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 psychotherapy for adult depression, efficacy of CBT for perfectionism, and a measure of ruptures in the therapeutic alliance.
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
January 2024
How Can Psychotherapists Accurately Measure a Therapeutic Alliance Rupture?
Babl, A., Rubel, J., Gómez Penedo, J. M., Berger, T., Grosse Holtforth, M., & Eubanks, C. F. (2023). Can session-by-session changes in self-reported alliance scores serve as a measure of ruptures in the therapeutic alliance? Journal of Consulting and Clinical Psychology. Advance online publication. https://doi.org/10.1037/ccp0000861
The therapeutic alliance is a robust predictor of patient outcomes in psychotherapy. One can define the alliance as the collaborative agreement between patient and therapist on the goals of therapy (what is the desired outcome) and tasks of therapy (how therapy should proceed), and the relational bond between patient and therapist. Ruptures in the therapeutic alliance are breakdowns or tensions in the relationship between therapist and patient in any of the three core components of the alliance (agreement on goals and tasks, and the bond). If ruptures go unaddressed, they can lead to poor outcomes or patient dropout. Despite the practical importance of the alliance and of identifying alliance ruptures, therapists often feel at a loss when it comes to detecting a rupture. Ruptures can be characterized by patient behaviours that indicate withdrawal from the therapist (going silent, abstract, or vague responses) or confrontation with the therapist (complaining or rejecting interventions). However, therapists may not always be aware that a rupture in the alliance has occurred, and so they may need help to identify an alliance rupture. One source of help is to have patients complete a brief self-report measure of the state of the therapeutic alliance at the end of each session. In this study, Babl and colleagues asked 58 patients with depression who received CBT to rate the therapeutic alliance with a short validated scale (i.e., the Working Alliance Inventory [WAI]) after each of 20 sessions. The authors also video-recorded each session and rated alliance ruptures within each session with the 3RS a validated observer rating scale. Although the 3RS is the best way to assess alliance ruptures, 3RS ratings require an intensive process of coding by expert judges. And so, if the WAI, which is a relatively easy procedure, can reliably identify ruptures, then this may give clinicians a way of knowing when a rupture occurred. Rubl and colleagues defined an alliance rupture as a significant drop in the patient’s WAI score from one session to the next (i.e., technically, they used a score 2 standard deviations lower than the patient’s average WAI score in all preceding sessions). They found that sessions for which the WAI indicated a drop in alliance ratings had significantly more rupture markers (as rated by the 3RS) than sessions that did not show a drop in alliance ratings.
Practice Implications
Although somewhat preliminary, the results of this study suggest that clinicians can use changes in patient-self-reported WAI scores from session to session to identify if a therapeutic alliance rupture occurred. If there is a precipitous drop in WAI scores after a session, then therapists might enquire with the patient about the state of the therapeutic alliance in the next session. That is, therapists might ask if there is still an agreement on the goals of therapy or if the therapy is proceeding in a way that is congruent with what the patient expects. Alternatively, the therapist may check in on the state of the therapeutic relationship, that is, to assess if the patient may feel some tension, disappointment, or frustration with the therapist. The goal is for therapists to use relatively easy-to-use measures like the WAI to help them make the most of the therapeutic alliance.
November 2023
Different Aspects of the Therapeutic Relationship Are Associated with Different Outcomes
Finsrud, I., Nissen-Lie, H. A., Ulvenes, P. G., Vrabel, K., Melsom, L., & Wampold, B. (2023). Emotional and cognitive processes in psychotherapy are associated with different aspects of the therapeutic relationship. Journal of Consulting and Clinical Psychology. Advance online publication. https://doi.org/10.1037/ccp0000853
One can understand the therapeutic relationship as having an emotional component and a cognitive component. Researchers have found that these two components of the therapeutic relationship can be conceptualized as two factors: a patient’s Confidence in the Therapist (a patient who perceives their therapist as warm, empathic, competent, and trustworthy), and a patient’s Confidence in the Treatment (a patient’s experience of the treatment as viable and as providing a meaningful way to accomplish change). These factors align with the therapeutic alliance in that Confidence in the Therapist is akin to the bond aspect of the alliance, and Confidence in the Treatment is like the collaborative agreement on the tasks and goals aspects of the alliance. In this large naturalistic study, Finsrund and colleagues assessed if Confidence in the Therapist and Confidence in the Treatment are related to different types of outcomes (change in emotional clarity vs change in rumination), and to different types of therapy (CBT vs psychodynamic). The study had 631 adult patients with anxiety or depressive disorders and 54 therapists who conducted either CBT or psychodynamic therapy. Therapists treated the patients in a hospital setting in Norway and patients completed measures of Confidence in the Therapist, Confidence in the Treatment, symptom outcomes, rumination, and emotional clarity on a weekly basis for up to 12 weeks of treatment. Patients were highly symptomatic and more than 89% had more than one clinical diagnosis. As expected, higher Confidence in the Therapist predicted emotional change (higher emotional clarity) and higher Confidence in the Treatment predicted cognitive change (lower rumination). However, higher Confidence in the Therapist predicted better emotional clarity only in the patients receiving psychodynamic therapy, whereas higher Confidence in the Treatment predicted less rumination in both CBT and psychodynamic therapy (although the effect appeared larger in CBT).
Practice Implications
The results are in line with the notion that different aspects of the therapeutic relationship play different roles depending on the outcomes that patients and therapists desire. In cognitively oriented therapies, therapists rely more heavily on providing a viable explanation of the symptoms, a treatment rationale that is consistent with the explanation, and tasks of therapy (homework, self-monitoring, behavioural experiments) that are consistent with the treatment rationale. In psychodynamically-oriented therapies, therapists focus on emotional and relational changes in which therapists and patients work through aspects of the therapeutic relationship that deal with their affective bond and their interpersonal work together. Effective therapists likely do both with patients – i.e., they come to an agreement on the tasks and goals of therapy (the rationale for treatment) and they repair ruptures in the therapeutic alliance as a means of achieving interpersonal learning and emotional change.
February 2023
Whose contribution (therapist or patient?) to the alliance mostly leads to change?
Wampold, B. E., & Flückiger, C. (2023). The alliance in mental health care: conceptualization, evidence and clinical applications. World Psychiatry, 22, 25–41. https://doi.org/10.1002/wps.21035
The therapeutic alliance is possibly the most researched concept in psychotherapy. The alliance consists to a collaborative agreement patient and therapist on the goals of therapy, a collaborative agreement on the tasks of therapy (how therapy should proceed), and the relational bond between therapist and patient (mutual liking and trust). The most recent meta-analysis of almost 300 studies showed that the correlation between the therapeutic alliance and patient outcomes was moderate in size (r = .29) and very stable across studies, treatment modalities, and patient populations. Another meta-analysis of studies that assessed outcomes and therapeutic alliance after every session showed that there is a reciprocal relationship between alliance and outcomes, demonstrating that the alliance is not simply a consequence of symptom improvement. In this sweeping review of the therapeutic alliance research and clinical literature, Wampold and Fluckiger asked “who is most responsible for the effects of the alliance – the patient or the therapist?”. The alliance is a dyadic construct about the interaction between therapist and patient. It could be that the patient contribution to the alliance is most important to their outcomes. A patient with insecure attachment, more symptoms, comorbid personality disorder, or low motivation might experience a poorer alliance with any therapist. Conversely, some therapists might be able to form a better alliance than other therapists across a wide range of patients, and this might be what results in better outcomes. Studies that disaggregate the total correlation of the alliance and outcome into patient and therapist contributions generally demonstrate that it is the therapist that is primarily responsible for the alliance-outcome association. That is, therapists who can form a stronger alliance with a wide range of patients also generally have better outcomes than other therapists. Even patients who tend to form a weaker alliance with therapists will develop a stronger alliance with therapists who generally have the skills to develop a strong alliance.
Practice Implications
When it comes to the therapeutic alliance, the therapist matters even for patients who struggle to form an alliance. It turns out that gender, age, ethnicity, profession, and theoretical orientation of the therapist do not matter as much as their interpersonal skills. These interpersonal skills include a therapist’s capacity to communicate hope and positive expectations, persuasiveness, emotional expression, warmth, understanding, acceptance, empathy, and ability to repair alliance ruptures. If a therapist wants to make the most of the therapeutic alliance to help their patients, then the therapist should develop and nurture these interpersonal skills for themselves.
January 2023
Working Alliance and Therapist Cultural Humility Reduce the Impact of Microaggressions
A lack of culturally competent care can have negative impacts on therapy outcomes for Black, Indigenous, People of Color (BIPOC) and for women who experience discrimination based on gender. Often these negative outcomes occur because of microaggressions – which are a form of alliance rupture in the therapeutic relationship caused by subtle, intentional, or unintentional messages that degrade BIPOC, women, and other historically excluded groups. The majority of BIPOC clients (81%) and women (53%) report experiencing a therapist microaggression over the course of psychotherapy. A therapist’s cultural humility (valuing the importance of culture in their client’s experience) and the therapeutic alliance (client-therapist collaborative agreement on tasks and goals of therapy) may reduce the negative impact of microaggressions committed by the therapist. This study by DeBlaere and colleagues looked at the association between microaggressions experienced by BIPOC women and therapy outcomes, and whether this association was reduced by higher levels of therapist cultural humility and therapeutic alliance. The clients were 288 BIPOC women who were treated by a psychotherapist (81% had a female therapist, and 46% had a White therapist). Both racial and gender microaggressions were associated with worse outcomes. Using structural equation modeling to assess indirect effects, the authors found a significant indirect effect of racial microaggressions (−.12, 95% CI [−.35, −.07]) and gender microaggressions (−.10, 95% CI [−.36, −.05]) on positive therapy outcomes, through both cultural humility and working alliance, accounting for 24% of the variance in outcomes. That is, the effect of microaggressions on outcomes was partly explained by the level of therapist cultural humility and by the therapeutic alliance. The most common racial microaggression reported by clients was: “My counselor avoided discussing or addressing cultural issues in our sessions”, and the most common gender microaggression was: “My therapist encouraged me to be less assertive so that I do not present myself as being aggressive”.
Practice Implications
Unfortunately, therapist racial and gender microaggressions are common. However, therapists who practice cultural humility and who work at developing a therapeutic alliance may commit fewer microaggressions and can more easily mitigate the negative effects of microaggressions should they occur. Taking steps to develop cultural humility, strengthening the alliance, and repairing alliance ruptures through professional development may be ways of improving therapy outcomes for BIPOC women.
December 2022
Can Psychotherapists be Trained to Maintain a Therapeutic Alliance?
Tasca, G. A., Ravitz, P., Hunter, J., Chyurlia, L., Baker, S., Balfour, L., Mcquaid, N., Pain, C., Compare, A., Brugnera, A., & Leszcz, M. (2022, November 10). Training community-based psychotherapists to maintain a therapeutic alliance: A Psychotherapy Practice Research Network study. Psychotherapy. Advance online publication.
The therapeutic alliance refers to a collaborative agreement between therapist and patient on the tasks and goals of therapy, and their relational bond. Research demonstrates that the alliance is one of the most reliable predictors of patient outcome. Much of the research on the alliance focused on asking either the patient or the therapist to rate the alliance. But the alliance is a dyadic concept, that is, it involves the shared perceptions of the therapeutic relationship by patient and therapist. More recent research has focused on patient-therapist congruence (degree of agreement or disagreement) of their perceptions of the alliance. The Psychotherapy Practice Research Network (PPRNet) recently completed a study in which community-based psychotherapists were trained to develop and maintain a therapeutic alliance. We examined if trained therapists were more congruent with their patients’ experience of the alliance than untrained therapists, and whether congruence in alliance ratings in one session of therapy was associated with better outcomes in the following session. Forty community-based psychotherapists were randomly assigned to be trained to develop and maintain the alliance or to receive no training. Patients were 117 adults who were seen in their therapists’ community-based practices. Training focused on helping therapists to understand and be responsive to their own and their patient’s mental states (intentions, feelings, thoughts) to be better attuned to their patient’s experience of the therapeutic relationship. The training included workshops and ongoing case consultations to help the clinician to strengthen the therapeutic relationship with the use of mentalizing, attachment theory, countertransference management, and metacommunication. Therapeutic alliance and well-being outcomes were measured at each of six consecutive early psychotherapy sessions. The results indicated that compared to untrained therapists, trained therapists and their patients were significantly more congruent in their alliance ratings. Patient well-being outcomes improved in a session when trained therapists and their patients agreed in their positive alliance ratings in a previous session. This association was not significant among untrained therapists and their patients.
Practice Implications
This study suggests that therapists can be trained to be more attuned to their patients’ experience of the therapeutic relationship, and that this congruence may make the alliance a more potent change agent. Training may make therapists more sensitive to their patients’ experience of the alliance across sessions. Therapists should be particularly attentive to the state of the therapeutic alliance from session to session and to track their patients’ experience of the alliance using skills like mentalizing. The PPRNet has converted this training program into a virtual self-paced platform, and we will test this new format in a study starting in 2023. We encourage community-based clinicians to receive the free training by participating in this new study. For more information about the training and new study, email pprnet@uottawa.ca.
The Therapeutic Alliance in Child and Adolescent Psychotherapy
Roest, J.J., Welmers-Van de Poll, M.J., Van der Helm, G.H.P., Stams, G.J.J.M., & Hoeve, M. (2022). A three-level meta-analysis on the alliance-outcome association in child and adolescent psychotherapy. Research on Child and Adolescent Psychopathology.
Much of the research and writing about the therapeutic alliance has focused on adult individual psychotherapy. However, there have been several recent meta-analyses of the alliance-outcome association in child populations. In one meta-analysis of 28 studies, for example, the mean alliance-outcome correlation was r = .19, which represents a small but positive effect. Most of these previous meta-analyses only looked at alliance rated at one time point (usually early in therapy) rather than focusing on the growth in the alliance across sessions. These previous meta-analyses also did not investigate the effect of alliance agreement on treatment outcomes (i.e., whether therapist and child were congruent in their ratings of the alliance). In this meta-analysis by Roest and colleagues, the authors tried to parse out these various factors that might affect the alliance-outcome association in studies of child and adolescent psychotherapy. The authors included 99 studies representing 8,496 children and 3,442 parents. They found that associations between child-therapist alliance and child outcomes (r = .17), growth in child-therapist alliance across sessions and child outcomes (r = .19), and parent-therapist alliance and child outcomes (r = 0.13) tended to be positive but small. However, associations between child-therapist alliance agreement (i.e., their congruence in alliance ratings) and child outcomes (r = .21) and the association between parent-therapist alliance and parent outcomes (r = 0.24) were positive and moderately large.
Practice Implications
It appears that the therapeutic alliance plays a role in positive outcomes for child and adolescent patients. Overall, the effects seem to be small, indicating that developing a good alliance may have a modest effect on a child’s outcomes. A more important effect might be noted in the agreement or congruence between therapist and child or adolescent client on their experience of the alliance. That is, a therapist who is more attuned to their patient’s experience of the therapeutic relationship might promote better outcomes. Attunement might require therapists to accurately reflect on the child’s experience of the relationship and of the therapist. Mentalizing (understanding oneself and others in terms of intentions and mental states) may be a key skill to develop for a therapist who works with children and adolescents.