Blog

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.

August 2013

Helpful and Hindering Events in Psychotherapy

Castonguay, L.G., Boswell, J.F., Zack, S., Baker, S., Boutselis, M., Chiswick, N., Damer, D., Hemmelstein, N., Jackson, J., Morford, M., Ragusea, S., Roper, G., Spayd, C., Weiszer, T., Borkovec, T.D., & Grosse Holtforth,, M. (2010). Helpful and hindering events in psychotherapy: A practice research network study. Psychotherapy: Theory, Research, Practice, and Training, 47, 327-344.

There are many reasons why I like this paper, and one reason is that it is a psychotherapy practice research network study (most of the co-authors are independent practice clinicians). This group of clinicians and researchers met on a number of occasions to define the research questions, including: “what do psychotherapists and clients find most and least helpful in a psychotherapy session?”; and “do psychotherapists and clients agree on what was most and least helpful?” The clinicians and researchers also discussed and agreed on the method for collecting and analysing the data. Thirteen independent practice clinicians participated (6 CBT, 4 psychodynamic, and 3 experiental/humanistic). For a period of 18 months, all new clients were invited to participate so that 121 clients with a variety of disorders enrolled in the study. Clients and therapists filled out (on an index card) parts of the Helpful Aspects of Therapy (HAT) measure, which asked them to report, describe, and rate particularly helpful and hindering events from the session they had just completed. For example clients and therapists were asked: “Did anything particularly helpful happen during this session?”; and “Did anything happen during this session which might have been hindering?” When participants answered “Yes” to either of these questions, they were asked to briefly describe the event(s), and then rate them on a scale from 1 to 4 for level of helpfulness or level of hindrance. Both clients and therapists did so at the end of every therapy session. Close to 1500 therapeutic events were recorded by the clients and therapists. The events were then coded and categorized according to type of event by independent raters using an established coding system. Clients rated self-awareness, problem clarification, and problem solution as the most helpful type of events, although self-awareness was significantly the most identified of all helpful events by clients. Therapists rated self-awareness, alliance strengthening, and problem clarification as the most helpful type of events. Therapists identified self-awareness and alliance strengthening significantly more often than any other helpful events. Hindering events were identified much less frequently by clients and therapists. Client identified poor fit (e.g., therapist tried something that didn’t fit the client’s experience) as the most frequent hindering event category. Therapists identified therapist omissions (i.e., failure to provide support or an intervention) as the most frequent hindering event category. Overall, with the exception of self-awareness, therapists and clients did not agree on what were the most helpful or hindering events in therapy.

Practice Implications

Results regarding self awareness indicate that providing clients with opportunities to achieve a clearer sense of their experience (e.g., emotions, behaviors, and perceptions of self) is frequently reported as beneficial by both clients and therapists. The events that therapists most frequently reported as detrimental were those in which they failed to be attuned to their clients’ needs. This may reflect therapists’ concerns with potential alliance ruptures. The overall lack of agreement between therapists and clients on helpful and hindering events raises the question about whether therapists are not aware enough of clients’ experiences, or whether clients are not knowledgeable about what is in fact therapeutic. Perhaps client and therapist ratings of events represent complementary perspectives on what works or does not work in psychotherapy. Regarding participating in research, these independent practice therapists reported that the procedure of writing down helpful and harmful events and reading what their clients wrote after each session had a positive impact on their practice. That is, the process of data collection became immediately relevant to their clinical work.

Author email: lgc3@psu.edu

May 2013

Are the Effects of Psychotherapy for Depression Overestimated?

Niemeyer, H., Musch, J., & Pietrowsky, R. (2013). Publication bias in meta-analyses of the efficacy of psychotherapeutic interventions for depression. Journal of Consulting and Clinical Psychology, 81, 58-74.

Meta-analyses are important ways of summarizing effects of medical and psychological interventions by aggregating effect sizes across a large number of studies. (Don’t stop reading, I promise this won’t get too statistical). The aggregated effect size from a meta analysis is more reliable than the findings of any individual study. That is why practice guidelines almost exclusively rely on meta analyses when making practice recommendations (see for example the Resources tab on this web site). However meta analyses are only as good as the data (i.e., studies) that go into them (hence, the old adage: “garbage in, garbage out”). For example, if the studies included in a meta analysis are a biased representation of all studies, then the meta analysis results will be unreliable leading to misleading practice guidelines. One problem that leads to unreliable meta analyses is called publication bias. Publication bias often refers to the tendency of peer reviewed journals not to publish studies with non-significant results (e.g., a study showing a treatment is no better than a control condition). Publication bias may also refer to active suppression of data by researchers or industry. Suppression of research results may occur because an intervention’s effects were not supported by the data, or the intervention was harmful to some study participants. In medical research, publication bias can have dire public health consequences (see this TED Talk). There is lots of evidence that publication bias has lead to a significant over-estimation of the effects of antidepressant medications (see Turner et al (2008) New England Journal of Medicine). Does publication bias exist in psychotherapy research, and if so does this mean that psychotherapy is not as effective as we think? A recent study by Niemeyer and colleagues (2013) addressed this question with the most up to date research and statistical techniques. They collected 31 data sets each of which included 6 or more studies of psychotherapeutic interventions (including published and unpublished studies) for depression. The majority of interventions tested were cognitive behavioral therapy, but interpersonal psychotherapy, and brief psychodynamic therapy were also included. The authors applied sophisticated statistical techniques to assess if publication bias existed. (Briefly, there are ways of assessing if the distribution of effect sizes across data sets fall in a predictable pattern called a “funnel plot” – specific significant deviations from this pattern indicate positive or negative publication bias). Niemeyer and colleagues found minimal evidence of publication bias in published research of psychotherapy for depression. This minimal bias had almost no impact on the size of the effect of psychotherapy for depression.

Practice Implications

This is a very important result indicating that despite a minor tendency toward a selective publication of positive results, the efficacy of all reviewed psychotherapy interventions for depression remained substantial, even after correcting for the publication bias. Niemeyer and colleagues’ findings demonstrate that publication bias alone cannot explain the considerable efficacy of psychotherapy for depression. Psychotherapeutic interventions can still be considered efficacious and recommended for the treatment of depression.

Author email address: helen.niemeyer@hhu.de

February 2013

Does Participating in Research Have a Negative Effect on Psychotherapy?

Town, J. M., Diener, M. J., Abbass, A., Leichsenring, F., Driessen, E., & Rabung, S. (2012). A meta-analysis of psychodynamic psychotherapy outcomes: Evaluating the effects of research-specific procedures. Psychotherapy, 49, 276-290.

One of the main reasons that some clinicians do not participate in research is that they argue that doing so will have a negative impact on the therapeutic relationship, the therapy process, and patient outcomes. Although I have heard this from clinicians of many theoretical orientations, this opinion is perhaps most strongly held by some colleagues with a psychodynamic orientation. I identify with psychodynamic theory and practice, so this opinion about research held by some of my colleagues has been very disconcerting to me. Up to now, the best I could say in defense of practice-based research of psychodynamic therapy was to talk about my own experiences, which have been highly positive and rewarding. A recent meta analysis by Town and colleagues from Dalhousie University changes all that. (First, a note about meta analysis. Meta analysis is a statistical way of combining the effects of many studies, each of which has a number of participants, into a common metric called an effect size. By combining studies, the end result is more meaningful and more reliable than the results of any single study on its own.). The meta analysis by Town and colleagues had 45 independent samples and over 1600 patients. Results indicated that psychodynamic treatments for a variety of disorders (e.g., depression, anxiety, personality disorders) showed a significant large positive treatment effect – this is not new. What is new is that compared to conditions in which no research-specific protocols were introduced, conditions that did use research protocols were no different in terms of patient outcomes up to one year post treatment. There was even a significant small positive effect of these research protocols on outcomes from post treatment to one year post treatment. Research-specific protocols included video recordings of therapy sessions, therapists following treatment manuals, fidelity checks to make sure therapists were accurately doing psychodynamic therapy, and psychometric measurements of processes and outcomes

Practice Implications

Research protocols do not have a negative impact on psychodynamic therapy outcomes. Perhaps research protocols should be introduced into all therapies to improve longer term outcomes in addition to studying therapy procedures and processes that work.

Author email: joel.town@dal.ca

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August 2013

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May 2013

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February 2013

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Psychotherapy Practice Research Network (PPRNet)