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 psychotherapies for borderline personality disorder, reliability of research on CBT plus ERP for Obsessive-Compulsive Disorder, and hope and expectancy factors.
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
Are Humanistic Psychotherapies Effective?
Elliot, R., Watson, J., Timulak, L., & Sharbanee, J. (2021). Research on humanistic-experiential psychotherapies: Updated review. In Barkham, W., Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield's Handbook of Psychotherapy and Behavior Change (7th ed.). Wiley. Chapter 13.
Humanistic or experiential psychotherapies have a long history going back to the work of Carl Rogers and Fritz Pearls in the 1960s. This is a broad umbrella of therapies that include person-centred therapy, gestalt, emotion-focused, psychodrama, and existential therapies. Most of these therapies see the therapeutic relationship as central and curative. The therapist tries to enter the client’s subjective world with empathy to understand the client’s experience and to provide a validating and corrective emotional experience. The goals of humanistic-experiential therapy include self-awareness, personal growth, and meaning-making in clients’ lives. In this chapter, Elliott and colleagues review and update the meta-analytic evidence for the effectiveness and efficacy of humanistic-experiential therapy. The uncontrolled pre- to post-treatment change from receiving humanistic-experiential therapy estimated from 97 studies was .86 (k = 94; 95% CI [.74, .97]), representing a large effect. Clients maintained their immediate post-treatment gains during the year following therapy (ESw = .88; k = 41; 95% CI [.67, 1.1]) and beyond (ESw = .92; k = 15; 95% CI [.52, 1.31]). Compared to no-treatment control groups in 15 randomized studies, humanistic-experiential therapy showed a large pre-post effect ESwc= .98 (95% CI [.55, 1.20]). Compared to all other therapies in 56 randomized trials, humanistic-experiential therapy produced equivalent outcomes, (ESwc = –.07; 95% CI [–.21, .07]). The outcomes compared specifically to CBT in which only bona-fide humanistic-experiential therapies were included (i.e., only studies in which the humanistic-experiential therapies were meant to be effective) also indicated a non-significant difference, (ES = –.15; k = 9; 95% CI [–.27, .03]).
Practice Implications
Dating back to the work of Carl Rogers, humanistic-experiential therapies have had an important impact on how many types of therapy is offered today. The emphasis of many therapies on empathy, the therapeutic relationship, and corrective emotional experience are hallmarks of humanistic-experiential therapies. The results of these updated meta-analyses indicate that humanistic-experiential therapies are effective in the short and longer term and are as effective as other forms of well-research psychotherapies.
April 2022
Countertransference and its Management
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.
Countertransference is one of the oldest concepts in psychotherapy dating back more than 100 years. More recently, some writers view countertransference as a pantheoretical concept, in other words it affects all therapists and occurring in all therapies. One definition of countertransference is that it is the “internal and external reactions in which unresolved conflicts of the therapist, usually but not always unconscious, are implicated”. Countertransference may provide important information about a patient’s interpersonal patterns, but it may also be an impediment to the therapist’s effectiveness. One prominent model of countertransference identifies its component parts to include: origins within the therapist (i.e., unresolved issues within the therapist that may interact with patient qualities); triggers caused by the patient’s transference (i.e., patient maladaptive interpersonal patterns) and other patient behaviors that may interact with the therapist’s unresolved issues; manifestations – or how the countertransference affects the therapist’s behaviors and responses toward the patient; the effects of these behaviors on the therapeutic relationship or the patient; and the therapist’s management of countertransference responses – or what the therapist does to maintain an equilibrium. In this part of the chapter, Constantino and colleagues review two meta-analyses of the impact of countertransference and its management on the patient. A meta-analysis of 14 studies indicated a small but significant correlation between therapist countertransference and poor patient outcomes (r = -0.16), and a second meta-analysis of 9 studies indicated a moderate and significant association between successful countertransference management and patient improvement (r = 0.39).
Practice Implications
Despite countertransference being a well-established topic in psychotherapy, the research is relatively new. The findings suggest that regardless of what type of therapy is practiced, therapists should be mindful of their countertransference reactions. It is important for therapists to monitor their internal mental and emotional states during a therapy session, and to note when they feel something that is not typical for them (bored, annoyed, attracted, overwhelmed, disgusted, distracted). A therapist’s management of these feelings may include remaining calm in the moment, self-reflection about the origins and triggers of their reactions, seeking consultation with a trusted colleague, and personal therapy to work on unresolved issue
Therapist Flexibility and Responsiveness
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.
One of the most intriguing findings from psychotherapy research is that adherence or competence to manual-prescribed techniques has almost no impact on patient mental health outcomes. That means that efforts to get therapists to follow a manual has no bearing on whether their patients get better. In fact, there is sufficient research to suggest that rigid adherence to a treatment model may be harmful to patients. Research suggests that purposefully moving away from protocols at times in therapy can be more validating, collaborative, and autonomy granting that sticking with the protocol. Thus, the over-zealous delivery of a treatment, despite good intentions, can be ineffective or harmful to patients. Some of the specific research in this area found that the patients of therapists who varied in their use of theory-prescribed interventions had better outcomes. Similarly, when psychodynamic therapists integrated cognitive and behavioral interventions, patients had better outcomes than when the therapists were less flexible. A similar concept to flexibility is therapist responsiveness, or their ability to respond to the specific therapeutic context. This might include therapists’ ability to develop a case formulation specific to the patient, and flexibly tailoring their interventions to that formulation. Therapist responsiveness and tailoring interventions to the patient may result in better outcomes.
Practice Implications
That the level of adherence to treatment manuals bears no relation to patient outcomes speaks to the speaks to problems associated with persistent and rigid adherence. Rigidity in applying a treatment model may lead to negative processes in therapy and poor patient outcomes. It is important for therapists to be responsive and attuned to their patients’ needs, progress, and treatment goals. That is, it likely more important to tailor treatment to the patient and their characteristics rather than trying to get the patient to adapt to the treatment.
March 2022
Patient Expectations and Preferences
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.
In this chapter, Constantino and colleagues review the effects of patient expectations of benefit and patient preferences for treatment. Patient outcome expectations is broadly related to the placebo effect. That is, there is a commonly known positive effect when patients expect that a treatment will help them get better. This effect occurs across all psychotherapies and is also seen in medical and pharmacological interventions. A meta-analysis of almost 13,00 patients in 81 studies found a small to moderate relationship (r = .18) between patient expectations of positive outcomes and the extent to which they improved. There is also evidence that outcome expectations improve the therapeutic alliance. The more optimistic patients are about getting better, the more they are likely to engage in a collaborative working relationship with their therapist. A related line of research addresses patient preferences for treatment. This refers to what is done in therapy, the characteristics of the therapist, and the length of therapy among others. Preferences can be grouped into three categories: activity preferences are the patient's desire for the psychotherapy to include specific therapist behaviors or interventions; treatment preferences are the patient's desire for a specific type of intervention to be used, such as psychotherapy vs. medication, or CBT vs. person-centered therapy; and therapist preferences are the patient's desire to work with a therapist who possesses specific characteristics (e.g., a certain gender, race, or interpersonal style). In a meta-analysis of 28 studies, patients who received their preferences were 1.79 times less likely to drop out of therapy compared to those who did not get their preference. The effect on patient outcomes were statistically significant but small (d = .28). The beneficial effect of preferences was stronger for those with anxiety or depressive disorders.
Practice Implications
Patients who have higher expectations of getting better are on their way to feeling remoralized, they are more likely to engage in a therapeutic relationship, and they are more likely to be collaborative in the therapy. Therapists can improve patient expectations by providing patients with a clear rationale for the interventions, a realistic sense of how long therapy will take, and a non-technical summary of the research evidence for the therapy they are providing. Patients who get what they prefer in a therapy or therapist also may experience better outcomes, especially if they have an anxiety or depressive disorder. Listening to what patients expect and want from therapy may help therapists to tailor the treatment to the patient’s wishes. Providing patients with more than one treatment option when possible may be one means of meeting patient expectations.
February 2022
What Have We Learned from Practice-Research Networks?
Castonguay, L.G., Barkham, M., Youn, S.J., & Page, A. (2021). Practice-based evidence: Findings from routine clinical settings. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7th ed.). Wiley. Chapter 6.
Practice-based evidence refers to research that is conducted as part of routine clinical practice. Often these studies do not impose strict research conditions like randomization of patients, and so they produce findings that are more relevant to psychotherapy as practiced real-world. In studies from practice-research networks, clinicians are often involved in the design and implementation of the study. Our Psychotherapy Practice-Research Network (PPRNet) is an example of a collaboration between researchers and clinicians to produce practice-based evidence. In a large survey, we found that most clinicians regardless of theoretical orientation wanted more research on the therapeutic relationship and on professional development. And so PPRNet developed a research program on training psychotherapists to identify and repair therapeutic alliance ruptures and microaggressions. In this chapter, Castonguay and colleagues review some of the key findings from practice research networks. First, White patients report better outcomes than Black patients in routine care, and these differences were linked back to the clinicians. That is, therapists varied in their effectiveness with racial and ethnic minority patients. Second, patients benefit when clinicians monitor the therapeutic alliance and outcomes on a session-to-session basis using reliable and valid measures. Noticing when a patient’s ratings of the alliance decline from one session to the next, might indicate a problem in the therapeutic relationship. Third, when monitoring the alliance, therapists should also rate the alliance. If a therapist’s ratings of the alliance are higher than their patients, then this may be a sign that the therapist is not paying attention to problems in the alliance. Fourth, developing and maintaining a strong therapeutic alliance likely will improve patient outcomes. Fifth, a reliable and valid assessment of client’s past and current interpersonal difficulties is likely to improve a therapist’s treatment plan for that patient.
Practice Implications
Doing research in clinical practices is not as well controlled as clinical trials research. But practice-based evidence is more relevant to how psychotherapy is done in the real world with real patients. The research is not so clear about why some therapists are more effective with racial and ethnic minority (REM) patients. However, complementary research suggests that some therapists who have a previously high level of multicultural orientation (cultural humility, open to conversations about culture, and cultural comfort) are more effective with REM patients. Also monitoring the therapeutic alliance with a valid scale on a session-to-session basis leads to better outcomes. Such monitoring will alert the therapist to resolve an alliance rupture if a patient’s ratings decrease from one session to the next. If therapists also rate the alliance and find that their scores are higher than their patient’s, then this may alert the therapist to a potential problem. Finally, knowing if a patient has current and past interpersonal problems can inform a therapist to focus on how those problems affect current symptoms and to talk about how those problems manifest themselves in the therapeutic relationship.
January 2022
How Much Therapy is Necessary?
Barkham, M. & Lambert, M.J. (2021). The efficacy and effectiveness of psychological therapies. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7th ed.). Wiley. Chapter 5.
For decades now, researchers have been trying to address the question of how many sessions of therapy is optimal for the average patient. In this part of the chapter, Barkham and Lambert review some of the research related to the question: how much therapy is necessary? Early research noted that it took about 13 sessions for 50% of patients to achieve clinically significant change, and 50 sessions was necessary for 75% of patients to achieve significant change. In other words, the number of sessions need to be doubled for another 25% of patients to improve. (Of note, half of patients did not improve after 13 sessions). Such research suggests a dose-response relationship, such that more therapy sessions result in more patients getting better – but the rate of return slows considerably with more sessions. The problem with this approach to estimating how many sessions are necessary is that it assumes that all patients improve at a consistent rate across sessions, but that may not be the case. Other researchers suggest that patient rate of change is individual, and that when a patient achieves a good enough level of change, they will terminate therapy. The research area is complicated by several factors. First, much of the research was conducted in university counselling centers with therapists in training, student patients, and bounded by the semester system. So, by definition, the therapy is time-limited and patients may be homogenous with regard to symptom severity. Second, some of the data in meta-analyses come from randomized controlled trials that by necessity represent brief treatments. Third, different modes of delivery in different countries appear to have an impact on how many sessions are delivered and what kind of therapy is offered. Fourth, patient severity at baseline may be related to longer treatments and slower rates of change.
Practice Implications
Although the dose-response research has been used in some settings to arbitrarily select treatment length offered to all patients, the results of this research may not be reliable. Predetermined fixed treatment lengths are likely not appropriate for patients. For example, greater patient severity at the start of treatment, and comorbidity and complexity of problems will likely result in such patients requiring a higher number of treatment sessions. A one-size-fits-all approach to determining how many sessions are offered to patients will likely negatively affect the most vulnerable of patients.