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Hill, C. & Knox, S. (2013). Training and supervision in psychotherapy. In M.E. Lambert (Ed.), Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change, 6^th Edition (pp. 775-811). New York: Wiley.

Research on training and supervision in psychotherapy has proven to be very difficult to conduct. Part of the difficulty with the research is that the process under study is highly complex with many interacting variables. Therapists and supervisors have different personal qualities, patients have different levels of problems, training programs differ, supervision styles differ, and therapists and supervisors differ in terms of experience, case load, knowledge, and training background. Nevertheless there exists a moderately large literature on training, supervision, and continuing education in psychotherapy. However, the findings so far have been mixed and somewhat disappointing. In their chapter in the Handbook, Hill and Knox (2013) tackle the difficult task of summarizing this literature and giving some coherence to the findings. Is training and supervision effective? Hill and Knox tentatively conclude that the answer is “yes”. They provide some evidence that novice therapists can be trained in helping skills, that trainees improve over the course of training, that supervision enhances trainees’ awareness of self and others and improves their autonomy, and that experienced therapists, including those in the community can be trained to use manuals. Despite these positive findings, the existing literature also provided some sobering results. These less supportive findings include: that nonsupervised therapists did not differ from supervised therapists on therapy alliance and patient outcomes, that supervision sometimes has negative effects on trainees and their patients, that therapist experience may not be related to better patient outcomes, and that some highly facilitative non-professionals can be just as effective as trained therapists. What contributes to making training and supervision effective? The research in psychotherapy training and medical education is clear on this question: hands-on experience is key to learning a practice-based skill such as psychotherapy. Practice is the most helpful component of skills training. In medical education research, systematic reviews have shown that traditional didactic learning (i.e., classroom style lectures) had no significant impact on physician behaviors or patient outcomes. However, interactive programs (especially supervised rehearsal of skills) did have a significant positive impact on physician behaviors and patient outcomes. Furthermore, psychotherapy supervisees reported that supervisors who were open, empathic, and who provided supportive nurturance in the context of a good supervisory alliance were most helpful to trainees to develop and improve their clinical skills.

Practice Implications

Practicing clinicians who want to get the most out of continuing education should look for opportunities in which they get hands-on experience and continuous supervision in providing the psychotherapy intervention. Other than acquiring a limited amount of knowledge, didactic training alone without practice will likely have little impact on practice. The research also indicates that supervisors and trainees who are able to develop a good supervisory alliance, and supervisors who are open and empathic are more likely to result in improved psychotherapy skills in trainees and better outcomes in patients. Binder and Henry (2010) describe the importance of “deliberate practice” in psychotherapy training and continuing education that includes: performing a task at an appropriate level of difficulty, receiving immediate and informative feedback from a supervisor, and having the opportunity to repeat the skill and correct errors.

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.

This month I consider the section in Crits-Christoph and colleagues’ chapter on the process of psychodynamic therapy (PDT). There are a number of PDT models, but they each share some fundamental aspects of treatment or purported mechanisms. One is insight or self understanding, in which patients learn about themselves and their relationships through interventions like interpretations. Self understanding is expected to help patients reduce symptoms by increasing adaptive responses in their important relationships. Transference interpretations may help patients understand their patterns within the therapy relationship, address or change these patterns, and generalize the changes to relationships outside of therapy. Another mechanism might be changes in defensive functioning. Defense mechanisms may be expressions and means of coping with unconscious conflict, needs, and motivations. Change in defensive functioning from less adaptive (e.g. acting out, passive aggression) to more adaptive (e.g., altruism, self observation) may be necessary to achieve improvement in symptoms. Crits-Christoph and colleagues addressed four questions in their review of research on the process of PDT. (1) Are the uses of PDT techniques like transference interpretations related to treatment outcomes?  A number of studies have associated the use of PDT interventions and outcomes, and the average effect size is moderate. In general, transference interpretations were associated with better treatment outcomes. However the findings for transference interpretations are complicated. For example, the use of too many transference interpretations may not be therapeutic and may result in poorer outcomes. A small number of studies looked at the quality or accuracy of transference interpretations and found a moderate relationship between accurate interpretations and good outcomes. Most of these studies did not control for previous improvement in outcomes, so an alternate explanation might be that patients whose symptoms improve facilitate therapists to provide more effective transference interpretations. (2) Is patient self-understanding or insight associated with positive outcomes in PDT? Crits-Christoph and colleagues concluded from their review that changes in self-understanding is an important part of the therapeutic process of PDT. The relationship between insight and outcomes were not evident in CBT or medication interventions, thus suggesting that self-understanding is a specific mechanism of PDT. (3) Is change in defensive functioning related to outcomes in PDT? Only four studies have looked at this question. The studies suggest that improved defensive functioning is related to good outcomes especially for those with more severe problems. However, it remains unclear whether change in defensive functioning causes change in symptoms or the other way around. (4) Is therapist competence in PDT related to treatment outcomes? There is some evidence that competence and adherence in delivering PDT were related to good patient outcomes. Some research also showed that competence and adherence to PDT protocols preceded or caused good outcomes.

Practice Implications

There is good evidence that transference interpretations are related to outcomes, but therapists need to use these judiciously. The research suggests that too many transference interpretations in those with lower levels of functioning, or inaccurate interpretations in general, can reduce outcomes or be related to poorer outcomes. There is also good evidence that patient self understanding of relationship patterns will result in positive outcomes. Self understanding or insight may be a specific mechanism by which PDT works that sets it apart from CBT and the effects of medications. The research also indicates some evidence for the positive effects of changes in defensive functioning, but it is not clear whether change in defenses is a cause of or caused by positive symptom outcomes. Therapist competence and adherence in delivering PDT is also related to good patient outcomes. This highlights the need for training and supervision in evidence based PDT interventions.

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 this section of their chapter in the Handbook, Crits-Christoph and colleagues (2013) review research on: (1) specific techniques of cognitive behavioural therapy (CBT), and (2) change mechanisms of CBT for depression. Research on techniques and mechanisms of change tests the specific or unique effects of a treatment and the rationale for its use. The first issue addresses whether therapist adherence and competence in using CBT techniques produce desired outcomes in patients. CBT techniques include: following an agenda, reviewing homework, asking about specific beliefs, practicing rational responses with patients, and asking patients to keep thought records. Crits-Christoph and colleagues (2013) report that the research findings on the association between using specific CBT techniques and depression outcomes are mixed. The strongest evidence is for concrete techniques such as setting agendas, reviewing homework, and practicing rational responses. However the number of studies that control for prior symptom change and other factors like therapeutic alliance is small, and so the evidence for the specific effects of CBT techniques remains meagre. The second issue addresses whether targeting depressogenic cognitions with CBT results in positive outcomes. Generally, CBT theory argues that the mechanisms by which CBT works is to focus on core depressogenic schemas (i.e., less consciously long held negative beliefs about the self), conscious negative automatic thoughts, and dysfunctional attitudes (i.e., patterns of automatic thoughts) that lead to or maintain depression. Theoretically, addressing these cognitions in CBT should reduce depressive symptoms. Overall, the research shows that both CBT and medication treatment for depression reduce self-reported negative thinking; that is, the effects on negative thinking were not specific to CBT. Few studies show that changes in cognitions precede changes in depressive symptoms, which is a key CBT tenet. The most promising findings suggest that learning compensatory skills (i.e., finding alternative explanations for negative events and thoughts, and problems solving) may be part of the mechanism by which CBT works, but again this mechanism may not be specific to CBT.

Practice Implications

CBT is an effective treatment for depression. CBT theory suggests that the reason for its effectiveness is the use of specific techniques (i.e., reviewing homework, asking for specific beliefs, practicing rational responses with patients, and asking patients to keep thought records) that target the purported causes of depression (i.e., depressogenic shemas, negative thoughts, and dysfunctional attitudes). Currently there is little research evidence that supports the specificity of CBT techniques or that supports the notion that specific changes in cognitions as a result of CBT reduce depression. Nevertheless, in general, concrete techniques (i.e., setting agendas, reviewing homework, and practicing rational responses) are clinically useful for depressed patients, as is learning compensatory skills like problem solving.

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.

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.

Bohart, A.C. & Wade, A.G. (2013). The client in psychotherapy. In M. Lambert (Ed.) Bergin and Garfield’s handbook of psychotherapy and behavior change (6^th ed.), pp. 219-257. Hoboken, NJ: Wiley.

Last month I blogged about the section in Bohart and Wade’s (2013) chapter that focused on client symptom severity and motivation. This month I focus on differences between clients and therapists on their perceptions of therapy processes and outcomes. In a previous blog (see June 2013), I reviewed a meta analysis that showed that given two equally effective treatments, clients should be given their preference in order to improve outcomes. Clearly, client perceptions and preferences are important, and perhaps more important than the therapist’s perceptions. Bohart and Wade (2013) reviewed a number of studies that demonstrated this. For example, studies show that client ratings of the therapeutic alliance predicted which therapists had better than average outcomes, whereas therapist ratings of the alliance did not predict outcomes.  In three other meta-analyses, client perceptions of therapist genuineness, empathy, and therapeutic presence were each more predictive of outcomes than the respective therapists’ assessments of their own genuineness, empathy, and therapeutic presence. Clients also value different outcomes compared to therapists and researchers. Most research on outcomes tends to focus on symptom reduction, but clients appear to have a broader view of good outcomes. In a qualitative study, clients focused on healthier relationship patterns, an increase in self-understanding that led to freedom from and avoidance of self-destructive behaviour, and stronger valuing of the self, in addition to symptom reduction. Others report that clients define good outcomes as reengaging in meaningful work and social roles, and restoring their self respect.

Practice Implications

Clients are more finely attuned to the therapeutic alliance than therapists, and perhaps are better at detecting relevant and helpful therapist stances. If you are interested in assessing therapeutic alliance or a therapist’s empathy, don’t ask the therapist, ask the client. This has implications for training therapists in helpful therapeutic relationship stances. Helping trainees find areas for continued development as a therapist (i.e., in terms of improving their empathy, genuineness, and therapeutic presence) may require asking their clients’ opinions. Client perceptions of therapist qualities are more relevant than therapist perceptions when assessing effective therapist relationship stances. Therapists should monitor client preferences, particularly if the client is having difficulty engaging in the therapy. If possible and reasonable, therapists should alter their relationship approach to a client based on client feedback. Regarding outcomes, therapists, researchers, and agencies should consider broader definitions of outcomes that are more aligned with what clients want and value. Improved self concept, improved relationships, and better social and work functioning may be just as important as symptom reduction for most clients.

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, you can read the Handbook table of content and sections of the book on Google Books.

Bohart, A.C. & Wade, A.G. (2013). The client in psychotherapy. In M. Lambert (Ed.) Bergin and Garfield’s handbook of psychotherapy and behavior change (6^th ed.), pp. 219-257. Hoboken, NJ: Wiley.

Last month I blogged about the section in Bohart and Wade’s (2013) chapter that focused on client attachment. This month I focus on other factors like severity of distress and comorbidity, and level of motivation. Some authors argue that client factors predict 30% of variance in outcomes. That accounts for more of psychotherapy outcome than therapist effects and therapeutic techniques combined. Severity of symptoms of anxiety and depression and functional impairment caused by this distress leads to poorer client prognosis. Further, individuals with more severe symptoms need more sessions to show improvement. Some research shows that those with greater symptoms change more than those with fewer symptoms. However, even though those with higher levels of distress show the most change, they are less likely to achieve recovery in which they return to a normal level of functioning. In most cases, clients with comorbid problems are less likely to do well. For example, comorbidity for personality disorder or substance abuse negatively impact outcome. Client motivation is also related to psychotherapy outcomes. Motivation can be internal (those that arise from the individual’s intrinsic interests or values) or external (those that arise from external rewards or punishments). Generally, internal motives (i.e., greater readiness to change) are better predictors of sustained behaviour change. The stages of change model describes readiness to change as occurring in progressive stages that include: (1) precontemplation, in which clients are not internally motivated; (2) contemplation in which clients move to the next stage where they recognize a problem but are not ready to take action; and (3) preparation for action in which clients are more internally motivated to change. The next two stages of the model do not speak to motivation but to action and maintenance of change. Norcross looked at clients’ readiness to change prior to therapy and its relationship to outcome. Greater readiness to change was moderately and significantly associated with better treatment outcomes.

Practice Implications

The results on severity and comorbidity suggest that providers and policy makers must consider increasing the number of treatment sessions to take into account clients who have greater initial severity and comorbidities, especially for those with comorbid personality disorders. Results related to motivation indicate that when client motivation to work in therapy comes from within and they show progress in their readiness to change, they are more likely to do well. Therapists need to find ways of mobilizing clients’ internal reasons for change. Motivational interviewing may be one means of doing so.