PPRNet Blog: November 2013

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 and sections of the book can be read on Google Books: Handbook on Google Books.

Clients and Therapists Differ in Their Perceptions of Psychotherapy.

Bohart, A.C. & Wade, A.G. (2013). The client in psychotherapy. In M. Lambert (Ed.) Bergin and Garfield’s handbook of psychotherapy and behavior change (6th ed.), pp. 219-257. Hoboken, NJ: Wiley.

Last month I blogged about the section in Bohart and Wade's (2013) chapter that focused on client symptom severity and motivation. This month I focus on differences between clients and therapists on their perceptions of therapy processes and outcomes. In a previous blog (see June 2013), I reviewed a meta analysis that showed that given two equally effective treatments, clients should be given their preference in order to improve outcomes. Clearly, client perceptions and preferences are important, and perhaps more important than the therapist’s perceptions. Bohart and Wade (2013) reviewed a number of studies that demonstrated this. For example, studies show that client ratings of the therapeutic alliance predicted which therapists had better than average outcomes, whereas therapist ratings of the alliance did not predict outcomes.  In three other meta-analyses, client perceptions of therapist genuineness, empathy, and therapeutic presence were each more predictive of outcomes than the respective therapists' assessments of their own genuineness, empathy, and therapeutic presence. Clients also value different outcomes compared to therapists and researchers. Most research on outcomes tends to focus on symptom reduction, but clients appear to have a broader view of good outcomes. In a qualitative study, clients focused on healthier relationship patterns, an increase in self-understanding that led to freedom from and avoidance of self-destructive behaviour, and stronger valuing of the self, in addition to symptom reduction. Others report that clients define good outcomes as reengaging in meaningful work and social roles, and restoring their self respect.

Practice Implications

Clients are more finely attuned to the therapeutic alliance than therapists, and perhaps are better at detecting relevant and helpful therapist stances. If you are interested in assessing therapeutic alliance or a therapist's empathy, don't ask the therapist, ask the client. This has implications for training therapists in helpful therapeutic relationship stances. Helping trainees find areas for continued development as a therapist (i.e., in terms of improving their empathy, genuineness, and therapeutic presence) may require asking their clients' opinions. Client perceptions of therapist qualities are more relevant than therapist perceptions when assessing effective therapist relationship stances. Therapists should monitor client preferences, particularly if the client is having difficulty engaging in the therapy. If possible and reasonable, therapists should alter their relationship approach to a client based on client feedback. Regarding outcomes, therapists, researchers, and agencies should consider broader definitions of outcomes that are more aligned with what clients want and value. Improved self concept, improved relationships, and better social and work functioning may be just as important as symptom reduction for most clients.

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Colli, A., Tanzilli, A., Dimaggio, G., & Lingiardi, V. (2013). Patient personality and therapist response: An empirical investigation. American Journal of Psychiatry.

Therapist emotional responses to patients may refer to emotional reactions or to countertransference. Emotional responses can inform therapeutic interventions if therapists view their responses as informative about the patient’s feelings, perspectives, and relationship patterns. Clinicians have an intuitive sense that specific patient characteristics tend to evoke distinct emotional reactions (i.e., countertransferences) in the therapist. However, there are very few studies that examine the association between patient personality features and therapist emotional responses. A study Colli and colleagues examined this issue. They sampled 203 therapists from two theoretical orientations (psychodynamic = 103; cognitive-behavioral = 100). Among the therapists, 58% were women, mean age was 43 years, average experience was 10 years, average time spent providing psychotherapy was 16 hours per week, and 78% were in private practice. Each therapist was asked to randomly select a patient in their caseload, and complete a validated personality assessment questionnaire about the patient. Three weeks later, and immediately following a therapy session with the patient, the therapist completed a validated therapist emotional response questionnaire. Half of the patients were women (53%), mean age was 34 years, average length of treatment was 5 months (once per week), and 72% were diagnosed with a personality disorder (either comorbid or as a primary diagnosis). Patient paranoid and antisocial features were associated with therapists feeling criticized/mistreated. Patient borderline personality features were associated with therapists feeling helpless/inadequate, overwhelmed/disorganized, and special/overinvolved. Patient narcissistic features were associated with therapists feeling disengaged. Patient dependent personality features were associated with therapists feeling both parental/protective and special/overinvolved. The results were not affected by clinicians' theoretical orientation. That is, psychodynamic and cognitive-behavioral therapists showed similar emotional responses to each patient personality pattern.

Practice Implications

The results do not appear to be an artifact of therapist theoretical orientation, and so the authors argue that patient interpersonal patterns are quite robust in evoking specific therapist countertransference. A therapist's emotional responses that are not primarily related to the therapist's own issues could be an important source of information about the patient's emotional and interpersonal patterns. Therapist emotional responses can also impede the therapist's work if the responses are not well understood. Therapists who treat those with borderline personality features may avoid their own experience of negative thoughts and feelings during a session and this may unwittingly manifest as a sudden confrontation of the patient. With patients who have narcissistic features, therapists may feel disengaged, unempathic, and emotionally mis-attuned, which could lead to an impasse or premature termination. Therapists who treat patients with dependent features may be overprotective and may avoid exploring the patient's painful feelings.

View the online copy of the Therapist Emotional Responses are Associated with Patient Personality article.

Author email address: antonello.colli@uniurb.it

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Munder, T., Brütsch, O., Leonhart, R., Gerger, H., & Barth, J. (2013). Researcher allegiance in psychotherapy outcome research: An overview of reviews. Clinical Psychology Review, 33, 501-511.

Although evidence for the efficacy of psychotherapy is largely uncontested, there remains debate about whether one type of treatment is more effective than another. This debate continues despite a recent American Psychological Association (APA) resolution on the equivalent efficacy of most systematic psychotherapy approaches. There are many aspects to this debate (e.g., some treatments are more researched than others and so appear to be better; symptom focused measurements are more sensitive to change and so may favour one treatment over another; some treatments are more amenable to manualization and short term application; etc.). One element of the debate that has received a lot of attention is researcher allegiance. Researcher allegiance refers to researchers preferring one treatment approach over another, and this preference may bias comparative outcome trials in favour of the preferred therapy. Researcher allegiance is measured by assessing primary researchers' publication history or by their self-declared preference for a particular therapy approach. There exist 30 meta analyses that assessed researcher allegiance since the 1980s. These meta analyses focused on different therapy types, client populations (adults, children), and research designs (randomized trials, naturalistic effectiveness studies). However, some meta analyses have reported contradictory results for the researcher allegiance effect. This could be due to the different foci of the meta analyses (i.e., different treatment approaches, patient populations, age groups, etc.), and also possibly due the allegiance of those conducting the meta analyses. Munder and colleagues (2013) conducted a mega analysis of these meta analyses. As the name implies, a mega analysis aggregates the findings of available meta analyses. Munder and colleagues found a significant moderate effect of researcher allegiance. Researcher allegiance was consistent across patient populations, age groups, outcome measures, type of study design, and year of publication.

Practice Implications

As the APA resolution indicates, psychotherapy is the informed and intentional application of clinical methods and interpersonal stances derived from established psychological principles. Evidence-based practice in psychotherapy is "the integration of the best available research with clinical expertise in the context of patient characteristics, culture and preferences". The results of this mega analysis undermine the claim of some comparative outcome studies that suggest that one evidence-based psychotherapy is more effective than another.

View the Researcher Allegiance in Psychotherapy Outcome Research abstract.
Author email: tmunder@uni-kassel.de

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Many times in a given month I will open a newspaper (oops, that belies my age – I should say “web-based news source”) or watch a TV evening newscast and see a story about a research study of a treatment that promises to cure some disease (i.e., cancer, dementia, depression, multiple sclerosis, schizophrenia, etc.). And yet, despite the repeated occurrence of these stories over many years, people still suffer from these diseases. Now, when I hear on the evening news that a study was published that could lead to a possible cure for depression, for example, I reach for the remote control. At the same time, psychotherapy clinicians often say to me that they cannot possibly stay on top of all of the research in their areas of specialty. First, they have a busy practice and don't have the time to wade through the mountains of studies that are published each month. Second, some of the research appears contradictory. For example, some studies show that psychodynamic therapy (PDT) is just as effective as cognitive behavioural therapy (CBT) for some disorders, whereas other studies find something quite different. One consequence of this is that many clinicians ignore research. Survey after survey shows that practicing psychotherapists often do not pay attention to research when making treatment decisions. Most clinicians are conscientious practitioners who want to do the best they can for their clients. But the volume of research is vast and apparently contradictory. What one needs is a sampling of many studies in order to make decisions about practice. Think of the results of an individual study as a single data point in a distribution of data (don't stop reading, this won't get too statistical). Distributions of data often have outliers – i.e., those single studies that have freak outcomes that are unlikely to be replicated. The studies that make it onto the evening news are freaks; that is, they are spectacular and so “newsworthy”. But the average effect of all the treatment studies for any given disorder will not likely show such spectacular outcomes. What should a conscientious clinician do?

Practice Implications

Single studies in psychotherapy and in other health areas are like the Wizard of Oz – they are not all that they appear to be and they promise more than they can deliver. I suggest that clinicians ignore single studies (for the most part) and focus their attention on meta-analyses and systematic reviews (and my Blog). Meta-analyses calculate the average effect size of many studies that ask similar questions (e.g., “are PDT and CBT effective for treating depression and is either treatment more effective”; “is there a meaningful relationship between therapeutic alliance and psychotherapy outcomes”, etc.). By averaging the effects of many studies, the outlier (freak) studies have less impact on the overall results, and the average effect of all studies is a better estimate of the real state of the research. Meta-analyses also weight studies for sample size. For example, studies with small sample sizes (i.e., those studies that are more likely to produce the freak results) tend to get a lower weighting than studies with more participants. So those small studies have less impact on the average effect size when considering all of the studies. That is why my Blog tends to focus on meta-analyses rather than single studies. (However, I will report on single studies if they have a unique sample, a very large sample, or ask an important but understudied question. I evaluate these single studies carefully before including them in my Blog. Nevertheless, clinicians should still pull back the curtain on those single studies and take them with a grain of salt). Meta analyses are not perfect and they can be subject to bias, but they are the best way to summarize the research. That is why practitioners should focus mainly on meta-analyses when using research to inform practice.