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.

April 2019

Therapeutic Alliance Rupture Repair

Eubanks, C. F., Muran, J. C., & Safran, J. D. (2018). Alliance rupture repair: A meta-analysis. Psychotherapy, 55(4), 508-519.

It is difficult to over-state the importance of developing and maintaining a therapeutic alliance in order for patients to experience a good outcome from psychotherapy. The alliance is the collaborative agreement between therapist and patient on the tasks and goals of therapy, and the emotional bond between therapist and patient. A previous meta-analysis found a moderate but highly reliable association between a good alliance and patient outcomes. The alliance is a trans theoretical construct – that is, it is important to all types of therapy regardless of theoretical orientation. Sometimes deteriorations in the alliance occur manifested by a disagreement on the goals, a lack of collaboration on the tasks, or a strain in the relational bond. Other terms for this phenomenon include weakenings, misattunements, challenges, resistances, enactments, and impasses. Such deteriorations can vary from minor tensions to major ruptures in the relationship. Tensions and ruptures in the alliance are common occurrences in therapy with some studies showing 50% of therapy cases experience at least a minor tension within the first six sessions of therapy. There are two main types of alliance tensions/ruptures. (1) Withdrawal tensions/ruptures occur when the patient moves away from the therapist, such as when the patient changes the subject, goes silent, and cancels appointments. These tensions/ruptures are more subtle and harder for therapists to detect. (2) Confrontation tensions/ruptures occur when the patient moves against the therapist, such as when the patient expresses dissatisfaction with or pressures or tries to control the therapist. These tensions/ruptures are more obvious, but also difficult for therapists to manage because of the feelings they evoke. In this meta-analysis, Eubanks and colleagues reviewed 11 studies representing 1,314 patients. They found that the association between rupture repair episodes and patient outcomes was on average moderately large r = .29, d = .62, 95% CI [.10, .47], p = .003.

Practice Implications

The research on alliance tensions/ruptures and repairs is still new but points to some important therapist practices that could improve patient outcomes. Therapists must be attuned to indications of tensions and ruptures in the therapeutic relationship. Therapists immediately need to attend to confrontation tensions/ruptures, in which patients express dissatisfaction or hostility. Similarly, therapists must address more subtle withdrawal tensions/ruptures, in which patients go silent, evade, or appease. Therapists can acknowledge the tension/rupture directly and nondefensively by inviting patients to explore their experience of the rupture. If necessary, therapists might change the tasks or goals of the therapy to better match the patient’s concerns. Therapists should empathize with a patient’s negative feelings about the therapy, and validate the patient for bringing up their concerns. If appropriate, therapists should take responsibility for their part in the tension/rupture and not blame the patient. Also, if the tension/rupture is a repetition of an interpersonal pattern for the patient (e.g., the patient tends to withdraw in relationships), then the therapist might consider carefully exploring the tension/rupture as it occurs in the therapy with the understanding that it is a repetitive pattern. Mainly, therapists need to anticipate that tensions and ruptures will occur in therapy, that they can be destabilizing for the therapist and therapeutic relationship, and so therapists need to recognize and know how to explore their own and their patient’s negative feelings.

Author email: catherine.eubanks@einstein.yu.edu

March 2019

Fitting Psychotherapy to Patient Coping Style

Beutler, L.E., Kimpara, S., Edwards, C.J., & Miller, K.D. (2018). Fitting psychotherapy to patient coping style: A meta‐analysis. Journal of Clinical Psychology, 74, 1980 – 1995.

This is another in a series of meta-analyses that assess client factors and their impact on outcomes. Researchers have been studying the impact of coping style in a number of different areas in social and clinical psychology for decades. Coping styles refers to characteristic ways of behaving in order to reduce discomfort and to adapt to changing circumstances. Everybody has preferred methods of coping, however when a coping style becomes extreme or rigid, then it can be pathological. Broadly speaking, researchers and clinicians categorize coping styles as internalizing or externalizing in nature and function. Those who primarily use internalizing coping tend to face change, distress, or threat by becoming internally focused, inner-blaming, inhibited, socially withdrawn, anxious, worrying, or working out issues by thinking them through. Those who primarily use externalizing coping tend to deal with stress by being externally focused, acting out, blaming others, confronting others, or using their social environment and support to manage their distress. Also, generally, one can define theories and practices of psychotherapy as those that are insight-oriented versus symptom-focused. Insight-oriented approaches emphasize that patients re-experience repressed emotions and develop self-understanding as a means of creating change. Symptom-focused approaches generally require patients to engage in new behaviors, new learning, or new perceptions followed and reinforced by social rewards. In this meta-analysis, Beutler and colleagues assess if patients with internalizing or externalizing coping styles achieve better outcomes if they received insight-oriented vs symptom-focused psychotherapy. That is, they assessed if patients matched to therapy focus based on their coping style might achieve better outcomes. They reviewed 18 studies including 57 types of treatment and almost 2,000 patients. Beutler and colleagues found that the mean therapy focus by coping style interaction was d = .60 for all studies (SE = 0.10; p < 0.001; CI 95% = 0.44–0.76). This suggests a medium to large effect in which matching therapy to coping style accounting for 23% of the variance in patient outcomes. Patients who use internalizing coping tend to do better in insight-oriented psychotherapy whereas those who use externalizing coping tend to do better in symptom-focused interventions.

Practice Implications

The results of this meta-analysis suggested that psychotherapists would do well to assess patients’ coping style during the intake assessment process and modify their treatments and interpersonal stances accordingly. Symptom-focused interventions, like those seen in behavioral or cognitive-behavioral therapies may work better for those with externalizing coping styles. On the other hand, insight or relationship-oriented interventions, like those seen in interpersonal or psychodynamic therapies, may be more apt for patients with internalizing coping styles. Despite this general rule, therapists should also be aware that client preferences, culture, and other transdiagnostic factors can effectively guide treatments and therapist stances.

Author email: larrybeutler@yahoo.com
Cohesion in Group Psychotherapy

Burlingame, G. M., McClendon, D. T., & Yang, C. (2018). Cohesion in group therapy: A meta-analysis. Psychotherapy, 55, 384-398.

Many writers consider group cohesion to be one of the most important concepts in group psychotherapy and that is a pre-requisite for positive patient outcomes. That is, patients in a group must feel a bond with the group and its members, must value the relationships in the group, and must see the group experience as a vehicle by which to achieve the change that they want. As Burlingame once noted, over time cohesion has become synonymous with the therapeutic relationship in group therapy. Although an important concept, cohesion has been elusive to define partly because of the complexity of group therapy itself. From the patient’s point of view, relationships in group therapy can take on three structural aspects in the form of member to member, member to group, and member to leader interactions. And so, cohesion may refer to the quality of the member’s relationship: to other members, to the group as a whole, and/or to the group leader. By “quality of group relationships”, clinicians and researchers often mean the positive affective bond (warmth, empathy, attraction, compatibility, trust) and working relationship (consensus on tasks and goals, willingness to work) that members have with other members, the group as a whole, and/or the group leaders. In this meta-analysis, Burlingame and colleagues identified 55 group therapy studies including over 6,000 patients that investigated the cohesion – outcome relationship. The average correlation of cohesion to patient outcomes in the 55 studies was statistically significant, r = .26 (95% CI [.20, .31], p = .01), suggesting a moderate effect. Leaders who had an interpersonal orientation had the highest cohesion – outcome relationship (r = .48), although leaders of other theoretical orientations also posted statistically significant but lower values. A greater group process orientation (r = .36), emphasizing greater interactions among group members (r = .36), composing groups of members with similar diagnoses or problems (r = .23), and groups lasting more than 20 sessions (r = .41) also each produced significantly higher cohesion – outcome correlations.

Practice Implications

The group cohesion – outcome relationship is highly reliable and suggests that clinicians of all theoretical orientations should routinely assess and enhance group cohesion to improve patient outcomes. Ways of increasing cohesion include emphasizing member to member interactions in a group, and discussing group processes as they occur. These processes may be related to members interacting with other members, with the group as a whole, or with the leader. In particular, group therapists should promote a positive emotional climate by handling conflict and avoidance when it arises in the group. This takes particular skills, training, and knowledge in group therapy processes, and so it is important for therapists to be aware of current practice guidelines for group therapy.

Author email: gary_burlingame@byu.edu
Psychological and Pharmacological Treatments for Generalized Anxiety Disorder

Carl, E., Witcraft, S.M., Kauffman, B.Y., Gillespie, E.M., Becker, E.S…. Powers, M.B. (2019). Psychological and pharmacological treatments for generalized anxiety disorder (GAD): a meta-analysis of randomized controlled trials. Cognitive Behaviour Therapy, DOI:10.1080/16506073.2018.1560358

Generalized anxiety disorder (GAD) is characterized by excessive and difficult to control worry about events or activities. GAD is associated with a high level of impairment in social functioning, work productivity, and health-related quality of life. GAD is also associated with a high level of medical costs and health care utilization. About 4.3% of the general population have experienced GAD at one time in their life. In this updated meta-analysis, Carl and colleagues reviewed the empirical literature to compare the effects of psychotherapies and pharmacotherapy to control conditions. Seventy-nine studies with over 11,000 participants were included in the review. In 39 comparisons, evidence-based psychotherapies outperformed control conditions on measures of anxiety at posttreatment (g = 0.76, 95% CI: 0.61–0.91, p < 0.001), suggesting a medium to large effect. Only 12 studies evaluated follow-up data, and they found that psychotherapy resulted in a small but statistically significant average effect on anxiety symptoms (g = 0.27, 95% CI: 0.00–0.53, p = 0.05). Compared to older patients, younger patients tended to do better in psychotherapy. Forty-three studies found that pharmacotherapy consistently outperformed control conditions at post-treatment (g = 0.38, 95% CI: 0.30–0.47, p < 0.001) suggesting a small effect. There were no studies that assessed pharmacotherapy at a follow-up date. Patient age or treatment dose did not affect outcomes of pharmacotherapy. The authors were careful to point out that that the effect sizes of psychotherapy and pharmacotherapy were not comparable in this meta-analysis because psychotherapy trials tended to use no-treatment controls whereas pharmacotherapy trials tended to use placebo controls, and the latter tends to produce more conservative (smaller) estimates of effects.

Practice Implications

Both psychotherapy and pharmacotherapy appear to be effective by post-treatment for patients with GAD. The effects of psychotherapy at follow-up is diminished, and no studies evaluated whether patients receiving pharmacotherapy maintained any gains at follow-up. Research has suggested that compared to psychotherapy, pharmacotherapy outcomes for depression at follow up is poorer. Although this study does not allow one to compare psychotherapy to pharmacotherapy, evidence from another meta-analysis suggests that patients would strongly prefer psychotherapy if given the choice. And patients receiving their preferred treatment tend to experience significantly better outcomes.

Author email: emilycarl@utexas.edu

February 2019

Client Preferences Affect Psychotherapy Outcomes

Swift, J. K., Callahan, J. L., Cooper, M., & Parkin, S. R. (2018). The impact of accommodating client preference in psychotherapy: A meta‐analysis. Journal of Clinical Psychology, 74(11), 1924-1937.

Here is another in a series of meta analyses looking at client factors that predict psychotherapy outcomes. In 2006 the American Psychological Association defined evidence-based practice in psychology as composed of 3 pillars: (1) the integration of the best available research combined with (2) clinical expertise in the context of (3) client characteristics including client preferences. Client preferences can be grouped into three broad categories. First, activity preferences refer to activities that a client hopes they and their therapists will engage in during treatment. For example, some clients may prefer homework between sessions, or therapists who interpret, or may prefer a type of therapy modality like group, couple, or individual treatment. Second, treatment preferences include client’s wishes for certain types of therapy approach like CBT, psychodynamic, interpersonal psychotherapy, peer-support, or others. Third, therapist preferences include a client’s desire for the type of therapist with which they would like to work. This might include preferences based on demographics, therapist personality, interpersonal style, culture, and so on. Studies that measure the impact of clients receiving their preferences may simply ask clients what they prefer, or might use a questionnaire of preferences. Some research found that clients are willing to give-up up to 40% in the treatment’s efficacy in order to ensure that they worked with a therapist with whom they would have a good relationship. In this meta-analysis, Swift and colleagues reviewed 53 studies that examined the association between client preferences and psychotherapy outcomes. In 28 studies that included data from 3,237 clients, the overall effect of client preference on psychotherapy drop out was statistically significant, such that clients who were not matched or not given a choice of treatment preference were 1.79 times more likely to drop out compared to those who did get their preference (95% CI: 1.44, 2.22; p < .001). In 53 studies of over 16,000 clients, the overall effect of clients receiving their preference on outcomes was also statistically significant (d = 0.28, 95% CI [0.17, 0.38], p < .001). Receiving a preferred treatment or therapist was associated with better client outcomes.

Practice Implications

The results of this body of research suggests that therapists will do well to attempt to accommodate client preferences in psychotherapy, unless they are impractical, or therapeutically or ethically counter-indicated. One can ask clients about their preferences for activities of therapy, therapist style and characteristics, and treatment type. Some of these decisions may require clients to be educated about their options, and so agencies may consider adopting decision aids. At the very least therapists should initiate a discussion with clients about what the client wants and what they can reasonably expect to receive. These discussions may occur at the beginning of treatment and revisited part way through as well. Therapists may also consider using more structured valid assessments of client preferences to help with this task.

Author email: Joshua.Keith.Swift@gmail.com
Client Outcome Expectations and Their Post-Treatment Outcomes

Constantino, M. J., Vîslă, A., Coyne, A. E., & Boswell, J. F. (2018). A meta-analysis of the association between patients’ early treatment outcome expectation and their posttreatment outcomes. Psychotherapy, 55(4), 473-485.

A concept similar to but distinct from client preferences is client expectations of outcomes. One of the first writers to discuss the importance of client expectations was Jerome Frank who argued that clients enter therapy demoralized, and that for therapy to be effective it must mobilize the client’s belief that treatment will work. Frank felt that outcome expectation is key to the process of remoralization for the client. Outcome expectations refer to clients’ personal predictions about how they will respond to treatment. Generally, problems may be signalled by clients who feel hopeless about the potential effectiveness of the therapy or therapist. But it is also possible for expectations to be unrealistically high, never met, and therefore disappointing. Clients may form outcome expectations before they start therapy, or the expectations may be shaped by early experiences in the therapy or with the therapist. Outcome expectations may develop, in part, based on how credible the therapy seems to the client, and or whether the therapist or therapy are consistent with the client’s preferences. Also, research indicates that higher realistic expectations likely leads to an improved therapeutic alliance, mainly because it facilitates collaboration of the client with the therapist. In this meta-analysis, Constantino and colleagues evaluated 72 studies (81 samples) of over 12,000 adult clients in which early outcome expectations were assessed and correlated with client outcomes at post-treatment. The overall effect of the meta-analysis was r = .18 (95% CI [.14, .22]), indicating a small, but statistically significant, positive effect. There were a few moderators of this relationship. The expectation – outcome correlation was larger for younger clients, and for therapies that used a treatment manual. Client diagnosis, treatment orientation, or treatment modality did not affect the correlation.

Practice Implications

Increasing a client’s expectation of a good outcome likely raises their hopes and goes some ways toward remoralizing the client. Therapists can assess their client’s outcome expectations early in therapy with a validated measure, and invite a discussion of these expectations. It may be useful to be aware of studies reviewed in the PPRNet blog, and to review with clients in a non-technical way the evidence for psychotherapy’s effectiveness. Although one should be inspiring about the potential outcomes of therapy for a client, therapists should not promise an unrealistic degree or speed of change. Therapists should express realistic confidence and competence in the psychotherapy that they are about to provide.

Author email: mconstantino@psych.umass.edu

This month...

Type of Research

Topics

April 2019

Practice Implications

March 2019

Practice Implications

Practice Implications

Practice Implications

February 2019

Practice Implications

Practice Implications

Psychotherapy Practice Research Network (PPRNet)