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Eubanks, C. F., Muran, J. C., & Safran, J. D. (2018). Alliance rupture repair: A meta-analysis. Psychotherapy, 55(4), 508-519.

It is difficult to over-state the importance of developing and maintaining a therapeutic alliance in order for patients to experience a good outcome from psychotherapy. The alliance is the collaborative agreement between therapist and patient on the tasks and goals of therapy, and the emotional bond between therapist and patient. A previous meta-analysis found a moderate but highly reliable association between a good alliance and patient outcomes. The alliance is a trans theoretical construct – that is, it is important to all types of therapy regardless of theoretical orientation. Sometimes deteriorations in the alliance occur manifested by a disagreement on the goals, a lack of collaboration on the tasks, or a strain in the relational bond. Other terms for this phenomenon include weakenings, misattunements, challenges, resistances, enactments, and impasses. Such deteriorations can vary from minor tensions to major ruptures in the relationship. Tensions and ruptures in the alliance are common occurrences in therapy with some studies showing 50% of therapy cases experience at least a minor tension within the first six sessions of therapy. There are two main types of alliance tensions/ruptures. (1) Withdrawal tensions/ruptures occur when the patient moves away from the therapist, such as when the patient changes the subject, goes silent, and cancels appointments. These tensions/ruptures are more subtle and harder for therapists to detect. (2) Confrontation tensions/ruptures occur when the patient moves against the therapist, such as when the patient expresses dissatisfaction with or pressures or tries to control the therapist. These tensions/ruptures are more obvious, but also difficult for therapists to manage because of the feelings they evoke. In this meta-analysis, Eubanks and colleagues reviewed 11 studies representing 1,314 patients. They found that the association between rupture repair episodes and patient outcomes was on average moderately large r = .29, d = .62, 95% CI [.10, .47], p = .003.

Practice Implications

The research on alliance tensions/ruptures and repairs is still new but points to some important therapist practices that could improve patient outcomes. Therapists must be attuned to indications of tensions and ruptures in the therapeutic relationship. Therapists immediately need to attend to confrontation tensions/ruptures, in which patients express dissatisfaction or hostility. Similarly, therapists must address more subtle withdrawal tensions/ruptures, in which patients go silent, evade, or appease. Therapists can acknowledge the tension/rupture directly and nondefensively by inviting patients to explore their experience of the rupture. If necessary, therapists might change the tasks or goals of the therapy to better match the patient’s concerns. Therapists should empathize with a patient’s negative feelings about the therapy, and validate the patient for bringing up their concerns. If appropriate, therapists should take responsibility for their part in the tension/rupture and not blame the patient. Also, if the tension/rupture is a repetition of an interpersonal pattern for the patient (e.g., the patient tends to withdraw in relationships), then the therapist might consider carefully exploring the tension/rupture as it occurs in the therapy with the understanding that it is a repetitive pattern. Mainly, therapists need to anticipate that tensions and ruptures will occur in therapy, that they can be destabilizing for the therapist and therapeutic relationship, and so therapists need to recognize and know how to explore their own and their patient’s negative feelings.

Author email: catherine.eubanks@einstein.yu.edu

Beutler, L.E., Kimpara, S., Edwards, C.J., & Miller, K.D. (2018). Fitting psychotherapy to patient coping style: A meta‐analysis. Journal of Clinical Psychology, 74, 1980 – 1995.

This is another in a series of meta-analyses that assess client factors and their impact on outcomes. Researchers have been studying the impact of coping style in a number of different areas in social and clinical psychology for decades. Coping styles refers to characteristic ways of behaving in order to reduce discomfort and to adapt to changing circumstances. Everybody has preferred methods of coping, however when a coping style becomes extreme or rigid, then it can be pathological. Broadly speaking, researchers and clinicians categorize coping styles as internalizing or externalizing in nature and function. Those who primarily use internalizing coping tend to face change, distress, or threat by becoming internally focused, inner-blaming, inhibited, socially withdrawn, anxious, worrying, or working out issues by thinking them through. Those who primarily use externalizing coping tend to deal with stress by being externally focused, acting out, blaming others, confronting others, or using their social environment and support to manage their distress. Also, generally, one can define theories and practices of psychotherapy as those that are insight-oriented versus symptom-focused. Insight-oriented approaches emphasize that patients re-experience repressed emotions and develop self-understanding as a means of creating change. Symptom-focused approaches generally require patients to engage in new behaviors, new learning, or new perceptions followed and reinforced by social rewards. In this meta-analysis, Beutler and colleagues assess if patients with internalizing or externalizing coping styles achieve better outcomes if they received insight-oriented vs symptom-focused psychotherapy. That is, they assessed if patients matched to therapy focus based on their coping style might achieve better outcomes. They reviewed 18 studies including 57 types of treatment and almost 2,000 patients. Beutler and colleagues found that the mean therapy focus by coping style interaction was d = .60 for all studies (SE = 0.10; p < 0.001; CI 95% = 0.44–0.76). This suggests a medium to large effect in which matching therapy to coping style accounting for 23% of the variance in patient outcomes. Patients who use internalizing coping tend to do better in insight-oriented psychotherapy whereas those who use externalizing coping tend to do better in symptom-focused interventions.

Practice Implications

The results of this meta-analysis suggested that psychotherapists would do well to assess patients’ coping style during the intake assessment process and modify their treatments and interpersonal stances accordingly. Symptom-focused interventions, like those seen in behavioral or cognitive-behavioral therapies may work better for those with externalizing coping styles. On the other hand, insight or relationship-oriented interventions, like those seen in interpersonal or psychodynamic therapies, may be more apt for patients with internalizing coping styles. Despite this general rule, therapists should also be aware that client preferences, culture, and other transdiagnostic factors can effectively guide treatments and therapist stances.

Author email: larrybeutler@yahoo.com

Constantino, M. J., Vîslă, A., Coyne, A. E., & Boswell, J. F. (2018). A meta-analysis of the association between patients’ early treatment outcome expectation and their posttreatment outcomes. Psychotherapy, 55(4), 473-485.

A concept similar to but distinct from client preferences is client expectations of outcomes. One of the first writers to discuss the importance of client expectations was Jerome Frank who argued that clients enter therapy demoralized, and that for therapy to be effective it must mobilize the client’s belief that treatment will work. Frank felt that outcome expectation is key to the process of remoralization for the client. Outcome expectations refer to clients’ personal predictions about how they will respond to treatment. Generally, problems may be signalled by clients who feel hopeless about the potential effectiveness of the therapy or therapist. But it is also possible for expectations to be unrealistically high, never met, and therefore disappointing. Clients may form outcome expectations before they start therapy, or the expectations may be shaped by early experiences in the therapy or with the therapist. Outcome expectations may develop, in part, based on how credible the therapy seems to the client, and or whether the therapist or therapy are consistent with the client’s preferences. Also, research indicates that higher realistic expectations likely leads to an improved therapeutic alliance, mainly because it facilitates collaboration of the client with the therapist. In this meta-analysis, Constantino and colleagues evaluated 72 studies (81 samples) of over 12,000 adult clients in which early outcome expectations were assessed and correlated with client outcomes at post-treatment. The overall effect of the meta-analysis was r = .18 (95% CI [.14, .22]), indicating a small, but statistically significant, positive effect. There were a few moderators of this relationship. The expectation – outcome correlation was larger for younger clients, and for therapies that used a treatment manual. Client diagnosis, treatment orientation, or treatment modality did not affect the correlation.

Practice Implications

Increasing a client’s expectation of a good outcome likely raises their hopes and goes some ways toward remoralizing the client. Therapists can assess their client’s outcome expectations early in therapy with a validated measure, and invite a discussion of these expectations. It may be useful to be aware of studies reviewed in the PPRNet blog, and to review with clients in a non-technical way the evidence for psychotherapy’s effectiveness. Although one should be inspiring about the potential outcomes of therapy for a client, therapists should not promise an unrealistic degree or speed of change. Therapists should express realistic confidence and competence in the psychotherapy that they are about to provide.

Author email: mconstantino@psych.umass.edu

Morales, K., Keum, B. T., Kivlighan, D. M., Jr., Hill, C. E., & Gelso, C. J. (2018). Therapist effects due to client racial/ethnic status when examining linear growth for client- and therapist-rated working alliance and real relationship. Psychotherapy, 55(1), 9-19.

Racial and ethnic minority (REM) clients tend to have less access to health care services, are less likely to seek services for mental illness, and may receive lower quality care. It is also possible that REM clients may be treated differently by psychotherapists, so that REM clients may have a different experience from non-REM clients of the therapeutic alliance (i.e., the collaborative agreement on tasks and goals of therapy, and the bond with the therapist). The alliance is a well-known factor that is related to client outcomes. If there is such a difference in how REM and non-REM clients experience the alliance, it is likely because of the therapist’s ability to establish and grow the alliance. Previous research showed that therapists and not clients are largely responsible for the alliance – outcome association. Research also demonstrated that some therapists are less effective with REM than with non-REM clients, possibly because of the differing experiences of and development of the therapeutic alliance. In this study, Morales and colleagues measured the therapeutic alliance after every session of therapy for 144 clients seen in a counselling center, almost half of whom were REM clients. The clients saw one of 19 therapists, so that each therapist (10 of whom were REM therapists) saw at least two REM and two non-REM clients. So, the researchers were able to see how each therapist developed a therapeutic alliance differently with REM and non-REM clients. The study found that higher therapeutic alliance between therapists and clients early in therapy was associated with clients remaining in therapy longer, and that the therapeutic alliance statistically significantly increased across sessions. However, therapists varied significantly in the alliance growth depending on whether they were treating REM or non-REM clients. Some therapists showed significant growth in the alliance with REM clients but not with non-REM clients, whereas other therapists showed significant growth in the alliance with non-REM but not with REM clients.

Practice Implications

There were significant differences between therapists in how they were able to develop a therapeutic alliance with racial and ethnic minority (REM) clients vs non-REM clients. The authors speculated that this difference might be due to the therapists’ level of multicultural orientation. A multicultural orientation is a way of being with clients that consists of cultural humility, using opportunities to examine culture, and cultural comfort. Having a multicultural orientation likely increases the level of therapeutic alliance and promotes its growth over time. Research shows that a client benefits when the therapist integrates the client’s cultural narrative into the psychotherapy.

Author email: kmorales@umd.edu

Simpson, S., Simionato, G., Smout, M., van Vresswijk, M.F., Hayes, C., Sougleris, C., & Reid, C. (2018). Burnout amongst clinical and counselling psychologist: The role of early maladaptive schemas and coping modes as vulnerability factors. Clinical Psychology and Psychotherapy, Online first DOI: 10.1002/cpp.2328.

Burnout in health professionals has become a global problem, with between 21% and 67% of mental health professionals reporting high levels. Researchers define burnout as including three components: emotional exhaustion (feeling emotionally exhausted from the work), depersonalization (feeling disconnected from patients), and reduced personal accomplishment in one’s work. Burnout is related to reduced capacity to perform professionally and to provide adequate care to patients. Much of the research has focused on institutional and workload factors as causes of burnout in health professionals. However, interpersonal factors like therapists’ early maladaptive schemas and coping mechanisms may also increase vulnerability to burnout. Early maladaptive schemas are self-defeating core beliefs and patterns that are repeated throughout one’s life and that have their origin in early life experiences. Maladaptive coping are thoughts and behaviors that one repeatedly engages in an unconscious or automatic way to minimize the activation of early maladaptive schemas. Maladaptive coping might include detachment, self-aggrandizement, attacking others, or over-compliance. In this study, Simpson and colleagues surveyed 443 clinical or counseling psychologists in Australia to assess if in fact early maladaptive schemas and maladaptive coping predicted burnout over and above job demands like workload. The mean age of the psychologists was 42.93 years (SD = 11.53), most were women (80.4%), who were married (52.8%), had attained a Masters degree (45.6%), and worked either in outpatient mental health centres (39.7%) or in private practice (33%). Most of the therapists (67%) indicated that over 50% of their client work involved trauma. Of the sample, 49.7% indicated at least a moderately high level of burnout on a standardized questionnaire, with emotional exhaustion as the highest type of burnout. The most common early maladaptive schemas among the psychologists were unrelenting standards and self-sacrifice. Detached coping was the most common coping mode. In terms of predicting burnout, job demands accounted for 10% of the variance in burnout, early maladaptive schemas accounted for an additional 18% of the variance in burnout over and above job demands, and maladaptive coping accounted for an additional 6% beyond maladaptive schemas and job demands.

Practice Implications

Work – life balance, managing clients with chronic and complex issues, and working with clients who experienced trauma can cause distress in mental health providers. Psychologists’ early maladaptive schemas like unrelenting standards and self-sacrifice in addition to maladaptive detached coping may represent the foundation of countertransference for some psychotherapists. These were significant predictors of therapist emotional exhaustion over and above workload. Psychotherapists would benefit from an increased awareness of their own early maladaptive schemas and coping mechanisms. Self-care, including professional development, consultations, peer support groups, and personal therapy throughout one’s career could reduce one’s susceptibility to burnout.

Laverdière, O., Kealy, D., Ogrodniczuk, J. S., & Morin, A. J. S. (2018). Psychological health profiles of Canadian psychotherapists: A wake up call on psychotherapists’ mental health. Canadian Psychology/Psychologie canadienne, 59(4), 315-322.

Patients prefer to work with psychotherapists whom they perceive as psychologically healthy and satisfied with their lives. Psychological health and satisfaction in therapists may be related to their ability to manage their own reactions to clients (countertransference), as well as to their ability to maintain personal and psychological well-being. However, the work circumstances on psychotherapists may compromise their psychological health. Patients often present in ways that may result in emotional reactions in therapists, such as self-doubt and frustration. Also, therapists may develop vicarious or secondary traumatic stress when exposed to patients with a history of trauma. Such emotional stressors may overwhelm therapists and contribute to burnout, distress, and lower quality of life. Previous research found that difficulties in therapist mental health may lead to emotional disengagement, patient early termination, and a lowered therapeutic alliance. Large-scale international surveys indicate that 87% of psychotherapists were involved in psychotherapy at some point in their careers. This suggests that many psychotherapists understand or have experienced the hazards of their work. In this survey of registered Canadian psychotherapists, Laverdière and colleagues were interested in the self-reported psychological health of psychotherapists. The sample included 240 psychotherapists who were mostly women (78%) and psychologists (84%), with a mean age of 42 years (SD = 11.66), practicing psychotherapy for an average of 13 years (SD = 9.42), and working primarily in independent practice (40%) or in an institutional setting (40%). Most identified their primary theoretical orientation as psychodynamic (31%), CBT (31%), integrative (22%), or humanistic (15%). Using a standardized measure of burnout, the authors found that 22% of psychotherapists were experiencing high levels of emotional exhaustion (with a further 20% in the moderate range), and 12% experienced a high level of depersonalization. Only 8% could be classified as having probable serious mental health issues and life dissatisfaction. The authors then developed statistical profiles of psychotherapists using latent class analysis. Using these profiles, 35% of psychotherapists were characterized by moderately high levels of burnout and distress and moderately low quality of life. A further 12% of psychotherapists had very high levels of burnout and distress and very low quality of life. Those with healthier profiles tended to be more experienced (B = .14, p = .008, OR = 1.15) and to have lower perceived workload (B = -1.10, p = .006, OR = .33).

Practice Implications

One in five psychotherapists in this survey were experiencing high levels of emotional exhaustion, and another 20% were in the moderately high range. Emotionally exhausted professionals are at higher risk of making errors, depersonalizing patients, and becoming emotionally exhausted. Psychotherapists at higher risk would benefit from organizational and therapeutic interventions. Peer support groups may help to alleviate some of the distress, as would regular consultation and supervision that partly focuses on countertransference and managing the stress of working with traumatized patients. Psychotherapists need to be aware of the risks involved in having a high workload, which is a well-known risk factor for poor mental health at work. On the positive side, greater experience as a psychotherapist may be a protective factor. Experience may bring with it more self-confidence, greater emotion regulation skills, and a better ability to manage countertransference.