Practice-Based Psychotherapy Research
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PPRNet Blog: September 2014

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

Giorgio A. Tasca

blogThe Effect of Therapist Empathy on Client Outcomes

Elliott, R., Bohart, A. C., Watson, J. C., & Greenberg, L. S. (2011). Empathy. Psychotherapy, 48(1), 43.

There has been a recent upsurge in interest in empathy in psychotherapy following scientific studies in the field of social neuroscience. This research has focused on activation in areas of the brain associated with emotional stimulation, perspective taking, and emotion regulation. Conceptualizations of the role of empathy in psychotherapy have a rich history in both client-centered and psychodynamic traditions. Carl Rogers defined empathy in part as “...the therapist’s sensitive ability and willingness to understand the client...from the client’s point of view.” Elliott and colleagues indicate three main modes of expressing therapeutic empathy: empathic rapport (compassionate understanding of the client’s experience); communicative attunement (ongoing effort to stay attuned with the client’s experience); and person empathy (experience-near understanding of the client’s world). In this meta-analysis of research on therapeutic empathy, Elliott and colleagues were interested in the strength of the relationship between therapist empathy and client outcome, and factors that might determine this relationship. Their meta-analysis included 57 different studies of 3,599 clients. The relationship between therapist empathy and client outcome was medium-sized (r = .31), and in the same order of magnitude as the alliance-outcome relationship. There were no differences between theoretical orientations in the size of the empathy-outcome relationship – in other words, empathy was equally important across types of therapy. Client measures of therapist empathy had the largest relationship to client outcome, whereas therapist ratings of empathy had the smallest association with client outcomes. In other words, if you are interested in therapist empathy, best to ask the client. Also, the empathy-outcome relationship was larger for less experienced (vs more experienced) therapists and for more severely (vs less severely) distressed clients. That is, empathy likely is most important for newer therapists and more distressed clients.

Practice Implications

Therapist empathy is essential to any psychotherapy regardless of orientation. Empathic attunement and expression is particularly important for clients of newer therapists, and for more distressed clients. Elliott and colleagues suggest that the empathic therapist’s primary goal is to understand the client’s experience and to communicate this understanding to the client. This can be done through: empathic affirmations (i.e., validating the client’s perspective); empathic evocations (bringing the client’s experience to life with rich, evocative, and concrete language); and empathic conjectures (making explicit what is implicit in the client’s narrative). Empathy can deepen client’s experiences, but therapeutic empathy also involves individualizing responses to the client. For example, some fragile patients may find typical expressions of empathy as too intrusive, whereas other clients may find therapeutic empathy to be too directive or too foreign. Being attuned to the client’s receptiveness to empathy is an important therapeutic skill. Elliott and colleagues emphasize that empathy should be grounded in authentic caring for the client and as part of a healthy therapeutic relationship.

View The Effect of Therapist Empathy on Client Outcomes abstract.

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blogLong-Term Effects of Psychotherapy for Depression

Steinert, C., Hofmann, M., Kruse, J., & Leichsenring, F. (2014). Relapse rates after psychotherapy for depression - stable long term effects? A meta-analysis. Journal of Affective Disorders.

As I reported in the June 2014 Blog depression is the most highly prevalent of the mental disorders with a lifetime prevalence of about 16%. It is responsible for enormous personal and economic burden for individuals and their families. Depression can occur as a single episode, however recurrence of depressive episodes can range from about 35% to 85% of those who were depressed. About 10% of cases experience chronic depression. Studies report that chronic or severe depression result in a lower response to interventions, including psychotherapy. Meta analytic research shows that a number of psychotherapeutic interventions are equally effective for treating depression (see also the July 2014 Blog). However, all of these meta analytic reviews of the effects of psychotherapy for depression referred to studies demonstrating short or medium term effectiveness. There are very few studies that report long term effectiveness of any type of treatment (psychological or pharmacological) for depression. This is a problem given the fluctuating and sometimes chronic course of the disorder. Randomized controlled trials of psychotherapy are expensive and time consuming, and collecting follow up data is difficult. And so it is not surprising that few studies assess outcomes after one or two years post treatment. Steinart and colleagues conducted a meta analysis looking specifically at studies that documented long term (i.e., greater than 2 years) post psychotherapy outcomes for depression. (A note on meta analyses: Meta analyses are a set of procedures that allow one to statistically combine the effects of many studies in order to estimate the average effect across many studies and participants. Meta analyses produce much more reliable results than any single study can produce, and so meta analyses are the best way of summarizing research to affect practice). Steinhart and colleagues found 11 studies of 966 patients that reported outcomes beyond 2 years post psychotherapy. Six of the studies compared psychotherapy to another intervention (e.g., medications, treatment as usual, clinical management). The authors found that 40% of patients treated with psychotherapy had at least one relapse in a follow up period averaging about 4 years. Compared to non-psychotherapy interventions psychotherapy had a significantly lower likelihood of experiencing a relapse. Despite the positive long term outcomes of psychotherapy for depression, the authors noted that there was a great deal of inconsistency across studies (i.e., heterogeneity), which lowers ones confidence in the reliability of these findings.

Practice Implications

There are very few studies of long term (> 2 years post treatment) outcomes of psychotherapy for depression. In the June and August PPRNet Blogs, I reported on a large scale worldwide reviews that indicate how pervasive depression can be, and how detrimental depression is to health and well being. Depression can be recurrent and chronic for some, so demonstrating long term outcomes is important. On the positive side, psychotherapy results in 60% of individuals not experiencing relapses 4 years post treatment, and psychotherapy resulted better long term outcomes than non-psychotherapy interventions. However, having so few studies that assess long term outcomes reduces our confidence in these findings. A number of psychotherapies including cognitive behavioral therapies, psychodynamic therapy, interpersonal psychotherapy, and others are effective for treating depression.

View Long-Term Effects of Psychotherapy for Depression full article on ScienceDirect.

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blogPsychotherapeutic Interventions to Promote Forgiveness

Wade, N.G., Hoyt, W.T., Kidwell, J.E., & Worthington, E.L. (2014). Efficacy of psychotherapeutic interventions to promote forgiveness: A meta-analysis. Journal of Consulting and Clinical Psychology, 82, 154-170.

Forgiveness can include reducing vengeful and angry thoughts and feelings, and may be accompanied by positive thoughts, feelings and motives towards the offending person. This does not necessarily include reconciliation with the offending person, nor does it require forgetting, condoning, or excusing the wrongdoing. Promoting forgiveness in psychotherapy includes helping clients move toward more positive and optimal functioning. There are two prominent empirically based models of forgiveness interventions. Enright’s model contains four phases: (1) uncovering negative thoughts about the offense, (2) decision to pursue forgiveness, (3) work toward understanding the offending person, and (4) discovery of unanticipated positive outcomes and empathy for the offending person. Worthington’s model has five steps: (1) recalling the hurt and emotions, (2) empathising with the offender, (3) altruistic view of forgiveness, (4) commitment to forgiveness, and (5) holding on to or maintaining forgiveness. Wade and colleagues conducted a meta analysis: to compare forgiveness outcomes and mental health outcomes of forgiveness interventions in general; to compare of forgiveness interventions to each other; and to compare forgiveness interventions to non-forgiveness psychotherapies or to control conditions. The meta analysis included 53 studies of 2,323 participants. Participants receiving forgiveness interventions reported significantly greater forgiveness compared to those not receiving treatment and compared to those who received alternative treatments that were not specific to forgiveness. Forgiveness interventions also resulted in greater positive changes in depression, anxiety, and hope compared to no-treatment conditions. There were no differences between Enright’s and Worthington’s approaches when duration of treatment and modality (individual vs group) were controlled. However, as an individual treatment, Enright’s model showed better outcomes. Longer duration of treatment was associated with greater forgiveness, and greater severity of the offense was also associated with greater forgiveness.

Practice Implications

Theoretically grounded forgiveness interventions may be the best choice to help a client to achieve resolution in the form of forgiveness. Other non-forgiveness therapeutic approaches may help but may not have as great an impact on forgiveness as those interventions that are specifically designed to improve forgiveness. Enright’s model delivered as an individual treatment was more effective than Worthington's approach which is designed mostly as a group intervention. In addition to improving forgiveness, both approaches also had significant positive impact on depression, anxiety, and hope. The forgiveness interventions worked better if provided for longer duration and in the context of more severe offenses.

View Psychotherapeutic Interventions to Promote Forgiveness abstract.

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