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.
This month...
…I blog about the treatment of depression, the effects of role induction in psychotherapy, and negative experiences in psychotherapy from clients’ perspective.
Type of Research
Topics
- ALL Topics (clear)
- Adherance
- Alliance and Therapeutic Relationship
- Anxiety Disorders
- Attachment
- Attendance, Attrition, and Drop-Out
- Client Factors
- Client Preferences
- Cognitive Therapy (CT) and Cognitive-Behavioural Therapy (CBT)
- Combination Therapy
- Common Factors
- Cost-effectiveness
- Depression and Depressive Symptoms
- Efficacy of Treatments
- Empathy
- Feedback and Progress Monitoring
- Group Psychotherapy
- Illness and Medical Comorbidities
- Interpersonal Psychotherapy (IPT)
- Long-term Outcomes
- Medications/Pharmacotherapy
- Miscellaneous
- 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
- Termination
- Therapist Factors
- Training
- Transference and Countertransference
- Trauma and/or PTSD
- Treatment Length and Frequency
May 2015
Is Exposure Necessary to Treat PTSD?
Markowitz, J.C., Petkova, E., Neria, Y., Van Meter, P.E., Zhao, Y., … Marshall, R.D. (2015). Is exposure necessary? A randomized controlled trial of Interpersonal Psychotherapy for PTSD. American Journal of Psychiatry, 172, 1-11.
Post-traumatic stress disorder (PTSD) is a condition caused by experiencing or witnessing a terrifying event. Symptoms may include flashbacks, nightmares and severe anxiety, as well as uncontrollable thoughts about the event. PTSD has a lifetime prevalence of 6.8%, which makes it a highly prevalent disorder. The main technique of empirically validated psychological treatments for PTSD involve exposing patients to safe reminders of the trauma including memories, with the intent of extinguishing the fear responses. This is the basis of cognitive behavioural therapy (CBT) with prolonged exposure, which is a consensus treatment for PTSD. However, not all patients benefit from CBT with prolonged exposure, and such treatment may be too difficult for some patients and therapists to tolerate. Markowitz and colleagues argued that PTSD symptoms reflect interpersonal issues including interpersonal withdrawal, mistrust, and hypervigilence. Interpersonal psychotherapy (IPT) is a time-limited efficacious treatment for depression that was adapted for this study for non-exposure based non-CBT treatment of PTSD. IPT was modified so that the first half of treatment focused on recognizing, naming, and expressing feelings in non-trauma related interpersonal situations. The second half of treatment focused on common IPT themes such as role disputes and role transitions. The authors argued that IPT helps individuals with PTSD gain mastery over social interactions and mobilize social supports. The authors conducted a randomized controlled trial that had a sufficient sample size to test a hypothesis of “non-inferiority”, that is to adequately test if PTSD and exposure based CBT were equally effective. Both treatments were compared to a progressive muscle relaxation (PMR) control condition. In all, 110 participants with chronic PTSD were recruited and randomized to IPT, CBT, or PMR. Most patients reported trauma of 14 years duration from either sexual or physical abuse, and half had a current comorbid depression. All three interventions resulted in large significant reductions in PTSD symptoms. IPT (63%) and CBT (47%) were not significantly different in rates of response (i.e., in which response was defined as 30% improvement in a clinician administered PTSD scale), but IPT had a significantly higher response rate than PMR (38%). Patients with comorbid depression were more likely to drop out of CBT with prolonged exposure than IPT.
Practice Implications
The results of the study suggest that IPT and CBT with exposure were equally effective in reducing symptoms of PTSD. It is important to keep in mind that this is one well-conducted trial that needs to be replicated by independent researchers in order to establish if the findings are truly reliable. Nevertheless, the findings contradict the widespread belief that patients with PTSD require exposure-based treatment in order to improve. IPT may be another option for the treatment of PTSD, especially for patients who cannot tolerate the prolonged exposure. Patients with comorbid depression may have the most difficulty tolerating prolonged exposure therapy, and so they may benefit from IPT as an alternative. IPT may help patients gain abilities in social interactions and social support, which may make it easier for them to spontaneously expose themselves to recollections of trauma.
March 2015
Interpersonal Psychotherapy and Cognitive Therapy for Depression
Lemmens, L.H.J.M., Arntz, A., Peeters, F., Hollon, S.D., Roefs, A., & Huibers, M.J.H. (2015). Clinical effectiveness of cognitive therapy v. interpersonal psychotherapy for depression: Results of a randomized controlled trial. Psychological Medicine, doi:10.1017/S0033291715000033
Generally, I prefer to report on meta analyses rather than individual studies mainly because findings from meta analyses are based on a larger number of studies and so are more reliable (see my November, 2013 blog). However, this study by Lemmens and colleagues represents a large clinical trial of 182 depressed patients who were randomized to cognitive therapy (CT), interpersonal psychotherapy (IPT), or a no-treatment control condition. The size of the trial provided the study with enough statistical power to test a hypothesis of non-inferiority of treatments. (A statistical note: A study finding of “non-inferiority” between treatments is sometimes unreliable because it is easier to detect such a finding with a small or poorly designed study. Studies with larger sample sizes provide greater statistical power, which in part makes a non-inferiority finding more reliable). A previous meta analysis showed both CT and IPT to be equally effective interventions for major depression. However, none of the studies in that meta analysis had sufficiently large sample sizes to reliably detect non-inferiority of interventions, none reported outcomes after post-treatment, and none of the studies used a no-treatment comparison condition. In their study, Lemmens and colleagues provided 16 to 20 sessions of individual therapy (45 minutes in length) to participants who met criteria for major depressive disorder. CT was based on Beck’s model and focused on identifying and altering cognitions, schemas, and attitudes associated with negative affect. IPT seeks to understand the social and interpersonal context of a patient’s depressive symptoms, and helps the patient to solve the interpersonal problem or change their relation to the problem, which may result in a resolution of the depressive symptoms. The study by Lemmens and colleagues was well designed in which: patients were randomized to conditions (CT, IPT, wait-list), 10 licensed therapists were expertly trained (5 CT therapists, 5 IPT therapists), and the therapies were competently delivered. Depressive symptoms significantly decreased for patients in both CT and IPT conditions with large effects, and these findings remained stable to 5 months post treatment. There were no differences between CT and IPT at post treatments and follow up, and both treatments were more effective than the waitlist control condition. Half of the sample had clinical improvements in symptoms, and 37% of patients were without depressive symptoms at 1 year follow up.
Practice Implications
CT and IPT did not differ in the treatment of depression in the short (post-treatment) and long term (follow up). The study does not address why two very different treatments led to similar positive outcomes. The authors suggest two possible reasons: (1) different specific treatment pathways led to similar results, or (2) change was driven by factors common to both treatments like motivation and therapeutic alliance.
December 2014
Does Cognitive Therapy Have an Enduring Effect Superior to Keeping Patients on Medication?
Cuijpers, P., Hollon, S. D., van Straten, A., Bockting, C., Berking, M., & Andersson, G. (2013). Does cognitive behaviour therapy have an enduring effect that is superior to keeping patients on continuation pharmacotherapy? A meta-analysis. BMJ open, 3(4).
In another in a series of meta analyses by this primarily Dutch group, Cuijpers and colleagues tackle the question of whether the longer term effects of cognitive behavioral therapy (CBT; a short time-limited treatment for depression) outweighs the long term effects of continuation on anti depression medications. CBT is considered an efficacious treatment for depression (see my June 2014 Blog). CBT also has comparable effects as antidepressant medications, but CBT tends to have lower rates of treatment drop outs. What is not clear is whether short term CBT leads to lasting change that is comparable to long term use of medications for depression. One could argue for example, that short term CBT or other comparable psychological interventions teaches patients skills or changes psychological functioning such that future recurrences of depression are less likely. That is, psychological interventions may cause changes that eventually will prevent relapse. Pharmacotherapy on the other hand, may not result in psychological change or acquisition of new skills to forestall a relapse. In fact, patients with chronic depression tend to be kept on medications indefinitely, and patients who recently remit (i.e., no longer have symptoms of depression) are typically kept on pharmacotherapy for another 6 to 12 months to reduce the risk of recurrence. Information about the relative longer term effects of short term treatment with a psychological intervention like CBT versus longer term maintenance on pharmacotherapy can help practitioners and patients decide on the best course of action depending on patient preferences. Cuijpers and colleagues asked: is short term CBT without continuation of treatment as effective as short term treatment of pharmacotherapy with and without long term continuation? They conducted a meta analysis in which the effects of short term CBT were compared to pharmacotherapy in adults diagnosed with depression across follow up periods of 6 to 18 months. Nine studies representing 506 patients were included in the meta analysis. There was a non-significant trend showing that short term CBT outperformed continuation pharmacotherapy at one-year post treatment. On the other hand, CBT resulted in better long term outcomes compared to pharmacotherapy that was discontinued at post treatment. The odds of dropping out of treatment were significantly higher for those receiving pharmacotherapy compared to CBT. There were no differences in any of the findings for type of antidepressant medications.
Practice Implications
The findings reaffirm CBT as a first-line treatment of depressive disorders. It also suggests that equally effective other psychological treatments may also have similar enduring effects compared to pharmacotherapy. Patients and providers need to consider all of the evidence when weighing the pros and cons of psychotherapy or medications for the treatment of depression. Although pharmacotherapy might be more widely available to patients through primary care physicians, the research is suggesting that enduring effects and treatment compliance are higher among those who have access to psychological interventions.
August 2014
Long-Term Outcome of Psychodynamic Therapy and CBT in Social Anxiety Disorder
Leichsenring, F., Salzer, S., Beutel, M.E., Herpertz, S., Hiller, W. et al. (2014). Long-term outcome of psychodynamic therapy and cognitive-behavioral therapy in social anxiety disorder. American Journal of Psychiatry, Advance online publication: doi:10.1176/appi.ajp.2014.13111514.
Social anxiety disorder is a highly prevalent mental disorder, with lifetime prevalence of about 12% in the population. As Leichsenring and colleagues note, the disorder has an early onset and can have a chronic course leading to many psychosocial impairments. Also, social anxiety disorder often is comorbid with depression. There is good evidence for the efficacy of cognitive behavioral therapy (CBT) for social anxiety disorder and some evidence for psychodynamic therapy (PDT), but most studies have only assessed short term outcomes. In this large mulit-center randomized controlled trial comparing CBT and PDT for social phobia, Leichsenring and colleagues report on outcomes up to 2 years post treatment. The study had 416 adult patients randomly assigned to one of the treatments, and 79 randomly assigned to a waiting list. Outcomes were reported at post, 6 months, 12 months, and 24 months post treatment, and included remission of social phobia, depression levels, and interpersonal problem scores. The CBT intervention for social phobia was based on the model by Clark and Wells. The PDT was based on Luborsky’s model but specifically adapted for social phobia. Participants received 25 sessions of individual therapy, and therapists received advanced training in the models. CBT resulted in significantly greater remission of social phobia than PDT at post treatment, but the difference was small. Remission rates at 6, 12, and 24 months post treatment were not different between treatments. At 2 years post treatment 39% of those receiving CBT and 38% of those receiving PDT no longer had clinical symptoms of social phobia. Results were similar for interpersonal problems in which CBT showed an earlier response, but the two treatments were equivalent at each follow up. Depression scores improved for both interventions at post and follow ups.
Practice Implications
The findings of this large study suggest that both CBT and PDT are effective treatments for social phobia. Although CBT had a small advantage at post treatment, PDT appeared to have an “incubation effect” in which patients continued to work on interpersonal problems and symptoms of social phobia over the longer term. Despite these positive outcomes, Leichsenring and colleagues suggest that there remains room for improvement in treating social phobia. Those who do not respond to these interventions may require different forms of treatment that is more specific, intense, or of longer duration. Leichsenring and colleagues also suggest integrating elements of the effective treatments within a single protocol. Although intuitively appealing, this integrated approach has not been tested.
June 2014
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.
Practice Implications
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.
March 2014
Barriers to Conducting CBT for Social Phobia
McAleavey, A.A., Castonguay, L.G., & Goldfried, M.R. (2014). Clinical experiences in conducting cognitive-behavioral therapy for social phobia. Behavior Therapy, 45, 21-35.
It might come as a surprise to some that social phobia (also called social anxiety disorder) is the most commonly diagnosed anxiety disorder, with a lifetime prevalence of about 12%. Symptoms include negative self-view, fear of embarrassment or criticism, and fear and/or avoidance of social situations. Cognitive behavioral therapy (CBT) is an effective treatment for social phobia with effects as large as pharmacotherapies. Despite this, there are several potential barriers to implementing CBT for social phobia in clinical practice. CBT involves exposure to feared situations (in vivo or simulated), identifying and altering maladaptive thoughts during exposure, producing testable hypotheses, and identifying cognitive errors. CBT is not uniformly effective for all patients with social phobia, exposure techniques are linked to dropping out and failure to initiate treatment, and there can be an increase in missed sessions and non-completion of homework related to avoidance. In this study, McAleavy and colleagues surveyed 276 psychotherapists who provided CBT for social phobia to assess problems or barriers clinicians encountered when applying CBT in practice. Possible barriers listed in the survey were derived from extensive interviews with experts who developed and researched CBT interventions for anxiety disorders. Survey respondents were mostly Ph.D. level clinical psychologists (59%), women (61%), who practiced in outpatient clinics or private practice, and had on average 12 years of post-degree experience. Many therapists reported using behavioral interventions, including developing a fear/avoidance hierarchy, in-session exposures, focusing on behavior in social situations, and specifically focusing on behavioral avoidance. Most also used cognitive homework (i.e., interventions focused on exploring or altering attributions or cognitions). The most frequent therapist endorsed barriers to implementing CBT for social phobia included: patient symptoms (i.e., severity, chronicity, and poor social skills); other patient characteristics (i.e., resistance to directiveness of treatment, inability to work independently between sessions, avoidant personality disorder, limited premorbid functioning, poor interpersonal skills, depressed mood); patient expectations (i.e., that therapist will do all the work; pessimism regarding therapy); patient specific beliefs (i.e., belief that fears are realistic, or that social anxiety is part of their personality); patient motivation (i.e., premature termination, attribution that gains are due to medications); and patient social system (i.e., social system endorses dependency, social isolation). A minority of CBT therapists endorsed a weak therapeutic alliance or aspects of the CBT intervention itself as posing a barrier.
Practice Implications
CBT therapists identified a number of barriers, mainly patient related, that might impede the implementation of CBT for social phobia. Given these barriers the authors suggested that therapists: (1) consider more intense, longer, or more specific treatments for more severe cases; (2) incorporate assessment of patient severity to guide decisions; (3) consider tailoring the level of treatment directiveness based on patient characteristics – i.e., more resistant patients may require a less directive approach and more control over the type and pace of interventions; (4) prepare patients on what to expect in the treatment before therapy begins; (5) find a balance between validating/accepting patients’ problematic beliefs that their fears might be realistic with encouragement to change; (6) add motivational interviewing for patients who are less motivated; (6) complete a thorough functional analysis of patients’ social systems at the start of therapy. McAleavey and colleagues noted that while therapeutic alliance difficulties was an infrequently endorsed barrier by therapists, such difficulties remain clinically important, especially in light of findings that indicate that negative reactions to patients are under-reported by therapists. Developing and maintaining a good alliance remains a key aspect of CBT for panic disorder.