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
July 2023
Therapeutic Relationship Factors that Do Not Work
Norcross, J.C. & Karpiak, C.P. (2023). Relationship factors. In S. D. Miller, D. Chow, S. Malins, and M. A. Hubble (Eds.) The Field Guide to Better Results: Evidence-Based Exercises to Improve Therapeutic Effectiveness. American Psychological Association. https://doi.org/10.1037/0000358-006
In their chapter, Norcross and Karpiak review the meta-analyses on therapeutic relationship factors that have a positive impact on patient outcomes. Aspects like therapist empathy, positive regard, genuineness, and developing and maintaining a therapeutic alliance have solid research support for their importance to patient outcomes. In fact, the research is clear that these relationship factors are more important (i.e., are better predictors of patient outcomes) than the brand of therapy conducted by the therapist. Part of this chapter by Norcross and Karpiak also identifies those therapist and relationship factors that do not work and that may be harmful to patients. One could simply reverse the effective behaviors identified in meta-analyses – so that low therapist empathy, poor therapeutic alliances, therapists who are incongruent in their words and actions, and who disregard alliance ruptures will have patients with worse outcomes. Research also identifies harmful behaviors by therapists. These might include rigidity in following prescriptions of an intervention, therapist overconfidence in their abilities, hostile behaviors, a confrontational style, and cultural arrogance. As an example, the authors discuss widespread policies mandating the use of specific treatment protocols, and training therapists in manualized treatments to the exclusion of relationship factors. Research shows that adherence or competence with treatment manuals is consistently unrelated to patient outcomes. By contrast relationship factors are highly related to patient outcomes. Research also suggests that therapist behaviors that blame patients, are sarcastic, critical, or hostile towards patients can lead to worse outcomes. Therapists whose assumptions about a patient that do not align with the patient’s experience, also tend to have patients who do not improve. Therapists may believe that they should know better, but if their knowledge does not fit the patient’s experience, then therapist and patient are not engaged in a collaborative endeavor. Finally, even if some therapies prescribe “confrontation” as a therapeutic stance, there is dubious evidence that using such an approach is helpful to patients.
Practice Implications
The research points to certain therapist behaviors that should be avoided when working with patients. Among these is rigid adherence to a treatment manual. Such rigid adherence by a therapist does not allow room for professional self-doubt, for aligning one’s approach to patient needs, and it might foster therapist over-confidence and a lack of humility. Each of these stances towards a patient reduces a therapist’s empathy and may put the patient in a position of reluctantly complying, feeling unheard and unappreciated, or dropping out of therapy.
Therapeutic Relationship Factors that Work
Norcross, J.C. & Karpiak, C.P. (2023). Relationship factors. In S. D. Miller, D. Chow, S. Malins, and M. A. Hubble (Eds.) The Field Guide to Better Results: Evidence-Based Exercises to Improve Therapeutic Effectiveness. American Psychological Association. https://doi.org/10.1037/0000358-006
Next to patient factors that affect outcomes in psychotherapy, the therapeutic relationship is the most important predictor or contributor to patient outcomes. The therapeutic relationship is important to in-person therapy and to therapy delivered virtually. There is no scientific doubt of the importance of the therapeutic relationship on patient outcomes. The relationship is managed and cultivated by the therapist’s attitudes and behaviors. And so, it is not surprising that therapists differ in their ability to facilitate the therapeutic relationship. However, it is also possible for therapists to improve their therapeutic relationship skills through training and supervision. The therapeutic relationship is important to all therapeutic orientations. In this part of the chapter, Norcross and Karpiak review the research on relationship factors that work including therapist empathy, positive regard, developing a therapeutic alliance, and repairing alliance ruptures when they occur. Empathy occurs when a patient experiences a therapist who perceives and expresses an accurate understanding of a patient’s feelings, perspectives, and experiences. Empathic responding is one of the strongest predictors of patient outcomes with effect sizes ranging from moderate to large (d = .58), but only when it is rated by the patient. Therapist ratings of their own empathy has a much lower association with patient outcomes. Positive regard is the therapist’s genuine liking and expressed appreciation for the patient as a person. That is, a therapist’s verbal and nonverbal expression that they value, care about, and believe in the patient. The key here is genuineness – that the therapist’s words are consistent with their intentions and feelings. Positive regard expressed in therapy is moderately related to patient outcomes (d = .57). The therapeutic alliance refers to the warm emotional bond between patient and therapist, and their collaborative agreement on the goals of therapy and how they will work towards those goals. More than 300 studies of over 30,000 patients indicate that the alliance is moderately related to patient outcomes (d = .57), and this is a highly reliable finding. Ruptures in the alliance are characterized by patient withdrawal from the therapist or therapy, or by confrontation in which the patient criticizes or is dissatisfied with the therapist or therapy. Therapists’ attempts to repair alliance ruptures is moderately related to positive patient outcomes (d = .62), and this skill is most important for newer therapists and therapists with a CBT orientation.
Practice Implications
A positive therapeutic relationship has a much bigger impact on patient outcomes than the specific type of therapy used by therapists. A therapist who narrowly focuses on the content of what a patient says and rigidly adheres to a treatment manual will reliably have patients who have worse outcomes. Therapists whom patients experience as truly empathic (not just expressing sympathy for a patient), who can genuinely feel and express positive regard for a patient, and who can develop and maintain a therapeutic alliance and repair alliance ruptures reliably will have patients who have better experiences of therapy and better outcomes. These therapist skills and capacities can be learned through deliberate practice, supervision, personal therapy, and by maintaining a stance of flexibility, openness, and humility.
Therapist Factors Related to Patient Outcomes
Nissen-Lie, H.A., Heinonen, E., & Delgadillo, J. (2023). Therapist factors. In S. D. Miller, D. Chow, S. Malins, and M. A. Hubble (Eds.) The Field Guide to Better Results: Evidence-Based Exercises to Improve Therapeutic Effectiveness. American Psychological Association. https://doi.org/10.1037/0000358-005.
The thing about therapists that people in the profession do not like to talk about is that some therapists are more effective than others. Meta-analyses indicate that about 5% of patient outcome variance can be explained by differences between therapists. Although this seems small, it accounts for about one-third of the total difference in outcomes among patients. One study found that patient recovery rates for the most effective therapists were twice that achieved by their least effective counterparts. In another study, 15% more patients recovered when they saw an “average” therapist compared to one of the least effective clinicians. One key problem is that therapists consistently over-estimate their own effectiveness, and consistently under-estimate the percentage of their patients who get worse. This makes it difficult for therapists to correct course when necessary or to engage in targeted professional and personal development. In this chapter, Niessen-Lie and colleagues review the research that identifies key therapist qualities that are related to better patient outcomes. It turns out that demographics of the therapist (sex, gender, ethnicity, age), experience level, profession, and education level are all unrelated to patient outcomes. In fact, there is some evidence that more experienced older therapists have slightly poorer outcomes than their younger counterparts. However, some therapist factors are important and known to be related to patient outcomes. For example, therapists who are consistently effective across different types of patients, patient severity, and diagnoses have the best outcomes. Another key therapist factor or attribute is interpersonal skill. This includes therapist empathy, warmth, the capacity to express emotions verbally, the ability to develop a therapeutic alliance with a variety of patients, and the capacity to tolerate and manage strong negative emotions in therapy. A third therapist factor is flexibility. Therapists who can be flexible in using therapeutic techniques within a given treatment tend to have patients with better outcomes. Finally, therapists who can maintain an attitude of humility tend to have better outcomes. Humility refers to an openness to other’s points of view, accepting that there is room for growth, and for pushing beyond one’s current skill level while taking care of oneself. Without this attitude, there is little motivation for continued learning, personal growth, and professional development.
Practice Implications
A therapist’s experience level, profession, experience, and other demographics have no bearing on their patients’ outcomes. However, we do know that being effective with a range of patients, interpersonal skills (empathy, verbal expression of emotions, and ability to tolerate strong emotions), flexibility in applying therapeutic interventions, and professional humility are related to patient outcomes. These therapist skills can be developed and improved during one’s career. Improving these skills require a therapist to be willing to examining when things do not go well in therapy (reviewing when patient outcomes are poor or a patient drops out), to reflect on one’s abilities, and to look for disconfirming evidence by asking “could I be wrong?” First, however, therapists must identify when therapy with a patient was ineffective. And for this, they may need the help of standardized assessments to monitor the state of the therapeutic relationship and patient progress.
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 (7th 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.
May 2022
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 (7th 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 (7th 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.