Practice-Based Psychotherapy Research
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PPRNet Blog: March 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


blogEfficacy and Effectiveness of Psychotherapy

Handbook of Psychotherapy and Behavior Change

The Handbook of Psychotherapy and Behavior Change is perhaps the most important compendium of psychotherapy research covering a large number of research areas. The Handbook is updated approximately every 10 years, and the most recent 6th edition was published in January 2013. In the coming months I will review one chapter a month in addition to commenting on psychotherapy research articles. Book chapters have more restrictive copy right rules about distributing content, so I will not provide author email addresses for these chapters. If you are interested, you can view the table of contents on Amazon.

Efficacy and Effectiveness of Psychotherapy

Lambert, M.J. (2013). The efficacy and effectiveness of psychotherapy. In M.J. Lambert (Ed.) Bergin and Garfield's handbook of psychotherapy and behaviour change (6th ed.), pp169-218. Hoboken, N.J.: Wiley.

This comprehensive chapter in the Handbook reviews research on the efficacy and effectiveness of psychotherapy. Lambert's reviews focus on meta-analyses, which is a way of summarizing effect sizes in a research area. The bottom line is that psychotherapy is effective so that 40% to 60% of clients show substantial benefit in controlled research trials, though the effect is likely smaller in routine practice.  Concurrently, a consistent proportion of adults (5% to 10%) deteriorate during psychotherapy. Patients who receive formal treatment are better off than those who receive no treatment, and bona fide treatments are superior to control conditions that provide only some aspects of effective treatment. When psychotherapy is offered by skilful therapists, on average clients experience appreciable gains and return to normal functioning. Fifty percent of patients achieve clinically significant gains after 8 sessions, and 50% achieve recovery after about 20 sessions of psychotherapy. The effects of psychotherapy tend to be long lasting. For example, only 25% treated depressed patients relapse, whereas 50% of those who receive antidepressants relapse. Research continues to support those therapies that have been rigorously tested, and differences in effectiveness between therapy types (e.g., cognitive behavioural therapy (CBT), psychodynamic, interpersonal, etc.) tend to be small or negligible for many disorders. Cognitive behavioural therapy is still the most tested therapy modality, though other treatments are also accumulating evidence of efficacy. Treatment is likely facilitated by a therapeutic relationship that is characterized by trust, understanding, acceptance, kindness, and warmth. The effect of the therapist providing the therapy is at least as large as the effect of different therapy techniques. That is, some therapists are unusually effective, whereas others may not help the majority of patients who seek their services. Continuous monitoring of outcomes and providing regular feedback to the therapist improves the therapy’s effectiveness.

Practice Implications

Providers and patients can be assured that a broad range of formally defined and tested psychotherapies when provided by skilful therapists are likely to result in appreciable gains in clients including a return to normal functioning. Therapy relationships characterized by trust, understanding, acceptance, and warmth can greatly facilitate change in depression, anxiety, inadequacy, and inner conflicts. When making a decision about which therapy to choose, clients would be wise to consider the therapist as a person at least as much as the type of therapy being offered. Treatment efforts should be based on the best evidence available for treatment types, therapist behaviors, and relationship factors. Routinely monitoring the effects of therapy with each patient will give the therapist ongoing information about their effectiveness and may improve their patients’ outcomes.

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blogDo Therapists Cry in Psychotherapy?

Blume-Marcovici, A. C., Stolberg, R. A.,& Khademi, M. (2013). Do therapists cry in therapy? The role of experience and other factors in therapists' tears. Psychotherapy. Advance online publication. doi: 10.1037/a0031384

There is almost no research on therapists crying during psychotherapy, and on its correlates and impact. A survey of therapists’ ethical behavior conducted 25 years ago asked a single question about crying, and 56.5% of respondents indicated that they cried in the presence of a client. By contrast there are several such surveys in medicine. Notably, a study of medical students and interns found that 68% medical students and 74% of medical interns had cried with patients. A recent survey by Blume-Marcovici and colleagues is the first of its kind since it was devoted to therapists crying in therapy and associated factors. They defined crying as: “tears in one's eyes due to emotional reasons”. The authors surveyed U.S. psychologists and had 541 respondents. The sample included 59% graduate students, and 41% licensed clinicians who had an average of 9.6 years experience. Seventy six percent were women, mean age was 36 years, 35% had a cognitive behavioural therapy (CBT) orientation, and 33% had some psychodynamic orientation (PDT). Respondents reported that 72% had cried in therapy. Those who cried reported crying in 6.6% of their sessions in the past 4 weeks. There were no differences between men and women, and there was no association between therapist crying and therapist personality traits or level of empathy. Therapists who cried more often in their daily life tended to cry more in therapy. PDT and CBT therapists did not differ in the amount they cried in their daily lives, however PDT therapists (88.9%) reported crying more often than CBT therapists (50.1%) in therapy. Further, older and more experienced therapists reported crying more often in therapy in the past month than younger and less experienced therapists. It is possible that older therapists may become more comfortable in using their clinical judgment, and so have fewer restrictions on their own affective displays. Of therapists who cried, 45.7% felt that the therapeutic relationship improved, and 1% reported that the relationship deteriorated due to crying. Patients, however, were not surveyed for their opinion about their therapist's crying.

Practice Implication

Crying among therapists may happen relatively frequently. Although this study is novel, it is the only one of its kind so one should be cautious about drawing practice implication. The challenge of therapists crying in therapy is that it can bend or break the therapeutic frame (e.g., is the therapist crying because of being overwhelmed and acting on his or her own needs, or is the therapist genuinely responding for and with the patient?). The survey suggests that therapist crying can strengthen the therapeutic relationship. This is more likely true when the therapist is attuned to the patient's needs, and when the crying signals a moment of positive emotional connection in the midst of painful feelings in the client. As with any event in therapy, a genuine and skilful exploration by the therapist and patient of the therapist's crying has the potential to strengthen the relationship.

View the Do Therapists Cry in Psychotherapy? article abstract.
Author email: ablume@alliant.edu

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blogWhat Are The Characteristics of More Effective Therapists?

Laska, K. M., Smith, T. L., Wislocki, A. P., Minami, T., & Wampold, B. E. (2013). Uniformity of evidence-based treatments in practice? Therapist effects in the delivery of cognitive processing therapy for PTSD. Journal of Counseling Psychology, 60(1), 31-41.

Some therapists are more effective than others. Why, and how can we improve therapist effectiveness? Previous researchers estimates that differences among therapists account for 8% of the outcome variance, which is as big or a bigger effect than differences between treatment types. Some argue that training and supervising therapists in evidence-based treatments (EBTs) can reduce differences between therapists. But if training in EBTs does not reduce differences, what are the therapist factors we should be focusing on to improve outcomes? A study by Laska and colleagues (2013) addresses some of these issues. In their study, 25 therapists (psychologists and social workers) in Veterans Administration (VA) hospitals were trained by a nationally recognized trainer in cognitive processing therapy (CPT) for post traumatic stress disorder (PTSD), and they treated 192 veterans. Therapists were trained to a standard level of competence in CPT, and they were supervised weekly by a certified expert in CPT. Differences between therapists’ effectiveness accounted for 12% of the outcome variance. In other words training and supervision in CPT did not appear to reduce differences between therapists, so that some therapists remained significantly more (or less) effective than others. The CPT expert supervisor was able to identify the more effective therapists even though she was blind to patient outcomes. She was also asked to list the qualities of these more successful therapists. Four areas emerged from the qualitative analysis of the supervisor interviews. (1) Reducing Avoidance – i.e., therapists’ ability to skilfully address patient avoidance of difficult areas or avoidance of therapy assignments, and not to collude with client avoidance; (2) Language in Supervision – i.e., therapists’ willingness to discuss struggles with cases, openness to discussing their contribution to impasses, and non-defensiveness in response to supervisor feedback; (3) Flexible Interpersonal Style – i.e., therapists’ ability both to join with and to challenge patients, to flexibly apply the manual so that they did not miss important interpersonal events in the therapy, but at the same time not to stray too far from the manual; and (4) Strong Therapeutic Alliance –i.e., therapists' genuineness with patients, ability to develop a bond, and to agree with patients on tasks and goals of therapy.

Practice Implications

Creating a culture within a practice setting in which therapists are routinely provided feedback about their clients’ ongoing progress and about the therapeutic relationship has the potential to improve patient care. Therapists’ ability to handle interpersonally challenging encounters with patients is what distinguishes the most competent therapists from others. Training and supervision of therapists should focus on facilitative interpersonal skills as well as on the specific treatment protocol.

View the What Are The Characteristics of More Effective Therapists? article abstract.
Author email: Kevin.Laska2@va.gov

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