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Curran, J., Parry, G.D., Hardy, G.E., Darling, J., Mason, A-M., Chambers, E. (2019). How Does therapy harm? A model of adverse process using task analysis in the meta-synthesis of service users’ experience. Frontiers in Psychology, 10:347. doi: 10.3389/fpsyg.2019.00347

Forty to 60% of patients do not recover after a course of psychotherapy, and approximately 5% to 8.2% are worse off. In the National Health Service in the UK, 5% of patients reported lasting bad effects of therapy. Although these appear to be small percentages, they represent a large number of patients. In Canada for example, over 1 million Canadians use psychotherapy each year, so 5% would represent 50,000 individuals. Therapists, for their part are poor at identifying patients who deteriorate in therapy. In this meta-synthesis of qualitative research, Curren and colleagues aimed to derive a model based on patients’ experiences of the factors that lead to negative outcomes. They conducted a narrative review of qualitative research findings and of patients’ testimony from a number of sources. They noted eight domains identified by patients that are associated with adverse events in psychotherapy. First, contextual factors refer organizational issues that affect access to or choice of therapy, cultural validity of the therapy, and lack of information about services. Second, pre-therapy factors refer to poor pre-therapy contracting between therapist and patient, and therapists that focus on symptoms rather than the client as a person. Third, therapist factors refer to therapist inflexibility, and therapists’ financial interests that influence their decisions about therapy. Fourth, client factors refer to client lack of understanding of therapy, fear, and demoralization. Fifth, relationship factors refer to a poor relational fit between therapist and patient, therapists perceived as shaming, therapists misusing power, and clients not feeling heard or understood. Sixth, therapist behaviors refer to boundary violations, rigidly applying techniques, therapist acting out, and therapist passivity. Seventh, therapy process refers to the type of therapy offered not matching patient needs, and patients not agreeing with the techniques. Eighth, endings refer to short term therapies that “open a can of worms” without resolution, and the client feeling abandoned.

Practice Implications

Therapists would do well to ensure that the patient’s voice is heard when it comes to preferences and cultural validity of the treatment. In particular, therapists should not rigidly apply techniques focused exclusively on symptom reduction. Instead, therapists should see patients’ problems within their interpersonal and cultural context and focus on outcomes related to the quality of life of patients. Therapists must attend to developing and maintaining the therapeutic alliance (agreement on tasks and goals of the therapy, and the relational bond with patients). Any signs of disruptions or tensions in the alliance should be identified and repaired. Patients require information about the therapy, what it entails, and how it will end before signing on to a course of treatment. Organizations must remove barriers to accessing treatment and provide therapies that represent a range of orientations and foci to meet patients’ needs.

Timuluk, L. & Keogh, D. (2017). The client’s perspective on (experiences of) psychotherapy: A practice-friendly review. Journal of Clinical Psychology, 73, 1556-1567.

Psychotherapy studies that ask clients for their perspective on the treatment or therapist are surprisingly rare. Researchers have conducted such studies over many decades, but there exist very few of them. This is curious given that respecting clients’ preferences for types of therapy or for therapists’ behaviors is predictive of good mental health outcomes. Giving voice to clients’ perspectives is consistent with the notion that psychotherapy is a co-constructed endeavour rather than something that a therapist does to a client (as is the case for a medical intervention). In this review, Timuluk and Keogh review the research in which patients were interviewed for their perspective on a wide range of aspects of psychotherapy. The research indicates a number of things that clients value, that help, and that hinder their progress in therapy. Clients value a number of therapist traits like friendliness, warmth, respect, offering appropriate guidance, and understanding. This research showed that clients recognize that the relationship (i.e., the alliance) has therapeutic effects. Clients report that many forms of therapist behaviors help to develop a therapeutic alliance including eye contact, smiling, warm personalized greetings, paraphrasing, identifying client feelings, and referring to material from previous sessions. Clients find some events in therapy to be unhelpful or that hinder their progress, like feeling exposed and unprotected, being emotionally overwhelmed, and feeling misunderstood by the therapist.

Practice Implications

Although clients do value therapist expertise in applying therapeutic techniques, they hold therapist personal qualities like warmth, authenticity, honesty, and dedication as necessary prerequisites for therapy. Clients view the therapist’s interpersonal manner as key to forming a therapeutic relationship. It is important that therapists are aware of how they feel towards a client (countertransference), and how these feelings might impact the way in which they communicate through body language, tone of voice, and behaviors. Effective therapists are willing to seek their client’s perspectives, and are open and non-defensive about what a client has to say about the therapy or therapist, even if negative. Therapist openness to feedback will inevitably lead to a stronger relationship and collaboration with the client, and to better outcomes for the client.

Norcross, J. C., & Wampold, B. E. (2019). Relationships and responsiveness in the psychological treatment of trauma: The tragedy of the APA Clinical Practice Guideline. Psychotherapy, 56(3), 391-399.

The American Psychological Association’s (APA) Clinical Practice Guideline for Posttraumatic Stress Disorder in Adults published in 2017 was met with a great deal of concern and criticism by the community of scholars and practitioners working with patients with PTSD. A key concern was that the APA used a biomedical model and not a psychological or contextual model in guiding their understanding of PTSD, their approach to what constitutes evidence, and to decisions about recommended treatments. In particular, the biomedical approach focuses almost exclusively on treatment methods, and down-plays the context of treatment (i.e., the relationship, patient factors, and therapist responsiveness). In this critique, Norcross and Wampold highlight the flaws in the APA Clinical Practice Guideline for PTSD, and the authors focus specifically on those variables that are known to predict patient outcomes but that were ignored by the Guideline. Norcross and Wampold highlighted that there exists numerous meta analyses that demonstrate that all bona fide psychotherapies work about equally well for trauma, and that the particular treatment method has little impact on PTSD outcomes. Yet, the restrictive review process undertaken by APA all but ignored this well-established finding. Also ignored was the research on the importance of the therapeutic relationship in the treatment of trauma. One review outlined nineteen studies that found that the therapeutic alliance was associated with or predicted reduction in PTSD symptoms. This is consistent with the general psychotherapy research literature, in which the alliance is the most researched and most reliable factor related to patient outcomes. Also missing from the PTSD Guideline was reference to a large body of research on therapist responsiveness to patient characteristics. Patients are more likely to improve if their therapists can adapt to the patient’s coping style, culture, preferences, level of resistance, and stage of change. In one study of cognitive-processing therapy (CPT; a treatment recommended by the APA Guideline), there were substantial differences between therapists in their patient’s PTSD symptom outcomes. That is, some therapists reliably were more effective than others, even though all therapists were trained in and supervised in providing the same manualized evidence-based treatment. Among the identified skills of the most effective CPT therapists were: a flexible interpersonal style, and an ability to develop and maintain a good therapeutic alliance across patients.

Practice Implications

There is growing consensus that the APA Clinical Practice Guideline for PTSD are based on dubious methodology and are of limited use to therapists and their patients with PTSD. Psychotherapists should practice a bona-fide therapy for PTSD, but should do so by taking into account the treatment context. In other words, more effective therapists are good at developing, maintaining, and repairing the therapeutic alliance across a range of patients. Effective therapists can also respond and adapt to patient characteristics such as level of resistance, coping style, culture, and stage of change. And so, even when providing a treatment based on the APA Guideline, therapists should nurture trust in the therapeutic relationship and be adaptive to their patients’ characteristics.

Duncan, B. L., & Reese, R. J. (2015). The Partners for Change Outcome Management System (PCOMS): Revisiting the client’s frame of reference. Psychotherapy, 52(4), 391-401.

Generally, psychotherapy is effective for a wide variety of disorders, but regardless, many clients do not benefit. Further, the research shows that some therapists are more effective than others, but therapists tend to grossly over-estimate their effectiveness. In one large survey, therapists reported that their outcomes were better than 75% of their peers, no therapist rated themselves as below average, and therapists tended to over-estimate their effectiveness and under-estimate client deterioration. One way to evaluate patient outcomes and processes is to engage in progress monitoring and feedback. This involves repeated brief assessments of client outcomes followed by real-time feedback to therapists to gauge client progress and signal potential problems. Several such systems exist including the Outcome Questionnaire-45.2 and the Partners for Change Outcome Management System (PCOMS). The PCOMS is made up of the Outcome Rating Scale (ORS) and the Session Rating Scale (SRS). The ORS measures distress in 3 atheoretical domains (personal, family, social) not based on diagnosis. The SRS is a measure of therapeutic alliance. Both the ORS and SRS are very short 4-item scales that can be administered before (ORS) and after (SRS) each session of therapy. In this paper, Duncan and Reese review the research supporting the use of the PCOMS. A meta analysis found that clients whose therapists received feedback with the PCOMS were 3.5 times more likely to experience reliable change and had less than half the chance of experiencing deterioration. Five randomized controlled trials demonstrated the advantage of the PCOMS over treatment as usual, including by reducing drop outs and achieving reliable change in fewer sessions.

Practice Implications

A lot of research has demonstrated that most therapists over-estimate their effectiveness and that many are not able to identify clients who are getting worse. It is time for therapists to acknowledge this positive bias of their effectiveness and their need for quality information in order to make good clinical decisions. Progress monitoring and feedback systems are one means by which therapists can receive quality information. The repeated use of the PCOMS for example, can help to identify when clients begin to deteriorate and/or when problems emerge with the therapeutic alliance. Being able to identify these issues early may allow therapists to act quickly to avert client deterioration or drop out.

Miller, S. D., Hubble, M. A., Chow, D., & Seidel, J. (2015). Beyond measures and monitoring: Realizing the potential of feedback-informed treatment. Psychotherapy, 52(4), 449-457.

Progress monitoring is the process of repeatedly assessing client functioning with validated measures and providing feedback to therapists. The feedback is designed to identify problems with the therapeutic relationship or with client deterioration by comparing client progress to similar clients. This allows therapists to change what they are doing, renegotiate aspects of therapy, or directly address the issues. Research is clear that progress monitoring significantly increases the proportion of clients who improve, reduces drop outs by a third, shortens the length of therapy, and reduces costs. Yet the research also indicates that only 12% of psychologists are using progress monitoring in their practice. If progress monitoring is so useful, then why aren`t more therapists using it? In this review, Miller and colleagues discuss some of the barriers and problems with using or adopting progress monitoring in clinical practice. They describe that even in the most favorable circumstances, it takes about two decades for new treatments to be integrated into routine care. Another issue is that recent surveys indicate that only about 33% of psychologists and 66% of training directors are aware of progress monitoring. Even for those who are aware, a common barrier might be cost and time to implement the procedures. Despite the brevity and low cost of the tools, like the PCOMS, they all place an additional burden on clinicians’ busy schedule. There is also the issue of staff turnover. As staff come and go, organizations may lose those who lead, train, and support the use of progress monitoring. Probably the biggest barrier is skepticism on the part of clinicians who might see the tools as too superficial, or who might be concerned that repeated measurement may somehow negatively affect the therapeutic relationship. However, research indicates that clients generally report positive experiences – they like being a more integral part of the assessment process, and they appreciate the ability to track their own progress. Finally, whereas clinicians may use progress monitoring to improve clinical decision-making, administrators may see it as a means of conducting performance reviews.

Practice Implications

In most health care fields, it can take 20 years for an innovation to make it into routine practice. That might be the case for progress monitoring. More clinicians need to know about it, be trained in its use, and see for themselves that the information is valid, of high quality, and that it can supplement their work in identifying clients who are not doing well. In particular, progress monitoring may be a means of enhancing the therapeutic alliance as it provides therapists and clients a vehicle to discuss how the therapy is going, what needs focus, and what to do if things go awry. Organizations need to treat progress monitoring as a means of helping therapists to improve their skills, and not as a means of auditing performance. Therapists need quality information upon which to make sound clinical decisions, and progress monitoring is one way of receiving this information.

Lingiardi, V., Muzi, L., Tanzilli, A., & Carone, N. (2017). Do therapists' subjective variables impact on psychodynamic psychotherapy outcomes? A systematic literature review. Clinical Psychology & Psychotherapy. Advance online publication.

Psychotherapists differ in their effectiveness such that some therapists are more effective than others, and these differences account for up to 9% of client outcomes. Despite this, not many studies have looked at therapist personal characteristics that might be associated with better or worse outcomes. In this systematic literature review, Lingiardi and colleagues focus on empirical studies of psychodynamic therapists and their personal characteristics that might affect therapeutic processes and client outcomes. The authors included only quantitative studies. Thirty studies representing nearly 1,400 therapists and 6,000 clients were included in the review. Most studies occurred in a naturalistic setting, and most therapists were female (66%) with an average of over 9 years of experience. The studies looked at various therapist personal characteristics and their association with therapeutic processes and client outcomes. Therapist attachment security (ability to engage in meaningful loving relationships and adaptively manage emotions) was associated with better client outcomes. Similarly, therapists who reported better experiences of parental care and better quality relationships with attachment figures tended to have clients who rated a more positive therapeutic alliance. In addition, therapist interpersonal functioning was evaluated in several studies. Therapists who were rated as more affiliative (warm, friendly) and less hostile (cold, rejecting) tended to have clients who achieved better outcomes. Further, therapist facilitative interpersonal skills (emotional expressiveness, verbal fluency, warmth, empathy) were associated with better client outcomes in short-term therapy. Finally, several studies assessed therapist self-concept (stable means by which one treats oneself). Therapists who were more hostile or negative toward the self tended to be more critical or ignoring of clients, which lead to poorer client outcomes.

Practice Implications

Therapist personal characteristics (attachment security), interpersonal skills (warmth, friendliness, empathy), and self concept (how one treats oneself) may account for why some therapists are more effective than others. Problems in these areas might lead to problematic countertransference (emotional reactions on the part of therapists triggered by client issues) or therapeutic alliance ruptures, both of which are related to poorer client outcomes. Therapists can learn methods of managing countertransference and repairing alliance ruptures. If the personal characteristics are persistent and problematic, therapists might consider personal therapy.