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Werbart, A., Von Below, C., Brun, J., & Gunnarsdottir, H. (2015). “Spinning one’s wheels”: Nonimproved patients view their psychotherapy. Psychotherapy Research, 25, 546-564.

The rate of patients who experience no change after receiving psychotherapy is about 35% to 40% in clinical trials. Further, about 5% to 10% get worse after treatment. So, in spite of the fact that psychotherapy is effective in general, a sizeable minority of patients do not benefit. There is also evidence that patients’ perception of therapy differs greatly from their therapists’. Therapists are often inaccurate in identifying or predicting patient outcomes, and patients’ judgements tend to better correspond with treatment outcomes. In this study, Werbart and colleagues evaluated outcomes of 134 patients who had elevated symptoms. The average age of patients was 22.4 years (range 18 – 26), so many were young adults. Almost all received a diagnosis ranging from depressive disorders, anxiety disorders, or personality disorders. The predominant treatment was psychoanalytic. Of the 134 patients, many experienced large improvements by the end of treatment. However, 20 patients remained clinically distressed and did not improve or deteriorated after receiving psychotherapy. The authors interviewed these 20 patients at termination and at three-year follow-up using a semi-structured interview. The interview asked patients for their experiences of therapy. The researchers transcribed the interviews and coded the transcripts using a known method of qualitative analysis called “grounded theory”. Three main themes related to poor outcomes were identified by these patients. (1) The therapy or therapist – in which: therapists were perceived by patients as passive or reticent, patients felt distant from the therapist, and patients did not understand the therapy method. (2) Outcomes of therapy – in which: the patient expected more from therapy, and symptoms and emotional problems remained in the “impaired” range at the end of treatment. (3) The impact of life circumstances – referring to negative impacts of events outside of the therapy.

Practice Implications

This is a small but unique study that interviewed patients who did not benefit from psychotherapy about their experiences of the treatment and therapist. Nonimproved patients described their therapist generally as too passive, distant, and uninvolved in the work of therapy. These patients described difficulty understanding the therapeutic method and the nature of the therapeutic relationship. The findings highlight the importance of the therapeutic alliance. To have a good alliance, patients and therapists have to agree on the tasks of therapy, agree on the goals that the therapy should achieve for the patient, and there should be a mutual liking or bond between patient and therapist. Those patients whose therapists pay attention to and foster a good alliance are more likely to experience good outcomes.

Owen, J., Adelson, J., Budge, S., Wampold, B., Kopta, M., Minami, T., & Miller, S. (2015). Trajectories of change in psychotherapy. Journal of Clinical Psychology, 71(9), 817–827.

Knowing the rate, or the trajectory, or the shape of client change across sessions of therapy can inform our understanding of how patients change, our policies of how many sessions to provide clients, and our clinical decisions if clients are no longer improving. The most popular models of client change across sessions include the “dose-effect model” and the “good-enough level model”. The dose-effect suggests that the more therapy patients receive the more they improve but, at a certain point, more sessions result in diminishing returns. In the August, 2013 PPRNet blog, I reviewed a chapter suggesting that 17% to 50% partially improve after about 7 sessions, and 50% patients fully recover after receiving about 21 sessions of therapy. Dose effect models might encourage some agencies to provide only the average number of sessions so that most patients will improve. The good-enough level model, on the other hand suggests that patients stay in therapy for varying lengths of time, and the number of sessions is determined by the point at which they feel better. In this study by Owen and colleagues, the authors take a different approach by looking at the patterns or trajectories of change that represent how and at what rate patients improve over time. In this very large study, they gathered session-by-session outcome data for over 10,000 clients seen at 47 treatment centres by over 500 different therapists. Client presenting problems and therapy orientations varied. Owen and colleagues identified 3 classes of patient change trajectories by using advanced statistical modeling of general distress outcomes across 5 to 25 sessions of therapy (average = 9.4 sessions). The largest class, representing 75% of clients, typified those who rapidly improved to session 5 and whose improvement plateaued to session 11, after which they improved again. This was called the “early and late change” class. The second largest class of patients, representing almost 20% of the sample, showed consistent linear change across the sessions. This was called the “slow and steady change” class. The third class of clients, representing about 5% of the sample, showed an initial decline in functioning up to session 5, followed by a steady improvement up to session 9, and then a plateau in improvement after session 9. This was called the “got worse before they got better” class.  This last group of clients had the most severe symptoms at the outset.

Practice Implications

This study indicates that one size does not fit all when it comes to how rapidly and in what manner patients change. “Early and late change” patients improve early on and then show another round of improvement later on in therapy. “Slow and steady” change patients show mild but consistent improvement across sessions of therapy. And those whose symptoms are more severe at the outset may “get worse before they get better”. This means that it may not be feasible to set an average fixed number of sessions for all patients, but rather therapists and agencies must rely on indices of reliable or good-enough change to determine optimal therapy length for each client. For example, “early and late change” patients may be working on different issues at different stages of therapy. Whereas clients who “show slow and steady” change may need to be in therapy longer before they realize sufficient improvement. For those patients with more severe symptoms who “get worse before they get better”, the therapy initially may be difficult but may ultimately induce change in the long run. In this case, therapists may need to provide enough of the current therapeutic approach before considering a change in the course of therapy.

Author email: Jesse.owen@louisville.edu

Farrell, N.R. & Deacon, B.J. (2015). The relative importance of relational and scientific characteristics of psychotherapy: Perceptions of community members vs. therapists. Journal of Behavior Therapy and Experimental Psychiatry. DOI: 10.1016/j.jbtep.2015.08.004

The American Psychological Association defines evidence-based practice (EBP) in psychotherapy as based on: (a) research evidence, (b) clinical expertise, and (c) client characteristics and preferences. We know for example, that clients who receive their preferred treatments better engage with therapy, drop out at a lower rate, and achieve better symptom outcomes. However, we know very little about clients’ preferences for the relative importance of the therapeutic relationship with an empathic therapist versus the scientific merit of the treatment they receive. We do know that therapists generally prefer research on the therapeutic relationship, and that therapists may place greater value on relationship issues versus research support for the treatments they provide. In this study Farrell and Deacon sample 200 members of the community about the relative importance of the relationship with a therapist versus the scientific basis of the treatment. The authors also surveyed a similar number of therapists about what therapists thought clients would prefer (relationship vs research evidence) in psychotherapy. Not surprisingly, community members rated both the therapeutic relationship and research evidence highly when indicating what they preferred should they receive psychotherapy. However, the authors found that members of the community rated the therapeutic relationship much more highly than they rated research evidence (d = 1.24). But the difference shrank (d = .24) when it came to treating panic disorder or obsessive compulsive disorder. Therapists tended to under-estimate the importance of community members’ preferences for scientific evidence for psychotherapy. The under-estimation was greater for therapists who placed less value on research. In other words, therapists who valued research less in their own practice were more likely to underestimate the importance of scientific credibility to members of the general public.

Practice Implications

This is by no means a perfect study. As readers of this blog know, I prefer to write about meta analyses, which are much more reliable than findings from a single study. However, it is quite rare to have a study on a large sample of members of the community, let alone one that asks about their perceptions and preferences about psychotherapy. The findings from this study suggest that members of the community highly value the therapeutic relationship and factors like therapist empathy. However, members of the community also place much faith in the scientific evidence that supports the use of psychotherapy. The preference for both a good therapeutic relationship coupled with research evidence may be very important to most people who may seek therapy. Therapists, particularly those who place less weight on research, should keep in mind that clients value the scientific evidence for psychotherapy.

Author email: bdeacon@uow.edu.au

Werbarta, A., Andersson, H., & Sandell, R. (2014). Dropout revisited: Patient- and therapist-initiated discontinuation of psychotherapy as a function of organizational instability. Psychotherapy Research, Online first publication: DOI: 10.1080/10503307.2014.883087.

Premature termination of psychotherapy in mental health care is a problem both in terms of patient outcomes and in terms of financial consequences for providers. Drop out rates for psychotherapy in general range from 20% to 75% with an average of 50%. In my April, 2013 blog I reported on a meta analysis by Swift and Greenberg (2012) in which they reported an overall drop out rate of 20% in randomized control trials; but the average drop out rate could be up to 38% in randomized trials depending on how premature termination was defined (failure to complete a treatment, attending less than half of sessions, stopping attending, or therapist judgment). Drop outs are commonly believed to represent therapeutic failures. Much of the research to predict psychotherapy non-completion has focused on patient variables like age, gender, symptom severity and others. This implicitly puts the responsibility for dropping out on the patient. Swift and Greenberg (2012) found that on average young, male, single patients with a personality disorder diagnosis were more likely to drop out. Therapist variables are less frequently studied, and the only therapist variable related to lower drop out was greater experience. Therapeutic orientations were not related to more or less dropping out. Very few studies have examined work conditions or organizational variables as predictors of premature terminations. Werbata and colleagues (2014) conducted a large study in 8 clinics in Sweden with 750 patients treated by 140 therapists. The clinics were three psychiatry outpatient units, three specialized psychotherapy units, one young adult psychotherapy unit, and one primary care setting that provided psychotherapy. Drop out was defined as unilateral termination in which either the patient or therapist discontinued the treatment. Of the patients who started therapy, 66% completed treatment and 34% terminated prematurely (19.7% of patients terminated the therapy, 14.3% were terminated by therapists). On average, clients were in their mid-30s, and most had a psychiatric diagnosis. The most common therapy was psychodynamic (59.1%) followed by integrative (19.0%), and cognitive behavioral (17.1%). The authors looked at patient variables (e.g., symptom severity), therapist variables (e.g., age, gender, etc.), and organizational stability. Ratings of organizational stability of the clinic were based on: the transparency of the clinic structure, the suitability of the organization to provide psychotherapy, the clarity of rules and decision-making policies regarding providing psychotherapy, and the clinic’s financial stability. Client variables such as: older age, greater level of psychopathology, and tendency to act out were moderately predictive of dropping out. Receiving treatment at a less stable clinic made it almost four times more likely for patients to initiate dropping out than to remain in therapy. Organizational instability was more important than patient factors in accounting for premature termination.

Practice Implications

Drop outs were almost four times higher in unstable clinics. Instability in organizations can create anxiety, cynicism, and disengagement in staff, which may have consequences for patient care. Financial and political problems within a clinic or institution, internal conflict related to treatment policy or disruptive administrative routines may affect the therapeutic relationship, which is generally more intimate and more important than in other health care contexts. Organizational instability can result in shortened or interrupted treatment, change in therapists, or therapists who are not fully engaged due to clinic stresses. For patients, these terminations may resemble earlier life losses or neglect that may have precipitated their need for therapy in the first place.

McAleavey, A.A., Castonguay, L.G., & Goldfried, M.R. (2014). Clinical experiences in conducting cognitive-behavioral therapy for social phobia. Behavior Therapy, 45, 21-35.

It might come as a surprise to some that social phobia (also called social anxiety disorder) is the most commonly diagnosed anxiety disorder, with a lifetime prevalence of about 12%. Symptoms include negative self-view, fear of embarrassment or criticism, and fear and/or avoidance of social situations. Cognitive behavioral therapy (CBT) is an effective treatment for social phobia with effects as large as pharmacotherapies. Despite this, there are several potential barriers to implementing CBT for social phobia in clinical practice. CBT involves exposure to feared situations (in vivo or simulated), identifying and altering maladaptive thoughts during exposure, producing testable hypotheses, and identifying cognitive errors.  CBT is not uniformly effective for all patients with social phobia, exposure techniques are linked to dropping out and failure to initiate treatment, and there can be an increase in missed sessions and non-completion of homework related to avoidance. In this study, McAleavy and colleagues surveyed 276 psychotherapists who provided CBT for social phobia to assess problems or barriers clinicians encountered when applying CBT in practice. Possible barriers listed in the survey were derived from extensive interviews with experts who developed and researched CBT interventions for anxiety disorders. Survey respondents were mostly Ph.D. level clinical psychologists (59%), women (61%), who practiced in outpatient clinics or private practice, and had on average 12 years of post-degree experience. Many therapists reported using behavioral interventions, including developing a fear/avoidance hierarchy, in-session exposures, focusing on behavior in social situations, and specifically focusing on behavioral avoidance. Most also used cognitive homework (i.e., interventions focused on exploring or altering attributions or cognitions).  The most frequent therapist endorsed barriers to implementing CBT for social phobia included: patient symptoms (i.e., severity, chronicity, and poor social skills); other patient characteristics (i.e., resistance to directiveness of treatment, inability to work independently between sessions, avoidant personality disorder, limited premorbid functioning, poor interpersonal skills, depressed mood); patient expectations (i.e., that therapist will do all the work; pessimism regarding therapy); patient specific beliefs (i.e., belief that fears are realistic, or that social anxiety is part of their personality); patient motivation (i.e., premature termination, attribution that gains are due to medications); and patient social system (i.e., social system endorses dependency, social isolation). A minority of CBT therapists endorsed a weak therapeutic alliance or aspects of the CBT intervention itself as posing a barrier.

Practice Implications

CBT therapists identified a number of barriers, mainly patient related, that might impede the implementation of CBT for social phobia. Given these barriers the authors suggested that therapists: (1) consider more intense, longer, or more specific treatments for more severe cases; (2) incorporate assessment of patient severity to guide decisions; (3) consider tailoring the level of treatment directiveness based on patient characteristics – i.e., more resistant patients may require a less directive approach and more control over the type and pace of interventions; (4) prepare patients on what to expect in the treatment before therapy begins; (5) find a balance between validating/accepting patients’ problematic beliefs that their fears might be realistic with encouragement to change; (6) add motivational interviewing for patients who are less motivated; (6) complete a thorough functional analysis of patients’ social systems at the start of therapy. McAleavey and colleagues noted that while therapeutic alliance difficulties was an infrequently endorsed barrier by therapists, such difficulties remain clinically important, especially in light of findings that indicate that negative reactions to patients are under-reported by therapists. Developing and maintaining a good alliance remains a key aspect of CBT for panic disorder.

Johnson, S.M, Burgess Moser, M., Beckes, L., Smith, A., Dalgliesh… Coan, J.A. (2013). Soothing the threatened brain: Leveraging contact comfort with emotionally focused therapy. PLoS ONE 8(11): e79314. doi:10.1371/journal.pone.0079314.

Attachment theory argues that a felt sense of connection to others provides a secure base and safe haven, thus increasing one’s tolerance for uncertainty and threat. Improved access to and experience of social resources likely help us regulate negative emotions thus reducing our perception of threat. In a previous study, women in a couple were confronted with a threat (the possibility of a shock to the ankle) while their brain was scanned by functional magnetic resonance imaging (fMRI). These women were either holding the hand of their spouse or the hand of a stranger. Women with the highest quality relationships showed lower threat response in the brain especially while they held the hand of their spouse. Holding the hand of a spouse with whom they had a loving relationship reduced the fear response in these women measured directly in the brain by fMRI. In the study by Johnson and colleagues (2013) the authors wanted to see if improving attachment relationship between couples following Emotionally Focused Couples Therapy (EFT) would result reduced responses to threat measured in the brain. Twenty-three couples completed a course of EFT (23 sessions on average) with experienced therapists. EFT is an evidence based couples treatment that conceptualizes couple distress as caused by unmet attachment needs. When feeling emotionally disconnected, partners in a couple may be anxiously blaming or withdrawing, and this pattern exacerbates relationship distress and threat. EFT focuses on repairing attachment bonds between spouses. In this trial, EFT significantly improved couples’ self reported distress from pre to post therapy. The brain of the female member of the couple was scanned in an fMRI before and after EFT. An electrode was fixed to her ankle, and she was threatened with a mild shock. This procedure took place while she was on her own and while she held her partner’s hand. Threat response was measured by activity in the prefrontal cortex and dorsal anterior cingulate cortex, both of which are associated with processing threat cues and negative affect. EFT resulted in a decrease activity in these areas of the brain from pre to post couples treatment, and these results were especially prominent during hand holding with the partner.

Practice Implications

There is emerging evidence that the effects of psychotherapy like EFT for couples, has a direct impact on the brain that correlates with patients’ self report. In addition, EFT appears to increase the attachment bond between couples and this helps them to regulate their emotions and to moderate their reactions to threat. This study by Johnson and colleagues (2013) also supports some fundamental tenets of attachment theory – that increasing attachment security is possible with psychotherapy and doing so improves affect regulation as measured in the brain. This has broad implications because strong social and attachment bonds help us live longer and enjoy better health.

Author email: jcoan@virginia.edu