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.
This month...
…I blog about the treatment of depression, the effects of role induction in psychotherapy, and negative experiences in psychotherapy from clients’ perspective.
Type of Research
Topics
- ALL Topics (clear)
- Adherance
- Alliance and Therapeutic Relationship
- Anxiety Disorders
- Attachment
- Attendance, Attrition, and Drop-Out
- Client Factors
- Client Preferences
- Cognitive Therapy (CT) and Cognitive-Behavioural Therapy (CBT)
- Combination Therapy
- Common Factors
- Cost-effectiveness
- Depression and Depressive Symptoms
- Efficacy of Treatments
- Empathy
- Feedback and Progress Monitoring
- Group Psychotherapy
- Illness and Medical Comorbidities
- Interpersonal Psychotherapy (IPT)
- Long-term Outcomes
- Medications/Pharmacotherapy
- Miscellaneous
- Neuroscience and Brain
- Outcomes and Deterioration
- Personality Disorders
- Placebo Effect
- Practice-Based Research and Practice Research Networks
- Psychodynamic Therapy (PDT)
- Resistance and Reactance
- Self-Reflection and Awareness
- Suicide and Crisis Intervention
- Termination
- Therapist Factors
- Training
- Transference and Countertransference
- Trauma and/or PTSD
- Treatment Length and Frequency
November 2014
Managing Countertransference: Meta-analytic Evidence
Hayes, J.A., Gelso, C.J., & Hummel, A.M. (2011). Managing countertransference. Psychotherapy, 48, 88-97.
This is another in a series of meta-analyses on relationship factors that work in psychotherapy that appeared also in John Norcross’ book Psychotherapy Relationships That Work. As I mentioned in previous blogs, meta-analyses represent the state of the art in systematically reviewing a research literature. In meta-analyses, the effect sizes from many studies are aggregated into an estimate of an overall effect that is much more reliable than any single study. In these meta-analyses, Hayes and colleagues assessed whether therapist countertransference had a negative effect on patient outcomes, and whether successful management of countertransference is related to better therapy outcomes. Traditionally, countertransference was seen as solely related to therapist unconscious conflicts, and countertransference was to be avoided. Broader conceptualizations view countertransference as representing all of the therapist’s reactions to the client. More interpersonal or relational models view countertransference as therapist reactions that complement a patient’s ways of relating, or see countertransference as mutually constructed by therapist and patient, so that the needs and conflicts of both patient and therapist contribute to the manifestation of countertransference in therapy. Hayes and colleagues argue that the definition of countertransference must include some aspect of therapist unresolved conflicts, and that countertransference in the therapist is potentially useful to understanding patient dynamics and personality style. Countertransference may be reflected in therapist anger, boredom, anxiety, despair, arousal, etc. These feelings range in intensity as well. According to Hayes and colleagues, successful management of countertransference might involve: self-insight (therapist being aware of their own feelings, attitudes, personality, etc.); self integration (therapist’s healthy character structure); anxiety management (therapist’s ability to control and understand own anxiety); empathy (the ability to put one’s self in the other’s shoes in order to focus on the client’s needs); and conceptualizing ability (therapist’s ability to draw on theory to understand the patient’s role in the therapeutic relationship). Hayes’ and colleagues meta-analyses included between 7 to 11 studies of 478 to 1065 participants. The findings showed that countertransference in the therapist was associated with negative patient outcomes, though the effect was small. Successful management of countertransference was associated with better therapy outcomes, and the effect was large.
Practice Implications
Successful management of countertransference is a characteristic of effective therapists. Therapists can work on a number of issues to reduce the negative impact of countertransference and to increase its utility in helping to understand certain patients. Therapists can work to gain self-understanding and work on their own psychological health. The research suggests the importance of therapists resolving their own major conflicts through personal therapy and clinical supervision. Having a good grasp of psychological theory and theories of therapy can also help with using countertransference effectively, as long as the theory is not used defensively by the therapist. Further, there is value in therapists admitting mistakes and acknowledging that their own conflict was the source of the error. Although countertransference theory and research focuses on the therapist, Hayes and colleagues acknowledge that some clients evoke greater and more intense countertransference reactions that others.
October 2014
Client Preferences Affect Satisfaction, Completion, and Outcome
Lindheim, O., Bennett, C.B., Trentacosta, C.J., & McLear, C. (2014). Client preferences affect treatment satisfaction, completion, and clinical outcome: A meta-analysis. Clinical Psychology Review, 34, 506-517.
Giving clients a choice about treatments or to receive their preferred treatment might improve treatment outcomes. Preference usually means clients passively receiving the treatment they prefer. Choice involves clients actively making a decision about which treatment option to receive. Clients may also make informed or uninformed preferences and choices. Informed preferences and choices refer to providing clients with information or education about treatment options. Having a choice or getting one’s preference between two or more efficacious treatments might have several beneficial effects. For example, some research shows that treatment preferences positively affect therapeutic alliance, possibly because clients may enter treatment with a more positive outlook about what intervention they receive. Patients receiving a preferred treatment may also have better overall communication with their providers which may lead to better outcomes. In their meta-analysis, Lindheim and colleagues were interested in the effects of client preference or choice on treatment satisfaction, completion, and clinical outcomes. The meta-analysis included 34 different studies. Client preference or choice of treatment was modestly but significantly and consistently related to satisfaction, completion rates, and to client outcomes. Clients who were involved in shared decision making, who chose a treatment condition, or who received their preference had higher satisfaction, increased completion rates, and better clinical outcomes compared to clients who were not involved in the decision, who did not choose, or who did not receive their preference. Setting (inpatient vs outpatient) or diagnosis did not have an effect on these findings.
Practice Implications
The findings highlight the clinical benefits of assessing client preferences and providing treatment options when two or more efficacious options are available. Increasingly, two or more efficacious options are available for common mental disorders like depression and anxiety. Many times, patients prefer psychotherapy over medications, for example. However, whereas medication prescriptions for mental disorders like depression rose dramatically in the past decades, rates of psychotherapy use remained stable or slightly declined. For those disorders for which two or more treatment options have comparable efficacy, client preference should be the deciding factor.
September 2014
The Effect of Therapist Empathy on Client Outcomes
Elliott, R., Bohart, A. C., Watson, J. C., & Greenberg, L. S. (2011). Empathy. Psychotherapy, 48(1), 43.
There has been a recent upsurge in interest in empathy in psychotherapy following scientific studies in the field of social neuroscience. This research has focused on activation in areas of the brain associated with emotional stimulation, perspective taking, and emotion regulation. Conceptualizations of the role of empathy in psychotherapy have a rich history in both client-centered and psychodynamic traditions. Carl Rogers defined empathy in part as “...the therapist’s sensitive ability and willingness to understand the client...from the client’s point of view.” Elliott and colleagues indicate three main modes of expressing therapeutic empathy: empathic rapport (compassionate understanding of the client’s experience); communicative attunement (ongoing effort to stay attuned with the client’s experience); and person empathy (experience-near understanding of the client’s world). In this meta-analysis of research on therapeutic empathy, Elliott and colleagues were interested in the strength of the relationship between therapist empathy and client outcome, and factors that might determine this relationship. Their meta analysis included 57 different studies of 3,599 clients. The relationship between therapist empathy and client outcome was medium-sized (r = .31), and in the same order of magnitude as the alliance-outcome relationship. There were no differences between theoretical orientations in the size of the empathy-outcome relationship – in other words, empathy was equally important across types of therapy. Client measures of therapist empathy had the largest relationship to client outcome, whereas therapist ratings of empathy had the smallest association with client outcomes. In other words, if you are interested in therapist empathy, best to ask the client. Also, the empathy-outcome relationship was larger for less experienced (vs more experienced) therapists and for more severely (vs less severely) distressed clients. That is, empathy likely is most important for newer therapists and more distressed clients.
Practice Implications
Therapist empathy is essential to any psychotherapy regardless of orientation. Empathic attunement and expression is particularly important for clients of newer therapists, and for more distressed clients. Elliott and colleagues suggest that the empathic therapist’s primary goal is to understand the client’s experience and to communicate this understanding to the client. This can be done through: empathic affirmations (i.e., validating the client’s perspective); empathic evocations (bringing the client’s experience to life with rich, evocative, and concrete language); and empathic conjectures (making explicit what is implicit in the client’s narrative). Empathy can deepen client’s experiences, but therapeutic empathy also involves individualizing responses to the client. For example, some fragile patients may find typical expressions of empathy as too intrusive, whereas other clients may find therapeutic empathy to be too directive or too foreign. Being attuned to the client’s receptiveness to empathy is an important therapeutic skill. Elliott and colleagues emphasize that empathy should be grounded in authentic caring for the client and as part of a healthy therapeutic relationship.
Long-Term Effects of Psychotherapy for Depression
Steinert, C., Hofmann, M., Kruse, J., & Leichsenring, F. (2014). Relapse rates after psychotherapy for depression - stable long term effects? A meta-analysis. Journal of Affective Disorders, http://dx.doi.org/10.1016/j.jad.2014.06.043
As I reported in the June 2014 Blog depression is the most highly prevalent of the mental disorders with a lifetime prevalence of about 16%. It is responsible for enormous personal and economic burden for individuals and their families. Depression can occur as a single episode, however recurrence of depressive episodes can range from about 35% to 85% of those who were depressed. About 10% of cases experience chronic depression. Studies report that chronic or severe depression result in a lower response to interventions, including psychotherapy. Meta analytic research shows that a number of psychotherapeutic interventions are equally effective for treating depression (see also the July 2014 Blog). However, all of these meta analytic reviews of the effects of psychotherapy for depression referred to studies demonstrating short or medium term effectiveness. There are very few studies that report long term effectiveness of any type of treatment (psychological or pharmacological) for depression. This is a problem given the fluctuating and sometimes chronic course of the disorder. Randomized controlled trials of psychotherapy are expensive and time consuming, and collecting follow up data is difficult. And so it is not surprising that few studies assess outcomes after one or two years post treatment. Steinert and colleagues conducted a meta analysis looking specifically at studies that documented long term (i.e., greater than 2 years) post psychotherapy outcomes for depression. (A note on meta analyses: Meta analyses are a set of procedures that allow one to statistically combine the effects of many studies in order to estimate the average effect across many studies and participants. Meta analyses produce much more reliable results than any single study can produce, and so meta analyses are the best way of summarizing research to affect practice). Steinert and colleagues found 11 studies of 966 patients that reported outcomes beyond 2 years post psychotherapy. Six of the studies compared psychotherapy to another intervention (e.g., medications, treatment as usual, clinical management). The authors found that 40% of patients treated with psychotherapy had at least one relapse in a follow up period averaging about 4 years. Compared to non-psychotherapy interventions psychotherapy had a significantly lower likelihood of experiencing a relapse. Despite the positive long term outcomes of psychotherapy for depression, the authors noted that there was a great deal of inconsistency across studies (i.e., hetereogeneity), which lowers ones confidence in the reliability of these findings.
Practice Implications
There are very few studies of long term (> 2 years post treatment) outcomes of psychotherapy for depression. In the June and August PPRNet Blogs, I reported on large scale worldwide reviews that indicate how pervasive depression can be, and how detrimental depression is to health and well being. Depression can be recurrent and chronic for some, so demonstrating long term outcomes is important. On the positive side, psychotherapy results in 60% of individuals not experiencing relapses 4 years post treatment, and psychotherapy resulted better long term outcomes than non-psychotherapy interventions. However, having so few studies that assess long term outcomes reduces our confidence in these findings. A number of psychotherapies including cognitive behavioral therapies, psychodynamic therapy, interpersonal psychotherapy, and others are effective for treating depression.
Psychotherapeutic Interventions to Promote Forgiveness
Wade, N.G., Hoyt, W.T., Kidwell, J.E., & Worthington, E.L. (2014). Efficacy of psychotherapeutic interventions to promote forgiveness: A meta-analysis. Journal of Consulting and Clinical Psychology, 82, 154-170.
Forgiveness can include reducing vengeful and angry thoughts and feelings, and may be accompanied by positive thoughts, feelings and motives towards the offending person. This does not necessarily include reconciliation with the offending person, nor does it require forgetting, condoning, or excusing the wrongdoing. Promoting forgiveness in psychotherapy includes helping clients move toward more positive and optimal functioning. There are two prominent empirically based models of forgiveness interventions. Enright’s model contains four phases: (1) uncovering negative thoughts about the offense, (2) decision to pursue forgiveness, (3) work toward understanding the offending person, and (4) discovery of unanticipated positive outcomes and empathy for the offending person. Worthington’s model has five steps: (1) recalling the hurt and emotions, (2) empathising with the offender, (3) altruistic view of forgiveness, (4) commitment to forgiveness, and (5) holding on to or maintaining forgiveness. Wade and colleagues conducted a meta analysis: to compare forgiveness outcomes and mental health outcomes of forgiveness interventions in general; to compare of forgiveness interventions to each other; and to compare forgiveness interventions to non-forgiveness psychotherapies or to control conditions. The meta analysis included 53 studies of 2,323 participants. Participants receiving forgiveness interventions reported significantly greater forgiveness compared to those not receiving treatment and compared to those who received alternative treatments that were not specific to forgiveness. Forgiveness interventions also resulted in greater positive changes in depression, anxiety, and hope compared to no-treatment conditions. There were no differences between Enright’s and Worthington’s approaches when duration of treatment and modality (individual vs group) were controlled. However, as an individual treatment, Enright’s model showed better outcomes. Longer duration of treatment was associated with greater forgiveness, and greater severity of the offense was also associated with greater forgiveness.
Practice Implications
Theoretically grounded forgiveness interventions may be the best choice to help a client to achieve resolution in the form of forgiveness. Other non-forgiveness therapeutic approaches may help but may not have as great an impact on forgiveness as those interventions that are specifically designed to improve forgiveness. Enright’s model delivered as an individual treatment was more effective than Worthington’s approach which is designed mostly as a group intervention. In addition to improving forgiveness, both approaches also had significant positive impact on depression, anxiety, and hope. The forgiveness interventions worked better if provided for longer duration and in the context of more severe offenses.
August 2014
Are Therapists or Clients Most Responsible for the Therapeutic Alliance-Outcome Relationship?
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.