Practice-Based Psychotherapy Research
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PPRNet Blog: December 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

blogDoes 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 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.

Practice Implications

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.

View the Does Cognitive Therapy Have an Enduring Effect Superior to Keeping Patients on Medication? article.
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blogAttitudes Toward Seeking Mental Health Care Have Become Increasingly Negative in the Past 40 Years

Mackenzie, C. S., Erickson, J., Deane, F. P., & Wright, M. (2014). Changes in attitudes toward seeking mental health services: A 40-year cross-temporal meta-analysis. Clinical Psychology Review, 34(2), 99-106.

Rates of treatment for mental disorders in developed countries have increased over time and this is largely due to the dramatic rise in the use of medications, such as antidepressants over the past 30 years. Concurrently the proportion of people receiving outpatient psychotherapy has declined. Despite the increase of pharmacological interventions, many mental health services in the US do not meet evidence based guidelines, and most people with mental disorders in the US and Canada are not receiving care. Barriers to accessing care include: lack of knowledge (not knowing where to get help); structural barriers (financial costs), and attitudes (stigma, belief that one should handle the problem oneself, and belief that treatment will not help). There is a great deal of evidence that negative attitudes about seeking and receiving help are the most consistent reasons related to low service utilization in Canada and the US. Efforts to reduce stigma, in part, have attempted to define mental illness as a medical or biological disorder likely with the intent of reducing blame of the individual for his or her problems. As Mackenzie and colleagues indicate, this coincided with an aggressive direct-to-consumer advertising of psychotropic medications for mental disorders. And so the perception that mental disorders are biological and that require biological treatments became entrenched in the population. However, as I summarized in the PPRNet October 2013 Blog endorsing neurobiological causes of mental illness is associated with seeing the disorder as persistent, unchangeable, and serious. This increases social distance, which is an aspect of stigma. In their meta analysis, Mackenzie and colleagues reviewed all published studies over the past 40 years that used the Attitudes Toward Seeking Professional Help Scale. They analysed 22 studies with a total sample size of 6,796. They used cross-temporal meta-analysis to correlate year of the study with total scores on the scale. The correlation was large and negative (r = -.53) indicating that participants’ help-seeking attitudes have become significantly more negative over time.

Practice Implications

Attitudes toward seeking mental health services have become increasingly negative over the past four decades, which is consistent with worsening public stigma about mental health. This has coincided with an increase in the use of psychotropic medications and a decline in psychotherapy during the same period, despite evidence that psychotherapy is as effective as medications and preferred by patients. As Mackenzie and colleagues suggest, it is possible that attitudes toward mental health care have become increasingly negative due to efforts to convince the public that mental disorders have a neurobiolobic etiology and require biological treatments. When appropriate, clinicians should not promote biological explanations at the expense of psychosocial explanations for mental disorders. Psychological explanations and treatments may result in patients experiencing a greater sense of optimism about change, and greater personal control over the treatments they receive.

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blogBurnout in Psychotherapists in Five Countries

Puig, A., Yoon, E., Callueng, C., An, S., & Lee, S. M. (2014). Burnout syndrome in psychotherapists: A comparative analysis of five nations. Psychological Services, 11(1), 87-96.

Psychotherapists can experience severe stress when working with some clients. The stress can be the result of work conditions like budget cuts and increased therapy caseloads, and from characteristics of the work itself like remaining compassionate with clients who experience significant emotional pain and trauma. In the May 2014 blog, I reported on research on secondary trauma experienced by therapists as an occupational hazard of working with traumatized patients. Although secondary trauma is distinct from burnout, the accumulation of these experiences by therapists coupled with other demands of the work can lead to burnout. Burnout syndrome is often defined as the failure to perform clinical tasks well because of discouragement, apathy, and the experience of emotional or physical drain. Burnout can affect both the therapist’s well being and patient outcomes. In this study by Puig and colleagues, the Counsellor Burnout Inventory (CBI) was given to therapists in five countries. The CBI measures therapist Exhaustion, sense of Incompetence, Negative Work Environment, and Deterioration in Personal Life. The samples of therapists were from countries that included the United States (n = 750), Korea (n = 382), Japan (n = 257), Philippines (n = 218), and Hong Kong (n = 222). Puig and colleagues argue that countries like the US may be characterized by a more individualistic cultural context, whereas other countries in Asia may have more collectivistic values. These cultural values and differing professional practice contexts may affect the experience of burnout by psychotherapists. The majority of therapists were female (67.3% to 85.3%) with average experience ranging from 5.34 years in Korea to 12.33 years in the US. Puig and colleagues translated the CBI from English and then conducted a confirmatory factor analysis that showed that the CBI is reliable and valid within each of these samples of therapists from different countries. Therapists in Hong Kong and the US had the highest scores on the Exhaustion scale. Puig and colleagues suggested that burnout in Hong Kong and US may be most affected by demands of the work that psychotherapists do in those countries. Psychotherapists from Japan reported highest levels on the Incompetence scale, suggesting that burnout in Japanese therapists might be most affected by a sense of low self efficacy and efficiency. Of all the nations, US therapists perceived their working environments most negatively. Deterioration in Personal Life scores were highest in Korea suggesting that burnout may contribute to low personal quality of life for Korean psychotherapists. All therapists reported low mean scores on the Devaluing Client scale, but those in the US and Philippines had the lowest mean scores. It appears that burnout is least affected by negative relationships with clients for all therapist groups.

Practice Implications

Therapists, policymakers, and administrators need to attend to increased stress related to psychotherapists’ work, the environment, and characteristics of clients who experience trauma. The impact of stress and burnout can be seen in therapists’ performance their personal lives and well-being. In addition, burnout can affect patient outcomes. Puig and colleagues suggest that psychotherapists can participate in professional development activities (e.g., workshops) to enhance their knowledge and skills in managing stress and maintaining a healthy and balanced work and personal life. Organizations should consider restructuring the social and work environment (e.g., workload), and clarifying and reassessing their expectations of therapists in order to prevent conflict and ambiguity. On his web site, Ken Pope provides a list of resources for therapist well-being and preventing burnout, and he discusses the ethics of therapist self-care.

View the Burnout in Psychotherapists in Five Countries article abstract.
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