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A CRITICAL REVIEW OF PSYCHOTHERAPY EFFICACY RESEARCH
Amitkumar Chougule Junior Resident Psychiatry
A SEARCH FOR ELUSIVE WINNER:
A CRITICAL REVIEW OF PSYCHOTHERAPY EFFICACY RESEARCH
INTRODUCTION
PSYCHOTHERAPY
EFFICACY
PSYCHOTHERAPY EFFICACY RESEARCH
CRITICAL REVIEW
ELUSIVE WINNER
CONCLUSION
What is Psychotherapy ?
Strupp (1986) specified that psychotherapy is the systematic
use of a human relationship for therapeutic purposes of
alleviating emotional distress by effecting enduring changes in a
patient’s thinking, feelings, and behavior
Psychotherapy refers to all forms of treatment in which:
1. The primary therapeutic agent is a person
2. Who relies exclusively on verbal, psychoeducational, or
behavioral methods
3. To ameliorate a broad array of behavioral and psychological
problems
4. Which fall under the contemporary medical terms, “mental
illnesses” and “psychiatric disorders
Major types of Psychotherapy
1. Psychoanalytically informed
2. Cognitive behaviorally informed
3. Experientially informed
4. Strategic systematically informed
Important terms in research methodology
Efficacy:1. The efficacy of treatment is determined by a clinical trial or trials
2. Variables are carefully controlled
3. To demonstrate that the relationship between the treatment and
outcome are relatively unambiguous
4. Efficacy studies emphasize the internal validity of the experimental
design
5. Enhances the ability of the investigator to make causal inferences
based on the findings
Internal validity
The confidence with which a causal relationship can be assumed to
exist between a study’s :
independent variables (e.g., forms of therapy) and
dependent variables (e.g., outcomes or effects in a therapy study)
Effectiveness1. The effectiveness of a treatment is studied in natural clinical
settings2. Effectiveness studies emphasize the external validity of the
experimental design 3. Demonstrate that the treatment can be beneficial in a typical
clinical setting in which fewer experimental variables are controlled
External validity
The confidence with which findings can be assumed to
“generalize” or extend to situations, people, measures, times, and
so on other than those particular to the study
Effect size:
1. A statistic that often is used in therapy research
2. Indicates the magnitude of the difference in outcomes (or “effects”)
found in a research study between alternative treatments
Psychotherapy research:
Psychotherapy research is a relatively young field
Goal is to create a scientific foundation for the practice of
psychotherapy
Hans Eysenck ( 1952 ) expressed doubts about the overall
efficacy of psychotherapy
DICHOTOMIES AFFECTING PSYCHOTHERAPY RESEARCH
Dichotomies have affected research at all levels:
At the level of participants (client versus therapist)
Types of therapy (cognitive therapy versus interpersonal therapy)
Duration of therapy (brief versus long-term)
Effective components (specific techniques versus common factors)
Therapy results (process versus outcome)
Areas of psychological research methods (qualitative versus
quantitative)
Statistical outcomes (significant versus not significant)
NIMH Treatment of Depression Collaborative Research Program (TDCRP)
TDCRP was the first time that:
A collaborative, multisite outcome study of psychotherapies was
conducted using the randomized controlled clinical trial research
strategy
From the mid-1980s to the present an increasing number of
outcome studies include:
1. Psychotherapeutic interventions
2. Pharmacological interventions
3. Their combination
Boundaries between psychotherapy and psychopharmacology
research became blurred
How Psychotherapy Research Relates to Other Mental Health Research
Psychotherapy research is different from other types of clinical
mental health research such as psychopharmacology (medication)
research
Psychotherapy research relies on outcome studies to measure the
effect of intervention
Outcome studies
1. Outcome studies measures the client’s response to
psychotherapy
2. Measures clinical significance of a change for the individual
client rather statistical significance
Definition of clinical significance is :
3. The client move from the “dysfunctional” to the “functional”
range on the measure
4. The client’s change is greater than a chance fluctuation due to
the measurement error of the instrument
Outcome studies are designed primarily to:
1. Test hypotheses
2. Answer questions about the effects of psychotherapy
Outcome is used as a synonym for effects
Outcome studies can be designed to answer comparative
treatment questions
Careful researchers need to pick the type of outcome measure
that will best answer their research question
Use of RCT in Psychotherapy research
The efficacy studies of psychotherapy are carried out by using RCTs
Superiority of a specific therapy can only be addressed by “head to
head” randomized control trials (RCT)
Here variables likely to influence outcome are controlled like:
1. Therapist experience
2. Treatment length, etc.
Studies also ensure that treatments are carried out in conformity
with their theoretical description
EFFICACY IN PSYCHOTHERAPY RESEARCH: A CRITICAL REVIEW
Study of efficacy through clinical trials has many benefits for
psychotherapy research:
1. Methodology of clinical trials allows for improved internal validity
through minimizing attrition
2. Ability to determine the specific factors that contribute to therapy
outcome by controlling for confounding variables
Continued…
3. Trials increase internal validity by controlling the types of
patients included in the study
4. Prospective participants of a clinical trial are usually screened to
ensure that participants meet predefined criteria
5. Participants with additional disorders are excluded
Continued…
6. Efficacy studies use treatment manuals to standardize
treatment delivery between therapists
7. The standardization of treatment delivery between therapists is
ensured by:
a) Training therapists prior to the study
b) Monitoring therapist adherence to the treatment during the
study
c) Supervising therapists who deviate from the treatment protocol
Continued…
8. Efficacy studies help in managing the “dose” of treatment by
ensuring that each patient has:
a) Undergone the complete treatment
b) Received sufficient dose needed for positive response
9. Efficacy studies are able to identify the impact of therapy from a
fixed number of sessions across treatment groups
Limitations of efficacy research are usually associated with its strengths
1. Main limitations are associated with the degree to which results
can be generalized to routine practice
2. In routine clinical practice, clinicians must help patients even when
they have multiple disorders, are extremely disturbed, or are even
subclinical
3. Clinician cannot undergo extensive training, monitoring or
supervision during practice
4. Patients often receive multiple treatments (e.g., medication,
group therapy) simultaneously
5. The presence of an untreated control group would provide an
ideal benchmark for studying efficacy but it is not ethically
viable to withhold treatment
6. Most of efficacy studies compare psychosocial interventions
with medication or the addition of psychosocial interventions to
pharmacological treatment
7. RCTs are the gold standard in evidence-based medicine, but the
results of these trials are often hard to apply in the context of a
medical practice (Rothwell 2005)
Individuals participating in clinical trials not always resemble the
patients that a clinician sees in psychotherapy
In general “research therapy” appears more effective than clinical
practice (Weisz and Jensen 1999)
This may relate to methodological issues like:
1. Use of focused and structured manualized treatments
2. Careful attention to ensure therapist adherence to protocol
3. Participants recruited by advertisement rather than through
clinical services
Because of the rigorous design demands clinical trials are limited in
their ability to generalize to routine practice
Thus they must be followed by effectiveness research studies
Solution for efficacy vs. effectiveness dilemma
Debate between efficacy and effectiveness research has a negative
impact on psychotherapy research
Efficacy research is viewed as the gold standard for building and
promoting evidence-based practice which has its origins in
evidence-based medicine
The practice of evidence-based medicine means integrating
individual clinical expertise with the best available external clinical
evidence from systematic research (Sackett et al., 1996, p. 71)
Evidence Based Practice
The term evidence based practice provides the potential for a
complementary term using the concept of chiasmus
Chiasmus (ky-AZ-mus, n.) refers to a reversal in the order of words in
two otherwise parallel phrases
The reversal in order of words yields the term practice-based evidence
Practice-based evidence means integrating both individual clinical
expertise and service-level parameters with the best available evidence
drawn from rigorous research activity carried out in routine clinical
settings
Practice Based Evidence and Evidence Based Practice
The concept of practice-based evidence is crucial as:
1. It identifies an equally valued approach to evidence-based practice by
reversing the order of words to achieve a ‘bottom-up’ approach
originating with the practitioner in contrast to a ‘top-down’ approach in
which evidence derived from (RCT) are channeled down to practitioners in
routine practice settings
2. The two parallel but reverse approaches of evidence-based practice and
practice-based evidence yield a greater product by their interplay than
achieved by either approach alone
Is Psychotherapy effective?
Meta-analytical studies of psychotherapy have demonstrated
unequivocally that psychotherapy is effective
The study by Smith et al. (1980) demonstrated that 80% of those
patients treated in psychotherapy fared better on outcome
measures than those who received no treatment
Research has demonstrated that psychotherapy often does pay for
itself in terms of medical-cost offset, increased productivity, and
life satisfaction
(Chiles, Lambert, & Hatch, 2002; Yates, 1994)
The research literature indicates that psychotherapy is safe and
effective across a wide range of psychological, addictive, health, and
relational problems for a large number of :
Children and youths
(Kazdin & Weisz, 2003; Weisz, Hawley, & Doss, 2004)
Adults
(Barlow, 2004; Nathan & Gorman, 2002; Roth & Fonagy, 2004; Wampold et al., 1997)
Older adults
(Duffy, 1999; Zarit & Knight,1996)
Compared with alternative approaches such as medications
psychological treatments are particularly enduring
(Hollon, Stewart, & Strunk, 2006)
The best effect sizes have been reported for:
Cognitive therapy for panic disorder (Clark et al. 1994, 1999 )
Cognitive therapy for post-traumatic stress disorders
(Ehlers and Clark 2003 , Ehlers et al. 2005)
Cognitive therapy for social phobia (Clark et al. 2006 , Clark et al. 2003)
CBT for generalized anxiety disorder
(Dugas et al. 2003 , Ladouceur et al. 2000)
Exposure and response prevention for obsessive-compulsive disorder
(OCD) (McLean et al. 2001 , Whittal et al. 2005 )
Exposure for specific phobias (Ost et al. 2001 , Ost et al. 1997 )
COMPARISON OF DIFFERENT TYPES OF PSYCHOTHERAPIES
Leichsenrig and colleagues have compared psychodynamic
psychotherapy (14 studies) with CBT (11 studies) in the treatment
of personality disorders (Leichsenrig and Leibling 2003)
Analysis of the studies demonstrated a large overall effect size
(1.46) for dynamic therapy as compared to (1.00) for CBT
This meta-analysis indicated that long-term changes with dynamic
treatment were achieved
BORDERLINE PERSONALITY DISORDER
RCTs show that personality disorders are less amenable to CBT
DBT an outgrowth of CBT is tailored for borderline personality
disorder( BPD)
Highly effective in treating suicidality and self-harm behaviors in
borderline women but not in treating depression
(Linehan et al. 1991, Linehan et al. 2006)
Psychodynamic treatment had similar effect sizes but also showed
improvement for depression and anxiety
(Bateman and Fonagy 1999, 2001)
Head-to-head comparisons showed equivocal results
Long-term vs. short term Psychotherapy
Most psychoanalysts would consider that the efficacy of short-term
once-a-week psychotherapy are not comparable to long-term
psychodynamic psychotherapy
The Boston Psychotherapy Study (Stanton et al. 1984):
1. RCT for patients with schizophrenia
2. Comparison between long-term psychoanalytic therapy
(2 or >/ week) with supportive therapy for patients (1/week)
3. No difference was found
Continued..
The Stockholm Outcome of Psychotherapy and Psychoanalysis
Project (Blomberg et al. 2001, Grant and Sandell 2004, Sandell et al. 2000) :
1. Followed 756 individuals who received National Insurance-
funded treatment for up to three years in psychoanalysis or
psychoanalytic psychotherapy
2. The groups were matched on many clinical variables
3. Analysis 4/5 sessions per week had similar outcomes when
compared with 1/2 sessions per week
A Search for elusive winner
image
Luborsky et al. (1993) have demonstrated that psychoanalytic
psychotherapy is as effective as cognitive, behavioral, experiential,
and group therapies and hypnotherapy
An ambitious comparison of following therapies for BPD showed
no difference: (Clarkin et al. 2007)
1. Transference focused psychotherapy(TFP)
2. Dialectical Behavior Therapy (DBT)
3. Supportive psychotherapy
Many large-scale careful studies, such as the Helsinki study found
no difference between therapies
(Knekt and Lindofrds 2004)
Majority of studies in which a behavioral therapy was compared
directly to a non-behavioral therapy (e.g., psychodynamic
psychotherapy) failed to detect statistically significant outcome
differences
Research has failed to show that any one method is more potent than the others
(with notable exceptions e.g., the superiority of CBT over IPT for
the treatment of OCD and other anxiety disorders)
Looking for components which can prove psychotherapy to be the ultimate winner
Consistent application of one method appears to be important for good
outcome
The non specific elements among psychotherapies are the effective
ingredients rather than their specific differences
One nonspecific component of all therapies that has been investigated is
the quality of the therapist/patient relationship
Studies revealed that a good therapist/patient relationship is a crucial
factor in the treatment’s outcome
(Lambert 2004, Luborsky et al. 1988)
Therapist Factors in Therapy Outcome
In Kim et al.’s (2006) analysis of the NIMH’s Treatment of
Depression Collaborative Research Project (NIMH TDCRP) dataset
5–10% of the variance in outcomes was shown to be associated
with therapist
Very large studies with datasets of over 5,000 patients,
consistently report large effects associated with therapists (Okiishi
et al. 2006)
Continued…
Therapist factors have been shown to be associated with the rate
of improvement
The therapist’s age, gender, and ethnicity appear to have little or
no impact on results
Findings suggest that the therapist’s experience does not help to
predict outcome
The important research challenges that must be addressed to become winner psychotherapy
Currently the therapist is left with few data supporting the superiority
of one type of psychotherapy over another for a given condition or
disorder
The important research challenges that need to be addressed are:
1. Determining efficacy for specific disorders
2. Developing treatment guidelines for interpersonal problems and
personality disorders
3. Developing reliable and valid self-report measures for core conflicts
Continued….
4. Measuring potential cost effectiveness of different therapies
5. Matching patients to treatment on the basis of personality,
functional level, or developmental stage
6. Examining whether and how experienced therapists can be
trained in short-term psychoanalytic treatments
7. Learning the limits of brief therapy and conditions or symptoms
for which longer term psychotherapy should be recommended
CONCLUSIONS
1. Psychotherapy is effective in treating a wide variety of clinical
conditions
2. The affinity between patient and therapist is a key factor in
effective therapy
3. Level of functioning and the ability to form a therapeutic alliance
are better predictors of outcome
4. Evidence suggests that common factors and not specific
techniques are crucial in therapy
Continued..
5. Long term therapy has no significant advantage over
short-term therapy
6. Finally research has failed to show that any one
psychotherapy method is more potent than the
others
Research into psychotherapy will require further investigation to
understand:
a) The mechanisms
b) Matching specific techniques with specific types or severity
levels of problems
c) The effect of dose and frequency of the therapy
It is the therapist who is winner and not the therapy
In our struggle to prove a winner psychotherapy one should make sure that our patient should not be the loser.....