Practice-Based Psychotherapy Research
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PPRNet Blog: December 2015

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 Therapist Adherence and Competence to a Treatment Manual Related to Patient Outcomes?

The Great Psychotherapy Debate: Starting in April, 2015 I will review parts of The Great Psychotherapy Debate (Wampold & Imel, 2015) in the PPRNet Blog. This is the second edition of a landmark and sometimes controversial book that surveys the evidence for what makes psychotherapy work. Since this is a book I will not provide the author email. However, you can view parts of the book in Google Books.

The conduct of psychotherapy trials almost always requires that therapists be adherent and competent in delivering a manualized therapy intervention. Treatment adherence usually refers to the extent to which a therapist used the intervention prescribed by a treatment manual. Therapist competence refers specifically to a therapist’s skill in delivering the therapy. So “competence” in the context of psychotherapy research typically refers only to performing a certain type of treatment. Wampold and Imel argue that these definitions are consistent with a Medical Model of psychotherapy that emphasizes delivering specific active ingredients of a treatment. The Contextual Model of psychotherapy, on the other hand might define a therapist as competent to the extent that the therapist is interpersonally skilled, empathic, and able to engage clients in the actions of the therapy. Wampold and Imel report on a meta analysis of 28 studies conducted by Webb and colleagues (2010) who found a small and non-significant relationship between therapist adherence and patient outcomes (r = .02), and a small and non-significant relationship between therapist competence and patient outcomes (r = .07). Type of treatment (e.g., CBT, IPT, dynamic) did not affect these associations – in other words adherence and competence were not more important to CBT than to other treatments. However, competence seemed to be more important for the treatment of depression (r = .28). Perhaps depression responds better to specific techniques. The finding that competence was generally not related to outcomes was surprising, however generally competence is narrowly defined as how well a therapist delivered the treatment not how well the therapist was able to establish a therapeutic context. Previous researchers concluded that when clients liked working with a therapist, clients got better, and therapists were rated as more competent as a result. A number of studies appear to indicate that therapist competence is really a function of the client’s characteristics not to what the therapist does. For example, clients with more severe personality problems could make a therapist appear less competent, and these clients may have poorer outcomes. If this is the case, it would create a paradoxical situation in which therapists’ appearance of competence (i.e., ability to deliver a manualized intervention well) is largely determined by the client and not by the therapist.

Practice Implications

In contrast to the findings about adherence and competence, the therapeutic alliance is robustly related to patient outcomes. Also in contrast, the size of the alliance-outcome relationship is almost entirely due to the skills of the therapist, not the client’s characteristics. In other words, therapist competence is not a matter of whether they can do a good job of following a manual, but rather therapist competence is likely a matter of creating the right conditions (i.e., interpersonal skill, alliance, empathy, etc.) for delivering evidence-based interventions by which many clients improve. However, some therapists are better at these facilitative interpersonal skills than others.

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blogCBT or Antidepressant Medications as the First-Line Treatment for Severe Depression

Weitz, E.S., Hollon, S.D., Twisk, J., van Straten, A., Huibers, M.J.H., David, D., …. Cuijpers, P. (2015). Baseline depression severity as moderator of depression outcomes between cognitive behavioral therapy vs pharmacotherapy: An individual patient data meta-analysis. JAMA Psychiatry. doi:10.1001/jamapsychiatry.2015.1516.

The American Psychiatric Association guidelines for the treatment of depression indicates that although psychotherapy is adequate for mild to moderate depression, anti-depressant medications are indicated for the treatment of severe depression in major depressive disorder. These recommendations are mainly based on the findings of the National Institute of Mental Health Treatment of Depression Collaborative Research Program that was published in the mid 1990s. Several authors since then have disputed this claim, but no meta-analyses have been done on the studies of head-to-head patient-level comparisons of psychotherapy vs antidepressant medications for the purpose of evaluating their relative efficacy for severity of depression. In this meta analysis, Weitz and colleagues look at medications vs psychotherapy for depression and then evaluate if initial severity of depressive symptoms helped to explain any differences. The authors looked at all studies that compared cognitive behavioral therapy (CBT) against antidepressant medications for depression. They focused on CBT because it was the most often studied of the psychotherapies in this context. A systematic review turned up 24 studies, and they were able to get original patient-level data from the authors of 16 of the 24 studies. This represented over 1,700 participants with major depression. These 16 studies were no different from the 8 studies that did not provide original data. Between 17% and 54% of the 1,700 depressed participants met criteria for severe depression at pre-treatment. There were no significant differences between antidepressant medications and CBT on clinically relevant outcomes in terms of “response” (i.e., improvement) or “remission” (i.e., symptom-free). In total, 63% of patients in the antidepressant medication condition and 58% of patients in the CBT condition responded to treatment, and 51% of patients in the antidepressant medication condition and 47% of patients in the CBT condition met criteria for remission. Most importantly, the effects of CBT and antidepressant medications on response to treatment or remission did not differ based on initial severity of depressive symptoms.

Practice Implications

Patients with severe depression were no more likely to require medication to get better than patients with less severe depression. This meta analysis that included the majority of studies that exist on the topic found no evidence to support the guidelines that severe depression should be treated with antidepressant medications over psychotherapy. The authors conclude that CBT may also be a first-line treatment for severe depression.

View a copy of the Baseline Depression Severity abstract.

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blogLong Term Psychodynamic Psychotherapy for Treatment Resistant Depression

Fonagy, P., Rost, F., Carlyle, J., McPherson, S., … Taylor, D. (2015). Pragmatic randomized controlled trial of long-term psychoanalytic psychotherapy for treatment-resistant depression: The Tavistock adult depression study (TADS). World Psychiatry, 14, 312-321.

Usually I do not write about individual studies, mainly because meta-analyses and systematic reviews are much more reliable. But occasionally a unique study is published that is important enough to report. This is a rare trial that focuses on "treatment-resistant" depression defined as long-standing depression that has not responded to at least two previous evidence-based interventions. Depression is known to have a relapsing chronic course for about 12% to 20% of patients. And not responding to treatment is highly predictive of non-response to future treatment for depression. Fonagy and colleagues argued that in order to be effective, treatments for chronic and resistant depression need to be longer and more complex than current time-limited evidence-based approaches. Further, they argued that follow ups should be of longer duration. The authors tested a manualized long term psychoanalytic psychotherapy (LTPP). The treatment involved 60 sessions over 18 months provided by 22 trained therapists. In this trial, the "control" condition was treatment as usual (TAU) as defined by the National Institute for Clinical Excellence in the United Kingdom. TAU was made up of short term evidence-based interventions like antidepressant medications or CBT provided by licensed trained professionals. LTPP plus TAU was compared to TAU alone for 129 patients randomly assigned to one of the conditions. At pre-treatment, the majority of patients scored in the severe range on the Beck Depression Inventory (BDI) or the Hamilton Depression Rating Scale (HDRS). The average patient had 4 previous unsuccessful treatments for depression. No differences were found between LTPP and TAU at post treatment, but differences began to emerge after 24 months. Complete remission was infrequent in both conditions after 42 months (14.9% LTPP vs 4.4% TAU). However, partial remission at 42 months was significantly more likely in LTPP (30.0%) than TAU (4.4%). Patients were significantly more likely not to meet DSM-IV criteria for depression at 42 months in LTPP (44%) than in TAU (10%). The differences between conditions in mean BDI and HDRS scores were significant and medium sized indicating greater improvement with LTPP.

Practice Implications

This is the first study of its kind to test a manualized LTPP for treatment resistant depression. Patients in LTPP were more likely to maintain gains whereas those receiving evidence-based TAU were more likely to relapse. Although this is only one study and should be interpreted cautiously, it does suggest that chronic treatment-resistant depression is more likely to respond to longer and more complex treatment, and that outcomes of such treatment tend to be maintained in the longer term.

View a copy of the Long-term Psychoanalytic Psychotherapy for Treatment-Resistant Depression article.

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