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The Great Psychotherapy Debate: Since in April, 2015 I review parts of The Great Psychotherapy Debate (Wampold & Imel, 2015) in the PPRNet Blog. This is the second edition of a landmark, and sometimes controversial, book that surveys the evidence for what makes psychotherapy work. You can view parts of the book in Google Books.

Wampold, B.E. & Imel, Z.E. (2015). The great psychotherapy debate: The evidence for what makes psychotherapy work (2^nd edition). New York: Routledge.

In this part of the book, Wampold and Imel reviewed the research literature on the therapeutic alliance. The therapeutic alliance is considered a pan-theoretical construct that is critical to the success of all psychotherapies. Alliance is defined as the: (a) agreement on the goals of therapy, (b) agreement on the tasks of therapy, and (c) the bond between therapist and client. Numerous meta analyses across several decades demonstrate a robust relationship between the alliance and therapy outcome. For example, Horvath and colleagues (2011) conducted a meta analysis with 190 studies that included over 14, 000 clients in which the average effect size was r = .28, indicating a moderate and significant association between alliance and outcomes. Some researchers argued that this is an under-estimation of the alliance outcome relationship. In Horvath and colleagues’ meta analysis, they found no difference between type of psychotherapy (CBT, interpersonal, dynamic) and the alliance – outcome relationship. However, the alliance may work differently in some therapies. For example, in CBT there is some evidence that the collaborative bond is not related to outcomes, but rather the agreement on tasks and goals is related to patient outcomes. This highlights that an alliance cannot happen without techniques; in other words, if techniques fail to engage the patient in the work of therapy, then the technique is not working properly. Wampold and Imel also reviewed the research on whether the therapist or the patient is most influential in developing an alliance. Using sophisticated statistical techniques, they were able to disentangle the effects of therapists and clients. More effective therapists were those who had stronger alliances with patients, and their patients had better outcomes. However, the patient’s contributions to developing an alliance were not significant. Finally, Wampold and Imel reviewed the research on whether early alliance causes good outcomes, or whether early outcomes causes a good alliance. If the latter were true, then the therapeutic alliance would simply be an artifact of early improvement – that is, the alliance would not be necessary for patients to improve. Most of the studies, which were conducted by researchers of different theoretical orientations, concluded that early alliance predicts outcomes and not the other way around. There is some evidence that change in the alliance and change in symptoms have a reciprocal impact – as the alliance grows the patient subsequently improves and as the patient improves the alliance subsequently grows.

Practice Implications

Clearly, developing and maintaining a therapeutic alliance is important to achieving good patient outcomes in psychotherapy. The alliance is not independent from techniques of psychotherapy. In other words, therapists and clients have to agree on the tasks and goals of treatment, and this agreement is fundamental to all treatment modalities offered to patients. If there is no agreement, then therapists have to consider changing course or discussing with the client ways of achieving an agreement. Over and above that, therapists and clients must have some interpersonal bond that is likely underpinned by the therapist’s empathy, positive regard, and concern for the client. The research is clear that it is the therapist who most strongly contributes to the development of an alliance, and so it is the therapist’s responsibility to nurture a positive working alliance.

Safran , J. D. & Kraus , J. (2014). Alliance ruptures, impasses and enactments: A relational perspective. Psychotherapy, 51, 381-387.

In this clinically oriented review, Safran and Kraus discuss the evidence related to alliance ruptures, repairing alliance ruptures, and methods of training in alliance rupture repair. Safran’s work represents “second generation” research on the therapeutic alliance. The therapeutic alliance refers to the relational bond between client and therapist and their agreement on tasks and goals of therapy. A positive alliance is associated with good client outcomes across a variety of therapeutic approaches. Therapeutic alliance ruptures in psychotherapy are inevitable, such that the alliance is continually being re-negotiated, both implicitly and explicitly, throughout the therapy. Such ruptures might include strains, tensions, or breakdowns that could interfere with the ongoing collaboration between therapist and client. Ruptures are associated with re-enactments of dysfunctional relational patterns, but they also may provide opportunities for change and growth in therapy. Safran’s model of alliance ruptures and repairs sees the processes in the client-therapist relationship as key to understanding the client’s relationship problems. Collaboratively addressing tensions in the alliance allows the client to develop more flexible ways of being in relationships and of experiencing themselves. Research by Safran and Muran (2000) suggest that it is rare not to have some minor strain occurring in the therapeutic alliance. Ruptures may occur in half of therapy cases within the first six sessions. Research indicates that unresolved ruptures are associated with deterioration in the alliance, poor outcome, and patients dropping out. In a meta-analysis, repairing alliance tensions by using evidence-based strategies was associated with improved patient outcomes and the effect was large. Alliance ruptures occur across theoretical orientations. For example, research on cognitive therapy showed an improvement in therapist-client interpersonal processes after therapists were trained in techniques to resolve alliance ruptures.

Practice Implications

Alliance ruptures can range in intensity from minor tensions to major rifts in collaboration. They may occur at any time in treatment, and may be present in single or across multiple sessions. Safran and Kraus describe two general types of ruptures. First, withdrawal ruptures occur when clients deal with ruptures or misunderstandings by falling silent. The resolution may involve the therapist exploring the client’s interpersonal fears, reasons for inhibiting negative feelings, and providing the client with an opportunity to communicate their needs. Second, confrontation ruptures occur when clients directly express anger, resentment or dissatisfaction with the therapist or therapy in a blaming manner. The resolution may involve the therapist empathically engaging with the client to facilitate feelings of disappointment, hurt, and vulnerability. Key to this process is the therapist’s meta-communication or mindfulness abilities. The therapist must be aware of the behavior associated with the rupture, collaboratively explore the rupture experience, help the client overcome avoidance of feelings related to the rupture, and explore the client’s needs and wishes that emerge while working through the rupture.

Hoglend, P. (2014). Exploration of the patient-therapist relationship in psychotherapy. American Journal of Psychiatry, 171, 1056-1066.

In this overview of patient-therapist relationship factors, Per Hoglend reviews research on transference in psychotherapy. He argues that transference and transference work is a specific technique that focuses on exploring the patient-therapist relationship. Hoglend takes a broad definition of transference as: the patient’s pattern of feelings, thoughts, perceptions, and behaviors that emerge in the therapeutic relationship and reflect the patient’s personality functioning. Hoglend also defines transference work as any therapist intervention that refers to or explains the patient’s experience of the therapist and their interaction. These interventions include the therapist: (1) addressing transactions in the patient-therapist relationship; (2) encouraging exploration of feelings and thoughts about the therapy or therapist; (3) encouraging the patient to discuss how he or she believes the therapist might feel or think about the patient; (4) including him or herself in interpreting the patient’s dynamics; and (5) interpreting repetitive interpersonal dynamics and linking these to the therapy relationship. More than 30 studies have been published on providing empirical evidence for the relationship between transference work in psychotherapy and positive patient interpersonal outcomes. Effect sizes of the association between transference work and patient outcomes tend to be large. Some of the research indicates that low frequency of transference interventions is useful, but that a higher frequency may lead to negative effects on the patient. Research on transference-focused psychotherapy indicates that it is as effective as dialectical behavior therapy and supportive psychotherapy for borderline personality disorder, but that transference-focused therapy produced better outcomes for attachment related functioning like mentalizing. In the First Experimental Study of Transference Work (FEST), Hoglend found that patients with low quality of object relations (i.e. a poorer ability to maintain close relationships and to regulate affect) benefited most from transference focused therapy. However, those with high quality of object relations did not require the transference work to get better. Also, women responded better to transference work than men. There are some studies of therapeutic approaches like cognitive behavior therapy, in which patients with depression had better outcomes when the patient-therapist relationship was explicitly discussed.

Practice Implications

Hoglend argues that transference work in psychotherapy is an active ingredient that can lead to specific change in some patients. Most studies that Hoglend reviewed showed significant and large associations between transference work and interpersonal changes in patients. Exploring the patient-therapist relationship appears to be most useful for female patients, those with difficult interpersonal relationships, and those with more severe personality pathology. Patients with more mature relationships may not benefit as much from transference work. Although generally effective, if transference work is used too frequently in a session it can also lead to negative patient outcomes.

Del Re, A.C., Fluckiger, C., Horvath, A.O., Symonds, D., & Wampold, B.E. (2012). Therapist effects in the therapeutic alliance-outcome relationship: A restricted-maximum likelihood meta-analysis. Clinical Psychology Review, 32, 642-649.

The therapeutic alliance, defined as the agreement on tasks and goals and the bond between therapist and patient, is one of the most researched concepts in psychotherapy. A meta-analysis of over 200 studies showed that the association between the therapeutic alliance and patient outcomes is moderate but robust (i.e., consistent across studies, patient types, and therapy types). Some have stated that the importance of the therapeutic alliance as reported in studies is an under-estimate of its real impact on patient outcomes. Del Re and colleagues argue that the main reason for this underestimation is that while the therapist’s effect on the alliance-outcome relationship might be large, the client’s effect might be quite small, and so the average of these two effects (which is what most studies report) will be diminished. Del Re and colleagues conducted the first meta analysis to assess the relative size of therapist versus client effects across many studies. Their strategy was clever. They looked at the ratio of the number of patients to therapists (PTR) within a study as a “predictor” of the alliance-outcome relationship across studies. This allowed them to examine the relative contribution of therapists and clients to the alliance-outcome relationship. Two extreme examples illustrate this ratio. (1) In one study, many patients might have been seen by only one therapist, in which case the alliance-outcome correlation could only be attributed to differences between clients since there was only one therapist. (2) In another study, each client might have been seen by a different therapist (i.e., there were as many therapists as clients), in which case the alliance-outcome correlation could only be attributed to differences between the therapists; that is, there are no differences between clients seen by the same therapist as this did not occur. The patient to therapist ratio (PTR) captures the variability between these two extreme examples across studies. Del Re and colleagues included 69 studies that provided enough information about the number of patients and therapists. The overall correlation between alliance and outcome was moderate, r = .27, which was very similar to what was found in a previous large meta-analysis. PTR was significantly associated with the alliance-outcome relationship even after controlling for a number of possible confounding variables. Patients accounted for almost 0% of the alliance-outcome relationship, whereas the effect of therapists was substantially larger, r = .40, accounting for 16% of the alliance-outcome association.

Practice Implications

Therapists’ capacity to develop an alliance with their patients is associated with outcomes. We also know that some therapists demonstrate better patient outcomes than others. So, therapists who consistently are better at forming alliances with patients likely have patients with better treatment outcomes. The quality of the alliance between patients and therapists appears to be the result of what therapists do or bring to the therapy. And so, on average, the therapist’s role in the alliance is most important for achieving good patient outcomes. Del Re and colleagues note that they were not able to look at the interaction between therapist and patient factors. For example, it may be possible that some therapists might form better alliances some types of patients, but not others. Integrating feedback systems so therapists can monitor the therapeutic alliance and patient outcomes may help therapists identify areas in which they need more training or supervision.

Tracey, T.J.G., Wampold, B.E., Lichtenberg, J.W., & Goodyear, R.K. (2014). Expertise in psychotherapy: An elusive goal? American Psychologist, 69, 218-229.

As I have reported many times in this blog, there is substantial evidence for the efficacy of psychotherapy. However, the quality of psychotherapy differs across therapists – that is, some therapists achieve better client outcomes than others. Tracey and colleagues (2014) ask: is it possible to demonstrate expertise in psychotherapy? They define expertise as “increased quality of performance that is gained with additional experience”. Professions that can demonstrate expertise include: astronomers, test pilots, chess masters, mathematicians, and accountants. But several professions may not demonstrate expertise, including: psychiatrists, college admissions officers, court judges, personnel selectors, and psychotherapists. The difference is that the former group has predictable outcomes and has access to quality feedback. In addition, Tracey and colleagues argue that psychotherapy lacks adequate models for how interventions produce benefits. As a result, adherence to treatment protocols (i.e., manuals) is not reliably associated with better patient outcomes. Further, more experienced therapists are not more effective than less experienced therapists. Experienced therapists might have more complete conceptualizations of client problems, but these conceptualizations may not be accurate. Finally, although therapists affect outcomes, client variables (e.g., motivation, severity of symptoms, expectations) likely explain the largest proportion of outcome variance. Tracey and colleagues argue that part of the problem is that psychotherapists do not engage in “deliberate practice”; that is, practice of a specific task (e.g., identifying a rupture in the alliance), receiving specific feedback (e.g., that a rupture was not identified), opportunity for repetition (e.g., to identify a subsequent rupture in the alliance), and opportunity for improvement afforded by error (e.g., better able to identify a future rupture and repairing that rupture). Generally the practice of psychotherapy provides little feedback about the accuracy of past clinical decisions. In other words there is a lack of quality information to help therapists develop into experts. Further, for a whole host of reasons, psychotherapists are notoriously poor at assessing client progress (i.e., like other humans, therapists engage in a number of biased evaluations of their performance). Quality information might be available from progress monitoring (i.e., continuous feedback to therapists about client outcomes), which has been shown to improve client outcomes. However, this may not aid therapists in developing expertise, since progress monitoring provides little information about what therapist behaviors are necessary to improve performance and client outcomes.

Practice Implications

Tracey and colleagues conclude that currently psychotherapy does not provide evidence that it is a profession with expertise. To achieve expertise, therapists need quality information not only about their patients’ outcomes but also about their own average outcomes (i.e. performance) relative to other therapists working with similar clients. And therapists need information on how to manage specific events in psychotherapy. Tracey and colleagues suggest therapists set aside time to generate hypotheses about one’s practice that can be disconfirmed, and then test these hypotheses. For example, if a therapist is experiencing a higher than average number of premature client terminations (which may follow a misunderstanding with the client), the therapist may hypothesize that he or she is not identifying key alliance ruptures. To test this hypothesis, the therapist could repeatedly assess the alliance (with a validated instrument) with some clients, use this information and not clinical judgement alone to identify alliance ruptures (i.e., a week to week severe downward trend in alliance scores), and implement an intervention to repair the alliance with these clients. Do clients with whom a therapist has implemented this procedure drop out at a lower rate? Does this process of deliberately identifying alliance ruptures and repairing them lead to enhanced therapist performance regarding alliance ruptures? This form of deliberate practice (testing disconfirmable hypotheses based on quality information) might lead to greater expertise in identifying alliance ruptures.

Handbook of Psychotherapy and Behavior Change: Starting in March 2013 I will review one chapter a month from the Handbook of Psychotherapy and Behavior Change in addition to reviewing psychotherapy research articles. Book chapters have more restrictive copy right rules than journal articles, so I will not provide author email addresses for these chapters. If you are interested, the Handbook table of content and sections of the book can be read on Google Books.

Crits-Christoph, P., Connolly Gibbons, M.B., & Mukherjee, D. (2013). Psychotherapy process-outcome research. In M.E. Lambert (Ed.), Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change, 6^th Edition (pp. 298-340). New York: Wiley.

In their chapter in the Handbook, Crits-Christoph and colleagues (2013) review research in which psychotherapy processes are related to patient outcomes. I reported in the July 2013 PPRNet Blog that therapeutic alliance is reliably correlated with treatment outcomes in a variety of disorders and treatment types. Alliance refers to an agreement on tasks and goals of therapy, and the bond between therapist and client. The common assumption is that alliance is a necessary condition that in part causes change in client symptoms. However therapeutic alliance studies tend to be correlational, that is, the studies show a relationship but the study designs do not allow one to say that alliance causes good outcomes. What if the opposite were true; what if early experiences of symptom reduction caused the therapeutic alliance to improve? If that were the case, then alliance would be an artificial and not particularly important aspect of psychotherapy. Crits-Christoph and colleagues (2013) review the literature on this topic. Some studies of cognitive behavioural therapy (CBT), for example, found that prior change in symptoms predicted later therapeutic alliance, but prior alliance did not predict later symptom change. In a more sophisticated study, Crits-Christoph and colleagues (2011) found that previous change in the alliance was related to later change in outcomes, but not vice versa. In the same study, the authors noted that measuring patient alliance at a single early session accounted for only 4.7% of the outcome variance at post treatment, whereas averaging assessments of alliance across 6 early sessions accounted for almost 15% of the outcome variance. In other words, averaging assessments across many sessions produced a more dependable measurement of alliance. Several studies now report a reciprocal relationship between alliance and outcome, indicating that change in alliance and change in outcomes across therapy sessions progress in a mutually reinforcing spiral. That is, early change in alliance causes subsequent change in outcome, which in turn results in further change in alliance, which precipitates more change in symptoms, etc. The review by Crits-Christoph and colleagues (2013) also noted that the importance of alliance seems to be greater for patients with a disorder like depression, compared to anxiety disorders.

Practice Implications

Developing an early alliance with a client is related to treatment outcomes. Measuring alliance repeatedly (not just once) will give the best indicator of the state of the therapeutic relationship. Patients and therapists who have a genuine liking for each other, who agree on how therapy will be conducted and on the goals of therapy will improve the chances that psychotherapy will be successful. Alliance and symptom change may work together throughout therapy so that improvement in one will cause change in the other on an ongoing basis across therapy sessions. Alliance may be particularly important for patients with depressive disorders that are characterized by isolation from others, loneliness, and low self esteem.