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Constantino, M.J., Boswell, J.F., & Coyne, A.E. (2021). Patient, therapist, and relational factors. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7^th ed.). Wiley. Chapter 7.

Countertransference is one of the oldest concepts in psychotherapy dating back more than 100 years. More recently, some writers view countertransference as a pantheoretical concept, in other words it affects all therapists and occurring in all therapies. One definition of countertransference is that it is the “internal and external reactions in which unresolved conflicts of the therapist, usually but not always unconscious, are implicated”. Countertransference may provide important information about a patient’s interpersonal patterns, but it may also be an impediment to the therapist’s effectiveness. One prominent model of countertransference identifies its component parts to include: origins within the therapist (i.e., unresolved issues within the therapist that may interact with patient qualities); triggers caused by the patient’s transference (i.e., patient maladaptive interpersonal patterns) and other patient behaviors that may interact with the therapist’s unresolved issues; manifestations – or how the countertransference affects the therapist’s behaviors and responses toward the patient; the effects of these behaviors on the therapeutic relationship or the patient; and the therapist’s management of countertransference responses – or what the therapist does to maintain an equilibrium. In this part of the chapter, Constantino and colleagues review two meta-analyses of the impact of countertransference and its management on the patient. A meta-analysis of 14 studies indicated a small but significant correlation between therapist countertransference and poor patient outcomes (r = -0.16), and a second meta-analysis of 9 studies indicated a moderate and significant association between successful countertransference management and patient improvement (r = 0.39).

Practice Implications

Despite countertransference being a well-established topic in psychotherapy, the research is relatively new. The findings suggest that regardless of what type of therapy is practiced, therapists should be mindful of their countertransference reactions. It is important for therapists to monitor their internal mental and emotional states during a therapy session, and to note when they feel something that is not typical for them (bored, annoyed, attracted, overwhelmed, disgusted, distracted). A therapist’s management of these feelings may include remaining calm in the moment, self-reflection about the origins and triggers of their reactions, seeking consultation with a trusted colleague, and personal therapy to work on unresolved issue

Constantino, M.J., Boswell, J.F., & Coyne, A.E. (2021). Patient, therapist, and relational factors. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7^th ed.). Wiley. Chapter 7.

Many times, clinicians are interested in knowing what the likelihood is of a patient improving, how long that improvement might take, and what to expect in terms of degree of improvement. Some of the patient factors that predict these outcomes are indicators of the patient’s mental health at the start of treatment. In this part of the chapter, Constantino and colleagues review the research on several mental health indicators and their association with treatment and outcomes. First, functional impairment refers to the degree of impaired daily living, disrupted work performance, and social maladjustment. Generally, the research indicates that greater functional impairment is associated with poorer outcomes, and when coupled with a dual diagnosis (substance use disorder or another mental health diagnosis) greater functional impairment is associated with longer and more costly treatments. Second, chronicity (longer symptom duration) is also related to poorer treatment outcomes and slower rate of improvement. Third, symptom severity had a mixed association with patient outcomes. Generally, very high or very low severity of symptoms was related to poorer outcomes. It is possible that very high symptom severity may interfere with a patient’s capacity to use therapy, but that very low symptom severity may lead to the patient being less motivated to change. The fourth area was diagnostic comorbidity. Patients with major depressive disorder and personality disorder are twice as likely to have a poor outcome from psychotherapy. Similarly, patients with primary substance use disorder and a comorbid diagnosis typically dropped out at a higher rate and had poorer outcomes.

Practice Implications

It is sometimes helpful for clinicians and patients to know what to expect from psychotherapy and how long therapy might take. The more a patient’s work and social functioning is impaired and the longer they have had symptoms, the more sessions of therapy they might need. This means that both patients and therapists need to be realistic about what to expect in terms of progress. The same might be true for comorbid symptoms when the primary diagnosis is major depression or substance use. The picture for symptom severity is a little more complicated. Patients with very high symptoms may require an initial focus on reducing symptoms by increasing social supports, containment, and other practical interventions for them to make good use of therapy. On the other hand, patients with very low symptom severity may need help initially to increase their motivation for treatment to prevent a relapse.

Constantino, M.J., Boswell, J.F., & Coyne, A.E. (2021). Patient, therapist, and relational factors. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7^th ed.). Wiley. Chapter 7.

There are certain patient characteristics that interact with therapist behaviors and interventions, and these interactions have an impact on patient outcomes. Two of these that are reviewed by Constantino and colleagues are patient coping style and resistance. In a broad sense, coping style can be characterized as internalizing or externalizing. Internalizing coping refers to being self-critical and directing blame inward when under stress. Externalizing coping refers to acting out when stressed or placing blame on others or the environment when under stress. A meta-analysis of 1,947 patients from 18 studies, examined the interaction between coping style (externalizing vs. internalizing) and psychotherapy type, categorized as insight oriented vs. symptom-focused. Insight-oriented approaches (e.g., psychodynamic, humanistic) prioritize increasing self-understanding and emotional experiencing, whereas symptom-focused approaches (e.g., cognitive, behavioral) focus on changing symptoms directly through altering behaviors, cognitions, and reinforcement contingencies. The authors found a medium interactive effect on outcome (d = .60), such that those who typically engaged in internalizing coping had better outcomes in insight-oriented treatments and those who typically used externalizing coping had better outcomes in symptom-focused treatments. The second patient factor that interacts with interventions is patient resistance (also known as reactance). Resistance involves emotional arousal when one perceives that another is controlling or limiting one’s freedom, and the behaviors one engages in to resist this control. A meta-analysis of 13 controlled studies with a total of 1,208 patients found that patients higher in resistance had better outcomes when their therapist took a less directive approach and patients lower in resistance had better outcomes when their therapist adopted a more directive approach (d = 0.79).

Practice Implications

Therapists should pay attention to and assess their patients’ coping style and level of resistance. This information will inform how therapists should approach these patients or what their interpersonal stance should look like. Patients with a more internalizing coping style may do better with a more insight-oriented approach to therapy. Patients with a more externalizing coping style may do better in a therapy that requires them to engage in problems solving and is symptom focused. Also, patients who appear to be highly resistant (wary of or not willing to follow suggestions) may respond better when a therapist takes a less directive or less authoritative interpersonal stance. Conversely, patients who are lower in resistance (more agreeable or compliant) may respond better to therapists who are more directive in their in their interpersonal style.

Constantino, M.J., Boswell, J.F., & Coyne, A.E. (2021). Patient, therapist, and relational factors. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7^th ed.). Wiley. Chapter 7.

In this chapter, Constantino and colleagues review the effects of patient expectations of benefit and patient preferences for treatment. Patient outcome expectations is broadly related to the placebo effect. That is, there is a commonly known positive effect when patients expect that a treatment will help them get better. This effect occurs across all psychotherapies and is also seen in medical and pharmacological interventions. A meta-analysis of almost 13,00 patients in 81 studies found a small to moderate relationship (r = .18) between patient expectations of positive outcomes and the extent to which they improved. There is also evidence that outcome expectations improve the therapeutic alliance. The more optimistic patients are about getting better, the more they are likely to engage in a collaborative working relationship with their therapist. A related line of research addresses patient preferences for treatment. This refers to what is done in therapy, the characteristics of the therapist, and the length of therapy among others. Preferences can be grouped into three categories: activity preferences are the patient's desire for the psychotherapy to include specific therapist behaviors or interventions; treatment preferences are the patient's desire for a specific type of intervention to be used, such as psychotherapy vs. medication, or CBT vs. person-centered therapy; and therapist preferences are the patient's desire to work with a therapist who possesses specific characteristics (e.g., a certain gender, race, or interpersonal style). In a meta-analysis of 28 studies, patients who received their preferences were 1.79 times less likely to drop out of therapy compared to those who did not get their preference. The effect on patient outcomes were statistically significant but small (d = .28). The beneficial effect of preferences was stronger for those with anxiety or depressive disorders.

Practice Implications

Patients who have higher expectations of getting better are on their way to feeling remoralized, they are more likely to engage in a therapeutic relationship, and they are more likely to be collaborative in the therapy. Therapists can improve patient expectations by providing patients with a clear rationale for the interventions, a realistic sense of how long therapy will take, and a non-technical summary of the research evidence for the therapy they are providing. Patients who get what they prefer in a therapy or therapist also may experience better outcomes, especially if they have an anxiety or depressive disorder. Listening to what patients expect and want from therapy may help therapists to tailor the treatment to the patient’s wishes. Providing patients with more than one treatment option when possible may be one means of meeting patient expectations.

Castonguay, L.G., Barkham, M., Youn, S.J., & Page, A. (2021). Practice-based evidence: Findings from routine clinical settings. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7^th ed.). Wiley. Chapter 6.

Practice-based evidence refers to research that is conducted as part of routine clinical practice. Often these studies do not impose strict research conditions like randomization of patients, and so they produce findings that are more relevant to psychotherapy as practiced real-world. In studies from practice-research networks, clinicians are often involved in the design and implementation of the study. Our Psychotherapy Practice-Research Network (PPRNet) is an example of a collaboration between researchers and clinicians to produce practice-based evidence. In a large survey, we found that most clinicians regardless of theoretical orientation wanted more research on the therapeutic relationship and on professional development. And so PPRNet developed a research program on training psychotherapists to identify and repair therapeutic alliance ruptures and microaggressions. In this chapter, Castonguay and colleagues review some of the key findings from practice research networks. First, White patients report better outcomes than Black patients in routine care, and these differences were linked back to the clinicians. That is, therapists varied in their effectiveness with racial and ethnic minority patients. Second, patients benefit when clinicians monitor the therapeutic alliance and outcomes on a session-to-session basis using reliable and valid measures. Noticing when a patient’s ratings of the alliance decline from one session to the next, might indicate a problem in the therapeutic relationship. Third, when monitoring the alliance, therapists should also rate the alliance. If a therapist’s ratings of the alliance are higher than their patients, then this may be a sign that the therapist is not paying attention to problems in the alliance. Fourth, developing and maintaining a strong therapeutic alliance likely will improve patient outcomes. Fifth, a reliable and valid assessment of client’s past and current interpersonal difficulties is likely to improve a therapist’s treatment plan for that patient.

Practice Implications

Doing research in clinical practices is not as well controlled as clinical trials research. But practice-based evidence is more relevant to how psychotherapy is done in the real world with real patients. The research is not so clear about why some therapists are more effective with racial and ethnic minority (REM) patients. However, complementary research suggests that some therapists who have a previously high level of multicultural orientation (cultural humility, open to conversations about culture, and cultural comfort) are more effective with REM patients. Also monitoring the therapeutic alliance with a valid scale on a session-to-session basis leads to better outcomes. Such monitoring will alert the therapist to resolve an alliance rupture if a patient’s ratings decrease from one session to the next. If therapists also rate the alliance and find that their scores are higher than their patient’s, then this may alert the therapist to a potential problem. Finally, knowing if a patient has current and past interpersonal problems can inform a therapist to focus on how those problems affect current symptoms and to talk about how those problems manifest themselves in the therapeutic relationship.

Constantino, M.J., Boswell, J.F., & Coyne, A.E. (2021). Patient, therapist, and relational factors. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7^th ed.). Wiley. Chapter 7.

Race refers to socially constructed perceptions of physical attributes shared by a group of people, whereas ethnicity refers to a group of people's shared cultural values,

attitudes, and behaviors. By extension, racial identity represents a sense of belonging that stems from a perception that one shares a heritage with a particular racial group. In this part of the chapter, Constantino and colleagues review the psychotherapy research on these important patient factors. The research suggests that racial and ethnic minority (REM) patients have more difficulty accessing therapy, and that the quality of mental health treatment that they receive is lower than for White patients. REM patients may be at greater risk for premature termination from therapy than White patients. One solution might be to match REM patients to therapists with similar identities. A meta-analysis of 52 studies found that patients significantly preferred a therapist of the same race or ethnicity (d = .32), and patients perceived therapists of the same race or ethnicity more positively. However, the same study found little benefit for patient outcomes of matching therapists and patients on their racial or ethnic identities. The exception was for African American patients who experienced significantly better outcomes when treated by a same race/ethnicity therapist, but the effect was small (d = 0.19).

Practice Implications

The mental health disparities and higher dropout rates experienced by racial and ethnic minority (REM) patients should be a cause of concern for all psychotherapists. As reported in the next blog entry, some therapists are significantly less effective when working with REM vs White patients, and some therapists are more effective when working with REM patients. Overall, the findings suggest that specific therapist behaviors and practices affect REM patients’ mental health outcomes. One way to improve these outcomes is to assess a patient’s cultural identity and to culturally adapt treatment to aspects of patients’ cultural backgrounds. Another approach is for therapists to develop multicultural competence and a multicultural orientation that includes cultural humility, openness to conversations about culture, and cultural comfort.