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The Great Psychotherapy Debate: Starting in April, 2015 I review parts of The Great Psychotherapy Debate (Wampold & Imel, 2015) in the PPRNet Blog. This is the second edition of a landmark, and sometimes controversial, book that surveys the evidence for what makes psychotherapy work. You can view parts of the book in Google Books.

Change in dysfunctional attitudes or cognitions is one of the specific mechanisms by which cognitive therapy (CT) is thought to be effective in the treatment of depression. In this part of their book, Wampold and Imel discuss the evidence that addresses the specific change mechanisms for CT. The reason they focus on CT is that CT is by far the most researched psychotherapy approach, and there is a substantial number of CT studies that have addressed this issue of change mechanisms. In an early meta analysis, Oei and Free (1995) found a significant relationship between change in cognitions and CT. However, in the same meta analysis, the authors found that CT and non-cognitive therapies did not differ in terms of their effects on cognitions. That is, most treatments, whether CT or not, appeared to change cognitions. In another study, three different interventions (behavioral activation, CT, and CT plus behavioral activation) all resulted in change in cognitions and improved depression. In other words, cognitive interventions do not seem to be needed to alter cognitions and reduce depression. Wampold and Imel argue that nonspecific processes in CT (and other psychotherapies for that matter) are largely responsible for the effectiveness of psychotherapy. For example, there is evidence to suggest that a number of patients show substantial symptom improvement early in treatment before specific cognitive techniques are introduced. Some have argued that this early favourable response is largely due to the effects of client expectations, reassurance, and remoralization rather than the specific procedures of the therapy. Moreover, patients who experience this remoralization early-on may be better at successfully applying techniques taught in CT. A large review of this literature concluded that there was insufficient evidence to support the notion that challenging thoughts was responsible for the positive effects of CT.

Practice Implications

This line of research appears to indicate that the specific practice of challenging thoughts or dysfunctional attitudes is not primarily responsible for patient change in CT. It may be that for any psychological treatment that has a cogent rationale for the disorder and is administered by an acknowledged expert, client progress may be determined largely by contextual factors. These factors may include a therapeutic alliance, client expectations of benefit, and client remoralization, which may in turn allow clients to benefit from the specific interventions of psychological treatments.

Fernandez, E., Salem, D., Swift, J. K., & Ramtahal, N. (2015, August 24). Meta-analysis of dropout from cognitive behavioral therapy: Magnitude, timing, and moderators. Journal of Consulting and Clinical Psychology. Advance online publication.

“Dropping out” refers to clients who discontinue therapy prematurely and against professional advice. In contrast, “refusing” refers to clients who do not start a therapy that is made available to them. Together, both dropping out and refusing are referred to as “attrition” from therapy. Attrition is a problem for clinicians because of loss of revenue and time, and a problem for clients because their mental health needs remain unmet. In a previous meta analysis that included 669 studies, Swift and Greenberg (2012) reported that the average drop out rate across all therapies was 19.7%. In this meta analysis, Fernandez and colleagues looked specifically at drop outs and refusers in cognitive behavioral therapy (CBT). The authors reviewed 115 studies that reported drop outs, 36 of which also reported on the number of participants who refused treatment before starting. The average percent of patients who refused CBT prior to starting treatment was 15.9%, and the average percent of patients who dropped out after starting CBT was 26.2%. So the total average attrition rate was 42.1%. Compared to any other disorder, patients with depression were significantly more likely to refuse CBT (21.6%) or to drop out (36.4%). It is possible that depressed patients have a harder time summoning the energy to participate in therapy, and experience lower hope, greater social withdrawal, and lower motivation once they initiate CBT. For those receiving e-therapies (e.g., internet, phone, and CD-based treatments), pre-treatment refusal rates were 10% to 15% higher than individual or group CBT, and drop outs from e-therapies were 10% higher compared to individual or group CBT. Those offered e-therapy might be ambivalent about its utility, the therapeutic alliance might be limited, and they might have a lower sense of engagement in the therapeutic process. Finally, a greater number of planned therapy sessions was related to lower attrition rates. Perhaps the promise of more sessions raised clients’ hopes of achieving better outcomes.

Practice Implications

These findings suggest that engaging and encouraging clients to participate in the therapy may have to start even before therapy begins. This may involve enhancing readiness by means of motivational interviewing, for example. Clients who are depressed are particularly likely to refuse treatment or drop out, and so clinicians must pay particular attention to the level of motivation and engagement of depressed clients. Although e-therapies are promising in that they may allow a therapist or agency to reach more people including those who live in remote areas, the attrition rate of e-therapies may be unacceptably high. Attrition may lead to demoralization and lowered expectations for treatment among these patients, which may negatively impact future treatment. Perhaps e-therapies should not be considered as a first-line treatment for those who can easily access individual or group therapy. Alternatively, the high attrition rates of e-therapies may be reduced by supplementing the intervention with some in-person therapy sessions to enhance engagement and a therapeutic alliance.

Weitz, E.S., Hollon, S.D., Twisk, J., van Straten, A., Huibers, M.J.H., David, D., …. Cuijpers, P. (2015). Baseline depression severity as moderator of depression outcomes between cognitive behavioral therapy vs pharmacotherapy: An individual patient data meta-analysis. JAMA Psychiatry. doi:10.1001/jamapsychiatry.2015.1516.

The American Psychiatric Association guidelines for the treatment of depression indicates that although psychotherapy is adequate for mild to moderate depression, anti-depressant medications are indicated for the treatment of severe depression in major depressive disorder. These recommendations are mainly based on the findings of the National Institute of Mental Health Treatment of Depression Collaborative Research Program that was published in the mid 1990s. Several authors since then have disputed this claim, but no meta-analyses have been done on the studies of head-to-head patient-level comparisons of psychotherapy vs antidepressant medications for the purpose of evaluating their relative efficacy for severity of depression. In this meta analysis, Weitz and colleagues look at medications vs psychotherapy for depression and then evaluate if initial severity of depressive symptoms helped to explain any differences. The authors looked at all studies that compared cognitive behavioral therapy (CBT) against antidepressant medications for depression. They focused on CBT because it was the most often studied of the psychotherapies in this context. A systematic review turned up 24 studies, and they were able to get original patient-level data from the authors of 16 of the 24 studies. This represented over 1,700 participants with major depression. These 16 studies were no different from the 8 studies that did not provide original data. Between 17% and 54% of the 1,700 depressed participants met criteria for severe depression at pre-treatment. There were no significant differences between antidepressant medications and CBT on clinically relevant outcomes in terms of “response” (i.e., improvement) or “remission” (i.e., symptom-free). In total, 63% of patients in the antidepressant medication condition and 58% of patients in the CBT condition responded to treatment, and 51% of patients in the antidepressant medication condition and 47% of patients in the CBT condition met criteria for remission. Most importantly, the effects of CBT and antidepressant medications on response to treatment or remission did not differ based on initial severity of depressive symptoms.

Practice Implications

Patients with severe depression were no more likely to require medication to get better than patients with less severe depression. This meta analysis that included the majority of studies that exist on the topic found no evidence to support the guidelines that severe depression should be treated with antidepressant medications over psychotherapy. The authors conclude that CBT may also be a first-line treatment for severe depression.

Bradley, R., Greene, J., Russ, E., Dutra, L., & Westen, D. (2005). A multidimensional meta-analysis of psychotherapy for PTSD. American Journal of Psychiatry, 162, 214–227.

The psychotherapy research literature on treatment of post traumatic stress disorder (PTSD) has focused on cognitive behavioral therapy (CBT, with exposure and/or cognitive restructuring) and eye movement desensitization and reprocessing (EMDR). Exposure therapy involves confronting memories of the trauma or cues related to the traumatic event. Other CBT skills include developing skills for anxiety management or challenging distorted cognitions. In EMDR the patient is asked to develop an image of the traumatic event while tracking a bilateral stimulus. Most studies demonstrate the effectiveness of CBT for PTSD in the short term. However, many studies have excluded patients with comorbid conditions. For example, patients with PTSD often also have significant other symptoms like depression, substance abuse, other anxiety disorders, and personality disorders. In this meta analysis, Bradley and colleagues were interested in documenting the overall efficacy of psychological treatments for PTSD. They also wanted to report on any evidence on the long term efficacy of treatments for PTSD, and on evidence of the effects of excluding patients with comorbid disorders. Bradley and colleagues included randomized controlled trials published between 1980 and 2003 (i.e., 26 studies representing 1,535 patients). Also, they looked at outcomes defined in a few ways: change in symptoms as documented by the effect size, proportion of patients no longer meeting diagnostic criteria for PTSD (but who may have residual symptoms), and proportion whose symptoms improved significantly. Across all treatments, the average pre to post effect size was large (d = 1.43), and comparisons to control conditions were also large (d = .83). The results suggested that psychotherapy produced substantial effects for PTSD. Differences between types of therapy (CBT, CBT with exposure, EMDR) were negligible. Fifty six percent of patients no longer met criteria for PTSD, and 65% showed improved symptoms. At follow ups, 62% no longer met diagnostic criteria for PTSD and 32% were deemed improved, but the number of studies with follow up data were small (k = 10) and so the results could be unreliable. Of those who started treatment, 78.9% completed the therapy. Of those who were assessed, 30% were excluded because of suicide risk, drug or alcohol abuse, or “other serious comorbidity”.

Practice Implications

Treatment guidelines from the International Society for Traumatic Stress Studies list a number of effective treatments for PTSD. The evidence for efficacy is strongest at post treatment, and more research is necessary to demonstrate efficacy in the longer term. There is currently little evidence that any one treatment approach is more effective than another, and some researchers are debating whether specific interventions like exposure is necessary to treat PTSD. Bradley and colleagues argue that we need more research on alternative treatments for PTSD and research on patients with multiple symptoms and comorbidities.

Author email: rbradl2@emory.edu

Kivlighan, D.M., Goldberg, S.B., Abbas, M., Pace, B.T., …Wampold, B.E. (2015). The enduring effects of psychodynamic treatments vis-à-vis alternative treatments: A multilevel longitudinal meta-analysis. Clinical Psychology Review, 40, 1-14.

There is a great deal of evidence that indicates uniform efficacy of a variety of psychotherapies for many common disorders. For example, in the July 2014 PPRNet Blog, I reviewed a meta-analysis comparing 7 psychotherapies for depression indicating no differences between the various treatments in terms of patient outcomes. Nevertheless proponents of cognitive behavioural therapy have claimed superiority to alternative treatments for decades. On the other hand proponents of psychodynamic therapies have argued that these treatments focus on personality change rather than symptoms, and so benefits of psychodynamic therapies will be longer lasting. In this meta analysis, Kivlighan and colleagues put these claims to the test. They selected studies in which a psychodynamic therapy was compared to one or more alternative treatment. Both the psychodynamic therapy and the alternative (most often CBT) had to be judged as “bona fide” therapies by independent raters (i.e., they had to be therapies that were delivered in a manner in which they could be expected to be effective by clients and therapists). Outcomes not only included specific symptoms (e.g., depression), but also non-targeted outcomes (e.g., improved self esteem in a study of treatment of anxiety), and personality outcomes. Effect sizes for outcomes were assessed at post-treatment and also at follow-ups. Twenty five studies directly comparing psychodynamic and non-psychodynamic therapies were included, representing 1690 patients. At post treatment, no significant differences were found between psychodynamic and non-psychodynamic treatments on targeted outcomes, non-targeted outcomes, and personality measures (all gs < .10). There was also no significant or meaningful effect of time to follow up on outcomes, indicating no differences between treatment types at any of the follow up periods.

Practice Implications

Psychodynamic and non-psychodynamic treatments were equally effective at post treatment and at follow ups for all outcomes, including personality variables. This challenges the belief that psychodynamic treatments uniquely affect personality and have longer lasting effects compared to other treatments. It also challenges the notion that CBT (by far the most common comparison treatment) is a superior therapy for patient outcomes. Pan-theoretical psychotherapy factors (client contributions, expectations, therapeutic alliance) may be more promising factors in understanding the long term benefits of psychotherapy. 

Author email: kivlighan@wisc.edu

Johnsen, T. J., & Friborg, O. (2015, May 11). The effects of cognitive behavioral therapy as an anti-depressive treatment is falling: A meta-analysis. Psychological Bulletin. Advance online publication. http://dx.doi.org/10.1037/bul0000015

Depression is a highly debilitating disorder and ranked third in terms of disease burden in the world. Cognitive behavioral therapy (CBT) is an effective treatment for depression that was introduced over 40 years ago. In part, CBT sees depression as caused by maladaptive thoughts that maintain emotional distress and dysfunctional behavior. Reducing depression is achieved by eliminating the impact of or chancing maladaptive thoughts. CBT is the most researched psychological treatment for depression, and the research goes back several decades. A number of technical variations and new additions have been made over the years to CBT to improve patient outcomes. The volume of research and its history provides a unique opportunity to assess time trends in the effects of CBT. In this meta analysis, Johnsen and Friborg asked: “have the effects of CBT changed over time”? They also looked at whether client factors (e.g., demographics, symptom severity), therapist factors (e.g., age, experience, training), common factors (e.g., therapeutic alliance, client expectancies), and technique factors (e.g., fidelity to a treatment manual) can explain these trends. Johnsen and Friborg reported on 70 studies of 2,426 patients conducted from 1977 to 2014. Males accounted for 30.9% of patients, 43% had comorbid psychiatric conditions, and the average patient was at least moderately depressed. The average effect of CBT in reducing depression was large (g = 1.46 after accounting for publication bias). Women had better outcomes, studies with poorer methodological quality showed larger effects, and patients of more experienced therapists had better outcomes. There were too few studies measuring therapeutic alliance to assess the effect of common factors on outcomes. Most interesting was a significant relationship between effect sizes and year of publication. That is, the effects of CBT declined significantly over the years, though the average effect remained large. Surprisingly, there was a steeper decline for studies that used a treatment manual compared to those that did not. No other variables were reliably associated with this decline.

Practice Implications

Women and patients of more experienced therapists appear to benefit most from CBT. Although the effects of CBT declined over time, the treatment remained highly effective. Johnsen and Friborg’s study could not easily explain this decline. The authors suggested that the placebo effect (expectation on the part of patients, researchers, and therapists) is typically stronger for new treatments. However, as time passes the strong initial expectations tend to wane thus reducing the overall effect of the intervention. They also suggested that CBT treatment outcomes may be improved not by technical variations and new additions, but by better ways of integrating common, therapist, and client factors.

Author email: tjj@psykologtromso.no