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
April 2021
Therapeutic Alliance Predicts Patient Outcomes Over and Above Other Factors
Flückiger, C., Del Re, A. C., Wlodasch, D., Horvath, A. O., Solomonov, N., & Wampold, B. E. (2020, March 26). Assessing the alliance–outcome association adjusted for patient characteristics and treatment processes: A meta-analytic summary of direct comparisons. Journal of Counseling Psychology. Advance online publication.
The therapeutic alliance is probably the most researched concept in psychotherapy. The alliance refers to a collaborative agreement on the tasks of therapy (what patients and therapists do in therapy, like homework, or examine the past or relationship issues), a collaborative agreement on the goals of therapy (what the desired outcomes might be), and the relational bond between patient and therapist (liking and respect for one another). The most recent meta-analysis of the alliance included 296 studies. The meta-analysis showed a moderate and robust relationship between higher alliance and better patient outcomes regardless of type of therapy, who rated the alliance, or how it was rated. Nevertheless, some still think that the alliance is a byproduct of other factors like patient symptom severity (less symptomatic patients may report a better alliance with therapists) or adherence to treatment manuals (higher therapist adherence may lead to a better alliance). In other words, some argue that the alliance may not directly affect outcomes and may not be that important. In this meta-analysis, Fluckiger and colleagues examined 60 studies with over 6,000 patients that reported the alliance-outcome relationship, and also the effects of patient characteristics like symptom severity and adherence to treatment manuals. Overall, the therapeutic alliance was significantly related to patient outcomes, r = .304 (95% CI [.253, .354], p < .001, k = 53). When the authors of the primary studies controlled for patient characteristics like symptom severity, the adjusted alliance - outcome correlation remained significant, r = .286 (95% CI [.226, .344], p = .001, k = 35). When the authors of primary studies controlled for the effects of therapist adherence to a treatment manual, the adjusted alliance – outcome correlation still remained significant, r = .242 (95% CI [.179, .306], p = .001, k = 13). The slight reduction in the alliance-outcome correlation caused by the effects of patient symptom severity or therapist adherence to a manual was not significant.
Practice Implications
Therapists’ capacity to develop a therapeutic alliance is a key factor to patients experiencing a good outcome from psychotherapy. This is true for many types of patients with differing levels of symptom severity, and also true regardless of type of therapy or level of therapist adherence to a treatment protocol. Developing shared treatment goals and agreeing on the tasks of therapy are important first steps. In addition, therapists and clients who like working together and share a sense of mutual respect are more likely to experience a successful therapy. Maintaining the alliance throughout therapy is also important. The alliance fluctuates across time indicating subtle or obvious ruptures or tensions that occur. Therapists’ skills at identifying and repairing alliance ruptures is critical to an ongoing collaborative relationship and to patients achieving the best possible outcomes.
December 2020
Psychotherapy for Those Who Do Not Respond to Treatment
Gloster, A. T., Rinner, M. T., Ioannou, M., Villanueva, J., Block, V. J., Ferrari, G., ... & Karekla, M. (2020). Treating treatment non-responders: A meta-analysis of randomized controlled psychotherapy trials. Clinical Psychology Review, 75, https://doi.org/10.1016/j.cpr.2019.101810.
Generally, there are a number of effective treatments for mental disorders including psychotherapy and medications. However, by some estimates, about 40% of patients with mood or anxiety disorders do not respond to these treatments. Research shows that patients who do not respond to initial treatments tend to have lower quality of life and higher mortality. By definition, treatment non-response indicates a failure of the treatment to achieve symptom reduction for patients. There is a research literature looking at the impact of introducing a subsequent treatment like psychotherapy for patients who do not respond to a previous treatment (most often a medication). In this meta-analysis Gloster and colleagues examined the efficacy of adding psychotherapy for patients who were not responsive to a previous treatment. They only included randomized controlled trials of patients diagnosed with mood or anxiety disorders. The authors found 18 studies of this kind that had 1734 participants. Most of the studies (80%) used medications as an initial treatment. The psychotherapies that were given to non-responders were quite varied including CBT, psychodynamic therapies, and DBT. The authors adjusted effect sizes downward for publication bias – or the estimated effects of negative studies that were not published. Even with that downward adjustment, adding psychotherapy after previous treatment non-response resulted in significant positive effect for patients in terms of reduced symptoms (SMD = 0.45; 95% CI: 0.16, 0.75). Similar findings were noted for quality of life. However, there was a lot of variability in effects across studies. Better outcomes were not associated with a particular diagnosis or treatment type. The positive effects remained significant at follow up, but they did not hold up after adjusting for publication bias (SMD = 0.359; 95% CI -0.349, 1.068, p > .05).
Practice Implications
The findings of this meta-analysis are promising for using psychotherapy for those who do not respond to initial treatment, mostly with medication. Both symptoms and quality of life improved moderately with a second round of treatment. This is notable because treatment non-responders may experience frustration and demoralization, and these patients tend to have chronic conditions that cause significant impairment. An important caveat is that the evidence for longer term improvements may not be reliable, and so it is not clear whether the positive effects are sustained. Offering a patient a re-start of treatment may help them to establish new hope for recovery if the subsequent treatment is framed as something different from the previous interventions that did not work for them.
November 2020
Therapist and Client Emotional Expression: A Meta-Analysis
Peluso, P. R., & Freund, R. R. (2018). Therapist and client emotional expression and psychotherapy outcomes: A meta-analysis. Psychotherapy, 55(4), 461–472.
Emotions and emotional experiences are key to being human, and therefore are key to psychotherapy processes and outcomes. Emotion-focused therapy, for example, emphasizing helping clients to overcome their avoidance of emotions by exploring emotions in therapy in order to achieve change. Nevertheless, many therapeutic orientations focus on emotional expression, avoidance of emotions, emotional experiences, and understanding emotions as a means of helping clients to change and to have a better existence. Therapists of all stripes tend to work at creating a therapeutic context so that patients can have a corrective emotional experience. Primary emotions are universal and include happiness, sadness, fear, surprise, disgust, and anger. Secondary emotions are influenced by context and include embarrassment, guilt, and pride. All emotions and their experiences are influenced by cultural contexts, attitudes, and rules. A key aspect of psychotherapy includes helping clients to organize or make meaning of their emotions, and such therapeutic work is associated with positive client outcomes. In this meta-analysis, Peluso and colleagues evaluated the research on therapist and client emotional expression in psychotherapy, and its relationship to client outcomes. Thirteen studies found the effects of therapists’ expression of affect during therapy on client outcomes after the end of therapy had a mean effect size of r = .28 (95% CI: .17, .35), which was statistically significant and moderately large. The 42 studies that looked at client expression of affect during therapy and how it related to client outcomes after therapy found an average effect size of r = .40 (95% CI: .32, .48), which was also statistically significant moderately large.
Practice Implications
This meta analysis emphasizes that emotions matter in psychotherapy. The capacity of therapists to judiciously express emotions, and to help clients to experience and make meaning of their emotions is an important therapeutic skill. Therapists need to focus on and validate clients’ emotions, and therapists should encourage clients to understand and process (i.e., make meaning of) their emotions. This work must occur in the context of a safe, trusting therapeutic relationship. Meaning making and emotional resolution should be considered as key therapeutic goals for most therapies.
September 2020
The Reciprocal Relationship Between the Alliance and Outcomes
Flückiger, C., Rubel, J., Del Re, A. C., Horvath, A. O., Wampold, B. E., Crits-Christoph, P., Atzil-Slonim, D., . . . Barber, J. P. (2020). The reciprocal relationship between alliance and early treatment symptoms: A two-stage individual participant data meta-analysis. Journal of Consulting and Clinical Psychology, 88(9), 829–843.
The therapeutic alliance (patient and therapist agreement on tasks and goals of therapy and their emotional bond) is the most researched concept in psychotherapy. The research clearly indicates that a positive alliance reliably predicts patient outcomes in terms of reduced symptoms. However, researchers still debate whether the alliance is at all necessary. That is, some argue that the alliance is the result of patients feeling better early in therapy, and so the alliance is only an outcome of early symptom reduction. If that is the case, then the alliance is an artifact of symptom reduction, and clinicians need not pay much attention to it. In this meta-analysis, Fluckiger and colleagues collected 17 studies representing over 5000 patients that evaluated whether alliance in a previous session predicted outcomes in a subsequent therapy session, and vice versa. In other words, they looked at all studies that evaluated if change in alliance preceded change in symptoms and if change in symptoms preceded change in the alliance. What is unique about this meta-analysis is that they gathered patient-level data from the original studies. That allowed them to test the therapeutic alliance theory for each individual patient on a session by session basis for the first 7 sessions of therapy. (For the stats geeks out there, the authors analysed within-person [between-session] effects using multilevel time-lagged models). Their analyses found that high alliance at a preceding session was related to lower symptoms at the subsequent session (B adjusted = -.065 (95% CI [-.092, -.038]; p < .0001)), and higher symptoms at the start of a session was related to lower post session alliance (B adjusted = -.148 (95% CI [-.215, -.081]; p < .0001). They also found that patients who generally reported high alliance scores showed a stronger alliance – outcome relationship, and those with greater symptoms had a weaker alliance - outcome relationship.
Practice Implications
This meta-analysis is another indication of the importance of therapists and patients coming to a collaborative agreement on the tasks of therapy (what is done during sessions) and the goals of therapy (what issues to work on), and of their relational bond. The alliance is not always easy to establish – especially with regard to agreeing on goals. Also, the alliance should not be forgotten once established – alliance ruptures or tensions occur frequently and can have a negative effect on patients’ mental health outcomes. Patients of psychotherapists who repair alliance tensions generally have better mental health outcomes.
July 2020
Is the Therapeutic Alliance Diminished by Videoconferencing Psychotherapy?
The working alliance is the collaboration between client and therapist on the tasks and goals of therapy, and it also includes the emotional bond. The alliance is the most researched concept in psychotherapy, and it is reliably related to good client outcomes. However, the alliance has been rarely studied in the context of videoconferencing psychotherapy (VCP). Delivering psychotherapy remotely was already gaining popularity prior to COVID-19 because of its potential to improve access to mental health care especially for people who live in remote areas. Some argue that face to face therapy might result in a higher therapeutic alliance because of the rich interpersonal cues, like eye contact and body posture that may facilitate collaboration and the bond. There is emerging evidence that VCP can be effective and that it may have comparable outcomes to face-to-face therapy. But what about the working alliance – does it develop in VCP similarly to face to face therapy? In this meta-analysis, Norwood and colleagues conducted a systematic review of the existing research on the working alliance in VCP. They found only 4 direct comparison randomized controlled studies on the topic, and on average VCP resulted in a lower working alliance compared to face to face therapy, but the difference was not statistically significant (n = 4; SMD = -0.30; 95% CI: -0.67, 0.07; p = 0.11). People who received treatment via VCP had similar levels of symptom reduction compared to those who received face to face therapy (n = 4; SMD = −0.03; 95% CI [−0.45, 0.40], p = 0.90).
Practice Implications
With only four direct comparison randomized trials to draw from, the results of this meta-analysis remained ambiguous with regard to the therapeutic alliance. Although the difference between VCP and face to face therapy was not statistically significant, it was not ignorable – an effect size of SMD = -0.30 suggests a small advantage for face to face therapy when it comes to the alliance. However, symptom outcomes were comparable between face to face and VCP. The results suggest that therapists who use VCP during a pandemic, must pay particular attention to developing and maintaining a therapeutic alliance by collaboratively agreeing on goals and tasks of therapy, and by focusing on establishing an affective bond with patients despite the limited nonverbal cues available with online psychotherapy.
March 2020
Drop-out From Using Smart Phone Apps for Depression is High
Torous, J., Lipschitz, J., Ng, M., & Firth, J. (2020). Dropout rates in clinical trials of smartphone apps for depressive symptoms: A systematic review and meta-analysis. Journal of Affective Disorders, 263, 413-419.
Depression is a leading cause of disability worldwide, and yet more than 50% of people do not have access to adequate therapy. One solution might be to provide individuals with smartphone apps to help screen, monitor, or provide treatment. Smart phones are ubiquitous, and depression apps are one of the most downloaded categories of apps by the public. Research seems to suggest that smartphone apps provide some positive results for members of the public, but these findings are compromised by the high drop-out rates reported in the primary studies. Further, one study found that although many people download the apps, only about 4% actually use them. Whereas smartphone apps appear attractive to the consumer, very few actually make use of and therefore benefit from them. In this systematic review, Torous and colleagues conduct a meta-analysis of drop-out rates from studies that test the use of smart phone apps. They found 18 independent studies representing data from 3,336 participants who received a psychological intervention for depression via a cell phone app, or who were in a placebo control condition. A total of 22 different apps were tested in the studies. Initially, the pooled drop-out rate from the depression app treatment arms appeared to be about 26.2% (95% C.I.=11.34% to 46.75%), which would be in line with average drop-out rates from randomized controlled trials of face to face psychotherapy. But, the authors noted two things. First, the drop-out rate from the placebo control conditions (14.2%; 95% C.I. = 8.236 to 23.406) was almost half as high as that found for the apps. Second, through some sophisticated statistical analyses, they found evidence of “publication bias” in this research area. This means that a number of studies testing these apps likely were completed but never published (i.e., these might be studies funded by an app manufacturer that demonstrated negative findings or high drop-out rates). When the authors statistically adjusted for publication bias, they found that the actual drop-out rate from the apps was about 47.8%. That is, almost half of users did not complete or dropped out of the studies. There were no differences in drop-out between types of interventions (CBT, mindfulness, or others), and studies with larger sample sizes (i.e., better quality studies) had higher drop-out rates.
Practice Implications
Although smartphone apps appear really attractive and may be potentially useful as an adjunct to face to face psychotherapy for depression, their utility is plagued by extremely low usage rates (4%) and high drop-out rates from studies (almost 50%). Leading writers and researchers define psychotherapy as primarily a healing relationship that also includes specific interventions. The key ingredient is the human relationship. Depressed or otherwise troubled individuals cannot (because of feeling demoralized) or will not interact with a machine for healing. One way or another, when it comes to smartphone apps, depressed individuals are voting with their feet. Given these findings, health care providers should consider the ethics of giving a depressed individual only e-therapy as the primary mode of treatment.