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Del Re, A.C., Fluckiger, C., Horvath, A.O., Symonds, D., & Wampold, B.E. (2012). Therapist effects in the therapeutic alliance-outcome relationship: A restricted-maximum likelihood meta-analysis. Clinical Psychology Review, 32, 642-649.

The therapeutic alliance, defined as the agreement on tasks and goals and the bond between therapist and patient, is one of the most researched concepts in psychotherapy. A meta-analysis of over 200 studies showed that the association between the therapeutic alliance and patient outcomes is moderate but robust (i.e., consistent across studies, patient types, and therapy types). Some have stated that the importance of the therapeutic alliance as reported in studies is an under-estimate of its real impact on patient outcomes. Del Re and colleagues argue that the main reason for this underestimation is that while the therapist’s effect on the alliance-outcome relationship might be large, the client’s effect might be quite small, and so the average of these two effects (which is what most studies report) will be diminished. Del Re and colleagues conducted the first meta analysis to assess the relative size of therapist versus client effects across many studies. Their strategy was clever. They looked at the ratio of the number of patients to therapists (PTR) within a study as a “predictor” of the alliance-outcome relationship across studies. This allowed them to examine the relative contribution of therapists and clients to the alliance-outcome relationship. Two extreme examples illustrate this ratio. (1) In one study, many patients might have been seen by only one therapist, in which case the alliance-outcome correlation could only be attributed to differences between clients since there was only one therapist. (2) In another study, each client might have been seen by a different therapist (i.e., there were as many therapists as clients), in which case the alliance-outcome correlation could only be attributed to differences between the therapists; that is, there are no differences between clients seen by the same therapist as this did not occur. The patient to therapist ratio (PTR) captures the variability between these two extreme examples across studies. Del Re and colleagues included 69 studies that provided enough information about the number of patients and therapists. The overall correlation between alliance and outcome was moderate, r = .27, which was very similar to what was found in a previous large meta-analysis. PTR was significantly associated with the alliance-outcome relationship even after controlling for a number of possible confounding variables. Patients accounted for almost 0% of the alliance-outcome relationship, whereas the effect of therapists was substantially larger, r = .40, accounting for 16% of the alliance-outcome association.

Practice Implications

Therapists’ capacity to develop an alliance with their patients is associated with outcomes. We also know that some therapists demonstrate better patient outcomes than others. So, therapists who consistently are better at forming alliances with patients likely have patients with better treatment outcomes. The quality of the alliance between patients and therapists appears to be the result of what therapists do or bring to the therapy. And so, on average, the therapist’s role in the alliance is most important for achieving good patient outcomes. Del Re and colleagues note that they were not able to look at the interaction between therapist and patient factors. For example, it may be possible that some therapists might form better alliances some types of patients, but not others. Integrating feedback systems so therapists can monitor the therapeutic alliance and patient outcomes may help therapists identify areas in which they need more training or supervision.

Tracey, T.J.G., Wampold, B.E., Lichtenberg, J.W., & Goodyear, R.K. (2014). Expertise in psychotherapy: An elusive goal? American Psychologist, 69, 218-229.

As I have reported many times in this blog, there is substantial evidence for the efficacy of psychotherapy. However, the quality of psychotherapy differs across therapists – that is, some therapists achieve better client outcomes than others. Tracey and colleagues (2014) ask: is it possible to demonstrate expertise in psychotherapy? They define expertise as “increased quality of performance that is gained with additional experience”. Professions that can demonstrate expertise include: astronomers, test pilots, chess masters, mathematicians, and accountants. But several professions may not demonstrate expertise, including: psychiatrists, college admissions officers, court judges, personnel selectors, and psychotherapists. The difference is that the former group has predictable outcomes and has access to quality feedback. In addition, Tracey and colleagues argue that psychotherapy lacks adequate models for how interventions produce benefits. As a result, adherence to treatment protocols (i.e., manuals) is not reliably associated with better patient outcomes. Further, more experienced therapists are not more effective than less experienced therapists. Experienced therapists might have more complete conceptualizations of client problems, but these conceptualizations may not be accurate. Finally, although therapists affect outcomes, client variables (e.g., motivation, severity of symptoms, expectations) likely explain the largest proportion of outcome variance. Tracey and colleagues argue that part of the problem is that psychotherapists do not engage in “deliberate practice”; that is, practice of a specific task (e.g., identifying a rupture in the alliance), receiving specific feedback (e.g., that a rupture was not identified), opportunity for repetition (e.g., to identify a subsequent rupture in the alliance), and opportunity for improvement afforded by error (e.g., better able to identify a future rupture and repairing that rupture). Generally the practice of psychotherapy provides little feedback about the accuracy of past clinical decisions. In other words there is a lack of quality information to help therapists develop into experts. Further, for a whole host of reasons, psychotherapists are notoriously poor at assessing client progress (i.e., like other humans, therapists engage in a number of biased evaluations of their performance). Quality information might be available from progress monitoring (i.e., continuous feedback to therapists about client outcomes), which has been shown to improve client outcomes. However, this may not aid therapists in developing expertise, since progress monitoring provides little information about what therapist behaviors are necessary to improve performance and client outcomes.

Practice Implications

Tracey and colleagues conclude that currently psychotherapy does not provide evidence that it is a profession with expertise. To achieve expertise, therapists need quality information not only about their patients’ outcomes but also about their own average outcomes (i.e. performance) relative to other therapists working with similar clients. And therapists need information on how to manage specific events in psychotherapy. Tracey and colleagues suggest therapists set aside time to generate hypotheses about one’s practice that can be disconfirmed, and then test these hypotheses. For example, if a therapist is experiencing a higher than average number of premature client terminations (which may follow a misunderstanding with the client), the therapist may hypothesize that he or she is not identifying key alliance ruptures. To test this hypothesis, the therapist could repeatedly assess the alliance (with a validated instrument) with some clients, use this information and not clinical judgement alone to identify alliance ruptures (i.e., a week to week severe downward trend in alliance scores), and implement an intervention to repair the alliance with these clients. Do clients with whom a therapist has implemented this procedure drop out at a lower rate? Does this process of deliberately identifying alliance ruptures and repairing them lead to enhanced therapist performance regarding alliance ruptures? This form of deliberate practice (testing disconfirmable hypotheses based on quality information) might lead to greater expertise in identifying alliance ruptures.

Handbook of Psychotherapy and Behavior Change: Starting in March 2013 I will review one chapter a month from the Handbook of Psychotherapy and Behavior Change in addition to reviewing psychotherapy research articles. Book chapters have more restrictive copy right rules than journal articles, so I will not provide author email addresses for these chapters. If you are interested, the Handbook table of content and sections of the book can be read on Google Books.

Crits-Christoph, P., Connolly Gibbons, M.B., & Mukherjee, D. (2013). Psychotherapy process-outcome research. In M.E. Lambert (Ed.), Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change, 6^th Edition (pp. 298-340). New York: Wiley.

In their chapter in the Handbook, Crits-Christoph and colleagues (2013) review research in which psychotherapy processes are related to patient outcomes. I reported in the July 2013 PPRNet Blog that therapeutic alliance is reliably correlated with treatment outcomes in a variety of disorders and treatment types. Alliance refers to an agreement on tasks and goals of therapy, and the bond between therapist and client. The common assumption is that alliance is a necessary condition that in part causes change in client symptoms. However therapeutic alliance studies tend to be correlational, that is, the studies show a relationship but the study designs do not allow one to say that alliance causes good outcomes. What if the opposite were true; what if early experiences of symptom reduction caused the therapeutic alliance to improve? If that were the case, then alliance would be an artificial and not particularly important aspect of psychotherapy. Crits-Christoph and colleagues (2013) review the literature on this topic. Some studies of cognitive behavioural therapy (CBT), for example, found that prior change in symptoms predicted later therapeutic alliance, but prior alliance did not predict later symptom change. In a more sophisticated study, Crits-Christoph and colleagues (2011) found that previous change in the alliance was related to later change in outcomes, but not vice versa. In the same study, the authors noted that measuring patient alliance at a single early session accounted for only 4.7% of the outcome variance at post treatment, whereas averaging assessments of alliance across 6 early sessions accounted for almost 15% of the outcome variance. In other words, averaging assessments across many sessions produced a more dependable measurement of alliance. Several studies now report a reciprocal relationship between alliance and outcome, indicating that change in alliance and change in outcomes across therapy sessions progress in a mutually reinforcing spiral. That is, early change in alliance causes subsequent change in outcome, which in turn results in further change in alliance, which precipitates more change in symptoms, etc. The review by Crits-Christoph and colleagues (2013) also noted that the importance of alliance seems to be greater for patients with a disorder like depression, compared to anxiety disorders.

Practice Implications

Developing an early alliance with a client is related to treatment outcomes. Measuring alliance repeatedly (not just once) will give the best indicator of the state of the therapeutic relationship. Patients and therapists who have a genuine liking for each other, who agree on how therapy will be conducted and on the goals of therapy will improve the chances that psychotherapy will be successful. Alliance and symptom change may work together throughout therapy so that improvement in one will cause change in the other on an ongoing basis across therapy sessions. Alliance may be particularly important for patients with depressive disorders that are characterized by isolation from others, loneliness, and low self esteem.

Handbook of Psychotherapy and Behavior Change: Starting in March 2013 I will review one chapter a month from the Handbook of Psychotherapy and Behavior Change in addition to reviewing psychotherapy research articles. Book chapters have more restrictive copy right rules than journal articles, so I will not provide author email addresses for these chapters. If you are interested, the Handbook table of content and sections of the book can be read on Google Books.

Baldwin, S. & Imel, Z.E. (2013). Therapist effects. In M.E. Lambert (Ed.), Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change, 6^th Edition (pp. 258-297). New York: Wiley.

Does it matter that some therapists are more effective than others? Can less effective therapists be trained to improve their outcomes and relationship quality with patients?  These are important questions not only for our patients’ well-being but also for the long term survival of psychotherapy as a health enterprise. If we do not measure outcomes and help therapists who are less effective, stakeholders (i.e., clients, families, agencies, insurance companies) may stop paying for the services. In the September 2013 blog I discussed a large study that showed that a few therapists were reliably harmful and some therapists were reliably helpful to their patients. That study also reported that most therapists were effective in 5 of 12 problem domains for which their patients sought help. What these findings and the Handbook chapter by Baldwin and Imel (2013) show is that there are significant between-therapist effects (i.e., therapists differed from each other on patient outcomes) and within-therapist effects (i.e., therapist outcomes within their own caseload differed based on the patients’ problems). Baldwin and Imel (2013) reported on their meta analysis in which between-therapist differences accounted for 5% of the outcome variance. That seems small, but it’s not. One study, for example, estimated that for each 100 patients that would be treated, the worst therapist compared to the best therapist would have 6 more patients who deteriorated. I would prefer my loved ones to be seen by the best therapist, even if the difference between best and worst is only 5%. Nevertheless, 95% of the variance in outcomes is within the therapist’s caseload. That is, the patient, other contextual variables, and the therapist-patient relationship are by far the biggest contributors to outcome. As Baldwin and Imel point out, not only are some therapists are more effective for some patients and not others, but also some therapists are better at developing a therapeutic relationship with some patients than with others. Baldwin and Imel reported that, on average, 9% of the variance in the quality of the therapeutic alliance is associated with the therapist – that’s a clinically meaningful effect.

Practice Implications

As Baldwin and Imel (2013) state, ignoring therapist accountability is detrimental to patients and to the mental health field in general. If stakeholders do not see evidence of positive outcomes, then they will withdraw funding, and patients will have even less access to services. Therapists differ in their outcomes, and outcomes also differ within each therapist’s caseload. If a primary goal is to improve therapist performance and patient outcomes, then therapists need to measure outcomes and therapeutic relationship quality. This knowledge about performance with specific patients can help therapists seek continuing education and training to improve outcomes and therapeutic alliances with specific patients for whom the therapist is less effective. This may require continuous outcome monitoring and real-time feedback to therapists regarding their patients’ outcomes (see my September 2013 blog in identifying clients who might deteriorate).

Handbook of Psychotherapy and Behavior Change: Starting in March 2013 I will review one chapter a month from the Handbook of Psychotherapy and Behavior Change in addition to reviewing psychotherapy research articles. Book chapters have more restrictive copy right rules than journal articles, so I will not provide author email addresses for these chapters. If you are interested, the Handbook table of content and sections of the book can be read on Google Books.

Bohart, A.C. & Wade, A.G. (2013). The client in psychotherapy. In M. Lambert (Ed.) Bergin and Garfield’s handbook of psychotherapy and behavior change (6^th ed.), pp. 219-257. Hoboken, NJ: Wiley.

Last month I blogged about the section in Bohart and Wade’s (2013) chapter that focused on client symptom severity and motivation. This month I focus on differences between clients and therapists on their perceptions of therapy processes and outcomes. In a previous blog (see June 2013), I reviewed a meta analysis that showed that given two equally effective treatments, clients should be given their preference in order to improve outcomes. Clearly, client perceptions and preferences are important, and perhaps more important than the therapist’s perceptions. Bohart and Wade (2013) reviewed a number of studies that demonstrated this. For example, studies show that client ratings of the therapeutic alliance predicted which therapists had better than average outcomes, whereas therapist ratings of the alliance did not predict outcomes.  In three other meta-analyses, client perceptions of therapist genuineness, empathy, and therapeutic presence were each more predictive of outcomes than the respective therapists’ assessments of their own genuineness, empathy, and therapeutic presence. Clients also value different outcomes compared to therapists and researchers. Most research on outcomes tends to focus on symptom reduction, but clients appear to have a broader view of good outcomes. In a qualitative study, clients focused on healthier relationship patterns, an increase in self-understanding that led to freedom from and avoidance of self-destructive behaviour, and stronger valuing of the self, in addition to symptom reduction. Others report that clients define good outcomes as reengaging in meaningful work and social roles, and restoring their self respect.

Practice Implications

Clients are more finely attuned to the therapeutic alliance than therapists, and perhaps are better at detecting relevant and helpful therapist stances. If you are interested in assessing therapeutic alliance or a therapist’s empathy, don’t ask the therapist, ask the client. This has implications for training therapists in helpful therapeutic relationship stances. Helping trainees find areas for continued development as a therapist (i.e., in terms of improving their empathy, genuineness, and therapeutic presence) may require asking their clients’ opinions. Client perceptions of therapist qualities are more relevant than therapist perceptions when assessing effective therapist relationship stances. Therapists should monitor client preferences, particularly if the client is having difficulty engaging in the therapy. If possible and reasonable, therapists should alter their relationship approach to a client based on client feedback. Regarding outcomes, therapists, researchers, and agencies should consider broader definitions of outcomes that are more aligned with what clients want and value. Improved self concept, improved relationships, and better social and work functioning may be just as important as symptom reduction for most clients.

Handbook of Psychotherapy and Behavior Change: Starting in March 2013 I will review one chapter a month from the Handbook of Psychotherapy and Behavior Change in addition to reviewing psychotherapy research articles. Book chapters have more restrictive copy right rules than journal articles, so I will not provide author email addresses for these chapters. If you are interested, the Handbook table of content can be viewed on Amazon.

Bohart, A.C. & Wade, A.G. (2013). The client in psychotherapy. In M. Lambert (Ed.) Bergin and Garfield’s handbook of psychotherapy and behavior change (6^th ed.), pp. 219-257. Hoboken, NJ: Wiley.

Some authors argue that client factors account for 30% of variance in outcomes. That represents a greater association to psychotherapy outcome than therapist effects and therapeutic techniques combined. In this part of the Handbook chapter on client factors, Bohart and Wade discuss client attachment. Bowlby found that attachment relationships were important and were different from other relationships. Attachment figures confer a sense of security and safety to infants that allow children to explore their environment and experience the self. Attachment patterns that develop in childhood tend to be stable throughout the lifespan, but attachment style can change with positive (i.e., psychotherapy, romantic relationships) and negative (i.e., traumatic events) experiences. Attachment security is associated with adaptive affect regulation, positive view of self and others, and reflective functioning that is related to mentalizing. Attachment anxiety is associated with maladaptive up-regulation of emotions, positive view of others but negative view of self, and reduced reflective functioning likely due to preoccupation with relationships and emotion dysregulation. Attachment avoidance is associated with maladaptive down-regulation of emotions, negative view of others and positive view of self (or negative view of others and negative view of self in the case of fearful avoidant attachment), and limited reflective functioning due to dismissing of emotions and relationships. There are also disorganized attachment states related to traumatic events. Those with attachment avoidance tend to be distrustful and less likely to seek psychotherapy. A meta-analysis by Levy and colleagues (2011) of 19 studies including 1467 clients found that attachment security was associated with good psychotherapy outcomes and attachment anxiety was negatively associated with good outcomes. No relationship was found for attachment avoidance and outcomes. Diener and Monroe (2011) conducted a separate meta analysis on attachment and therapeutic alliance which included 17 studies with 886 clients. They found that clients with secure attachments had better alliances with their therapist and those with insecure attachments (anxious or avoidant) had weaker alliances.

Practice Implications

The research is clear that client attachment style influences how clients enter therapy, engage with the therapist, and experience outcomes. Attachment style likely affects specific therapy behaviors like self-disclosure and amount of exploration. In his book Attachment and Psychotherapy, David Wallin (2007) translates attachment theory into a framework for adult psychotherapy by tailoring interventions to specific attachment styles. For example, clients with greater attachment anxiety may do better in psychotherapy when the therapist: helps with down regulation of client emotional experiences, behaves in a way that does not evoke client fears of abandonment or loss, and helps clients improve reflective functioning by encouraging a thoughtful appraisal of their behaviors. On the other hand clients with greater attachment avoidance may require a therapist who: slowly introduces the client to greater attention to emotional experiences, does not demand too much from the client in terms of closeness in therapy at the outset, and encourages reflective functioning by helping the client understand the association between defensive avoidance of affect and relationship problems.