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
Do Clinicians Agree on Transtheoretical Principles of Change?
Twomey, C., O’Reilly, G., & Goldfried, M. R. (2023, April 20). Consensus on the perceived presence of transtheoretical principles of change in routine psychotherapy practice: A survey of clinicians and researchers. Psychotherapy. Advance online publication. https://dx.doi.org/10.1037/pst0000489
Way back in 1982 Marvin Goldfried hypothesized that there were five transtheoretical principles of change that are part of every method of effective psychotherapies. However, for several decades since Goldfield’s hypothesis, the emphasis in training and research of psychotherapy has been on specific techniques and schools of psychotherapy. Despite the proliferation of therapy schools (there are now more than 500!), there is no evidence that any one bona fide therapeutic orientation is more effective than others, and patient outcomes over the decades have not improved. Recently, there has been a resurgence of interest in transtheoretical principles of change that might move the science and practice psychotherapy forward. Goldfried’s five transtheoretical principles are those strategies common to all theoretical orientations of therapy that since then have received substantial research support. First, fostering the patient’s hope, positive expectations, and motivation has been associated with positive outcomes in psychotherapy. Second, facilitating the therapeutic alliance is associated with positive outcomes, and unresolved alliance ruptures are associated with negative outcomes. Third, increasing patients’ insight is moderately associated with treatment outcomes across orientations. Fourth, encouraging patients to engage in corrective experiences is consistent with the importance of gradual exposure to feared situations and feelings. And fifth, ongoing reality testing corresponds to the long-established finding that adaptive behaviors can be strengthened through repetition and reinforcement. In this large survey of 1198 psychotherapists and researchers, Twomey and colleagues were interested to see if there was a consensus among psychotherapists on these five principles. Consensus was defined as survey respondents indicating that they agreed or strongly agreed that each principle was present in their own approach to psychotherapy. Ninety-three percent of respondents practiced psychotherapy, their average age in years was 50, 51% were women, 62% were psychologists, and they represented a wide range of theoretical orientations. Strong consensus (i.e., on average they strongly agreed) was found for the first three principles: fostering patients’ hope and expectations, facilitating a therapeutic alliance, and increasing patients’ insight. Good consensus (i.e., on average they agreed) was found for encouraging patients to engage in corrective experiences, and ongoing reality testing. There were no differences or associations noted with any of the demographic variables (age, profession, years of practice) nor for theoretical orientation.
The results suggested that while some research continues to emphasize techniques specific to orientations of therapy, most clinicians agree on important principles of change that cut across orientations. These principles indicate that psychotherapists should (1) increase positive expectations by preparing patients for what will happen in therapy (duration, method, goals) and explaining why certain aspects of therapy are important, (2) foster the alliance by encouraging ongoing collaboration regarding the goals and methods of therapy, (3) encourage insight by collaboratively developing a case formulation that brings relevant issues into greater awareness for the patient, (4) provide patients with corrective experiences by encouraging exposure to difficult situations, interpersonal challenges, and working through alliance ruptures, and (5) help patients to be aware of and repeat corrective experiences over time as a means of fostering reality testing.
Multiple Microaggressions and Therapy Outcomes
DeBlaere, C., Zelaya, D. G., Dean, J.-A. B., Chadwick, C. N., Davis, D. E., Hook, J. N., & Owen, J. (2023). Multiple microaggressions and therapy outcomes: The indirect effects of cultural humility and working alliance with Black, Indigenous, women of color clients. Professional Psychology: Research and Practice, 54(2), 115–124. https://doi.org/10.1037/pro0000497
Many Black, Indigenous, Women of Color (BIWOC) underutilize mental health care partly because of lack of culturally competent care, and the anticipation of bias and discrimination often experienced by Black, Indigenous, People of Color (BIPOC). One way that such bias and discrimination is expressed in a therapy context is through racial microaggressions which are subtle, intentional, or unintentional messages that degrade BIPOC. Another way that bias and discrimination is expressed is through gender microaggressions which are intentional or unintentional behaviors that exclude, demean, oppress, or express indifference towards women. Research indicates that up to 89% of BIPOC clients and 53% of women experienced a microaggression from their therapist. Both racial and gender microaggressions committed by therapists are related to poorer therapeutic alliance and client outcomes. One might also consider BIWOC clients to be doubly susceptible to microaggressions due the intersecting nature of their identities as a person of color and as a woman. One way to limit the effects of microaggressions is for therapists to take a stance of cultural humility and to foster a therapeutic alliance. Cultural humility refers to a therapist’s way of being with a client that values the importance of culture in the client’s experience. In this study by DeBlaere and colleagues, the authors surveyed 288 BIWOC clients who were currently or recently in psychotherapy to assess the association between microaggressions and outcomes, and whether cultural humility and a therapeutic alliance might reduce the impact of microaggressions. The clients saw a female therapist 81% of the time and a White therapist 46% of the time. DeBlaere and colleagues found that 89% of the sample reported at least one instance of a racial microaggression by their therapist, and 43% reported some form of gender microaggression. White and male therapists were more likely to commit these microaggressions. The most common racial microaggression involved therapists avoiding discussing or addressing cultural issues, and the most common gender microaggression involved therapists encouraging female clients to be less assertive so that the client might not appear aggressive. Racial and gender microaggressions were both negatively related to therapy outcomes. The authors also found that cultural humility and therapeutic alliance both mediated and helped to explain the effects of microaggressions on outcomes. That is, the negative effects of a racial or gender microaggression on outcomes were reduced when the client experienced the therapist as having a higher level of cultural humility, which then led to a stronger therapeutic alliance, that in turn led to a better outcome.
This study points to the potential of therapist cultural humility and their capacity to maintain a therapeutic alliance as key to reducing the impact of racial and gender microaggressions on client outcomes. The findings reinforce the importance of therapists examining their own cultural biases and making discussions of culture and racism explicit in therapy. This is especially important for White male therapists. Such a process might cultivate cultural humility in the therapist that will mitigate the negative impact of a microaggression should it occur.
Interpretations and Outcomes: A Systematic Review
Zilcha-Mano, S., Fisher, H., Dolev-Amit, T., Keefe, J. R., & Barber, J. P. (2023). A systematic review of the association between interpretations and immediate, intermediate, and distal outcomes. Psychotherapy. Advance online publication. https://doi.org/10.1037/pst0000479
Interpretation is a therapeutic technique that refers to a psychotherapist who recognizes and seeks to raise the patient’s awareness and understanding of recurrent maladaptive patterns. An interpretation goes beyond what the patient says or recognizes consciously and gives a new meaning or explanation for behaviours, thoughts, or feelings so that the patient sees their problems in a new way. In other words, the effect of an interpretation is to raise a patient’s insight into their problems. Interpretation is a transtheoretical technique, although it is often associated with psychodynamic therapies. Some interpretations are interpersonal in nature (focused on maladaptive relationship patterns inside and outside of the therapeutic relationship), and some are intrapersonal in nature (e.g., focused on the conflict between ones wishes/desires and how one ideally sees oneself). In this systematic review of the research on interpretation, Zilcha-Mano and colleagues included 18 studies that tested the association between interpretation and outcomes. Previous reviews found a mixed association between interpretation and outcomes possibly because of the different methods of assessing interpretation and different way of conceptualizing outcomes. What is unique about this review is that it categorized outcomes as immediate (e.g., in-session alliance, disclosure, emotional expression), intermediate (e.g., next-session alliance strength, session depth), and distal (e.g., change in symptoms from pre- to post-treatment). Since there were so few studies in each of these outcome categories (6 studies of immediate, 4 studies of intermediate, and 12 studies of distal outcomes), the authors did not conduct a meta-analysis, but rather counted studies that supported or did not support the use of interpretation for each of these categories of outcomes. For immediate outcomes, half of the studies reported a positive association with interpretation (whereas half of studies showed a neutral or negative association). That is, on average patients in those studies tended to react positively to therapist interpretations during the session with increased therapeutic alliance or emotional processing. For intermediate outcomes, half the studies reported a positive association with interpretation (as opposed to neutral or negative association). That is, on average the results suggested that interpretation in in a previous session was associated with patients experiencing a better alliance and session depth in the subsequent session. For distal outcomes, there was mixed evidence with most studies reporting a neutral effect of interpretation on pre- to post-symptom change.
It is challenging to draw explicit practice implications from a research area that is complex and not yet large enough to allow for a meta-analysis. However, using a mixture of these research findings and clinical experience, Zilcha-Mano and colleagues suggest some therapeutic practices that may be helpful. They suggest, for example that therapists (1) observe the immediate and intermediate outcomes of an interpretation (i.e., does the patient rejected it or does it deepen the therapeutic work?), (2) check with patients about how they feel about the interpretation, (3) prioritize accurate and experience-near interpretation (those that the patient can immediately recognize and understand), (4) monitor the strength of the alliance before, during, and after an interpretation, (5) consider that an interpretation may be more beneficial for patients with poorer quality of relationships and self-concepts than for those with better relationship and self-functioning, and (6) be aware that interpretations may not be beneficial and could be harmful if delivered at the wrong time or if not attuned to the patient’s needs and capacities
More Treatment But No Less Depression
Ormel, J., Hollon, S.D., Kessler, R.C., Cuijpers, P., & Monroe, S.M. (2022). More treatment but no less depression: The treatment-prevalence paradox. Clinical Psychology Review, 91, 102111.
It is widely believed that treatments for major depression (psychotherapy and antidepressant medications) have improved patients’ symptoms since the 1980s. Mental health expenditures and access to treatment for major depressive disorder (depression) have also increased during that time, especially for antidepressant medications. However, we have not witnessed a reduction in the population prevalence (proportion of people who experienced a condition during their lifetime) or incidence (proportion of people who currently have the condition) of depression. How can it be that we perceive treatments to be more effective and available but rates of depression in the population have not budged? In this comprehensive conceptual analysis with a review of the evidence, Ormel and colleagues examined possible reasons for what they describe as the treatment-prevalence paradox. First, one could argue that prevalence and incidence rates are inflated due to a recent greater recognition and acceptance of depression in society. If that’s the case, then any reduction in prevalence or incidence caused by new treatments may be offset by more people coming forward and admitting to having depression. However, epidemiological studies are conducted by trained interviewers using standardized diagnostic criteria, which should reduce any inflation caused by spurious reporting. In fact, large epidemiological studies do not show an increase in incidence of depression over time, so that incidence in the U.S. remains approximately 1.5% and worldwide prevalence remains about 4.7%. Second, it is possible that randomized controlled trials might over-estimate the efficacy of psychotherapy or medication for depression. Thus, even if these treatments are more available, they may not impact population prevalence or incidence rates because they are not as effective as we once thought. The authors found that meta-analyses that adjusted for publication bias (the tendency of researchers or industry not to publish negative findings or to put a positive spin on such findings) reported treatment efficacy to be modest. That is, only about 30% of patients recover from depression following psychotherapy or medications. Third, it is also possible that the actual efficacy of psychotherapy or medications to prevent relapse or recurrence in the longer term is too small to reduce population prevalence or incidence of depression. That seems to be the case. Even if 30% of patients respond initially to treatments like CBT or medications, about half of these initial responders relapse at 1- or two-years post treatment. And many of those who do not relapse still struggle with residual symptoms.
The authors concluded that even though access to psychotherapy or medications have increased and the treatments supposedly have become better over the decades, therapies have not moved the needle on population prevalence or incidence of depression. Clinicians might consider talking to patients honestly about the efficacy of the treatments they are offering without unnecessarily demoralizing patients. That is, treatments considered to be the “gold standard” by researchers and practice guidelines are only modestly effective. When a patient does not benefit from “gold standard” treatments, it should be considered a failure of the treatment and not a function of “patient non-responsiveness”. It is also quite likely that brief
Whose contribution (therapist or patient?) to the alliance mostly leads to change?
Wampold, B. E., & Flückiger, C. (2023). The alliance in mental health care: conceptualization, evidence and clinical applications. World Psychiatry, 22, 25–41. https://doi.org/10.1002/wps.21035
The therapeutic alliance is possibly the most researched concept in psychotherapy. The alliance consists to a collaborative agreement patient and therapist on the goals of therapy, a collaborative agreement on the tasks of therapy (how therapy should proceed), and the relational bond between therapist and patient (mutual liking and trust). The most recent meta-analysis of almost 300 studies showed that the correlation between the therapeutic alliance and patient outcomes was moderate in size (r = .29) and very stable across studies, treatment modalities, and patient populations. Another meta-analysis of studies that assessed outcomes and therapeutic alliance after every session showed that there is a reciprocal relationship between alliance and outcomes, demonstrating that the alliance is not simply a consequence of symptom improvement. In this sweeping review of the therapeutic alliance research and clinical literature, Wampold and Fluckiger asked “who is most responsible for the effects of the alliance – the patient or the therapist?”. The alliance is a dyadic construct about the interaction between therapist and patient. It could be that the patient contribution to the alliance is most important to their outcomes. A patient with insecure attachment, more symptoms, comorbid personality disorder, or low motivation might experience a poorer alliance with any therapist. Conversely, some therapists might be able to form a better alliance than other therapists across a wide range of patients, and this might be what results in better outcomes. Studies that disaggregate the total correlation of the alliance and outcome into patient and therapist contributions generally demonstrate that it is the therapist that is primarily responsible for the alliance-outcome association. That is, therapists who can form a stronger alliance with a wide range of patients also generally have better outcomes than other therapists. Even patients who tend to form a weaker alliance with therapists will develop a stronger alliance with therapists who generally have the skills to develop a strong alliance.
When it comes to the therapeutic alliance, the therapist matters even for patients who struggle to form an alliance. It turns out that gender, age, ethnicity, profession, and theoretical orientation of the therapist do not matter as much as their interpersonal skills. These interpersonal skills include a therapist’s capacity to communicate hope and positive expectations, persuasiveness, emotional expression, warmth, understanding, acceptance, empathy, and ability to repair alliance ruptures. If a therapist wants to make the most of the therapeutic alliance to help their patients, then the therapist should develop and nurture these interpersonal skills for themselves.
Adding Short-Term Psychodynamic Psychotherapy to Antidepressants
Driessen, E., Fokkema, M., Dekker, J.J.M., Peen, J., Van, H.L…. Cuijpers, P. (2022). Which patients benefit from adding short-term psychodynamic psychotherapy to antidepressants in the treatment of depression? A systematic review and meta-analysis of individual participant data. Psychological Medicine.
Short-term psychodynamic psychotherapy (STPP) and anti-depressant medications are both considered empirically supported treatments for depression. And there have been several trials demonstrating the efficacy of long-term psychoanalytic psychotherapy for treatment-resistant depression. Despite this research, it remains unclear which patient might benefit from anti-depressant medication alone and which patient might benefit from adding STPP to the antidepressants. The best use of scarce resources makes this an important question. There are challenges to doing a meta-analysis of patient characteristics that predict different outcomes in antidepressants alone versus antidepressants plus STPP. A key challenge is that common meta-analyses use study-level data (an overall summary of the effect size found in a study), and so statistical power often is limited by the small number of studies. The unique aspect of this study by Driessen and colleagues is that they conducted a meta-analysis of patient-level data. That is, they got individual patient data from the authors of the seven studies that specifically tested the effects of antidepressants alone vs antidepressants plus STPP. So instead of being limited by seven summary effect size statistics, the authors had a sample of 482 patient effect sizes to work with. The effect of adding STPP to antidepressants was larger for participants with high rather than low baseline depression scores [B = −0.49, 95% CI: −0.61 to −0.37, p < 0.0001], for participants with ⩽8 rather than more years of education (B = −0.66, 95% CI −1.05 to −0.27, p < 0.0009), and for participants with a depressive episode duration of >2 years rather than <1 year (B = −0.68, 95% CI −1.31 to −0.05, p = 0.03) or less than 1–2 years (B = −0.86, 95% CI −1.66 to −0.06, p = 0.04). At follow-up, higher baseline depression scores and longer depressive episode duration were still associated with better outcomes for those receiving a combination of antidepressants plus STPP.
The results of this patient-level meta-analysis suggests that adding short-term psychodynamic psychotherapy to antidepressant medication might be particularly efficacious for patients with higher initial levels of depression and/or with longer duration of depressive symptoms. It is possible that the addition of a psychological treatment like STPP may tackle some of the underlying psychological vulnerabilities whose treatment is necessary for those who have more persistent and severe depressive symptoms.