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.

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.

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.

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.

June 2023

What People Want From Therapy

Delboy, S. & Michaels, L. (2021). Going beneath the surface: What people want from therapy. Psychoanalytic Inquiry, 41:8, 603-623. DOI: 10.1080/07351690.2021.1992232

There has been an increased interest in and demand for mental health care, and so one can imagine that the public might have questions or opinions about psychotherapy. Moreover, research has shown that patients who get the type of treatment that they expect or want are more likely to have better outcomes. However, it is rare that researchers ask the public what they want from therapy. In this unique study, Delboy and Michaels conducted a survey of US citizens about their perceptions and preferences for psychotherapy. Their sample of 1,535 respondents were deliberately selected to be representative of US census data for age, gender, ethnicity, socioeconomic status, and geographic region. The survey asked what people what they wanted from therapy: 70% indicated that they wanted to “learning skills and coping strategies”, which is like what is offered in manualized treatment modalities. However, 70% also wanted to “better understand oneself and the root of one’s issues”, which is like what is offered in depth, insight, and relational therapies. When forced to choose between a “therapy that takes fewer sessions and helps manage symptoms” and a “therapy that takes longer but addresses the root causes of problems”, 91% chose a longer therapy focused on root causes. Over 60% of the sample indicated that they wanted to “share feelings without judgement” and to “feel heard and understood by someone who cares”, which suggests that people value these qualities in the therapist and the therapeutic relationship. Interestingly, two thirds of the sample recognized that therapy takes time “to understand and resolve” one’s issues and problems. And less than 10% did not want to understand their problems or examine issues from childhood. Regarding the reasons of their mental health issues, 50% reported that relationship patterns are an important source of their distress, whereas only 10% attributed mental health problems to a “chemical imbalance” in the brain.

Practice Implications

Patients tend to do better when they get the treatment that they prefer. A similar percentage of the public (70%) wanted to “learn coping strategies” and to “better understand” themselves. However, when asked to choose, the vast majority (91%) preferred to better understand themselves and to address the root causes of problems. In addition, most people recognized that therapy takes more time than is often offered in time limited treatments. This is consistent with large surveys of patients that indicated that it took over 50 sessions before significant symptom relief was achieved. It is time for insurance providers, clinicians, and training programs to begin to take stock of client preferences when paying for, providing, and training for psychotherapy.

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September 2023

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August 2023

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July 2023

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June 2023

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