Category: Therapy

Have we overestimated the effectiveness of psychotherapy?

Depression ReliefBy Christian Jarrett

Most people who undertake psychotherapy seem to benefit from it. How do we know? Arguably, the most important evidence comes from meta-analyses that combine the results from many – sometimes hundreds – of randomly controlled trials. Based on this, it’s been estimated that psychotherapy is effective for about 80 per cent of people (meanwhile, between five to 10 per cent of clients may suffer adverse effects).

But now the more concerning news: a team of researchers led by Evangelos Evangelou at the University of Ioannina, Greece has assessed the quality of 247 of these psychotherapy meta-analyses and they report in Acta Psychiatrica Scandinavica that many of them have serious methodological short-comings.

Coincidentally, a separate research group led by Brent Roberts at the University of Illinois, Urbana-Champaign has just published in Journal of Personality some of the first observational data on how people’s personalities change after undertaking psychotherapy. In contrast to what’s been found in the clinical literature, they report that people who’ve been in therapy seem to show negative changes in personality and other psychological outcomes.

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Concerning study says psychotherapy research has a problem with undeclared researcher bias

sharp riseBy Alex Fradera

When a good doctor encounters research comparing the effectiveness of drugs A and B, she knows to beware the fact that B was created by the people paying the researchers’ salaries. Pharmaceutical industry funding can be complex, but the general principle of declaring financial conflicts of interest is now embedded in medical research culture. Unfortunately, research into psychological therapies doesn’t yet seem to have got its house in order in an equivalent way. That’s according to a new open access article in the journal BMJ Open which suggests that, while there is less risk in this field of financially-based conflicts, researchers may be particularly vulnerable to non-financial biases, a problem that hasn’t been adequately acknowledged until now.

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A little discussed effect of therapy: it changes your personality

By Christian Jarrett

Imagine the arrival of some high-tech brain device for treating mental health problems. It’s effective for many, but there’s an important side-effect. It changes your personality. Alarm ensues as campaigners warn that users risk being altered fundamentally for years to come. Now replay this scenario but replace the neuro-gizmo with good old-fashioned psychotherapy, and realise this: we’re talking fact, not fiction. A new meta-analysis in Psychological Bulletin has looked at 207 psychotherapy and related studies published between 1959 and 2013, involving over 20,000 participants, with measures of personality taken repeatedly over time. The analysis has found that just a few weeks of therapy is associated with significant and long-lasting changes in clients’ personalities, especially reductions in the trait of Neuroticism and increases in Extraversion.

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The evidence for the psychological benefits of animals is surprisingly weak

Senior woman lying with a dog on a white chairBy Christian Jarrett

To see a man’s face light up as he strokes a dog, to hear a child’s laughter as her hamster tickles her skin, it just seems obvious that animals are good for our state of mind. Let’s hope so because not only do millions of us own pets, but also animals are being used therapeutically in an increasing number of contexts, from residential care homes to airports, prisons, hospitals, schools and universities. Unfortunately, as detailed by psychologist Molly Crossman in her new review in the Journal of Clinical Psychology, the research literature has simply not kept pace with the widespread embrace of animal contact as a form of therapy in itself, or as a therapy adjunct. In short, we don’t know whether animal contact is psychologically beneficial, and if it is, we have no idea how.

Continue reading “The evidence for the psychological benefits of animals is surprisingly weak”

Why some clinical psychologists are ignoring official best practice guidelines

Man with a worried look on his face talking to a womanBy Christian Jarrett

In England there’s an independent health advisory body that provides guidelines to clinicians working in the NHS, to make sure that wherever patients are in the country, they receive the best possible evidence-backed care. The National Institute for Health and Care Excellence (NICE) was set up in 1999 and many of its guidelines pertain to mental health, and they often promote psychological approaches – for example, the guidelines for depression state that talking therapies should be the first-line of treatment for all but the most severely affected patients. While clinical and counselling psychologists have been involved in producing these guidelines, many of their colleagues – especially those in practice – are highly critical of them. Why? A series of interviews with 11 clinical psychologists, published in Clinical Psychology and Psychotherapy, sheds new light on the scepticism and concern felt towards NICE guidelines, and why some psychologists are even deliberately ignoring them.

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It can be a good thing for a therapist and client to disagree about the client’s problems

Rapport between a client and therapist is important for therapy to be successful, and part of that is agreeing about the aims of the exercise. You’d think this would include the therapist and client agreeing about the specific nature of the client’s psychological problems. In fact, a new study in Psychotherapy Research finds disagreement isn’t harmful to therapy and can even be beneficial.

Rolf Holmqvist and his colleagues recruited 846 therapy clients as they started a course of therapy at a Swedish primary care centre, most of them after having been referred by their family doctor. Seventy-three therapists, most of them psychologists and social workers, also took part.

Separately, the clients and therapists rated the nature of clients’ mental health problems at the start of therapy and again at the end. After each session, therapists and clients also completed measures of their “working alliance” – essentially their rapport and how well they felt that they collaborated.

Focusing on depression and anxiety, the researchers found that there was only moderate agreement between therapists and clients about whether these problems were present or not – for example, for just under half the clients, the therapists reported that the clients were depressed or anxious when the client themselves did not.

What’s more, amount of agreement on the presence or not of depression was not related to the success of therapy in reducing the clients’ self-rated symptoms, nor to ratings of working alliance. And regarding anxiety, some of the most successful outcomes were actually seen in those instances where the therapists rated the client as anxious, but the client did not seem themselves as having anxiety.

The study has some issues, such as that the therapists’ and clients’ views on the clients’ problems were measured in different ways, and that the research can’t say who had the more accurate insight because there was no third-party, objective measure of the clients’ problems, so far as this is possible. Notwithstanding these issues, the researchers said their findings were “remarkable” and that they suggest “patient and therapist may have different ways of understanding the patient’s problem without detriment for the treatment result – or event to its benefit.”

_________________________________ ResearchBlogging.org

Holmqvist, R., Philips, B., & Mellor-Clark, J. (2015). Client and therapist agreement about the client’s problems—Associations with treatment alliance and outcome Psychotherapy Research, 26 (4), 399-409 DOI: 10.1080/10503307.2015.1013160

Post written by Christian Jarrett (@psych_writer) for the BPS Research Digest.

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How often does psychotherapy make people feel worse?

We hear a lot about the unwelcome side-effects of psychiatric drugs, but not so much about the fact that therapy can also leave people feeling worse than they did already. Data is thin on the ground, but best estimates suggest that between 5 to 10 per cent of therapy clients experience a worsening of their symptoms. Now a study in The British Journal of Psychiatry has provided further evidence, from the clients’ perspective, about the prevalence of harmful therapy outcomes, with around 1 in 20 of thousands of participants saying that they had experienced “lasting bad effects” from therapy.

Mike Crawford and his colleagues surveyed nearly 15,000 people who were currently receiving, or had recently ended, out-patient therapy for depression or anxiety via the National Health Service in England and Wales. Of the 14,270 people who answered the question about potential adverse effects of therapy, 763 said that they agreed strongly or slightly that their therapy had resulted in lasting bad effects, a proportion the researchers described as a “substantial minority”.

The most common form of therapy was CBT but other therapies the participants had received included psychodynamic therapy, counselling and solution-focused therapy. The survey suggested that no particular therapy approach was more often associated with bad outcomes. However, participants who said they were unsure what kind of therapy they’d received or who said they’d received an “other” form of therapy (not listed on the survey) were more likely to report bad effects, as were those who indicated they hadn’t been given sufficient information about therapy before it started.

Participants from ethnic and sexual minorities were also more likely to report lasting bad effects – the researchers don’t know why this might be but they said it may indicate a need for more emphasis on “cultural competence” in therapists’ training.

Therapeutic harm is a difficult issue to study – among other things, it’s possible that any symptom deterioration would have happened anyway (of course this problem of interpretation also works the other way in that any symptom improvement may actually have been quicker without therapy). But nearly all psychologists are in agreement that adverse effects from therapy are a real risk, and that we need to know more about how commonly they occur and how to reduce the likelihood of them happening. This study therefore provides some welcome data on an important topic.

Indeed, Crawford and his team point out that well over a million people in England have received psychological treatment for common mental disorders in recent years, which means (based on the new data) that “thousands of people could have  experienced negative effects from treatment”. The researchers advised that “clinicians delivering psychological therapies should ensure that people feel that they have sufficient information about treatment before it starts and obtain informed consent to treatment by ensuring that people considering psychological treatment for their condition are aware that there is the potential for both positive and negative effects.”

_________________________________ ResearchBlogging.org

Crawford, M., Thana, L., Farquharson, L., Palmer, L., Hancock, E., Bassett, P., Clarke, J., & Parry, G. (2016). Patient experience of negative effects of psychological treatment: results of a national survey The British Journal of Psychiatry, 208 (3), 260-265 DOI: 10.1192/bjp.bp.114.162628

further reading
When therapy causes harm
What do clients think of psychotherapy that doesn’t work?
The mistakes that lead therapists to infer psychotherapy was effective, when it wasn’t

Post written by Christian Jarrett (@psych_writer) for the BPS Research Digest.

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Can psychosocial interventions extend the lives of cancer patients?

The idea that prolonged stress is bad for your health is uncontroversial. And few things can be more stressful than receiving a cancer diagnosis and undergoing treatment. It makes sense, then, to consider that psychological interventions, aimed at providing cancer patients with emotional support and guidance on coping, might be beneficial. However, this is a delicate, controversial topic.

Not only is the evidence for the benefits of psychosocial interventions extremely mixed, but some cancer patients and their relatives have understandably railed against the “cruel” suggestion that they might live longer if only they looked on the bright side and didn’t get so stressed.

It’s against this background that researchers in South Korea have conducted a new review of the effects of psychological interventions on cancer patients’ survival time. Their study published in Psychology and Health is a meta-analysis which means that they have combined the results from prior research to get an overview of the current evidence base.

The researchers, led by P.J. Oh at Sahmyook University, found over 4,000 studies that looked promising, published between 1966 and 2014. However, once the researchers included only those papers that were randomised controlled trials and that included interventions delivered by professionals and had data on patient survival times, they were left with just 15 suitable studies conducted in five different countries and involving a total of 2940 participants with an average age of 52 years. The studies involved different types of intervention including psychoeducational programmes, CBT and supportive-expressive groups (a form of psychodynamic psychotherapy). The patients in the studies had a range of different cancers at different stages, including breast cancer, gastrointestinal cancer and melanoma.

Looking at all the data from all 15 studies, there was no evidence that psychosocial interventions prolong the lives of cancer patients. However, because of the huge variation between the studies in terms of the interventions and the types of patient, the researchers also broke down the evidence into sub-categories and here the picture was more promising. For example, by excluding six studies that had exclusively involved patients with late-stage cancer, the researchers found that psychosocial interventions reduced the likelihood of patients dying during the course of the study (follow up times varied from one to 12 years) by 27 per cent, on average. “Stress reduction, if that is the causal mechanism, may have to occur earlier to achieve positive results,” the researchers said.

Other details to emerge included the finding that a positive benefit of psychosocial interventions was only apparent for studies involving patients with gastrointestinal cancer, although there was too little data to speculate as to whether this finding is meaningful or a chance result. Comparing the different types of intervention, the strongest positive evidence was for one-on-one programmes compared with groups, and for psychoeducational approaches delivered by medical doctors and nurses, as opposed to psychologists or other non-medical professionals.

Psychoeducational interventions involve health education, coping skills training, stress management and psychological support, and the researchers speculated their benefit might arise through a mixture of reducing patients’ distress, encouraging healthy behaviours and treatment compliance. “In addition, supportive social relationships might buffer the effects of cancer-related stress on immunity and thereby facilitate the recovery of immune mechanisms and may be important for cancer resistance,” they said.

Critics may question whether it is reasonable to combine results from such varied studies as was done in the current meta-analysis, and the researchers acknowledged that many of the studies were not as robust in their methodology as they should be. However, they end their review on a positive note: “a tentative conclusion can be reached,” they said, “that psychosocial interventions offered at early stage may provide enduring late benefits and possibly longer survival.”

_________________________________ ResearchBlogging.org

Oh, P., Shin, S., Ahn, H., & Kim, H. (2016). Meta-analysis of psychosocial interventions on survival time in patients with cancer Psychology & Health, 31 (4), 396-419 DOI: 10.1080/08870446.2015.1111370

Post written by Christian Jarrett (@psych_writer) for the BPS Research Digest.

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The ideal therapist doubts their professional skills, but loves themselves as a person

Given a choice, you might think it better to undertake psychotherapy with a confident therapist than a self-doubting one. After all, you want a firm hand to guide you through a storm. But in fact, there’s evidence that therapy clients do better when their therapist has professional self-doubts. In a new paper published in Clinical Psychology and Psychotherapy, Helene Nissen-Lie and her colleagues tested their idea that therapist self-doubt might not always be helpful, and specifically that the ideal mix is professional doubt combined with personal self-compassion.

To see if this is true, the researchers analysed data from 255 mental health clients treated at 16 outpatient clinics in Norway by 70 different psychotherapists (including 46 psychologists, 14 psychiatrists and 8 physiotherapists specialising in a form of “psychodynamic body treatment”). The clients are described as having a wide range of clinical symptoms and disorders, the most frequent diagnoses being anxiety disorder and depression, and over half the sample met the diagnostic criteria for a personality disorder. The majority of the therapists followed a psychodynamic approach, just over 29 per cent were humanistic therapists and over 28 per cent used cognitive techniques.

The therapists filled out questionnaires about their professional doubts and confidence (for example, they said whether they ever worried that they were doing more harm than good); answered questions about their coping strategies; and also about how much compassion they showed themselves (for example, they said whether they cherished themselves, or whether they are their own worst enemy; how much they self-protect or self-blame). The clients meanwhile completed measures of their interpersonal problems and their symptom distress before and after treatment, and periodically for two years after treatment ended (the results are based on comparing pre-treatment scores with the average of the distress and symptom scores that were recorded at all the post-treatment time points).

Consistent with past research, therapists who were self-doubting appeared to be more effective at their job – their clients showed greater reductions in interpersonal distress. But furthermore, and as the researchers predicted, there was an interaction between therapists’ self-doubt and self-compassion. That is, the most successful client outcomes were seen for therapists who expressed a combination of professional self-doubt and greater personal self-compassion. This combination “seems to pave the way for an open, self-reflective stance that allows psychotherapists to respect the complexity of their work, and, when needed, to correct the therapeutic course in order to help clients more effectively with their challenges,” the researchers said.

_________________________________ ResearchBlogging.org

Nissen-Lie, H., Rønnestad, M., Høglend, P., Havik, O., Solbakken, O., Stiles, T., & Monsen, J. (2015). Love Yourself as a Person, Doubt Yourself as a Therapist? Clinical Psychology & Psychotherapy DOI: 10.1002/cpp.1977

further reading
The mistakes that lead therapists to infer psychotherapy was effective, when it wasn’t
Clinical psychology trainees outperform experienced therapists on knowledge and skills
Older, more experienced therapists cry more often in therapy

Post written by Christian Jarrett (@psych_writer) for the BPS Research Digest.

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The Psychology of Mindfulness, Digested

26223-thinkstockphotos-77742590Right now, mindfulness is a hot topic in psychology and beyond. In 2012, 40 new papers on mindfulness were published every month, a number that has probably risen since. Last September, the Guardian journalist Barney Ronay noted that a staggering 37 new books had been released on the topic that very week. There are numerous conferences devoted to mindfulness around the world, multiple organisations and even dedicated science journals and magazines. And yet, a dissenting voice in this chorus of enthusiasm, a new book out last month – The Buddha Pill: Can Meditation Change You? – warned that mindfulness is not harmless. To bring you up to speed in a jiffy, here we digest the psychology of mindfulness:
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