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
April 2018
Politics in the Therapy Room during the Trump Era
Solomonov, N. & Barber, J.P. (2018). Patients’ perspectives on political self-disclosure, the therapeutic alliance, and the infiltration of politics into the therapy room in the Trump era. Journal of Clinical Psychology, DOI: 10.1002/jclp.22609.
Most studies of psychotherapy do not take into account the current political climate, and most therapists do not think about the impact of their politics on clients. Studies have focused on the effects of large historical-political events on therapy, but mainly in terms of client reactions to the events. Such studies typically assume that therapist and client shared or agreed on perspectives of the event. However, the 2016 U.S. presidential election was extremely polarizing and may represent one of those events in which clients and therapists do not agree. What if clients and therapists disagreed about the experience of the election and its aftermath – what might be the impact on their therapeutic alliance? To what extent are polarizing politics discussed in therapy, and how are these discussions experienced by clients? Solomonov and Barber conducted a national survey among 604 psychotherapy clients from the 50 U.S. states. The mean age of the sample was 33.82 years (SD = 11.10), 57% were women, 58% were Caucasian, 48% indicated that they voted for Hilary Clinton and 32% indicated that they voted for Donald Trump. Overall, 64% of patients indicated that they had spoken about politics with the therapist (66% of Trump supporters and 70% of Clinton supporters). Among Trump supporters, 38% of clients indicated that their therapist was a Republican, whereas 35% thought their therapist was a Democrat. Among Clinton supporters, only 14% said their therapist was a Republican and 64% perceived their therapist was a Democrat. Thirty percent of clients reported that their therapist explicitly disclosed their political views, and 38% of clients reported that even though their therapist did not explicitly disclose their political views the client could easily guess the therapist’s views. Clients who believed their therapist shared their political views reported significantly higher therapeutic alliance with the therapist than those who believed their therapist did not share their views. Clients who voted for Clinton reported significant increases in expression of negative feelings from before to after the election, whereas Trump supporters did not report a significant increase in negative feelings. Neither Trump nor Clinton supporters reported an increase in positive emotions pre and post election.
Practice Implications
About two thirds of clients in the U.S. have political discussions with their therapists, and almost half wanted to talk more about politics during sessions. Even though general self-disclosure among therapists is relatively infrequent, political self-disclosure among therapists about the 2016 U.S. election seemed to occur much more frequently. It is possible that political instability and the polarizing political climate in the U.S. may contribute to more self-disclosure of a political kind among therapists. This could have an impact on therapy. Clients who perceived their therapists to share political views reported a better therapeutic alliance than those who had divergent political views from their therapist. Similarities in values between therapist and client have long been known to be associated with the therapeutic alliance. The study demonstrates that in the current political climate in the U.S., client perceptions of shared or divergent values with therapists make their way into the therapeutic space.
February 2018
Client Honesty in Psychotherapy
Love, M. & Farber, B.A. (2018). Honesty in psychotherapy: Results of an online survey comparing high vs. low self-concealers, Psychotherapy Research, DOI: 10.1080/10503307.2017.1417652.
An important task of psychotherapy is for therapists to provide a context within which clients feel comfortable disclosing difficult feelings, thoughts, and other experiences in their lives. Self-disclosure likely improves the therapeutic alliance (agreeing on tasks and goals, and an emotional bond between therapist and client), which is necessary for good outcomes. In fact, research indicates that client self-disclosure is generally associated with positive outcomes in therapy. And yet a number of surveys report that clients keep secrets or lie to their therapists. Clients appear to struggle between being honest and self-disclosing versus the fear or anxiety related to doing so. Research indicates that one can describe individuals as high self-concealers in most relationships in their lives. Such individuals consistently conceal negative aspects of themselves from others to help manage their anxiety in relationships in the short term. However, in the long term, high levels of self-concealment increases rumination and anxiety and reduces coping. In this study, Love and Farber conducted an online survey of 572 participants who were currently in therapy or were in therapy in the past year. The sample characteristics and the type of therapy they received were surprisingly similar to a nationally representative sample of clients who seek treatment, though this online survey sample was somewhat younger. Over 84% of clients in this survey reported being dishonest about at least one topic with their therapist. Most frequent topics for being dishonest included: details of sex life (33.9%), suicidal thoughts (21.9%), self-harm (14.5%), real reactions to therapist comments (18.9%), whether therapy was helping (15.7%), and family secrets (16.3%). The most predominant motive for dishonesty was embarrassment or shame (63.6%), followed by doubts that the therapist would understand (27.0%), fear of overwhelming emotions (18.1%), and disappointing or hurting the therapist (16.4%). Not surprisingly, clients who tended to conceal their experiences reported disclosing less distressful information and also reported a lower therapeutic alliance with their therapists. Almost half of high self-concealers reported that dishonesty hurt their therapeutic progress.
Practice Implications
Topics like suicidal ideation and sex are particularly difficult to speak about honestly in therapy, especially for those who are uncomfortable with disclosing in general. Most clients are willing to discuss difficult topics with therapists if the therapist inquires sensitively and directly. High self-concealers are highly attuned to how therapists might react, and these clients anticipate shame or judgement. Therapists need to monitor the state of the therapeutic relationship with each client, especially the client’s perception of therapist warmth and trustworthiness. This could include monitoring for any ruptures in the therapeutic alliance. Further, therapists may need to communicate that self-concealment serves a short term purpose to reduce anxiety, but has a long term cost in terms of amplifying distress.
November 2017
Do Psychotherapy Trainees Get Better with More Training?
Owen, J., Wampold, B. E., Kopta, M., Rousmaniere, T., & Miller, S. D. (2016). As good as it gets? Therapy outcomes of trainees over time. Journal of Counseling Psychology, 63, 12-19.
Does psychotherapy training improve trainees’ knowledge and skills? Do trainees improve in their ability to produce positive client outcomes over time? The research on training psychotherapists is mostly inconclusive. Some studies show little or no difference between trainees and experienced therapists, and others found no association between level of experience and client outcomes. On the other hand, some researchers have found a relationship between training and competence in delivering a particular type of treatment. Overall, the research seems to show that there is a lot of variability between therapists in their outcomes and on how training affects their practice and their clients’ outcomes. However, rarely do these studies assess outcomes within the same trainee over time as they accumulate more training. In this study, Owen and colleagues evaluate if psychotherapy trainees’ client outcomes improved with training over time. They assessed 114 psychology trainees at different levels of training in 47 clinics across the U.S. These training therapists saw over 1100 clients over at least a 12-month period, and many therapists were followed for three years. The average client improved, but with small effects (d = .31, CIs not reported). Therapists were more effective with clients who were more distressed (d = .66) than clients who were less distressed (d = .10), probably because more distressed clients had more room to improve. Trainees’ outcomes improved significantly over time, although their average improvement over time was small. Most importantly, trainees’ improvements over time varied so that the researchers were able to identify four patterns of change over a three year period of training: (1) one group of trainees started out with moderately good outcomes and their outcomes remained moderately good over time; (2) a second group started out with small positive effects in their client outcomes and they improved to achieve moderately good outcomes by their third year; (3) a third group of trainees started out with small positive client outcomes but their outcomes got worse by their third year; and (4) a fourth group started out with poor outcomes and improved to achieve small positive outcomes by year 3 of their training.
Practice Implications
Trainees appear to have various trajectories in their ability to foster positive client outcomes over time, and, at times, that trajectory is negative. Trainees whose outcomes get worse over time (group 3) or who do not achieve at least moderately good outcomes (group 4) may need specific training to foster better interpersonal effectiveness, empathy, management of countertransference, and humility. In general, therapists should assess their clients’ outcomes with progress monitoring tools in order to use the feedback to improve their outcomes over time. If outcomes are not positive on average, then therapists should consider remediation, further training, or consultation.
September 2017
Therapists’ Perspectives on Psychotherapy Termination
Westmacott, R. & Hunsley, J. (2017). Psychologists’ perspectives on therapy termination and the use of therapy engagement/retention strategies. Clinical Psychology and Psychotherapy, 24, 687–696.
The average psychotherapy client attends a median of about 3 to 5 sessions, which is substantially less than the number of sessions the average client needs to realize a clinically significant decline in symptoms. Premature termination (clients ending therapy unilaterally) occurs in 19% of cases in research trials and in as many as 38% of clients in community practices. And so premature termination is mental health problem for clients and an economic problem for therapists and agencies. Clients terminate therapy prematurely for a variety of reasons including: dissatisfaction with therapy or the therapist, achieving their goals, and practical barriers (appointment times, travel, cost). Therapists tend to underestimate the proportion of unilateral terminations from their practice, and underestimate negative outcomes and client negative perceptions of therapy and therapists. In this study, Westmacott and Hunsley, surveyed psychologists who provide psychotherapy (N=269) on their perspectives on their clients’ reasons for termination and the strategies they use to retain their clients in therapy. Therapists reported that 33.3% of their clients terminated prematurely, which is somewhat lower than the percentage reported in previous research. Most psychologists (65.7%) tended to attribute the most important reasons for premature termination before the third session to clients’ lack of motivation to change (rated as very important or important on a scale). A much smaller percentage (15.8%) attributed waiting too long for services as the most important reason for premature termination before session 3. The most important reason for premature termination after the third session was most often attributed to clients reaching their treatment goals (54.8%). Regarding strategies to retain clients - almost all psychologists (96.8%) indicated that they fostered a strong alliance, 74.3% indicated that they negotiated at treatment plan, 58.0% prepared clients for therapy, 38.7% used motivational enhancement strategies, 33.0% used client outcome monitoring, and 17.8% used appointment reminders.
Practice Implications
This survey of psychologists suggests that psychotherapists may somewhat underestimate the number of clients who prematurely terminate therapy. Psychotherapists may also overly attribute dropping out to client-focused factors (low motivation, achieving outcomes), rather than therapist-focused factors (dissatisfaction with therapist or therapy), setting-focused factors (negative impression of the office and staff), or practically-focused factors (appointment times, cost). Many therapists reported using alliance-building and negotiating a treatment plan to retain clients. However, few therapists used other evidence-based methods like systematic outcome monitoring, and fewer still used appointment reminders. Therapists should consider therapist-focused and setting-focused reasons for client termination, and to use outcome monitoring and appointment reminders to reduce drop-outs from their practices.
August 2017
What Characterizes Effective Therapists?
Wampold, B. E., Baldwin, S. A., Holtforth, M. G., & Imel, Z. E. (2017). What characterizes effective therapists. In L.G. Castonguay and C.E. Hill (Eds.) How and why are some therapists better than others? Understanding therapist effects. Washington, DC: American Psychological Association.
The research on therapist effects indicates that some therapists are more effective than others. Previous research showed that therapist characteristics like age, race, ethnicity, gender, and experience are not consistently related to patient outcomes. Neither is therapist competence and adherence to a treatment approach. In this chapter, Wampold and colleagues ask the question: what characterizes effective therapists? The research is complicated because it is difficult to disentangle therapist effects from patient factors. That is, it is possible that some clients (i.e., those who are more motivated, likeable, and psychologically minded) might create favorable conditions for some therapists to be more effective. However, recent advances in statistical methods have allowed researchers to isolate the effects of therapist characteristics from patient factors. Based on this new research, Wampold and colleagues identified four characteristics of effective therapists. (1) The ability to form an alliance across a range of patients. The therapeutic alliance is defined as the agreement on tasks and goals of therapy, and the affective bond between therapist and patient. Alliance is reliably associated with good patient outcomes. Research shows that therapists and not clients are primarily responsible for the alliance-outcome relationship. (2) Facilitative interpersonal skills – which includes verbal fluency, warmth, empathy, and emotional expression. These skills in a therapist are a strong predictor of patient outcomes. (3) Professional self doubt – or healthy skepticism about one’s abilities and skills leading to self-reflective practice has also been found to predict positive patient outcome. (4) Deliberate practice - defined as individualized training activities especially designed to improve specific aspects of an individual’s performance through repetition and successive refinement. The amount of time outside of therapy that therapists engage in improving targeted therapeutic skills predicted patient outcomes.
Practice Implications
Some therapists are better than others - and demographics, professional affiliation, training, and adherence to a manual do not differentiate better therapists. Four factors are emerging as indicators of better therapists. Ability to develop, maintain, and repair a therapeutic alliance is well known to predict patient outcomes and it appears that therapists are largely responsible for the condition of the alliance. Therapists’ ability to be verbal, warm, and empathic is also key to patient outcomes. Professional skepticism about one’s abilities that lead to reflective practice is also an important characteristic in order to continually improve one’s abilities and monitor one’s outcomes. And, finally therapists who spend time outside of therapy deliberately and repetitively practicing skills will achieve better patient outcomes.
April 2017
Do All Therapists Do That When Saying Goodbye?
Norcross, J.C., Zimmerman, B.E., Greenberg, R.P., & Swift, J.K. (2017). Do all therapists say that when saying goodbye? A study of commonalities in termination behaviors. Psychotherapy, 54, 66-75.
One of the things common to all psychotherapy relationships is that they come to an end. The endings may be premature or planned. They may be well managed or poorly managed. In this article by Norcross and colleagues, the authors ask: what do expert therapists typically do when there is a planned termination with a client? A planned termination is “an intentional process that occurs over time when a client has achieved most of the goals of treatment, and/or when psychotherapy must end for other reasons”. By contrast, premature termination occurs when the client ends treatment unilaterally. In successful cases the client and therapist typically predetermine the end date and have time to work toward the ending. Different theoretical orientations write about different aspects of termination. For example, from a psychodynamic perspective, therapists focus on clients’ old and new methods of coping, feelings related to the impending loss of the relationship, review gains, and work to equalize the relationship. From an experiential perspective, therapists might recognize that clients continue to change after therapy, help clients work through feelings of loss and separation of the therapeutic relationship, and consolidate new meanings. Cognitive-behavioral therapists might help clients to maintain gains made in therapy, review new skills, and prevent relapse. Do therapists who practice these and other theoretical approaches differ in terms of how they manage termination in psychotherapy? Norcross and colleagues surveyed 65 nominated experts representing six theoretical orientations of psychotherapy (psychodynamic, humanistic, CBT, interpersonal, multicultural, and integrative). Each orientation was represented by at least 10 expert therapists. The survey included 80 items related to termination that were drawn from books, chapters, and treatment manuals. The experts indicated the frequency with which they engaged in each behavior or the task related to termination. Therapist behaviors or tasks that received very strong consensus (>90% of therapists reporting “frequently” or “almost always” doing these) included: supporting the client’s progress, helping to consolidate gains made in therapy, following ethical practice (e.g., avoiding abandonment), attributing gains to the client’s effort, talking about what helped or went well, and collaborating with the client to set a date and pace of termination. Strong consensus (80% to 90% of therapists reported frequently doing these) behaviors or tasks included: focus on processing feelings around termination, having the client practice new skills, normalizing the probability of relapse, and prompting the client to think of a future without therapy. Of the 80 Items, 27 did not reach consensus among the therapists (i.e., only 21% to 59% of therapists agreed on these items). Out of the 80 items, only 8 (10% of items) showed significant differences between theoretical orientations (e.g., compared to other orientations, CBT therapists tended to do more of: preparing clients for relapse, and systematically assessing client outcomes near termination).
Practice Implications
This survey of 65 experts of varying psychotherapy orientations highlighted a wide range of commonalities in terms of how they managed termination with clients. While there was some uniqueness among orientations, most therapists tended to: process feelings about termination and the relationship with clients, discuss future functioning and coping, helped clients to use new skills, framed the client’s personal development as ongoing beyond therapy, prepared explicitly for termination, and reflected on the client’s gains.