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 variables leading to poor outcomes, aspects of the therapeutic relationship and outcomes, and psychological therapies and patient quality of life.
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
November 2022
How and for Whom Does the Therapeutic Alliance Work?
Research and understanding of the role of the therapeutic alliance in helping patients get better is evolving quickly. The therapeutic alliance is composed of patient-therapist collaborative agreement on the tasks and goals of therapy, and their relational bond. It is the most consistent predictor of patient outcomes. Much of the recent evolution in the research and theory of the alliance is driven by advances in statistical methods that disentangle (1) trait-like alliance from (2) state-like alliance. Trait-like alliance refers to the patient’s characteristic capacity to cooperate and make use of a therapeutic opportunity. State-like alliance refers the patient’s session by session increase or decrease in their alliance to the therapist regardless of their characteristic capacity. In this review of advances in research and theory on trait-like and state-like alliance, Zilcha-Mano and colleagues discuss the roles of these differing aspects of the alliance in helping to determine what therapist interpersonal stances will work best for which patient. The authors review research indicating that trait-like alliance (patients’ and therapists’ pre-therapy interpersonal capacity to cooperate and form a bond) provides a context for therapeutic interventions. That is, therapists with better interpersonal skills and patients with fewer interpersonal problems (i.e., alliance traits) tend to quickly and easily form a therapeutic alliance that provides a fertile ground for therapeutic interventions to take root. For these patients and therapists, a good alliance allows specific interventions of CBT (exposure and response prevention), psychodynamic therapy (transference interpretations), EFT (two chair technique) and others to work. The authors also review research indicating that state-like alliance (session by session growth in the therapeutic alliance) may be the key therapeutic tool for patients who begin therapy with greater interpersonal problems and lower trait alliance capacity. For these patients, an increase in their trust and bond with the therapist results in better treatment outcomes. Strengthening the alliance across therapy sessions may be a mechanism by which a corrective interpersonal experience with the therapist produces change in how the patient sees themselves (as deserving positive regard from others) and sees others (as caring and trustworthy).
Practical Implications
Clinicians working with patients who have lower interpersonal problems and a higher characteristic trait-like capacity to cooperate will do well to come to a collaborative agreement with the patient on a treatment plan and goals early in therapy. Such patients will do well with many types of therapeutic interventions. However, for patients with greater interpersonal problems (difficulties trusting, problems with interpersonal boundaries, lower reflective capacity), the key to effective therapy may be to grow the alliance from session to session. Therapists may engage in supportive interpersonal stances that include warmth, positive regard, empathy, and active listening. Therapists should focus their training on increasing their responsiveness to patients based on patient characteristics, and to assess the level of the therapeutic alliance at the start of therapy and from session to session.
What are Best Practices for Psychotherapy with Indigenous Peoples
In 2016 2.8% of the Canadian population identified as First Nations, 1.7% as Metis, and 0.2% as Inuit. In Canada there are 634 First Nations each with their own traditions, governance structures, and land claims. Colonial violence and land dispossession has led to Indigenous Peoples suffering from many mental health inequities. Indigenous samples are rarely evaluated in clinical trials of psychotherapy. And psychotherapy, as typically delivered, is a practice that is embedded in European cultural values which may not be appropriate for Indigenous Peoples. Defining best practices in psychotherapy with Indigenous Peoples may indeed be thorny given the historical context and values inherent in psychotherapy practice. In this article, Wendt and colleagues review four paths to providing psychotherapy to Indigenous clients, but each path has their challenges. The first path is to offer on empirically supported therapies for specific identifiable disorders. However, out of the hundreds of clinical trials available, only six were conducted that specifically focused on American Indian clients and all for alcohol use problems. Most empirically supported therapies were not validated for use with Indigenous clients, and some argue that this may make these treatments potentially harmful. The second path is to culturally adapt interventions so that the original therapies are maintained but adapted to the needs and culture of the Indigenous population. Some research suggests that cultural adaptations result in moderately better outcomes. Deeper adaptations incorporate cultural beliefs and promote cultural identity and connections to the Indigenous community. However, cultural adaptations tend to preserve a disorder-centric approach to problems rather than seeing problems in terms of a balance between mental, emotional, and spiritual health. The third path involves emphasizing the psychotherapy relationship, the working alliance, and promotion of hope – also known as the common factors approach to psychotherapy. This is highly collaborative approach to how therapy progresses and to maintaining a reciprocal balance in the therapeutic relationship. However, this approach does not necessarily address the European cultural values inherent in most psychotherapies. The fourth path involves efforts to strengthen and revitalize traditional Indigenous practices and cultural education as a means of healing. These might include integrating sweat lodges, the Medicine Wheel, and talking circles. This path embodies a “culture as treatment” approach in which problems are seen within historical losses of identity, purpose, and place. A report from the Canadian Psychological Association and the Psychology Foundation of Canada calls for psychologists to “view themselves as facilitators and supporters of the healing wisdom and knowledge that is already present in Indigenous communities”. However, as Wendt and colleagues note, there are practical barriers to this approach, and even if “culture as treatment” is seen by some as self-evidently effective, it has rarely been researched.
Practice Implications
Mental health professionals should avoid being unwitting agents of assimilation when providing clinical care to Indigenous clients. Primarily, clinicians should maintain a stance of cultural humility. Traditional indigenous approaches to mental health are important as a long-term strategy, including traditional understandings of problems, traditional healing, and Indigenous-led cultural interventions. All of this, however, is limited by inadequately addressed colonial harms, poverty, and legal obstacles to Indigenous Nations’ sovereignty.
The Efficacy of Psychotherapies and Pharmacotherapies for Mental Disorders in Adults
Estimates of the efficacy of psychological or pharmacological treatments depend in part on to what they are compared. One might expect, for example, that these first line treatments for mental disorders may appear more effective if compared to no treatment and may appear less effective when compared to treatment as usual or a placebo. Reviews indicate that compared to no treatment, psychotherapies demonstrate a moderate effect (g = .67). However, some argue that comparisons to no treatment represent “weak” controls that over-estimate the efficacy of treatments. Compounding this problem is that poorly designed randomized controlled trials tend to result in larger estimates of effects in favor of the treatments. In this large umbrella review, Leichsenring and colleagues conducted a meta-analysis of meta-analyses of randomized controlled trials in which psychotherapy and medications are compared to no treatment, treatment as usual, placebo, and to each other. Different forms of psychotherapy (CBT, psychodynamic, interpersonal, EFT) were included. This meta-review had 3,782 randomized controlled trials representing 650,514 patients with a range of mental disorders (depression, anxiety, eating disorders, OCD, PTSD…). The authors’ analyses resulted in a standardized mean difference (SMD) of 0.34 (95% CI: 0.26-0.42) for psychotherapies and 0.36 (95% CI: 0.32-0.41) for pharmacotherapies compared with placebo or TAU. Usually, this is interpreted as a small effect such that about 7 patients need to be treated before one achieves remission. The SMD for head-to-head comparisons of psychotherapies vs. pharmacotherapies was 0.11 (95% CI: –0.05 to 0.26) indicating no significant difference between the two types of treatments. The SMD for the combined psychotherapy and medication compared to either monotherapy (psychotherapy alone or medications alone) was 0.31 (95% CI: 0.19-0.44), suggesting that some patients achieve better outcomes if they got combined treatment, but again the effect is small. A troubling finding of this meta-review was that between 1% and 17% of studies were high quality, meaning that most studies likely resulted in biased (inflated) results for both treatments.
Practice Implications
Psychotherapy and medications, or their combination as practiced in randomized controlled trials appear to help a relatively modest proportion of patients. Most of these trials involved short term highly manualized interventions that do not address the diversity and complexity of patients seen by psychotherapists in real world practices. For example, studies in clinically representative contexts show that most patients require many more therapy sessions than provided in clinical trials. Psychotherapy researchers and clinicians need to refocus efforts on therapeutic factors (therapeutic alliance, progress monitoring) and therapist interpersonal stances (interpersonal skill, empathy, countertransference management) that likely impact patient mental health outcomes.
October 2022
Therapists Report Less Therapeutic Skill in Telepsychology vs In Person Therapy
Lin, T., Stone, S. J., Heckman, T. G., & Anderson, T. (2021). Zoom-in to zone-out: Therapists report less therapeutic skill in telepsychology versus face-to-face therapy during the COVID-19 pandemic. Psychotherapy, 58, 449–459.
The COVID-19 pandemic has confronted psychotherapists with several challenges including rapidly switching their practice to using teletherapy (videoconferencing, phone, and other virtual media). The use of teletherapy in clinical work increased from 7.1% prior to the pandemic to 85.5% during the pandemic. And estimates suggest that at least one-third of clinical work will be performed by teletherapy post-pandemic. Over a third of psychologists reported that they lacked training in using teletherapy, and they believe that their skills in this domain are inadequate. Therapists have raised a number of concerns in past surveys including issues related to privacy, professional self-doubt, technological competence, challenges to the therapeutic relationship, and problems with implementing some interventions. In this survey of 440 therapists and trainees, Lin and colleagues were particularly interested in therapists’ perceptions of the impact of teletherapy relative to in person therapy on the therapeutic process and patient outcomes. Videoconferencing was the most frequently used modality by 73.56% of surveyed therapists. The survey asked if three broad areas of practice were affected by teletherapy compared to in person therapy. These areas included common therapeutic factors (level of therapist empathy, emotional expression, warmth, alliance bond), extra-therapeutic patient factors (the patient’s environment that impacted their ability to engage in homework or use prescribed resources), and perceived patient outcomes (therapist ratings of patient symptom reduction, satisfaction, clinical improvement). Therapists in the survey were representative of the population of therapists in the US, and 82% of them provided all their clinical work in recent months by teletherapy. Compared to in person therapy, therapists reported poorer skills related to common therapeutic factors (d = 0.86), somewhat greater impact of extra-therapeutic factors (d = 0.36), and perceived poorer patient outcomes (d = 0.68) in teletherapy. Therapists who were younger, preferred emotion-focused or relational therapies, and with no prior training reported a relatively greater decrease in therapeutic skills in teletherapy compared to in-person therapy.
Practice Implications
By far, most therapists believed that providing psychotherapy by virtual means reduced their capacity to use common therapeutic stances including empathy, warmth, and the therapeutic alliance. Some of this might be affected by the psychological distance caused by the virtual format and difficulties with reading body language and other non-verbal cues. Therapists perceived that patient outcomes suffered as a result. This was particularly true for younger therapists, possibly because of the impact of adopting the new modality on their professional self-confidence. Also, therapists who preferred experiential or interpersonally based therapies felt particularly challenged possibly because these therapies may be more reliant on emotional communication and discerning patient interpersonal behaviors. Training and support are needed for therapists and trainees to improve their confidence in providing teletherapy.
Confidence in the Therapist and in Treatment
Finsrud, I., Nissen-Lie, H. A., Ulvenes, P., Melsom, L., Vrabel, K., & Wampold, B. (2022, September). Confidence in the therapist and confidence in the treatment predict symptomatic improvement week by week in therapy: A latent curve modeling approach. Journal of Counseling Psychology. Advance online publication.
In his classic book Persuasion and Healing, Jerome Frank suggested that all psychotherapies involve a trusting emotionally charged relationship with a sanctioned healer who has a good rationale for their interventions. The common factors approach to psychotherapy was born from this kind of thinking. Carl Rogers, for example, argued that to be effective therapists had to engage in unconditional positive regard, empathic understanding, and a genuine non-defensive stance. Contemporary therapeutic alliance theory emphasizes similar factors plus the patient’s expectation of benefit from therapy created through accepting the rationale for the therapy and agreement on the tasks and goals of therapy. From this research and theory, one can see that a patient’s confidence in the therapist and confidence in the treatment may be key common factors underlying effective therapies. Confidence in the therapist refers to a patient who believes that the therapist has the relational skills to help, and that the therapist is working in the patient’s best interest. Confidence in treatment refers to the patient’s belief that the rationale for treatment is meaningful, and that the treatment itself will remedy their problems. In this study, Finsrud and colleagues were interested in whether confidence in the therapist or treatment in one session predicted symptom reduction in the next session. Or was it the other way around – does symptom reduction increase a patient’s confidence? If the results showed the latter, then confidence is result of symptom improvement and so has little or no therapeutic value. The study had 587 adults receiving inpatient treatment for a variety of disorders and treated by psychotherapists of different orientations. Patients completed a measure of confidence in the therapist and treatment, and a scale of their depressive symptoms twice a week for an average of 12 weeks. The authors used sophisticated statistical modeling techniques to examine the effect of a patient’s preceding levels of confidence in therapist or treatment on the patient’s subsequent session symptoms, and vice versa. The researchers found that an increase in confidence in the therapist and confidence in the treatment predicted a decrease in symptoms in the next session. They also found that a reduction in symptoms predicted an increase in confidence in the therapist and in treatment in the next session.
Practice Implications
Patients’ confidence in the therapist and in the treatment both contribute to symptom reduction over and above early symptom change. In other words, the patient’s perception of the therapist as a person and their expectations that the treatment will be helpful are likely key factors that predict a reduction in symptoms. Therapists must have positive regard, genuineness, and empathy towards patients to facilitate the patients’ confidence in the therapist as a person. And therapists must provide a clear rationale for the treatment and develop a collaborative understanding with patients on how therapy will be done (agreement on the tasks) and what the desired outcomes will be (agreement on the goals).
Progress Feedback Narrow the Gap Between More and Less Effective Therapists
Delgadillo, J., Deisenhofer, A.-K., Probst, T., Shimokawa, K., Lambert, M. J., & Kleinstäuber, M. (2022). Progress feedback narrows the gap between more and less effective therapists: A therapist effects meta-analysis of clinical trials. Journal of Consulting and Clinical Psychology, 90, 559–567.
Some therapists are more effective than others. This is often referred to as the therapist effect. Somewhere between 1% and 29% of patient outcomes can be attributed to which therapist the patient receives. In general, therapists with high facilitative interpersonal skills, high humility, and an ability to withstand difficulties in practice (i.e., ruptures, burnout) may be more clinically effective. To improve outcomes in therapy, some have suggested using routine outcome monitoring and progress feedback. This involves regularly measuring and tracking patient progress with standardized self-report scales throughout treatment and providing the clinician with this information during therapy. Progress feedback allows the therapist to compare their patient’s progress against norms and against the patient’s own progress in preceding sessions. If the patient is not progressing or is deteriorating, then the therapist is alerted to address the issue. Research indicates that progress feedback makes therapy more effective. Less is known about how progress feedback leads to better outcomes. In this meta-analysis, Delgadillo and colleagues assessed the impact of progress feedback on the therapist effect – that is, does progress feedback improve the outcomes of less effective therapists? The meta-analysis was of six clinical trials with data from 4,549 patients and 131 therapists who were randomly assigned to a progress feedback condition or to a control condition without progress feedback. The variability between therapists (ICC = .011) suggested that 1.1% of the overall variance in patient outcomes was due to therapist effects. However, feedback was associated with a significant reduction in the therapist effect (ICC = .009) by 18.2%. A closer look at the data indicated that progress feedback narrowed the gap between more and less effective therapists, such that patients of less effective therapists benefitted the most from their therapist receiving feedback.
Practice Implications
In this meta-analysis conducted on data from controlled studies, there were few under-performing therapists. However, implementing progress feedback was clinically important to achieve better outcomes among some of these therapists. That is, even a single underperforming therapist could attain relatively poor outcomes with dozens or even hundreds of patients. Who the therapist is matters – and some therapists (and their patients) can benefit from supplementing clinical judgement with reliable feedback about patient progress throughout the course of psychotherapy.