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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

Yulish, N. E., Goldberg, S. B., Frost, N. D., Abbas, M., Oleen-Junk, N. A., Kring, M., . . . Wampold, B. E. (2017). The importance of problem-focused treatments: A meta-analysis of anxiety treatments. Psychotherapy, 54(4), 321-338.

Typically, meta-analyses indicate that the differences between treatments in client outcomes are small or non-existent. When a treatment is found to be more effective than a comparison condition, it is usually because the treatment (and not the comparison) is focused on the particular problem that is measured as the main outcome variable. The contextual model of change in psychotherapy posits three paths to client change: 1) therapist empathy and the real therapeutic relationship; 2) client expectations related to the therapist’s explanation of the problems and of how the therapy will reduce these problems (e.g., agreement on tasks and goals, which are aspects of therapeutic alliance); and 3) the direct specific interventions of the therapy to address these problems. In this meta-analysis, Yulish and colleagues examine aspects of the second and third component of the contextual model by examining if the difference between treatments for anxiety disorders is due to the relative differences in their focus on symptoms. In this systematic review, the authors identified 135 randomized controlled trials of direct comparisons of psychotherapy for anxiety disorders. They then rated each treatment and control condition for: the amount of explanation provided to clients for their symptoms, the amount of explanation provided to clients for the treatment approach, and the specificity of the interventions to address the symptoms. In a series of meta-regressions the authors found that: 1) explanations for the symptoms and for the treatment approach, and 2) treatments that were more symptom focused resulted in larger treatment effects. When the authors pit explanations against symptom focus to predict outcomes, they found that providing clients with an explanation for symptoms and interventions (which resulted in higher client expectations of receiving benefit) was more important than the symptom focus of the treatment.

Practice Implications

This study suggests three mechanisms by which psychotherapy may lead to symptom relief for anxiety disorders: 1) providing clients with a clear explanation of symptoms and of therapeutic interventions, 2) having an agreement about the tasks and goals of therapy (i.e., therapeutic alliance), and 3) engaging in specific therapeutic actions that derive from the explanation of symptoms. Sitting with a client, being warm and accepting, expressing empathy and understanding, but not providing the client an explanation for his or her distress or a means to overcoming that distress may not be good enough. Such approaches may be beneficial for some with anxiety disorders, but they fail to fully make use of the factors that lead to effective therapy. The expectations of benefit created by the explanation of symptoms and interventions, in addition to specific therapeutic actions that are consistent with the explanation, may play a critical role in reducing symptoms of anxiety.

Author email: bwampold@wisc.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

Hayes, J. A., Owen, J., Nissen-Lie, H. A. (2017). The contribution of client culture to differential therapist effectiveness. In L. G. Castonguay and C. E. Hill (Eds.) How and why are some therapists better than others? Understanding therapist effects (Ch. 9). Washington: American Psychological Association.

Some therapists may have better client outcomes because they are more adept at working with clients of different cultures. In this chapter, Hayes and colleagues define culture as referring to a group of people who share common history, values, beliefs, symbols, and rituals. The cultural groups to which one may belong include those based on: gender, religion, ethnicity, disability status, sexual orientation, race, and age, among others. Research suggests that culturally adapted therapy is more effective than unadapted therapy for racial minority clients. This may be due to more effective therapists being able to explain clients’ mental health problems and provide a rationale for specific therapy interventions that is congruent with the client’s beliefs. The most common model of multicultural therapy is multicultural competence, which is defined by having knowledge of various cultural groups, skills to navigate cultural processes, and self-awareness of personal bias. However, Hayes and colleagues argue for a multicultural orientation model in which a therapist is humble, respectful, and open to addressing culture in therapy. Whereas multicultural therapy is about acquiring knowledge, multicultural orientation refers to a way of being with clients. Hayes and colleagues review the research literature that indicates that therapists with cultural expertise are those who acknowledge when they do not have specific knowledge about a culture, have a high tolerance for not knowing, and at the same time recognize that cultural socialization affect clients’ mental health. A multicultural orientation is intended to bolster and support current therapeutic practices. For example, therapists may recognize that they need to better understand clients’ heritage when deciding whether or not to challenging a deeply held core belief related to the clients’ culture. In support of this, Hayes and colleagues review the research that indicates that: (1) client perception of therapist humility is related to client outcomes, especially for clients with a strong cultural identity; (2) clients who perceived that their therapist missed opportunities to discuss cultural issues in session had worse therapy outcomes; (3) clients who perceived therapists as culturally oriented experienced the therapy as more credible; and (4) therapist cultural comfort was related to better client outcomes.

Practice Implications

The authors suggest that therapists ask open-ended questions to clients regarding their cultural identity, such as asking the role that religion and spirituality play in their lives. This would allow therapists to learn about client cultural identity in the client’s own words. It is particularly important for therapists to maintain a stance of humility and cultural comfort, and to attend to opportunities to work productively with cultural issues in therapy in order to improve their clients’ outcomes.

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.