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 therapist empathy, psychotherapeutic treatment for borderline personality disorder, and research on psychological treatment of depression.
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
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.
June 2023
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.
May 2023
Do Clinicians Agree on Transtheoretical Principles of Change?
Twomey, C., O’Reilly, G., & Goldfried, M. R. (2023, April 20). Consensus on the perceived presence of transtheoretical principles of change in routine psychotherapy practice: A survey of clinicians and researchers. Psychotherapy. Advance online publication. https://dx.doi.org/10.1037/pst0000489
Way back in 1982 Marvin Goldfried hypothesized that there were five transtheoretical principles of change that are part of every method of effective psychotherapies. However, for several decades since Goldfield’s hypothesis, the emphasis in training and research of psychotherapy has been on specific techniques and schools of psychotherapy. Despite the proliferation of therapy schools (there are now more than 500!), there is no evidence that any one bona fide therapeutic orientation is more effective than others, and patient outcomes over the decades have not improved. Recently, there has been a resurgence of interest in transtheoretical principles of change that might move the science and practice psychotherapy forward. Goldfried’s five transtheoretical principles are those strategies common to all theoretical orientations of therapy that since then have received substantial research support. First, fostering the patient’s hope, positive expectations, and motivation has been associated with positive outcomes in psychotherapy. Second, facilitating the therapeutic alliance is associated with positive outcomes, and unresolved alliance ruptures are associated with negative outcomes. Third, increasing patients’ insight is moderately associated with treatment outcomes across orientations. Fourth, encouraging patients to engage in corrective experiences is consistent with the importance of gradual exposure to feared situations and feelings. And fifth, ongoing reality testing corresponds to the long-established finding that adaptive behaviors can be strengthened through repetition and reinforcement. In this large survey of 1198 psychotherapists and researchers, Twomey and colleagues were interested to see if there was a consensus among psychotherapists on these five principles. Consensus was defined as survey respondents indicating that they agreed or strongly agreed that each principle was present in their own approach to psychotherapy. Ninety-three percent of respondents practiced psychotherapy, their average age in years was 50, 51% were women, 62% were psychologists, and they represented a wide range of theoretical orientations. Strong consensus (i.e., on average they strongly agreed) was found for the first three principles: fostering patients’ hope and expectations, facilitating a therapeutic alliance, and increasing patients’ insight. Good consensus (i.e., on average they agreed) was found for encouraging patients to engage in corrective experiences, and ongoing reality testing. There were no differences or associations noted with any of the demographic variables (age, profession, years of practice) nor for theoretical orientation.
Practice Implications
The results suggested that while some research continues to emphasize techniques specific to orientations of therapy, most clinicians agree on important principles of change that cut across orientations. These principles indicate that psychotherapists should (1) increase positive expectations by preparing patients for what will happen in therapy (duration, method, goals) and explaining why certain aspects of therapy are important, (2) foster the alliance by encouraging ongoing collaboration regarding the goals and methods of therapy, (3) encourage insight by collaboratively developing a case formulation that brings relevant issues into greater awareness for the patient, (4) provide patients with corrective experiences by encouraging exposure to difficult situations, interpersonal challenges, and working through alliance ruptures, and (5) help patients to be aware of and repeat corrective experiences over time as a means of fostering reality testing.
Multiple Microaggressions and Therapy Outcomes
DeBlaere, C., Zelaya, D. G., Dean, J.-A. B., Chadwick, C. N., Davis, D. E., Hook, J. N., & Owen, J. (2023). Multiple microaggressions and therapy outcomes: The indirect effects of cultural humility and working alliance with Black, Indigenous, women of color clients. Professional Psychology: Research and Practice, 54(2), 115–124. https://doi.org/10.1037/pro0000497
Many Black, Indigenous, Women of Color (BIWOC) underutilize mental health care partly because of lack of culturally competent care, and the anticipation of bias and discrimination often experienced by Black, Indigenous, People of Color (BIPOC). One way that such bias and discrimination is expressed in a therapy context is through racial microaggressions which are subtle, intentional, or unintentional messages that degrade BIPOC. Another way that bias and discrimination is expressed is through gender microaggressions which are intentional or unintentional behaviors that exclude, demean, oppress, or express indifference towards women. Research indicates that up to 89% of BIPOC clients and 53% of women experienced a microaggression from their therapist. Both racial and gender microaggressions committed by therapists are related to poorer therapeutic alliance and client outcomes. One might also consider BIWOC clients to be doubly susceptible to microaggressions due the intersecting nature of their identities as a person of color and as a woman. One way to limit the effects of microaggressions is for therapists to take a stance of cultural humility and to foster a therapeutic alliance. Cultural humility refers to a therapist’s way of being with a client that values the importance of culture in the client’s experience. In this study by DeBlaere and colleagues, the authors surveyed 288 BIWOC clients who were currently or recently in psychotherapy to assess the association between microaggressions and outcomes, and whether cultural humility and a therapeutic alliance might reduce the impact of microaggressions. The clients saw a female therapist 81% of the time and a White therapist 46% of the time. DeBlaere and colleagues found that 89% of the sample reported at least one instance of a racial microaggression by their therapist, and 43% reported some form of gender microaggression. White and male therapists were more likely to commit these microaggressions. The most common racial microaggression involved therapists avoiding discussing or addressing cultural issues, and the most common gender microaggression involved therapists encouraging female clients to be less assertive so that the client might not appear aggressive. Racial and gender microaggressions were both negatively related to therapy outcomes. The authors also found that cultural humility and therapeutic alliance both mediated and helped to explain the effects of microaggressions on outcomes. That is, the negative effects of a racial or gender microaggression on outcomes were reduced when the client experienced the therapist as having a higher level of cultural humility, which then led to a stronger therapeutic alliance, that in turn led to a better outcome.
Practice Implications
This study points to the potential of therapist cultural humility and their capacity to maintain a therapeutic alliance as key to reducing the impact of racial and gender microaggressions on client outcomes. The findings reinforce the importance of therapists examining their own cultural biases and making discussions of culture and racism explicit in therapy. This is especially important for White male therapists. Such a process might cultivate cultural humility in the therapist that will mitigate the negative impact of a microaggression should it occur.
Interpretations and Outcomes: A Systematic Review
Zilcha-Mano, S., Fisher, H., Dolev-Amit, T., Keefe, J. R., & Barber, J. P. (2023). A systematic review of the association between interpretations and immediate, intermediate, and distal outcomes. Psychotherapy. Advance online publication. https://doi.org/10.1037/pst0000479
Interpretation is a therapeutic technique that refers to a psychotherapist who recognizes and seeks to raise the patient’s awareness and understanding of recurrent maladaptive patterns. An interpretation goes beyond what the patient says or recognizes consciously and gives a new meaning or explanation for behaviours, thoughts, or feelings so that the patient sees their problems in a new way. In other words, the effect of an interpretation is to raise a patient’s insight into their problems. Interpretation is a transtheoretical technique, although it is often associated with psychodynamic therapies. Some interpretations are interpersonal in nature (focused on maladaptive relationship patterns inside and outside of the therapeutic relationship), and some are intrapersonal in nature (e.g., focused on the conflict between ones wishes/desires and how one ideally sees oneself). In this systematic review of the research on interpretation, Zilcha-Mano and colleagues included 18 studies that tested the association between interpretation and outcomes. Previous reviews found a mixed association between interpretation and outcomes possibly because of the different methods of assessing interpretation and different way of conceptualizing outcomes. What is unique about this review is that it categorized outcomes as immediate (e.g., in-session alliance, disclosure, emotional expression), intermediate (e.g., next-session alliance strength, session depth), and distal (e.g., change in symptoms from pre- to post-treatment). Since there were so few studies in each of these outcome categories (6 studies of immediate, 4 studies of intermediate, and 12 studies of distal outcomes), the authors did not conduct a meta-analysis, but rather counted studies that supported or did not support the use of interpretation for each of these categories of outcomes. For immediate outcomes, half of the studies reported a positive association with interpretation (whereas half of studies showed a neutral or negative association). That is, on average patients in those studies tended to react positively to therapist interpretations during the session with increased therapeutic alliance or emotional processing. For intermediate outcomes, half the studies reported a positive association with interpretation (as opposed to neutral or negative association). That is, on average the results suggested that interpretation in in a previous session was associated with patients experiencing a better alliance and session depth in the subsequent session. For distal outcomes, there was mixed evidence with most studies reporting a neutral effect of interpretation on pre- to post-symptom change.
Practice Implications
It is challenging to draw explicit practice implications from a research area that is complex and not yet large enough to allow for a meta-analysis. However, using a mixture of these research findings and clinical experience, Zilcha-Mano and colleagues suggest some therapeutic practices that may be helpful. They suggest, for example that therapists (1) observe the immediate and intermediate outcomes of an interpretation (i.e., does the patient rejected it or does it deepen the therapeutic work?), (2) check with patients about how they feel about the interpretation, (3) prioritize accurate and experience-near interpretation (those that the patient can immediately recognize and understand), (4) monitor the strength of the alliance before, during, and after an interpretation, (5) consider that an interpretation may be more beneficial for patients with poorer quality of relationships and self-concepts than for those with better relationship and self-functioning, and (6) be aware that interpretations may not be beneficial and could be harmful if delivered at the wrong time or if not attuned to the patient’s needs and capacities
April 2023
More Treatment But No Less Depression
Ormel, J., Hollon, S.D., Kessler, R.C., Cuijpers, P., & Monroe, S.M. (2022). More treatment but no less depression: The treatment-prevalence paradox. Clinical Psychology Review, 91, 102111.
It is widely believed that treatments for major depression (psychotherapy and antidepressant medications) have improved patients’ symptoms since the 1980s. Mental health expenditures and access to treatment for major depressive disorder (depression) have also increased during that time, especially for antidepressant medications. However, we have not witnessed a reduction in the population prevalence (proportion of people who experienced a condition during their lifetime) or incidence (proportion of people who currently have the condition) of depression. How can it be that we perceive treatments to be more effective and available but rates of depression in the population have not budged? In this comprehensive conceptual analysis with a review of the evidence, Ormel and colleagues examined possible reasons for what they describe as the treatment-prevalence paradox. First, one could argue that prevalence and incidence rates are inflated due to a recent greater recognition and acceptance of depression in society. If that’s the case, then any reduction in prevalence or incidence caused by new treatments may be offset by more people coming forward and admitting to having depression. However, epidemiological studies are conducted by trained interviewers using standardized diagnostic criteria, which should reduce any inflation caused by spurious reporting. In fact, large epidemiological studies do not show an increase in incidence of depression over time, so that incidence in the U.S. remains approximately 1.5% and worldwide prevalence remains about 4.7%. Second, it is possible that randomized controlled trials might over-estimate the efficacy of psychotherapy or medication for depression. Thus, even if these treatments are more available, they may not impact population prevalence or incidence rates because they are not as effective as we once thought. The authors found that meta-analyses that adjusted for publication bias (the tendency of researchers or industry not to publish negative findings or to put a positive spin on such findings) reported treatment efficacy to be modest. That is, only about 30% of patients recover from depression following psychotherapy or medications. Third, it is also possible that the actual efficacy of psychotherapy or medications to prevent relapse or recurrence in the longer term is too small to reduce population prevalence or incidence of depression. That seems to be the case. Even if 30% of patients respond initially to treatments like CBT or medications, about half of these initial responders relapse at 1- or two-years post treatment. And many of those who do not relapse still struggle with residual symptoms.
Practice Implications
The authors concluded that even though access to psychotherapy or medications have increased and the treatments supposedly have become better over the decades, therapies have not moved the needle on population prevalence or incidence of depression. Clinicians might consider talking to patients honestly about the efficacy of the treatments they are offering without unnecessarily demoralizing patients. That is, treatments considered to be the “gold standard” by researchers and practice guidelines are only modestly effective. When a patient does not benefit from “gold standard” treatments, it should be considered a failure of the treatment and not a function of “patient non-responsiveness”. It is also quite likely that brief