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British Medical Bulletin 57:115-132 (2001)
© 2001 Oxford University Press

Counselling and interpersonal therapies for depression: towards securing an evidence-base

Michael Barkham* and Gillian E Hardy* {dagger}

*Psychological Therapies Research Centre, School of Psychology, University of Leeds, Leeds, UK
{dagger}Clinical Psychology Unit, Department of Psychology, University of Sheffield, Sheffield, UK


   Abstract
Top
 Footnotes
 Abstract
Introduction
 Counselling as a treatment...
 Interpersonal therapies
 Conclusions
 References
 
Both generic counselling (delivered by BACP level counsellors in primary care settings) and the interpersonal therapies place a central value on the role and function of relationships – both within and outside the practice setting – as a vehicle for understanding and treating people presenting with depression. Recent studies have compared generic counselling with antidepressant medication, usual GP care, cognitive-behaviour therapy (CBT), and as an adjunct to GP care (i.e. in combination with GP care). Findings suggest either that there is no difference between generic counselling and other treatment conditions, or that there are small advantages to counselling over usual GP care but only in the short-term with such differences disappearing at 1-year. Studies investigating the interpersonal therapies (IPT) have established that the content of such therapies differ in their content from behavioural and cognitive therapies despite the outcomes being broadly similar. Considerable research effort has focused on the process of change in IP therapies. Important factors include the level of prior commitment by the patient to psychological therapy and their confidence in the therapist. Patients with well assimilated problems tend to do better in CBT than psychodynamic-interpersonal therapy. Therapists need to be flexible and responsive to patient needs particularly concerning interpersonal and attachment issues. Future research in counselling needs to identify the effective components of generic counselling and relate these to a theoretical base. In the IP therapies, there needs to be a greater focus on the change outside the therapy session and on the effectiveness of such therapies in non-research settings.


   Introduction
Top
 Footnotes
 Abstract
 Introduction
Counselling as a treatment...
 Interpersonal therapies
 Conclusions
 References
 
In this chapter, we review recent findings focusing on the efficacy and effectiveness of counselling and the interpersonal therapies in the treatment of depression. In contrast to cognitive therapy, there is considerably less research evidence derived from either counselling or the interpersonal therapies. Accordingly, the aim of this chapter is to provide an overview of the best available evidence that underpins the knowledge base for counselling and the interpersonal therapies as interventions for depression. For the purposes of this chapter, the commonality of approach lies in the centrality of the realm of the ‘interpersonal’. Counselling is included with the psychological therapies in academic texts addressing the need for an evidence-based culture1Go as well as in Department of Health strategic documents2Go. However, each discipline has its own philosophy and tradition such that at the level of delivery, it is reasonable to consider each separately. Accordingly, the chapter is divided into two parts: the first presents the evidence for counselling and the second presents the evidence for the interpersonal therapies for depression.


   Counselling as a treatment for depression
Top
 Footnotes
 Abstract
 Introduction
 Counselling as a treatment...
Interpersonal therapies
 Conclusions
 References
 
Definitions

Two important aspects of counselling require clarification. First, in terms of the approach itself, there are four components that define a generic counselling approach as set out by the British Association of Counselling and Psychotherapy (formally the British Association of Counselling)3Go. These are:

  1. Counselling is the skilled and principled use of relationships that develop self-knowledge, emotional acceptance and growth, and personal resources.
  2. The overall aim is to live more fully and satisfyingly.
  3. Counselling may be concerned with addressing and resolving specific problems, making decisions, coping with crises, working through inner feelings and inner conflict, or improving relationships with others.
  4. The counsellor's role is to facilitate the patient's work in ways that respect the patient's values, personal resources, and capacity for self-determination.

Second, counselling has recently been more appropriately defined in relation to a specific setting – in particular, that of primary care. Indeed, counselling in primary care is increasingly becoming recognised as a bona fide profession in its own right4Go,5Go.

Overview to research in counselling

The research literature through the 1990s yielded discouraging results for counselling and presented challenges to its evidence-base. For example, reviews concluded that there was little evidence for the effectiveness of generic counselling over routine GP care6Go and urgently called for more research into the efficacy of counselling7Go. Set against this background, 4 studies have recently been carried out. The first study is a Cochrane Review that, although not specific to depression, sets a marker for establishing the amount of research on counselling that meets the criteria for inclusion in a Cochrane data base8Go. The second study is a partially randomised preference trial assessing the effectiveness of counselling versus antidepressant medication delivered by GPs for the treatment of depression in primary care9Go,10Go. The remaining two studies were carried out under the Health Technology Assessment (HTA) programme. One comprises a randomised controlled trial of non-directive counselling, cognitive-behaviour therapy and usual GP care in the management of depression as well as mixed anxiety and depression in primary care11GoGo–13Go. The other is a randomised controlled trial evaluating the effectiveness and cost-effectiveness of counselling patients with chronic depression14Go. All three primary studies used the Beck Depression Inventory (BDI) as a common outcome measure making comparisons across studies easier15Go. The remainder of this section on counselling will focus on these studies.

Cochrane Review of counselling

The Cochrane Review8Go considered the evidence for the effectiveness and cost-effectiveness of primary care counselling by assessing pragmatic trials of counselling. That is, trials that evaluated counselling as carried out under normal conditions. The review assessed randomised controlled trials and controlled patient preference trials of counselling in primary care completed prior to April 1998. Importantly in this review, counselling was defined as ‘non-directive’. Hence, it excluded approaches that were labelled as cognitive, cognitive-behavioural, or behavioural, and included studies utilising counsellors who were accredited at British Association of Counselling (BAC) level or higher. The setting was defined as being provided in the GP's surgery. The outcome measures used were of psychological symptoms, recovery, social and occupational functioning, and patient satisfaction.

The search strategy revealed in excess of 2000 research articles of which 38 required detailed assessment for inclusion but only 4 articles met the inclusion criteria16GoGoGo–19Go. In terms of the overall findings, data from the 4 studies showed a between-group effect size advantage of 0.30 to counselling over standard GP care. Although a relatively small effect size, it is equivalent to stating that the average patient receiving counselling was better than approximately 62% of patients receiving standard GP care. The findings from this study confirm the paucity of research in counselling that meets the current ‘gold standard’. However, where such studies do exist, they suggest that generic counselling for problems presented in primary care – of which a substantive proportion would be depressive symptoms – is at least as good as routine GP care, if not better.

Counselling versus antidepressants for depression in primary care

In the treatment of depression specifically, psychotropic medication is used as a front-line treatment method. Rather than comparing counselling with standard GP care, a more focused question would be to ask how counselling compares with the delivery of antidepressant medication. This question was addressed in a study carried out in the Trent Region and which also aimed to establish whether providing patients with a choice between these two treatment methods affected their outcome9Go. The randomised trial comprised 52 patients assigned to counselling and 51 to antidepressant treatment. In the preference group, 140 patients chose counselling compared with 80 choosing antidepressants. Patients in the randomised trial had a moderate-to-high level of depression as indicated by the BDI (mean = 27.0).

At 8 weeks after entry into the study, there was no significant difference in the BDI scores between the two groups: unadjusted BDI scores were 15.2 (counselling group) and 14.8 (antidepressant group). Using the Research Diagnostic Criteria for depression, there was no difference in the response rate for the two groups, each yielding 69% of patients having resolved their depression. However, if all non-responders were assumed to be treatment failures, then the rates became 48% (counselling) and 57% (antidepressants), an odds-ratio of 1.42. At 12 month follow-up, there was no significant difference reported in the mean BDI scores between the two treatment groups in the randomised controlled trial10Go. There was also no evidence of a treatment by preference interaction. Hence, the randomised and patient preference groups were combined. Overall, the study reported similar outcomes (i.e. end state BDI) for counselled (BDI mean = 13.2) versus those receiving antidepressants (BDI mean = 12.8). The extent of pre-post treatment change can be represented by a within-group change effect size (ES; pre-treatment score minus post-treatment score divided by the pooled standard deviation of the pre-treatment scores for all groups). Figure 1 presents the change ESs at post-treatment and 12 month follow-up for this study. The difference in ESs at post-treatment approaches zero and at 12 months is small (i.e. 0.25).



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  		Fig. 1 Comparison of within-group effect sizes for the Trent, London/Manchester, and Derbyshire counselling studies at initial follow-up and 12-month follow-up.

 
Non-directive counselling in the management of depression in primary care

A logical extension to the comparison of counselling with psychotropic medication is to compare counselling with another brand of psychological therapy. A twin-site study carried out in London and Manchester addressed this issue by establishing the clinical and cost-effectiveness of two forms of intervention – NDC and CBT – compared with treatment-as-usual from the GP in the management of depression in primary care settings11GoGo–13Go. The study was a pragmatic RCT accompanied by two further allocation methods which took into account patient preference: (i) the option of treatment (i.e. preference allocation); and (ii) the option to be randomised to one of the psychological interventions only. The sample comprised 464 patients of whom 197 were randomised between the 3 treatments; 137 selected a specific treatment; and 130 were randomly allocated between one of the two psychological treatments. Follow-up assessments were at 4 and 12 months. The study comprised 24 GP practices in Greater Manchester and in London and comprised a total of 73 GPs.

Treatments comprised two brief psychological interventions delivered in 12 sessions or less. One was non-directive counselling (NDC) and was provided by counsellors were met accreditation for the British Association for Counselling (now the British Association for Counselling and Psychotherapy). The other was cognitive-behaviour therapy (CBT) and was provided by clinical psychologists who were qualified for accreditation by the British Association for Behavioural and Cognitive Psychotherapies (BABCP). Usual GP care comprised standard interactions with patients relating to their presenting symptoms and the prescription of medication. GPs were asked not to refer patients assigned to this condition for psychological interventions for a minimum period of 4 months.

The intake scores on the BDI for patients in the 3-way randomised group were 25.4 (NDC), 27.6 (CBT), and 26.5 (GP group). Outcomes included measures of depressive symptoms as well as general psychiatric symptoms, social functioning, and patient satisfaction. The outcomes, as represented by mean BDI scores, for patients randomised to one of the 3 treatment groups at 4 months and 12 months respectively were 11.5 and 11.1 (NDC), 12.7 and 9.3 (CBT), and 17.2 and 10.2 (GP care). The within-group change ESs are presented in Figure 1. At 4 months, there is a clear advantage to counselling (and CBT) over usual GP care represented by a medium ES advantage to counselling (and a slightly larger ES for CBT). Economic costs were calculated at both 4 months and 12 months and for direct, indirect, and societal (i.e. the sum of direct and indirect costs) costs. The results are summarised in Figure 2. Although this shows a consistent trend for NDC to have greater direct and indirect costs, the differences were not significant at either 4 months or 12 months between the randomised groups in total societal costs, total direct costs, or total indirect costs. The results of the efficacy data and the cost data can then be considered together. The significantly greater clinical effectiveness of both psychological interventions (CBT and NDC) at 4 months means that these treatments were more cost-effective approaches than standard GP care to reducing patients' depressive symptoms within this specific time frame.



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  		Fig. 2 Comparison of the average cost per patient (£s) in the London/Manchester study receiving CBT, counselling, and usual GP care at 4 month and 12 month follow-up.

 
Results suggested that the provision of brief psychological therapies in general practice is associated with greater short-term clinical benefit as compared with GP care. At 12 months, the psychological therapies yielded outcomes and costs broadly similar to standard GP care. Hence, it was concluded that service provision could be determined on other grounds (e.g. patient preferences).

Counselling patients with chronic depression

The previous two studies investigated counselling as a ‘single’ intervention compared with antidepressants, CBT, or usual GP care. A different question concerns the added value of providing counselling in combination with routine GP care. One study carried out in Derbyshire adopted this approach to evaluate the added value of counselling and routine GP care for patients presenting with chronic depression14Go. Hence, the two arms of the trial comprised counselling in combination with routine GP care versus routine GP care alone. This trial focused on patients presenting with mild-to-moderate symptoms of depression that they had experienced for the previous 6 months or more. However, no explicit or independent assessment of chronicity is reported. Patients presented with depression or anxiety as their main symptom and the severity level was operationalised in terms of a score of 14 or above on the BDI. Exclusion criteria included the following: severe depression or anxiety or anxiety only, ‘hard-to-treat’ patients (i.e. frequent attenders with unexplainable physical symptoms), and those who had received counselling in the past 6 months. There was no clinical assessment of presenting problems and all data are based on self-report schedules. Treatment was provided by 8 counsellors working across 9 GP settings and all were BAC accredited. Of the 8 counsellors, 6 took a broadly psychodynamic approach and 2 a mainly cognitive approach. Treatment was to be kept within 6–12 sessions (according to HA guidelines).

At intake, the mean BDI scores for the ‘combination’ and ‘alone’ groups were 21.5 and 19.9, respectively, a difference which approached statistical significance. More patients in the counselling group were prescribed medication at intake. At 6 months' follow-up, this difference disappeared. In addition, there were no statistically significant differences between groups in outcomes at 6 months (mean BDI = 16.0 for both groups) or at 12 months (mean BDI = 15.0 and 15.3 for combination and alone groups, respectively). However, as shown in Figure 1, the within-group ES was greater for counselling and GP care in combination although the difference in ES between the 2 groups was small. The authors acknowledge that one weakness of the trial design was that there were two different counselling approaches. Hence, they analysed the study only including PD-treated patients and similar results were obtained. Given the broad equivalence of the outcomes of the two groups, the study turned to address the question of which treatment is the more cost-effective? No significant cost differences were found between the groups at any time once the intervention costs had been excluded. However, receiving counselling increased the primary care costs during the interventions period – a cost that was not offset at a later stage via a reduction in service use.

Summary of counselling and depression

In summary, there is now a developing evidence-base suggesting the efficacy of counselling for the treatment of depression. Key studies have been presented above and are summarised in Box 1. The counselling studies described have utilised sensitive and informative designs (e.g. patient preference trials) which go some way to being able to generalise results from efficacy trials to routine practice. However, a counter argument lies in the cost in research terms and their complexity. To provide a balance to the focus on outcomes, process studies of generic counselling need to be implemented to better specify the effective ingredients of generic counselling.


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  		Box 1 Summary of counselling research on depression

 

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  		Box 2 Summary of research on interpersonal therapies for depression

 

   Interpersonal therapies
Top
 Footnotes
 Abstract
 Introduction
 Counselling as a treatment...
 Interpersonal therapies
Conclusions
 References
 
Forms of interpersonal therapies

Psychodynamic and interpersonal models and treatments of depression are based on the premise that depression occurs in a social and interpersonal context that needs to be understood for improvement to occur20GoGoGoGo–24Go. Psychoanalytic theorists, and more recently cognitive theorists25Go have described how early childhood experiences of interpersonal processes are important precursors of depression, in particular, the quality of the child–parent (usually mother) relationship.

In contrast, interpersonal theorists have tended to focus on the functional role of depression, looking at how problematic interpersonal interactions develop when a person becomes depressed.

There are three main forms of structured therapies used in research studies that have developed from interpersonal theories. These include interpersonal psychotherapy (IPT)26Go, psychodynamic-interpersonal therapy (PDIPT)27Go,28Go, and short-term psychodynamic psychotherapy (STPDT)29GoGo–31Go. IPT contrasts with the latter two forms of therapy in that it focuses on current rather than past relationships, and on the patient's social context rather than personality features that have their origin in early experiences. The distinctive feature of PDIP therapy is that patients are encouraged to focus on their here and now experiences, particularly emotional and relationship experiences. Both PDIPT and STPDT incorporate psychodynamic understandings of the early origins of depressive experiences. In this chapter when referring generally to these therapies we have used the term interpersonal therapy (IPT).

Content of interpersonal therapies

In a review of the distinctive features of IP therapies32Go, seven types of interventions have been identified: (i) a focus on patients' emotions; (ii) an exploration of resistance or factors that inhibit the progress of therapy; (iii) discussion of patterns evident in patients' relationships and experiences; (iv) an emphasis on the past; (v) an emphasis on patients' interpersonal experiences; (vi) an exploration of the therapeutic relationship; and (vii) an exploration of patients' wishes and fantasies.

Confirmation of these distinctive features is found in studies that compare IP therapies with other (generally cognitive and behavioural [CB]) therapies. For example, a study was carried out of the therapeutic focus in PDIP and CB sessions from the Second Psychotherapy Project (SPP2)33Go. The study applied the five scales of the Coding System of Therapeutic Focus to two sessions of each SPP2 patient who had received 16 sessions of therapy. The authors found a large number of differences between the therapeutic focuses in the two treatment modes. In PDIP sessions, therapists were more likely to note how patients might be behaving in a way which could interfere with the process of therapy. There was a greater focus on the therapist and on the patient's parents and past life, including childhood, and on linking together different aspects of the patient's life, such as events that occurred at different times and with different individuals. Therapists in PDIP sessions were less likely to focus on external situations and the future than therapists in CB sessions. PDIP sessions were also characterised by a significantly greater focus on emotion than CB sessions.

In addition, therapist's session intentions for CB and PDIP therapies were investigated in the SPP2 study34Go. Results showed significant differences between the two therapy types, with less of the intentions of re-inforcing and encouraging change, patients' cognition's and behaviours, and getting information in PDIP, and more of the intentions of feelings-awareness, insight and patient–therapist relationship problems. Further examination of the differences between IP and other therapies has focused on the therapeutic relationship. For example, based on a self report alliance measure35Go, patients who received CB therapy rated their relationship with their therapist as slightly more positive than patients who had PDIP therapy. They also reported a stronger partnership with, and greater confidence in, their therapist.

‘Impact’ refers to a session's immediate subjective effects, including patients' evaluations of the session, their assessment of the session's specific character, and their post-session affective state. Patients' reactions to sessions must logically intervene between session process and the final outcome of the treatment. PDIP and CB therapy of the Sheffield Projects were clearly experienced differently by patients and therapists. Patients reported that PDIP sessions were less smooth (i.e. less comfortable and more distressing) and less problem focused (i.e. both less emphasis in defining and working on the problem) than CB sessions. Patients also reported more negative impacts in PDIP compared to CB therapy36Go. Changes in impact for PDIP sessions were significantly greater than those for CB. For example, although initial patient ratings of session smoothness, positive mood and therapeutic relationship were less positive for PDIP than for CB therapy, this difference was not significant by the end of therapy. This may reflect difficult early sessions in PDIP, with an emotional focus, which became smoother, with a better patient–therapist relationship, over time. Problem solving also showed greater change in PDIP, indicating that this process was less evident in early sessions. In PDIP therapy, more severely depressed patients rated sessions as rougher and their post-session mood was less positive than those with more mild depression. This pattern was not found for CB patients.

Treatment efficacy

Studies focusing on the outcomes of IP therapies have been reviewed37Go,38Go. The conclusions of these reviews are still current: generally, trials have found IP therapies to be effective in the treatment of depression. Comparative studies have found the outcomes of different therapies to be similar, although in a minority of early studies found STPD therapies to be less effective than the comparison therapy39Go,40Go .The primary clinical trial of IPT is the NIMH Treatment of Depression Study41Go,42Go. This study compared the efficacy of IPT, cognitive therapy (CT), imipramine and a control condition of a placebo tablet plus clinical management, delivered across three different sites. All patients met criteria for major depressive disorder. Essentially all three active treatments produced similar reductions in depressive symptoms, overall functioning and social adjustment. Subsequent re-analysis of the data found that imipramine and IPT were more effective than CT for patients who were more severely depressed at the start of treatment.

The Second Sheffield Psychotherapy Project (SPP2)28Go,43Go compared PDIP therapy with a CB therapy delivered as either 8 or 16 weekly sessions in which patients were stratified for severity according to the BDI (low, moderate, severe). This study found that reductions in patients' depressive symptoms and improvements in their self-esteem and general well-being were substantial and broadly similar following either CB or PDIP psychotherapy. Figure 3 presents the change ESs at 3 month and 12 month follow-up for PDIP and CBT for 8 and 16 session treatments calculated by averaging the ESs for each of the three severity levels within each treatment condition. A related study from the Sheffield group investigated 3 sessions of PDIP versus CBT. Reported pre-post ESs after the 3 sessions were 0.83 for CBT and 0.92 for PDIP. At 12 months, these fell to 0.55 and 0.86, respectively44Go.



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  		Fig. 3 Comparison of the average within-group effect size in the Second Sheffield Psychotherapy Project for each of the treatment modalities (CBT or PI therapy) x duration (8 or 16 sessions) at 3 month and 12 month follow-up.

 
In summary, the available evidence, although not large, comprises a select number of high quality trials that show IP therapies to perform broadly as well as CT, which is often viewed as the more researched treatment of depression. However, more studies are required in this area, particularly focusing on the psychodynamic therapies.

Individual differences in treatment outcome

Martial status significantly contributed to overall outcome differences in SPP228Go and the NIMH study41Go,42Go: single patients were significantly more depressed (as indicated by their BDI scores), 3 months and 1 year after treatment, than were married, divorced or widowed patients. In SPP2, patients' ratings of their treatment's credibility was also predictive of treatment outcome45Go: the greater the patients' expectations of treatment, both immediately before and immediately after their first session, the greater their improvements in therapy. This latter finding was significant only for patients who received the shorter of the two therapy lengths, although it applied regardless of therapy type. For patients who received 16 sessions of therapy, their expectations of treatment did not predict outcome at either the end or in the middle of therapy.

Patient characteristics found to differentially predict outcome in SPP2 were patients' endorsement of treatment principles45Go and diagnosis of a Cluster C personality disorder46Go. Cluster C personality disorders include dependent, avoidant and obsessive-compulsive disorders, which are the personality disorders most frequently associated with depression47Go. In CB therapy, neither patients' endorsements of any treatment principles nor a diagnosis of a personality disorder predicted treatment outcome. In contrast, patients who indicated lower endorsement of either CB or PDIP treatment principles, or patients who had a diagnosis of a personality disorder, did less well in PDIP therapy than those patients who highly endorsed CB or PDIP treatment principles, or who had no personality disorder diagnosis. The former findings suggest that maximum benefit from psychotherapy would not be achieved by simply offering patients the therapy they preferred. What appears to be more important, at least for PDIP therapy, is the extent of endorsement of the patient's psychological treatment. This aptitude or knowledge enables patients to make better use of PDIP therapy45Go. In the NIMH study, IPT was found to be more effective than CT for depressed patients with elevated levels of obsessive personality48Go. Single patients also improved more in IPT than in CT, leading these authors to suggest that patients did better in therapies that ‘matched’ their personality or interpersonal styles.

The possibility that therapists are responsive to the interpersonal style of patients was examined in a study using SPP2 data. It was hypothesised that patient interpersonal styles would ‘pull’ therapists to respond differentially even within theoretically pure, manualised therapies. SPP2 patients were divided according to their predominant interpersonal styles. Patients were classified as either overinvolved, underinvolved, or balanced in close interpersonal relationships. Therapists' responses to patients were then examined using the Therapist Session Intentions (TSI)34Go and independent ratings of therapist interventions (Sheffield Psychotherapy Rating Scale)49Go. These measures contain scales that tap CB and PDIP specific techniques and therapists tended to use more affective and relationship-oriented interventions with overinvolved patients, consistent with these patients' overriding concern about maintaining relationships. Therapists tended to use more cognitive treatment methods with underinvolved patients consistent with these patients' more distant, cognitive approaches to relationships. This finding was only significant for CB therapy50Go. This may be because therapists were able to use a greater range of interventions in CB than in PDIP therapy. PDIP procedures aimed at maintaining the therapeutic alliance and dealing with affect may be easily ‘borrowed’ by CB therapists as part of the collaborative approach, whereas addressing faulty cognitions and setting behavioural tasks are not easily woven into PDIP therapy.

A further study was conducted to help understand the process of responsiveness a qualitative study examining sections of therapy transcript was conducted. Transcripts that contained events that patients indicated had been the most helpful in the session were analysed. Patients' attachment style, attachment issues, and therapist response to the identified attachment issues were categorised51Go. Attachment issues tended to focus on three themes: (i) concerns about loss or rejection; (ii) conflict and danger; and (iii) the need for closeness or proximity. The authors hypothesised that therapists' responses to patients' attachment issues would be mediated by patients' attachment styles and indeed there is evidence for this: therapists responded to patients with preoccupied attachment styles with reflective interventions and to patients with dismissing styles with interpretative interventions51Go.

Processes of change

Effective targeting of treatment depends, in part, on patients' presentation of their problems. The assimilation model52Go describes how patients present and may resolve their problems and how therapists' interventions assist in this process. The assimilation model argues that patients describe their problems in a way that reflects the degree to which they have assimilated a problematic experience into their own schemata. Schemata here represent cognitive structures that provide meaning and, therefore, link together a person's experiences. Several case studies have provided evidence that patients progress through the stages of assimilation during successful PDIP therapy53Go,54Go.

The assimilation model also suggests that patients with poorly assimilated problems should do better in PDIP therapy. Therapists using PDIP therapies often consider the patient's presenting complaints as reflecting experiences that are not yet accessible or are avoided (low levels of assimilation). In these therapies, formulation of the problem and insight (moderate levels of assimilation) are often the therapeutic goals. Patients indicated that early sessions of PDIP therapy had lower levels of problem solving, were rougher, and had lower ratings of post-session positive mood than CB sessions36Go. CB therapies, in contrast, focus more on known problems, applying rational and practical solutions (high levels of assimilation). This suggests that patients with relatively clearly described problems will do better in CB therapies. This is consistent with the notion that therapists' begin work at lower levels of the assimilation model in PDIP therapy. Significant differences were found between the assimilation levels in good sessions of PDIP and CB sessions55Go. In PDIP sessions, therapy tended to focus on themes at lower assimilation levels, with a mean level between the stages of vague awareness and problem statement. In contrast, in CB sessions therapy focused on themes at higher assimilation levels, with a mean level between the stages of understanding and application. It was found that patients entering therapy with relatively well assimilated problems did better in CB than PDIP therapy56Go. However, patients with poorly assimilated problems did equally well in both CB and PDIP therapy.

Summary of IP therapies and depression

There are three main forms of IP that have been studied. These therapies have been found to differ in their content to the cognitive and behavioural therapies, although treatment outcomes for depression remain similar across therapies. Important factors influencing treatment outcome in IP therapies are engaging patients in the process of treatment; providing an appropriate focus to treatment; and recognising the impact of patients' interpersonal histories on the treatment process itself, and on the ability of patients to maintain the gains they make in treatment.

PDIP therapy appears to require patients' commitment to psychological therapy prior to therapy starting. So, for example, both patients' treatment preferences and degree of psychological orientation predicted outcome in PDIP therapy. In addition, patients with well assimilated problems did better in CB than PDIP therapy in SPP2. These findings suggest therapists should socialise patients into the treatment process, and carefully assess patients needs and formulate their problems, so that therapy can both clarify and be targeted at key patient problems.

Together the studies suggest that it is important for therapists to be flexible and responsive to patient needs, especially to the interpersonal or attachment issues that confront patients. Patients also did better in therapy if they were confident in their therapists, as attachment theory would predict. In particular, assimilation of problematic experiences seems to occur when therapists are firm, collaborative and challenging.

Finally, important and distinctive elements of PDIP therapy have been found to focus on two elements. First, finding the right language that captures the patients' experiences and is understood by both therapist and patient is a central component of PDIP therapy27Go and highlighted by a number of studies51Go,57Go. Second, studies have linked change in therapy to the experiential element of PDIP therapy, namely the experiencing of feelings and events in the here and now55Go,58Go.


   Conclusions
Top
 Footnotes
 Abstract
 Introduction
 Counselling as a treatment...
 Interpersonal therapies
 Conclusions
References
 
The above efficacy studies have made considerable headway in securing the evidence-base for counselling and the IP therapies. This meets the current need for evidence-based practice in the psychological therapies59Go. However, there now needs to be a concerted effort to support and carry out studies in routine settings (i.e. effectiveness studies) that will deliver to the complementary paradigm of practice-based evidence60Go. Although the studies reported here employed a common outcome measure (i.e. the BDI) – largely because of the focus on depression – studies of counselling and the IP therapies are likely to comprise more heterogeneous samples and there is need for the adoption of a pan-theoretical outcome measure61Go. The strength of the research in the IP therapies is in the focus on investigating what is happening and how this might account for change. In this respect, research in the IP therapies had yielded greater understanding of the models of change. A focus for future research would be on the inter-session change process as opposed to focusing on the session itself, and on broadening the evidence-base to non-research settings.


   Footnotes
Top
 Footnotes
Abstract
 Introduction
 Counselling as a treatment...
 Interpersonal therapies
 Conclusions
 References
 
Correspondence to: Prof. Michael Barkham, Psychological Therapies Research Centre, University of Leeds, 17 Blenheim Terrace, Leeds LS2 9JT, UK


   References
Top
 Footnotes
 Abstract
 Introduction
 Counselling as a treatment...
 Interpersonal therapies
 Conclusions
 References
 

  1. Rowland N, Goss S. (eds) Evidence-Based Counselling and Psychological Therapies. London: Routledge; 2000
  2. Department of Health. Treatment Choice in Psychological Therapies and Counselling: Evidence Based Clinical Practice Guidelines. London: The Stationery Office; 2001
  3. British Association of Counselling (BAC). Code of Ethics and Practice for Counsellors. Rugby: BAC; 1992
  4. Mellor-Clark J, Simms-Ellis RE, Burton M. National Survey of Counsellors Working in Primary Care: Evidence for Growing Professionalisation. Occasional paper 79. London: Royal College of General Practitioners, 2001
  5. Mellor-Clark J. (ed) Symposium: developing practice and evidence for counselling in primary care. Br J Guidance Counselling 2000; 28: 157–266
  6. Roth A, Fonagy P. What Works for Whom? A Critical Review of Psychotherapy Research. New York: Guilford, 1996
  7. Godber E. Is Counselling in Primary Care Growing too Fast? A Clinical, Economic and Strategic Assessment. Southampton: Institute for Health Policy Studies, University of Southampton, 1996
  8. Rowland N, Godfrey C, Bower P, Mellor-Clark J, Heywood P, Hardy R. Counselling in primary care: a systematic review of the research evidence. Br J Guidance Counselling 2000; 28: 215–31
  9. Bedi N, Chilvers C, Churchill R et al. Assessing effectiveness of treatment of depression in primary care. Partially randomised preference trial. Br J Psychiatry 2000; 177: 312–8[Abstract/Free Full Text]
  10. Chilvers C, Dewey M, Fielding K et al. Antidepressant drugs and generic counselling for treatment of major depression in primary care: randomised trial with patient preference arm. BMJ 2001; 322: 772–5[Abstract/Free Full Text]
  11. King M, Sibbald B, Ward E et al. Randomised controlled trial of non-directive counselling, cognitive-behaviour therapy and usual general practitioner care in the management of depression as well as mixed anxiety and depression in primary care. Health Technol Assess 2000; 4: 19
  12. Ward E, King M, Lloyd M et al. Randomised controlled trial of non-directive counselling, cognitive-behaviour therapy, and usual general practitioner care for patients with depression. I: Clinical effectiveness. BMJ 2000; 321: 1383–8[Abstract/Free Full Text]
  13. Bower P, Byford S, Sibbald B et al. Randomised controlled trial of non-directive counselling, cognitive-behaviour therapy, and usual general practitioner care for patients with depression. II: Cost-effectiveness. BMJ 2000; 321: 1389–92[Abstract/Free Full Text]
  14. Simpson S, Corney R, Fitzgerald P, Beecham J. A randomised controlled trial to evaluate the effectiveness and cost-effectiveness of counselling patients with chronic depression. Health Technol Assess 2000; 4: 36
  15. Beck AT, Ward CH, Mendelson M, Mock J, Erlbaugh J. An inventory for measuring depression. Arch Gen Psychiatry 1961; 4: 561–71[Abstract/Free Full Text]
  16. Boot D, Gillies P, Fenelon J, Reubin R, Wilkins M, Gray P. Evaluation of the short term impact of counselling in general practice. Patient Educ Counsel 1984; 24: 79–89
  17. Friedli K, King M, Lloyd M, Horder J. Randomised controlled assessment of non-directive psychotherapy versus routine general-practice care. Lancet 1997; 350: 1662–5[Web of Science][Medline]
  18. Harvey I, Nelson S, Llyons R, Unwin C, Monaghan S, Peters T. A randomised controlled trial and economic evaluation of counselling in primary care. Br J Gen Pract 1998; 48: 1043–8[Web of Science][Medline]
  19. Hemmings A. Counselling in primary care: a randomised controlled trial. Patient Educ Counsel 1997; 32: 219–30[Web of Science][Medline]
  20. Brown GW, Harris T. Social Origins of Depression. New York: Free Press, 1978
  21. Cohen MB, Baker G, Cohen R, Fromm-Reichmann F, Weigert EV. An intensive study of 12 cases of manic-depressive psychosis. 1954. Reprinted in: Coyne JC (ed) Essential Papers on Depression. New York: New York University Press, 1985
  22. Coyne JC. Depression and the response of others. J Abnorm Psychol 1976; 85: 127–40
  23. Freud S. Morning and melancholia (1917). Reprinted in: Coyne JC (ed) Essential Papers on Depression. New York: New York University Press, 1985
  24. Mendelson M. Psychoanalytic Concepts of Depression. Springfield, IL: Thomas, 1960
  25. Alloy LB. The developmental origins of cognitive vulnerability to depression: negative interpersonal context leads to personal vulnerability. Cog Ther Res 2001; 25: 349–51
  26. Klerman GL, Weismann NM, Rounsaville BJ, Chevron ES. Interpersonal Psychotherapy of Depression. New York: Basic Books, 1984
  27. Hobson RF. Forms of Feeling: The Heart of Psychotherapy. New York: Basic Books, 1985
  28. Shapiro DA, Barkham M, Rees A, Hardy GE, Reynolds S, Startup M. Effects of treatment duration and severity of depression on the effectiveness of cognitive-behavioral and psychodynamic-interpersonal psychotherapy. J Consult Clin Psychol 1994; 62: 522–34[Web of Science][Medline]
  29. Malan DH. The Frontier of Brief Psychotherapy. New York: Plenum, 1976
  30. Luborsky L. Principles of Psychoanalytic Psychotherapy: A Manual for Supportive-Expressive Treatment. New York: Basic Books, 1984
  31. Strupp HH, Binder JL. Psychotherapy in a New Key: A Guide to Time – Limited Dynamic Psychotherapy. New York: Basic Books, 1984
  32. Blagys MD, Hilsenroth MJ. Distinctive features of short-term psychodynamic-interpersonal psychotherapy: a review of the comparative psychotherapy literature. Clin Psychol Sci Pract 2000; 7: 167–88[Medline]
  33. Goldfried MR, Castonguay LG, Hayes AM, Drozd JF, Shapiro DA. A comparative analysis of the therapeutic focus in cognitive-behavioral and psycho-dynamic-interpersonal sessions. J Consult Clin Psychol 1997; 65: 740–8[Web of Science][Medline]
  34. Stiles WB, Startup M, Hardy GE et al. Therapist intentions in cognitive-behavioral and psychodynamic-interpersonal psychotherapy. J Counsel Psychol 1996; 43: 402–14[Web of Science]
  35. Agnew-Davies R, Stiles WB, Hardy GE, Barkham M, Shapiro DA. Alliance structure assessed by the Agnew Relationship Measure (ARM). Br J Clin Psychol 1998; 37: 155–72[Web of Science][Medline]
  36. Reynolds S, Stiles WB, Barkham B, Shapiro DA, Hardy GE, Rees A. Acceleration of changes in session impact during contrasting time-limited psychotherapies. J Consult Clin Psychol 1996; 64: 577–86[Web of Science][Medline]
  37. Roth A, Fonagy P. What Works for Whom: A Critical Review of Psychotherapy Research. New York: Guilford, 1996
  38. Shapiro DA. Efficacy of psychodynamic, interpersonal, and experiential therapies. In: Checkley S. (Ed) The Management of Depression. Oxford: Blackwell, 1998
  39. MacLean PD, Hakstian AR. Clinical depression: comparative efficacy of outpatient treatments. J Consult Clin Psychol 1979; 47: 818–36[Web of Science][Medline]
  40. Steuer JL, Mintz J, Hammen CL et al. Cognitive–behavioral and psychodynamic group psychotherapy in treatment of geriatric depression. J Consult Clin Psychol 1984; 52: 180–9[Web of Science][Medline]
  41. Elkin I, Shea MT, Watkins JT et al. NIMH Treatment of Depression Collaborative Research Program: general effectiveness of treatments. Arch Gen Psychiatry 1989; 46: 971–83[Abstract/Free Full Text]
  42. Elkin I. The NIMH Treatment of Depression Collaborative Research Program: where we began and where we are. In: Bergin AE, Garfield SL. (eds) Handbook of Psychotherapy and Behavior Change, 4th edn. New York: Wiley, 1994
  43. Shapiro DA, Rees A, Barkham M, Hardy GE, Reynolds S, Startup M. Effects of treatment duration and severity of depression the maintenance of gains after cognitive-behavioral and psychodynamic-interpersonal psychotherapy. J Consult Clin Psychol 1995; 63: 378–87[Web of Science][Medline]
  44. Barkham M, Shapiro DA, Rees A, Hardy GE. Psychotherapy in two-plus-one sessions: outcomes of a randomized controlled trial of cognitive-behavioral and psychodynamic-interpersonal therapy for subsyndromal depression. J Consult Clin Psychol 1999; 67: 201–11[Web of Science][Medline]
  45. Hardy GE, Barkham M, Shapiro DA, Reynolds S, Rees A, Stiles WB. Credibility and outcome of cognitive-behavioural and psychodynamic-interpersonal psychotherapy. Br J Clin Psychol 1995; 34: 555–69[Web of Science][Medline]
  46. Hardy GE, Barkham M, Shapiro DA, Stiles WB, Rees A, Reynolds S. Impact of cluster C personality disorders on outcomes of contrasting brief psychotherapies for depression. J Consult Clin Psychol 1995; 63: 997–1004[Web of Science][Medline]
  47. Pilkonis PA, Frank E. Personality pathology in recurrent depression: Nature, prevalence, and relationship to treatment response. Am J Psychiatry 1988; 145: 435–41[Abstract/Free Full Text]
  48. Barber J, Muenz P, Larry R. The role of avoidance and obsessiveness in matching patients for cognitive and interpersonal psychotherapy: empirical findings from the Treatment for Depression Collaborative Research Program. J Consult Clin Psychol 1996; 64: 951–8[Web of Science][Medline]
  49. Startup M, Shapiro DA. Therapist treatment fidelity in prescriptive vs. exploratory therapy. Br J Clin Psychol 1993; 32: 443–56[Web of Science][Medline]
  50. Hardy GE, Stiles WB, Barkham M, Startup M. Therapist responsiveness to client interpersonal styles during time-limited treatments for depression. J Consult Clin Psychol 1988; 66: 304–12
  51. Hardy GE, Aldridge J, Davidson C, Reilly S, Rowe C, Shapiro DA. Therapist responsiveness to client attachment styles and issues observed in client-identified significant events in psychodynamic-interpersonal psychotherapy. Psychother Res 1999; 9: 36–53[Web of Science]
  52. Stiles WB, Elliott R, Llewelyn SP et al. Assimilation of problematic experiences by clients in psychotherapy. Psychotherapy 1990; 27: 411–20[Web of Science]
  53. Field SD, Barkham M, Shapiro DA, Stiles WB. Assessment of assimilation in psychotherapy. A quantitative case study of problematic experiences with a significant other. J Counsel Psychol 1994; 41: 397–406[Web of Science]
  54. Stiles WB, Morrison L, Haw S, Harper H, Shapiro DA, Firth-Cozens J. Longitudinal study of assimilation in exploratory psychotherapy. Psychotherapy 1991; 28: 195–206[Web of Science]
  55. Mackay HE, Barkham M, Stiles WB. Staying with the feeling: an anger event in psychodynamic-interpersonal therapy. J Counsel Psychol 1998; 45: 279–89[Web of Science]
  56. Stiles WB, Shankland M, Wright J, Field S. Aptitude-treatment interactions based on clients' assimilation of their presenting problems. J Consult Clin Psychol 1997; 65: 889–93[Web of Science][Medline]
  57. Elliott R, Shapiro DA. Client and therapist as analysts of significant events. In: Toukmanian SG, Rennie DL. (eds) Psychotherapeutic Change: Theory Guide and Descriptive Research Strategies. Newbury Park, CA: Sage, 1992
  58. Hardy GE, Rees A, Barkham M, Shapiro DA, Field SD, Elliott R. ‘Whingeing versus working’: Comprehensive Process Analysis of a vague awareness event. Psychother Res 1998; 8: 334–53[Web of Science]
  59. Parry G. Evidence-based psychotherapy: an overview. In: Rowland N, Goss S. (eds) Evidence-Based Counselling and Psychological Therapies. London: Routledge, 2000
  60. Barkham M, Mellor-Clark J. Rigour and relevance: practice-based evidence in the psychological therapies. In: Rowland N, Goss S. (eds) Evidence-Based Counselling and Psychological Therapies. London: Routledge, 2000
  61. Barkham M, Margison F, Leach C et al. Service profiling and outcomes benchmarking using the CORE-OM: towards practice-based evidence in the psychological therapies. J Consult Clin Psychol 2001; 69: 184–96[Web of Science][Medline]

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G. Whitfield and C. Williams
The evidence base for cognitive-behavioural therapy in depression: delivery in busy clinical settings
Adv. Psychiatr. Treat., January 1, 2003; 9(1): 21 - 30.
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