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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.

May 2019

Therapist Empathy and Client Outcome

Elliott, R., Bohart, A. C., Watson, J. C., & Murphy, D. (2018). Therapist empathy and client outcome: An updated meta-analysis. Psychotherapy, 55(4), 399-410.

As early as the 1940s Carl Rogers spoke about the key role played by therapist empathy in determining client outcomes. Many clinical writers consider empathy as a therapist ability or trait that enables one to understand the other person’s feelings, perspectives, or motivations. Rogers defined empathy as the therapist’s sensitive ability and willingness to understand the client’s thoughts, feelings, and struggles from the client’s point of view. Three main modes of empathy include: rapport in which the therapist shows deliberate compassion for the client, communicative attunement in which the therapist stays attuned to the client’s moment to moment experience, and person empathy in which the therapist makes a sustained effort to understand the historical context of the client’s experience. There is recent neuroscience research showing specific brain processes at work when one automatically or unconsciously mirrors others’ experiences, when one deliberately tries to take an other’s perspective, and when one vicariously experiences others’ distress. Empathy is similar to unconditional positive regard, but empathy further involves the immersion of the therapist in the client’s experience. In this meta-analysis, Elliott and colleagues were particularly interested in the association between therapist empathy and client outcomes. The meta-analytic review included 82 independent samples and 6,138 clients. The overall study-level weighted correlation was medium-sized, r = .28 (95%CI: .22, .33), which is equivalent to a d = .58. In other words, therapist empathy accounted for approximately 9% of client outcome variance, which is similar to the effects of the therapeutic alliance and larger than the effects of specific treatment methods. Measuring therapist empathy by the client resulted in the largest association with outcomes, whereas measuring therapist empathy from the therapist’s perspective had the smallest association with outcomes. There were no differences between therapeutic approaches when it came to the empathy-outcome association.

Practice Implications

Psychotherapists have known for decades that empathic attunement with a client’s internal experiences is a key factor to clients getting better. Effective therapists of any orientation understand their clients’ goals and tasks, their moment to moment experiences in session, and their unspoken nuances. This requires therapists to continually adjust their assumptions and understanding. Client outcomes depend to some extent on how well the therapist receives, listens, respects, attends to, and responds to what the client experiences in therapy. Regularly assessing and focusing on the client’s experience of therapist empathy (not the therapist’s assessment of their own empathy) is most useful to help therapists modify their interpersonal stances and improve their clients’ outcomes.

Author email: robert.elliott@strath.ac.uk
Positive Regard and Psychotherapy Outcome

Farber, B. A., Suzuki, J. Y., & Lynch, D. A. (2018). Positive regard and psychotherapy outcome: A meta-analytic review. Psychotherapy, 55(4), 411-423.

A concept similar to therapist empathy is the notion of therapist unconditional positive regard. Carl Rogers argued that the three factors of positive regard, empathy, and genuineness were the necessary and sufficient conditions for therapeutic change. Rogers’ pioneering work paved the way for the view that the relationship in psychotherapy was the critical factor in determining clients’ positive outcomes. Rogers defined unconditional positive regard as: the extent to which the therapist finds him- or herself experiencing a warm acceptance of each aspect of the client’s experience. It means caring for and prizing the client as a separate person. Other similar terms include: acceptance, non-possessive warmth, and therapist affirmation. Whereas empathy involves immersing oneself in the client’s internal frame of reference in order to truly understand the client’s experience, positive regard refers to unconditional acceptance of the attitudes held by the client and an expression by the therapist of the client’s inherent worthiness as a person. Often, empathy and positive regard go hand in hand, but not always. It is possible to empathize with a client’s pain (loss of a loved one), but not be accepting of aspects of the client’s behavior (coldness toward and disengagement from others). In this meta-analysis, Farber and colleagues reviewed 64 studies comprising 3,528 participants. The aggregated effect size of the association between positive regard and outcomes was small, g = .36, but statistically significant (95% CI: 0.28, 0.44). One of the key moderators of this association was severity of client psychopathology, such that positive regard had a significantly greater effect for clients with lower severity of psychopathology.

Practice Implications

The authors concluded that affirming clients may serve many important functions. Positive regard may strengthen a client’s sense of self and agency, and the belief in their ability to engage in a positive relationship. Positive regard likely reinforces clients’ engagement in therapy, increases self-disclosures, and facilitates the therapeutic alliance. Unconditional positive regard requires therapists to express positive feelings and attitudes to clients. This means communicating a caring, respectful positive attitude that affirms a client’s sense of self worth.

Author email: farber@tc.edu
Experiential Dynamic Psychotherapy for Psychiatric Conditions

Lilliengren, P., Johansson, R., Lindqvist, K., Mechler, J., & Andersson, G. (2016). Efficacy of experiential dynamic therapy for psychiatric conditions: A meta-analysis of randomized controlled trials. Psychotherapy, 53(1), 90-104.

There is growing research support for the efficacy of short-term psychodynamic psychotherapies to treat common mental health problems. A subtype of short-term psychodynamic psychotherapies is called experiential-dynamic therapy (EDT), which goes by a number of different names such as Fosha’s accelerated experiential-dynamic psychotherapy, and McCullough’s affect phobia therapy. A fundamental assumption of EDT is that conditions like depression, anxiety and personality disorders are by-products of an individual’s attempts to regulate strong emotions associated with adverse experiences in attachment relationships during childhood. When the attachment system and associated affects are re-awakened in current relationships, the individual may engage in maladaptive coping that leads to difficulties in relationships. While EDTs may focus on helping patients to understand how their attachment difficulties lead to inhibitory affects and maladaptive defenses, the treatment favors interventions that facilitate direct experience of underlying emotions in the here and now of the therapy. In this meta-analysis, Lilliengren and colleagues reviewed 28 studies with 1,782 adult patients who had a mood, anxiety, personality, or mixed disorder. Compared to inactive controls, EDT showed a moderate and significant effect at post-treatment (range: d = .39 to .65) and at follow-up assessments (range: d = .26 to .62), with largest effects for depression and anxiety. When researchers compared EDT to cognitive-behavioral therapy (CBT) in five studies, there were no significant effects at post-treatment (d = .02, 95% CI: -.24, .28) or follow-up (d = .07, 95% CI: -.22, .36). The average quality of EDT studies was good. In fact, studies with larger samples, that used blind randomization and assessments, and appropriate statistical tests showed larger effects for EDT. Drop-out rates for EDT (16.3%) were similar to other treatments.

Practice Implications

Experiential-dynamic therapy (EDT), which is a variant of short-term psychodynamic psychotherapy, was more effective than no-treatment and just as effective as evidence-based treatments like CBT. The findings are similar to those reported in many comparative outcome studies in which any bona-fide psychotherapy is effective for many disorders. The average quality of the EDT studies was quite good, suggesting that the findings were reliable and valid, and perhaps underestimating the true effects of EDT.

Author email: peter.lilliengren@psychology.su.se

April 2019

Therapeutic Alliance Rupture Repair

Eubanks, C. F., Muran, J. C., & Safran, J. D. (2018). Alliance rupture repair: A meta-analysis. Psychotherapy, 55(4), 508-519.

It is difficult to over-state the importance of developing and maintaining a therapeutic alliance in order for patients to experience a good outcome from psychotherapy. The alliance is the collaborative agreement between therapist and patient on the tasks and goals of therapy, and the emotional bond between therapist and patient. A previous meta-analysis found a moderate but highly reliable association between a good alliance and patient outcomes. The alliance is a trans theoretical construct – that is, it is important to all types of therapy regardless of theoretical orientation. Sometimes deteriorations in the alliance occur manifested by a disagreement on the goals, a lack of collaboration on the tasks, or a strain in the relational bond. Other terms for this phenomenon include weakenings, misattunements, challenges, resistances, enactments, and impasses. Such deteriorations can vary from minor tensions to major ruptures in the relationship. Tensions and ruptures in the alliance are common occurrences in therapy with some studies showing 50% of therapy cases experience at least a minor tension within the first six sessions of therapy. There are two main types of alliance tensions/ruptures. (1) Withdrawal tensions/ruptures occur when the patient moves away from the therapist, such as when the patient changes the subject, goes silent, and cancels appointments. These tensions/ruptures are more subtle and harder for therapists to detect. (2) Confrontation tensions/ruptures occur when the patient moves against the therapist, such as when the patient expresses dissatisfaction with or pressures or tries to control the therapist. These tensions/ruptures are more obvious, but also difficult for therapists to manage because of the feelings they evoke. In this meta-analysis, Eubanks and colleagues reviewed 11 studies representing 1,314 patients. They found that the association between rupture repair episodes and patient outcomes was on average moderately large r = .29, d = .62, 95% CI [.10, .47], p = .003.

Practice Implications

The research on alliance tensions/ruptures and repairs is still new but points to some important therapist practices that could improve patient outcomes. Therapists must be attuned to indications of tensions and ruptures in the therapeutic relationship. Therapists immediately need to attend to confrontation tensions/ruptures, in which patients express dissatisfaction or hostility. Similarly, therapists must address more subtle withdrawal tensions/ruptures, in which patients go silent, evade, or appease. Therapists can acknowledge the tension/rupture directly and nondefensively by inviting patients to explore their experience of the rupture. If necessary, therapists might change the tasks or goals of the therapy to better match the patient’s concerns. Therapists should empathize with a patient’s negative feelings about the therapy, and validate the patient for bringing up their concerns. If appropriate, therapists should take responsibility for their part in the tension/rupture and not blame the patient. Also, if the tension/rupture is a repetition of an interpersonal pattern for the patient (e.g., the patient tends to withdraw in relationships), then the therapist might consider carefully exploring the tension/rupture as it occurs in the therapy with the understanding that it is a repetitive pattern. Mainly, therapists need to anticipate that tensions and ruptures will occur in therapy, that they can be destabilizing for the therapist and therapeutic relationship, and so therapists need to recognize and know how to explore their own and their patient’s negative feelings.

Author email: catherine.eubanks@einstein.yu.edu
Goal Consensus and Collaboration in Psychotherapy

Tryon, G. S., Birch, S. E., & Verkuilen, J. (2018). Meta-analyses of the relation of goal consensus and collaboration to psychotherapy outcome. Psychotherapy, 55(4), 372-383.

A key element of the therapeutic alliance is for therapists and clients to collaboratively come to a consensus about what they will work on. Goal consensus is part of the agreement between therapist and client, and in part it defines what will be the tasks of therapy. The tasks of therapy (i.e., what a therapist and client do in therapy to alleviate the problems or address issues) follow from the goals and conceptualization of the problems. At times goal consensus is straight forward. The client wants to feel less depressed and the therapist proposes certain therapeutic actions to help the client to be relieved of their depressive symptoms. However at other times, despite an agreement on the main symptoms, the client may not agree with a therapist’s conceptualization and tasks of therapy. For example, a therapist might believe that the client’s history of abuse and/or their current problem with alcohol may underlie the depression, but the client does not want to address these underlying issues. In such an example, the therapist and client only barely agree on a goal, and may not agree on how to go about alleviating the symptoms. In some cases there is outright disagreement, a misunderstanding, or vagueness about the goals, and so there is no consensus and therefore no basis for a collaboration. Collaboration and goal consensus are pan-theoretical processes that apply to all forms of therapy. However, research in the past decade has focused almost exclusively on behavioral or cognitive therapy studies using homework compliance as the index of collaboration. Tyron and colleagues conducted a meta-analysis of 54 studies of the association between goal consensus and client outcomes and found a moderate and significant correlation, r = .24 with 95% CI [.19, .28]. They also reported similar findings from a meta-analysis of 53 studies of therapist and client goal collaboration and client outcomes, in which they found a moderate and significant effect, r = .29, 95% CI [.24, .34].

Practice Implications

These meta-analyses show a positive link between goal consensus and collaboration with psychotherapy outcomes. Therapists should clarify clients’ goals for therapy, and therapists should share their conceptualization of the clients’ issues or symptoms. This conceptualization will determine to some extent the tasks or methods of therapy. For some clients, this process may take time and require revisiting throughout the course of treatment. Collaborative work to establish the goals and focus of therapy may in and of itself be therapeutic for those clients who have long standing interpersonal problems. Therapists should seek input from clients about the formulation and treatment plans, and be prepared to adjust their intentions according to client preferences. Therapists could invite continuous client feedback about the goals and tasks of therapy and monitor client progress. Then therapists can use this feedback to modify their interpersonal stances and treatment methods.

Author email: gtryon@gc.cuny.edu
Group Psychotherapy for Borderline Personality Disorder

McLaughlin, S.P.B., Barkowski, S., Burlingame, G.M., Strauss, B., & Rosendahl, J. (2019). Group psychotherapy for borderline personality disorder: A meta-Analysis of randomized-controlled trials. Psychotherapy. Advance online publication. http://dx.doi.org/10.1037/pst0000211

Borderline personality disorder (BPD) is characterized by fear of abandonment, unstable intense relationships, rapid changes in identity and self-image, impulsivity, wide mood swings, periods of intense anger, and ongoing feelings of emptiness. These symptoms sometimes lead to suicidal behavior or non-suicidal self-injury. Often, those with BPD report a very stressful childhood that included sexual and/or physical abuse, and neglect. Borderline personality disorder is the most common of the personality disorders and is associated with severe social psychological impairment such that those with BPD often have unstable employment, are involved in abusive relationships, and engage in risky behaviors. A diagnosis of BPD is also associated with a high rate of mortality due to suicide. Practice guidelines indicate that psychotherapy is a key component to the treatment of BPD. Two psychological treatment approaches that incorporate group interventions are dialectical behavior therapy (DBT) and mentalization-based treatment (MBT). In DBT patients learn specific skills to alter maladaptive ways of regulating emotions in a group context. In MBT, an attachment-based treatment, the focus is on building trust in others through group interactions that generalize to other social relationships. In this meta-analysis, McLaughlin and colleagues reviewed 24 studies that compared group treatment for BPD to treatment as usual, which included a variety of interventions like supportive groups, pharmacotherapy, individual therapy, and others. Some of the treatments for BPD were stand-alone groups and some groups were part of a larger comprehensive program. Participants attended between 12 and 130 sessions, and group size ranged from 4 to 12 members. The meta-analysis revealed that group treatment for BPD versus treatment as usual resulted in moderate to large effect on BPD symptoms: g = .72, CI: [.41, 1.04], p < .001. The effects of group treatment versus treatment as usual on suicidality produced a moderate effect, g = .46, CI: [.22, .71], p < .001. The authors reported similar results for secondary outcomes like depression, anxiety, and general mental health. Drop-out rates were similar between group treatments (26.26%) and treatment as usual (28.26%). There were no differences in the effects of group therapy orientations on any of the outcomes or on drop-out rates.

Practice Implications

The results of this meta-analysis indicated the value of group treatment for BPD not only for core symptoms and suicidality, but also for symptoms related to quality of life (depression, anxiety). Theoretical orientation did not explain any of the findings, suggesting that treatments like DBT and MBT in a group format are equally effective. Therapists and patients can feel confident that group treatment for BPD are among the most effective treatments available.

Author email: mclaughlin.stevie@gmail.com

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May 2019

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April 2019

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