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
May 2022
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.
Practice Implications
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.
The Therapist Effect: Or Does the Therapist Matter?
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.
The early days of psychotherapy research treated psychotherapists in a clinical trial as largely interchangeable. That is, it was assumed that therapists were more alike than different and so their impact to patient outcomes were ignored. Some of this was thought to be achieved by training therapists to be highly adherent to a treatment protocol. The thinking was that if every therapist followed the manual faithfully, then any differences among therapists would disappear. Never mind that research indicates that therapist adherence to or competence in delivering a manualized treatment is largely unrelated to patient outcomes. In this part of the chapter, Wampold and Owen examine the question of “does the therapist matter to the patient’s outcomes.” In other words, are there differences between therapists when it comes to patient outcomes? It turns out that between 3% and 15% of patient outcomes in highly controlled randomized trials is attributable to differences between therapists. This might seem like a small percentage, but it is larger than outcomes associated with differences between treatment orientations or the effects of specific interventions. And these are highly controlled trials partly designed to reduce therapist differences. In everyday clinical practice in which there is less control over therapists, the lowest estimate of therapist effects is about 6% but could be as high as 12%. The effect of the therapist is probably higher for more severely symptomatic patients.
Practice Implications
Which therapist a patient sees matters, and this is particularly true for patients who have more severe symptoms. That is more severe patients may do much worse or much better in therapy depending on which therapist they see. A therapist’s capacity to follow a treatment manual does not predict patient outcomes, but other factors like interpersonal skills, openness to lifelong learning, and getting reliable feedback about patient outcomes may be those skills and practices that matter to patient outcomes.
Interpersonal Complementarity: Therapist Responsiveness to Patient Interpersonal Behaviors
Constantino, M.J., Boswell, J.F., & Coyne, A.E. (2021). Patient, therapist, and relational factors. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7th ed.). Wiley. Chapter 7.
Interpersonal behaviors can be characterized by the level of affiliation (i.e., friendliness vs hostility) and of interdependence (i.e., dominance vs submissiveness). Interpersonal complementarity refers to two people in an interaction whose behaviors are matched on affiliation (friendliness evokes friendliness in the other) and reciprocity in terms of interdependence (dominance evokes submission or submission evokes dominance in the other). So friendly-dominant behaviors in one person tends to evoke friendly-submissive behavior in another and vice versa, and similarly, hostile-dominant behaviors in one person tend to evoke hostile-submission in the other and vice versa. Complementary interactions are comfortable and do not cause anxiety, they reinforce the interactional styles of the participants, and they tend to continue unchanged. Non-complementary interactions do cause anxiety, and they either change or they terminate. In this part of the chapter, Constantino and colleagues review the research on the role of complementarity between therapists and patients. Therapists on average tend to behave in a friendly-dominant style and many but not all patients tend to respond in a friendly-submissive style. The most interesting findings of this line of research is that the number of complementarity interactions between therapists and patients tend to change across stages of successful therapy. In early sessions, patient-therapist interactions tend to be highly complementary. Interactions in the middle of therapy tend to be lower in complementarity. And at the end of therapy, patients and therapists tend to return to higher levels of complementarity. Hostile therapist interactions are rare, and when they occur it is almost exclusively in unsuccessful therapy cases.
Practice Implications
This research has a lot to say about how therapists should respond to patients’ interpersonal behaviors and styles. Therapists should always remain affiliative or friendly (or at least neutral) and avoid hostile interactions with patients. The research indicates even a small number of hostile responses from therapists may lead to negative outcomes or dropping out. The research seems to indicate that (a) higher therapist-patient interpersonal complementarity early in therapy is related to establishing rapport and a therapeutic alliance, (b) lower complementarity in the mid stage of therapy might indicate that therapists are engaging patients differently in order to help change patient patterns of interpersonal relating, and (c) a return to higher complementarity at the end of therapy may indicate therapists reinforcing changes and patients experiencing a new sense of self within the therapeutic relationship.
April 2022
Countertransference and its Management
Constantino, M.J., Boswell, J.F., & Coyne, A.E. (2021). Patient, therapist, and relational factors. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7th ed.). Wiley. Chapter 7.
Countertransference is one of the oldest concepts in psychotherapy dating back more than 100 years. More recently, some writers view countertransference as a pantheoretical concept, in other words it affects all therapists and occurring in all therapies. One definition of countertransference is that it is the “internal and external reactions in which unresolved conflicts of the therapist, usually but not always unconscious, are implicated”. Countertransference may provide important information about a patient’s interpersonal patterns, but it may also be an impediment to the therapist’s effectiveness. One prominent model of countertransference identifies its component parts to include: origins within the therapist (i.e., unresolved issues within the therapist that may interact with patient qualities); triggers caused by the patient’s transference (i.e., patient maladaptive interpersonal patterns) and other patient behaviors that may interact with the therapist’s unresolved issues; manifestations – or how the countertransference affects the therapist’s behaviors and responses toward the patient; the effects of these behaviors on the therapeutic relationship or the patient; and the therapist’s management of countertransference responses – or what the therapist does to maintain an equilibrium. In this part of the chapter, Constantino and colleagues review two meta-analyses of the impact of countertransference and its management on the patient. A meta-analysis of 14 studies indicated a small but significant correlation between therapist countertransference and poor patient outcomes (r = -0.16), and a second meta-analysis of 9 studies indicated a moderate and significant association between successful countertransference management and patient improvement (r = 0.39).
Practice Implications
Despite countertransference being a well-established topic in psychotherapy, the research is relatively new. The findings suggest that regardless of what type of therapy is practiced, therapists should be mindful of their countertransference reactions. It is important for therapists to monitor their internal mental and emotional states during a therapy session, and to note when they feel something that is not typical for them (bored, annoyed, attracted, overwhelmed, disgusted, distracted). A therapist’s management of these feelings may include remaining calm in the moment, self-reflection about the origins and triggers of their reactions, seeking consultation with a trusted colleague, and personal therapy to work on unresolved issue
Therapist Flexibility and Responsiveness
Constantino, M.J., Boswell, J.F., & Coyne, A.E. (2021). Patient, therapist, and relational factors. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7th ed.). Wiley. Chapter 7.
One of the most intriguing findings from psychotherapy research is that adherence or competence to manual-prescribed techniques has almost no impact on patient mental health outcomes. That means that efforts to get therapists to follow a manual has no bearing on whether their patients get better. In fact, there is sufficient research to suggest that rigid adherence to a treatment model may be harmful to patients. Research suggests that purposefully moving away from protocols at times in therapy can be more validating, collaborative, and autonomy granting that sticking with the protocol. Thus, the over-zealous delivery of a treatment, despite good intentions, can be ineffective or harmful to patients. Some of the specific research in this area found that the patients of therapists who varied in their use of theory-prescribed interventions had better outcomes. Similarly, when psychodynamic therapists integrated cognitive and behavioral interventions, patients had better outcomes than when the therapists were less flexible. A similar concept to flexibility is therapist responsiveness, or their ability to respond to the specific therapeutic context. This might include therapists’ ability to develop a case formulation specific to the patient, and flexibly tailoring their interventions to that formulation. Therapist responsiveness and tailoring interventions to the patient may result in better outcomes.
Practice Implications
That the level of adherence to treatment manuals bears no relation to patient outcomes speaks to the speaks to problems associated with persistent and rigid adherence. Rigidity in applying a treatment model may lead to negative processes in therapy and poor patient outcomes. It is important for therapists to be responsive and attuned to their patients’ needs, progress, and treatment goals. That is, it likely more important to tailor treatment to the patient and their characteristics rather than trying to get the patient to adapt to the treatment.
Multicultural Competence and Orientation
Constantino, M.J., Boswell, J.F., & Coyne, A.E. (2021). Patient, therapist, and relational factors. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7th ed.). Wiley. Chapter 7.
Therapist multicultural competence is a commitment to increasing one’s knowledge of patient’s cultural background, tailoring interventions to a patient’s culture, and understanding the impact of one’s own cultural background. Multicultural competence research has looked at its impact on clinical interactions. In a meta-analysis of 15 studies, therapist multicultural competence was associated with lower levels of patient drop-out from therapy (r = 0.26) and with greater patient improvement (r = 0.24). An interesting finding of these meta-analyses is that whereas patient ratings of a therapist’s multicultural competence was significantly associated with better patient outcomes (r = 0.38), therapist ratings of their own multicultural competence was not significantly associated with outcomes (r = 0.06). In other words, if one is interested in a therapist’s multicultural competence then one should ask the patient, not the therapist. A related but broader concept is multicultural orientation. The multicultural orientation framework is not so much a theoretical approach but a “way of being” for a therapist. The three aspects of multicultural orientation include cultural humility (in which a therapist takes an open and curious stance towards the patient’s identities), cultural opportunities (in which the therapist actively explores a patient’s cultural beliefs and values), and cultural comfort (or the extent to which a therapist feels at ease working with cultural dynamics). A systematic review of multicultural orientation theory identified 9 articles that found that therapist cultural humility was associated with better therapeutic alliances, fewer in-session microaggressions, and greater patient improvement.
Practice Implications
The research on multicultural competence suggest that therapists should regularly assess a patient’s cultural identities for adapting the therapeutic approach. This assessment should focus on the patient’s, not the therapist’s, evaluation of the therapist’s multicultural competence. It is also important for therapists to build their knowledge of specific cultural groups when tailoring their treatments. Regarding a multicultural orientation, it appears that a therapist’s cultural humility is critically important. That is a therapist who is open, non-defensive, and curious regarding a patient’s identities will be most helpful to patients of various cultures.