Practice-Based Psychotherapy Research
To Improve The Wellbeing Of Our Community
PPRNet Blog: June 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
Vasiliadis, H-M., Dezetter, A., Latimer, A., Drapeau, M., & Lesage, A. (2017). Assessing costs and benefits of insuring psychological services as part of Medicare for depression in Canada. Psychiatric Services in Advance: https://doi.org/10.1176/appi.ps.201600395
About 20% of the population have a mental disorder like depression during their lifetime, and depression is associated with a number of negative health outcomes like mortality, health system costs, and low quality of life. Most patients prefer psychotherapy over medications, but there are significant barriers to accessing psychotherapy, with cost as the biggest barrier. Recently in the United Kingdom, a cost-benefit analysis was used to argue that the development of the Improving Access to Psychological Therapies (IAPT) program would pay for itself in five years. The IAPT is a system of reimbursing psychological therapies through the publicly funded National Health Service in the UK. Similar models are in place in France and Australia. Vasiliadis and colleagues also conducted an economic study in Canada to evaluate the cost-effectiveness of providing psychological services as part of Canada`s Medicare system. They did so by using economic modeling of incidences of depression among patients over a 40-year period, and assessing the relative costs and outcomes of increasing publicly funded access to psychotherapy compared with the status quo. They used known incidence rates for depression in the adult population (2.9%), and estimated health service use from the Canadian Community Health Survey (CHS), and estimated costs (hospitalizations, GP visits, specialist visits, seeing a psychologist or counsellor, antidepressant prescriptions) from provincial health billing manuals. They also used the existing research literature to estimate the average effects of psychotherapy for depression on various outcomes (quality of life, suicide and attempts, health service use, etc.). Adequate mental health services for depression was defined as either 8 sessions of psychotherapy or use of antidepressants. They found that 36.7% of Canadians with depression did not use mental health services, and only 67.4% of those who did access treatment received adequate care. In the economic models that were tested, increasing access to care resulted in a projected decrease in depression, suicidality, health system and societal costs. Increasing access would cost an additional $123 million per year, but savings to society in terms of reduced health system costs and increased productivity was $246 million per year. In other words, for every $1 spent by Medicare on psychotherapy, Canada would recoup $2 in reduced costs and increased productivity.
The findings of this Canadian study echo those of similar economic studies done in the UK, France, and Australia. Increasing access to psychotherapy for depression through Medicare is more effective and less costly than the status quo. In fact this Canadian study may underestimate potential gains because it did not account for the increased use of the health system by depressed people with chronic medical conditions. Currently, public expenditures for mental health and addictions in Canada account for only 7.2% of the total health budget. An increase of 0.07% of the total health budget to cover psychological services would result in health care cost savings, improved mental health, reductions in disability, and increased productivity among Canadians.
Click here for the article abstract.
Author email: email@example.com
Zilcha-Mano, S. (2017). Is the alliance really therapeutic? Revisiting this question in light of recent methodological advances. American Psychologist, 72, 311-325.
The therapeutic alliance is often defined as the agreement between the client and therapist on the goals and tasks of treatment within the context of an affective bond. The alliance is associated with good treatment outcomes regardless of how it is measured, who measures it, when it is measured, and what type of therapy is offered. But researchers and theorists debate the causal role of the alliance in therapy. Is the therapeutic alliance simply a byproduct of an effective treatment (i.e. people begin feel better in therapy and therefore experience a better alliance)? Or is the alliance a client trait which is a necessary factor that enables effective treatments to work (i.e., some clients are better at developing an alliance which is required for therapeutic interventions to take hold). Or is the alliance a state-like factor that fluctuates over time and is therapeutic in and of itself (i.e., the growth in the alliance by itself is sufficient to induce symptom change). In this review of recent advanced methods to research the alliance, Zilcha-Mano provides an overview of statistics that model the session to session dynamic fluctuations and impacts of growth in the therapeutic alliance. She argues convincingly that for the most part, the alliance is not a byproduct of symptom improvement. Using this advanced methodology research indicates that session by session change in symptoms do not precede change in the alliance. The research supporting trait-like aspects of the alliance indicates that some clients are more adept than others at developing an alliance with their therapists. Therefore an early alliance in therapy indicates a client trait that provides a necessary context for effective therapies to do their work. However, research also shows that the alliance changes dynamically over the course of treatment, and that change in the alliance from a preceding session predicts change in symptoms in subsequent sessions. This indicates that alliance also has state-like elements that dynamically fluctuate and influence outcomes, which provides evidence that this aspect of the alliance is therapeutic in and of itself.
The accumulating research evidence indicate that the therapeutic alliance is a key aspect of successful therapies. New research is showing how to best manage the alliance, like how to repair alliance ruptures. The research also indicates that the role of the alliance may differ according to client characteristics. Those clients who arrive for treatment with better trait-like characteristics (more adaptive representations of self, more adaptive relationships with others) may be better able to create a strong alliance early. For these clients, the alliance may not be highly therapeutic in itself, but rather set the context for therapy interventions to work. However, some clients find it difficult to maintain satisfying relationships with others including the therapist. For these clients, state-like changes in the alliance may be essential for treatment – that is, developing a strong alliance over the course of treatment may be therapeutic in itself to improve their interpersonal relationships outside of therapy.
Click here for article abstract.
Author email: firstname.lastname@example.org
Palpacuer, C., Gallet, L., Drapier, D., Reymann, J-M., Falissard, B., & Naudet, Florian (2016). Specific and non-specific effects of psychotherapeutic interventions for depression: Results from a meta-analysis of 84 studies. Journal of Psychiatric Research, http://dx.doi.org/10.1016/j.jpsychires.2016.12.015.
Specific effect in psychotherapy refer to those technical interventions that are based on a treatment model that are specific to a particular modality. For example, the effects on symptoms caused by transference interpretations, cognitive restructuring, or exposure might all be considered specific effects. Non-specific effects is a very broad term that sometimes refers to effects on symptoms caused by common factors across all psychotherapies like therapist empathy, therapeutic alliance, or positive regard. Non-specific effects has also been used to refer to any extra-therapeutic effects that are more peripherally related to treatments, like type of control groups used in a study, researcher allegiance, number of treatment sessions, or length of follow-up. In this meta-analysis of 84 studies of over 6000 participants, Palpacuer and colleagues examined the association between non-specific factors (defined as intervention format [group or individual], client demographics, number of treatment sessions, length of follow up, and researcher allegiance to one of the treatment modalities) and treatment outcomes for depression. First, they looked at whether the specific type of intervention (cognitive behavioral, psychodynamic, interpersonal, problem solving, and others) was associated with reductions in depressive symptoms. Second, they assessed if the non-specific factors added to the prediction of improved depressive symptoms and accounted for some of the effects of specific types of interventions. Similar to previous findings, all psychotherapies were significantly more effective than waiting-list controls. However, the effects of the specific intervention approaches became non-significant when the non-specific factors were included in the analysis. That is, non-specific factors seemed to account for some of the effects of the specific treatments. In particular, if the study was conducted in North America vs Europe (β = 0.55, 95% CI: 0.22; 0.90), if the researcher had an allegiance to a particular therapeutic approach (β = 0.29, 95% CI: 0.07; 0.52), or if the number of sessions was higher (β = 0.03, 95% CI: 0.01; 0.04) then depressive outcomes were better.
This meta analysis of over 87 studies suggests that although various psychotherapies are effective, there remain questions about how and why they work. For example, the findings suggest that North American patients may have different expectations and higher responses to treatment, that a researcher`s belief in the effectiveness of their favored intervention actually improves patients` outcomes, and that a higher number of sessions may also result in better outcomes. These factors appear to account for an important proportion of the specific effects of each type of psychotherapy.