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.....