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.

May 2019

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.

Practice Implications

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.

Author email: robert.elliott@strath.ac.uk
Positive Regard and Psychotherapy Outcome

Farber, B. A., Suzuki, J. Y., & Lynch, D. A. (2018). Positive regard and psychotherapy outcome: A meta-analytic review. Psychotherapy, 55(4), 411-423.

A concept similar to therapist empathy is the notion of therapist unconditional positive regard. Carl Rogers argued that the three factors of positive regard, empathy, and genuineness were the necessary and sufficient conditions for therapeutic change. Rogers’ pioneering work paved the way for the view that the relationship in psychotherapy was the critical factor in determining clients’ positive outcomes. Rogers defined unconditional positive regard as: the extent to which the therapist finds him- or herself experiencing a warm acceptance of each aspect of the client’s experience. It means caring for and prizing the client as a separate person. Other similar terms include: acceptance, non-possessive warmth, and therapist affirmation. Whereas empathy involves immersing oneself in the client’s internal frame of reference in order to truly understand the client’s experience, positive regard refers to unconditional acceptance of the attitudes held by the client and an expression by the therapist of the client’s inherent worthiness as a person. Often, empathy and positive regard go hand in hand, but not always. It is possible to empathize with a client’s pain (loss of a loved one), but not be accepting of aspects of the client’s behavior (coldness toward and disengagement from others). In this meta-analysis, Farber and colleagues reviewed 64 studies comprising 3,528 participants. The aggregated effect size of the association between positive regard and outcomes was small, g = .36, but statistically significant (95% CI: 0.28, 0.44). One of the key moderators of this association was severity of client psychopathology, such that positive regard had a significantly greater effect for clients with lower severity of psychopathology.

Practice Implications

The authors concluded that affirming clients may serve many important functions. Positive regard may strengthen a client’s sense of self and agency, and the belief in their ability to engage in a positive relationship. Positive regard likely reinforces clients’ engagement in therapy, increases self-disclosures, and facilitates the therapeutic alliance. Unconditional positive regard requires therapists to express positive feelings and attitudes to clients. This means communicating a caring, respectful positive attitude that affirms a client’s sense of self worth.

Author email: farber@tc.edu

April 2019

Therapeutic Alliance Rupture Repair

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
Goal Consensus and Collaboration in Psychotherapy

Tryon, G. S., Birch, S. E., & Verkuilen, J. (2018). Meta-analyses of the relation of goal consensus and collaboration to psychotherapy outcome. Psychotherapy, 55(4), 372-383.

A key element of the therapeutic alliance is for therapists and clients to collaboratively come to a consensus about what they will work on. Goal consensus is part of the agreement between therapist and client, and in part it defines what will be the tasks of therapy. The tasks of therapy (i.e., what a therapist and client do in therapy to alleviate the problems or address issues) follow from the goals and conceptualization of the problems. At times goal consensus is straight forward. The client wants to feel less depressed and the therapist proposes certain therapeutic actions to help the client to be relieved of their depressive symptoms. However at other times, despite an agreement on the main symptoms, the client may not agree with a therapist’s conceptualization and tasks of therapy. For example, a therapist might believe that the client’s history of abuse and/or their current problem with alcohol may underlie the depression, but the client does not want to address these underlying issues. In such an example, the therapist and client only barely agree on a goal, and may not agree on how to go about alleviating the symptoms. In some cases there is outright disagreement, a misunderstanding, or vagueness about the goals, and so there is no consensus and therefore no basis for a collaboration. Collaboration and goal consensus are pan-theoretical processes that apply to all forms of therapy. However, research in the past decade has focused almost exclusively on behavioral or cognitive therapy studies using homework compliance as the index of collaboration. Tyron and colleagues conducted a meta-analysis of 54 studies of the association between goal consensus and client outcomes and found a moderate and significant correlation, r = .24 with 95% CI [.19, .28]. They also reported similar findings from a meta-analysis of 53 studies of therapist and client goal collaboration and client outcomes, in which they found a moderate and significant effect, r = .29, 95% CI [.24, .34].

Practice Implications

These meta-analyses show a positive link between goal consensus and collaboration with psychotherapy outcomes. Therapists should clarify clients’ goals for therapy, and therapists should share their conceptualization of the clients’ issues or symptoms. This conceptualization will determine to some extent the tasks or methods of therapy. For some clients, this process may take time and require revisiting throughout the course of treatment. Collaborative work to establish the goals and focus of therapy may in and of itself be therapeutic for those clients who have long standing interpersonal problems. Therapists should seek input from clients about the formulation and treatment plans, and be prepared to adjust their intentions according to client preferences. Therapists could invite continuous client feedback about the goals and tasks of therapy and monitor client progress. Then therapists can use this feedback to modify their interpersonal stances and treatment methods.

Author email: gtryon@gc.cuny.edu

March 2019

Cohesion in Group Psychotherapy

Burlingame, G. M., McClendon, D. T., & Yang, C. (2018). Cohesion in group therapy: A meta-analysis. Psychotherapy, 55, 384-398.

Many writers consider group cohesion to be one of the most important concepts in group psychotherapy and that is a pre-requisite for positive patient outcomes. That is, patients in a group must feel a bond with the group and its members, must value the relationships in the group, and must see the group experience as a vehicle by which to achieve the change that they want. As Burlingame once noted, over time cohesion has become synonymous with the therapeutic relationship in group therapy. Although an important concept, cohesion has been elusive to define partly because of the complexity of group therapy itself. From the patient’s point of view, relationships in group therapy can take on three structural aspects in the form of member to member, member to group, and member to leader interactions. And so, cohesion may refer to the quality of the member’s relationship: to other members, to the group as a whole, and/or to the group leader. By “quality of group relationships”, clinicians and researchers often mean the positive affective bond (warmth, empathy, attraction, compatibility, trust) and working relationship (consensus on tasks and goals, willingness to work) that members have with other members, the group as a whole, and/or the group leaders. In this meta-analysis, Burlingame and colleagues identified 55 group therapy studies including over 6,000 patients that investigated the cohesion – outcome relationship. The average correlation of cohesion to patient outcomes in the 55 studies was statistically significant, r = .26 (95% CI [.20, .31], p = .01), suggesting a moderate effect. Leaders who had an interpersonal orientation had the highest cohesion – outcome relationship (r = .48), although leaders of other theoretical orientations also posted statistically significant but lower values. A greater group process orientation (r = .36), emphasizing greater interactions among group members (r = .36), composing groups of members with similar diagnoses or problems (r = .23), and groups lasting more than 20 sessions (r = .41) also each produced significantly higher cohesion – outcome correlations.

Practice Implications

The group cohesion – outcome relationship is highly reliable and suggests that clinicians of all theoretical orientations should routinely assess and enhance group cohesion to improve patient outcomes. Ways of increasing cohesion include emphasizing member to member interactions in a group, and discussing group processes as they occur. These processes may be related to members interacting with other members, with the group as a whole, or with the leader. In particular, group therapists should promote a positive emotional climate by handling conflict and avoidance when it arises in the group. This takes particular skills, training, and knowledge in group therapy processes, and so it is important for therapists to be aware of current practice guidelines for group therapy.

Author email: gary_burlingame@byu.edu
Psychological and Pharmacological Treatments for Generalized Anxiety Disorder

Carl, E., Witcraft, S.M., Kauffman, B.Y., Gillespie, E.M., Becker, E.S…. Powers, M.B. (2019). Psychological and pharmacological treatments for generalized anxiety disorder (GAD): a meta-analysis of randomized controlled trials. Cognitive Behaviour Therapy, DOI:10.1080/16506073.2018.1560358

Generalized anxiety disorder (GAD) is characterized by excessive and difficult to control worry about events or activities. GAD is associated with a high level of impairment in social functioning, work productivity, and health-related quality of life. GAD is also associated with a high level of medical costs and health care utilization. About 4.3% of the general population have experienced GAD at one time in their life. In this updated meta-analysis, Carl and colleagues reviewed the empirical literature to compare the effects of psychotherapies and pharmacotherapy to control conditions. Seventy-nine studies with over 11,000 participants were included in the review. In 39 comparisons, evidence-based psychotherapies outperformed control conditions on measures of anxiety at posttreatment (g = 0.76, 95% CI: 0.61–0.91, p < 0.001), suggesting a medium to large effect. Only 12 studies evaluated follow-up data, and they found that psychotherapy resulted in a small but statistically significant average effect on anxiety symptoms (g = 0.27, 95% CI: 0.00–0.53, p = 0.05). Compared to older patients, younger patients tended to do better in psychotherapy. Forty-three studies found that pharmacotherapy consistently outperformed control conditions at post-treatment (g = 0.38, 95% CI: 0.30–0.47, p < 0.001) suggesting a small effect. There were no studies that assessed pharmacotherapy at a follow-up date. Patient age or treatment dose did not affect outcomes of pharmacotherapy. The authors were careful to point out that that the effect sizes of psychotherapy and pharmacotherapy were not comparable in this meta-analysis because psychotherapy trials tended to use no-treatment controls whereas pharmacotherapy trials tended to use placebo controls, and the latter tends to produce more conservative (smaller) estimates of effects.

Practice Implications

Both psychotherapy and pharmacotherapy appear to be effective by post-treatment for patients with GAD. The effects of psychotherapy at follow-up is diminished, and no studies evaluated whether patients receiving pharmacotherapy maintained any gains at follow-up. Research has suggested that compared to psychotherapy, pharmacotherapy outcomes for depression at follow up is poorer. Although this study does not allow one to compare psychotherapy to pharmacotherapy, evidence from another meta-analysis suggests that patients would strongly prefer psychotherapy if given the choice. And patients receiving their preferred treatment tend to experience significantly better outcomes.

Author email: emilycarl@utexas.edu

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May 2019

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April 2019

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March 2019

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