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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.

April 2017

Do All Therapists Do That When Saying Goodbye?

Norcross, J.C., Zimmerman, B.E., Greenberg, R.P., & Swift, J.K. (2017). Do all therapists say that when saying goodbye? A study of commonalities in termination behaviors. Psychotherapy, 54, 66-75.

One of the things common to all psychotherapy relationships is that they come to an end. The endings may be premature or planned. They may be well managed or poorly managed. In this article by Norcross and colleagues, the authors ask: what do expert therapists typically do when there is a planned termination with a client? A planned termination is “an intentional process that occurs over time when a client has achieved most of the goals of treatment, and/or when psychotherapy must end for other reasons”. By contrast, premature termination occurs when the client ends treatment unilaterally. In successful cases the client and therapist typically predetermine the end date and have time to work toward the ending. Different theoretical orientations write about different aspects of termination. For example, from a psychodynamic perspective, therapists focus on clients’ old and new methods of coping, feelings related to the impending loss of the relationship, review gains, and work to equalize the relationship. From an experiential perspective, therapists might recognize that clients continue to change after therapy, help clients work through feelings of loss and separation of the therapeutic relationship, and consolidate new meanings. Cognitive-behavioral therapists might help clients to maintain gains made in therapy, review new skills, and prevent relapse. Do therapists who practice these and other theoretical approaches differ in terms of how they manage termination in psychotherapy? Norcross and colleagues surveyed 65 nominated experts representing six theoretical orientations of psychotherapy (psychodynamic, humanistic, CBT, interpersonal, multicultural, and integrative). Each orientation was represented by at least 10 expert therapists. The survey included 80 items related to termination that were drawn from books, chapters, and treatment manuals. The experts indicated the frequency with which they engaged in each behavior or the task related to termination. Therapist behaviors or tasks that received very strong consensus (>90% of therapists reporting “frequently” or “almost always” doing these) included: supporting the client’s progress, helping to consolidate gains made in therapy, following ethical practice (e.g., avoiding abandonment), attributing gains to the client’s effort, talking about what helped or went well, and collaborating with the client to set a date and pace of termination. Strong consensus (80% to 90% of therapists reported frequently doing these) behaviors or tasks included: focus on processing feelings around termination, having the client practice new skills, normalizing the probability of relapse, and prompting the client to think of a future without therapy. Of the 80 Items, 27 did not reach consensus among the therapists (i.e., only 21% to 59% of therapists agreed on these items). Out of the 80 items, only 8 (10% of items) showed significant differences between theoretical orientations (e.g., compared to other orientations, CBT therapists tended to do more of: preparing clients for relapse, and systematically assessing client outcomes near termination).

Practice Implications

This survey of 65 experts of varying psychotherapy orientations highlighted a wide range of commonalities in terms of how they managed termination with clients. While there was some uniqueness among orientations, most therapists tended to: process feelings about termination and the relationship with clients, discuss future functioning and coping, helped clients to use new skills, framed the client’s personal development as ongoing beyond therapy, prepared explicitly for termination, and reflected on the client’s gains.

March 2017

Creating a Climate for Improving Therapist Expertise

Goldberg, S.B., Babins-Wagner, R., Rousmaniere, T., Berzins, S., Hoyt, W.T., Whipple, J.L., Miller, S.D., & Wampold, B.E. (2016). Creating a climate for therapist improvement: A case study of an agency focused on outcomes and deliberate practice. Psychotherapy, 53, 367-375.

There is a lot of evidence that psychotherapy is effective – a result that has been demonstrated in randomized trials and in naturalistic setting. As I have noted numerous times in this Blog, psychotherapy is as effective as medications but without the side effects and with longer lasting results. However, there is room for improvement, especially in the effectiveness of individual therapists. Health care organizations are increasingly interested in quality improvement, which refers to efforts to make changes in practice that will lead to better patient outcomes, better care, and better professional development. One approach to quality improvement in medicine has been through audit and feedback – which involves measuring a clinician’s practice, comparing the clinician’s outcomes to professional standards, and giving the clinician feedback. In psychotherapy, the analogue is routine outcome monitoring in which patient progress is monitored with standardized measures throughout therapy, and therapists receive ongoing feedback on each patient’s progress relative to the average patient with that disorder. We know that therapists tend not to improve in terms of patient outcomes with experience alone, and some authors argue that one of the things that therapists are missing is good quality information about their clients’ progress. What would happen if an agency or organization decided to make it a priority to provide therapists with quality information about client progress? This paper by Goldberg and colleagues is a case study in which an agency deliberately created a culture of quality feedback and professional development to improve therapist expertise, therapist intentional practice, and client outcomes. The case study is of a community mental health agency in Alberta. Over 5,000 clients were seen by 153 therapists over a 7 year period (2008 to 2015) as part of the study. Clients received at least three sessions of therapy (mean = 6.53 sessions, SD = 5.02), and had a range of disorders typically seen in a mental health clinic. Therapists included 49.7% licensed or provisionally licensed professionals at the masters or doctoral level from different professions (e.g., social work, psychology, pastoral counselling), and 50.3% practicum students. Throughout the 7 years of the study, therapists saw an average of 33.52 clients (SD = 26.24). In 2008, the agency required the staff to collect outcome measures of all clients before each session (although patient scores were not tied to staff performance evaluations). This policy change caused a 40% turnover in clinical staff within 4 months (clearly a large minority of therapists did not want to participate in this new clinic directive)! These staff positions were replaced and staffing was stable after that point. In addition to requiring clinicians to provide measures on all patients (although patients could decline to participate), the agency provided monthly clinical consultations with an external consultant as a means of professional development. During these consultation, clinicians were encouraged to bring cases that were not progressing well in order to get feedback on their most challenging patients. Discussions were organized around therapeutic alliance, i.e., clarifying goals and preferences, and ways of facilitating engagement. The overall results showed a significant decline in distress among patients over the course of treatment. Of most interest was that therapists on average showed a significant improvement in their outcomes over time. That is, contrary to research showing that therapists do not improve over time when left to their own devices, therapists in this agency that received feedback and professional education around difficult cases did improve significantly.

Practice Implications

The findings of this study indicate that psychotherapists can improve over time if they receive quality information about client progress, and if they receive professional development that is tied to this information (i.e., concrete suggestions for ways of working with difficult clients). In other words, it is possible for therapist to develop expertise over time under some conditions. A significant challenge in this case study was that a number of therapists left the agency due to the quality improvement efforts. Some therapists are sensitive to or feel threatened by outcome monitoring. However, therapists who remained or who were subsequently hired by the agency showed a reliable increase in their expertise and client outcomes as a result of deliberate intentional practice, quality feedback about client progress, and concrete professional development focused on the therapeutic alliance.
Long-Term Medical Conditions Reduce Outcomes in Psychotherapy

Dalgadilo, J., Dawson, A., Gilbody, S., & Bohnke, J.R. (2017). Impact of long-term medical conditions on the outcomes of psychological therapy for depression and anxiety. British Journal of Psychiatry, 210, 47-53.

Twenty percent of people have long-term medical conditions, and this percentage rises to 58% for people over 60. These long-term conditions account for approximately 70% of health care costs in the UK. The most prevalent long-term conditions in the population include: hypertension, chronic pain, gastrointestinal disorders, asthma, diabetes, heart disease, and chronic obstructive pulmonary disease. Do these conditions reduce the outcomes of psychological therapies? Dalgadilo and colleagues conducted a large study in the UK of patients who accessed publicly funded psychological services. The authors looked at what impact long-medical problems had on psychological intervention outcomes. Patients accessing the public system in the UK received stepped care - so that they were first given self help followed by a second step of intensive psychotherapy, if they needed it. The sample for the study included over 28,000 patients with a mean age of just over 38 years. About 23.2% had a long-term condition. Sixty-eight percent only received the low intensity self help, and 32% required the intensive psychotherapy. Those with long-term conditions, compared to those without long-term conditions, tended to report higher levels of distress and lower quality of life at the outset. Long-term conditions that were associated with poorer psychological intervention outcomes included: chronic pain, chronic obstructive pulmonary disorder, severe mental health problems, and diabetes. The effects were small (d = .20) to medium (d = .50) sized (confidence intervals not reported). Those with long-term conditions were more likely to receive high intensity psychotherapy after the self help. However, poorer outcomes for those with long-term conditions, compared to those without long-term conditions, were still apparent after they received the intensive psychotherapy.

Practice Implications

Compared to those without long-term medical conditions, those with long-term conditions have a higher level of impairment to start with and tend to finish therapy with greater depression and anxiety. The study points to the need to integrate psychological therapies in medical practices - especially for those with long-term medical conditions. Certain conditions like chronic pain, and having multiple conditions increase psychological distress and likely reduce patient mental health outcomes.

January 2017

Ways In Which Research Can Be Biased

Leichsenring, F. Abbass, A., Hilsenroth, M.J., Leweke, F., Luyten, P., ….Steinert, C. (2016). Bias in research: Risk factors for non-replicability in psychotherapy and pharmacotherapy research. Psychological Medicine, doi:10.1017/S003329171600324X.

An important feature of research is that it should be replicable. That is, another researcher should be able to obtain the same finding as the original study as a pre-requisite for the validity of the conclusions. A recent estimate for cognitive and social psychology research is that only about 36% to 47% of studies are successfully replicated. Another study showed similar low replicability of psychotherapy and pharmacotherapy research. Results that are neither replicable nor valid can lead to improper treatment recommendations. Leichsenring and colleagues review several research biases that affect the replicability of findings in psychotherapy and pharmacotherapy research, and they discuss how to limit these biases. Psychotherapy trials often involve an established treatment approach that is pit against a comparison treatment in a head to head contest. Below I list some of the biases detailed by Leichsenring and colleagues that may affect the validity of psychotherapy trials. First, in psychotherapy trials a large proportion of the differences in outcomes between a treatment and a comparison may be due to the researcher’s allegiance to a particular therapy modality. This may be expressed unconsciously by selecting outcome measures that are more sensitive to the effects of one type of treatment versus another. For example the Beck Depression Inventory (BDI) is particularly sensitive to changes in cognitions, whereas the Hamilton Depression Rating Scale (HDRS) is particularly sensitive to physiological side effects related to antidepressant medications. One way to deal with researcher allegiance effects is to include researchers and therapists who have an allegiance to both of the treatments that are under study. Second, the integrity of the comparison treatment may be impaired. That is the comparison treatment may not be carried out exactly as originally intended. This could occur in pharmacological trials in which doses do not match clinical practice, or in psychotherapy trials in which therapists in the comparison treatment may be told to ignore key symptoms. Properly training and supervising therapists and not constraining them by the study protocol is important to avoid this type of bias. Third, some studies make a lot of noise about small effects that are statistically significant. When two bona-fide psychotherapies are compared the differences tend to be small – this is a common finding. Small differences, even if statistically significant, often turn out to be random, unimportant, and of little clinical significance. Concurrent with this problem is that sometimes researchers will use multiple outcome measures, find significant differences only with some, and report these as meaningful. This refers to selectively emphasizing a small number of findings among a larger number of analyses, which are likely due to chance variation and therefore not replicable.

Practice Implications

What should a clinician do when reading a comparative outcome study of psychotherapy? There are some technical red flags for research bias that require specialized knowledge (e.g., small sample sizes and their effect on reliability, over-interpreting statistical significance in the context of small effects, and non-registration of a trial). But there are a few less technical things to look for. First, I suggest that clinicians focus primarily on meta-analyses and not on single research studies. Although not perfect, meta-analyses review a whole body of literature, and are more likely to give a reliable estimate of the state of the research in a particular area. Second, clinicians should ask some important questions about the particular study: (a) are the results unusual (i.e., when comparing 2 bona-fide treatments, is one “significantly” better; or are the results spectacular); (b) does the research team represent only one treatment orientation; and (c) do the researchers reduce the integrity of the comparison treatment in some way (e.g., by not training and supervising therapists properly, by unreasonably limiting what therapists can do)?

November 2016

When Clients and Therapists Agree on Client Functioning

Bar-Kalifa, E., Atzil-Slonim, D., Rafaeli, E., Peri, T., Rubel, J., & Lutz, W. (2016, October 24). Therapist–client agreement in assessments of clients’ functioning. Journal of Consulting and Clinical Psychology. Advance online publication. http://dx.doi.org/10.1037/ccp0000157.

There has been a lot of research in the past decade on progress monitoring (i.e., regularly providing reliable feedback to therapists on client outcomes, the alliance, and client functioning). This research indicates that client outcomes can be enhanced if therapists have ongoing information on how their client or the relationship is progressing. In this innovative research by Bar-Kalifa and colleagues, the authors studied 77 therapists who saw a total of 384 clients. The therapists were experienced at providing cognitive-behavioral therapy. Clients for the most part had a depressive or anxiety disorder and were seen for an average of 36 sessions. Client outcomes were measured pre- and post-treatment. Emotional and psychological functioning during the past week was rated by the client before each session, and the same measure was given to the therapist to rate their client at the end of each session. After therapists made their rating, they were given ongoing feedback (i.e., progress monitoring) about how their clients’ rated their own functioning during the past week. Did clients and therapists agree on level of client functioning, was this agreement stable over time, and was this agreement or disagreement related to client outcomes? The authors used sophisticated statistical modeling to separate the effects of client ratings of their functioning from therapists’ ratings, and to examine the impact of the changing relationship between therapist and client ratings over time on client outcomes. The authors found little difference in the level of client and therapist ratings of client functioning, and they found that therapists tended to be accurate (i.e., congruent with clients) in tracking client functioning over time. More importantly, the ability of therapists to accurately track client functioning from session to session was related to better client outcomes in terms of key symptoms of depression and anxiety.

Practice Implications

The ability of therapists to accurately track client functioning over time was related to better client outcomes. This means that therapists who were aware of their clients’ functioning through feedback methods were better equipped to help their clients. In particular, information about how client functioning was changing from session to session might have allowed therapists to take corrective action for clients who were not doing well from one session to another. This information might have allowed therapists to reconsider a treatment formulation for a particular client, for example. Therapists should be aware of how a client is doing at a particular session, but more importantly therapists should be sensitive to fluctuations in client functioning across sessions. This might be best achieved with ongoing progress monitoring.

October 2016

The Long Reach of Nurturing Family Environments

Waldinger, R.J. & Schulz, M.S. (2016). The long reach of nurturing family environments: Links with midlife emotion-regulatory styles and late-life security in intimate relationships. Psychological Science. DOI: 10.1177/0956797616661556.

Although, not a psychotherapy study, this research has important implications for psychological treatment of adults, including older adults. This research, drawn from the original Grant study, is extraordinary because the sample is from a 78-year long study of 81 men. The original cohort of over 200 men were first assessed as adolescents and young adults between 1939 and 1942. At that time, the original authors conducted intensive interviews of the adolescents` family experiences and current life situations. These men were re-interviewed in mid-life in the 1960s (aged between 45 and 50 years), which included interviews and assessments of challenges in relationships, work functioning, and physical health. Waldinger and Schulz recently re-interviewed these men and their current partner in late-life (aged between 75 and 85 years), with interviews focusing on their current partner relationship. Raters reviewed audio recordings and notes from all the interviews and coded for: (a) quality of family environment in childhood (distant, hostile vs cohesive, warm) - taken from the first interview; (b) style of regulating emotions (suppressive, maladaptive vs engaged, adaptive) – taken from the midlife interview; and (c) security of attachment with their current partner (secure, comforting vs insecure, anxious) – taken from the late-life interview. The authors found that more nurturing early family environments were significantly linked with late-life attachment security with a partner (r = .23, 95% CI = .01, .45), and early family environment was significantly related to midlife adaptive emotion regulation strategies (r = .29, 95% CI = .06, .50). Also, adaptive emotion regulation strategies in midlife were significantly correlated with greater late-life attachment security (r = .23, 95% CI = .05, .51). These are medium-sized correlations, but they are remarkable because they represent associations between variables that were assessed decades apart. Through a statistical mediation analysis, the authors also reported that adaptiveness of emotion-regulation strategies partially explained why positive childhood family environments may lead to late-life attachment security (accounting for 6% of the variance).

Practice Implications

This compelling study adds to the argument that early family environment shapes the way adults regulate their emotions, which in turn affects how they experience relationships in old age. More securely attached adults were better able to meet two challenges associated with aging: accepting vulnerability in depending on a partner, and accepting the responsibility of being depended upon by that partner. The early family environment indeed has a long reach. Psychotherapy directed at reducing the effects of childhood adversity takes on a heightened meaning in the context of these findings. Treatment for adults who struggle with the consequences of non-nurturing early environments should include improving emotion regulation strategies.

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April 2017

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March 2017

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January 2017

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November 2016

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October 2016

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Psychotherapy Practice Research Network (PPRNet)