Practice-Based Psychotherapy Research
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PPRNet Blog: January 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

blogIs Therapeutic Alliance Really That Important?

Handbook of Psychotherapy and Behavior Change

Starting in March 2013 I will review one chapter a month from the Handbook of Psychotherapy and Behavior Change in addition to reviewing psychotherapy research articles. Book chapters have more restrictive copy right rules than journal articles, so I will not provide author email addresses for these chapters. If you are interested, the Handbook table of content and sections of the book can be read on Google Books:

Is Therapeutic Alliance Really That Important?

Crits-Christoph, P., Connolly Gibbons, M.B., & Mukherjee, D. (2013). Psychotherapy process-outcome research. In M.E. Lambert (Ed.), Bergin and Garfield's Handbook of Psychotherapy and Behavior Change, 6th Edition (pp. 298-340). New York: Wiley.

In their chapter in the Handbook, Crits-Christoph and colleagues (2013) review research in which psychotherapy processes are related to patient outcomes. I reported in the July 2013 PPRNet Blog that therapeutic alliance is reliably correlated with treatment outcomes in a variety of disorders and treatment types. Alliance refers to an agreement on tasks and goals of therapy, and the bond between therapist and client. The common assumption is that alliance is a necessary condition that in part causes change in client symptoms. However therapeutic alliance studies tend to be correlational, that is, the studies show a relationship but the study designs do not allow one to say that alliance causes good outcomes. What if the opposite were true; what if early experiences of symptom reduction caused the therapeutic alliance to improve? If that were the case, then alliance would be an artificial and not particularly important aspect of psychotherapy. Crits-Christoph and colleagues (2013) review the literature on this topic. Some studies of cognitive behavioural therapy (CBT), for example, found that prior change in symptoms predicted later therapeutic alliance, but prior alliance did not predict later symptom change. In a more sophisticated study, Crits-Christoph and colleagues (2011) found that previous change in the alliance was related to later change in outcomes, but not vice versa. In the same study, the authors noted that measuring patient alliance at a single early session accounted for only 4.7% of the outcome variance at post treatment, whereas averaging assessments of alliance across 6 early sessions accounted for almost 15% of the outcome variance. In other words, averaging assessments across many sessions produced a more dependable measurement of alliance. Several studies now report a reciprocal relationship between alliance and outcome, indicating that change in alliance and change in outcomes across therapy sessions progress in a mutually reinforcing spiral. That is, early change in alliance causes subsequent change in outcome, which in turn results in further change in alliance, which precipitates more change in symptoms, etc. The review by Crits-Christoph and colleagues (2013) also noted that the importance of alliance seems to be greater for patients with a disorder like depression, compared to anxiety disorders.

Practice Implications

Developing an early alliance with a client is related to treatment outcomes. Measuring alliance repeatedly (not just once) will give the best indicator of the state of the therapeutic relationship. Patients and therapists who have a genuine liking for each other, who agree on how therapy will be conducted and on the goals of therapy will improve the chances that psychotherapy will be successful. Alliance and symptom change may work together throughout therapy so that improvement in one will cause change in the other on an ongoing basis across therapy sessions. Alliance may be particularly important for patients with depressive disorders that are characterized by isolation from others, loneliness, and low self esteem.

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blogHow Much Psychotherapy is Needed to Treat Depression?

Cuijpers, P., Huibers, M., Ebert, D.D., Koole, S.L., & Andersson, G. (2013). How much psychotherapy is needed to treat depression? A metaregression analysis. Journal of Affective Disorders, 147, 1-13.

The question of the number of psychotherapy sessions and of frequency sessions (i.e., number of sessions per week) that are optimal for good outcomes could have implications for how psychotherapy is practiced and how it is reimbursed. In my August 2013 PPRNet Blog, I reported on research that indicated half of patients recover after 21 sessions of psychotherapy. However, that also means that half do not recover in that number of sessions. Many of those who do not recover require another 29 sessions to recover. Research and practice in psychotherapy is largely based on a “one-session-per-week” model. Some researchers, however, have found that an increase in the frequency sessions per week could improve or speed up outcomes. Cuijpers and colleagues (2013) did a meta-regression to assess these questions for short-term psychotherapies for depression. (Meta-regression is a type of meta-analysis in which predictors from many studies are aggregated and their averaged effects on the aggregated outcome are assessed. This produces much more reliable findings than are possible from a single study.) The authors assessed predictors such as the number and frequency of sessions, and they looked at symptom outcomes for depression. The authors found 70 controlled studies that included 5403 patients. More than two-thirds of the studies included CBT as the psychotherapy. Average length of treatment was 11 sessions, and the maximum number of sessions was 24. The number of sessions across studies ranged from .44 to 2 per week, and the average per week was 1. The overall effect size for the treatment was medium sized (g = .59), though the effect became smaller (g = .40) when publication bias was corrected. (Publication bias refers to the likelihood that some less favorable studies or results were not published thus creating an overestimation of the effect of the treatment. See my May 2013 PPRNet Blog). Cuijper and colleagues' meta-regression showed a small but significant association between greater number of sessions and outcomes for depression; but more importantly, a greater number of sessions per week had a considerably larger positive influence on the effects of psychotherapy for depression.

Practice Implications

The findings from Cuijpers and colleagues (2013) meta-regression are particularly relevant to time limited treatment of depression with CBT. The total number of sessions was less important than the frequency of sessions per week. The results suggest that increasing the intensity or frequency of CBT sessions per week might result in a more efficient therapy and faster relief for patients with depression.

View the How Much Psychotherapy is Needed to Treat Depression? article abstract.
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blogEmotionally Focused Couples Therapy Reduces Threat Response in the Brain

Johnson, S.M, Burgess Moser, M., Beckes, L., Smith, A., Dalgliesh… Coan, J.A. (2013).  Soothing the threatened brain: Leveraging contact comfort with emotionally focused therapy. PLoS ONE 8(11): e79314. doi:10.1371/journal.pone.0079314.

Attachment theory argues that a felt sense of connection to others provides a secure base and safe haven, thus increasing one's tolerance for uncertainty and threat. Improved access to and experience of social resources likely help us regulate negative emotions thus reducing our perception of threat. In a previous study, women in a couple were confronted with a threat (the possibility of a shock to the ankle) while their brain was scanned by functional magnetic resonance imaging (fMRI). These women were either holding the hand of their spouse or the hand of a stranger. Women with the highest quality relationships showed lower threat response in the brain especially while they held the hand of their spouse. Holding the hand of a spouse with whom they had a loving relationship reduced the fear response in these women measured directly in the brain by fMRI. In the study by Johnson and colleagues (2013) the authors wanted to see if improving attachment relationship between couples following Emotionally Focused Couples Therapy (EFT) would result reduced responses to threat measured in the brain. Twenty-three couples completed a course of EFT (23 sessions on average) with experienced therapists. EFT is an evidence based couples treatment that conceptualizes couple distress as caused by unmet attachment needs. When feeling emotionally disconnected, partners in a couple may be anxiously blaming or withdrawing, and this pattern exacerbates relationship distress and threat. EFT focuses on repairing attachment bonds between spouses. In this trial, EFT significantly improved couples’ self reported distress from pre to post therapy. The brain of the female member of the couple was scanned in an fMRI before and after EFT. An electrode was fixed to her ankle, and she was threatened with a mild shock. This procedure took place while she was on her own and while she held her partner’s hand. Threat response was measured by activity in the prefrontal cortex and dorsal anterior cingulate cortex, both of which are associated with processing threat cues and negative affect. EFT resulted in a decrease activity in these areas of the brain from pre to post couples treatment, and these results were especially prominent during hand holding with the partner.

Practice Implications

There is emerging evidence that the effects of psychotherapy like EFT for couples, has a direct impact on the brain that correlates with patients' self report. In addition, EFT appears to increase the attachment bond between couples and this helps them to regulate their emotions and to moderate their reactions to threat. This study by Johnson and colleagues (2013) also supports some fundamental tenets of attachment theory – that increasing attachment security is possible with psychotherapy and doing so improves affect regulation as measured in the brain. This has broad implications because strong social and attachment bonds help us live longer and enjoy better health.

View the Emotionally Focused Couples Therapy Reduces Threat Response in the Brain article.
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