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Bell, E. C., Marcus, D. K., & Goodlad, J. K. (2013). Are the parts as good as the whole? A meta-analysis of component treatment studies. Journal of Consulting and Clinical Psychology, 81, 722-736.

Component studies (i.e., dismantling treatments or adding to existing treatments) may provide a method for identifying whether specific active ingredients in psychotherapy contribute to client outcomes. In a dismantling design, at least one element of the treatment is removed and the full treatment is compared to this dismantled version. In additive designs, an additional component is added to an existing treatment to examine whether the addition improves client outcomes. If the dismantled or added component is an active ingredient, then the condition with fewer components should yield less improvement. Among other things, results from dismantling or additive design studies can help clinicians make decisions about which components of treatments to add or remove with some clients who are not responding. For example, Jacobson and colleagues (1996) conducted a dismantling study of cognitive-behavioral therapy (CBT) for depression. They compared: (1) the full package of CBT, (2) behavioral activation (BA) plus CBT modification of automatic thoughts, and (3) BA alone. This study failed to find differences among the three treatment conditions. These findings were interpreted to indicate that BA was as effective as CBT, and there followed an increased interest in behavioral treatments for depression. However, relying on a single study to influence practice is risky because single studies are often statistically underpowered and their results are not as reliable as the collective body of research. One way to evaluate the collective research is by meta analysis, which allows one to assess an overall effect size in the available literature (see my November, 2013 blog on why clinicians should rely on meta analyses). In their meta analysis, Bell and colleagues (2013) collected 66 component studies from 1980 to 2010. For the dismantling studies, there were no significant differences between the full treatments and the dismantled treatments. For the additive studies, the treatment with the added component yielded a small but significant effect at treatment completion and at follow-up. These effects were only found for the specific problems that were targeted by the treatment. Effects were smaller and non-non-significant for other outcomes such as quality of life.

Practice Implications

Psychotherapists are sometimes faced with a decision about whether to supplement current treatments with an added component, or whether to remove a component that may not be helping. Adding components to existing treatments leads to modestly improved outcomes at least with regard to targeted symptoms. Removing components appears not to have an impact on outcomes. The findings of Bell and colleagues’ (2013) meta analysis suggest that specific components or active ingredients of current treatments’ have a significant but small effect on outcomes. Some writers, such as Wampold, have argued that the small effects of specific components highlight the greater importance of common factors in psychotherapy (i.e., therapeutic alliance, client expectations, therapist empathy, etc.). This may be especially the case when it comes to improving a patient’s quality of life.

Author email: david.marcus@wsu.edu

Munder, T., Brütsch, O., Leonhart, R., Gerger, H., & Barth, J. (2013). Researcher allegiance in psychotherapy outcome research: An overview of reviews. Clinical Psychology Review, 33, 501-511.

Although evidence for the efficacy of psychotherapy is largely uncontested, there remains debate about whether one type of treatment is more effective than another. This debate continues despite a recent American Psychological Association (APA) resolution on the equivalent efficacy of most systematic psychotherapy approaches. There are many aspects to this debate (e.g., some treatments are more researched than others and so appear to be better; symptom focused measurements are more sensitive to change and so may favour one treatment over another; some treatments are more amenable to manualization and short term application; etc.). One element of the debate that has received a lot of attention is researcher allegiance. Researcher allegiance refers to researchers preferring one treatment approach over another, and this preference may bias comparative outcome trials in favour of the preferred therapy. Researcher allegiance is measured by assessing primary researchers’ publication history or by their self-declared preference for a particular therapy approach. There exist 30 meta analyses that assessed researcher allegiance since the 1980s. These meta analyses focused on different therapy types, client populations (adults, children), and research designs (randomized trials, naturalistic effectiveness studies). However, some meta analyses have reported contradictory results for the researcher allegiance effect. This could be due to the different foci of the meta analyses (i.e., different treatment approaches, patient populations, age groups, etc.), and also possibly due the allegiance of those conducting the meta analyses. Munder and colleagues (2013) conducted a mega analysis of these meta analyses. As the name implies, a mega analysis aggregates the findings of available meta analyses. Munder and colleagues found a significant moderate effect of researcher allegiance. Researcher allegiance was consistent across patient populations, age groups, outcome measures, type of study design, and year of publication.

Practice Implications

As the APA resolution indicates, psychotherapy is the informed and intentional application of clinical methods and interpersonal stances derived from established psychological principles. Evidence-based practice in psychotherapy is "the integration of the best available research with clinical expertise in the context of patient characteristics, culture and preferences". The results of this mega analysis undermine the claim of some comparative outcome studies that suggest that one evidence-based psychotherapy is more effective than another.

Author email: tmunder@uni-kassel.de

Horvath, A.O., Fluckiger, C., Del Re, A.C., & Symonds, D. (2011). Alliance in individual psychotherapy. Psychotherapy, 48, 9-16.

The psychotherapy alliance is probably the most researched concept in psychotherapy. A PsychInfo search of terms including the word “alliance” will turn up over 7000 hits. Although the concept of alliance has been around at least since the 1950s, the commonly acceptable pan-theoretical definition that is currently used was proposed by Bordin in the 1970s. This definition emphasizes the conscious aspects of the collaboration between therapist and client, and involves three elements: agreement on goals, agreement on tasks, and the bond between client and therapist. What is important in terms of developing the alliance is the therapist’s ability to step back from his or her own agenda and emphasize, prioritize, and negotiate the collaborative relationship. This allows for the selection of an intervention that is congruent with client expectations, which then will foster a high level of mutuality. Horvath and colleagues conducted a large meta analysis of alliance - outcome research from the years 1991 to 2009 that included 190 independent studies and over 14,000 participants. The overall relationship between alliance and outcome was statistically significant and moderate in size. This was a highly reliable effect. The results were consistent regardless of which measure was used, who rated the alliance (client, therapist, independent rater), or what type of treatment was studied (i.e., CBT, IPT, Psychodynamic, etc). Similar results were found in separate published meta analyses of child and adolescent psychotherapy and of family and couple therapy, though the effect is larger in couple therapy.

Practice Implications

The quality of the alliance is an index of the level of mutual and collaborative commitment to therapy by the therapist and client. Its distinguishing feature is the focus on therapy as a collaborative enterprise. Establishing a good alliance prevents clients from dropping out, and the sense of collaboration creates a context to introduce new ways of addressing the client’s concerns. In the early phases of therapy, tailoring the methods of therapy (tasks) to suit the specific client’s needs, expectations, and capacities is important in building the alliance. Misjudging the client’s experience of the alliance (i.e., believing that it is in good shape when the client does not share this perception) could render therapeutic interventions less effective. Horvath and colleagues suggest active monitoring the clients’ alliance throughout treatment. Therapists’ nondefensive responses to client negativity or hostility are critical for maintaining a good alliance. Research indicates that therapists who are good at building a strong alliance tend to have better alliances with most of their clients. However, the reverse is also true – some therapists consistently struggle to establish and maintain a good alliance with their clients. The strength of the alliance often fluctuates when therapists’ challenge clients to deal with difficult issues, when misunderstandings arise, and when transference occurs and/or is highlighted. Resolution of these normal variations is associated with good treatment outcomes. The next blog entry discusses research on alliance ruptures and repairs.

Author email: horvath@sfu.ca

Swift, J. K., Callahan, J. L., Ivanovic, M., & Kominiak, N. (2013, March 11). Further examination of the psychotherapy preference effect: A meta-regression analysis. Journal of Psychotherapy Integration. Advance online publication. doi: 10.1037/a0031423

Client preferences consist of preferences regarding the type of treatment offered (e.g., preference for psychotherapy or medication, preference for a behavioral approach to treatment or an insight oriented one), desires for a certain type of therapist or provider (e.g., preference for an older therapist, a female provider, or a therapist who has a nurturing personality style), and preferences about what roles and behaviors will take place in session (e.g., preference for the therapist to take a listening role or an advice giving role). In a previously published meta analysis Swift and colleagues (2011) reviewed data from 35 studies that compared preference-matched and non-matched clients. A small but significant preference outcome effect was found, indicating that preference-matched clients show greater improvements over the course of therapy, and that clients whose preferences were not matched were almost twice as likely to discontinue treatment prematurely. In this follow up meta regression study, Swift and colleagues assessed whether preference accommodation is more or less important for types of disorders, types of treatments, or different demographics like sex or age. (Meta regression involves accumulating data from across many studies to assess predictors [e.g., sex, age, diagnosis, treatment type, etc.] of the preference effect). For example, some research has indicated that men prefer therapists with more feminine traits and that men prefer pharmacological interventions. But does accommodating these preferences affect outcomes and drop out rates? Is matching preferences essential for younger clients? Is matching preferences more important for women or ethnic minorities? The authors analysed data from 33 studies representing 6,058 clients to address some of these questions. The only variable that predicted the influence that preferences have on rates of premature termination was the length of the intervention. That is, it may be more important to accommodate client preferences for briefer therapies. Perhaps, as clients continue in therapy for longer durations, other variables such as the therapeutic alliance play a bigger role in determining whether or not one drops out prematurely. It is also possible that as treatment continues, clients may experience a shift in preferences to more closely match the treatment conditions that they were given. Once this shift in preferences has occurred, preferences are no longer mismatched, and the risk of dropping out may be diminished.

Practice Implications

This study provides evidence that incorporating client preferences may be important for all types of clients. Generally, when client preferences are accommodated, clients show greater improvements while in treatment and are less likely to discontinue the intervention prematurely. As much as is practical, practitioners might collaboratively work with clients to identify what preferences they hold for treatment, and to discuss those preferences in the context of what is the most effective treatment that is available. This is particularly important for psychotherapies of shorter duration..

Author email: joshua.keith.swift@gmail.com

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. The Handbook is updated approximately every 10 years, and the most recent 6^th edition was published in January 2013. In the coming months I will review one chapter a month in addition to commenting on psychotherapy research articles. Book chapters have more restrictive copy right rules about distributing content, so I will not provide author email addresses for these chapters. If you are interested, you can view the table of contents on Amazon.

Lambert, M.J. (2013). The efficacy and effectiveness of psychotherapy. In M.J. Lambert (Ed.) Bergin and Garfield’s handbook of psychotherapy and behaviour change (6^th ed.), pp169-218. Hoboken, N.J.: Wiley.

This comprehensive chapter in the Handbook reviews research on the efficacy and effectiveness of psychotherapy. Lambert’s reviews focus on meta-analyses, which is a way of summarizing effect sizes in a research area. The bottom line is that psychotherapy is effective so that 40% to 60% of clients show substantial benefit in controlled research trials, though the effect is likely smaller in routine practice.  Concurrently, a consistent proportion of adults (5% to 10%) deteriorate during psychotherapy. Patients who receive formal treatment are better off than those who receive no treatment, and bona fide treatments are superior to control conditions that provide only some aspects of effective treatment. When psychotherapy is offered by skilful therapists, on average clients experience appreciable gains and return to normal functioning. Fifty percent of patients achieve clinically significant gains after 8 sessions, and 50% achieve recovery after about 20 sessions of psychotherapy. The effects of psychotherapy tend to be long lasting. For example, only 25% treated depressed patients relapse, whereas 50% of those who receive antidepressants relapse. Research continues to support those therapies that have been rigorously tested, and differences in effectiveness between therapy types (e.g., cognitive behavioural therapy (CBT), psychodynamic, interpersonal, etc.) tend to be small or negligible for many disorders. Cognitive behavioural therapy is still the most tested therapy modality, though other treatments are also accumulating evidence of efficacy. Treatment is likely facilitated by a therapeutic relationship that is characterized by trust, understanding, acceptance, kindness, and warmth. The effect of the therapist providing the therapy is at least as large as the effect of different therapy techniques. That is, some therapists are unusually effective, whereas others may not help the majority of patients who seek their services. Continuous monitoring of outcomes and providing regular feedback to the therapist improves the therapy’s effectiveness.

Practice Implications

Providers and patients can be assured that a broad range of formally defined and tested psychotherapies when provided by skilful therapists are likely to result in appreciable gains in clients including a return to normal functioning. Therapy relationships characterized by trust, understanding, acceptance, and warmth can greatly facilitate change in depression, anxiety, inadequacy, and inner conflicts. When making a decision about which therapy to choose, clients would be wise to consider the therapist as a person at least as much as the type of therapy being offered. Treatment efforts should be based on the best evidence available for treatment types, therapist behaviors, and relationship factors. Routinely monitoring the effects of therapy with each patient will give the therapist ongoing information about their effectiveness and may improve their patients’ outcomes.

Town, J. M., Diener, M. J., Abbass, A., Leichsenring, F., Driessen, E., & Rabung, S. (2012). A meta-analysis of psychodynamic psychotherapy outcomes: Evaluating the effects of research-specific procedures. Psychotherapy, 49, 276-290.

One of the main reasons that some clinicians do not participate in research is that they argue that doing so will have a negative impact on the therapeutic relationship, the therapy process, and patient outcomes. Although I have heard this from clinicians of many theoretical orientations, this opinion is perhaps most strongly held by some colleagues with a psychodynamic orientation. I identify with psychodynamic theory and practice, so this opinion about research held by some of my colleagues has been very disconcerting to me. Up to now, the best I could say in defense of practice-based research of psychodynamic therapy was to talk about my own experiences, which have been highly positive and rewarding. A recent meta analysis by Town and colleagues from Dalhousie University changes all that. (First, a note about meta analysis. Meta analysis is a statistical way of combining the effects of many studies, each of which has a number of participants, into a common metric called an effect size. By combining studies, the end result is more meaningful and more reliable than the results of any single study on its own.). The meta analysis by Town and colleagues had 45 independent samples and over 1600 patients. Results indicated that psychodynamic treatments for a variety of disorders (e.g., depression, anxiety, personality disorders) showed a significant large positive treatment effect – this is not new. What is new is that compared to conditions in which no research-specific protocols were introduced, conditions that did use research protocols were no different in terms of patient outcomes up to one year post treatment. There was even a significant small positive effect of these research protocols on outcomes from post treatment to one year post treatment. Research-specific protocols included video recordings of therapy sessions, therapists following treatment manuals, fidelity checks to make sure therapists were accurately doing psychodynamic therapy, and psychometric measurements of processes and outcomes

Practice Implications

Research protocols do not have a negative impact on psychodynamic therapy outcomes. Perhaps research protocols should be introduced into all therapies to improve longer term outcomes in addition to studying therapy procedures and processes that work.

Author email: joel.town@dal.ca