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
Working Alliance and Therapist Cultural Humility Reduce the Impact of Microaggressions
DeBlaere, C., Zelaya, D. G., Dean, J.-A. B., Chadwick, C. N., Davis, D. E., Hook, J. N., & Owen, J. (2022, December 8). 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. Advance online publication.
A lack of culturally competent care can have negative impacts on therapy outcomes for Black, Indigenous, People of Color (BIPOC) and for women who experience discrimination based on gender. Often these negative outcomes occur because of microaggressions – which are a form of alliance rupture in the therapeutic relationship caused by subtle, intentional, or unintentional messages that degrade BIPOC, women, and other historically excluded groups. The majority of BIPOC clients (81%) and women (53%) report experiencing a therapist microaggression over the course of psychotherapy. A therapist’s cultural humility (valuing the importance of culture in their client’s experience) and the therapeutic alliance (client-therapist collaborative agreement on tasks and goals of therapy) may reduce the negative impact of microaggressions committed by the therapist. This study by DeBlaere and colleagues looked at the association between microaggressions experienced by BIPOC women and therapy outcomes, and whether this association was reduced by higher levels of therapist cultural humility and therapeutic alliance. The clients were 288 BIPOC women who were treated by a psychotherapist (81% had a female therapist, and 46% had a White therapist). Both racial and gender microaggressions were associated with worse outcomes. Using structural equation modeling to assess indirect effects, the authors found a significant indirect effect of racial microaggressions (−.12, 95% CI [−.35, −.07]) and gender microaggressions (−.10, 95% CI [−.36, −.05]) on positive therapy outcomes, through both cultural humility and working alliance, accounting for 24% of the variance in outcomes. That is, the effect of microaggressions on outcomes was partly explained by the level of therapist cultural humility and by the therapeutic alliance. The most common racial microaggression reported by clients was: “My counselor avoided discussing or addressing cultural issues in our sessions”, and the most common gender microaggression was: “My therapist encouraged me to be less assertive so that I do not present myself as being aggressive”.
Unfortunately, therapist racial and gender microaggressions are common. However, therapists who practice cultural humility and who work at developing a therapeutic alliance may commit fewer microaggressions and can more easily mitigate the negative effects of microaggressions should they occur. Taking steps to develop cultural humility, strengthening the alliance, and repairing alliance ruptures through professional development may be ways of improving therapy outcomes for BIPOC women.
Therapists Report Less Therapeutic Skill in Telepsychology vs In Person Therapy
Lin, T., Stone, S. J., Heckman, T. G., & Anderson, T. (2021). Zoom-in to zone-out: Therapists report less therapeutic skill in telepsychology versus face-to-face therapy during the COVID-19 pandemic. Psychotherapy, 58, 449–459.
The COVID-19 pandemic has confronted psychotherapists with several challenges including rapidly switching their practice to using teletherapy (videoconferencing, phone, and other virtual media). The use of teletherapy in clinical work increased from 7.1% prior to the pandemic to 85.5% during the pandemic. And estimates suggest that at least one-third of clinical work will be performed by teletherapy post-pandemic. Over a third of psychologists reported that they lacked training in using teletherapy, and they believe that their skills in this domain are inadequate. Therapists have raised a number of concerns in past surveys including issues related to privacy, professional self-doubt, technological competence, challenges to the therapeutic relationship, and problems with implementing some interventions. In this survey of 440 therapists and trainees, Lin and colleagues were particularly interested in therapists’ perceptions of the impact of teletherapy relative to in person therapy on the therapeutic process and patient outcomes. Videoconferencing was the most frequently used modality by 73.56% of surveyed therapists. The survey asked if three broad areas of practice were affected by teletherapy compared to in person therapy. These areas included common therapeutic factors (level of therapist empathy, emotional expression, warmth, alliance bond), extra-therapeutic patient factors (the patient’s environment that impacted their ability to engage in homework or use prescribed resources), and perceived patient outcomes (therapist ratings of patient symptom reduction, satisfaction, clinical improvement). Therapists in the survey were representative of the population of therapists in the US, and 82% of them provided all their clinical work in recent months by teletherapy. Compared to in person therapy, therapists reported poorer skills related to common therapeutic factors (d = 0.86), somewhat greater impact of extra-therapeutic factors (d = 0.36), and perceived poorer patient outcomes (d = 0.68) in teletherapy. Therapists who were younger, preferred emotion-focused or relational therapies, and with no prior training reported a relatively greater decrease in therapeutic skills in teletherapy compared to in-person therapy.
By far, most therapists believed that providing psychotherapy by virtual means reduced their capacity to use common therapeutic stances including empathy, warmth, and the therapeutic alliance. Some of this might be affected by the psychological distance caused by the virtual format and difficulties with reading body language and other non-verbal cues. Therapists perceived that patient outcomes suffered as a result. This was particularly true for younger therapists, possibly because of the impact of adopting the new modality on their professional self-confidence. Also, therapists who preferred experiential or interpersonally based therapies felt particularly challenged possibly because these therapies may be more reliant on emotional communication and discerning patient interpersonal behaviors. Training and support are needed for therapists and trainees to improve their confidence in providing teletherapy.
Do Psychotherapists Get Better with Experience and Training?
Wampold, B. & Owen, J. (2021). Therapist effects: History, methods, magnitude, and characteristics of effective therapists. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7th ed.). Wiley. Chapter 9.
One of the defining characteristics of expertise is the overall improvement in skills and performance over the course of one’s career. We can identify, for example, that there are experts in chess, tennis, surgery, and musical performance based on performance. Expertise in these areas is explicitly developed partly because there is clear and immediate feedback regarding performance (i.e., a tennis player knows immediately that they missed a serve, and so they make an adjustment on the next serve). In psychotherapy, this is not so easy. Therapists rarely receive immediate feedback about their specific interventions or interpersonal responsiveness to a patient. In this part of the chapter, Wampold and Owen review the research on the relationship between therapist experience and training and patient outcomes. They focus on high quality studies that disentangled therapist from patient effects. Overall, the evidence does not support the notion that the more experience that a therapist accumulates the better their patients’ outcomes. In fact, one study that tracked therapists over time (up to 18 years) found that patients’ outcomes got slightly worse with more experience. Similar findings occur for training of student therapists. For the most part, more training that student therapists received over a 12-to-42-month period was not associated with better patient outcomes. There is some evidence that trainees can improve their capacity to develop a therapeutic alliance, and that with more deliberate practice (focused, immediate attention and feedback on specific skills) therapists can realize better outcomes with their patients.
As a senior therapist who is very involved in training, I find these results discouraging. Nevertheless, the solutions offered by the research do provide a ray of hope. Providing therapists with specific and immediate feedback about patient outcomes and therapeutic processes (e.g., ratings of patient distress and of the alliance after every session), has the potential for helping therapists to inform their practice, make adjustments, and develop expertise. Deliberate practice of specific skills in psychotherapy (e.g., ways of addressing an alliance rupture or of responding to intense emotion) may also improve therapist expertise and patient outcomes. It is also quite possible that the focus on learning specific manualized protocols, which is often the goal of graduate and post-graduate training, may not be the most effective training and professional development.
Psychotherapist burnout affects patient outcomes
Delgadillo, J., Saxon, D., & Barkham, M. (2018). Associations between therapists’ occupational burnout and their patients’ depression and anxiety treatment outcomes. Depression and Anxiety, 35, 844-850.
Providing psychotherapy can be challenging for the therapist. Vicarious trauma, secondary traumatic stress, and compassion fatigue among psychotherapists are well documented. In addition, organizational conditions in publicly funded mental health programs like workload, safety issues, and lack of supervision and support can lead to higher rates of therapist burnout. Surveys document that between 21% and 67% of mental health workers experience burnout. Occupational burnout can take many forms, but it is typically defined as emotional exhaustion and disengagement that lead to lower levels of therapist empathy, engagement, and depersonalization. One could speculate that burnout among therapists leads to worse patient outcomes because of the impact of disengagement on the therapeutic alliance. However few if any studies examined the association between therapist burnout and patient mental health outcomes. In this study, Dalgillo and colleagues assessed therapist burnout and job satisfaction in 49 therapists, and they assessed depression and anxiety outcomes in 2223 of their patients. The therapists provided treatment as part of the UK’s Increasing Access to Psychotherapy (IAPT) program. The analyses controlled for therapist case mix. That means that differences between therapists’ caseload (patient level of impairment, social economic status, and severity of symptoms) were controlled so that the findings were unique to the effect of therapist burnout and job satisfaction on patient mental health outcomes. Higher therapist disengagement (an index of burnout) and lower therapist job satisfaction were significantly associated with poorer treatment outcomes for patients. In addition, higher burnout was related to lower job satisfaction among therapists.
This is one of the first studies to show a direct association between therapist burnout and low job satisfaction with patient mental health outcomes. It is possible that these findings are specific to the UK’s IAPT program, in which therapists might feel a lower sense of control over their work. Nevertheless, organizations need to design mental health delivery in such a manner as to enhance psychotherapist autonomy, coping, and resilience, as these are likely related to therapist burnout and poorer patient mental health outcomes.
Therapeutic Alliance Predicts Patient Outcomes Over and Above Other Factors
Flückiger, C., Del Re, A. C., Wlodasch, D., Horvath, A. O., Solomonov, N., & Wampold, B. E. (2020, March 26). Assessing the alliance–outcome association adjusted for patient characteristics and treatment processes: A meta-analytic summary of direct comparisons. Journal of Counseling Psychology. Advance online publication.
The therapeutic alliance is probably the most researched concept in psychotherapy. The alliance refers to a collaborative agreement on the tasks of therapy (what patients and therapists do in therapy, like homework, or examine the past or relationship issues), a collaborative agreement on the goals of therapy (what the desired outcomes might be), and the relational bond between patient and therapist (liking and respect for one another). The most recent meta-analysis of the alliance included 296 studies. The meta-analysis showed a moderate and robust relationship between higher alliance and better patient outcomes regardless of type of therapy, who rated the alliance, or how it was rated. Nevertheless, some still think that the alliance is a byproduct of other factors like patient symptom severity (less symptomatic patients may report a better alliance with therapists) or adherence to treatment manuals (higher therapist adherence may lead to a better alliance). In other words, some argue that the alliance may not directly affect outcomes and may not be that important. In this meta-analysis, Fluckiger and colleagues examined 60 studies with over 6,000 patients that reported the alliance-outcome relationship, and also the effects of patient characteristics like symptom severity and adherence to treatment manuals. Overall, the therapeutic alliance was significantly related to patient outcomes, r = .304 (95% CI [.253, .354], p < .001, k = 53). When the authors of the primary studies controlled for patient characteristics like symptom severity, the adjusted alliance - outcome correlation remained significant, r = .286 (95% CI [.226, .344], p = .001, k = 35). When the authors of primary studies controlled for the effects of therapist adherence to a treatment manual, the adjusted alliance – outcome correlation still remained significant, r = .242 (95% CI [.179, .306], p = .001, k = 13). The slight reduction in the alliance-outcome correlation caused by the effects of patient symptom severity or therapist adherence to a manual was not significant.
Therapists’ capacity to develop a therapeutic alliance is a key factor to patients experiencing a good outcome from psychotherapy. This is true for many types of patients with differing levels of symptom severity, and also true regardless of type of therapy or level of therapist adherence to a treatment protocol. Developing shared treatment goals and agreeing on the tasks of therapy are important first steps. In addition, therapists and clients who like working together and share a sense of mutual respect are more likely to experience a successful therapy. Maintaining the alliance throughout therapy is also important. The alliance fluctuates across time indicating subtle or obvious ruptures or tensions that occur. Therapists’ skills at identifying and repairing alliance ruptures is critical to an ongoing collaborative relationship and to patients achieving the best possible outcomes.
Identifying Outcomes for Depression That Matter to Patients
Chevance, A., Ravaud, P., Tomlinson, A., Le Berre, C., Teufer, B., … Tran, V.T. (2020). Identifying outcomes for depression that matter to patients, informal caregivers, and health-care professionals: Qualitative content analysis of a large international online survey. The Lancet Psychiatry, 7, 692-702.
One of the criticisms of mental health treatment research is that the outcomes measured in these studies are those that matter to researchers but may not matter as much to patients. Common outcome measures of depression like the Beck Depression Inventory (BDI), the Patient Health Questionnaire (PHQ-9) or the Hamilton Depression Rating Scale (HDRS) were developed by researchers because of their relative ease of use, and their sensitivity to change following treatment. But these measures provide a narrow view of what it is like to experience depression because they focus only on a limited set of symptoms. But is symptom reduction the only thing that matters to patients and their loved ones? In this large-scale study by Chevance and colleagues, the authors surveyed over 1900 patients with a mood disorder, 464 informal caregivers (family members), and 627 health care providers from a wide range of mental health disciplines. The survey extended across dozens of countries and sampled a range of age groups. The authors asked patients open ended questions about what outcomes are important to them in the treatment of their depression, and then the responses were analyzed using a qualitative method. Chevance and colleagues identified two broad categories important to patients: symptoms and functioning. Regarding symptoms, patients identified several domains in which they wanted to experience improvements. These included: their perception of their self (e.g., self-esteem, self-confidence), physical symptoms (e.g., sleep, energy level), cognitive symptoms (e.g., social interest, cognitive distortions, motivation), emotional symptoms (e.g., mental pain, anxiety, sadness), and symptoms related to burden of suicidal thoughts. Regarding functioning, patients identified four domains in which they wished to see improvements. These included: elementary functioning (e.g., self-care, coping with daily tasks, autonomy), social functioning (e.g., social isolation, interpersonal relationships, family life), professional functioning (e.g., loss of job/studies, professional responsibilities), and complex functioning (e.g., coping with daily life, financial issues, personal growth).
Clearly, patients, their loved ones, and those who provide treatment have a much broader view than researchers of what constitutes important outcomes to their mental health treatment for depression. The two most common symptom outcomes identified by patients were psychic pain and the burden imposed by suicidal ideation, yet these rarely assessed as primary outcomes in psychotherapy studies. And outcomes like social functioning, family relationships, and personal growth are not primary outcomes, and often they are not assessed at all in research studies. Clinicians would do well to take a broader view of what is important to patients, and to keep in mind their patients wishes as they develop collaborative goals for treatment with patients. It may be useful not only to use standardized scales to aid in developing treatment plans, but also to ask patients what they hope to gain from therapy should the treatment be successful.