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 client perspectives on psychotherapy failure, therapeutic alliance, and alliance ruptures and resolutions and symptom severity.
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
March 2015
The Efficacy of Existential Therapies for Physically Ill Patients
Vos, J., Craig, M., & Cooper, M. (2015). Existential therapies: A meta-analysis of their effects on psychological outcomes. Journal of Consulting and Clinical Psychology, 83, 115-128.
Existential therapies are a group of psychological interventions that address questions about existence, and they assume that by overcoming existential distress, psychological problems may be decreased. Underlying existential therapy is the assumption that: people need a meaning or purpose, individuals have a capacity to choose and actualize this potential, people will do better when they face challenges rather than avoid them, and human experiencing is related to others’ experiences. Vos and colleagues list four main schools of existential therapies: Daseinanalysis which focuses on free expression and greater openness to the world; logo-therapies which are aimed at helping clients establish meaning in their lives through didactics, British existential therapy which encourages clients to explore their experiences, and the existential-humanistic approach which help clients face mortality, freedom, isolation, and meaninglessness. Vos and colleagues review the research literature showing that meaning in life and positive well-being are associated with coping with stressful life events including life threatening illnesses. In this meta-analysis, the authors review the randomized controlled trials of different types of existential therapies to assess the efficacy of the treatments compared to a control condition like social support groups, being on a waiting list, or receiving care as usual. They grouped outcomes into four areas: meaning in life, psychopathology, self-efficacy, and physical well-being. Their meta-analysis included 15 studies of 1,792 participants, 13 of the studies were with medically ill patients, and 10 of those studies were aimed at patients with cancer. Effects of existential therapy versus a control condition on meaning in life tended to be positive and moderate. Effects on psychopathology and self-efficacy were positive and small. The effects of existential therapies versus a control condition on physical well-being were not significant. There were no differences between the types of existential therapy, though the number of studies was small to adequately assess these differences.
Practice Implications
Clients seem to benefit from group therapy interventions focused on meaning compared to social support groups, being on a waiting list, or receiving care as usual. Medically ill patients who received existential therapy found greater meaning in their lives, and the effects were moderate to large. Their psychopathology and self-efficacy also improved significantly but effects were small. The quality and number of studies was not optimal which limits the confidence one can have in these findings. The authors conclude that despite the small number of studies, existential therapies that use structured interventions that incorporate psychoeducation and discussions on meaning in life are a promising treatment for physically ill patients.
January 2015
Methods of Repairing Alliance Ruptures
Safran , J. D. & Kraus , J. (2014). Alliance ruptures, impasses and enactments: A relational perspective. Psychotherapy, 51, 381-387.
In this clinically oriented review, Safran and Kraus discuss the evidence related to alliance ruptures, repairing alliance ruptures, and methods of training in alliance rupture repair. Safran’s work represents “second generation” research on the therapeutic alliance. The therapeutic alliance refers to the relational bond between client and therapist and their agreement on tasks and goals of therapy. A positive alliance is associated with good client outcomes across a variety of therapeutic approaches. Therapeutic alliance ruptures in psychotherapy are inevitable, such that the alliance is continually being re-negotiated, both implicitly and explicitly, throughout the therapy. Such ruptures might include strains, tensions, or breakdowns that could interfere with the ongoing collaboration between therapist and client. Ruptures are associated with re-enactments of dysfunctional relational patterns, but they also may provide opportunities for change and growth in therapy. Safran’s model of alliance ruptures and repairs sees the processes in the client-therapist relationship as key to understanding the client’s relationship problems. Collaboratively addressing tensions in the alliance allows the client to develop more flexible ways of being in relationships and of experiencing themselves. Research by Safran and Muran (2000) suggest that it is rare not to have some minor strain occurring in the therapeutic alliance. Ruptures may occur in half of therapy cases within the first six sessions. Research indicates that unresolved ruptures are associated with deterioration in the alliance, poor outcome, and patients dropping out. In a meta-analysis, repairing alliance tensions by using evidence-based strategies was associated with improved patient outcomes and the effect was large. Alliance ruptures occur across theoretical orientations. For example, research on cognitive therapy showed an improvement in therapist-client interpersonal processes after therapists were trained in techniques to resolve alliance ruptures.
Practice Implications
Alliance ruptures can range in intensity from minor tensions to major rifts in collaboration. They may occur at any time in treatment, and may be present in single or across multiple sessions. Safran and Kraus describe two general types of ruptures. First, withdrawal ruptures occur when clients deal with ruptures or misunderstandings by falling silent. The resolution may involve the therapist exploring the client’s interpersonal fears, reasons for inhibiting negative feelings, and providing the client with an opportunity to communicate their needs. Second, confrontation ruptures occur when clients directly express anger, resentment or dissatisfaction with the therapist or therapy in a blaming manner. The resolution may involve the therapist empathically engaging with the client to facilitate feelings of disappointment, hurt, and vulnerability. Key to this process is the therapist’s meta-communication or mindfulness abilities. The therapist must be aware of the behavior associated with the rupture, collaboratively explore the rupture experience, help the client overcome avoidance of feelings related to the rupture, and explore the client’s needs and wishes that emerge while working through the rupture.
December 2014
Burnout in Psychotherapists in Five Countries
Puig, A., Yoon, E., Callueng, C., An, S., & Lee, S. M. (2014). Burnout syndrome in psychotherapists: A comparative analysis of five nations. Psychological Services, 11(1), 87-96.
Psychotherapists can experience severe stress when working with some clients. The stress can be the result of work conditions like budget cuts and increased therapy caseloads, and from characteristics of the work itself like remaining compassionate with clients who experience significant emotional pain and trauma. In the May 2014 blog, I reported on research on secondary trauma experienced by therapists as an occupational hazard of working with traumatized patients. Although secondary trauma is distinct from burnout, the accumulation of these experiences by therapists coupled with other demands of the work can lead to burnout. Burnout syndrome is often defined as the failure to perform clinical tasks well because of discouragement, apathy, and the experience of emotional or physical drain. Burnout can affect both the therapist’s well being and patient outcomes. In this study by Puig and colleagues, the Counsellor Burnout Inventory (CBI) was given to therapists in five countries. The CBI measures therapist Exhaustion, sense of Incompetence, Negative Work Environment, and Deterioration in Personal Life. The samples of therapists were from countries that included the United States (n = 750), Korea (n = 382), Japan (n = 257), Philippines (n = 218), and Hong Kong (n = 222). Puig and colleagues argue that countries like the US may be characterized by a more individualistic cultural context, whereas other countries in Asia may have more collectivistic values. These cultural values and differing professional practice contexts may affect the experience of burnout by psychotherapists. The majority of therapists were female (67.3% to 85.3%) with average experience ranging from 5.34 years in Korea to 12.33 years in the US. Puig and colleagues translated the CBI from English and then conducted a confirmatory factor analysis that showed that the CBI is reliable and valid within each of these samples of therapists from different countries. Therapists in Hong Kong and the US had the highest scores on the Exhaustion scale. Puig and colleagues suggested that burnout in Hong Kong and US may be most affected by demands of the work that psychotherapists do in those countries. Psychotherapists from Japan reported highest levels on the Incompetence scale, suggesting that burnout in Japanese therapists might be most affected by a sense of low self efficacy and efficiency. Of all the nations, US therapists perceived their working environments most negatively. Deterioation in Personal Life scores were highest in Korea suggesting that burnout may contribute to low personal quality of life for Korean psychotherapists. All therapists reported low mean scores on the Devaluing Client scale, but those in the US and Philippines had the lowest mean scores. It appears that burnout is least affected by negative relationships with clients for all therapist groups.
Practice Implications
Therapists, policymakers, and administrators need to attend to increased stress related to psychotherapists’ work, the environment, and characteristics of clients who experience trauma. The impact of stress and burnout can be seen in therapists’ performance their personal lives and well-being. In addition, burnout can affect patient outcomes. Puig and colleagues suggest that psychotherapists can participate in professional development activities (e.g., workshops) to enhance their knowledge and skills in managing stress and maintaining a healthy and balanced work and personal life. Organizations should consider restructuring the social and work environment (e.g., workload), and clarifying and reassessing their expectations of therapists in order to prevent conflict and ambiguity. On his web site, Ken Pope provides a list of resources for therapist well-being and preventing burnout, and he discusses the ethics of therapist self-care.
November 2014
Transference in Psychotherapy: A Review of the Research
Hoglend, P. (2014). Exploration of the patient-therapist relationship in psychotherapy. American Journal of Psychiatry, 171, 1056-1066.
In this overview of patient-therapist relationship factors, Per Hoglend reviews research on transference in psychotherapy. He argues that transference and transference work is a specific technique that focuses on exploring the patient-therapist relationship. Hoglend takes a broad definition of transference as: the patient’s pattern of feelings, thoughts, perceptions, and behaviors that emerge in the therapeutic relationship and reflect the patient’s personality functioning. Hoglend also defines transference work as any therapist intervention that refers to or explains the patient’s experience of the therapist and their interaction. These interventions include the therapist: (1) addressing transactions in the patient-therapist relationship; (2) encouraging exploration of feelings and thoughts about the therapy or therapist; (3) encouraging the patient to discuss how he or she believes the therapist might feel or think about the patient; (4) including him or herself in interpreting the patient’s dynamics; and (5) interpreting repetitive interpersonal dynamics and linking these to the therapy relationship. More than 30 studies have been published on providing empirical evidence for the relationship between transference work in psychotherapy and positive patient interpersonal outcomes. Effect sizes of the association between transference work and patient outcomes tend to be large. Some of the research indicates that low frequency of transference interventions is useful, but that a higher frequency may lead to negative effects on the patient. Research on transference-focused psychotherapy indicates that it is as effective as dialectical behavior therapy and supportive psychotherapy for borderline personality disorder, but that transference-focused therapy produced better outcomes for attachment related functioning like mentalizing. In the First Experimental Study of Transference Work (FEST), Hoglend found that patients with low quality of object relations (i.e. a poorer ability to maintain close relationships and to regulate affect) benefited most from transference focused therapy. However, those with high quality of object relations did not require the transference work to get better. Also, women responded better to transference work than men. There are some studies of therapeutic approaches like cognitive behavior therapy, in which patients with depression had better outcomes when the patient-therapist relationship was explicitly discussed.
Practice Implications
Hoglend argues that transference work in psychotherapy is an active ingredient that can lead to specific change in some patients. Most studies that Hoglend reviewed showed significant and large associations between transference work and interpersonal changes in patients. Exploring the patient-therapist relationship appears to be most useful for female patients, those with difficult interpersonal relationships, and those with more severe personality pathology. Patients with more mature relationships may not benefit as much from transference work. Although generally effective, if transference work is used too frequently in a session it can also lead to negative patient outcomes.
Managing Countertransference: Meta-analytic Evidence
Hayes, J.A., Gelso, C.J., & Hummel, A.M. (2011). Managing countertransference. Psychotherapy, 48, 88-97.
This is another in a series of meta-analyses on relationship factors that work in psychotherapy that appeared also in John Norcross’ book Psychotherapy Relationships That Work. As I mentioned in previous blogs, meta-analyses represent the state of the art in systematically reviewing a research literature. In meta-analyses, the effect sizes from many studies are aggregated into an estimate of an overall effect that is much more reliable than any single study. In these meta-analyses, Hayes and colleagues assessed whether therapist countertransference had a negative effect on patient outcomes, and whether successful management of countertransference is related to better therapy outcomes. Traditionally, countertransference was seen as solely related to therapist unconscious conflicts, and countertransference was to be avoided. Broader conceptualizations view countertransference as representing all of the therapist’s reactions to the client. More interpersonal or relational models view countertransference as therapist reactions that complement a patient’s ways of relating, or see countertransference as mutually constructed by therapist and patient, so that the needs and conflicts of both patient and therapist contribute to the manifestation of countertransference in therapy. Hayes and colleagues argue that the definition of countertransference must include some aspect of therapist unresolved conflicts, and that countertransference in the therapist is potentially useful to understanding patient dynamics and personality style. Countertransference may be reflected in therapist anger, boredom, anxiety, despair, arousal, etc. These feelings range in intensity as well. According to Hayes and colleagues, successful management of countertransference might involve: self-insight (therapist being aware of their own feelings, attitudes, personality, etc.); self integration (therapist’s healthy character structure); anxiety management (therapist’s ability to control and understand own anxiety); empathy (the ability to put one’s self in the other’s shoes in order to focus on the client’s needs); and conceptualizing ability (therapist’s ability to draw on theory to understand the patient’s role in the therapeutic relationship). Hayes’ and colleagues meta-analyses included between 7 to 11 studies of 478 to 1065 participants. The findings showed that countertransference in the therapist was associated with negative patient outcomes, though the effect was small. Successful management of countertransference was associated with better therapy outcomes, and the effect was large.
Practice Implications
Successful management of countertransference is a characteristic of effective therapists. Therapists can work on a number of issues to reduce the negative impact of countertransference and to increase its utility in helping to understand certain patients. Therapists can work to gain self-understanding and work on their own psychological health. The research suggests the importance of therapists resolving their own major conflicts through personal therapy and clinical supervision. Having a good grasp of psychological theory and theories of therapy can also help with using countertransference effectively, as long as the theory is not used defensively by the therapist. Further, there is value in therapists admitting mistakes and acknowledging that their own conflict was the source of the error. Although countertransference theory and research focuses on the therapist, Hayes and colleagues acknowledge that some clients evoke greater and more intense countertransference reactions that others.
October 2014
Client Preferences Affect Satisfaction, Completion, and Outcome
Lindheim, O., Bennett, C.B., Trentacosta, C.J., & McLear, C. (2014). Client preferences affect treatment satisfaction, completion, and clinical outcome: A meta-analysis. Clinical Psychology Review, 34, 506-517.
Giving clients a choice about treatments or to receive their preferred treatment might improve treatment outcomes. Preference usually means clients passively receiving the treatment they prefer. Choice involves clients actively making a decision about which treatment option to receive. Clients may also make informed or uninformed preferences and choices. Informed preferences and choices refer to providing clients with information or education about treatment options. Having a choice or getting one’s preference between two or more efficacious treatments might have several beneficial effects. For example, some research shows that treatment preferences positively affect therapeutic alliance, possibly because clients may enter treatment with a more positive outlook about what intervention they receive. Patients receiving a preferred treatment may also have better overall communication with their providers which may lead to better outcomes. In their meta-analysis, Lindheim and colleagues were interested in the effects of client preference or choice on treatment satisfaction, completion, and clinical outcomes. The meta-analysis included 34 different studies. Client preference or choice of treatment was modestly but significantly and consistently related to satisfaction, completion rates, and to client outcomes. Clients who were involved in shared decision making, who chose a treatment condition, or who received their preference had higher satisfaction, increased completion rates, and better clinical outcomes compared to clients who were not involved in the decision, who did not choose, or who did not receive their preference. Setting (inpatient vs outpatient) or diagnosis did not have an effect on these findings.
Practice Implications
The findings highlight the clinical benefits of assessing client preferences and providing treatment options when two or more efficacious options are available. Increasingly, two or more efficacious options are available for common mental disorders like depression and anxiety. Many times, patients prefer psychotherapy over medications, for example. However, whereas medication prescriptions for mental disorders like depression rose dramatically in the past decades, rates of psychotherapy use remained stable or slightly declined. For those disorders for which two or more treatment options have comparable efficacy, client preference should be the deciding factor.