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.

November 2023

Therapist Qualities That Lead to Treatment Failure or Termination

Alfonsson, S., Fagernäs, S., Sjöstrand, G., & Tyrberg, M. J. (2023). Psychotherapist variables that may lead to treatment failure or termination—A qualitative analysis of patients’ perspectives. Psychotherapy. Advance online publication. https://doi.org/10.1037/pst0000503

Research indicates that about 14% of patients terminated psychotherapy because it did not help them, and 7% because they were not comfortable with their therapist. Psychotherapists have difficulty identifying when patients are at risk of terminating the treatment, and many therapists do not identify when a patient is getting worse. In other words, therapists may not be a good source of understanding when and why patients do not improve and leave therapy. When researchers ask therapists to speculate about why a patient terminated prematurely, the therapists often focus on patient-related factors and not therapist-related factors. In this study, Alfonsson and colleagues interviewed 24 adult patients who had a negative experience in therapy or who terminated prematurely within the past year. Alfonsson and colleagues’ goal was to gather patient perspectives on what went wrong to begin to understand the phenomenon and to guide future training and practice of therapists. Qualitative analysis of the interview transcripts yielded four main categories of therapist variables as perceived by the patient that led to negative outcomes. The first main category was the Therapist's Negative Traits. This included therapist inflexibility/rigidity regarding their assessment of the patient and treatment plan, unengaged therapists who were not paying attention during sessions, unempathetic therapists who did not express warmth or caring for the patient’s situation, and insecure therapists who were too uncertain or oversensitive. The second main category was Therapist Unprofessionalism. This included therapists who were too superficial and avoided difficult topics, therapists who were informal such that they acted too familiar, or they were too affected by their own moods, therapists who were perceived to break confidentiality, and therapists who were nontransparent and seemed to withhold information. The third main category was Therapist Incompetence. This included therapists who were unstructured in their treatment and lacked focus, therapists who had a poor understanding of the patient’s problems by missing important issues or not understanding the patient’s situation, therapists with poor knowledge and lacked competence in a particular treatment model, and therapists who were too passive by not providing active treatment. The fourth category was Therapist Mismatch in which patients did not feel that they connected with the therapist.

Practice Implications

Some of the therapist factors are practical in nature such as those in the Therapist Incompetence category and parts of the Therapist Unprofessionalism category. For such issues, therapists may need more training that focuses on ethical practice, gaining better knowledge of psychopathology and treatment, and applying such knowledge to therapy with various patients. However, other factors like Therapist Negative Traits and parts of the Therapist Unprofessionalism category may be more challenging. These refer to personal traits of the therapist such as a perceived lack of empathy, personal insecurity, rigidity, and a tendency to remain superficial. Changing these traits may require therapists to engage in ongoing supervision and personal therapy. Therapists can also engage in routine outcome and process monitoring to get session-to-session feedback about patient experiences, symptoms, and the therapeutic alliance to help identify when things are not going well in the therapy before the patient drops out.

July 2023

Therapeutic Relationship Factors that Do Not 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

In their chapter, Norcross and Karpiak review the meta-analyses on therapeutic relationship factors that have a positive impact on patient outcomes. Aspects like therapist empathy, positive regard, genuineness, and developing and maintaining a therapeutic alliance have solid research support for their importance to patient outcomes. In fact, the research is clear that these relationship factors are more important (i.e., are better predictors of patient outcomes) than the brand of therapy conducted by the therapist. Part of this chapter by Norcross and Karpiak also identifies those therapist and relationship factors that do not work and that may be harmful to patients. One could simply reverse the effective behaviors identified in meta-analyses – so that low therapist empathy, poor therapeutic alliances, therapists who are incongruent in their words and actions, and who disregard alliance ruptures will have patients with worse outcomes. Research also identifies harmful behaviors by therapists. These might include rigidity in following prescriptions of an intervention, therapist overconfidence in their abilities, hostile behaviors, a confrontational style, and cultural arrogance. As an example, the authors discuss widespread policies mandating the use of specific treatment protocols, and training therapists in manualized treatments to the exclusion of relationship factors. Research shows that adherence or competence with treatment manuals is consistently unrelated to patient outcomes. By contrast relationship factors are highly related to patient outcomes. Research also suggests that therapist behaviors that blame patients, are sarcastic, critical, or hostile towards patients can lead to worse outcomes. Therapists whose assumptions about a patient that do not align with the patient’s experience, also tend to have patients who do not improve. Therapists may believe that they should know better, but if their knowledge does not fit the patient’s experience, then therapist and patient are not engaged in a collaborative endeavor. Finally, even if some therapies prescribe “confrontation” as a therapeutic stance, there is dubious evidence that using such an approach is helpful to patients.

Practice Implications

The research points to certain therapist behaviors that should be avoided when working with patients. Among these is rigid adherence to a treatment manual. Such rigid adherence by a therapist does not allow room for professional self-doubt, for aligning one’s approach to patient needs, and it might foster therapist over-confidence and a lack of humility. Each of these stances towards a patient reduces a therapist’s empathy and may put the patient in a position of reluctantly complying, feeling unheard and unappreciated, or dropping out of therapy.
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.
Therapist Factors Related to Patient Outcomes

Nissen-Lie, H.A., Heinonen, E., & Delgadillo, J. (2023). Therapist 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/10.1037/0000358-005.

The thing about therapists that people in the profession do not like to talk about is that some therapists are more effective than others. Meta-analyses indicate that about 5% of patient outcome variance can be explained by differences between therapists. Although this seems small, it accounts for about one-third of the total difference in outcomes among patients. One study found that patient recovery rates for the most effective therapists were twice that achieved by their least effective counterparts. In another study, 15% more patients recovered when they saw an “average” therapist compared to one of the least effective clinicians. One key problem is that therapists consistently over-estimate their own effectiveness, and consistently under-estimate the percentage of their patients who get worse. This makes it difficult for therapists to correct course when necessary or to engage in targeted professional and personal development. In this chapter, Niessen-Lie and colleagues review the research that identifies key therapist qualities that are related to better patient outcomes. It turns out that demographics of the therapist (sex, gender, ethnicity, age), experience level, profession, and education level are all unrelated to patient outcomes. In fact, there is some evidence that more experienced older therapists have slightly poorer outcomes than their younger counterparts. However, some therapist factors are important and known to be related to patient outcomes. For example, therapists who are consistently effective across different types of patients, patient severity, and diagnoses have the best outcomes. Another key therapist factor or attribute is interpersonal skill. This includes therapist empathy, warmth, the capacity to express emotions verbally, the ability to develop a therapeutic alliance with a variety of patients, and the capacity to tolerate and manage strong negative emotions in therapy. A third therapist factor is flexibility. Therapists who can be flexible in using therapeutic techniques within a given treatment tend to have patients with better outcomes. Finally, therapists who can maintain an attitude of humility tend to have better outcomes. Humility refers to an openness to other’s points of view, accepting that there is room for growth, and for pushing beyond one’s current skill level while taking care of oneself. Without this attitude, there is little motivation for continued learning, personal growth, and professional development.

Practice Implications

A therapist’s experience level, profession, experience, and other demographics have no bearing on their patients’ outcomes. However, we do know that being effective with a range of patients, interpersonal skills (empathy, verbal expression of emotions, and ability to tolerate strong emotions), flexibility in applying therapeutic interventions, and professional humility are related to patient outcomes. These therapist skills can be developed and improved during one’s career. Improving these skills require a therapist to be willing to examining when things do not go well in therapy (reviewing when patient outcomes are poor or a patient drops out), to reflect on one’s abilities, and to look for disconfirming evidence by asking “could I be wrong?” First, however, therapists must identify when therapy with a patient was ineffective. And for this, they may need the help of standardized assessments to monitor the state of the therapeutic relationship and patient progress.

October 2022

Progress Feedback Narrow the Gap Between More and Less Effective Therapists

Delgadillo, J., Deisenhofer, A.-K., Probst, T., Shimokawa, K., Lambert, M. J., & Kleinstäuber, M. (2022). Progress feedback narrows the gap between more and less effective therapists: A therapist effects meta-analysis of clinical trials. Journal of Consulting and Clinical Psychology, 90, 559–567.

Some therapists are more effective than others. This is often referred to as the therapist effect. Somewhere between 1% and 29% of patient outcomes can be attributed to which therapist the patient receives. In general, therapists with high facilitative interpersonal skills, high humility, and an ability to withstand difficulties in practice (i.e., ruptures, burnout) may be more clinically effective. To improve outcomes in therapy, some have suggested using routine outcome monitoring and progress feedback. This involves regularly measuring and tracking patient progress with standardized self-report scales throughout treatment and providing the clinician with this information during therapy. Progress feedback allows the therapist to compare their patient’s progress against norms and against the patient’s own progress in preceding sessions. If the patient is not progressing or is deteriorating, then the therapist is alerted to address the issue. Research indicates that progress feedback makes therapy more effective. Less is known about how progress feedback leads to better outcomes. In this meta-analysis, Delgadillo and colleagues assessed the impact of progress feedback on the therapist effect – that is, does progress feedback improve the outcomes of less effective therapists? The meta-analysis was of six clinical trials with data from 4,549 patients and 131 therapists who were randomly assigned to a progress feedback condition or to a control condition without progress feedback. The variability between therapists (ICC = .011) suggested that 1.1% of the overall variance in patient outcomes was due to therapist effects. However, feedback was associated with a significant reduction in the therapist effect (ICC = .009) by 18.2%. A closer look at the data indicated that progress feedback narrowed the gap between more and less effective therapists, such that patients of less effective therapists benefitted the most from their therapist receiving feedback.

Practice Implications

In this meta-analysis conducted on data from controlled studies, there were few under-performing therapists. However, implementing progress feedback was clinically important to achieve better outcomes among some of these therapists. That is, even a single underperforming therapist could attain relatively poor outcomes with dozens or even hundreds of patients. Who the therapist is matters – and some therapists (and their patients) can benefit from supplementing clinical judgement with reliable feedback about patient progress throughout the course of psychotherapy.

June 2022

Therapist Facilitative Interpersonal Skills

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 (7^th ed.). Wiley. Chapter 9.

Is therapist interpersonal skill a therapeutic “competence”? Past research on this important topic has been hampered by a couple of methodological challenges. First, asking therapists to self-report on their own social skills and empathy may result in a self-serving bias and is not related to patient outcomes. A second challenge is that therapists’ competence may be influenced by patient characteristics. For example, a therapist seeing an angry patient with low motivation to change might appear less competent than the same therapist seeing an agreeable patient who is highly motivated. Until recently these issues have limited the research on therapist characteristics that indicate therapeutic competence. In this part of the chapter, Wampold and Owen review some of the research that overcomes this limitation. Some researchers conducted a series of studies in which therapists watched videos of standardized patients with different characteristics, and the therapists’ responses to the videos were recorded. In this way, all therapists “saw” the same patients. Therapists’ responses to the videos were coded for facilitative interpersonal skills; that is, for therapist verbal fluency, hope, emotional expression, warmth, empathy, and alliance capacity. In one study, therapist facilitative interpersonal skills assessed with these standardized patient videos predicted outcomes of real patients seen by the therapists in their practices. In another study, student therapists completed the therapist facilitative interpersonal skills assessment at the very beginning of their training. These facilitative skills predicted outcomes obtained when the trainees began seeing patients later in their training. In an interpersonally challenging situation, like some therapeutic encounters where affect is strong, the interpersonal skills of therapists were robust predictors of patient outcome.

Practice Implications

The research showing that therapist interpersonal skills predict patient outcomes is beginning to redefine what it means to be a competent therapist. Research reviewed elsewhere in this blog indicated that adhering to a treatment manual or protocol is not related to patient outcomes. Instead, therapists’ capacity to use verbal skills to express emotions, to be empathic, to develop a therapeutic alliance with a variety of patients, and to repair therapeutic alliance ruptures appear to be much more reliable predictors of patient outcomes. Training programs and professional development should focus on these important skills.

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November 2023

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July 2023

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October 2022

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June 2022

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Psychotherapy Practice Research Network (PPRNet)