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.

July 2023

Therapeutic Relationship Factors that Do Not Work

Norcross, J.C. & Karpiak, C.P. (2023). Relationship factors. In S. D. Miller, D. Chow, S. Malins, and M. A. Hubble (Eds.) The Field Guide to Better Results: Evidence-Based Exercises to Improve Therapeutic Effectiveness. American Psychological Association. https://doi.org/10.1037/0000358-006

In their chapter, Norcross and Karpiak review the meta-analyses on therapeutic relationship factors that have a positive impact on patient outcomes. Aspects like therapist empathy, positive regard, genuineness, and developing and maintaining a therapeutic alliance have solid research support for their importance to patient outcomes. In fact, the research is clear that these relationship factors are more important (i.e., are better predictors of patient outcomes) than the brand of therapy conducted by the therapist. Part of this chapter by Norcross and Karpiak also identifies those therapist and relationship factors that do not work and that may be harmful to patients. One could simply reverse the effective behaviors identified in meta-analyses – so that low therapist empathy, poor therapeutic alliances, therapists who are incongruent in their words and actions, and who disregard alliance ruptures will have patients with worse outcomes. Research also identifies harmful behaviors by therapists. These might include rigidity in following prescriptions of an intervention, therapist overconfidence in their abilities, hostile behaviors, a confrontational style, and cultural arrogance. As an example, the authors discuss widespread policies mandating the use of specific treatment protocols, and training therapists in manualized treatments to the exclusion of relationship factors. Research shows that adherence or competence with treatment manuals is consistently unrelated to patient outcomes. By contrast relationship factors are highly related to patient outcomes. Research also suggests that therapist behaviors that blame patients, are sarcastic, critical, or hostile towards patients can lead to worse outcomes. Therapists whose assumptions about a patient that do not align with the patient’s experience, also tend to have patients who do not improve. Therapists may believe that they should know better, but if their knowledge does not fit the patient’s experience, then therapist and patient are not engaged in a collaborative endeavor. Finally, even if some therapies prescribe “confrontation” as a therapeutic stance, there is dubious evidence that using such an approach is helpful to patients.

Practice Implications

The research points to certain therapist behaviors that should be avoided when working with patients. Among these is rigid adherence to a treatment manual. Such rigid adherence by a therapist does not allow room for professional self-doubt, for aligning one’s approach to patient needs, and it might foster therapist over-confidence and a lack of humility. Each of these stances towards a patient reduces a therapist’s empathy and may put the patient in a position of reluctantly complying, feeling unheard and unappreciated, or dropping out of therapy.
Therapeutic Relationship Factors that Work

Norcross, J.C. & Karpiak, C.P. (2023). Relationship factors. In S. D. Miller, D. Chow, S. Malins, and M. A. Hubble (Eds.) The Field Guide to Better Results: Evidence-Based Exercises to Improve Therapeutic Effectiveness. American Psychological Association. https://doi.org/10.1037/0000358-006

Next to patient factors that affect outcomes in psychotherapy, the therapeutic relationship is the most important predictor or contributor to patient outcomes. The therapeutic relationship is important to in-person therapy and to therapy delivered virtually. There is no scientific doubt of the importance of the therapeutic relationship on patient outcomes. The relationship is managed and cultivated by the therapist’s attitudes and behaviors. And so, it is not surprising that therapists differ in their ability to facilitate the therapeutic relationship. However, it is also possible for therapists to improve their therapeutic relationship skills through training and supervision. The therapeutic relationship is important to all therapeutic orientations. In this part of the chapter, Norcross and Karpiak review the research on relationship factors that work including therapist empathy, positive regard, developing a therapeutic alliance, and repairing alliance ruptures when they occur. Empathy occurs when a patient experiences a therapist who perceives and expresses an accurate understanding of a patient’s feelings, perspectives, and experiences. Empathic responding is one of the strongest predictors of patient outcomes with effect sizes ranging from moderate to large (d = .58), but only when it is rated by the patient. Therapist ratings of their own empathy has a much lower association with patient outcomes. Positive regard is the therapist’s genuine liking and expressed appreciation for the patient as a person. That is, a therapist’s verbal and nonverbal expression that they value, care about, and believe in the patient. The key here is genuineness – that the therapist’s words are consistent with their intentions and feelings. Positive regard expressed in therapy is moderately related to patient outcomes (d = .57). The therapeutic alliance refers to the warm emotional bond between patient and therapist, and their collaborative agreement on the goals of therapy and how they will work towards those goals. More than 300 studies of over 30,000 patients indicate that the alliance is moderately related to patient outcomes (d = .57), and this is a highly reliable finding. Ruptures in the alliance are characterized by patient withdrawal from the therapist or therapy, or by confrontation in which the patient criticizes or is dissatisfied with the therapist or therapy. Therapists’ attempts to repair alliance ruptures is moderately related to positive patient outcomes (d = .62), and this skill is most important for newer therapists and therapists with a CBT orientation.

Practice Implications

A positive therapeutic relationship has a much bigger impact on patient outcomes than the specific type of therapy used by therapists. A therapist who narrowly focuses on the content of what a patient says and rigidly adheres to a treatment manual will reliably have patients who have worse outcomes. Therapists whom patients experience as truly empathic (not just expressing sympathy for a patient), who can genuinely feel and express positive regard for a patient, and who can develop and maintain a therapeutic alliance and repair alliance ruptures reliably will have patients who have better experiences of therapy and better outcomes. These therapist skills and capacities can be learned through deliberate practice, supervision, personal therapy, and by maintaining a stance of flexibility, openness, and humility.
Therapist Factors Related to Patient Outcomes

Nissen-Lie, H.A., Heinonen, E., & Delgadillo, J. (2023). Therapist factors. In S. D. Miller, D. Chow, S. Malins, and M. A. Hubble (Eds.) The Field Guide to Better Results: Evidence-Based Exercises to Improve Therapeutic Effectiveness. American Psychological Association. https://doi.org/10.1037/0000358-005.

The thing about therapists that people in the profession do not like to talk about is that some therapists are more effective than others. Meta-analyses indicate that about 5% of patient outcome variance can be explained by differences between therapists. Although this seems small, it accounts for about one-third of the total difference in outcomes among patients. One study found that patient recovery rates for the most effective therapists were twice that achieved by their least effective counterparts. In another study, 15% more patients recovered when they saw an “average” therapist compared to one of the least effective clinicians. One key problem is that therapists consistently over-estimate their own effectiveness, and consistently under-estimate the percentage of their patients who get worse. This makes it difficult for therapists to correct course when necessary or to engage in targeted professional and personal development. In this chapter, Niessen-Lie and colleagues review the research that identifies key therapist qualities that are related to better patient outcomes. It turns out that demographics of the therapist (sex, gender, ethnicity, age), experience level, profession, and education level are all unrelated to patient outcomes. In fact, there is some evidence that more experienced older therapists have slightly poorer outcomes than their younger counterparts. However, some therapist factors are important and known to be related to patient outcomes. For example, therapists who are consistently effective across different types of patients, patient severity, and diagnoses have the best outcomes. Another key therapist factor or attribute is interpersonal skill. This includes therapist empathy, warmth, the capacity to express emotions verbally, the ability to develop a therapeutic alliance with a variety of patients, and the capacity to tolerate and manage strong negative emotions in therapy. A third therapist factor is flexibility. Therapists who can be flexible in using therapeutic techniques within a given treatment tend to have patients with better outcomes. Finally, therapists who can maintain an attitude of humility tend to have better outcomes. Humility refers to an openness to other’s points of view, accepting that there is room for growth, and for pushing beyond one’s current skill level while taking care of oneself. Without this attitude, there is little motivation for continued learning, personal growth, and professional development.

Practice Implications

A therapist’s experience level, profession, experience, and other demographics have no bearing on their patients’ outcomes. However, we do know that being effective with a range of patients, interpersonal skills (empathy, verbal expression of emotions, and ability to tolerate strong emotions), flexibility in applying therapeutic interventions, and professional humility are related to patient outcomes. These therapist skills can be developed and improved during one’s career. Improving these skills require a therapist to be willing to examining when things do not go well in therapy (reviewing when patient outcomes are poor or a patient drops out), to reflect on one’s abilities, and to look for disconfirming evidence by asking “could I be wrong?” First, however, therapists must identify when therapy with a patient was ineffective. And for this, they may need the help of standardized assessments to monitor the state of the therapeutic relationship and patient progress.

June 2023

What People Want From Therapy

Delboy, S. & Michaels, L. (2021). Going beneath the surface: What people want from therapy. Psychoanalytic Inquiry, 41:8, 603-623. DOI: 10.1080/07351690.2021.1992232

There has been an increased interest in and demand for mental health care, and so one can imagine that the public might have questions or opinions about psychotherapy. Moreover, research has shown that patients who get the type of treatment that they expect or want are more likely to have better outcomes. However, it is rare that researchers ask the public what they want from therapy. In this unique study, Delboy and Michaels conducted a survey of US citizens about their perceptions and preferences for psychotherapy. Their sample of 1,535 respondents were deliberately selected to be representative of US census data for age, gender, ethnicity, socioeconomic status, and geographic region. The survey asked what people what they wanted from therapy: 70% indicated that they wanted to “learning skills and coping strategies”, which is like what is offered in manualized treatment modalities. However, 70% also wanted to “better understand oneself and the root of one’s issues”, which is like what is offered in depth, insight, and relational therapies. When forced to choose between a “therapy that takes fewer sessions and helps manage symptoms” and a “therapy that takes longer but addresses the root causes of problems”, 91% chose a longer therapy focused on root causes. Over 60% of the sample indicated that they wanted to “share feelings without judgement” and to “feel heard and understood by someone who cares”, which suggests that people value these qualities in the therapist and the therapeutic relationship. Interestingly, two thirds of the sample recognized that therapy takes time “to understand and resolve” one’s issues and problems. And less than 10% did not want to understand their problems or examine issues from childhood. Regarding the reasons of their mental health issues, 50% reported that relationship patterns are an important source of their distress, whereas only 10% attributed mental health problems to a “chemical imbalance” in the brain.

Practice Implications

Patients tend to do better when they get the treatment that they prefer. A similar percentage of the public (70%) wanted to “learn coping strategies” and to “better understand” themselves. However, when asked to choose, the vast majority (91%) preferred to better understand themselves and to address the root causes of problems. In addition, most people recognized that therapy takes more time than is often offered in time limited treatments. This is consistent with large surveys of patients that indicated that it took over 50 sessions before significant symptom relief was achieved. It is time for insurance providers, clinicians, and training programs to begin to take stock of client preferences when paying for, providing, and training for psychotherapy.
Patient Experience of Lasting Negative Effects of Psychotherapy

McQuaid, A., Sanatinia, R., Farquharson, L. et al. (2021). Patient experience of lasting negative effects of psychological interventions for anxiety and depression in secondary mental health care services: A national cross-sectional study. BMC Psychiatry, 21, 578. https://doi.org/10.1186/s12888-021-03588-2

One in six adults experience either depression or anxiety that affect their social functioning or quality of life. Most treatment guidelines indicate psychotherapy as a first line treatment for these common mental health problems because of the positive effects of therapy documented by research. Despite the effectiveness of psychotherapies, researchers pay little attention to potential negative impacts of psychological treatments. Negative effects might include worsening of symptoms, emergence of new symptoms, loss of self-esteem, among others. National surveys in the U.K. noted that 5% of patients reported lasting negative effects from psychological treatment. People who had preferences for therapy that were not met tended to have more negative effects, and service policy constraints may also influence patients’ experiences of negative effects. In this analysis of national survey data, McQuaid and colleagues considered all patients who completed therapy during a one-year period in the National Health Service (NHS) in the U.K. These patients received treatment in a secondary care service – that is, a service for those with moderate to severe symptoms. The survey asked whether patients experienced lasting “bad” effects from the treatment, and the authors assessed several service policies and procedures as correlates of these negative experiences. Of those patients who received service, 662 (14.8%) responded to the survey. Overall, 14.1% reported “agreeing” that they experienced a lasting bad effect, and another 13.7% reported a “neutral” response to this item. The likelihood of reporting a neutral or lasting negative effect was greater among those who felt that they did not receive timely therapy (they waited too long, or it was too difficult to access services), who did not receive enough sessions of treatment (most of the therapy in the NHS is short-term), and whose therapists did not discuss the patient’s progress in therapy.

Practice Implications

This study is not perfect by any means, but it does highlight system and service issues that may result in worsening of symptoms among patients, especially those with moderate to severe symptoms. Remaining on a wait list for too long may lead to worsening symptoms – which indicates that it might be best for some patients to be referred elsewhere if it is feasible. Not providing a sufficient dose of therapy (enough sessions) may also lead patient symptoms to be worse at the end of treatment. The disappointment and frustration associated with ending therapy too early may impact patients’ self-esteem, mood, and hopes for recovery. Clinicians might consider how much therapy they can offer before proceeding with someone who has moderate to severe symptoms. Finally, therapists should have regular discussions with patients about their progress and perhaps use progress monitoring as a tool to facilitate these discussions.
Is CBT the Gold Standard for Psychotherapy?

Leichsenring, F. & Steinert, C. (2017). Is CBT the gold standard for psychotherapy? The need for plurality in treatment and research. JAMA, 318(14), 1323–1324. doi:10.1001/jama.2017.13737

Mental disorders are common in the population and are associated with significant impairment and economic costs. For many mental disorders, psychotherapy is considered as a first line treatment, and 75% of patients prefer psychotherapy to medications. For the past few decades CBT has been considered by some as the gold standard of the psychotherapeutic treatments, and this claim is based primarily on interpretations of the research evidence. The phrase “gold standard” implies a few things: that the evidence for the treatment’s efficacy is undisputable, and that the therapy is the most effective treatment available. In this viewpoint article, Leichsenring and Steinert raise concerns about the evidence for these claims about CBT. First, the quality of the evidence is quite low (based on ratings of randomization procedures, blind assessments, sufficient sample sizes). Only 17% of randomized controlled trials of CBT were considered high quality (83% were of low or moderate quality), and researchers have long known that lower quality studies inflate effect sizes. That is, the effects of CBT may be over-estimated, especially in the lower quality studies conducted in the early years of psychotherapy research. Second, there is evidence that researcher allegiance (the researcher’s belief in the superiority of the treatment) also inflates the effects of CBT. In some studies, for example, the therapy compared to CBT was designed to fail which made CBT look relatively more effective. Third, the true efficacy of CBT may be smaller than previously believed. Compared to treatment as usual (clinical management or medication reviews), the true effects of CBT may be small and yet inflated because of researcher allegiance. Publication bias (the tendency for researchers not to publish negative or neutral findings) may further diminish the perceived efficacy of CBT. Finally, there is no clear evidence that CBT is more effective than other psychotherapies for anxiety and depressive disorders. This has been a consistent finding over multiple meta-analyses published over the past 50 years.

Practice Implications

The research evidence does not support the claim that CBT is the “gold standard” (most effective) therapy for mental disorders. CBT is beneficial for some patients, but so are other bona fide therapies. CBT is the most studied therapy, but quantity of research does not translate into quality. Prematurely claiming that one therapy is the gold standard closes many doors for patients, clinicians, researchers, and trainees. Outcomes for patients need to be substantially improved perhaps by providing patients and clinicians with more options. Researchers should broaden their agendas to study what are the common therapeutic elements of psychotherapy. And trainees deserve more than a uniform approach to understanding the people they will treat.

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