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.

November 2018

Adapting Therapy to Each Client: Becoming an Evidence-Based Therapist I

Norcross, J.C. & Wampold, B.E. (2018). A new therapy for each patient: Evidence‐based relationships and responsiveness. Journal of Clinical Psychology, Online First, DOI: 10.1002/jclp.22678

Over the next several months, I will review in this blog results of a number of meta-analyses conducted recently on patient factors and relationship factors in psychotherapy. These factors provide evidence-based guidance to psychotherapists on how best to relate to and adapt to clients so that psychotherapy is more effective. This introductory article by Norcross and Wampold is an overview of the nine meta analyses related to transdiagnostic client factors to which therapists can adapt their interpersonal stances and treatment. The goal is to enhance treatment effectiveness by therapists tailoring therapy to individual client characteristics that are related to outcomes. Decades of research indicate that client transdiagnostic characteristics have more influence on outcomes than the particular treatment method, and likely more influence than the particular client diagnosis. The research indicates that giving the identical treatment to every client without adaptation to client characteristics is not an effective approach to providing psychotherapy. These meta analyses of client factors indicate that therapists should select different interventions and relational stances according to the client and the context. What are these client characteristics and therapist adaptations that are reliably related to outcomes? The client factors most strongly related to outcomes include therapist adaptations to: client culture/race/ethnicity (99 studies, g = .50); client preferences for type of therapy (51 studies, g = .28), client religion/spirituality (97 studies, g = .13 to .43), client stage of change (76 studies, g = .41), client reactance/resistance level (13 studies, g = .78), client coping style (32 studies, g = .53), and client attachment style (32 studies, g = .35). Over the next months, I will be reviewing in more detail these meta analyses of client factors and the practice implications of each so that therapists can use this evidence-base to help them to adapt to particular client characteristics.

Practice Implications

Practitioners will find that fitting the therapy to clients’ culture, stage of change, religion/spirituality, reactance/resistance, coping style, and attachment style will improve treatment outcomes. Doing so will have a greater impact on outcomes than the particular type of therapy provided or adapting treatment to the particular client diagnosis. The results of this large body of evidence suggests that therapists should no longer ask: “what is my theoretical orientation” but rather they should ask: “what relationship, adaptation, and approach will be most effective with this particular client”.
Psychotherapy Relationships That Work: Becoming an Evidence-Based Therapist II

Norcross, J. C., & Lambert, M. J. (2018). Psychotherapy relationships that work III. Psychotherapy, 55(4), 303-315.

Relationship factors in psychotherapy are some of the most important predictors of patient outcomes. They outweigh factors like the type of therapy provided in determining whether patients get better after psychotherapy. In this second overview article, Norcross and Lambert provide a review of 17 meta-analyses of relationship factors in psychotherapy that contribute to positive outcomes. Like the review of patient factors also found in this blog and E-Newsletter, this article briefly outlines those evidence-based relationship factors that reliably predict patient outcomes in psychotherapy. The therapeutic relationship refers to how the therapist and patient relate to each other, or their interpersonal behaviors. By contrast, techniques or interventions refer to what is done by the therapist. Practice guidelines typically focus on interventions or therapeutic orientation. As the authors argue, what is missing from treatment guidelines are the person of the therapist and the therapeutic relationship – evidence for which is backed up by 5 decades of research. Even in studies of highly structured manualized psychotherapy for a specific disorder in which efforts were made to reduce the effect of individual therapist, up to 18% of outcomes (a moderate to large effect) could be attributed to the person of the therapist. By contrast somewhere between 0% and 10% of outcomes (a small to moderate effect) is attributable to specific treatment methods. So, which therapeutic relationship factors are reliably related to patient outcomes? These include: the therapeutic alliance in individual therapy (306 studies, g = .57) couple therapy (40 studies, g = .62), and adolescent psychotherapy (43 studies, g = .40), collaboration (53 studies, g = .61) and goal consensus (54 studies, g = .49), cohesion in group therapy (55 studies, g = .56), therapist empathy (82 studies, g = .58), collecting and delivering client feedback or progress monitoring (24 studies, g = .14 to .49), managing countertransference (9 studies, g = .84), and repairing therapeutic alliance ruptures (11 studies, g = .62) among others. Over the next few months, I will be reviewing these meta analyses in more detail to discuss how therapists can use this evidence base to improve their patients’ outcomes.

Practice Implications

The research as a whole indicates that therapists should make the creation and cultivation of the therapeutic relationship a primary goal of therapy. Factors such as managing the therapeutic alliance, repairing alliance ruptures, engaging in ongoing progress monitoring, managing countertransference and others should be used to modify treatments and interpersonal stances in order to maximize outcomes. When seeking out professional development and training, practitioners should focus on evidence-based relationship factors (managing the alliance, judicious self disclosure, managing emotional expression, promoting credibility of the treatment, collecting formal feedback, managing countertransference) in addition to focusing on evidence-based treatments.
Adult Attachment as a Predictor of Psychotherapy Outcomes: A Meta Analysis

Levy, K.N., Kivity, Y., Johnson, B.N., & Gooch, C.V. (2018). Adult attachment as a predictor and moderator of psychotherapy outcome: A meta‐analysis. Journal of Clinical Psychology. Online first publication, DOI: 10.1002/jclp.22685.

Adult attachment refers to characteristic ways people manage their emotions and relationship styles. Securely attached individuals adaptively and flexibly experience emotions and they are able to give and receive love and support to others. Insecure attachment can be sub-categorized as avoidant or anxious attachment. Those who are anxiously attached tend to up-regulate their feelings so that they may feel easily overwhelmed, and they tend to be preoccupied with relationship loss. Those with avoidant attachment styles tend to down-regulate their emotions so that they have difficulty experiencing or expressing feelings, and they might dismiss the importance of relationships as a means of protecting themselves. John Bowlby, the founder of attachment theory, argued that psychotherapy had the potential to serve as a secure base from which individuals might explore themselves and relationships. He also described the therapist as a temporary attachment figure with which the patient might develop an emotional bond to promote change and for a corrective experience. In this meta-analysis, Levy and colleagues looked at whether attachment dimensions can change in psychotherapy and whether they can predict improvement in patient symptoms pre- to post-therapy. (A note on meta analysis. It is a method of systematically reviewing a research literature, combining the effect sizes in that literature, and summarizing these effects. Because meta analyses usually contain many studies, their results are much more reliable than the results of any single study, and so they provide the most solid basis for making practice recommendations). In this meta analysis, Levy and colleagues included 36 studies, totaling 3,158 clients. Higher client attachment security (or lower attachment insecurity) at the start of therapy was associated with better outcomes by post-treatment (r = 0.17, p < 0.001, 95% CI = [0.13, 0.22], k = 32). Also, greater improvement in attachment security (change in attachment security from pre- to post-treatment) predicted better outcomes (r = 0.16, p < 0.001, 95% CI = [0.07, 0.25], k = 15). When looked at separately, higher levels of either attachment anxiety or attachment avoidance were associated with poorer outcomes, and change in either type of attachment insecurity was associated with better outcomes. These effects appeared to be consistent regardless of the type of therapy (non-interpersonal vs interpersonal therapies).

Practice Implications

Although attachment insecurity is associated with poorer outcomes, change in attachment insecurity is possible with psychotherapy and this change is associated with better symptom outcomes. Therapists should expect longer and more challenging treatment with patients who are anxiously attached. Anxiously attached individuals may appear engaged early in therapy, but they are quick to anger, feel rejected, and become overwhelmed. Such individuals may benefit from help to contain their emotional experiences by repeating the treatment frame and increasing structure. They may also benefit from interpersonally-oriented therapy focused on reducing their preoccupation with relationship loss. Avoidantly attached individuals may appear aloof, but they may be easily overwhelmed by demands for closeness. Therapists may have to carefully balance the amount of interpersonal space or demands in treatment with these clients so that they remain in therapy.

October 2018

Super-shrinks and Pseudo-shrinks: Therapists Differ in Their Outcomes

Okiishi, J., Lambert, M. J., Nielsen, S. L., & Ogles, B. M. (2003). Waiting for supershrink: An empirical analysis of therapist effects. Clinical Psychology & Psychotherapy, 10(6), 361-373.

Much of psychotherapy research has focused on searching for effective psychotherapies rather than focusing on effective psychotherapists. Research on psychotherapies generally assumes that therapists are equally effective or relatively less important to patient outcomes than the interventions themselves. Therapists in clinical trials are trained to follow a manual in an attempt to reduce the therapists’ impact on patient outcomes, and to focus the study on the specific ingredients of the therapy itself. However, research indicates that the degree to which a therapist follows a manual has little bearing on patient outcomes, and that therapists do differ in terms of their patients’ outcomes. In one large study, between 33% and 65% of therapists was ineffective or harmful. Okiishi and colleagues asked if it is possible to identify highly effective therapists (“super-shrinks”) and highly ineffective therapists (“pseudo-shrinks”) based on their patients’ outcomes. The therapists were 56 men and women who treated 1779 clients in a university counselling centre. Each therapist saw at least 15 clients, so that there was a good sampling of therapists’ outcomes across a variety of clients. Therapists had a range of experience, training, and theoretical orientations. Clients were adults who had moderate to severe problems with anxiety, depression, or adjustment. Outcomes were measured after every session, and the average number of sessions was 5.16 (SD = 7.20). On average clients improved so that their level of distress significantly declined. Therapist characteristics (sex, experience, training background, theoretical orientation) did not predict patient outcomes. However, client change varied significantly, so that some clients improved at a faster rate than others, some did not change, and some got worse. There were no differences between therapists in their clients’ level of distress, so therapists had equivalent caseloads in terms of client initial distress. However, therapists significantly differed from each other in terms of their clients’ outcomes. For example, the top 3 therapists consistently had clients who got better (super-shrinks), and the bottom 3 therapists consistently had clients who got worse (pseudo-shrinks).

Practice Implications

One would hope that a loved one would get to see a “super-shrink” therapist, since these therapists seem to consistently have clients who do well in therapy. But what about the average or “pseudo-shrink” therapist– what can be done to elevate their skills and their patients’ outcomes? We’ve discussed in this blog several things therapists can do to improve their outcomes, including: using progress monitoring in their practice, receiving training focused on deliberate practice, and seeking out specific continuing education around developing, maintaining, and repairing the therapeutic alliance.
Patients’ Experiences With Routine Outcome Monitoring

Solstad, S.M., Castonguay, L.G., & Moltu, C. (2018). Patients’ experiences with routine outcome monitoring and clinical feedback systems: A systematic review and synthesis of qualitative empirical literature. Psychotherapy Research. doi=10.1080/10503307.2017.1326645.

Routine outcome monitoring or progress monitoring involves assessing client outcomes or the therapeutic alliance on a weekly basis in psychotherapy, and then giving feedback to the therapist about how the client is doing relative to the previous week and relative to similar clients. Research on progress monitoring indicates that it improves outcomes and it reduces by half the number of clients who might get worse. Despite its benefits, many therapists are not aware of progress monitoring or are reluctant to use the procedure. Some have expressed concerns that progress monitoring could interfere with the therapeutic relationship. However, very few studies have asked clients about their experiences of progress monitoring. In this synthesis of qualitative studies, Solstad and colleagues reviewed 16 studies in which clients were interviewed about their experiences of progress monitoring. The authors used a procedure in which they identified common themes across the studies and categorized client statements within those themes (e.g., thematic analysis). The authors were interested in identifying what were the hindering and helpful processes in clients’ experiences of their therapists’ use of progress monitoring. Four main themes emerged from the research. First, some clients voiced suspicion of how the progress monitoring data was going to be used and why the procedure was implemented. That is, clients sometimes felt that filling out questionnaires weekly was mainly a bureaucratic exercise, or possibly a means to justify reducing services. Second, some clients felt the questionnaires were not flexible enough to capture the complexity of mental health and of client concerns. The questionnaires often focused on symptoms, but clients were also interested in the therapeutic relationship, family, and social functioning. Third, some clients wanted to be more fully informed about the rationale for progress monitoring so that they could feel more empowered to define their own outcomes and treatment plans. Fourth, some clients found progress monitoring to help them to see graphically their own progress, to become more engaged in treatment planning, and to participate in collaborative and reflective discussions with their therapist.

Practice Implications

If psychotherapists choose to use progress monitoring in their practices, they should make sure that clients know what the data will be used for and that the exercise is not just a bureaucratic process. The practice of outcome or progress monitoring can be used to stimulate reflection not only in the therapist but also in the client. Reviewing the client data together might enhance conversations about therapy, the therapeutic relationship, and help to establish realistic goals for therapy. Therapists might consider not only measuring symptom progress repeatedly, but also measuring the working alliance on a regular basis.
Psychotherapy for Eating Disorders

Grenon, R., Carlucci, S., Brugnera, A., Schwartze, D., … Tasca, G. A. (2018). Psychotherapy for eating disorders: A meta-analysis of direct comparisons, Psychotherapy Research, DOI: 10.1080/10503307.2018.1489162

Eating disorders can cause a great deal of physical and mental impairment because of the severity of the symptoms and because of comorbid conditions like depression, anxiety, substance use, and others. Anorexia nervosa (AN) occurs in about 0.5% of the population, bulimia nervosa (BN) occurs in about 1.5% of the population, and binge-eating disorder (BED) occurs in about 3.5% of the population. Treatment guidelines include both cognitive behavioral therapy (CBT) and interpersonal psychotherapy (IPT) as front line interventions for BN and BED. However, results from previous meta analyses of psychological treatments for eating disorders were confounded by not focusing exclusively on randomized controlled trials, mixing studies of adult and adolescent samples, combining an array of outcomes rather than separately reporting primary (eating disorder symptoms) and secondary (interpersonal problems, depression) outcomes, and not distinguishing between bona fide psychotherapies (like CBT, IPT, psychodynamic therapy, and others) from non-bona fide treatments (like self help, behavioral weight loss supportive counseling). Grenon and colleagues conducted a meta analysis of psychotherapies for eating disorders to examine if: psychotherapy is effective compared to a wait list, if bona fide psychotherapy and non-bona fide treatment differ in outcomes, and if one type of psychotherapy (i.e., CBT) was more effective than other bona fide psychotherapies (like IPT, behavior therapy, psychodynamic therapy, dialectical behavior therapy). Their meta analysis included 35 randomized controlled trials of direct comparisons. Psychotherapy was significantly more effective than a wait-list control at post treatment, so that 53.89% of patients were abstinent of symptoms after psychotherapy compared to only 8.92% who were abstinent in the wait-list group. Bona fide psychotherapies (51% abstinent) were significantly more effective than non-bona fide treatments (40% abstinent) at post treatment, and dropout in bona fide psychotherapies (17.5%) was significantly lower than in non-bona fide treatment (29.1%). Further, the difference between CBT and other bona fide psychotherapies was not significant.

Practice Implications

Psychotherapy for eating disorders are effective for patients with BN or BED. There were too few studies of those with AN to come to any conclusions about their treatment. Patients with BN or BED are best treated with a bona fide psychotherapy that involves face to face psychological therapy like CBT, IPT, psychodynamic therapy, dialectical behavior therapy, or behavior therapy. Non-bona fide treatments like self help, behavioral weight loss, and supportive counseling should only be used as an adjunct to bona fide psychotherapy for eating disorders.

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November 2018

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October 2018

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Psychotherapy Practice Research Network (PPRNet)