Coping style and psychotherapy

People tend to cope with problems and difficulties in different ways. Some people bottle things up and become anxious and depressed while others show less sympathy to others, behave insensitively and become angry. Psychologists call these techniques internalizing and externalizing respectively. Psychotherapists are increasingly trying to tailor their treatments to individual patients - whether it be their preferences about treatment, or cultural, social or religious background - and a team of researchers from the University of Palo Alto looked into whether tailoring treatment to coping style would make it more effective. They reviewed 12 studies, covering a total of 1,291 people and found that people who externalized their problems did better with treatments that targeted their behaviour while people who internalized them did better with treatments designed to help them get insights into their thought processes.

Beutler, Larry E. ... [et al] - Coping style Journal of Clinical Psychology: in session 67(2), 1-8 

Study backs religious and spiritual therapies

Religion can be defined as adherence to a belief system and practices associated with a tradition in which there is agreement about what is believed and practiced whereas spirituality can be defined as a more general feeling of closeness and connectedness to the sacred. In recent years psychotherapists have been trying to incorporate both - where appropriate and where the patient wants it - into psychotherapy. A team of researchers from Virginia Commonwealth University reviewed 46 studies, covering a total of 3,290 people, into the effectiveness of 'religious accommodative' and 'nonreligious spirituality' therapies. They found that patients receiving these therapies showed greater improvements in psychological and spiritual outcomes than those receiving alternative secular therapies.

Worthington, Everett L. ... [et al] - Religion and Spirituality Journal of clinical psychology: in session 67(2), 1--11

Resistance, reactance and psychotherapy

Despite expressing a sincere wish to recover some patients behave in almost exactly the opposite way from that suggested by their psychotherapist - something sometimes called patient resistance. However, a team of researchers from Palo Alto University in California thought that patient resistance was a term which was too pejorative to patients and decided to call it patient reactance instead in an acknowledgement that the therapist's approach could also play a part in this happening. The researchers looked at 12 studies into this issue covering a total of 1,102 participants. They found that those patients who were more inclined to follow their therapist's advice benefited more from a more directive approach (i.e. being told what to do) whereas patients who had high levels of resistance/reactance benefited more from a nondirective approach.

Beutler, Larry E. ... [et al] - Resistance/Reactance Level Journal of Clinical Psychology: in session Vol. 67(2), 1-10 (2011)

Talking and trauma

Talking or writing about trauma that one might have experienced (emotional disclosure) is widely seen as being therapeutic for people but the evidence about this is mixed and the best way of achieving it is unclear. Researchers from Wayne State University in Detroit looked into this issue in a study of 214 people who had 'unresolved stressful experiences.' Some of the participants formed a control group while the rest of them had a 30-minute session of either written or private spoken disclosure, talking to a passive listener or talking to an active facilitator. After six weeks both the disclosure groups and the control group showed similar reductions in stress i.e. disclosure had no more effect than the passage of time. However, those people who had spoken or written about their experiences did show more post-traumatic growth; something defined as finding meaning in the experience, changing one's priorities, seeing new possibilities, increasing understanding and appreciation of life, improving relationships and making spiritual changes. There was no difference between the different methods of disclosure in the amount of post-traumatic growth they engendered.

Slavin-Spenny, Olga M. ... [et al] - The Effects of Different Methods of Emotional Disclosure: Differentiating

Post-Traumatic Growth From Stress Symptoms Journal of Clinical Psychology  DOI: 10.1002/jclp.20750

Motivation, depression and psychotherapy

Over the last 20 years researchers have begun to recognise that other factors - apart from the kind of treatment used and the nature of people's mental-health problems - affect whether psychotherapy gets people better or not. Two of the most important factors are the therapeutic alliance - the relationship between a psychotherapist and their client - and autonomous motivation which is defined as the extent to which people feel they have gone into treatment of their own free will and without external pressure. A team of researchers from the University of Toronto and McGill University in Montreal studied 74 people being treated for depression who each received 16 sessions of interpersonal therapy. Their study found that overall both the therapeutic alliance and autonomous motivation predicted remission from depression. However, for those patients whose depression was highly-recurrent autonomous motivation had no effect at all in whether they got better.

McBride, Carolina ... [et al] - Autonomous and controlled motivation and interpersonal therapy for depression: Moderating role of recurrent depression British Journal of Clinical Psychology Volume 49, Number 4, November 2010, 529-545

Internet therapy - how many people drop out?

The internet is used more and more to deliver treatment for mental-health problems and research has shown that internet-based treatment is effective for a number of different psychological conditions. However, there are worries about the number of people who drop out of internet-based treatment and researchers from Griffith University in Brisbane and Queensland University of Technology reviewed 19 studies into this issue carried out between 1990 and April 2009. The studies had dropout rates between two and 83% with the average rate being 31%. The researchers also found that there was little evidence to suggest which factors made it more likely that people would drop out of internet therapy.

Melville, Katherine M.; Casey, Leanne M.; Kavanagh, David J. - Dropout from Internet-based treatment for psychological disorders British Journal of Clinical Psychology 49 (4), November 2010, 455-471

Major review gives thumbs up to self-help

In guided self-help patients take home a standardized psychological treatment and work through it more or less independently. The treatment can be written down in a book or be available via a web site, television, video or audio and some support is given by a professional therapist or coach. P. Cuijpers from the VU University in Amsterdam reviewed 21 studies, including 810 participants, comparing face-to-face therapy with guided self-help. They concluded that guided self-help was just as effective as face-to-face therapy, that its effects lasted for a year and that people were just as likely to carry on with their treatment.

Cuijpers, P. ... [et al] - Is guided self-help as effective as face-to-face psychotherapy for depression and anxiety disorders? A systematic review and meta-analysis of comparative outcome studies Psychological Medicine (2010), 40, 1943–1957

Getting better slowly or gradually - does it make a difference?

People having psychotherapy quite often make sudden gains, displaying abrupt and substantial improvements in symptoms from one session to the next. Sudden gains have been investigated in the context of randomised controlled trials (RCTs), tightly-controlled studies designed to compare one treatment with another, and in therapy carried out by experts but researchers from American University in Washington D.C. looked to see whether these gains could occur in other contexts. They studied 106 outpatients being treated in a university-based psychotherapy training clinic. Overall sudden gains were identified in 29% of the patients, gains which tended to occur early in therapy. However, the gains were more likely to be reversed than in RCTs which usually involve more-experienced therapists. 54% of the sample showed gradual gains which tended to occur later in therapy. Those patients who had had sudden gains did significantly better by the end of therapy than those who showed more gradual gains.

Greenfield, M. F., Gunthert, K. C. and Haaga, D. A. - Sudden gains versus gradual gains in a psychotherapy training clinic Journal of Clinical Psychology n/a. doi: 10.1002/jclp.20748

How many sessions does it take to get better?

Many governments, and private-sector medical companies, limit the number of sessions of psychotherapy that people are entitled to. This is done on financial grounds but there is a lack of research into how many sessions people actually need to get better. A team of researchers, led by Paul Harnett from the University of Queensland, studied this issue by tracking the progress of 125 people as they started psychological treatment. The researchers found that it took 8 sessions for 50% of the clients to show some signs of recovery and 21 sessions for 85% of people to do so. To make a full recovery it took 14 sessions for 50% of the clients to have recovered and 23 sessions for 70% of them to get better. This was much less than the present policies of both the public and private sector in Australia and the researchers recommended a minimum number of 20 sessions for people.

Harnett, Paul, O'Donovan, Analise and Lambert, Michael J. - The dose response relationship in psychotherapy: implications for social policy Clinical Psychologist July 2010, 14(2), 39-44

How to tell and what to do if clients go downhill

About 5-10% of people actually get worse after starting psychotherapy. Studies comparing therapists who got feedback when their clients worsened showed that their clients did better than those people with therapists who were left to carry on regardless - suggesting that not all therapists know when their clients are going downhill. Researchers from the Indiana University of Pennsylvania looked into this issue by giving questionnaires to clients to assess their mental state and comparing them with the therapists' own notes. They found that 'therapists had considerable difficulty recognising client deterioration.' Other therapists were asked how they would judge if a client was going downhill and most replied that they would judge from their clients' symptoms rather than using a standardised rating scale. The most popular options for what to do if a client worsened were to make a referral for medication, to increase the frequency of therapy sessions, to gather more information, to discuss the deterioration with the client, to counsult other therapists and to change the treatment approach in some way.

Hatfield, Derek ... [et al] - Do we know when our clients get worse? An investigation of therapists' ability to detect negative client change Clinical Psychology and Psychotherapy January-February 2010, 17(1), 25-32

Review of the evidence backs psychodynamic psychotherapy

Psychodynamic psychotherapy (PP) has lost out to cognitive behaviour therapy (CBT) and medication over the last few years but a review of the research by Jonathan Shedler of the University of Colorado suggests that it may be just as effective and have long-lasting benefits. PP focuses on the psychological causes of people's problems and uses self-reflection and self-examination. The relationship between the client and the therapist is seen as very important as this is thought to mirror problems the client might have in their other relationships. Shedler reviewed eight meta-analyses covering a total of 160 studies and found that PP had a significant effect that was longer lasting than that of CBT or medication. PP was found to be effective for a wide variety of conditions including depression, anxiety and personality disorders.

You can find out more about this research at

http://www.sciencedaily.com/releases/2010/01/100125094501.htm?utm_source=feedburner&utm_medium=feed&utm_campaign=Feed%3A+sciencedaily+%28ScienceDaily%3A+Latest+Science+News%29&utm_content=Google+Reader

Therapists' therapy and the therapetic alliance

The idea that therapists should themselves have therapy goes right back to Freud and a number of studies since then have backed the idea that therapists who have had therapy are more effective than those who haven't. The therapeutic alliance is the relationship between the therapist and the patient and includes agreement on goals, assignment of tasks and the development of bonds. It is known to have a big impact on the effectiveness of therapy yet there has been little research into the effects of therapists' therapy on the therapeutic alliance. Researchers from Adelphi University in New York compared therapists who had and had not received therapy as they assessed 60 outpatients. They found that there was no difference between the two groups in the quality of the therapeutic alliance as rated by the patients. However, the therapists who had received therapy were more confident, felt they had more agreement about goals and were happier overall with the therapeutic alliance. Those therapists who had had therapy themselves also treated their patients for twice as long as the other group.

Gold, Stephanie H. and Hilsenroth, Mark J. - Effects of graduate clinicians' personal therapy on therapeutic alliance Clinical Psychology and Psychotherapy May-June 2009, 16(3), 159-171

Positive psychology helps for depression

A lot of clinical psychology deals with people's problems, weaknesses and perceived abnormalities. Positive psychology, however, prefers to concentrate on building up people's strengths and aims to foster qualities such as confidence, optimism and hope. A review of 51 studies, which included a total of 4,266 people, by researchers at the University of California, Riverside, looked into the effectiveness of positive psychology interventions at treating depression. The results showed that they significantly enhanced well-being and decreased depression. The treatments worked best with people who were older and highly-motivated to improve. Individual interventions worked better than group therapy and longer periods of treatment were more effective than shorter ones.

Sin, Nancy L. and Lyubomirsky, Sonja - Enhancing well-being and alleviating depressive symptoms with positive psychology interventions: a practice-friendly meta-analysis Journal of Clinical Psychology May 2009, 65(5), 467-487

Milieu therapy: 'raising' good citizens

Milieu therapy is a form of psychotherapy that involves the use of therapeutic communities. Clients join a group of 30 or so people for between 9 and 18 months and during their stay they are encouraged to take responsibility for themselves and others within the unit. It is thought to be useful in treating personality and behaviour disorders and is widely used in Scandinavia. A team of Norwegian researchers looked at how milieu therapy worked in one such unit in Norway. They found that in ways the unit was similar to a traditional nuclear family. The clients were often seen as 'harmed children' and were taught self-management skills. The staff aimed to provide a caring atmosphere while the clients sometimes seemed to behave in a child-like manner. In a sense the milieu was 'raising' the clients to transform their 'odd' behaviour and 'nonconforming' lifestyles and produce 'self-governing' individuals.

Oeye, Christine ... [et al] - Raising adults as children? A report on milieu therapy in a psychiatric ward in Norway Issues in Mental Health Nursing 30(3), 151-158

Building a good therapeutic alliance

The therapeutic alliance - therapist and client working together towards recovery - plays a significant role in psychotherapy and is an important factor in its success and effectiveness. However, the role of the therapist in the development of the alliance has not been extensively investigated and studies of the alliance in long-term psychotherapy are virtually non-existent. Norwegian researchers studied the therapeutic alliance in 201 clients and 61 therapists in long-term (more than 120 sessions) therapy. The higher therapists scored on the cold/detached scale of personality measurement - being distanced, disconnected or indifferent - the worse the alliance. The more professional training the therapists had had the worse the patients rated the quality of the alliance. The more experienced the therapists were the lower they rated the quality of the alliance. Therapists who reported better maternal care up to their adolescence were more likely to have patients who thought they had a good therapeutic alliance.

Hersoug, Anne Grete ... [et al] - Therapist characteristics influencing the quality of alliance in long-term psychotherapy Clinical Psychology and Psychotherapy March-April 2009, 16(2), 100-110

The Human Givens Approach

The Human Givens Approach works with the idea that humans are born with a body of knowledge, developed through evolution, that has become so familiar that it is not recognised as knowledge and simply taken for granted. The knowledge is made up of physical and emotional needs and the abilities to meet them. The approach tries to get people to recognise these 'givens' and give them extra abilities, through therapy, where they are needed. Therapists place a high value on relaxation in order for clients to think their way through a process and use breathing exercises to achieve this. Clients are set individual goals including communication skills, how to be assertive and dealing with depression. The approach also believes that it is important for people to have a social life within their community.

You can find out more about the Human Givens Approach at

www.hgi.org.uk

New web site on online therapy

A new website about online therapy has been set up for mental-health professionals. The site contains articles, discussion boards and resources and will look into issues such as therapists' roles on 'virtual world' sites such as Second Life.

You can find the site at

www.onlinetherapyinstitute.com

Sudden improvements, lasting gains

People going through psychotherapy often demonstrate sudden, dramatic improvements suggesting that they have had some kind of epiphany that has dramatically altered their outlook on life and way of thinking. These sudden changes represent genuine improvement in people's condition and those who show sudden improvements from one session to the next are more likely to show a greater and longer-lasting improvement after the end of therapy. A team of researchers at the University of Virginia in the U.S. looked into sudden improvement in 30 people going through a 12-week course of cognitive behaviour therapy (CBT) for panic disorder. 43% of the clients showed at least one dramatic burst of improvement during the course of therapy. Half of those who had had a dramatic improvement had had it between the first and second sessions, while the other half had experienced it later on. However, only the later improvers had better symptoms at the end of the study compared to people who had shown no dramatic improvement. The later improvers showed a greater improvement in their fear of anxiety-related symptoms at the end of their course of therapy, and at a six-month follow-up.

Clerkin, E., Teachman, B. and Janik, S. Smith - Sudden gains in group cognitive-behavioural therapy for panic disorder Behaviour Research and Therapy 2008

Psychotherapy for bipolar disorder

Despite advances in drug treatment most people with bipolar disorder cannot be treated with medication alone. Up to 50% of bipolar patients do not recover from acute manic episodes within a year and only 25% achieve full recovery of function. Rates of recurrence average 40-60% in 1-2 years even when patients undergo pharmacotherapy. Patients spend as much as 47% of their lives in symptomatic states, especially depressive states and only about 40% of patients are fully adherent with medication regimes in the year following an episode. So psychotherapy still has a crucial role to play in this condition. A review of 18 trials into the effectiveness of psychological interventions by David J. Miklowitz from the University of Colorado found that family therapy, interpersonal therapy and systemic care were the most effective at preventing recurrences when initiated after an acute episode, whereas cognitive behavioural therapy and group psychoeducation were most effective when initiated during a period of recovery. Individual psychoeducational and systematic care programmes were more effective for manic than for depressive symptoms whereas family therapy and cognitive behavioural therapy were more effective for depressive than for manic symptoms.

Miklowitz, David J. - Adjunctive psychotherapy for bipolar disorder: state of the evidence American Journal of Psychiatry November 2008, 165(11), 1408-1419

Long and short-term psychotherapy. Is brief always better?

Long-term psychodynamic psychotherapy (LTPP) has suffered at the expense of briefer forms of therapy, such as cognitive and family therapy. However, a review of studies into the effectiveness of LTPP has found that it can have a large and positive effect. The review looked at 11 randomised controlled trials and 12 observational studies. The pooled results suggested that psychodynamic therapy could work better for people with complex mental illnesses than briefer alternatives.

JAMA 2008; 300:1551-1565