Humanistic Therapies Versus Other Psycho

Humanistic therapies versus other psychological therapies for
depression (Protocol)
Churchill R, Davies P, Caldwell D, Moore THM, Jones H, Lewis G, Hunot V
This is a reprint of a Cochrane protocol, prepared and maintained by The Cochrane Collaboration and published in The Cochrane
Library 2010, Issue 9
http://www.thecochranelibrary.com
Humanistic therapies versus other psychological therapies for depression (Protocol)

Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
WHAT’S NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Humanistic therapies versus other psychological therapies for depression (Protocol) i

[Intervention Protocol]
Humanistic therapies versus other psychological therapies for

depression
Rachel Churchill1 , Philippa Davies1 , Deborah Caldwell2 , Theresa HM Moore1 , Hannah Jones3 , Glyn Lewis2 , Vivien Hunot1
1 AcademicUnit of Psychiatry, School of Social and Community Medicine, University of Bristol, Bristol, UK. 2 School of Social
and Community Medicine, University of Bristol, Bristol, UK. 3 Cochrane Schizophrenia Group, The University of Nottingham,
Nottingham, UK
Contact address: Rachel Churchill, Academic Unit of Psychiatry, School of Social and Community Medicine, University of Bristol,
Oakfield House, Oakfield Grove, Bristol, BS8 2BN, UK. rachel.churchill@ccdan.org. rachel.churchill@bristol.ac.uk.
Editorial group: Cochrane Depression, Anxiety and Neurosis Group.

Publication status and date: Edited (no change to conclusions), published in Issue 7, 2012.
Citation: Churchill R, Davies P, Caldwell D, Moore THM, Jones H, Lewis G, Hunot V. Humanistic therapies versus other
psychological therapies for depression. Cochrane Database of Systematic Reviews 2010, Issue 9. Art. No.: CD008700. DOI:
10.1002/14651858.CD008700.
ABSTRACT
This is the protocol for a review and there is no abstract. The objectives are as follows:
1. To examine the effectiveness and acceptability of all humanistic therapies compared with all other psychological therapy
approaches for acute depression.
2. To examine the effectiveness and acceptability of different humanistic therapy models (person-centred, gestalt, process-
experiential, transactional analysis, existential and non-directive therapies) compared with all other psychological therapy approaches
for acute depression.
3. To examine the effectiveness and acceptability of all humanistic therapies compared with different psychological therapy
approaches (psychodynamic, behavioural, humanistic, integrative, cognitive-behavioural) for acute depression.
BACKGROUND ture of depression, and people with severe depression may develop
psychotic symptoms (APA 2000).
Depression is the third leading cause of disease burden world-
wide and is expected to show a rising trend over the next 20 years
Description of the condition (WHO 2004; WHO 2008). A recent European study has esti-
Major depression is characterised by persistent low mood and loss mated the point prevalence of major depression and dysthymia
of interest in pleasurable activities, accompanied by a range of at 3.9% and 1.1% respectively (ESEMeD/MHEDEA 2004). As
symptoms including weight loss, insomnia, fatigue, loss of energy, the largest source of non-fatal disease burden in the world, ac-
inappropriate guilt, poor concentration and morbid thoughts of counting for 12% of years lived with disability (Ustun 2004), de-
death (APA 2000). Somatic complaints are also a common fea- pression is associated with marked personal, social and economic
Humanistic therapies versus other psychological therapies for depression (Protocol) 1
morbidity, loss of functioning and productivity and creates signif- termined by events, and implying a lack of free will) and towards
icant demands on service providers in terms of workload (NICE client choice and responsibility (Pilgrim 2002). Key psychological
2009). Depression is also associated with a significantly increased therapies considered as humanistic in approach include Gestalt
risk of mortality (Cuijpers 2002). The strength of this association, therapy (Perls 1976), existential therapy (Deurzen 1997), trans-
even taking account of confounders such as physical impairment, actional analysis (Berne 1961), person-centred therapy (Rogers
health-related behaviours and socio-economic factors, has been 1951), and process-experiential therapy (a manualised humanistic
shown to be comparable to, or greater than, the strength of the intervention combining person-centred therapy and emotion-fo-
association between smoking and mortality (Mykletun 2009). cused therapy) (Greenberg 1998).To date, person-centred therapy
remains the most commonly used psychotherapeutic approach in
UK health care settings (Stiles 2008) (see Types of interventions
Description of the intervention section for a detailed description of each type of therapy).
Clinical guidelines recommend pharmacological and psycholog-

ical interventions, alone or in combination, in the treatment of
moderate to severe depression (NICE 2009). Antidepressant pre- How the intervention might work
scribing has increased dramatically in many Western countries over Humanistic psychological therapies are based on the premise that
the last 20 years, mainly with the advent of selective serotonin people are ‘self-actualizing’, that is, they have an inherent tendency
reuptake inhibitors and newer agents such as venlafaxine. Antide- to develop their potential (Rogers 1951; Maslow 1970). Other
pressants continue to be the mainstay of treatment for depression defining characteristics of humanistic therapies include the belief
in health care settings (Ellis 2004, NICE 2009). that people are self-aware, are free to choose how they will live,
Whilst antidepressants are of proven efficacy for the acute treat- are responsible for the choices they make, and are unique entities
ment of depression (Guaiana 2007; Arroll 2009; Cipriani 2009a; that need to be understood in the context of their individual ex-
Cipriani 2009b; Cipriani 2009c), adherence rates remain very low periences and characteristics (Cain 2002).
(Hunot 2007; van Geffen 2009), due in part to patients’ concerns In clinical practice, manualised or highly specific treatments for
about side effects and possible dependency (Hunot 2007). Fur- psychological disorders are largely avoided by humanistic thera-
thermore, surveys consistently demonstrate patients’ preference pists, on the basis that therapy should be individualised to fit with
for psychological therapies over that of antidepressants (Churchill the personal goals, preferences and values of each client. Whilst
2000; Riedel-Heller 2005). Therefore, psychological therapies contemporary models of humanistic therapies may differ some-
provide an important alternative intervention for depressive dis- what from a conceptual perspective and in terms of strategies/tech-
orders. niques, all emphasise the ‘growth-inducing power’ (Cain 2002) of
A diverse range of psychological therapies is now available for the therapeutic relationship. Therapist ‘core conditions’ of empa-
the treatment of common mental disorders (Pilgrim 2002). Psy- thy, genuineness and unconditional positive regard, described by
chological therapies may be broadly categorised into four sepa- Rogers 1951 as ‘the definable climate of facilitative psychological
rate philosophical and theoretical schools, comprising psychoana- attitudes’, are considered as cornerstones of therapy. Creation of
lytic/dynamic (Freud 1949; Klein 1960; Jung 1963), behavioural an optimal interpersonal environment to facilitate client insight,
(Watson 1924; Skinner 1953; Marks 1981), humanistic (Maslow leading to acceptance, change and personal growth with resulting
1943; Rogers 1951; May 1961) and cognitive approaches (Lazarus potential for a reduction in depression symptoms (Cain 2002).
1971; Beck 1979). Each of these four schools contains a num- Presenting problems are person rather than disorder-focused, and
ber of differing and overlapping psychotherapeutic approaches. individuals are treated as experts in their psychological distress.
Some psychotherapeutic approaches explicitly integrate compo- Whilst formal reduction in symptoms is not regarded as a goal in
nents from several theoretical schools (e.g. cognitive analytic ther- humanistic therapies practice, depression symptoms may decrease
apy (Ryle 1990)), or have been developed to address specific char- or remit as the client experiences increased self-acceptance and
acteristics associated with particular disorders (e.g. interpersonal personal growth.
therapy for depression (Klerman 1984)).
During the first half of the twentieth century, psychology had been
dominated by two schools of thought, behaviourism and psycho-
analysis. Humanistic psychological therapies were developed in
Why it is important to do this review
the 1950s and 60s as a protest against the diagnostic and pre- Clinical guidelines recommend cognitive behavioural therapy
scriptive approaches characterised by the analytic and behavioural (CBT) and interpersonal therapy as first-line treatments for peo-
schools (Thorne 2007). These so-called ‘third force’ psychology ple with moderate to major depressive disorder (Ballenger 2001;
approaches (Maslow 1959) brought about a paradigm shift, away NICE 2009) and counselling (which may include humanistic,
from the ’psychological determinism’ (the philosophical view that psychodynamic, or cognitive behavioural approaches, applied dis-
human cognition, behaviour, decision, and action, is causally de- cretely or integratively) for mild depression. The evidence-base

for humanistic therapy approaches in the treatment of common Randomised controlled trials (RCTs) will be eligible for inclusion
mental disorders in general, and specifically in depressive disor- in the review. Trials employing a cross-over design will be included
ders, is less extensive than for CBT-oriented therapies. Recent sys- in the review (whilst acknowledging that this design is rarely used
tematic reviews have been limited to person-centred/experiential in psychological therapy trials), using data from the first active
therapies (Elliott 2009), have combined a group of heterogeneous treatment stage only. Cluster RCTs will also be eligible for inclu-
supportive therapy approaches (Churchill 2001; Cuijpers 2008), sion.
conducted a narrative review only (Greenberg 2006), have not Quasi-randomised controlled trials, in which treatment assign-
conducted head to head comparisons (Elliott 2009) or are now ment is decided through methods such as alternate days of the
out of date (Churchill 2001). week, will not be eligible for inclusion.
Given that a high proportion of therapists and counsellors em-
ployed in UK primary care settings continue to use a person-cen-
tred approach (Stiles 2008), comprehensive review and meta-anal- Types of participants
ysis of currently available evidence is called for to ensure that as
far as possible it successfully represents and informs future health
care policy and clinical practice in the treatment of depressive dis- Participant characteristics
orders. Furthermore, acknowledging the diversity of approaches Studies of men and women aged ≥18 years will be included. A
under the umbrella of humanistic psychological therapies, exam- Cochrane review on psychotherapy for depression in children and
ination of the efficacy and comparative efficacy of differing hu- adolescents (<18 years) has been undertaken separately and is soon
manistic therapy approaches for the treatment of depression is of to be published (Watanabe 2004). The increasing prevalence of
considerable importance. This review forms part of a programme memory decline (Ivnik 1992), cognitive impairment (Rait 2005)
of 12 reviews covering behavioural, cognitive behavioural, psycho- and multiple comorbid physical disorders/polypharmacy (Chen
dynamic, interpersonal, cognitive analytic and other integrative, 2001) in individuals over 74 years may differentially influence the
humanistic and mindfulness-based ’third wave’ cognitive and be- process and effect of psychological therapy interventions. There-
havioural psychological therapies, all compared with treatment as fore, to ensure that older patients are appropriately represented
usual or with one another. in the review (Bayer 2000; McMurdo 2005) an upper age cut-
off of <75 years will be used (when a study may have included
individuals ≥75, we will include it so long as the average age is
<75), and a previously published Cochrane review on psychother-
OBJECTIVES apeutic treatments for older depressed people (Wilson 2008) will
be updated concurrently by the authors.
1. To examine the effectiveness and acceptability of all
humanistic therapies compared with all other psychological
therapy approaches for acute depression. Setting
2. To examine the effectiveness and acceptability of different Studies may be conducted in primary care and community-based
humanistic therapy models (person-centred, gestalt, process- settings, or in secondary or specialist settings, and will include
experiential, transactional analysis, existential and non-directive referrals as well as volunteers. Studies involving inpatients will be
therapies) compared with all other psychological therapy excluded. Studies that focus on specific populations - nurses, care
approaches for acute depression. givers, depressed participants at a specific work place - will be
included if the participants all meet the criteria for depression.
3. To examine the effectiveness and acceptability of all
humanistic therapies compared with different psychological
therapy approaches (psychodynamic, behavioural, humanistic,
Diagnosis
integrative, cognitive-behavioural) for acute depression.
We will include all studies that focus on acute phase treatment of
clinically diagnosed depression.
1. Studies adopting any standardised diagnostic criteria to define
METHODS
participants suffering from an acute phase unipolar depressive dis-
order will be included. Accepted diagnostic criteria include Feigh-
ner criteria, Research Diagnostic Criteria, DSM-III (APA 1980),
Criteria for considering studies for this review DSM- III-R (APA 1987), DSM-IV-TR (APA 2000) or ICD-10
(WHO 1992) criteria. Earlier studies may have used ICD-9 (
WHO 1978), but ICD-9 is not based on operationalised criteria,
Types of studies so studies using ICD-9 will be excluded from this category.

2. Mild, moderate and severe depressive disorders are all found in 1. Person-centred therapy (Rogerian or client-centred therapy)
primary care (Mitchell 2009; Rait 2009; Roca 2009). In order to In person-centred therapy (PCT), core conditions of empathy,
fully represent the broad spectrum of severity of depressive symp- genuineness and unconditional positive regard, considered to be
toms encountered by healthcare professionals in primary care, the ’antithesis’ of a therapeutic technique (Cooper 2008) are con-
studies that used non-operationalised diagnostic criteria or used sidered sufficient to facilitate personality change (Rogers 1951).
a validated clinician or self-report depression symptom question- Use of a non-directive stance by the therapist is a key feature of
naire, such as Hamilton Rating Scale for Depression (Hamilton PCT (Mearns 2007). Moving through three phases of trust, inti-
1960) and Beck Depression Inventory (Beck 1961), to identify macy and mutuality within the therapeutic relationship (Mearns
depression caseness based on a recognised threshold, will also be 2007), change occurs as the client shifts from a negative evalua-
included. However, the influence of including this category of tion of self towards a belief that they are worth caring for (Thorne
studies will be examined in a sensitivity analysis. 2002).
Accepted strategies for classifying mild, moderate and severe de-
pression will be employed based, where possible, on those crite-
ria used in the evidence syntheses underpinning the NICE 2009
guidelines for depression. 2. Gestalt therapy
Studies focusing on chronic depression or treatment resistant de- Gestalt therapy focuses on the process of human contact, described
pression, i.e. studies that listed these conditions as inclusion crite- as the contact or ‘need cycle’ (Strumpfel 2006). The cycle begins
ria, will be excluded from the review. Studies in which participants with an emotional impulse and is completed when the need is
are receiving treatment to prevent relapse following a depressive gratified and assimilated. Disturbances to the contact cycle, such
episode (that is, where participants are not depressed at study en- as the belief that ‘I am not allowed to get angry’, are seen as the
try) will also be excluded. basis of pathology and become the focus of therapy (Strumpfel
Studies of people described as ‘at risk of suicide’ or with dysthymia 2006). Gestalt therapists support and provoke exploration of dis-
or other affective disorders such as panic disorder a will be included turbances within the ‘here and now’ experience of the therapeutic
if the participants meet criteria for depression as stated above, but encounter, with the aim of resolving the disturbance and helping
will be excluded if not. the client to complete the contact cycle. Originally conducted us-
We will not include subgroup analyses of people with depression, ing a confrontational style (Perls 1976), Gestalt therapy models
selected out of people with mixed diagnoses, because such studies have become ‘softer’ and more dialogue-based (Yontef 1998). Ex-
would be susceptible to publication bias (the authors reported such periments remain a central tenet of Gestalt therapy approaches,
subgroup studies because the results were “interesting”). In other through use of a range of techniques such as exaggeration (re-
words we will include such studies only if the inclusion criteria for peating and intensifying a particular behaviour to bring uncon-
the entire study satisfied our eligibility criteria. scious emotional processes into awareness), dramatising (assuming
roles of influential people in clients’ lives through staging family
scenes), artwork, dance/other physical movement and two-chair/
Comorbidity empty chair work (exploration of conflict within the client) as part
Studies involving participants with comorbid physical or common of the experiential learning process (Strumpfel 2006).
mental disorders will be eligible for inclusion, as long as the co-
morbidity is not the focus of the study. In other words, we will
exclude such studies which focused on depression among patients
3. Experiential therapies
with Parkinson’s disease or after acute myocardial infarction but
will accept such studies which may have included some partici- Experiential therapies, include focused-oriented psychotherapy
pants with Parkinson’s disease or acute myocardial infarction. (Gendlin 1996) and emotion-focused therapy, manualised as pro-
cess-experiential therapy (Greenberg 2005). Focus-oriented psy-
chotherapy integrates ‘levels of interventiveness’ techniques (the
Types of interventions degree on which a therapist brings in material from outside the
client’s frame of reference, and the degree to which this is done
from the stance of authority or expertise) (Warner 2000) with
Experimental intervention Rogers’ therapeutic conditions to help clients to attend to their
The review recognises the overlap between different orientations moment-by-moment experiencing, and so enhance insight and
(Sanders 2007) and the variations even within specific orienta- therapeutic change. Similarly, process-experiential therapy, still in
tions, such as person-centred or gestalt therapy (Cooper 2008). development, uses techniques such as two-chair and empty chair
Whilst acknowledging this variation and overlap, humanistic ther- dialogue, drawn from gestalt therapy and cognitive/information
apy approaches will be grouped into six main categories based on processing psychology to enable here and now experiencing of
the theoretical principles set out by trial authors. emotional processes (Sanders 2007).

4. Transactional analysis Comparators
Whilst drawing from a broad range of influences, including psy- The control comparison will be all other types of psychological
chodynamic, cognitive behavioural and existential theory, transac- therapies, categorised as psychodynamic, behavioural, integrative,
tional analysis is considered essentially to be consistent with core cognitive behavioural and third wave CBT approaches.
beliefs of humanistic psychology theory and practice (Berne 1961;
Tudor 2002). The primary goal of transactional analysis is the
creation of a meaningful working alliance, within which trans-
formation and development can occur. Ego states, transactions, 1. Psychodynamic therapies
scripts and games are cornerstones of transactional analysis the- Grounded in psychoanalytic theory (Freud 1949), psychodynamic
ory and practice, and these may be explored using eight sequen- therapy (PD) uses the therapeutic relationship to explore and re-
tial ‘therapeutic operations’ of interrogation, specification, con- solve unconscious conflict, through transference and interpreta-
frontation, explanation, illustration, confirmation interpretation tion, with development of insight and circumscribed character
and crystallisation, once the working alliance has been established change as therapeutic goals, and relief of symptomatology as an in-
(Tudor 2002). direct outcome. Brief therapy models have been devised by Malan
1963, Mann 1973 and Strupp 1984.
5. Existential therapy
2. Behavioural therapies
Existential therapy is described as a rich tapestry of intersecting
therapeutic practices, all of which orientate themselves around Building on Skinner’s theory of depression as an interruption in
the shared concern of ‘human lived existence’ (Cooper 2003). In established sequences of health behaviour positively reinforced by
clinical practice, existential therapists have a preference for au- the social environment (Skinner 1953), behavioural therapies fo-
tonomous, individualised approaches with clients rather than a cus attention on increasing access to pleasant events and positive re-
single all-encompassing system (Cooper 2003). In Yalom’s exis- inforcers. The frequency of aversive events is decreased (Lewinsohn
tential therapy (Yalom 1980), clients are encouraged to confront 1972) through monitoring of pleasant events, activity scheduling,
four ultimate existential concerns of death, freedom, isolation and social skills development and time management training (Hopko
meaninglessness. In contrast, van Deurzen’s approach explores four 2003).
dimensions of worldly being, consisting of physical, personal, so-
cial and spiritual dimensions (van Deurzen 2002). In other exis-
tential therapy approaches, practitioners work with clients to focus
in on subjective experiences (Bugental 1978) or to focus out on 3. Interpersonal, cognitive analytic and other integrative
their responsibilities to others (Frankl 1984). therapies
Integrative therapies are approaches that combine components of
different psychological therapy models. Integrative therapy mod-
els include interpersonal therapy (IPT) (Klerman 1984), cognitive
6. Non-directive/supportive therapies analytic therapy (CAT) (Ryle 1990), and Hobson’s conversational
model (Hobson 1985), manualised as psychodynamic interper-
Therapies described as ‘non-directive’ or ‘supportive’, and not ex- sonal therapy (Shapiro 1990). With its focus on the interpersonal
plicitly underpinned by humanistic theory, principles and support- context, IPT was developed in order to specify what was thought
ing references, will be included in the review. The impact of their to be a set of helpful procedures commonly used in psychother-
inclusion will be examined in sensitivity analyses (see Methods apy for depressed outpatients (Weissman 2007), drawing in part
section). from attachment theory (Bowlby 1980) and cognitive behavioural
therapy (www.interpersonalpsychotherapy.org, 9/9/09), within a
time-limited framework. CAT, also devised as a time-limited psy-
chotherapy, integrates components from cognitive and psychody-
7. Other humanistic therapies namic approaches. The conversational model integrates psycho-
dynamic, interpersonal and person-centred model components.
Where studies of other humanistic therapy approaches not listed Counselling interventions traditionally draw from a wide range
above are identified, a post-hoc decision will be made about their of psychological therapy models, including person-centred, psy-
inclusion in the review, and the impact of their inclusion with be chodynamic and cognitive behavioural approaches, applied inte-
examined in a sensitivity analysis (see Methods section). gratively, according to the theoretical orientation of practitioners

(Stiles 2008). Therefore, studies of counselling will usually be in- Excluded interventions
cluded in the integrative therapies reviews. However if the coun- Studies of long-term, continuation or maintenance therapy in-
selling intervention consists of a single discrete psychological ther- terventions designed to prevent relapse of depression or to treat
apy approach, it will be categorised as such, even if the intervention chronic depressive disorders will be excluded from the review. Sim-
is referred to as ’counselling’. If the intervention is manualised, ilarly studies of interventions designed to prevent a future episode
this will inform our classification. of depression will be excluded.
Guided self-help, in which the practitioner provides brief face to
face non-therapeutic support to patients who are using a self-help
psychological therapy intervention, will be excluded.
4. Cognitive behavioural therapies Psychological therapy that is provided wholly by telephone or over
the Internet will not be eligible for inclusion.
In cognitive behavioural therapy, therapists aim to work collabo-
Studies of dual modality treatments, in which patients are ran-
ratively with clients to understand the link between thoughts, feel-
domised to receive a humanistic therapy intervention combined
ings and behaviour, and to identify and modify unhelpful think-
with pharmacological treatment and compared with a treatment
ing patterns, underlying assumptions and idiosyncratic cognitive
as usual control condition, will be excluded from the current re-
schema about the self, others and the world (Beck 1979). Cogni-
view, and will be examined in a separate programme of reviews on
tive change methods for depression are targeted at the automatic
combination treatments for depression.
thought level in the first instance, and include thought catching,
Component or dismantling studies, in which the effectiveness of
reality testing, task assignment and generating alterative strategies
individual components of a humanistic therapeutic approach are
(Williams 1997). Behavioural experiments are then used to re-
investigated, will not be included. Data from these studies will
evaluate underlying beliefs and assumptions (Bennett-Levy 2004).
be extracted and included in a separate overview of psychological
therapies for depression, in which multiple treatments meta-anal-
ysis (MTM) will be used to compare the relative effectiveness of
all psychotherapies, regardless of whether they have been directly
5. Mindfulness-based ’third wave’ cognitive and behavioural compared in direct RCTs. If there is sufficient data, we will use the
therapies MTM model proposed in Welton 2009 to allow conclusions to
Third wave CBT approaches conceptualise cognitive thought pro- be drawn regarding which components, or combination of com-
cesses as a form of ‘private behaviour’ (Hayes 2006; Hofmann ponents, are most effective at reducing depressive symptoms. See
2008). Third wave CBT target the individual’s relationship with Unit of analysis issues for further detail on MTM.
cognitions and emotions, focusing primarily on the function of Psychological therapy models based on social constructionist prin-
cognitions such as thought suppression or experiential avoidance ciples (that focus on the ways in which individuals and groups
(an attempt or desire to suppress unwanted internal experiences, participate in the construction of their perceived social reality) in-
such as emotions, thoughts, and bodily sensations) (Hofmann cluding couples therapy, family therapy, solution-focused therapy,
2008). A range of strategies, including mindfulness exercises, ac- narrative therapy, personal construct therapy, neuro-linguistic pro-
ceptance of unwanted thoughts and feelings, and cognitive dif- gramming and brief problem-solving (Watzlavick 1974) will be
fusion (stepping back and seeing thoughts as just thoughts), are excluded. These therapies work with patterns and dynamics of re-
used to bring about change in the thinking process. Drawing from lating within and between family, social and cultural systems in or-
psychodynamic and humanistic principles, third wave CBT ap- der to create a socially constructed framework of ideas (O’Connell
proaches also place great emphasis on use of the therapeutic rela- 2007), rather than focusing on one individual’s reality. Previously
tionship. published Cochrane reviews on couples therapy for depression
(Barbato 2006) and family therapy for depression (Henken 2007)
will be updated concurrently.
Where the description of an intervention suggests it does not meet
Format of psychological therapies the inclusion criteria for an active psychological therapy approach,
The psychological therapy intervention is required to be delivered that study/study arm will be excluded from this review. If the
through face to face meetings between the patient and therapist. intervention involved significant time spent with the patient, the
Interventions in which face to face therapy is augmented by tele- review team will take a post hoc decision about whether it should
phone or Internet-based support will be included in the review. be included as an attention placebo/control in a linked review on
Psychological therapy approaches conducted on either an individ- humanistic therapies versus treatment as usual for depression.
ual or on a group basis will be eligible for inclusion. There is no
limit to the number of sessions and we accept psychological ther-
Types of outcome measures
apy delivered in only one session.

Primary outcomes 8. Economic outcomes (e.g. days of work absence/ability to
return to work, number of appointments with primary care
1. Treatment efficacy: the number of patients who respond to
physician, number of referrals to secondary services, use of
treatment, based on changes on Beck Depression Inventory
additional treatments) where reported, will be summarised in
(BDI) (Beck 1961), Hamilton Rating Scale for Depression
narrative form.
(HAM-D) (Hamilton 1960) or Montgomery-Asberg Depression
Rating Scale (MADRS) (Montgomery 1979), or any other
validated depression scale. Many studies define response by 50%
or greater reduction on BDI, HAM-D etc. but some studies
Search methods for identification of studies
define response using Jacobson’s Reliable Change Index; we will
accept the study authors’ original definition. If the original
Electronic searches
authors report several outcomes corresponding with our
definition of response, we will give preference to BDI for self-
rating scale and HAM-D for observer-rating scale. CCDANCTR Registers
2. Treatment acceptability: the number of participants who
We will search two clinical trials registers created and main-
drop out of psychological therapy treatment for any reason.
tained by the Cochrane Depression, Anxiety and Neurosis Group
(CCDAN), the CCDANCTR-Studies Register and the CC-
DANCTR-References Register. References to trials for inclusion
Secondary outcomes in the Group’s registers are collated from routine (weekly) searches
of MEDLINE, EMBASE and PsycINFO, quarterly searches of
1. The number of patients who remit on treatment, based on
the Cochrane Central Register of Controlled Trials (CENTRAL)
the endpoint absolute status of the patients, as measured by Beck
and additional ad hoc searches of other databases (PSYNDEX,
Depression Inventory (BDI) (Beck 1961), Hamilton Rating
LILACS, AMED, CINAHL). These searches employ generic
Scale for Depression (HAM-D) (Hamilton 1960) or
terms for depression anxiety and neuroses; together with sensitive
Montgomery-Asberg Depression Rating Scale (MADRS) (
(database specific) RCT filters.
Montgomery 1979), or any other validated depression scale.
Examples of definitions of remission include 10 or less on BDI, 7
References to trials are also sourced from international trials reg-
or less on HAM-D or 10 or less on MADRS; we will accept the
isters via the World Health Organisation’s trials portal (http://
study authors’ original definition. If the original authors report
apps.who.int/trialsearch/); drug companies; the hand-searching of
several outcomes corresponding with our definition of response,
key journals, conference proceedings and other (non-Cochrane)
we will give preference to BDI for self-rating scale and HAM-D
systematic reviews and meta-analyses.
for observer-rating scale.
2. Improvement in depression symptoms, based on a
Details of the generic search strategies can be found in the ‘Spe-
continuous outcome of group mean scores at the end of
cialized Register’ section of the Cochrane Depression, Anxiety and
treatment using BDI, HAM-D, MADRS, or any other validated
Neurosis Group’s module text.
depression scale.
3. Improvement in overall symptoms, using the Clinical
Global Impressions Scale (CGI) (Guy 1976). 1. The CCDANCTR-Studies Register
4. Improvement in anxiety symptoms, measured using a The CCDANCTR-Studies Register contains over 11,000 trials for
validated continuous scale, either assessor-rated, such as the the treatment or prevention of depression, anxiety and neurosis.
Hamilton Anxiety Scale [HAM-A] (Hamilton 1959) or self- Each trial has been coded using the EU-Psi coding manual (as
report, including the Trait subscale of the Spielberger State-Trait a guide) and includes information on intervention, condition,
Anxiety Inventory (STAI-T) (Spielberger 1983) and the Beck comorbidities, age, treatment setting etc.
Anxiety Inventory (BAI) (Beck 1988). The studies register will be searched using the following search
5. Adverse effects, such as completed suicides, attempted terms:
suicides and worsening of symptoms, where reported, will be Condition = (depress* or dysthymi*) and Intervention = (*therap*
summarised in narrative form. or training)
6. Social adjustment, social functioning including the Global
Assessment of Function (Luborsky 1962) scores, where reported,
will be summarised in narrative form. 2. The CCDANCTR-References Register
7. Quality of life, using validated measures such as the SF-36 The CCDANCTR-References Register contains bibliographic
(Ware 1993), HoNOS (Wing 1994) and WHOQOL (WHOQL records of reports of trials coded in the CCDANCTR-Studies Reg-
1998), where reported, will be summarised in narrative form. ister together with several other uncoded references (total number

of records=24,500). This register will be searched using a compre- outcomes including adverse events, follow-up and methods of sta-
hensive list of terms for ‘psychotherapies’ as indicated in Appendix tistical analysis will be abstracted from the original reports into
1. Records already retrieved from the search of the CCDANCTR- specially designed paper forms then entered into a spreadsheet.
Studies Register will be de-duplicated.
Management of time points

Searching other resources Post-treatment outcomes and outcomes at each reported follow-
up point will be summarised. Where appropriate and if the data
allow, outcomes will be categorised as short term (up to 6 months
1. Reference lists post-treatment), medium term (7 to 12 months post-treatment)
The references of all selected studies will be searched for more long term (longer than 12 months).
published reports and citations of unpublished studies. Relevant
review papers will be checked.
Assessment of risk of bias in included studies
Risk of bias will be assessed for each included study using the
2. Personal communication Cochrane Collaboration ’risk of bias’ tool (Higgins 2008a). The
Subject experts will be contacted to check that all relevant studies, following six domains will be considered:
either published or unpublished, have been considered for inclu- 1. Sequence generation: Was the allocation sequence
sion. adequately generated?
2. Allocation concealment: Was allocation adequately
concealed?
3. Blinding of participants, personnel and outcome assessors
Data collection and analysis
for each main outcome or class of outcomes: Was knowledge of
the allocated treatment adequately prevented during the study?
4. Incomplete outcome data for each main outcome or class of
Selection of studies outcomes: Were incomplete outcome data adequately addressed?
Two review authors (RC and VH) will examine the abstracts of 5. Selective outcome reporting: Are reports of the study free of
all publications obtained through the search strategy. Full articles suggestion of selective outcome reporting?
of all the studies identified by either of the review authors will 6. Other sources of bias: Was the study apparently free of
then be obtained and inspected by the same two review authors other problems that could put it at a high risk of bias? Additional
for trials meeting the following criteria: items to be included here are therapist qualifications, treatment
1. Randomised controlled trial; fidelity and researcher allegiance/conflict of interest.
2. Participants have depression diagnosed by operationalised A description of what was reported to have happened in each study
criteria; and will be provided, and a judgement on the risk of bias will be made
3. Any humanistic therapy approach, to include supportive or for each domain within and across studies, based on the following
non-directive placebo control therapies, compared with any three categories:
other psychological therapy approach. A. Yes (low risk of bias)
Conflicts of opinion regarding eligibility of a study will be dis- B. Unclear
cussed with a third review author, having retrieved the full paper C. No (high risk of bias).
and consulted the authors if necessary, until consensus is reached. Two independent review authors will assess the risk of bias in se-
External subject or methodological experts will be consulted if lected studies. Any disagreement will be discussed with a third
necessary. review author. Where necessary, the authors of the studies will be
contacted for further information. All risk of bias data will be pre-
sented graphically and described in the text. Allocation conceal-
Data extraction and management ment will be used as a marker of trial quality for the purposes of
Data will be extracted by two review authors, with data from each undertaking sensitivity analyses.
study being extracted independently by two of these authors. Any
disagreement will be discussed with an additional review author
and where necessary, the authors of the studies will be contacted Measures of treatment effect
for further information. Continuous outcomes: where studies have used the same outcome
Information relating to study population, sample size, interven- measure for comparison, data will be pooled by calculating the
tions, comparators, potential biases in the conduct of the trial, mean difference (MD). Where different measures are used to assess

the same outcome , data will be pooled with standardised mean Dealing with missing data
difference (SMD) and 95% confidence intervals calculated. Missing dichotomous data will be managed through intention to
Dichotomous outcomes: these outcomes will be analysed by cal- treat (ITT) analysis, in which it will be assumed that patients
culating a pooled odds ratio (OR) and 95% confidence intervals who dropped out after randomisation had a negative outcome.
for each comparison. Because ORs can be difficult to interpret, Best / worse case scenarios will also be calculated for the clinical
these pooled ORs will be converted to relative risks (RR) using the response outcome, in which it will be assumed that dropouts in
formula provided in The Cochrane Handbook (Higgins 2008a) the active treatment group had positive outcomes and those in
and presented in this form for ease of interpretation. the control group had negative outcomes (best case scenario), and
that dropouts in the active treatment group had negative outcomes
and those in the control group had positive outcomes (worst case
Unit of analysis issues scenario), thus providing boundaries for the observed treatment
Multiple-arm studies (those with greater than two intervention effect. If there is a large amount of missing information then these
arms) can pose analytical problems in pair-wise meta-analysis. For best / worst case scenarios will be given greater emphasis in the
studies with more than two relevant active treatment arms data presentation of the results.
will be managed in this review as follows: Missing continuous data will either analysed on an endpoint basis,
including only participants with a final assessment, or analysed us-
ing last observation carried forward to the final assessment (LOCF)
if LOCF data were reported by the trial authors. Where SDs are
Continuous data
missing, attempts will be made to obtain these data through con-
Means, SDs and number of participants for each active treatment tacting trial authors. Where SDs are not available from trial au-
group will be pooled across treatment arms as a function of the thors, they will be calculated from P values, t-values, confidence in-
number of participants in each arm to be compared against the tervals or standard errors, where reported in articles (Deeks 1997).
control group (Law 2003; Higgins 2008a; Higgins 2008c). Where the vast majority of actual SDs are available and only a
minority of SDs are unavailable or unobtainable, a method used
for imputing SDs and calculating percentage responders devised
Dichotomous data by Furukawa and colleagues (Furukawa 2005; Furukawa 2006)
will be used. Where this method is employed, data will be inter-
Data from relevant active intervention arms will be collapsed into a
preted with caution, taking account of the degree of heterogeneity
single arm for comparison or data from relevant active intervention
observed. A sensitivity analysis will also be undertaken to examine
arms will be split equally between comparator arms.
the effect of the decision to use imputed data.
Where additional figures are not available or obtainable, and it is
not deemed appropriate to use the Furukawa method described
Multiple treatment meta-analysis above, the study data will not be included in the comparison of
One method which retains the individual identity of each inter- interest.
vention and allows multiple intervention comparisons to be made,
without the need to lump or split intervention arms, is a mul-
tiple treatment meta-analysis (MTM) (Lu 2004; Caldwell 2005; Assessment of heterogeneity
Cipriani 2009c). MTM (also known as Mixed Treatment Com- Statistical heterogeneity will be formally tested using the chi2 test,
parison or Network Meta-analysis) refers to ensembles of trial ev- which provides evidence of variation in effect estimates beyond
idence in which direct and indirect evidence on relative treatment that of chance. Since the chi2 test has low power to assess het-
effects are pooled. The objective of an MTM analysis is to combine erogeneity where a small number of participants or trials are in-
all the available trial evidence into an internally consistent set of cluded, the P value will be conservatively set at 0.1. Heterogeneity
estimates while respecting the randomisation in the evidence. An will also be quantified using the I2 statistic, which calculates the
MTM provides estimates of the effect of each intervention relative percentage of variability due to heterogeneity rather than chance.
to every other, whether or not they have been directly compared in We expect, a priori, that there will be considerable clinical hetero-
trials. One can also calculate the probability that each treatment geneity between studies and so I2 values in the range of 50% to
is the most effective. We do not intend to use an MTM in this 90% will be considered to represent substantial statistical hetero-
review, as we are unlikely to have sufficient data for the analysis. geneity and will be explored further. However, the importance of
However, this review forms part of a series of 12 reviews which the observed I2 will depend on the magnitude and direction of
will contribute studies to an overview of reviews (Higgins 2008b; treatment effects and the strength of evidence for heterogeneity
Becker 2009) in which MTM will be used as the main analytical (Higgins 2003; Deeks 2009). Forest plots generated in RevMan
strategy. 5 now also provide an estimate of tau2 , the between-study vari-

ance in a random-effects meta-analysis. To give an indication of 1. Baseline depression severity: the severity of depression on
the spread of true intervention effects we will use the tau2 esti- entering the trial is expected to have an impact on outcomes.
mate to form an approximate range of intervention effects using Heterogeneity analyses will categorise baseline severity as mild,
the method outlined in section 9.5.4 of the Cochrane Handbook moderate or severe.
for Systematic Reviews of Interventions (Deeks 2009). This will be 2. Number of sessions: there are likely to be differences in the
undertaken for the primary outcomes only. numbers of therapy sessions received and this is expected to
affect treatment outcome. Numbers of sessions will be
categorised as 1 to 7 sessions, 8 to 12 sessions, 13 to 20 sessions
Assessment of reporting biases and more than 20 sessions.
As far as possible, the impact of reporting biases will be minimised 3. Type of comparison: the type of comparator used is likely to
by undertaking comprehensive searches of multiple sources (in- influence the observed effectiveness of the intervention. Where
cluding trial registries), increasing efforts to identify unpublished possible, comparators will be categorised according as
material, and including non-English language publications. psychodynamic, BT, integrative, CBT and third wave CBT.
We will also try and identify outcome reporting bias in trials by 4. Strength of therapeutic alliance/perceived therapist
recording all trial outcomes, planned and reported and noting empathy, based on validated measures such as the Barrett-
where there are missing outcomes. Where we find evidence of Lennard Relationship Inventory (Barrett-Lennard 1986) or
missing outcomes, we will attempt to obtain any available data Working Alliance Inventory (Horvath 1986): where reported,
direct from the authors. this information will be summarised in narrative form.
Where sufficient numbers of trials allow for a meaningful analysis,
funnel plots will be constructed to establish the potential influence
Sensitivity analysis
of reporting biases and small study effects.
1. Fidelity to treatment: studies that have not assessed fidelity
to the psychological therapy model(s) under evaluation through
Data synthesis assessment of audio or videotapes of therapy sessions will be
Given the potential heterogeneity of psychological therapy ap- excluded
proaches for inclusion, together with the likelihood of differing 2. Study quality: allocation concealment will be used as a
secondary comorbid mental disorders in the population of inter- marker of trial quality. Studies that have not used allocation
est, a random-effects model will be used in all analyses. concealment will be excluded.
3. Trials where missing data has been imputed will be
excluded.
Subgroup analysis and investigation of heterogeneity 4. Antidepressant treatment (naturalistic use; combination
treatment used in both psychological therapy arms)
5. Trials included in the review following post-hoc decisions
Clinical heterogeneity about their eligibility as following humanistic therapeutic
approaches will be excluded.
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Indicates the major publication for the study

APPENDICES
Appendix 1. CCDAN-CTR References Register search (psychotherapies for depression)

Title, Abstract, Keywords = (depress* or dysthymi*)
and
Title, Abstract, Keywords = ((*therap* and ((acceptance* or commitment*) or “activity scheduling” or alderian or art or aversion or
brief or “client cent*” or cognitive or color or colour or “compassion-focused” or “compassion* focus*” or compassionate or conjoint or
conversion or conversational or couples or dance or dialectic* or diffusion or distraction or eclectic or “emotion* focus*” or emotion-
focus* or existential or experiential or exposure or expressive or family or focus-oriented or “focus oriented” or freudian or gestalt
or group or humanistic or implosive or insight or integrative or interpersonal or jungian or kleinian or marital or metacognitive or
meta-cognitive or milieu or morita or multimodal or multi-modal or music or narrative or nondirective or non-directive or “non
directive” or nonspecific or non-specific or “non specific” or “object relations” or “personal construct” or “person cent*” or person-
cent* or persuasion or play or “pleas* event*” or primal or problem-focused or “problem focused” or problem-solving or “problem
solving” or process-experiential or “process experiential” or psychodynamic or “rational emotive” or reality or “reciprocal inhibition” or
relationship* or reminiscence or restructuring or rogerian or schema* or self-control* or “self control*” or “short term” or short-term or
sex or “social effectiveness” or “social skill*” or socio-environment* or “socio environment*” or “solution focused” or solution-focused
or “stress management” or supportive or time-limited or “time limited” or “third wave” or transference or transtheoretical or validation))
or abreaction or “acting out” or “age regression” or ((assertive* or autogenic or mind or sensitivity) and train*) or autosuggestion or
“balint group” or ((behavior* or behaviour*) and (activation or therap* or treatment or contracting or modification)) or biofeedback
or catharsis or cognitive or “mind training” or counsel* or “contingency management” or countertransference or “covert sensitization”
or “eye movement desensiti*” or “crisis intervention” or “dream analysis” or “emotional freedom” or “free association” or “functional
analys*” or griefwork or “guided imagery” or hypno* or imagery or meditation* or “mental healing” or mindfulness* or psychoanaly*
or psychodrama or psychoeducat* or “psycho* support*” or psychotherap* or relaxation or “role play*” or “self analysis” or “self esteem”
or “sensitivity training” or “support* group*” or therapist or “therapeutic technique*” or “transactional analysis”)
WHAT’S NEW
Date Event Description
7 June 2012 Amended Minor changes to methods
HISTORY
Protocol first published: Issue 9, 2010
CONTRIBUTIONS OF AUTHORS
Rachel Churchill conceived, designed, secured funding for, and is managing this programme of linked reviews. She has worked on all
aspects of the development of this project, including building a review team, protocol development, developing a search strategy and
compiling data-extraction forms. Dr Churchill is responsible for writing and preparing this review. Along with Dr Vivien Hunot, she
conducted the original review on which this programme is based. She is guarantor of the individual reviews in this programme of work.
Philippa Davies contributed to the design of the review and development of the protocol.
Deborah Caldwell provided methodological and statistical advice for each of 12 linked protocols assessing the effects of different
psychotherapies for depression. She contributed to the design of the data extraction form, Drafted some sections of the protocols and
commented on the protocol manuscripts. She designed the plan for the multiple treatment meta-analysis for the overview of reviews.
Theresa Moore is managing the organisation of data for the 12 linked reviews of psychotherapies for depression including the search
results, tracking of papers, and management of references for the project. She has developed the data collection forms. She designed
the database and spreadsheets for data collection and has contributed to writing sections of the protocols and commented on text of
the protocols.
Glyn Lewis provided a clinical perspective on 12 linked psychotherapies for depression protocols.
Vivien Hunot provided theoretical and clinical expertise for designing this programme of linked reviews, drawing from her training
and clinical practice as a psychotherapeutic counsellor and cognitive behavioural therapist in NHS primary care settings. She worked
on protocol development, developing a search strategy and compiling data extraction forms, and wrote the protocols for each review.
Along with Dr Rachel Churchill, she conducted the original review on which this programme is based.
DECLARATIONS OF INTEREST
None known.
SOURCES OF SUPPORT
Internal sources
• University of Bristol, UK.
External sources
• NIHR Programme Grant - UK Department of Health, UK.


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Humanistic therapies versus other psychological therapies for

Churchill R, Davies P, Caldwell D, Moore THM, Jones H, Lewis G, Hunot V

Humanistic therapies versus other psychological therapies for depression (Protocol)

Humanistic therapies versus other psychological therapies for depression (Protocol) i

Humanistic therapies versus other psychological therapies for

Editorial group: Cochrane Depression, Anxiety and Neurosis Group.

Clinical guidelines recommend pharmacological and psycholog-

Humanistic therapies versus other psychological therapies for depression (Protocol) 2

Humanistic therapies versus other psychological therapies for depression (Protocol) 3

Humanistic therapies versus other psychological therapies for depression (Protocol) 4

Humanistic therapies versus other psychological therapies for depression (Protocol) 5

Humanistic therapies versus other psychological therapies for depression (Protocol) 6

Humanistic therapies versus other psychological therapies for depression (Protocol) 7

Management of time points

Humanistic therapies versus other psychological therapies for depression (Protocol) 8

Humanistic therapies versus other psychological therapies for depression (Protocol) 9

Additional references 4th Edition. Washington DC: American Psychiatric

Humanistic therapies versus other psychological therapies for depression (Protocol) 15

Appendix 1. CCDAN-CTR References Register search (psychotherapies for depression)

Date Event Description

7 June 2012 Amended Minor changes to methods

Humanistic therapies versus other psychological therapies for depression (Protocol) 17

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