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.

November 2013

Therapist Emotional Responses are Associated with Patient Personality

Colli, A., Tanzilli, A., Dimaggio, G., & Lingiardi, V. (2013). Patient personality and therapist response: An empirical investigation. American Journal of Psychiatry.

Therapist emotional responses to patients may refer to emotional reactions or to countertransference. Emotional responses can inform therapeutic interventions if therapists view their responses as informative about the patient’s feelings, perspectives, and relationship patterns. Clinicians have an intuitive sense that specific patient characteristics tend to evoke distinct emotional reactions (i.e., countertransferences) in the therapist. However, there are very few studies that examine the association between patient personality features and therapist emotional responses. A study Colli and colleagues examined this issue. They sampled 203 therapists from two theoretical orientations (psychodynamic = 103; cognitive-behavioral = 100). Among the therapists, 58% were women, mean age was 43 years, average experience was 10 years, average time spent providing psychotherapy was 16 hours per week, and 78% were in private practice. Each therapist was asked to randomly select a patient in their caseload, and complete a validated personality assessment questionnaire about the patient. Three weeks later, and immediately following a therapy session with the patient, the therapist completed a validated therapist emotional response questionnaire. Half of the patients were women (53%), mean age was 34 years, average length of treatment was 5 months (once per week), and 72% were diagnosed with a personality disorder (either comorbid or as a primary diagnosis). Patient paranoid and antisocial features were associated with therapists feeling criticized/mistreated. Patient borderline personality features were associated with therapists feeling helpless/inadequate, overwhelmed/disorganized, and special/overinvolved. Patient narcissistic features were associated with therapists feeling disengaged. Patient dependent personality features were associated with therapists feeling both parental/protective and special/overinvolved. The results were not affected by clinicians’ theoretical orientation. That is, psychodynamic and cognitive-behavioral therapists showed similar emotional responses to each patient personality pattern.

Practice Implications

The results do not appear to be an artifact of therapist theoretical orientation, and so the authors argue that patient interpersonal patterns are quite robust in evoking specific therapist countertransference. A therapist’s emotional responses that are not primarily related to the therapist’s own issues could be an important source of information about the patient’s emotional and interpersonal patterns. Therapist emotional responses can also impede the therapist’s work if the responses are not well understood. Therapists who treat those with borderline personality features may avoid their own experience of negative thoughts and feelings during a session and this may unwittingly manifest as a sudden confrontation of the patient. With patients who have narcissistic features, therapists may feel disengaged, unempathic, and emotionally mis-attuned, which could lead to an impasse or premature termination. Therapists who treat patients with dependent features may be overprotective and may avoid exploring the patient’s painful feelings.

Author email address: antonello.colli@uniurb.it

October 2013

Do Psychotherapists with Different Orientations Stereotype Each Other?

Larsson, B. P., Broberg, A. G., & Kaldo, V. (2013). Do psychotherapists with different theoretical orientations stereotype or prejudge each other? Journal of Contemporary Psychotherapy, 1-10.

A remarkable difference between the field of psychotherapy and other health care or scientific areas is that psychotherapy is organized in different and somewhat competing theoretical orientations or schools. Leading thinkers of psychotherapy integration, have emphasized how this division presents an obstacle to integration and therefore to progress within the practice and science of psychotherapy. One of these obstacles could be persistent stereotypes that psychotherapists might have about other therapists who practice from a different theoretical orientation. Social psychologists have long known that people in one group (e.g., an in-group) may misjudge or stereotype people in other groups (e.g., out-groups). Stereotypes may be negative if members of an in-group hold a positive bias toward their in-group coupled with antagonism toward members of an out-group. Do psychotherapists stereotype other therapists who practice from a different theoretical orientation? A recent study by Larsson and colleagues addressed this question. They surveyed 416 therapists divided into four ‘pure’ self-reported schools: 161 psychodynamic therapists, 93 cognitive therapists, 95 behavioural therapists, and 67 integrative/eclectic therapists. Most were women (76%), mean age was in the mid 50s, mean experience was 5 to 10 years, and they represented a variety of disciplines including psychology, psychiatry, social work, and nursing. In the first section of the survey, therapists indicated what focus they deemed most important to their own psychotherapeutic work, including: (1) therapeutic relationship, (2) patient’s thoughts, (3) patient’s feelings, (4) patient’s behaviour, or (5) connection between the patient’s thoughts, feelings, and behaviors. Therapists then estimated how they thought psychotherapists from other orientations would rate each of these foci. In the second section of the survey, therapists completed scales about what they deemed were important aspects of psychodynamic, cognitive, behavioral, and eclectic/integrative therapy, respectively. Once again, they rated how they thought therapists from the other orientations would respond. Self-ratings of therapists within each orientation indicated the ‘true’ (i.e., prototypical) opinions of each orientation. The differences between ‘true’ opinions of the in-group versus the in-group’s ratings of therapists from other orientations (i.e. of the out-group) indicated the level of misjudgement or stereotyping. Of the 18 areas on which out-groups were rated, 11 were significantly misjudged by the in-group. Eclectic/integrative therapists were much less likely to stereotype therapists of cognitive or psychodynamic orientations, who were equally likely to stereotype others. The belief that one’s own orientation compared to others is better characterized as an applied science (a belief endorsed most often by cognitive therapists) was a statistically stronger predictor of stereotyping than orientation per se.

Practice Implications

Some researchers argue that different orientations are more similar in their practice of psychotherapy than theory would predict. Furthermore, research about common factors in psychotherapy suggests that these factors may be more important than techniques specific to a school of psychotherapy. However, as long as there are different therapeutic orientations there will likely remain a tendency among some psychotherapists to search for differences rather than to look for similarities between their own and other orientations. This may lead to stereotyping (i.e., an inaccurate opinion about therapists of other orientations), and perhaps negative stereotyping. Psychotherapists and researchers may want to keep in mind the tendency to stereotype clinicians from other orientations when talking to or about other psychotherapists. Such stereotyping is likely an impediment to good client care and research.

Author email: billy.larsson@psy.gu.se

September 2013

Some Therapists are Reliably Effective and a Few are Reliably Harmful

Kraus, D. R., Castonguay, L., Boswell, J. F., Nordberg, S. S., & Hayes, J. A. (2011). Therapist effectiveness: Implications for accountability and patient care. Psychotherapy Research, 21, 267-276.

Some patients benefit from psychotherapy, some do not, and a few get worse. Research has indicated that patient motivation, client-therapist match, and client characteristics might be associated with better or worse client outcomes. What about the contribution of the therapist? Do some therapists consistently have patients with better outcomes or with worse outcomes? Are consistently effective therapists effective for most patient problem areas or only some? Answers to these questions have important public health, funding, continuing education, and training implications. In a large study conducted in the U.S., Kraus and colleagues assessed 12 patient domains (sexual functioning, work functioning, violence, social functioning, anxiety, substance abuse, psychosis, quality of life, sleep, suicidality, depression, and mania) with a standardized reliable measure (the Treatment Outcome Package). The measure was used in a variety of public and private clinics and practices. Almost 700 therapists were sampled (including social workers 43%, mental health counsellors 35%, psychologists 10%, others 12%), with an average of 11 years experience. Ten cases were selected from each therapist caseload, so almost 7000 patients were included that received at least 16 sessions of therapy (16 sessions is an adequate dose for 50% of patients to improve – see my August, 2013 blog). The patients were, for the most part, representative of a typical caseload with regard to age, sex, and problem area as compared to previous national (U.S.) research. The authors used a reliable change index to classify patients as reliably improved, unchanged, or reliably worsened. The reliable change index is a way of assessing if change from session 1 to 16 on average exceeded the scale’s measurement error so that the change was considered reliable (i.e., not due to error). Reliable change for each therapist’s 10 patients was calculated so that a therapist could be classified as “effective” (i.e., on average their patients reliably improved), “ineffective” (i.e., on average their patients did not change), or “harmful” (i.e., on average their patients reliably worsened). The frequency of effective therapists ranged from a low of 29% in treating symptoms of sexual dysfunction to a high of 67% in treating symptoms of depression. Harmful therapists ranged from a low of 3% in treating depressive symptoms to a high of 16% in treating symptoms of substance abuse and violence. When looking at competency areas (i.e., areas of reliable effectiveness), the median number of areas of therapist competence was 5 out of 12 problem areas. Only 1 therapist of the approximately 700 therapists was competent in 11 of 12 domains, and none were competent in all 12 domains. Being effective in one domain was not correlated with effectiveness in another domain. So, one cannot infer that if a therapist was effective in treating depression he or she would also be effective in treating social dysfunction, for example.

Practice Implications

There was tremendous variability in therapist skill and areas of competence in this very large sample of therapists. Between 3% and 16% of therapists were classified as reliably harmful to their patients, and between 29% and 67% were reliably effective depending on the problem area they were treating. Therapists who were effective in one domain could be harmful in another. Most therapists had some areas in which they were consistently effective, usually around 5. However, as indicated by previous research, without routine measurement, therapists may not be aware of clients for whom they are consistently helpful or harmful. Routine monitoring of outcomes could guide the matching of client problems to therapists, and could direct therapists to areas for continuing education, training, or personal therapy.

Author email: dkraus@bhealthlabs.com

August 2013

Helpful and Hindering Events in Psychotherapy

Castonguay, L.G., Boswell, J.F., Zack, S., Baker, S., Boutselis, M., Chiswick, N., Damer, D., Hemmelstein, N., Jackson, J., Morford, M., Ragusea, S., Roper, G., Spayd, C., Weiszer, T., Borkovec, T.D., & Grosse Holtforth,, M. (2010). Helpful and hindering events in psychotherapy: A practice research network study. Psychotherapy: Theory, Research, Practice, and Training, 47, 327-344.

There are many reasons why I like this paper, and one reason is that it is a psychotherapy practice research network study (most of the co-authors are independent practice clinicians). This group of clinicians and researchers met on a number of occasions to define the research questions, including: “what do psychotherapists and clients find most and least helpful in a psychotherapy session?”; and “do psychotherapists and clients agree on what was most and least helpful?” The clinicians and researchers also discussed and agreed on the method for collecting and analysing the data. Thirteen independent practice clinicians participated (6 CBT, 4 psychodynamic, and 3 experiental/humanistic). For a period of 18 months, all new clients were invited to participate so that 121 clients with a variety of disorders enrolled in the study. Clients and therapists filled out (on an index card) parts of the Helpful Aspects of Therapy (HAT) measure, which asked them to report, describe, and rate particularly helpful and hindering events from the session they had just completed. For example clients and therapists were asked: “Did anything particularly helpful happen during this session?”; and “Did anything happen during this session which might have been hindering?” When participants answered “Yes” to either of these questions, they were asked to briefly describe the event(s), and then rate them on a scale from 1 to 4 for level of helpfulness or level of hindrance. Both clients and therapists did so at the end of every therapy session. Close to 1500 therapeutic events were recorded by the clients and therapists. The events were then coded and categorized according to type of event by independent raters using an established coding system. Clients rated self-awareness, problem clarification, and problem solution as the most helpful type of events, although self-awareness was significantly the most identified of all helpful events by clients. Therapists rated self-awareness, alliance strengthening, and problem clarification as the most helpful type of events. Therapists identified self-awareness and alliance strengthening significantly more often than any other helpful events. Hindering events were identified much less frequently by clients and therapists. Client identified poor fit (e.g., therapist tried something that didn’t fit the client’s experience) as the most frequent hindering event category. Therapists identified therapist omissions (i.e., failure to provide support or an intervention) as the most frequent hindering event category. Overall, with the exception of self-awareness, therapists and clients did not agree on what were the most helpful or hindering events in therapy.

Practice Implications

Results regarding self awareness indicate that providing clients with opportunities to achieve a clearer sense of their experience (e.g., emotions, behaviors, and perceptions of self) is frequently reported as beneficial by both clients and therapists. The events that therapists most frequently reported as detrimental were those in which they failed to be attuned to their clients’ needs. This may reflect therapists’ concerns with potential alliance ruptures. The overall lack of agreement between therapists and clients on helpful and hindering events raises the question about whether therapists are not aware enough of clients’ experiences, or whether clients are not knowledgeable about what is in fact therapeutic. Perhaps client and therapist ratings of events represent complementary perspectives on what works or does not work in psychotherapy. Regarding participating in research, these independent practice therapists reported that the procedure of writing down helpful and harmful events and reading what their clients wrote after each session had a positive impact on their practice. That is, the process of data collection became immediately relevant to their clinical work.

Author email: lgc3@psu.edu

June 2013

Parallel Process in Psychotherapy Supervision

Tracey, T. J., Bludworth, J., & Glidden-Tracey, C. E. (2011). Are there parallel processes in psychotherapy supervision? An empirical examination. Psychotherapy, 49(3), 330-343.

Parallel process was first proposed in the psychodynamic literature as the replication of the therapeutic relationship in supervision. Parallel process is also recognized as an important aspect of supervision in developmental and interactional models of supervision, even though those models do not endorse the unconscious aspects of parallel process. Parallel processes in supervision occur when: (1) the trainee therapist brings the interaction pattern that occurs between the trainee therapist and client into supervision and enacts the same pattern but with the trainee therapist in the client’s role, or (2) the trainee therapist takes the interaction pattern in supervision back into the therapy session as the therapist, now enacting the supervisor’s role. For example, a client comes into therapy seeking guidance because things are not going well in his relationships. He desires structure and direction from the trainee therapist (client’s behaviour is submissive). The trainee therapist attempts to help the client by providing guidance (therapist’s behaviour is relatively dominant). The client then responds with “Yes, but…” to suggestions offered by the trainee therapist (client’s behaviour is non-affiliative). The trainee therapist over time starts to become subtly “critical” of the client (therapist matches the non-affiliative client behavior). The trainee therapist goes into supervision complaining about the client’s “resistence” and the trainee therapist asks for help and direction from the supervisor (trainee therapist increases his submissive behavior in a parallel enactment of the client’s submissive stance). As the supervisor provides some direction (supervisor increases her dominance), the trainee therapist responds with “Yes, but. . .” (trainee therapist increases his non-affiliative behavior). The supervisor engages in more “critical” comments than usual in response to the therapist (supervisor matches the non-affiliative trainee behavior). In this way, the supervision interaction becomes a relative replication of the therapy relationship, captured in the parallel amounts of dominance/submission and affiliation/non-affiliation exhibited by the participants in relation to each other. Tracey and colleagues (2012) studied this phenomenon by coding moment by moment interpersonal interactions using an interpersonal circumplex model (i.e. a model that assesses relative dominance and affiliation) among 17 triads of clients/trainee therapists/supervisors in a series of single case replications. The authors hypothesized that relative dominance and affiliation would be parallel between clients/trainee therapist pairs and corresponding trainee therapist/supervisor pairs in contiguous sessions. Significant results were found for each dyad within the 17 client/trainee therapist/supervisor triads. Therapists in the role of trainee altered their behavior away from their usual in supervision to act somewhat more like particular clients did in the previous therapy session. Supervisors tended to engage in complementary interpersonal responses in the subsequent supervision session. This provided evidence for parallel process at an interpersonal level of interactions. Further, positive client outcome was associated with increasing similarity of trainee therapist behavior to the supervisor over time on both dominance and affiliation. That is, the more therapists acted like their supervisors in the previous supervision meeting on both dominance and affiliation, the better the client outcome.

Practice Implications

This article provides intriguing evidence for an interpersonal model of parallel process. Supervisors may choose to communicate with the trainee about how the trainee therapist and client are interacting, as well as how the trainee and supervisor are interacting. In this way, the supervisor makes the implicit aspects of the parallel process more explicit for the trainee therapist. The trainee then can make choices about how best to proceed based on the new understanding of the interactional pattern at the process and content levels of interaction. For example, a therapist and supervisor can come to understand a block in the supervisory alliance as a parallel to a similar impediment in the trainee therapist-client relationship. A supervisor working through the block in supervision to create a more collegial and affiliative environment may model for the trainee therapist ways in which to effectively and collaboratively work with their client.

Author email: Terence.Tracey@asu.edu

March 2013

What Are The Characteristics of More Effective Therapists?

Laska, K. M., Smith, T. L., Wislocki, A. P., Minami, T., & Wampold, B. E. (2013). Uniformity of evidence-based treatments in practice? Therapist effects in the delivery of cognitive processing therapy for PTSD. Journal of Counseling Psychology, 60(1), 31-41.

Some therapists are more effective than others. Why, and how can we improve therapist effectiveness? Previous researchers estimates that differences among therapists account for 8% of the outcome variance, which is as big or a bigger effect than differences between treatment types. Some argue that training and supervising therapists in evidence-based treatments (EBTs) can reduce differences between therapists. But if training in EBTs does not reduce differences, what are the therapist factors we should be focusing on to improve outcomes? A study by Laska and colleagues (2013) addresses some of these issues. In their study, 25 therapists (psychologists and social workers) in Veterans Administration (VA) hospitals were trained by a nationally recognized trainer in cognitive processing therapy (CPT) for post traumatic stress disorder (PTSD), and they treated 192 veterans. Therapists were trained to a standard level of competence in CPT, and they were supervised weekly by a certified expert in CPT. Differences between therapists’ effectiveness accounted for 12% of the outcome variance. In other words training and supervision in CPT did not appear to reduce differences between therapists, so that some therapists remained significantly more (or less) effective than others. The CPT expert supervisor was able to identify the more effective therapists even though she was blind to patient outcomes. She was also asked to list the qualities of these more successful therapists. Four areas emerged from the qualitative analysis of the supervisor interviews. (1) Reducing Avoidance – i.e., therapists’ ability to skilfully address patient avoidance of difficult areas or avoidance of therapy assignments, and not to collude with client avoidance; (2) Language in Supervision – i.e., therapists’ willingness to discuss struggles with cases, openness to discussing their contribution to impasses, and non-defensiveness in response to supervisor feedback; (3) Flexible Interpersonal Style – i.e., therapists’ ability both to join with and to challenge patients, to flexibly apply the manual so that they did not miss important interpersonal events in the therapy, but at the same time not to stray too far from the manual; and (4) Strong Therapeutic Alliance –i.e., therapists’ genuineness with patients, ability to develop a bond, and to agree with patients on tasks and goals of therapy.

Practice Implications

Creating a culture within a practice setting in which therapists are routinely provided feedback about their clients’ ongoing progress and about the therapeutic relationship has the potential to improve patient care. Therapists’ ability to handle interpersonally challenging encounters with patients is what distinguishes the most competent therapists from others. Training and supervision of therapists should focus on facilitative interpersonal skills as well as on the specific treatment protocol.

Author email: Kevin.Laska2@va.gov

This month...

Type of Research

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November 2013

Practice Implications

October 2013

Practice Implications

September 2013

Practice Implications

August 2013

Practice Implications

June 2013

Practice Implications

March 2013

Practice Implications

Psychotherapy Practice Research Network (PPRNet)