New RCTs: Acceptance and Commitment Therapy is effective for treatment resistant clients

New RCTs: Acceptance and Commitment Therapy is effective for treatment resistant clients

Two recent randomized control trials seem to indicate that acceptance and commitment therapy (ACT) is a good option for people who have no benefitted from prior treatment. A lot of people don’t respond to their first round of treatment, so this is good news for a lot of people. This research adds to a growing list of studies showing that ACT is helpful across a large range of conditions and life difficulties.

ACT outperforms CBT for people who had not previously responded to therapy


In a study published in July of 2014 the investigators compared group-based ACT to group-based CBT (treatment as usual) for 61 participants.  These participants came to the study with a range of diagnoses and all had participated in previous psychotherapy for which they did not receive a significant beneficial response.  The results of the study showed that both groups showed initial benefit, however in the group that received ACT treatment the benefits were completely sustained at a 6 month follow up assessment.


ACT works for people with panic disorder that didn’t respond to previous treatment


Another RCT published in March of 2015 tested ACT as an intervention for “treatment-resistant patients” struggling with panic disorder and/or agoraphobia.  There were 43  participants in this study and they all had received evidenced-based, standard of care treatment (mean number of previous sessions = 42) with unsuccessful results.

The participants were grouped into the conditions of treatment, short-term wait-list and delayed treatment and each offered 8 sessions over 4 weeks of manualized ACT treatment.  The results show a medium-to-large effect sizes with sustained and improved results a 6 month follow up assessment.

The authors conclude that this data suggest that ACT is a viable treatment option for panic disorder and agoraphobia treatment-resistant patients.

Research into treatment recommendations and factors concerning non-responders to psychotherapy is a clear gap in the current literature.  However, these studies are building evidence that ACT is a robust treatment that appears to offer patients something useful that other treatments were not able to provide.

Newest Data on Shame and Drinking Published at Western Psychological Association Conference

Newest Data on Shame and Drinking Published at Western Psychological Association Conference

Last Friday, Portland Psychotherapy research assistants Monica Bahan, Megan Cheslock, and Jackie Potter presented a research poster at the annual Western Psychological Association convention, which took place in Portland. Their poster detailed findings from one of our ongoing studies exploring the relationship between shame, guilt, and drinking behavior. The findings were based on the first 88 participants in the study, all volunteers from the Portland area.

Congratulations to Monica, Megan, and Jackie on their first presentation!

Jason Luoma, Ph.D.

Author: Jason Luoma, Ph.D.

Jason is a psychologist who researches ways to help people with chronic shame and stigma and also works clinically with people struggling with those same problems.

A Meta-Analysis Comparing Psychotherapy and Medication for OCD

A Meta-Analysis Comparing Psychotherapy and Medication for OCD

This post was featured on our client-centered blog The Art and Science of Living Well, but I thought it would be of interest to therapists as well.

The post is about a finding from a meta-analysis by Cuipjers and colleagues that looked at studies comparing medication against psychotherapy in the treatment of anxiety disorders and depression. For obsessive-compulsive disorder, the researchers found a clear advantage of evidence-based psychotherapy for OCD above medication.

You can read the post by clicking here, and it includes links to the original article, which you can download for free.

Enough already: Let’s move on from meta-analyses of psychoanalytic psychotherapy and do the hard work of quality studies

Enough already: Let’s move on from meta-analyses of psychoanalytic psychotherapy and do the hard work of quality studies

The past few years has seen an increasing push to demonstrate the legitimacy of long-term psychodynamic and psychoanalytic therapies (e.g., Leichsenring & Rabung, 2008). It seems proponents of psychodynamic therapy are trying to play catch up. There’s an enormous amount of research support for cognitive behavioral approaches; by contrast, controlled research for psychodynamic approaches is sparse.

Since long-term psychoanalytic psychotherapy is a mouthful, we’ll follow the cue of those before us and call it LTPP for short.

It’s unfortunate there’s not a lot of controlled research on LTPP, as I think controlled studies carefully examining the processes and outcomes of psychodynamic therapies could only enhance our understanding of treatment. As a way to bolster support, some psychodynamic researchers have taken what studies exist and published meta-analyses of the existing research. Some of the recent ones concluded that LTPP is an effective treatment for a variety of psychiatric conditions (De Maat, 2009; Leichsenring & Rabung, 2008, 2011). These findings were not without controversy, however.

You may have noticed, for example, that Leichsenring and Rabung are listed twice. There’s a reason for this: their 2008 meta-analysis was widely criticized for miscalculating effect sizes. According to critics, the researchers had simply looked at pre-post changes (within-group difference) rather than comparing LTPP against the control conditions (between-group differences). The researchers redid their analysis in the 2011 meta-analyses and found LTPP was effective, albeit to a lesser degree.

Although I think meta-analyses on psychodynamic therapy have been over-played of late, I was excited about a new one published in Clinical Psychology Review (Smit et al., 2012). This article is a collaboration of Dutch researchers and John Ioannidis. I perked up at the mention of Dr. Ioannidis’ involvement.

Who is John Ioannidis?

Not to give short shrift to the others involved, but I was really excited by Ioannidis’ presence on this article. Ioannidis, a medical researcher with several academic appointments, has become one of the foremost experts in the credibility of medical research. He published a hugely influential paper arguing that most medical findings are inaccurate, and he was even profiled in The Atlantic. With his name attached to this piece, I could be confident that the methodology of this meta-analysis had been scrupulously thought out and executed.

A little background on meta-analysis

Meta-analyses are a way of consolidating a number of studies on a particular area of focus that allows for comparison across studies. Researchers may then draw more general conclusions from a bunch of data. This is done by converting the results from each individual study into effect sizes.

Like any tool, meta-analyses are only as good as the way they are used. Researchers make decisions about what studies to include (and not to include), what outcomes to look at, and how to run the analyses. As they say, “garbage in, garbage out.” Moreover, meta-analyses are no substitute for rigorously controlled studies.

The bottom line: meta-analyses of low quality research lead to low quality conclusions

The reason why I’m hoping this article will be the final word on this topic for now is that it ultimately points to the need for more high quality data.

In contrast to previous meta-analyses, the researchers in this study had difficulty drawing firm conclusion about LTPP because the available research was generally of low quality. Their main criticism is that LTPP was often compared against substandard treatments. The authors call these “straw man” comparisons, as there is little reason to believe these control conditions are effective. In the few studies that compare LTPP against evidence-based treatments such as dialectical behavior therapy, LTPP does not fare so well, according the researchers.

What this means is that without well-controlled studies of LTPP against established treatments for specific psychiatric problems. It is difficult to gauge the effectiveness of LTPP. The few highly quality studies available suggest that when LTPP is compared against bona fide treatments, it doesn’t appear to be particularly effective. Hopefully, researchers will now take a break from meta-analysis and focus their efforts towards creating more high quality, controlled studies comparing LTPP to treatments with a strong track record.

Let’s move on and do the work…

I think we’ve seen enough meta-analyses on LTPP for the time being. If a strong argument for LTPP is to be made, it will require a focus on quality, controlled research that compares LTPP to bona fide treatments for specific conditions.

But don’t take my word for it: I highly recommend reading the study yourself. For a scientific article, it’s actually quite lucid and readable. I obtained it by following James Coyne’s suggestion in the blog post that alerted me to this article, and emailing the author, Arnoud Arntz, who quickly and thoughtfully sent me a copy:

Motivating Clinicians to Learn and Use Exposure Therapy

Motivating Clinicians to Learn and Use Exposure Therapy

Although exposure-based treatments have been around for several decades, and exposure is arguably at the core of the most effective treatments for anxiety-related disorders, only a minority of clinicians actually use exposure in an intentional and planful way. Barriers include lack of knowledge, as well as concerns about potential harm, and a perceived rigidity in using exposure. One promising avenue for overcoming some of these barriers is easily accessible Internet-based training. A group of researchers associated with Behavioral Tech, the umbrella organization at the heart of the dissemination of Dialectical Behavior Therapy (DBT), conducted a study aimed at encouraging clinicians to use exposure-based treatments and training them in its use (i.e., Harned, Dimeff, Woodcock, & Skutch, 2011).


The Three Conditions Used in the Study

The researchers created an online multimedia training in exposure therapy. A total of 51 participants were randomly assigned to one of three conditions:

  1. An online training in exposure therapy (ET OLT), 
  2. Online training in exposure therapy plus 1-2 phone calls from the experimenters. In these brief calls, the experimenters responded to questions and attempted to increase engagement through using Motivational Interviewing. Motivational interviewing is a well-supported approach, but I should note that, as the authors admit, it’s impossible to know whether motivational interviewing had a unique effect, or whether the participants simply found it helpful to talk to the experimenters. 
  3. In an attempt to have a placebo condition (control OLT), a third of the participants didn’t receive exposure training at all. Instead, they received an online instruction in using DBT to validate clients

What Did They Find?

As it turns out, online training appears to be a viable means of educating therapists about exposure therapy and increasing therapist confidence in using exposure. The addition of the phone calls appeared to improve attitudes towards exposure therapy beyond the training alone, but it’s hard to know for certain whether this is because the phone calls were rooted in motivational interviewing or simply because the therapists had a chance to talk through their concerns with a knowledgeable and sympathetic person.

Limitations and What We Can Take Away

I’ll mention here that participants were recruited from a DBT listserv. That participants were on a DBT listserv suggests that the pool of people were more favorably disposed towards evidence-based therapy than, for example, a Jungian listserv. That these individuals also volunteered for a research study further narrows the sample into people open to learn these sorts of treatments. Consequently, this isn’t a completely random sample of therapists.
One take home message from this study: access to decent training is major barrier to using exposure, and this barrier can be surmounted through online training. I think this is a pretty important point. There are therapists who want more training in exposure therapy, and the Internet is a very viable way of making training available.
Additionally, a brief (< 20 minutes) phone call or two can help grease the wheels and increase likelihood that someone will use the treatment.
The researchers looked at a number of other variables, but at the risk of cluttering this post, I’ll leave those out. If you’re interested, you can download a pdf of the article through NIH by clicking on the link below.


Harnad, M.S., Dimeff, L.A., Woodcock, E.A., & Skutch, J.M. (2011). Overcoming barriers to disseminating exposure therapies for anxiety disorders: A pilot randomized controlled trial of training methods. Journal of Anxiety Disorders, 25, 155-163.