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.

June 2018

What Do Patients Value in a Psychotherapist?

Boswell, J. F., Constantino, M. J., Oswald, J. M., Bugatti, M., Goodwin, B., & Yucel, R. (2018). Mental health care consumers’ relative valuing of clinician performance information. Journal of Consulting and Clinical Psychology, 86(4), 301-308.

Research has shown that some therapists are more effective than others both in terms of their overall effectiveness and in terms of their effectiveness with specific patient problems. Further, despite advances in medicine on this topic, there is little or no information provided to patients about a therapist’s track record on overall effectiveness. In any case, little is known about what patients value in psychotherapists and how much they are willing to give up in order to get what they value. For example, do patients prefer therapists who are highly effective for most problems, and would they be willing to tolerate a poorer therapeutic relationship in order to work with such a highly effective therapist? In this study, Boswell and colleagues employed a relative valuing procedure often used in economics to assess the relative value to patients of different therapist characteristics and performance. Patients were asked how much they were willing to give up on one therapist characteristic (therapist’s overall effectiveness with clients [i.e., overall track record]) in order to receive more of some other characteristic (therapist specific effectiveness in a problem domain, a better therapeutic alliance, lower cost of therapy). The study included 403 patients treated in mental health clinics in the U.S. Patient characteristics were typical of those seen in such clinics – predominantly they had problems with depression or anxiety, were 41 years old on average, mostly women (68.5%), and receiving individual psychotherapy (89.3%). In general, patients highly valued a therapist with a track record of general overall effectiveness. However, patients were willing to give up more of their therapists overall effectiveness if the therapist had a track record of successfully treating their specific problem (e.g., therapist A has lower general efficacy but has demonstrated greater specific efficacy for depression). Patients were also willing to sacrifice therapist general effectiveness in order to pay less for therapy (vs paying a higher fee for a more effective therapist), and in order to work with a provider with whom they would have a better therapeutic alliance (vs a lower alliance with a more generally effective therapist). Surprisingly, patients placed a lower value on factors like therapist gender and race. Younger patients put greater value on therapist performance data (i.e., their track record data), suggesting a generational effect in which younger clients tend to prefer to make decisions based on available data.

Practice Implications

Patients were willing to give up some therapist general effectiveness in order to work with someone who has a track record of being effective for their specific problem, who costs less, and with whom they could have a better therapeutic alliance. Fortunately, therapist general efficacy and domain specific efficacy tend to be highly correlated, and so patients may not have to choose between these. The findings also suggest that patients may be willing to see a therapist who is less generally effective if it meant they could have a good relational experience with the therapist. Research indicates that therapists are able to improve their outcomes and therapeutic alliances with additional training and deliberate practice.

May 2018

Predicting Not Starting and Dropping Out From Publicly Funded Psychotherapy

Andrzej Werbart & Mo Wang (2012). Predictors of not starting and dropping out from psychotherapy in Swedish public service settings, Nordic Psychology, 64, 128-146.

There are few empirical studies looking at patients who are offered but who do not take up psychotherapy. This is a particularly important issue in publicly funded psychotherapy programs in which large numbers of patients who need mental health services to not access the service or leave before receiving adequate treatment. Evidence from the Improving Access to Psychotherapy (IAPT) program in the United Kingdom suggests that about half of patients who are offered psychotherapy either do not take it up or drop out prematurely and unilaterally. Knowledge about what determines treatment rejection or dropping out is critical in designing and developing publicly funded psychotherapy so that not only access but also patient outcomes are improved. In this study from the national Swedish psychotherapy program that is publicly funded, Werbart and colleagues looked at data from 13 clinics in which 189 therapists treated almost 1400 patients. Therapists were experienced (median experience = 5 years), and most received advanced psychotherapy training. Patients had a wide array of problems and severity. Of the patients, 13.6% never started therapy even though they were referred and assessed for treatment, and of those who started 17.4% dropped out of treatment. So a total of 31% never received adequate treatment and did not benefit for psychotherapy. Patients who never started therapy tended to be younger, unemployed, and with higher levels of mental illness. Patients who remained in therapy once they started tended to be older, had more problems with trauma or loss, and had more severe illness although they were not a danger to themselves or others. Never starting treatment and dropping out were both associated with clinics that had greater institutional instability. Clinic instability was defined as a clinic with: unclear treatment goals and guidelines, not well adapted to providing psychotherapy, unclear policies around who and how therapy is conducted, less cooperation among professionals, and financial problems.

Practice Implications

Jurisdictions around the world, including in Canada, are looking to offer publicly funded psychotherapy, yet there is little research to guide how to improve uptake and retention of patients within the system. Such systems might focus pre-therapy efforts to retain patients who are younger and with greater mental health problems. In particular, public systems need to pay attention to clinic and institutional stability. How patients experience the clinic environment (as welcoming and integrated), how treating professionals cooperate, the clarity and structure of treatment guidelines and goals, and the financial stability of a clinic all appear to have an impact on whether patients actually access and complete a course of psychotherapy.

February 2018

Experts Agree on Strategies to Repair Alliance Ruptures

Eubanks, C. F., Burckell, L. A., & Goldfried, M. R. (2017, December 21). Clinical consensus strategies to repair ruptures in the therapeutic alliance. Journal of Psychotherapy Integration. Advance online publication.

Research is clear that the therapeutic alliance (i.e., agreement on tasks and goals of therapy, and the bond between client and therapist) is an important predictor of client outcomes across theoretical orientations. It is also clear that ruptures or strains in the alliance occur often and can have a negative effect on client outcomes. One can define two types of ruptures: (1) withdrawal ruptures, in which the client moves away from the therapist by shutting down, changing the focus, or not completing session assignments; and (2) confrontation ruptures, in which the client moves against the therapist so that the relationship quality is low, the client is not collaborative, and the client does not agree with the goals of therapy. Repairing alliance ruptures can have a positive effect on client outcomes, and therapists can learn to repair alliance ruptures. What are the best strategies that a therapist can use to repair alliance ruptures? In this study of expert consensus, Eubanks and colleagues surveyed clinicians in three broad and different surveys. In the first survey, the authors asked 330 professional social workers and psychologists from a variety of theoretical orientations to describe situations in which they encountered alliance ruptures in clinical practice. The researchers categorized situations described by clinicians as withdrawal ruptures or as confrontation ruptures, and then the authors selected those scenarios that best represented each type of rupture. In a second independent survey, 177 clinicians indicated how they would advise a colleague seeking consultation to respond to each scenario of a therapeutic alliance rupture. Clinicians generated between 35 and 45 strategies to repair each type of alliance rupture. In the final part of the survey, training directors in psychology and social work programs nominated peer experts to rate the strategies for alliance repair, so that 134 peer-nominated expert clinicians provided ratings. There was a high level of consensus among experts such that between 55% and 74% agreed on effective strategies to repair alliance ruptures. Experts agreed that during the session in which the alliance rupture occurred therapists should: explore and empathize with the client`s anger at the therapist, and validate or legitimize the client`s position on the issue related to the rupture. Experts also agreed that in future sessions clinicians can use other strategies like: helping the client manage and cope with painful feelings related to the rupture, helping the client clarify and explore their emotions related to the rupture, and exploring the meaning and patterns of problematic relationships outside of therapy.

Practice Implications

Experts agreed that the best strategies to repair therapeutic alliance ruptures were to deal with the therapeutic bond (e.g., explore and empathize with the client`s anger at the therapist) and to validate the client`s position on the issue related to the rupture. Other strategies like helping the client cope with their reactions and feelings, and exploring the meaning and patterns related to the client`s response were also rated as helpful. Less helpful strategies included therapists communicating about the limits of therapy, and therapist self-disclosure of their reaction to the rupture.

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June 2018

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May 2018

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February 2018

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Psychotherapy Practice Research Network (PPRNet)