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Eubanks, C. F., Burckell, L. A., & Goldfried, M. R. (2017, December 21). Clinical consensus strategies to repair ruptures in the therapeutic alliance. Journal of Psychotherapy Integration. Advance online publication.

Research is clear that the therapeutic alliance (i.e., agreement on tasks and goals of therapy, and the bond between client and therapist) is an important predictor of client outcomes across theoretical orientations. It is also clear that ruptures or strains in the alliance occur often and can have a negative effect on client outcomes. One can define two types of ruptures: (1) withdrawal ruptures, in which the client moves away from the therapist by shutting down, changing the focus, or not completing session assignments; and (2) confrontation ruptures, in which the client moves against the therapist so that the relationship quality is low, the client is not collaborative, and the client does not agree with the goals of therapy. Repairing alliance ruptures can have a positive effect on client outcomes, and therapists can learn to repair alliance ruptures. What are the best strategies that a therapist can use to repair alliance ruptures? In this study of expert consensus, Eubanks and colleagues surveyed clinicians in three broad and different surveys. In the first survey, the authors asked 330 professional social workers and psychologists from a variety of theoretical orientations to describe situations in which they encountered alliance ruptures in clinical practice. The researchers categorized situations described by clinicians as withdrawal ruptures or as confrontation ruptures, and then the authors selected those scenarios that best represented each type of rupture. In a second independent survey, 177 clinicians indicated how they would advise a colleague seeking consultation to respond to each scenario of a therapeutic alliance rupture. Clinicians generated between 35 and 45 strategies to repair each type of alliance rupture. In the final part of the survey, training directors in psychology and social work programs nominated peer experts to rate the strategies for alliance repair, so that 134 peer-nominated expert clinicians provided ratings. There was a high level of consensus among experts such that between 55% and 74% agreed on effective strategies to repair alliance ruptures. Experts agreed that during the session in which the alliance rupture occurred therapists should: explore and empathize with the client`s anger at the therapist, and validate or legitimize the client`s position on the issue related to the rupture. Experts also agreed that in future sessions clinicians can use other strategies like: helping the client manage and cope with painful feelings related to the rupture, helping the client clarify and explore their emotions related to the rupture, and exploring the meaning and patterns of problematic relationships outside of therapy.

Practice Implications

Experts agreed that the best strategies to repair therapeutic alliance ruptures were to deal with the therapeutic bond (e.g., explore and empathize with the client`s anger at the therapist) and to validate the client`s position on the issue related to the rupture. Other strategies like helping the client cope with their reactions and feelings, and exploring the meaning and patterns related to the client`s response were also rated as helpful. Less helpful strategies included therapists communicating about the limits of therapy, and therapist self-disclosure of their reaction to the rupture.

Anderson, T., Crowley, M. E. J., Himawan, L., Holmberg, J. K., & Uhlin, B. D. (2016). Therapist facilitative interpersonal skills and training status: A randomized clinical trial on alliance and outcome. Psychotherapy Research, 26(5), 511-529.

Research on therapist effects indicates that there are differences between therapists so that some therapists are more effective than others. Therapist effects account for about 9% of client outcomes, which represents a moderate and therefore important effect. Differences between therapists do not seem to be accounted for by differing levels of adherence to or competence in delivering a manualized treatment. However, some researchers argue that therapist effects can be accounted for by differing level of facilitative interpersonal skills. That is, therapists vary in the level of interpersonal skills, and this difference accounts for a significant proportion of client outcomes. Therapist facilitative interpersonal skills might include: empathy, positive regard, warmth, ability to establish and repair therapeutic alliances, verbal fluency, emotional expression, and the ability to enhance client expectations of improvement. In this unique analogue study, Anderson and colleagues selected 23 “therapists” who were rated as very high or as very low on facilitative interpersonal skills. For example, highly skilled “therapists” scored high on a self-report measure of social skills and also demonstrated high interpersonal skills in their responses to video vignettes of therapy. Therapists also differed on their training status: half of the “therapists” were advanced clinical psychology graduate students, and the other half were graduate students from other programs (social sciences, humanities) who had no clinical training at all. The 66 clients were volunteers from a large undergraduate student research pool who met diagnostic criteria for a mental disorder (anxiety or depression) and were moderately to highly distressed. Clients were randomly assigned to receive treatment or to a wait-list control condition, so that 46 clients (2 per therapist) received treatment and 22 received no treatment. Compared to those in the control condition, clients who received treatment on average improved in terms of level of distress, regardless of which “therapist” they were assigned to. The training status of “therapists” (those with clinical training versus those without clinical training) had no effect on client outcomes or on the therapeutic alliance. Compared to “therapists” with low facilitative interpersonal skills, those with high interpersonal skills (regardless of training status) had significantly better client outcomes and significantly higher levels of the alliance.

Practice Implications

This was an analogue study in which some “therapists” were non-clinicians, so one must take the results with a grain of salt. Nevertheless, clients started out distressed, had a diagnosable disorder, and on average they achieved significant reduction in distress if they received therapy. Whether “therapists” had any clinical training did not affect outcomes, that is, non-clinical “therapists” did just as well as clinical trainees. However, higher “therapist” facilitative interpersonal skills regardless of training status lead to better client outcomes. These findings provide support for the notion that a therapist who is: empathic, warm, able to establish and repair therapeutic alliances, verbally fluent, emotionally expressive, and able to enhance client expectations of improvement will be more effective in reducing their clients’ levels of distress.

Author email: andersot@ohio.edu

Erekson, D. M., Janis, R., Bailey, R. J., Cattani, K., & Pedersen, T. R. (2017). A longitudinal investigation of the impact of psychotherapist training: Does training improve client outcomes? Journal of Counseling Psychology, 64(5), 514-524.

The research on the effects of therapist training on client outcomes has not been very encouraging. Most studies indicate that more therapist training, better adherence to and competence in a treatment manual, and greater experience are not related to improved client outcomes. The profession would like to think that therapists affect client outcomes so that more training and experience might be related to better outcomes. One could argue that the research in this area is hampered by many studies not following the same therapists across time over stages of training. That is, many studies compare client outcomes between novices and licensed professionals – but these studies do not really address the question “does an individual therapist get better as he or she accumulates more years of training and experience?” In this unique study, Erekson and colleagues track client outcomes of 22 therapists over a 10 year period starting from the therapists’ early training in a doctoral program in psychology to their first years as licensed psychologists working in a counselling centre. On average, the psychotherapists saw 183.95 (SD = 103.23) student clients during that time (range: 62 to 449 clients). The clients primarily had clinically impairing problems with anxiety and depression. Stages of training were defined as: graduate trainee, intern, post-doctoral fellow, and licensed professional. The average client moderately improved (d = .72) in terms of symptoms from the start to the end of their therapy. When looking at therapists’ effects across stages of training, the authors controlled for client initial severity and size of therapist caseload. The results indicated that 4 of the 22 therapists improved in their client outcomes over stages of training, 10 remained the same, and 8 therapists worsened over time. On average, client outcomes remained the same across a therapist’s stage of training. However, average client rate of change (i.e., how quickly a therapist’s client improved) became slower as therapists achieved more training and experience.

Practice Implications

This study adds to the weight of evidence that therapist training and experience as currently conceptualized do not result in better outcomes among clients. One possible explanation for why psychotherapist trainees do as well or better than when they are licensed professionals may lie in the structure of training programs. Trainees in graduate school and internships typically receive a high level of supervision and learning experiences, and must deliberately report client progress on an ongoing basis. Therapists who are licensed professionals are not required to maintain these practices, and so they may not be practicing deliberately. Researchers and clinical writers identify deliberate practice as an important means by which practicing psychotherapists can maintain and improve their skills in interpersonal effectiveness and therapeutic alliance.

Author email: david_erekson@byu.edu

Holmqvist Larsson, M.H., Falkenström, F., Andersson, G., & Holmqvist, R. (2018). Alliance ruptures and repairs in psychotherapy in primary care. Psychotherapy Research, 28, 123-136.

The therapeutic alliance is related to treatment outcome, so that a moderate amount of client improvement can be attributed to a positive alliance. More recent research on the alliance identifies ruptures in the alliance (i.e., disagreements on tasks and goals of therapy, or a tension in the relational bond between client and therapist) as predictive of poor client outcomes. Conversely repairing alliance ruptures (i.e., renegotiating tasks and goals of therapy, or repairing a strain in the relationship) is related to better client outcomes. Therapists can be trained to identify and repair alliance ruptures and this has a positive impact on clients. In this large study in a naturalistic primary care setting, Holmqvist Larsson and colleagues assessed how frequent alliance ruptures and repairs of ruptures occurred. They used a conservative definition of alliance rupture based on a meaningful decline in client self-reported measurement of alliance from one session to another. A repair of the alliance was defined as a return to previous levels of the alliance within 3 sessions after a rupture. Clients were 605 adults with depressive or anxiety disorders who received a variety of therapeutic orientations (CBT or psychodynamic) from one of 79 therapists. Ruptures with no subsequent repairs occurred in 10.7% of the cases, and ruptures followed by a repair occurred in 14.7% of the cases. Clients with more severe symptoms were significantly more likely to experience a rupture in the alliance with their therapist. Unrepaired ruptures were associated with poorer client outcomes, and repairing ruptures appeared to reverse the negative effects so that outcomes improved. In therapies of longer duration (14 sessions or more), a rupture-repair sequence was associated with even better outcomes than in those cases that experienced no rupture at all.

Practice Implications

About 25% of cases experienced an alliance rupture, even by this conservative definition of a rupture. Clients whose therapists were able to identify and repair the ruptures achieved the best outcomes, especially in therapies of longer duration. Therapists need to able to identify alliance ruptures, particularly in clients with higher distress; and therapists must be able to repair these ruptures so that these clients can achieve better outcomes. The results also suggest that the process of alliance rupture and repair may be highly therapeutic in and of itself.

Author email: mattias.holmqvist.larsson@liu.se

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.

Practice Implications

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.

Westmacott, R. & Hunsley, J. (2017). Psychologists’ perspectives on therapy termination and the use of therapy engagement/retention strategies. Clinical Psychology and Psychotherapy, 24, 687–696.

The average psychotherapy client attends a median of about 3 to 5 sessions, which is substantially less than the number of sessions the average client needs to realize a clinically significant decline in symptoms. Premature termination (clients ending therapy unilaterally) occurs in 19% of cases in research trials and in as many as 38% of clients in community practices. And so premature termination is mental health problem for clients and an economic problem for therapists and agencies. Clients terminate therapy prematurely for a variety of reasons including: dissatisfaction with therapy or the therapist, achieving their goals, and practical barriers (appointment times, travel, cost). Therapists tend to underestimate the proportion of unilateral terminations from their practice, and underestimate negative outcomes and client negative perceptions of therapy and therapists. In this study, Westmacott and Hunsley, surveyed psychologists who provide psychotherapy (N=269) on their perspectives on their clients’ reasons for termination and the strategies they use to retain their clients in therapy. Therapists reported that 33.3% of their clients terminated prematurely, which is somewhat lower than the percentage reported in previous research. Most psychologists (65.7%) tended to attribute the most important reasons for premature termination before the third session to clients’ lack of motivation to change (rated as very important or important on a scale). A much smaller percentage (15.8%) attributed waiting too long for services as the most important reason for premature termination before session 3. The most important reason for premature termination after the third session was most often attributed to clients reaching their treatment goals (54.8%). Regarding strategies to retain clients - almost all psychologists (96.8%) indicated that they fostered a strong alliance, 74.3% indicated that they negotiated at treatment plan, 58.0% prepared clients for therapy, 38.7% used motivational enhancement strategies, 33.0% used client outcome monitoring, and 17.8% used appointment reminders.

Practice Implications

This survey of psychologists suggests that psychotherapists may somewhat underestimate the number of clients who prematurely terminate therapy. Psychotherapists may also overly attribute dropping out to client-focused factors (low motivation, achieving outcomes), rather than therapist-focused factors (dissatisfaction with therapist or therapy), setting-focused factors (negative impression of the office and staff), or practically-focused factors (appointment times, cost). Many therapists reported using alliance-building and negotiating a treatment plan to retain clients. However, few therapists used other evidence-based methods like systematic outcome monitoring, and fewer still used appointment reminders. Therapists should consider therapist-focused and setting-focused reasons for client termination, and to use outcome monitoring and appointment reminders to reduce drop-outs from their practices.