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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.

August 2013

Helpful and Hindering Events in Psychotherapy

Castonguay, L.G., Boswell, J.F., Zack, S., Baker, S., Boutselis, M., Chiswick, N., Damer, D., Hemmelstein, N., Jackson, J., Morford, M., Ragusea, S., Roper, G., Spayd, C., Weiszer, T., Borkovec, T.D., & Grosse Holtforth,, M. (2010). Helpful and hindering events in psychotherapy: A practice research network study. Psychotherapy: Theory, Research, Practice, and Training, 47, 327-344.

There are many reasons why I like this paper, and one reason is that it is a psychotherapy practice research network study (most of the co-authors are independent practice clinicians). This group of clinicians and researchers met on a number of occasions to define the research questions, including: “what do psychotherapists and clients find most and least helpful in a psychotherapy session?”; and “do psychotherapists and clients agree on what was most and least helpful?” The clinicians and researchers also discussed and agreed on the method for collecting and analysing the data. Thirteen independent practice clinicians participated (6 CBT, 4 psychodynamic, and 3 experiental/humanistic). For a period of 18 months, all new clients were invited to participate so that 121 clients with a variety of disorders enrolled in the study. Clients and therapists filled out (on an index card) parts of the Helpful Aspects of Therapy (HAT) measure, which asked them to report, describe, and rate particularly helpful and hindering events from the session they had just completed. For example clients and therapists were asked: “Did anything particularly helpful happen during this session?”; and “Did anything happen during this session which might have been hindering?” When participants answered “Yes” to either of these questions, they were asked to briefly describe the event(s), and then rate them on a scale from 1 to 4 for level of helpfulness or level of hindrance. Both clients and therapists did so at the end of every therapy session. Close to 1500 therapeutic events were recorded by the clients and therapists. The events were then coded and categorized according to type of event by independent raters using an established coding system. Clients rated self-awareness, problem clarification, and problem solution as the most helpful type of events, although self-awareness was significantly the most identified of all helpful events by clients. Therapists rated self-awareness, alliance strengthening, and problem clarification as the most helpful type of events. Therapists identified self-awareness and alliance strengthening significantly more often than any other helpful events. Hindering events were identified much less frequently by clients and therapists. Client identified poor fit (e.g., therapist tried something that didn’t fit the client’s experience) as the most frequent hindering event category. Therapists identified therapist omissions (i.e., failure to provide support or an intervention) as the most frequent hindering event category. Overall, with the exception of self-awareness, therapists and clients did not agree on what were the most helpful or hindering events in therapy.

Practice Implications

Results regarding self awareness indicate that providing clients with opportunities to achieve a clearer sense of their experience (e.g., emotions, behaviors, and perceptions of self) is frequently reported as beneficial by both clients and therapists. The events that therapists most frequently reported as detrimental were those in which they failed to be attuned to their clients’ needs. This may reflect therapists’ concerns with potential alliance ruptures. The overall lack of agreement between therapists and clients on helpful and hindering events raises the question about whether therapists are not aware enough of clients’ experiences, or whether clients are not knowledgeable about what is in fact therapeutic. Perhaps client and therapist ratings of events represent complementary perspectives on what works or does not work in psychotherapy. Regarding participating in research, these independent practice therapists reported that the procedure of writing down helpful and harmful events and reading what their clients wrote after each session had a positive impact on their practice. That is, the process of data collection became immediately relevant to their clinical work.

Author email: lgc3@psu.edu

March 2013

Do Therapists Cry in Psychotherapy?

Blume-Marcovici, A. C., Stolberg, R. A., & Khademi, M. (2013). Do therapists cry in therapy? The role of experience and other factors in therapists' tears. Psychotherapy. Advance online publication. doi:10.1037/a0031384

There is almost no research on therapists crying during psychotherapy, and on its correlates and impact. A survey of therapists’ ethical behavior conducted 25 years ago asked a single question about crying, and 56.5% of respondents indicated that they cried in the presence of a client. By contrast there are several such surveys in medicine. Notably, a study of medical students and interns found that 68% medical students and 74% of medical interns had cried with patients. A recent survey by Blume-Marcovici and colleagues is the first of its kind since it was devoted to therapists crying in therapy and associated factors. They defined crying as: “tears in one’s eyes due to emotional reasons”. The authors surveyed U.S. psychologists and had 541 respondents. The sample included 59% graduate students, and 41% licensed clinicians who had an average of 9.6 years experience. Seventy six percent were women, mean age was 36 years, 35% had a cognitive behavioural therapy (CBT) orientation, and 33% had some psychodynamic orientation (PDT). Respondents reported that 72% had cried in therapy. Those who cried reported crying in 6.6% of their sessions in the past 4 weeks. There were no differences between men and women, and there was no association between therapist crying and therapist personality traits or level of empathy. Therapists who cried more often in their daily life tended to cry more in therapy. PDT and CBT therapists did not differ in the amount they cried in their daily lives, however PDT therapists (88.9%) reported crying more often than CBT therapists (50.1%) in therapy. Further, older and more experienced therapists reported crying more often in therapy in the past month than younger and less experienced therapists. It is possible that older therapists may become more comfortable in using their clinical judgment, and so have fewer restrictions on their own affective displays. Of therapists who cried, 45.7% felt that the therapeutic relationship improved, and 1% reported that the relationship deteriorated due to crying. Patients, however, were not surveyed for their opinion about their therapist’s crying.

Practice Implication

Crying among therapists may happen relatively frequently. Although this study is novel, it is the only one of its kind so one should be cautious about drawing practice implication. The challenge of therapists crying in therapy is that it can bend or break the therapeutic frame (e.g., is the therapist crying because of being overwhelmed and acting on his or her own needs, or is the therapist genuinely responding for and with the patient?). The survey suggests that therapist crying can strengthen the therapeutic relationship. This is more likely true when the therapist is attuned to the patient’s needs, and when the crying signals a moment of positive emotional connection in the midst of painful feelings in the client. As with any event in therapy, a genuine and skilful exploration by the therapist and patient of the therapist’s crying has the potential to strengthen the relationship.

Author email: ablume@alliant.edu

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August 2013

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March 2013

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Psychotherapy Practice Research Network (PPRNet)