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 the treatment of depression, the effects of role induction in psychotherapy, and negative experiences in psychotherapy from clients’ perspective.
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
September 2022
Client Perspectives on Psychotherapy Failure
The research indicates that between 5% to 10% of patients get worse during psychotherapy, as many as 30% do not improve, and about 20% drop out of therapy. And so, despite the overall efficacy of psychotherapy, treatment failure (not improving, getting worse, and dropping out) is a big problem. Surprisingly, there is very little research to understand what happens when therapy is unsuccessful. Some of the research that exists asks therapists for their opinions, but we already know that therapists are not good at detecting patients who get worse, therapists overestimate patient satisfaction, and therapists often overestimate their effectiveness relative to peers. Very few studies have asked patients directly about their experience, their understanding, and the impact of psychotherapy not working for them. In this qualitative study, Knox and colleagues interviewed 13 adult patients who reported that their psychotherapy was a failure. The patients reported a variety of reasons for seeking therapy in the first place (depression, anxiety, trauma), and they received a median of 20 to 30 sessions of therapy. Of the therapists that patients saw, 62% were female whose average wage was in the 40s, from different professions (psychology, social work, counsellors), and different contexts (private practice, universities, community health clinics). Typically, patients defined a psychotherapy failure as one that negatively affected them (made them feel worse, did not meet their treatment goals, and characterized by problems in the therapeutic relationship). Often patients raised their concerns with the therapist prior to the final session, but the issue did not resolve. Patients also reported that after termination their symptoms worsened, they felt more hopeless regarding themselves, and they were less optimistic about therapy in the future. Patients noted that therapist behaviors contributed to the failure, such as: therapist insensitivity, apparent incompetence, not checking in with patients’ experiences of the therapy, not focusing on the patients’ goals, and not addressing concerns about the therapy raised by patients.
Practice Implications
Unfortunately, a non-trivial percentage of patients get worse or don’t benefit from therapy. There were immediate impacts (patients felt worse) and also longer-term impacts (patients’ symptoms continued to deteriorate and they were less optimistic about trying therapy again). Therapists should regularly check in with patients about how they are experiencing the therapy. If a patient expresses concern about how therapy is progressing, therapists must listen and non-defensively hear what the patient is saying while acknowledging that it is difficult for patients to speak up. Therapists who make an error should own the mistake and correct course if necessary or refer to another professional. Regular outcome monitoring (repeated measurement of patient symptoms) and process monitoring (repeated measurement of the therapeutic alliance) may help therapists to supplement their clinical judgement to determine if the patient’s symptoms are deteriorating or if they are dissatisfied.
Is the Therapeutic Alliance Therapeutic? It Depends.
The therapeutic alliance is the most studied concept in psychotherapy and is perhaps the most reliable predictor of patient outcomes. But there are two possible explanations for this finding. First, meta-analyses indicate that patients who report higher overall levels of the alliance tend to experience better outcomes at the end of therapy. Second, other meta-analyses report that if a patient’s alliance improves from one session to the next, regardless of their overall level of the alliance, they report a better outcome. The distinction between the two explanations is important. In the first case, one could argue that some patients who have a general tendency to develop a strong alliance also have a general ability to benefit from any treatment. In the second case, one could argue that a patient’s general tendency to develop an alliance does not matter as much as experiencing a growth in their alliance with the therapist from one session to the next. In other words, is the effect of the therapeutic alliance due to a general capacity of the patient to engage in any therapeutic relationship, or is the effect due to growth in the alliance itself being an active mechanism of change in therapy? In this study, Zilcha-Mano and colleagues compared two treatments for depression from a randomized controlled trial: (1) supportive expressive therapy (SET) that relied on primarily specific interventions and secondarily on the overall level of the alliance to help patients change, and (2) supportive therapy (ST) that primarily relied on growth in the alliance as the main therapeutic factor for change. The authors used sophisticated statistical modelling of session-to-session change in depression and change in the alliance to separate out the effects of a patient’s general tendency to develop a good alliance from the growth of the alliance session to session. The researchers also compared SET and ST on the effects of general tendency to develop an alliance versus growth in the alliance from session to session. The findings indicated that the general tendency of patients to experience a good alliance predicted better outcomes in both therapies. That is, patients who already had a capacity to engage in the therapeutic relationship got better regardless of the type of therapy. However, growth in the alliance predicted better outcomes only in ST and not SET. That is, for ST in which the alliance itself was considered a mechanism of change, patients’ symptoms improved when there was growth in the alliance from one session to the next independent of their general capacity to engage.
Practice Implications
The results of the study, like previous meta-analyses, suggested that patients who have a higher general capacity to develop a therapeutic alliance have better outcomes regardless of the therapy. This is a “rich get richer” finding, in which more agreeable patients tend to get better with any treatment they receive. However, the findings also suggested that it is also possible for patients with a lower general capacity for a good therapeutic alliance to improve. For such patients, therapists might prioritize developing and maintaining the alliance on a session-to-session basis. This might be accomplished by taking a more supportive approach, by identifying and acknowledging alliance ruptures, and by repairing such ruptures through negotiating new tasks and goals or strengthening the therapeutic bond.
An Alliance Rupture in One Session Leads to Greater Symptoms in the Next Session
The therapeutic alliance is the collaborative agreement between patient and therapist on the tasks and goals of therapy, and their affective bond. Meta-analyses of over 200 studies show clearly that a higher overall level of the alliance is a reliable predictor of better patient outcomes at the end of treatment. The research is also more specific about how the alliance works - patients whose alliance ratings in one session is higher than their own overall average tend to have fewer symptoms in the next session. During treatment, the state of the alliance may be characterized by rupture and repair episodes. That is, therapists and patients commonly have minor or major disagreements on the tasks and goals of therapy or a disruption in their relational bond, and therapists often try to repair this disagreement or disruption. Confrontation ruptures occur when patients directly show their concern, and withdrawal ruptures occur when patients might have difficulty either recognizing their feelings or directly expressing them. Ruptures are ubiquitous - they occur in every form of therapy and with therapists of every skill level. Resolutions, when done well by therapists, allow the patient and therapist to come to a stronger collaboration on the tasks and goals of therapy or to strengthen their bond. A meta-analysis showed that patients who experience resolution episodes after a rupture had better treatment outcomes. However, most of these studies focused on the effects of higher or lower overall levels of ruptures relative to resolutions on post-treatment outcomes. Few of the studies looked at the impact of a rupture and/or resolution during a session on the outcome or the level of the alliance at the end of the session. In this study, Babl and colleagues specifically looked at whether a rupture during a session is associated with poorer alliance and poorer outcomes after the session, and if a resolution of the rupture is related to a better alliance and better outcomes. The study included 56 patients who received 25 sessions of integrative cognitive therapy for depression or anxiety and who were treated by one of 33 therapists. Independent coders rated alliance ruptures and resolutions from video recordings of 4 therapy sessions throughout treatment. Therapeutic alliance and patient outcomes were assessed after each session with reliable questionnaires. Higher intensity ruptures overall were associated with lower alliance ratings across all sessions. Sessions with more intense confrontation ruptures were associated with poorer alliance ratings after the session. Alliance ruptures and repairs were not associated with patient outcomes.
Practice Implications
It may be important for therapists to continuously monitor the state of the therapeutic alliance with each patient and to identify any instances in which the patient is engaging in a confrontation or withdrawal rupture. Therapists may successfully address such ruptures by openly and non-defensively discussing a rupture should it occur, taking responsibility for the rupture if appropriate, regularly talking with patients about the state of the therapeutic relationship, and re-negotiating the tasks and goals of therapy if necessary.
August 2022
Brief Online DBT Was Not Effective to Reduce Self Harm
Self-harm or non-suicidal self-injury is a significant problem that might affect 6% of the population seeking medical attention. And so, health systems are considering ways of scaling up treatments to reduce incidences of self-harm behaviors. Previous research showed that traditionally delivered dialectical behavior therapy (DBT) may reduce the incidence of suicide attempts. In this very large study of over 18,000 patients, Simon and colleagues tested whether two low intensity (and therefore low cost) outreach programs in addition to usual care provided to outpatients could reduce self-harm. Patients who reported suicidal thoughts in the past two weeks from several large health systems in the U.S. were randomly assigned to receive (1) care as usual, or (2) care management which included regular messages to motivate patients to follow-up with usual care, or (3) an interactive online program based on DBT supported by a skills coach that focused on mindfulness, current emotions, opposite action, and paced breathing. Both care management and the DBT based online program were in addition to usual care. The main outcome was fatal or non-fatal self-harm within 18 months. The results indicated that 3.10% of those who only received usual care experienced self-harm, 3.27% of those who received care management experienced self-harm, and 3.98% of those who received the online DBT based skills program experienced self-harm. A statistical comparison found a significantly higher risk of self-harm in the DBT based skills training group compared to usual care alone (hazard ratio, 1.29; 97.5% CI, 1.02-1.64; p = .015). When the authors looked at uptake or participation in the programs over a 9-month period, 17% of those who were offered usual care remained engaged in the program but only 2% of those offered the DBT based skills program remained engaged.
Practice Implications
This study is unusual in a couple of ways. First, it is very large and so it provides reliable findings that represent what might occur in actual practice. Second, the study reports a negative finding for a psychological intervention. The study indicates that trying to scale up a self-harm prevention program by providing it online even with live coaching resulted in significantly poorer outcomes than only usual care. Very few people (only 2%) continued with the online program after starting it. These results are similar to findings from previous research of online delivered therapy in which many people start but do not continue with such programs. Very few those who need mental health care want to interact with a program, and outcomes of such programs are modest at best.
November 2021
Emotional Experiences of Psychotherapists
Chui, H., & Liu, F. (2021). Emotional experience of psychotherapists: A latent profile analysis. Psychotherapy, 58(3), 401–413.
Working with client emotional experiences in therapy is a core aspect of the psychotherapist’s work, regardless of their theoretical orientation. And so, therapists’ performance and their own well-being may be impacted by their capacity to experience and regulate their own emotions. Emotional reactivity refers to one’s sensitivity, intensity, and duration of emotional experience. Emotion regulation refers to the capacity to manage and express emotions and may be considered an interpersonal competency for therapists. Such competency likely involves flexible expression of emotion and a capacity for empathy. A better understanding of how therapists experience emotions might inform therapists’ use of empathy to facilitate their work with clients. In this study, Chui and Liu surveyed 314 English speaking and 589 Chinese speaking psychotherapists and asked them about their experiences of emotional reactivity, their emotion regulation, and empathy. Their data allowed them to develop profiles of psychotherapists along dimensions of emotional experience. Three latent profiles emerged in both the English and Chinese speaking samples of therapists. The highest proportion of English-speaking therapists (58%) were categorized as “Calm Regulators”, which indicated therapists with low emotional reactivity and few problems with emotion regulation. Next, 34.4% of English-speaking therapists were characterized as “Moderate Experiencers”, and 7.6% were “Emotional Feelers”. The latter profile included therapists who were emotionally over-reactive and who had greatest difficulty with regulating their emotions. As one might expect, those with the Calm Regulator profile had higher capacity for perspective taking, higher empathic concern, and lower personal distress than therapists in the other profiles. Also, therapists who were older, with more education, female, and with a psychodynamic orientation were more likely to have the Calm Regulator profile. Results were remarkably similar in the Chinese speaking sample, in which Calm Regulators also reported higher levels of counsellor self-efficacy.
Practice Implications
Therapists with the “Emotional Feelers” profile (i.e., that have higher levels of emotional reactivity and more difficulty regulating their emotions) may be at higher risk of burnout and of being less effective in their work. As a profession we often discuss clients’ individual differences in emotional experience and emotion regulation, but we spend less time considering these important interpersonal competencies in therapists. Recent surveys suggest that almost 50% of therapists may be at high risk of mental health problems. Psychotherapists, trainers, and supervisors need to pay more attention to therapists’ capacity to regulate their emotions, and its impact on their capacity to be emotionally flexible and empathic with clients. Therapists might consider personal therapy as a means of building this capacity.
Therapists are Not Equally Effective Across Sexual Orientations
Drinane, J. M., Roberts, T., Winderman, K., Freeman, V. F., & Wang, Y.-W. (2021, October 14). The myth of the safe space: Sexual orientation disparities in therapist effectiveness. Journal of Counselling Psychology. Advance online publication.
In general, differences between therapists account for 5% to 10% of the variance in client treatment outcomes. Some of these differences can be accounted for by therapists’ capacity to adjust to or to work with diverse client characteristics. For example, certain therapists more effectively espouse cultural humility and pursue opportunities for cultural conversations than other therapists, and this likely affects client outcomes. Most of the research on therapist effects related to diversity has focused on race/ethnicity. Very few studies to date have looked at therapist differences regarding sexual minority statuses. Therapists can engage in unhelpful practices including microaggressions toward sexual minority patients. Microaggressions can be unintended or subtle expressions of prejudice that are harmful to the recipient. Microaggressions that sexual minority patients experience may include communicating that one’s sexual orientation is a cause of distress, minimizing the importance of sexual orientation identity, and over-identification with LGBTQ clients. Further, patients with sexual minority statuses are at increased risk for adverse mental health outcomes possibly caused by the experience of minority stress related to stigma, prejudice, and discrimination. In this study, Drinane and colleagues a sample of 1,725 clients treated by 50 therapists in a university counselling center. About 17.7% of the client sample endorsed a sexual minority status. An unexpected finding was that sexual minority clients did not have worse mental outcomes than heterosexual clients. However, therapists varied in the extent to which their clients improved and how that improvement varied by sexual orientation status. Some therapists had queer clients who experienced more change than their heterosexual clients, whereas other therapists had heterosexual clients who experienced more change than their queer clients.
Practice Implications
The findings of this study indicate that therapists influence their clients outcomes differently based on the clients’ sexual orientation identity. Those therapists whose queer clients had worse outcomes than their heterosexual clients may be inadvertently engaging in microaggressions. Professional development that focuses on increasing the ability to consider sexual minority client experiences may lead psychotherapists to respond to sexual minority clients without prejudice. Therapists should consider how their own values shape their behaviors and interventions across client populations.