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Eubanks, C. F., Muran, J. C., & Safran, J. D. (2018). Alliance rupture repair: A meta-analysis. Psychotherapy, 55(4), 508-519.

It is difficult to over-state the importance of developing and maintaining a therapeutic alliance in order for patients to experience a good outcome from psychotherapy. The alliance is the collaborative agreement between therapist and patient on the tasks and goals of therapy, and the emotional bond between therapist and patient. A previous meta-analysis found a moderate but highly reliable association between a good alliance and patient outcomes. The alliance is a trans theoretical construct – that is, it is important to all types of therapy regardless of theoretical orientation. Sometimes deteriorations in the alliance occur manifested by a disagreement on the goals, a lack of collaboration on the tasks, or a strain in the relational bond. Other terms for this phenomenon include weakenings, misattunements, challenges, resistances, enactments, and impasses. Such deteriorations can vary from minor tensions to major ruptures in the relationship. Tensions and ruptures in the alliance are common occurrences in therapy with some studies showing 50% of therapy cases experience at least a minor tension within the first six sessions of therapy. There are two main types of alliance tensions/ruptures. (1) Withdrawal tensions/ruptures occur when the patient moves away from the therapist, such as when the patient changes the subject, goes silent, and cancels appointments. These tensions/ruptures are more subtle and harder for therapists to detect. (2) Confrontation tensions/ruptures occur when the patient moves against the therapist, such as when the patient expresses dissatisfaction with or pressures or tries to control the therapist. These tensions/ruptures are more obvious, but also difficult for therapists to manage because of the feelings they evoke. In this meta-analysis, Eubanks and colleagues reviewed 11 studies representing 1,314 patients. They found that the association between rupture repair episodes and patient outcomes was on average moderately large r = .29, d = .62, 95% CI [.10, .47], p = .003.

Practice Implications

The research on alliance tensions/ruptures and repairs is still new but points to some important therapist practices that could improve patient outcomes. Therapists must be attuned to indications of tensions and ruptures in the therapeutic relationship. Therapists immediately need to attend to confrontation tensions/ruptures, in which patients express dissatisfaction or hostility. Similarly, therapists must address more subtle withdrawal tensions/ruptures, in which patients go silent, evade, or appease. Therapists can acknowledge the tension/rupture directly and nondefensively by inviting patients to explore their experience of the rupture. If necessary, therapists might change the tasks or goals of the therapy to better match the patient’s concerns. Therapists should empathize with a patient’s negative feelings about the therapy, and validate the patient for bringing up their concerns. If appropriate, therapists should take responsibility for their part in the tension/rupture and not blame the patient. Also, if the tension/rupture is a repetition of an interpersonal pattern for the patient (e.g., the patient tends to withdraw in relationships), then the therapist might consider carefully exploring the tension/rupture as it occurs in the therapy with the understanding that it is a repetitive pattern. Mainly, therapists need to anticipate that tensions and ruptures will occur in therapy, that they can be destabilizing for the therapist and therapeutic relationship, and so therapists need to recognize and know how to explore their own and their patient’s negative feelings.

Author email: catherine.eubanks@einstein.yu.edu

Hayes, J. A., Gelso, C. J., Goldberg, S., & Kivlighan, D. M. (2018). Countertransference management and effective psychotherapy: Meta-analytic findings. Psychotherapy, 55(4), 496-507.

This is another meta analysis from the Psychotherapy Relationship That Work series that will be published in a book by Norcross and Wampold in 2019. Psychotherapists’ unresolved personal conflicts and the cognitive, emotional, or behavioural manifestations of these conflicts in therapy are called countertransference. Countertransference can result in reactions within the therapist that negatively affect their relationship with patients and patient outcomes. Successfully managing these reactions may be an important aspect of positive outcomes in psychotherapy. The old view of countertransference, dating back to Freud, was that countertransference was detrimental to therapy, and therapists had to work to keep their personal reactions out of therapy. More contemporary views see therapist countertransference as inevitable and as providing potentially important information about the patient. In their model of countertransference management, Hayes and Gelso identified five aspects managing countertransference. 1) Origins of countertransference refer to therapists gaining an understanding of their unresolved issues from their past that can interact with patient characteristics in therapy (therapist unresolved family issues, low professional self esteem). 2) Triggers refer to specific issues within the patient that stimulate a specific unresolved issue in the therapist (the patient is competitive and the therapist has a fragile professional self esteem). 3) Manifestations refer to therapist cognitive, behavioural, or affective reactions to triggers and origins (the therapist puts the competitive client in his or her place). 4) Effects refer to the impact of countertransference manifestations on the therapy process or outcome (patient who is put in his or her place drops out or goes silent). 5) Management refers to therapists’ strategies to manage countertransference, including self awareness, self care, consultation and supervision, or personal therapy. In this series of meta analyses, Hayes and colleagues found that: (1) countertransference reactions are associated with poorer therapy outcomes (r = -.16, p = .02, 95% CI [-.30, -.03], d = -0.33, k = 14 studies, N = 973); (2) therapists’ management of countertransference reduces countertransference reactions (r = -.27, p = .001, 95% CI [-.43, -.10], d = -0.55, k = 13 studies, N = 1,065); and (3) successful countertransference management is related to better therapy outcomes (r = .39, p = .001, 95% CI [.17, .60], d = 0.84, k = 9 studies, N = 392 participants).

Practice Implications

The research on countertransference management is still in its early stages but results are promising. Therapists’ ability to identify unresolved issues within themselves, how these issues interact with specific patient behaviors and clinical presentations, and management of therapist reactions are important to their work. The work of psychotherapy is fraught with emotional challenges and potential pitfalls for the therapist. Every therapist will experience confusing or challenging emotional reactions to a client. Better understanding and management of these reactions and their manifestations will not only lead to better patient outcomes, but also to greater therapist personal well-being and work satisfaction.

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.

Practice Implications

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.

Cameron, S. K., Rodgers, J., & Dagnan, D. (2018). The relationship between the therapeutic alliance and clinical outcomes in cognitive behaviour therapy for adults with depression: A meta‐analytic review. Clinical Psychology and Psychotherapy, DOI: 10.1002/cpp.2180.

The therapeutic alliance refers to the collaborative agreement between therapist and client on the tasks of therapy (homework, treatment approach, intervention style) and goals of therapy (to reduce depressive symptoms, to improve interpersonal relationships, to cope better with stress), plus the emotional bond between therapist and client. The alliance is part of a larger concept of therapeutic relationship that also includes the real relationship between client and therapist and the transference relationship (maladaptive relational patterns in the client based on a history of relationships with parental figures). The alliance is thought to be a common factor across different therapeutic orientations, including cognitive behavioral therapy (CBT), time-limited psychodynamic psychotherapy (TLPP), and interpersonal psychotherapy (IPT). In fact, the alliance is known to have a moderate and robust relationship to client outcomes regardless of who rates the alliance (therapist, client, observer), which measure is used, and when in therapy the alliance is rated (early, middle, late). Although Beck emphasized the alliance as a key therapeutic principle in CBT, some CBT writers argue that the alliance is not so important. In this study, Cameron and colleagues conducted a meta analysis of 13 randomized controlled trials that assessed the relationship between therapeutic alliance and CBT outcomes for depression in adult clients. The overall mean correlation between therapeutic alliance and outcome was r = 0.26 (95% CI [.19–.32]), which indicates a moderate and significant relationship. This is very close to the value found in a larger meta analysis of over 200 alliance – outcome studies.

Practice Implications

The study demonstrates the importance of the therapeutic alliance to client outcomes in CBT. The association was at similar levels to those found in other types of therapy. Therapists conducting CBT should attend to building and maintaining an alliance, which provides a context to facilitate CBT interventions. If a client is not completing homework for example, it is likely that there is a lack of agreement on tasks of therapy, and this part of the alliance may need to be renegotiated. Therapists may also benefit from routinely assessing the alliance in therapy with their clients on a session by session basis using short and easy to use measures. Reviewing these scales regularly can alert a therapist to potential problems in the alliance and the need to repair any tensions or ruptures.

Palpacuer, C., Gallet, L., Drapier, D., Reymann, J-M., Falissard, B., & Naudet, Florian (2016). Specific and non-specific effects of psychotherapeutic interventions for depression: Results from a meta-analysis of 84 studies. Journal of Psychiatric Research.

Specific effect in psychotherapy refer to those technical interventions that are based on a treatment model that are specific to a particular modality. For example, the effects on symptoms caused by transference interpretations, cognitive restructuring, or exposure might all be considered specific effects. Non-specific effects is a very broad term that sometimes refers to effects on symptoms caused by common factors across all psychotherapies like therapist empathy, therapeutic alliance, or positive regard. Non-specific effects has also been used to refer to any extra-therapeutic effects that are more peripherally related to treatments, like type of control groups used in a study, researcher allegiance, number of treatment sessions, or length of follow-up. In this meta-analysis of 84 studies of over 6000 participants, Palpacuer and colleagues examined the association between non-specific factors (defined as intervention format [group or individual], client demographics, number of treatment sessions, length of follow up, and researcher allegiance to one of the treatment modalities) and treatment outcomes for depression. First, they looked at whether the specific type of intervention (cognitive behavioral, psychodynamic, interpersonal, problem solving, and others) was associated with reductions in depressive symptoms. Second, they assessed if the non-specific factors added to the prediction of improved depressive symptoms and accounted for some of the effects of specific types of interventions. Similar to previous findings, all psychotherapies were significantly more effective than waiting-list controls. However, the effects of the specific intervention approaches became non-significant when the non-specific factors were included in the analysis. That is, non-specific factors seemed to account for some of the effects of the specific treatments. In particular, if the study was conducted in North America vs Europe (β = 0.55, 95% CI: 0.22; 0.90), if the researcher had an allegiance to a particular therapeutic approach (β = 0.29, 95% CI: 0.07; 0.52), or if the number of sessions was higher (β = 0.03, 95% CI: 0.01; 0.04) then depressive outcomes were better.

Practice Implications

This meta analysis of over 87 studies suggests that although various psychotherapies are effective, there remain questions about how and why they work. For example, the findings suggest that North American patients may have different expectations and higher responses to treatment, that a researcher's belief in the effectiveness of their favored intervention actually improves patients' outcomes, and that a higher number of sessions may also result in better outcomes. These factors appear to account for an important proportion of the specific effects of each type of psychotherapy.

Cristea, I.A., Gentili, C., Cotet, C.D., Palomba, D., Barbui, C., & Cuijpers, P. (2017). Efficacy of psychotherapies for borderline personality disorder: A systematic review and meta-analysis. JAMA Psychiatry. doi:10.1001/jamapsychiatry.2016.4287.

Borderline personality disorder (BPD) is a debilitating disorder characterized by: severe instability of emotions, relationships, and behaviors. More than 75% of those with BPD have engaged in deliberate self-harm, and suicide rates are between 8% and 10%. BPD is the most common of the personality disorders with a high level of functional impairment. Several psychotherapies have been developed to treat BPD. Most notably, dialectical behavior therapy (DBT), cognitive behavioral therapy (CBT), and psychodynamic treatments like mentalization-based and transference-focused psychotherapy. This meta-analysis by Cristea and colleagues examined the efficacy of psychotherapy for BPD. Studies included in the meta-analysis (33 trials of 2256 clients) were randomized controlled trials in which a psychotherapy was compared to a control condition for adults with BPD. For all borderline-relevant outcomes (combined borderline symptoms, self-harm, parasuicidal and suicidal behaviors) yielded a significant but small effect of the psychotherapies over control conditions at post treatment (g = 0.35; 95%CI: 0.20, 0.50). At follow up, there was again a significant effect of the psychotherapies over control conditions with a moderate effect (g = 0.45; 95% CI: 0.15, 0.75). When the different treatment types were looked at separately, DBT (g = 0.34; 95% CI: 0.15, 0.53) and psychodynamic approaches (g = 0.41; 95% CI: 0.12, 0.69) were more effective than control interventions, while CBT (g = 0.24; 95% CI: −0.01, 0.49) was not. The authors also reported a significant amount of publication bias, suggesting that published results may be positively biased in favor of the psychotherapies.

Practice Implications

The results indicate a small effect of psychotherapies at post-treatment and a moderate effect at follow-up for the treatment of BPD. DBT and psychodynamic treatment were significantly more effective than control conditions, whereas CBT was not. However, all effects were likely inflated by publication bias, indicating a tendency to publish only positive findings. Nevertheless, various independent psychotherapies demonstrated efficacy for symptoms of self harm, suicide, and general psychopathology in BPD.