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 CBT, negative effects of psychological interventions, and what people want from therapy.
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
Cognitive Therapy for Depression
Hollon, S.D. & Beck, A.T. (2013). Cognitive and cognitive-behavioral therapies. In M.E. Lambert (Ed.), Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change, 6th Edition (pp. 393-442). New York: Wiley.
Cognitive (CT) and cognitive behavioural therapies (CBT) are among the most empirically supported and widely practiced psychological interventions. CT emphasizes the role of meaning in their models of depression and CT interventions emphasise testing the accuracy of beliefs. More behavioural approaches like CBT see change in terms of classical or operant conditioning of behaviours, in which cognitive strategies are incorporated to facilitate behavioural change. In this section of their chapter, Hollon and Beck review research on CT for depression. Depression is the single most prevalent mental disorder and is a leading cause of disability in the world (see this month’s blog entry on the global burden of depression). Most patients have multiple episodes of depression (i.e., recurrent) and about 25% have episodes that last for 2 years or more (i.e., chronic). CT posits that depressed individuals have negative automatic thoughts that are organized into depressogenic automatic beliefs (or underlying assumptions) that put them at risk for relapse. Automatic beliefs can be organized in latent (or unconscious) schemas often laid down in childhood and activated by later stress that influence the way information is organized. In CT patients are taught to evaluate their beliefs (also called empirical disconfirmation), conduct “experiments” to test their accuracy and to modify core beliefs and reduce maladaptive interpersonal behaviours. Most reviews show that CT for depression is superior to no treatment (with large effects) and at least as effective as alternative psychological or pharmacological interventions. Most patients show a good response to CT with about one third showing complete remission. Although some practice guidelines have concluded that medications are preferred to CBT (or any psychotherapy) for severe depression, more recent meta analyses show that CT is as efficacious as medications and is likely better in the long term. CT also has an enduring effect that protects clients against symptoms returning. Medications, on the other hand suppress depressive symptoms only as long as the patient continues to take the treatment, but medications do not reduce underlying risk. As a result, relapse rates for medication treatment of depression are much higher than for CT. These findings suggest that patients who receive CT learn something that reduces risk for recurrence, which is the single biggest advantage that CT has over medications. Further, CT is free from problematic side effects that may occur with medications.
CT and CBT are the most tested psychological treatments for depression and the evidence indicates that many patients benefit. CT and CBT are as effective as medications for reducing acute distress related to depression, and even for those with more severe depression when implemented by experienced therapists. CT has an enduring effect not found in medications, may also help prevent future episodes of depression, and may prevent relapse after medications are discontinued.
Meta Analysis on the Effectiveness of Psychodynamic Therapy for Anxiety Disorders
Keefe, J.R., McCarthy, K.S., Dinger, U., Zilcha-Mano, S., Barber, J.P. (2014). A meta analytic review of psychodynamic therapies for anxiety disorders. Clinical Psychology Review, http://dx.doi.org/10.1016/j.cpr.2014.03.004.
Anxiety disorders are one of the most prevalent psychiatric conditions, with combined lifetime prevalence near 17%. Anxiety disorders have high rates of comorbidity with other Axis I and II psychiatric disorders, and are associated with substantial physical and mental health burden. Several well-established treatments for anxiety disorders exist, including cognitive-behavioral therapies (CBT). However, not all patients with anxiety disorders benefit from current treatments, and there is some evidence that some aspects of CBT are not well tolerated leading to patient non-compliance with therapist directives. Hence, other treatment options such as psychodynamic therapies (PDTs). Should be tested for efficacy with patents with anxiety problems. PDTs have been studied and found to be efficacious for other types of disorders especially for depression. As Keefer and colleagues note, psychodynamic theory conceptualizes anxiety symptoms as originating from relational contexts that give rise to painful feelings (e.g., feelings of loss or abandonment, a wish to express anger or assert oneself). The patient engages in disavowal defenses against these intense, negative feelings and desires, and so avoids their experiences, and develops anxiety symptoms (e.g., panic attack triggered by experiences of loss or anger). Psychodynamic therapists encourage the patient to discuss the contexts in which their symptoms arise in order to understand the occurrence of symptoms. Therapists help the patient make connections between prior interpersonal and intrapsychic events that lead to negative feelings and anxiety-producing defenses. The goal is to allow the patient to try new ways of getting their needs met without anxiety while using more adaptive defenses. Exposure to feared or avoided situations during therapy sessions or in real life may also be encouraged by therapists. PDT may be less directive that CBT in treating anxiety disorders, and this may be useful for patients who do not respond well to directive interventions. Keefe and colleagues conducted a meta analysis of PDT for anxiety disorders and included 14 controlled studies of 1,037adults. Most of the treatments to which PDT was compared were CBT. PDT was significantly more effective than no treatment control conditions and the effect was medium. PDT did not differ significantly from alternative treatments like CBT at post-treatment, one year follow-up, and follow up beyond one year. Almost half of patients who received PDT were no longer symptomatic at post-treatment, and the drop out rate from PDT was 17%.
The findings of this meta analysis suggests that psychodynamic therapy (PDT) is effective in treating anxiety disorders including generalized anxiety disorder, social phobia, panic disorder and others. PDT was well tolerated by patients as the drop out rate was relatively low at 17%. PDT was as effective as CBT when the two treatments were compared to each other. PDT provides therapists and patients with a primary or alternative approach to treatment of anxiety disorders, and should be considered for those patients who do not respond well to the more highly directive nature of CBT.
Global Burden of Depression
Ferrari, A.J., Charlson, F.J., Norman, R.E., Patten, S.B., Freedman, G., et al. (2013). Burden of depressive disorders by country, sex, age, and year: Findings from the global burden of disease study 2010. PLoS Medicine, 10(11): e1001547. doi:10.1371/journal.pmed.1001547.
Depressive disorders are among the most common mental disorders that previously were described as a leading cause of burden in the world. In epidemiological literature, burden is defined in several ways. One common metric is “disability adjusted life years” (DALYs) which represents loss of a healthy year of life. DALYs can be aggregated into the “years of life lived with disability” (YLD). Another metric is the “years of life lost due to premature mortality” (YLL). Each of these metrics of burden can be estimated from aggregating data from a number of studies and meta analyses that assess burden world wide. Such epidemiologic studies can also look at relative burden across countries, ages, and sex. In the 2000 Global Burden of Disease report, depressive disorders were the third leading cause of burden after lower respiratory infections and diarrhoeal diseases. Depression was also the leading cause of disability, responsible for 13.4% of years of life living with disability in women and 8.3% in men. In this study by Ferrari and colleagues, the authors provide a 2010 update to the Global Burden of Disease report for major depressive disorder and dysthymia. Major depressive episode is the experience of depressed mood almost all day, every day, for at least 2 weeks. Dysthymia involves a less severely depressed mood with duration of at least 2 years, a chronic rather than episodic course, but with low rates of remission. Ferrari and colleagues reviewed over 700 studies from 1980 to 2010. Prevalence (i.e., current rate) of major depression and dysthymia in the world population is 5.95%, representing nearly 400 million people. Major depression (4.4%) occurs more frequently than dysthymia (1.55%). Major depression occurs more frequently among women (5.5%) than men (3.2%). Major depression accounted for 8.2% of all years lost to disability, making it the second leading cause after low back pain. The percent of years lost due to disability increased since 1990, largely due to population increases and aging of the world population. The highest level of burden due to depression was seen in Afghanistan and the lowest in Japan. In terms of world regions, North Africa and Latin America showed the highest levels of burden due to depression. The authors also reported that 2.9% of disability adjusted life years from ischemic heart disease can be attributed to major depression.
This study joins others in past decades to define depression as a leading cause of years lost to disability worldwide, with over 400 million people suffering from a depressive disorder. The increasing burden of depression is partly due to decreasing mortality caused by other diseases in developing countries and population aging. Countries that have recently experienced conflict (e.g., Afghanistan, North Africa, Middle East) were particularly burdened by depression. But research has also linked depression to intimate partner violence and child sexual abuse. Mortality is elevated with major depression, as is disability related to other medical problems like heart disease. This epidemiological research points to the importance of identifying and treating depression in the population. Psychotherapeutic interventions provide highly effective treatments for depression.
Practice Research Networks
Castonguay, L., Barkham, M., Lutz, W., & McAleavey, A. (2013). Practice-oriented research: Approaches and applications. In M.E. Lambert (Ed.), Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change, 6th Edition (pp. 85-133). New York: Wiley.
In this chapter of the Handbook, Castonguay and colleagues (2013) review research methods and results associated with practice research networks (PRN). There is substantial evidence to show that psychotherapists often are not influenced by research findings when they prepare their case formulations and conduct interventions. As a result, clients may not be benefiting fully from nearly 60 years of research in psychotherapy methods and processes. There may be several explanations for this divide. Clinicians may perceive psychotherapy research, especially the emphasis on empirically supported treatments, as limited in its clinical relevance. Researchers may pay limited attention to concerns of clinicians when developing research strategies and treatment manuals. The end result is that clinicians feel disenfranchised from the research field, and therefore unaffected by the findings. Clinicians may pay more attention to psychotherapy research if they were more involved and “owned” the research and findings. One solution is to develop PRN based on a partnership of practitioners and researchers in which they collaborate on all aspects of a study; i.e., generation of ideas, implementation, and publication. Castonguay and colleagues (2013) report on the research generated by several PRNs in the U.S. The American Psychiatric Institute for Research and Education’s PRN (APIRE-PRN) conducted several studies including: one study that found that compared to White patients, African Americans were less likely to be prescribed second generation antipsychotic medications, which are considered to be the treatment of choice by psychiatrists; and a second study that reported that presence of a personality disorder, low Global Assessment of Functioning scores, and seeing a psychiatrist at a discounted fee was associated with treatment non-compliance. The Pennsylvania Psychological Association PRN (PPA-PRN) conducted several studies, including one study that found that better patient outcomes were associated with: higher expectancy for change among clients, lower client interpersonal problems, greater number of therapy sessions, and lower therapist case load. A second PPA-PRN study that I reported in my August 2013 Blog found that therapist efforts to foster client awareness of their emotions, thoughts, and behaviors were perceived as particularly helpful by both clients and therapists. Finally, the National Drug Abuse Treatment Clinical Trials Network (CTN) conducted several studies with the intent of bringing drug abuse researchers into the real world and creating opportunities for clinicians to participate in research. This network completed over 50 trials. For example, in one trial, researchers found evidence for better retention, treatment engagement, and family functioning for brief strategic family therapy compared to treatment as usual.
A qualitative study reported by Castonguay and colleagues (2010) indicated that clinician involvement in PRN research fostered new learning as well as a sense of community with other professionals with shared goals. Therapists also indicated that their clients perceived their research participation as intrinsically meaningful and an opportunity to contribute to scientific knowledge. However, participating in a PRN had its challenges as well. Clinicians had to remember detailed procedures, at times practitioners had to depart from their clinical routine, and clinicians had to find time to complete questionnaires and other procedures. Castonguay and colleagues (2010) recommended that practice based research procedures in a PRN remain simple and clear, that clinicians have to have ready access to research staff for consultations, and that incentives have to be built in for clients and clinicians to participate. Studies in which research goals and clinical goals are indistinguishable are most likely to succeed.
Indirect Exposure to Trauma Can Lead to Job Burnout and Secondary Traumatic Stress Among Mental Health Providers.
Cieslak, R., Shoji, K., Douglas, A., Melville, E., Luszczynska, A., & Benight, C.C. (2014). A meta-analysis of the relationship between job burnout and secondary traumatic stress among workers with indirect exposure to trauma. Psychological Services, 11, 75-86.
The concept of job burnout was originally developed to document negative consequences of work related exposure to stressful situations experienced by various professionals such as police officers, paramedics, emergency room clinicians, etc. Job burnout can be defined as emotional exhaustion and disengagement. However, recent research on mental health providers has extended the focus beyond job burnout caused by direct exposure, to investigate the consequences of indirect exposure through contact with people who have experienced traumatic events, exposure to graphic trauma content reported by the survivor, or exposure to people’s cruelty to one another. These are sometimes referred to as secondary exposure or indirect exposure to trauma. Professionals indirectly exposed to trauma through their work could experience consequences or symptoms that have been conceptualized as secondary post-traumatic stress, vicarious traumatization, and compassion fatigue, which can collectively be called secondary traumatic stress (STS). STS may include three clusters of symptoms: intrusive re-experiencing of the traumatic material, avoidance of trauma triggers and emotions, and increased physical arousal. Compassion fatigue was defined as a substantial reduction in the mental health providers’ empathic capacity. Cieslak and colleagues (2014) conducted a meta analysis to assess the strength of associations between job burnout and other psychosocial consequences of work-related indirect exposure to trauma in professionals working with trauma survivors. They reviewed 41 studies that included 8,256 workers. The association between secondary traumatic stress (STS) and job burnout in professionals was significant and large. Workers were more likely to experience compassion fatigue and emotional exhaustion compared to PTSD-like symptoms and depersonalization, however, even the association with PTSD-like symptoms and depersonalization was moderate and significant. Both women and men were susceptible to STS, but the effect was larger in women.
Burnout and other consequences of indirect exposure to trauma are likely to be high among mental health professionals. Burnout will affect professionals’ well being and quality of life, and will diminish their effectiveness with patients through reduced empathy and increased disengagement. Mental health professionals who are exposed to secondary trauma should be aware of the potential for negative personal consequences, and assess their own level of emotional exhaustion, empathic capacity, and engagement. Mental health professionals should seek help if they re-experience the events, engage in avoidance of trauma triggers and emotions, and experience heightened arousal. Taking care of oneself through consultation with trusted colleagues, change in work contexts, social supports, and personal therapy could help to forestall compassion fatigue and burnout. Educational programs to improve self awareness and mindful communication may reduce burnout in mental health professionals.
Patients with High Levels of Resistance Respond Better to Less Directive Psychotherapy.
Beutler, L.E., Harwood, T.M., Michelson, A., Song, X., & Holman, J. (2011). Resistance/Reactance level. Journal of Clinical Psychology, 67, 133-142.
Patient resistance to psychotherapy is a persistent and perplexing problem. Resistance can be defined as patient behavior that is directly or indirectly contrary to therapist recommendations or to the health of the patient. However, the label “resistance” implies that the problem lies entirely within the patient, i.e., that the patient is the problem. Beutler and colleagues (2011) argue that it is more accurate to define the problem as “reactance”, which refers to the relational or co-constructed nature of psychotherapy. The notion of reactance (instead of resistance) suggests that the therapist also plays a role in the resistance, since the therapist is also responsible to create a context within which highly ambivalent clients do or do not thrive. Failure to thrive could be viewed as a poor fit between patient and therapy. Using social psychological theory, Beutler and colleagues conceptualized reactance as a state of mind aroused in the patients when he or she perceives their freedom to be limited by the therapy. A therapist may elicit resistant behavior from a patient by assuming more control of the patient’s behavior within and outside of the therapy sessions than is tolerable, by using confrontational techniques, and by creating and failing to repair alliance ruptures. Beutler and colleagues argued that therapist directiveness was a key factor in determining reactance in the therapy. Therapist directiveness refers to the extent to which a therapist dictates the pace and direction of therapy. Beutler and colleagues conducted a meta analysis to assess if therapist directiveness was associated with poorer outcome in patients who were more resistant in therapy. The meta analysis included 12 studies with 1,103 patients. They found that higher patient resistance was related to poorer outcomes, and the effect was moderate. The interaction between therapist directiveness and patient level of resistance directly affected outcomes, and this effect was significant and large. That is, greater therapist directiveness with patients who were more resistant resulted in poorer outcomes. Conversely, patients who were low in resistance responded well to more directive therapy.
Therapists should view some manifestations of client resistance as a signal that they are using ineffective methods. A therapist’s response to resistant states in a patient requires: acknowledgement and reflection of the patient’s concerns; discussion of the therapeutic relationship; and renegotiation of the therapeutic contract regarding goals and therapeutic roles. These therapist responses are designed to provide the patient with a greater sense of control over the process. High reactance indicates that a treatment should: de-emphasize therapist authority and guidance, employ tasks that are designed to provide the patient with control and self-direction, and de-emphasize the use of rigid homework assignments. As Beutler and colleagues indicate, resistance is best characterized as a problem of the therapy relationship (not of the patient) and as such, becomes a problem for the therapist and patient to solve. The skilled therapist can find a way to stimulate change and reduce a patient’s fear of losing control or freedom.