Blog
The Psychotherapy Practice Research Network (PPRNet) blog began in 2013 in response to psychotherapy clinicians, researchers, and educators who expressed interest in receiving regular information about current practice-oriented psychotherapy research. It offers a monthly summary of two or three published psychotherapy research articles. Each summary is authored by Dr. Tasca and highlights practice implications of selected articles. Past blogs are available in the archives. This content is only available in English.
This month...
…I blog about therapist empathy, psychotherapeutic treatment for borderline personality disorder, and research on psychological treatment of depression.
Type of Research
Topics
- ALL Topics (clear)
- Adherance
- Alliance and Therapeutic Relationship
- Anxiety Disorders
- Attachment
- Attendance, Attrition, and Drop-Out
- Client Factors
- Client Preferences
- Cognitive Therapy (CT) and Cognitive-Behavioural Therapy (CBT)
- Combination Therapy
- Common Factors
- Cost-effectiveness
- Depression and Depressive Symptoms
- Efficacy of Treatments
- Empathy
- Feedback and Progress Monitoring
- Group Psychotherapy
- Illness and Medical Comorbidities
- Interpersonal Psychotherapy (IPT)
- Long-term Outcomes
- Medications/Pharmacotherapy
- Miscellaneous
- Neuroscience and Brain
- Outcomes and Deterioration
- Personality Disorders
- Placebo Effect
- Practice-Based Research and Practice Research Networks
- Psychodynamic Therapy (PDT)
- Resistance and Reactance
- Self-Reflection and Awareness
- Suicide and Crisis Intervention
- Termination
- Therapist Factors
- Training
- Transference and Countertransference
- Trauma and/or PTSD
- Treatment Length and Frequency
December 2023
Is empathic accuracy enough? The role of therapists’ interventions in the associations between empathic accuracy and session outcome.
Stolowicz-Melman, D., Lazarus, G., & Atzil-Slonim, D. (2023). Is empathic accuracy enough? The role of therapists’ interventions in the associations between empathic accuracy and session outcome. Journal of Counseling Psychology, 70(6), 682–690. https://doi.org/10.1037/cou0000708
Therapist empathy (as rated by patients) is a well-known predictor of positive patient outcomes in psychotherapy. Empathy can take many forms (empathic resonance, expressed empathy, received empathy), but one that is less well-researched is the therapist’s empathic accuracy. Empathic accuracy refers to the congruence (agreement) between a patient’s emotional state and the therapist’s perception of the patient’s emotional state. That is, therapists’ capacity to accurately perceive their patient’s inner experiences. In this study, Stolowicz-Melman and colleagues assessed therapist and patient congruence in therapists’ ratings of the patient’s emotional state during a session. The authors also looked at the impact of that congruence (or lack of congruence) on the patient’s ratings of the session’s effectiveness (session outcomes). In addition, the researchers examined whether different types of therapist interventions affected the impact of congruence (empathic accuracy) on a patient’s evaluation of a session. The authors hypothesized that more exploratory interventions (therapists identifying and labelling feelings, focusing on moment-to-moment client emotions) and fewer directive interventions (therapists setting an agenda, reviewing homework) would result in a stronger association between therapist empathic accuracy and session outcomes as rated by the patient. The study had 81 patients and 50 therapists. Patients and therapists rated the patient’s mood after each of at least 6 sessions of therapy. The congruence (agreement) between the patient's and therapist's rating of the client's mood was an index of therapist empathic accuracy. Clients also evaluated the effectiveness of each session of therapy. The results suggested that greater therapist empathic accuracy for negative emotions was associated with better session evaluations (outcomes) rated by patients. Exploratory, and not directive, interventions resulted in a stronger effect of therapist empathic accuracy for negative emotions on session evaluations.
Practice Implications
The results suggest that therapists need to recognize negative emotions in their patients, offer support and empathy, and at the same time help the patient explore and process these emotions. Empathic accuracy is not enough, however, when a patient is experiencing a negative emotion. Patients need therapists to help them recognize their experiences and to explore their meaning in words. As Stolowicz-Melman and colleagues conclude, therapist exploration of patients’ emotions may help patients tolerate and regulate painful feelings and achieve better session results.
November 2023
Therapist Qualities That Lead to Treatment Failure or Termination
Alfonsson, S., Fagernäs, S., Sjöstrand, G., & Tyrberg, M. J. (2023). Psychotherapist variables that may lead to treatment failure or termination—A qualitative analysis of patients’ perspectives. Psychotherapy. Advance online publication. https://doi.org/10.1037/pst0000503
Research indicates that about 14% of patients terminated psychotherapy because it did not help them, and 7% because they were not comfortable with their therapist. Psychotherapists have difficulty identifying when patients are at risk of terminating the treatment, and many therapists do not identify when a patient is getting worse. In other words, therapists may not be a good source of understanding when and why patients do not improve and leave therapy. When researchers ask therapists to speculate about why a patient terminated prematurely, the therapists often focus on patient-related factors and not therapist-related factors. In this study, Alfonsson and colleagues interviewed 24 adult patients who had a negative experience in therapy or who terminated prematurely within the past year. Alfonsson and colleagues’ goal was to gather patient perspectives on what went wrong to begin to understand the phenomenon and to guide future training and practice of therapists. Qualitative analysis of the interview transcripts yielded four main categories of therapist variables as perceived by the patient that led to negative outcomes. The first main category was the Therapist's Negative Traits. This included therapist inflexibility/rigidity regarding their assessment of the patient and treatment plan, unengaged therapists who were not paying attention during sessions, unempathetic therapists who did not express warmth or caring for the patient’s situation, and insecure therapists who were too uncertain or oversensitive. The second main category was Therapist Unprofessionalism. This included therapists who were too superficial and avoided difficult topics, therapists who were informal such that they acted too familiar, or they were too affected by their own moods, therapists who were perceived to break confidentiality, and therapists who were nontransparent and seemed to withhold information. The third main category was Therapist Incompetence. This included therapists who were unstructured in their treatment and lacked focus, therapists who had a poor understanding of the patient’s problems by missing important issues or not understanding the patient’s situation, therapists with poor knowledge and lacked competence in a particular treatment model, and therapists who were too passive by not providing active treatment. The fourth category was Therapist Mismatch in which patients did not feel that they connected with the therapist.
Practice Implications
Some of the therapist factors are practical in nature such as those in the Therapist Incompetence category and parts of the Therapist Unprofessionalism category. For such issues, therapists may need more training that focuses on ethical practice, gaining better knowledge of psychopathology and treatment, and applying such knowledge to therapy with various patients. However, other factors like Therapist Negative Traits and parts of the Therapist Unprofessionalism category may be more challenging. These refer to personal traits of the therapist such as a perceived lack of empathy, personal insecurity, rigidity, and a tendency to remain superficial. Changing these traits may require therapists to engage in ongoing supervision and personal therapy. Therapists can also engage in routine outcome and process monitoring to get session-to-session feedback about patient experiences, symptoms, and the therapeutic alliance to help identify when things are not going well in the therapy before the patient drops out.
Different Aspects of the Therapeutic Relationship Are Associated with Different Outcomes
Finsrud, I., Nissen-Lie, H. A., Ulvenes, P. G., Vrabel, K., Melsom, L., & Wampold, B. (2023). Emotional and cognitive processes in psychotherapy are associated with different aspects of the therapeutic relationship. Journal of Consulting and Clinical Psychology. Advance online publication. https://doi.org/10.1037/ccp0000853
One can understand the therapeutic relationship as having an emotional component and a cognitive component. Researchers have found that these two components of the therapeutic relationship can be conceptualized as two factors: a patient’s Confidence in the Therapist (a patient who perceives their therapist as warm, empathic, competent, and trustworthy), and a patient’s Confidence in the Treatment (a patient’s experience of the treatment as viable and as providing a meaningful way to accomplish change). These factors align with the therapeutic alliance in that Confidence in the Therapist is akin to the bond aspect of the alliance, and Confidence in the Treatment is like the collaborative agreement on the tasks and goals aspects of the alliance. In this large naturalistic study, Finsrund and colleagues assessed if Confidence in the Therapist and Confidence in the Treatment are related to different types of outcomes (change in emotional clarity vs change in rumination), and to different types of therapy (CBT vs psychodynamic). The study had 631 adult patients with anxiety or depressive disorders and 54 therapists who conducted either CBT or psychodynamic therapy. Therapists treated the patients in a hospital setting in Norway and patients completed measures of Confidence in the Therapist, Confidence in the Treatment, symptom outcomes, rumination, and emotional clarity on a weekly basis for up to 12 weeks of treatment. Patients were highly symptomatic and more than 89% had more than one clinical diagnosis. As expected, higher Confidence in the Therapist predicted emotional change (higher emotional clarity) and higher Confidence in the Treatment predicted cognitive change (lower rumination). However, higher Confidence in the Therapist predicted better emotional clarity only in the patients receiving psychodynamic therapy, whereas higher Confidence in the Treatment predicted less rumination in both CBT and psychodynamic therapy (although the effect appeared larger in CBT).
Practice Implications
The results are in line with the notion that different aspects of the therapeutic relationship play different roles depending on the outcomes that patients and therapists desire. In cognitively oriented therapies, therapists rely more heavily on providing a viable explanation of the symptoms, a treatment rationale that is consistent with the explanation, and tasks of therapy (homework, self-monitoring, behavioural experiments) that are consistent with the treatment rationale. In psychodynamically-oriented therapies, therapists focus on emotional and relational changes in which therapists and patients work through aspects of the therapeutic relationship that deal with their affective bond and their interpersonal work together. Effective therapists likely do both with patients – i.e., they come to an agreement on the tasks and goals of therapy (the rationale for treatment) and they repair ruptures in the therapeutic alliance as a means of achieving interpersonal learning and emotional change.
June 2023
Patient Experience of Lasting Negative Effects of Psychotherapy
McQuaid, A., Sanatinia, R., Farquharson, L. et al. (2021). Patient experience of lasting negative effects of psychological interventions for anxiety and depression in secondary mental health care services: A national cross-sectional study. BMC Psychiatry, 21, 578. https://doi.org/10.1186/s12888-021-03588-2
One in six adults experience either depression or anxiety that affect their social functioning or quality of life. Most treatment guidelines indicate psychotherapy as a first line treatment for these common mental health problems because of the positive effects of therapy documented by research. Despite the effectiveness of psychotherapies, researchers pay little attention to potential negative impacts of psychological treatments. Negative effects might include worsening of symptoms, emergence of new symptoms, loss of self-esteem, among others. National surveys in the U.K. noted that 5% of patients reported lasting negative effects from psychological treatment. People who had preferences for therapy that were not met tended to have more negative effects, and service policy constraints may also influence patients’ experiences of negative effects. In this analysis of national survey data, McQuaid and colleagues considered all patients who completed therapy during a one-year period in the National Health Service (NHS) in the U.K. These patients received treatment in a secondary care service – that is, a service for those with moderate to severe symptoms. The survey asked whether patients experienced lasting “bad” effects from the treatment, and the authors assessed several service policies and procedures as correlates of these negative experiences. Of those patients who received service, 662 (14.8%) responded to the survey. Overall, 14.1% reported “agreeing” that they experienced a lasting bad effect, and another 13.7% reported a “neutral” response to this item. The likelihood of reporting a neutral or lasting negative effect was greater among those who felt that they did not receive timely therapy (they waited too long, or it was too difficult to access services), who did not receive enough sessions of treatment (most of the therapy in the NHS is short-term), and whose therapists did not discuss the patient’s progress in therapy.
Practice Implications
This study is not perfect by any means, but it does highlight system and service issues that may result in worsening of symptoms among patients, especially those with moderate to severe symptoms. Remaining on a wait list for too long may lead to worsening symptoms – which indicates that it might be best for some patients to be referred elsewhere if it is feasible. Not providing a sufficient dose of therapy (enough sessions) may also lead patient symptoms to be worse at the end of treatment. The disappointment and frustration associated with ending therapy too early may impact patients’ self-esteem, mood, and hopes for recovery. Clinicians might consider how much therapy they can offer before proceeding with someone who has moderate to severe symptoms. Finally, therapists should have regular discussions with patients about their progress and perhaps use progress monitoring as a tool to facilitate these discussions.
January 2023
Working Alliance and Therapist Cultural Humility Reduce the Impact of Microaggressions
A lack of culturally competent care can have negative impacts on therapy outcomes for Black, Indigenous, People of Color (BIPOC) and for women who experience discrimination based on gender. Often these negative outcomes occur because of microaggressions – which are a form of alliance rupture in the therapeutic relationship caused by subtle, intentional, or unintentional messages that degrade BIPOC, women, and other historically excluded groups. The majority of BIPOC clients (81%) and women (53%) report experiencing a therapist microaggression over the course of psychotherapy. A therapist’s cultural humility (valuing the importance of culture in their client’s experience) and the therapeutic alliance (client-therapist collaborative agreement on tasks and goals of therapy) may reduce the negative impact of microaggressions committed by the therapist. This study by DeBlaere and colleagues looked at the association between microaggressions experienced by BIPOC women and therapy outcomes, and whether this association was reduced by higher levels of therapist cultural humility and therapeutic alliance. The clients were 288 BIPOC women who were treated by a psychotherapist (81% had a female therapist, and 46% had a White therapist). Both racial and gender microaggressions were associated with worse outcomes. Using structural equation modeling to assess indirect effects, the authors found a significant indirect effect of racial microaggressions (−.12, 95% CI [−.35, −.07]) and gender microaggressions (−.10, 95% CI [−.36, −.05]) on positive therapy outcomes, through both cultural humility and working alliance, accounting for 24% of the variance in outcomes. That is, the effect of microaggressions on outcomes was partly explained by the level of therapist cultural humility and by the therapeutic alliance. The most common racial microaggression reported by clients was: “My counselor avoided discussing or addressing cultural issues in our sessions”, and the most common gender microaggression was: “My therapist encouraged me to be less assertive so that I do not present myself as being aggressive”.
Practice Implications
Unfortunately, therapist racial and gender microaggressions are common. However, therapists who practice cultural humility and who work at developing a therapeutic alliance may commit fewer microaggressions and can more easily mitigate the negative effects of microaggressions should they occur. Taking steps to develop cultural humility, strengthening the alliance, and repairing alliance ruptures through professional development may be ways of improving therapy outcomes for BIPOC women.
October 2022
Therapists Report Less Therapeutic Skill in Telepsychology vs In Person Therapy
Lin, T., Stone, S. J., Heckman, T. G., & Anderson, T. (2021). Zoom-in to zone-out: Therapists report less therapeutic skill in telepsychology versus face-to-face therapy during the COVID-19 pandemic. Psychotherapy, 58, 449–459.
The COVID-19 pandemic has confronted psychotherapists with several challenges including rapidly switching their practice to using teletherapy (videoconferencing, phone, and other virtual media). The use of teletherapy in clinical work increased from 7.1% prior to the pandemic to 85.5% during the pandemic. And estimates suggest that at least one-third of clinical work will be performed by teletherapy post-pandemic. Over a third of psychologists reported that they lacked training in using teletherapy, and they believe that their skills in this domain are inadequate. Therapists have raised a number of concerns in past surveys including issues related to privacy, professional self-doubt, technological competence, challenges to the therapeutic relationship, and problems with implementing some interventions. In this survey of 440 therapists and trainees, Lin and colleagues were particularly interested in therapists’ perceptions of the impact of teletherapy relative to in person therapy on the therapeutic process and patient outcomes. Videoconferencing was the most frequently used modality by 73.56% of surveyed therapists. The survey asked if three broad areas of practice were affected by teletherapy compared to in person therapy. These areas included common therapeutic factors (level of therapist empathy, emotional expression, warmth, alliance bond), extra-therapeutic patient factors (the patient’s environment that impacted their ability to engage in homework or use prescribed resources), and perceived patient outcomes (therapist ratings of patient symptom reduction, satisfaction, clinical improvement). Therapists in the survey were representative of the population of therapists in the US, and 82% of them provided all their clinical work in recent months by teletherapy. Compared to in person therapy, therapists reported poorer skills related to common therapeutic factors (d = 0.86), somewhat greater impact of extra-therapeutic factors (d = 0.36), and perceived poorer patient outcomes (d = 0.68) in teletherapy. Therapists who were younger, preferred emotion-focused or relational therapies, and with no prior training reported a relatively greater decrease in therapeutic skills in teletherapy compared to in-person therapy.
Practice Implications
By far, most therapists believed that providing psychotherapy by virtual means reduced their capacity to use common therapeutic stances including empathy, warmth, and the therapeutic alliance. Some of this might be affected by the psychological distance caused by the virtual format and difficulties with reading body language and other non-verbal cues. Therapists perceived that patient outcomes suffered as a result. This was particularly true for younger therapists, possibly because of the impact of adopting the new modality on their professional self-confidence. Also, therapists who preferred experiential or interpersonally based therapies felt particularly challenged possibly because these therapies may be more reliant on emotional communication and discerning patient interpersonal behaviors. Training and support are needed for therapists and trainees to improve their confidence in providing teletherapy.