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.
…I blog about psychotherapy for borderline personality disorder, capacity to metnalize and therapy resistant depression, and negative effects of psychotherapy
Type of Research
- ALL Topics (clear)
- Alliance and Therapeutic Relationship
- Anxiety Disorders
- Attendance, Attrition, and Drop-Out
- Client Factors
- Client Preferences
- Cognitive Therapy (CT) and Cognitive-Behavioural Therapy (CBT)
- Combination Therapy
- Common Factors
- Depression and Depressive Symptoms
- Efficacy of Treatments
- Feedback and Progress Monitoring
- Group Psychotherapy
- Illness and Medical Comorbidities
- Interpersonal Psychotherapy (IPT)
- Long-term Outcomes
- 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
- Therapist Factors
- Transference and Countertransference
- Trauma and/or PTSD
- Treatment Length and Frequency
Psychotherapy for Those Who Do Not Respond to Treatment
Gloster, A. T., Rinner, M. T., Ioannou, M., Villanueva, J., Block, V. J., Ferrari, G., ... & Karekla, M. (2020). Treating treatment non-responders: A meta-analysis of randomized controlled psychotherapy trials. Clinical Psychology Review, 75, https://doi.org/10.1016/j.cpr.2019.101810.
Generally, there are a number of effective treatments for mental disorders including psychotherapy and medications. However, by some estimates, about 40% of patients with mood or anxiety disorders do not respond to these treatments. Research shows that patients who do not respond to initial treatments tend to have lower quality of life and higher mortality. By definition, treatment non-response indicates a failure of the treatment to achieve symptom reduction for patients. There is a research literature looking at the impact of introducing a subsequent treatment like psychotherapy for patients who do not respond to a previous treatment (most often a medication). In this meta-analysis Gloster and colleagues examined the efficacy of adding psychotherapy for patients who were not responsive to a previous treatment. They only included randomized controlled trials of patients diagnosed with mood or anxiety disorders. The authors found 18 studies of this kind that had 1734 participants. Most of the studies (80%) used medications as an initial treatment. The psychotherapies that were given to non-responders were quite varied including CBT, psychodynamic therapies, and DBT. The authors adjusted effect sizes downward for publication bias – or the estimated effects of negative studies that were not published. Even with that downward adjustment, adding psychotherapy after previous treatment non-response resulted in significant positive effect for patients in terms of reduced symptoms (SMD = 0.45; 95% CI: 0.16, 0.75). Similar findings were noted for quality of life. However, there was a lot of variability in effects across studies. Better outcomes were not associated with a particular diagnosis or treatment type. The positive effects remained significant at follow up, but they did not hold up after adjusting for publication bias (SMD = 0.359; 95% CI -0.349, 1.068, p > .05).
The findings of this meta-analysis are promising for using psychotherapy for those who do not respond to initial treatment, mostly with medication. Both symptoms and quality of life improved moderately with a second round of treatment. This is notable because treatment non-responders may experience frustration and demoralization, and these patients tend to have chronic conditions that cause significant impairment. An important caveat is that the evidence for longer term improvements may not be reliable, and so it is not clear whether the positive effects are sustained. Offering a patient a re-start of treatment may help them to establish new hope for recovery if the subsequent treatment is framed as something different from the previous interventions that did not work for them.
How Does Therapy Harm?
Curran, J., Parry, G.D., Hardy, G.E., Darling, J., Mason, A-M., Chambers, E. (2019). How Does therapy harm? A model of adverse process using task analysis in the meta-synthesis of service users’ experience. Frontiers in Psychology, 10:347. doi: 10.3389/fpsyg.2019.00347
Forty to 60% of patients do not recover after a course of psychotherapy, and approximately 5% to 8.2% are worse off. In the National Health Service in the UK, 5% of patients reported lasting bad effects of therapy. Although these appear to be small percentages, they represent a large number of patients. In Canada for example, over 1 million Canadians use psychotherapy each year, so 5% would represent 50,000 individuals. Therapists, for their part are poor at identifying patients who deteriorate in therapy. In this meta-synthesis of qualitative research, Curren and colleagues aimed to derive a model based on patients’ experiences of the factors that lead to negative outcomes. They conducted a narrative review of qualitative research findings and of patients’ testimony from a number of sources. They noted eight domains identified by patients that are associated with adverse events in psychotherapy. First, contextual factors refer organizational issues that affect access to or choice of therapy, cultural validity of the therapy, and lack of information about services. Second, pre-therapy factors refer to poor pre-therapy contracting between therapist and patient, and therapists that focus on symptoms rather than the client as a person. Third, therapist factors refer to therapist inflexibility, and therapists’ financial interests that influence their decisions about therapy. Fourth, client factors refer to client lack of understanding of therapy, fear, and demoralization. Fifth, relationship factors refer to a poor relational fit between therapist and patient, therapists perceived as shaming, therapists misusing power, and clients not feeling heard or understood. Sixth, therapist behaviors refer to boundary violations, rigidly applying techniques, therapist acting out, and therapist passivity. Seventh, therapy process refers to the type of therapy offered not matching patient needs, and patients not agreeing with the techniques. Eighth, endings refer to short term therapies that “open a can of worms” without resolution, and the client feeling abandoned.
Therapists would do well to ensure that the patient’s voice is heard when it comes to preferences and cultural validity of the treatment. In particular, therapists should not rigidly apply techniques focused exclusively on symptom reduction. Instead, therapists should see patients’ problems within their interpersonal and cultural context and focus on outcomes related to the quality of life of patients. Therapists must attend to developing and maintaining the therapeutic alliance (agreement on tasks and goals of the therapy, and the relational bond with patients). Any signs of disruptions or tensions in the alliance should be identified and repaired. Patients require information about the therapy, what it entails, and how it will end before signing on to a course of treatment. Organizations must remove barriers to accessing treatment and provide therapies that represent a range of orientations and foci to meet patients’ needs.
Therapist and Client Emotional Expression: A Meta-Analysis
Peluso, P. R., & Freund, R. R. (2018). Therapist and client emotional expression and psychotherapy outcomes: A meta-analysis. Psychotherapy, 55(4), 461–472.
Emotions and emotional experiences are key to being human, and therefore are key to psychotherapy processes and outcomes. Emotion-focused therapy, for example, emphasizing helping clients to overcome their avoidance of emotions by exploring emotions in therapy in order to achieve change. Nevertheless, many therapeutic orientations focus on emotional expression, avoidance of emotions, emotional experiences, and understanding emotions as a means of helping clients to change and to have a better existence. Therapists of all stripes tend to work at creating a therapeutic context so that patients can have a corrective emotional experience. Primary emotions are universal and include happiness, sadness, fear, surprise, disgust, and anger. Secondary emotions are influenced by context and include embarrassment, guilt, and pride. All emotions and their experiences are influenced by cultural contexts, attitudes, and rules. A key aspect of psychotherapy includes helping clients to organize or make meaning of their emotions, and such therapeutic work is associated with positive client outcomes. In this meta-analysis, Peluso and colleagues evaluated the research on therapist and client emotional expression in psychotherapy, and its relationship to client outcomes. Thirteen studies found the effects of therapists’ expression of affect during therapy on client outcomes after the end of therapy had a mean effect size of r = .28 (95% CI: .17, .35), which was statistically significant and moderately large. The 42 studies that looked at client expression of affect during therapy and how it related to client outcomes after therapy found an average effect size of r = .40 (95% CI: .32, .48), which was also statistically significant moderately large.
This meta analysis emphasizes that emotions matter in psychotherapy. The capacity of therapists to judiciously express emotions, and to help clients to experience and make meaning of their emotions is an important therapeutic skill. Therapists need to focus on and validate clients’ emotions, and therapists should encourage clients to understand and process (i.e., make meaning of) their emotions. This work must occur in the context of a safe, trusting therapeutic relationship. Meaning making and emotional resolution should be considered as key therapeutic goals for most therapies.
The Reciprocal Relationship Between the Alliance and Outcomes
Flückiger, C., Rubel, J., Del Re, A. C., Horvath, A. O., Wampold, B. E., Crits-Christoph, P., Atzil-Slonim, D., . . . Barber, J. P. (2020). The reciprocal relationship between alliance and early treatment symptoms: A two-stage individual participant data meta-analysis. Journal of Consulting and Clinical Psychology, 88(9), 829–843.
The therapeutic alliance (patient and therapist agreement on tasks and goals of therapy and their emotional bond) is the most researched concept in psychotherapy. The research clearly indicates that a positive alliance reliably predicts patient outcomes in terms of reduced symptoms. However, researchers still debate whether the alliance is at all necessary. That is, some argue that the alliance is the result of patients feeling better early in therapy, and so the alliance is only an outcome of early symptom reduction. If that is the case, then the alliance is an artifact of symptom reduction, and clinicians need not pay much attention to it. In this meta-analysis, Fluckiger and colleagues collected 17 studies representing over 5000 patients that evaluated whether alliance in a previous session predicted outcomes in a subsequent therapy session, and vice versa. In other words, they looked at all studies that evaluated if change in alliance preceded change in symptoms and if change in symptoms preceded change in the alliance. What is unique about this meta-analysis is that they gathered patient-level data from the original studies. That allowed them to test the therapeutic alliance theory for each individual patient on a session by session basis for the first 7 sessions of therapy. (For the stats geeks out there, the authors analysed within-person [between-session] effects using multilevel time-lagged models). Their analyses found that high alliance at a preceding session was related to lower symptoms at the subsequent session (B adjusted = -.065 (95% CI [-.092, -.038]; p < .0001)), and higher symptoms at the start of a session was related to lower post session alliance (B adjusted = -.148 (95% CI [-.215, -.081]; p < .0001). They also found that patients who generally reported high alliance scores showed a stronger alliance – outcome relationship, and those with greater symptoms had a weaker alliance - outcome relationship.
This meta-analysis is another indication of the importance of therapists and patients coming to a collaborative agreement on the tasks of therapy (what is done during sessions) and the goals of therapy (what issues to work on), and of their relational bond. The alliance is not always easy to establish – especially with regard to agreeing on goals. Also, the alliance should not be forgotten once established – alliance ruptures or tensions occur frequently and can have a negative effect on patients’ mental health outcomes. Patients of psychotherapists who repair alliance tensions generally have better mental health outcomes.
Why Does Where a Patient Lives Affect Their Outcomes in Psychotherapy?
Firth, N., Saxon, D., Stiles, W. B., & Barkham, M. (2019). Therapist and clinic effects in psychotherapy: A three-level model of outcome variability. Journal of Consulting and Clinical Psychology, 87(4), 345–356.
Patients vary in their outcomes from receiving psychotherapy. That is some patients receive more benefit than others or receive benefit more quickly than others. Previous research indicates that factors like higher symptom severity and socioeconomic deprivation are factors that lead to poorer outcomes. There is also evidence that some therapists are more effective than others so that 5% to 10% of patient outcomes depend on which therapist the patient sees. There is also research showing that the location of the clinic may reflect systematic differences in patient outcomes. This may be due to differences in clinic patient populations, to therapist recruiting practices, resource allocation, and accessibility. Research in population health suggest that local neighborhoods affect physical health. In this large study of over 26,000 patients receiving psychological therapy in the United Kingdom (UK) health system, Firth and colleagues estimated how much of patient outcomes were due to differences among patients, differences among therapists, and difference among clinics. Patients received person-centred, psychodynamic, cognitive-behavioral, or supportive therapies. Drop-out rates from therapy was 33%. Average age of patients was 38.4 years (SD = 12.94) and 69.3% were women. Most patients experienced anxiety (71.8%) and/or depression (54%). There were 462 therapists in the study working at 30 clinics throughout the UK. Up to 58.4% of patients who provided post-treatment data (i.e., completed therapy) showed reliable and clinically meaningful improvement, but there were large differences in patient improvement rates across the clinics (range: 23.4% to 75.2%) and across therapists (6.7% to 100%). Patient severity explained a large proportion of therapist differences. That is, whereas many therapists were effective with less severely symptomatic patients, relatively fewer therapists were effective with more severely symptomatic patients. Patient unemployment, location of the clinic in a more economically deprived area, and the proportion non-White patients in the area explained most of the differences between clinics. Patients who were employed and living in an economically advantaged neighborhood composed of mostly White residents had better outcomes.
We know from previous research that some therapists are more effective than others and these differences are more pronounced with more severely symptomatic patients. However, this study suggests that larger social factors like racism, systematic bias, and microaggressions also play a role in patient outcomes. Economic deprivation likely affects the level of funding and resources allocated to some clinics. Psychotherapists and funding sources need to take into account the broader socioeconomic, ethnic/racial, and geographic context in which the patient lives when planning and offering services to patients.
Is the Therapeutic Alliance Diminished by Videoconferencing Psychotherapy?
Norwood, C., Moghaddam, N.G., Malins, S., & Sabin-Farrell, R. (2018). Working alliance and outcome effectiveness in videoconferencing psychotherapy: A systematic review and noninferiority meta‐analysis. Clinical Psychology and Psychotherapy, 25, 797-808.
The working alliance is the collaboration between client and therapist on the tasks and goals of therapy, and it also includes the emotional bond. The alliance is the most researched concept in psychotherapy, and it is reliably related to good client outcomes. However, the alliance has been rarely studied in the context of videoconferencing psychotherapy (VCP). Delivering psychotherapy remotely was already gaining popularity prior to COVID-19 because of its potential to improve access to mental health care especially for people who live in remote areas. Some argue that face to face therapy might result in a higher therapeutic alliance because of the rich interpersonal cues, like eye contact and body posture that may facilitate collaboration and the bond. There is emerging evidence that VCP can be effective and that it may have comparable outcomes to face-to-face therapy. But what about the working alliance – does it develop in VCP similarly to face to face therapy? In this meta-analysis, Norwood and colleagues conducted a systematic review of the existing research on the working alliance in VCP. They found only 4 direct comparison randomized controlled studies on the topic, and on average VCP resulted in a lower working alliance compared to face to face therapy, but the difference was not statistically significant (n = 4; SMD = -0.30; 95% CI: -0.67, 0.07; p = 0.11). People who received treatment via VCP had similar levels of symptom reduction compared to those who received face to face therapy (n = 4; SMD = −0.03; 95% CI [−0.45, 0.40], p = 0.90).
With only four direct comparison randomized trials to draw from, the results of this meta-analysis remained ambiguous with regard to the therapeutic alliance. Although the difference between VCP and face to face therapy was not statistically significant, it was not ignorable – an effect size of SMD = -0.30 suggests a small advantage for face to face therapy when it comes to the alliance. However, symptom outcomes were comparable between face to face and VCP. The results suggest that therapists who use VCP during a pandemic, must pay particular attention to developing and maintaining a therapeutic alliance by collaboratively agreeing on goals and tasks of therapy, and by focusing on establishing an affective bond with patients despite the limited nonverbal cues available with online psychotherapy.