Practice-Based Psychotherapy Research
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PPRNet Blog: February 2016


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 Therapists Can Do To Improve Their Patients' Outcomes

Wampold, B.E. & Imel, Z.E. (2015). The great psychotherapy debate (2nd ed.). New York: Routledge.

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.

In the concluding chapter of their book, Wampold and Imel discuss the evidence and strategies that therapists can use to improve patient outcomes. As indicated in previous PPRNet Blogs, Wampold and Imel concluded that the differences between specific treatment approaches is small. In other words, Wampold and Imel argue that there is no good evidence that one bona fide psychotherapy is more effective than another for most disorders. By "bona fide" treatments, they mean psychotherapy that: provides the client with a plausible theory/explanation of the disorder, delivers a structured intervention based on the plausible theory, and is offered by an effective therapist. The authors also found that contextual factors (e.g., therapeutic alliance, therapist empathy, client expectations) accounted for a sizeable proportion of patient outcomes. A key element in this understanding of effective therapy is the role of the therapist. The authors reviewed various studies and meta analyses that showed that therapists differ widely in their outcomes and in their ability to establish a therapeutic alliance. Unfortunately, therapists tend to be overly-optimistic about their clients' outcomes. Therapists often do not have quality data on their clients' progress, and the complexities of the therapeutic work makes it difficult for therapists to keep in mind all aspects of the therapy that is helpful or not helpful to clients. For example, some therapists may be good at establishing an alliance, but they may not be so good at providing a viable treatment structure. Other therapists may be highly empathic with clients who have moderately severe symptoms, but the same therapists may not respond as empathically with more difficult clients. Outcome or process monitoring (i.e., providing therapists with reliable information about the ongoing status of patient symptoms or about the quality of the therapeutic relationship) provides an evidence-based aid in helping therapists to improve their clients' outcomes.

Practice Implications

Regardless of the type of psychotherapy they use, therapists are responsible for achieving good outcomes for their clients. This includes continually developing therapeutic skills over time. There is some evidence that a reflective attitude towards one's psychotherapy practice is helpful. Unfortunately, therapists may not be continually improving or reflecting on their practice. This is indicated by research showing that trainees and interns appear to be as competent as experienced clinicians. Therapists need quality information about their clients in order to improve their own practice and clients' outcomes. But psychotherapy practice is complex, the therapeutic relationship is multifaceted, and clients are variable in their presenting issues and life experiences. All of these make it difficult for any therapist to make accurate decisions in therapy. Progress or process monitoring (i.e., continually measuring outcomes and relationship processes with a psychometrically valid instrument), may be one way for therapists to receive high quality feedback about patient progress in order to improve their psychotherapy practice.

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blogHow Effective is Computerized CBT in Treating Depression in Primary Care?

Gilbody, S., Littlewood, E., Hewitt, C., Brierley, Tharmanathan, P. … White, D. (2015). Computerised cognitive behaviour therapy (cCBT) as treatment for depression in primary care (REEACT trial): Large scale pragmatic randomised controlled trial. BMJ, 351, h5627. Doi: 10.1136/bmj.h5627

Depression is one of the most common reasons why people see family physicians for consultation. The personal and economic burden of depression is high, such that depression is the leading cause of disability worldwide. Effective treatments for depression include antidepressant medications and psychotherapy. Cognitive behavioral therapy (CBT) is an effective treatment for depression, but is not always accessible for those who live in remote areas, and for those who cannot easily find or afford a trained psychotherapist. One solution, touted by some is to provide computerized CBT (cCBT) via internet or CD. In fact, the National Institute for Health and Care Excellence (NICE) in the UK recommend cCBT programs as a first step of care for depression. Commercially available cCBT programs include "Beating the Blues", and freely available programs include "MoodGYM". Previous research shows a large effect of cCBT for reducing depressive symptoms, but non-adherence (i.e., not completing the modules) and patient dropout rates tend to be high. Another issue is that most of the studies of cCBT were conducted by the developers of the programs, and so there may be researcher allegiance effects that could bias the findings. In this large trial, Gilbody and colleagues asked: "How effective is supported computerized cognitive behavior therapy (cCBT) when it is offered in addition to usual primary care in adults with depression?" The authors recruited 691 depressed patients seen in primary care with a general practitioner (GP) in the UK. All participants had access to a computer and high speed internet. The participants were randomly assigned to receive: (1) usual GP care plus 8 50-minute sessions of Beating the Blues, or (2) usual GP care plus 6 weekly modules of MoodGYM, or (3) only usual GP care. Usual GP care included providing antidepressants, counselling, or brief psychotherapy which are all offered as part of the UK National Health Service. Computerized CBT was supported by weekly telephone calls followed by reminder emails to encourage participants to access, use, and complete the programs. At 4 months after the start of treatment, about half of all participants were no longer depressed, and there were no differences between the three study conditions on any of the outcomes (e.g., depression, quality of life). The results were consistent up to 2 years post treatment. However, only about 17% of those receiving one of the cCBT treatments completed all of the sessions. The average number of sessions completed of cCBT was very low (Beating the Blues = 2 out of 8 sessions; MoodGYM = 1 out of 6 sessions). The authors concluded that there was no significant benefit of adding supported cCBT to usual GP care.

Practice Implications

Adding cCBT to usual GP care did not provide added benefit to depressed patients. Low adherence and low engagement with cCBT likely reduced the utility of computerized delivery of therapy. It is possible that more intensively supported cCBT (i.e., with weekly face to face contacts) might have improved the added value of cCBT, but would also have reduced the practically utility and accessibility of cCBT. Those who are depressed might have difficulty with summoning the energy and concentration necessary to repeatedly log on to computers and engage in computerized or internet based treatment.

View a copy of the How Effective is Computerized CBT in Treating Depression in Primary Care? article.

Author email: simon.gilbody@york.ac.uk

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blogPatients' Experiences of Clinicians' Crying During Psychotherapy

Tritt, A., Kelly, J., & Waller, G. (2015). Patients' experiences of clinicians' crying during psychotherapy for eating disorders. Psychotherapy, 52(3), 373-380.

Psychotherapy can be an emotionally intensive experience for both patients and therapists. In a large survey, more than 70% of therapists reported having cried in therapy, and 30% cried during the past month. Therapists who cried almost always saw the experience as positive or neutral (99.2%) for the patient and the therapeutic relationship. Do clients feel the same way about therapists who cry? In this study, Tritt and colleagues surveyed 188 adult patients with an eating disorder who were recently in psychotherapy. Of those, 107 (56.9%) reported that their therapist had cried during therapy. There was no association between frequency of therapist crying and therapist age, patient diagnosis, or type of psychotherapy (i.e., manual-based or not). Therapists who cried a moderate amount were seen by clients as having a positive demeanor (i.e., happy, firm, consistent), whereas therapists who cried more extremely were rated by clients as having a more negative demeanor (i.e., anxious, angry, bored). If therapists who cried were generally perceived by clients to have a positive demeanor, then therapist crying had a positive impact on therapy. That is, clients reported a greater respect for the therapist, greater willingness to express emotions, and higher willingness to undertake therapy in the future. However, if therapists who cried were generally perceived by clients to have a negative demeanor, then therapist crying had a negative impact on therapy. That is, clients were less willing to express emotions in therapy and to undertake therapy in the future. Further, if the therapist who cried was rated as having a negative demeanor, the client experienced more self blame, assumed that there was something wrong in the therapist's life, and that the therapist and client did not share the same perspective on the client's life and treatment.

Practice Implications

This small but unique and interesting survey sheds some light on clients' experiences of therapists who cry during therapy. More than half of clients experienced their therapist crying during therapy. In contrast to surveys of therapists who tend to evaluate therapist crying as exclusively positive or neutral, this survey found that many but not all clients experienced therapist crying as positive. It depends on how the client perceives the therapist as a person. Therapists who are seen by clients as happy, firm and consistent may assume that patients will experience their crying as a positive indicator of the therapeutic relationship. However, therapists who are seen by clients as anxious, bored, or angry cannot assume that clients will see their tears as being positive for therapy.

View a copy of the Patients' Experiences of Clinicians' Crying During Psychotherapy abstract.

Author email: g.waller@sheffield.ac.uk

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