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.
…I blog about transtheoretical principles of change, microaggressions and outcomes, interpretations and outcomes.
Type of Research
- ALL Topics (clear)
- Alliance and Therapeutic Relationship
- Anxiety Disorders
- Attendance, Attrition, and Drop-Out
- Client Factors
- Client Preferences
- Cognitive Therapy (CT) and Cognitive-Behavioural Therapy (CBT)
- Combination Therapy
- Common Factors
- Depression and Depressive Symptoms
- Efficacy of Treatments
- Feedback and Progress Monitoring
- Group Psychotherapy
- Illness and Medical Comorbidities
- Interpersonal Psychotherapy (IPT)
- Long-term Outcomes
- 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
- Therapist Factors
- Transference and Countertransference
- Trauma and/or PTSD
- Treatment Length and Frequency
Adapting Therapy to Each Client: Becoming an Evidence-Based Therapist I
Norcross, J.C. & Wampold, B.E. (2018). A new therapy for each patient: Evidence‐based relationships and responsiveness. Journal of Clinical Psychology, Online First, DOI: 10.1002/jclp.22678
Over the next several months, I will review in this blog results of a number of meta-analyses conducted recently on patient factors and relationship factors in psychotherapy. These factors provide evidence-based guidance to psychotherapists on how best to relate to and adapt to clients so that psychotherapy is more effective. This introductory article by Norcross and Wampold is an overview of the nine meta analyses related to transdiagnostic client factors to which therapists can adapt their interpersonal stances and treatment. The goal is to enhance treatment effectiveness by therapists tailoring therapy to individual client characteristics that are related to outcomes. Decades of research indicate that client transdiagnostic characteristics have more influence on outcomes than the particular treatment method, and likely more influence than the particular client diagnosis. The research indicates that giving the identical treatment to every client without adaptation to client characteristics is not an effective approach to providing psychotherapy. These meta analyses of client factors indicate that therapists should select different interventions and relational stances according to the client and the context. What are these client characteristics and therapist adaptations that are reliably related to outcomes? The client factors most strongly related to outcomes include therapist adaptations to: client culture/race/ethnicity (99 studies, g = .50); client preferences for type of therapy (51 studies, g = .28), client religion/spirituality (97 studies, g = .13 to .43), client stage of change (76 studies, g = .41), client reactance/resistance level (13 studies, g = .78), client coping style (32 studies, g = .53), and client attachment style (32 studies, g = .35). Over the next months, I will be reviewing in more detail these meta analyses of client factors and the practice implications of each so that therapists can use this evidence-base to help them to adapt to particular client characteristics.
Practitioners will find that fitting the therapy to clients’ culture, stage of change, religion/spirituality, reactance/resistance, coping style, and attachment style will improve treatment outcomes. Doing so will have a greater impact on outcomes than the particular type of therapy provided or adapting treatment to the particular client diagnosis. The results of this large body of evidence suggests that therapists should no longer ask: “what is my theoretical orientation” but rather they should ask: “what relationship, adaptation, and approach will be most effective with this particular client”.
Psychotherapy Relationships That Work: Becoming an Evidence-Based Therapist II
Norcross, J. C., & Lambert, M. J. (2018). Psychotherapy relationships that work III. Psychotherapy, 55(4), 303-315.
Relationship factors in psychotherapy are some of the most important predictors of patient outcomes. They outweigh factors like the type of therapy provided in determining whether patients get better after psychotherapy. In this second overview article, Norcross and Lambert provide a review of 17 meta-analyses of relationship factors in psychotherapy that contribute to positive outcomes. Like the review of patient factors also found in this blog and E-Newsletter, this article briefly outlines those evidence-based relationship factors that reliably predict patient outcomes in psychotherapy. The therapeutic relationship refers to how the therapist and patient relate to each other, or their interpersonal behaviors. By contrast, techniques or interventions refer to what is done by the therapist. Practice guidelines typically focus on interventions or therapeutic orientation. As the authors argue, what is missing from treatment guidelines are the person of the therapist and the therapeutic relationship – evidence for which is backed up by 5 decades of research. Even in studies of highly structured manualized psychotherapy for a specific disorder in which efforts were made to reduce the effect of individual therapist, up to 18% of outcomes (a moderate to large effect) could be attributed to the person of the therapist. By contrast somewhere between 0% and 10% of outcomes (a small to moderate effect) is attributable to specific treatment methods. So, which therapeutic relationship factors are reliably related to patient outcomes? These include: the therapeutic alliance in individual therapy (306 studies, g = .57) couple therapy (40 studies, g = .62), and adolescent psychotherapy (43 studies, g = .40), collaboration (53 studies, g = .61) and goal consensus (54 studies, g = .49), cohesion in group therapy (55 studies, g = .56), therapist empathy (82 studies, g = .58), collecting and delivering client feedback or progress monitoring (24 studies, g = .14 to .49), managing countertransference (9 studies, g = .84), and repairing therapeutic alliance ruptures (11 studies, g = .62) among others. Over the next few months, I will be reviewing these meta analyses in more detail to discuss how therapists can use this evidence base to improve their patients’ outcomes.
The research as a whole indicates that therapists should make the creation and cultivation of the therapeutic relationship a primary goal of therapy. Factors such as managing the therapeutic alliance, repairing alliance ruptures, engaging in ongoing progress monitoring, managing countertransference and others should be used to modify treatments and interpersonal stances in order to maximize outcomes. When seeking out professional development and training, practitioners should focus on evidence-based relationship factors (managing the alliance, judicious self disclosure, managing emotional expression, promoting credibility of the treatment, collecting formal feedback, managing countertransference) in addition to focusing on evidence-based treatments.
Adult Attachment as a Predictor of Psychotherapy Outcomes: A Meta Analysis
Levy, K.N., Kivity, Y., Johnson, B.N., & Gooch, C.V. (2018). Adult attachment as a predictor and moderator of psychotherapy outcome: A meta‐analysis. Journal of Clinical Psychology. Online first publication, DOI: 10.1002/jclp.22685.
Adult attachment refers to characteristic ways people manage their emotions and relationship styles. Securely attached individuals adaptively and flexibly experience emotions and they are able to give and receive love and support to others. Insecure attachment can be sub-categorized as avoidant or anxious attachment. Those who are anxiously attached tend to up-regulate their feelings so that they may feel easily overwhelmed, and they tend to be preoccupied with relationship loss. Those with avoidant attachment styles tend to down-regulate their emotions so that they have difficulty experiencing or expressing feelings, and they might dismiss the importance of relationships as a means of protecting themselves. John Bowlby, the founder of attachment theory, argued that psychotherapy had the potential to serve as a secure base from which individuals might explore themselves and relationships. He also described the therapist as a temporary attachment figure with which the patient might develop an emotional bond to promote change and for a corrective experience. In this meta-analysis, Levy and colleagues looked at whether attachment dimensions can change in psychotherapy and whether they can predict improvement in patient symptoms pre- to post-therapy. (A note on meta analysis. It is a method of systematically reviewing a research literature, combining the effect sizes in that literature, and summarizing these effects. Because meta analyses usually contain many studies, their results are much more reliable than the results of any single study, and so they provide the most solid basis for making practice recommendations). In this meta analysis, Levy and colleagues included 36 studies, totaling 3,158 clients. Higher client attachment security (or lower attachment insecurity) at the start of therapy was associated with better outcomes by post-treatment (r = 0.17, p < 0.001, 95% CI = [0.13, 0.22], k = 32). Also, greater improvement in attachment security (change in attachment security from pre- to post-treatment) predicted better outcomes (r = 0.16, p < 0.001, 95% CI = [0.07, 0.25], k = 15). When looked at separately, higher levels of either attachment anxiety or attachment avoidance were associated with poorer outcomes, and change in either type of attachment insecurity was associated with better outcomes. These effects appeared to be consistent regardless of the type of therapy (non-interpersonal vs interpersonal therapies).
Although attachment insecurity is associated with poorer outcomes, change in attachment insecurity is possible with psychotherapy and this change is associated with better symptom outcomes. Therapists should expect longer and more challenging treatment with patients who are anxiously attached. Anxiously attached individuals may appear engaged early in therapy, but they are quick to anger, feel rejected, and become overwhelmed. Such individuals may benefit from help to contain their emotional experiences by repeating the treatment frame and increasing structure. They may also benefit from interpersonally-oriented therapy focused on reducing their preoccupation with relationship loss. Avoidantly attached individuals may appear aloof, but they may be easily overwhelmed by demands for closeness. Therapists may have to carefully balance the amount of interpersonal space or demands in treatment with these clients so that they remain in therapy.
How Reliable is the Association Between Therapeutic Alliance and Patient Outcomes?
Flückiger, C., Del Re, A. C., Wampold, B. E., & Horvath, A. O. (2018). The alliance in adult psychotherapy: A meta-analytic synthesis. Psychotherapy. Advance online publication. http://dx.doi.org/10.1037/pst0000172
The therapeutic alliance is one of the most researched concepts in psychotherapy. The alliance, also called the working alliance or therapeutic alliance, consists of the collaborative agreement between patient and therapist on the tasks (what to do) and goals (what to achieve) of their therapeutic work together. Alliance also includes the relational or emotional bond between therapist and patient. It is different from therapist empathy, transference, countertransference, the real relationship and other concepts related to the therapeutic relationship. Researchers and clinicians have known for years about the importance of developing and maintaining an alliance to achieving patient outcomes. The growing research in this area now allows one to see how stable this finding is. Fluckiger and colleagues conducted a meta analysis of 306 studies with over 30,000 patients that assessed the alliance-outcome relationship. The research occurred in naturalistic settings (during regular clinical practice) and in randomized controlled trials. The overall effect size based on 295 independent comparisons was r = .278 (95% CI: .256, .299), indicating a statistically significant medium-sized association accounting for about 8% of treatment outcomes. To put this in perspective, this effect is as large as or larger than the effects of many common medical interventions. The type of therapy made no difference to this finding - the alliance was just as important to CBT as it was to psychodynamic, interpersonal, and emotionally focused therapies. The alliance-outcome correlation was somewhat smaller, though still significant among those with substance-use disorders, but otherwise was consistent for all other disorders tested (depression, anxiety, PTSD, borderline personality disorder). The alliance measure used, who rated the alliance, when it was assessed, and the outcome that was measured tended to have a small or no impact on the results. The alliance-outcome relationship was just as important to everyday clinical practice as it was in randomized controlled trials.
The alliance-outcome association is highly reliable or stable across a number of therapies, diagnoses, measurements, and study designs. This very large body of research suggests that therapists should: (1) build and maintain an emotional bond, and agreement on tasks and goals with patients throughout therapy; (2) develop the alliance early by focusing on agreement on treatment and goals; (3) address ruptures in the alliance early and immediately; and (4) assess the strength and quality of the alliance regularly throughout treatment from the patient’s perspective using a well-known brief alliance measure.
Do Common Factors Matter in Psychotherapy?
Cuijpers, P., Driessen, E., Hollon, S. D., van Oppen, P., Barth, J., & Andersson, G. (2012). The efficacy of non-directive supportive therapy for adult depression: a meta-analysis. Clinical psychology review, 32(4), 280-291.
The research evidence indicates that there is very little difference between different types of psychotherapy (CBT, IPT, PDT, EFT, and others) in patient outcomes, especially for depression. Nondirective supportive treatment (NDST) also shows positive outcomes for various disorders. NDST is often used as a “placebo” condition in psychotherapy trials to control for common or non-specific factors. Common factors refer to those aspects that are common to all therapies, but that are not specific to any one therapy (e.g., therapist interpersonal skills, therapeutic alliance, client expectations). NDST does not involve specific therapeutic interventions like cognitive restructuring, transference interpretations, two-chair techniques, etc. In this meta analysis, Cuijpers and colleagues assessed those randomized controlled trials for depression in which specific treatments (e.g., CBT, PDT, IPT, EFT) or no treatment control conditions were directly compared to NDST. By doing so, the authors were able to estimate how much of patient outcomes were attributable to: specific effects of treatments (the difference between a specific intervention and NDST), common effects of treatment (the difference between NDST and no treatment), and extra-therapeutic factors (the effects of no treatment). The meta analysis included 31 studies with over 2500 patients with depression. Twenty-one comparisons included CBT, and the rest included IPT, PDT, or EFT. NDST was significantly less effective than other specific therapies (e.g., CBT, IPT, PDT, or EFT) at post-treatments g = −0.20 (95% CI: −0.32 to −0.08), but the effect was quite small. The difference between NDST and CBT alone (the most researched treatment type) was not statistically significant. Interestingly, when the authors controlled for researcher allegiance (an indication of which treatment was preferred by the researcher), the superior effects of specific treatments over NDST disappeared. NDST was significantly more effective than no-treatment, and the effect was moderate, g=0.58 (95% CI: 0.45–0.72). Pre- to post-treatment change in symptoms in the control condition was statistically significant, g = 0.39 (95% CI: 0.03–0.74), indicating the positive effects of extra-therapeutic factors on depressive symptoms (e.g., events in the patient’s life not related to therapy). Overall, the authors were able to estimate that almost 50% of patient outcomes could be attributed to common factors (therapist interpersonal skills, therapeutic alliance, client expectations, etc.), about 17% was due to specific therapy techniques (cognitive restructuring, two chair techniques, IPT interventions), and about 33% was due to extra-therapeutic factors (e.g., the natural course of depressive symptoms or other events in the patient’s life).
Factors like therapist interpersonal skills and managing the therapeutic relationship appear to account for most (50%) of why patients with depression get better. The specific interventions based on therapy models like CBT account for relatively less of patient outcomes (17%). The natural course of the disorder and other events in patients’ lives account for about a third of patient improvement. Therapists can learn how to maximize the effects of common factor skills through deliberate practice and training to identify and repair alliance ruptures to help their patients get better.
The Quality of Psychotherapy Research Affects The Size of Treatment Effects for CBT
Cuijpers, P., Cristea, I.A., Karyotaki, E., Reijnders, M., Huibers, M.J.J. (2016). How effective are cognitive behavior therapies for major depression and anxiety disorders? A meta-analytic update of the evidence. World Psychiatry, 15, 245-258.
You might think that an esoteric topic like study quality should not really be of interest or concern to clinicians – but it is an important topic with practice implications. In this meta analysis Pim Cuijpers and his research group updated the meta analytic evidence for the efficacy of cognitive behavioral therapy (CBT) for a variety of disorders (major depressive disorder [MDD], generalized anxiety disorder [GAD], panic disorder [PAD], and social anxiety disorder [SAD]). The important thing about meta analyses is that the method combines the effect sizes from all relevant studies into a single metric – an average effect size. These average effect sizes are much more reliable than findings from any one single study. In fact, whenever possible, clinical decision-making should be based on a meta analysis and systematic review and not on a single study. Meta analyses also allow one to give more weight to those studies that have larger sample sizes, and that employ better methodologies. Even more, meta analytic techniques allow one to adjust the averaged effect size by taking into account publication bias (i.e., an indication of the effects from studies that might have been completed but were never published, likely because they had unfavorable findings). Usually, average effect sizes are lower when they are adjusted for study quality and publication bias. Cuijpers and colleagues’ meta analyses found that the unadjusted average effects of CBT were large for each of the disorders (ranging from g = .75 to .88 [confidence intervals not reported]). However adjusting for publication bias reduced the effects to medium-sized for MDD (g = .65) and GAD (g = .59). Only 17.4% of the individual studies of CBT were considered to be of “high quality” (i.e., studies that use the best methodology to reduce bias, like random allocation, blinding, using all the available data, etc.). After adjusting for study quality, the effects of CBT for SAD (g = .61) and PAD (g = .76) were also reduced to medium-sized. Not surprisingly, the effects of CBT were largest when the treatment was compared to a wait-list no-treatment control group. The effects were small to moderate when CBT was compared to treatment as usual or to a placebo.
Even when adjusting for study quality and publication bias, the average effects of CBT were medium-sized for a variety of common disorders compared to control conditions. Unfortunately, the quality of the studies was not high for most trials, reducing the effect sizes and lowering our confidence in the efficacy of the treatment. Nevertheless, the findings of this meta analysis suggest that CBT will likely have moderate effects for the average patient with MDD, SAD, PAD, and GAD.