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.

June 2022

Therapist Facilitative Interpersonal Skills

Wampold, B. & Owen, J. (2021). Therapist effects: History, methods, magnitude, and characteristics of effective therapists. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7^th ed.). Wiley. Chapter 9.

Is therapist interpersonal skill a therapeutic “competence”? Past research on this important topic has been hampered by a couple of methodological challenges. First, asking therapists to self-report on their own social skills and empathy may result in a self-serving bias and is not related to patient outcomes. A second challenge is that therapists’ competence may be influenced by patient characteristics. For example, a therapist seeing an angry patient with low motivation to change might appear less competent than the same therapist seeing an agreeable patient who is highly motivated. Until recently these issues have limited the research on therapist characteristics that indicate therapeutic competence. In this part of the chapter, Wampold and Owen review some of the research that overcomes this limitation. Some researchers conducted a series of studies in which therapists watched videos of standardized patients with different characteristics, and the therapists’ responses to the videos were recorded. In this way, all therapists “saw” the same patients. Therapists’ responses to the videos were coded for facilitative interpersonal skills; that is, for therapist verbal fluency, hope, emotional expression, warmth, empathy, and alliance capacity. In one study, therapist facilitative interpersonal skills assessed with these standardized patient videos predicted outcomes of real patients seen by the therapists in their practices. In another study, student therapists completed the therapist facilitative interpersonal skills assessment at the very beginning of their training. These facilitative skills predicted outcomes obtained when the trainees began seeing patients later in their training. In an interpersonally challenging situation, like some therapeutic encounters where affect is strong, the interpersonal skills of therapists were robust predictors of patient outcome.

Practice Implications

The research showing that therapist interpersonal skills predict patient outcomes is beginning to redefine what it means to be a competent therapist. Research reviewed elsewhere in this blog indicated that adhering to a treatment manual or protocol is not related to patient outcomes. Instead, therapists’ capacity to use verbal skills to express emotions, to be empathic, to develop a therapeutic alliance with a variety of patients, and to repair therapeutic alliance ruptures appear to be much more reliable predictors of patient outcomes. Training programs and professional development should focus on these important skills.
Research on Clinical Supervision

Knox, S. & Hill, C.E. (2021). Training and supervision in psychotherapy: What we know and where we need to go. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7^th ed.). Wiley. Chapter 10.

Supervision is a key aspect of training to be a mental health professional. There is also a gate-keeping role in that supervisors evaluate whether trainees are sufficiently competent to graduate and to seek credentialing or licensure. Most clinical supervision is either individual in nature (one supervisor and one trainee) but some training programs also employ a group supervision format. Despite a long history of supervision as a key training modality in psychotherapy, the research is surprisingly sparse and inconclusive about the utility of supervision. In this part of the chapter, Knox and Hill review some of the research on clinical supervision. The findings suggest that some supervisors are better at establishing a supervisory alliance with trainees than other supervisors. Supervisor traits that facilitate a supervisory alliance and other positive outcomes (supervisee satisfaction, insight, growth, increased confidence, enhanced work with clients; stronger supervision relationship) included supervisor openness, credibility, and capacity to maintain appropriate boundaries. Supervisor empathy, engaging in reflective practice, and attending to parallel process in supervision were associated with supervisee satisfaction, increased supervisee self-disclosure, reduced supervisee anxiety, and improved supervisee work with clients. On the other hand, supervisors’ errors in technique (minimal input in supervision, gender discrimination, nonadherence to ethical guidelines) were linked with supervisee discouragement, negative emotions, reduced involvement and satisfaction, and weaker supervisory alliances. Finally, a strong supervisory alliance (i.e., agreement on training goals, agreement on tasks of supervision, and the supervisory relational bond) is associated with reduced supervisee anxiety, increased supervisee self-disclosure and self-efficacy. Despite the positive effects on the trainee’s sense of competence, comfort, and self-efficacy, there is little research linking supervision to better patient outcomes.

Practice Implications

The research suggests that the quality of the supervisory relationship has an impact on the supervisee and on the supervision process. Supervisors who are open, engaging, warm and empathic are more likely to engage supervisees to be self-disclosing and self-reflective in their work. Supervisors should focus on developing a solid supervisory alliance by establishing supervision goals (a collaborative agreement between supervisee and supervisor on the desired outcomes of the supervision), the tasks of supervision (how the supervision will proceed, what will be discussed or learned), and to help the trainee to experience supervision as a safe environment to explore new ways of being with their clients.
The Evidence for Psychodynamic Therapy

Barber, J., Muran, J.C., McCarthy, K., Keefe, J.R., & Zilchamano, S. (2021). Research on dynamic therapies. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7^th ed.). Wiley. Chapter 12.

One of the persistent myths about psychotherapy is that among treatments that are meant to be effective, some treatments are more effective than others. There are complex historical reasons for such claims, but one therapy that has been most negatively affected by this narrative in psychodynamic therapy. Once a prominent treatment model up to the 1970s, psychodynamic therapy has fallen out of favor among some researchers and is sometimes disparaged as having no evidence base to support its efficacy. In this part of the chapter, Barber and colleagues review the research on the efficacy for psychodynamic therapy for a variety disorders. At the time of writing the chapter, the authors identified 245 randomized controlled trials of psychodynamic therapy. Randomized controlled trials are considered by some as representing the highest quality evidence for interventions. In a number of meta analyses, psychodynamic therapies have demonstrated efficacy compared to control groups in the treatment of mood, anxiety, personality, and somatic disorders, with effects lasting into posttreatment follow-up. In the treatment of suicidality and self-harm, psychodynamic therapies are more effective than control treatments, such as treatment as usual, routine psychiatric care, enhanced usual care, placebo, or any other comparison, including with a different psychological therapy. Long-term psychodynamic therapies for complex or chronic disorders (e.g., borderline personality disorder; treatment-resistant depression) outperformed active and inactive controls. A meta-analysis assessing statistical equivalence in trials comparing psychodynamic therapies to other gold-standard treatments found no evidence that other treatments were more effective. In treatment of unipolar mood disorders, adding short-term psychodynamic therapy to psychopharmacology improved depression symptoms over medications alone (g = 0.26 at termination; g = 0.50 at follow-up).

Practice Implications

Some who practice psychodynamic therapy may feel that the research has been stacked against this treatment modality. And while the narrative is certainly one sided, the evidence is not. Psychodynamic therapy has a robust evidence base for a variety of disorders for which it was tested. Meta analyses consistently demonstrate psychodynamic therapy is as effective as other so called gold standard treatments and provides added value to the treatment of depression over and above medications alone.

May 2022

Do Psychotherapists Get Better with Experience and Training?

Wampold, B. & Owen, J. (2021). Therapist effects: History, methods, magnitude, and characteristics of effective therapists. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7^th ed.). Wiley. Chapter 9.

One of the defining characteristics of expertise is the overall improvement in skills and performance over the course of one’s career. We can identify, for example, that there are experts in chess, tennis, surgery, and musical performance based on performance. Expertise in these areas is explicitly developed partly because there is clear and immediate feedback regarding performance (i.e., a tennis player knows immediately that they missed a serve, and so they make an adjustment on the next serve). In psychotherapy, this is not so easy. Therapists rarely receive immediate feedback about their specific interventions or interpersonal responsiveness to a patient. In this part of the chapter, Wampold and Owen review the research on the relationship between therapist experience and training and patient outcomes. They focus on high quality studies that disentangled therapist from patient effects. Overall, the evidence does not support the notion that the more experience that a therapist accumulates the better their patients’ outcomes. In fact, one study that tracked therapists over time (up to 18 years) found that patients’ outcomes got slightly worse with more experience. Similar findings occur for training of student therapists. For the most part, more training that student therapists received over a 12-to-42-month period was not associated with better patient outcomes. There is some evidence that trainees can improve their capacity to develop a therapeutic alliance, and that with more deliberate practice (focused, immediate attention and feedback on specific skills) therapists can realize better outcomes with their patients.

Practice Implications

As a senior therapist who is very involved in training, I find these results discouraging. Nevertheless, the solutions offered by the research do provide a ray of hope. Providing therapists with specific and immediate feedback about patient outcomes and therapeutic processes (e.g., ratings of patient distress and of the alliance after every session), has the potential for helping therapists to inform their practice, make adjustments, and develop expertise. Deliberate practice of specific skills in psychotherapy (e.g., ways of addressing an alliance rupture or of responding to intense emotion) may also improve therapist expertise and patient outcomes. It is also quite possible that the focus on learning specific manualized protocols, which is often the goal of graduate and post-graduate training, may not be the most effective training and professional development.
The Therapist Effect: Or Does the Therapist Matter?

Wampold, B. & Owen, J. (2021). Therapist effects: History, methods, magnitude, and characteristics of effective therapists. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7^th ed.). Wiley. Chapter 9.

The early days of psychotherapy research treated psychotherapists in a clinical trial as largely interchangeable. That is, it was assumed that therapists were more alike than different and so their impact to patient outcomes were ignored. Some of this was thought to be achieved by training therapists to be highly adherent to a treatment protocol. The thinking was that if every therapist followed the manual faithfully, then any differences among therapists would disappear. Never mind that research indicates that therapist adherence to or competence in delivering a manualized treatment is largely unrelated to patient outcomes. In this part of the chapter, Wampold and Owen examine the question of “does the therapist matter to the patient’s outcomes.” In other words, are there differences between therapists when it comes to patient outcomes? It turns out that between 3% and 15% of patient outcomes in highly controlled randomized trials is attributable to differences between therapists. This might seem like a small percentage, but it is larger than outcomes associated with differences between treatment orientations or the effects of specific interventions. And these are highly controlled trials partly designed to reduce therapist differences. In everyday clinical practice in which there is less control over therapists, the lowest estimate of therapist effects is about 6% but could be as high as 12%. The effect of the therapist is probably higher for more severely symptomatic patients.

Practice Implications

Which therapist a patient sees matters, and this is particularly true for patients who have more severe symptoms. That is more severe patients may do much worse or much better in therapy depending on which therapist they see. A therapist’s capacity to follow a treatment manual does not predict patient outcomes, but other factors like interpersonal skills, openness to lifelong learning, and getting reliable feedback about patient outcomes may be those skills and practices that matter to patient outcomes.
Interpersonal Complementarity: Therapist Responsiveness to Patient Interpersonal Behaviors

Constantino, M.J., Boswell, J.F., & Coyne, A.E. (2021). Patient, therapist, and relational factors. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7^th ed.). Wiley. Chapter 7.

Interpersonal behaviors can be characterized by the level of affiliation (i.e., friendliness vs hostility) and of interdependence (i.e., dominance vs submissiveness). Interpersonal complementarity refers to two people in an interaction whose behaviors are matched on affiliation (friendliness evokes friendliness in the other) and reciprocity in terms of interdependence (dominance evokes submission or submission evokes dominance in the other). So friendly-dominant behaviors in one person tends to evoke friendly-submissive behavior in another and vice versa, and similarly, hostile-dominant behaviors in one person tend to evoke hostile-submission in the other and vice versa. Complementary interactions are comfortable and do not cause anxiety, they reinforce the interactional styles of the participants, and they tend to continue unchanged. Non-complementary interactions do cause anxiety, and they either change or they terminate. In this part of the chapter, Constantino and colleagues review the research on the role of complementarity between therapists and patients. Therapists on average tend to behave in a friendly-dominant style and many but not all patients tend to respond in a friendly-submissive style. The most interesting findings of this line of research is that the number of complementarity interactions between therapists and patients tend to change across stages of successful therapy. In early sessions, patient-therapist interactions tend to be highly complementary. Interactions in the middle of therapy tend to be lower in complementarity. And at the end of therapy, patients and therapists tend to return to higher levels of complementarity. Hostile therapist interactions are rare, and when they occur it is almost exclusively in unsuccessful therapy cases.

Practice Implications

This research has a lot to say about how therapists should respond to patients’ interpersonal behaviors and styles. Therapists should always remain affiliative or friendly (or at least neutral) and avoid hostile interactions with patients. The research indicates even a small number of hostile responses from therapists may lead to negative outcomes or dropping out. The research seems to indicate that (a) higher therapist-patient interpersonal complementarity early in therapy is related to establishing rapport and a therapeutic alliance, (b) lower complementarity in the mid stage of therapy might indicate that therapists are engaging patients differently in order to help change patient patterns of interpersonal relating, and (c) a return to higher complementarity at the end of therapy may indicate therapists reinforcing changes and patients experiencing a new sense of self within the therapeutic relationship.

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June 2022

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May 2022

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