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 psychotherapy for borderline personality disorder, capacity to metnalize and therapy resistant depression, and negative effects of psychotherapy
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
Emotional Experiences of Psychotherapists
Chui, H., & Liu, F. (2021). Emotional experience of psychotherapists: A latent profile analysis. Psychotherapy, 58(3), 401–413.
Working with client emotional experiences in therapy is a core aspect of the psychotherapist’s work, regardless of their theoretical orientation. And so, therapists’ performance and their own well-being may be impacted by their capacity to experience and regulate their own emotions. Emotional reactivity refers to one’s sensitivity, intensity, and duration of emotional experience. Emotion regulation refers to the capacity to manage and express emotions and may be considered an interpersonal competency for therapists. Such competency likely involves flexible expression of emotion and a capacity for empathy. A better understanding of how therapists experience emotions might inform therapists’ use of empathy to facilitate their work with clients. In this study, Chui and Liu surveyed 314 English speaking and 589 Chinese speaking psychotherapists and asked them about their experiences of emotional reactivity, their emotion regulation, and empathy. Their data allowed them to develop profiles of psychotherapists along dimensions of emotional experience. Three latent profiles emerged in both the English and Chinese speaking samples of therapists. The highest proportion of English-speaking therapists (58%) were categorized as “Calm Regulators”, which indicated therapists with low emotional reactivity and few problems with emotion regulation. Next, 34.4% of English-speaking therapists were characterized as “Moderate Experiencers”, and 7.6% were “Emotional Feelers”. The latter profile included therapists who were emotionally over-reactive and who had greatest difficulty with regulating their emotions. As one might expect, those with the Calm Regulator profile had higher capacity for perspective taking, higher empathic concern, and lower personal distress than therapists in the other profiles. Also, therapists who were older, with more education, female, and with a psychodynamic orientation were more likely to have the Calm Regulator profile. Results were remarkably similar in the Chinese speaking sample, in which Calm Regulators also reported higher levels of counsellor self-efficacy.
Therapists with the “Emotional Feelers” profile (i.e., that have higher levels of emotional reactivity and more difficulty regulating their emotions) may be at higher risk of burnout and of being less effective in their work. As a profession we often discuss clients’ individual differences in emotional experience and emotion regulation, but we spend less time considering these important interpersonal competencies in therapists. Recent surveys suggest that almost 50% of therapists may be at high risk of mental health problems. Psychotherapists, trainers, and supervisors need to pay more attention to therapists’ capacity to regulate their emotions, and its impact on their capacity to be emotionally flexible and empathic with clients. Therapists might consider personal therapy as a means of building this capacity.
Therapist Reflective Functioning and Client Outcomes
Cologan, J., Schweiter, R.D., & Nolte, T. (2017). Therapist reflective functioning, therapist attachment style, and therapist effectiveness. Administration Policy and Mental Health, DOI: 10.1007/s10488-017-0790-5.
Differences between therapists account for about 8% of patient outcomes, which is a moderate effect and therefore an important factor. Constructs such as therapist personality characteristics and facilitative interpersonal skills may play a key role in how effective therapists can be with their clients. An important therapist quality might be reflective functioning, or mentalization. Reflective functioning refers to the ability to conceptualize, identify, and understand mental states in oneself and in others, and how mental states affect behaviour and functioning. For example, reflective functioning is the basis for predicting others’ behaviors, understanding social nuances and others’ intentions, and also one’s own behaviors and internal experiences. Fundamentally for a therapist, reflective functioning is necessary for empathy, which is a key therapeutic quality. Another key issue for therapists might be their own attachment security, or their characteristic ways of relating to others in interpersonal relationships. Securely attached therapists (those who have a positive view of self and others in relationships) may be able to develop a better therapeutic alliance with clients. Insecurely attached therapists (those who are avoidant in relationships or who are preoccupied in relationships), may struggle to a greater extent with developing and maintaining an alliance. In this study, Cologan and colleagues assessed reflective functioning and attachment security in 25 therapists from different theoretical orientations who treated 1001 adult clients who mostly had problems with depression or anxiety. Client outcomes were measured pre and post treatment. On average clients experienced a reduction in their symptoms after psychotherapy. Clients of therapists with higher levels of reflective functioning experienced better outcomes. Therapist attachment insecurity did not have a direct effect on client outcomes.
As with other studies, therapists in this study varied in their outcomes, so that some had better outcomes than others. Level of therapist reflective functioning (ability to mentalize) accounted for a large proportion of this difference. Therapists who had greater skills with understanding their own and clients’ behaviors in terms of mental states (intentions, motivations, psychological and emotional needs, internal conflicts) likely were better able to empathize and develop an alliance with their clients. These are skills that therapists can learn with practice, consultation, personal therapy, and training.
Client Honesty in Psychotherapy
Love, M. & Farber, B.A. (2018). Honesty in psychotherapy: Results of an online survey comparing high vs. low self-concealers, Psychotherapy Research, DOI: 10.1080/10503307.2017.1417652.
An important task of psychotherapy is for therapists to provide a context within which clients feel comfortable disclosing difficult feelings, thoughts, and other experiences in their lives. Self-disclosure likely improves the therapeutic alliance (agreeing on tasks and goals, and an emotional bond between therapist and client), which is necessary for good outcomes. In fact, research indicates that client self-disclosure is generally associated with positive outcomes in therapy. And yet a number of surveys report that clients keep secrets or lie to their therapists. Clients appear to struggle between being honest and self-disclosing versus the fear or anxiety related to doing so. Research indicates that one can describe individuals as high self-concealers in most relationships in their lives. Such individuals consistently conceal negative aspects of themselves from others to help manage their anxiety in relationships in the short term. However, in the long term, high levels of self-concealment increases rumination and anxiety and reduces coping. In this study, Love and Farber conducted an online survey of 572 participants who were currently in therapy or were in therapy in the past year. The sample characteristics and the type of therapy they received were surprisingly similar to a nationally representative sample of clients who seek treatment, though this online survey sample was somewhat younger. Over 84% of clients in this survey reported being dishonest about at least one topic with their therapist. Most frequent topics for being dishonest included: details of sex life (33.9%), suicidal thoughts (21.9%), self-harm (14.5%), real reactions to therapist comments (18.9%), whether therapy was helping (15.7%), and family secrets (16.3%). The most predominant motive for dishonesty was embarrassment or shame (63.6%), followed by doubts that the therapist would understand (27.0%), fear of overwhelming emotions (18.1%), and disappointing or hurting the therapist (16.4%). Not surprisingly, clients who tended to conceal their experiences reported disclosing less distressful information and also reported a lower therapeutic alliance with their therapists. Almost half of high self-concealers reported that dishonesty hurt their therapeutic progress.
Topics like suicidal ideation and sex are particularly difficult to speak about honestly in therapy, especially for those who are uncomfortable with disclosing in general. Most clients are willing to discuss difficult topics with therapists if the therapist inquires sensitively and directly. High self-concealers are highly attuned to how therapists might react, and these clients anticipate shame or judgement. Therapists need to monitor the state of the therapeutic relationship with each client, especially the client’s perception of therapist warmth and trustworthiness. This could include monitoring for any ruptures in the therapeutic alliance. Further, therapists may need to communicate that self-concealment serves a short term purpose to reduce anxiety, but has a long term cost in terms of amplifying distress.
Do Psychotherapy Trainees Get Better with More Training?
Owen, J., Wampold, B. E., Kopta, M., Rousmaniere, T., & Miller, S. D. (2016). As good as it gets? Therapy outcomes of trainees over time. Journal of Counseling Psychology, 63, 12-19.
Does psychotherapy training improve trainees’ knowledge and skills? Do trainees improve in their ability to produce positive client outcomes over time? The research on training psychotherapists is mostly inconclusive. Some studies show little or no difference between trainees and experienced therapists, and others found no association between level of experience and client outcomes. On the other hand, some researchers have found a relationship between training and competence in delivering a particular type of treatment. Overall, the research seems to show that there is a lot of variability between therapists in their outcomes and on how training affects their practice and their clients’ outcomes. However, rarely do these studies assess outcomes within the same trainee over time as they accumulate more training. In this study, Owen and colleagues evaluate if psychotherapy trainees’ client outcomes improved with training over time. They assessed 114 psychology trainees at different levels of training in 47 clinics across the U.S. These training therapists saw over 1100 clients over at least a 12-month period, and many therapists were followed for three years. The average client improved, but with small effects (d = .31, CIs not reported). Therapists were more effective with clients who were more distressed (d = .66) than clients who were less distressed (d = .10), probably because more distressed clients had more room to improve. Trainees’ outcomes improved significantly over time, although their average improvement over time was small. Most importantly, trainees’ improvements over time varied so that the researchers were able to identify four patterns of change over a three year period of training: (1) one group of trainees started out with moderately good outcomes and their outcomes remained moderately good over time; (2) a second group started out with small positive effects in their client outcomes and they improved to achieve moderately good outcomes by their third year; (3) a third group of trainees started out with small positive client outcomes but their outcomes got worse by their third year; and (4) a fourth group started out with poor outcomes and improved to achieve small positive outcomes by year 3 of their training.
Trainees appear to have various trajectories in their ability to foster positive client outcomes over time, and, at times, that trajectory is negative. Trainees whose outcomes get worse over time (group 3) or who do not achieve at least moderately good outcomes (group 4) may need specific training to foster better interpersonal effectiveness, empathy, management of countertransference, and humility. In general, therapists should assess their clients’ outcomes with progress monitoring tools in order to use the feedback to improve their outcomes over time. If outcomes are not positive on average, then therapists should consider remediation, further training, or consultation.
What Characterizes Effective Therapists?
Wampold, B. E., Baldwin, S. A., Holtforth, M. G., & Imel, Z. E. (2017). What characterizes effective therapists. In L.G. Castonguay and C.E. Hill (Eds.) How and why are some therapists better than others? Understanding therapist effects. Washington, DC: American Psychological Association.
The research on therapist effects indicates that some therapists are more effective than others. Previous research showed that therapist characteristics like age, race, ethnicity, gender, and experience are not consistently related to patient outcomes. Neither is therapist competence and adherence to a treatment approach. In this chapter, Wampold and colleagues ask the question: what characterizes effective therapists? The research is complicated because it is difficult to disentangle therapist effects from patient factors. That is, it is possible that some clients (i.e., those who are more motivated, likeable, and psychologically minded) might create favorable conditions for some therapists to be more effective. However, recent advances in statistical methods have allowed researchers to isolate the effects of therapist characteristics from patient factors. Based on this new research, Wampold and colleagues identified four characteristics of effective therapists. (1) The ability to form an alliance across a range of patients. The therapeutic alliance is defined as the agreement on tasks and goals of therapy, and the affective bond between therapist and patient. Alliance is reliably associated with good patient outcomes. Research shows that therapists and not clients are primarily responsible for the alliance-outcome relationship. (2) Facilitative interpersonal skills – which includes verbal fluency, warmth, empathy, and emotional expression. These skills in a therapist are a strong predictor of patient outcomes. (3) Professional self doubt – or healthy skepticism about one’s abilities and skills leading to self-reflective practice has also been found to predict positive patient outcome. (4) Deliberate practice - defined as individualized training activities especially designed to improve specific aspects of an individual’s performance through repetition and successive refinement. The amount of time outside of therapy that therapists engage in improving targeted therapeutic skills predicted patient outcomes.
Some therapists are better than others - and demographics, professional affiliation, training, and adherence to a manual do not differentiate better therapists. Four factors are emerging as indicators of better therapists. Ability to develop, maintain, and repair a therapeutic alliance is well known to predict patient outcomes and it appears that therapists are largely responsible for the condition of the alliance. Therapists’ ability to be verbal, warm, and empathic is also key to patient outcomes. Professional skepticism about one’s abilities that lead to reflective practice is also an important characteristic in order to continually improve one’s abilities and monitor one’s outcomes. And, finally therapists who spend time outside of therapy deliberately and repetitively practicing skills will achieve better patient outcomes.
Lying in Psychotherapy: What Clients Don’t Tell Their Therapist
Blanchard, M. & Farber, B.A. (2016). Lying in psychotherapy: Why and what clients don’t tell their therapist about therapy and their relationship, Counselling Psychology Quarterly, 29, 90-112.
Clients’ disclosure of their thoughts and feelings are key aspects of psychotherapy, and trust is at the heart of the therapeutic relationship. However clients are not always honest with their therapist. Clients may keep secrets, hide negative reactions to interventions, minimize, spin, or tell outright lies. In this study, Blanchard and Farber asked: “what do clients lie about in therapy and why”. The authors used a broad definition of dishonesty that included: consciously twisting the facts, minimizing, exaggerating, omitting, and pretending to agree with the therapist. The authors excluded delusions, repression, denial, and other forms of unconscious deception. Blanchard and Farber were particularly interested in client dishonesty about therapy itself and about the therapist. The authors conducted an online survey of psychotherapy clients recruited from a community sample in a U.S. city, and 547 adult clients responded. The sample was surprisingly similar to a therapy-using population reported in the National Survey on Drug Use and Health. Most clients were women (78%), White (80%), saw a female therapist (71%), received CBT (35.4%) or psychodynamic therapy (18%), and were treated for depression (64%) and/or anxiety (49%) disorders. The survey asked about a wide range of possible topics for dishonesty such as use of drugs or alcohol, desire for revenge, pretending to agree with the therapist, etc. With this broad definition of conscious dishonesty, 93% of clients reported lying to their therapist, in which the average number of topics lied about per client was 8.4 (SD = 6.6). Those who lied more often also reported a general tendency in their lives to conceal negative personal information (r = .45). Only 6.8% of clients reported having told zero lies in therapy. Some topics were highly endorsed by clients – for example, 54% endorsed lying about “how badly I really feel – I minimized”, 25% did not disclose “my thoughts about suicide” and “my use of drugs or alcohol”. Other topics (endorsed by 5% to 25% of clients) included lies about eating habits, self-harm, infidelity, violent fantasies, experiences of physical or sexual abuse, and religious beliefs. About 72.6% of clients lied about at least one therapy-related topic, including: “pretending to like my therapist’s comments or suggestions” (29%), “reason for missing an appointment” (29%), “pretending to find therapy more effective than I do” (28%), “pretending to do the homework” (26%), “my real opinion of the therapist (19%), “not saying I want to end therapy (16%), and “my therapist makes me feel uncomfortable” (13%). Other items were relatively rare in the sample including “my romantic or sexual feeling about my therapist” (5%). Survey respondents were then asked why they were dishonest. Reasons why clients were dishonest included: “wanting to be polite”, “I didn’t want my therapist to feel he was bad at his job”, “I didn’t want to look bad or feel embarrassed”, “I would feel bad if I told her it really didn’t help me”, “wanting to avoid my therapist’s disapproval”, and “wanting to avoid upsetting my therapist”.
Using a broad definition of dishonesty, this study found that 93% of clients did not tell the truth in one way or another to their therapist. Concern about self-judgments (i.e., embarrassment) or external judgments (i.e., avoiding therapist’s disapproval) may lead most clients to be less than honest at some times. Over 70% of clients reported lying about an aspect of therapy itself or of the therapeutic relationship. Clients appear to be particularly sensitive to upsetting or disappointing their therapist. This suggests the importance of therapists monitoring the level of emotional safety, trust, and alliance in the therapeutic relationship. Therapists may have to accept a certain level of dissimulation by clients in the therapy. Engaging in empathy, positive regard, and a focused attention on the therapeutic relationship may be important for therapists in order to overcome a level of fear or distrust among some clients about their self-judgement or the therapist`s judgment. These findings suggest that clients may benefit from therapists who receive training in identifying and resolving therapeutic alliance ruptures.