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 the treatment of depression, the effects of role induction in psychotherapy, and negative experiences in psychotherapy from clients’ perspective.
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
June 2013
Parallel Process in Psychotherapy Supervision
Tracey, T. J., Bludworth, J., & Glidden-Tracey, C. E. (2011). Are there parallel processes in psychotherapy supervision? An empirical examination. Psychotherapy, 49(3), 330-343.
Parallel process was first proposed in the psychodynamic literature as the replication of the therapeutic relationship in supervision. Parallel process is also recognized as an important aspect of supervision in developmental and interactional models of supervision, even though those models do not endorse the unconscious aspects of parallel process. Parallel processes in supervision occur when: (1) the trainee therapist brings the interaction pattern that occurs between the trainee therapist and client into supervision and enacts the same pattern but with the trainee therapist in the client’s role, or (2) the trainee therapist takes the interaction pattern in supervision back into the therapy session as the therapist, now enacting the supervisor’s role. For example, a client comes into therapy seeking guidance because things are not going well in his relationships. He desires structure and direction from the trainee therapist (client’s behaviour is submissive). The trainee therapist attempts to help the client by providing guidance (therapist’s behaviour is relatively dominant). The client then responds with “Yes, but…” to suggestions offered by the trainee therapist (client’s behaviour is non-affiliative). The trainee therapist over time starts to become subtly “critical” of the client (therapist matches the non-affiliative client behavior). The trainee therapist goes into supervision complaining about the client’s “resistence” and the trainee therapist asks for help and direction from the supervisor (trainee therapist increases his submissive behavior in a parallel enactment of the client’s submissive stance). As the supervisor provides some direction (supervisor increases her dominance), the trainee therapist responds with “Yes, but. . .” (trainee therapist increases his non-affiliative behavior). The supervisor engages in more “critical” comments than usual in response to the therapist (supervisor matches the non-affiliative trainee behavior). In this way, the supervision interaction becomes a relative replication of the therapy relationship, captured in the parallel amounts of dominance/submission and affiliation/non-affiliation exhibited by the participants in relation to each other. Tracey and colleagues (2012) studied this phenomenon by coding moment by moment interpersonal interactions using an interpersonal circumplex model (i.e. a model that assesses relative dominance and affiliation) among 17 triads of clients/trainee therapists/supervisors in a series of single case replications. The authors hypothesized that relative dominance and affiliation would be parallel between clients/trainee therapist pairs and corresponding trainee therapist/supervisor pairs in contiguous sessions. Significant results were found for each dyad within the 17 client/trainee therapist/supervisor triads. Therapists in the role of trainee altered their behavior away from their usual in supervision to act somewhat more like particular clients did in the previous therapy session. Supervisors tended to engage in complementary interpersonal responses in the subsequent supervision session. This provided evidence for parallel process at an interpersonal level of interactions. Further, positive client outcome was associated with increasing similarity of trainee therapist behavior to the supervisor over time on both dominance and affiliation. That is, the more therapists acted like their supervisors in the previous supervision meeting on both dominance and affiliation, the better the client outcome.
Practice Implications
This article provides intriguing evidence for an interpersonal model of parallel process. Supervisors may choose to communicate with the trainee about how the trainee therapist and client are interacting, as well as how the trainee and supervisor are interacting. In this way, the supervisor makes the implicit aspects of the parallel process more explicit for the trainee therapist. The trainee then can make choices about how best to proceed based on the new understanding of the interactional pattern at the process and content levels of interaction. For example, a therapist and supervisor can come to understand a block in the supervisory alliance as a parallel to a similar impediment in the trainee therapist-client relationship. A supervisor working through the block in supervision to create a more collegial and affiliative environment may model for the trainee therapist ways in which to effectively and collaboratively work with their client.
Author email: Terence.Tracey@asu.edu
March 2013
What Are The Characteristics of More Effective Therapists?
Laska, K. M., Smith, T. L., Wislocki, A. P., Minami, T., & Wampold, B. E. (2013). Uniformity of evidence-based treatments in practice? Therapist effects in the delivery of cognitive processing therapy for PTSD. Journal of Counseling Psychology, 60(1), 31-41.
Some therapists are more effective than others. Why, and how can we improve therapist effectiveness? Previous researchers estimates that differences among therapists account for 8% of the outcome variance, which is as big or a bigger effect than differences between treatment types. Some argue that training and supervising therapists in evidence-based treatments (EBTs) can reduce differences between therapists. But if training in EBTs does not reduce differences, what are the therapist factors we should be focusing on to improve outcomes? A study by Laska and colleagues (2013) addresses some of these issues. In their study, 25 therapists (psychologists and social workers) in Veterans Administration (VA) hospitals were trained by a nationally recognized trainer in cognitive processing therapy (CPT) for post traumatic stress disorder (PTSD), and they treated 192 veterans. Therapists were trained to a standard level of competence in CPT, and they were supervised weekly by a certified expert in CPT. Differences between therapists’ effectiveness accounted for 12% of the outcome variance. In other words training and supervision in CPT did not appear to reduce differences between therapists, so that some therapists remained significantly more (or less) effective than others. The CPT expert supervisor was able to identify the more effective therapists even though she was blind to patient outcomes. She was also asked to list the qualities of these more successful therapists. Four areas emerged from the qualitative analysis of the supervisor interviews. (1) Reducing Avoidance – i.e., therapists’ ability to skilfully address patient avoidance of difficult areas or avoidance of therapy assignments, and not to collude with client avoidance; (2) Language in Supervision – i.e., therapists’ willingness to discuss struggles with cases, openness to discussing their contribution to impasses, and non-defensiveness in response to supervisor feedback; (3) Flexible Interpersonal Style – i.e., therapists’ ability both to join with and to challenge patients, to flexibly apply the manual so that they did not miss important interpersonal events in the therapy, but at the same time not to stray too far from the manual; and (4) Strong Therapeutic Alliance –i.e., therapists’ genuineness with patients, ability to develop a bond, and to agree with patients on tasks and goals of therapy.
Practice Implications
Creating a culture within a practice setting in which therapists are routinely provided feedback about their clients’ ongoing progress and about the therapeutic relationship has the potential to improve patient care. Therapists’ ability to handle interpersonally challenging encounters with patients is what distinguishes the most competent therapists from others. Training and supervision of therapists should focus on facilitative interpersonal skills as well as on the specific treatment protocol.
Author email: Kevin.Laska2@va.gov