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Norcross, J.C., Zimmerman, B.E., Greenberg, R.P., & Swift, J.K. (2017). Do all therapists say that when saying goodbye? A study of commonalities in termination behaviors. Psychotherapy, 54, 66-75.

One of the things common to all psychotherapy relationships is that they come to an end. The endings may be premature or planned. They may be well managed or poorly managed. In this article by Norcross and colleagues, the authors ask: what do expert therapists typically do when there is a planned termination with a client? A planned termination is “an intentional process that occurs over time when a client has achieved most of the goals of treatment, and/or when psychotherapy must end for other reasons”. By contrast, premature termination occurs when the client ends treatment unilaterally. In successful cases the client and therapist typically predetermine the end date and have time to work toward the ending. Different theoretical orientations write about different aspects of termination. For example, from a psychodynamic perspective, therapists focus on clients’ old and new methods of coping, feelings related to the impending loss of the relationship, review gains, and work to equalize the relationship. From an experiential perspective, therapists might recognize that clients continue to change after therapy, help clients work through feelings of loss and separation of the therapeutic relationship, and consolidate new meanings. Cognitive-behavioral therapists might help clients to maintain gains made in therapy, review new skills, and prevent relapse. Do therapists who practice these and other theoretical approaches differ in terms of how they manage termination in psychotherapy? Norcross and colleagues surveyed 65 nominated experts representing six theoretical orientations of psychotherapy (psychodynamic, humanistic, CBT, interpersonal, multicultural, and integrative). Each orientation was represented by at least 10 expert therapists. The survey included 80 items related to termination that were drawn from books, chapters, and treatment manuals. The experts indicated the frequency with which they engaged in each behavior or the task related to termination. Therapist behaviors or tasks that received very strong consensus (>90% of therapists reporting “frequently” or “almost always” doing these) included: supporting the client’s progress, helping to consolidate gains made in therapy, following ethical practice (e.g., avoiding abandonment), attributing gains to the client’s effort, talking about what helped or went well, and collaborating with the client to set a date and pace of termination. Strong consensus (80% to 90% of therapists reported frequently doing these) behaviors or tasks included: focus on processing feelings around termination, having the client practice new skills, normalizing the probability of relapse, and prompting the client to think of a future without therapy. Of the 80 Items, 27 did not reach consensus among the therapists (i.e., only 21% to 59% of therapists agreed on these items). Out of the 80 items, only 8 (10% of items) showed significant differences between theoretical orientations (e.g., compared to other orientations, CBT therapists tended to do more of: preparing clients for relapse, and systematically assessing client outcomes near termination).

Practice Implications

This survey of 65 experts of varying psychotherapy orientations highlighted a wide range of commonalities in terms of how they managed termination with clients. While there was some uniqueness among orientations, most therapists tended to: process feelings about termination and the relationship with clients, discuss future functioning and coping, helped clients to use new skills, framed the client’s personal development as ongoing beyond therapy, prepared explicitly for termination, and reflected on the client’s gains.

Farrell, N.R. & Deacon, B.J. (2015). The relative importance of relational and scientific characteristics of psychotherapy: Perceptions of community members vs. therapists. Journal of Behavior Therapy and Experimental Psychiatry. DOI: 10.1016/j.jbtep.2015.08.004

The American Psychological Association defines evidence-based practice (EBP) in psychotherapy as based on: (a) research evidence, (b) clinical expertise, and (c) client characteristics and preferences. We know for example, that clients who receive their preferred treatments better engage with therapy, drop out at a lower rate, and achieve better symptom outcomes. However, we know very little about clients’ preferences for the relative importance of the therapeutic relationship with an empathic therapist versus the scientific merit of the treatment they receive. We do know that therapists generally prefer research on the therapeutic relationship, and that therapists may place greater value on relationship issues versus research support for the treatments they provide. In this study Farrell and Deacon sample 200 members of the community about the relative importance of the relationship with a therapist versus the scientific basis of the treatment. The authors also surveyed a similar number of therapists about what therapists thought clients would prefer (relationship vs research evidence) in psychotherapy. Not surprisingly, community members rated both the therapeutic relationship and research evidence highly when indicating what they preferred should they receive psychotherapy. However, the authors found that members of the community rated the therapeutic relationship much more highly than they rated research evidence (d = 1.24). But the difference shrank (d = .24) when it came to treating panic disorder or obsessive compulsive disorder. Therapists tended to under-estimate the importance of community members’ preferences for scientific evidence for psychotherapy. The under-estimation was greater for therapists who placed less value on research. In other words, therapists who valued research less in their own practice were more likely to underestimate the importance of scientific credibility to members of the general public.

Practice Implications

This is by no means a perfect study. As readers of this blog know, I prefer to write about meta analyses, which are much more reliable than findings from a single study. However, it is quite rare to have a study on a large sample of members of the community, let alone one that asks about their perceptions and preferences about psychotherapy. The findings from this study suggest that members of the community highly value the therapeutic relationship and factors like therapist empathy. However, members of the community also place much faith in the scientific evidence that supports the use of psychotherapy. The preference for both a good therapeutic relationship coupled with research evidence may be very important to most people who may seek therapy. Therapists, particularly those who place less weight on research, should keep in mind that clients value the scientific evidence for psychotherapy.

Author email: bdeacon@uow.edu.au

Castonguay, L.G., Boswell, J.F., Zack, S., Baker, S., Boutselis, M., Chiswick, N., Damer, D., Hemmelstein, N., Jackson, J., Morford, M., Ragusea, S., Roper, G., Spayd, C., Weiszer, T., Borkovec, T.D., & Grosse Holtforth,, M. (2010). Helpful and hindering events in psychotherapy: A practice research network study. Psychotherapy: Theory, Research, Practice, and Training, 47, 327-344.

There are many reasons why I like this paper, and one reason is that it is a psychotherapy practice research network study (most of the co-authors are independent practice clinicians). This group of clinicians and researchers met on a number of occasions to define the research questions, including: “what do psychotherapists and clients find most and least helpful in a psychotherapy session?”; and “do psychotherapists and clients agree on what was most and least helpful?” The clinicians and researchers also discussed and agreed on the method for collecting and analysing the data. Thirteen independent practice clinicians participated (6 CBT, 4 psychodynamic, and 3 experiental/humanistic). For a period of 18 months, all new clients were invited to participate so that 121 clients with a variety of disorders enrolled in the study. Clients and therapists filled out (on an index card) parts of the Helpful Aspects of Therapy (HAT) measure, which asked them to report, describe, and rate particularly helpful and hindering events from the session they had just completed. For example clients and therapists were asked: “Did anything particularly helpful happen during this session?”; and “Did anything happen during this session which might have been hindering?” When participants answered “Yes” to either of these questions, they were asked to briefly describe the event(s), and then rate them on a scale from 1 to 4 for level of helpfulness or level of hindrance. Both clients and therapists did so at the end of every therapy session. Close to 1500 therapeutic events were recorded by the clients and therapists. The events were then coded and categorized according to type of event by independent raters using an established coding system. Clients rated self-awareness, problem clarification, and problem solution as the most helpful type of events, although self-awareness was significantly the most identified of all helpful events by clients. Therapists rated self-awareness, alliance strengthening, and problem clarification as the most helpful type of events. Therapists identified self-awareness and alliance strengthening significantly more often than any other helpful events. Hindering events were identified much less frequently by clients and therapists. Client identified poor fit (e.g., therapist tried something that didn’t fit the client’s experience) as the most frequent hindering event category. Therapists identified therapist omissions (i.e., failure to provide support or an intervention) as the most frequent hindering event category. Overall, with the exception of self-awareness, therapists and clients did not agree on what were the most helpful or hindering events in therapy.

Practice Implications

Results regarding self awareness indicate that providing clients with opportunities to achieve a clearer sense of their experience (e.g., emotions, behaviors, and perceptions of self) is frequently reported as beneficial by both clients and therapists. The events that therapists most frequently reported as detrimental were those in which they failed to be attuned to their clients’ needs. This may reflect therapists’ concerns with potential alliance ruptures. The overall lack of agreement between therapists and clients on helpful and hindering events raises the question about whether therapists are not aware enough of clients’ experiences, or whether clients are not knowledgeable about what is in fact therapeutic. Perhaps client and therapist ratings of events represent complementary perspectives on what works or does not work in psychotherapy. Regarding participating in research, these independent practice therapists reported that the procedure of writing down helpful and harmful events and reading what their clients wrote after each session had a positive impact on their practice. That is, the process of data collection became immediately relevant to their clinical work.

Author email: lgc3@psu.edu

Blume-Marcovici, A. C., Stolberg, R. A., & Khademi, M. (2013). Do therapists cry in therapy? The role of experience and other factors in therapists' tears. Psychotherapy. Advance online publication. doi:10.1037/a0031384

There is almost no research on therapists crying during psychotherapy, and on its correlates and impact. A survey of therapists’ ethical behavior conducted 25 years ago asked a single question about crying, and 56.5% of respondents indicated that they cried in the presence of a client. By contrast there are several such surveys in medicine. Notably, a study of medical students and interns found that 68% medical students and 74% of medical interns had cried with patients. A recent survey by Blume-Marcovici and colleagues is the first of its kind since it was devoted to therapists crying in therapy and associated factors. They defined crying as: “tears in one’s eyes due to emotional reasons”. The authors surveyed U.S. psychologists and had 541 respondents. The sample included 59% graduate students, and 41% licensed clinicians who had an average of 9.6 years experience. Seventy six percent were women, mean age was 36 years, 35% had a cognitive behavioural therapy (CBT) orientation, and 33% had some psychodynamic orientation (PDT). Respondents reported that 72% had cried in therapy. Those who cried reported crying in 6.6% of their sessions in the past 4 weeks. There were no differences between men and women, and there was no association between therapist crying and therapist personality traits or level of empathy. Therapists who cried more often in their daily life tended to cry more in therapy. PDT and CBT therapists did not differ in the amount they cried in their daily lives, however PDT therapists (88.9%) reported crying more often than CBT therapists (50.1%) in therapy. Further, older and more experienced therapists reported crying more often in therapy in the past month than younger and less experienced therapists. It is possible that older therapists may become more comfortable in using their clinical judgment, and so have fewer restrictions on their own affective displays. Of therapists who cried, 45.7% felt that the therapeutic relationship improved, and 1% reported that the relationship deteriorated due to crying. Patients, however, were not surveyed for their opinion about their therapist’s crying.

Practice Implication

Crying among therapists may happen relatively frequently. Although this study is novel, it is the only one of its kind so one should be cautious about drawing practice implication. The challenge of therapists crying in therapy is that it can bend or break the therapeutic frame (e.g., is the therapist crying because of being overwhelmed and acting on his or her own needs, or is the therapist genuinely responding for and with the patient?). The survey suggests that therapist crying can strengthen the therapeutic relationship. This is more likely true when the therapist is attuned to the patient’s needs, and when the crying signals a moment of positive emotional connection in the midst of painful feelings in the client. As with any event in therapy, a genuine and skilful exploration by the therapist and patient of the therapist’s crying has the potential to strengthen the relationship.

Author email: ablume@alliant.edu