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.

July 2021

Matching Patients to Therapists’ Strengths

Constantino, M.J., Boswell, J.F., Coyne, A.E., Swales, T.P., & Kraus, D.R. (2021). Effect of matching therapists to patients vs assignment as usual on adult psychotherapy outcomes: A randomized clinical trial. JAMA Psychiatry, doi: 10:1001/jamapsychiatry.2021.1221.

We know that about 60% of patients do not benefit fully from the psychotherapy they receive and that therapists differ in their effectiveness. In one study, above average therapists were twice as effective as below average therapists. In fact, most therapists are reliably effective for some presenting problems, but not for all. What if we could match a patient to a therapist based on what the therapist is good at? In this unique study in a large mental health treatment network, Constantino and colleagues evaluated the past effectiveness of 48 therapists who treated at least 5 patients each across a variety of patient problem domains. The authors identified those patient problem domains for which each therapist was reliably effective or ineffective using valid psychometric measures. Then the researchers randomly assigned 218 patients in the mental health treatment network to receive care as usual (patients were assigned to therapists based on which therapist was available at the time of referral), or to receive treatment from a therapist who was reliably effective for the patient’s problems. Out of 9 possible patient problem domains, therapists had an average of 1.56 (SD = 1.66) patient domains for which they were reliably effective and an average of 0.96 (SD = 1.65) patient problem domains for which they were reliably ineffective. Over 87% of therapists had at least one strength on which they could be matched to a patient, and 10.4% were reliably ineffective for all patient problem domains. To a moderate degree, patients treated by a therapist matched to their problem domain experienced greater weekly reductions in their general impairment compared with patients in the care as usual group (d = 0.75). Relative to their own average outcomes, a therapist achieved better patient outcomes when treating a matched patient than when treating a care as usual patient.

Practice Implications

This is the first study of its kind and so it needs to be replicated. Most therapists had a few patient domains for which they were effective. About 10% of therapists were ineffective across all patient domains. The results of the trial suggested that therapists are likely more effective with some patients than others, depending on the patient’s problems. Therapists should assess their outcomes with a range of patient problems and evaluate their effectiveness using valid psychometric instruments. If a therapist finds that they are less effective with some patients, then the therapist should receive more training and supervision for treating that patient problem.
Adverse Effects of Psychotherapy in Patients with Depression

Moritz, S., Nestoriuc, Y., Rief, W., Klein, J.P., Jelinek, L., Peth, J. (2019). It can’t hurt, right? Adverse effects of psychotherapy in patients with depression. European Archives of Psychiatry and Clinical Neuroscience, 269, 577–586.

Only recently have psychotherapy researchers begun to document adverse events or negative outcomes in treatment trials. Research demonstrates that in everyday clinical practice, clinicians generally are unable to identify patients who get worse because of therapy. Unfortunately, the field remains unclear as to what constitutes an adverse event in psychotherapy. Moritz and colleagues refined and shortened a questionnaire filled out by patients about adverse events that they may have experienced in a recent psychotherapy. The authors defined an adverse event as consisting of three aspects. First, side effects were defined as the patient experiencing an unintended negative effect including stigma, relationships deteriorating, and greater symptoms. Second, malpractice was defined as the patient judging that the therapist provided a treatment that was not appropriate to the problem at hand. Third, unethical conduct was defined as a therapist abusing a patient in some manner. In addition, the authors also had a scale of positive effects experienced by patients due to the therapy. For this study, Moritz and colleagues recruited 135 patients who were diagnosed with depression and asked them to fill out the questionnaire about adverse events in their most recent psychotherapy. Most patients (95.6%) reported at least one positive effect of the psychotherapy that they received. However, at least one adverse event was reported by 52.5% of patients. Side effects were endorsed most frequently by 38.5% of patients. Malpractice was endorsed second most frequently by 26.7% of patients. Finally, unethical conduct was endorsed by 8.1% of patients. Not surprisingly, adverse events in therapy were negatively correlated with positive effects of therapy (r = -.24). Adverse events were not associated with patient factors like gender, or therapy factors like type of therapy or profession of the therapist.

Practice Implications

This study by Moritz and colleagues is far from perfect, but it does begin a conversation about acknowledging that psychotherapy is not necessarily a benign event for some patients. In a previous study for example, 42% of patients with obsessive compulsive disorder experienced more or worsening symptoms due to exposure techniques used in CBT. Psychotherapists are notoriously poor at identifying patients who get worse from therapy, and so some therapists use aids like continuous progress monitoring to track patient progress and identify when therapy may be harmful.
Psychotherapist burnout affects patient outcomes

Delgadillo, J., Saxon, D., & Barkham, M. (2018). Associations between therapists’ occupational burnout and their patients’ depression and anxiety treatment outcomes. Depression and Anxiety, 35, 844-850.

Providing psychotherapy can be challenging for the therapist. Vicarious trauma, secondary traumatic stress, and compassion fatigue among psychotherapists are well documented. In addition, organizational conditions in publicly funded mental health programs like workload, safety issues, and lack of supervision and support can lead to higher rates of therapist burnout. Surveys document that between 21% and 67% of mental health workers experience burnout. Occupational burnout can take many forms, but it is typically defined as emotional exhaustion and disengagement that lead to lower levels of therapist empathy, engagement, and depersonalization. One could speculate that burnout among therapists leads to worse patient outcomes because of the impact of disengagement on the therapeutic alliance. However few if any studies examined the association between therapist burnout and patient mental health outcomes. In this study, Dalgillo and colleagues assessed therapist burnout and job satisfaction in 49 therapists, and they assessed depression and anxiety outcomes in 2223 of their patients. The therapists provided treatment as part of the UK’s Increasing Access to Psychotherapy (IAPT) program. The analyses controlled for therapist case mix. That means that differences between therapists’ caseload (patient level of impairment, social economic status, and severity of symptoms) were controlled so that the findings were unique to the effect of therapist burnout and job satisfaction on patient mental health outcomes. Higher therapist disengagement (an index of burnout) and lower therapist job satisfaction were significantly associated with poorer treatment outcomes for patients. In addition, higher burnout was related to lower job satisfaction among therapists.

Practice Implications

This is one of the first studies to show a direct association between therapist burnout and low job satisfaction with patient mental health outcomes. It is possible that these findings are specific to the UK’s IAPT program, in which therapists might feel a lower sense of control over their work. Nevertheless, organizations need to design mental health delivery in such a manner as to enhance psychotherapist autonomy, coping, and resilience, as these are likely related to therapist burnout and poorer patient mental health outcomes.

June 2021

Psychotherapy for Sub-Clinical Depression in Children and Adolescents

Cuijpers, P., Pineda, B.S., Ng, M.Y, Weisz, J.R., Muñoz, R.F., Gentili, C., Quero, S., Karyotaki, E. (2021). A meta-analytic review: Psychological treatment of subthreshold depression in children and adolescents. Journal of the American Academy of Child & Adolescent Psychiatry, Online first publication.

Depression occurs in 2.6% of children and adolescents, with as many as 14% of adolescents meeting criteria for a depressive disorder before the age of 18. Depression in youths is related to a number of impairments, negative health outcomes, and to increased risk of depression as an adult. Subthreshold depression represents clinically important depressive symptoms that does not meet diagnostic criteria for major depression or dysthymia. Like major depression, subthreshold depression is related to impairment and increased mortality. Subthreshold depression in adolescents is related to increased risk for developing other disorders including future depressive disorders in adulthood. In this meta analysis, Cuijpers and colleagues present a review of direct comparison randomized controlled trials of psychological interventions for children and adolescents with subthreshold depression. The meta-analysis included 12 trials representing over 1500 children and adolescents. Eight studies tested CBT, and the others tested IPT or supportive therapy. The pooled effect size of the difference between the psychological interventions and control conditions at post treatment was g = 0.38 (95% CI: 0.14 to 0.63), indicating a small to moderate effect of psychological therapies to reduce subthreshold depression in children and adolescents. The authors found some evidence of publication bias (i.e., the likelihood that some studies were conducted but never published) and after adjusting for this bias, the effect size dropped to g = .24 (95% CI: -0.06 to 0.54) which was not statistically significant. There were only two studies of the treatment of children which showed small non-significant effects, g = 0.01 (95% CI: -1.16 to 1.18), however the effects of treatment for adolescents were considerably better, g = .44 (95% CI: 0.16 to 0.71). Longer term follow-up data (6 to 18 months) did not show sustained effects of treatment. Children and adolescents had a 48% lower chance of developing a depressive disorder if they received treatment, although this was not statistically significant.

Practice Implications

The small number of studies limits what one can say about the effects of psychological treatment for subthreshold depression in children and adolescents. The effects were small to moderate at post treatment, but the effects were statistically significant only for adolescents and not for children. Longer term effects of treatments were non-significant, and there was no significant effect on the incidence of depressive disorders at follow up. Despite the disappointing findings, the authors concluded that interventions for subthreshold depression may have positive immediate effects at post treatment for adolescents.
The Emotionally Burdened Psychotherapist

Nissen-Lie, H. A., Orlinsky, D. E., & Rønnestad, M. H. (2021). The emotionally burdened psychotherapist: Personal and situational risk factors. Professional Psychology: Research and Practice. Advance online publication.

To provide good treatment, a psychotherapist must have enough mental and emotional energy to be attuned to the different states of their patients. However, sometimes emotional reserves of therapists can dwindle because of personal or professional burdens. As a result, many therapists report the experience of burnout that inevitably has a negative effect on their patients. Therapists’ personal burdens can be defined as stress in one’s personal life, feeling worry or concern, experiencing conflict within one’s family, or loss of a loved one. These therapist personal burdens could be enduring vulnerabilities or short-lived stressors, but they nevertheless have an impact on the therapist’s effectiveness. Higher stress in a therapist’s personal life is related to more avoidant coping, and lower capacity to stay focused, engaged, and empathic with patients. In this large-scale survey of over 12,000 psychotherapists worldwide (e.g., Norway, US, Canada, UK, Australia, Denmark, China), Nissen-Lie and colleagues looked to identify past and current personal and situational factors that were linked to the experience of personal burden among psychotherapists. The therapists were mostly married or in a committed relationship (72%), half were psychologists, the average length of clinical practice was 12 years (SD = 9.2), and therapists worked almost evenly across the major theoretical orientations (including CBT, psychodynamic, systemic, and behavioral). The most salient predictors of personal burden among psychotherapists were: current health and financial worries, early trauma or abuse, attachment anxiety (i.e., concern about abandonment and difficulty regulating negative emotions), dominant and demanding behavior in relationships, lower work satisfaction, and younger age. Cumulatively, these variables accounted for a substantial amount (30%) of the variance in personal burden.

Practice Implications

Increasingly, research is pointing to negative life events and work experiences that may limit a therapists’ capacity to be engaged and empathic with patients. Focus on therapist well-being should be an important part of clinical training and supervision. Previous research found that receiving personal therapy, obtaining clinical supervision, working shorter hours, and lower caseloads improved empathy and wellbeing among psychotherapists.
Psychotherapies for Depression

Cuijpers, P., Quero, S., Noma, H., Ciharova, M., Miguel, C., Karyotaki, E., Cipriani, A., Cristea, I.A., Furukawa, T.O. (2021). Psychotherapies for depression: A network meta-analysis covering efficacy, acceptability and long-term outcomes of all main treatment types. World Psychiatry, 20, 283-293.

Depressive disorders are common, and they have an important negative impact on quality of life and on mortality. For that reason, the treatment of depression is critical. The most commonly tested psychotherapy is CBT but others like interpersonal psychotherapy (IPT), psychodynamic therapy (PDT), and behavioral activation (BA) have also been tested. In this network meta analysis, Cuijpers and colleagues simultaneously test the effects of different psychotherapies for depression. Network meta-analysis, fundamentally, works by the transitivity assumption: if treatment A = treatment B, and treatment B = treatment C, then treatment A = treatment C even if Treatments A and C were never tested against each other in the same study. This procedure is not without controversy: what if the studies of treatment A vs B are all higher quality (thus resulting in lower effects) than studies of treatments B vs C? Is it fair to equate the studies by comparing treatments A and C when we know study quality impacts effect sizes? Nevertheless, network meta-analyses are used by some to aggregate many studies and to estimate relative outcomes across treatment types. Cuijpers included 331 studies (representing over 34,000 patients) in their network meta-analysis. CBT was tested in over 63% of trials, but other therapies (PDT, IPT, BA) were tested as well. All psychotherapies were more efficacious than care-as-usual and wait list controls with almost no significant differences between therapies for treating depression, except non-directive therapy was less efficacious than other therapies. (Non-directive therapy was often treated as a placebo control condition in studies, and so it may have been delivered in a way that limited its efficacy). CBT, IPT, PDT and BA all were more efficacious than care as usual at 12 months follow up.

Practice Implications

Overall, this network meta-analysis of psychotherapies for depression echoes the findings of many meta-analyses that preceded it. All psychotherapies that were examined, except for non-directive therapy, were equally efficacious for treating depression. When initiating therapy, it may be more important for therapists to be responsive to patient characteristics than to focus on which brand of therapy to deliver. For example, patients with internalizing coping styles may do better with insight oriented therapies, those with high levels of resistance/reactance may require a therapist that is less directive, and patients from marginalized race and ethnic communities may do better with a therapist who is multiculturally competent.

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July 2021

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June 2021

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