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
December 2022
Can Psychotherapists be Trained to Maintain a Therapeutic Alliance?
Tasca, G. A., Ravitz, P., Hunter, J., Chyurlia, L., Baker, S., Balfour, L., Mcquaid, N., Pain, C., Compare, A., Brugnera, A., & Leszcz, M. (2022, November 10). Training community-based psychotherapists to maintain a therapeutic alliance: A Psychotherapy Practice Research Network study. Psychotherapy. Advance online publication.
The therapeutic alliance refers to a collaborative agreement between therapist and patient on the tasks and goals of therapy, and their relational bond. Research demonstrates that the alliance is one of the most reliable predictors of patient outcome. Much of the research on the alliance focused on asking either the patient or the therapist to rate the alliance. But the alliance is a dyadic concept, that is, it involves the shared perceptions of the therapeutic relationship by patient and therapist. More recent research has focused on patient-therapist congruence (degree of agreement or disagreement) of their perceptions of the alliance. The Psychotherapy Practice Research Network (PPRNet) recently completed a study in which community-based psychotherapists were trained to develop and maintain a therapeutic alliance. We examined if trained therapists were more congruent with their patients’ experience of the alliance than untrained therapists, and whether congruence in alliance ratings in one session of therapy was associated with better outcomes in the following session. Forty community-based psychotherapists were randomly assigned to be trained to develop and maintain the alliance or to receive no training. Patients were 117 adults who were seen in their therapists’ community-based practices. Training focused on helping therapists to understand and be responsive to their own and their patient’s mental states (intentions, feelings, thoughts) to be better attuned to their patient’s experience of the therapeutic relationship. The training included workshops and ongoing case consultations to help the clinician to strengthen the therapeutic relationship with the use of mentalizing, attachment theory, countertransference management, and metacommunication. Therapeutic alliance and well-being outcomes were measured at each of six consecutive early psychotherapy sessions. The results indicated that compared to untrained therapists, trained therapists and their patients were significantly more congruent in their alliance ratings. Patient well-being outcomes improved in a session when trained therapists and their patients agreed in their positive alliance ratings in a previous session. This association was not significant among untrained therapists and their patients.
Practice Implications
This study suggests that therapists can be trained to be more attuned to their patients’ experience of the therapeutic relationship, and that this congruence may make the alliance a more potent change agent. Training may make therapists more sensitive to their patients’ experience of the alliance across sessions. Therapists should be particularly attentive to the state of the therapeutic alliance from session to session and to track their patients’ experience of the alliance using skills like mentalizing. The PPRNet has converted this training program into a virtual self-paced platform, and we will test this new format in a study starting in 2023. We encourage community-based clinicians to receive the free training by participating in this new study. For more information about the training and new study, email pprnet@uottawa.ca.
October 2022
Therapists Report Less Therapeutic Skill in Telepsychology vs In Person Therapy
Lin, T., Stone, S. J., Heckman, T. G., & Anderson, T. (2021). Zoom-in to zone-out: Therapists report less therapeutic skill in telepsychology versus face-to-face therapy during the COVID-19 pandemic. Psychotherapy, 58, 449–459.
The COVID-19 pandemic has confronted psychotherapists with several challenges including rapidly switching their practice to using teletherapy (videoconferencing, phone, and other virtual media). The use of teletherapy in clinical work increased from 7.1% prior to the pandemic to 85.5% during the pandemic. And estimates suggest that at least one-third of clinical work will be performed by teletherapy post-pandemic. Over a third of psychologists reported that they lacked training in using teletherapy, and they believe that their skills in this domain are inadequate. Therapists have raised a number of concerns in past surveys including issues related to privacy, professional self-doubt, technological competence, challenges to the therapeutic relationship, and problems with implementing some interventions. In this survey of 440 therapists and trainees, Lin and colleagues were particularly interested in therapists’ perceptions of the impact of teletherapy relative to in person therapy on the therapeutic process and patient outcomes. Videoconferencing was the most frequently used modality by 73.56% of surveyed therapists. The survey asked if three broad areas of practice were affected by teletherapy compared to in person therapy. These areas included common therapeutic factors (level of therapist empathy, emotional expression, warmth, alliance bond), extra-therapeutic patient factors (the patient’s environment that impacted their ability to engage in homework or use prescribed resources), and perceived patient outcomes (therapist ratings of patient symptom reduction, satisfaction, clinical improvement). Therapists in the survey were representative of the population of therapists in the US, and 82% of them provided all their clinical work in recent months by teletherapy. Compared to in person therapy, therapists reported poorer skills related to common therapeutic factors (d = 0.86), somewhat greater impact of extra-therapeutic factors (d = 0.36), and perceived poorer patient outcomes (d = 0.68) in teletherapy. Therapists who were younger, preferred emotion-focused or relational therapies, and with no prior training reported a relatively greater decrease in therapeutic skills in teletherapy compared to in-person therapy.
Practice Implications
By far, most therapists believed that providing psychotherapy by virtual means reduced their capacity to use common therapeutic stances including empathy, warmth, and the therapeutic alliance. Some of this might be affected by the psychological distance caused by the virtual format and difficulties with reading body language and other non-verbal cues. Therapists perceived that patient outcomes suffered as a result. This was particularly true for younger therapists, possibly because of the impact of adopting the new modality on their professional self-confidence. Also, therapists who preferred experiential or interpersonally based therapies felt particularly challenged possibly because these therapies may be more reliant on emotional communication and discerning patient interpersonal behaviors. Training and support are needed for therapists and trainees to improve their confidence in providing teletherapy.
Confidence in the Therapist and in Treatment
Finsrud, I., Nissen-Lie, H. A., Ulvenes, P., Melsom, L., Vrabel, K., & Wampold, B. (2022, September). Confidence in the therapist and confidence in the treatment predict symptomatic improvement week by week in therapy: A latent curve modeling approach. Journal of Counseling Psychology. Advance online publication.
In his classic book Persuasion and Healing, Jerome Frank suggested that all psychotherapies involve a trusting emotionally charged relationship with a sanctioned healer who has a good rationale for their interventions. The common factors approach to psychotherapy was born from this kind of thinking. Carl Rogers, for example, argued that to be effective therapists had to engage in unconditional positive regard, empathic understanding, and a genuine non-defensive stance. Contemporary therapeutic alliance theory emphasizes similar factors plus the patient’s expectation of benefit from therapy created through accepting the rationale for the therapy and agreement on the tasks and goals of therapy. From this research and theory, one can see that a patient’s confidence in the therapist and confidence in the treatment may be key common factors underlying effective therapies. Confidence in the therapist refers to a patient who believes that the therapist has the relational skills to help, and that the therapist is working in the patient’s best interest. Confidence in treatment refers to the patient’s belief that the rationale for treatment is meaningful, and that the treatment itself will remedy their problems. In this study, Finsrud and colleagues were interested in whether confidence in the therapist or treatment in one session predicted symptom reduction in the next session. Or was it the other way around – does symptom reduction increase a patient’s confidence? If the results showed the latter, then confidence is result of symptom improvement and so has little or no therapeutic value. The study had 587 adults receiving inpatient treatment for a variety of disorders and treated by psychotherapists of different orientations. Patients completed a measure of confidence in the therapist and treatment, and a scale of their depressive symptoms twice a week for an average of 12 weeks. The authors used sophisticated statistical modeling techniques to examine the effect of a patient’s preceding levels of confidence in therapist or treatment on the patient’s subsequent session symptoms, and vice versa. The researchers found that an increase in confidence in the therapist and confidence in the treatment predicted a decrease in symptoms in the next session. They also found that a reduction in symptoms predicted an increase in confidence in the therapist and in treatment in the next session.
Practice Implications
Patients’ confidence in the therapist and in the treatment both contribute to symptom reduction over and above early symptom change. In other words, the patient’s perception of the therapist as a person and their expectations that the treatment will be helpful are likely key factors that predict a reduction in symptoms. Therapists must have positive regard, genuineness, and empathy towards patients to facilitate the patients’ confidence in the therapist as a person. And therapists must provide a clear rationale for the treatment and develop a collaborative understanding with patients on how therapy will be done (agreement on the tasks) and what the desired outcomes will be (agreement on the goals).
September 2022
Client Perspectives on Psychotherapy Failure
The research indicates that between 5% to 10% of patients get worse during psychotherapy, as many as 30% do not improve, and about 20% drop out of therapy. And so, despite the overall efficacy of psychotherapy, treatment failure (not improving, getting worse, and dropping out) is a big problem. Surprisingly, there is very little research to understand what happens when therapy is unsuccessful. Some of the research that exists asks therapists for their opinions, but we already know that therapists are not good at detecting patients who get worse, therapists overestimate patient satisfaction, and therapists often overestimate their effectiveness relative to peers. Very few studies have asked patients directly about their experience, their understanding, and the impact of psychotherapy not working for them. In this qualitative study, Knox and colleagues interviewed 13 adult patients who reported that their psychotherapy was a failure. The patients reported a variety of reasons for seeking therapy in the first place (depression, anxiety, trauma), and they received a median of 20 to 30 sessions of therapy. Of the therapists that patients saw, 62% were female whose average wage was in the 40s, from different professions (psychology, social work, counsellors), and different contexts (private practice, universities, community health clinics). Typically, patients defined a psychotherapy failure as one that negatively affected them (made them feel worse, did not meet their treatment goals, and characterized by problems in the therapeutic relationship). Often patients raised their concerns with the therapist prior to the final session, but the issue did not resolve. Patients also reported that after termination their symptoms worsened, they felt more hopeless regarding themselves, and they were less optimistic about therapy in the future. Patients noted that therapist behaviors contributed to the failure, such as: therapist insensitivity, apparent incompetence, not checking in with patients’ experiences of the therapy, not focusing on the patients’ goals, and not addressing concerns about the therapy raised by patients.
Practice Implications
Unfortunately, a non-trivial percentage of patients get worse or don’t benefit from therapy. There were immediate impacts (patients felt worse) and also longer-term impacts (patients’ symptoms continued to deteriorate and they were less optimistic about trying therapy again). Therapists should regularly check in with patients about how they are experiencing the therapy. If a patient expresses concern about how therapy is progressing, therapists must listen and non-defensively hear what the patient is saying while acknowledging that it is difficult for patients to speak up. Therapists who make an error should own the mistake and correct course if necessary or refer to another professional. Regular outcome monitoring (repeated measurement of patient symptoms) and process monitoring (repeated measurement of the therapeutic alliance) may help therapists to supplement their clinical judgement to determine if the patient’s symptoms are deteriorating or if they are dissatisfied.
Is the Therapeutic Alliance Therapeutic? It Depends.
The therapeutic alliance is the most studied concept in psychotherapy and is perhaps the most reliable predictor of patient outcomes. But there are two possible explanations for this finding. First, meta-analyses indicate that patients who report higher overall levels of the alliance tend to experience better outcomes at the end of therapy. Second, other meta-analyses report that if a patient’s alliance improves from one session to the next, regardless of their overall level of the alliance, they report a better outcome. The distinction between the two explanations is important. In the first case, one could argue that some patients who have a general tendency to develop a strong alliance also have a general ability to benefit from any treatment. In the second case, one could argue that a patient’s general tendency to develop an alliance does not matter as much as experiencing a growth in their alliance with the therapist from one session to the next. In other words, is the effect of the therapeutic alliance due to a general capacity of the patient to engage in any therapeutic relationship, or is the effect due to growth in the alliance itself being an active mechanism of change in therapy? In this study, Zilcha-Mano and colleagues compared two treatments for depression from a randomized controlled trial: (1) supportive expressive therapy (SET) that relied on primarily specific interventions and secondarily on the overall level of the alliance to help patients change, and (2) supportive therapy (ST) that primarily relied on growth in the alliance as the main therapeutic factor for change. The authors used sophisticated statistical modelling of session-to-session change in depression and change in the alliance to separate out the effects of a patient’s general tendency to develop a good alliance from the growth of the alliance session to session. The researchers also compared SET and ST on the effects of general tendency to develop an alliance versus growth in the alliance from session to session. The findings indicated that the general tendency of patients to experience a good alliance predicted better outcomes in both therapies. That is, patients who already had a capacity to engage in the therapeutic relationship got better regardless of the type of therapy. However, growth in the alliance predicted better outcomes only in ST and not SET. That is, for ST in which the alliance itself was considered a mechanism of change, patients’ symptoms improved when there was growth in the alliance from one session to the next independent of their general capacity to engage.
Practice Implications
The results of the study, like previous meta-analyses, suggested that patients who have a higher general capacity to develop a therapeutic alliance have better outcomes regardless of the therapy. This is a “rich get richer” finding, in which more agreeable patients tend to get better with any treatment they receive. However, the findings also suggested that it is also possible for patients with a lower general capacity for a good therapeutic alliance to improve. For such patients, therapists might prioritize developing and maintaining the alliance on a session-to-session basis. This might be accomplished by taking a more supportive approach, by identifying and acknowledging alliance ruptures, and by repairing such ruptures through negotiating new tasks and goals or strengthening the therapeutic bond.
An Alliance Rupture in One Session Leads to Greater Symptoms in the Next Session
The therapeutic alliance is the collaborative agreement between patient and therapist on the tasks and goals of therapy, and their affective bond. Meta-analyses of over 200 studies show clearly that a higher overall level of the alliance is a reliable predictor of better patient outcomes at the end of treatment. The research is also more specific about how the alliance works - patients whose alliance ratings in one session is higher than their own overall average tend to have fewer symptoms in the next session. During treatment, the state of the alliance may be characterized by rupture and repair episodes. That is, therapists and patients commonly have minor or major disagreements on the tasks and goals of therapy or a disruption in their relational bond, and therapists often try to repair this disagreement or disruption. Confrontation ruptures occur when patients directly show their concern, and withdrawal ruptures occur when patients might have difficulty either recognizing their feelings or directly expressing them. Ruptures are ubiquitous - they occur in every form of therapy and with therapists of every skill level. Resolutions, when done well by therapists, allow the patient and therapist to come to a stronger collaboration on the tasks and goals of therapy or to strengthen their bond. A meta-analysis showed that patients who experience resolution episodes after a rupture had better treatment outcomes. However, most of these studies focused on the effects of higher or lower overall levels of ruptures relative to resolutions on post-treatment outcomes. Few of the studies looked at the impact of a rupture and/or resolution during a session on the outcome or the level of the alliance at the end of the session. In this study, Babl and colleagues specifically looked at whether a rupture during a session is associated with poorer alliance and poorer outcomes after the session, and if a resolution of the rupture is related to a better alliance and better outcomes. The study included 56 patients who received 25 sessions of integrative cognitive therapy for depression or anxiety and who were treated by one of 33 therapists. Independent coders rated alliance ruptures and resolutions from video recordings of 4 therapy sessions throughout treatment. Therapeutic alliance and patient outcomes were assessed after each session with reliable questionnaires. Higher intensity ruptures overall were associated with lower alliance ratings across all sessions. Sessions with more intense confrontation ruptures were associated with poorer alliance ratings after the session. Alliance ruptures and repairs were not associated with patient outcomes.
Practice Implications
It may be important for therapists to continuously monitor the state of the therapeutic alliance with each patient and to identify any instances in which the patient is engaging in a confrontation or withdrawal rupture. Therapists may successfully address such ruptures by openly and non-defensively discussing a rupture should it occur, taking responsibility for the rupture if appropriate, regularly talking with patients about the state of the therapeutic relationship, and re-negotiating the tasks and goals of therapy if necessary.