Practice-Based Psychotherapy Research
To Improve The Wellbeing Of Our Community

PPRNet Blog: August 2014

Giorgio A. TascaAt 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

Giorgio A. Tasca

blogAre Therapists or Clients Most Responsible for the Therapeutic Alliance-Outcome Relationship?

Del Re, A.C., Fluckiger, C., Horvath, A.O., Symonds, D., & Wampold, B.E. (2012). Therapist effects in the therapeutic alliance-outcome relationship: A restricted-maximum likelihood meta-analysis. Clinical Psychology Review, 32, 642-649.

The therapeutic alliance, defined as the agreement on tasks and goals of therapy, and the bond between therapist and patient, is one of the most researched concepts in psychotherapy. A meta-analysis of over 200 studies showed that the association between the therapeutic alliance and patient outcomes is moderate but robust (i.e., consistent across studies, patient types, and therapy types). Some have stated that the importance of the therapeutic alliance as reported in studies is an under-estimate of its real impact on patient outcomes. Del Re and colleagues argue that the main reason for this underestimation is that while the therapist’s effect on the alliance-outcome relationship might be large, the client’s effect might be quite small, and so the average of these two effects (which is what most studies report) will be diminished. Del Re and colleagues conducted the first meta analysis to assess the relative size therapist versus client effects across many studies. Their strategy was clever. They looked at the ratio of the number of patients to therapists (PTR) within a study as a “predictor” of the alliance-outcome relationship across studies. This allowed them to examine the relative contribution of therapists and clients to the alliance-outcome relationship. Two extreme examples illustrate this ratio. (1) In one study, many patients might have been seen by only one therapist, in which case the alliance-outcome correlation could only be attributed to differences between clients since there was only one therapist. (2) In another study, each client might have been seen by a different therapist (i.e., there were as many therapists as clients), in which case the alliance-outcome correlation could only be attributed to differences between the therapists; that is there are no differences between clients seen by the same therapist as this did not occur. The patient to therapist ratio (PTR) captures the variability between these two extreme examples across studies. Del Re and colleagues included 69 studies that provided enough information about the number of patients and therapists. The overall correlation between alliance and outcome was moderate, r = .27, which was very similar to what was found in a previous large meta-analysis. PTR was significantly associated with the alliance-outcome relationship even after controlling for a number of possible confounding variables. Patients accounted for almost 0% of the alliance-outcome relationship, whereas the effect of therapists was substantially larger, r = .40, accounting for 16% of the alliance-outcome association.

Practice Implications

Therapists’ capacity to develop an alliance with their patients is associated with outcomes. We also know that some therapists demonstrate better patient outcomes than others. So, therapists who consistently are better at forming alliances with patients likely have patients with better treatment outcomes. The quality of the alliance between patients and therapists appears to be the result of what therapists do or bring to the therapy. And so, on average, the therapist’s role in the alliance is most important for achieving good patient outcomes. Del Re and colleagues note that they were not able to look at the interaction between therapist and patient factors. For example, it may be possible that some therapists might form better alliances some types of patients, but not others. Integrating feedback systems so therapists can monitor the therapeutic alliance and patient outcomes may help therapists identify areas in which they need more training or supervision.

View the Are Therapists or Clients Most Responsible for the Therapeutic Alliance-Outcome Relationship? article abstract.

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blogLong-Term Outcome of Psychodynamic Therapy and Cognitive-Behavioral Therapy 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 multi-centre 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.

View the Long-Term Outcome of Psychodynamic Therapy and Cognitive-Behavioral Therapy in Social Anxiety Disorder article abstract.

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blogDepression as a Risk Factor for Poor Prognosis Among Patients with Acute Coronary Syndrome

Lichtman, J.H., Froelicher, E.S., Blumenthal, J.A., Carney, R.A., Doering, L.V., et al. (2014). Depression as a risk factor for poor prognosis among patients with acute coronary syndrome: Systematic review and recommendations: A scientific statement from the American Heart Association. Circulation, 129, 1350-1369.

There are about 15.4 million US adults with coronary heart disease. About 20% of those hospitalized for an acute coronary syndrome (ACS; that includes myocardial infarction or unstable angina) meet diagnostic criteria for major depression. An even larger percentage of those with heart disease show sub-clinical levels of depressive symptoms. As I reported in the June 2014 PPRNet Blog about 4% of the population suffer from depression, and so the rates of depression are substantially higher among those with ACS. There is a large body of research showing a reliable association between depression and increased morbidity and mortality after ACS. The goal of this scientific statement by the American Heart Association is to review current evidence for the role of depression as a risk factor among patients with ACS. The authors were particularly interested in studies looking at: (1) all cause mortality, (2) cardiac mortality, and (3) composite outcomes including mortality and nonfatal events. Fifty three studies, representing tens of thousands of patients were included in the review. Twenty one of 32 published studies indicated that depression is a risk factor for all-cause mortality after ACS. Fewer studies looked at the relationship between depression and cardiac mortality, but 8 of 12 studies suggested that depression is a risk factor for cardiac mortality after ACS. Finally evidence from 17 of 22 studies suggested that depression was a risk factor for combined outcomes of cardiac mortality, all cause mortality, and nonfatal cardiac events. The authors also reported on meta analyses looking at the association between depression and mortality following myocardial infarction. Depression increased the risk in individuals of mortality from 1.6 to 2.3 times. The authors concluded that the American Heart Association should elevate depression to the status of a risk factor for adverse medical events in patients with ACS.

Practice Implications

This scientific statement by the American Heart Association published in a technical journal read by cardiologists is important because it acknowledges a mental health problem as a risk factor for mortality from a common medical disease. The evidence is quite strong that depression increases the risk of death in those with heart disease, especially acute coronary syndrome (ACS). Some of the mechanisms for the risk include genetic/physiological factors like inflammation, platelet aggregation, and the serotonin system that are associated with both depression and ACS. In addition, depression can also result in less physical activity and poorer self care which could exacerbate a number of health problems that increase the risk for cardiac disease. Depression is also associated with increases in high risk health behaviors like smoking, sedentary lifestyle, and non-adherence to medical treatment. Assessing for and treating depression among patients who have a history of or are at risk of heart disease is important. If such a patient is depressed or has elevated depressive symptoms, then the depression should be treated in order to reduce the risk of death due to medical problems. In the July 2014 PPRNet Blog, I reported on a network meta analysis showing the positive effects of 7 psychotherapies for depression.

View the Depression as a Risk Factor for Poor Prognosis Among Patients with Acute Coronary Syndrome article.

Author email: Not available

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