Practice-Based Psychotherapy Research
To Improve The Wellbeing Of Our Community
PPRNet Blog: July 2014
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
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: Handbook Google Books.
Psychodynamic Therapy for Personality Disorders
Barber, J.P., Muran, J.C., McCarthy, K.S., & Keefe, J.R. (2013). Research on dynamic therapies. In M.E. Lambert (Ed.), Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change, 6th Edition (pp. 443-494). New York: Wiley.
In this part of their chapter, Barber and colleagues (2013) summarize the research on the efficacy of dynamic therapies for personality disorders. As the authors indicate, dynamic therapies refer to a family of interventions that: focus on the unconscious, affect, cognitions and interpersonal relationships; use interpretations and clarifications; consider transference and countertransference; and use the therapeutic relationship to improve self understanding and self-awareness. Following Magnavita (1997), the authors describe dynamic therapies specifically for personality disorders as identifying maladaptive, recurring patterns of thinking, behaving and emotional responding with the intent of restructuring these through linking current and transference patterns to early attachment and trauma. Barber and colleagues conducted meta analyses of available research on dynamic therapies for personality disorders. They combined several outcomes based on patient and observer reports as an index of general outcome. In seven studies representing 452 patients, dynamic therapies for personality disorders were more effective than control conditions (i.e., treatment as usual, or wait-lists), and the size of the effect was moderate. They found no significant differences between dynamic therapies and other types of therapy for personality disorders. Dynamic therapies had significant advantages over control conditions for general symptomatology, interpersonal problems, personality pathology, and suicidality. These therapeutic effects were maintained to short-term follow up.
There are now several dynamic therapies for personality disorders that have substantial research evidence for their efficacy. For example, Transference Focused Psychotherapy for borderline personality disorder is considered a “well-established” treatment by the American Psychological Association Division 12. Mentalization-based treatment is also considered to be “probably efficacious”. Other “probably efficacious” dynamic therapies include: includes McCullough-Vaillant’s short term dynamic psychotherapy (STDP) and brief relational therapy for Cluster C personality disorders (i.e., avoidant, dependent, obsessive-compulsive); and intensive STDP for general personality disorder
Tracey, T.J.G., Wampold, B.E., Lichtenberg, J.W., & Goodyear, R.K. (2014). Expertise in psychotherapy: An elusive goal? American Psychologist, 69, 218-229.
As I have reported many times in this blog, there is substantial evidence for the efficacy of psychotherapy. However, the quality of psychotherapy differs across therapists – that is, some therapists achieve better client outcomes than others. Tracey and colleagues (2014) ask: is it possible to demonstrate expertise in psychotherapy? They define expertise as “increased quality of performance that is gained with additional experience”. Professions that can demonstrate expertise include: astronomers, test pilots, chess masters, mathematicians, and accountants. But several professions may not demonstrate expertise, including: psychiatrists, college admissions officers, court judges, personnel selectors, and psychotherapists. The difference is that the former group have predictable outcomes and have access to quality feedback. In addition, Tracey and colleagues argue that psychotherapy lacks adequate models for how interventions produce benefits. As a result, adherence to treatment protocols (i.e., manuals) is not reliably associated with better patient outcomes. Further, more experienced therapists are not more effective than less experienced therapists. Experienced therapists might have more complete conceptualizations of client problems, but these conceptualizations may not be accurate. Finally, although therapists affect outcomes, client variables (e.g., motivation, severity of symptoms, expectations) likely explain the largest proportion of outcome variance. Tracey and colleagues argue that part of the problem is that psychotherapists do not engage in “deliberate practice”; that is, practice of a specific task (e.g., identifying a rupture in the alliance), receiving specific feedback (e.g., that a rupture was not identified), opportunity for repetition (e.g., to identify a subsequent rupture in the alliance), and opportunity for improvement afforded by error (e.g., better able to identify a future rupture and repairing that rupture). Generally the practice of psychotherapy provides little feedback about the accuracy of past clinical decisions. In other words there is a lack of quality information to help therapists develop into experts. Further, for a whole host of reasons, psychotherapists are notoriously poor at assessing client progress (i.e., like other humans, therapists engage in a number of biased evaluations of their performance). Quality information might be available from progress monitoring (i.e., continuous feedback to therapists about client outcomes), which has been shown to improve client outcomes. However, this may not aid therapists in developing expertise, since progress monitoring provides little information about what therapist behaviors are necessary to improve performance and client outcomes.
Tracey and colleagues conclude that currently psychotherapy does not provide evidence that it is a profession with expertise. To achieve expertise, therapists need quality information not only about their patients’ outcomes but also about their own average outcomes (i.e. performance) relative to other therapists working with similar clients. And therapists need information on how to manage specific events in psychotherapy. Tracey and colleagues suggest setting aside time to generate hypotheses about one’s practice that can be disconfirmed, and then testing these hypotheses. For example, if a therapist is experiencing a higher than average number of premature client terminations (which may follow a misunderstanding with the client), the therapist may hypothesize that he or she is not identifying key alliance ruptures. To test this hypothesis, the therapist could repeatedly assess the alliance (with a validated instrument) with some clients, use this information (and not clinical judgement alone) to identify alliance ruptures (i.e., a severe week to week downward trend in alliance scores), and implement an intervention to repair the alliance with these clients. Do clients with whom a therapist has implemented this procedure drop out at a lower rate? Does this process of deliberately identifying alliance ruptures and repairing them lead to enhanced therapist performance in the future regarding alliance ruptures? This form of deliberate practice (testing hypotheses that are based on quality information and that could be disconfirmed) might lead to greater expertise in identifying alliance ruptures.
View the Is There Such a Thing as Expertise in Psychotherapy? article abstract.
Author email: firstname.lastname@example.org.
Barth, J., Munder, T., Gerger, H., Nuesch, E., Trelle, S. et al. (2013) Comparative efficacy of seven psychotherapeutic Interventions for patients with depression: A network meta-analysis. PLoS Med 10(5): e1001454. doi:10.1371/journal.pmed.1001454
As I wrote about in the June, 2014 blog, depression is a highly burdensome disorder and is the third leading cause of disability worldwide after lower respiratory infections and diarrhoeal diseases. Depression occurs in 4.4% of the world population. Identifying effective treatment for depression is critical to reduce its health and economic burden. There is broad based consensus that psychotherapy is effective for depression, but there remains ongoing debate about which therapies are more effective. Establishing the relative efficacy of psychotherapy for depression is important because many patients do not respond to any one type of treatment – and so they may benefit from different options. Although some meta-analyses have synthesized research that compared pairs of treatments against one another within studies, these meta analyses do not allow one to pool these comparisons of treatments across studies in a comprehensive way. The study by Barth and colleagues uses a relatively new method called network meta analysis in which many treatments can be compared to each other at once by pooling comparisons of treatments to alternate treatments across a number of studies. As a result the authors were able in one meta analysis to compare the relative efficacy of seven different treatments for depression. The seven therapies were defined as follows: (1) Interpersonal Psychotherapy: a brief structured therapy that focuses on interpersonal issues in depression; (2) Behavioral Activation: raises the patient’s awareness of pleasant activities and seeks to increase the patient’s positive interactions with the environment; (3) Cognitive Behavioral Therapy: focuses on a patient’s negative beliefs, how they affect current and future behavior, and restructures the beliefs; (4) Problem Solving Therapy: defines a patient’s problems, proposes solutions for each problem, and then selects the best solution; (5) Psychodynamic Therapy: focuses on unresolved conflicts and relationships and the impact they have on a patient’s current functioning; (6) Social Skills Therapy: teaches skills that help to build and maintain healthy relationships; and (7) Supportive Counseling: aims to help patients talk about their experiences and emotions, and offers empathy. The network meta analysis included 198 clinical trials that represented 15,118 patients in which the seven psychotherapies were compared to each other or to a control condition. All seven psychotherapies were better than wait list controls or usual care, with moderate to large differences. That is, the average patient receiving psychotherapy was better off than about half those in a control condition. Researchers found small or no differences when the seven therapies were compared to each other. Treatments worked equally well for different patient groups (e.g., younger vs older; post natal depression; etc.), and in different modalities (individual vs group).
All seven therapies were effective in reducing depression and none of the seven therapies in this network meta analysis stood out as superior to the others. The findings suggest that patients have a number of viable options for psychotherapeutic treatment for depression. This is important because, about 40% of patients do not benefit from the treatments they do receive, though they may benefit from another approach and will require other options. Client preferences may play a critical role in determining outcomes for some. If possible, patients should be given the option of the type treatment they may prefer or the option of the type of therapist with which they may be most comfortable.
View the Comparing Seven Psychotherapies for Depression article.
Author email: email@example.com