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Mackenzie, C. S., Erickson, J., Deane, F. P., & Wright, M. (2014). Changes in attitudes toward seeking mental health services: A 40-year cross-temporal meta-analysis. Clinical Psychology Review, 34(2), 99-106.

Rates of treatment for mental disorders in developed countries have increased over time and this is largely due to the dramatic rise in the use of medications, such as antidepressants over the past 30 years. Concurrently the proportion of people receiving outpatient psychotherapy has declined. Despite the increase of pharmacological interventions, many mental health services in the US do not meet evidence based guidelines, and most people with mental disorders in the US and Canada are not receiving care. Barriers to accessing care include: lack of knowledge (not knowing where to get help); structural barriers (financial costs), and attitudes (stigma, belief that one should handle the problem oneself, and belief that treatment will not help). There is a great deal of evidence that negative attitudes about seeking and receiving help are the most consistent reasons related to low service utilization in Canada and the US. Efforts to reduce stigma, in part, have attempted to define mental illness as a medical or biological disorder likely with the intent of reducing blame of the individual for his or her problems. As Mackenzie and colleagues indicate, this coincided with an aggressive direct-to-consumer advertising of psychotropic medications for mental disorders. And so the perception that mental disorders are biological and that require biological treatments became entrenched in the population. However, as I summarized in the PPRNet October 2013 Blog endorsing neurobiological causes of mental illness is associated with seeing the disorder as persistent, unchangeable, and serious. This increases social distance, which is an aspect of stigma. In their meta analysis, Mackenzie and colleagues reviewed all published studies over the past 40 years that used the Attitudes Toward Seeking Professional Help Scale. They analysed 22 studies with a total sample size of 6,796. They used cross-temporal meta-analysis to correlate year of the study with total scores on the scale. The correlation was large and negative (r = -.53) indicating that participants’ help-seeking attitudes have become significantly more negative over time.

Practice Implications

Attitudes toward seeking mental health services have become increasingly negative over the past four decades, which is consistent with worsening public stigma about mental health. This has coincided with an increase in the use of psychotropic medications and a decline in psychotherapy during the same period, despite evidence that psychotherapy is as effective as medications and preferred by patients. As Mackenzie and colleagues suggest, it is possible that attitudes toward mental health care have become increasingly negative due to efforts to convince the public that mental disorders have a neurobiolobic etiology and require biological treatments. When appropriate, clinicians should not promote biological explanations at the expense of psychosocial explanations for mental disorders. Psychological explanations and treatments may result in patients experiencing a greater sense of optimism about change, and greater personal control over the treatments they receive.

Elliott, R.E., Greenberg, L.S., Watson, J. Timulak, L., & Briere, E. (2013). Research on humanistic-experiential psychotherapies. In M.E. Lambert (Ed.), Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change, 6th Edition (pp. 495-538). New York: Wiley.

Humanistic or experiential psychotherapies (HEP) include: person centred therapy, gestalt therapy, emotion-focused therapy, existential psychotherapy, and others. Elliott and colleagues argue that each of these approaches share the characteristic of valuing the centrality of an empathic and therapeutic relationship. That is, an authentic relationship between patient and therapist provides the client with a new and emotionally validating experience. HEP methods that deepen client emotional experiences occur within an empathic relationship, and interpersonal safety is key to enhancing a client’s attention for self awareness and exploration. Despite the long history of research in HEP, these treatments are often used as “control” conditions in outcome studies of psychotherapies – that is, to control for “non-specific” or relationship factors. Elliott and colleagues conducted meta analyses on the effectiveness of humanistic-experiential therapies. Overall, they included 199 studies of over 14,000 patients. Pre to post treatment effect sizes were large (d = .95), indicating a positive effect HEP across a wide range of clients. (A note on effect sizes: Cohen’s d < .20 represents a negligible effect; d = .20 to .49 is a small effect; d = .50 to .79 is a moderate effect; and d > .80 is a large effect). Compared to a wait-list control (62 studies), the positive effect of HEP was significant with a moderate effect size for the difference (d = .76).  There were 135 studies that compared HEP to other active forms of psychotherapy. The difference between HEP and non-HEP therapies were trivial and non significant (d = .01). In the 76 studies that compared HEP to cognitive behavioral therapy (CBT), those who received CBT had better outcomes, but the effects were negligible (d = .13). The authors reported that there is enough evidence to indicate that HEP are efficacious for depressive disorders, substance misuse, and relationship problems; and HEP are probably efficacious for anxiety and psychotic disorders.

Practice Implications

The research on outcomes of humanistic-existential psychotherapies (HEP) provides support for the effectiveness of these therapies for a variety of disorders, and provides further support for the importance of the facilitative and relationship factors that help patients get better. Empathy, genuineness, positive regard each comes with research support to indicate their importance to patient outcomes.  Elliot and colleagues conclude that the education of psychotherapists is incomplete without greater emphasis on HEP and its facilitative components.

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.

Keefe, J.R., McCarthy, K.S., Dinger, U., Zilcha-Mano, S., Barber, J.P. (2014). A meta analytic review of psychodynamic therapies for anxiety disorders. Clinical Psychology Review, http://dx.doi.org/10.1016/j.cpr.2014.03.004.

Anxiety disorders are one of the most prevalent psychiatric conditions, with combined lifetime prevalence near 17%. Anxiety disorders have high rates of comorbidity with other Axis I and II psychiatric disorders, and are associated with substantial physical and mental health burden. Several well-established treatments for anxiety disorders exist, including cognitive-behavioral therapies (CBT). However, not all patients with anxiety disorders benefit from current treatments, and there is some evidence that some aspects of CBT are not well tolerated leading to patient non-compliance with therapist directives. Hence, other treatment options such as psychodynamic therapies (PDTs). Should be tested for efficacy with patents with anxiety problems. PDTs have been studied and found to be efficacious for other types of disorders especially for depression. As Keefer and colleagues note, psychodynamic theory conceptualizes anxiety symptoms as originating from relational contexts that give rise to painful feelings (e.g., feelings of loss or abandonment, a wish to express anger or assert oneself). The patient engages in disavowal defenses against these intense, negative feelings and desires, and so avoids their experiences, and develops anxiety symptoms (e.g., panic attack triggered by experiences of loss or anger). Psychodynamic therapists encourage the patient to discuss the contexts in which their symptoms arise in order to understand the occurrence of symptoms. Therapists help the patient make connections between prior interpersonal and intrapsychic events that lead to negative feelings and anxiety-producing defenses. The goal is to allow the patient to try new ways of getting their needs met without anxiety while using more adaptive defenses. Exposure to feared or avoided situations during therapy sessions or in real life may also be encouraged by therapists. PDT may be less directive that CBT in treating anxiety disorders, and this may be useful for patients who do not respond well to directive interventions. Keefe and colleagues conducted a meta analysis of PDT for anxiety disorders and included 14 controlled studies of 1,037adults. Most of the treatments to which PDT was compared were CBT. PDT was significantly more effective than no treatment control conditions and the effect was medium. PDT did not differ significantly from alternative treatments like CBT at post-treatment, one year follow-up, and follow up beyond one year. Almost half of patients who received PDT were no longer symptomatic at post-treatment, and the drop out rate from PDT was 17%.

Practice Implications

The findings of this meta analysis suggests that psychodynamic therapy (PDT) is effective in treating anxiety disorders including generalized anxiety disorder, social phobia, panic disorder and others. PDT was well tolerated by patients as the drop out rate was relatively low at 17%. PDT was as effective as CBT when the two treatments were compared to each other. PDT provides therapists and patients with a primary or alternative approach to treatment of anxiety disorders, and should be considered for those patients who do not respond well to the more highly directive nature of CBT.

Cieslak, R., Shoji, K., Douglas, A., Melville, E., Luszczynska, A., & Benight, C.C. (2014). A meta-analysis of the relationship between job burnout and secondary traumatic stress among workers with indirect exposure to trauma. Psychological Services, 11, 75-86.

The concept of job burnout was originally developed to document negative consequences of work related exposure to stressful situations experienced by various professionals such as police officers, paramedics, emergency room clinicians, etc. Job burnout can be defined as emotional exhaustion and disengagement. However, recent research on mental health providers has extended the focus beyond job burnout caused by direct exposure, to investigate the consequences of indirect exposure through contact with people who have experienced traumatic events, exposure to graphic trauma content reported by the survivor, or exposure to people’s cruelty to one another. These are sometimes referred to as secondary exposure or indirect exposure to trauma. Professionals indirectly exposed to trauma through their work could experience consequences or symptoms that have been conceptualized as secondary post-traumatic stress, vicarious traumatization, and compassion fatigue, which can collectively be called secondary traumatic stress (STS). STS may include three clusters of symptoms: intrusive re-experiencing of the traumatic material, avoidance of trauma triggers and emotions, and increased physical arousal. Compassion fatigue was defined as a substantial reduction in the mental health providers’ empathic capacity. Cieslak and colleagues (2014) conducted a meta analysis to assess the strength of associations between job burnout and other psychosocial consequences of work-related indirect exposure to trauma in professionals working with trauma survivors. They reviewed 41 studies that included 8,256 workers. The association between secondary traumatic stress (STS) and job burnout in professionals was significant and large. Workers were more likely to experience compassion fatigue and emotional exhaustion compared to PTSD-like symptoms and depersonalization, however, even the association with PTSD-like symptoms and depersonalization was moderate and significant. Both women and men were susceptible to STS, but the effect was larger in women.

Practice Implications

Burnout and other consequences of indirect exposure to trauma are likely to be high among mental health professionals. Burnout will affect professionals’ well being and quality of life, and will diminish their effectiveness with patients through reduced empathy and increased disengagement.  Mental health professionals who are exposed to secondary trauma should be aware of the potential for negative personal consequences, and assess their own level of emotional exhaustion, empathic capacity, and engagement. Mental health professionals should seek help if they re-experience the events, engage in avoidance of trauma triggers and emotions, and experience heightened arousal. Taking care of oneself through consultation with trusted colleagues, change in work contexts, social supports, and personal therapy could help to forestall compassion fatigue and burnout. Educational programs to improve self awareness and mindful communication may reduce burnout in mental health professionals.

Kvaale, E. P., Haslam, N., & Gottdiener, W. H. (2013). The ‘side effects’ of medicalization: A meta-analytic review of how biogenetic explanations affect stigma. Clinical Psychology Review, 33, 782-794.

Psychotherapists may wonder how best to explain a psychological problem to their clients and their family members. Will their explanation help to reduce stigma and increase hope? Laypeople, clinicians, and researchers increasingly understand psychological problems in biomedical terms. Further, some anti-stigma campaigns describe mental health problems, including depression, as biological, medical illnesses. Reducing stigma is important to improve uptake of therapy, reduce an internalized sense of defectiveness, and increase hope and self esteem. Some argue that understanding psychological problems as biologically based will combat stigma by reducing blame and punitive treatment. Kvaale and colleagues asked whether there is a cost to medicalization of psychological problems by unwittingly promoting the stereotype that those with a mental illness have a deep seated, fixed, and defining essence. Proponents of medicalization hope that such an approach will reduce blame for a mental illness, and will result in less desire for social distance from the mentally ill. However, medicalization might also result in: an increased belief that those with psychological problems are dangerous; and greater pessimism and hopelessness about the prognosis (i.e., a belief that the problem can not be improved). A meta-analysis by Kvaale and colleagues looked at experimental studies of student and community based samples in which explanations for a psychological problem was manipulated to include biomedical explanations versus psychological explanations or no explanations. The meta-analysis aimed to examine the causal effects of biogenetic explanations for psychological problems on: blame, perceived dangerousness, social distance, and prognostic pessimism. Regarding blame, the authors reviewed 14 studies that included 2326 participants and found that biogenetic explanations were associated with a decreased tendency to blame individuals with psychological problems. Regarding perceived dangerousness, the authors reviewed 10 studies with 1207 participants, and found that biogenetic explanations were associated with an increase in perceiving those with psychological problems as dangerous. However this result is tentative because publication bias may have resulted in an over estimation of the association (see my May 2013 blog on publication bias [“Are the Effects of Psychotherapy for Depression Overestimated?”]). Regarding social distance, the authors reviewed 16 studies with 2692 participants, but found no relationship between biogenetic explanations and reduced social distance. Regarding prognostic pessimism, the authors reviewed 16 studies with 3469 participants, and found that biogenetic explanations were associated with greater pessimism about the prognosis of a psychological problem.

Practice Implications

The meta analysis by Kvaale and colleagues found that biomedical explanations for psychological problems typically decrease blame, but increase prognostic pessimism and perceptions of dangerousness, although the latter conclusion is somewhat tentative. The findings lead one to be skeptical of the view that stigma will be reduced by promoting an understanding of psychological problems as biogenetic diseases. Kvaale and colleagues suggest that the affected individual, family members and mental health professionals could be more pessimistic about change because of a biomedical explanation, thus impeding the patient’s recovery process. Psychotherapists should share information about the biogenetic factors of psychological problems. However, this must be done with caution. Kvaale and colleagues conclude that explanations that invoke biomedical factors may reduce blame but also may have unintended side-effects. Biogenetic explanations should not be promoted at the expense of psychosocial explanations, which may have more optimistic implications.

Author email: e.kvaale@student.unimelb.edu.au