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.

August 2017

What Characterizes Effective Therapists?

Wampold, B. E., Baldwin, S. A., Holtforth, M. G., & Imel, Z. E. (2017). What characterizes effective therapists. In L.G. Castonguay and C.E. Hill (Eds.) How and why are some therapists better than others? Understanding therapist effects. Washington, DC: American Psychological Association.

The research on therapist effects indicates that some therapists are more effective than others. Previous research showed that therapist characteristics like age, race, ethnicity, gender, and experience are not consistently related to patient outcomes. Neither is therapist competence and adherence to a treatment approach. In this chapter, Wampold and colleagues ask the question: what characterizes effective therapists? The research is complicated because it is difficult to disentangle therapist effects from patient factors. That is, it is possible that some clients (i.e., those who are more motivated, likeable, and psychologically minded) might create favorable conditions for some therapists to be more effective. However, recent advances in statistical methods have allowed researchers to isolate the effects of therapist characteristics from patient factors. Based on this new research, Wampold and colleagues identified four characteristics of effective therapists. (1) The ability to form an alliance across a range of patients. The therapeutic alliance is defined as the agreement on tasks and goals of therapy, and the affective bond between therapist and patient. Alliance is reliably associated with good patient outcomes. Research shows that therapists and not clients are primarily responsible for the alliance-outcome relationship. (2) Facilitative interpersonal skills – which includes verbal fluency, warmth, empathy, and emotional expression. These skills in a therapist are a strong predictor of patient outcomes. (3) Professional self doubt – or healthy skepticism about one’s abilities and skills leading to self-reflective practice has also been found to predict positive patient outcome. (4) Deliberate practice - defined as individualized training activities especially designed to improve specific aspects of an individual’s performance through repetition and successive refinement. The amount of time outside of therapy that therapists engage in improving targeted therapeutic skills predicted patient outcomes.

Practice Implications

Some therapists are better than others - and demographics, professional affiliation, training, and adherence to a manual do not differentiate better therapists. Four factors are emerging as indicators of better therapists. Ability to develop, maintain, and repair a therapeutic alliance is well known to predict patient outcomes and it appears that therapists are largely responsible for the condition of the alliance. Therapists’ ability to be verbal, warm, and empathic is also key to patient outcomes. Professional skepticism about one’s abilities that lead to reflective practice is also an important characteristic in order to continually improve one’s abilities and monitor one’s outcomes. And, finally therapists who spend time outside of therapy deliberately and repetitively practicing skills will achieve better patient outcomes.

June 2017

Is the Alliance Really Therapeutic?

Zilcha-Mano, S. (2017). Is the alliance really therapeutic? Revisiting this question in light of recent methodological advances. American Psychologist, 72, 311-325.

The therapeutic alliance is often defined as the agreement between the client and therapist on the goals and tasks of treatment within the context of an affective bond. The alliance is associated with good treatment outcomes regardless of how it is measured, who measures it, when it is measured, and what type of therapy is offered. But researchers and theorists debate the causal role of the alliance in therapy. Is the therapeutic alliance simply a byproduct of an effective treatment (i.e. people begin feel better in therapy and therefore experience a better alliance)? Or is the alliance a client trait which is a necessary factor that enables effective treatments to work (i.e., some clients are better at developing an alliance which is required for therapeutic interventions to take hold). Or is the alliance a state-like factor that fluctuates over time and is therapeutic in and of itself (i.e., the growth in the alliance by itself is sufficient to induce symptom change). In this review of recent advanced methods to research the alliance, Zilcha-Mano provides an overview of statistics that model the session to session dynamic fluctuations and impacts of growth in the therapeutic alliance. She argues convincingly that for the most part, the alliance is not a byproduct of symptom improvement. Using this advanced methodology research indicates that session by session change in symptoms do not precede change in the alliance. The research supporting trait-like aspects of the alliance indicates that some clients are more adept than others at developing an alliance with their therapists. Therefore an early alliance in therapy indicates a client trait that provides a necessary context for effective therapies to do their work. However, research also shows that the alliance changes dynamically over the course of treatment, and that change in the alliance from a preceding session predicts change in symptoms in subsequent sessions. This indicates that alliance also has state-like elements that dynamically fluctuate and influence outcomes, which provides evidence that this aspect of the alliance is therapeutic in and of itself.

Practice Implications

The accumulating research evidence indicate that the therapeutic alliance is a key aspect of successful therapies. New research is showing how to best manage the alliance, like how to repair alliance ruptures. The research also indicates that the role of the alliance may differ according to client characteristics. Those clients who arrive for treatment with better trait-like characteristics (more adaptive representations of self, more adaptive relationships with others) may be better able to create a strong alliance early. For these clients, the alliance may not be highly therapeutic in itself, but rather set the context for therapy interventions to work. However, some clients find it difficult to maintain satisfying relationships with others including the therapist. For these clients, state-like changes in the alliance may be essential for treatment – that is, developing a strong alliance over the course of treatment may be therapeutic in itself to improve their interpersonal relationships outside of therapy.

April 2017

Do All Therapists Do That When Saying Goodbye?

Norcross, J.C., Zimmerman, B.E., Greenberg, R.P., & Swift, J.K. (2017). Do all therapists say that when saying goodbye? A study of commonalities in termination behaviors. Psychotherapy, 54, 66-75.

One of the things common to all psychotherapy relationships is that they come to an end. The endings may be premature or planned. They may be well managed or poorly managed. In this article by Norcross and colleagues, the authors ask: what do expert therapists typically do when there is a planned termination with a client? A planned termination is “an intentional process that occurs over time when a client has achieved most of the goals of treatment, and/or when psychotherapy must end for other reasons”. By contrast, premature termination occurs when the client ends treatment unilaterally. In successful cases the client and therapist typically predetermine the end date and have time to work toward the ending. Different theoretical orientations write about different aspects of termination. For example, from a psychodynamic perspective, therapists focus on clients’ old and new methods of coping, feelings related to the impending loss of the relationship, review gains, and work to equalize the relationship. From an experiential perspective, therapists might recognize that clients continue to change after therapy, help clients work through feelings of loss and separation of the therapeutic relationship, and consolidate new meanings. Cognitive-behavioral therapists might help clients to maintain gains made in therapy, review new skills, and prevent relapse. Do therapists who practice these and other theoretical approaches differ in terms of how they manage termination in psychotherapy? Norcross and colleagues surveyed 65 nominated experts representing six theoretical orientations of psychotherapy (psychodynamic, humanistic, CBT, interpersonal, multicultural, and integrative). Each orientation was represented by at least 10 expert therapists. The survey included 80 items related to termination that were drawn from books, chapters, and treatment manuals. The experts indicated the frequency with which they engaged in each behavior or the task related to termination. Therapist behaviors or tasks that received very strong consensus (>90% of therapists reporting “frequently” or “almost always” doing these) included: supporting the client’s progress, helping to consolidate gains made in therapy, following ethical practice (e.g., avoiding abandonment), attributing gains to the client’s effort, talking about what helped or went well, and collaborating with the client to set a date and pace of termination. Strong consensus (80% to 90% of therapists reported frequently doing these) behaviors or tasks included: focus on processing feelings around termination, having the client practice new skills, normalizing the probability of relapse, and prompting the client to think of a future without therapy. Of the 80 Items, 27 did not reach consensus among the therapists (i.e., only 21% to 59% of therapists agreed on these items). Out of the 80 items, only 8 (10% of items) showed significant differences between theoretical orientations (e.g., compared to other orientations, CBT therapists tended to do more of: preparing clients for relapse, and systematically assessing client outcomes near termination).

Practice Implications

This survey of 65 experts of varying psychotherapy orientations highlighted a wide range of commonalities in terms of how they managed termination with clients. While there was some uniqueness among orientations, most therapists tended to: process feelings about termination and the relationship with clients, discuss future functioning and coping, helped clients to use new skills, framed the client’s personal development as ongoing beyond therapy, prepared explicitly for termination, and reflected on the client’s gains.

November 2016

Cultural Adaptation of Psychotherapy

Hall, G.C.N., Ibarak, A.Y., Huang, E.R., Marti, C.N., & Stice, E. (2016). A meta-analysis of cultural adaptations of psychological interventions. Behavior Therapy.

Cultural adaptation of psychological interventions involves identifying cultural contexts of behaviors and developing constructs of mental health functioning relevant to the cultural context. Most cultural adaptation of psychotherapies involves taking existing treatments originally developed for those of European ancestry and adapting them for another specific cultural group or context. However, a few efforts exist in which new treatments were developed within a particular culture to address culture-specific concerns. Eight dimensions along which interventions could be culturally adapted include: language, people, metaphors, content, concepts, goals, methods, and context. Some researchers have expressed concern that cultural adaptation could distance an intervention from its evidence-base, and reduce its effectiveness. In this meta analysis by Hall and colleagues, the researchers look closely at the effects all culturally adapted treatments and prevention methods. They reviewed 78 studies that included nearly 14,000 participants. All studies included culturally adapted interventions for individuals of non-European ancestry. For example, these included studies that adapted CBT interventions for various disorders (mainly depression and anxiety disorders), or studies that match therapist to client in terms of ethnicity. Only 5% of studies created a new intervention developed within a particular culture, whereas the vast majority of studies adapted an existing treatment initially developed for clients of European ancestry. The average effect size was g = .67 (confidence intervals not reported), indicating that culturally adapted interventions produced better outcomes than comparison conditions. Culturally adapted interventions were also more likely to result in better outcomes than the same interventions that were not adapted (g = .52). Effect sizes for cultural adaptation in treatment studies (g = .72) were larger than for prevention studies (g = .25), likely because participants in treatment studies had higher levels of initial psychopathology. There was little evidence that matching therapist and client on ethnicity was helpful.

Practice Implications

This meta analysis provides compelling evidence that cultural adaptation of existing treatments can result in more positive outcomes compared to not adapting the same treatment. The effect sizes may even underestimate the true effects of cultural adaptation because the outcome variables like measures of depression were rarely adapted to a specific culture (e.g., depression among Chinese participants may be expressed differently than depression among European participants, and most depression measures were created by and for Europeans).

August 2016

Clients’ Experiences of Psychotherapy

Levitt, H.M., Pomerville, A., & Surace, F.I. (2016). A qualitative meta-analysis examining clients’ experiences in psychotherapy: A new agenda. Psychological Bulletin. Online First Publication, April 28, 2016.

Much of psychotherapy research over the past several decades has focused on therapy outcomes, with the general conclusion that outcomes are equivalent across major psychotherapy orientations. Some of the effects of psychotherapy can be explained by relational factors (e.g., therapeutic alliance). There is also a growing and interesting line of research about therapist variables and therapist effects (see this month’s PPRNet blog on differences between therapists’ outcomes in a large UK sample). Many experts argue that client effects and characteristics account for the largest amount of variance in therapy outcomes. That is, who clients are and what experiences they have are the largest determinants of whether psychotherapy will be helpful. However the client’s experience is often neglected in psychotherapy research reviews. Levitt and colleagues conducted a qualitative meta analysis of qualitative studies of clients’ experiences in psychotherapy. Qualitative research typically involves interviewing clients about their experiences in therapy and coding the transcripts of these interviews. Methods of synthesizing and categorizing themes from client narratives, such as the grounded theory method and thematic analysis, create a rich source of understanding about how clients experience change in psychotherapy. Levitt and colleagues applied qualitative methods to synthesize 109 qualitative studies of over 1400 clients as a way of analysing this research. Six clusters or themes emerged from their qualitative meta analysis: (1) clients experienced therapy as a process of identifying and understanding personal patterns; (2) clients who felt understood and had their experiences validated were able to internalize the therapist’s voice; (3) clients experienced the structure of therapy (spacing of sessions and time allotted to sessions) and therapist expertise as generating credibility for the therapy, but also at times the structure reduced clients’ experience of therapeutic relationship’s authenticity; (4) clients experienced an inherent power differential with therapists that was sometimes compounded by differences in race, gender, and class; (5) clients played a major role in the therapeutic process, and clients felt pleased when they were invited to take the lead; (6) clients’ experiences of being cared-for supported their ability to recognize maladaptive patterns and address unmet vulnerable needs.

Practice Implications

This qualitative meta analysis highlights the important role played by the client’s experience and by the therapy context in promoting good outcomes. The results suggested that better outcomes may be achieved when: (1) therapists encourage clients’ curiosity about their cognitive, emotional and relational patterns; (2) therapists engage in an accepting and caring relationship in order to help clients decrease their defensiveness about vulnerable topics; (3) therapists maintain the therapeutic structure in order to increase clients’ sense of confidence in the process; (4) therapists explicitly acknowledge power differences and repair alliance ruptures; (5) therapists encourage clients to take an active role in therapy as a means of self-healing; and (6) therapists regularly check with clients about the fit of interventions, in-session needs, and treatment goals.
Psychotherapy That is Culturally Congruent for Chinese Clients

Xu, H. & Tracey, T.J.G. (2016). Cultural congruence with psychotherapy efficacy: A network meta-analytic examination in China. Journal of Counseling Psychology, 63, 359-365.

Cultural congruence refers to providing psychotherapy that is consistent with the client’s cultural context in its description of the etiology of symptoms and in its therapeutic procedures. In general, congruence of treatments with clients’ expectation, preferences, and beliefs is related to greater psychotherapy efficacy. And specifically identifying culturally appropriate or adapted treatments is important because this is often related to better therapy outcomes for ethnic and racial minorities. Psychotherapy as a professional practice developed recently in China. Cognitive-behavioral, existential-humanistic, and psychodynamic therapies have taken their place along side indigenous therapies including Naikan therapy, Taoism cognitive therapy, and Morita therapy. Historically in China mental health problems were seen as a disturbance in ying-yang or a sin committed in a previous life. Healing practices included engaging in altruism or religious practices to achieve redemption. Xu and Tracey argue that Chinese culture strongly endorses an experiential and subjective orientation and is less aligned with analytic and objective orientations. Using this understanding, the authors expected that experiential-humanistic and indigenous therapies would be more congruent and therefore more effective than cognitive-behavioral education or psychodynamic therapy in alleviating mental health issues. In this meta analysis, Xu and Tracey reported on 235 studies conducted in China that compared the various treatments to a control condition or to each other. There were too few studies of psychodynamic therapy, so it was not included in the analyses. All treatments were effective compared to a control condition with large effect sizes (g = .85 to 1.18). However, whereas experiential-humanistic and indigenous therapies were equally effective, each was significantly more effective (g = .34) than cognitive-behavioral psychoeducation.

Practice Implications

The three modalities, experiential-humanistic, indigenous, and cognitive-behavioral psychoeducation were effective. However the two therapies that were more experiential and subjective in nature were more effective to reduce Chinese clients’ symptoms. When working with Chinese clients, therapists may achieve better outcomes if they work on more experiential components (e.g., feelings and therapeutic relationship) and focus on subjective experiences (e.g., introspection and reflection). The results of the meta analysis suggest that when working with Chinese clients interpersonal processes and emotions should be the clinical focus and take priority over dysfunctional cognitions and psychoeducation.

This month...

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August 2017

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June 2017

Practice Implications

April 2017

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November 2016

Practice Implications

August 2016

Practice Implications

Practice Implications

Psychotherapy Practice Research Network (PPRNet)