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Handbook of Psychotherapy and Behavior Change: Starting in March 2013 I will review one chapter a month from the Handbook of Psychotherapy and Behavior Change in addition to reviewing psychotherapy research articles. Book chapters have more restrictive copy right rules than journal articles, so I will not provide author email addresses for these chapters. If you are interested, the Handbook table of content and sections of the book can be read on Google Books.

Crits-Christoph, P., Connolly Gibbons, M.B., & Mukherjee, D. (2013). Psychotherapy process-outcome research. In M.E. Lambert (Ed.), Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change, 6^th Edition (pp. 298-340). New York: Wiley.

In their chapter in the Handbook, Crits-Christoph and colleagues (2013) review research in which psychotherapy processes are related to patient outcomes. I reported in the July 2013 PPRNet Blog that therapeutic alliance is reliably correlated with treatment outcomes in a variety of disorders and treatment types. Alliance refers to an agreement on tasks and goals of therapy, and the bond between therapist and client. The common assumption is that alliance is a necessary condition that in part causes change in client symptoms. However therapeutic alliance studies tend to be correlational, that is, the studies show a relationship but the study designs do not allow one to say that alliance causes good outcomes. What if the opposite were true; what if early experiences of symptom reduction caused the therapeutic alliance to improve? If that were the case, then alliance would be an artificial and not particularly important aspect of psychotherapy. Crits-Christoph and colleagues (2013) review the literature on this topic. Some studies of cognitive behavioural therapy (CBT), for example, found that prior change in symptoms predicted later therapeutic alliance, but prior alliance did not predict later symptom change. In a more sophisticated study, Crits-Christoph and colleagues (2011) found that previous change in the alliance was related to later change in outcomes, but not vice versa. In the same study, the authors noted that measuring patient alliance at a single early session accounted for only 4.7% of the outcome variance at post treatment, whereas averaging assessments of alliance across 6 early sessions accounted for almost 15% of the outcome variance. In other words, averaging assessments across many sessions produced a more dependable measurement of alliance. Several studies now report a reciprocal relationship between alliance and outcome, indicating that change in alliance and change in outcomes across therapy sessions progress in a mutually reinforcing spiral. That is, early change in alliance causes subsequent change in outcome, which in turn results in further change in alliance, which precipitates more change in symptoms, etc. The review by Crits-Christoph and colleagues (2013) also noted that the importance of alliance seems to be greater for patients with a disorder like depression, compared to anxiety disorders.

Practice Implications

Developing an early alliance with a client is related to treatment outcomes. Measuring alliance repeatedly (not just once) will give the best indicator of the state of the therapeutic relationship. Patients and therapists who have a genuine liking for each other, who agree on how therapy will be conducted and on the goals of therapy will improve the chances that psychotherapy will be successful. Alliance and symptom change may work together throughout therapy so that improvement in one will cause change in the other on an ongoing basis across therapy sessions. Alliance may be particularly important for patients with depressive disorders that are characterized by isolation from others, loneliness, and low self esteem.

Handbook of Psychotherapy and Behavior Change: Starting in March 2013 I will review one chapter a month from the Handbook of Psychotherapy and Behavior Change in addition to reviewing psychotherapy research articles. Book chapters have more restrictive copy right rules than journal articles, so I will not provide author email addresses for these chapters. If you are interested, the Handbook table of content and sections of the book can be read on Google Books.

Bohart, A.C. & Wade, A.G. (2013). The client in psychotherapy. In M. Lambert (Ed.) Bergin and Garfield’s handbook of psychotherapy and behavior change (6^th ed.), pp. 219-257. Hoboken, NJ: Wiley.

Last month I blogged about the section in Bohart and Wade’s (2013) chapter that focused on client symptom severity and motivation. This month I focus on differences between clients and therapists on their perceptions of therapy processes and outcomes. In a previous blog (see June 2013), I reviewed a meta analysis that showed that given two equally effective treatments, clients should be given their preference in order to improve outcomes. Clearly, client perceptions and preferences are important, and perhaps more important than the therapist’s perceptions. Bohart and Wade (2013) reviewed a number of studies that demonstrated this. For example, studies show that client ratings of the therapeutic alliance predicted which therapists had better than average outcomes, whereas therapist ratings of the alliance did not predict outcomes.  In three other meta-analyses, client perceptions of therapist genuineness, empathy, and therapeutic presence were each more predictive of outcomes than the respective therapists’ assessments of their own genuineness, empathy, and therapeutic presence. Clients also value different outcomes compared to therapists and researchers. Most research on outcomes tends to focus on symptom reduction, but clients appear to have a broader view of good outcomes. In a qualitative study, clients focused on healthier relationship patterns, an increase in self-understanding that led to freedom from and avoidance of self-destructive behaviour, and stronger valuing of the self, in addition to symptom reduction. Others report that clients define good outcomes as reengaging in meaningful work and social roles, and restoring their self respect.

Practice Implications

Clients are more finely attuned to the therapeutic alliance than therapists, and perhaps are better at detecting relevant and helpful therapist stances. If you are interested in assessing therapeutic alliance or a therapist’s empathy, don’t ask the therapist, ask the client. This has implications for training therapists in helpful therapeutic relationship stances. Helping trainees find areas for continued development as a therapist (i.e., in terms of improving their empathy, genuineness, and therapeutic presence) may require asking their clients’ opinions. Client perceptions of therapist qualities are more relevant than therapist perceptions when assessing effective therapist relationship stances. Therapists should monitor client preferences, particularly if the client is having difficulty engaging in the therapy. If possible and reasonable, therapists should alter their relationship approach to a client based on client feedback. Regarding outcomes, therapists, researchers, and agencies should consider broader definitions of outcomes that are more aligned with what clients want and value. Improved self concept, improved relationships, and better social and work functioning may be just as important as symptom reduction for most clients.

Handbook of Psychotherapy and Behavior Change: Starting in March 2013 I will review one chapter a month from the Handbook of Psychotherapy and Behavior Change in addition to reviewing psychotherapy research articles. Book chapters have more restrictive copy right rules than journal articles, so I will not provide author email addresses for these chapters. If you are interested, you can read the Handbook table of content and sections of the book on Google Books.

Bohart, A.C. & Wade, A.G. (2013). The client in psychotherapy. In M. Lambert (Ed.) Bergin and Garfield’s handbook of psychotherapy and behavior change (6^th ed.), pp. 219-257. Hoboken, NJ: Wiley.

Last month I blogged about the section in Bohart and Wade’s (2013) chapter that focused on client attachment. This month I focus on other factors like severity of distress and comorbidity, and level of motivation. Some authors argue that client factors predict 30% of variance in outcomes. That accounts for more of psychotherapy outcome than therapist effects and therapeutic techniques combined. Severity of symptoms of anxiety and depression and functional impairment caused by this distress leads to poorer client prognosis. Further, individuals with more severe symptoms need more sessions to show improvement. Some research shows that those with greater symptoms change more than those with fewer symptoms. However, even though those with higher levels of distress show the most change, they are less likely to achieve recovery in which they return to a normal level of functioning. In most cases, clients with comorbid problems are less likely to do well. For example, comorbidity for personality disorder or substance abuse negatively impact outcome. Client motivation is also related to psychotherapy outcomes. Motivation can be internal (those that arise from the individual’s intrinsic interests or values) or external (those that arise from external rewards or punishments). Generally, internal motives (i.e., greater readiness to change) are better predictors of sustained behaviour change. The stages of change model describes readiness to change as occurring in progressive stages that include: (1) precontemplation, in which clients are not internally motivated; (2) contemplation in which clients move to the next stage where they recognize a problem but are not ready to take action; and (3) preparation for action in which clients are more internally motivated to change. The next two stages of the model do not speak to motivation but to action and maintenance of change. Norcross looked at clients’ readiness to change prior to therapy and its relationship to outcome. Greater readiness to change was moderately and significantly associated with better treatment outcomes.

Practice Implications

The results on severity and comorbidity suggest that providers and policy makers must consider increasing the number of treatment sessions to take into account clients who have greater initial severity and comorbidities, especially for those with comorbid personality disorders. Results related to motivation indicate that when client motivation to work in therapy comes from within and they show progress in their readiness to change, they are more likely to do well. Therapists need to find ways of mobilizing clients’ internal reasons for change. Motivational interviewing may be one means of doing so.

Handbook of Psychotherapy and Behavior Change: Starting in March 2013 I will review one chapter a month from the Handbook of Psychotherapy and Behavior Change in addition to reviewing psychotherapy research articles. Book chapters have more restrictive copy right rules than journal articles, so I will not provide author email addresses for these chapters. If you are interested, the Handbook table of content can be viewed on Amazon.

Bohart, A.C. & Wade, A.G. (2013). The client in psychotherapy. In M. Lambert (Ed.) Bergin and Garfield’s handbook of psychotherapy and behavior change (6^th ed.), pp. 219-257. Hoboken, NJ: Wiley.

Some authors argue that client factors account for 30% of variance in outcomes. That represents a greater association to psychotherapy outcome than therapist effects and therapeutic techniques combined. In this part of the Handbook chapter on client factors, Bohart and Wade discuss client attachment. Bowlby found that attachment relationships were important and were different from other relationships. Attachment figures confer a sense of security and safety to infants that allow children to explore their environment and experience the self. Attachment patterns that develop in childhood tend to be stable throughout the lifespan, but attachment style can change with positive (i.e., psychotherapy, romantic relationships) and negative (i.e., traumatic events) experiences. Attachment security is associated with adaptive affect regulation, positive view of self and others, and reflective functioning that is related to mentalizing. Attachment anxiety is associated with maladaptive up-regulation of emotions, positive view of others but negative view of self, and reduced reflective functioning likely due to preoccupation with relationships and emotion dysregulation. Attachment avoidance is associated with maladaptive down-regulation of emotions, negative view of others and positive view of self (or negative view of others and negative view of self in the case of fearful avoidant attachment), and limited reflective functioning due to dismissing of emotions and relationships. There are also disorganized attachment states related to traumatic events. Those with attachment avoidance tend to be distrustful and less likely to seek psychotherapy. A meta-analysis by Levy and colleagues (2011) of 19 studies including 1467 clients found that attachment security was associated with good psychotherapy outcomes and attachment anxiety was negatively associated with good outcomes. No relationship was found for attachment avoidance and outcomes. Diener and Monroe (2011) conducted a separate meta analysis on attachment and therapeutic alliance which included 17 studies with 886 clients. They found that clients with secure attachments had better alliances with their therapist and those with insecure attachments (anxious or avoidant) had weaker alliances.

Practice Implications

The research is clear that client attachment style influences how clients enter therapy, engage with the therapist, and experience outcomes. Attachment style likely affects specific therapy behaviors like self-disclosure and amount of exploration. In his book Attachment and Psychotherapy, David Wallin (2007) translates attachment theory into a framework for adult psychotherapy by tailoring interventions to specific attachment styles. For example, clients with greater attachment anxiety may do better in psychotherapy when the therapist: helps with down regulation of client emotional experiences, behaves in a way that does not evoke client fears of abandonment or loss, and helps clients improve reflective functioning by encouraging a thoughtful appraisal of their behaviors. On the other hand clients with greater attachment avoidance may require a therapist who: slowly introduces the client to greater attention to emotional experiences, does not demand too much from the client in terms of closeness in therapy at the outset, and encourages reflective functioning by helping the client understand the association between defensive avoidance of affect and relationship problems.

Lambert, M. J. (2012). Helping clinicians to use and learn from research-based systems: The OQ-analyst. Psychotherapy, 49(2), 109.

One of the more interesting and clinically relevant trends in psychotherapy research and practice in the past 10 years is the emergence of research on continuous progress monitoring. Continuous progress monitoring occurs when a patient is given a standardized self report measure before a session and the results of patient functioning are fed back to the therapist. (This is distinct from a clinician asking a patient for a verbal account of how he or she is doing this week). The standardized self report assessment is often done repeatedly, sometimes before every session or every fixed number of sessions. Measures, such as the Outcome Questionnaire (OQ) for adults or youths, was specifically designed for this purpose. The OQ assesses symptoms, interpersonal functioning, and life functioning, and clients are identified as improving (i.e., on course), or at risk of deteriorating. Recently, a small meta analysis of 3 to 4 studies representing 454 to 558 clients on the effects of progress monitoring found a moderate relationship between monitoring plus feedback and client outcomes. The method is particularly effective in changing the course of outcomes for patients who are deteriorating. Large research reviews of evidence based treatments in randomized controlled trials show that about 40% to 60% of patients improve or recover from psychotherapy, 30% to 50% may not benefit, and 3% to 14% deteriorate (see my March 2013 blog). These proportions are likely less positive in everyday practice in which clients are not highly screened to meet research inclusion criteria. Unfortunately, clinicians’ views of their own client outcomes are unrealistically positive. In one survey, clinicians in routine practice reported that about 85% of their clients improved or recovered. About 90% of therapists rated themselves in the upper quartile and none rated themselves as below average (50^th percentile). Also there is serious doubt about the ability of clinicians to identify clients during the course of therapy, who ultimately deteriorate. In the paper by Lambert on the use of the Outcome Questionnaire (OQ), he reviewed several studies on continuous progress monitoring in everyday practice. Each therapist was asked to practice as they routinely do with half their usual caseload. With the other half of their caseload clients completed the OQ and the therapist received feedback before every session about patient progress. The feedback did not make a difference for clients who made steady progress (i.e., on track) from week to week. However, continuous progress monitoring did make a difference for the 20% to 30% who showed some sign of deteriorating at some point in treatment. Notifying therapists that these patients were in trouble reduced the rate of deterioration from 20.1% to 5.5%, and monitoring and feedback increased positive outcomes from 22.3% to 55.5%.

Practice Implications

Lambert reported that clinicians in these “practice as usual” studies were initially skeptical but quite surprised at the outcomes related to continuous progress monitoring. Standardized assessments appear to get around the problem of clinician over-estimation of their patients’ positive outcomes. Clinicians were able to more accurately identify clients at risk of deteriorating likely resulting in the therapist doing something different to forestall the negative consequences. Lambert argues that it is in the best interest of at-risk patients to have their symptoms, interpersonal functioning, and life functioning formally monitored throughout treatment. However, clinicians are likely to resist doing so because they believe that they are already highly successful, and even more so than the typical outcomes produced by clinical trials. Formal monitoring of client outcomes has little downside for clinicians (it is inexpensive and requires little training), and it has many upsides for clients, especially those who are at risk for deteriorating.

Author email: michael_lambert@byu.edu

Handbook of Psychotherapy and Behavior Change: Starting in March 2013 I will review one chapter a month in the Handbook of Psychotherapy and Behavior Change in addition to reviewing psychotherapy research articles. Book chapters have more restrictive copy right rules than journal articles, so I will not provide author email addresses. If you are interested, the Handbook table of content can be viewed on Amazon.

Lambert, M.J. (2013). The efficacy and effectiveness of psychotherapy. In M.J. Lambert (Ed.) Bergin and Garfield’s handbook of psychotherapy and behaviour change (6^th ed.), pp. 169-218. Hoboken, N.J.: Wiley.

An important issue for patients, therapists, and agencies is the optimal dosage of psychotherapy that is necessary to reduce impairment and improve life functioning. In this part of the Handbook chapter on Efficacy and Effectiveness of Psychotherapy, Lambert tackles the issue of the psychotherapy dose-response relationship by reviewing the existing literature. That literature tends to focus on naturalistic national (U.S.) samples of patients (often N > 6,000) receiving routine care in Health Maintenance Organizations, Employee Assistance Programs, and Community Mental Health Clinics. Outcomes tend to be assessed by patient self report, and can include symptoms, character traits, quality of life, and interpersonal functioning, among others. Lambert defines “improved” patients as those who reliably changed but still are within the dysfunctional range on a measure, and he defines “recovered” patients as those who both reliably improved and were no longer in the dysfunctional range. He concluded that on average 50% of patients who begin treatment in the dysfunctional range achieve recovery following 21 sessions of psychotherapy. On the flip side, half of patients do not achieve recovery after 21 sessions. Almost 50 sessions are necessary for 75% of patients to recover. In other words, there is a rapid rate of recovery in which half of patients recover after 21 sessions, but then the rate of recovery slows down so that it takes up to 50 sessions for an additional 25% of patients to recover. The rates of recovery also differ depending on what is measured. Symptoms (depression, anxiety, etc.) tend to recover more quickly than characterological or interpersonal problems. Further, some patients experience sudden symptom gains in therapy that are long lasting. Between 17% and 50% of patients experience the majority of their symptom improvements within 7 sessions, and these early changes accounted for 50% of total symptom gains in therapy.

Practice Implications

The question of how much therapy is enough is important for practical and theoretical reasons. Research on this topic can help patients, therapists, and agencies make decisions about treatment planning. Research suggests that a sizeable proportion of patients (50%) reliably improve after 7 sessions and a similar percentage recover after 21 sessions. However, limiting treatment to less than 20 sessions will mean that about half of patients will not achieve a substantial benefit from therapy. Session limits need to be assessed carefully depending on how the patient is doing and what outcomes are important or valued. Agencies or clinicians that firmly set limits on the number of psychotherapy sessions that are too low will have the majority of their patients showing some improvement but not recovering.