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 who is most responsible for the effects of the alliance, quality of life outcomes for psychological treatment of persistent depression, and cognitive behvaviour therapy for 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 2022
The Efficacy of Group Therapy
Burlingame, G.M. & Strauss, B. (2021). Efficacy of small group treatments: Foundations for evidence-based practice. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7th ed.). Wiley. Chapter 17.
Group therapy involves one or more therapists treating more than two individuals together in a group setting. Ideally, group therapy not only includes specific individualized interventions of a theoretical orientation (cognitive restructuring, behavioral activation, transference interpretations) but also makes use of group-specific factors known to predict patient outcomes (development of group cohesion, social learning, peer feedback). In this chapter, Burlingame and Strauss report on the efficacy of group therapy for a number of disorders and relative to individual therapy. In a meta-analysis of 68 studies for a variety of disorders and different theoretical orientations, there was no difference between individual therapy and group therapy in terms of primary symptom outcomes (g = -0.03). One of the challenges of practicing group therapy is that some patients and providers might perceive group therapy as less effective or less desirable than individual therapy. However, meta-analyses of patient acceptance of treatment (percent of patients assigned to group or individual therapy and who follow through with treatment) or of patient drop out after starting treatment shows no difference between individual and group therapy. Regarding outcomes for specific disorders, over 11 meta-analyses have been published in the past decade as part of an international effort to document the effects of group therapy. For major depressive disorder, group therapy was more effective than treatment as usual (g = 0.69) and as effective as pharmacotherapy (g = 0.08). Group therapy was more effective than no treatment for social anxiety disorder (g = 0.84), panic disorder (g = 1.08), OCD (g = 0.97), eating disorders (g = 0.79), substance use disorder (g = 0.28), and PTSD (g = 0.70). For all these disorders, group therapy was as effective as another active treatment to which it was compared (individual therapy or pharmacotherapy).
Practice Implications
Patients and practitioners may have concerns about group therapy (that it is not private, that the time is divided among several patients, that outcomes may not be as good as individual therapy). Clinicians are advised to take these concerns seriously and to respond to them with an explanation based on the research – that is, that group therapy: is as effective as individual therapy, is probably more cost efficient than individual therapy, and is as well tolerated as individual therapy. Many group therapists use pre-group preparation of patients to help them understand the utility of group therapy. Referral sources may need to be educated about the accumulating research on the efficacy of group therapy. This seems particularly important as clinics, hospitals, private practices, and community agencies grapple with fewer resources to provide adequate care. Group therapy, when done well by clinicians who are adequately trained in group interventions may be a means of increasing accessibility to care for many.
June 2022
Therapist Facilitative Interpersonal Skills
Wampold, B. & Owen, J. (2021). Therapist effects: History, methods, magnitude, and characteristics of effective therapists. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7th ed.). Wiley. Chapter 9.
Is therapist interpersonal skill a therapeutic “competence”? Past research on this important topic has been hampered by a couple of methodological challenges. First, asking therapists to self-report on their own social skills and empathy may result in a self-serving bias and is not related to patient outcomes. A second challenge is that therapists’ competence may be influenced by patient characteristics. For example, a therapist seeing an angry patient with low motivation to change might appear less competent than the same therapist seeing an agreeable patient who is highly motivated. Until recently these issues have limited the research on therapist characteristics that indicate therapeutic competence. In this part of the chapter, Wampold and Owen review some of the research that overcomes this limitation. Some researchers conducted a series of studies in which therapists watched videos of standardized patients with different characteristics, and the therapists’ responses to the videos were recorded. In this way, all therapists “saw” the same patients. Therapists’ responses to the videos were coded for facilitative interpersonal skills; that is, for therapist verbal fluency, hope, emotional expression, warmth, empathy, and alliance capacity. In one study, therapist facilitative interpersonal skills assessed with these standardized patient videos predicted outcomes of real patients seen by the therapists in their practices. In another study, student therapists completed the therapist facilitative interpersonal skills assessment at the very beginning of their training. These facilitative skills predicted outcomes obtained when the trainees began seeing patients later in their training. In an interpersonally challenging situation, like some therapeutic encounters where affect is strong, the interpersonal skills of therapists were robust predictors of patient outcome.
Practice Implications
The research showing that therapist interpersonal skills predict patient outcomes is beginning to redefine what it means to be a competent therapist. Research reviewed elsewhere in this blog indicated that adhering to a treatment manual or protocol is not related to patient outcomes. Instead, therapists’ capacity to use verbal skills to express emotions, to be empathic, to develop a therapeutic alliance with a variety of patients, and to repair therapeutic alliance ruptures appear to be much more reliable predictors of patient outcomes. Training programs and professional development should focus on these important skills.
Research on Clinical Supervision
Knox, S. & Hill, C.E. (2021). Training and supervision in psychotherapy: What we know and where we need to go. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7th ed.). Wiley. Chapter 10.
Supervision is a key aspect of training to be a mental health professional. There is also a gate-keeping role in that supervisors evaluate whether trainees are sufficiently competent to graduate and to seek credentialing or licensure. Most clinical supervision is either individual in nature (one supervisor and one trainee) but some training programs also employ a group supervision format. Despite a long history of supervision as a key training modality in psychotherapy, the research is surprisingly sparse and inconclusive about the utility of supervision. In this part of the chapter, Knox and Hill review some of the research on clinical supervision. The findings suggest that some supervisors are better at establishing a supervisory alliance with trainees than other supervisors. Supervisor traits that facilitate a supervisory alliance and other positive outcomes (supervisee satisfaction, insight, growth, increased confidence, enhanced work with clients; stronger supervision relationship) included supervisor openness, credibility, and capacity to maintain appropriate boundaries. Supervisor empathy, engaging in reflective practice, and attending to parallel process in supervision were associated with supervisee satisfaction, increased supervisee self-disclosure, reduced supervisee anxiety, and improved supervisee work with clients. On the other hand, supervisors’ errors in technique (minimal input in supervision, gender discrimination, nonadherence to ethical guidelines) were linked with supervisee discouragement, negative emotions, reduced involvement and satisfaction, and weaker supervisory alliances. Finally, a strong supervisory alliance (i.e., agreement on training goals, agreement on tasks of supervision, and the supervisory relational bond) is associated with reduced supervisee anxiety, increased supervisee self-disclosure and self-efficacy. Despite the positive effects on the trainee’s sense of competence, comfort, and self-efficacy, there is little research linking supervision to better patient outcomes.
Practice Implications
The research suggests that the quality of the supervisory relationship has an impact on the supervisee and on the supervision process. Supervisors who are open, engaging, warm and empathic are more likely to engage supervisees to be self-disclosing and self-reflective in their work. Supervisors should focus on developing a solid supervisory alliance by establishing supervision goals (a collaborative agreement between supervisee and supervisor on the desired outcomes of the supervision), the tasks of supervision (how the supervision will proceed, what will be discussed or learned), and to help the trainee to experience supervision as a safe environment to explore new ways of being with their clients.
The Evidence for Psychodynamic Therapy
Barber, J., Muran, J.C., McCarthy, K., Keefe, J.R., & Zilchamano, S. (2021). Research on dynamic therapies. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7th ed.). Wiley. Chapter 12.
One of the persistent myths about psychotherapy is that among treatments that are meant to be effective, some treatments are more effective than others. There are complex historical reasons for such claims, but one therapy that has been most negatively affected by this narrative in psychodynamic therapy. Once a prominent treatment model up to the 1970s, psychodynamic therapy has fallen out of favor among some researchers and is sometimes disparaged as having no evidence base to support its efficacy. In this part of the chapter, Barber and colleagues review the research on the efficacy for psychodynamic therapy for a variety disorders. At the time of writing the chapter, the authors identified 245 randomized controlled trials of psychodynamic therapy. Randomized controlled trials are considered by some as representing the highest quality evidence for interventions. In a number of meta analyses, psychodynamic therapies have demonstrated efficacy compared to control groups in the treatment of mood, anxiety, personality, and somatic disorders, with effects lasting into posttreatment follow-up. In the treatment of suicidality and self-harm, psychodynamic therapies are more effective than control treatments, such as treatment as usual, routine psychiatric care, enhanced usual care, placebo, or any other comparison, including with a different psychological therapy. Long-term psychodynamic therapies for complex or chronic disorders (e.g., borderline personality disorder; treatment-resistant depression) outperformed active and inactive controls. A meta-analysis assessing statistical equivalence in trials comparing psychodynamic therapies to other gold-standard treatments found no evidence that other treatments were more effective. In treatment of unipolar mood disorders, adding short-term psychodynamic therapy to psychopharmacology improved depression symptoms over medications alone (g = 0.26 at termination; g = 0.50 at follow-up).
Practice Implications
Some who practice psychodynamic therapy may feel that the research has been stacked against this treatment modality. And while the narrative is certainly one sided, the evidence is not. Psychodynamic therapy has a robust evidence base for a variety of disorders for which it was tested. Meta analyses consistently demonstrate psychodynamic therapy is as effective as other so called gold standard treatments and provides added value to the treatment of depression over and above medications alone.
May 2022
The Therapist Effect: Or Does the Therapist Matter?
Wampold, B. & Owen, J. (2021). Therapist effects: History, methods, magnitude, and characteristics of effective therapists. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7th ed.). Wiley. Chapter 9.
The early days of psychotherapy research treated psychotherapists in a clinical trial as largely interchangeable. That is, it was assumed that therapists were more alike than different and so their impact to patient outcomes were ignored. Some of this was thought to be achieved by training therapists to be highly adherent to a treatment protocol. The thinking was that if every therapist followed the manual faithfully, then any differences among therapists would disappear. Never mind that research indicates that therapist adherence to or competence in delivering a manualized treatment is largely unrelated to patient outcomes. In this part of the chapter, Wampold and Owen examine the question of “does the therapist matter to the patient’s outcomes.” In other words, are there differences between therapists when it comes to patient outcomes? It turns out that between 3% and 15% of patient outcomes in highly controlled randomized trials is attributable to differences between therapists. This might seem like a small percentage, but it is larger than outcomes associated with differences between treatment orientations or the effects of specific interventions. And these are highly controlled trials partly designed to reduce therapist differences. In everyday clinical practice in which there is less control over therapists, the lowest estimate of therapist effects is about 6% but could be as high as 12%. The effect of the therapist is probably higher for more severely symptomatic patients.
Practice Implications
Which therapist a patient sees matters, and this is particularly true for patients who have more severe symptoms. That is more severe patients may do much worse or much better in therapy depending on which therapist they see. A therapist’s capacity to follow a treatment manual does not predict patient outcomes, but other factors like interpersonal skills, openness to lifelong learning, and getting reliable feedback about patient outcomes may be those skills and practices that matter to patient outcomes.
Interpersonal Complementarity: Therapist Responsiveness to Patient Interpersonal Behaviors
Constantino, M.J., Boswell, J.F., & Coyne, A.E. (2021). Patient, therapist, and relational factors. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7th ed.). Wiley. Chapter 7.
Interpersonal behaviors can be characterized by the level of affiliation (i.e., friendliness vs hostility) and of interdependence (i.e., dominance vs submissiveness). Interpersonal complementarity refers to two people in an interaction whose behaviors are matched on affiliation (friendliness evokes friendliness in the other) and reciprocity in terms of interdependence (dominance evokes submission or submission evokes dominance in the other). So friendly-dominant behaviors in one person tends to evoke friendly-submissive behavior in another and vice versa, and similarly, hostile-dominant behaviors in one person tend to evoke hostile-submission in the other and vice versa. Complementary interactions are comfortable and do not cause anxiety, they reinforce the interactional styles of the participants, and they tend to continue unchanged. Non-complementary interactions do cause anxiety, and they either change or they terminate. In this part of the chapter, Constantino and colleagues review the research on the role of complementarity between therapists and patients. Therapists on average tend to behave in a friendly-dominant style and many but not all patients tend to respond in a friendly-submissive style. The most interesting findings of this line of research is that the number of complementarity interactions between therapists and patients tend to change across stages of successful therapy. In early sessions, patient-therapist interactions tend to be highly complementary. Interactions in the middle of therapy tend to be lower in complementarity. And at the end of therapy, patients and therapists tend to return to higher levels of complementarity. Hostile therapist interactions are rare, and when they occur it is almost exclusively in unsuccessful therapy cases.
Practice Implications
This research has a lot to say about how therapists should respond to patients’ interpersonal behaviors and styles. Therapists should always remain affiliative or friendly (or at least neutral) and avoid hostile interactions with patients. The research indicates even a small number of hostile responses from therapists may lead to negative outcomes or dropping out. The research seems to indicate that (a) higher therapist-patient interpersonal complementarity early in therapy is related to establishing rapport and a therapeutic alliance, (b) lower complementarity in the mid stage of therapy might indicate that therapists are engaging patients differently in order to help change patient patterns of interpersonal relating, and (c) a return to higher complementarity at the end of therapy may indicate therapists reinforcing changes and patients experiencing a new sense of self within the therapeutic relationship.