Non-directive supportive therapy (NDST) has been defined as “a psychological treatment in which therapists do not engage in any therapeutic strategies other than active listening and offering support, focusing on participants’ problems and concerns” (Arean et al., 2010).
We know from research studies that there are many types of psychological therapy that work well in treating depression in adults. These include cognitive behaviour therapy, interpersonal psychotherapy, behavioural activation therapy and problem-solving therapy.
However, the meta-analyses that have been conducted over recent years have failed to show any significant differences in the effectiveness of these different treatments, which has led some researchers to speculate that most effects of psychological treatments are caused by common, non-specific factors and not by particular techniques (Cuijpers, 1998).
In 1992 Michael Lambert published a book in which he estimated that 40% of the improvement in clients was caused by extra-therapeutic change, 30% by the therapeutic relationship, 15% by client expectations, and the remaining 15% by specific techniques (Lambert, 1992).
This new study is the first meta-analysis to compare non-directive supportive therapy (NDST) with controls and other psychotherapies in the treatment of adult depression. A main objective of the research was to estimate the contribution that different factors had on recovery.
The research team found 31 studies (involving 2,508 patents in total) to include in their analysis. They searched the www.evidencebasedpsychotherapies.org database, which is a continuously updated database of randomised controlled and comparative studies examining the effects of psychotherapy for adult depression. The quality of the included studies was varied, with 8 of the 31 studies meeting all of the quality criteria and 12 meeting 3 out of 4.
Here’s what they found:
- NDST is effective in the treatment of depression in adults (g = 0.58; 95% CI: 0.45–0.72)
- NDST appears to be less effective than other psychological therapies, but these differences disappear when the analysis controls for researcher allegiances. Put another way, studies written by researchers who have a vested interest in a specific therapy tend to over-estimate the effects of that treatment (surprise surprise)
- The research team estimated that:
- Extra-therapeutic factors (including spontaneous recovery and community resources) are responsible for 33.3% of improvement
- Non-specific factors are responsible for 49.6% of improvement
- Specific factors are responsible for 17.1% of improvement
The researchers concluded:
Despite it’s limitations, this study has made it clear that NDST has a considerable effect on mild to moderate depression, that most of the effects of therapy for adult depression is accounted for by non-specific factors, and that the contribution of specific techniques in these patients is limited at best and may in fact be absent for many.
Links
- Cuijpers, P et al. The efficacy of non-directive supportive therapy for adult depression: A meta-analysis. Clinical Psychology Review 32, 2012, 280–291. [PubMed abstract]
- Arean, P. A. et al (2010). Problem-solving therapy and supportive therapy in older adults with major depression and executive dysfunction. The American Journal of Psychiatry, 167, 1391–1398.
- Cuijpers, P. (1998). Minimising interventions in the treatment and prevention of depression: Taking the consequences of the ‘Dodo bird verdict’. Journal of Mental Health, 7, 355–365. [Abstract]
- Lambert, M. J. (1992). Psychotherapy outcome research: Implications for integrative and eclectic therapists. In J. C. Norcross, & M. R. Goldfield (Eds.), Handbook of psychotherapy integration (pp. 94–129). New York: Basic Books.
I think it is perhaps very true that distinctions between therapies – and equally and in similar form, boundaries between disorders – are not as clear cut and discontinuous as their clinical proponents feel. There are artificial, over-played, specious distinctions in both therapy and diagnosis which is a symptom of clinical and academic history. There is an over-developed bubble of esoterica here. Together these specialised forms of high-concept collaboration on theory and practice try to understand and be complimentary to good progress between the zeniths of healthy and unhealthy patterns in personal functions and interactions, but far less helpfully and accurately than they should. The reality of what therapy is and what it tries to heal is fundamentally mundane variation of social mechanisms and personal states respectively. Not even always at it’s more outlying forms, merely those that were captured in formalised diagnosis and treatment.
We find geological texts and study and satellite photgraphs useful but to live on the ground with local knowledge, non-verbal understanding and heuristic theories and mnemonic narratives is useful every day.
The grains of truth in the psycho-analytic theory of transference is perhaps only expressed in a different way by the parental and child schemas of CBT-based schema therapy. It looks that way in the case of borderline personality disorder now I frequent support groups! But both are quite alien narratives to try to bring into conversation.
In this example of transference vs schema modes, different patients could have a more natural sympathy with one way or another of expressing this single non-platonic hub of a re-occurring functional pattern, or with neither and yet still experience it. If I make sense with these borrowed words. I think the science needs to build their theroretical models and test strategies piece by piece, variable against variable, for the sake of formal accuracy rather more than it should test established modalities for overall effectiveness. I think it’s really important that therapists are honest with patients about the nature of modalities – therapy being as much a purposeful art, even when it is generally tried and tested. There are rules to the use of perspective and the use of different paint mediums, and degrees of photo-reality that are objectively testable; therefore don’t be precious about the distinction between art and science, nor say that testable therapy is all-scientific.
Perhaps it helps in therapy for the therapist to have a good likeness in their mental picture, to start with a good mental model of the patient. And there is equally room for muddiness in this as there is for objective testability: classifying and creating a taxonomy of mental mental disorders is a process of cooperatively evolving a set of conceptual artifacts that refer to patterns in reality rather than contain them. Some people fit clearly into one disorder or another, or a few together. Others don’t, or are ‘a hodge-podge of clinical features’. There is a disconnect between therapy and diagnostic models. But in similar form, some points of a therapeutic model and strategy appear to carry more veracity, more practical use, more weight. And other factors outside of the model carry a lot of weight too. And the fit for each patient is relative. A therapist makes educated guesses and choices during the therapy process. Each therapy process is a hodge-podge of communication and theoretical transmission each with a slightly different flavour – one that either works or does not for the individual patient concerned. Therefore the various skills of the therapist and empathy/connection/compatibility with the patient underlie the decisions and success of a therapist. If these could be quantified it might predict how good a fit the therapy, patient, and therapist are together. That would be interesting and be quite useful.
When different therapists make educated guesses about what emphasis should be followed in the limited therapy time, and guess which modalities and strategies will help, there has to be lots of factors that affect how good these guesses are and how effective it is, for instance trait similarity.
I reckon therapist effectiveness increases with trait-similarity with the patient and increasing shared socio-cultural reference points up to a certain point and then drops off, in a bell curve. We should use user-friendly graphical scientific models, especially useful to show to keep Joe Patient in the loop. These emphasise continuous trait variation and unify psychiatry and psychology; particularly in the comparison of therapist-client relationship variables. I would love to see a more detailed analysis of the client-therapist relationship.
Going back to the idea of variation and continuity, I imagine coinciding pattern and partial continuity as a wide landscape of variation in a similar meta-pattern to the relationships between biological species, which is then imperfectly classified and discovered and revised in an on-going process. In psychiatric disorders the disease classification will shift just like historical taxanomical divisions and the placing of individual specimens is revised over time. But we are not specimens. Perhaps in that way the classification of geological and geographical features is a better analogy. Some rock specimens or topography or seaside dunes share features of more than one classification category or have unclear on indeterminate/intermediate presentation and that due to the precise and perhaps unusual mix of factors acting on them. Ideally the main familiar classifications represent the most common features and their origins, but the classifications could still need to be revised. Going back to psychiatry, perhaps there is a need for a different approach to revision. The DSM V is quite contraversial and a political as much as a scientific piece. As was always the case – prospectors, powers-that-be and the conservationist and the community were always very interested in geology geography. And this is even more fundamental. Nevertheless there is a job in representing the increased awareness of this complexity into useful theoretical and clinical work. Food for thought: http://www.ocfoundation.org/EO_TS.aspx This is an interesting but not particularly carefully researched and selected resource, it was a share in an OCD support group on facebook. It is a clinical perspective on diagnostic overlap and spectrum approaches. I think it doesn’t go far enough. But it’s a good start based on a particular practice focus.
If by convergent and indeed conversant thinking, clinicians and patients, the ordinary folk, start arriving at the same conclusions, and pick up more of those who currently slip through the remedial nets that would be good.
I apologise for wordiness! And to be clear it wasn’t the article I linked to that wasn’t well researched but only my selection of it that was not researched!
The skill is identifying with the depressed person their strenghs and needs and integrating a variety of techniques that will help the person. Therfore the therapist having a toolbox of techniques available to them,may be what is required.However this maybe excatly what NDST is delivering.On the other hand most current systems cite the evidence based intervention myth that CBT has the most evidenced for everything,perpetuating the myth that only CBT can treat common mental health problems and in this evidence based industry CBT is king.However as depression seems to be more common in areas of high socioeconomic need and in females and ethnic minority groups,iis it possible that therapy masks the real depression proplem being political?