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.

May 2022

Do Psychotherapists Get Better with Experience and Training?

Wampold, B. & Owen, J. (2021). Therapist effects: History, methods, magnitude, and characteristics of effective therapists. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7^th ed.). Wiley. Chapter 9.

One of the defining characteristics of expertise is the overall improvement in skills and performance over the course of one’s career. We can identify, for example, that there are experts in chess, tennis, surgery, and musical performance based on performance. Expertise in these areas is explicitly developed partly because there is clear and immediate feedback regarding performance (i.e., a tennis player knows immediately that they missed a serve, and so they make an adjustment on the next serve). In psychotherapy, this is not so easy. Therapists rarely receive immediate feedback about their specific interventions or interpersonal responsiveness to a patient. In this part of the chapter, Wampold and Owen review the research on the relationship between therapist experience and training and patient outcomes. They focus on high quality studies that disentangled therapist from patient effects. Overall, the evidence does not support the notion that the more experience that a therapist accumulates the better their patients’ outcomes. In fact, one study that tracked therapists over time (up to 18 years) found that patients’ outcomes got slightly worse with more experience. Similar findings occur for training of student therapists. For the most part, more training that student therapists received over a 12-to-42-month period was not associated with better patient outcomes. There is some evidence that trainees can improve their capacity to develop a therapeutic alliance, and that with more deliberate practice (focused, immediate attention and feedback on specific skills) therapists can realize better outcomes with their patients.

Practice Implications

As a senior therapist who is very involved in training, I find these results discouraging. Nevertheless, the solutions offered by the research do provide a ray of hope. Providing therapists with specific and immediate feedback about patient outcomes and therapeutic processes (e.g., ratings of patient distress and of the alliance after every session), has the potential for helping therapists to inform their practice, make adjustments, and develop expertise. Deliberate practice of specific skills in psychotherapy (e.g., ways of addressing an alliance rupture or of responding to intense emotion) may also improve therapist expertise and patient outcomes. It is also quite possible that the focus on learning specific manualized protocols, which is often the goal of graduate and post-graduate training, may not be the most effective training and professional development.

April 2022

Countertransference and its Management

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
Therapist Flexibility and Responsiveness

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.

One of the most intriguing findings from psychotherapy research is that adherence or competence to manual-prescribed techniques has almost no impact on patient mental health outcomes. That means that efforts to get therapists to follow a manual has no bearing on whether their patients get better. In fact, there is sufficient research to suggest that rigid adherence to a treatment model may be harmful to patients. Research suggests that purposefully moving away from protocols at times in therapy can be more validating, collaborative, and autonomy granting that sticking with the protocol. Thus, the over-zealous delivery of a treatment, despite good intentions, can be ineffective or harmful to patients. Some of the specific research in this area found that the patients of therapists who varied in their use of theory-prescribed interventions had better outcomes. Similarly, when psychodynamic therapists integrated cognitive and behavioral interventions, patients had better outcomes than when the therapists were less flexible. A similar concept to flexibility is therapist responsiveness, or their ability to respond to the specific therapeutic context. This might include therapists’ ability to develop a case formulation specific to the patient, and flexibly tailoring their interventions to that formulation. Therapist responsiveness and tailoring interventions to the patient may result in better outcomes.

Practice Implications

That the level of adherence to treatment manuals bears no relation to patient outcomes speaks to the speaks to problems associated with persistent and rigid adherence. Rigidity in applying a treatment model may lead to negative processes in therapy and poor patient outcomes. It is important for therapists to be responsive and attuned to their patients’ needs, progress, and treatment goals. That is, it likely more important to tailor treatment to the patient and their characteristics rather than trying to get the patient to adapt to the treatment.

March 2022

Patient Factors: Impairment, Chronicity, and Severity

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.
Patient Coping Style and Resistence

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.
Patient Expectations and Preferences

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.

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May 2022

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April 2022

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March 2022

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