Psychotherapy for the treatment of depression: A comprehensive review of controlled outcome research.

Previous quantitative reviews of research on the efficacy of psychotherapy for depression have included only a subset of the available research or limited their focus to a single outcome measure. The present review offers a more comprehensive quantitative integration of this literature. Using studies that compared psychotherapy with either no treatment or another form of treatment, this article assesses (1) the overall effectiveness of psychotherapy for depressed clients, (2) its effectiveness relative to pharmacotherapy, and (3) the clinical significance of treatment outcomes. Findings from the review confirm that depressed clients benefit substantially from psychotherapy, and these gains appear comparable to those observed with pharmacotherapy. Initial analysis suggested some differences in the efficacy of various types of treatment; however, once the influence of investigator allegiance was removed, there remained no evidence for the relative superiority of any 1 approach. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Third-party payment and the outcome of psychotherapy.

Theorists have long debated whether the efficacy of psychotherapy is enhanced when clients are required to pay for their treatment. The aim of the present experiment was to assess this issue in a naturally occurring clinical setting. Clients in the study were individuals who had sought psychotherapy from a low-cost treatment center. One group of clients paid the fees normally charged by the treatment center, whereas another randomly selected group did not pay because a grant was used to cover the cost of their therapy. Results failed to reveal any reliable difference in the outcomes of clients who had paid for treatment and those whose treatment had been subsidized. These findings suggest that the effectiveness of psychotherapy is not impaired when someone other than the client pays for the therapy. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The outcome of psychotherapy with children.

Examined 75 studies, published between 1952 and 1983, in which children who received psychotherapy were compared with controls or children receiving another form of treatment. Only those studies using Ss younger than a mean age of 13 yrs at the time of treatment were included. Exceptions to the age limitation were made only if separate analyses for younger children were reported or if individual data from older Ss could be eliminated. Results show that therapy with children was similar in effectiveness to therapy with adults; treated children achieved outcomes about two-thirds of a standard deviation better than untreated children. Although behavioral treatments appeared to be more effective than nonbehavioral treatments, this apparent superiority was due largely to the types of outcome and target problems included in behavioral studies. No differences in outcome were found to result from other treatment characteristics such as the use of play in therapy or the administration of treatment individually or in groups. The evidence suggests that previous doubts about the overall efficacy of psychotherapy with children can be laid to rest. A bibliography of the studies examined is appended. (17 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A comparison of trauma-focused and present-focused group therapy for survivors of childhood sexual abuse: A randomized controlled trial.

This randomized controlled trial compared trauma-focused group psychotherapy (TFGT) with present-focused group psychotherapy (PFGT) and a waitlist condition for 166 survivors of childhood sexual abuse who were at risk for HIV infection. Primary outcomes included risk for HIV infection (based on sexual revictimization, drug and alcohol use, and risky sex) and posttraumatic stress disorder (PTSD) symptoms. It was hypothesized that TFGT would be superior to the PFGT and waitlist conditions and that receiving either treatment (combining both TFGT and PFGT) would be superior to no treatment (waitlist condition). Intention-to-treat analyses for HIV risk found that all conditions reduced risk; however, there was no effect for condition on HIV risk. Intention-to-treat analyses for PTSD symptoms found a reduction for all conditions. There was no advantage for either TFGT or PFGT in reducing PTSD symptoms; however, there was an effect for treatment compared with the waitlist condition. On secondary outcomes, there was a greater reduction in anger for TFGT compared with PFGT, and when comparing treatment with the waitlist condition, there was a greater reduction in hyperarousal, reexperiencing, anger, and impaired self-reference for the treatment condition. Adequate dose analyses generally confirmed the intention-to-treat findings and additionally found that treatment led to reductions in depression, dissociation, and sexual concerns. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Empirical search for psychotherapists' gender competence in psychotherapy.

Over the past half century, psychotherapy research has demonstrated that psychotherapy outcomes do not vary based on clients’ gender (Clarkin & Levy, 2004; Garfield, 1994; Wierzbicki & Pekarik, 1993). However, most studies assumed that all psychotherapists are equally competent to treat men and women, thus potentially missing essential information about variations in psychotherapy outcomes. In fact, there is a paucity of studies that have examined if psychotherapists’ gender competence truly exists. We propose that psychotherapists’ gender competence should be defined as the psychotherapist’s ability to achieve positive psychotherapy outcomes with either female or male clients. This study examined the relationship between clients’ gender and psychotherapy outcomes and if psychotherapists varied in their abilities to produce positive psychotherapy outcomes for female and male clients. The sample included 93 male and 229 female clients treated by 31 psychotherapists. Consistent with previous research, the results demonstrated that clients’ gender was not related to psychotherapy outcomes. However, compared to other psychotherapists, some psychotherapists were better at treating men, whereas others were better at treating women. The results of this study demonstrate that psychotherapists’ gender competence exists and relates directly to the psychotherapy outcomes (i.e., psychological well-being) of clients. Implications for psychotherapy practice, training, and research are offered. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Mindfulness meditation and substance use in an incarcerated population.

Despite the availability of various substance abuse treatments, alcohol and drug misuse and related negative consequences remain prevalent. Vipassana meditation (VM), a Buddhist mindfulness-based practice, provides an alternative for individuals who do not wish to attend or have not succeeded with traditional addiction treatments. In this study, the authors evaluated the effectiveness of a VM course on substance use and psychosocial outcomes in an incarcerated population. Results indicate that after release from jail, participants in the VM course, as compared with those in a treatment-as-usual control condition, showed significant reductions in alcohol, marijuana, and crack cocaine use. VM participants showed decreases in alcohol-related problems and psychiatric symptoms as well as increases in positive psychosocial outcomes. The utility of mindfulness-based treatments for substance use is discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Comparative efficacy of individual and group psychotherapy: A meta-analytic perspective.

Recent reviews of the group psychotherapy literature indicate that group is a beneficial and cost-effective treatment format. However, collective findings on the differential efficacy of group when compared with individual therapy remain problematic, incomplete, or controversial. To remedy this problem, the authors conducted a meta-analysis of 23 outcome studies that directly compared the effectiveness of the individual and group therapy formats when they were used within the same study. Results were consistent with previous reports that indicated no difference in outcome between the group and individual formats. This finding generally held true when client, therapist, methodology, treatment, and group variables were examined for possible relationship with effect sizes comparing group and individual therapy. Results bolster past findings that group therapy can be used as an efficacious cost-effective alternative to individual therapy under many different conditions. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Therapeutic Bonding in Group as an Explanatory Variable of Progress in the Social Competence of Students With Learning Disabilities.

This study, conducted in Israel, explores the efficacy of an expressive-supportive group psychotherapy in helping adolescents with learning disabilities (LD) and attention deficits (ADD and ADHD) to increase social competence and friendship. Bonding with the therapist and group members was tested as an explanatory variable of outcomes. The study included 87 students with LD from seven different schools who had been referred to school counseling centers because of social, emotional, and behavior difficulties. The students in each school were randomly divided into experimental and wait-list conditions. Children in the experimental conditions (n = 42) participated in seven small groups, in 15 weekly sessions of group therapy conducted by trained school counselors. Results indicated gains on the social competence measure, but not on the friendship-intimacy measure. Therapist-related bonding was more frequently related to outcomes than member-related bonding. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Sudden gains in the treatment of depression in a partial hospitalization program.

Objective: This study examines sudden gains (SGs), or rapid improvements in symptoms, among adults in treatment for depression in a partial hospitalization program (PHP). This study identifies the proportion of people who experience SGs in a PHP, when SGs occur in treatment, and the association of SGs with outcomes at the end of treatment. Method: The sample included 664 adults consecutively admitted to a PHP program for treatment of depression. Patients were administered the 24-item Behavior and Symptom Identification Scale and the short form of the Quality of Life Enjoyment and Satisfaction Questionnaire. We conducted t tests, multiple regressions, and generalized estimating equations (GEE). Results: Over 40% of the sample experienced SGs, and most of those who experienced SGs did so by the 2nd week of treatment. SGs were associated with significantly greater improvement in depression and quality of life scores at the end of treatment. Results of the GEE indicate that although depression scores significantly decreased for the entire sample, the SG group improved to a greater degree than the group without SGs. Conclusions: The proportion of SGs among people in a PHP is similar to proportions found in traditional outpatient psychotherapy, suggesting that a subset of people receiving psychotherapy may be predisposed to SGs. The timing of SGs in a PHP suggests that SGs are associated with the dose of treatment received. Future research should focus on identifying people predisposed to SGs, as well as the mechanisms by which SGs occur. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Bias in meta-analytic estimates of the absolute efficacy of psychotherapy.

Meta-analytic estimates of the absolute efficacy of psychotherapy indicate an effect size of approximately 0.80. However, various biases in primary and meta-analytic studies may have influenced this estimate. This study examines 4 nonsystematic biases that increase error variance (i.e., nonrandomized designs, methodological deficiencies, failure to use the study as the unit of analysis, and violations of homogeneity), 4 underestimation biases that primarily concern psychometric issues (i.e., unreliability of outcome measures, failure to report nonsignificant effect sizes, nonoptimal composite outcome measures, and nonstandardized outcome measures), and 8 overestimation biases (i.e., excluding nonsignificant effects from calculations of effect size estimates, failure to adjust for small sample bias, failure to separate studies using single-group pre-post designs vs. control group designs, using unweighted average effect sizes, analyzing biased partial samples that reflect treatment dropout and research attrition, researcher allegiance bias, publication bias, and wait-list control group bias). Wherever possible, evidence regarding the magnitude of these biases is presented, and methods for addressing these biases separately and collectively are discussed. Implications of the meta-analytic evidence on psychotherapy for the effect sizes of other psychological interventions are also considered. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Effects of video-based therapy preparation targeting experiential acceptance or the therapeutic alliance.

Preparation for psychotherapy may enhance the psychotherapeutic process, reduce drop-outs, and improve outcomes, but the effective mechanisms of such preparation are poorly understood. Previous studies have rarely targeted specific processes that are associated with positive therapy outcomes. This randomized experiment compared the effects of preparatory videos that targeted either the Therapeutic Alliance, Experiential Acceptance, or a Control video on early therapeutic process variables in 105 patients seen in individual therapy. Participants watched the videos just before their first therapy session. No significant differences were found between the Alliance and Experiential Acceptance videos on patient recommendations, immediate affective reactions, or working alliance and attrition after the first session. However, the Therapeutic Alliance video produced an immediate increase in negative mood relative to the Control video, whereas the Experiential acceptance video produced a slight increase in positive mood relative to the Alliance video. Surprisingly, patients who viewed the Alliance video were rated significantly lower than the control group on therapist-rated alliance after the first session. These findings suggest there may be specific process effects in the early phase of treatment based on the type of pretraining material used, and also indicate that video-based pretraining efforts could be counterproductive. Furthermore, this research contributes to the literature by providing insights into methodological considerations for future work on the use of technology in psychotherapy and challenges associated with preparing people for successful psychotherapy. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

The effectiveness of psychotherapy: The Consumer Reports study.

Consumer Reports (1995, November) published an article which concluded that patients benefitted very substantially from psychotherapy, that long-term treatment did considerably better than short-term treatment, and that psychotherapy alone did not differ in effectiveness from medication plus psychotherapy. Furthermore, no specific modality of psychotherapy did better than any other for any disorder; psychologists, psychiatrists, and social workers did not differ in their effectiveness as treaters; and all did better than marriage counselors and long-term family doctoring. Patients whose length of therapy or choice of therapist was limited by insurance or managed care did worse. The methodological virtues and drawbacks of this large-scale survey are examined and contrasted with the more traditional efficacy study, in which patients are randomized into a manualized, fixed duration treatment or into control groups. I conclude that the Consumer Reports survey complements the efficacy method, and that the best features of these two methods can be combined into a more ideal method that will best provide empirical validation of psychotherapy. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Assessment considerations in the identification of failing psychotherapy: Bringing the negatives out of the darkroom.

Although failures in psychotherapy are widely acknowledged, minimal attention has been given to their assessment. However, early detection of failing psychotherapy is essential if harmful and cost-ineffective outcomes are to be avoided. Prior approaches to the study of psychotherapy failure are considered and a conceptual framework for detecting failing treatment is presented. The identification of failing psychotherapy requires the use of assessment practices that are theory-based, ongoing, have treatment utility, and are sensitive to intermediate outcomes and individual change. It is recommended that specific strategies for the detection of failing treatment, and an integration of assessment and treatment practices more generally, can be advanced through the development of an assessment infrastructure that is sensitive to both clinical and research needs. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Brief Treatments for Cannabis Dependence: Findings From a Randomized Multisite Trial.

This study evaluated the efficacy of 2 brief interventions for cannabis-dependent adults. A multisite randomized controlled trial compared cannabis use outcomes across 3 study conditions: (a) 2 sessions of motivational enhancement therapy (MET); (b) 9 sessions of multicomponent therapy that included MET, cognitive-behavioral therapy, and case management; and (c) a delayed treatment control (DTC) condition. Participants were 450 adult marijuana smokers with a Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) diagnosis of cannabis dependence. Assessments were conducted at baseline, and at 4, 9, and 15 months postrandomization. The 9-session treatment reduced marijuana smoking and associated consequences significantly more than the 2-session treatment, which also reduced marijuana use relative to the DTC condition. Most differences between treatments were maintained over the follow-up period. Discussion focuses on the relative efficacy of these brief treatments and the clinical significance of the observed changes in marijuana use. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Provision of psychotherapy for a statewide population of Medicaid beneficiaries with schizophrenia.

This study uses 1,995 Medicaid-paid claims from Georgia to examine factors influencing the provision of psychotherapy services to patients with schizophrenia. Measures of services included individual and group psychotherapy and were derived using the Physician's Current Procedural Terminology, 4th edition (CPT-4) codes. Approximately one in four patients received psychotherapy during the study period. When controlling for other factors, psychotherapy use was less likely for African American than White patients and more likely for women, those with comorbid substance abuse, and those with severe physical comorbidities. Compared with those not treated with an antipsychotic, those being treated with typical antipsychotics did not differ in psychotherapy use, but those treated with atypical antipsychotics were significantly more likely also to be receiving psychotherapy. Among psychotherapy users, individual psychotherapy alone was most common. Compared with those receiving only individual psychotherapy, the probability of receiving additional group therapy or group therapy alone was elevated for African American patients, those in metropolitan areas, and those with comorbid substance abuse. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Cognitive-behavioral therapy for intermittent explosive disorder: A pilot randomized clinical trial.

No randomized clinical trials have evaluated the efficacy of psychotherapy for intermittent explosive disorder (IED). In the present study, the authors tested the efficacy of 12-week group and individual cognitive-behavioral therapies (adapted from J. L. Deffenbacher & M. McKay, 2000) by comparing them with a wait-list control in a randomized clinical trial among adults with IED (N = 45). Aggression, anger, and associated symptoms were assessed at baseline, midtreatment, posttreatment, and 3-month follow-up. Group and individual cognitive-behavioral therapy tended not to differ, with each reducing aggression, anger, hostile thinking, and depressive symptoms, while improving anger control relative to wait-list participants. Posttreatment effect sizes were large. These effects were maintained at 3-month follow-up. Findings provide initial support for the use of multicomponent cognitive-behavioral therapy in the treatment of IED. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Benchmarking the effectiveness of psychotherapy treatment for adult depression in a managed care environment: A preliminary study.

This preliminary study evaluated the effectiveness of psychotherapy treatment for adult clinical depression provided in a natural setting by benchmarking the clinical outcomes in a managed care environment against effect size estimates observed in published clinical trials. Overall results suggest that effect size estimates of effectiveness in a managed care context were comparable to effect size estimates of efficacy observed in clinical trials. Relative to the 1-tailed 95th-percentile critical effect size estimates, effectiveness of treatment provided in this setting was observed to be between 80% (patients with comorbidity and without antidepressants) and 112% (patients without comorbidity concurrently on antidepressants) as compared to the benchmarks. Because the nature of the treatments delivered in the managed care environment were unknown, it was not possible to make conclusions about treatments. However, while replications are warranted, concerns that psychotherapy delivered in a naturalistic setting is inferior to treatments delivered in clinical trials appear unjustified. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Less Directiveness by Therapists Improves Drinking Outcomes of Reactant Clients in Alcoholism Treatment.

In this study, the authors examined the impact of the interaction between clients' trait reactance and therapists' directiveness on the effectiveness of psychotherapy treatment for alcoholism. Ratings of videotaped treatment sessions were used to measure clients' reactance (N = 141) and therapists' directiveness. Models tested for the interaction as a predictor of 1-year posttreatment drinking quantity and frequency. Results indicate that directiveness had a negative impact on outcomes for clients at medium and high levels of reactance but did not affect drinking among clients low in reactance. Increased therapist use of interpretation, confrontation, and introduction of topics was most predictive of more frequent and larger quantities of drinking among reactant clients. This study suggests that research on treatment process can yield significant theoretical and clinical benefits. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Comparative effectiveness of psychotherapies for depressed elders.

Ninety-one elders with a major depressive disorder (MDD) were treated for 16 to 20 sessions of behavioral, cognitive, or brief psychodynamic psychotherapy. Prior to treatment 20 of these subjects were assigned to a 6-week delayed treatment control condition. By the end of 6 weeks patients in the treatment conditions showed improvement, whereas controls did not. Overall, 52% of the treatment sample attained remission by termination; another 18% showed significant improvement. The remainder still met criteria for MDD at the conclusion of therapy. A number of outcome measures indicated no significant main effects for group and no significant Group?×?Time interactions, suggesting that all three modalities were equally effective in obtaining positive results. The number of elders responding to these treatments compares favorably with younger samples in other studies, indicating the efficacy of psychotherapy for the treatment of depression in the elderly. (PsycINFO Database Record (c) 2010 APA, all rights reserved)