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 2022

The Efficacy of Group Therapy

Burlingame, G.M. & Strauss, B. (2021). Efficacy of small group treatments: Foundations for evidence-based practice. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7^th ed.). Wiley. Chapter 17.

Group therapy involves one or more therapists treating more than two individuals together in a group setting. Ideally, group therapy not only includes specific individualized interventions of a theoretical orientation (cognitive restructuring, behavioral activation, transference interpretations) but also makes use of group-specific factors known to predict patient outcomes (development of group cohesion, social learning, peer feedback). In this chapter, Burlingame and Strauss report on the efficacy of group therapy for a number of disorders and relative to individual therapy. In a meta-analysis of 68 studies for a variety of disorders and different theoretical orientations, there was no difference between individual therapy and group therapy in terms of primary symptom outcomes (g = -0.03). One of the challenges of practicing group therapy is that some patients and providers might perceive group therapy as less effective or less desirable than individual therapy. However, meta-analyses of patient acceptance of treatment (percent of patients assigned to group or individual therapy and who follow through with treatment) or of patient drop out after starting treatment shows no difference between individual and group therapy. Regarding outcomes for specific disorders, over 11 meta-analyses have been published in the past decade as part of an international effort to document the effects of group therapy. For major depressive disorder, group therapy was more effective than treatment as usual (g = 0.69) and as effective as pharmacotherapy (g = 0.08). Group therapy was more effective than no treatment for social anxiety disorder (g = 0.84), panic disorder (g = 1.08), OCD (g = 0.97), eating disorders (g = 0.79), substance use disorder (g = 0.28), and PTSD (g = 0.70). For all these disorders, group therapy was as effective as another active treatment to which it was compared (individual therapy or pharmacotherapy).

Practice Implications

Patients and practitioners may have concerns about group therapy (that it is not private, that the time is divided among several patients, that outcomes may not be as good as individual therapy). Clinicians are advised to take these concerns seriously and to respond to them with an explanation based on the research – that is, that group therapy: is as effective as individual therapy, is probably more cost efficient than individual therapy, and is as well tolerated as individual therapy. Many group therapists use pre-group preparation of patients to help them understand the utility of group therapy. Referral sources may need to be educated about the accumulating research on the efficacy of group therapy. This seems particularly important as clinics, hospitals, private practices, and community agencies grapple with fewer resources to provide adequate care. Group therapy, when done well by clinicians who are adequately trained in group interventions may be a means of increasing accessibility to care for many.
Cognitive-Behavioral Therapy for Depression

Newman, M.G., Agras, W.S., Haaga, D.A.F., & Jarrett, R.B. (2021). Cognitive, behavioral, and cognitive-behavioral therapy. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7^th ed.). Wiley. Chapter 14.

Cognitive-behavioral therapy (CBT) is the most researched psychotherapy for many disorders including depressive disorders. Depression is a global health problem that affects physical and emotional health and is associated with many adverse effects (substance dependence, poverty, illness). And so, finding good treatment options for patients with depression is an important goal. Many treatment guidelines view CBT as one of the first-line treatments for depression based on the research that demonstrates its efficacy. In this chapter of the Handbook, Newman and colleagues review the research on the efficacy of CBT. Immediately post-treatment, the effect sizes for CBT were medium to large when compared to treatment as usual (g = .59, 95% CI [0.42, 0.76]), placebo control groups (g = 0.51, 95% CI [0.32, 0.69]) and wait list/no treatment control groups (g = 0.83, 95% CI [0.72, 0.94]). The effects of CBT for depression tend not to differ from other bona-fide psychotherapies including interpersonal psychotherapy (IPT) (g = –0.09, 95% CI [–0.39, 0.20]), psychodynamic therapies (g = 0.25, 95% CI [–0.07, 0.58]), and supportive psychotherapy (g = 0.15, 95% CI [–0.06, 0.25]). The effects of CBT are also similar to those achieved with anti-depressant medications (g = 0.03, 95% CI [-0.13, 0.18]). Approximately 41% of patients with major depression who receive CBT have significantly fewer depressive symptoms immediately post-treatment than the average patient treated in a placebo or waiting list/no treatment control group. There have been some criticisms of the effect size estimates for CBT in some of these studies. For example, research indicates that newer and higher quality studies have resulted in smaller effects. And so there remains concerns that the overall effects of CBT for depression may be over-estimated.

Practice Implications

Treatment guidelines indicate that CBT is one of the first-line treatment for depressive disorders along with anti-depressant medications and other psychological therapies. CBT appears to improve both short-term and longer-term outcomes for some adults. There is also some evidence that if CBT is combined with pharmacotherapy, then patients might experience even greater improvement. CBT may result in patients learning something about themselves and their depression, which might reduce relapse and recurrence of the depression, although evidence for the latter is still uncertain.
Are Humanistic Psychotherapies Effective?

Elliot, R., Watson, J., Timulak, L., & Sharbanee, J. (2021). Research on humanistic-experiential psychotherapies: Updated review. In Barkham, W., Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield's Handbook of Psychotherapy and Behavior Change (7th ed.). Wiley. Chapter 13.

Humanistic or experiential psychotherapies have a long history going back to the work of Carl Rogers and Fritz Pearls in the 1960s. This is a broad umbrella of therapies that include person-centred therapy, gestalt, emotion-focused, psychodrama, and existential therapies. Most of these therapies see the therapeutic relationship as central and curative. The therapist tries to enter the client’s subjective world with empathy to understand the client’s experience and to provide a validating and corrective emotional experience. The goals of humanistic-experiential therapy include self-awareness, personal growth, and meaning-making in clients’ lives. In this chapter, Elliott and colleagues review and update the meta-analytic evidence for the effectiveness and efficacy of humanistic-experiential therapy. The uncontrolled pre- to post-treatment change from receiving humanistic-experiential therapy estimated from 97 studies was .86 (k = 94; 95% CI [.74, .97]), representing a large effect. Clients maintained their immediate post-treatment gains during the year following therapy (ESw = .88; k = 41; 95% CI [.67, 1.1]) and beyond (ESw = .92; k = 15; 95% CI [.52, 1.31]). Compared to no-treatment control groups in 15 randomized studies, humanistic-experiential therapy showed a large pre-post effect ES_wc= .98 (95% CI [.55, 1.20]). Compared to all other therapies in 56 randomized trials, humanistic-experiential therapy produced equivalent outcomes, (ESwc = –.07; 95% CI [–.21, .07]). The outcomes compared specifically to CBT in which only bona-fide humanistic-experiential therapies were included (i.e., only studies in which the humanistic-experiential therapies were meant to be effective) also indicated a non-significant difference, (ES = –.15; k = 9; 95% CI [–.27, .03]).

Practice Implications

Dating back to the work of Carl Rogers, humanistic-experiential therapies have had an important impact on how many types of therapy is offered today. The emphasis of many therapies on empathy, the therapeutic relationship, and corrective emotional experience are hallmarks of humanistic-experiential therapies. The results of these updated meta-analyses indicate that humanistic-experiential therapies are effective in the short and longer term and are as effective as other forms of well-research psychotherapies.

June 2022

Therapist Facilitative Interpersonal Skills

Wampold, B. & Owen, J. (2021). Therapist effects: History, methods, magnitude, and characteristics of effective therapists. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7^th ed.). Wiley. Chapter 9.

Is therapist interpersonal skill a therapeutic “competence”? Past research on this important topic has been hampered by a couple of methodological challenges. First, asking therapists to self-report on their own social skills and empathy may result in a self-serving bias and is not related to patient outcomes. A second challenge is that therapists’ competence may be influenced by patient characteristics. For example, a therapist seeing an angry patient with low motivation to change might appear less competent than the same therapist seeing an agreeable patient who is highly motivated. Until recently these issues have limited the research on therapist characteristics that indicate therapeutic competence. In this part of the chapter, Wampold and Owen review some of the research that overcomes this limitation. Some researchers conducted a series of studies in which therapists watched videos of standardized patients with different characteristics, and the therapists’ responses to the videos were recorded. In this way, all therapists “saw” the same patients. Therapists’ responses to the videos were coded for facilitative interpersonal skills; that is, for therapist verbal fluency, hope, emotional expression, warmth, empathy, and alliance capacity. In one study, therapist facilitative interpersonal skills assessed with these standardized patient videos predicted outcomes of real patients seen by the therapists in their practices. In another study, student therapists completed the therapist facilitative interpersonal skills assessment at the very beginning of their training. These facilitative skills predicted outcomes obtained when the trainees began seeing patients later in their training. In an interpersonally challenging situation, like some therapeutic encounters where affect is strong, the interpersonal skills of therapists were robust predictors of patient outcome.

Practice Implications

The research showing that therapist interpersonal skills predict patient outcomes is beginning to redefine what it means to be a competent therapist. Research reviewed elsewhere in this blog indicated that adhering to a treatment manual or protocol is not related to patient outcomes. Instead, therapists’ capacity to use verbal skills to express emotions, to be empathic, to develop a therapeutic alliance with a variety of patients, and to repair therapeutic alliance ruptures appear to be much more reliable predictors of patient outcomes. Training programs and professional development should focus on these important skills.
Research on Clinical Supervision

Knox, S. & Hill, C.E. (2021). Training and supervision in psychotherapy: What we know and where we need to go. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7^th ed.). Wiley. Chapter 10.

Supervision is a key aspect of training to be a mental health professional. There is also a gate-keeping role in that supervisors evaluate whether trainees are sufficiently competent to graduate and to seek credentialing or licensure. Most clinical supervision is either individual in nature (one supervisor and one trainee) but some training programs also employ a group supervision format. Despite a long history of supervision as a key training modality in psychotherapy, the research is surprisingly sparse and inconclusive about the utility of supervision. In this part of the chapter, Knox and Hill review some of the research on clinical supervision. The findings suggest that some supervisors are better at establishing a supervisory alliance with trainees than other supervisors. Supervisor traits that facilitate a supervisory alliance and other positive outcomes (supervisee satisfaction, insight, growth, increased confidence, enhanced work with clients; stronger supervision relationship) included supervisor openness, credibility, and capacity to maintain appropriate boundaries. Supervisor empathy, engaging in reflective practice, and attending to parallel process in supervision were associated with supervisee satisfaction, increased supervisee self-disclosure, reduced supervisee anxiety, and improved supervisee work with clients. On the other hand, supervisors’ errors in technique (minimal input in supervision, gender discrimination, nonadherence to ethical guidelines) were linked with supervisee discouragement, negative emotions, reduced involvement and satisfaction, and weaker supervisory alliances. Finally, a strong supervisory alliance (i.e., agreement on training goals, agreement on tasks of supervision, and the supervisory relational bond) is associated with reduced supervisee anxiety, increased supervisee self-disclosure and self-efficacy. Despite the positive effects on the trainee’s sense of competence, comfort, and self-efficacy, there is little research linking supervision to better patient outcomes.

Practice Implications

The research suggests that the quality of the supervisory relationship has an impact on the supervisee and on the supervision process. Supervisors who are open, engaging, warm and empathic are more likely to engage supervisees to be self-disclosing and self-reflective in their work. Supervisors should focus on developing a solid supervisory alliance by establishing supervision goals (a collaborative agreement between supervisee and supervisor on the desired outcomes of the supervision), the tasks of supervision (how the supervision will proceed, what will be discussed or learned), and to help the trainee to experience supervision as a safe environment to explore new ways of being with their clients.
The Evidence for Psychodynamic Therapy

Barber, J., Muran, J.C., McCarthy, K., Keefe, J.R., & Zilchamano, S. (2021). Research on dynamic therapies. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7^th ed.). Wiley. Chapter 12.

One of the persistent myths about psychotherapy is that among treatments that are meant to be effective, some treatments are more effective than others. There are complex historical reasons for such claims, but one therapy that has been most negatively affected by this narrative in psychodynamic therapy. Once a prominent treatment model up to the 1970s, psychodynamic therapy has fallen out of favor among some researchers and is sometimes disparaged as having no evidence base to support its efficacy. In this part of the chapter, Barber and colleagues review the research on the efficacy for psychodynamic therapy for a variety disorders. At the time of writing the chapter, the authors identified 245 randomized controlled trials of psychodynamic therapy. Randomized controlled trials are considered by some as representing the highest quality evidence for interventions. In a number of meta analyses, psychodynamic therapies have demonstrated efficacy compared to control groups in the treatment of mood, anxiety, personality, and somatic disorders, with effects lasting into posttreatment follow-up. In the treatment of suicidality and self-harm, psychodynamic therapies are more effective than control treatments, such as treatment as usual, routine psychiatric care, enhanced usual care, placebo, or any other comparison, including with a different psychological therapy. Long-term psychodynamic therapies for complex or chronic disorders (e.g., borderline personality disorder; treatment-resistant depression) outperformed active and inactive controls. A meta-analysis assessing statistical equivalence in trials comparing psychodynamic therapies to other gold-standard treatments found no evidence that other treatments were more effective. In treatment of unipolar mood disorders, adding short-term psychodynamic therapy to psychopharmacology improved depression symptoms over medications alone (g = 0.26 at termination; g = 0.50 at follow-up).

Practice Implications

Some who practice psychodynamic therapy may feel that the research has been stacked against this treatment modality. And while the narrative is certainly one sided, the evidence is not. Psychodynamic therapy has a robust evidence base for a variety of disorders for which it was tested. Meta analyses consistently demonstrate psychodynamic therapy is as effective as other so called gold standard treatments and provides added value to the treatment of depression over and above medications alone.

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July 2022

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June 2022

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Psychotherapy Practice Research Network (PPRNet)