Practice-Based Psychotherapy Research
To Improve The Wellbeing Of Our Community
PPRNet Blog: January 2017
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 firstname.lastname@example.org.
Giorgio A. Tasca
Burlingame, G.M., Seebeck, J.D., Janis, R.A., Whitcomb, K.E., Barkowski, S., Rosendahl, J., & Strauss, B. (2016). Outcome differences between individual and group formats when identical and nonidentical treatments, patients, and doses are compared: A 25-year meta-analytic perspective. Psychotherapy, 53, 446-461.
With increasing service demands being put on mental health systems, clinicians and administrators are looking to more efficient ways of providing care to more patients. One option is group therapy in which more patients can be treated with fewer resources. However, are groups as effective as individual therapy for mental disorders? This meta-analysis by Burlingame and colleagues addresses this question by examining 67 studies in which group and individual therapy were directly compared within the same study. The majority of studies included adults with anxiety, mood, or substance use disorders, with some studies focusing on medical conditions, eating or personality disorders. Two-thirds of studies were of cognitive-behavioral therapy, but other treatment types like interpersonal, psychodynamic, and supportive therapy were also tested. Groups were defined as having at least 3 patients per group. The average number of sessions for group and individual therapy were equivalent (group M = 14.67, SD = 8.75; individual 15.94, SD = 14.37)), and as expected group therapy sessions were longer in minutes (M = 100.39, SD = 30.87) than individual therapy sessions (M = 56.55, SD = 14.37) given the multi-person demands of groups. Groups were primarily closed to new members after starting, they tended to have homogenous membership based on diagnosis, and groups tended to be co-led by 2 therapists. Individual and group therapy were not significantly different for all disorders and outcomes at post-treatment (g = -0.03; 95%CI = -0.10, 0.04), short-term follow-up (g = 0.01; 95% CI = -0.13, 0.11), and long-term follow-up (g = 0.00; 95% CI= -0.12, 0.13). Drop out rates for group therapy (17.28%) and individual therapy (14.96%) were not significantly different (OR = 1.10; 95% CI = 0.90, 1.33), and patients were likely to accept group therapy (88.76%) as often as they accepted individual therapy (84.83%) when one or the other was offered. Pre- to post-treatment effect sizes were moderately large for both interventions (group: g = 0.60, 95% CI = 0.48, 0.72; individual: g = 0.53, 95% CI = 0.42, 0.65). Patients presenting with depression, substance us, anxiety, or eating disorders had the highest level of improvement.
When identical treatments, patients, and doses are compared, individual and group therapy resulted in equivalent outcomes across of a variety of disorders. This is good news for clinicians and agencies looking to maximize resources to treat more patients. However, running a group is more complex than providing individual therapy. Finding a sufficient number of patients to start a group, assessing and preparing each patient prior to starting a group, writing a note per patient per session, and managing attrition is logistically more challenging. Further, most therapists are not formally trained to provide group interventions and so they may find the task of managing a substantially larger amount of within-session group process information to be complex. Finally, as Burlingame and colleagues indicate, there are institutional considerations so that group programs require a milieu that supports group referrals and flexibility in scheduling. Nevertheless the findings of this meta analysis indicate the potential for group therapy to provide efficacious treatments for mental disorders.
Click here for an abstract of Outcome Differences Between Individual and Group Formats
Author email: email@example.com
Goodyear, I.M., Reynolds, S., Barrett, B., Byford, S., Dubicka, B., ….Fonagy, P. (2016). Cognitive behavioural therapy and short-term psychoanalytical psychotherapy versus a brief psychosocial intervention in adolescents with unipolar major depressive disorder (IMPACT): A multicentre, pragmatic, observer-blind, randomised controlled superiority trial. Lancet Psychiatry, Online first publication: http://dx.doi.org/10.1016/S2215-0366(16)30378-9.
Major depression affects a large proportion of adolescents worldwide. The Global Burden of Disease Study Found that depressive disorders accounted for over 40% of disease burden caused by all mental and substance use disorders, with the highest burden occurring for those between the ages of 10 and 29. Although there is good evidence for cognitive-behavioral therapy (CBT) to treat depression in adolescents, data is scarce for long term outcomes – which is an important issue because maintaining treatment gains reduces the risk for relapse. There is also little research on alternative treatments to CBT and their long term effects. In this large study, Goodyear and colleagues (2016) randomly assigned 470 adolescents with major depression to receive CBT, short-term psychoanalytical therapy (STPT), or a brief psychosocial intervention (BPI). CBT was based on a commonly used model but adapted to include parents and emphasized behavioural techniques. The STPT model emphasized the child – therapist relationship in which the therapist emphasized understanding feelings and difficulties in ones life. STPT also included some family meeting. BPI on the other hand focused on psychoeducation about depression, was task and goal oriented, and emphasized interpersonal activities. The study also compared cost-effectiveness of the three treatments – that is, whether the treatments’ costs relative to their effectiveness were different. There were some advantages in terms of reduced depression to both CBT and STPT compared to BPI at 36 weeks and 52 weeks post treatment, but these advantages disappeared by 86 weeks follow-up. Across all three treatments, about 77% of adolescents with depression were in remission (i.e., no longer depressed) by 86 weeks post-treatment. There were no differences between the three treatments in terms of cost-effectiveness.
This is one of those rare studies that is large enough to adequately compare the efficacy of alternative treatments for adolescents with major depression. CBT, STPT, and BPI were all associated with reduced depression in adolescents, and with maintenance of these improvements 1 year after the start of treatment. Both BPI and STPT provide alternative choices to CBT for patients and therapists.
Click here for a copy of the IMPACT study article.
Author email: firstname.lastname@example.org
Leichsenring, F. Abbass, A., Hilsenroth, M.J., Leweke, F., Luyten, P., ….Steinert, C. (2016). Bias in research: Risk factors for non-replicability in psychotherapy and pharmacotherapy research. Psychological Medicine, doi:10.1017/S003329171600324X.
An important feature of research is that it should be replicable. That is, another researcher should be able to obtain the same finding as the original study as a pre-requisite for the validity of the conclusions. A recent estimate for cognitive and social psychology research is that only about 36% to 47% of studies are successfully replicated. Another study showed similar low replicability of psychotherapy and pharmacotherapy research. Results that are neither replicable nor valid can lead to improper treatment recommendations. Leichsenring and colleagues review several research biases that affect the replicability of findings in psychotherapy and pharmacotherapy research, and they discuss how to limit these biases. Psychotherapy trials often involve an established treatment approach that is pit against a comparison treatment in a head to head contest. Below I list some of the biases detailed by Leichsenring and colleagues that may affect the validity of psychotherapy trials. First, in psychotherapy trials a large proportion of the differences in outcomes between a treatment and a comparison may be due to the researcher’s allegiance to a particular therapy modality. This may be expressed unconsciously by selecting outcome measures that are more sensitive to the effects of one type of treatment versus another. For example the Beck Depression Inventory (BDI) is particularly sensitive to changes in cognitions, whereas the Hamilton Depression Rating Scale (HDRS) is particularly sensitive to physiological side effects related to antidepressant medications. One way to deal with researcher allegiance effects is to include researchers and therapists who have an allegiance to both of the treatments that are under study. Second, the integrity of the comparison treatment may be impaired. That is the comparison treatment may not be carried out exactly as originally intended. This could occur in pharmacological trials in which doses do not match clinical practice, or in psychotherapy trials in which therapists in the comparison treatment may be told to ignore key symptoms. Properly training and supervising therapists and not constraining them by the study protocol is important to avoid this type of bias. Third, some studies make a lot of noise about small effects that are statistically significant. When two bona-fide psychotherapies are compared the differences tend to be small – this is a common finding. Small differences, even if statistically significant, often turn out to be random, unimportant, and of little clinical significance. Concurrent with this problem is that sometimes researchers will use multiple outcome measures, find significant differences only with some, and report these as meaningful. This refers to selectively emphasizing a small number of findings among a larger number of analyses, which are likely due to chance variation and therefore not replicable.
What should a clinician do when reading a comparative outcome study of psychotherapy? There are some technical red flags for research bias that require specialized knowledge (e.g., small sample sizes and their effect on reliability, over-interpreting statistical significance in the context of small effects, and non-registration of a trial). But there are a few less technical things to look for. First, I suggest that clinicians focus primarily on meta-analyses and not on single research studies. Although not perfect, meta-analyses review a whole body of literature, and are more likely to give a reliable estimate of the state of the research in a particular area. Second, clinicians should ask some important questions about the particular study: (a) are the results unusual (i.e., when comparing 2 bona-fide treatments, is one “significantly” better; or are the results spectacular); (b) does the research team represent only one treatment orientation; and (c) do the researchers reduce the integrity of the comparison treatment in some way (e.g., by not training and supervising therapists properly, by unreasonably limiting what therapists can do)?
Click here for the abstract of Bias in ResearchAuthor email: email@example.com