialty, providing group therapy requires specialized education and training in order to offer effective care. Continuing education opportunities exist with the Society of Group Psychology and Group Psychotherapy and with the American Group Psychotherapy Association.

Flückiger, C., Rubel, J., Del Re, A. C., Horvath, A. O., Wampold, B. E., Crits-Christoph, P., Atzil-Slonim, D., . . . Barber, J. P. (2020). The reciprocal relationship between alliance and early treatment symptoms: A two-stage individual participant data meta-analysis. Journal of Consulting and Clinical Psychology, 88(9), 829–843.

The therapeutic alliance (patient and therapist agreement on tasks and goals of therapy and their emotional bond) is the most researched concept in psychotherapy. The research clearly indicates that a positive alliance reliably predicts patient outcomes in terms of reduced symptoms. However, researchers still debate whether the alliance is at all necessary. That is, some argue that the alliance is the result of patients feeling better early in therapy, and so the alliance is only an outcome of early symptom reduction. If that is the case, then the alliance is an artifact of symptom reduction, and clinicians need not pay much attention to it. In this meta-analysis, Fluckiger and colleagues collected 17 studies representing over 5000 patients that evaluated whether alliance in a previous session predicted outcomes in a subsequent therapy session, and vice versa. In other words, they looked at all studies that evaluated if change in alliance preceded change in symptoms and if change in symptoms preceded change in the alliance. What is unique about this meta-analysis is that they gathered patient-level data from the original studies. That allowed them to test the therapeutic alliance theory for each individual patient on a session by session basis for the first 7 sessions of therapy. (For the stats geeks out there, the authors analysed within-person [between-session] effects using multilevel time-lagged models). Their analyses found that high alliance at a preceding session was related to lower symptoms at the subsequent session (B adjusted = -.065 (95% CI [-.092, -.038]; p < .0001)), and higher symptoms at the start of a session was related to lower post session alliance (B adjusted = -.148 (95% CI [-.215, -.081]; p < .0001). They also found that patients who generally reported high alliance scores showed a stronger alliance – outcome relationship, and those with greater symptoms had a weaker alliance - outcome relationship.

Practice Implications

This meta-analysis is another indication of the importance of therapists and patients coming to a collaborative agreement on the tasks of therapy (what is done during sessions) and the goals of therapy (what issues to work on), and of their relational bond. The alliance is not always easy to establish – especially with regard to agreeing on goals. Also, the alliance should not be forgotten once established – alliance ruptures or tensions occur frequently and can have a negative effect on patients’ mental health outcomes. Patients of psychotherapists who repair alliance tensions generally have better mental health outcomes.

Keefe, J. R., McMain, S. F., McCarthy, K. S., Zilcha-Mano, S., Dinger, U., Sahin, Z., Graham, K., & Barber, J. P. (2019, December 5). A meta-analysis of psychodynamic treatments for borderline and Cluster C personality disorders. Personality Disorders: Theory, Research, and Treatment. Advance online publication.

Personality disorders are common mental conditions affecting between 6.1% and 9.1% of the population. Having a comorbid personality disorder predicts a number of negative outcomes from psychotherapy including lower remission rates, greater resistance to therapy, and greater relapse after therapy. Psychodynamic therapies are one of two classes of therapy that have been repeatedly tested in clinical trials for personality disorders (the other being cognitive-behavioral therapies). Psychodynamic therapies aim to help patients improve their personality functioning, including attachment, mentalization, and maturity of defense mechanisms. Dynamic therapies for personality disorders include transference-focused therapy, affect-phobia therapy, mentalization based treatment, and good psychiatric management. In this meta-analysis, Keefe and colleagues systematically assessed whether psychodynamic therapy was as effective as other active treatments and more effective than no treatment. They also evaluated the quality of the studies. They found 16 randomized controlled studies of over 1100 patients that directly compared psychodynamic therapy to another therapy or to a control condition. Outcomes included personality disorder symptoms, suicidality, general symptoms, and drop-out rates. Overall, psychodynamic therapy was as effective as other therapies when it came to all of these outcomes, and the drop-out rates were equivalent. Psychodynamic therapy was more effective than no treatment for personality disorder symptoms (g = 0.63; 95% CI [0.87, 0.41], SE = 0.08, p = .002), suicidality (g = 0.67; 95% CI [1.13, 0.20], SE = 0.15, p = .020), and general symptoms (g = 0.38;95% CI [0.68, 0.08], SE = 0.13, p = .019). Average study quality was high, suggesting that one could be confident in the overall findings of this meta analysis.

Practice Implications

For all outcomes, psychodynamic therapies were as effective as other active treatments and more effective than no-treatment controls for borderline personality disorder and for mixed Cluster C disorders (dependent, avoidant, and obsessive-compulsive personality disorders). The authors concluded that psychodynamic therapies are effective in treating personality disorders like borderline personality disorder and those with Cluster C personality disorders.

Norwood, C., Moghaddam, N.G., Malins, S., & Sabin-Farrell, R. (2018). Working alliance and outcome effectiveness in videoconferencing psychotherapy: A systematic review and noninferiority meta‐analysis. Clinical Psychology and Psychotherapy, 25, 797-808.

The working alliance is the collaboration between client and therapist on the tasks and goals of therapy, and it also includes the emotional bond. The alliance is the most researched concept in psychotherapy, and it is reliably related to good client outcomes. However, the alliance has been rarely studied in the context of videoconferencing psychotherapy (VCP). Delivering psychotherapy remotely was already gaining popularity prior to COVID-19 because of its potential to improve access to mental health care especially for people who live in remote areas. Some argue that face to face therapy might result in a higher therapeutic alliance because of the rich interpersonal cues, like eye contact and body posture that may facilitate collaboration and the bond. There is emerging evidence that VCP can be effective and that it may have comparable outcomes to face-to-face therapy. But what about the working alliance – does it develop in VCP similarly to face to face therapy?  In this meta-analysis, Norwood and colleagues conducted a systematic review of the existing research on the working alliance in VCP. They found only 4 direct comparison randomized controlled studies on the topic, and on average VCP resulted in a lower working alliance compared to face to face therapy, but the difference was not statistically significant (n = 4; SMD = -0.30; 95% CI: -0.67, 0.07; p = 0.11). People who received treatment via VCP had similar levels of symptom reduction compared to those who received face to face therapy (n = 4; SMD = −0.03; 95% CI [−0.45, 0.40], p = 0.90).

Practice Implications

With only four direct comparison randomized trials to draw from, the results of this meta-analysis remained ambiguous with regard to the therapeutic alliance. Although the difference between VCP and face to face therapy was not statistically significant, it was not ignorable – an effect size of SMD = -0.30 suggests a small advantage for face to face therapy when it comes to the alliance. However, symptom outcomes were comparable between face to face and VCP. The results suggest that therapists who use VCP during a pandemic, must pay particular attention to developing and maintaining a therapeutic alliance by collaboratively agreeing on goals and tasks of therapy, and by focusing on establishing an affective bond with patients despite the limited nonverbal cues available with online psychotherapy.

Effectiveness and Adherence of Telephone-Administered Psychotherapy

Castro, A., Gili, M., Ricci-Cagello, I., Roca, M., Gilbody, S., Perez-Ara, A., Segui, A., & McMillan, D. (2020). Effectiveness and adherence of telephone-administered psychotherapy for depression: A systematic review and meta-analysis. Journal of Affective Disorders, 260, 514-526.

The COVID-19 pandemic has resulted in psychotherapy providers moving to online and telephone-delivered interventions. But questions remain about the efficacy of delivering psychotherapy in these formats to patients with depression. Depression is highly prevalent as it affects about 320 million people around the world and causes serious disability and lowered quality of life. Psychotherapy is effective in treating depression, however there are significant barriers to people accessing face-to-face psychotherapy including cost, stigma, distance, and disability. Telephone-delivered psychotherapy may minimize these barriers. One potential question that may arise is whether patients will adhere to telephone-delivered psychotherapy. That is, will patients find telephone sessions acceptable as indicted by the rate of starting therapy and of attending sessions? In this systematic review and meta-analysis, Castro and colleagues evaluated whether telephone-delivered psychotherapy for depression is as effective as other active treatments and more effective than no-treatment. The authors also examined the level of adherence/acceptability to telephone administered treatment, determined by the percent of scheduled sessions actually attended by a patient. The sample of studies was small such the authors only found a total of 11 direct comparison randomized controlled trials. These trials represented almost 1400 patients. The only treatment tested in these trials were CBT-oriented. Four studies found that telephone-delivered therapy produced significantly larger reductions in depressive symptoms when compared to no treatment controls (mean SMD = -0.48; 95% CI: -0.82 to -0.14). In four other studies telephone-administered therapy was just as effective as an active control (e.g., medication or self-help). The weighted average percentage of scheduled telephone sessions that patients attended was 73%, and the percent of patients who started telephone therapy after the initial referral was about 90%. These percentages indicating adherence and acceptability are similar to findings reported from individual psychotherapy studies.

Practice Implications

There are few randomized controlled trials that assess the efficacy of telephone-administered psychotherapy, and these studies were limited to only one type of intervention. However, the findings from this meta-analysis suggested that telephone-delivered psychotherapy may be efficacious and as effective as some other active treatments. Further, telephone therapy may be acceptable to patients in that they start and attend sessions at a rate similar to face-to-face therapy. These preliminary findings provide clinicians who provide telephone psychotherapy during this period of physical distancing due to COVID-19 with some evidence for the utility of telephone delivered treatment.