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
Research on Clinical Supervision
Knox, S. & Hill, C.E. (2021). Training and supervision in psychotherapy: What we know and where we need to go. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7th ed.). Wiley. Chapter 10.
Supervision is a key aspect of training to be a mental health professional. There is also a gate-keeping role in that supervisors evaluate whether trainees are sufficiently competent to graduate and to seek credentialing or licensure. Most clinical supervision is either individual in nature (one supervisor and one trainee) but some training programs also employ a group supervision format. Despite a long history of supervision as a key training modality in psychotherapy, the research is surprisingly sparse and inconclusive about the utility of supervision. In this part of the chapter, Knox and Hill review some of the research on clinical supervision. The findings suggest that some supervisors are better at establishing a supervisory alliance with trainees than other supervisors. Supervisor traits that facilitate a supervisory alliance and other positive outcomes (supervisee satisfaction, insight, growth, increased confidence, enhanced work with clients; stronger supervision relationship) included supervisor openness, credibility, and capacity to maintain appropriate boundaries. Supervisor empathy, engaging in reflective practice, and attending to parallel process in supervision were associated with supervisee satisfaction, increased supervisee self-disclosure, reduced supervisee anxiety, and improved supervisee work with clients. On the other hand, supervisors’ errors in technique (minimal input in supervision, gender discrimination, nonadherence to ethical guidelines) were linked with supervisee discouragement, negative emotions, reduced involvement and satisfaction, and weaker supervisory alliances. Finally, a strong supervisory alliance (i.e., agreement on training goals, agreement on tasks of supervision, and the supervisory relational bond) is associated with reduced supervisee anxiety, increased supervisee self-disclosure and self-efficacy. Despite the positive effects on the trainee’s sense of competence, comfort, and self-efficacy, there is little research linking supervision to better patient outcomes.
The research suggests that the quality of the supervisory relationship has an impact on the supervisee and on the supervision process. Supervisors who are open, engaging, warm and empathic are more likely to engage supervisees to be self-disclosing and self-reflective in their work. Supervisors should focus on developing a solid supervisory alliance by establishing supervision goals (a collaborative agreement between supervisee and supervisor on the desired outcomes of the supervision), the tasks of supervision (how the supervision will proceed, what will be discussed or learned), and to help the trainee to experience supervision as a safe environment to explore new ways of being with their clients.
Do Psychotherapists Get Better with Experience and Training?
Wampold, B. & Owen, J. (2021). Therapist effects: History, methods, magnitude, and characteristics of effective therapists. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7th ed.). Wiley. Chapter 9.
One of the defining characteristics of expertise is the overall improvement in skills and performance over the course of one’s career. We can identify, for example, that there are experts in chess, tennis, surgery, and musical performance based on performance. Expertise in these areas is explicitly developed partly because there is clear and immediate feedback regarding performance (i.e., a tennis player knows immediately that they missed a serve, and so they make an adjustment on the next serve). In psychotherapy, this is not so easy. Therapists rarely receive immediate feedback about their specific interventions or interpersonal responsiveness to a patient. In this part of the chapter, Wampold and Owen review the research on the relationship between therapist experience and training and patient outcomes. They focus on high quality studies that disentangled therapist from patient effects. Overall, the evidence does not support the notion that the more experience that a therapist accumulates the better their patients’ outcomes. In fact, one study that tracked therapists over time (up to 18 years) found that patients’ outcomes got slightly worse with more experience. Similar findings occur for training of student therapists. For the most part, more training that student therapists received over a 12-to-42-month period was not associated with better patient outcomes. There is some evidence that trainees can improve their capacity to develop a therapeutic alliance, and that with more deliberate practice (focused, immediate attention and feedback on specific skills) therapists can realize better outcomes with their patients.
As a senior therapist who is very involved in training, I find these results discouraging. Nevertheless, the solutions offered by the research do provide a ray of hope. Providing therapists with specific and immediate feedback about patient outcomes and therapeutic processes (e.g., ratings of patient distress and of the alliance after every session), has the potential for helping therapists to inform their practice, make adjustments, and develop expertise. Deliberate practice of specific skills in psychotherapy (e.g., ways of addressing an alliance rupture or of responding to intense emotion) may also improve therapist expertise and patient outcomes. It is also quite possible that the focus on learning specific manualized protocols, which is often the goal of graduate and post-graduate training, may not be the most effective training and professional development.
Burnout in Psychotherapists
Simionato, G. K., & Simpson, S. (2018). Personal risk factors associated with burnout among psychotherapists: A systematic review of the literature. Journal of Clinical Psychology. Advance online publication.
Burnout is an important factor in work-related problems for psychotherapists. Burnout is defined as a type of stress associated with feelings of exhaustion, disconnection, and self-doubt related to emotionally involved work in helping professions. Maslach described burnout as being composed of three factors: emotional exhaustion (personal and emotional fatigue at work), depersonalization (negative feelings about clients and the work), and a reduced sense of personal accomplishment (low personally related work successes). Psychotherapists are inclined to burnout because of the emotionally taxing work during which they must remain empathic. In order to protect themselves and conserve energy, psychotherapists may detach from clients, which may lead to a lower sense of work satisfaction and work accomplishments. High levels of burnout reduce a psychotherapist’s ability to take care of themselves and their clients. In this systematic literature review, Simionato and Simpson found 40 studies that empirically examined burnout among psychotherapists and the possible correlates or causes. Results of the 40 articles represented almost 9,000 therapists. Over 54% of therapists reported moderate to high levels of stress related to burnout. On average, therapists reported moderate to high levels of emotional exhaustion, depersonalization, and low personal accomplishment. Younger age was the most frequently identified risk factor for psychotherapist burnout, as was over-involvement with client problems. The authors suggested that the association between burnout and being younger may be due to being less experienced and to higher levels of unattainable standards for clinical practice and client outcomes. In addition, being female was associated with higher reported levels of burnout. This may be due to stress related to women having to juggle demands of both work and domestic responsibilities. Young clinicians are more likely to have young families, and women may be particularly prone to work-life conflict while managing the demands of both.
Over half of psychotherapists reported moderate to high levels of burnout that could affect their work, their clients’ outcomes, and their personal well being. Training programs might facilitate self-awareness and the capacity for psychotherapists to reflect on their personal strengths, limitations, and maximum workload capacity in order to find the best fit between their personality, circumstances, and job demands. Practicing therapists might consider personal therapy to help cope better with demands of work and home life. Surveys of psychotherapists consistently showed that about 70% have sought psychotherapy at some point in their careers.
Therapeutic Relationship Predicts Pharmacological Treatment Outcomes
Totura, C.M.W., Fields, S.A., & Kraver, M.S. (2018). The role of the therapeutic relationship in psychopharmacological treatment outcomes: A meta-analytic review. Psychiatric Services, 69, 41-47.
There is evidence to suggest that pharmacological treatments are effective for a wide range of disorders. However, a high level of adherence to taking psychotropic medications is necessary in order for them to have a chance of working. Medical interventions in general do not work well when patients are non-adherent to the regimen, and non-adherence is a significant problem in medicine. Treatment adherence is particularly problematic in those with a mental health condition. Low adherence may have to do with problems with the medications themselves, like unpleasant side effects. And low adherence also may be due to issues related to mental health impairment, like low motivation and problems with reasoning. A particular issue in mental health treatment is the manner in which patients receive the medication. Unlike some medical interventions, psychotropic medications are often taken by patients on their own and away from the clinic or hospital. In psychotherapy, we know that a good therapeutic alliance improves outcomes partly because a good alliance provides a context within which psychological interventions can work (i.e., clients may be more adherent to the treatment recommendations) and partly because the alliance itself may be therapeutic. In this meta analysis, Totura and colleagues examine if there is an association between the therapeutic alliance and mental health outcomes for patients who receive pharmacological interventions for their mental illness symptoms. Eight studies of 59 samples representing over 1,000 patients were included. Four studies were of pharmacological treatment for affective disorders, two for schizophrenia, and two for mixed diagnoses. The results indicated a statistically significant and moderate effect: z = .30 (CI=.20, .39, SE=.048, z=6.192, p=.05), such that greater therapeutic alliance predicted better mental health outcomes among patients receiving pharmacotherapy.
Higher quality of the physician-patient relationship was related to better mental health treatment outcomes for patients taking pharmacotherapy. The therapeutic alliance appears to be just as import in pharmacological treatment as it is in psychotherapy. It is possible that a good alliance with the provider may increase patient adherence, which may lead to better outcomes. It is also possible, however, that the alliance itself is therapeutic. That is, negotiating an alliance and repairing alliance tensions may lead to positive changes in patients’ ability to cope with emotions and to make the most of their social supports. The results also suggest the importance of training physicians in communication skills to improve therapeutic relationships.
Research on Training and Continuing Education in Psychotherapy
Hill, C. & Knox, S. (2013). Training and supervision in psychotherapy. In M.E. Lambert (Ed.), Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change, 6th Edition (pp. 775-811). New York: Wiley.
Research on training and supervision in psychotherapy has proven to be very difficult to conduct. Part of the difficulty with the research is that the process under study is highly complex with many interacting variables. Therapists and supervisors have different personal qualities, patients have different levels of problems, training programs differ, supervision styles differ, and therapists and supervisors differ in terms of experience, case load, knowledge, and training background. Nevertheless there exists a moderately large literature on training, supervision, and continuing education in psychotherapy. However, the findings so far have been mixed and somewhat disappointing. In their chapter in the Handbook, Hill and Knox (2013) tackle the difficult task of summarizing this literature and giving some coherence to the findings. Is training and supervision effective? Hill and Knox tentatively conclude that the answer is “yes”. They provide some evidence that novice therapists can be trained in helping skills, that trainees improve over the course of training, that supervision enhances trainees’ awareness of self and others and improves their autonomy, and that experienced therapists, including those in the community can be trained to use manuals. Despite these positive findings, the existing literature also provided some sobering results. These less supportive findings include: that nonsupervised therapists did not differ from supervised therapists on therapy alliance and patient outcomes, that supervision sometimes has negative effects on trainees and their patients, that therapist experience may not be related to better patient outcomes, and that some highly facilitative non-professionals can be just as effective as trained therapists. What contributes to making training and supervision effective? The research in psychotherapy training and medical education is clear on this question: hands-on experience is key to learning a practice-based skill such as psychotherapy. Practice is the most helpful component of skills training. In medical education research, systematic reviews have shown that traditional didactic learning (i.e., classroom style lectures) had no significant impact on physician behaviors or patient outcomes. However, interactive programs (especially supervised rehearsal of skills) did have a significant positive impact on physician behaviors and patient outcomes. Furthermore, psychotherapy supervisees reported that supervisors who were open, empathic, and who provided supportive nurturance in the context of a good supervisory alliance were most helpful to trainees to develop and improve their clinical skills.
Practicing clinicians who want to get the most out of continuing education should look for opportunities in which they get hands-on experience and continuous supervision in providing the psychotherapy intervention. Other than acquiring a limited amount of knowledge, didactic training alone without practice will likely have little impact on practice. The research also indicates that supervisors and trainees who are able to develop a good supervisory alliance, and supervisors who are open and empathic are more likely to result in improved psychotherapy skills in trainees and better outcomes in patients. Binder and Henry (2010) describe the importance of “deliberate practice” in psychotherapy training and continuing education that includes: performing a task at an appropriate level of difficulty, receiving immediate and informative feedback from a supervisor, and having the opportunity to repeat the skill and correct errors.