Practice-Based Psychotherapy Research
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PPRNet Blog: December 2017


Giorgio A. TascaAt the PPRNet conference in November 2012 over 100 psychotherapy clinicians, researchers, and educators were very keen to receive ongoing information about psychotherapy research that is practice-oriented and presented in an easily readable format. And so the PPRNet Blog was born.

About once a month I will review and summarize two or three published psychotherapy research articles. As part of the summary, I will highlight the practice implications of the research.

Because of copyright issues, we cannot post the full text of the articles, but we will provide a link to the abstract on the publisher's web site. I will also post the author's email address. Most authors are very happy to share their work. So if you want a copy of the article send the author an email with a request for a pdf or reprint.

At the bottom of each review you can post a comment, and comment on your colleagues' comments. I will update these as frequently as possible.

If you have ideas for an article to review or a topic you would like to see covered, please send me an email at pprnet@toh.on.ca.

Giorgio A. Tasca


blogAlliance ruptures and repairs in psychotherapy in primary care

Holmqvist Larsson, M.H., Falkenström, F., Andersson, G., & Holmqvist, R. (2018). Alliance ruptures and repairs in psychotherapy in primary care. Psychotherapy Research, 28, 123-136.

The therapeutic alliance is related to treatment outcome, so that a moderate amount of client improvement can be attributed to a positive alliance. More recent research on the alliance identifies ruptures in the alliance (i.e., disagreements on tasks and goals of therapy, or a tension in the relational bond between client and therapist) as predictive of poor client outcomes. Conversely repairing alliance ruptures (i.e., renegotiating tasks and goals of therapy, or repairing a strain in the relationship) is related to better client outcomes. Therapists can be trained to identify and repair alliance ruptures and this has a positive impact on clients. In this large study in a naturalistic primary care setting, Holmqvist Larsson and colleagues assessed how frequent alliance ruptures and repairs of ruptures occurred. They used a conservative definition of alliance rupture based on a meaningful decline in client self-reported measurement of alliance from one session to another. A repair of the alliance was defined as a return to previous levels of the alliance within 3 sessions after a rupture. Clients were 605 adults with depressive or anxiety disorders who received a variety of therapeutic orientations (CBT or psychodynamic) from one of 79 therapists. Ruptures with no subsequent repairs occurred in 10.7% of the cases, and ruptures followed by a repair occurred in 14.7% of the cases. Clients with more severe symptoms were significantly more likely to experience a rupture in the alliance with their therapist. Unrepaired ruptures were associated with poorer client outcomes, and repairing ruptures appeared to reverse the negative effects so that outcomes improved. In therapies of longer duration (14 sessions or more), a rupture-repair sequence was associated with even better outcomes than in those cases that experienced no rupture at all.

Practice Implications
About 25% of cases experienced an alliance rupture, even by this conservative definition of a rupture. Clients whose therapists were able to identify and repair the ruptures achieved the best outcomes, especially in therapies of longer duration. Therapists need to able to identify alliance ruptures, particularly in clients with higher distress; and therapists must be able to repair these ruptures so that these clients can achieve better outcomes. The results also suggest that the process of alliance rupture and repair may be highly therapeutic in and of itself.

Click here for article abstract

Author email: mattias.holmqvist.larsson@liu.se

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blogDoes Therapist Training Improve Client Outcomes?

Erekson, D. M., Janis, R., Bailey, R. J., Cattani, K., & Pedersen, T. R. (2017). A longitudinal investigation of the impact of psychotherapist training: Does training improve client outcomes? Journal of Counseling Psychology, 64(5), 514-524.

The research on the effects of therapist training on client outcomes has not been very encouraging. Most studies indicate that more therapist training, better adherence to and competence in a treatment manual, and greater experience are not related to improved client outcomes. The profession would like to think that therapists affect client outcomes so that more training and experience might be related to better outcomes. One could argue that the research in this area is hampered by many studies not following the same therapists across time over stages of training. That is, many studies compare client outcomes between novices and licensed professionals – but these studies do not really address the question “does an individual therapist get better as he or she accumulates more years of training and experience?” In this unique study, Erekson and colleagues track client outcomes of 22 therapists over a 10 year period starting from the therapists’ early training in a doctoral program in psychology to their first years as licensed psychologists working in a counselling centre. On average, the psychotherapists saw 183.95 (SD = 103.23) student clients during that time (range: 62 to 449 clients). The clients primarily had clinically impairing problems with anxiety and depression. Stages of training were defined as: graduate trainee, intern, post-doctoral fellow, and licensed professional. The average client moderately improved (d = .72) in terms of symptoms from the start to the end of their therapy. When looking at therapists’ effects across stages of training, the authors controlled for client initial severity and size of therapist caseload. The results indicated that 4 of the 22 therapists improved in their client outcomes over stages of training, 10 remained the same, and 8 therapists worsened over time. On average, client outcomes remained the same across a therapist’s stage of training. However, average client rate of change (i.e., how quickly a therapist’s client improved) became slower as therapists achieved more training and experience.

Practice Implications
This study adds to the weight of evidence that therapist training and experience as currently conceptualized do not result in better outcomes among clients. One possible explanation for why psychotherapist trainees do as well or better than when they are licensed professionals may lie in the structure of training programs. Trainees in graduate school and internships typically receive a high level of supervision and learning experiences, and must deliberately report client progress on an ongoing basis. Therapists who are licensed professionals are not required to maintain these practices, and so they may not be practicing deliberately. Researchers and clinical writers identify deliberate practice as an important means by which practicing psychotherapists can maintain and improve their skills in interpersonal effectiveness and therapeutic alliance.

Click here for article abstract.

Author email: david_erekson@byu.edu

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blogLong-Term Effects of Psychological Treatment for Youth with PTSD

Gutermann, J., Schwartzkopff, L., & Steil, R. (2017). Meta-analysis of the long-term treatment effects of psychological interventions in youth with PTSD symptoms. Clinical Child and Family Psychology Review, 20, 422-434.

Natural disasters, physical abuse, sexual abuse, war, accidents, loss and severe illness are traumatic events that can occur during childhood and adolescence. These potentially traumatic events are highly prevalent in youth, and approximately 15% of children and adolescents who have been exposed to traumatic events meet the diagnostic criteria for post-traumatic stress disorder (PTSD). Criteria for a diagnosis of PTSD include: intrusive memories of the traumatic event, avoidance, hyperarousal, and negative change in mood or cognitions. PTSD symptoms are also highly stable over time, and so without intervention they do not tend to improve. In this meta-analysis, Gutermann and colleagues assess the effects of psychological treatments for PTSD in youth, with a special emphasis on their long term therapeutic effects. Forty-seven studies of 3767 participants were included in the analyses. Traumas were varied and included childhood abuse, physical abuse, accidents, wars, and natural disasters. About 68% of interventions were CBT-oriented, and 67% were provided in a group therapy format. The uncontrolled pre-treatment to follow-up effect sizes for PTSD symptoms was large for studies with a follow-up period greater than 6 months (N = 30; g = .99, CI .83, 1.16). However, when psychological interventions were compared to treatment as usual or an active control group in a randomized controlled trial, the effects at post-treatment were small (N = 6; g = .38, CI .03–.74), and effects at follow up periods combined were also small (N = 19; g = .38, CI .20, .55).

Practice Implications
Psychological interventions resulted large effects to reduce PTSD symptoms from pre-treatment to follow-up from treatment. However, compared to treatment as usual or other active control groups, psychological treatments resulted in small effects in the longer term. There were too few studies to assess different treatment approaches, age groups, and modalities (group vs individual). Nevertheless, the results provide support for the efficacy of psychological treatments for PTSD in youth with modest effects at follow-up.

Click here for article abstract.

Author email: Gutermann@psych.uni-frankfurt.de

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