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Castonguay, L.G., Boswell, J.F., Zack, S., Baker, S., Boutselis, M., Chiswick, N., Damer, D., Hemmelstein, N., Jackson, J., Morford, M., Ragusea, S., Roper, G., Spayd, C., Weiszer, T., Borkovec, T.D., & Grosse Holtforth,, M. (2010). Helpful and hindering events in psychotherapy: A practice research network study. Psychotherapy: Theory, Research, Practice, and Training, 47, 327-344.

There are many reasons why I like this paper, and one reason is that it is a psychotherapy practice research network study (most of the co-authors are independent practice clinicians). This group of clinicians and researchers met on a number of occasions to define the research questions, including: “what do psychotherapists and clients find most and least helpful in a psychotherapy session?”; and “do psychotherapists and clients agree on what was most and least helpful?” The clinicians and researchers also discussed and agreed on the method for collecting and analysing the data. Thirteen independent practice clinicians participated (6 CBT, 4 psychodynamic, and 3 experiental/humanistic). For a period of 18 months, all new clients were invited to participate so that 121 clients with a variety of disorders enrolled in the study. Clients and therapists filled out (on an index card) parts of the Helpful Aspects of Therapy (HAT) measure, which asked them to report, describe, and rate particularly helpful and hindering events from the session they had just completed. For example clients and therapists were asked: “Did anything particularly helpful happen during this session?”; and “Did anything happen during this session which might have been hindering?” When participants answered “Yes” to either of these questions, they were asked to briefly describe the event(s), and then rate them on a scale from 1 to 4 for level of helpfulness or level of hindrance. Both clients and therapists did so at the end of every therapy session. Close to 1500 therapeutic events were recorded by the clients and therapists. The events were then coded and categorized according to type of event by independent raters using an established coding system. Clients rated self-awareness, problem clarification, and problem solution as the most helpful type of events, although self-awareness was significantly the most identified of all helpful events by clients. Therapists rated self-awareness, alliance strengthening, and problem clarification as the most helpful type of events. Therapists identified self-awareness and alliance strengthening significantly more often than any other helpful events. Hindering events were identified much less frequently by clients and therapists. Client identified poor fit (e.g., therapist tried something that didn’t fit the client’s experience) as the most frequent hindering event category. Therapists identified therapist omissions (i.e., failure to provide support or an intervention) as the most frequent hindering event category. Overall, with the exception of self-awareness, therapists and clients did not agree on what were the most helpful or hindering events in therapy.

Practice Implications

Results regarding self awareness indicate that providing clients with opportunities to achieve a clearer sense of their experience (e.g., emotions, behaviors, and perceptions of self) is frequently reported as beneficial by both clients and therapists. The events that therapists most frequently reported as detrimental were those in which they failed to be attuned to their clients’ needs. This may reflect therapists’ concerns with potential alliance ruptures. The overall lack of agreement between therapists and clients on helpful and hindering events raises the question about whether therapists are not aware enough of clients’ experiences, or whether clients are not knowledgeable about what is in fact therapeutic. Perhaps client and therapist ratings of events represent complementary perspectives on what works or does not work in psychotherapy. Regarding participating in research, these independent practice therapists reported that the procedure of writing down helpful and harmful events and reading what their clients wrote after each session had a positive impact on their practice. That is, the process of data collection became immediately relevant to their clinical work.

Author email: lgc3@psu.edu

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.

Forand, N.R., DeRubeis, R.J., & Amsterdam, J.D. (2013). Combining medication and psychotherapy in the treatment of major mental disorders. In M.J. Lambert (Ed.) Bergin and Garfield’s handbook of psychotherapy and behaviour change (6^th ed.), pp. 735-774. Hoboken, N.J.: Wiley.

This comprehensive chapter covers evidence for combining medication and psychotherapy for several disorders. This month I report on the section of the chapter on schizophrenia. Practice guidelines recommend antipsychotic medications as the first line treatment for Schizophrenia. However, up to 30% of individuals show an initial poor response and an additional 30% of patients continue to experience symptoms. Medication side effects can be debilitating, resulting in poor adherence and therefore reduced effectiveness. Further, Schizophrenia spectrum disorders are heterogenous in presentation and course, and so a “one size fits all” approach will not be effective for some or many. Psychotherapies can enhance the effectiveness of medications at different phases of treatment to hasten recovery or reduce medication-resistant symptoms. CBT for schizophrenia was developed to treat persistent medication-resistant positive psychotic symptoms (i.e., positive symptoms refer to delusions, hallucinations, disorganized speech and behaviour; whereas negative symptoms refer to restrictions in: emotions, thoughts, speech, and initiating goal directed behaviors). CBT focuses on reappraising the power and source of hallucinations, evaluating delusions, and addressing motivational deficits. CBT appears to be effective for chronic symptoms of schizophrenia with small to moderate effects, and these effects appear to be enduring. There is currently less and mixed evidence for CBT to speed recovery from first episode psychosis and to improve relapse rates. There is also evidence suggesting the effects of family psychoeducation to reduce relapse and to improve caregiver outcomes. However, family psychoeducation requires the participation of a caregiver, which may be a challenge that limits its utility. There is promising research on multidisciplinary rehabilitation programs that include case management, behaviour management, social skills training, social cognitive training, and cognitive remediation. There is also controversial research on providing psychological interventions alone or in a staged approach (i.e, in which earlier and less severe stages are treated with more benign interventions, and later stages are treated more aggressively with medication). However there are as yet no well-controlled clinical data to support this approach.

Practice Implications

Adjunctive psychosocial treatments appear to improve symptomatic and functional outcomes in individuals with schizophrenia spectrum disorders. CBT is best suited for treating chronic positive psychotic symptoms, but its effect on relapse prevention is equivocal. Individuals who are at risk for relapse might benefit from family psychoeducation, if the caregiver can be engaged. Multidisciplinary rehabilitation programs are a promising avenue of treatment.

Horvath, A.O., Fluckiger, C., Del Re, A.C., & Symonds, D. (2011). Alliance in individual psychotherapy. Psychotherapy, 48, 9-16.

The psychotherapy alliance is probably the most researched concept in psychotherapy. A PsychInfo search of terms including the word “alliance” will turn up over 7000 hits. Although the concept of alliance has been around at least since the 1950s, the commonly acceptable pan-theoretical definition that is currently used was proposed by Bordin in the 1970s. This definition emphasizes the conscious aspects of the collaboration between therapist and client, and involves three elements: agreement on goals, agreement on tasks, and the bond between client and therapist. What is important in terms of developing the alliance is the therapist’s ability to step back from his or her own agenda and emphasize, prioritize, and negotiate the collaborative relationship. This allows for the selection of an intervention that is congruent with client expectations, which then will foster a high level of mutuality. Horvath and colleagues conducted a large meta analysis of alliance - outcome research from the years 1991 to 2009 that included 190 independent studies and over 14,000 participants. The overall relationship between alliance and outcome was statistically significant and moderate in size. This was a highly reliable effect. The results were consistent regardless of which measure was used, who rated the alliance (client, therapist, independent rater), or what type of treatment was studied (i.e., CBT, IPT, Psychodynamic, etc). Similar results were found in separate published meta analyses of child and adolescent psychotherapy and of family and couple therapy, though the effect is larger in couple therapy.

Practice Implications

The quality of the alliance is an index of the level of mutual and collaborative commitment to therapy by the therapist and client. Its distinguishing feature is the focus on therapy as a collaborative enterprise. Establishing a good alliance prevents clients from dropping out, and the sense of collaboration creates a context to introduce new ways of addressing the client’s concerns. In the early phases of therapy, tailoring the methods of therapy (tasks) to suit the specific client’s needs, expectations, and capacities is important in building the alliance. Misjudging the client’s experience of the alliance (i.e., believing that it is in good shape when the client does not share this perception) could render therapeutic interventions less effective. Horvath and colleagues suggest active monitoring the clients’ alliance throughout treatment. Therapists’ nondefensive responses to client negativity or hostility are critical for maintaining a good alliance. Research indicates that therapists who are good at building a strong alliance tend to have better alliances with most of their clients. However, the reverse is also true – some therapists consistently struggle to establish and maintain a good alliance with their clients. The strength of the alliance often fluctuates when therapists’ challenge clients to deal with difficult issues, when misunderstandings arise, and when transference occurs and/or is highlighted. Resolution of these normal variations is associated with good treatment outcomes. The next blog entry discusses research on alliance ruptures and repairs.

Author email: horvath@sfu.ca

Safran, J.D., Muran, J.C., & Eubanks-Carter, C. (2011). Repairing alliance ruptures. Psychotherapy, 48, 80-87.

One of the most consistent findings emerging from psychotherapy research is that the quality of the therapeutic alliance predicts outcome across a range of different treatments, and that a weakened alliance is correlated with dropping out of psychotherapy. Jeremy Safran and his colleagues have characterized a “second generation” of alliance research that attempts to clarify the factors leading to the development of the alliance as well as those processes involved in repairing ruptures in the alliance when they occur. A rupture in the therapeutic alliance is defined as a tension or breakdown in the collaborative relationship between patient and therapist. These could include: disagreement on goals of therapy, disagreements on the tasks of therapy, or strains in the patient - therapist bond. Ruptures may vary in intensity from relatively minor tensions, of which one or both of the participants may be only vaguely aware, to major breakdowns in collaboration, understanding, or communication. Similar concepts include: empathic failure, therapeutic impasse, and misunderstanding event. For example, a therapist returned from holidays to a session with a patient with whom she previously had a good alliance. The patient appeared more sullen, and quieter than usual in this session. The patient rated the alliance lower following the session, and the therapist felt the same. In the next session the therapist asked about the change in the patient and explored reasons for the change. It emerged that the patient’s old feelings of loss and abandonment re-surfaced with the therapist’s absence, and the patient felt resentment when the therapist returned. Examining this pattern resolved the rupture and led to continued gains by the patient especially regarding the relational theme of abandonment. In a small meta analysis by Safran and colleagues, 3 studies representing 148 patients were reviewed. The relationship between rupture-repair episodes and treatment outcomes was significant, though modest. In a subsequent meta analysis of 8 studies representing 376 patients, the relationship between an intervention to repair alliance ruptures and positive outcomes was significant and large.

Practice Implications

A therapist’s non-defensive response to a client’s negative feelings about the therapy is critical to repairing a rupture. Safran and colleagues suggest 6 strategies for therapists to deal with alliance ruptures. (1) Repeating the therapeutic rationale can help to repair a strained alliance. (2) Changing tasks or goals can make the therapy and its objectives more meaningful to the patient. (3) Clarifying misunderstandings at a surface level by acknowledging how the patient might feel misunderstood or criticized by the therapist. (4) Exploring relational themes associated with the rupture, could help the therapist and patient understand the patient’s relational themes and reactions. (5) Linking the alliance rupture to common patterns in the patient’s life, as in the example provided above, allows the patient to change the pattern in the therapeutic relationship. (6) Providing a new relational experience such that the therapist’s non-defensive response and willingness to repair the rupture may be a new and positive experience for the patient leading to a better alliance and laying the groundwork for further change.

Author email: safranj@newschool.edu

Handbook of Psychotherapy and Behavior Change: Starting in March 2013 I will review one chapter a month from thenHandbook 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.

Burlingame, G.M., Strauss, B., & Joyce, A.S. (2013). Change mechanisms and effectiveness of small group treatments. In M.J. Lambert (Ed.) Bergin and Garfield’s handbook of psychotherapy and behaviour change (6^thed.), pp. 640-689. Hoboken, N.J.: Wiley.

Group treatments are the most common types of interventions offered in community, organizational, institutional, and hospital settings. They occur in many contexts including: outpatients, inpatients, day hospital, private practice, community health, support groups, drop-in centres, and educational organizations. Despite the extent of their application, group treatments receive relatively little research attention compared to individual psychotherapy or medication interventions. (Not to mention the pervasive and mistaken notion that group therapy is like doing individual therapy with 8-10 patients at once, or that individual therapy training is sufficient to be expert in group therapy). There are many reasons for this relatively lower amount of research, including the lack of expertise in and understanding of group practice among clinical researchers, and the substantially greater difficulty in running a clinical trial of group therapy (of the latter I have ample experience and war wounds). Nevertheless, Burlingame and colleagues summarized more than 250 studies that estimated the efficacy or effectiveness of group therapy for 12 disorders or populations. The findings indicate good or excellent evidence for the efficacy of group treatments for many disorders or patient groups (e.g., panic, social phobia, OCD, eating disorders, substance abuse, trauma related disorders, coping with breast cancer, schizophrenia, and personality disorders). There are also promising results for other disorders (e.g., mood, pain, and inpatients). Although there are substantially more studies on group CBT, most studies that compare different models (including IPT, psychodynamic, DBT, etc.) often produce equivalent outcomes. There is also lots of evidence that group therapy is as effective as individual therapy or medications for most disorders. In one U.S. study on panic disorder, group psychotherapy was the most cost effective (i.e., cost per rate of improvement) of the interventions ($246) compared to individual therapy ($565) and medications ($447). There is also research on the effects of specific characteristics of groups. For example, research on group composition (i.e., heterogenous vs homogeneous in terms of patient population or functioning) has produced mixed results, though there is emerging evidence that heterogeneous groups tend to benefit those who are lower functioning. Further, research on group cohesion (i.e., the bond between the individual and the group) which is a construct related to but distinct from alliance, is positively associated with treatment outcomes with a moderate effect size.

Practice Implications

Group treatments are as effective as individual therapy or medications, and are likely more cost effective. However group therapy is more complicated to practice and to study. Burlingame and colleagues suggest using empirically validated interventions, and ongoing assessment of client outcomes. They also suggest following the American Group Psychotherapy Association (AGPA) practice guidelines (see the Resources page on our web site), that include best practices for creating a successful group, appropriately selecting clients, preparing clients for group, evidence based interventions, and ethics issues related to group practice. Finally, Burlingame and colleagues emphasize using AGPA recommended measures and resources in developing and assessing a therapy group. These include: (1) group selection and group preparation which may involve handouts for group leaders and members about what to expect and how to get the most from group therapy; (2) assessing group processes repeatedly during group therapy using measures like the Therapeutic Factors Inventory or the Working Alliance Inventory; and (3) measuring client outcomes by using an instrument like the Outcome Questionnaire-45. Repeated measurement and feedback of processes and outcomes to the therapist may improve the group’s effectiveness.

Swift, J. K., Callahan, J. L., Ivanovic, M., & Kominiak, N. (2013, March 11). Further examination of the psychotherapy preference effect: A meta-regression analysis. Journal of Psychotherapy Integration. Advance online publication. doi: 10.1037/a0031423

Client preferences consist of preferences regarding the type of treatment offered (e.g., preference for psychotherapy or medication, preference for a behavioral approach to treatment or an insight oriented one), desires for a certain type of therapist or provider (e.g., preference for an older therapist, a female provider, or a therapist who has a nurturing personality style), and preferences about what roles and behaviors will take place in session (e.g., preference for the therapist to take a listening role or an advice giving role). In a previously published meta analysis Swift and colleagues (2011) reviewed data from 35 studies that compared preference-matched and non-matched clients. A small but significant preference outcome effect was found, indicating that preference-matched clients show greater improvements over the course of therapy, and that clients whose preferences were not matched were almost twice as likely to discontinue treatment prematurely. In this follow up meta regression study, Swift and colleagues assessed whether preference accommodation is more or less important for types of disorders, types of treatments, or different demographics like sex or age. (Meta regression involves accumulating data from across many studies to assess predictors [e.g., sex, age, diagnosis, treatment type, etc.] of the preference effect). For example, some research has indicated that men prefer therapists with more feminine traits and that men prefer pharmacological interventions. But does accommodating these preferences affect outcomes and drop out rates? Is matching preferences essential for younger clients? Is matching preferences more important for women or ethnic minorities? The authors analysed data from 33 studies representing 6,058 clients to address some of these questions. The only variable that predicted the influence that preferences have on rates of premature termination was the length of the intervention. That is, it may be more important to accommodate client preferences for briefer therapies. Perhaps, as clients continue in therapy for longer durations, other variables such as the therapeutic alliance play a bigger role in determining whether or not one drops out prematurely. It is also possible that as treatment continues, clients may experience a shift in preferences to more closely match the treatment conditions that they were given. Once this shift in preferences has occurred, preferences are no longer mismatched, and the risk of dropping out may be diminished.

Practice Implications

This study provides evidence that incorporating client preferences may be important for all types of clients. Generally, when client preferences are accommodated, clients show greater improvements while in treatment and are less likely to discontinue the intervention prematurely. As much as is practical, practitioners might collaboratively work with clients to identify what preferences they hold for treatment, and to discuss those preferences in the context of what is the most effective treatment that is available. This is particularly important for psychotherapies of shorter duration..

Author email: joshua.keith.swift@gmail.com