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.
…I blog about CBT, negative effects of psychological interventions, and what people want from therapy.
Type of Research
- ALL Topics (clear)
- Alliance and Therapeutic Relationship
- Anxiety Disorders
- Attendance, Attrition, and Drop-Out
- Client Factors
- Client Preferences
- Cognitive Therapy (CT) and Cognitive-Behavioural Therapy (CBT)
- Combination Therapy
- Common Factors
- Depression and Depressive Symptoms
- Efficacy of Treatments
- Feedback and Progress Monitoring
- Group Psychotherapy
- Illness and Medical Comorbidities
- Interpersonal Psychotherapy (IPT)
- Long-term Outcomes
- 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
- Therapist Factors
- Transference and Countertransference
- Trauma and/or PTSD
- Treatment Length and Frequency
Rate of Drop-Out From Psychotherapy Differs by Treatment Type, but Only for Some Disorders
Swift, J. K., & Greenberg, R. P. (2014). A treatment by disorder meta-analysis of dropout from psychotherapy. Journal of Psychotherapy Integration, 24(3), 193-207.
In one of my first PPRNet Blogs I reported on a meta analysis by Swift and Greenberg (2012) in which they found that almost 1 in 5 patients in clinical trials dropped out of therapy. There were no differences between therapeutic orientations in the drop out rates. However, the authors did report that those with eating disorders (23.9%) and personality disorders (25.6%) dropped out at a higher rate than other disorders. Premature termination from therapy is an important problem in that those who drop out are less satisfied and have poorer outcomes than treatment completers. In this follow up to their meta analysis, Swift and Greenberg ask the interesting question of whether premature termination differs across therapy orientations for any of the specific disorders. They compared the drop out rates of different treatment approaches for each of 12 separate disorders. The studies defined drop out in various ways, including: unilateral termination, not attending a set number of sessions, not achieving clinically significant change, etc. Treatment orientations, included: behavior therapy, cognitive–behavioral therapies, dialectical behavior therapy (DBT), psychodynamic psychotherapies, solution-focused therapy, interpersonal psychotherapy, humanistic/existential/supportive psychotherapies, and integrative approaches. Primary diagnoses included: depression, eating disorders, borderline personality disorder, other personality disorder, somatoform disorder, bereavement, obsessive compulsive disorder, generalized anxiety disorder, panic disorder, post-traumatic stress disorder (PTSD), psychotic disorders, and social phobia. The authors conducted 12 meta analyses, one for each disorder to compare the therapy approaches. Overall, they included 587 studies. There were no differences in drop out rates among therapy approaches for 9 of the 12 disorders. For depression, integrative therapy had significantly lower drop out rates than other approaches (10.9% vs 19.2%), and for PTSD integrative therapy also had the lowest drop out rate compared to other treatments (8.8% vs 21.0%). Also, for PTSD, exposure based interventions had the highest drop out rates (up to 28.5%). For eating disorders, DBT had the lowest drop out rates compared to other approaches (5.9% vs 24.2%), but this was largely explained by older patient samples and shorter duration of treatment in DBT.
There were no differences between treatments in drop out rates for 9 of 12 disorders. Swift and Greenberg argued that for these disorders, other factors (e.g., therapeutic alliance, client expectations) rather than specific techniques were enough to keep clients in therapy. For depression and PTSD, integrative treatments resulted in the lowest drop out rates. This suggests that therapists might consider incorporating techniques from other orientations that increase the acceptability of therapy for their clients with depression and PTSD. Use of exposure based interventions for PTSD may require a significant amount of work to prepare clients in order to reduce higher drop out rates.
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.
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.
Are Humanistic-Experiential Therapies Effective? Review and Meta-Analyses
Elliott, R.E., Greenberg, L.S., Watson, J. Timulak, L., & Briere, E. (2013). Research on humanistic-experiential psychotherapies. In M.E. Lambert (Ed.), Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change, 6th Edition (pp. 495-538). New York: Wiley.
Humanistic or experiential psychotherapies (HEP) include: person centred therapy, gestalt therapy, emotion-focused therapy, existential psychotherapy, and others. Elliott and colleagues argue that each of these approaches share the characteristic of valuing the centrality of an empathic and therapeutic relationship. That is, an authentic relationship between patient and therapist provides the client with a new and emotionally validating experience. HEP methods that deepen client emotional experiences occur within an empathic relationship, and interpersonal safety is key to enhancing a client’s attention for self awareness and exploration. Despite the long history of research in HEP, these treatments are often used as “control” conditions in outcome studies of psychotherapies – that is, to control for “non-specific” or relationship factors. Elliott and colleagues conducted meta analyses on the effectiveness of humanistic-experiential therapies. Overall, they included 199 studies of over 14,000 patients. Pre to post treatment effect sizes were large (d = .95), indicating a positive effect HEP across a wide range of clients. (A note on effect sizes: Cohen’s d < .20 represents a negligible effect; d = .20 to .49 is a small effect; d = .50 to .79 is a moderate effect; and d > .80 is a large effect). Compared to a wait-list control (62 studies), the positive effect of HEP was significant with a moderate effect size for the difference (d = .76). There were 135 studies that compared HEP to other active forms of psychotherapy. The difference between HEP and non-HEP therapies were trivial and non significant (d = .01). In the 76 studies that compared HEP to cognitive behavioral therapy (CBT), those who received CBT had better outcomes, but the effects were negligible (d = .13). The authors reported that there is enough evidence to indicate that HEP are efficacious for depressive disorders, substance misuse, and relationship problems; and HEP are probably efficacious for anxiety and psychotic disorders.
The research on outcomes of humanistic-existential psychotherapies (HEP) provides support for the effectiveness of these therapies for a variety of disorders, and provides further support for the importance of the facilitative and relationship factors that help patients get better. Empathy, genuineness, positive regard each comes with research support to indicate their importance to patient outcomes. Elliot and colleagues conclude that the education of psychotherapists is incomplete without greater emphasis on HEP and its facilitative components.
Psychological Interventions for Post Traumatic Stress Disorder
Gerger, H., Munder, T., Gemperli, E., Nuesch, E., Trelle, S., Juni, P., & Barth, J. (2014). Integrating fragmented evidence by network meta-analysis. Relative effectiveness of psychological interventions for adults with post-traumatic stress disorder. Psychological Medicine, doi:10.1017/S0033291714000853.
Gerger and colleagues conducted a network meta-analysis to summarize the evidence on the effectiveness of psychological interventions for post-traumatic stress disorder (PTSD). Psychological trauma is common in the population (between 40% and 90% lifetime prevalence), and many people develop symptoms following the trauma that may turn into PTSD. For example people may re-experience the traumatic event, avoid stimuli related to the traumatic event, or experience increased arousal. Even those who do not meet DSM-IV criteria for PTSD may still have severe impairment and chronic symptoms. Specific interventions for PTSD include exposure to trauma related stimuli or working through cognitions related to the trauma. Non-specific interventions might include supportive therapy or relaxation treatments. As I mentioned in previous blogs, meta-analyses are the best way to summarize the evidence of existing research in order to make clinical decisions about practice. Meta-analyses allow us to pool the effect sizes from individual studies of many patients into an average effect. This method provides the most reliable estimates of the effects of treatments – no single study can be as reliable. Network meta-analysis is a relatively new method that not only allows one to accumulate results from trials that directly compare the same two treatments, but it also allows indirect comparisons of a treatment and another treatment that was tested in a different study. In their network meta-analysis, Gerger and colleagues included 66 studies representing 4,196 patients. Specific treatments included cognitive behavioral therapies (CBT), eye movement disensitization and reprocessing (EMDR), and exposure based therapy (ET). Non-specific interventions included stress management (SM) and supportive therapy (ST). The positive effect of specific interventions (CBT, EMDR, and ET) compared to a wait-list control was large. The positive effect of non-specific interventions (SM, ST) compared to a wait-list control was moderate. There were no differences in effectiveness among the psychological interventions, except EMDR outperformed ST. However, this difference disappeared when only the large scale trials were considered (results from large scale trials tend to be more reliable). Patients with a formal diagnosis of PTSD appear to benefit more from psychological interventions than those with sub-clinical PTSD, though both groups improved.
Different specific interventions for PTSD (CBT, EMDR, ET) appear to have similar positive benefits with large effects. Indirect interventions show moderately positive effects. Supportive therapy (ST) may be beneficial, but the authors indicated that it is too early to conclude that ST is as effective as direct specific interventions. All patients benefit from psychological interventions, though those with more severe symptoms stand to gain the most. Given the similar outcomes of interventions and the number of effective interventions, researchers are now arguing that factors such as access, acceptability, and patient preference should influence the choice of treatment.
Long-Term Effects of Psychotherapy for Depression
Steinert, C., Hofmann, M., Kruse, J., & Leichsenring, F. (2014). Relapse rates after psychotherapy for depression - stable long term effects? A meta-analysis. Journal of Affective Disorders, http://dx.doi.org/10.1016/j.jad.2014.06.043
As I reported in the June 2014 Blog depression is the most highly prevalent of the mental disorders with a lifetime prevalence of about 16%. It is responsible for enormous personal and economic burden for individuals and their families. Depression can occur as a single episode, however recurrence of depressive episodes can range from about 35% to 85% of those who were depressed. About 10% of cases experience chronic depression. Studies report that chronic or severe depression result in a lower response to interventions, including psychotherapy. Meta analytic research shows that a number of psychotherapeutic interventions are equally effective for treating depression (see also the July 2014 Blog). However, all of these meta analytic reviews of the effects of psychotherapy for depression referred to studies demonstrating short or medium term effectiveness. There are very few studies that report long term effectiveness of any type of treatment (psychological or pharmacological) for depression. This is a problem given the fluctuating and sometimes chronic course of the disorder. Randomized controlled trials of psychotherapy are expensive and time consuming, and collecting follow up data is difficult. And so it is not surprising that few studies assess outcomes after one or two years post treatment. Steinert and colleagues conducted a meta analysis looking specifically at studies that documented long term (i.e., greater than 2 years) post psychotherapy outcomes for depression. (A note on meta analyses: Meta analyses are a set of procedures that allow one to statistically combine the effects of many studies in order to estimate the average effect across many studies and participants. Meta analyses produce much more reliable results than any single study can produce, and so meta analyses are the best way of summarizing research to affect practice). Steinert and colleagues found 11 studies of 966 patients that reported outcomes beyond 2 years post psychotherapy. Six of the studies compared psychotherapy to another intervention (e.g., medications, treatment as usual, clinical management). The authors found that 40% of patients treated with psychotherapy had at least one relapse in a follow up period averaging about 4 years. Compared to non-psychotherapy interventions psychotherapy had a significantly lower likelihood of experiencing a relapse. Despite the positive long term outcomes of psychotherapy for depression, the authors noted that there was a great deal of inconsistency across studies (i.e., hetereogeneity), which lowers ones confidence in the reliability of these findings.
There are very few studies of long term (> 2 years post treatment) outcomes of psychotherapy for depression. In the June and August PPRNet Blogs, I reported on large scale worldwide reviews that indicate how pervasive depression can be, and how detrimental depression is to health and well being. Depression can be recurrent and chronic for some, so demonstrating long term outcomes is important. On the positive side, psychotherapy results in 60% of individuals not experiencing relapses 4 years post treatment, and psychotherapy resulted better long term outcomes than non-psychotherapy interventions. However, having so few studies that assess long term outcomes reduces our confidence in these findings. A number of psychotherapies including cognitive behavioral therapies, psychodynamic therapy, interpersonal psychotherapy, and others are effective for treating depression.
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.
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.