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.

October 2017

Therapists’ Appropriate Responsiveness to Clients

Stiles, W. B. & Horvath, A. O. (2017). Appropriate responsiveness as a contribution to therapist effects. In L. Castonguay and C. Hill (Eds.). How and why some therapists are better than others?: Understanding therapist effects (Ch. 4). Washington: American Psychological Association.

Appropriate responsiveness refers to therapists’ ability to adapt their techniques to the client’s requirements and circumstances. This might include planning treatment based on how the client is responding, using the client’s evolving responses to treatment as a guide to interventions, and adjusting interventions already in progress in light of subtle signs of client uptake. Appropriate responsiveness may depend on a client’s diagnosis, education, personality, stage of life, values, stage of therapy, among others. Responsiveness also depends on therapists’ skills, personality, theoretical orientation, and history of the therapeutic relationship. In this chapter, Stiles and Horvath review the literature on relationship variables that predict therapy outcomes and interpret these findings in the context of therapist responsiveness. To illustrate, previous research showed that therapists’ rigid adherence to a treatment manual was associated with worse client outcomes – or to state it differently, therapist adherence flexibility was associated with better outcomes. This flexibility is an indication of appropriate responsiveness on the part of the therapist. Stiles and Horvath also argue that most of the relationship variables that predict client outcomes reflect whether therapists appropriately respond to the circumstances of the client at a particular point in therapy. That is, evidence-based relationship factors like alliance, cohesion, empathy, goal consensus, positive regard, and others evaluate whether the therapist successfully tailored interventions and behaviors to the client’s unique personality and circumstances. For example, therapeutic alliance (the affective bond, and agreement on tasks and goals of therapy) indicates that the therapist selected interventions that were appropriate to the client, introduced them at the right time, and was attentive to and interested in the client’s progress. In support of this, the authors cite research showing that the therapeutic alliance is largely a function of the therapists’ responsiveness and not the client’s characteristics. That is, therapists are largely responsible for the quality of the therapeutic alliance.

Practice Implications

Research is increasingly indicating that therapists’ ability to respond appropriately to clients on a moment-to-moment basis is a key therapeutic factor. In other words, therapists who can build strong alliances, repair alliance ruptures, work for goal consensus and collaboration, manage countertransference, and be empathic are those who respond to the changing nature of client characteristics and needs in therapy. Supervision that provides feedback to therapists on these therapeutic factors, mastering a framework to guide interventions, client progress monitoring and feedback, and acquiring knowledge of client personality and cultural factors can sensitise therapists to their client’s changing requirements and allow them to respond therapeutically.
Therapeutic Alliance in the Treatment of Adolescents

Murphy, R. & Hutton, P. (2017). Therapist variability, patient reported therapeutic alliance, and clinical outcomes in adolescents undergoing mental health treatment: A systematic review and meta-analysis. The Journal of Child Psychology and Psychiatry, doi:10.1111/jcpp.12767.

The therapeutic alliance refers to the affective bond between therapist and client, and their agreement on the tasks and goals of therapy. The alliance is a well-known predictor of outcomes in adult psychotherapy with a mean alliance-outcome correlation of r = .28. Less is known about the role of the alliance in the treatment of adolescents. Some reviews indicate that the alliance-outcome relationship in children and adolescents is weaker than observed among adults, but these reviews may have been flawed since they included both children and adolescents in the same review, and the number of studies they reviewed was small. A large rigorous systematic review of adolescents’ perceptions of the alliance can provide insight into their experience of psychological treatment and inform routine mental health practice. In their meta analysis, Murphy and Hutton reviewed studies of clinical samples of adolescents between the age of 12 – 19 who received psychological treatment. The authors made sure that the measures of alliance and outcomes were reliable, they excluded studies of those with medical and neurocognitive problems, and included only studies with adolescents (i.e., excluding studies with primarily children). Twenty-seven studies with almost 3,000 participants were included. Main presenting problems of adolescent patients were: substance use, eating disorders, behavioral difficulties, and a range of mood and anxiety disorders. The mean weighted effect size of the alliance-outcome relationship among studies of psychological treatment of adolescents was r = .29 (95% CI: 0.21, 0.37; p < .001) indicating a moderate effect.

Practice Implication

This is the largest meta analysis of the alliance-outcome relationship in the psychological treatment of adolescents with mental health problems. The alliance was moderately associated with outcomes, and so therapeutic alliance may be a reliable predictor of clinical progress in the treatment of adolescents. The findings suggest that those working with adolescents should routinely assess the alliance after each session in order to evaluate if they need to address relational barriers to positive outcomes. For example, if the alliance markedly declines from one session to the next, then clinicians should address potential problems in their relationship with the adolescent client, renegotiate goals, or renegotiate the tasks of therapy.
Group Psychotherapy for Eating Disorders

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.

September 2017

Does it Matter Which Therapist a Client Gets?

Barkham, M., Lutz, W., Lambert, M., & Saxon, D. (2017). Therapist effects, effective therapists, and the law of variability. In L.G. Castonguay and C.E. Hill (Eds.) How and why are some therapists better than others? Understanding therapist effects. Washington, DC: American Psychological Association.

Psychotherapy research has often focused on the differences between treatment types (CBT, interpersonal psychotherapy, psychodynamic therapy), which has overshadowed research on what makes for an effective therapist. Psychotherapists represent the most costly important component of psychotherapy, and only recently has research begun to catch up to the importance of therapist effects. The term “therapist effects” refers to differences between therapists (i.e., variability) in their clients’ outcomes. In this chapter, Barkham and colleagues review some of the research on effective therapists. Best estimates of therapist effects suggest that differences between therapists account for about 8% of client outcomes – which is considered a medium effect and larger than the variance accounted for by the type of therapy that a client receives. Psychotherapy research often tries to control for therapist effects by training therapists to adhere to a manual, however adherence to a manual does not substantially reduce therapist effects, and adherence is not related to patient outcomes. The implication is that which therapist a client sees matters to the client’s mental health outcomes. The best research on the topic indicates that about 20% of therapists are substantially better than the average therapist, and 20% are substantially worse than the average. (The good news is that 60% of therapists [the average] are equally and positively effective). In that study of 119 therapists, the least effective therapists had about 40% of their clients recover, whereas the most effective therapists had about 76% of their clients recover. In other words, the better therapists were almost twice as effective as the worse therapists. In a re-examination of previous data, Barkham and colleagues looked at whether other variables, like client symptom severity, played a role in therapist effects. They found that differences among therapists was higher as client baseline severity increased. That is, the gap between better and worse therapists increased when client symptoms were more severe and complex. Good therapists were better equipped to handle more complex cases.

Practice Implications

There are important differences between therapists in their effectiveness, and this makes a difference to clients. It is particularly important for clients with more severe symptoms to be matched with more effective therapists. Previous research indicates that the level of therapist interpersonal skills (alliance, empathy, warmth, emotional expression, verbal skills) can account for significant proportion of therapist effects, and so training therapists in these interpersonal skills will improve client outcomes. Also, therapists who receive continuous reliable feedback throughout therapy about their client’s symptom levels can also drastically reduce client drop-outs and the number of clients who get worse during treatment.

August 2017

What Characterizes Effective Therapists?

Wampold, B. E., Baldwin, S. A., Holtforth, M. G., & Imel, Z. E. (2017). What characterizes effective therapists. In L.G. Castonguay and C.E. Hill (Eds.) How and why are some therapists better than others? Understanding therapist effects. Washington, DC: American Psychological Association.

The research on therapist effects indicates that some therapists are more effective than others. Previous research showed that therapist characteristics like age, race, ethnicity, gender, and experience are not consistently related to patient outcomes. Neither is therapist competence and adherence to a treatment approach. In this chapter, Wampold and colleagues ask the question: what characterizes effective therapists? The research is complicated because it is difficult to disentangle therapist effects from patient factors. That is, it is possible that some clients (i.e., those who are more motivated, likeable, and psychologically minded) might create favorable conditions for some therapists to be more effective. However, recent advances in statistical methods have allowed researchers to isolate the effects of therapist characteristics from patient factors. Based on this new research, Wampold and colleagues identified four characteristics of effective therapists. (1) The ability to form an alliance across a range of patients. The therapeutic alliance is defined as the agreement on tasks and goals of therapy, and the affective bond between therapist and patient. Alliance is reliably associated with good patient outcomes. Research shows that therapists and not clients are primarily responsible for the alliance-outcome relationship. (2) Facilitative interpersonal skills – which includes verbal fluency, warmth, empathy, and emotional expression. These skills in a therapist are a strong predictor of patient outcomes. (3) Professional self doubt – or healthy skepticism about one’s abilities and skills leading to self-reflective practice has also been found to predict positive patient outcome. (4) Deliberate practice - defined as individualized training activities especially designed to improve specific aspects of an individual’s performance through repetition and successive refinement. The amount of time outside of therapy that therapists engage in improving targeted therapeutic skills predicted patient outcomes.

Practice Implications

Some therapists are better than others - and demographics, professional affiliation, training, and adherence to a manual do not differentiate better therapists. Four factors are emerging as indicators of better therapists. Ability to develop, maintain, and repair a therapeutic alliance is well known to predict patient outcomes and it appears that therapists are largely responsible for the condition of the alliance. Therapists’ ability to be verbal, warm, and empathic is also key to patient outcomes. Professional skepticism about one’s abilities that lead to reflective practice is also an important characteristic in order to continually improve one’s abilities and monitor one’s outcomes. And, finally therapists who spend time outside of therapy deliberately and repetitively practicing skills will achieve better patient outcomes.

May 2017

What is the Therapist’s Contribution to Patient Drop-out?

Saxon, D., Barkham, M., Foster, A., & Parry, G. (2016). The contribution of therapist effects to patient dropout and deterioration in the psychological therapies. Clinical Psychology and Psychotherapy, DOI: 10.1002/cpp.2028.

Sometimes patients experience negative outcomes in psychotherapy. For example, some patients drop out of therapy (i.e., they unilaterally decide to leave therapy before making any progress or before the endpoint planned with the therapist). In a previous meta-analysis of 669 studies, dropout rates ranged from 17% to 26% in psychotherapy trials. In this study, Saxon and colleagues were interested in the therapist effect on drop out. In other words, what is the impact of the individual therapist on negative outcomes like patients unilaterally terminating treatment? To examine the therapist effect one can look at differences between therapists in the average number of patients who drop out within their caseload. The authors looked at over 10,000 patients seen by 85 therapists from 14 sites in the United Kingdom initiative for Improving Access to Psychological Therapies. Therapists were selected if they saw more than 30 patients, and patients were included if they attended more than one session of therapy. Patient mean age was 40.3 (SD = 13.0), 71.2% were women, most were White (95%) and employed (76%). Of all the patients, 76.8% had some level of depression and 82.7% had some level of anxiety. Over 90% of the patients scored in the clinical range for symptom severity at pre-treatment. Patient symptom severity seen by a particular therapist was controlled in this study so that therapists who tended to treat severe cases were not penalized (i.e., case mix was controlled). Patients who dropped out represented 33.8% of the sample, with over half of these patients unilaterally terminating before the third session. The mean number of sessions for treatment completers was 6.1 (SD = 2.68). Therapist differences (i.e., the therapist effect) accounted for 12.6% (CI = 9.1, 17.4) of the patient drop out variance. In other words, about a quarter of therapists had a significantly greater number of drop outs compared to the average therapist. The mean dropout rate for the average therapist was 29.7% (SD = 6.4), the mean dropout rate for the above average therapist was 12.0% (SD = 7.3), whereas the mean dropout rate for the below average therapist was 49.0% (SD = 10.4).

Practice Implications

Who a patient gets as a therapist appears to have an important impact on whether the patient remains in therapy. Almost half of clients dropped out if they saw a poorly performing therapist (and nearly a quarter of therapists were poorly performing). By contrast, highly performing therapists only had a 12% drop out rate. Therapist variables that are known to be related to negative outcomes like dropping out include: lack of empathy, negative countertransference, and disagreements with patients about the therapy process. Previous research showed that therapeutic orientation is not related to negative outcomes. Therapists who are perform below average on when it comes to patient dropout might be able to use progress monitoring or some other means of measuring their patients’ outcomes to their advantage. These therapists may require more support, supervision, or training to improve their patients’ outcomes.

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October 2017

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September 2017

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August 2017

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May 2017

Practice Implications

Psychotherapy Practice Research Network (PPRNet)