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.
…I blog about psychotherapy for borderline personality disorder, capacity to metnalize and therapy resistant depression, and negative effects of psychotherapy
Type of Research
- ALL Topics (clear)
- Alliance and Therapeutic Relationship
- Anxiety Disorders
- Attendance, Attrition, and Drop-Out
- Client Factors
- Client Preferences
- Cognitive Therapy (CT) and Cognitive-Behavioural Therapy (CBT)
- Combination Therapy
- Common Factors
- Depression and Depressive Symptoms
- Efficacy of Treatments
- Feedback and Progress Monitoring
- Group Psychotherapy
- Illness and Medical Comorbidities
- Interpersonal Psychotherapy (IPT)
- Long-term Outcomes
- 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
- Therapist Factors
- Transference and Countertransference
- Trauma and/or PTSD
- Treatment Length and Frequency
Adverse Effects of Psychotherapy in Patients with Depression
Moritz, S., Nestoriuc, Y., Rief, W., Klein, J.P., Jelinek, L., Peth, J. (2019). It can’t hurt, right? Adverse effects of psychotherapy in patients with depression. European Archives of Psychiatry and Clinical Neuroscience, 269, 577–586.
Only recently have psychotherapy researchers begun to document adverse events or negative outcomes in treatment trials. Research demonstrates that in everyday clinical practice, clinicians generally are unable to identify patients who get worse because of therapy. Unfortunately, the field remains unclear as to what constitutes an adverse event in psychotherapy. Moritz and colleagues refined and shortened a questionnaire filled out by patients about adverse events that they may have experienced in a recent psychotherapy. The authors defined an adverse event as consisting of three aspects. First, side effects were defined as the patient experiencing an unintended negative effect including stigma, relationships deteriorating, and greater symptoms. Second, malpractice was defined as the patient judging that the therapist provided a treatment that was not appropriate to the problem at hand. Third, unethical conduct was defined as a therapist abusing a patient in some manner. In addition, the authors also had a scale of positive effects experienced by patients due to the therapy. For this study, Moritz and colleagues recruited 135 patients who were diagnosed with depression and asked them to fill out the questionnaire about adverse events in their most recent psychotherapy. Most patients (95.6%) reported at least one positive effect of the psychotherapy that they received. However, at least one adverse event was reported by 52.5% of patients. Side effects were endorsed most frequently by 38.5% of patients. Malpractice was endorsed second most frequently by 26.7% of patients. Finally, unethical conduct was endorsed by 8.1% of patients. Not surprisingly, adverse events in therapy were negatively correlated with positive effects of therapy (r = -.24). Adverse events were not associated with patient factors like gender, or therapy factors like type of therapy or profession of the therapist.
This study by Moritz and colleagues is far from perfect, but it does begin a conversation about acknowledging that psychotherapy is not necessarily a benign event for some patients. In a previous study for example, 42% of patients with obsessive compulsive disorder experienced more or worsening symptoms due to exposure techniques used in CBT. Psychotherapists are notoriously poor at identifying patients who get worse from therapy, and so some therapists use aids like continuous progress monitoring to track patient progress and identify when therapy may be harmful.
The Emotionally Burdened Psychotherapist
Nissen-Lie, H. A., Orlinsky, D. E., & Rønnestad, M. H. (2021). The emotionally burdened psychotherapist: Personal and situational risk factors. Professional Psychology: Research and Practice. Advance online publication.
To provide good treatment, a psychotherapist must have enough mental and emotional energy to be attuned to the different states of their patients. However, sometimes emotional reserves of therapists can dwindle because of personal or professional burdens. As a result, many therapists report the experience of burnout that inevitably has a negative effect on their patients. Therapists’ personal burdens can be defined as stress in one’s personal life, feeling worry or concern, experiencing conflict within one’s family, or loss of a loved one. These therapist personal burdens could be enduring vulnerabilities or short-lived stressors, but they nevertheless have an impact on the therapist’s effectiveness. Higher stress in a therapist’s personal life is related to more avoidant coping, and lower capacity to stay focused, engaged, and empathic with patients. In this large-scale survey of over 12,000 psychotherapists worldwide (e.g., Norway, US, Canada, UK, Australia, Denmark, China), Nissen-Lie and colleagues looked to identify past and current personal and situational factors that were linked to the experience of personal burden among psychotherapists. The therapists were mostly married or in a committed relationship (72%), half were psychologists, the average length of clinical practice was 12 years (SD = 9.2), and therapists worked almost evenly across the major theoretical orientations (including CBT, psychodynamic, systemic, and behavioral). The most salient predictors of personal burden among psychotherapists were: current health and financial worries, early trauma or abuse, attachment anxiety (i.e., concern about abandonment and difficulty regulating negative emotions), dominant and demanding behavior in relationships, lower work satisfaction, and younger age. Cumulatively, these variables accounted for a substantial amount (30%) of the variance in personal burden.
Increasingly, research is pointing to negative life events and work experiences that may limit a therapists’ capacity to be engaged and empathic with patients. Focus on therapist well-being should be an important part of clinical training and supervision. Previous research found that receiving personal therapy, obtaining clinical supervision, working shorter hours, and lower caseloads improved empathy and wellbeing among psychotherapists.
Does Clinical Training Lead to Greater Therapist Interpersonal Skills?
Wolfer, C., Visla, A., Held, J., Hilpert, P., & Fluckiger, C. (2021). Assessing interpersonal skills—A comparison of trainee therapists' and students' interpersonal skills assessed with two established assessments for interpersonal skills. Clinical Psychology and Psychotherapy, 28, 226-232.
Differences between therapists may account for 2% to 8% of the variance in patient mental health outcomes. This seems like a small amount, but the effect is as large as the specific effects caused by interventions of any therapeutic orientation. One of the factors that accounts for differences between therapists is therapist interpersonal skills such as empathy, respectfulness, warmth, openness, and willingness to collaborate. These skills can be learned and likely allow some individuals to be more effective when encountering challenging or complex interpersonal situations. One might think that such skills would be a pre-requisite for entering psychotherapy training, but that may not be the case. A study of training therapists found that more than half of novices were unhelpful to their patients. In this study by Wolfer and colleagues, the authors were interested in seeing if therapists at different stages of training had different levels of these important interpersonal skills. That is, do trainees as a higher level of training acquire more of these skills than those prior to receiving training. This was a small study comparing 19 therapists in clinical training versus 17 students in psychology but with no clinical training. Clinical trainees were in the program for at least 2 years, and received many hours of supervision. All participants watched a video recording of difficult patient statements. Participants’ reactions to the patient video were recorded and then trained raters coded the responses for level of interpersonal skills. Trainee therapists scored significantly higher than students on two scales of interpersonal skills, even after controlling for age. In fact, trainee therapists were over 13 times more likely to demonstrate facilitative interpersonal skills than untrained students. Although being in a clinical training program was associated with greater interpersonal skills, level of experience of clinical trainees (range 2 to 5 years of training) was not related to the level of interpersonal skills.
This is a relatively small study, so one should consider the findings quite cautiously. Nevertheless, it is one of the few studies to assess interpersonal skills in therapists. It is possible that only those with more interpersonal skills choose to be trained as clinicians – that is, only especially skilled students may go on to receive clinical training. However, the trainees’ substantial amount of clinical training (observing clinicians handle complex situations, receiving supervision to enhance self-reflection) may have facilitated growth in their interpersonal skills. As in previous research, clinical experience alone was not related to therapist interpersonal skill.
The COVID-19 Telepsychology Revolution
Pierce, B. S., Perrin, P. B., Tyler, C. M., McKee, G. B., & Watson, J. D. (2021). The COVID-19 telepsychology revolution: A national study of pandemic-based changes in U.S. mental health care delivery. American Psychologist, 76(1), 14-25.
The COVID-19 pandemic has changed many things in our lives – how we connect with loved ones, how we play, and how we work. The pandemic has also affected typical coping strategies like seeking social support to improve or maintain mental health. Not surprisingly then, COVID-19 and the public health measures enacted to reduce its transmission has altered how therapists and patients engage in psychotherapy. On the positive side, this revolution in how psychotherapy is provided could lead to increased access for some patients living in rural and remote areas, those with severe anxiety, or those with physical disabilities that impede their mobility. In addition, some regulatory bodies in American states have relaxed rules that restrict inter-state practice and strict privacy requirements so that psychotherapy may remain accessible to patients during these times. Prior to the pandemic only about 21% of psychologists ever used telepsychology in their clinical practices, and many reported significant challenges to using telepsychology in their workplaces. Clinicians were also skeptical of the utility of telepsychology and its potential to negatively impact the therapeutic relationship. In one pre-pandemic survey, 75% of psychologists were not willing to refer their patients to telepsychology. Has the pandemic changed current perceptions and future expectations of psychotherapists’ use of telepsychology? In this large survey of over 2100 American psychologists, Pierce and colleagues documented past, current, and future use of telepsychology. Before the pandemic, on average only 7.07% (SD = 14.86) of psychologists’ practices involved telepsychology. During the pandemic 85.53% (SD = 29.24) of psychologists’ practice was made up of telepsychology. This represents nearly a 12-fold increase. Psychologists projected that in the future, after the pandemic, 34.96% (SD = 28.35) of their practice would consist of telepsychology. That is, after the pandemic, almost all psychologists who responded (89.19%) plan to use some form of telepsychology in at least in one third of their clinical work.
These survey results suggest that telepsychology may be here to stay, even after the pandemic. Psychotherapists however require training to use telepsychology effectively and to feel more effective in their use of the technology. This trend will increase access for some marginalized patients, and some therapists will likely want to maintain the convenience afforded by telepsychology (reduced overhead, less travel). Psychological providers and regulatory bodies will have to adapt to the new reality. With more use and experience may come more self-confidence and perhaps more relaxed regulatory restrictions on the use of telepsychology.
Social Support and Therapeutic Bond Interact to Predict Client Outcomes
Zimmermann, D., Wampold, B.E., Rubel, J., Schwartz, B., Poster, K., … & Lutz, W. (2020) The influence of extra-therapeutic social support on the association between therapeutic bond and treatment outcome, Psychotherapy Research, DOI: 10.1080/10503307.2020.1847344
Researchers have known for many years that the number of social supports and the size of a patient’s social network have a positive impact on patient outcomes in psychotherapy. Social supports reduce loneliness, and higher loneliness is an important cause of distress. Research has also demonstrated quite convincingly that the relationship in psychotherapy plays an important role in patient mental health outcomes. The therapeutic alliance, for example, is one of the most researched concepts in psychotherapy and shows a clear and positive association with client improvement across a number of theoretical orientations and client problems. The therapeutic alliance is the collaborative agreement between client and therapist on the tasks and goals of therapy, and also their relational bond. The bond includes trust, respect, and confidence in the therapist. This is important because aspects of mental health, like emotion regulation, develop partly in social and intimate relationships, including in the therapeutic relationship. If the therapeutic relationship works to reduce loneliness and improve emotion regulation, then a positive therapeutic relationship will be particularly important for clients with less social support. In this study, Zimmerman and colleagues examined if an extra-therapeutic factor (social support) interacted with an intra-therapeutic factor (therapeutic alliance) to predict client outcomes. Over 1200 adult clients were treated by 164 experienced therapists who were guided by CBT manuals. Patients received 42.77 sessions on average (SD = 19.97), social support was assessed at the start of treatment, and alliance and outcomes were monitored after every session. On average, clients improved throughout treatment. Clients who had more social supports and who reported a better bond with their therapist improved the most. Of particular interest was the interaction between social support and bond. Those clients with lower social supports benefitted more if they also had a good therapeutic bond, and clients with a good therapeutic bond did well regardless of their level of social support.
Both extra-therapeutic social support and intra-therapeutic bond with the therapist uniquely contributed to better outcomes for clients. However, a good therapeutic bond with the therapist appears to be particularly important for all clients, especially those with low levels of social supports. Psychotherapists would do well to assess the level and quality of their clients’ social support. And in all cases, especially for clients with low social support, therapists should work to develop and maintain a supportive and trusting therapeutic bond with their clients.
Can Therapists Train to Improve their Capacity to Mentalize?
Ensink, K., Maheux, J., Normandin, L., Sabourin, S., … & Parent, K. (2013). The impact of mentalization training on the reflective function of novice therapists: A randomized controlled trial, Psychotherapy Research, 23, 526-538, DOI: 10.1080/10503307.2013.800950
Recently, researchers and clinicians have been discussing the importance of therapists’ capacity to mentalize. That is, the capacity of therapists to be aware of mental states within themselves and clients, to identify and reflect upon emotional experiences of clients, and to understand the impact of client emotions and life experiences on the therapist’s capacity to be present, empathic, and effective. Most training programs in psychology and psychiatry focus almost exclusively on techniques – the rational application of psychological theory to diagnose and treat. These programs rarely, if ever, focus on training student therapists to mentalize. And yet, much of effective therapy also involves active listening, empathic understanding, developing a therapeutic bond, and consciously and deliberately imagining clients’ mental states. Without such skills, therapists may be susceptible to engage in anti-therapeutic acts (acting out, disengaging, verbalizing anger and frustration, feeling ineffective, burning out) born out of un-reflected personal reactions to clients and their experiences. In their study, Ensink and colleagues tested a training program designed to improve the capacity to mentalize in student therapists compared to therapists who only received traditional training in identifying psychopathology and applying therapeutic techniques. Mentalizing training involved 30 hours of experiential workshops that provided feedback to students on identifying their own reactions that might interfere with understanding the client, reflecting on their reactions, and considering how this reflection might help to understand the patient better. Capacity to mentalize was assessed by rating responses and reactions of student therapists in both conditions (mentalizing training vs traditional didactic training) to videos of clients in therapy. All novice therapists (in both training conditions) started at relatively low levels of reflectivity (an index of mentalizing), suggesting that students did not start the training program with these skills. Trainees in the mentalizing training group showed significant improvement in their capacity to mentalize, whereas students in the traditional didactic training showed a significant decline in their reflective capacity to mentalize.
Psychotherapists do not start their training with high capacities to mentalize and so they may require training to hone this skill. Also, therapists who receive no such training do not spontaneously acquire these skills. Clients often have experiences that are perceived as foreign to trainee therapists, and so therapists may feel ill equipped to empathize, understand, and respond emotionally to such challenging client experiences. Therapists can be trained to identify their internal experiences (negative or positive emotional reactions that may be related to the client’s and/or therapist’s unresolved issues) that may interfere with establishing a productive therapeutic relationship. Increasing the capacity to mentalize may reduce therapists work-related stress as it affords therapists a greater measure of control and mastery over challenging encounters with some clients.