Practice-Based Psychotherapy Research
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PPRNet Blog: March 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 pprnet@toh.on.ca.

Giorgio A. Tasca


blogThe Processes of Psychodynamic Therapy

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 on Google Books.

The Process of Psychodynamic Therapy

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.

This month I consider the section in Crits-Christoph and colleagues' chapter on the process of psychodynamic therapy (PDT). There are a number of PDT models, but they each share some fundamental aspects of treatment or purported mechanisms. One is insight or self understanding, in which patients learn about themselves and their relationships through interventions like interpretations. Self understanding is expected to help patients reduce symptoms by increasing adaptive responses in their important relationships. Transference interpretations may help patients understand their patterns within the therapy relationship, address or change these patterns, and generalize the changes to relationships outside of therapy. Another mechanism might be changes in defensive functioning. Defense mechanisms may be expressions and means of coping with unconscious conflict, needs, and motivations. Change in defensive functioning from less adaptive (e.g. acting out, passive aggression) to more adaptive (e.g., altruism, self observation) may be necessary to achieve improvement in symptoms. Crits-Christoph and colleagues addressed four questions in their review of research on the process of PDT. (1) Are the uses of PDT techniques like transference interpretations related to treatment outcomes?  A number of studies have associated the use of PDT interventions and outcomes, and the average effect size is moderate. In general, transference interpretations were associated with better treatment outcomes. However the findings for transference interpretations are complicated. For example, the use of too many transference interpretations may not be therapeutic and may result in poorer outcomes. A small number of studies looked at the quality or accuracy of transference interpretations and found a moderate relationship between accurate interpretations and good outcomes. Most of these studies did not control for previous improvement in outcomes, so an alternate explanation might be that patients whose symptoms improve facilitate therapists to provide more effective transference interpretations. (2) Is patient self-understanding or insight associated with positive outcomes in PDT? Crits-Christoph and colleagues concluded from their review that changes in self-understanding is an important part of the therapeutic process of PDT. The relationship between insight and outcomes were not evident in CBT or medication interventions, thus suggesting that self-understanding is a specific mechanism of PDT. (3) Is change in defensive functioning related to outcomes in PDT? Only four studies have looked at this question. The studies suggest that improved defensive functioning is related to good outcomes especially for those with more severe problems. However, it remains unclear whether change in defensive functioning causes change in symptoms or the other way around. (4) Is therapist competence in PDT related to treatment outcomes? There is some evidence that competence and adherence in delivering PDT were related to good patient outcomes. Some research also showed that competence and adherence to PDT protocols preceded or caused good outcomes.

Practice Implications

There is good evidence that transference interpretations are related to outcomes, but therapists need to use these judiciously. The research suggests that too many transference interpretations in those with lower levels of functioning, or inaccurate interpretations in general, can reduce outcomes or be related to poorer outcomes. There is also good evidence that patient self understanding of relationship patterns will result in positive outcomes. Self understanding or insight may be a specific mechanism by which PDT works that sets it apart from CBT and the effects of medications. The research also indicates some evidence for the positive effects of changes in defensive functioning, but it is not clear whether change in defenses is a cause of or caused by positive symptom outcomes. Therapist competence and adherence in delivering PDT is also related to good patient outcomes. This highlights the need for training and supervision in evidence based PDT interventions.

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blogBarriers to Conducting CBT for Social Phobia

McAleavey, A.A., Castonguay, L.G., & Goldfried, M.R. (2014). Clinical experiences in conducting cognitive-behavioral therapy for social phobia. Behavior Therapy, 45, 21-35.

It might come as a surprise to some that social phobia (also called social anxiety disorder) is the most commonly diagnosed anxiety disorder, with a lifetime prevalence of about 12%. Symptoms include negative self-view, fear of embarrassment or criticism, and fear and/or avoidance of social situations. Cognitive behavioral therapy (CBT) is an effective treatment for social phobia with effects as large as pharmacotherapies. Despite this, there are several potential barriers to implementing CBT for social phobia in clinical practice. CBT involves exposure to feared situations (in vivo or simulated), identifying and altering maladaptive thoughts during exposure, producing testable hypotheses, and identifying cognitive errors.  CBT is not uniformly effective for all patients with social phobia, exposure techniques are linked to dropping out and failure to initiate treatment, and there can be an increase in missed sessions and non-completion of homework related to avoidance. In this study, McAleavy and colleagues surveyed 276 psychotherapists who provided CBT for social phobia to assess problems or barriers clinicians encountered when applying CBT in practice. Possible barriers listed in the survey were derived from extensive interviews with experts who developed and researched CBT interventions for anxiety disorders. Survey respondents were mostly Ph.D. level clinical psychologists (59%), women (61%), who practiced in outpatient clinics or private practice, and had on average 12 years of post-degree experience. Many therapists reported using behavioral interventions, including developing a fear/avoidance hierarchy, in-session exposures, focusing on behavior in social situations, and specifically focusing on behavioral avoidance. Most also used cognitive homework (i.e., interventions focused on exploring or altering attributions or cognitions).  The most frequent therapist endorsed barriers to implementing CBT for social phobia included: patient symptoms (i.e., severity, chronicity, and poor social skills); other patient characteristics (i.e., resistance to directiveness of treatment, inability to work independently between sessions, avoidant personality disorder, limited premorbid functioning, poor interpersonal skills, depressed mood); patient expectations (i.e., that therapist will do all the work; pessimism regarding therapy); patient specific beliefs (i.e., belief that fears are realistic, or that social anxiety is part of their personality); patient motivation (i.e., premature termination, attribution that gains are due to medications); and patient social system (i.e., social system endorses dependency, social isolation). A minority of CBT therapists endorsed a weak therapeutic alliance or aspects of the CBT intervention itself as posing a barrier.

Practice Implications

CBT therapists identified a number of barriers, mainly patient related, that might impede the implementation of CBT for social phobia. Given these barriers the authors suggested that therapists: (1) consider more intense, longer, or more specific treatments for more severe cases; (2) incorporate assessment of patient severity to guide decisions; (3) consider tailoring the level of treatment directiveness based on patient characteristics – i.e., more resistant patients may require a less directive approach and more control over the type and pace of interventions; (4) prepare patients on what to expect in the treatment before therapy begins; (5) find a balance between validating/accepting patients' problematic beliefs that their fears might be realistic with encouragement to change; (6) add motivational interviewing for patients who are less motivated; (6) complete a thorough functional analysis of patients' social systems at the start of therapy. McAleavey and colleagues noted that while therapeutic alliance difficulties was an infrequently endorsed barrier by therapists, such difficulties remain clinically important, especially in light of findings that indicate that negative reactions to patients are under-reported by therapists. Developing and maintaining a good alliance remains a key aspect of CBT for social phobia.

View the Barriers to Conducting CBT for Social Phobia article.
Author email: aam239@psu.edu.

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blogAdding Psychotherapy to Medications for Depression and Anxiety

Cuijpers, P., Sijbrandij, E.M., Koole, S.L., Andersson, G., Beekman, A.T. & Reynolds, C.F. (2014). Adding psychotherapy to antidepressant medication in depression and anxiety disorders: A meta-analysis. World Psychiatry, 13(1), 56-67.

Anxiety and depressive disorders occur at a high rate and are very burdensome to those who suffer. These disorders are also related to high levels of health care costs, loss of productivity, and lower quality of life. Both pharmacological and psychotherapeutic interventions are effective, yet in recent years there has been a trend for patients to receive psychotropic interventions alone rather than psychotherapy. Cuijpers and colleagues (2014) conducted a meta analysis comparing pharmacotherapy alone versus pharmacotherapy combined with psychotherapy. Studies in the meta analysis included a variety of disorders such as depressive disorders and anxiety disorders. (Meta analysis is an important tool to review and combine the effects of interventions across a large number of studies. Rather than simply counting studies with positive, neutral, or negative findings, meta analysis allows one to calculate an effect size, average the effect sizes across different studies, and look at predictors or moderators of the effects. Aggregated effect sizes in a meta analysis are much more reliable [i.e., dependable] than any single study result). Cuijpers and colleagues' meta analysis included 52 studies with 3,623 patients. Most studies tested cognitive behavioral therapy, though a large minority also included interpersonal psychotherapy and psychodynamic therapy. Most studies used selective serotonin reuptake inhibitors (SSRI), though some included tricyclic antidepressants and others. There was a moderately large overall difference between pharmacotherapy versus combined pharmacotherapy plus psychotherapy for major depression, panic disorder, and obsessive compulsive disorder (OCD). That is, adding psychotherapy resulted in a clinically meaningful improvement above and beyond pharmacotherapy alone. There were no significant differences found for type of antidepressant medication or for type of psychotherapy. Eleven studies included a placebo control condition to which medication alone vs medication plus psychotherapy was compared. The effect of combining medication and psychotherapy was twice as large as the effect of medication alone when compared to a placebo control condition. Nineteen studies followed patients after treatment (from 3 to 24 months post treatment), and the superiority of combined treatment versus medication alone remained strong and significant well into follow up.

Practice Implications

There has been a trend over the past decade to provide medication as a first line of treatment for depression and anxiety disorders. However, the results of this meta analysis indicate that monotherapy with medication alone is not optimal treatment for most patients, and that psychotherapy results in additive clinically meaningful improvement for most patients. The additive effects of psychotherapy are especially pronounced for major depression, panic disorder, and OCD.

View the Adding Psychotherapy to Medications for Depression and Anxiety article.
Author email: p.cuijpers@psy.vu.nl

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