Blog
The Psychotherapy Practice Research Network (PPRNet) blog began in 2013 in response to psychotherapy clinicians, researchers, and educators who expressed interest in receiving regular information about current practice-oriented psychotherapy research. It offers a monthly summary of two or three published psychotherapy research articles. Each summary is authored by Dr. Tasca and highlights practice implications of selected articles. Past blogs are available in the archives. This content is only available in English.
This month...
…I blog about the treatment of depression, the effects of role induction in psychotherapy, and negative experiences in psychotherapy from clients’ perspective.
Type of Research
Topics
- ALL Topics (clear)
- Adherance
- Alliance and Therapeutic Relationship
- Anxiety Disorders
- Attachment
- Attendance, Attrition, and Drop-Out
- Client Factors
- Client Preferences
- Cognitive Therapy (CT) and Cognitive-Behavioural Therapy (CBT)
- Combination Therapy
- Common Factors
- Cost-effectiveness
- Depression and Depressive Symptoms
- Efficacy of Treatments
- Empathy
- Feedback and Progress Monitoring
- Group Psychotherapy
- Illness and Medical Comorbidities
- Interpersonal Psychotherapy (IPT)
- Long-term Outcomes
- Medications/Pharmacotherapy
- Miscellaneous
- Neuroscience and Brain
- Outcomes and Deterioration
- Personality Disorders
- Placebo Effect
- Practice-Based Research and Practice Research Networks
- Psychodynamic Therapy (PDT)
- Resistance and Reactance
- Self-Reflection and Awareness
- Suicide and Crisis Intervention
- Termination
- Therapist Factors
- Training
- Transference and Countertransference
- Trauma and/or PTSD
- Treatment Length and Frequency
August 2023
Therapists Tend to Overestimate their Effectiveness
Constantino, M. J., Boswell, J. F., Coyne, A. E., Muir, H. J., Gaines, A. N., & Kraus, D. R. (2023). Therapist perceptions of their own measurement-based, problem-specific effectiveness. Journal of Consulting and Clinical Psychology, 91(8), 474–484. https://doi.org/10.1037/ccp0000813
Previous research showed that therapists may be over-confident about their effectiveness. In one study, 91% of therapists felt that they were more effective than 75% of their peers, and 100% of therapists felt that they were more effective than 50% of their peers. These therapist perceptions relative to their peers are statistically impossible. What is the impact of this over-confidence on patient outcomes? In this study, Constantino and colleagues evaluated the perceptions and outcomes of 50 therapists who treated 1,363 patients (about 27 patients per therapist). Most therapists practiced CBT, integrative, or interpersonal psychotherapy. Patients had a variety of problems including depression, anxiety, sleep, social functioning, etc. Patients self-report of symptoms in 12 problem domains (depression, anxiety, etc.) from pre to post treatment. Therapists were asked to report on their perception of their effectiveness by rating from “mostly effective” to “mostly ineffective” for each patient problem domain. Then therapists’ ratings of their effectiveness were compared to their patients’ actual measurement-based outcomes from pre- to post-treatment. In this manner, therapists were classified as accurately estimating their outcomes, or as underestimating their outcomes, or as overestimating their outcomes compared to their patients’ outcome data. The researchers also controlled for case mix (complexity and size of the therapists’ caseload) and patient symptom severity at pre-treatment. For 7 of 12 patient problem domains, at least half of the therapists overestimated their own effectiveness. For the remaining 5 domains, most therapists accurately estimated their effectiveness. There were no domains for which most therapists underestimated their effectiveness. In 11 of the 12 patient problems, therapists were no better than chance at predicting their own effectiveness compared to patient rating. However, therapists who underestimation their effectiveness had patients with better outcomes at post-treatment, and this effect was stronger for patients with higher pre-treatment symptom severity. Conversely, therapists who overestimated their outcomes had patients with worse outcomes, and this effect was stronger for patients with higher pre-treatment symptom severity.
Practice Implications
Relative to patient self-reported measurement-based outcomes, therapists tend to be over-confident about their effectiveness. This over-confidence has implications for patients’ outcomes. Patients of therapists who show more humility about their effectiveness (tend to be neutral or under-estimate their effectiveness) have better outcomes. This is particularly true for patients with more severe symptoms. One of the few therapist factors known to predict better outcomes is professional self-doubt - the willingness to critically evaluate one’s practices and to continually improve one’s skills. Self-doubt may allow therapists to be more alert to potential signals that the therapy is off course, that they might have committed a micro-aggression, or that there was a therapeutic alliance rupture. Humility might allow the therapist to flexibly respond, change course, or repair the therapeutic relationship when necessary.
Characteristics of Psychologists Conducting Psychotherapy
Norcross, J. C., Rocha, M. N., & Chrysler, A. A. (2023, May 18). Psychologists conducting psychotherapy in 2022: Contemporary practices and historical patterns of the Society for the Advancement of Psychotherapy. Psychotherapy. Advance online publication. https://dx.doi.org/10.1037/pst0000493
Every 10 years or so the Society for Advancement of Psychotherapy (American Psychological Association, Division 29) conducts a survey of its membership to take a snapshot of their characteristics and activities. The membership is a diverse group of practicing psychotherapists and psychotherapy researchers with doctoral degrees in psychology in the U.S. The Society’s membership is not representative of all psychologists who practice psychotherapy, but the fact that the survey has taken place every decade since 1981 allows one to get a sense of some historical trends in the field. Previous surveys showed an increasingly female and culturally diverse membership. Theoretical orientations have tended to favor psychodynamic and cognitive-behavioral models, and primary employment has shifted from hospitals and community clinics to independent practices and universities. In this survey, Norcross and colleagues randomly selected 1000 members of the Society and received a 48% return rate. 65% were male and 35% were female, and the proportion of women has steadily grown from 27% in 1981. Most of the sample was White (90%). The average age was 68 years (SD = 13), and there has been a steady increase in age since 1981 when the average age was 46. On average, psychologists devoted 44% of their professional time to psychotherapy, 11% to research and writing, and 10% to teaching. There has been a gradual decline in the percentage of psychologists routinely supervising from 65% in 1981 to 37% in 2022. The percentage of psychologists providing diagnosis and assessment also declined from 55% in 2012 to 37% in 2022. Most psychologists (99%) provided individual therapy, but many also provided couple therapy (75%), and group therapy (20%) during some of their professional time. Psychologists working in public hospitals and community clinics continued to decrease from 16% in 1981 to 3% in 2022. In 2022, the most frequent theoretical orientations were psychodynamic/relational (29%), integrative (26%), and cognitive/cognitive-behavioral (CBT; 18%). CBT has steadily increased in popularity from 8% in 1981 to 18% in 2022. Of the respondents, 82% indicated that they received personal therapy at least once during their career. On average, 94% were satisfied at least to some degree with their careers, and 78% indicated that if they had to do it over again, they would choose to pursue a career in psychotherapy.
Practice Implications
This survey is not perfect and it likely is not representative of the population of psychologists who provide psychotherapy. Nevertheless, it does suggest some interesting historical trends. The average psychotherapist in these surveys appears to be getting older over time. This may indicate that younger psychotherapists are not aligning themselves with traditional organizations that provide a community of like-minded professionals. That is unfortunate as it limits the continuing education and supportive networks that could be available to a younger professional. On the positive side, many psychotherapists have pursued personal therapy during their careers and this trend has been consistent over the years. Further most psychotherapists are quite satisfied with their careers despite the stress related to doing this type of work.
June 2023
What People Want From Therapy
Delboy, S. & Michaels, L. (2021). Going beneath the surface: What people want from therapy. Psychoanalytic Inquiry, 41:8, 603-623. DOI: 10.1080/07351690.2021.1992232
There has been an increased interest in and demand for mental health care, and so one can imagine that the public might have questions or opinions about psychotherapy. Moreover, research has shown that patients who get the type of treatment that they expect or want are more likely to have better outcomes. However, it is rare that researchers ask the public what they want from therapy. In this unique study, Delboy and Michaels conducted a survey of US citizens about their perceptions and preferences for psychotherapy. Their sample of 1,535 respondents were deliberately selected to be representative of US census data for age, gender, ethnicity, socioeconomic status, and geographic region. The survey asked what people what they wanted from therapy: 70% indicated that they wanted to “learning skills and coping strategies”, which is like what is offered in manualized treatment modalities. However, 70% also wanted to “better understand oneself and the root of one’s issues”, which is like what is offered in depth, insight, and relational therapies. When forced to choose between a “therapy that takes fewer sessions and helps manage symptoms” and a “therapy that takes longer but addresses the root causes of problems”, 91% chose a longer therapy focused on root causes. Over 60% of the sample indicated that they wanted to “share feelings without judgement” and to “feel heard and understood by someone who cares”, which suggests that people value these qualities in the therapist and the therapeutic relationship. Interestingly, two thirds of the sample recognized that therapy takes time “to understand and resolve” one’s issues and problems. And less than 10% did not want to understand their problems or examine issues from childhood. Regarding the reasons of their mental health issues, 50% reported that relationship patterns are an important source of their distress, whereas only 10% attributed mental health problems to a “chemical imbalance” in the brain.
Practice Implications
Patients tend to do better when they get the treatment that they prefer. A similar percentage of the public (70%) wanted to “learn coping strategies” and to “better understand” themselves. However, when asked to choose, the vast majority (91%) preferred to better understand themselves and to address the root causes of problems. In addition, most people recognized that therapy takes more time than is often offered in time limited treatments. This is consistent with large surveys of patients that indicated that it took over 50 sessions before significant symptom relief was achieved. It is time for insurance providers, clinicians, and training programs to begin to take stock of client preferences when paying for, providing, and training for psychotherapy.
Patient Experience of Lasting Negative Effects of Psychotherapy
McQuaid, A., Sanatinia, R., Farquharson, L. et al. (2021). Patient experience of lasting negative effects of psychological interventions for anxiety and depression in secondary mental health care services: A national cross-sectional study. BMC Psychiatry, 21, 578. https://doi.org/10.1186/s12888-021-03588-2
One in six adults experience either depression or anxiety that affect their social functioning or quality of life. Most treatment guidelines indicate psychotherapy as a first line treatment for these common mental health problems because of the positive effects of therapy documented by research. Despite the effectiveness of psychotherapies, researchers pay little attention to potential negative impacts of psychological treatments. Negative effects might include worsening of symptoms, emergence of new symptoms, loss of self-esteem, among others. National surveys in the U.K. noted that 5% of patients reported lasting negative effects from psychological treatment. People who had preferences for therapy that were not met tended to have more negative effects, and service policy constraints may also influence patients’ experiences of negative effects. In this analysis of national survey data, McQuaid and colleagues considered all patients who completed therapy during a one-year period in the National Health Service (NHS) in the U.K. These patients received treatment in a secondary care service – that is, a service for those with moderate to severe symptoms. The survey asked whether patients experienced lasting “bad” effects from the treatment, and the authors assessed several service policies and procedures as correlates of these negative experiences. Of those patients who received service, 662 (14.8%) responded to the survey. Overall, 14.1% reported “agreeing” that they experienced a lasting bad effect, and another 13.7% reported a “neutral” response to this item. The likelihood of reporting a neutral or lasting negative effect was greater among those who felt that they did not receive timely therapy (they waited too long, or it was too difficult to access services), who did not receive enough sessions of treatment (most of the therapy in the NHS is short-term), and whose therapists did not discuss the patient’s progress in therapy.
Practice Implications
This study is not perfect by any means, but it does highlight system and service issues that may result in worsening of symptoms among patients, especially those with moderate to severe symptoms. Remaining on a wait list for too long may lead to worsening symptoms – which indicates that it might be best for some patients to be referred elsewhere if it is feasible. Not providing a sufficient dose of therapy (enough sessions) may also lead patient symptoms to be worse at the end of treatment. The disappointment and frustration associated with ending therapy too early may impact patients’ self-esteem, mood, and hopes for recovery. Clinicians might consider how much therapy they can offer before proceeding with someone who has moderate to severe symptoms. Finally, therapists should have regular discussions with patients about their progress and perhaps use progress monitoring as a tool to facilitate these discussions.
March 2023
Capacity to Mentalize Predicted Outcomes in Inpatient Therapy for Resistant Depression
Halstensen, K., Gjestad, R., Luyten, P., Wampold, B., Granqvist, P., Stålsett, G., & Johnson, S. U. (2021). Depression and mentalizing: A psychodynamic therapy process study. Journal of Counseling Psychology, 68(6), 705–718.
Mentalizing, or reflective functioning, refers to someone’s capacity to view themselves and others in terms of mental states (i.e., behaviors are interpreted in terms of feelings, wishes, desires, values, and goals). This capacity underlies skills like empathy, emotion regulation, and interpersonal functioning. Diminished mentalizing can aggravate depressed mood through negative biases in one’s perceptions of others and relationships and might prevent the reflection needed to regulate emotions. Individuals with mentalizing deficits might hypo mentalize so that they are very uncertain about the thoughts, feelings, or attitudes that underlie their own and others’ behaviors. Such individuals may experience apathy associated with depression. Others might hyper mentalize, that is they are too certain about what goes on in the minds of others, which means they may misinterpret or misunderstand the intentions and behaviors of others. Such individuals can experience chronic emptiness due to the lack of genuine connection with others. In this study, Halstensen and colleagues assessed if mentalizing predicted outcomes in 57 patients with treatment resistant depression who received inpatient therapy in Norway. This was a naturalistic study of intensive psychodynamic inpatient therapy. The average chronicity of depression was 11.7 years, all patients received previous unsuccessful psychological or medical treatment, and most had a comorbid diagnosis (e.g., panic disorder, social anxiety disorder). Measurements of mentalizing and depression were taken pre-treatment, during therapy, and up to one year post treatment. Depressive symptoms improved from pre-treatment to one year follow-up with a large effect (d = 1.47; α mean = −.09 per week, p = .001). The capacity to mentalize did not improve on average during that period, although there was a lot of individual variability in mentalizing scores. Interestingly, there was an increase in depressive symptoms at the outset of treatment that then declined significantly by post-treatment. Higher pre-treatment levels of mentalizing were associated with better depressive symptom outcomes (b = −16.80, p = .043), and those patients who improved their mentalizing capacity experienced stronger improvements in depressive symptoms.
Practice Implications
Although all patients were severely and chronically depressed, their capacities to mentalize varied significantly (some had higher and others lower levels). Patients in this study who had a high initial level of mentalizing capacity profited most from the intensive therapy. They seemed to be able to engage in the emotional work associated with the initial phase of intensive inpatient treatment for depression. On the other hand, patients in this study who had low levels mentalizing skills were likely to be non-responsive to intensive treatment. Patients with limited mentalizing capacity may require more support and more work to help them develop the reflective capacities necessary to understand their own and others’ behaviors in terms mental states.
Negative Effects of Psychotherapy
Strauss, B., Gawlytta, R., Schleu, A., & Frenzl, D. (2021). Negative effects of psychotherapy: Estimating the prevalence in a random national sample. BJPsych Open, 7(6), E186.
The focus of psychotherapy research tends to be on establishing the effectiveness of psychotherapies for various disorders. Rarely do psychotherapy studies report negative effects or negative outcomes. Some researchers estimate that about 5% of patients experience worsening of symptoms by the end of psychotherapy. However, there are very few investigations of clients’ experiences of the negative impact of therapy and fewer still that ask clients in the general population who had a course of therapy. In this national survey of the general population, Strauss and colleagues asked 5562 individuals if they received psychotherapy in the past 6 years. Of the total sample, 244 indicated that they had or are currently in treatment. These individuals had characteristics similar to patients seen in treatment. The mean age was 55.1 years (SD = 15/2), 63.4% had shorter term therapy of less than a year, 41% reported an anxiety disorder and 77% had a mood disorder, 63.1% saw a female therapist, and 69.2% saw a psychologist. These individuals were asked a series of questions regarding their experiences as clients in therapy. Rates of positive change due to therapy varied by the problems that they noted. For example, 26.6% indicated that they had a better relationship with their parents due to therapy, whereas 67.7% experienced improved mood. On average 88.6% agreed that they had a positive working relationship with the therapist. However, about 19% dropped out of therapy and an additional 13.1% changed therapist during treatment, indicating negative experiences or outcomes. Patient problems that had the highest deterioration rates (i.e., worsened) were physical well-being (13.1%), ability to work (13.1%), vitality (11.1%), sexual problems (10.6%) and problems with self-esteem (10.3%). The most common negative effect attributed to specifically to the treatment was the resurfacing of unpleasant memories (57.8% in the total sample). Other such problems like sleep problems, stress, and unpleasant feelings were reported 27.9% to 36.9% of the time. Of the total sample, 56.6% reported having had at least one negative effect caused by their experience in psychotherapy. Boundary violations and malpractice were very rarely reported by this sample of patients.
Practice Implications
Much of the research and clinical writing of psychotherapy tends to focus on whether it is effective and to document its positive effects. However, an important minority of patients experience worsening of symptoms and/or unpleasant or negative effects of psychotherapy. Some might argue that painful feelings that emerge in some clients is a necessary process when the client works through conflicting feelings or perceptions of themselves and others. A collaborative agreement between therapist and client on how therapy might proceed, how it works, or the goals of therapy will go a long way to limit the negative impact of working through unpleasant feelings in therapy. Nevertheless, therapists should monitor dropout rates in their practice and worsening symptoms in their clients and adjust their therapy and interpersonal stances accordingly.