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 variables leading to poor outcomes, aspects of the therapeutic relationship and outcomes, and psychological therapies and patient quality of life.
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
November 2014
Managing Countertransference: Meta-analytic Evidence
Hayes, J.A., Gelso, C.J., & Hummel, A.M. (2011). Managing countertransference. Psychotherapy, 48, 88-97.
This is another in a series of meta-analyses on relationship factors that work in psychotherapy that appeared also in John Norcross’ book Psychotherapy Relationships That Work. As I mentioned in previous blogs, meta-analyses represent the state of the art in systematically reviewing a research literature. In meta-analyses, the effect sizes from many studies are aggregated into an estimate of an overall effect that is much more reliable than any single study. In these meta-analyses, Hayes and colleagues assessed whether therapist countertransference had a negative effect on patient outcomes, and whether successful management of countertransference is related to better therapy outcomes. Traditionally, countertransference was seen as solely related to therapist unconscious conflicts, and countertransference was to be avoided. Broader conceptualizations view countertransference as representing all of the therapist’s reactions to the client. More interpersonal or relational models view countertransference as therapist reactions that complement a patient’s ways of relating, or see countertransference as mutually constructed by therapist and patient, so that the needs and conflicts of both patient and therapist contribute to the manifestation of countertransference in therapy. Hayes and colleagues argue that the definition of countertransference must include some aspect of therapist unresolved conflicts, and that countertransference in the therapist is potentially useful to understanding patient dynamics and personality style. Countertransference may be reflected in therapist anger, boredom, anxiety, despair, arousal, etc. These feelings range in intensity as well. According to Hayes and colleagues, successful management of countertransference might involve: self-insight (therapist being aware of their own feelings, attitudes, personality, etc.); self integration (therapist’s healthy character structure); anxiety management (therapist’s ability to control and understand own anxiety); empathy (the ability to put one’s self in the other’s shoes in order to focus on the client’s needs); and conceptualizing ability (therapist’s ability to draw on theory to understand the patient’s role in the therapeutic relationship). Hayes’ and colleagues meta-analyses included between 7 to 11 studies of 478 to 1065 participants. The findings showed that countertransference in the therapist was associated with negative patient outcomes, though the effect was small. Successful management of countertransference was associated with better therapy outcomes, and the effect was large.
Practice Implications
Successful management of countertransference is a characteristic of effective therapists. Therapists can work on a number of issues to reduce the negative impact of countertransference and to increase its utility in helping to understand certain patients. Therapists can work to gain self-understanding and work on their own psychological health. The research suggests the importance of therapists resolving their own major conflicts through personal therapy and clinical supervision. Having a good grasp of psychological theory and theories of therapy can also help with using countertransference effectively, as long as the theory is not used defensively by the therapist. Further, there is value in therapists admitting mistakes and acknowledging that their own conflict was the source of the error. Although countertransference theory and research focuses on the therapist, Hayes and colleagues acknowledge that some clients evoke greater and more intense countertransference reactions that others.
October 2014
Are Humanistic-Experiential Therapies Effective? Review and Meta-Analyses
Elliott, R.E., Greenberg, L.S., Watson, J. Timulak, L., & Briere, E. (2013). Research on humanistic-experiential psychotherapies. In M.E. Lambert (Ed.), Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change, 6th Edition (pp. 495-538). New York: Wiley.
Humanistic or experiential psychotherapies (HEP) include: person centred therapy, gestalt therapy, emotion-focused therapy, existential psychotherapy, and others. Elliott and colleagues argue that each of these approaches share the characteristic of valuing the centrality of an empathic and therapeutic relationship. That is, an authentic relationship between patient and therapist provides the client with a new and emotionally validating experience. HEP methods that deepen client emotional experiences occur within an empathic relationship, and interpersonal safety is key to enhancing a client’s attention for self awareness and exploration. Despite the long history of research in HEP, these treatments are often used as “control” conditions in outcome studies of psychotherapies – that is, to control for “non-specific” or relationship factors. Elliott and colleagues conducted meta analyses on the effectiveness of humanistic-experiential therapies. Overall, they included 199 studies of over 14,000 patients. Pre to post treatment effect sizes were large (d = .95), indicating a positive effect HEP across a wide range of clients. (A note on effect sizes: Cohen’s d < .20 represents a negligible effect; d = .20 to .49 is a small effect; d = .50 to .79 is a moderate effect; and d > .80 is a large effect). Compared to a wait-list control (62 studies), the positive effect of HEP was significant with a moderate effect size for the difference (d = .76). There were 135 studies that compared HEP to other active forms of psychotherapy. The difference between HEP and non-HEP therapies were trivial and non significant (d = .01). In the 76 studies that compared HEP to cognitive behavioral therapy (CBT), those who received CBT had better outcomes, but the effects were negligible (d = .13). The authors reported that there is enough evidence to indicate that HEP are efficacious for depressive disorders, substance misuse, and relationship problems; and HEP are probably efficacious for anxiety and psychotic disorders.
Practice Implications
The research on outcomes of humanistic-existential psychotherapies (HEP) provides support for the effectiveness of these therapies for a variety of disorders, and provides further support for the importance of the facilitative and relationship factors that help patients get better. Empathy, genuineness, positive regard each comes with research support to indicate their importance to patient outcomes. Elliot and colleagues conclude that the education of psychotherapists is incomplete without greater emphasis on HEP and its facilitative components.
Psychological Interventions for Post Traumatic Stress Disorder
Gerger, H., Munder, T., Gemperli, E., Nuesch, E., Trelle, S., Juni, P., & Barth, J. (2014). Integrating fragmented evidence by network meta-analysis. Relative effectiveness of psychological interventions for adults with post-traumatic stress disorder. Psychological Medicine, doi:10.1017/S0033291714000853.
Gerger and colleagues conducted a network meta-analysis to summarize the evidence on the effectiveness of psychological interventions for post-traumatic stress disorder (PTSD). Psychological trauma is common in the population (between 40% and 90% lifetime prevalence), and many people develop symptoms following the trauma that may turn into PTSD. For example people may re-experience the traumatic event, avoid stimuli related to the traumatic event, or experience increased arousal. Even those who do not meet DSM-IV criteria for PTSD may still have severe impairment and chronic symptoms. Specific interventions for PTSD include exposure to trauma related stimuli or working through cognitions related to the trauma. Non-specific interventions might include supportive therapy or relaxation treatments. As I mentioned in previous blogs, meta-analyses are the best way to summarize the evidence of existing research in order to make clinical decisions about practice. Meta-analyses allow us to pool the effect sizes from individual studies of many patients into an average effect. This method provides the most reliable estimates of the effects of treatments – no single study can be as reliable. Network meta-analysis is a relatively new method that not only allows one to accumulate results from trials that directly compare the same two treatments, but it also allows indirect comparisons of a treatment and another treatment that was tested in a different study. In their network meta-analysis, Gerger and colleagues included 66 studies representing 4,196 patients. Specific treatments included cognitive behavioral therapies (CBT), eye movement disensitization and reprocessing (EMDR), and exposure based therapy (ET). Non-specific interventions included stress management (SM) and supportive therapy (ST). The positive effect of specific interventions (CBT, EMDR, and ET) compared to a wait-list control was large. The positive effect of non-specific interventions (SM, ST) compared to a wait-list control was moderate. There were no differences in effectiveness among the psychological interventions, except EMDR outperformed ST. However, this difference disappeared when only the large scale trials were considered (results from large scale trials tend to be more reliable). Patients with a formal diagnosis of PTSD appear to benefit more from psychological interventions than those with sub-clinical PTSD, though both groups improved.
Practice Implications
Different specific interventions for PTSD (CBT, EMDR, ET) appear to have similar positive benefits with large effects. Indirect interventions show moderately positive effects. Supportive therapy (ST) may be beneficial, but the authors indicated that it is too early to conclude that ST is as effective as direct specific interventions. All patients benefit from psychological interventions, though those with more severe symptoms stand to gain the most. Given the similar outcomes of interventions and the number of effective interventions, researchers are now arguing that factors such as access, acceptability, and patient preference should influence the choice of treatment.
Client Preferences Affect Satisfaction, Completion, and Outcome
Lindheim, O., Bennett, C.B., Trentacosta, C.J., & McLear, C. (2014). Client preferences affect treatment satisfaction, completion, and clinical outcome: A meta-analysis. Clinical Psychology Review, 34, 506-517.
Giving clients a choice about treatments or to receive their preferred treatment might improve treatment outcomes. Preference usually means clients passively receiving the treatment they prefer. Choice involves clients actively making a decision about which treatment option to receive. Clients may also make informed or uninformed preferences and choices. Informed preferences and choices refer to providing clients with information or education about treatment options. Having a choice or getting one’s preference between two or more efficacious treatments might have several beneficial effects. For example, some research shows that treatment preferences positively affect therapeutic alliance, possibly because clients may enter treatment with a more positive outlook about what intervention they receive. Patients receiving a preferred treatment may also have better overall communication with their providers which may lead to better outcomes. In their meta-analysis, Lindheim and colleagues were interested in the effects of client preference or choice on treatment satisfaction, completion, and clinical outcomes. The meta-analysis included 34 different studies. Client preference or choice of treatment was modestly but significantly and consistently related to satisfaction, completion rates, and to client outcomes. Clients who were involved in shared decision making, who chose a treatment condition, or who received their preference had higher satisfaction, increased completion rates, and better clinical outcomes compared to clients who were not involved in the decision, who did not choose, or who did not receive their preference. Setting (inpatient vs outpatient) or diagnosis did not have an effect on these findings.
Practice Implications
The findings highlight the clinical benefits of assessing client preferences and providing treatment options when two or more efficacious options are available. Increasingly, two or more efficacious options are available for common mental disorders like depression and anxiety. Many times, patients prefer psychotherapy over medications, for example. However, whereas medication prescriptions for mental disorders like depression rose dramatically in the past decades, rates of psychotherapy use remained stable or slightly declined. For those disorders for which two or more treatment options have comparable efficacy, client preference should be the deciding factor.
September 2014
The Effect of Therapist Empathy on Client Outcomes
Elliott, R., Bohart, A. C., Watson, J. C., & Greenberg, L. S. (2011). Empathy. Psychotherapy, 48(1), 43.
There has been a recent upsurge in interest in empathy in psychotherapy following scientific studies in the field of social neuroscience. This research has focused on activation in areas of the brain associated with emotional stimulation, perspective taking, and emotion regulation. Conceptualizations of the role of empathy in psychotherapy have a rich history in both client-centered and psychodynamic traditions. Carl Rogers defined empathy in part as “...the therapist’s sensitive ability and willingness to understand the client...from the client’s point of view.” Elliott and colleagues indicate three main modes of expressing therapeutic empathy: empathic rapport (compassionate understanding of the client’s experience); communicative attunement (ongoing effort to stay attuned with the client’s experience); and person empathy (experience-near understanding of the client’s world). In this meta-analysis of research on therapeutic empathy, Elliott and colleagues were interested in the strength of the relationship between therapist empathy and client outcome, and factors that might determine this relationship. Their meta analysis included 57 different studies of 3,599 clients. The relationship between therapist empathy and client outcome was medium-sized (r = .31), and in the same order of magnitude as the alliance-outcome relationship. There were no differences between theoretical orientations in the size of the empathy-outcome relationship – in other words, empathy was equally important across types of therapy. Client measures of therapist empathy had the largest relationship to client outcome, whereas therapist ratings of empathy had the smallest association with client outcomes. In other words, if you are interested in therapist empathy, best to ask the client. Also, the empathy-outcome relationship was larger for less experienced (vs more experienced) therapists and for more severely (vs less severely) distressed clients. That is, empathy likely is most important for newer therapists and more distressed clients.
Practice Implications
Therapist empathy is essential to any psychotherapy regardless of orientation. Empathic attunement and expression is particularly important for clients of newer therapists, and for more distressed clients. Elliott and colleagues suggest that the empathic therapist’s primary goal is to understand the client’s experience and to communicate this understanding to the client. This can be done through: empathic affirmations (i.e., validating the client’s perspective); empathic evocations (bringing the client’s experience to life with rich, evocative, and concrete language); and empathic conjectures (making explicit what is implicit in the client’s narrative). Empathy can deepen client’s experiences, but therapeutic empathy also involves individualizing responses to the client. For example, some fragile patients may find typical expressions of empathy as too intrusive, whereas other clients may find therapeutic empathy to be too directive or too foreign. Being attuned to the client’s receptiveness to empathy is an important therapeutic skill. Elliott and colleagues emphasize that empathy should be grounded in authentic caring for the client and as part of a healthy therapeutic relationship.
Long-Term Effects of Psychotherapy for Depression
Steinert, C., Hofmann, M., Kruse, J., & Leichsenring, F. (2014). Relapse rates after psychotherapy for depression - stable long term effects? A meta-analysis. Journal of Affective Disorders, http://dx.doi.org/10.1016/j.jad.2014.06.043
As I reported in the June 2014 Blog depression is the most highly prevalent of the mental disorders with a lifetime prevalence of about 16%. It is responsible for enormous personal and economic burden for individuals and their families. Depression can occur as a single episode, however recurrence of depressive episodes can range from about 35% to 85% of those who were depressed. About 10% of cases experience chronic depression. Studies report that chronic or severe depression result in a lower response to interventions, including psychotherapy. Meta analytic research shows that a number of psychotherapeutic interventions are equally effective for treating depression (see also the July 2014 Blog). However, all of these meta analytic reviews of the effects of psychotherapy for depression referred to studies demonstrating short or medium term effectiveness. There are very few studies that report long term effectiveness of any type of treatment (psychological or pharmacological) for depression. This is a problem given the fluctuating and sometimes chronic course of the disorder. Randomized controlled trials of psychotherapy are expensive and time consuming, and collecting follow up data is difficult. And so it is not surprising that few studies assess outcomes after one or two years post treatment. Steinert and colleagues conducted a meta analysis looking specifically at studies that documented long term (i.e., greater than 2 years) post psychotherapy outcomes for depression. (A note on meta analyses: Meta analyses are a set of procedures that allow one to statistically combine the effects of many studies in order to estimate the average effect across many studies and participants. Meta analyses produce much more reliable results than any single study can produce, and so meta analyses are the best way of summarizing research to affect practice). Steinert and colleagues found 11 studies of 966 patients that reported outcomes beyond 2 years post psychotherapy. Six of the studies compared psychotherapy to another intervention (e.g., medications, treatment as usual, clinical management). The authors found that 40% of patients treated with psychotherapy had at least one relapse in a follow up period averaging about 4 years. Compared to non-psychotherapy interventions psychotherapy had a significantly lower likelihood of experiencing a relapse. Despite the positive long term outcomes of psychotherapy for depression, the authors noted that there was a great deal of inconsistency across studies (i.e., hetereogeneity), which lowers ones confidence in the reliability of these findings.
Practice Implications
There are very few studies of long term (> 2 years post treatment) outcomes of psychotherapy for depression. In the June and August PPRNet Blogs, I reported on large scale worldwide reviews that indicate how pervasive depression can be, and how detrimental depression is to health and well being. Depression can be recurrent and chronic for some, so demonstrating long term outcomes is important. On the positive side, psychotherapy results in 60% of individuals not experiencing relapses 4 years post treatment, and psychotherapy resulted better long term outcomes than non-psychotherapy interventions. However, having so few studies that assess long term outcomes reduces our confidence in these findings. A number of psychotherapies including cognitive behavioral therapies, psychodynamic therapy, interpersonal psychotherapy, and others are effective for treating depression.