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 psychotherapy for borderline personality disorder, capacity to metnalize and therapy resistant depression, and negative effects of psychotherapy
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
Progress Feedback Narrow the Gap Between More and Less Effective Therapists
Delgadillo, J., Deisenhofer, A.-K., Probst, T., Shimokawa, K., Lambert, M. J., & Kleinstäuber, M. (2022). Progress feedback narrows the gap between more and less effective therapists: A therapist effects meta-analysis of clinical trials. Journal of Consulting and Clinical Psychology, 90, 559–567.
Some therapists are more effective than others. This is often referred to as the therapist effect. Somewhere between 1% and 29% of patient outcomes can be attributed to which therapist the patient receives. In general, therapists with high facilitative interpersonal skills, high humility, and an ability to withstand difficulties in practice (i.e., ruptures, burnout) may be more clinically effective. To improve outcomes in therapy, some have suggested using routine outcome monitoring and progress feedback. This involves regularly measuring and tracking patient progress with standardized self-report scales throughout treatment and providing the clinician with this information during therapy. Progress feedback allows the therapist to compare their patient’s progress against norms and against the patient’s own progress in preceding sessions. If the patient is not progressing or is deteriorating, then the therapist is alerted to address the issue. Research indicates that progress feedback makes therapy more effective. Less is known about how progress feedback leads to better outcomes. In this meta-analysis, Delgadillo and colleagues assessed the impact of progress feedback on the therapist effect – that is, does progress feedback improve the outcomes of less effective therapists? The meta-analysis was of six clinical trials with data from 4,549 patients and 131 therapists who were randomly assigned to a progress feedback condition or to a control condition without progress feedback. The variability between therapists (ICC = .011) suggested that 1.1% of the overall variance in patient outcomes was due to therapist effects. However, feedback was associated with a significant reduction in the therapist effect (ICC = .009) by 18.2%. A closer look at the data indicated that progress feedback narrowed the gap between more and less effective therapists, such that patients of less effective therapists benefitted the most from their therapist receiving feedback.
In this meta-analysis conducted on data from controlled studies, there were few under-performing therapists. However, implementing progress feedback was clinically important to achieve better outcomes among some of these therapists. That is, even a single underperforming therapist could attain relatively poor outcomes with dozens or even hundreds of patients. Who the therapist is matters – and some therapists (and their patients) can benefit from supplementing clinical judgement with reliable feedback about patient progress throughout the course of psychotherapy.
Therapist Genuineness and Patient Outcomes
Kolden, G.G., Austin, S.A., Wang, C-C., Chang, Y., & Klein, M. (2018). Congurence/genuineness: A meta-analysis. Psychotherapy, 55, 424-433.
More than 60 years ago Carl Rogers first described congruence or genuineness in the psychotherapy relationship as one of the necessary conditions for patients to improve. Congruence has two components. The intrapersonal component refers to mindful genuineness, personal awareness, and authenticity in relationships. The interpersonal component refers to the capacity to express ones’ internal experiences to another person. Rogers argued that patients often experience incongruence with regard to their internal states (they may avoid or fear the experience or expression of what they think or feel). He also stated that therapists’ congruence in the relationship with a patient is a pre-requisite for positive regard and empathy toward the patient. In this meta-analysis, Kolden and colleagues do a systematic review of the relationship between therapist congruence and patient outcomes. The review included 21 studies representing 1,192 patients. The weighted effect size for congruence and psychotherapy outcome was r = .23 (95% CI: .13, .32), representing on average a moderately large effect. Theoretical orientation did not affect the congruence – outcome association. However older therapists with more experience showed a significantly stronger congruence – outcome relationship. Also, therapy with younger patients was associated with a larger congruence – outcome relationship.
Research continues to support fundamental therapeutic factors defined by Rogers many decades ago. In this case, congruence/genuineness (or the therapist’s ability to know their internal experience and communicate it respectfully to patients) is positively related to patient outcomes. This is especially true for older therapists (who may have a greater capacity for genuineness) and for younger patients – (for whom therapist genuineness may be particularly important). Patients who may have a greater need for and expectation of genuineness are likely to develop a stronger therapeutic alliance with a highly congruent therapist. Patients in a congruent therapeutic relationship learn that it is a safe space, that they matter as a person, and that the therapist is committed and accepting. All of which are precursors to a successful therapy.
Client Preferences Affect Psychotherapy Outcomes
Swift, J. K., Callahan, J. L., Cooper, M., & Parkin, S. R. (2018). The impact of accommodating client preference in psychotherapy: A meta‐analysis. Journal of Clinical Psychology, 74(11), 1924-1937.
Here is another in a series of meta analyses looking at client factors that predict psychotherapy outcomes. In 2006 the American Psychological Association defined evidence-based practice in psychology as composed of 3 pillars: (1) the integration of the best available research combined with (2) clinical expertise in the context of (3) client characteristics including client preferences. Client preferences can be grouped into three broad categories. First, activity preferences refer to activities that a client hopes they and their therapists will engage in during treatment. For example, some clients may prefer homework between sessions, or therapists who interpret, or may prefer a type of therapy modality like group, couple, or individual treatment. Second, treatment preferences include client’s wishes for certain types of therapy approach like CBT, psychodynamic, interpersonal psychotherapy, peer-support, or others. Third, therapist preferences include a client’s desire for the type of therapist with which they would like to work. This might include preferences based on demographics, therapist personality, interpersonal style, culture, and so on. Studies that measure the impact of clients receiving their preferences may simply ask clients what they prefer, or might use a questionnaire of preferences. Some research found that clients are willing to give-up up to 40% in the treatment’s efficacy in order to ensure that they worked with a therapist with whom they would have a good relationship. In this meta-analysis, Swift and colleagues reviewed 53 studies that examined the association between client preferences and psychotherapy outcomes. In 28 studies that included data from 3,237 clients, the overall effect of client preference on psychotherapy drop out was statistically significant, such that clients who were not matched or not given a choice of treatment preference were 1.79 times more likely to drop out compared to those who did get their preference (95% CI: 1.44, 2.22; p < .001). In 53 studies of over 16,000 clients, the overall effect of clients receiving their preference on outcomes was also statistically significant (d = 0.28, 95% CI [0.17, 0.38], p < .001). Receiving a preferred treatment or therapist was associated with better client outcomes.
The results of this body of research suggests that therapists will do well to attempt to accommodate client preferences in psychotherapy, unless they are impractical, or therapeutically or ethically counter-indicated. One can ask clients about their preferences for activities of therapy, therapist style and characteristics, and treatment type. Some of these decisions may require clients to be educated about their options, and so agencies may consider adopting decision aids. At the very least therapists should initiate a discussion with clients about what the client wants and what they can reasonably expect to receive. These discussions may occur at the beginning of treatment and revisited part way through as well. Therapists may also consider using more structured valid assessments of client preferences to help with this task.
Author email: Joshua.Keith.Swift@gmail.com
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.
Clients’ Experiences of Psychotherapy
Levitt, H.M., Pomerville, A., & Surace, F.I. (2016). A qualitative meta-analysis examining clients’ experiences in psychotherapy: A new agenda. Psychological Bulletin. Online First Publication, April 28, 2016.
Much of psychotherapy research over the past several decades has focused on therapy outcomes, with the general conclusion that outcomes are equivalent across major psychotherapy orientations. Some of the effects of psychotherapy can be explained by relational factors (e.g., therapeutic alliance). There is also a growing and interesting line of research about therapist variables and therapist effects (see this month’s PPRNet blog on differences between therapists’ outcomes in a large UK sample). Many experts argue that client effects and characteristics account for the largest amount of variance in therapy outcomes. That is, who clients are and what experiences they have are the largest determinants of whether psychotherapy will be helpful. However the client’s experience is often neglected in psychotherapy research reviews. Levitt and colleagues conducted a qualitative meta analysis of qualitative studies of clients’ experiences in psychotherapy. Qualitative research typically involves interviewing clients about their experiences in therapy and coding the transcripts of these interviews. Methods of synthesizing and categorizing themes from client narratives, such as the grounded theory method and thematic analysis, create a rich source of understanding about how clients experience change in psychotherapy. Levitt and colleagues applied qualitative methods to synthesize 109 qualitative studies of over 1400 clients as a way of analysing this research. Six clusters or themes emerged from their qualitative meta analysis: (1) clients experienced therapy as a process of identifying and understanding personal patterns; (2) clients who felt understood and had their experiences validated were able to internalize the therapist’s voice; (3) clients experienced the structure of therapy (spacing of sessions and time allotted to sessions) and therapist expertise as generating credibility for the therapy, but also at times the structure reduced clients’ experience of therapeutic relationship’s authenticity; (4) clients experienced an inherent power differential with therapists that was sometimes compounded by differences in race, gender, and class; (5) clients played a major role in the therapeutic process, and clients felt pleased when they were invited to take the lead; (6) clients’ experiences of being cared-for supported their ability to recognize maladaptive patterns and address unmet vulnerable needs.
This qualitative meta analysis highlights the important role played by the client’s experience and by the therapy context in promoting good outcomes. The results suggested that better outcomes may be achieved when: (1) therapists encourage clients’ curiosity about their cognitive, emotional and relational patterns; (2) therapists engage in an accepting and caring relationship in order to help clients decrease their defensiveness about vulnerable topics; (3) therapists maintain the therapeutic structure in order to increase clients’ sense of confidence in the process; (4) therapists explicitly acknowledge power differences and repair alliance ruptures; (5) therapists encourage clients to take an active role in therapy as a means of self-healing; and (6) therapists regularly check with clients about the fit of interventions, in-session needs, and treatment goals.
Therapist Interpersonal Skills Account for Patient Outcomes
Schottke, H., Fluckiger, C., Goldberg, S.B., Eversmann, & Lange, J. (2016). Predicting psychotherapy outcome based on therapist interpersonal skills: A five-year longitudinal study of a therapist assessment protocol. Psychotherapy Research, DOI: 0.1080/10503307.2015.1125546
Therapist effects, or differences between therapists, account for an important amount of patient outcomes (i.e., 5% to 7%). Two therapist characteristics most consistently proposed as predictors of patient outcomes are: therapist competence/adherence to a treatment manual, and therapist interpersonal skills. A recent meta analysis found that therapist adherence or competence were not significantly related to patient outcomes. However, there has been very little research on therapists’ interpersonal capacities. These capacities might include factors like: empathy, warmth, ability to respond well to patient hostility, sensitivity to interpersonal process in therapy, and ability to address alliance ruptures. In this paper, Schottke and colleagues (2016) conducted a five year study with 41 therapists and 264 patients in which they assessed the impact of therapist interpersonal skills on patient outcomes. The therapists were all post-graduate trainees and who practiced a manual oriented cognitive behavioral therapy (CBT) or psychodynamic therapy (PDT). The patients were adults mainly treated for depression, and many had co-morbid problems. What was unique about the study is that the therapist interpersonal skill was rated before they received formal training, and the rating were done by trained reliable judges. The judges rated the therapist trainees on interpersonal skills including: clear and positive communication, empathy, warmth, managing criticism, and willingness to cooperate. Patients were assessed pre- and post-treatment on general symptom outcomes. Higher therapist interpersonal skills were reliably associated with better patient outcomes, even after controlling for symptoms severity and number of comorbid diagnoses. In this study, therapist interpersonal capacities measured before receiving formal training and supervision was a significant predictor of patient outcomes after training was initiated.
The findings of this study indicate that therapists’ talent should in part be characterized by interpersonal competencies that include clear communication, empathy, respectful management of criticism, warmth, and willingness to cooperate. It could be that therapist trainees with high interpersonal skills engage in an extensive degree of deliberate practice that may account for better patient outcomes.