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.

May 2019

Positive Regard and Psychotherapy Outcome

Farber, B. A., Suzuki, J. Y., & Lynch, D. A. (2018). Positive regard and psychotherapy outcome: A meta-analytic review. Psychotherapy, 55(4), 411-423.

A concept similar to therapist empathy is the notion of therapist unconditional positive regard. Carl Rogers argued that the three factors of positive regard, empathy, and genuineness were the necessary and sufficient conditions for therapeutic change. Rogers’ pioneering work paved the way for the view that the relationship in psychotherapy was the critical factor in determining clients’ positive outcomes. Rogers defined unconditional positive regard as: the extent to which the therapist finds him- or herself experiencing a warm acceptance of each aspect of the client’s experience. It means caring for and prizing the client as a separate person. Other similar terms include: acceptance, non-possessive warmth, and therapist affirmation. Whereas empathy involves immersing oneself in the client’s internal frame of reference in order to truly understand the client’s experience, positive regard refers to unconditional acceptance of the attitudes held by the client and an expression by the therapist of the client’s inherent worthiness as a person. Often, empathy and positive regard go hand in hand, but not always. It is possible to empathize with a client’s pain (loss of a loved one), but not be accepting of aspects of the client’s behavior (coldness toward and disengagement from others). In this meta-analysis, Farber and colleagues reviewed 64 studies comprising 3,528 participants. The aggregated effect size of the association between positive regard and outcomes was small, g = .36, but statistically significant (95% CI: 0.28, 0.44). One of the key moderators of this association was severity of client psychopathology, such that positive regard had a significantly greater effect for clients with lower severity of psychopathology.

Practice Implications

The authors concluded that affirming clients may serve many important functions. Positive regard may strengthen a client’s sense of self and agency, and the belief in their ability to engage in a positive relationship. Positive regard likely reinforces clients’ engagement in therapy, increases self-disclosures, and facilitates the therapeutic alliance. Unconditional positive regard requires therapists to express positive feelings and attitudes to clients. This means communicating a caring, respectful positive attitude that affirms a client’s sense of self worth.

Author email: farber@tc.edu

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
Goal Consensus and Collaboration in Psychotherapy

Tryon, G. S., Birch, S. E., & Verkuilen, J. (2018). Meta-analyses of the relation of goal consensus and collaboration to psychotherapy outcome. Psychotherapy, 55(4), 372-383.

A key element of the therapeutic alliance is for therapists and clients to collaboratively come to a consensus about what they will work on. Goal consensus is part of the agreement between therapist and client, and in part it defines what will be the tasks of therapy. The tasks of therapy (i.e., what a therapist and client do in therapy to alleviate the problems or address issues) follow from the goals and conceptualization of the problems. At times goal consensus is straight forward. The client wants to feel less depressed and the therapist proposes certain therapeutic actions to help the client to be relieved of their depressive symptoms. However at other times, despite an agreement on the main symptoms, the client may not agree with a therapist’s conceptualization and tasks of therapy. For example, a therapist might believe that the client’s history of abuse and/or their current problem with alcohol may underlie the depression, but the client does not want to address these underlying issues. In such an example, the therapist and client only barely agree on a goal, and may not agree on how to go about alleviating the symptoms. In some cases there is outright disagreement, a misunderstanding, or vagueness about the goals, and so there is no consensus and therefore no basis for a collaboration. Collaboration and goal consensus are pan-theoretical processes that apply to all forms of therapy. However, research in the past decade has focused almost exclusively on behavioral or cognitive therapy studies using homework compliance as the index of collaboration. Tyron and colleagues conducted a meta-analysis of 54 studies of the association between goal consensus and client outcomes and found a moderate and significant correlation, r = .24 with 95% CI [.19, .28]. They also reported similar findings from a meta-analysis of 53 studies of therapist and client goal collaboration and client outcomes, in which they found a moderate and significant effect, r = .29, 95% CI [.24, .34].

Practice Implications

These meta-analyses show a positive link between goal consensus and collaboration with psychotherapy outcomes. Therapists should clarify clients’ goals for therapy, and therapists should share their conceptualization of the clients’ issues or symptoms. This conceptualization will determine to some extent the tasks or methods of therapy. For some clients, this process may take time and require revisiting throughout the course of treatment. Collaborative work to establish the goals and focus of therapy may in and of itself be therapeutic for those clients who have long standing interpersonal problems. Therapists should seek input from clients about the formulation and treatment plans, and be prepared to adjust their intentions according to client preferences. Therapists could invite continuous client feedback about the goals and tasks of therapy and monitor client progress. Then therapists can use this feedback to modify their interpersonal stances and treatment methods.

Author email: gtryon@gc.cuny.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

February 2019

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
Therapists Differ in How They Develop a Working Alliance with Ethnic Minority Clients

Morales, K., Keum, B. T., Kivlighan, D. M., Jr., Hill, C. E., & Gelso, C. J. (2018). Therapist effects due to client racial/ethnic status when examining linear growth for client- and therapist-rated working alliance and real relationship. Psychotherapy, 55(1), 9-19.

Racial and ethnic minority (REM) clients tend to have less access to health care services, are less likely to seek services for mental illness, and may receive lower quality care. It is also possible that REM clients may be treated differently by psychotherapists, so that REM clients may have a different experience from non-REM clients of the therapeutic alliance (i.e., the collaborative agreement on tasks and goals of therapy, and the bond with the therapist). The alliance is a well-known factor that is related to client outcomes. If there is such a difference in how REM and non-REM clients experience the alliance, it is likely because of the therapist’s ability to establish and grow the alliance. Previous research showed that therapists and not clients are largely responsible for the alliance – outcome association. Research also demonstrated that some therapists are less effective with REM than with non-REM clients, possibly because of the differing experiences of and development of the therapeutic alliance. In this study, Morales and colleagues measured the therapeutic alliance after every session of therapy for 144 clients seen in a counselling center, almost half of whom were REM clients. The clients saw one of 19 therapists, so that each therapist (10 of whom were REM therapists) saw at least two REM and two non-REM clients. So, the researchers were able to see how each therapist developed a therapeutic alliance differently with REM and non-REM clients. The study found that higher therapeutic alliance between therapists and clients early in therapy was associated with clients remaining in therapy longer, and that the therapeutic alliance statistically significantly increased across sessions. However, therapists varied significantly in the alliance growth depending on whether they were treating REM or non-REM clients. Some therapists showed significant growth in the alliance with REM clients but not with non-REM clients, whereas other therapists showed significant growth in the alliance with non-REM but not with REM clients.

Practice Implications

There were significant differences between therapists in how they were able to develop a therapeutic alliance with racial and ethnic minority (REM) clients vs non-REM clients. The authors speculated that this difference might be due to the therapists’ level of multicultural orientation. A multicultural orientation is a way of being with clients that consists of cultural humility, using opportunities to examine culture, and cultural comfort. Having a multicultural orientation likely increases the level of therapeutic alliance and promotes its growth over time. Research shows that a client benefits when the therapist integrates the client’s cultural narrative into the psychotherapy.

Author email: kmorales@umd.edu

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May 2019

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April 2019

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March 2019

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February 2019

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Psychotherapy Practice Research Network (PPRNet)