Practice-Based Psychotherapy Research
To Improve The Wellbeing Of Our Community
PPRNet Blog: March 2015
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
Boswell, J.F., Kraus, D.R., Miller, S.D., & Lambert, M.J. (2015). Implementing routine outcome monitoring in clinical practice: Benefits, challenges, and solutions. Psychotherapy Research, 25, 6-19.
Routine outcome monitoring (ROM) refers to: (1) systematically assessing patient outcomes at every session, (2) comparing patient scores and progress to a database of similar patients, (3) using algorithms or decision tools to identify patients who are not improving or deteriorating, (4) providing regular and immediate feedback to therapists about the patient, and (5) in some cases providing clinical decision aids to help therapists improve outcomes for patients who are not improving or who are deteriorating. Boswell and colleagues review the research related to ROM. Generally, about 30% to 50% of patients do not respond to treatment, and 8% of patients tend to get worse during treatment. Therapists tend to overestimate their patients’ improvement, and so therapists may not always identify patients who do not respond or get worse. Therapists may need assessment aids to help them make decisions about patient progress and treatment. Boswell and colleagues point out that ROM have a proven ability to predict treatment failure and other negative outcomes. In a meta analysis of over 6,000 patients, the average patient at risk of a negative outcome whose therapist received ROM feedback prior to every session was better off than 70% of at-risk patients whose therapist received no feedback. When therapists are provided feedback and suggestions for interventions, their patients had almost four times higher odds of achieving clinically significant improvement. Boswell and colleagues list a number of barriers that psychotherapists and agencies experience to implementing ROM in their practices. Many therapists are not aware of or have no experience with ROM, and so they may not be aware of its benefits to their practice and patients. Time and money are two practical issues that may arise. This type of assessment is not always reimbursed and the average clinician may feel that they do not have enough time to reflect on routine assessment and feedback so as to reconsider their interventions. Agencies may not understand the value of allocating resources to this type of testing (although medically oriented agencies would not hesitate to order a blood test or an x-ray). Finally, some therapists might experience ROM as intrusive, as impeding the therapeutic relationship, and as a means for an agency to control therapist decisions.
Routine outcome monitoring (ROM) has clear benefits to patients, therapists, and agencies. To overcome barriers, therapists and agencies could implement ROM as part of routine clinical care, and advertise this as an evidence-based practice that will benefit prospective patients. Clients generally appreciate knowing that they will receive the best possible care. ROM can enhance the therapeutic relationship if it is presented to clients as a collaborative endeavor. For example, if a patient is not improving or is deteriorating, therapists can discuss this with patients as well as a plan to alter aspects of the treatment in order to improve the prospects for a better outcome. Therapists can choose from a number of possible ROM options to best tailor the approach to their clients based on cost, time, and relevance. Currently, there are several outcome monitoring systems available to clinicians including: the Partners for Change Outcome Management System (PCOMS), the Treatment Outcome Package (TOPS), the Clinical Outcomes in Routine Evaluation (CORE), and the Outcome Questionnaire (OQ) system.
View the Implementing Routine Outcome Monitoring in Clinical Practice abstract.
Author email: email@example.com
Vos, J., Craig, M., & Cooper, M. (2015). Existential therapies: A meta-analysis of their effects on psychological outcomes. Journal of Consulting and Clinical Psychology, 83, 115-128.
Existential therapies are a group of psychological interventions that address questions about existence, and they assume that by overcoming existential distress, psychological problems may be decreased. Underlying existential therapy is the assumption that: people need a meaning or purpose, individuals have a capacity to choose and actualize this potential, people will do better when they face challenges rather than avoid them, and human experiencing is related to others’ experiences. Vos and colleagues list four main schools of existential therapies: Daseinanalysis which focuses on free expression and greater openness to the world; logo-therapies which are aimed at helping clients establish meaning in their lives through didactics, British existential therapy which encourages clients to explore their experiences, and the existential-humanistic approach which help clients face mortality, freedom, isolation, and meaninglessness. Vos and colleagues review the research literature showing that meaning in life and positive well-being are associated with coping with stressful life events including life threatening illnesses. In this meta-analysis, the authors review the randomized controlled trials of different types of existential therapies to assess the efficacy of the treatments compared to a control condition like social support groups, being on a waiting list, or receiving care as usual. They grouped outcomes into four areas: meaning in life, psychopathology, self-efficacy, and physical well-being. Their meta-analysis included 15 studies of 1,792 participants, 13 of the studies were with medically ill patients, and 10 of those studies were aimed at patients with cancer. Effects of existential therapy versus a control on meaning in life tended to be positive and moderate. Effects on psychopathology and self-efficacy were positive and small. The effects of existential therapies versus a control condition on physical well-being were not significant. There were no differences between the types of existential therapy, though the number of studies was small to adequately assess these differences.
Clients seem to benefit from group therapy interventions focused on meaning compared to social support groups, being on a waiting list, or receiving care as usual. Medically ill patients who received existential therapy found greater meaning in their lives, and the effects were moderate to large. Their psychopathology and self-efficacy also improved significantly but effects were small. The quality and number of studies was not optimal which limits the confidence one can have in these findings. The authors conclude that despite the small number of studies, existential therapies that use structured interventions that incorporate psycho-education and discussions on meaning in life are a promising treatment for physically ill patients.
View the The Efficacy of Existential Therapies for Physically Ill Patients abstract.
Author email: firstname.lastname@example.org
Lemmens, L.H.J.M., Arntz, A., Peeters, F., Hollon, S.D., Roefs, A., & Huibers, M.J.H. (2015). Clinical effectiveness of cognitive therapy v. interpersonal psychotherapy for depression: Results of a randomized controlled trial. Psychological Medicine, doi:10.1017/S0033291715000033
Generally, I prefer to report on meta analyses rather than individual studies mainly because findings from meta analyses are based on a larger number of studies and so are more reliable (see my November, 2013 blog). However, this study by Lemmens and colleagues represents a large clinical trial of 182 depressed patients who were randomized to cognitive therapy (CT), interpersonal psychotherapy (IPT), or a no-treatment control condition. The size of the trial provided the study with enough statistical power to test a hypothesis of non-inferiority of treatments. (A statistical note: A study finding of “non-inferiority” between treatments is sometimes unreliable because it is easier to detect such a finding with a small or poorly designed study. Studies with larger sample sizes provide greater statistical power, which in part makes a non-inferiority finding more reliable). A previous meta analysis showed both CT and IPT to be equally effective interventions for major depression. However, none of the studies in that meta analysis had sufficiently large sample sizes to reliably detect non-inferiority of interventions, none reported outcomes after post-treatment, and none of the studies used a no-treatment comparison condition. In their study, Lemmens and colleagues provided 16 to 20 sessions of individual therapy (45 minutes in length) to participants who met criteria for major depressive disorder. CT (archived) was based on Beck’s model and focused on identifying and altering cognitions, schemas, and attitudes associated with negative affect. IPT seeks to understand the social and interpersonal context of a patient’s depressive symptoms, and helps the patient to solve the interpersonal problem or change their relation to the problem, which may result in a resolution of the depressive symptoms. The study by Lemmens and colleagues was well designed in which: patients were randomized to conditions (CT, IPT, wait-list), 10 licensed therapists were expertly trained (5 CT therapists, 5 IPT therapists), and the therapies were competently delivered. Depressive symptoms significantly decreased for patients in both CT and IPT conditions with large effects, and these findings remained stable to 5 months post treatment. There were no differences between CT and IPT at post treatments and follow up, and both treatments were more effective than the waitlist control condition. Half of the sample had clinical improvements in symptoms, and 37% of patients were without depressive symptoms at 1 year follow up.
CT and IPT did not differ in the treatment of depression in the short (post-treatment) and long term (follow up). The study does not address why two very different treatments led to similar positive outcomes. The authors suggest two possible reasons: (1) different specific treatment pathways led to similar results, or (2) change was driven by factors common to both treatments like motivation and therapeutic alliance.