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 therapist empathy, psychotherapeutic treatment for borderline personality disorder, and research on psychological treatment of depression.
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
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 (7th 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 (7th 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.
Multicultural Competence and Orientation
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 (7th ed.). Wiley. Chapter 7.
Therapist multicultural competence is a commitment to increasing one’s knowledge of patient’s cultural background, tailoring interventions to a patient’s culture, and understanding the impact of one’s own cultural background. Multicultural competence research has looked at its impact on clinical interactions. In a meta-analysis of 15 studies, therapist multicultural competence was associated with lower levels of patient drop-out from therapy (r = 0.26) and with greater patient improvement (r = 0.24). An interesting finding of these meta-analyses is that whereas patient ratings of a therapist’s multicultural competence was significantly associated with better patient outcomes (r = 0.38), therapist ratings of their own multicultural competence was not significantly associated with outcomes (r = 0.06). In other words, if one is interested in a therapist’s multicultural competence then one should ask the patient, not the therapist. A related but broader concept is multicultural orientation. The multicultural orientation framework is not so much a theoretical approach but a “way of being” for a therapist. The three aspects of multicultural orientation include cultural humility (in which a therapist takes an open and curious stance towards the patient’s identities), cultural opportunities (in which the therapist actively explores a patient’s cultural beliefs and values), and cultural comfort (or the extent to which a therapist feels at ease working with cultural dynamics). A systematic review of multicultural orientation theory identified 9 articles that found that therapist cultural humility was associated with better therapeutic alliances, fewer in-session microaggressions, and greater patient improvement.
Practice Implications
The research on multicultural competence suggest that therapists should regularly assess a patient’s cultural identities for adapting the therapeutic approach. This assessment should focus on the patient’s, not the therapist’s, evaluation of the therapist’s multicultural competence. It is also important for therapists to build their knowledge of specific cultural groups when tailoring their treatments. Regarding a multicultural orientation, it appears that a therapist’s cultural humility is critically important. That is a therapist who is open, non-defensive, and curious regarding a patient’s identities will be most helpful to patients of various cultures.
March 2022
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 (7th 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.
February 2022
What Have We Learned from Practice-Research Networks?
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 (7th 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.
Psychological Therapies for Culturally Diverse Populations
Barkham, M. & Lambert, M.J. (2021). The efficacy and effectiveness of psychological therapies. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7th ed.). Wiley. Chapter 5.
Psychological therapies are culturally bound practices with certain values built into them. For example, common therapies prize independence in patients and rapport in the therapeutic relationship. However, some cultures may value community rather than independence, and respect rather than rapport. In this part of the chapter, Barkham and Lambert ask: what is the effect of a conventional psychotherapy that is based on the values of a dominant culture when applied to a different ethnic or racial group? In one small meta-analysis of 9 and 16 studies, culturally adapted interventions were significantly more effective than unadapted interventions g = 0.52 (95% CI [0.15, 0.90]) and resulted in close to 5 times greater odds of remission. Adaptation usually refers to incorporating some cultural practices into the therapy, adapting the language of the therapist, or providing a therapist who is from the same culture as the patient. Similarly, there is research on the effects of a multicultural competency and multicultural orientation of the therapist. These competencies refer to therapists who learn about a patient’s culture, use culturally relevant treatment strategies, and are aware of their own assumptions and biases regarding the patient’s culture. A meta-analysis of 18 studies reviewed the impact of a therapist’s multicultural competence on various aspect of therapy. Therapist multicultural competence accounted for 37% of the working alliance, 52% of patient satisfaction, 38% of a patient’s perception of therapist competence, and 34% of depth of the session. However, therapist multicultural competence accounted for only 8% of patient outcomes. More recently, some authors have discussed the importance of multicultural orientation, which refers to a therapist’s cultural humility as an attitude towards the patient’s culture, a therapist’s willingness to explore the patient’s racial and cultural identities, and the therapist’s comfort with cultural diversity.
Practice Implications
The research on the impact of psychotherapy on diverse patient populations is still rather small, but some practice implications can be gleaned. Adapting therapies to the patient’s culture and identity likely will improve patient mental health outcomes. The adaptation might include incorporating cultural practices, metaphors, and values into the therapy, and providing therapy in the language of the patient, or finding a therapist from the same cultural background as the patient. Similarly, there is evidence that therapists who are multiculturally competent (learn about the patient’s culture and checks their own biases) can provide a deeper therapeutic experience for their patients. Emerging research on therapist multicultural orientation suggests that a therapist’s cultural humility, willingness to engage in cultural conversations, and comfort with diverse cultures may lead to better experiences of therapy for their patients.