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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.

Wampold, B. E. (2015). How important are the common factors in psychotherapy? An update. World Psychiatry, 14, 270-277.

What is the evidence for the common factors in psychotherapy and how important are they to patient outcomes? In their landmark book, The Great Psychotherapy Debate, Wampold and Imel cover this ground is some detail, and I reviewed a number of the issues raised in their book in the PPRNet blog over the past year. This article by Wampold provides a condensed summary of the research evidence for the common factors in psychotherapy, including: therapeutic alliance, therapist empathy, client expectations, cultural adaptation of treatments, and therapist effects. Therapeutic alliance refers to therapist and client agreement on tasks and goals of therapy, and the bond between therapist and client. A meta-analysis of the therapeutic alliance included over 200 studies of 14,000 patients and found a medium effect of alliance on patient outcomes (d = .57) across a variety of disorders and therapeutic orientations. A number of studies are also concluding that the alliance consistently predicts good outcomes, but that early good outcomes do not consistently predict a subsequent higher alliance. Further, therapists and not patients were primarily responsible for the alliance-outcome relationship. Another common factor, empathy, is thought to be necessary for cooperation, goal sharing, and social interactions. A meta-analysis of therapist empathy that included 59 studies and over 3,500 patients found that the relationship between empathy and patient outcome was moderately large (d = .63). Patient expectations that they will receive benefit from a structured therapy that explains their symptoms can be quite powerful in increasing hope for relief. A meta-analysis of 46 studies found a small but statistically significant relationship (d = .24) between client expectations and outcome. Cultural adaptation of treatments refers to providing an explanation of the symptoms and treatment that are acceptable to the client in the context of their culture. A meta analysis of 21 studies found that cultural adaptation of evidence-based treatments by using an explanation congruent with the client’s culture was more effective than unadapted evidence-based treatments, and the effect was modest (d = .32). Finally, therapist effects, refers to some therapists consistently achieving better outcomes than other therapists regardless of the patients’ characteristics or treatments delivered. A meta analysis of 17 studies of therapist effects in naturalistic settings found a moderately large effect of therapist differences (d = .55).

Practice Implications

These common factors of psychotherapy appear to be more important to patient outcomes than therapist adherence to a specific protocol and therapist competence in delivering the protocol. As Wampold argues, therapist competence should be redefined as the therapist’s ability to form stronger alliances across a variety of patients. Effective therapists tend to have certain qualities, including: a higher level of facilitative interpersonal skills, a tendency to express more professional self doubt, and they engage in more time outside of therapy practicing various psychotherapy skills.

Werbart, A., Von Below, C., Brun, J., & Gunnarsdottir, H. (2015). “Spinning one’s wheels”: Nonimproved patients view their psychotherapy. Psychotherapy Research, 25, 546-564.

The rate of patients who experience no change after receiving psychotherapy is about 35% to 40% in clinical trials. Further, about 5% to 10% get worse after treatment. So, in spite of the fact that psychotherapy is effective in general, a sizeable minority of patients do not benefit. There is also evidence that patients’ perception of therapy differs greatly from their therapists’. Therapists are often inaccurate in identifying or predicting patient outcomes, and patients’ judgements tend to better correspond with treatment outcomes. In this study, Werbart and colleagues evaluated outcomes of 134 patients who had elevated symptoms. The average age of patients was 22.4 years (range 18 – 26), so many were young adults. Almost all received a diagnosis ranging from depressive disorders, anxiety disorders, or personality disorders. The predominant treatment was psychoanalytic. Of the 134 patients, many experienced large improvements by the end of treatment. However, 20 patients remained clinically distressed and did not improve or deteriorated after receiving psychotherapy. The authors interviewed these 20 patients at termination and at three-year follow-up using a semi-structured interview. The interview asked patients for their experiences of therapy. The researchers transcribed the interviews and coded the transcripts using a known method of qualitative analysis called “grounded theory”. Three main themes related to poor outcomes were identified by these patients. (1) The therapy or therapist – in which: therapists were perceived by patients as passive or reticent, patients felt distant from the therapist, and patients did not understand the therapy method. (2) Outcomes of therapy – in which: the patient expected more from therapy, and symptoms and emotional problems remained in the “impaired” range at the end of treatment. (3) The impact of life circumstances – referring to negative impacts of events outside of the therapy.

Practice Implications

This is a small but unique study that interviewed patients who did not benefit from psychotherapy about their experiences of the treatment and therapist. Nonimproved patients described their therapist generally as too passive, distant, and uninvolved in the work of therapy. These patients described difficulty understanding the therapeutic method and the nature of the therapeutic relationship. The findings highlight the importance of the therapeutic alliance. To have a good alliance, patients and therapists have to agree on the tasks of therapy, agree on the goals that the therapy should achieve for the patient, and there should be a mutual liking or bond between patient and therapist. Those patients whose therapists pay attention to and foster a good alliance are more likely to experience good outcomes.

The Great Psychotherapy Debate: Since in April, 2015 I review parts of The Great Psychotherapy Debate (Wampold & Imel, 2015) in the PPRNet Blog. This is the second edition of a landmark, and sometimes controversial, book that surveys the evidence for what makes psychotherapy work. You can view parts of the book in Google Books.

Wampold, B.E. & Imel, Z.E. (2015). The great psychotherapy debate: The evidence for what makes psychotherapy work (2^nd edition). New York: Routledge.

In this part of the book, Wampold and Imel discuss the importance of client expectations on psychotherapy outcomes. In particular, they equate client expectations with the placebo effect. In the July, 2015 PPRNet blog, I discussed Wampold and Imel’s distinction between the Contextual Model of psychotherapy and the Medical Model of psychotherapy. One pathway of the Contextual Model indicates that patients who accept an explanation for their disorder and who agree with therapists about therapy interventions, experience expectations that have a powerful impact on patients’ emotions and cognitions. The placebo effect has long been known to improve patients’ response to medical interventions. The placebo effect is defined as the difference between a supposedly inert event or medication and the natural course of the disorder. By contrast, the specific effect of an intervention or medication (e.g., an antidepressant) is defined as the difference between the medication and the placebo (i.e., the effect of a medication over and above the effect of a placebo). In one important meta analysis, the placebo effect accounted for about 68% of the antidepressants’ impact on depression scores. In other words, the placebo effect (i.e., the expectation of receiving help) has a powerful impact on depression. Generating an expectation of improvement (“this pill is an antidepressant that will reduce your depression”) involves: (1) providing a plausible explanation for the disorder (“depression is biochemical imbalance, and this pill [actually an inert placebo] will help”), and (2) having a relationship with an empathic provider. Client expectations of improvement result in mental health outcomes that approach the effects of standard medical treatment for depression. In psychotherapy, creating expectations about the effectiveness of the intervention, providing an explanation of the disorder based on psychological and biological theories, and agreeing on the tasks and goals of therapy are an integral part of the treatment. In other words, the placebo response is part of what makes psychotherapy work, and good therapists capitalize on its effects.

Practice Implications

Patient expectations about the effectiveness of the therapy, their agreement with the therapist on the tasks and goals of therapy, and the therapist’s empathy toward the patient are key aspects that will increase the effectiveness of a therapeutic intervention. The explanation of the disorder and the treatment approach are embedded in psychological theories that typically underpin evidence-based psychotherapies.

Owen, J., Adelson, J., Budge, S., Wampold, B., Kopta, M., Minami, T., & Miller, S. (2015). Trajectories of change in psychotherapy. Journal of Clinical Psychology, 71(9), 817–827.

Knowing the rate, or the trajectory, or the shape of client change across sessions of therapy can inform our understanding of how patients change, our policies of how many sessions to provide clients, and our clinical decisions if clients are no longer improving. The most popular models of client change across sessions include the “dose-effect model” and the “good-enough level model”. The dose-effect suggests that the more therapy patients receive the more they improve but, at a certain point, more sessions result in diminishing returns. In the August, 2013 PPRNet blog, I reviewed a chapter suggesting that 17% to 50% partially improve after about 7 sessions, and 50% patients fully recover after receiving about 21 sessions of therapy. Dose effect models might encourage some agencies to provide only the average number of sessions so that most patients will improve. The good-enough level model, on the other hand suggests that patients stay in therapy for varying lengths of time, and the number of sessions is determined by the point at which they feel better. In this study by Owen and colleagues, the authors take a different approach by looking at the patterns or trajectories of change that represent how and at what rate patients improve over time. In this very large study, they gathered session-by-session outcome data for over 10,000 clients seen at 47 treatment centres by over 500 different therapists. Client presenting problems and therapy orientations varied. Owen and colleagues identified 3 classes of patient change trajectories by using advanced statistical modeling of general distress outcomes across 5 to 25 sessions of therapy (average = 9.4 sessions). The largest class, representing 75% of clients, typified those who rapidly improved to session 5 and whose improvement plateaued to session 11, after which they improved again. This was called the “early and late change” class. The second largest class of patients, representing almost 20% of the sample, showed consistent linear change across the sessions. This was called the “slow and steady change” class. The third class of clients, representing about 5% of the sample, showed an initial decline in functioning up to session 5, followed by a steady improvement up to session 9, and then a plateau in improvement after session 9. This was called the “got worse before they got better” class.  This last group of clients had the most severe symptoms at the outset.

Practice Implications

This study indicates that one size does not fit all when it comes to how rapidly and in what manner patients change. “Early and late change” patients improve early on and then show another round of improvement later on in therapy. “Slow and steady” change patients show mild but consistent improvement across sessions of therapy. And those whose symptoms are more severe at the outset may “get worse before they get better”. This means that it may not be feasible to set an average fixed number of sessions for all patients, but rather therapists and agencies must rely on indices of reliable or good-enough change to determine optimal therapy length for each client. For example, “early and late change” patients may be working on different issues at different stages of therapy. Whereas clients who “show slow and steady” change may need to be in therapy longer before they realize sufficient improvement. For those patients with more severe symptoms who “get worse before they get better”, the therapy initially may be difficult but may ultimately induce change in the long run. In this case, therapists may need to provide enough of the current therapeutic approach before considering a change in the course of therapy.

Author email: Jesse.owen@louisville.edu

Farrell, N.R. & Deacon, B.J. (2015). The relative importance of relational and scientific characteristics of psychotherapy: Perceptions of community members vs. therapists. Journal of Behavior Therapy and Experimental Psychiatry. DOI: 10.1016/j.jbtep.2015.08.004

The American Psychological Association defines evidence-based practice (EBP) in psychotherapy as based on: (a) research evidence, (b) clinical expertise, and (c) client characteristics and preferences. We know for example, that clients who receive their preferred treatments better engage with therapy, drop out at a lower rate, and achieve better symptom outcomes. However, we know very little about clients’ preferences for the relative importance of the therapeutic relationship with an empathic therapist versus the scientific merit of the treatment they receive. We do know that therapists generally prefer research on the therapeutic relationship, and that therapists may place greater value on relationship issues versus research support for the treatments they provide. In this study Farrell and Deacon sample 200 members of the community about the relative importance of the relationship with a therapist versus the scientific basis of the treatment. The authors also surveyed a similar number of therapists about what therapists thought clients would prefer (relationship vs research evidence) in psychotherapy. Not surprisingly, community members rated both the therapeutic relationship and research evidence highly when indicating what they preferred should they receive psychotherapy. However, the authors found that members of the community rated the therapeutic relationship much more highly than they rated research evidence (d = 1.24). But the difference shrank (d = .24) when it came to treating panic disorder or obsessive compulsive disorder. Therapists tended to under-estimate the importance of community members’ preferences for scientific evidence for psychotherapy. The under-estimation was greater for therapists who placed less value on research. In other words, therapists who valued research less in their own practice were more likely to underestimate the importance of scientific credibility to members of the general public.

Practice Implications

This is by no means a perfect study. As readers of this blog know, I prefer to write about meta analyses, which are much more reliable than findings from a single study. However, it is quite rare to have a study on a large sample of members of the community, let alone one that asks about their perceptions and preferences about psychotherapy. The findings from this study suggest that members of the community highly value the therapeutic relationship and factors like therapist empathy. However, members of the community also place much faith in the scientific evidence that supports the use of psychotherapy. The preference for both a good therapeutic relationship coupled with research evidence may be very important to most people who may seek therapy. Therapists, particularly those who place less weight on research, should keep in mind that clients value the scientific evidence for psychotherapy.

Author email: bdeacon@uow.edu.au