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Tracey, T. J., Bludworth, J., & Glidden-Tracey, C. E. (2011). Are there parallel processes in psychotherapy supervision? An empirical examination. Psychotherapy, 49(3), 330-343.

Parallel process was first proposed in the psychodynamic literature as the replication of the therapeutic relationship in supervision. Parallel process is also recognized as an important aspect of supervision in developmental and interactional models of supervision, even though those models do not endorse the unconscious aspects of parallel process. Parallel processes in supervision occur when: (1) the trainee therapist brings the interaction pattern that occurs between the trainee therapist and client into supervision and enacts the same pattern but with the trainee therapist in the client’s role, or (2) the trainee therapist takes the interaction pattern in supervision back into the therapy session as the therapist, now enacting the supervisor’s role. For example, a client comes into therapy seeking guidance because things are not going well in his relationships. He desires structure and direction from the trainee therapist (client’s behaviour is submissive). The trainee therapist attempts to help the client by providing guidance (therapist’s behaviour is relatively dominant). The client then responds with “Yes, but…” to suggestions offered by the trainee therapist (client’s behaviour is non-affiliative). The trainee therapist over time starts to become subtly “critical” of the client (therapist matches the non-affiliative client behavior). The trainee therapist goes into supervision complaining about the client’s “resistence” and the trainee therapist asks for help and direction from the supervisor (trainee therapist increases his submissive behavior in a parallel enactment of the client’s submissive stance). As the supervisor provides some direction (supervisor increases her dominance), the trainee therapist responds with “Yes, but. . .” (trainee therapist increases his non-affiliative behavior). The supervisor engages in more “critical” comments than usual in response to the therapist (supervisor matches the non-affiliative trainee behavior). In this way, the supervision interaction becomes a relative replication of the therapy relationship, captured in the parallel amounts of dominance/submission and affiliation/non-affiliation exhibited by the participants in relation to each other. Tracey and colleagues (2012) studied this phenomenon by coding moment by moment interpersonal interactions using an interpersonal circumplex model (i.e. a model that assesses relative dominance and affiliation) among 17 triads of clients/trainee therapists/supervisors in a series of single case replications. The authors hypothesized that relative dominance and affiliation would be parallel between clients/trainee therapist pairs and corresponding trainee therapist/supervisor pairs in contiguous sessions. Significant results were found for each dyad within the 17 client/trainee therapist/supervisor triads. Therapists in the role of trainee altered their behavior away from their usual in supervision to act somewhat more like particular clients did in the previous therapy session. Supervisors tended to engage in complementary interpersonal responses in the subsequent supervision session. This provided evidence for parallel process at an interpersonal level of interactions. Further, positive client outcome was associated with increasing similarity of trainee therapist behavior to the supervisor over time on both dominance and affiliation. That is, the more therapists acted like their supervisors in the previous supervision meeting on both dominance and affiliation, the better the client outcome.

Practice Implications

This article provides intriguing evidence for an interpersonal model of parallel process. Supervisors may choose to communicate with the trainee about how the trainee therapist and client are interacting, as well as how the trainee and supervisor are interacting. In this way, the supervisor makes the implicit aspects of the parallel process more explicit for the trainee therapist. The trainee then can make choices about how best to proceed based on the new understanding of the interactional pattern at the process and content levels of interaction. For example, a therapist and supervisor can come to understand a block in the supervisory alliance as a parallel to a similar impediment in the trainee therapist-client relationship. A supervisor working through the block in supervision to create a more collegial and affiliative environment may model for the trainee therapist ways in which to effectively and collaboratively work with their client.

Author email: Terence.Tracey@asu.edu

Handbook of Psychotherapy and Behavior Change: Starting in March 2013 I will review one chapter a month the Handbook of Psychotherapy and Behavior Change in addition to reviewing psychotherapy research articles. Book chapters have more restrictive copy right rules than journal articles, so I will not provide author email addresses for these chapters. If you are interested, the Handbook table of content can be viewed on Amazon.

Forand, N.R., DeRubeis, R.J., & Amsterdam, J.D. (2013). Combining medication and psychotherapy in the treatment of major mental disorders. In M.J. Lambert (Ed.) Bergin and Garfield’s handbook of psychotherapy and behaviour change (6^th ed.), pp. 735-774. Hoboken, N.J.: Wiley.

This comprehensive chapter covers evidence for combining medication and psychotherapy for several disorders. This month I report on the section of the chapter on depression. Psychotherapy and antidepressant medications appear to have similar efficacy in short-term treatment trials, though psychotherapy has better outcomes than medication in the longer term. Psychotherapeutic treatments including Brief Dynamic Therapy (BDT), Interpersonal Psychotherapy (IPT), and Cognitive Behavioral Therapy (CBT) confer enduring benefit by preventing relapse and recurrence when compared to discontinuing medication. Antidepressant medication is modestly effective during initial short-term treatments with remission rates less than 50% and long term recurrence range from 40% to 85%. Combining medication with psychotherapy provides a small to moderate short term advantage over monotherapy of medication or psychotherapy. Combining medication and psychotherapy is more useful for when considering chronicity rather than severity of depression. The results are consistent for BDT, IPT, and for CBT.  In the longer term, efficacy of combined treatments is not better than either monotherapy. Taken together, the evidence for combined therapy for depression is modestly positive with little evidence that treatments interfere with each other (by contrast, see the March 2013 blog for findings of interference in combined therapy for anxiety disorders). Nevertheless, prolonged continuation of medication monotherapy is an added expense that is often ineffective. In fact, prolonged antidepressant medication maintenance can worsen the course of depressive illness for some, and efficacy tends to fade after 3 to 6 months of maintenance. Finally, there is emerging evidence of progressive tolerance (tachyphylaxis) or even worsening of symptoms during medication maintenance. Studies suggest that psychotherapy added to maintenance medication was associated with decreased relapse rates when compared to medication alone in the longer term.

Practice implications

Combined treatments (antidepressant medication plus psychotherapy) for major depression provide modest incremental improvements in response over monotherapy. Results of combination treatments are better, though still modest, for those with chronic depression. The evidence does not support the use of combined treatments for mild to moderate depression, unless the individual does not responds to initial monotherapy. Practitioners could consider monotherapy (i.e., psychotherapy or medication) first, followed by switching therapy or augmenting therapy for non-responders. If a patient is started on short term monotherapy of medication, practitioners may consider switching to psychotherapy for better long term relapse prevention.

Ulvenes, P. G., Berggraf, L., Hoffart, A., Stiles, T. C., Svartberg, M., McCullough, L., & Wampold, B. E. (2012). Different processes for different therapies: Therapist actions, therapeutic bond, and outcome. Psychotherapy, 49(3), 291-302.

One of the few truisms of psychotherapy is that the therapeutic alliance is important to treatment outcomes. But does the alliance work similarly in Cognitive Behavioral Therapy (CBT) and in Psychodynamic Therapy (PDT)? Therapeutic alliance is defined by three elements: the bond between client and therapist, agreement on tasks, and agreement on goals. Compared to PDT therapists, CBT therapists tend to focus more on cognitions and focus less on emotions, and so the bond may be less important in CBT than agreement on tasks and goals. Will the bond between client and therapist be differentially affected by the differing focus on emotions between CBT and PDT? A study by Ulvenes and colleagues (2012) looked at this question. This study is a follow up study of a randomized controlled trial comparing CBT to PDT for the treatment of cluster C personality traits (i.e. individuals who have trouble in experiencing and expressing emotions, and in developing close relationships). Fifty clients were randomized to either CBT or PDT, therapy was short term, and therapists were experienced and competent in delivering their therapy. In the previous study the authors reported that CBT and PDT were both equally effective in treating clients with cluster C personality disorder. In the current study, the authors found that therapist avoidance of affect was associated with developing a greater bond with patients in both CBT and PDT. That is, Cluster C patients liked their therapists better if the therapists avoided talking about the clients’ feelings. However, focusing on affect in PDT was also associated with positive outcome. In other words, therapists who avoided talking about emotions in PDT helped the patient like the therapist better, but this was counterproductive for good outcome. PDT therapists had to manage to create a bond despite their focus on affect in order to achieve good outcomes. On the other hand, focusing on affect in CBT was associated with poorer outcome. That is, therapists who avoided affect in CBT, which is consistent with the treatment model, had clients who experienced both a better bond and better outcomes. Therapeutic alliance is important for all therapies, but may operate quite differently depending on how much the therapy focuses on affect (PDT) or on cognitions (CBT).

Practice Implications

PDT therapists working with cluster C patients have to negotiate a complex task of maintaining a bond despite the treatment model’s focus on emotions in order to achieve good outcomes. CBT therapists will do well to be consistent with the treatment model and focus primarily on cognitions to help with the bond and promote good outcomes. CBT therapists in particular may need to develop a strong bond before agreeing on tasks and goals, which are also keys to a therapeutic alliance.

Author email: pal.ulvenes@modum-bad.no

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

Handbook of Psychotherapy and Behavior Change: The Handbook of Psychotherapy and Behavior Change is perhaps the most important compendium of psychotherapy research covering a large number of research areas related to psychotherapy. Starting in March 2013, I will review one chapter a month in addition to reviewing psychotherapy research articles. Book chapters have more restrictive copy right rules than journal articles, so I will not provide author email addresses for these chapters. If you are interested, the Handbook table of content can be viewed on Amazon.

Forand, N.R., DeRubeis, R.J., & Amsterdam, J.D. (2013). Combining medication and psychotherapy in the treatment of major mental disorders. In M.J. Lambert (Ed.) Bergin and Garfield’s handbook of psychotherapy and behaviour change (6^th ed.), pp. 735-774. Hoboken, N.J.: Wiley.

This comprehensive chapter covers evidence for combining medication and psychotherapy for several disorders. This month I report on the section of the chapter on anxiety disorders. Monotherapy of medication or psychotherapy are each effective in treating anxiety disorders, though relapse rates can be high. Simultaneously combining medications and psychotherapy is a common practice that is endorsed by several treatment guidelines. Some may also believe that medication and psychotherapy have additive effects or that those who do not respond to one treatment might respond simultaneously to the other. For panic disorder, short term outcomes slightly favour combined therapy of medications (e.g., antidepressants like SSRIs) and psychotherapy (i.e., that often include exposure). However, long term outcome data indicate that combined treatment was no different than cognitive behavioural therapy (CBT) alone. There is also evidence that medications may interfere with exposure-based treatment of panic disorder so that relapse is greater with combination therapy. It is possible for example that medications may suppress fear-related cognitions thus preventing encoding of corrective information, and/or medication may inhibit extinction learning by suppressing cortisol secretion (in the short term) that facilitates consolidation of memories. The evidence for combining medication and psychotherapy for social anxiety disorder, post traumatic stress disorder, generalized anxiety disorder (GAD), and obsessive compulsive disorder are more mixed but still not clearly supportive of long term superiority of simultaneously combining medications and psychotherapy. Other combination approaches appear to show more promise. For example, there is better evidence for starting with a monotherapy initially and adding an alternative therapy for non-responders. Starting with medications first may allow allows cortisol to normalize over time perhaps reducing medication-induced inhibition of extinction learning. Then treatments such as exposure based CBT or brief dynamic therapy for GAD may be additionally helpful to those who do not respond to medication alone. The existing trials tend not to show evidence of incremental benefit of adding medication after initiating psychotherapy. CBT may be effective in helping individuals taper medications while maintaining treatment gains.

Practice implications

Simultaneously combining medication and psychotherapy for anxiety disorders may be common practice. There is an overall lack of evidence that combining treatments improves outcomes, especially in the longer term. Evidence points to medications interfering with the effectiveness of psychotherapy when they are initiated simultaneously. Compared to monotherapy, combined treatments are more complex, time-consuming, expensive, and expose the patient to increased side effect risk. Combination treatments may be best reserved for those who are refractory to initial monotherapy.

Swift, J.K. & Greenberg, R.P. (2012). Premature discontinuation in adult psychotherapy: A meta analysis. Journal of Consulting and Clinical Psychology, 80, 557-589.

Premature termination or drop out from psychotherapy has long been a significant problem for the practice of psychotherapy. Drop out can be variously defined as: not completing the course of treatment, unilateral termination on the patient’s part without therapist input, and not attending a specified number of sessions, among others. One of the largest meta analyses on the topic was done in 1993, and at that time the average drop out rate was 46.86%. This is a serious problem for a number of reasons. First, the average patient needs approximately 18 sessions to improve, and so early dropping out means that these patients do not benefit. Second, therapists can become demoralized at such drop out rates, and therapists who are not confident in their procedures are less likely to be effective. Third, the agency or practice loses important sources of funding or revenue. And fourth, society in general continues to manage the burden of a significant portion of its population not being at their best. The meta analysis by Swift and Greenberg (2012) is the largest of its kind, comprising 669 studies representing 83, 834 patients. The average drop out rate, largely defined as not completing treatment and unilateral termination without therapist input, was 19.79%. This appears to be a substantial drop from the previous 1993 number of 46.86%, but still represents one in five psychotherapy patients. Swift and Greenberg suggest that perhaps the more recent focus on evidence based treatments and short term treatments, and more systematic and consistent reporting of drop outs from studies may account for the lower numbers. No differences were found in drop out rates between treatment orientations (e.g., CBT vs others) and no differences in treatment format (e.g., individual vs group). Time-limited (20.7%) and manualized (18.3%) treatments tended to have lower drop out rates than non-time-limited (29%) and non-manualized (28.3%) treatments. Patients with eating disorders (29.3%) and personality disorders (25.6%) had the highest drop out rates. As did patients who were younger and less educated. Drop out rates in effectiveness studies (26%), that are more similar to everyday clinical practice, was higher than highly controlled randomized trials (17%). Trainee therapists (26.6%) tended to have higher drop out rates than experienced therapists (17.2%).

Practice Implications

At least one in five clients are likely to drop out of psychotherapy. Clinicians should particularly work on retention with younger clients and those with a personality or eating disorder diagnosis. Extra efforts to prevent dropout should also be emphasized for trainees and in university-based clinic settings. A number of strategies for reducing premature discontinuation in therapy have been identified, including discussing expectations regarding therapy roles and behaviors, providing education about adequate treatment duration, addressing motivation, repairing alliance ruptures, using therapist feedback, addressing client preferences, providing time-limited interventions, and increasing perspective convergence in the psychotherapy dyad. A number of these are described in greater detail in the following blog entry.

Author email: Joshua.Keith.Swift@gmail.com