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 content from the updated edition of the Handbook of Psychotherapy and Behavior Change, published in 2021: the effectiveness of psychotherapist training, the therapist effect, and therapist responsiveness to patient interpersonal behaviours.
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
May 2021
The Impact of Patient Suicide on Psychotherapists
Sandford, D.M., Kirtley, O.J., Thwaites, R., & O’Connor, R.C. (2021). The impact on mental health practitioners of the death of a patient by suicide: A systematic review. Clinical Psychology and Psychotherapy, 28, 261-294.
In the UK, it is estimated that up to 27% of those who commit suicide have been in contact with a mental health professional in the past year. Even though suicide is a rare event, a mental health practitioner is likely to experience at least one instance of a patient suicide during their career. A psychotherapist who experiences a patient suicide could experience symptoms of burnout, PTSD, grief, and a sense of being overwhelmed. Sandford and colleagues conducted a systematic review of the existing research on the impact of a patient’s suicide, experiences of support by the practitioner, and factors that may minimize the negative impacts of patient suicide. They reviewed 54 quantitative and qualitative studies in order to synthesize the research. Professionals included psychiatrists, psychologists, psychotherapists, counsellors, and other mental health professionals. The most common responses of professionals to a patient suicide were guilt, blame, shock, anger, sadness, and grief. Over 20% of practitioners met criteria for PTSD in some studies. Many practitioners across all studies reported some negative impact on their personal life, with 24% identifying severe emotional impact (lower mood, poor sleep). Following a patient suicide, practitioners reported an increased focus on risk assessment, greater caution in their practices, and increased self-doubt about their own judgement. The average practitioner reported an impact that lasted about 4 weeks. A closer therapeutic relationship with the patient, patients who were younger, and the fear of blame and litigation were each associated with a higher level of distress in therapists. However, the impact was not related to therapist gender, age, or experience. Most practitioners felt inadequately prepared for dealing with a patient suicide. But protective factors included support from colleagues, friends and family, and supportive supervision.
Practice Implications
Even if suicide is a rare event in the population, an important minority of patients who commit suicide were in contact with a mental health professional in the preceding year. And so, one might expect to have a patient who commits suicide during one’s career that will have a negative impact on one’s own well-being and professional practice. Increased awareness of the incidence of suicide, informal social supports, and empathic supervision may mitigate the negative impacts. So will tailored training experiences on managing one’s own reactions to patients, as well as a professional work environment that is non-blaming and supportive.
Therapists Are Mostly Responsible for the Therapeutic Alliance
Del Re, A. C., Flückiger, C., Horvath, A. O., & Wampold, B. E. (2021). Examining therapist effects in the alliance–outcome relationship: A multilevel meta-analysis. Journal of Consulting and Clinical Psychology. Advance online publication.
The therapeutic alliance has been consistently found to be a reliable predictor of patient outcomes. The alliance in therapy refers to the patient and therapist collaborative agreement on the tasks of therapy and the goals of therapy, as well as their emotional bond. Previous research suggested that the therapist contribution to the alliance accounted for a significant proportion of patient outcomes. That is, some therapists are better than others at forming a good alliance across a variety of patients, and those therapists who can form a good alliance have patients that achieve better outcomes. If therapists are responsible for most of the effects of a positive therapeutic alliance, then efforts should be directed toward training therapists to improve the alliance. In this meta-analysis of 152 studies, Del Re and colleagues used Patient-Therapist Ratio (PTR) as a proxy to estimate the contribution of the therapist to the alliance. Large PTR refers to many patients per therapist, whereas a low PTR refers to few patients per therapist. A significant effect of low PTR on the alliance – outcome relationship would indicate that most of the effect of the alliance on outcomes was due to the therapist. The overall effect of the alliance on patient outcomes was moderately large (r = .275, 95% CI = .247, .302) and similar to what was found in previous research. In other words, a higher therapeutic alliance between patient and therapist was related to better patient outcomes. PTR was a significant moderator of the alliance – outcome relationship (ß = −0.006, 95% CI = −0.010, −0.002). That is, the therapist had a significant contribution to the alliance – outcome association. There was no evidence of publication bias in the research, and other potential confounds did not significantly reduced the effect of the therapist on the alliance and outcomes.
Practice Implications
The strength of the relationship of the therapeutic alliance to patient outcomes is mostly due to the therapist’s characteristics or actions. That is, therapists are largely responsible for the therapeutic alliance and its impact on patient outcomes. Previous research suggested that more effective therapists have the interpersonal skills to manage interpersonally challenging situations. More effective therapist interpersonal skills include: verbal fluency, instilling hope, persuasiveness, emotional expression, warmth, empathy, and the capacity to repair alliance ruptures. Therapists who are capable of engaging in these facilitative interpersonal behaviors across a range of patients are more likely to achieve outcomes for their patients.
Does Clinical Training Lead to Greater Therapist Interpersonal Skills?
Wolfer, C., Visla, A., Held, J., Hilpert, P., & Fluckiger, C. (2021). Assessing interpersonal skills—A comparison of trainee therapists' and students' interpersonal skills assessed with two established assessments for interpersonal skills. Clinical Psychology and Psychotherapy, 28, 226-232.
Differences between therapists may account for 2% to 8% of the variance in patient mental health outcomes. This seems like a small amount, but the effect is as large as the specific effects caused by interventions of any therapeutic orientation. One of the factors that accounts for differences between therapists is therapist interpersonal skills such as empathy, respectfulness, warmth, openness, and willingness to collaborate. These skills can be learned and likely allow some individuals to be more effective when encountering challenging or complex interpersonal situations. One might think that such skills would be a pre-requisite for entering psychotherapy training, but that may not be the case. A study of training therapists found that more than half of novices were unhelpful to their patients. In this study by Wolfer and colleagues, the authors were interested in seeing if therapists at different stages of training had different levels of these important interpersonal skills. That is, do trainees as a higher level of training acquire more of these skills than those prior to receiving training. This was a small study comparing 19 therapists in clinical training versus 17 students in psychology but with no clinical training. Clinical trainees were in the program for at least 2 years, and received many hours of supervision. All participants watched a video recording of difficult patient statements. Participants’ reactions to the patient video were recorded and then trained raters coded the responses for level of interpersonal skills. Trainee therapists scored significantly higher than students on two scales of interpersonal skills, even after controlling for age. In fact, trainee therapists were over 13 times more likely to demonstrate facilitative interpersonal skills than untrained students. Although being in a clinical training program was associated with greater interpersonal skills, level of experience of clinical trainees (range 2 to 5 years of training) was not related to the level of interpersonal skills.
Practice Implications
This is a relatively small study, so one should consider the findings quite cautiously. Nevertheless, it is one of the few studies to assess interpersonal skills in therapists. It is possible that only those with more interpersonal skills choose to be trained as clinicians – that is, only especially skilled students may go on to receive clinical training. However, the trainees’ substantial amount of clinical training (observing clinicians handle complex situations, receiving supervision to enhance self-reflection) may have facilitated growth in their interpersonal skills. As in previous research, clinical experience alone was not related to therapist interpersonal skill.
April 2021
Therapeutic Alliance Predicts Patient Outcomes Over and Above Other Factors
Flückiger, C., Del Re, A. C., Wlodasch, D., Horvath, A. O., Solomonov, N., & Wampold, B. E. (2020, March 26). Assessing the alliance–outcome association adjusted for patient characteristics and treatment processes: A meta-analytic summary of direct comparisons. Journal of Counseling Psychology. Advance online publication.
The therapeutic alliance is probably the most researched concept in psychotherapy. The alliance refers to a collaborative agreement on the tasks of therapy (what patients and therapists do in therapy, like homework, or examine the past or relationship issues), a collaborative agreement on the goals of therapy (what the desired outcomes might be), and the relational bond between patient and therapist (liking and respect for one another). The most recent meta-analysis of the alliance included 296 studies. The meta-analysis showed a moderate and robust relationship between higher alliance and better patient outcomes regardless of type of therapy, who rated the alliance, or how it was rated. Nevertheless, some still think that the alliance is a byproduct of other factors like patient symptom severity (less symptomatic patients may report a better alliance with therapists) or adherence to treatment manuals (higher therapist adherence may lead to a better alliance). In other words, some argue that the alliance may not directly affect outcomes and may not be that important. In this meta-analysis, Fluckiger and colleagues examined 60 studies with over 6,000 patients that reported the alliance-outcome relationship, and also the effects of patient characteristics like symptom severity and adherence to treatment manuals. Overall, the therapeutic alliance was significantly related to patient outcomes, r = .304 (95% CI [.253, .354], p < .001, k = 53). When the authors of the primary studies controlled for patient characteristics like symptom severity, the adjusted alliance - outcome correlation remained significant, r = .286 (95% CI [.226, .344], p = .001, k = 35). When the authors of primary studies controlled for the effects of therapist adherence to a treatment manual, the adjusted alliance – outcome correlation still remained significant, r = .242 (95% CI [.179, .306], p = .001, k = 13). The slight reduction in the alliance-outcome correlation caused by the effects of patient symptom severity or therapist adherence to a manual was not significant.
Practice Implications
Therapists’ capacity to develop a therapeutic alliance is a key factor to patients experiencing a good outcome from psychotherapy. This is true for many types of patients with differing levels of symptom severity, and also true regardless of type of therapy or level of therapist adherence to a treatment protocol. Developing shared treatment goals and agreeing on the tasks of therapy are important first steps. In addition, therapists and clients who like working together and share a sense of mutual respect are more likely to experience a successful therapy. Maintaining the alliance throughout therapy is also important. The alliance fluctuates across time indicating subtle or obvious ruptures or tensions that occur. Therapists’ skills at identifying and repairing alliance ruptures is critical to an ongoing collaborative relationship and to patients achieving the best possible outcomes.
Does Mindfulness Lead to Greater Empathy Among Psychotherapists?
Cooper, D., Yap, K., O’Brien, M. et al. (2020). Mindfulness and empathy among counseling and psychotherapy professionals: A systematic review and meta-analysis. Mindfulness, 11, 2243–2257.
Just about every theoretical model of psychotherapy recognizes that therapist empathy is a necessary and fundamental component of treatment. A meta-analysis showed that higher therapist empathy as rated by patients was a moderately strong predictor of outcomes. Despite its importance, training programs in counseling, clinical psychology, and psychotherapy have not found effective ways of increasing empathy among trainees. Some might argue that more mindful therapists might be more attentive and accepting of aversive emotions and therefore more open to entering a client’s world or experiences. Rogers defined empathy as the capacity to enter into the private perceptual world of the other, and it involves taking another’s perspective and being emotionally moved. Measures of empathy assess dimensions such as personal distress, empathic concern, fantasy, and perspective taking. Mindfulness, on the other hand is defined by some as an open and receptive attention and awareness to one’s own present experiences. The theory is that having this receptive mindful attitude is necessary to develop empathy for others. If this is the case, then mindfulness training might foster a greater empathic attitude among psychotherapists and trainees. In this study, Cooper and colleagues (2020) conducted a meta-analysis to examine the relationship between dimensions of mindfulness and empathy among psychotherapy trainees. They also looked at studies that examined if training in mindfulness was associated with greater empathy among trainees. The results from up to 10 studies showed that greater levels of mindfulness were associated with less personal distress, r = − .42, 95% CI [− .55, − .27], and greater perspective taking, r = .28, 95% CI [.15, .40]. However, there was no significant relationship between mindfulness and empathic concern or fantasy. When aggregating the findings of the six studies that examined the effect of mindfulness training on increasing trainee therapist empathy, there were no significant effects on any of the empathy scales.
Practice Implications
This is not a well-developed research area because of the few studies and small sample sizes, and so results should be taken with a grain of salt. Meta-analyses clearly show that therapist empathy is important to patients and their outcomes. Higher levels of mindfulness were associated with greater perspective taking and lower personal distress. Mindfulness might help therapists to disengage from internal experiences and free up resources to be empathic to patients’ distress. However, the existing research does not support the use of mindfulness training to improve therapist empathy.
Adding Psychotherapy to Pharmacotherapy for Depression
Guidi, J. & Fava, G.A. (2021). Sequential combination of pharmacotherapy and psychotherapy in major depressive disorder: A systematic review and meta-analysis. JAMA Psychiatry, 78, 261-269.
A sequential model of treatment suggests that one apply two treatments consecutively in order to reduce relapse of symptoms. This might include pharmacotherapy followed by psychotherapy, or vice versa. One reason to consider a second consecutive treatment for depression is that many individuals continue to have symptoms after a first treatment, and having residual symptoms is related to higher relapse rates. Another reason is that many with depressive disorders have comorbid symptoms of anxiety or other disorders, and so one course of treatment may not be enough for such complex situations. In this study, Guidi and Fava conducted a meta-analysis to examine if sequential combination of medications and psychotherapy reduced the risk of relapse for major depression. They reviewed 17 randomized controlled trials representing 2283 adult patients that examined the sequential use of psychotherapy following medications. The primary outcome was remission of depressive symptoms. The methodological quality of the studies was high. After adjusting for publication bias, the sequential approach was significant (RR = 0.885; 95% CI, 0.793-0.988), indicating that sequencing treatment resulted in a lower risk of relapse or recurrence. Continuing versus discontinuing medications during psychotherapy did not result in any advantage for patients. However, providing psychotherapy while continuing with antidepressant medications reduced rates of relapse and recurrence, RR = 0.821 (95% CI, 0.710-0.949).
Practice Implications
The chronic and recurrent nature of major depression is an important clinical challenge. The results of Guidi and Fava’s meta-analysis suggests that adding psychotherapy following pharmacotherapy, either alone or in combination with pharmacotherapy, will reduce the risk of relapse from major depression. Discontinuing medications is reasonable after adding psychotherapy in order to help patients with major depression to stay symptom free. The results support the notion that psychotherapy results in patients acquiring skills to regulate their emotions, and that this might result in reduced relapse of depressive symptoms. Such skill acquisition does not take place with pharmacotherapy alone.