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 therapist variables leading to poor outcomes, aspects of the therapeutic relationship and outcomes, and psychological therapies and patient quality of life.
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
October 2023
How Reliable is the Research on CBT Plus ERP for Obsessive-Compulsive Disorder?
Reid, J.E., Laws, K.R., Drummond, L., Vismara, M. Grancini, B., Mpavaenda, D., Fineberg, N.A. (2021). Cognitive behavioural therapy with exposure and response prevention in the treatment of obsessive-compulsive disorder: A systematic review and meta-analysis of randomized controlled trials. Comprehensive Psychiatry, 106, 152223. https://doi.org/10.1016/j.comppsych.2021.152223.
Cognitive-behavioural therapy (CBT) combined with exposure and response prevention (ERP) is considered by many the treatment of choice for obsessive-compulsive disorder (OCD). However, questions remain about the size of its effects, the reliability of the research, and the relative efficacy of CBT plus ERP compared to other psychological treatments. Reid and colleagues conducted a systematic review and meta-analysis of randomized controlled trials of CBT with ERP in patients of all ages with OCD. They included 36 studies with 2000 patients (537 children/adolescents and 1483 adults) receiving treatment and 1015 in control conditions. When compared against all control conditions, CBT with ERP showed a significant and large effect (g = 0.74: 95% CI = 0.51 to 0.97 k =36). While CBT with ERP was more effective than a “psychological placebo” (e.g., progressive relaxation; g = 1.13: 95% CI 0.71 to 1.55, k = 10) and no treatment control conditions (g = 1.27: 95% CI 0.79 to 1.75), it was no more effective than other active forms of psychological therapy (g = −0.05: 95% CI −0.27 to 0.16, k = 8). When compared to pharmacological treatment with an adequate dosage of selective serotonin reuptake inhibitors, CBT with ERP was marginally better with a small effect (g = 0.32: 95% CI -0.00 to 0.64, p = 0.05). Researcher allegiance or bias had a big impact on the effects of CBT with ERP. Researcher allegiance refers to studies conducted by researchers who prefer, favour, or have a vested interest in the treatment they are testing. In the studies identified as having researcher allegiance, a large favourable effect for CBT with ERP emerged (g = 0.95: 95% CI 0.69 to 1.2). By contrast, in trials where the authors did not identify researcher allegiance (k= 8), CBT with ERP showed no significant effects (g = 0.02: 95% CI−0.29 to 0.33). This difference was statistically significant (Q = 20.33, p < 0.005). There was no evidence of publication bias, but 28 of the 36 studies had a high risk of bias (in which there were deficiencies in the research design, procedures, or data analyses).
Practice Implications
At this point, CBT plus ERP is the most studied treatment for OCD, and it appears to be effective in reducing symptoms post-treatment. However, this meta-analysis raises more questions than it answers about the reliability of the research. Other active treatments (e.g., CBT without ERP) appear just as effective, which suggests that ERP may not be necessary to treat OCD. Researchers who favor or have a vested interest in CBT plus ERP produce much larger effects for their preferred treatment, and the quality of most of the research is low. Such findings lower one’s confidence in the conclusions drawn from the research.
July 2023
Therapeutic Relationship Factors that Work
Norcross, J.C. & Karpiak, C.P. (2023). Relationship factors. In S. D. Miller, D. Chow, S. Malins, and M. A. Hubble (Eds.) The Field Guide to Better Results: Evidence-Based Exercises to Improve Therapeutic Effectiveness. American Psychological Association. https://doi.org/10.1037/0000358-006
Next to patient factors that affect outcomes in psychotherapy, the therapeutic relationship is the most important predictor or contributor to patient outcomes. The therapeutic relationship is important to in-person therapy and to therapy delivered virtually. There is no scientific doubt of the importance of the therapeutic relationship on patient outcomes. The relationship is managed and cultivated by the therapist’s attitudes and behaviors. And so, it is not surprising that therapists differ in their ability to facilitate the therapeutic relationship. However, it is also possible for therapists to improve their therapeutic relationship skills through training and supervision. The therapeutic relationship is important to all therapeutic orientations. In this part of the chapter, Norcross and Karpiak review the research on relationship factors that work including therapist empathy, positive regard, developing a therapeutic alliance, and repairing alliance ruptures when they occur. Empathy occurs when a patient experiences a therapist who perceives and expresses an accurate understanding of a patient’s feelings, perspectives, and experiences. Empathic responding is one of the strongest predictors of patient outcomes with effect sizes ranging from moderate to large (d = .58), but only when it is rated by the patient. Therapist ratings of their own empathy has a much lower association with patient outcomes. Positive regard is the therapist’s genuine liking and expressed appreciation for the patient as a person. That is, a therapist’s verbal and nonverbal expression that they value, care about, and believe in the patient. The key here is genuineness – that the therapist’s words are consistent with their intentions and feelings. Positive regard expressed in therapy is moderately related to patient outcomes (d = .57). The therapeutic alliance refers to the warm emotional bond between patient and therapist, and their collaborative agreement on the goals of therapy and how they will work towards those goals. More than 300 studies of over 30,000 patients indicate that the alliance is moderately related to patient outcomes (d = .57), and this is a highly reliable finding. Ruptures in the alliance are characterized by patient withdrawal from the therapist or therapy, or by confrontation in which the patient criticizes or is dissatisfied with the therapist or therapy. Therapists’ attempts to repair alliance ruptures is moderately related to positive patient outcomes (d = .62), and this skill is most important for newer therapists and therapists with a CBT orientation.
Practice Implications
A positive therapeutic relationship has a much bigger impact on patient outcomes than the specific type of therapy used by therapists. A therapist who narrowly focuses on the content of what a patient says and rigidly adheres to a treatment manual will reliably have patients who have worse outcomes. Therapists whom patients experience as truly empathic (not just expressing sympathy for a patient), who can genuinely feel and express positive regard for a patient, and who can develop and maintain a therapeutic alliance and repair alliance ruptures reliably will have patients who have better experiences of therapy and better outcomes. These therapist skills and capacities can be learned through deliberate practice, supervision, personal therapy, and by maintaining a stance of flexibility, openness, and humility.
May 2023
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.
Practice Implications
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.
Practice Implications
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.
Practice Implications
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
November 2022
What are Best Practices for Psychotherapy with Indigenous Peoples
In 2016 2.8% of the Canadian population identified as First Nations, 1.7% as Metis, and 0.2% as Inuit. In Canada there are 634 First Nations each with their own traditions, governance structures, and land claims. Colonial violence and land dispossession has led to Indigenous Peoples suffering from many mental health inequities. Indigenous samples are rarely evaluated in clinical trials of psychotherapy. And psychotherapy, as typically delivered, is a practice that is embedded in European cultural values which may not be appropriate for Indigenous Peoples. Defining best practices in psychotherapy with Indigenous Peoples may indeed be thorny given the historical context and values inherent in psychotherapy practice. In this article, Wendt and colleagues review four paths to providing psychotherapy to Indigenous clients, but each path has their challenges. The first path is to offer on empirically supported therapies for specific identifiable disorders. However, out of the hundreds of clinical trials available, only six were conducted that specifically focused on American Indian clients and all for alcohol use problems. Most empirically supported therapies were not validated for use with Indigenous clients, and some argue that this may make these treatments potentially harmful. The second path is to culturally adapt interventions so that the original therapies are maintained but adapted to the needs and culture of the Indigenous population. Some research suggests that cultural adaptations result in moderately better outcomes. Deeper adaptations incorporate cultural beliefs and promote cultural identity and connections to the Indigenous community. However, cultural adaptations tend to preserve a disorder-centric approach to problems rather than seeing problems in terms of a balance between mental, emotional, and spiritual health. The third path involves emphasizing the psychotherapy relationship, the working alliance, and promotion of hope – also known as the common factors approach to psychotherapy. This is highly collaborative approach to how therapy progresses and to maintaining a reciprocal balance in the therapeutic relationship. However, this approach does not necessarily address the European cultural values inherent in most psychotherapies. The fourth path involves efforts to strengthen and revitalize traditional Indigenous practices and cultural education as a means of healing. These might include integrating sweat lodges, the Medicine Wheel, and talking circles. This path embodies a “culture as treatment” approach in which problems are seen within historical losses of identity, purpose, and place. A report from the Canadian Psychological Association and the Psychology Foundation of Canada calls for psychologists to “view themselves as facilitators and supporters of the healing wisdom and knowledge that is already present in Indigenous communities”. However, as Wendt and colleagues note, there are practical barriers to this approach, and even if “culture as treatment” is seen by some as self-evidently effective, it has rarely been researched.
Practice Implications
Mental health professionals should avoid being unwitting agents of assimilation when providing clinical care to Indigenous clients. Primarily, clinicians should maintain a stance of cultural humility. Traditional indigenous approaches to mental health are important as a long-term strategy, including traditional understandings of problems, traditional healing, and Indigenous-led cultural interventions. All of this, however, is limited by inadequately addressed colonial harms, poverty, and legal obstacles to Indigenous Nations’ sovereignty.