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Clients of Therapists Who Are Flexible Have Better Outcomes

Katz, M., Hilsenroth, M. J., Gold, J. R., Moore, M., Pitman, S. R., Levy, S. R., & Owen, J. (2019). Adherence, flexibility, and outcome in psychodynamic treatment of depression. Journal of Counseling Psychology, 66(1), 94–103.

Psychodynamic and cognitive-behavioral (CB) treatments are quite different in how therapy is delivered, but both are equally effective for depression. Such findings suggest that various types of specific interventions can positively impact client outcomes. A possible mechanisms of therapeutic action is that effective therapists may be particularly responsive to their clients’ behaviors and needs. That is, effective therapists may be flexible in how adherent they are to the techniques of a therapeutic orientation. Therapists who are flexible in their adherence to a therapeutic technique may promote a better therapeutic alliance (i.e., a therapist’s and client’s collaborative agreement on the goals of therapy and what to do in therapy). In this study, Katz and colleagues examined whether the flexible use of some CB techniques by psychodynamic therapists was related to better client outcomes in terms of depressive symptoms. Forty six patients diagnosed with depression were treated by 26 advanced graduate student therapists who were trained to practice psychodynamic therapy. Psychodynamic therapy techniques included: a focus on affect and affect expression, identifying relational patterns and patterns of thoughts and feelings, emphasizing past experiences and interpersonal relationships, working on the therapeutic alliance, and restructuring defense mechanisms. The researchers video recorded two early sessions of therapy which were independently rated to assess the degree to which therapists adhered to psychodynamic therapy principles or to CB therapy principles. Client depression outcomes were assessed pre- and post-therapy. Higher ratings of psychodynamic therapy adherence were related to better patient depression outcomes at post-treatment. In addition, the clients of psychodynamic therapists who used some CB techniques early in therapy had the best outcomes. In other words, the use of psychodynamic techniques was sufficient for clients to improve, but flexible use of some CB techniques by psychodynamic therapists provided added benefit. The CB techniques that were most often integrated by the therapists included: actively initiating topics and therapeutic activities, explaining the rationale of an intervention, focusing on the future, and providing psychoeducation about symptoms.

Practice Implications

Clients in this study improved on average from psychodynamic therapy, and psychodynamic interventions were related to better outcomes. However, clients of therapists who flexibly integrated a small amount of CB techniques benefitted more from the psychodynamic techniques. Research is increasingly showing that therapist flexibility in treatment adherence is related to better patient outcomes. For psychodynamic therapists, flexibility in treatment adherence leads to clients being more responsive to the interventions and having better outcomes.

Timuluk, L. & Keogh, D. (2017). The client’s perspective on (experiences of) psychotherapy: A practice-friendly review. Journal of Clinical Psychology, 73, 1556-1567.

Psychotherapy studies that ask clients for their perspective on the treatment or therapist are surprisingly rare. Researchers have conducted such studies over many decades, but there exist very few of them. This is curious given that respecting clients’ preferences for types of therapy or for therapists’ behaviors is predictive of good mental health outcomes. Giving voice to clients’ perspectives is consistent with the notion that psychotherapy is a co-constructed endeavour rather than something that a therapist does to a client (as is the case for a medical intervention). In this review, Timuluk and Keogh review the research in which patients were interviewed for their perspective on a wide range of aspects of psychotherapy. The research indicates a number of things that clients value, that help, and that hinder their progress in therapy. Clients value a number of therapist traits like friendliness, warmth, respect, offering appropriate guidance, and understanding. This research showed that clients recognize that the relationship (i.e., the alliance) has therapeutic effects. Clients report that many forms of therapist behaviors help to develop a therapeutic alliance including eye contact, smiling, warm personalized greetings, paraphrasing, identifying client feelings, and referring to material from previous sessions. Clients find some events in therapy to be unhelpful or that hinder their progress, like feeling exposed and unprotected, being emotionally overwhelmed, and feeling misunderstood by the therapist.

Practice Implications

Although clients do value therapist expertise in applying therapeutic techniques, they hold therapist personal qualities like warmth, authenticity, honesty, and dedication as necessary prerequisites for therapy. Clients view the therapist’s interpersonal manner as key to forming a therapeutic relationship. It is important that therapists are aware of how they feel towards a client (countertransference), and how these feelings might impact the way in which they communicate through body language, tone of voice, and behaviors. Effective therapists are willing to seek their client’s perspectives, and are open and non-defensive about what a client has to say about the therapy or therapist, even if negative. Therapist openness to feedback will inevitably lead to a stronger relationship and collaboration with the client, and to better outcomes for the client.

Owen, J., Tao, K. W., Imel, Z. E., Wampold, B. E., & Rodolfa, E. (2014). Addressing racial and ethnic microaggressions in therapy. Professional Psychology: Research and Practice, 45(4), 283–290.

Overt forms of racism and prejudice still occur in society, and less overt forms are likely more prevalent. Microaggression are those less overt forms of racism and prejudice that may include direct and indirect insults, slights, and discriminatory messages. Specific types of microaggression are: microinvalidations (e.g., denying that racism exists), microassaults (e.g., direct racism but done in private), and microinsults (e.g., believing a group’s cultural norms are pathological). Microaggression are by definition ambiguous and subtle, and they may target culture, race, gender, sexual orientation, and other group identities. Microaggressions are associated with psychological distress in the recipient. Microaggressions can also occur in therapy if a patient perceives a therapist’s dismissing or negating messages about the patient’s culture, or if a therapist engages in culturally inappropriate interventions. Microaggressions represent a special type of therapeutic alliance rupture that could lead to negative patient outcomes. It is also possible that therapists and clients who address microaggressions after they occur are capable of repairing the alliance rupture and moving forward with a stronger relationship. However, there is very little research of the impact of client perceived microaggressions on the therapeutic alliance. In this unique study, Owen and colleagues asked 120 racial and ethnic minority university counselling centre patients treated by 33 different therapists (23 of whom were White) to rate their experience microaggressions, to indicate if the microaggression was discussed, and to rate the therapeutic alliance. In total, 53.3% of patients experienced a microaggression in therapy, and of those patients, 68.4% were treated by a racial or ethnic minority therapist. Clients who reported fewer microaggressions also reported stronger therapeutic alliances (r = .28, p = .01). Of the patients who reported a microaggression, only 24% (13 patients) reported that the microaggression was discussed by the therapist. Of these 13 patients, almost all (12 patients) reported that the discussion was successful. Therapist and patient dyads who successfully discussed the microaggression: (1) had alliance scores comparable to patients who did not experience a microaggression, and (2) had alliance scores that were significantly higher than dyads who experienced but did not discuss the microaggression.

Practice Implications

Microaggressions appear to be ubiquitous in daily life and in psychotherapy – no therapist is immune. More than 53% of patients in this study reported a microaggression, despite what was likely their therapists’ good intentions. Microaggression are a special case of therapeutic alliance ruptures, which are known to be associated with poor patient outcomes. Therapists must develop a strong multicultural orientation and take a culturally humble stance with clients from a different culture or group. This involves therapists being attuned to the possibility of committing a microaggression, inviting patients to alert the therapist should a microaggression occur, and being open to clarifying misunderstandings and owning missteps.

Courtois, C. A. & Brown, L. S. (2019). Guideline orthodoxy and resulting limitations of the American Psychological Association’s Clinical Practice Guideline for the Treatment of PTSD in Adults. Psychotherapy, 56(3), 329-339.

Recently the American Psychological Association (APA) published clinical practice guidelines for the treatment of post-traumatic stress disorder (PTSD). The reaction from the clinical community that treats those with PTSD, client groups, and from many academic and research quarters was swift and negative. APA received almost 900 comments in their public consultations from many who felt the document was overly prescriptive, overly symptom-focused, and narrow in its recommendations. In this interesting inside look at the process, the Chair of the PTSD Practice Guidelines Committee (Christine Courtois) and a senior member of the Committee (Laura Brown) wrote a scathing commentary of the process imposed on them by APA that constrained the Committee’s access to information which affected their decisions. The Committee was bound by APA’s use of the Institute of Medicine (IOM) rules for developing practice guidelines. In other words, a psychological organization (APA) used a biomedical model to define what is relevant research, how to define treatment, what is an appropriate outcome, and how to decide on recommendations. As a result, the APA Committee reached several conclusions/decisions that were biased or premature. First, they defined PTSD only by its symptom presentation and not for the complex disorder that it is. In other words, PTSD was viewed almost exclusively from within a framework that defined it as only a fear-based response to a stressor. Such an approach downplays any developmental or attachment-related factors in the genesis or maintenance of PTSD. Second, the Committee was instructed to ignore a vast array of research on therapist factors, relationship factors, and client factors in psychotherapy. This runs counter to many clinicians’ views that one cannot engage in technical interventions related to PTSD symptoms without the patient experiencing a heightened sense of security in their relationship with the therapist. This also meant that the Committee largely ignored cultural and diversity factors. Third, the treatment recommendations focused on time-limited exposure-based interventions – which is a natural outcome of the first two decisions (i.e., seeing PTSD as only fear-based, ignoring issues of development, and ignoring relational factors in the treatment context). The authors were also disappointed that the APA ignored its own policy on evidence-based practice that puts equal weight on research, clinician expertise, and client factors when making clinical decisions. In the end the authors clearly were not confident in the narrow focus of the Clinical Practice Guideline, and they were concerned that clinicians, researchers, policy makers, and third party funders could misuse the Guideline to limit research, theory, and funding.

Practice Implications

In this extraordinary piece, the Chair and a senior committee member of the PTSD Practice Guideline Committee were highly critical of the process and outcome of APA’s effort to develop clinical practice guidelines for PTSD. The authors did not diminish the importance of exposure-based interventions for PTSD, however they did argue that these interventions must be offered only after clinicians take a sufficient amount of time to create a clinical context characterized by clients experiencing heightened safety in the therapeutic relationship, and to into account client preferences and culture. Further, clinicians should be highly sensitive to attachment-related insecurities and developmental traumas that may lengthen the treatment and that may have a complicating impact on the therapeutic relationship.

Norcross, J. C., & Wampold, B. E. (2019). Relationships and responsiveness in the psychological treatment of trauma: The tragedy of the APA Clinical Practice Guideline. Psychotherapy, 56(3), 391-399.

The American Psychological Association’s (APA) Clinical Practice Guideline for Posttraumatic Stress Disorder in Adults published in 2017 was met with a great deal of concern and criticism by the community of scholars and practitioners working with patients with PTSD. A key concern was that the APA used a biomedical model and not a psychological or contextual model in guiding their understanding of PTSD, their approach to what constitutes evidence, and to decisions about recommended treatments. In particular, the biomedical approach focuses almost exclusively on treatment methods, and down-plays the context of treatment (i.e., the relationship, patient factors, and therapist responsiveness). In this critique, Norcross and Wampold highlight the flaws in the APA Clinical Practice Guideline for PTSD, and the authors focus specifically on those variables that are known to predict patient outcomes but that were ignored by the Guideline. Norcross and Wampold highlighted that there exists numerous meta analyses that demonstrate that all bona fide psychotherapies work about equally well for trauma, and that the particular treatment method has little impact on PTSD outcomes. Yet, the restrictive review process undertaken by APA all but ignored this well-established finding. Also ignored was the research on the importance of the therapeutic relationship in the treatment of trauma. One review outlined nineteen studies that found that the therapeutic alliance was associated with or predicted reduction in PTSD symptoms. This is consistent with the general psychotherapy research literature, in which the alliance is the most researched and most reliable factor related to patient outcomes. Also missing from the PTSD Guideline was reference to a large body of research on therapist responsiveness to patient characteristics. Patients are more likely to improve if their therapists can adapt to the patient’s coping style, culture, preferences, level of resistance, and stage of change. In one study of cognitive-processing therapy (CPT; a treatment recommended by the APA Guideline), there were substantial differences between therapists in their patient’s PTSD symptom outcomes. That is, some therapists reliably were more effective than others, even though all therapists were trained in and supervised in providing the same manualized evidence-based treatment. Among the identified skills of the most effective CPT therapists were: a flexible interpersonal style, and an ability to develop and maintain a good therapeutic alliance across patients.

Practice Implications

There is growing consensus that the APA Clinical Practice Guideline for PTSD are based on dubious methodology and are of limited use to therapists and their patients with PTSD. Psychotherapists should practice a bona-fide therapy for PTSD, but should do so by taking into account the treatment context. In other words, more effective therapists are good at developing, maintaining, and repairing the therapeutic alliance across a range of patients. Effective therapists can also respond and adapt to patient characteristics such as level of resistance, coping style, culture, and stage of change. And so, even when providing a treatment based on the APA Guideline, therapists should nurture trust in the therapeutic relationship and be adaptive to their patients’ characteristics.

Friedlander, M. L., Escudero, V., Welmers-van de Poll, M. J., & Heatherington, L. (2018). Meta-analysis of the alliance–outcome relation in couple and family therapy. Psychotherapy, 55(4), 356-371.

In individual psychotherapy the therapist’s tasks include to develop an alliance with one patient. Goals and tasks of therapy need to be collaboratively negotiated, and therapists need to develop an emotional bond with the patient. The alliance also has to be nurtured continuously throughout treatment. This process is more complicated in couple and family therapy. Only in couple and family therapy (and in group therapy) does a therapist have to develop an alliance with multiple people simultaneously. The challenge is greater when family members are in conflict, or when the therapist’s alliance is stronger with one member than another. Such “split” alliances can be problematic especially when family members view their experiences of the therapist differently. To complicate things more, therapists have to be aware of the alliance within the family or couple system. That is, are the family members allied with each other – do they agree on therapy goals and tasks, and are they able to maintain an emotional connection to each other? In addition, just as therapeutic alliance ruptures can occur in individual therapy, so can they occur in couple and family therapy. An alliance rupture may occur when a there is a “split” alliance or when a patient responds to the therapist or other family members with confrontation or withdrawal behaviors. In this meta-analysis of therapeutic alliance in couple and family therapy, Friedlander and colleagues included 48 studies with a total of 2,568 families and 1,545 couples. The correlation between quality of the alliance and outcome was significant (r = .297, 95% CI [0.223, 0.351], p < .001), indicating that a stronger alliance was related to better outcomes. There was some evidence of publication bias suggesting that this estimate may be over-inflated, but even after adjusting for publication bias the correlation was still significant. The correlation between split alliances and outcome was also significant (r = .316, 95% CI [0.157, 0.458], p < .001), indicating that more split alliances contributed to poorer outcomes. The correlations were similar in strength both in couple and in family therapy, and the alliance was important in all therapeutic orientations. However, correlations were larger when the targeted child in the family was younger, and when families were seeking help and not mandated.

Practice Implications

Like in individual therapy, the therapeutic alliance in couple and family therapy is important to improve the outcomes of patients. Regardless of therapeutic orientation, therapists must spend time and effort developing therapeutic alliances with each member of the system, and must try to maintain relatively equal alliances with each family member to avoid splits in the alliance. Therapists should be particularly aware of any confrontation and withdrawal behaviors towards the therapist or within the family or couple as these may indicate an alliance rupture. In such instances, therapists should emphasize shared goals and feelings, validate the common struggle among family members, and focus on the emotional bond with the disaffected patient. Each person’s alliance matters, and family member alliances are not interchangeable. Assessing the alliance with each member throughout therapy will identify potential problems and facilitate better outcomes.