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.

August 2023

Client Factors that Predict Outcomes

Swift, J. K., Owen, J., & Miller, S. D. (2023). Client factors. In S. D. Miller, D. Chow, S. Malins, & M. A. Hubble (Eds.), The field guide to better results: Evidence-based exercises to improve therapeutic effectiveness (pp. 47–78). American Psychological Association. https://doi.org/10.1037/0000358-004

Research over 5 decades has demonstrated that client contributions explain the majority of the variance in psychotherapy outcome. That is, patient factors are much more predictive than the type of therapy offered. Effective therapists adjust their interactions and interpersonal stances to relevant patient characteristics. Most demographic variables are not related related to patient outcomes (age, gender, education level, socio-economic status). In this chapter, Swift and colleagues review the research on patient factors that are reliably associated with improvements in psychotherapy. Here I review of few of these factors. Role expectations and preferences refer to patients’ beliefs and preferences about what is likely to happen in therapy – that is, type of therapy, type of therapist, how active or passive the patient or therapist will be, and how long therapy might last. Research indicates that pre-therapy education and preparation results in improved client outcomes (d = .34). Patients’ motivation is also associated with more engagement and better results. Therapists who tailor interventions to patient motivation level result in better outcomes (d = .41). Client attachment style is also associated with patient outcomes such that those with more secure attachments tend to experience greater symptom relief (d = .35), and that reductions in insecure attachment is also related to better outcomes. Finally, reactance or resistance refers to the emotional reaction of patients when they feel stressed or threatened. This may result in rejecting an intervention or therapist. A recent meta-analysis found a large positive effect (d = .79) when therapists of highly resistant patients took a more passive stance and when therapists of less resistant patients took a more active stance in therapy.

Practice Implications

Studies suggest how best to adapt interventions and therapist interpersonal stances for some patients based on their characteristics. Regarding expectations and preferences, therapists might spend time preparing their patients for what will happen in therapy and by collaboratively coming to an agreement on how therapy will proceed. Therapists should also tailor their interventions to the level of their patient’s motivation by focusing on supportive interventions when motivation is low (patients at the pre-contemplation stage of change), or helping the patient to set goals and make plans for changing behaviors when the level of motivation is moderate (patients at the preparation stage of change). For attachment insecurity, therapists who engage in interventions to help clients to experience more attachment security might see greater effects of therapy. These interventions might involve improving the patient’s quality of relationships, emotion regulation, and reflective capacities. The findings also suggest that therapists should be less directive with patients who have high levels of reactance or resistance but more directive for patients who have lower levels of reactance or resistance. These therapist interpersonal stances tailored to level of patient expectations, attachment style, motivation, and resistance have a better chance of engaging the client in therapy.

October 2022

Therapists Report Less Therapeutic Skill in Telepsychology vs In Person Therapy

Lin, T., Stone, S. J., Heckman, T. G., & Anderson, T. (2021). Zoom-in to zone-out: Therapists report less therapeutic skill in telepsychology versus face-to-face therapy during the COVID-19 pandemic. Psychotherapy, 58, 449–459.

The COVID-19 pandemic has confronted psychotherapists with several challenges including rapidly switching their practice to using teletherapy (videoconferencing, phone, and other virtual media). The use of teletherapy in clinical work increased from 7.1% prior to the pandemic to 85.5% during the pandemic. And estimates suggest that at least one-third of clinical work will be performed by teletherapy post-pandemic. Over a third of psychologists reported that they lacked training in using teletherapy, and they believe that their skills in this domain are inadequate. Therapists have raised a number of concerns in past surveys including issues related to privacy, professional self-doubt, technological competence, challenges to the therapeutic relationship, and problems with implementing some interventions. In this survey of 440 therapists and trainees, Lin and colleagues were particularly interested in therapists’ perceptions of the impact of teletherapy relative to in person therapy on the therapeutic process and patient outcomes. Videoconferencing was the most frequently used modality by 73.56% of surveyed therapists. The survey asked if three broad areas of practice were affected by teletherapy compared to in person therapy. These areas included common therapeutic factors (level of therapist empathy, emotional expression, warmth, alliance bond), extra-therapeutic patient factors (the patient’s environment that impacted their ability to engage in homework or use prescribed resources), and perceived patient outcomes (therapist ratings of patient symptom reduction, satisfaction, clinical improvement). Therapists in the survey were representative of the population of therapists in the US, and 82% of them provided all their clinical work in recent months by teletherapy. Compared to in person therapy, therapists reported poorer skills related to common therapeutic factors (d = 0.86), somewhat greater impact of extra-therapeutic factors (d = 0.36), and perceived poorer patient outcomes (d = 0.68) in teletherapy. Therapists who were younger, preferred emotion-focused or relational therapies, and with no prior training reported a relatively greater decrease in therapeutic skills in teletherapy compared to in-person therapy.

Practice Implications

By far, most therapists believed that providing psychotherapy by virtual means reduced their capacity to use common therapeutic stances including empathy, warmth, and the therapeutic alliance. Some of this might be affected by the psychological distance caused by the virtual format and difficulties with reading body language and other non-verbal cues. Therapists perceived that patient outcomes suffered as a result. This was particularly true for younger therapists, possibly because of the impact of adopting the new modality on their professional self-confidence. Also, therapists who preferred experiential or interpersonally based therapies felt particularly challenged possibly because these therapies may be more reliant on emotional communication and discerning patient interpersonal behaviors. Training and support are needed for therapists and trainees to improve their confidence in providing teletherapy.

May 2022

Interpersonal Complementarity: Therapist Responsiveness to Patient Interpersonal Behaviors

Constantino, M.J., Boswell, J.F., & Coyne, A.E. (2021). Patient, therapist, and relational factors. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7^th ed.). Wiley. Chapter 7.

Interpersonal behaviors can be characterized by the level of affiliation (i.e., friendliness vs hostility) and of interdependence (i.e., dominance vs submissiveness). Interpersonal complementarity refers to two people in an interaction whose behaviors are matched on affiliation (friendliness evokes friendliness in the other) and reciprocity in terms of interdependence (dominance evokes submission or submission evokes dominance in the other). So friendly-dominant behaviors in one person tends to evoke friendly-submissive behavior in another and vice versa, and similarly, hostile-dominant behaviors in one person tend to evoke hostile-submission in the other and vice versa. Complementary interactions are comfortable and do not cause anxiety, they reinforce the interactional styles of the participants, and they tend to continue unchanged. Non-complementary interactions do cause anxiety, and they either change or they terminate. In this part of the chapter, Constantino and colleagues review the research on the role of complementarity between therapists and patients. Therapists on average tend to behave in a friendly-dominant style and many but not all patients tend to respond in a friendly-submissive style. The most interesting findings of this line of research is that the number of complementarity interactions between therapists and patients tend to change across stages of successful therapy. In early sessions, patient-therapist interactions tend to be highly complementary. Interactions in the middle of therapy tend to be lower in complementarity. And at the end of therapy, patients and therapists tend to return to higher levels of complementarity. Hostile therapist interactions are rare, and when they occur it is almost exclusively in unsuccessful therapy cases.

Practice Implications

This research has a lot to say about how therapists should respond to patients’ interpersonal behaviors and styles. Therapists should always remain affiliative or friendly (or at least neutral) and avoid hostile interactions with patients. The research indicates even a small number of hostile responses from therapists may lead to negative outcomes or dropping out. The research seems to indicate that (a) higher therapist-patient interpersonal complementarity early in therapy is related to establishing rapport and a therapeutic alliance, (b) lower complementarity in the mid stage of therapy might indicate that therapists are engaging patients differently in order to help change patient patterns of interpersonal relating, and (c) a return to higher complementarity at the end of therapy may indicate therapists reinforcing changes and patients experiencing a new sense of self within the therapeutic relationship.

March 2022

Patient Factors: Impairment, Chronicity, and Severity

Constantino, M.J., Boswell, J.F., & Coyne, A.E. (2021). Patient, therapist, and relational factors. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7^th ed.). Wiley. Chapter 7.

Many times, clinicians are interested in knowing what the likelihood is of a patient improving, how long that improvement might take, and what to expect in terms of degree of improvement. Some of the patient factors that predict these outcomes are indicators of the patient’s mental health at the start of treatment. In this part of the chapter, Constantino and colleagues review the research on several mental health indicators and their association with treatment and outcomes. First, functional impairment refers to the degree of impaired daily living, disrupted work performance, and social maladjustment. Generally, the research indicates that greater functional impairment is associated with poorer outcomes, and when coupled with a dual diagnosis (substance use disorder or another mental health diagnosis) greater functional impairment is associated with longer and more costly treatments. Second, chronicity (longer symptom duration) is also related to poorer treatment outcomes and slower rate of improvement. Third, symptom severity had a mixed association with patient outcomes. Generally, very high or very low severity of symptoms was related to poorer outcomes. It is possible that very high symptom severity may interfere with a patient’s capacity to use therapy, but that very low symptom severity may lead to the patient being less motivated to change. The fourth area was diagnostic comorbidity. Patients with major depressive disorder and personality disorder are twice as likely to have a poor outcome from psychotherapy. Similarly, patients with primary substance use disorder and a comorbid diagnosis typically dropped out at a higher rate and had poorer outcomes.

Practice Implications

It is sometimes helpful for clinicians and patients to know what to expect from psychotherapy and how long therapy might take. The more a patient’s work and social functioning is impaired and the longer they have had symptoms, the more sessions of therapy they might need. This means that both patients and therapists need to be realistic about what to expect in terms of progress. The same might be true for comorbid symptoms when the primary diagnosis is major depression or substance use. The picture for symptom severity is a little more complicated. Patients with very high symptoms may require an initial focus on reducing symptoms by increasing social supports, containment, and other practical interventions for them to make good use of therapy. On the other hand, patients with very low symptom severity may need help initially to increase their motivation for treatment to prevent a relapse.
Patient Coping Style and Resistence

Constantino, M.J., Boswell, J.F., & Coyne, A.E. (2021). Patient, therapist, and relational factors. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7^th ed.). Wiley. Chapter 7.

There are certain patient characteristics that interact with therapist behaviors and interventions, and these interactions have an impact on patient outcomes. Two of these that are reviewed by Constantino and colleagues are patient coping style and resistance. In a broad sense, coping style can be characterized as internalizing or externalizing. Internalizing coping refers to being self-critical and directing blame inward when under stress. Externalizing coping refers to acting out when stressed or placing blame on others or the environment when under stress. A meta-analysis of 1,947 patients from 18 studies, examined the interaction between coping style (externalizing vs. internalizing) and psychotherapy type, categorized as insight oriented vs. symptom-focused. Insight-oriented approaches (e.g., psychodynamic, humanistic) prioritize increasing self-understanding and emotional experiencing, whereas symptom-focused approaches (e.g., cognitive, behavioral) focus on changing symptoms directly through altering behaviors, cognitions, and reinforcement contingencies. The authors found a medium interactive effect on outcome (d = .60), such that those who typically engaged in internalizing coping had better outcomes in insight-oriented treatments and those who typically used externalizing coping had better outcomes in symptom-focused treatments. The second patient factor that interacts with interventions is patient resistance (also known as reactance). Resistance involves emotional arousal when one perceives that another is controlling or limiting one’s freedom, and the behaviors one engages in to resist this control. A meta-analysis of 13 controlled studies with a total of 1,208 patients found that patients higher in resistance had better outcomes when their therapist took a less directive approach and patients lower in resistance had better outcomes when their therapist adopted a more directive approach (d = 0.79).

Practice Implications

Therapists should pay attention to and assess their patients’ coping style and level of resistance. This information will inform how therapists should approach these patients or what their interpersonal stance should look like. Patients with a more internalizing coping style may do better with a more insight-oriented approach to therapy. Patients with a more externalizing coping style may do better in a therapy that requires them to engage in problems solving and is symptom focused. Also, patients who appear to be highly resistant (wary of or not willing to follow suggestions) may respond better when a therapist takes a less directive or less authoritative interpersonal stance. Conversely, patients who are lower in resistance (more agreeable or compliant) may respond better to therapists who are more directive in their in their interpersonal style.
Patient Expectations and Preferences

Constantino, M.J., Boswell, J.F., & Coyne, A.E. (2021). Patient, therapist, and relational factors. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7^th ed.). Wiley. Chapter 7.

In this chapter, Constantino and colleagues review the effects of patient expectations of benefit and patient preferences for treatment. Patient outcome expectations is broadly related to the placebo effect. That is, there is a commonly known positive effect when patients expect that a treatment will help them get better. This effect occurs across all psychotherapies and is also seen in medical and pharmacological interventions. A meta-analysis of almost 13,00 patients in 81 studies found a small to moderate relationship (r = .18) between patient expectations of positive outcomes and the extent to which they improved. There is also evidence that outcome expectations improve the therapeutic alliance. The more optimistic patients are about getting better, the more they are likely to engage in a collaborative working relationship with their therapist. A related line of research addresses patient preferences for treatment. This refers to what is done in therapy, the characteristics of the therapist, and the length of therapy among others. Preferences can be grouped into three categories: activity preferences are the patient's desire for the psychotherapy to include specific therapist behaviors or interventions; treatment preferences are the patient's desire for a specific type of intervention to be used, such as psychotherapy vs. medication, or CBT vs. person-centered therapy; and therapist preferences are the patient's desire to work with a therapist who possesses specific characteristics (e.g., a certain gender, race, or interpersonal style). In a meta-analysis of 28 studies, patients who received their preferences were 1.79 times less likely to drop out of therapy compared to those who did not get their preference. The effect on patient outcomes were statistically significant but small (d = .28). The beneficial effect of preferences was stronger for those with anxiety or depressive disorders.

Practice Implications

Patients who have higher expectations of getting better are on their way to feeling remoralized, they are more likely to engage in a therapeutic relationship, and they are more likely to be collaborative in the therapy. Therapists can improve patient expectations by providing patients with a clear rationale for the interventions, a realistic sense of how long therapy will take, and a non-technical summary of the research evidence for the therapy they are providing. Patients who get what they prefer in a therapy or therapist also may experience better outcomes, especially if they have an anxiety or depressive disorder. Listening to what patients expect and want from therapy may help therapists to tailor the treatment to the patient’s wishes. Providing patients with more than one treatment option when possible may be one means of meeting patient expectations.

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August 2023

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October 2022

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May 2022

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March 2022

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