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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.

Finsrud, I., Nissen-Lie, H. A., Ulvenes, P., Melsom, L., Vrabel, K., & Wampold, B. (2022, September). Confidence in the therapist and confidence in the treatment predict symptomatic improvement week by week in therapy: A latent curve modeling approach. Journal of Counseling Psychology. Advance online publication.

In his classic book Persuasion and Healing, Jerome Frank suggested that all psychotherapies involve a trusting emotionally charged relationship with a sanctioned healer who has a good rationale for their interventions. The common factors approach to psychotherapy was born from this kind of thinking. Carl Rogers, for example, argued that to be effective therapists had to engage in unconditional positive regard, empathic understanding, and a genuine non-defensive stance. Contemporary therapeutic alliance theory emphasizes similar factors plus the patient’s expectation of benefit from therapy created through accepting the rationale for the therapy and agreement on the tasks and goals of therapy. From this research and theory, one can see that a patient’s confidence in the therapist and confidence in the treatment may be key common factors underlying effective therapies. Confidence in the therapist refers to a patient who believes that the therapist has the relational skills to help, and that the therapist is working in the patient’s best interest. Confidence in treatment refers to the patient’s belief that the rationale for treatment is meaningful, and that the treatment itself will remedy their problems. In this study, Finsrud and colleagues were interested in whether confidence in the therapist or treatment in one session predicted symptom reduction in the next session. Or was it the other way around – does symptom reduction increase a patient’s confidence? If the results showed the latter, then confidence is result of symptom improvement and so has little or no therapeutic value. The study had 587 adults receiving inpatient treatment for a variety of disorders and treated by psychotherapists of different orientations. Patients completed a measure of confidence in the therapist and treatment, and a scale of their depressive symptoms twice a week for an average of 12 weeks. The authors used sophisticated statistical modeling techniques to examine the effect of a patient’s preceding levels of confidence in therapist or treatment on the patient’s subsequent session symptoms, and vice versa. The researchers found that an increase in confidence in the therapist and confidence in the treatment predicted a decrease in symptoms in the next session. They also found that a reduction in symptoms predicted an increase in confidence in the therapist and in treatment in the next session.

Practice Implications

Patients’ confidence in the therapist and in the treatment both contribute to symptom reduction over and above early symptom change. In other words, the patient’s perception of the therapist as a person and their expectations that the treatment will be helpful are likely key factors that predict a reduction in symptoms. Therapists must have positive regard, genuineness, and empathy towards patients to facilitate the patients’ confidence in the therapist as a person. And therapists must provide a clear rationale for the treatment and develop a collaborative understanding with patients on how therapy will be done (agreement on the tasks) and what the desired outcomes will be (agreement on the goals).

Norcross, J. C., & Wampold, B. E. (2019). Relationships and responsiveness in the psychological treatment of trauma: The tragedy of the APA Clinical Practice Guideline. Psychotherapy, 56(3), 391-399.

The American Psychological Association’s (APA) Clinical Practice Guideline for Posttraumatic Stress Disorder in Adults published in 2017 was met with a great deal of concern and criticism by the community of scholars and practitioners working with patients with PTSD. A key concern was that the APA used a biomedical model and not a psychological or contextual model in guiding their understanding of PTSD, their approach to what constitutes evidence, and to decisions about recommended treatments. In particular, the biomedical approach focuses almost exclusively on treatment methods, and down-plays the context of treatment (i.e., the relationship, patient factors, and therapist responsiveness). In this critique, Norcross and Wampold highlight the flaws in the APA Clinical Practice Guideline for PTSD, and the authors focus specifically on those variables that are known to predict patient outcomes but that were ignored by the Guideline. Norcross and Wampold highlighted that there exists numerous meta analyses that demonstrate that all bona fide psychotherapies work about equally well for trauma, and that the particular treatment method has little impact on PTSD outcomes. Yet, the restrictive review process undertaken by APA all but ignored this well-established finding. Also ignored was the research on the importance of the therapeutic relationship in the treatment of trauma. One review outlined nineteen studies that found that the therapeutic alliance was associated with or predicted reduction in PTSD symptoms. This is consistent with the general psychotherapy research literature, in which the alliance is the most researched and most reliable factor related to patient outcomes. Also missing from the PTSD Guideline was reference to a large body of research on therapist responsiveness to patient characteristics. Patients are more likely to improve if their therapists can adapt to the patient’s coping style, culture, preferences, level of resistance, and stage of change. In one study of cognitive-processing therapy (CPT; a treatment recommended by the APA Guideline), there were substantial differences between therapists in their patient’s PTSD symptom outcomes. That is, some therapists reliably were more effective than others, even though all therapists were trained in and supervised in providing the same manualized evidence-based treatment. Among the identified skills of the most effective CPT therapists were: a flexible interpersonal style, and an ability to develop and maintain a good therapeutic alliance across patients.

Practice Implications

There is growing consensus that the APA Clinical Practice Guideline for PTSD are based on dubious methodology and are of limited use to therapists and their patients with PTSD. Psychotherapists should practice a bona-fide therapy for PTSD, but should do so by taking into account the treatment context. In other words, more effective therapists are good at developing, maintaining, and repairing the therapeutic alliance across a range of patients. Effective therapists can also respond and adapt to patient characteristics such as level of resistance, coping style, culture, and stage of change. And so, even when providing a treatment based on the APA Guideline, therapists should nurture trust in the therapeutic relationship and be adaptive to their patients’ characteristics.

Cuijpers, P., Driessen, E., Hollon, S. D., van Oppen, P., Barth, J., & Andersson, G. (2012). The efficacy of non-directive supportive therapy for adult depression: a meta-analysis. Clinical psychology review, 32(4), 280-291.

The research evidence indicates that there is very little difference between different types of psychotherapy (CBT, IPT, PDT, EFT, and others) in patient outcomes, especially for depression. Nondirective supportive treatment (NDST) also shows positive outcomes for various disorders. NDST is often used as a “placebo” condition in psychotherapy trials to control for common or non-specific factors. Common factors refer to those aspects that are common to all therapies, but that are not specific to any one therapy (e.g., therapist interpersonal skills, therapeutic alliance, client expectations). NDST does not involve specific therapeutic interventions like cognitive restructuring, transference interpretations, two-chair techniques, etc. In this meta analysis, Cuijpers and colleagues assessed those randomized controlled trials for depression in which specific treatments (e.g., CBT, PDT, IPT, EFT) or no treatment control conditions were directly compared to NDST. By doing so, the authors were able to estimate how much of patient outcomes were attributable to: specific effects of treatments (the difference between a specific intervention and NDST), common effects of treatment (the difference between NDST and no treatment), and extra-therapeutic factors (the effects of no treatment). The meta analysis included 31 studies with over 2500 patients with depression. Twenty-one comparisons included CBT, and the rest included IPT, PDT, or EFT. NDST was significantly less effective than other specific therapies (e.g., CBT, IPT, PDT, or EFT) at post-treatments g = −0.20 (95% CI: −0.32 to −0.08), but the effect was quite small. The difference between NDST and CBT alone (the most researched treatment type) was not statistically significant. Interestingly, when the authors controlled for researcher allegiance (an indication of which treatment was preferred by the researcher), the superior effects of specific treatments over NDST disappeared. NDST was significantly more effective than no-treatment, and the effect was moderate, g=0.58 (95% CI: 0.45–0.72). Pre- to post-treatment change in symptoms in the control condition was statistically significant, g = 0.39 (95% CI: 0.03–0.74), indicating the positive effects of extra-therapeutic factors on depressive symptoms (e.g., events in the patient’s life not related to therapy). Overall, the authors were able to estimate that almost 50% of patient outcomes could be attributed to common factors (therapist interpersonal skills, therapeutic alliance, client expectations, etc.), about 17% was due to specific therapy techniques (cognitive restructuring, two chair techniques, IPT interventions), and about 33% was due to extra-therapeutic factors (e.g., the natural course of depressive symptoms or other events in the patient’s life).

Practical Implications

Factors like therapist interpersonal skills and managing the therapeutic relationship appear to account for most (50%) of why patients with depression get better. The specific interventions based on therapy models like CBT account for relatively less of patient outcomes (17%). The natural course of the disorder and other events in patients’ lives account for about a third of patient improvement. Therapists can learn how to maximize the effects of common factor skills through deliberate practice and training to identify and repair alliance ruptures to help their patients get better.

Grenon, R., Schwartze, D., Hammond, N., Ivanova, I., Mcquaid, N., Proulx, G., & Tasca, G. A. (2017). Group psychotherapy for eating disorders: A meta-analysis. International Journal of Eating Disorders. DOI: 10.1002/eat.22744

Group therapy has an evidence base indicating its efficacy for many disorders. Groups represent a social microcosm in which interpersonal factors that underlie psychological distress and symptoms can be effectively addressed. Group therapeutic factors include peer interpersonal feedback, social learning, emotional expression, and group cohesion. Theories of eating disorder symptoms include interpersonal problems and affect dysregulation as maintenance factors. Many treatment guidelines indicate that individual and group CBT are the treatments of choice for eating disorders. However, there are no meta analyses that specifically look at the efficacy of group therapy for eating disorders. In this study, Grenon and colleagues assess if: (a) group psychotherapy for eating disorders is efficacious compared to wait-list controls, (b) group therapy is effective compared to other active treatments (self help, individual therapy, medications), and (c) group CBT is more effective than other types of group therapy (group interpersonal therapy [GIPT], group psychodynamic-interpersonal psychotherapy [GPIP], or group dialectical behavior therapy [GDBT]). The authors reviewed 27 randomized controlled trials with over 1800 patients that provided direct comparisons of group therapy for eating disorders. The mean drop out rate from group therapy was 16.47% (SD = 13.46), which is similar to what is reported for psychotherapy trials in general. Group therapy was significantly more effective than wait list controls in achieving abstinence from binge eating and purging (RR = 5.51, 95% CI: 3.73, 8.12), decreasing the frequency of binge eating and/or purging (g = 0.70, 95% CI: 0.51, 0.90), and reducing related psychopathology (g = 0.49, 95% CI: 0.32, 0.66). Group psychotherapy had an overall rate of abstinence from binge eating of 51.38%, while wait-list control conditions had an overall abstinence rate of 6.51%. Similar findings were achieved a follow-ups. The effects of group psychotherapy and other active treatments (e.g., behavioral weight loss, self-help, individual psychotherapy) did not differ on any outcome at post-treatment or at follow-ups. Group CBT and other forms of group psychotherapy did not differ significantly on outcomes at any time point.

Practice Implications

The results add to a growing body of research that indicates that group psychotherapy is as effective as other treatments, including individual therapy, to treat mental disorders. Despite the fact that practice guidelines indicate that CBT is the treatment of choice for eating disorders, this meta analysis did not provide evidence that group CBT was more effective than other types of group treatments. Clinicians considering group interventions for eating disorders or other mental health problems will do well to make use of group therapeutic factors like interpersonal learning, peer feedback, emotional expression, and group cohesion to improve patient outcomes.

Palpacuer, C., Gallet, L., Drapier, D., Reymann, J-M., Falissard, B., & Naudet, Florian (2016). Specific and non-specific effects of psychotherapeutic interventions for depression: Results from a meta-analysis of 84 studies. Journal of Psychiatric Research.

Specific effect in psychotherapy refer to those technical interventions that are based on a treatment model that are specific to a particular modality. For example, the effects on symptoms caused by transference interpretations, cognitive restructuring, or exposure might all be considered specific effects. Non-specific effects is a very broad term that sometimes refers to effects on symptoms caused by common factors across all psychotherapies like therapist empathy, therapeutic alliance, or positive regard. Non-specific effects has also been used to refer to any extra-therapeutic effects that are more peripherally related to treatments, like type of control groups used in a study, researcher allegiance, number of treatment sessions, or length of follow-up. In this meta-analysis of 84 studies of over 6000 participants, Palpacuer and colleagues examined the association between non-specific factors (defined as intervention format [group or individual], client demographics, number of treatment sessions, length of follow up, and researcher allegiance to one of the treatment modalities) and treatment outcomes for depression. First, they looked at whether the specific type of intervention (cognitive behavioral, psychodynamic, interpersonal, problem solving, and others) was associated with reductions in depressive symptoms. Second, they assessed if the non-specific factors added to the prediction of improved depressive symptoms and accounted for some of the effects of specific types of interventions. Similar to previous findings, all psychotherapies were significantly more effective than waiting-list controls. However, the effects of the specific intervention approaches became non-significant when the non-specific factors were included in the analysis. That is, non-specific factors seemed to account for some of the effects of the specific treatments. In particular, if the study was conducted in North America vs Europe (β = 0.55, 95% CI: 0.22; 0.90), if the researcher had an allegiance to a particular therapeutic approach (β = 0.29, 95% CI: 0.07; 0.52), or if the number of sessions was higher (β = 0.03, 95% CI: 0.01; 0.04) then depressive outcomes were better.

Practice Implications

This meta analysis of over 87 studies suggests that although various psychotherapies are effective, there remain questions about how and why they work. For example, the findings suggest that North American patients may have different expectations and higher responses to treatment, that a researcher's belief in the effectiveness of their favored intervention actually improves patients' outcomes, and that a higher number of sessions may also result in better outcomes. These factors appear to account for an important proportion of the specific effects of each type of psychotherapy.