Practice-Based Psychotherapy Research
To Improve The Wellbeing Of Our Community
PPRNet Blog: September 2018
At the PPRNet conference in November 2012 over 100 psychotherapy clinicians, researchers, and educators were very keen to receive ongoing information about psychotherapy research that is practice-oriented and presented in an easily readable format. And so the PPRNet Blog was born.
About once a month I will review and summarize two or three published psychotherapy research articles. As part of the summary, I will highlight the practice implications of the research.
Because of copyright issues, we cannot post the full text of the articles, but we will provide a link to the abstract on the publisher's web site. I will also post the author's email address. Most authors are very happy to share their work. So if you want a copy of the article send the author an email with a request for a pdf or reprint.
At the bottom of each review you can post a comment, and comment on your colleagues' comments. I will update these as frequently as possible.
If you have ideas for an article to review or a topic you would like to see covered, please send me an email at email@example.com.
Giorgio A. Tasca
Munder, T., Fluckiger, C., Leichsenring, F, Abbass, A.A., Hilsenroth, M.J., … Wampold, B.E. (2018). Is psychotherapy effective? A re-analysis of treatments for depression. Epidemiology and Psychiatric Sciences, 1-7. https://doi.org/10.1017/S2045796018000355.
Based on a deeply flawed review in 1952, Hans Eysenck declared that psychotherapy was no more effective than custodial care for treating mental disorders. Later, he qualified this by stating that behaviour therapy was effective and other forms of psychotherapy were not. These statements touched off decades of angst and debate in the psychotherapy community, and also resulted in a great deal of research about psychotherapy’s effectiveness. By the 1970s the new research technique of meta-analysis was developed and was applied to psychotherapy research. In their seminal meta analysis of controlled studies, Smith and Glass found that psychotherapy was useful and with large effects compared to no treatment. And yet the debate continues. In 2018, Cuijpers argued that waitlist control groups (i.e., a common control condition in psychotherapy studies in which patients receive no treatment) are an inappropriate comparison leading to exaggerated estimates of the effects of psychotherapy. Recently, Munder and colleagues argued that waitlist controls are a way of estimating the natural course of the disorder (what would happen with no treatment) plus the effect of expecting to receive treatment (client expectations of receiving treatment tend to have a positive impact on symptoms). In fact, research shows that pre- to post-study effect sizes for the waiting period is approximately g = .40, or a medium effect. In other words, waiting for therapy in a study results in a moderate proportion of individuals getting better on their own without treatment. Therefore, Munder and colleagues argued that comparing psychotherapy to a waitlist control is appropriate and may be a conservative estimate of psychotherapy’s effects (i.e., psychotherapy has to outperform the effects of clients expecting treatment to help them). In their meta analysis, Munder and colleagues re-analysed 71 studies of psychotherapy for depression compared to a waitlist control condition. They found that the effect size in favour of psychotherapy was g = 0.75 (SE = 0.09) indicating a moderate to large effect. Psychotherapy was also more effective than care as usual (i.e., compared to another intervention that was not psychotherapy), g = 0.31 (SE = 0.11). There were no differences between types of psychotherapy (CBT, IPT, PDT, etc.) for depression outcomes.
Despite various attempts during the history of psychotherapy to downplay or disparage its efficacy, research continues to show that psychotherapy is in fact effective. The average effect size compared to the natural history of depression is moderate to large (and that is likely an under-estimate). Again, there is no evidence that one type of psychotherapy is superior to another for treating depression. It is time for the field to move beyond questions of efficacy of psychotherapy and of the relative efficacy of different treatments, and look to understanding therapist interpersonal stances, client characteristics, and relationship factors that may improve outcomes from psychotherapy.
Reese, R. J., Duncan, B. L., Bohanske, R. T., Owen, J. J., & Minami, T. (2014). Benchmarking outcomes in a public behavioral health setting: Feedback as a quality improvement strategy. Journal of Consulting and Clinical Psychology, 82(4), 731-742.
Psychotherapy has demonstrated its efficacy in randomized controlled trials. But do these findings in highly controlled studies translate to everyday practice in publicly funded agencies that treat low income clients? Previous research in the US showed that outcomes of treatment-as-usual in public behavioural health agencies are generally not positive, so that only 20 to 35% of clients reliably improved. One approach to improving outcomes is to transport specific evidence-based treatments into practice settings. For example, research on applying CBT for panic and depression in a publicly funded agency resulted in similar outcomes to those achieved in randomized controlled trials. However, an alternative strategy of improving outcomes is to use continuous outcome monitoring, which involves repeated (weekly) measurement of client outcomes with reliable scales, and feedback to therapists on the client’s status relative to previous sessions and relative to other similar clients. Research has demonstrated that this strategy improves client outcomes and reduces the number of clients who deteriorate. In this study, Reese and colleagues examined the outcomes of a large public behavioural health service in the U.S. that treats low-income individuals. The service implemented repeated outcome monitoring of clients with feedback to therapists. Over 5,000 clients mainly with depression, mood, and anxiety disorders were treated by 84 therapists who were licensed at the masters degree or higher. The clients completed the Outcome Rating Scale (a measure of symptom outcome) prior to each session, and the Session Rating Scale (a measure of the therapeutic alliance) after each session. Therapists received two days of training on how to use these measures and on the continuous feedback they were provided in order to improve their treatment of clients and their outcomes. Outcomes from this public behavioural health service were compared to previous large studies in publicly funded settings that implemented specific evidence-based treatments. The findings were similar, with about 42% showing reliable pre- to post-treatment improvement. The results of implementing continuous outcome monitoring with feedback for depressive symptoms were also large and positive (d = 1.34). These effects were similar to benchmarks established in randomized controlled trials of specific psychotherapies.
Continuous outcome feedback enables therapists to identify clients who are not benefiting
from a given treatment, so that clinicians may collaboratively design different interventions or change their interpersonal stances. The inclusion of outcome monitoring and feedback in this publicly funded psychotherapy system, resulted in outcomes that were: better than what is often seen in such public service settings, equivalent to those public systems that implemented specific evidence based treatments, and similar to those reported in highly controlled randomized trials. The authors concluded that adding routine outcome monitoring and feedback is a viable alternative to transporting specific evidence based treatments to publicly funded psychotherapy programs. The measures used in this study are available free for individuals to use at: https://betteroutcomesnow.com/.
Jennissen, S., Huber, J., Ehrenthal, J.C., Schauenburg, H., & Dinger, U. (2018). Association between insight and outcome of psychotherapy: Systematic review and meta-analysis. The American Journal of Psychiatry. Published Online: https://doi.org/10.1176/appi.ajp.2018.17080847
For many authors, one of the purported mechanisms of change in psychotherapy is insight. In fact, the utility of insight for clients with mental health problems was first proposed over 120 years ago by Freud and Breuer. Briefly, insight refers to higher levels of self-understanding that might result in fewer negative automatic reactions to stress and other challenges, more positive emotions, and greater flexibility in cognitive and interpersonal functioning. Although insight is a key factor in some psychodynamic models, it also plays a role in other forms of psychotherapy. Experiential psychotherapy emphasises gaining a new perspective through experiencing, and for CBT insight relates to becoming more aware of automatic thoughts. Jennissen and colleagues defined insight as patients understanding: the relationship between past and present experiences, their typical relationship patterns, and the associations between interpersonal challenges, emotional experiences, and psychological symptoms. In this study, Jennissen and colleagues conducted a systematic review and meta analysis of the insight-outcome relationship, that is the relationship between client self-understanding and symptom reduction. They reviewed studies of adults seeking psychological treatment including individual or group therapy. The predictor variable was an empirical measure of insight assessed during treatment but prior to when final outcomes were evaluated. The outcome was some reliable and empirical measure related to symptom improvement, pre- to post- treatment. The review turned up 22 studies that included over 1100 patients mostly with anxiety or depressive disorders who attended a median of 20 sessions of therapy. The overall effect size of the association between insight and outcome was r = 0.31 (95% CI=0.22–0.40, p < 0.05), which represents a medium effect. Moderator analyses found no effect of type of therapy or diagnosis on this mean effect size, though the power of these analyses was low.
The magnitude of the association between insight and outcome is similar to the effects of other therapeutic factors such as the therapeutic alliance. When gaining insight, patients may achieve a greater self-understanding, which allows them to reduce distorted perceptions of themselves, and better integrate unpleasant experiences into their conscious life. Symptoms may be improved by self-understanding because of the greater sense of control and master that it provides, and by the new solutions and adaptive ways of living that become available to clients.