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

PPRNet Blog: August 2017


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 pprnet@toh.on.ca.

Giorgio A. Tasca


blogWhat Characterizes Effective Therapists?

Wampold, B.E., Baldwin, S.A., Holtforth, M.G., & Imel, Z.E. (2017). What characterizes effective therapists. In L.G. Castonguay and C.E. Hill (Eds.) How and why are some therapists better than others? Understanding therapist effects. Washington, DC: American Psychological Association.

The research on therapist effects indicates that some therapists are more effective than others. Previous research showed that therapist characteristics like age, race, ethnicity, gender, and experience are not consistently related to patient outcomes. Neither is therapist competence and adherence to a treatment approach. In this chapter, Wampold and colleagues ask the question: what characterizes effective therapists? The research is complicated because it is difficult to disentangle therapist effects from patient factors. That is, it is possible that some clients (i.e., those who are more motivated, likeable, and psychologically minded) might create favorable conditions for some therapists to be more effective. However, recent advances in statistical methods have allowed researchers to isolate the effects of therapist characteristics from patient factors. Based on this new research, Wampold and colleagues identified four characteristics of effective therapists. (1) The ability to form an alliance across a range of patients. The therapeutic alliance is defined as the agreement on tasks and goals of therapy, and the affective bond between therapist and patient. Alliance is reliably associated with good patient outcomes. Research shows that therapists and not clients are primarily responsible for the alliance-outcome relationship. (2) Facilitative interpersonal skills – which includes verbal fluency, warmth, empathy, and emotional expression. These skills in a therapist are a strong predictor of patient outcomes. (3) Professional self doubt – or healthy skepticism about one’s abilities and skills leading to self-reflective practice has also been found to predict positive patient outcome. (4) Deliberate practice - defined as individualized training activities especially designed to improve specific aspects of an individual’s performance through repetition and successive refinement. The amount of time outside of therapy that therapists engage in improving targeted therapeutic skills predicted patient outcomes.

Practice Implications
Some therapists are better than others - and demographics, professional affiliation, training, and adherence to a manual do not differentiate better therapists. Four factors are emerging as indicators of better therapists. Ability to develop, maintain, and repair a therapeutic alliance is well known to predict patient outcomes and it appears that therapists are largely responsible for the condition of the alliance. Therapists’ ability to be verbal, warm, and empathic is also key to patient outcomes. Professional skepticism about one’s abilities that lead to reflective practice is also an important characteristic in order to continually improve one’s abilities and monitor one’s outcomes. And, finally therapists who spend time outside of therapy deliberately and repetitively practicing skills will achieve better patient outcomes.

Click here for chapter abstract
Author email: bwampold@wisc.edu

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blogEfficacy of Group Psychotherapy for Panic Disorder

Schwartze, D., Barkowski, S., Strauss, B., Burlingame, G., Barth, J., & Rosendahl, J. (2017). Efficacy of group therapy for panic disorder: Meta-analysis of randomized controlled trials. Group Dynamics, 21, 77-93.

Panic disorder (PD) is characterized by recurrent episodes of intense fear or discomfort accompanied by physical and cognitive symptoms that may include sweating, trembling, or fear of dying. The panic attacks can lead to avoidant behavior that results in isolation, impaired functioning and lower quality of life. Often, those with PD also experience agoraphobia or an intense fear of having a panic attack in public, open spaces, or in a crowd. PD has a lifetime prevalence of 5% among adults in the US. Patients with PD use health care services at a higher rate than the general population, and those with PD may not receive adequate treatment. An evidence-based treatment for PD is cognitive behavioral therapy (CBT). Practice guidelines for PD recommend pharmacotherapy and psychotherapy with CBT. However, these practice guidelines do not take into account group therapy for PD. In this meta analysis, Schwartze and colleagues included group treatment studies of PD that were randomized controlled trials (RCT) and in which direct comparisons of group therapy to other treatments were conducted. RCTs of direct comparisons provide the best quality evidence of the efficacy of a treatment approach. The authors included 15 studies (14 of which were of group CBT for panic) that had 864 patients. There was a large significant effect on panic and agoraphobic symptoms favoring group over no-treatment controls (k = 9; g = 1.08; 95% CI [0.82, 1.34]; p = .001). Similar results were found for depressive symptoms and general anxiety symptoms. There was no significant difference between group and alternative PD treatments (pharmacotherapy, individual therapy) on the primary outcomes (k = 6; g = 0.18; 95% CI [-0.14, 0.49]; p = .264). Again similar results were found for depression and anxiety symptoms. In total 78% of patients with PD were symptom-free after group psychotherapy, compared with 33% in no-treatment control groups, and 71% in alternative treatment.

Practice Implications
The number of studies were small, but the results of this meta analysis indicate that group therapy is an effective treatment for PD and perhaps as effective as typical alternatives like pharmacotherapy and individual therapy. Group CBT protocols usually involve multiple components such as (a) education regarding the etiology and maintenance of PD, (b) cognitive restructuring (identifying and modifying panic-related cognitions), (c) exposure to external situations (in vivo exposure) or internal bodily sensations (interoceptive exposure), (d) relaxation training and/or breathing retraining. Group therapy may also provide a lower cost, more accessible, and possibly as effective treatment alternative than individual therapy for PD.

Click here for article abstract.

Author email: dominique.schwartze@med.uni-jena.de

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blogInterventions for PTSD for Survivors of Mass Violence

Morina, N., Malek, M., Nickerson, A., & Bryant, R.A. (2017). Meta-analysis of interventions for posttraumatic stress disorder and depression in adult survivors of mass violence in low- and middle-income countries. Depression and Anxiety, DOI: 10.1002/da.22618

There is a high prevalence of post-traumatic stress disorder (PTSD) in countries that have experienced civil war and mass violence, and given the number of open conflict, the prevalence is likely increasing. Most people affected are from low- to middle-income countries. Both PTSD and depression confer a large personal, social, health, and economic burden especially when untreated. Research in Western countries show that psychological treatment of PTSD is effective, but there are practical barriers to transporting and adapting these interventions to low- and middle-income countries. In this meta-analysis, Morina and colleagues do a systematic review of psychological interventions for PTSD conducted of adult survivors of war in low- and middle-income countries. Treatments included trauma-focused cognitive-behavioral therapy, interpersonal psychotherapy, eye movement desensitization and reprocessing and several others. In total, 2,124 treated participants and 934 participants in the waitlist condition were included in the analyses. In the 18 trials that were included, symptoms of PTSD and depression were measured. The average drop-out rate was 11.5%. Across all active interventions (k = 16), a large pre–post effect size was found, g = 1.29; 95% CI = [0.99; 1.59] for PTSD. The average between-group effect size comparing active treatments versus control conditions at post-treatment was small to medium, g = 0.39; 95% CI = [0.249; 0.55], and at follow-up was large, g = 0.93; 95% CI = [0.56; 1.31], k = 10. Pre-post effect size for depression was equally large g = 1.28; 95% CI = [0.96; 1.61]. The effect size comparing active treatments versus control conditions for depression at posttreatment (k = 11) was large, g = 0.86; 95% CI = [0.54; 1.18], and at follow-up was medium to large, g = 0.90; 95% CI = [0.49; 1.33], k = 5.

Practice Implications
Evidence-based psychological treatments developed in high-income countries are also effective in reducing symptoms of PTSD and depression in adults who experienced war-time conditions in low- and middle-income countries. Although not directly tested, the evidence suggests that different evidence-based treatments were equally effective. Even if drop-out rates were low, practical barriers still existed, including the number of sessions of these treatments (average was 10 sessions), the need for trained personnel, and the need for face to face meetings. The authors suggested that collaborative care models should be evaluated and tested which aim to enhance the reach of efficacious treatments within primary care to optimize the number of patients who can benefit from these interventions.

Click here for article abstract.

Author email: morina@uni-muenster.de