Blog
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.
This month...
…I blog about the treatment of depression, the effects of role induction in psychotherapy, and negative experiences in psychotherapy from clients’ perspective.
Type of Research
Topics
- ALL Topics (clear)
- Adherance
- Alliance and Therapeutic Relationship
- Anxiety Disorders
- Attachment
- Attendance, Attrition, and Drop-Out
- Client Factors
- Client Preferences
- Cognitive Therapy (CT) and Cognitive-Behavioural Therapy (CBT)
- Combination Therapy
- Common Factors
- Cost-effectiveness
- Depression and Depressive Symptoms
- Efficacy of Treatments
- Empathy
- Feedback and Progress Monitoring
- Group Psychotherapy
- Illness and Medical Comorbidities
- Interpersonal Psychotherapy (IPT)
- Long-term Outcomes
- Medications/Pharmacotherapy
- Miscellaneous
- 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
- Termination
- Therapist Factors
- Training
- Transference and Countertransference
- Trauma and/or PTSD
- Treatment Length and Frequency
September 2023
Clients’ Negative Experience of Psychotherapy
Vybíral, Z., Ogles, B.M., Řiháček, T., Urbancová, B., & Gocieková, V. (2023) Negative experiences in psychotherapy from clients’ perspective: A qualitative meta-analysis, Psychotherapy Research, DOI: 10.1080/10503307.2023.2226813
Psychotherapy research tends to focus on positive patient outcomes – or patients who get better. More recently, psychotherapy researchers have focused on negative outcomes and client experiences of negative events in psychotherapy. Approximately 5% of clients get worse, 20% of clients in clinical trials drop out, and about 66% of clients do not recover by the end of treatment. All of this suggests that some clients have negative experiences during therapy that may interfere with their progress. One can learn a lot from studying processes that do not go well. Potentially, therapists can learn what not to do, how to avoid pitfalls, how to recognize when the client has a negative experience, and how to repair an error. In this qualitative meta-analysis, Vybiral and colleagues reviewed 51 studies that recorded client statements from post-treatment interviews. Through qualitative analysis, the authors reported four major clusters representing clients' negative experiences, specific therapist behaviours within each cluster, and the percentage of studies in which clients noted these specific behaviors. The first cluster was Therapist Misbehaviors including therapists not listening (17% of studies), therapists not understanding (37%), therapists perceived incompetence (37%), therapists devaluing clients (56%), therapists judging (33%), and therapists using the client for their own benefit (27%). The second cluster was Hindering Aspects of the Therapeutic Relationship including therapists’ lack of empathy (44%), lack of trust in the therapist (21%), clients experiencing confusion (23%), and poor interpersonal match (25%). The third cluster was Poor Treatment Fit including negative evaluation of the procedures or practical aspects of treatment (33%), unmet client expectations about therapy (33%), lack of fit with the interventions (65%), and dissatisfaction with how therapy ended (50%). The fourth cluster was Negative Impacts of Treatment including that therapy was unhelpful (46%), that problems increased (37%), fearing the therapy process (50%), loss of hope (23%), unpleasant feelings during therapy (60%), negative thoughts caused by therapy (35%).
Practice Implications
This research indicates that the qualities of the therapist, the therapeutic relationship, the treatment provided, and the outcomes are key to clients’ perceptions of their therapy experience. A therapist's positive regard, genuineness, and empathy have long been considered necessary conditions for successful therapy. In addition, there is substantial research on the importance of the therapist and client developing a collaborative agreement on the goals of therapy and how therapy proceeds, that is – aspects of the therapeutic alliance. Therapists also must keep in mind that clients must develop realistic expectations of therapy like its duration, what gets discussed, and how therapy proceeds. Expectations are well-known predictors of client outcomes. Finally, therapists must monitor patient outcomes and processes, and modify what they are doing if the client experiences a precipitous increase in symptoms or a decrease in the alliance from one session to the next.
Preparing Patients for Psychotherapy
Swift, J. K., Penix, E. A., & Li, A. (2023, March 13). A meta-analysis of the effects of role induction in psychotherapy. Psychotherapy. Advance online publication. https://dx.doi.org/10.1037/pst0000475
Many patients struggle with the start of psychotherapy. In fact, many patients drop out of psychotherapy within the first few sessions likely because of anxiety or their expectations not being met. One way of helping patients start therapy on the right foot is to prepare them for what to expect and how therapy will proceed. Patient preparation, also known as role induction, is the process of providing patients with education for psychotherapy to ensure they have accurate expectations of their role, their therapist’s role, a rationale for treatment activities, and approximate treatment duration. This discussion with patients often occurs early in therapy and sometimes in the initial assessment session. Therapists might provide the information on their websites, on paper when the patient comes to the first session, or verbally during the session. In this meta-analysis, Swift and colleagues did a systematic review of the research on patient preparation and found 17 studies on the topic that met their criteria. Patients who received role induction had more positive behaviours during the subsequent session (accurate knowledge, appropriate expectations, higher satisfaction) compared to patients who did not get the preparation (d = 0.64, 95% CI [0.25, 1.03], p < .01, r = .31). Patients who received pre-therapy preparation were 1.64 times less likely to drop out of therapy than those who were not given the preparation (95% CI [1.06, 2.53], p = .03). The overall effect on post-treatment outcomes (symptom reduction) was statistically significant, such that those who received the role induction were more likely to have better outcomes than those who did not (d = 0.33, 95% CI [0.11, 0.55], p < .01, r = .16), although the effect was small. The largest effect occurred when role induction focused on the expected roles of the patient and therapist and on the duration of therapy. Also, larger effects occurred when therapists provided patients with the information in person and verbally rather than in a written format.
Practice Implications
It might be useful to assess the patient’s knowledge of psychotherapy, including what they expect their roles to be, what the therapist’s role is, how treatment will proceed, and the expected duration of treatment. This information might lead to a discussion about what to expect and what is realistic in therapy and this discussion should occur at the very start of therapy. A therapist might provide more information on those areas in which a patient may misunderstand or may have unrealistic expectations. Regardless, it is a good idea to discuss patient and therapist roles and to provide a rationale for the treatment. Preparing patients will have a greater impact if therapists provide the information as part of a verbal discussion that is personalized to the patient and is culturally appropriate.
Psychological Treatment of Depression
Cuijpers, P., Miguel, C., Harrer, M., Plessen, C.Y., ….Karyotaki, E. (2023). Psychological treatment of depression: A systematic overview of a ‘Meta-Analytic Research Domain’. Journal of Affective Disorders, 335, 141-151. https://doi.org/10.1016/j.jad.2023.05.011
About 280 million people worldwide suffer from depression, and this has enormous economic consequences for society. The main treatments for depression include pharmacotherapy and psychotherapy, with over 850 randomized controlled trials (RCTs)of psychotherapy assessing outcomes across all age groups. There are over 100 meta-analyses looking at the effects of psychotherapy for depression, but no single review of the entire literature exists. In this “Meta-analytic Research Domain”, Cuijpers and colleagues describe their attempts to develop a “living” systematic review that they updated regularly. In this update, the authors provide an overview of what has been learned from RCTs of psychotherapy in the treatment of depression. To start, they used the American Psychological Association's definition of psychotherapy as “the informed and intentional application of clinical methods and interpersonal stances derived from established psychological principles for the purpose of assisting people to modify their behaviours, cognitions, emotions, and/or personal characteristics…”. The effects of psychotherapy for depression appear to be moderate. The overall response rate (50% reduction in symptoms) was 41% for psychotherapy and 16% for no treatment. Remission from depression (no clinically elevated depressive symptoms) at post-treatment was about 33%, whereas about 10% of patients in control conditions (no treatment or treatment as usual) remitted after therapy. These effects of time-limited psychotherapy are maintained in the longer term. Although CBT is the most studied therapy, there are no differences between different types of psychotherapy in the treatment of depression. Psychotherapy is effective across the lifespan, but the effects for children and adolescents tend to be smaller. Combined treatment of psychotherapy and pharmacotherapy was more effective than psychotherapy alone (RR = 1.27; 95% CI: 1.14-1.29) or pharmacotherapy alone (RR = 1.25; 95% CI: 1.13-1.37). Most patients in these studies had moderate to severe depression. The average response rate (50% reduction in symptoms) was 29% for psychotherapy or pharmacotherapy alone, but combining treatments resulted in 12% to 16% higher response rate. Psychotherapy was more effective than pharmacotherapy at 6 months to 12 months follow-up. One key downside of the research is that Cuijpers and colleagues classified only 31% of studies as having a low risk of bias (i.e., high-quality studies with sufficient sample sizes and other state-of-the-art procedures), and the risk of publication bias (suppression of negative findings) was high. Low-quality studies and publication bias tend to inflate the effects of treatments.
Practice Implications
There is a large and varied research literature on the effects of psychotherapy on depression. The authors noted no differences among the time-limited therapies, so bona fide and tested treatments will be equally effective. Overall, time-limited psychotherapy is modestly to moderately better than no treatment, with about one-third of treated patients no longer being depressed after time-limited psychotherapy. Results in more severely depressed patients are better with combined treatment of pharmacotherapy plus psychotherapy.
August 2023
Therapists Tend to Overestimate their Effectiveness
Constantino, M. J., Boswell, J. F., Coyne, A. E., Muir, H. J., Gaines, A. N., & Kraus, D. R. (2023). Therapist perceptions of their own measurement-based, problem-specific effectiveness. Journal of Consulting and Clinical Psychology, 91(8), 474–484. https://doi.org/10.1037/ccp0000813
Previous research showed that therapists may be over-confident about their effectiveness. In one study, 91% of therapists felt that they were more effective than 75% of their peers, and 100% of therapists felt that they were more effective than 50% of their peers. These therapist perceptions relative to their peers are statistically impossible. What is the impact of this over-confidence on patient outcomes? In this study, Constantino and colleagues evaluated the perceptions and outcomes of 50 therapists who treated 1,363 patients (about 27 patients per therapist). Most therapists practiced CBT, integrative, or interpersonal psychotherapy. Patients had a variety of problems including depression, anxiety, sleep, social functioning, etc. Patients self-report of symptoms in 12 problem domains (depression, anxiety, etc.) from pre to post treatment. Therapists were asked to report on their perception of their effectiveness by rating from “mostly effective” to “mostly ineffective” for each patient problem domain. Then therapists’ ratings of their effectiveness were compared to their patients’ actual measurement-based outcomes from pre- to post-treatment. In this manner, therapists were classified as accurately estimating their outcomes, or as underestimating their outcomes, or as overestimating their outcomes compared to their patients’ outcome data. The researchers also controlled for case mix (complexity and size of the therapists’ caseload) and patient symptom severity at pre-treatment. For 7 of 12 patient problem domains, at least half of the therapists overestimated their own effectiveness. For the remaining 5 domains, most therapists accurately estimated their effectiveness. There were no domains for which most therapists underestimated their effectiveness. In 11 of the 12 patient problems, therapists were no better than chance at predicting their own effectiveness compared to patient rating. However, therapists who underestimation their effectiveness had patients with better outcomes at post-treatment, and this effect was stronger for patients with higher pre-treatment symptom severity. Conversely, therapists who overestimated their outcomes had patients with worse outcomes, and this effect was stronger for patients with higher pre-treatment symptom severity.
Practice Implications
Relative to patient self-reported measurement-based outcomes, therapists tend to be over-confident about their effectiveness. This over-confidence has implications for patients’ outcomes. Patients of therapists who show more humility about their effectiveness (tend to be neutral or under-estimate their effectiveness) have better outcomes. This is particularly true for patients with more severe symptoms. One of the few therapist factors known to predict better outcomes is professional self-doubt - the willingness to critically evaluate one’s practices and to continually improve one’s skills. Self-doubt may allow therapists to be more alert to potential signals that the therapy is off course, that they might have committed a micro-aggression, or that there was a therapeutic alliance rupture. Humility might allow the therapist to flexibly respond, change course, or repair the therapeutic relationship when necessary.
Client Factors that Predict Outcomes
Swift, J. K., Owen, J., & Miller, S. D. (2023). Client factors. In S. D. Miller, D. Chow, S. Malins, & M. A. Hubble (Eds.), The field guide to better results: Evidence-based exercises to improve therapeutic effectiveness (pp. 47–78). American Psychological Association. https://doi.org/10.1037/0000358-004
Research over 5 decades has demonstrated that client contributions explain the majority of the variance in psychotherapy outcome. That is, patient factors are much more predictive than the type of therapy offered. Effective therapists adjust their interactions and interpersonal stances to relevant patient characteristics. Most demographic variables are not related related to patient outcomes (age, gender, education level, socio-economic status). In this chapter, Swift and colleagues review the research on patient factors that are reliably associated with improvements in psychotherapy. Here I review of few of these factors. Role expectations and preferences refer to patients’ beliefs and preferences about what is likely to happen in therapy – that is, type of therapy, type of therapist, how active or passive the patient or therapist will be, and how long therapy might last. Research indicates that pre-therapy education and preparation results in improved client outcomes (d = .34). Patients’ motivation is also associated with more engagement and better results. Therapists who tailor interventions to patient motivation level result in better outcomes (d = .41). Client attachment style is also associated with patient outcomes such that those with more secure attachments tend to experience greater symptom relief (d = .35), and that reductions in insecure attachment is also related to better outcomes. Finally, reactance or resistance refers to the emotional reaction of patients when they feel stressed or threatened. This may result in rejecting an intervention or therapist. A recent meta-analysis found a large positive effect (d = .79) when therapists of highly resistant patients took a more passive stance and when therapists of less resistant patients took a more active stance in therapy.
Practice Implications
Studies suggest how best to adapt interventions and therapist interpersonal stances for some patients based on their characteristics. Regarding expectations and preferences, therapists might spend time preparing their patients for what will happen in therapy and by collaboratively coming to an agreement on how therapy will proceed. Therapists should also tailor their interventions to the level of their patient’s motivation by focusing on supportive interventions when motivation is low (patients at the pre-contemplation stage of change), or helping the patient to set goals and make plans for changing behaviors when the level of motivation is moderate (patients at the preparation stage of change). For attachment insecurity, therapists who engage in interventions to help clients to experience more attachment security might see greater effects of therapy. These interventions might involve improving the patient’s quality of relationships, emotion regulation, and reflective capacities. The findings also suggest that therapists should be less directive with patients who have high levels of reactance or resistance but more directive for patients who have lower levels of reactance or resistance. These therapist interpersonal stances tailored to level of patient expectations, attachment style, motivation, and resistance have a better chance of engaging the client in therapy.
Characteristics of Psychologists Conducting Psychotherapy
Norcross, J. C., Rocha, M. N., & Chrysler, A. A. (2023, May 18). Psychologists conducting psychotherapy in 2022: Contemporary practices and historical patterns of the Society for the Advancement of Psychotherapy. Psychotherapy. Advance online publication. https://dx.doi.org/10.1037/pst0000493
Every 10 years or so the Society for Advancement of Psychotherapy (American Psychological Association, Division 29) conducts a survey of its membership to take a snapshot of their characteristics and activities. The membership is a diverse group of practicing psychotherapists and psychotherapy researchers with doctoral degrees in psychology in the U.S. The Society’s membership is not representative of all psychologists who practice psychotherapy, but the fact that the survey has taken place every decade since 1981 allows one to get a sense of some historical trends in the field. Previous surveys showed an increasingly female and culturally diverse membership. Theoretical orientations have tended to favor psychodynamic and cognitive-behavioral models, and primary employment has shifted from hospitals and community clinics to independent practices and universities. In this survey, Norcross and colleagues randomly selected 1000 members of the Society and received a 48% return rate. 65% were male and 35% were female, and the proportion of women has steadily grown from 27% in 1981. Most of the sample was White (90%). The average age was 68 years (SD = 13), and there has been a steady increase in age since 1981 when the average age was 46. On average, psychologists devoted 44% of their professional time to psychotherapy, 11% to research and writing, and 10% to teaching. There has been a gradual decline in the percentage of psychologists routinely supervising from 65% in 1981 to 37% in 2022. The percentage of psychologists providing diagnosis and assessment also declined from 55% in 2012 to 37% in 2022. Most psychologists (99%) provided individual therapy, but many also provided couple therapy (75%), and group therapy (20%) during some of their professional time. Psychologists working in public hospitals and community clinics continued to decrease from 16% in 1981 to 3% in 2022. In 2022, the most frequent theoretical orientations were psychodynamic/relational (29%), integrative (26%), and cognitive/cognitive-behavioral (CBT; 18%). CBT has steadily increased in popularity from 8% in 1981 to 18% in 2022. Of the respondents, 82% indicated that they received personal therapy at least once during their career. On average, 94% were satisfied at least to some degree with their careers, and 78% indicated that if they had to do it over again, they would choose to pursue a career in psychotherapy.
Practice Implications
This survey is not perfect and it likely is not representative of the population of psychologists who provide psychotherapy. Nevertheless, it does suggest some interesting historical trends. The average psychotherapist in these surveys appears to be getting older over time. This may indicate that younger psychotherapists are not aligning themselves with traditional organizations that provide a community of like-minded professionals. That is unfortunate as it limits the continuing education and supportive networks that could be available to a younger professional. On the positive side, many psychotherapists have pursued personal therapy during their careers and this trend has been consistent over the years. Further most psychotherapists are quite satisfied with their careers despite the stress related to doing this type of work.