Practice-Based Psychotherapy Research
To Improve The Wellbeing Of Our Community
PPRNet Blog: February 2015
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
Laska, K. M., Gurman, A. S., & Wampold, B. E. (2014). Expanding the lens of evidence-based practice in psychotherapy: A common factors perspective. Psychotherapy, 51(4), 467-481.
In this wide ranging review of the Common Factors (CF) perspective in psychotherapy, Laska and colleagues tackle the complex issues of defining CF and describing the evidence. The authors argue that CF in psychotherapy are not a vague set of ideas that fit under the label of “non-specific factors” or “relationship factors”. They also state that there is an unnecessary dichotomy between the concepts of empirically supported treatments (EST) and CF. In EST, specific and brief manualized therapies for specific disorders are tested in highly controlled randomized trials. ESTs purport that efficacious psychotherapies contain specific techniques based on an articulated theory of the disorder, and a specific mechanism of change for that disorder (e.g., depression is partly caused by depressogenic beliefs and so CBT for depression specifically targets cognitive distortions). There are published lists of ESTs for many disorders. However, Laska and colleagues argue that there is little evidence of the specificity of these treatments. For example, in dismantling studies, an intervention like CBT for depression is compared to a dismantled version that removes an “active ingredient” [e.g., by providing only behavioral activation as an intervention], with little difference in patient outcomes between the full and dismantled versions. Further, for a number of disorders, several therapies based on very different theories of the disorder and of change are equally effective. In contrast to the EST approach, Laska and colleagues describe the CF approach which focuses on factors that are necessary and sufficient for patient change across psychotherapies, such as: (1) an emotional bond between client and therapist, (2) a healing setting for therapy, (3) a therapist who provides a theoretically and culturally relevant explanation for emotional distress, (4) an adaptive explanation that is acceptable to clients, and (5) procedures that lead clients to do something that is positive and helpful. Nevertheless, CF does not provide therapists with a license to do whatever they want without consideration for the evidence of a therapy’s efficacy. Rather CF does encourage therapists to make use of specific factors found in ESTs and to practice with a purpose. In support of the importance of CF, Laska and colleagues review the evidence from a number of meta analyses that show that CF (i.e., alliance, empathy, collaboration, positive regard, genuineness, therapist effects) each account for 5% to 11.5% of patient outcomes. These are moderate to large effects. Specific ingredients of psychotherapies or differences between ESTs account for 0% to 1% of patient outcomes, which represent small effects.
An excessive focus or reliance on empirically supported therapies (EST) may unnecessarily limit what the profession and funders consider to be evidence-based practice. A common factors (CF) approach provides scientific evidence for effective therapeutic practices that are necessary in addition to the specific treatments found in lists of ESTs. To be effective, therapists should be able to: (1) develop a therapeutic alliance and repair ruptures to the alliance, (2) provide a safe context for the therapy, (3) be able to communicate sound psychological theory for the client’s distress based on evidence, (4) suggest a course of action that is based on evidence, and (5) conduct therapy based on established theories of distress and healing. Laska and colleagues argue that systematic patient progress monitoring and ongoing monitoring of the therapeutic alliance may be an effective method of quality improvement of therapists’ outcomes. Progress monitoring may provide therapists with information about areas for continuing education to improve their patients’ outcomes.
Ehring, T., Welboren, R., Morina, N., Wicherts, J.M., Freitag, J., & Emmelkamp, P.M.G (2014). Meta-analysis of psychological treatments for posttraumatic stress disorder in adult survivors of childhood abuse. Clinical Psychology Review, 34, 645-657.
Post-traumatic stress disorder (PTSD) occurs at a very high frequency among those who experienced childhood physical and/or sexual abuse. As adults these individuals often request mental health services. Previous meta analyses of psychotherapies for PTSD have combined samples of those with PTSD due to childhood maltreatment and those due to trauma in adulthood. This meta analysis by Ehring and colleagues is the first specifically to look at treatment of PTSD in those with childhood abuse. Some argue that PTSD due to childhood abuse is different because of the high level of complex symptoms like emotion regulation problems, impulsivity, depression, dissociation, substance abuse, and others. And so treatments for PTSD related to childhood abuse may require different characteristics and may have different outcomes. Further, there is a long standing debate about whether trauma-focused treatments are appropriate for those with PTSD who have high levels of complex symptoms. There is concern for example that the focus on trauma memories may exacerbate symptoms like dissociation. Previous reviews showed that treatments targeting the trauma memory (i.e., focus on processing the memory and its meaning) had the largest effect on PTSD outcomes. This is likely because of the impact that memory processes (i.e., re-accessing memories, maladaptive attributions of memories) have on the maintenance of the disorder. Would these large treatment effects also be found in PTSD that resulted specifically from childhood abuse? (A note about meta analyses: meta analyses are the best way to synthesize a research area because this method combines the effect sizes from multiple studies into a single effect size. The findings of meta analyses are much more reliable than findings from any single study. See my November 2013 blog). Ehring and colleagues conducted a meta analysis of 16 studies that included over 1200 participants with PTSD due to childhood abuse. Treatments included: trauma-focused cognitive behavioral therapy (CBT), non-trauma-focused CBT, eye movement desensitization and reprocessing (EMDR), and others. Psychological interventions were effective for PTSD related to childhood abuse, and the effects were large for both PTSD symptom severity and for other symptoms (i.e., depression, anxiety, dissociation). Psychological interventions were more effective that control conditions (i.e., wait lists or treatments as usual), and these effects were moderate. Effects remained large or moderate well into post-treatment follow-ups. Trauma focused treatments were more effective than non-trauma-focused treatments, and individual interventions were more effective than group-based interventions.
Psychological interventions for PTSD in adults who experienced childhood abuse are effective in reducing symptom severity with moderate to large effects. Other symptoms like anxiety, depression, and dissociation also showed large positive changes in these individuals. Research shows that trauma-focused treatments are under-used in routine practice. This may be due to the concern that trauma-focused treatments may not be safe in some individuals with complex symptoms. Trauma-focused treatments may lead to higher effects than non-trauma focused treatments, indicating the potential importance of processing the trauma memory.
Rutherford, B.R., Pott, E., Tandler, J.M., Wall, M.M., Roose, S.P., & Lieberman, J.A. (2014). Placebo response in antipsychotic clinical trials: A meta-analysis. JAMA Psychiatry, doi:10.1001/jamapsychiatry.2014.1319.
The placebo response refers to improvements in symptoms among participants in medication trials that cannot be specifically attributed to the active ingredient of the intervention. For this reason, it is common to have a placebo control condition in trials of medications. In these trials, some participants are randomly assigned to the medication condition, and some are randomly assigned to a placebo control condition. Typically, the placebo is a pill that looks exactly like the medication but that has no active ingredient. Both patients and providers are blind or unaware of whether the patient is receiving the active medication or the placebo. The placebo response is usually attributed to a number of sources: (1) the patient’s expectation of receiving benefit, (2) the patient’s contact with a caring provider and the healing effect of factors like therapeutic alliance and provider empathy, (3) statistical and measurement error, and (4) random changes in patient symptoms that are unrelated to the medication or the placebo. The first two sources are psychological factors that are often specifically active and purposefully enhanced in psychotherapies. That is, some psychotherapists actively work to develop an alliance with the patient and to align therapeutic interventions with patient expectations and preferences. (For a broader discussion, see my review of Common Factors in this month’s PPRNet blog.) The placebo response can sometimes be quite powerful such that antidepressant medications, and antipsychotic medications for example, only tend to be modestly superior to placebo. People with schizophrenia have cognitive difficulties that may reduce their expectations of receiving benefits from treatment. These patients also have significant interpersonal difficulties so that their alliance with health care providers may be significantly hampered. For these reasons, it may be possible that the placebo response may play a smaller role in the medical treatment of patients with schizophrenia. Rutherford and colleagues conducted a meta analysis of 105 studies of over 24,000 participants from 1960 to the present. Their goal was to examine if the average drug-placebo difference decreased significantly over time (i.e. across years of publication). They found that the placebo response significantly increased from 1960 to the present, that is, the average placebo patient tended to get worse in the 1960s, but by the 2000s the average placebo participant tended to get better. The effect of this trend was large (r = .52). By contrast, treatment change associated with antipsychotic medications decreased over time, and the effect of this trend was moderate (r = -.26). The authors suggested possible explanations for this trend. The average participant in drug trials in the 1960s was more severely ill than the average patient enrolled in drug trials in the 2000s. It is possible that the placebo response is more powerful in less severely ill individuals. Also, the authors suggested that a number of study design factors (e.g., multi-site vs single site trials, financial incentives to recruit more patients may result in less severely ill and younger samples) may also contribute to this trend.
One of the practical implications of these findings is that drug companies may be less inclined to fund research and development of new medications for mental illnesses if the research is increasingly showing only modest benefits over control conditions. On the other hand, health care workers who provide: support and empathy, a positive therapeutic alliance, positive expectations about benefits of treatment, attention to patient preferences, and a coherent narrative to understand their patient’s illness may help to enhance the effects of interventions including antipsychotic medications. This may be especially true for younger and less severely ill individuals with schizophrenia.
View the Placebo Response is Increasing in Trials of Antipsychotic Medications article.
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