The Psychotherapy Practice Research Network (PPRNet) blog began in 2013 in response to psychotherapy clinicians, researchers, and educators who expressed interest in receiving regular information about current practice-oriented psychotherapy research. It offers a monthly summary of two or three published psychotherapy research articles. Each summary is authored by Dr. Tasca and highlights practice implications of selected articles. Past blogs are available in the archives. This content is only available in English.
…I blog about psychotherapy for borderline personality disorder, capacity to metnalize and therapy resistant depression, and negative effects of psychotherapy
Type of Research
- ALL Topics (clear)
- Alliance and Therapeutic Relationship
- Anxiety Disorders
- Attendance, Attrition, and Drop-Out
- Client Factors
- Client Preferences
- Cognitive Therapy (CT) and Cognitive-Behavioural Therapy (CBT)
- Combination Therapy
- Common Factors
- Depression and Depressive Symptoms
- Efficacy of Treatments
- Feedback and Progress Monitoring
- Group Psychotherapy
- Illness and Medical Comorbidities
- Interpersonal Psychotherapy (IPT)
- Long-term Outcomes
- Neuroscience and Brain
- Outcomes and Deterioration
- Personality Disorders
- Placebo Effect
- Practice-Based Research and Practice Research Networks
- Psychodynamic Therapy (PDT)
- Resistance and Reactance
- Self-Reflection and Awareness
- Suicide and Crisis Intervention
- Therapist Factors
- Transference and Countertransference
- Trauma and/or PTSD
- Treatment Length and Frequency
No Added Value to Adding Antidepressants to Psychotherapy
Karyotaki, E., Smit, Y., Henningsen, H., Huibers, M.J.H., Robays, J., de Beurs, D., & Cuijpers, P. (2016). Combining pharmacotherapy and psychotherapy or monotherapy for major depression? A meta-analysis on the long-term effects. Journal of Affective Disorders, 194, 144-152.
Depression is a highly prevalent disorder and is expected to become the second largest cause of disability by 2020. Part of the reason for this high level of burden is that depression tends to be a recurrent disorder with high rates of mortality and morbidity. The post-treatment effects of psychotherapy and pharmacotherapy for treating mild to moderate depression are comparable, and combining the two interventions appears to result in better outcomes. Treatment guidelines recommend pharmacotherapy for at least six months to prevent relapse of depressive symptoms. But to what extent does combined antidepressants with psychotherapy result in a different response than pharmacotherapy or psychotherapy alone in the longer term? The meta analysis by Karotaki and colleagues was conducted to address this question. They defined psychotherapy to include any psychological intervention between a therapist and patient that was verbal in nature, and that included in-person, internet-based, telephone, or bibliotherapy components. Types of psychotherapy included CBT, interpersonal, dynamic, and problem solving therapy. Only studies with outcomes at six months or longer (up to 48 months) after the start of treatment were included. The meta analysis included 23 studies with a total of 2164 patients with major depression who receive combined therapy in at least one arm of the study. Antidepressants included SSRIs, SNRIs, and tricyclic medications. In the acute phase treatment (i.e., in studies of treatment during the occurrence of depressive symptoms), combining antidepressants with psychotherapy was more effective than antidepressants alone. But combined treatment was not more effect than psychotherapy alone at six months or longer after the start of treatment. In maintenance treatment (i.e., in studies to prevent relapse of depression) psychotherapy with antidepressants was more effective that pharmacotherapy alone. Type of psychotherapy or medication did not affect any of the results.
The meta analysis suggests that in the treatment of patients who currently have depressive symptoms (acute phase) psychotherapy alone is as effective in the long run as combining psychotherapy with antidepressants. However combination treatment is more effective that antidepressants alone, presumably because of the added value of psychotherapy. To prevent relapse (maintenance phase), combined treatment of pharmacotherapy and psychotherapy was more effective than antidepressants alone. Psychotherapy may be a viable alternative to combined treatment with medications for treatment of current active depressive symptoms. Psychotherapy often results in patients improving their interpersonal skills and coping mechanisms which they can then use to sustain their improvements in the longer term.
Clients’ Experiences of Psychotherapy
Levitt, H.M., Pomerville, A., & Surace, F.I. (2016). A qualitative meta-analysis examining clients’ experiences in psychotherapy: A new agenda. Psychological Bulletin. Online First Publication, April 28, 2016.
Much of psychotherapy research over the past several decades has focused on therapy outcomes, with the general conclusion that outcomes are equivalent across major psychotherapy orientations. Some of the effects of psychotherapy can be explained by relational factors (e.g., therapeutic alliance). There is also a growing and interesting line of research about therapist variables and therapist effects (see this month’s PPRNet blog on differences between therapists’ outcomes in a large UK sample). Many experts argue that client effects and characteristics account for the largest amount of variance in therapy outcomes. That is, who clients are and what experiences they have are the largest determinants of whether psychotherapy will be helpful. However the client’s experience is often neglected in psychotherapy research reviews. Levitt and colleagues conducted a qualitative meta analysis of qualitative studies of clients’ experiences in psychotherapy. Qualitative research typically involves interviewing clients about their experiences in therapy and coding the transcripts of these interviews. Methods of synthesizing and categorizing themes from client narratives, such as the grounded theory method and thematic analysis, create a rich source of understanding about how clients experience change in psychotherapy. Levitt and colleagues applied qualitative methods to synthesize 109 qualitative studies of over 1400 clients as a way of analysing this research. Six clusters or themes emerged from their qualitative meta analysis: (1) clients experienced therapy as a process of identifying and understanding personal patterns; (2) clients who felt understood and had their experiences validated were able to internalize the therapist’s voice; (3) clients experienced the structure of therapy (spacing of sessions and time allotted to sessions) and therapist expertise as generating credibility for the therapy, but also at times the structure reduced clients’ experience of therapeutic relationship’s authenticity; (4) clients experienced an inherent power differential with therapists that was sometimes compounded by differences in race, gender, and class; (5) clients played a major role in the therapeutic process, and clients felt pleased when they were invited to take the lead; (6) clients’ experiences of being cared-for supported their ability to recognize maladaptive patterns and address unmet vulnerable needs.
This qualitative meta analysis highlights the important role played by the client’s experience and by the therapy context in promoting good outcomes. The results suggested that better outcomes may be achieved when: (1) therapists encourage clients’ curiosity about their cognitive, emotional and relational patterns; (2) therapists engage in an accepting and caring relationship in order to help clients decrease their defensiveness about vulnerable topics; (3) therapists maintain the therapeutic structure in order to increase clients’ sense of confidence in the process; (4) therapists explicitly acknowledge power differences and repair alliance ruptures; (5) therapists encourage clients to take an active role in therapy as a means of self-healing; and (6) therapists regularly check with clients about the fit of interventions, in-session needs, and treatment goals.
Psychotherapy That is Culturally Congruent for Chinese Clients
Xu, H. & Tracey, T.J.G. (2016). Cultural congruence with psychotherapy efficacy: A network meta-analytic examination in China. Journal of Counseling Psychology, 63, 359-365.
Cultural congruence refers to providing psychotherapy that is consistent with the client’s cultural context in its description of the etiology of symptoms and in its therapeutic procedures. In general, congruence of treatments with clients’ expectation, preferences, and beliefs is related to greater psychotherapy efficacy. And specifically identifying culturally appropriate or adapted treatments is important because this is often related to better therapy outcomes for ethnic and racial minorities. Psychotherapy as a professional practice developed recently in China. Cognitive-behavioral, existential-humanistic, and psychodynamic therapies have taken their place along side indigenous therapies including Naikan therapy, Taoism cognitive therapy, and Morita therapy. Historically in China mental health problems were seen as a disturbance in ying-yang or a sin committed in a previous life. Healing practices included engaging in altruism or religious practices to achieve redemption. Xu and Tracey argue that Chinese culture strongly endorses an experiential and subjective orientation and is less aligned with analytic and objective orientations. Using this understanding, the authors expected that experiential-humanistic and indigenous therapies would be more congruent and therefore more effective than cognitive-behavioral education or psychodynamic therapy in alleviating mental health issues. In this meta analysis, Xu and Tracey reported on 235 studies conducted in China that compared the various treatments to a control condition or to each other. There were too few studies of psychodynamic therapy, so it was not included in the analyses. All treatments were effective compared to a control condition with large effect sizes (g = .85 to 1.18). However, whereas experiential-humanistic and indigenous therapies were equally effective, each was significantly more effective (g = .34) than cognitive-behavioral psychoeducation.
The three modalities, experiential-humanistic, indigenous, and cognitive-behavioral psychoeducation were effective. However the two therapies that were more experiential and subjective in nature were more effective to reduce Chinese clients’ symptoms. When working with Chinese clients, therapists may achieve better outcomes if they work on more experiential components (e.g., feelings and therapeutic relationship) and focus on subjective experiences (e.g., introspection and reflection). The results of the meta analysis suggest that when working with Chinese clients interpersonal processes and emotions should be the clinical focus and take priority over dysfunctional cognitions and psychoeducation.
Is it Feasible to Have a Nationally Funded Psychotherapy Service?
Community and Mental Health Team, Health and Social Care Information Centre (2015). Psychological therapies; Annual report on the use of IAPT services: England 2014/15.
There have been calls from mental health professional organizations and by the media to provide publicly funded psychotherapy in Canada. Rates of common mental disorders in Canada are high, such that about 20% of the population will personally experience a mental illness in their lifetime. In 1998, the estimated direct and indirect economic cost of mental illness in Canada was $7.9 billion (all figures are in Canadian dollars). Current estimates of costs to fund a public psychotherapy service in Canada may be about $1 billion to $2.8 billion – which far outweighs the cost. Most outpatient psychotherapy in Canada is provided by professionals in private practice who charge somewhere between $100 and $200 per session, costing Canadians nearly $1 billion per year. Some people are fortunate to have workplace insurance that covers some but not all of the costs, but most people in Canada do not have insurance and so they pay out of pocket or they go untreated. Research shows us that approximately 13 to 18 sessions are needed for 50% of clients to get better with psychotherapy. Which means that even with an insurance plan, many Canadians who need psychotherapy will find it to be a financial burden. Since 2008, the National Health Service in England implemented the Improving Access to Psychotherapies (IAPT) services to provide publicly funded psychotherapy to the population. The psychological treatments provided through IAPT are evidence-based (e.g., CBT, interpersonal psychotherapy, brief dynamic psychotherapy for depression). For mild to moderate problems, individuals get low intensity interventions first (i.e., self help, internet based interventions), followed by more intensive psychotherapy if needed. Treatment outcomes are measured from pre- to post-treatment with valid standardized measures of depression and anxiety. At post-treatment, patients are categorized as reliably deteriorated, not changed, improved, and recovered. The goal of the IAPT is to achieve 50% recovery rates among patients. In their online 2014-15 annual report, the IAPT service reported that it treated over 400,000 patients in that year. 44.8% of patients were rated as reliably recovered – that is over 180,000 mentally ill patients improved and no longer had a mental illness. Reliable improvement was seen in 60.8% of patients – this included recovered patients plus those who still had a disorder but were feeling significantly better than when they started. Recovery was highest for people 65 years and older (57.8%). Rates of recovery were similar for depression (44.6%) and anxiety (47.8%) disorders, and between men and women. Waiting times for treatment was less than 28 days for 66.0% of patients.
The experience in England with the IAPT is instructive for Canada. The IAPT service provides evidence-based psychological therapies within a publicly funded national health service. The IAPT approached its target of 50% of patients recovering from mental illness, and over 60% of patients were reliably improved. Waiting times were low for most patients. Given the experience in England’s National Health Service, the implementation of a national strategy for psychotherapy appears to be feasible and effective. Will political leaders in Canada be able to see the financial and human value of publicly funded psychotherapy?
Long-Term Efficacy of Psychological Therapies for Irritable Bowel Syndrome
Laird, K.T., Tanner-Smith, E.E., Russell, A.C., Hollon, S.D., & Walker, L.S. (2016). Short-term and long-term efficacy of psychological therapies for irritable bowel syndrome: A systematic review and meta-analysis. Clinical Gastroenterology and Hepatology.
Irritable bowel syndrome (IBS) is a gastrointestinal (GI) disorder that affects 5% to 16% of the population. People with IBS have reduced quality of life similar to those with heart disease, heart failure, and diabetes. Previous meta analyses indicated that psychological therapies are just as effective as antidepressant medications immediately after treatment for improving symptoms of IBS. However, whether psychological therapies have longer lasting effects is unknown. It is important to patients and providers to know the longer term effects of psychological treatments for IBS because the disorder has a fluctuating course, and so symptoms may reappear after treatment is completed. In their meta analysis, Laird and colleagues reviewed 41 studies that recruited almost 2,300 adult patients. [A note about meta analysis: Meta analysis combines the standardized effect sizes (d) across many studies to estimate an average effect size. This means that meta analyses are much more reliable than any single study, and when possible they should be the basis for practice recommendations]. Psychological therapies for IBS often included cognitive behavioral therapy (CBT), but also included relaxation therapy, mindfulness, hypnosis, behavioral treatment, and psychodynamic therapies. Control conditions often were: supportive therapy, education, fake treatment for biofeedback or hypnosis, online discussion groups, treatment as usual, or wait-list controls. Psychological therapies were more effective than control conditions immediately post-treatment in improving GI symptoms, and the effects were moderately large (d = .69). Psychological therapies remained more effective than control conditions up to 6 months post-treatment (d = .76), and from 6 months to 1 year post-treatment (d = .73). CBT and other treatments (e.g., relaxation, hypnosis) were equally effective; and individual and group delivered treatments were no different in their efficacy. The number of sessions, duration of sessions, and frequency of sessions did not impact the efficacy of psychological interventions.
Determining the longer term efficacy of psychological treatment for IBS is important because the symptoms tend to be recurrent and sometimes are chronic. Psychological treatments reduce GI symptoms in adults with IBS, and the effects appear to be long lasting – at least up to 1 year post-treatment. The average individual who received psychotherapy was better off than 75% of control condition participants.
Direct Psychological Interventions Reduce Suicide and Suicide Attempts
Meerwijk, E.L., Parekh, A., Oquendo, M.A., Allen, I.E., Franck, L.S., & Lee, K.A. (2016). Direct versus indirect psychosocial and behavioural interventions to prevent suicide and suicide attempts: A systematic review and meta-analysis. Lancet Psychiatry.
The World Health Organization reports that more than 800,000 people die of suicide per year around the world. However suicide prevention efforts over the past decade have fallen short of targets. In fact, the prevalence rates of suicide in the US have risen steadily since 2000 to about 1.3% of the population in 2014. Many who kill themselves have a mental disorder like depression, anxiety disorders, substance abuse, psychoses, or personality disorders. Best practices suggest that directly addressing suicidal thoughts and behaviors during treatment, rather than only addressing symptoms like depression and hopelessness, are most effective in reducing suicide. However, there are no meta analyses of randomized controlled trials that specifically assess the relative utility of direct versus indirect psychological interventions. In their meta analysis, Meerwijk and colleagues looked at psychosocial interventions aimed to prevent suicide or to treat mental illness associated with suicide. They included 31 studies representing over 13,000 participants. Interventions included cognitive behavioral therapy (CBT), dialectical behavior therapy (DBT), case management, social skills training, and supportive telephone calls. Depending on the target problem, the interventions either directly addressed suicidal behavior or they indirectly addressed suicidal behavior. Mean duration of treatment was over 11 months. Studies that looked at direct or indirect interventions were each compared to control groups that received some form of usual care in the community, or psychiatric management, or general practitioner care. Individuals who received usual care were 1.5 times more likely to die of or attempt suicide compared to those receiving direct or indirect psychological interventions. There was a 35% lower odds of suicide and attempts with direct interventions compared to usual care; and an 18% lower odds of suicide and attempts with indirect interventions compared to usual care. The difference between the effectiveness of direct versus indirect interventions was large (d = .77), suggesting that direct interventions were more effective than indirect interventions at reducing suicide and suicide attempts.
This is the largest meta analysis of its kind. Most direct interventions to prevent suicide and suicidal behaviors were based on CBT and DBT. Indirectly addressing suicide by focusing on depressive symptoms, anxiety, and hopelessness was somewhat effective compared to usual care. However, direct interventions that included talking about the patient’s suicidal thoughts and behaviors and how best to cope were most effective.