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McPherson, S., Wicks, C. & Tercelli, I. (2020). Patient experiences of psychological therapy for depression: A qualitative metasynthesis. BMC Psychiatry, 20, 313. https://doi.org/10.1186/s12888-020-02682-1

Many times, researchers choose what to study in psychotherapy trials without really consulting patients who are receiving the care. For example, researchers are often primarily interested in how well psychotherapies reduce symptoms in patients with a particular disorder, or researchers might be interested in certain constructs that might affect patient outcomes (e.g., therapeutic alliance, therapist empathy). But are these the things that patients are really interested in when they seek psychological therapy? Although many treatment guidelines emphasize patient choice and experience, none of them take research of patient experiences into account to develop the guidelines. When presented with findings from randomized controlled trials of psychotherapy, patients reported that the research was of limited value in helping them make an informed choice about therapy. In this metasynthesis of qualitative studies, McPherson and colleagues aimed to bring together qualitative evidence concerning adult patients’ experiences of psychotherapy for depression. Qualitative research typically involves interviewing patients and systematically categorizing their responses into meaningful themes. The authors found 38 qualitative studies involving patient interviews of their experiences in receiving psychotherapy for depression. Several key themes emerged from the analysis. First, many people who receive remote therapy primarily from a computer program felt dissatisfied because of the lack of or limited contact with a real person therapist. Most patients did not feel connected to the computerized therapy and so their motivation waned quickly. Second, patients found psychological models and techniques to be less relevant than their need for help with their immediate family or social problems that likely triggered their depressive symptoms. This points to the primary importance of quality of life and of the social and cultural context for patients, despite that many psychological therapies tend to focus on symptoms almost exclusively. Third, this metasynthesis pointed to reports of negative effects of therapy, in which some therapeutic techniques like body scans induced flashbacks in some patients. Other patients had mixed or sometimes negative feelings about requirements for homework, which sometimes felt overwhelming, culturally out of step, or irrelevant.

Practice Implications

This metasynthesis of patient experiences in psychotherapy point to the importance of asking patients about their goals, expectations, and preferences in therapy. The findings highlight the importance of some common factors across therapies (e.g., therapist warmth and humanness, collaborative agreement on tasks and goals, and patient factors like culture and individual differences). Patients prefer human connection with therapists, and they tend to place less value on techniques of therapy. Patients also tend to value outcomes related to quality of life, social connection, and they want therapy consistent with their cultural values. Patients should be fully involved in a collaborative discussion about which therapy you offer them, how you provide the therapy, and what they want to achieve in therapy.

Timuluk, L. & Keogh, D. (2017). The client’s perspective on (experiences of) psychotherapy: A practice-friendly review. Journal of Clinical Psychology, 73, 1556-1567.

Psychotherapy studies that ask clients for their perspective on the treatment or therapist are surprisingly rare. Researchers have conducted such studies over many decades, but there exist very few of them. This is curious given that respecting clients’ preferences for types of therapy or for therapists’ behaviors is predictive of good mental health outcomes. Giving voice to clients’ perspectives is consistent with the notion that psychotherapy is a co-constructed endeavour rather than something that a therapist does to a client (as is the case for a medical intervention). In this review, Timuluk and Keogh review the research in which patients were interviewed for their perspective on a wide range of aspects of psychotherapy. The research indicates a number of things that clients value, that help, and that hinder their progress in therapy. Clients value a number of therapist traits like friendliness, warmth, respect, offering appropriate guidance, and understanding. This research showed that clients recognize that the relationship (i.e., the alliance) has therapeutic effects. Clients report that many forms of therapist behaviors help to develop a therapeutic alliance including eye contact, smiling, warm personalized greetings, paraphrasing, identifying client feelings, and referring to material from previous sessions. Clients find some events in therapy to be unhelpful or that hinder their progress, like feeling exposed and unprotected, being emotionally overwhelmed, and feeling misunderstood by the therapist.

Practice Implications

Although clients do value therapist expertise in applying therapeutic techniques, they hold therapist personal qualities like warmth, authenticity, honesty, and dedication as necessary prerequisites for therapy. Clients view the therapist’s interpersonal manner as key to forming a therapeutic relationship. It is important that therapists are aware of how they feel towards a client (countertransference), and how these feelings might impact the way in which they communicate through body language, tone of voice, and behaviors. Effective therapists are willing to seek their client’s perspectives, and are open and non-defensive about what a client has to say about the therapy or therapist, even if negative. Therapist openness to feedback will inevitably lead to a stronger relationship and collaboration with the client, and to better outcomes for the client.

Cuijpers, P. (2020) Measuring success in the treatment of depression: What is most important to patients? Expert Review of Neurotherapeutics, 20, 123-125.

There is lots of evidence now that psychotherapies of various types are efficacious for the treatment of depression. Psychotherapy trials focus largely on depressive symptoms, and define major depression according to psychiatric diagnostic manuals. However, the diagnosis of major depression, for example, is not a unitary construct. That is, it is simply a collection of symptoms and signs that are purported to make up a category of disorder. In fact, people with major depression are quite varied on a whole range of things, like severity, coping style, motivation, attachment style, personality, and extent of comorbidity with other diagnoses. This means that many psychotherapy studies may be focusing on patient outcomes (i.e., reduction of depressive symptoms) that may or may not be important to patients. In this paper, Cuijpers reviews the literature on what patients want from psychotherapy. He found that while symptom reduction was important to patients with depressive disorders, it was not the only outcome they wanted from psychotherapy. Patients also want to have a more fulfilling lives, to return to productive work, to solve conflicts with close loved ones, to learn to live with a chronic disability or disease, to learn to handle the effects of trauma, and other quality of life issues. Fortunately, some studies do report the effects of psychotherapy on quality of life, social functioning, anxiety, hopelessness, and interpersonal problems. However, even these studies treat such outcomes as if they were uniformly important to all patients in the study. Very few studies take a personalized approach to patient outcomes, in which the outcomes of interest are those determined by each patient specific to their own circumstances and wishes.

Practice Implications

Psychotherapists who practice from an evidence-informed perspective often try to measure outcomes in their own practices using reliable measurements. However, many of these measurements may be too general for any specific patient, or they may represent outcomes that do not align with what the individual patient wants. Practicing clinicians who assess outcomes in their own practices, may want to consider supplementing standard symptom outcome measures with more personalized assessments for patients.

Swift, J. K., Callahan, J. L., Cooper, M., & Parkin, S. R. (2018). The impact of accommodating client preference in psychotherapy: A meta‐analysis. Journal of Clinical Psychology, 74(11), 1924-1937.

Here is another in a series of meta analyses looking at client factors that predict psychotherapy outcomes. In 2006 the American Psychological Association defined evidence-based practice in psychology as composed of 3 pillars: (1) the integration of the best available research combined with (2) clinical expertise in the context of (3) client characteristics including client preferences. Client preferences can be grouped into three broad categories. First, activity preferences refer to activities that a client hopes they and their therapists will engage in during treatment. For example, some clients may prefer homework between sessions, or therapists who interpret, or may prefer a type of therapy modality like group, couple, or individual treatment. Second, treatment preferences include client’s wishes for certain types of therapy approach like CBT, psychodynamic, interpersonal psychotherapy, peer-support, or others. Third, therapist preferences include a client’s desire for the type of therapist with which they would like to work. This might include preferences based on demographics, therapist personality, interpersonal style, culture, and so on. Studies that measure the impact of clients receiving their preferences may simply ask clients what they prefer, or might use a questionnaire of preferences. Some research found that clients are willing to give-up up to 40% in the treatment’s efficacy in order to ensure that they worked with a therapist with whom they would have a good relationship. In this meta-analysis, Swift and colleagues reviewed 53 studies that examined the association between client preferences and psychotherapy outcomes. In 28 studies that included data from 3,237 clients, the overall effect of client preference on psychotherapy drop out was statistically significant, such that clients who were not matched or not given a choice of treatment preference were 1.79 times more likely to drop out compared to those who did get their preference (95% CI: 1.44, 2.22; p < .001). In 53 studies of over 16,000 clients, the overall effect of clients receiving their preference on outcomes was also statistically significant (d = 0.28, 95% CI [0.17, 0.38], p < .001). Receiving a preferred treatment or therapist was associated with better client outcomes.

Practice Implications

The results of this body of research suggests that therapists will do well to attempt to accommodate client preferences in psychotherapy, unless they are impractical, or therapeutically or ethically counter-indicated. One can ask clients about their preferences for activities of therapy, therapist style and characteristics, and treatment type.  Some of these decisions may require clients to be educated about their options, and so agencies may consider adopting decision aids. At the very least therapists should initiate a discussion with clients about what the client wants and what they can reasonably expect to receive. These discussions may occur at the beginning of treatment and revisited part way through as well. Therapists may also consider using more structured valid assessments of client preferences to help with this task.

Author email: Joshua.Keith.Swift@gmail.com

Solstad, S.M., Castonguay, L.G., & Moltu, C. (2018). Patients’ experiences with routine outcome monitoring and clinical feedback systems: A systematic review and synthesis of qualitative empirical literature. Psychotherapy Research. doi=10.1080/10503307.2017.1326645.

Routine outcome monitoring or progress monitoring involves assessing client outcomes or the therapeutic alliance on a weekly basis in psychotherapy, and then giving feedback to the therapist about how the client is doing relative to the previous week and relative to similar clients. Research on progress monitoring indicates that it improves outcomes and it reduces by half the number of clients who might get worse. Despite its benefits, many therapists are not aware of progress monitoring or are reluctant to use the procedure. Some have expressed concerns that progress monitoring could interfere with the therapeutic relationship. However, very few studies have asked clients about their experiences of progress monitoring. In this synthesis of qualitative studies, Solstad and colleagues reviewed 16 studies in which clients were interviewed about their experiences of progress monitoring. The authors used a procedure in which they identified common themes across the studies and categorized client statements within those themes (e.g., thematic analysis). The authors were interested in identifying what were the hindering and helpful processes in clients’ experiences of their therapists’ use of progress monitoring. Four main themes emerged from the research. First, some clients voiced suspicion of how the progress monitoring data was going to be used and why the procedure was implemented. That is, clients sometimes felt that filling out questionnaires weekly was mainly a bureaucratic exercise, or possibly a means to justify reducing services. Second, some clients felt the questionnaires were not flexible enough to capture the complexity of mental health and of client concerns. The questionnaires often focused on symptoms, but clients were also interested in the therapeutic relationship, family, and social functioning. Third, some clients wanted to be more fully informed about the rationale for progress monitoring so that they could feel more empowered to define their own outcomes and treatment plans. Fourth, some clients found progress monitoring to help them to see graphically their own progress, to become more engaged in treatment planning, and to participate in collaborative and reflective discussions with their therapist.

Practice Implications

If psychotherapists choose to use progress monitoring in their practices, they should make sure that clients know what the data will be used for and that the exercise is not just a bureaucratic process. The practice of outcome or progress monitoring can be used to stimulate reflection not only in the therapist but also in the client. Reviewing the client data together might enhance conversations about therapy, the therapeutic relationship, and help to establish realistic goals for therapy. Therapists might consider not only measuring symptom progress repeatedly, but also measuring the working alliance on a regular basis.

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.