Practice-Based Psychotherapy Research
To Improve The Wellbeing Of Our Community
PPRNet Blog: October 2013
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
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, you can read the Handbook table of content and sections of the book on Google Books: Handbook on Google Books.
Client Severity, Comorbidity, and Motivation to Change
Bohart, A.C. & Wade, A.G. (2013). The client in psychotherapy. In M. Lambert (Ed.) Bergin and Garfield's handbook of psychotherapy and behavior change (6th ed.), pp. 219-257. Hoboken, NJ: Wiley.
Last month I blogged about the section in Bohart and Wade’s (2013) chapter that focused on client attachment. This month I focus on other factors like severity of distress and comorbidity, and level of motivation. Some authors argue that client factors predict 30% of variance in outcomes. That accounts for more of psychotherapy outcome than therapist effects and therapeutic techniques combined. Severity of symptoms of anxiety and depression and functional impairment caused by this distress leads to poorer client prognosis. Further, individuals with more severe symptoms need more sessions to show improvement. Some research shows that those with greater symptoms change more than those with fewer symptoms. However, even though those with higher levels of distress show the most change, they are less likely to achieve recovery in which they return to a normal level of functioning. In most cases, clients with comorbid problems are less likely to do well. For example, comorbidity for personality disorder or substance abuse negatively impact outcome. Client motivation is also related to psychotherapy outcomes. Motivation can be internal (those that arise from the individual’s intrinsic interests or values) or external (those that arise from external rewards or punishments). Generally, internal motives (i.e., greater readiness to change) are better predictors of sustained behaviour change. The stages of change model describes readiness to change as occurring in progressive stages that include: (1) precontemplation, in which clients are not internally motivated; (2) contemplation in which clients move to the next stage where they recognize a problem but are not ready to take action; and (3) preparation for action in which clients are more internally motivated to change. The next two stages of the model do not speak to motivation but to action and maintenance of change. Norcross looked at clients’ readiness to change prior to therapy and its relationship to outcome. Greater readiness to change was moderately and significantly associated with better treatment outcomes.
The results on severity and comorbidity suggest that providers and policy makers must consider increasing the number of treatment sessions to take into account clients who have greater initial severity and comorbidities, especially for those with comorbid personality disorders. Results related to motivation indicate that when client motivation to work in therapy comes from within and they show progress in their readiness to change, they are more likely to do well. Therapists need to find ways of mobilizing clients’ internal reasons for change. Motivational interviewing may be one means of doing so.
Larsson, B. P., Broberg, A. G., & Kaldo, V. (2013). Do psychotherapists with different theoretical orientations stereotype or prejudge each other? Journal of Contemporary Psychotherapy, 1-10.
A remarkable difference between the field of psychotherapy and other health care or scientific areas is that psychotherapy is organized in different and somewhat competing theoretical orientations or schools. Leading thinkers of psychotherapy integration, have emphasized how this division presents an obstacle to integration and therefore to progress within the practice and science of psychotherapy. One of these obstacles could be persistent stereotypes that psychotherapists might have about other therapists who practice from a different theoretical orientation. Social psychologists have long known that people in one group (e.g., an in-group) may misjudge or stereotype people in other groups (e.g., out-groups). Stereotypes may be negative if members of an in-group hold a positive bias toward their in-group coupled with antagonism toward members of an out-group. Do psychotherapists stereotype other therapists who practice from a different theoretical orientation? A recent study by Larsson and colleagues addressed this question. They surveyed 416 therapists divided into four ‘pure’ self-reported schools: 161 psychodynamic therapists, 93 cognitive therapists, 95 behavioural therapists, and 67 integrative/eclectic therapists. Most were women (76%), mean age was in the mid 50s, mean experience was 5 to 10 years, and they represented a variety of disciplines including psychology, psychiatry, social work, and nursing. In the first section of the survey, therapists indicated what focus they deemed most important to their own psychotherapeutic work, including: (1) therapeutic relationship, (2) patient's thoughts, (3) patient's feelings, (4) patient's behaviour, or (5) connection between the patient's thoughts, feelings, and behaviors. Therapists then estimated how they thought psychotherapists from other orientations would rate each of these foci. In the second section of the survey, therapists completed scales about what they deemed were important aspects of psychodynamic, cognitive, behavioral, and eclectic/integrative therapy, respectively. Once again, they rated how they thought therapists from the other orientations would respond. Self-ratings of therapists within each orientation indicated the ‘true’ (i.e., prototypical) opinions of each orientation. The differences between ‘true’ opinions of the in-group versus the in-group's ratings of therapists from other orientations (i.e. of the out-group) indicated the level of misjudgement or stereotyping. Of the 18 areas on which out-groups were rated, 11 were significantly misjudged by the in-group. Eclectic/integrative therapists were much less likely to stereotype therapists of cognitive or psychodynamic orientations, who were equally likely to stereotype others. The belief that one's own orientation compared to others is better characterized as an applied science (a belief endorsed most often by cognitive therapists) was a statistically stronger predictor of stereotyping than orientation per se.
Some researchers argue that different orientations are more similar in their practice of psychotherapy than theory would predict. Furthermore, research about common factors in psychotherapy suggests that these factors may be more important than techniques specific to a school of psychotherapy. However, as long as there are different therapeutic orientations there will likely remain a tendency among some psychotherapists to search for differences rather than to look for similarities between their own and other orientations. This may lead to stereotyping (i.e., an inaccurate opinion about therapists of other orientations), and perhaps negative stereotyping. Psychotherapists and researchers may want to keep in mind the tendency to stereotype clinicians from other orientations when talking to or about other psychotherapists. Such stereotyping is likely an impediment to good client care and research.
McHugh, K.R., Whitton, S.W., Peckham, A.D., Welge, J.A., & Otto, M.W. (2013). Patient preference for psychological vs pharmacological treatment of psychiatric disorders: A meta-analytic review. Journal of Clinical Psychiatry, 74, 595-602.
For the most part psychotherapy and pharmacological interventions have equivalent positive effects on depression in the short term, and psychotherapy has better outcomes in the long term (see my May, 2013 blog). There is also evidence that the effects of medications for depression are overestimated (also in the May 2013 blog). Despite all of this evidence, psychotherapy use has remained the same or declined slightly over the past 10 years (currently at about 3.4% of the population), whereas medication use for depression has doubled to over 10% of the population. At the same time, guidelines for evidenced based practice emphasize incorporating patient preferences when there is an absence of evidence-based decision rules for treatment selection. Providing patients with their preferred treatment is associated with better treatment uptake and outcomes (see June 2013 blog). McHugh and colleagues conducted a meta analysis to review the literature on patient preferences for psychological versus pharmacological interventions for mental health disorders among adults. They included studies with treatment and non-treatment seeking samples of patients with a variety of disorders. (A quick note about meta-analysis. Meta analysis is a way of statistically combining the effect sizes from a number of studies into a common metric so that an average effect size can be calculated. Meta analysis is now the standard by which studies are reviewed. Meta analysis results are much more reliable than any single study and so represent the best way to inform clinical practice from research findings). McHugh and colleagues identified 34 studies representing over 90,000 participants. Most studies were of depressive disorders and anxiety disorders. When given a preference, 75% of participants preferred psychotherapy over medication to treat their mental health problem. In treatment seeking samples, the percentage was lower at 69%, but still significantly in favour of psychotherapy. Younger people and women were more likely to prefer psychotherapy, though the findings still showed a preference for psychotherapy among older people and men. The availability of combining psychotherapy and medication did not affect the results, so that even when given the option of both psychotherapy and medication people still preferred psychotherapy alone.
In all subsamples, participants were 3 times more likely to prefer psychotherapy to medication for their mental disorder. Patient preference for treatment is a core component of evidence based mental health practice that improves outcome and reduces drop outs. Without evidence for superiority for one treatment over another, patients should be given their preference, and on average patients overwhelmingly prefer psychotherapy. To optimize outcomes in clinical settings, providers should consider patient preferences, including their preference for psychotherapy over medication.
Kvaale, E. P., Haslam, N., & Gottdiener, W. H. (2013). The ‘side effects’ of medicalization: A meta-analytic review of how biogenetic explanations affect stigma. Clinical Psychology Review, 33, 782-794.
Psychotherapists may wonder how best to explain a psychological problem to their clients and their family members. Will their explanation help to reduce stigma and increase hope? Laypeople, clinicians, and researchers increasingly understand psychological problems in biomedical terms. Further, some anti-stigma campaigns describe mental health problems, including depression, as biological, medical illnesses. Reducing stigma is important to improve uptake of therapy, reduce an internalized sense of defectiveness, and increase hope and self esteem. Some argue that understanding psychological problems as biologically based will combat stigma by reducing blame and punitive treatment. Kvaale and colleagues asked whether there is a cost to medicalization of psychological problems by unwittingly promoting the stereotype that those with a mental illness have a deep seated, fixed, and defining essence. Proponents of medicalization hope that such an approach will reduce blame for a mental illness, and will result in less desire for social distance from the mentally ill. However, medicalization might also result in: an increased belief that those with psychological problems are dangerous; and greater pessimism and hopelessness about the prognosis (i.e., a belief that the problem can not be improved). A meta-analysis by Kvaale and colleagues looked at experimental studies of student and community based samples in which explanations for a psychological problem was manipulated to include biomedical explanations versus psychological explanations or no explanations. The meta-analysis aimed to examine the causal effects of biogenetic explanations for psychological problems on: blame, perceived dangerousness, social distance, and prognostic pessimism. Regarding blame, the authors reviewed 14 studies that included 2326 participants and found that biogenetic explanations were associated with a decreased tendency to blame individuals with psychological problems. Regarding perceived dangerousness, the authors reviewed 10 studies with 1207 participants, and found that biogenetic explanations were associated with an increase in perceiving those with psychological problems as dangerous. However this result is tentative because publication bias may have resulted in an over estimation of the association (see my May 2013 blog on publication bias [“Are the Effects of Psychotherapy for Depression Overestimated?”]). Regarding social distance, the authors reviewed 16 studies with 2692 participants, but found no relationship between biogenetic explanations and reduced social distance. Regarding prognostic pessimism, the authors reviewed 16 studies with 3469 participants, and found that biogenetic explanations were associated with greater pessimism about the prognosis of a psychological problem.
The meta analysis by Kvaale and colleagues found that biomedical explanations for psychological problems typically decrease blame, but increase prognostic pessimism and perceptions of dangerousness, although the latter conclusion is somewhat tentative. The findings lead one to be skeptical of the view that stigma will be reduced by promoting an understanding of psychological problems as biogenetic diseases. Kvaale and colleagues suggest that the affected individual, family members and mental health professionals could be more pessimistic about change because of a biomedical explanation, thus impeding the patient’s recovery process. Psychotherapists should share information about the biogenetic factors of psychological problems. However, this must be done with caution. Kvaale and colleagues conclude that explanations that invoke biomedical factors may reduce blame but also may have unintended side-effects. Biogenetic explanations should not be promoted at the expense of psychosocial explanations, which may have more optimistic implications.