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.
…I blog about psychotherapy for borderline personality disorder, capacity to metnalize and therapy resistant depression, and negative effects of psychotherapy
Type of Research
- ALL Topics (clear)
- Alliance and Therapeutic Relationship
- Anxiety Disorders
- Attendance, Attrition, and Drop-Out
- Client Factors
- Client Preferences
- Cognitive Therapy (CT) and Cognitive-Behavioural Therapy (CBT)
- Combination Therapy
- Common Factors
- Depression and Depressive Symptoms
- Efficacy of Treatments
- Feedback and Progress Monitoring
- Group Psychotherapy
- Illness and Medical Comorbidities
- Interpersonal Psychotherapy (IPT)
- Long-term Outcomes
- Neuroscience and Brain
- Outcomes and Deterioration
- Personality Disorders
- Placebo Effect
- Practice-Based Research and Practice Research Networks
- Psychodynamic Therapy (PDT)
- Resistance and Reactance
- Self-Reflection and Awareness
- Suicide and Crisis Intervention
- Therapist Factors
- Transference and Countertransference
- Trauma and/or PTSD
- Treatment Length and Frequency
Emotional Experiences of Psychotherapists
Chui, H., & Liu, F. (2021). Emotional experience of psychotherapists: A latent profile analysis. Psychotherapy, 58(3), 401–413.
Working with client emotional experiences in therapy is a core aspect of the psychotherapist’s work, regardless of their theoretical orientation. And so, therapists’ performance and their own well-being may be impacted by their capacity to experience and regulate their own emotions. Emotional reactivity refers to one’s sensitivity, intensity, and duration of emotional experience. Emotion regulation refers to the capacity to manage and express emotions and may be considered an interpersonal competency for therapists. Such competency likely involves flexible expression of emotion and a capacity for empathy. A better understanding of how therapists experience emotions might inform therapists’ use of empathy to facilitate their work with clients. In this study, Chui and Liu surveyed 314 English speaking and 589 Chinese speaking psychotherapists and asked them about their experiences of emotional reactivity, their emotion regulation, and empathy. Their data allowed them to develop profiles of psychotherapists along dimensions of emotional experience. Three latent profiles emerged in both the English and Chinese speaking samples of therapists. The highest proportion of English-speaking therapists (58%) were categorized as “Calm Regulators”, which indicated therapists with low emotional reactivity and few problems with emotion regulation. Next, 34.4% of English-speaking therapists were characterized as “Moderate Experiencers”, and 7.6% were “Emotional Feelers”. The latter profile included therapists who were emotionally over-reactive and who had greatest difficulty with regulating their emotions. As one might expect, those with the Calm Regulator profile had higher capacity for perspective taking, higher empathic concern, and lower personal distress than therapists in the other profiles. Also, therapists who were older, with more education, female, and with a psychodynamic orientation were more likely to have the Calm Regulator profile. Results were remarkably similar in the Chinese speaking sample, in which Calm Regulators also reported higher levels of counsellor self-efficacy.
Therapists with the “Emotional Feelers” profile (i.e., that have higher levels of emotional reactivity and more difficulty regulating their emotions) may be at higher risk of burnout and of being less effective in their work. As a profession we often discuss clients’ individual differences in emotional experience and emotion regulation, but we spend less time considering these important interpersonal competencies in therapists. Recent surveys suggest that almost 50% of therapists may be at high risk of mental health problems. Psychotherapists, trainers, and supervisors need to pay more attention to therapists’ capacity to regulate their emotions, and its impact on their capacity to be emotionally flexible and empathic with clients. Therapists might consider personal therapy as a means of building this capacity.
Does Mindfulness Lead to Greater Empathy Among Psychotherapists?
Cooper, D., Yap, K., O’Brien, M. et al. (2020). Mindfulness and empathy among counseling and psychotherapy professionals: A systematic review and meta-analysis. Mindfulness, 11, 2243–2257.
Just about every theoretical model of psychotherapy recognizes that therapist empathy is a necessary and fundamental component of treatment. A meta-analysis showed that higher therapist empathy as rated by patients was a moderately strong predictor of outcomes. Despite its importance, training programs in counseling, clinical psychology, and psychotherapy have not found effective ways of increasing empathy among trainees. Some might argue that more mindful therapists might be more attentive and accepting of aversive emotions and therefore more open to entering a client’s world or experiences. Rogers defined empathy as the capacity to enter into the private perceptual world of the other, and it involves taking another’s perspective and being emotionally moved. Measures of empathy assess dimensions such as personal distress, empathic concern, fantasy, and perspective taking. Mindfulness, on the other hand is defined by some as an open and receptive attention and awareness to one’s own present experiences. The theory is that having this receptive mindful attitude is necessary to develop empathy for others. If this is the case, then mindfulness training might foster a greater empathic attitude among psychotherapists and trainees. In this study, Cooper and colleagues (2020) conducted a meta-analysis to examine the relationship between dimensions of mindfulness and empathy among psychotherapy trainees. They also looked at studies that examined if training in mindfulness was associated with greater empathy among trainees. The results from up to 10 studies showed that greater levels of mindfulness were associated with less personal distress, r = − .42, 95% CI [− .55, − .27], and greater perspective taking, r = .28, 95% CI [.15, .40]. However, there was no significant relationship between mindfulness and empathic concern or fantasy. When aggregating the findings of the six studies that examined the effect of mindfulness training on increasing trainee therapist empathy, there were no significant effects on any of the empathy scales.
This is not a well-developed research area because of the few studies and small sample sizes, and so results should be taken with a grain of salt. Meta-analyses clearly show that therapist empathy is important to patients and their outcomes. Higher levels of mindfulness were associated with greater perspective taking and lower personal distress. Mindfulness might help therapists to disengage from internal experiences and free up resources to be empathic to patients’ distress. However, the existing research does not support the use of mindfulness training to improve therapist empathy.
Therapist Empathy and Client Outcome
Elliott, R., Bohart, A. C., Watson, J. C., & Murphy, D. (2018). Therapist empathy and client outcome: An updated meta-analysis. Psychotherapy, 55(4), 399-410.
As early as the 1940s Carl Rogers spoke about the key role played by therapist empathy in determining client outcomes. Many clinical writers consider empathy as a therapist ability or trait that enables one to understand the other person’s feelings, perspectives, or motivations. Rogers defined empathy as the therapist’s sensitive ability and willingness to understand the client’s thoughts, feelings, and struggles from the client’s point of view. Three main modes of empathy include: rapport in which the therapist shows deliberate compassion for the client, communicative attunement in which the therapist stays attuned to the client’s moment to moment experience, and person empathy in which the therapist makes a sustained effort to understand the historical context of the client’s experience. There is recent neuroscience research showing specific brain processes at work when one automatically or unconsciously mirrors others’ experiences, when one deliberately tries to take an other’s perspective, and when one vicariously experiences others’ distress. Empathy is similar to unconditional positive regard, but empathy further involves the immersion of the therapist in the client’s experience. In this meta-analysis, Elliott and colleagues were particularly interested in the association between therapist empathy and client outcomes. The meta-analytic review included 82 independent samples and 6,138 clients. The overall study-level weighted correlation was medium-sized, r = .28 (95%CI: .22, .33), which is equivalent to a d = .58. In other words, therapist empathy accounted for approximately 9% of client outcome variance, which is similar to the effects of the therapeutic alliance and larger than the effects of specific treatment methods. Measuring therapist empathy by the client resulted in the largest association with outcomes, whereas measuring therapist empathy from the therapist’s perspective had the smallest association with outcomes. There were no differences between therapeutic approaches when it came to the empathy-outcome association.
Psychotherapists have known for decades that empathic attunement with a client’s internal experiences is a key factor to clients getting better. Effective therapists of any orientation understand their clients’ goals and tasks, their moment to moment experiences in session, and their unspoken nuances. This requires therapists to continually adjust their assumptions and understanding. Client outcomes depend to some extent on how well the therapist receives, listens, respects, attends to, and responds to what the client experiences in therapy. Regularly assessing and focusing on the client’s experience of therapist empathy (not the therapist’s assessment of their own empathy) is most useful to help therapists modify their interpersonal stances and improve their clients’ outcomes.
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Psychotherapy Relationships That Work: Becoming an Evidence-Based Therapist II
Norcross, J. C., & Lambert, M. J. (2018). Psychotherapy relationships that work III. Psychotherapy, 55(4), 303-315.
Relationship factors in psychotherapy are some of the most important predictors of patient outcomes. They outweigh factors like the type of therapy provided in determining whether patients get better after psychotherapy. In this second overview article, Norcross and Lambert provide a review of 17 meta-analyses of relationship factors in psychotherapy that contribute to positive outcomes. Like the review of patient factors also found in this blog and E-Newsletter, this article briefly outlines those evidence-based relationship factors that reliably predict patient outcomes in psychotherapy. The therapeutic relationship refers to how the therapist and patient relate to each other, or their interpersonal behaviors. By contrast, techniques or interventions refer to what is done by the therapist. Practice guidelines typically focus on interventions or therapeutic orientation. As the authors argue, what is missing from treatment guidelines are the person of the therapist and the therapeutic relationship – evidence for which is backed up by 5 decades of research. Even in studies of highly structured manualized psychotherapy for a specific disorder in which efforts were made to reduce the effect of individual therapist, up to 18% of outcomes (a moderate to large effect) could be attributed to the person of the therapist. By contrast somewhere between 0% and 10% of outcomes (a small to moderate effect) is attributable to specific treatment methods. So, which therapeutic relationship factors are reliably related to patient outcomes? These include: the therapeutic alliance in individual therapy (306 studies, g = .57) couple therapy (40 studies, g = .62), and adolescent psychotherapy (43 studies, g = .40), collaboration (53 studies, g = .61) and goal consensus (54 studies, g = .49), cohesion in group therapy (55 studies, g = .56), therapist empathy (82 studies, g = .58), collecting and delivering client feedback or progress monitoring (24 studies, g = .14 to .49), managing countertransference (9 studies, g = .84), and repairing therapeutic alliance ruptures (11 studies, g = .62) among others. Over the next few months, I will be reviewing these meta analyses in more detail to discuss how therapists can use this evidence base to improve their patients’ outcomes.
The research as a whole indicates that therapists should make the creation and cultivation of the therapeutic relationship a primary goal of therapy. Factors such as managing the therapeutic alliance, repairing alliance ruptures, engaging in ongoing progress monitoring, managing countertransference and others should be used to modify treatments and interpersonal stances in order to maximize outcomes. When seeking out professional development and training, practitioners should focus on evidence-based relationship factors (managing the alliance, judicious self disclosure, managing emotional expression, promoting credibility of the treatment, collecting formal feedback, managing countertransference) in addition to focusing on evidence-based treatments.
Therapist Reflective Functioning and Client Outcomes
Cologan, J., Schweiter, R.D., & Nolte, T. (2017). Therapist reflective functioning, therapist attachment style, and therapist effectiveness. Administration Policy and Mental Health, DOI: 10.1007/s10488-017-0790-5.
Differences between therapists account for about 8% of patient outcomes, which is a moderate effect and therefore an important factor. Constructs such as therapist personality characteristics and facilitative interpersonal skills may play a key role in how effective therapists can be with their clients. An important therapist quality might be reflective functioning, or mentalization. Reflective functioning refers to the ability to conceptualize, identify, and understand mental states in oneself and in others, and how mental states affect behaviour and functioning. For example, reflective functioning is the basis for predicting others’ behaviors, understanding social nuances and others’ intentions, and also one’s own behaviors and internal experiences. Fundamentally for a therapist, reflective functioning is necessary for empathy, which is a key therapeutic quality. Another key issue for therapists might be their own attachment security, or their characteristic ways of relating to others in interpersonal relationships. Securely attached therapists (those who have a positive view of self and others in relationships) may be able to develop a better therapeutic alliance with clients. Insecurely attached therapists (those who are avoidant in relationships or who are preoccupied in relationships), may struggle to a greater extent with developing and maintaining an alliance. In this study, Cologan and colleagues assessed reflective functioning and attachment security in 25 therapists from different theoretical orientations who treated 1001 adult clients who mostly had problems with depression or anxiety. Client outcomes were measured pre and post treatment. On average clients experienced a reduction in their symptoms after psychotherapy. Clients of therapists with higher levels of reflective functioning experienced better outcomes. Therapist attachment insecurity did not have a direct effect on client outcomes.
As with other studies, therapists in this study varied in their outcomes, so that some had better outcomes than others. Level of therapist reflective functioning (ability to mentalize) accounted for a large proportion of this difference. Therapists who had greater skills with understanding their own and clients’ behaviors in terms of mental states (intentions, motivations, psychological and emotional needs, internal conflicts) likely were better able to empathize and develop an alliance with their clients. These are skills that therapists can learn with practice, consultation, personal therapy, and training.
Client Honesty in Psychotherapy
Love, M. & Farber, B.A. (2018). Honesty in psychotherapy: Results of an online survey comparing high vs. low self-concealers, Psychotherapy Research, DOI: 10.1080/10503307.2017.1417652.
An important task of psychotherapy is for therapists to provide a context within which clients feel comfortable disclosing difficult feelings, thoughts, and other experiences in their lives. Self-disclosure likely improves the therapeutic alliance (agreeing on tasks and goals, and an emotional bond between therapist and client), which is necessary for good outcomes. In fact, research indicates that client self-disclosure is generally associated with positive outcomes in therapy. And yet a number of surveys report that clients keep secrets or lie to their therapists. Clients appear to struggle between being honest and self-disclosing versus the fear or anxiety related to doing so. Research indicates that one can describe individuals as high self-concealers in most relationships in their lives. Such individuals consistently conceal negative aspects of themselves from others to help manage their anxiety in relationships in the short term. However, in the long term, high levels of self-concealment increases rumination and anxiety and reduces coping. In this study, Love and Farber conducted an online survey of 572 participants who were currently in therapy or were in therapy in the past year. The sample characteristics and the type of therapy they received were surprisingly similar to a nationally representative sample of clients who seek treatment, though this online survey sample was somewhat younger. Over 84% of clients in this survey reported being dishonest about at least one topic with their therapist. Most frequent topics for being dishonest included: details of sex life (33.9%), suicidal thoughts (21.9%), self-harm (14.5%), real reactions to therapist comments (18.9%), whether therapy was helping (15.7%), and family secrets (16.3%). The most predominant motive for dishonesty was embarrassment or shame (63.6%), followed by doubts that the therapist would understand (27.0%), fear of overwhelming emotions (18.1%), and disappointing or hurting the therapist (16.4%). Not surprisingly, clients who tended to conceal their experiences reported disclosing less distressful information and also reported a lower therapeutic alliance with their therapists. Almost half of high self-concealers reported that dishonesty hurt their therapeutic progress.
Topics like suicidal ideation and sex are particularly difficult to speak about honestly in therapy, especially for those who are uncomfortable with disclosing in general. Most clients are willing to discuss difficult topics with therapists if the therapist inquires sensitively and directly. High self-concealers are highly attuned to how therapists might react, and these clients anticipate shame or judgement. Therapists need to monitor the state of the therapeutic relationship with each client, especially the client’s perception of therapist warmth and trustworthiness. This could include monitoring for any ruptures in the therapeutic alliance. Further, therapists may need to communicate that self-concealment serves a short term purpose to reduce anxiety, but has a long term cost in terms of amplifying distress.