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.
This month...
…I blog about psychotherapy for adult depression, efficacy of CBT for perfectionism, and a measure of ruptures in the therapeutic alliance.
Type of Research
Topics
- ALL Topics (clear)
- Adherance
- Alliance and Therapeutic Relationship
- Anxiety Disorders
- Attachment
- Attendance, Attrition, and Drop-Out
- Client Factors
- Client Preferences
- Cognitive Therapy (CT) and Cognitive-Behavioural Therapy (CBT)
- Combination Therapy
- Common Factors
- Cost-effectiveness
- Depression and Depressive Symptoms
- Efficacy of Treatments
- Empathy
- Feedback and Progress Monitoring
- Group Psychotherapy
- Illness and Medical Comorbidities
- Interpersonal Psychotherapy (IPT)
- Long-term Outcomes
- Medications/Pharmacotherapy
- Miscellaneous
- 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
- Termination
- Therapist Factors
- Training
- Transference and Countertransference
- Trauma and/or PTSD
- Treatment Length and Frequency
December 2023
Is empathic accuracy enough? The role of therapists’ interventions in the associations between empathic accuracy and session outcome.
Stolowicz-Melman, D., Lazarus, G., & Atzil-Slonim, D. (2023). Is empathic accuracy enough? The role of therapists’ interventions in the associations between empathic accuracy and session outcome. Journal of Counseling Psychology, 70(6), 682–690. https://doi.org/10.1037/cou0000708
Therapist empathy (as rated by patients) is a well-known predictor of positive patient outcomes in psychotherapy. Empathy can take many forms (empathic resonance, expressed empathy, received empathy), but one that is less well-researched is the therapist’s empathic accuracy. Empathic accuracy refers to the congruence (agreement) between a patient’s emotional state and the therapist’s perception of the patient’s emotional state. That is, therapists’ capacity to accurately perceive their patient’s inner experiences. In this study, Stolowicz-Melman and colleagues assessed therapist and patient congruence in therapists’ ratings of the patient’s emotional state during a session. The authors also looked at the impact of that congruence (or lack of congruence) on the patient’s ratings of the session’s effectiveness (session outcomes). In addition, the researchers examined whether different types of therapist interventions affected the impact of congruence (empathic accuracy) on a patient’s evaluation of a session. The authors hypothesized that more exploratory interventions (therapists identifying and labelling feelings, focusing on moment-to-moment client emotions) and fewer directive interventions (therapists setting an agenda, reviewing homework) would result in a stronger association between therapist empathic accuracy and session outcomes as rated by the patient. The study had 81 patients and 50 therapists. Patients and therapists rated the patient’s mood after each of at least 6 sessions of therapy. The congruence (agreement) between the patient's and therapist's rating of the client's mood was an index of therapist empathic accuracy. Clients also evaluated the effectiveness of each session of therapy. The results suggested that greater therapist empathic accuracy for negative emotions was associated with better session evaluations (outcomes) rated by patients. Exploratory, and not directive, interventions resulted in a stronger effect of therapist empathic accuracy for negative emotions on session evaluations.
Practice Implications
The results suggest that therapists need to recognize negative emotions in their patients, offer support and empathy, and at the same time help the patient explore and process these emotions. Empathic accuracy is not enough, however, when a patient is experiencing a negative emotion. Patients need therapists to help them recognize their experiences and to explore their meaning in words. As Stolowicz-Melman and colleagues conclude, therapist exploration of patients’ emotions may help patients tolerate and regulate painful feelings and achieve better session results.
November 2023
Therapist Qualities That Lead to Treatment Failure or Termination
Alfonsson, S., Fagernäs, S., Sjöstrand, G., & Tyrberg, M. J. (2023). Psychotherapist variables that may lead to treatment failure or termination—A qualitative analysis of patients’ perspectives. Psychotherapy. Advance online publication. https://doi.org/10.1037/pst0000503
Research indicates that about 14% of patients terminated psychotherapy because it did not help them, and 7% because they were not comfortable with their therapist. Psychotherapists have difficulty identifying when patients are at risk of terminating the treatment, and many therapists do not identify when a patient is getting worse. In other words, therapists may not be a good source of understanding when and why patients do not improve and leave therapy. When researchers ask therapists to speculate about why a patient terminated prematurely, the therapists often focus on patient-related factors and not therapist-related factors. In this study, Alfonsson and colleagues interviewed 24 adult patients who had a negative experience in therapy or who terminated prematurely within the past year. Alfonsson and colleagues’ goal was to gather patient perspectives on what went wrong to begin to understand the phenomenon and to guide future training and practice of therapists. Qualitative analysis of the interview transcripts yielded four main categories of therapist variables as perceived by the patient that led to negative outcomes. The first main category was the Therapist's Negative Traits. This included therapist inflexibility/rigidity regarding their assessment of the patient and treatment plan, unengaged therapists who were not paying attention during sessions, unempathetic therapists who did not express warmth or caring for the patient’s situation, and insecure therapists who were too uncertain or oversensitive. The second main category was Therapist Unprofessionalism. This included therapists who were too superficial and avoided difficult topics, therapists who were informal such that they acted too familiar, or they were too affected by their own moods, therapists who were perceived to break confidentiality, and therapists who were nontransparent and seemed to withhold information. The third main category was Therapist Incompetence. This included therapists who were unstructured in their treatment and lacked focus, therapists who had a poor understanding of the patient’s problems by missing important issues or not understanding the patient’s situation, therapists with poor knowledge and lacked competence in a particular treatment model, and therapists who were too passive by not providing active treatment. The fourth category was Therapist Mismatch in which patients did not feel that they connected with the therapist.
Practice Implications
Some of the therapist factors are practical in nature such as those in the Therapist Incompetence category and parts of the Therapist Unprofessionalism category. For such issues, therapists may need more training that focuses on ethical practice, gaining better knowledge of psychopathology and treatment, and applying such knowledge to therapy with various patients. However, other factors like Therapist Negative Traits and parts of the Therapist Unprofessionalism category may be more challenging. These refer to personal traits of the therapist such as a perceived lack of empathy, personal insecurity, rigidity, and a tendency to remain superficial. Changing these traits may require therapists to engage in ongoing supervision and personal therapy. Therapists can also engage in routine outcome and process monitoring to get session-to-session feedback about patient experiences, symptoms, and the therapeutic alliance to help identify when things are not going well in the therapy before the patient drops out.
Different Aspects of the Therapeutic Relationship Are Associated with Different Outcomes
Finsrud, I., Nissen-Lie, H. A., Ulvenes, P. G., Vrabel, K., Melsom, L., & Wampold, B. (2023). Emotional and cognitive processes in psychotherapy are associated with different aspects of the therapeutic relationship. Journal of Consulting and Clinical Psychology. Advance online publication. https://doi.org/10.1037/ccp0000853
One can understand the therapeutic relationship as having an emotional component and a cognitive component. Researchers have found that these two components of the therapeutic relationship can be conceptualized as two factors: a patient’s Confidence in the Therapist (a patient who perceives their therapist as warm, empathic, competent, and trustworthy), and a patient’s Confidence in the Treatment (a patient’s experience of the treatment as viable and as providing a meaningful way to accomplish change). These factors align with the therapeutic alliance in that Confidence in the Therapist is akin to the bond aspect of the alliance, and Confidence in the Treatment is like the collaborative agreement on the tasks and goals aspects of the alliance. In this large naturalistic study, Finsrund and colleagues assessed if Confidence in the Therapist and Confidence in the Treatment are related to different types of outcomes (change in emotional clarity vs change in rumination), and to different types of therapy (CBT vs psychodynamic). The study had 631 adult patients with anxiety or depressive disorders and 54 therapists who conducted either CBT or psychodynamic therapy. Therapists treated the patients in a hospital setting in Norway and patients completed measures of Confidence in the Therapist, Confidence in the Treatment, symptom outcomes, rumination, and emotional clarity on a weekly basis for up to 12 weeks of treatment. Patients were highly symptomatic and more than 89% had more than one clinical diagnosis. As expected, higher Confidence in the Therapist predicted emotional change (higher emotional clarity) and higher Confidence in the Treatment predicted cognitive change (lower rumination). However, higher Confidence in the Therapist predicted better emotional clarity only in the patients receiving psychodynamic therapy, whereas higher Confidence in the Treatment predicted less rumination in both CBT and psychodynamic therapy (although the effect appeared larger in CBT).
Practice Implications
The results are in line with the notion that different aspects of the therapeutic relationship play different roles depending on the outcomes that patients and therapists desire. In cognitively oriented therapies, therapists rely more heavily on providing a viable explanation of the symptoms, a treatment rationale that is consistent with the explanation, and tasks of therapy (homework, self-monitoring, behavioural experiments) that are consistent with the treatment rationale. In psychodynamically-oriented therapies, therapists focus on emotional and relational changes in which therapists and patients work through aspects of the therapeutic relationship that deal with their affective bond and their interpersonal work together. Effective therapists likely do both with patients – i.e., they come to an agreement on the tasks and goals of therapy (the rationale for treatment) and they repair ruptures in the therapeutic alliance as a means of achieving interpersonal learning and emotional change.
July 2023
Therapeutic Relationship Factors that Do Not Work
Norcross, J.C. & Karpiak, C.P. (2023). Relationship factors. In S. D. Miller, D. Chow, S. Malins, and M. A. Hubble (Eds.) The Field Guide to Better Results: Evidence-Based Exercises to Improve Therapeutic Effectiveness. American Psychological Association. https://doi.org/10.1037/0000358-006
In their chapter, Norcross and Karpiak review the meta-analyses on therapeutic relationship factors that have a positive impact on patient outcomes. Aspects like therapist empathy, positive regard, genuineness, and developing and maintaining a therapeutic alliance have solid research support for their importance to patient outcomes. In fact, the research is clear that these relationship factors are more important (i.e., are better predictors of patient outcomes) than the brand of therapy conducted by the therapist. Part of this chapter by Norcross and Karpiak also identifies those therapist and relationship factors that do not work and that may be harmful to patients. One could simply reverse the effective behaviors identified in meta-analyses – so that low therapist empathy, poor therapeutic alliances, therapists who are incongruent in their words and actions, and who disregard alliance ruptures will have patients with worse outcomes. Research also identifies harmful behaviors by therapists. These might include rigidity in following prescriptions of an intervention, therapist overconfidence in their abilities, hostile behaviors, a confrontational style, and cultural arrogance. As an example, the authors discuss widespread policies mandating the use of specific treatment protocols, and training therapists in manualized treatments to the exclusion of relationship factors. Research shows that adherence or competence with treatment manuals is consistently unrelated to patient outcomes. By contrast relationship factors are highly related to patient outcomes. Research also suggests that therapist behaviors that blame patients, are sarcastic, critical, or hostile towards patients can lead to worse outcomes. Therapists whose assumptions about a patient that do not align with the patient’s experience, also tend to have patients who do not improve. Therapists may believe that they should know better, but if their knowledge does not fit the patient’s experience, then therapist and patient are not engaged in a collaborative endeavor. Finally, even if some therapies prescribe “confrontation” as a therapeutic stance, there is dubious evidence that using such an approach is helpful to patients.
Practice Implications
The research points to certain therapist behaviors that should be avoided when working with patients. Among these is rigid adherence to a treatment manual. Such rigid adherence by a therapist does not allow room for professional self-doubt, for aligning one’s approach to patient needs, and it might foster therapist over-confidence and a lack of humility. Each of these stances towards a patient reduces a therapist’s empathy and may put the patient in a position of reluctantly complying, feeling unheard and unappreciated, or dropping out of therapy.
Therapeutic Relationship Factors that Work
Norcross, J.C. & Karpiak, C.P. (2023). Relationship factors. In S. D. Miller, D. Chow, S. Malins, and M. A. Hubble (Eds.) The Field Guide to Better Results: Evidence-Based Exercises to Improve Therapeutic Effectiveness. American Psychological Association. https://doi.org/10.1037/0000358-006
Next to patient factors that affect outcomes in psychotherapy, the therapeutic relationship is the most important predictor or contributor to patient outcomes. The therapeutic relationship is important to in-person therapy and to therapy delivered virtually. There is no scientific doubt of the importance of the therapeutic relationship on patient outcomes. The relationship is managed and cultivated by the therapist’s attitudes and behaviors. And so, it is not surprising that therapists differ in their ability to facilitate the therapeutic relationship. However, it is also possible for therapists to improve their therapeutic relationship skills through training and supervision. The therapeutic relationship is important to all therapeutic orientations. In this part of the chapter, Norcross and Karpiak review the research on relationship factors that work including therapist empathy, positive regard, developing a therapeutic alliance, and repairing alliance ruptures when they occur. Empathy occurs when a patient experiences a therapist who perceives and expresses an accurate understanding of a patient’s feelings, perspectives, and experiences. Empathic responding is one of the strongest predictors of patient outcomes with effect sizes ranging from moderate to large (d = .58), but only when it is rated by the patient. Therapist ratings of their own empathy has a much lower association with patient outcomes. Positive regard is the therapist’s genuine liking and expressed appreciation for the patient as a person. That is, a therapist’s verbal and nonverbal expression that they value, care about, and believe in the patient. The key here is genuineness – that the therapist’s words are consistent with their intentions and feelings. Positive regard expressed in therapy is moderately related to patient outcomes (d = .57). The therapeutic alliance refers to the warm emotional bond between patient and therapist, and their collaborative agreement on the goals of therapy and how they will work towards those goals. More than 300 studies of over 30,000 patients indicate that the alliance is moderately related to patient outcomes (d = .57), and this is a highly reliable finding. Ruptures in the alliance are characterized by patient withdrawal from the therapist or therapy, or by confrontation in which the patient criticizes or is dissatisfied with the therapist or therapy. Therapists’ attempts to repair alliance ruptures is moderately related to positive patient outcomes (d = .62), and this skill is most important for newer therapists and therapists with a CBT orientation.
Practice Implications
A positive therapeutic relationship has a much bigger impact on patient outcomes than the specific type of therapy used by therapists. A therapist who narrowly focuses on the content of what a patient says and rigidly adheres to a treatment manual will reliably have patients who have worse outcomes. Therapists whom patients experience as truly empathic (not just expressing sympathy for a patient), who can genuinely feel and express positive regard for a patient, and who can develop and maintain a therapeutic alliance and repair alliance ruptures reliably will have patients who have better experiences of therapy and better outcomes. These therapist skills and capacities can be learned through deliberate practice, supervision, personal therapy, and by maintaining a stance of flexibility, openness, and humility.
Therapist Factors Related to Patient Outcomes
Nissen-Lie, H.A., Heinonen, E., & Delgadillo, J. (2023). Therapist factors. In S. D. Miller, D. Chow, S. Malins, and M. A. Hubble (Eds.) The Field Guide to Better Results: Evidence-Based Exercises to Improve Therapeutic Effectiveness. American Psychological Association. https://doi.org/10.1037/0000358-005.
The thing about therapists that people in the profession do not like to talk about is that some therapists are more effective than others. Meta-analyses indicate that about 5% of patient outcome variance can be explained by differences between therapists. Although this seems small, it accounts for about one-third of the total difference in outcomes among patients. One study found that patient recovery rates for the most effective therapists were twice that achieved by their least effective counterparts. In another study, 15% more patients recovered when they saw an “average” therapist compared to one of the least effective clinicians. One key problem is that therapists consistently over-estimate their own effectiveness, and consistently under-estimate the percentage of their patients who get worse. This makes it difficult for therapists to correct course when necessary or to engage in targeted professional and personal development. In this chapter, Niessen-Lie and colleagues review the research that identifies key therapist qualities that are related to better patient outcomes. It turns out that demographics of the therapist (sex, gender, ethnicity, age), experience level, profession, and education level are all unrelated to patient outcomes. In fact, there is some evidence that more experienced older therapists have slightly poorer outcomes than their younger counterparts. However, some therapist factors are important and known to be related to patient outcomes. For example, therapists who are consistently effective across different types of patients, patient severity, and diagnoses have the best outcomes. Another key therapist factor or attribute is interpersonal skill. This includes therapist empathy, warmth, the capacity to express emotions verbally, the ability to develop a therapeutic alliance with a variety of patients, and the capacity to tolerate and manage strong negative emotions in therapy. A third therapist factor is flexibility. Therapists who can be flexible in using therapeutic techniques within a given treatment tend to have patients with better outcomes. Finally, therapists who can maintain an attitude of humility tend to have better outcomes. Humility refers to an openness to other’s points of view, accepting that there is room for growth, and for pushing beyond one’s current skill level while taking care of oneself. Without this attitude, there is little motivation for continued learning, personal growth, and professional development.
Practice Implications
A therapist’s experience level, profession, experience, and other demographics have no bearing on their patients’ outcomes. However, we do know that being effective with a range of patients, interpersonal skills (empathy, verbal expression of emotions, and ability to tolerate strong emotions), flexibility in applying therapeutic interventions, and professional humility are related to patient outcomes. These therapist skills can be developed and improved during one’s career. Improving these skills require a therapist to be willing to examining when things do not go well in therapy (reviewing when patient outcomes are poor or a patient drops out), to reflect on one’s abilities, and to look for disconfirming evidence by asking “could I be wrong?” First, however, therapists must identify when therapy with a patient was ineffective. And for this, they may need the help of standardized assessments to monitor the state of the therapeutic relationship and patient progress.