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 content from the updated edition of the Handbook of Psychotherapy and Behavior Change, published in 2021: the effectiveness of psychotherapist training, the therapist effect, and therapist responsiveness to patient interpersonal behaviours.
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
October 2018
Patients’ Experiences With Routine Outcome Monitoring
Solstad, S.M., Castonguay, L.G., & Moltu, C. (2018). Patients’ experiences with routine outcome monitoring and clinical feedback systems: A systematic review and synthesis of qualitative empirical literature. Psychotherapy Research. doi=10.1080/10503307.2017.1326645.
Routine outcome monitoring or progress monitoring involves assessing client outcomes or the therapeutic alliance on a weekly basis in psychotherapy, and then giving feedback to the therapist about how the client is doing relative to the previous week and relative to similar clients. Research on progress monitoring indicates that it improves outcomes and it reduces by half the number of clients who might get worse. Despite its benefits, many therapists are not aware of progress monitoring or are reluctant to use the procedure. Some have expressed concerns that progress monitoring could interfere with the therapeutic relationship. However, very few studies have asked clients about their experiences of progress monitoring. In this synthesis of qualitative studies, Solstad and colleagues reviewed 16 studies in which clients were interviewed about their experiences of progress monitoring. The authors used a procedure in which they identified common themes across the studies and categorized client statements within those themes (e.g., thematic analysis). The authors were interested in identifying what were the hindering and helpful processes in clients’ experiences of their therapists’ use of progress monitoring. Four main themes emerged from the research. First, some clients voiced suspicion of how the progress monitoring data was going to be used and why the procedure was implemented. That is, clients sometimes felt that filling out questionnaires weekly was mainly a bureaucratic exercise, or possibly a means to justify reducing services. Second, some clients felt the questionnaires were not flexible enough to capture the complexity of mental health and of client concerns. The questionnaires often focused on symptoms, but clients were also interested in the therapeutic relationship, family, and social functioning. Third, some clients wanted to be more fully informed about the rationale for progress monitoring so that they could feel more empowered to define their own outcomes and treatment plans. Fourth, some clients found progress monitoring to help them to see graphically their own progress, to become more engaged in treatment planning, and to participate in collaborative and reflective discussions with their therapist.
Practice Implications
If psychotherapists choose to use progress monitoring in their practices, they should make sure that clients know what the data will be used for and that the exercise is not just a bureaucratic process. The practice of outcome or progress monitoring can be used to stimulate reflection not only in the therapist but also in the client. Reviewing the client data together might enhance conversations about therapy, the therapeutic relationship, and help to establish realistic goals for therapy. Therapists might consider not only measuring symptom progress repeatedly, but also measuring the working alliance on a regular basis.
August 2018
The Partners for Change Outcome Monitoring System
Duncan, B. L., & Reese, R. J. (2015). The Partners for Change Outcome Management System (PCOMS): Revisiting the client’s frame of reference. Psychotherapy, 52(4), 391-401.
Generally, psychotherapy is effective for a wide variety of disorders, but regardless, many clients do not benefit. Further, the research shows that some therapists are more effective than others, but therapists tend to grossly over-estimate their effectiveness. In one large survey, therapists reported that their outcomes were better than 75% of their peers, no therapist rated themselves as below average, and therapists tended to over-estimate their effectiveness and under-estimate client deterioration. One way to evaluate patient outcomes and processes is to engage in progress monitoring and feedback. This involves repeated brief assessments of client outcomes followed by real-time feedback to therapists to gauge client progress and signal potential problems. Several such systems exist including the Outcome Questionnaire-45.2 and the Partners for Change Outcome Management System (PCOMS). The PCOMS is made up of the Outcome Rating Scale (ORS) and the Session Rating Scale (SRS). The ORS measures distress in 3 atheoretical domains (personal, family, social) not based on diagnosis. The SRS is a measure of therapeutic alliance. Both the ORS and SRS are very short 4-item scales that can be administered before (ORS) and after (SRS) each session of therapy. In this paper, Duncan and Reese review the research supporting the use of the PCOMS. A meta analysis found that clients whose therapists received feedback with the PCOMS were 3.5 times more likely to experience reliable change and had less than half the chance of experiencing deterioration. Five randomized controlled trials demonstrated the advantage of the PCOMS over treatment as usual, including by reducing drop outs and achieving reliable change in fewer sessions.
Practice Implications
A lot of research has demonstrated that most therapists over-estimate their effectiveness and that many are not able to identify clients who are getting worse. It is time for therapists to acknowledge this positive bias of their effectiveness and their need for quality information in order to make good clinical decisions. Progress monitoring and feedback systems are one means by which therapists can receive quality information. The repeated use of the PCOMS for example, can help to identify when clients begin to deteriorate and/or when problems emerge with the therapeutic alliance. Being able to identify these issues early may allow therapists to act quickly to avert client deterioration or drop out.
Why Therapists Tend Not To Use Progress Monitoring
Miller, S. D., Hubble, M. A., Chow, D., & Seidel, J. (2015). Beyond measures and monitoring: Realizing the potential of feedback-informed treatment. Psychotherapy, 52(4), 449-457.
Progress monitoring is the process of repeatedly assessing client functioning with validated measures and providing feedback to therapists. The feedback is designed to identify problems with the therapeutic relationship or with client deterioration by comparing client progress to similar clients. This allows therapists to change what they are doing, renegotiate aspects of therapy, or directly address the issues. Research is clear that progress monitoring significantly increases the proportion of clients who improve, reduces drop outs by a third, shortens the length of therapy, and reduces costs. Yet the research also indicates that only 12% of psychologists are using progress monitoring in their practice. If progress monitoring is so useful, then why aren`t more therapists using it? In this review, Miller and colleagues discuss some of the barriers and problems with using or adopting progress monitoring in clinical practice. They describe that even in the most favorable circumstances, it takes about two decades for new treatments to be integrated into routine care. Another issue is that recent surveys indicate that only about 33% of psychologists and 66% of training directors are aware of progress monitoring. Even for those who are aware, a common barrier might be cost and time to implement the procedures. Despite the brevity and low cost of the tools, like the PCOMS, they all place an additional burden on clinicians’ busy schedule. There is also the issue of staff turnover. As staff come and go, organizations may lose those who lead, train, and support the use of progress monitoring. Probably the biggest barrier is skepticism on the part of clinicians who might see the tools as too superficial, or who might be concerned that repeated measurement may somehow negatively affect the therapeutic relationship. However, research indicates that clients generally report positive experiences – they like being a more integral part of the assessment process, and they appreciate the ability to track their own progress. Finally, whereas clinicians may use progress monitoring to improve clinical decision-making, administrators may see it as a means of conducting performance reviews.
Practice Implications
In most health care fields, it can take 20 years for an innovation to make it into routine practice. That might be the case for progress monitoring. More clinicians need to know about it, be trained in its use, and see for themselves that the information is valid, of high quality, and that it can supplement their work in identifying clients who are not doing well. In particular, progress monitoring may be a means of enhancing the therapeutic alliance as it provides therapists and clients a vehicle to discuss how the therapy is going, what needs focus, and what to do if things go awry. Organizations need to treat progress monitoring as a means of helping therapists to improve their skills, and not as a means of auditing performance. Therapists need quality information upon which to make sound clinical decisions, and progress monitoring is one way of receiving this information.
May 2018
Therapist Characteristics That Affect Client Outcomes
Lingiardi, V., Muzi, L., Tanzilli, A., & Carone, N. (2017). Do therapists' subjective variables impact on psychodynamic psychotherapy outcomes? A systematic literature review. Clinical Psychology & Psychotherapy. Advance online publication.
Psychotherapists differ in their effectiveness such that some therapists are more effective than others, and these differences account for up to 9% of client outcomes. Despite this, not many studies have looked at therapist personal characteristics that might be associated with better or worse outcomes. In this systematic literature review, Lingiardi and colleagues focus on empirical studies of psychodynamic therapists and their personal characteristics that might affect therapeutic processes and client outcomes. The authors included only quantitative studies. Thirty studies representing nearly 1,400 therapists and 6,000 clients were included in the review. Most studies occurred in a naturalistic setting, and most therapists were female (66%) with an average of over 9 years of experience. The studies looked at various therapist personal characteristics and their association with therapeutic processes and client outcomes. Therapist attachment security (ability to engage in meaningful loving relationships and adaptively manage emotions) was associated with better client outcomes. Similarly, therapists who reported better experiences of parental care and better quality relationships with attachment figures tended to have clients who rated a more positive therapeutic alliance. In addition, therapist interpersonal functioning was evaluated in several studies. Therapists who were rated as more affiliative (warm, friendly) and less hostile (cold, rejecting) tended to have clients who achieved better outcomes. Further, therapist facilitative interpersonal skills (emotional expressiveness, verbal fluency, warmth, empathy) were associated with better client outcomes in short-term therapy. Finally, several studies assessed therapist self-concept (stable means by which one treats oneself). Therapists who were more hostile or negative toward the self tended to be more critical or ignoring of clients, which lead to poorer client outcomes.
Practice Implications
Therapist personal characteristics (attachment security), interpersonal skills (warmth, friendliness, empathy), and self concept (how one treats oneself) may account for why some therapists are more effective than others. Problems in these areas might lead to problematic countertransference (emotional reactions on the part of therapists triggered by client issues) or therapeutic alliance ruptures, both of which are related to poorer client outcomes. Therapists can learn methods of managing countertransference and repairing alliance ruptures. If the personal characteristics are persistent and problematic, therapists might consider personal therapy.
April 2018
Therapist Multicultural Orientation Improves Client Outcomes
Davis, D. E., DeBlaere, C., Owen, J., Hook, J. N., Rivera, D. P., Choe, E., . . . Placeres, V. (2018). The multicultural orientation framework: A narrative review. Psychotherapy, 55(1), 89-100.
Many therapists have better outcomes with White or European clients than clients from diverse racial or ethnic minorities, and this might be due to racial and ethnic microaggressions that sometimes occur in therapy. Microaggression refer to intentional or unintentional brief commonplace verbal, behavioural, or environmental indignities that are experienced as derogatory or negative by racial and ethnic minority clients. A multicultural orientation refers to how the cultural worldviews, values, and beliefs of clients and therapists interact to co-create a relational experience in therapy. Therapist multicultural orientation has three elements. First, cultural humility, in which a therapist is able to maintain an interpersonal stance that is open to the client’s experience of cultural identity. Second, cultural opportunity, in which the therapist uses events in therapy to explore a client’s cultural identity in depth. Third, cultural comfort in which a therapist feels at ease, open, and calm with diverse clients. These elements are important in order to negotiate a therapeutic alliance (i.e. agreement on tasks and goals of therapy, and the emotional bond between client and therapist). In this narrative review, Davis and colleagues look at the small existing research on multicultural orientation and how that research can inform therapists’ practices. The authors found that in the two studies on the topic, greater therapist cultural humility was associated with better client outcomes. Several studies found that cultural humility was associated with a positive therapeutic alliance, and that therapist cultural humility was associated with fewer microaggressions as experienced by racial and ethnic minority clients. Finally, missed opportunities by therapists to explore the meaning of culture and identity were associated with negative client outcomes. Presumably, such missed opportunities meant that therapists did not recognize and repair cultural ruptures.
Practice Implications
The research on multicultural orientation suggests several practice implications. (1) Cultural humility requires therapists to explore their automatic cultural assumptions because if they remain unexplored they may be harmful to clients. (2) Therapists should overtly discuss the importance of cultural identities with clients in order to help both therapist and client develop a more complex understanding of the issues that bring the client to therapy. (3) A strong therapeutic alliance may require the therapist to incorporate their client’s cultural worldview and perspective when conceptualizing the client’s problems. (4) Depending on the client’s cultural worldview, therapists may consult with the client’s family and/or spiritual leaders when negotiating a culturally acceptable way of addressing the client’s problems. (5) Therapists need to identify for themselves when their values conflict with those of the client, and seek consultation or supervision when they do.
February 2018
Therapeutic Relationship Predicts Pharmacological Treatment Outcomes
Totura, C.M.W., Fields, S.A., & Kraver, M.S. (2018). The role of the therapeutic relationship in psychopharmacological treatment outcomes: A meta-analytic review. Psychiatric Services, 69, 41-47.
There is evidence to suggest that pharmacological treatments are effective for a wide range of disorders. However, a high level of adherence to taking psychotropic medications is necessary in order for them to have a chance of working. Medical interventions in general do not work well when patients are non-adherent to the regimen, and non-adherence is a significant problem in medicine. Treatment adherence is particularly problematic in those with a mental health condition. Low adherence may have to do with problems with the medications themselves, like unpleasant side effects. And low adherence also may be due to issues related to mental health impairment, like low motivation and problems with reasoning. A particular issue in mental health treatment is the manner in which patients receive the medication. Unlike some medical interventions, psychotropic medications are often taken by patients on their own and away from the clinic or hospital. In psychotherapy, we know that a good therapeutic alliance improves outcomes partly because a good alliance provides a context within which psychological interventions can work (i.e., clients may be more adherent to the treatment recommendations) and partly because the alliance itself may be therapeutic. In this meta analysis, Totura and colleagues examine if there is an association between the therapeutic alliance and mental health outcomes for patients who receive pharmacological interventions for their mental illness symptoms. Eight studies of 59 samples representing over 1,000 patients were included. Four studies were of pharmacological treatment for affective disorders, two for schizophrenia, and two for mixed diagnoses. The results indicated a statistically significant and moderate effect: z = .30 (CI=.20, .39, SE=.048, z=6.192, p=.05), such that greater therapeutic alliance predicted better mental health outcomes among patients receiving pharmacotherapy.
Practice Implications
Higher quality of the physician-patient relationship was related to better mental health treatment outcomes for patients taking pharmacotherapy. The therapeutic alliance appears to be just as import in pharmacological treatment as it is in psychotherapy. It is possible that a good alliance with the provider may increase patient adherence, which may lead to better outcomes. It is also possible, however, that the alliance itself is therapeutic. That is, negotiating an alliance and repairing alliance tensions may lead to positive changes in patients’ ability to cope with emotions and to make the most of their social supports. The results also suggest the importance of training physicians in communication skills to improve therapeutic relationships.