Practice-Based Psychotherapy Research
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PPRNet Blog: July 2013


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


blogCombining Medication and Psychotherapy for Schizophrenia

Handbook of Psychotherapy and Behavior Change

Starting in March 2013 I will review one chapter a month from the Handbook of Psychotherapy and Behavior Change in addition to reviewing psychotherapy research articles. Book chapters have more restrictive copy right rules than journal articles, so I will not provide author email addresses for these chapters. If you are interested, the Handbook table of content can be viewed on Amazon: Handbook table of content on Amazon.

Combining Medication and Psychotherapy for Schizophrenia

Forand, N.R., DeRubeis, R.J., & Amsterdam, J.D. (2013). Combining medication and psychotherapy in the treatment of major mental disorders. In M.J. Lambert (Ed.) Bergin and Garfield’s handbook of psychotherapy and behaviour change (6th ed.), pp. 735-774. Hoboken, N.J.: Wiley.

This comprehensive chapter covers evidence for combining medication and psychotherapy for several disorders. This month I report on the section of the chapter on schizophrenia. Practice guidelines recommend antipsychotic medications as the first line treatment for Schizophrenia. However, up to 30% of individuals show an initial poor response and an additional 30% of patients continue to experience symptoms. Medication side effects can be debilitating, resulting in poor adherence and therefore reduced effectiveness. Further, Schizophrenia spectrum disorders are heterogenous in presentation and course, and so a “one size fits all” approach will not be effective for some or many. Psychotherapies can enhance the effectiveness of medications at different phases of treatment to hasten recovery or reduce medication-resistant symptoms. CBT for schizophrenia was developed to treat persistent medication-resistant positive psychotic symptoms (i.e., positive symptoms refer to delusions, hallucinations, disorganized speech and behaviour; whereas negative symptoms refer to restrictions in: emotions, thoughts, speech, and initiating goal directed behaviors). CBT focuses on reappraising the power and source of hallucinations, evaluating delusions, and addressing motivational deficits. CBT appears to be effective for chronic symptoms of schizophrenia with small to moderate effects, and these effects appear to be enduring. There is currently less and mixed evidence for CBT to speed recovery from first episode psychosis and to improve relapse rates. There is also evidence suggesting the effects of family psychoeducation to reduce relapse and to improve caregiver outcomes. However, family psychoeducation requires the participation of a caregiver, which may be a challenge that limits its utility. There is promising research on multidisciplinary rehabilitation programs that include case management, behaviour management, social skills training, social cognitive training, and cognitive remediation. There is also controversial research on providing psychological interventions alone or in a staged approach (i.e, in which earlier and less severe stages are treated with more benign interventions, and later stages are treated more aggressively with medication). However there are as yet no well-controlled clinical data to support this approach.

Practice Implications

Adjunctive psychosocial treatments appear to improve symptomatic and functional outcomes in individuals with schizophrenia spectrum disorders. CBT is best suited for treating chronic positive psychotic symptoms, but its effect on relapse prevention is equivocal. Individuals who are at risk for relapse might benefit from family psychoeducation, if the caregiver can be engaged. Multidisciplinary rehabilitation programs are a promising avenue of treatment.

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blogPractice Implications of Therapeutic Alliance Research

Horvath, A.O., Fluckiger, C., Del Re, A.C., & Symonds, D. (2011). Alliance in individual psychotherapy. Psychotherapy, 48, 9-16.

The psychotherapy alliance is probably the most researched concept in psychotherapy. A PsychInfo search of terms including the word “alliance” will turn up over 7000 hits. Although the concept of alliance has been around at least since the 1950s, the commonly acceptable pan-theoretical definition that is currently used was proposed by Bordin in the 1970s. This definition emphasizes the conscious aspects of the collaboration between therapist and client, and involves three elements: agreement on goals, agreement on tasks, and the bond between client and therapist. What is important in terms of developing the alliance is the therapist’s ability to step back from his or her own agenda and emphasize, prioritize, and negotiate the collaborative relationship. This allows for the selection of an intervention that is congruent with client expectations, which then will foster a high level of mutuality. Horvath and colleagues conducted a large meta analysis of alliance - outcome research from the years 1991 to 2009 that included 190 independent studies and over 14,000 participants. The overall relationship between alliance and outcome was statistically significant and moderate in size. This was a highly reliable effect. The results were consistent regardless of which measure was used, who rated the alliance (client, therapist, independent rater), or what type of treatment was studied (i.e., CBT, IPT, Psychodynamic, etc). Similar results were found in separate published meta analyses of child and adolescent psychotherapy and of family and couple therapy, though the effect is larger in couple therapy.

Practice Implications

The quality of the alliance is an index of the level of mutual and collaborative commitment to therapy by the therapist and client. Its distinguishing feature is the focus on therapy as a collaborative enterprise. Establishing a good alliance prevents clients from dropping out, and the sense of collaboration creates a context to introduce new ways of addressing the client’s concerns. In the early phases of therapy, tailoring the methods of therapy (tasks) to suit the specific client’s needs, expectations, and capacities is important in building the alliance. Misjudging the client’s experience of the alliance (i.e., believing that it is in good shape when the client does not share this perception) could render therapeutic interventions less effective. Horvath and colleagues suggest active monitoring the clients’ alliance throughout treatment. Therapists’ nondefensive responses to client negativity or hostility are critical for maintaining a good alliance. Research indicates that therapists who are good at building a strong alliance tend to have better alliances with most of their clients. However, the reverse is also true – some therapists consistently struggle to establish and maintain a good alliance with their clients. The strength of the alliance often fluctuates when therapists’ challenge clients to deal with difficult issues, when misunderstandings arise, and when transference occurs and/or is highlighted. Resolution of these normal variations is associated with good treatment outcomes. The next blog entry discusses research on alliance ruptures and repairs.

View the Practice Implications of Therapeutic Alliance Research article abstract.
Author email: horvath@sfu.ca

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blogRepairing Therapeutic Alliance Ruptures

Safran, J.D., Muran, J.C., & Eubanks-Carter, C. (2011). Repairing alliance ruptures. Psychotherapy, 48, 80-87.

One of the most consistent findings emerging from psychotherapy research is that the quality of the therapeutic alliance predicts outcome across a range of different treatments, and that a weakened alliance is correlated with dropping out of psychotherapy. Jeremy Safran and his colleagues have characterized a “second generation” of alliance research that attempts to clarify the factors leading to the development of the alliance as well as those processes involved in repairing ruptures in the alliance when they occur. A rupture in the therapeutic alliance is defined as a tension or breakdown in the collaborative relationship between patient and therapist. These could include: disagreement on goals of therapy, disagreements on the tasks of therapy, or strains in the patient - therapist bond. Ruptures may vary in intensity from relatively minor tensions, of which one or both of the participants may be only vaguely aware, to major breakdowns in collaboration, understanding, or communication. Similar concepts include: empathic failure, therapeutic impasse, and misunderstanding event. For example, a therapist returned from holidays to a session with a patient with whom she previously had a good alliance. The patient appeared more sullen, and quieter than usual in this session. The patient rated the alliance lower following the session, and the therapist felt the same. In the next session the therapist asked about the change in the patient and explored reasons for the change. It emerged that the patient’s old feelings of loss and abandonment re-surfaced with the therapist's absence, and the patient felt resentment when the therapist returned. Examining this pattern resolved the rupture and led to continued gains by the patient especially regarding the relational theme of abandonment. In a small meta analysis by Safran and colleagues, 3 studies representing 148 patients were reviewed. The relationship between rupture-repair episodes and treatment outcomes was significant, though modest. In a subsequent meta analysis of 8 studies representing 376 patients, the relationship between an intervention to repair alliance ruptures and positive outcomes was significant and large.

Practice Implications

A therapist's non-defensive response to a client’s negative feelings about the therapy is critical to repairing a rupture. Safran and colleagues suggest 6 strategies for therapists to deal with alliance ruptures. (1) Repeating the therapeutic rationale can help to repair a strained alliance. (2) Changing tasks or goals can make the therapy and its objectives more meaningful to the patient. (3) Clarifying misunderstandings at a surface level by acknowledging how the patient might feel misunderstood or criticized by the therapist. (4) Exploring relational themes associated with the rupture, could help the therapist and patient understand the patient's relational themes and reactions. (5) Linking the alliance rupture to common patterns in the patient's life, as in the example provided above, allows the patient to change the pattern in the therapeutic relationship. (6) Providing a new relational experience such that the therapist's non-defensive response and willingness to repair the rupture may be a new and positive experience for the patient leading to a better alliance and laying the groundwork for further change.

View the Repairing Therapeutic Alliance Ruptures online copy of the article.
View the Repairing Therapeutic Alliance Ruptures article abstract.
Author email: safranj@newschool.edu

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