Practice-Based Psychotherapy Research
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PPRNet Blog: January 2018


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


blogThe Importance of Focusing on Problems in Psychotherapy

Yulish, N. E., Goldberg, S. B., Frost, N. D., Abbas, M., Oleen-Junk, N. A., Kring, M., . . . Wampold, B. E. (2017). The importance of problem-focused treatments: A meta-analysis of anxiety treatments. Psychotherapy, 54(4), 321-338.

Typically, meta-analyses indicate that the differences between treatments in client outcomes are small or non-existent. When a treatment is found to be more effective than a comparison condition, it is usually because the treatment (and not the comparison) is focused on the particular problem that is measured as the main outcome variable. The contextual model of change in psychotherapy posits three paths to client change: 1) therapist empathy and the real therapeutic relationship; 2) client expectations related to the therapist’s explanation of the problems and of how the therapy will reduce these problems (e.g., agreement on tasks and goals, which are aspects of therapeutic alliance); and 3) the direct specific interventions of the therapy to address these problems. In this meta-analysis, Yulish and colleagues examine aspects of the second and third component of the contextual model by examining if the difference between treatments for anxiety disorders is due to the relative differences in their focus on symptoms. In this systematic review, the authors identified 135 randomized controlled trials of direct comparisons of psychotherapy for anxiety disorders. They then rated each treatment and control condition for: the amount of explanation provided to clients for their symptoms, the amount of explanation provided to clients for the treatment approach, and the specificity of the interventions to address the symptoms. In a series of meta-regressions the authors found that: 1) explanations for the symptoms and for the treatment approach, and 2) treatments that were more symptom focused resulted in larger treatment effects. When the authors pit explanations against symptom focus to predict outcomes, they found that providing clients with an explanation for symptoms and interventions (which resulted in higher client expectations of receiving benefit) was more important than the symptom focus of the treatment.

Practice Implications
This study suggests three mechanisms by which psychotherapy may lead to symptom relief for anxiety disorders: 1) providing clients with a clear explanation of symptoms and of therapeutic interventions, 2) having an agreement about the tasks and goals of therapy (i.e., therapeutic alliance), and 3) engaging in specific therapeutic actions that derive from the explanation of symptoms. Sitting with a client, being warm and accepting, expressing empathy and understanding, but not providing the client an explanation for his or her distress or a means to overcoming that distress may not be good enough. Such approaches may be beneficial for some with anxiety disorders, but they fail to fully make use of the factors that lead to effective therapy. The expectations of benefit created by the explanation of symptoms and interventions, in addition to specific therapeutic actions that are consistent with the explanation, may play a critical role in reducing symptoms of anxiety.

Click here for article abstract

Author email: bwampold@wisc.edu

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blogThe Effect of Therapists’ Internalized Models of Relationships

Steel, C., Macdonald, J., & Schroder, T. (2017). A systematic review of the effect of therapists’ internalized models of relationships on the quality of the therapeutic relationship. Journal of Clinical Psychology. Advance online publication. http://dx.doi.org/10.1002/jclp.22484

Therapists likely respond differently to different clients, due to their own personal characteristics and unconscious processes. Relational theory suggests that the therapist’s particular qualities combine with the client’s particular qualities to form a unique interpersonal context. The interpersonal context of therapy may be influenced by client and therapist internalized patterns of relating which are likely formed in early childhood. The attachment theory concept of internal working models is one way to understand therapists’ internalized patterns of relating. Internal working models are like templates that help one to predict how relationships with others work. Internal working models of self indicate the quality of one’s self-concept. In this systematic review, Steel and colleagues examined a total 22 studies and asked: do therapists’ secure attachments and positive internal working models affect the quality of the therapeutic relationship with clients? There were too few studies on the specific concepts to conduct meta analyses to aggregate effect sizes, so the authors simply reviewed the literature. Eighteen of 22 studies showed an association between therapist internalized relational models/attachment security/self concept and the therapeutic relationship. Three of four studies that looked specifically at therapist attachment found that therapist secure attachment was associated with a more positive therapeutic relationship. Among these studies, all forms of therapist attachment insecurity were associated with poorer relationship quality with clients and with lower levels of therapist empathy. Four of five studies that examined the effects of internal working models of self indicated that greater therapist negative self-concepts (i.e., self-criticism, neglecting of self, hostility towards self) was associated with a poorer therapeutic alliance with clients.

Practice Implications
Therapist effects (i.e., the differences between therapists) are emerging as important predictors of client outcomes. It is possible that therapists’ views of others and of self (i.e., internal working models) contribute to these differences. However, there are relatively few studies that examine psychotherapists’ views of self and of others and the impact on therapy. The research that does exist suggests important issues for therapists to consider. Therapists that are insecurely attached (i.e., are dismissive of the importance of relationships or are overly preoccupied with relationships) may have problems in developing positive therapeutic relationships and may be perceived as less empathic by clients. Therapists who have an overly negative view of their self (i.e., self critical, self neglecting) may struggle with developing a therapeutic alliance with clients. The findings suggest that clinicians need to be aware of their internalized relational models. The process of recognizing, reflecting on, and extricating from maladaptive interpersonal patterns and self-concepts may require supervision and/or personal therapy.

Click here for article abstract.

Author email: katiecatherinesteel@gmail.com

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blogTherapists’ Interpersonal Skills Make a Difference

Anderson, T., Crowley, M. E. J., Himawan, L., Holmberg, J. K., & Uhlin, B. D. (2016). Therapist facilitative interpersonal skills and training status: A randomized clinical trial on alliance and outcome. Psychotherapy Research, 26(5), 511-529.

Research on therapist effects indicates that there are differences between therapists so that some therapists are more effective than others. Therapist effects account for about 9% of client outcomes, which represents a moderate and therefore important effect. Differences between therapists do not seem to be accounted for by differing levels of adherence to or competence in delivering a manualized treatment. However, some researchers argue that therapist effects can be accounted for by differing level of facilitative interpersonal skills. That is, therapists vary in the level of interpersonal skills, and this difference accounts for a significant proportion of client outcomes. Therapist facilitative interpersonal skills might include: empathy, positive regard, warmth, ability to establish and repair therapeutic alliances, verbal fluency, emotional expression, and the ability to enhance client expectations of improvement. In this unique analogue study, Anderson and colleagues selected 23 “therapists” who were rated as very high or as very low on facilitative interpersonal skills. For example, highly skilled “therapists” scored high on a self-report measure of social skills and also demonstrated high interpersonal skills in their responses to video vignettes of therapy. Therapists also differed on their training status: half of the “therapists” were advanced clinical psychology graduate students, and the other half were graduate students from other programs (social sciences, humanities) who had no clinical training at all. The 66 clients were volunteers from a large undergraduate student research pool who met diagnostic criteria for a mental disorder (anxiety or depression) and were moderately to highly distressed. Clients were randomly assigned to receive treatment or to a wait-list control condition, so that 46 clients (2 per therapist) received treatment and 22 received no treatment. Compared to those in the control condition, clients who received treatment on average improved in terms of level of distress, regardless of which “therapist” they were assigned to. The training status of “therapists” (those with clinical training versus those without clinical training) had no effect on client outcomes or on the therapeutic alliance. Compared to “therapists” with low facilitative interpersonal skills, those with high interpersonal skills (regardless of training status) had significantly better client outcomes and significantly higher levels of the alliance.

Practice Implications
This was an analogue study in which some “therapists” were non-clinicians, so one must take the results with a grain of salt. Nevertheless, clients started out distressed, had a diagnosable disorder, and on average they achieved significant reduction in distress if they received therapy. Whether “therapists” had any clinical training did not affect outcomes, that is, non-clinical “therapists” did just as well as clinical trainees. However, higher “therapist” facilitative interpersonal skills regardless of training status lead to better client outcomes. These findings provide support for the notion that a therapist who is: empathic, warm, able to establish and repair therapeutic alliances, verbally fluent, emotionally expressive, and able to enhance client expectations of improvement will be more effective in reducing their clients’ levels of distress.

Click here for article abstract.

Author email: andersot@ohio.edu

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