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.

March 2017

Creating a Climate for Improving Therapist Expertise

Goldberg, S.B., Babins-Wagner, R., Rousmaniere, T., Berzins, S., Hoyt, W.T., Whipple, J.L., Miller, S.D., & Wampold, B.E. (2016). Creating a climate for therapist improvement: A case study of an agency focused on outcomes and deliberate practice. Psychotherapy, 53, 367-375.

There is a lot of evidence that psychotherapy is effective – a result that has been demonstrated in randomized trials and in naturalistic setting. As I have noted numerous times in this Blog, psychotherapy is as effective as medications but without the side effects and with longer lasting results. However, there is room for improvement, especially in the effectiveness of individual therapists. Health care organizations are increasingly interested in quality improvement, which refers to efforts to make changes in practice that will lead to better patient outcomes, better care, and better professional development. One approach to quality improvement in medicine has been through audit and feedback – which involves measuring a clinician’s practice, comparing the clinician’s outcomes to professional standards, and giving the clinician feedback. In psychotherapy, the analogue is routine outcome monitoring in which patient progress is monitored with standardized measures throughout therapy, and therapists receive ongoing feedback on each patient’s progress relative to the average patient with that disorder. We know that therapists tend not to improve in terms of patient outcomes with experience alone, and some authors argue that one of the things that therapists are missing is good quality information about their clients’ progress. What would happen if an agency or organization decided to make it a priority to provide therapists with quality information about client progress? This paper by Goldberg and colleagues is a case study in which an agency deliberately created a culture of quality feedback and professional development to improve therapist expertise, therapist intentional practice, and client outcomes. The case study is of a community mental health agency in Alberta. Over 5,000 clients were seen by 153 therapists over a 7 year period (2008 to 2015) as part of the study. Clients received at least three sessions of therapy (mean = 6.53 sessions, SD = 5.02), and had a range of disorders typically seen in a mental health clinic. Therapists included 49.7% licensed or provisionally licensed professionals at the masters or doctoral level from different professions (e.g., social work, psychology, pastoral counselling), and 50.3% practicum students. Throughout the 7 years of the study, therapists saw an average of 33.52 clients (SD = 26.24). In 2008, the agency required the staff to collect outcome measures of all clients before each session (although patient scores were not tied to staff performance evaluations). This policy change caused a 40% turnover in clinical staff within 4 months (clearly a large minority of therapists did not want to participate in this new clinic directive)! These staff positions were replaced and staffing was stable after that point. In addition to requiring clinicians to provide measures on all patients (although patients could decline to participate), the agency provided monthly clinical consultations with an external consultant as a means of professional development. During these consultation, clinicians were encouraged to bring cases that were not progressing well in order to get feedback on their most challenging patients. Discussions were organized around therapeutic alliance, i.e., clarifying goals and preferences, and ways of facilitating engagement. The overall results showed a significant decline in distress among patients over the course of treatment. Of most interest was that therapists on average showed a significant improvement in their outcomes over time. That is, contrary to research showing that therapists do not improve over time when left to their own devices, therapists in this agency that received feedback and professional education around difficult cases did improve significantly.

Practice Implications

The findings of this study indicate that psychotherapists can improve over time if they receive quality information about client progress, and if they receive professional development that is tied to this information (i.e., concrete suggestions for ways of working with difficult clients). In other words, it is possible for therapist to develop expertise over time under some conditions. A significant challenge in this case study was that a number of therapists left the agency due to the quality improvement efforts. Some therapists are sensitive to or feel threatened by outcome monitoring. However, therapists who remained or who were subsequently hired by the agency showed a reliable increase in their expertise and client outcomes as a result of deliberate intentional practice, quality feedback about client progress, and concrete professional development focused on the therapeutic alliance.

February 2017

The Importance of Psychosocial Factors in Mental Health Treatment

Greenberg, R.P. (2016). The rebirth of psychosocial importance in a drug-filled world. American Psychologist, 71, 781-791.

In this thoughtful piece, Greenberg reviews the research on psychosocial factors that affect mental health treatment outcomes – including for medications and in psychotherapy. There has been an important shift in the last few decades to view mental disorders, including depression, as biologically based. For example, surveys indicate that the public’s belief in biological causes of mental illness rose from 77% to 88% during a 10 year period. During the same period the belief in the primacy of biological treatment for mental disorders rose from 48% to 60%. Further, 20% of women and 15% of men in the US are currently taking antidepressant medications. Some of these trends are due to direct to consumer marketing of medications by the pharmaceutical industry, which saw a 300% increase in sales in antidepressants. Some of these trends are also due to Federal agencies like the National Institute of Mental Health that vigorously pursued an agenda of biological research. But what is the evidence for a purely biological view of mental health? Greenberg notes that the evidence is poor. For example, no one has been able to demonstrate that a chemical imbalance actually exists to explain depressive symptoms – which undermines the reason for using medications to treat depression. Further, research on the efficacy of antidepressant medications shows that they perform only slightly better than a placebo pill, prompting a former editor of The New England Journal of Medicine to declare that this difference is unlikely to be clinically meaningful. The placebo effect is essentially a psychosocial effect. It refers to: the patient’s experience of a caring relationship with a credible professional, and the patient’s expectations and hopes of getting better. Placebo is a very real phenomenon that also has an impact on purely medical interventions like surgeries. In psychotherapy trials, relational/contextual factors like therapeutic alliance, expectations, therapist empathy, and countertransference likely account for more of the client’s outcomes than the particular therapeutic technique that is used. In both psychotherapy and medication treatments for depression, it appears that the more patients perceived their doctors as caring, empathic, open, and sincere, the greater their symptom improvement. There is also good evidence that psychotherapy is as effective and antidepressants for mild to moderate depression, and that antidepressants are slightly superior for chronic depression. However, even the latter should be interpreted carefully and within the context that patients prefer psychotherapy, their adherence to medications is poorer, side effects are worse for medications, and drop out rates are lower for psychotherapy.

Practice Implications

Patients benefit from antidepressant medications, but perhaps not exactly for the reasons that they are told. Psychosocial factors likely account for a large proportion of the effects of many medically-based interventions for mental disorders. Psychosocial factors are actively used in many psychotherapies, and therapists’ qualities like their ability to establish an alliance, empathy, and professionalism account for a moderate to large proportion of why patients get better.

October 2016

Clients’ Experiential Depth in Therapy Predicts Better Outcomes

Pascual-Leone, A. & Yeryomenko, N. (2016). The client “experiencing” scale as a predictor of treatment outcomes: A meta-analysis on psychotherapy process, Psychotherapy Research, DOI: 10.1080/10503307.2016.1152409

A key issue in existential-humanistic psychotherapy is the degree to which therapy encourages clients to explore new feelings and meanings in relation to the self. This is often called ‘experiential depth’ or simply ‘experiencing’. Carl Roger highlighted the need for clients to increase their awareness, accept their feelings, and use their feelings as information to further explore and understand themselves. The notion of ‘depth of experiencing’ refers to the degree to which clients engage and explore their feelings moment by moment in therapy to increase personal meaning-making. One way of assessing experiential depth is with the Client Experiencing Scale. Low scores on the scale indicate unengaged levels of experiencing, in which clients recount events in an emotionally neutral or disengaged manner. High scores indicate more introspection as clients begin to process their experiences and identify feelings that lead to creating new meanings that contribute to resolving their problems. In this meta analysis of the Client Experiencing Scale, Pascual-Leone and Yeryomenko systematically reviewed the research literature and found 10 studies of 406 clients that evaluated the scale`s association with client outcomes. The therapies in the meta analysis included experiential-humanistic approaches, CBT, and interpersonal psychotherapy. Overall, they found a moderate association (r = .25; 95% CI: .16, .33) between higher client experiencing and better treatment outcomes. The association was similar for different therapeutic orientations and stages of therapy. On average, client depth of experiencing tended to increase from the early to later stages of treatment.

Practice Implications

Compared to those who did not engage with their experiences in a meaningful way, clients who were internally focused, engaged in exploration, referred to their emotions, and who reflected on their experiences had better outcomes. Experiential depth allowed clients to create new meanings to resolve personal problems. Therapist interventions that deliberately point the client to a deeper level of experiencing, are likely to result in clients following suit and deepen their own process.

August 2016

Therapists Affect Patient Dropout and Deterioration

Saxon, D., Barkham, M., Foster, A., & Parry, G. (2016). The contribution of therapist effects to patient dropout and deterioration in the psychological therapies. Clinical Psychology and Psychotherapy. Advanced online publication, DOI: 10.1002/cpp.2028.

Outcomes for patients receiving psychotherapy are generally positive, but not always. For example, patients might drop out of therapy (i.e., unilaterally end therapy). In clinical trials, the average drop out rate is somewhere between 17% and 26% of patients. Also, patients might deteriorate during therapy (i.e., show a reliable negative change in symptoms from pre- to post-therapy). On average, about 8.2% of patients show a reliable deterioration after therapy. In this large study from a practice-based research network in the UK, Saxon and colleagues were interested in estimating the effect that therapists had on patient drop out and deterioration. Therapist effects refer to differences between therapists and the effects of this difference on patient outcomes. The authors were also interested in whether therapist effects predicted negative outcomes after controlling for therapist case-mix (i.e., patient variables like severity of symptoms, risk of self harm). Their study included 85 therapists who treated more than 10,000 adult patients over a 10-year period. Each therapist saw between 30 and 468 patients at one of 14 sites in the UK. About half of patients had moderate to severe depressive symptoms, and/or moderate to severe anxiety symptoms prior to starting therapy. Outcomes were measured with a reliable and valid psychometric instrument at pre- and post-treatment. The proportion of patients who dropped out of therapy was 33.8%. Patients who dropped out attended an average of 2.8 sessions (SD = 1.91), whereas treatment completers attended an average of 6.1 sessions (SD = 2.68). About 23.5% of therapists had drop out rates that were significantly worse than average. These below average therapists (n = 13) had 49% of their patients drop out, whereas above average therapists (n = 20) had only 12% of their patients drop out. Most patients who completed therapy improved (72.2%), but about 7.2% of patients deteriorated to some degree. The average therapist (i.e., 74% of therapists) had 4.6% of their patients who got worse, whereas below average therapists (i.e., 4.7% of therapists) had up to 14.9% of their patients who got worse. That is, almost 3 times as many patients deteriorated with below average therapists.

Practice Implications

We know from previous studies that the type and amount of therapist training or theoretical orientation are not predictive of patient outcomes. However, previous research does suggest that therapists’ lack of empathy, negative countertransference, over-use of transference interpretations, and disagreement with patients about therapy process was associated with negative outcomes. Patient safety concerns might necessitate below average therapists to be identified and provided with greater support, supervision, and training.

July 2016

Long-Term Efficacy of Psychological Therapies for Irritable Bowel Syndrome

Laird, K.T., Tanner-Smith, E.E., Russell, A.C., Hollon, S.D., & Walker, L.S. (2016). Short-term and long-term efficacy of psychological therapies for irritable bowel syndrome: A systematic review and meta-analysis. Clinical Gastroenterology and Hepatology.

Irritable bowel syndrome (IBS) is a gastrointestinal (GI) disorder that affects 5% to 16% of the population. People with IBS have reduced quality of life similar to those with heart disease, heart failure, and diabetes. Previous meta analyses indicated that psychological therapies are just as effective as antidepressant medications immediately after treatment for improving symptoms of IBS. However, whether psychological therapies have longer lasting effects is unknown. It is important to patients and providers to know the longer term effects of psychological treatments for IBS because the disorder has a fluctuating course, and so symptoms may reappear after treatment is completed. In their meta analysis, Laird and colleagues reviewed 41 studies that recruited almost 2,300 adult patients. [A note about meta analysis: Meta analysis combines the standardized effect sizes (d) across many studies to estimate an average effect size. This means that meta analyses are much more reliable than any single study, and when possible they should be the basis for practice recommendations]. Psychological therapies for IBS often included cognitive behavioral therapy (CBT), but also included relaxation therapy, mindfulness, hypnosis, behavioral treatment, and psychodynamic therapies. Control conditions often were: supportive therapy, education, fake treatment for biofeedback or hypnosis, online discussion groups, treatment as usual, or wait-list controls. Psychological therapies were more effective than control conditions immediately post-treatment in improving GI symptoms, and the effects were moderately large (d = .69). Psychological therapies remained more effective than control conditions up to 6 months post-treatment (d = .76), and from 6 months to 1 year post-treatment (d = .73). CBT and other treatments (e.g., relaxation, hypnosis) were equally effective; and individual and group delivered treatments were no different in their efficacy. The number of sessions, duration of sessions, and frequency of sessions did not impact the efficacy of psychological interventions.

Practice Implications

Determining the longer term efficacy of psychological treatment for IBS is important because the symptoms tend to be recurrent and sometimes are chronic. Psychological treatments reduce GI symptoms in adults with IBS, and the effects appear to be long lasting – at least up to 1 year post-treatment. The average individual who received psychotherapy was better off than 75% of control condition participants.

June 2016

Therapist Interpersonal Skills Account for Patient Outcomes

Schottke, H., Fluckiger, C., Goldberg, S.B., Eversmann, & Lange, J. (2016). Predicting psychotherapy outcome based on therapist interpersonal skills: A five-year longitudinal study of a therapist assessment protocol. Psychotherapy Research, DOI: 0.1080/10503307.2015.1125546

Therapist effects, or differences between therapists, account for an important amount of patient outcomes (i.e., 5% to 7%). Two therapist characteristics most consistently proposed as predictors of patient outcomes are: therapist competence/adherence to a treatment manual, and therapist interpersonal skills. A recent meta analysis found that therapist adherence or competence were not significantly related to patient outcomes. However, there has been very little research on therapists’ interpersonal capacities. These capacities might include factors like: empathy, warmth, ability to respond well to patient hostility, sensitivity to interpersonal process in therapy, and ability to address alliance ruptures. In this paper, Schottke and colleagues (2016) conducted a five year study with 41 therapists and 264 patients in which they assessed the impact of therapist interpersonal skills on patient outcomes. The therapists were all post-graduate trainees and who practiced a manual oriented cognitive behavioral therapy (CBT) or psychodynamic therapy (PDT). The patients were adults mainly treated for depression, and many had co-morbid problems. What was unique about the study is that the therapist interpersonal skill was rated before they received formal training, and the rating were done by trained reliable judges. The judges rated the therapist trainees on interpersonal skills including: clear and positive communication, empathy, warmth, managing criticism, and willingness to cooperate. Patients were assessed pre- and post-treatment on general symptom outcomes. Higher therapist interpersonal skills were reliably associated with better patient outcomes, even after controlling for symptoms severity and number of comorbid diagnoses. In this study, therapist interpersonal capacities measured before receiving formal training and supervision was a significant predictor of patient outcomes after training was initiated.

Practice Implications

The findings of this study indicate that therapists’ talent should in part be characterized by interpersonal competencies that include clear communication, empathy, respectful management of criticism, warmth, and willingness to cooperate. It could be that therapist trainees with high interpersonal skills engage in an extensive degree of deliberate practice that may account for better patient outcomes.

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Type of Research

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March 2017

Practice Implications

February 2017

Practice Implications

October 2016

Practice Implications

August 2016

Practice Implications

July 2016

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June 2016

Practice Implications

Psychotherapy Practice Research Network (PPRNet)