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.
…I blog about CBT, negative effects of psychological interventions, and what people want from therapy.
Type of Research
- ALL Topics (clear)
- Alliance and Therapeutic Relationship
- Anxiety Disorders
- Attendance, Attrition, and Drop-Out
- Client Factors
- Client Preferences
- Cognitive Therapy (CT) and Cognitive-Behavioural Therapy (CBT)
- Combination Therapy
- Common Factors
- Depression and Depressive Symptoms
- Efficacy of Treatments
- Feedback and Progress Monitoring
- Group Psychotherapy
- Illness and Medical Comorbidities
- Interpersonal Psychotherapy (IPT)
- Long-term Outcomes
- 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
- Therapist Factors
- Transference and Countertransference
- Trauma and/or PTSD
- Treatment Length and Frequency
The Partners for Change Outcome Monitoring System
Duncan, B. L., & Reese, R. J. (2015). The Partners for Change Outcome Management System (PCOMS): Revisiting the client’s frame of reference. Psychotherapy, 52(4), 391-401.
Generally, psychotherapy is effective for a wide variety of disorders, but regardless, many clients do not benefit. Further, the research shows that some therapists are more effective than others, but therapists tend to grossly over-estimate their effectiveness. In one large survey, therapists reported that their outcomes were better than 75% of their peers, no therapist rated themselves as below average, and therapists tended to over-estimate their effectiveness and under-estimate client deterioration. One way to evaluate patient outcomes and processes is to engage in progress monitoring and feedback. This involves repeated brief assessments of client outcomes followed by real-time feedback to therapists to gauge client progress and signal potential problems. Several such systems exist including the Outcome Questionnaire-45.2 and the Partners for Change Outcome Management System (PCOMS). The PCOMS is made up of the Outcome Rating Scale (ORS) and the Session Rating Scale (SRS). The ORS measures distress in 3 atheoretical domains (personal, family, social) not based on diagnosis. The SRS is a measure of therapeutic alliance. Both the ORS and SRS are very short 4-item scales that can be administered before (ORS) and after (SRS) each session of therapy. In this paper, Duncan and Reese review the research supporting the use of the PCOMS. A meta analysis found that clients whose therapists received feedback with the PCOMS were 3.5 times more likely to experience reliable change and had less than half the chance of experiencing deterioration. Five randomized controlled trials demonstrated the advantage of the PCOMS over treatment as usual, including by reducing drop outs and achieving reliable change in fewer sessions.
A lot of research has demonstrated that most therapists over-estimate their effectiveness and that many are not able to identify clients who are getting worse. It is time for therapists to acknowledge this positive bias of their effectiveness and their need for quality information in order to make good clinical decisions. Progress monitoring and feedback systems are one means by which therapists can receive quality information. The repeated use of the PCOMS for example, can help to identify when clients begin to deteriorate and/or when problems emerge with the therapeutic alliance. Being able to identify these issues early may allow therapists to act quickly to avert client deterioration or drop out.
Why Therapists Tend Not To Use Progress Monitoring
Miller, S. D., Hubble, M. A., Chow, D., & Seidel, J. (2015). Beyond measures and monitoring: Realizing the potential of feedback-informed treatment. Psychotherapy, 52(4), 449-457.
Progress monitoring is the process of repeatedly assessing client functioning with validated measures and providing feedback to therapists. The feedback is designed to identify problems with the therapeutic relationship or with client deterioration by comparing client progress to similar clients. This allows therapists to change what they are doing, renegotiate aspects of therapy, or directly address the issues. Research is clear that progress monitoring significantly increases the proportion of clients who improve, reduces drop outs by a third, shortens the length of therapy, and reduces costs. Yet the research also indicates that only 12% of psychologists are using progress monitoring in their practice. If progress monitoring is so useful, then why aren`t more therapists using it? In this review, Miller and colleagues discuss some of the barriers and problems with using or adopting progress monitoring in clinical practice. They describe that even in the most favorable circumstances, it takes about two decades for new treatments to be integrated into routine care. Another issue is that recent surveys indicate that only about 33% of psychologists and 66% of training directors are aware of progress monitoring. Even for those who are aware, a common barrier might be cost and time to implement the procedures. Despite the brevity and low cost of the tools, like the PCOMS, they all place an additional burden on clinicians’ busy schedule. There is also the issue of staff turnover. As staff come and go, organizations may lose those who lead, train, and support the use of progress monitoring. Probably the biggest barrier is skepticism on the part of clinicians who might see the tools as too superficial, or who might be concerned that repeated measurement may somehow negatively affect the therapeutic relationship. However, research indicates that clients generally report positive experiences – they like being a more integral part of the assessment process, and they appreciate the ability to track their own progress. Finally, whereas clinicians may use progress monitoring to improve clinical decision-making, administrators may see it as a means of conducting performance reviews.
In most health care fields, it can take 20 years for an innovation to make it into routine practice. That might be the case for progress monitoring. More clinicians need to know about it, be trained in its use, and see for themselves that the information is valid, of high quality, and that it can supplement their work in identifying clients who are not doing well. In particular, progress monitoring may be a means of enhancing the therapeutic alliance as it provides therapists and clients a vehicle to discuss how the therapy is going, what needs focus, and what to do if things go awry. Organizations need to treat progress monitoring as a means of helping therapists to improve their skills, and not as a means of auditing performance. Therapists need quality information upon which to make sound clinical decisions, and progress monitoring is one way of receiving this information.
Do Common Factors Matter in Psychotherapy?
Cuijpers, P., Driessen, E., Hollon, S. D., van Oppen, P., Barth, J., & Andersson, G. (2012). The efficacy of non-directive supportive therapy for adult depression: a meta-analysis. Clinical psychology review, 32(4), 280-291.
The research evidence indicates that there is very little difference between different types of psychotherapy (CBT, IPT, PDT, EFT, and others) in patient outcomes, especially for depression. Nondirective supportive treatment (NDST) also shows positive outcomes for various disorders. NDST is often used as a “placebo” condition in psychotherapy trials to control for common or non-specific factors. Common factors refer to those aspects that are common to all therapies, but that are not specific to any one therapy (e.g., therapist interpersonal skills, therapeutic alliance, client expectations). NDST does not involve specific therapeutic interventions like cognitive restructuring, transference interpretations, two-chair techniques, etc. In this meta analysis, Cuijpers and colleagues assessed those randomized controlled trials for depression in which specific treatments (e.g., CBT, PDT, IPT, EFT) or no treatment control conditions were directly compared to NDST. By doing so, the authors were able to estimate how much of patient outcomes were attributable to: specific effects of treatments (the difference between a specific intervention and NDST), common effects of treatment (the difference between NDST and no treatment), and extra-therapeutic factors (the effects of no treatment). The meta analysis included 31 studies with over 2500 patients with depression. Twenty-one comparisons included CBT, and the rest included IPT, PDT, or EFT. NDST was significantly less effective than other specific therapies (e.g., CBT, IPT, PDT, or EFT) at post-treatments g = −0.20 (95% CI: −0.32 to −0.08), but the effect was quite small. The difference between NDST and CBT alone (the most researched treatment type) was not statistically significant. Interestingly, when the authors controlled for researcher allegiance (an indication of which treatment was preferred by the researcher), the superior effects of specific treatments over NDST disappeared. NDST was significantly more effective than no-treatment, and the effect was moderate, g=0.58 (95% CI: 0.45–0.72). Pre- to post-treatment change in symptoms in the control condition was statistically significant, g = 0.39 (95% CI: 0.03–0.74), indicating the positive effects of extra-therapeutic factors on depressive symptoms (e.g., events in the patient’s life not related to therapy). Overall, the authors were able to estimate that almost 50% of patient outcomes could be attributed to common factors (therapist interpersonal skills, therapeutic alliance, client expectations, etc.), about 17% was due to specific therapy techniques (cognitive restructuring, two chair techniques, IPT interventions), and about 33% was due to extra-therapeutic factors (e.g., the natural course of depressive symptoms or other events in the patient’s life).
Factors like therapist interpersonal skills and managing the therapeutic relationship appear to account for most (50%) of why patients with depression get better. The specific interventions based on therapy models like CBT account for relatively less of patient outcomes (17%). The natural course of the disorder and other events in patients’ lives account for about a third of patient improvement. Therapists can learn how to maximize the effects of common factor skills through deliberate practice and training to identify and repair alliance ruptures to help their patients get better.
What Do Patients Value in a Psychotherapist?
Boswell, J. F., Constantino, M. J., Oswald, J. M., Bugatti, M., Goodwin, B., & Yucel, R. (2018). Mental health care consumers’ relative valuing of clinician performance information. Journal of Consulting and Clinical Psychology, 86(4), 301-308.
Research has shown that some therapists are more effective than others both in terms of their overall effectiveness and in terms of their effectiveness with specific patient problems. Further, despite advances in medicine on this topic, there is little or no information provided to patients about a therapist’s track record on overall effectiveness. In any case, little is known about what patients value in psychotherapists and how much they are willing to give up in order to get what they value. For example, do patients prefer therapists who are highly effective for most problems, and would they be willing to tolerate a poorer therapeutic relationship in order to work with such a highly effective therapist? In this study, Boswell and colleagues employed a relative valuing procedure often used in economics to assess the relative value to patients of different therapist characteristics and performance. Patients were asked how much they were willing to give up on one therapist characteristic (therapist’s overall effectiveness with clients [i.e., overall track record]) in order to receive more of some other characteristic (therapist specific effectiveness in a problem domain, a better therapeutic alliance, lower cost of therapy). The study included 403 patients treated in mental health clinics in the U.S. Patient characteristics were typical of those seen in such clinics – predominantly they had problems with depression or anxiety, were 41 years old on average, mostly women (68.5%), and receiving individual psychotherapy (89.3%). In general, patients highly valued a therapist with a track record of general overall effectiveness. However, patients were willing to give up more of their therapists overall effectiveness if the therapist had a track record of successfully treating their specific problem (e.g., therapist A has lower general efficacy but has demonstrated greater specific efficacy for depression). Patients were also willing to sacrifice therapist general effectiveness in order to pay less for therapy (vs paying a higher fee for a more effective therapist), and in order to work with a provider with whom they would have a better therapeutic alliance (vs a lower alliance with a more generally effective therapist). Surprisingly, patients placed a lower value on factors like therapist gender and race. Younger patients put greater value on therapist performance data (i.e., their track record data), suggesting a generational effect in which younger clients tend to prefer to make decisions based on available data.
Patients were willing to give up some therapist general effectiveness in order to work with someone who has a track record of being effective for their specific problem, who costs less, and with whom they could have a better therapeutic alliance. Fortunately, therapist general efficacy and domain specific efficacy tend to be highly correlated, and so patients may not have to choose between these. The findings also suggest that patients may be willing to see a therapist who is less generally effective if it meant they could have a good relational experience with the therapist. Research indicates that therapists are able to improve their outcomes and therapeutic alliances with additional training and deliberate practice.
Burnout in Psychotherapists
Simionato, G. K., & Simpson, S. (2018). Personal risk factors associated with burnout among psychotherapists: A systematic review of the literature. Journal of Clinical Psychology. Advance online publication.
Burnout is an important factor in work-related problems for psychotherapists. Burnout is defined as a type of stress associated with feelings of exhaustion, disconnection, and self-doubt related to emotionally involved work in helping professions. Maslach described burnout as being composed of three factors: emotional exhaustion (personal and emotional fatigue at work), depersonalization (negative feelings about clients and the work), and a reduced sense of personal accomplishment (low personally related work successes). Psychotherapists are inclined to burnout because of the emotionally taxing work during which they must remain empathic. In order to protect themselves and conserve energy, psychotherapists may detach from clients, which may lead to a lower sense of work satisfaction and work accomplishments. High levels of burnout reduce a psychotherapist’s ability to take care of themselves and their clients. In this systematic literature review, Simionato and Simpson found 40 studies that empirically examined burnout among psychotherapists and the possible correlates or causes. Results of the 40 articles represented almost 9,000 therapists. Over 54% of therapists reported moderate to high levels of stress related to burnout. On average, therapists reported moderate to high levels of emotional exhaustion, depersonalization, and low personal accomplishment. Younger age was the most frequently identified risk factor for psychotherapist burnout, as was over-involvement with client problems. The authors suggested that the association between burnout and being younger may be due to being less experienced and to higher levels of unattainable standards for clinical practice and client outcomes. In addition, being female was associated with higher reported levels of burnout. This may be due to stress related to women having to juggle demands of both work and domestic responsibilities. Young clinicians are more likely to have young families, and women may be particularly prone to work-life conflict while managing the demands of both.
Over half of psychotherapists reported moderate to high levels of burnout that could affect their work, their clients’ outcomes, and their personal well being. Training programs might facilitate self-awareness and the capacity for psychotherapists to reflect on their personal strengths, limitations, and maximum workload capacity in order to find the best fit between their personality, circumstances, and job demands. Practicing therapists might consider personal therapy to help cope better with demands of work and home life. Surveys of psychotherapists consistently showed that about 70% have sought psychotherapy at some point in their careers.
Therapist Characteristics That Affect Client Outcomes
Lingiardi, V., Muzi, L., Tanzilli, A., & Carone, N. (2017). Do therapists' subjective variables impact on psychodynamic psychotherapy outcomes? A systematic literature review. Clinical Psychology & Psychotherapy. Advance online publication.
Psychotherapists differ in their effectiveness such that some therapists are more effective than others, and these differences account for up to 9% of client outcomes. Despite this, not many studies have looked at therapist personal characteristics that might be associated with better or worse outcomes. In this systematic literature review, Lingiardi and colleagues focus on empirical studies of psychodynamic therapists and their personal characteristics that might affect therapeutic processes and client outcomes. The authors included only quantitative studies. Thirty studies representing nearly 1,400 therapists and 6,000 clients were included in the review. Most studies occurred in a naturalistic setting, and most therapists were female (66%) with an average of over 9 years of experience. The studies looked at various therapist personal characteristics and their association with therapeutic processes and client outcomes. Therapist attachment security (ability to engage in meaningful loving relationships and adaptively manage emotions) was associated with better client outcomes. Similarly, therapists who reported better experiences of parental care and better quality relationships with attachment figures tended to have clients who rated a more positive therapeutic alliance. In addition, therapist interpersonal functioning was evaluated in several studies. Therapists who were rated as more affiliative (warm, friendly) and less hostile (cold, rejecting) tended to have clients who achieved better outcomes. Further, therapist facilitative interpersonal skills (emotional expressiveness, verbal fluency, warmth, empathy) were associated with better client outcomes in short-term therapy. Finally, several studies assessed therapist self-concept (stable means by which one treats oneself). Therapists who were more hostile or negative toward the self tended to be more critical or ignoring of clients, which lead to poorer client outcomes.
Therapist personal characteristics (attachment security), interpersonal skills (warmth, friendliness, empathy), and self concept (how one treats oneself) may account for why some therapists are more effective than others. Problems in these areas might lead to problematic countertransference (emotional reactions on the part of therapists triggered by client issues) or therapeutic alliance ruptures, both of which are related to poorer client outcomes. Therapists can learn methods of managing countertransference and repairing alliance ruptures. If the personal characteristics are persistent and problematic, therapists might consider personal therapy.