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.

December 2023

Is empathic accuracy enough? The role of therapists’ interventions in the associations between empathic accuracy and session outcome.

Stolowicz-Melman, D., Lazarus, G., & Atzil-Slonim, D. (2023). Is empathic accuracy enough? The role of therapists’ interventions in the associations between empathic accuracy and session outcome. Journal of Counseling Psychology, 70(6), 682–690. https://doi.org/10.1037/cou0000708

Therapist empathy (as rated by patients) is a well-known predictor of positive patient outcomes in psychotherapy. Empathy can take many forms (empathic resonance, expressed empathy, received empathy), but one that is less well-researched is the therapist’s empathic accuracy. Empathic accuracy refers to the congruence (agreement) between a patient’s emotional state and the therapist’s perception of the patient’s emotional state. That is, therapists’ capacity to accurately perceive their patient’s inner experiences. In this study, Stolowicz-Melman and colleagues assessed therapist and patient congruence in therapists’ ratings of the patient’s emotional state during a session. The authors also looked at the impact of that congruence (or lack of congruence) on the patient’s ratings of the session’s effectiveness (session outcomes). In addition, the researchers examined whether different types of therapist interventions affected the impact of congruence (empathic accuracy) on a patient’s evaluation of a session. The authors hypothesized that more exploratory interventions (therapists identifying and labelling feelings, focusing on moment-to-moment client emotions) and fewer directive interventions (therapists setting an agenda, reviewing homework) would result in a stronger association between therapist empathic accuracy and session outcomes as rated by the patient. The study had 81 patients and 50 therapists. Patients and therapists rated the patient’s mood after each of at least 6 sessions of therapy. The congruence (agreement) between the patient's and therapist's rating of the client's mood was an index of therapist empathic accuracy. Clients also evaluated the effectiveness of each session of therapy. The results suggested that greater therapist empathic accuracy for negative emotions was associated with better session evaluations (outcomes) rated by patients. Exploratory, and not directive, interventions resulted in a stronger effect of therapist empathic accuracy for negative emotions on session evaluations.

Practice Implications

The results suggest that therapists need to recognize negative emotions in their patients, offer support and empathy, and at the same time help the patient explore and process these emotions. Empathic accuracy is not enough, however, when a patient is experiencing a negative emotion. Patients need therapists to help them recognize their experiences and to explore their meaning in words. As Stolowicz-Melman and colleagues conclude, therapist exploration of patients’ emotions may help patients tolerate and regulate painful feelings and achieve better session results.

November 2023

Therapist Qualities That Lead to Treatment Failure or Termination

Alfonsson, S., Fagernäs, S., Sjöstrand, G., & Tyrberg, M. J. (2023). Psychotherapist variables that may lead to treatment failure or termination—A qualitative analysis of patients’ perspectives. Psychotherapy. Advance online publication. https://doi.org/10.1037/pst0000503

Research indicates that about 14% of patients terminated psychotherapy because it did not help them, and 7% because they were not comfortable with their therapist. Psychotherapists have difficulty identifying when patients are at risk of terminating the treatment, and many therapists do not identify when a patient is getting worse. In other words, therapists may not be a good source of understanding when and why patients do not improve and leave therapy. When researchers ask therapists to speculate about why a patient terminated prematurely, the therapists often focus on patient-related factors and not therapist-related factors. In this study, Alfonsson and colleagues interviewed 24 adult patients who had a negative experience in therapy or who terminated prematurely within the past year. Alfonsson and colleagues’ goal was to gather patient perspectives on what went wrong to begin to understand the phenomenon and to guide future training and practice of therapists. Qualitative analysis of the interview transcripts yielded four main categories of therapist variables as perceived by the patient that led to negative outcomes. The first main category was the Therapist's Negative Traits. This included therapist inflexibility/rigidity regarding their assessment of the patient and treatment plan, unengaged therapists who were not paying attention during sessions, unempathetic therapists who did not express warmth or caring for the patient’s situation, and insecure therapists who were too uncertain or oversensitive. The second main category was Therapist Unprofessionalism. This included therapists who were too superficial and avoided difficult topics, therapists who were informal such that they acted too familiar, or they were too affected by their own moods, therapists who were perceived to break confidentiality, and therapists who were nontransparent and seemed to withhold information. The third main category was Therapist Incompetence. This included therapists who were unstructured in their treatment and lacked focus, therapists who had a poor understanding of the patient’s problems by missing important issues or not understanding the patient’s situation, therapists with poor knowledge and lacked competence in a particular treatment model, and therapists who were too passive by not providing active treatment. The fourth category was Therapist Mismatch in which patients did not feel that they connected with the therapist.

Practice Implications

Some of the therapist factors are practical in nature such as those in the Therapist Incompetence category and parts of the Therapist Unprofessionalism category. For such issues, therapists may need more training that focuses on ethical practice, gaining better knowledge of psychopathology and treatment, and applying such knowledge to therapy with various patients. However, other factors like Therapist Negative Traits and parts of the Therapist Unprofessionalism category may be more challenging. These refer to personal traits of the therapist such as a perceived lack of empathy, personal insecurity, rigidity, and a tendency to remain superficial. Changing these traits may require therapists to engage in ongoing supervision and personal therapy. Therapists can also engage in routine outcome and process monitoring to get session-to-session feedback about patient experiences, symptoms, and the therapeutic alliance to help identify when things are not going well in the therapy before the patient drops out.
Different Aspects of the Therapeutic Relationship Are Associated with Different Outcomes

Finsrud, I., Nissen-Lie, H. A., Ulvenes, P. G., Vrabel, K., Melsom, L., & Wampold, B. (2023). Emotional and cognitive processes in psychotherapy are associated with different aspects of the therapeutic relationship. Journal of Consulting and Clinical Psychology. Advance online publication. https://doi.org/10.1037/ccp0000853

One can understand the therapeutic relationship as having an emotional component and a cognitive component. Researchers have found that these two components of the therapeutic relationship can be conceptualized as two factors: a patient’s Confidence in the Therapist (a patient who perceives their therapist as warm, empathic, competent, and trustworthy), and a patient’s Confidence in the Treatment (a patient’s experience of the treatment as viable and as providing a meaningful way to accomplish change). These factors align with the therapeutic alliance in that Confidence in the Therapist is akin to the bond aspect of the alliance, and Confidence in the Treatment is like the collaborative agreement on the tasks and goals aspects of the alliance. In this large naturalistic study, Finsrund and colleagues assessed if Confidence in the Therapist and Confidence in the Treatment are related to different types of outcomes (change in emotional clarity vs change in rumination), and to different types of therapy (CBT vs psychodynamic). The study had 631 adult patients with anxiety or depressive disorders and 54 therapists who conducted either CBT or psychodynamic therapy. Therapists treated the patients in a hospital setting in Norway and patients completed measures of Confidence in the Therapist, Confidence in the Treatment, symptom outcomes, rumination, and emotional clarity on a weekly basis for up to 12 weeks of treatment. Patients were highly symptomatic and more than 89% had more than one clinical diagnosis. As expected, higher Confidence in the Therapist predicted emotional change (higher emotional clarity) and higher Confidence in the Treatment predicted cognitive change (lower rumination). However, higher Confidence in the Therapist predicted better emotional clarity only in the patients receiving psychodynamic therapy, whereas higher Confidence in the Treatment predicted less rumination in both CBT and psychodynamic therapy (although the effect appeared larger in CBT).

Practice Implications

The results are in line with the notion that different aspects of the therapeutic relationship play different roles depending on the outcomes that patients and therapists desire. In cognitively oriented therapies, therapists rely more heavily on providing a viable explanation of the symptoms, a treatment rationale that is consistent with the explanation, and tasks of therapy (homework, self-monitoring, behavioural experiments) that are consistent with the treatment rationale. In psychodynamically-oriented therapies, therapists focus on emotional and relational changes in which therapists and patients work through aspects of the therapeutic relationship that deal with their affective bond and their interpersonal work together. Effective therapists likely do both with patients – i.e., they come to an agreement on the tasks and goals of therapy (the rationale for treatment) and they repair ruptures in the therapeutic alliance as a means of achieving interpersonal learning and emotional change.

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.
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.

June 2023

Patient Experience of Lasting Negative Effects of Psychotherapy

McQuaid, A., Sanatinia, R., Farquharson, L. et al. (2021). Patient experience of lasting negative effects of psychological interventions for anxiety and depression in secondary mental health care services: A national cross-sectional study. BMC Psychiatry, 21, 578. https://doi.org/10.1186/s12888-021-03588-2

One in six adults experience either depression or anxiety that affect their social functioning or quality of life. Most treatment guidelines indicate psychotherapy as a first line treatment for these common mental health problems because of the positive effects of therapy documented by research. Despite the effectiveness of psychotherapies, researchers pay little attention to potential negative impacts of psychological treatments. Negative effects might include worsening of symptoms, emergence of new symptoms, loss of self-esteem, among others. National surveys in the U.K. noted that 5% of patients reported lasting negative effects from psychological treatment. People who had preferences for therapy that were not met tended to have more negative effects, and service policy constraints may also influence patients’ experiences of negative effects. In this analysis of national survey data, McQuaid and colleagues considered all patients who completed therapy during a one-year period in the National Health Service (NHS) in the U.K. These patients received treatment in a secondary care service – that is, a service for those with moderate to severe symptoms. The survey asked whether patients experienced lasting “bad” effects from the treatment, and the authors assessed several service policies and procedures as correlates of these negative experiences. Of those patients who received service, 662 (14.8%) responded to the survey. Overall, 14.1% reported “agreeing” that they experienced a lasting bad effect, and another 13.7% reported a “neutral” response to this item. The likelihood of reporting a neutral or lasting negative effect was greater among those who felt that they did not receive timely therapy (they waited too long, or it was too difficult to access services), who did not receive enough sessions of treatment (most of the therapy in the NHS is short-term), and whose therapists did not discuss the patient’s progress in therapy.

Practice Implications

This study is not perfect by any means, but it does highlight system and service issues that may result in worsening of symptoms among patients, especially those with moderate to severe symptoms. Remaining on a wait list for too long may lead to worsening symptoms – which indicates that it might be best for some patients to be referred elsewhere if it is feasible. Not providing a sufficient dose of therapy (enough sessions) may also lead patient symptoms to be worse at the end of treatment. The disappointment and frustration associated with ending therapy too early may impact patients’ self-esteem, mood, and hopes for recovery. Clinicians might consider how much therapy they can offer before proceeding with someone who has moderate to severe symptoms. Finally, therapists should have regular discussions with patients about their progress and perhaps use progress monitoring as a tool to facilitate these discussions.

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December 2023

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November 2023

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August 2023

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June 2023

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Psychotherapy Practice Research Network (PPRNet)