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.
…I blog about transtheoretical principles of change, microaggressions and outcomes, interpretations and outcomes.
Type of Research
- ALL Topics (clear)
- Alliance and Therapeutic Relationship
- Anxiety Disorders
- Attendance, Attrition, and Drop-Out
- Client Factors
- Client Preferences
- Cognitive Therapy (CT) and Cognitive-Behavioural Therapy (CBT)
- Combination Therapy
- Common Factors
- Depression and Depressive Symptoms
- Efficacy of Treatments
- Feedback and Progress Monitoring
- Group Psychotherapy
- Illness and Medical Comorbidities
- Interpersonal Psychotherapy (IPT)
- Long-term Outcomes
- 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
- Therapist Factors
- Transference and Countertransference
- Trauma and/or PTSD
- Treatment Length and Frequency
Working Alliance and Therapist Cultural Humility Reduce the Impact of Microaggressions
DeBlaere, C., Zelaya, D. G., Dean, J.-A. B., Chadwick, C. N., Davis, D. E., Hook, J. N., & Owen, J. (2022, December 8). Multiple microaggressions and therapy outcomes: The indirect effects of cultural humility and working alliance with Black, Indigenous, Women of Color clients. Professional Psychology: Research and Practice. Advance online publication.
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”.
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.
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.
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 email@example.com.
Is the Therapeutic Alliance Therapeutic? It Depends.
Zilcha-Mano, S., & Ben David-Sela, T. (2022, August 4). Is Alliance Therapeutic in Itself? It Depends. Journal of Counseling Psychology. Advance online publication.
The therapeutic alliance is the most studied concept in psychotherapy and is perhaps the most reliable predictor of patient outcomes. But there are two possible explanations for this finding. First, meta-analyses indicate that patients who report higher overall levels of the alliance tend to experience better outcomes at the end of therapy. Second, other meta-analyses report that if a patient’s alliance improves from one session to the next, regardless of their overall level of the alliance, they report a better outcome. The distinction between the two explanations is important. In the first case, one could argue that some patients who have a general tendency to develop a strong alliance also have a general ability to benefit from any treatment. In the second case, one could argue that a patient’s general tendency to develop an alliance does not matter as much as experiencing a growth in their alliance with the therapist from one session to the next. In other words, is the effect of the therapeutic alliance due to a general capacity of the patient to engage in any therapeutic relationship, or is the effect due to growth in the alliance itself being an active mechanism of change in therapy? In this study, Zilcha-Mano and colleagues compared two treatments for depression from a randomized controlled trial: (1) supportive expressive therapy (SET) that relied on primarily specific interventions and secondarily on the overall level of the alliance to help patients change, and (2) supportive therapy (ST) that primarily relied on growth in the alliance as the main therapeutic factor for change. The authors used sophisticated statistical modelling of session-to-session change in depression and change in the alliance to separate out the effects of a patient’s general tendency to develop a good alliance from the growth of the alliance session to session. The researchers also compared SET and ST on the effects of general tendency to develop an alliance versus growth in the alliance from session to session. The findings indicated that the general tendency of patients to experience a good alliance predicted better outcomes in both therapies. That is, patients who already had a capacity to engage in the therapeutic relationship got better regardless of the type of therapy. However, growth in the alliance predicted better outcomes only in ST and not SET. That is, for ST in which the alliance itself was considered a mechanism of change, patients’ symptoms improved when there was growth in the alliance from one session to the next independent of their general capacity to engage.
The results of the study, like previous meta-analyses, suggested that patients who have a higher general capacity to develop a therapeutic alliance have better outcomes regardless of the therapy. This is a “rich get richer” finding, in which more agreeable patients tend to get better with any treatment they receive. However, the findings also suggested that it is also possible for patients with a lower general capacity for a good therapeutic alliance to improve. For such patients, therapists might prioritize developing and maintaining the alliance on a session-to-session basis. This might be accomplished by taking a more supportive approach, by identifying and acknowledging alliance ruptures, and by repairing such ruptures through negotiating new tasks and goals or strengthening the therapeutic bond.
An Alliance Rupture in One Session Leads to Greater Symptoms in the Next Session
Babl, A., Berger, T., Gómez Penedo, J. M., Grosse Holtforth, M., Caspar, F., & Eubanks, C. F. (2022). Disaggregating between- and within-patient effects of ruptures and resolutions on the therapeutic alliance and symptom severity. Psychotherapy. Advance online publication.
The therapeutic alliance is the collaborative agreement between patient and therapist on the tasks and goals of therapy, and their affective bond. Meta-analyses of over 200 studies show clearly that a higher overall level of the alliance is a reliable predictor of better patient outcomes at the end of treatment. The research is also more specific about how the alliance works - patients whose alliance ratings in one session is higher than their own overall average tend to have fewer symptoms in the next session. During treatment, the state of the alliance may be characterized by rupture and repair episodes. That is, therapists and patients commonly have minor or major disagreements on the tasks and goals of therapy or a disruption in their relational bond, and therapists often try to repair this disagreement or disruption. Confrontation ruptures occur when patients directly show their concern, and withdrawal ruptures occur when patients might have difficulty either recognizing their feelings or directly expressing them. Ruptures are ubiquitous - they occur in every form of therapy and with therapists of every skill level. Resolutions, when done well by therapists, allow the patient and therapist to come to a stronger collaboration on the tasks and goals of therapy or to strengthen their bond. A meta-analysis showed that patients who experience resolution episodes after a rupture had better treatment outcomes. However, most of these studies focused on the effects of higher or lower overall levels of ruptures relative to resolutions on post-treatment outcomes. Few of the studies looked at the impact of a rupture and/or resolution during a session on the outcome or the level of the alliance at the end of the session. In this study, Babl and colleagues specifically looked at whether a rupture during a session is associated with poorer alliance and poorer outcomes after the session, and if a resolution of the rupture is related to a better alliance and better outcomes. The study included 56 patients who received 25 sessions of integrative cognitive therapy for depression or anxiety and who were treated by one of 33 therapists. Independent coders rated alliance ruptures and resolutions from video recordings of 4 therapy sessions throughout treatment. Therapeutic alliance and patient outcomes were assessed after each session with reliable questionnaires. Higher intensity ruptures overall were associated with lower alliance ratings across all sessions. Sessions with more intense confrontation ruptures were associated with poorer alliance ratings after the session. Alliance ruptures and repairs were not associated with patient outcomes.
It may be important for therapists to continuously monitor the state of the therapeutic alliance with each patient and to identify any instances in which the patient is engaging in a confrontation or withdrawal rupture. Therapists may successfully address such ruptures by openly and non-defensively discussing a rupture should it occur, taking responsibility for the rupture if appropriate, regularly talking with patients about the state of the therapeutic relationship, and re-negotiating the tasks and goals of therapy if necessary.
Patients Crying in Psychotherapy
Genova, F., Zingaretti, P., Gazzillo, F., Tanzilli, A., Lingiardi, V., Katz, M., & Hilsenroth, M. (2021). Patients’ crying experiences in psychotherapy and relationship with working alliance, therapeutic change and attachment styles. Psychotherapy, 58(1), 160–171.
Crying often reflects deep feeling and may play a role in the expression of these feelings. In psychotherapy, crying may be an important experience in helping patients to experience and express their emotions. In previous research, patients who had a strong therapeutic alliance with their therapist also felt that crying allowed them to communicate feelings that they could not express verbally. Researchers also report that patients cry in 14% to 21% of sessions, and that crying may be an indicator of healing when it is assisted by therapist interventions. In this study, Genova and colleagues explored the association between patients’ crying during therapy and the therapeutic alliance and therapeutic change. In a survey, 106 adult patients (mean age = 30.94 years, SD = 8.74) were asked to complete several questionnaires about crying in therapy, crying in their lives in general, the therapeutic alliance, and their outcomes in therapy. Of all patients, 83% reported crying at least once in therapy, suggesting that patient crying during therapy is a common event. Most patients (67.4%) talked to their therapist about crying. Many patients reported negative feelings like sadness (53.5%), frustration (38.4%), or powerlessness (28.2%) after crying in therapy. However, other patients also reported positive feels after crying like relief (45.3%), feeling emotionally touched (34.1%), or a sense of warmth (24.7%). Some patients (41.9%) reported that crying in therapy improved their relationship with their therapist, and no patient reported that crying worsened their therapeutic relationship. There was a significant positive correlation between feeling relieved after crying and the therapeutic alliance (r = .29), but a significant negative correlation between feeling depressed after crying and the therapeutic alliance (r = -.30). Positive feelings after crying were also associated with patient rated improvement in therapy (r = .29 to r = .34). However, negative feelings, such as more tension after crying, were related to poorer outcomes (r = -.27).
When patients and therapists have a strong therapeutic alliance (collaborative agreement on the goals and tasks of therapy, and a relational bond), patients experience their crying as a useful event to resolve negative feelings. This is especially true when crying leads to greater awareness and new realizations and when the therapist is supportive. It is critical for therapists to explore their patients’ crying in therapy as it represents an opportunity to deepen the therapeutic relationship and the patient’s self-awareness and self-efficacy.
Social Support and Therapeutic Bond Interact to Predict Client Outcomes
Zimmermann, D., Wampold, B.E., Rubel, J., Schwartz, B., Poster, K., … & Lutz, W. (2020) The influence of extra-therapeutic social support on the association between therapeutic bond and treatment outcome, Psychotherapy Research, DOI: 10.1080/10503307.2020.1847344
Researchers have known for many years that the number of social supports and the size of a patient’s social network have a positive impact on patient outcomes in psychotherapy. Social supports reduce loneliness, and higher loneliness is an important cause of distress. Research has also demonstrated quite convincingly that the relationship in psychotherapy plays an important role in patient mental health outcomes. The therapeutic alliance, for example, is one of the most researched concepts in psychotherapy and shows a clear and positive association with client improvement across a number of theoretical orientations and client problems. The therapeutic alliance is the collaborative agreement between client and therapist on the tasks and goals of therapy, and also their relational bond. The bond includes trust, respect, and confidence in the therapist. This is important because aspects of mental health, like emotion regulation, develop partly in social and intimate relationships, including in the therapeutic relationship. If the therapeutic relationship works to reduce loneliness and improve emotion regulation, then a positive therapeutic relationship will be particularly important for clients with less social support. In this study, Zimmerman and colleagues examined if an extra-therapeutic factor (social support) interacted with an intra-therapeutic factor (therapeutic alliance) to predict client outcomes. Over 1200 adult clients were treated by 164 experienced therapists who were guided by CBT manuals. Patients received 42.77 sessions on average (SD = 19.97), social support was assessed at the start of treatment, and alliance and outcomes were monitored after every session. On average, clients improved throughout treatment. Clients who had more social supports and who reported a better bond with their therapist improved the most. Of particular interest was the interaction between social support and bond. Those clients with lower social supports benefitted more if they also had a good therapeutic bond, and clients with a good therapeutic bond did well regardless of their level of social support.
Both extra-therapeutic social support and intra-therapeutic bond with the therapist uniquely contributed to better outcomes for clients. However, a good therapeutic bond with the therapist appears to be particularly important for all clients, especially those with low levels of social supports. Psychotherapists would do well to assess the level and quality of their clients’ social support. And in all cases, especially for clients with low social support, therapists should work to develop and maintain a supportive and trusting therapeutic bond with their clients.