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
September 2023
Clients’ Negative Experience of Psychotherapy
Vybíral, Z., Ogles, B.M., Řiháček, T., Urbancová, B., & Gocieková, V. (2023) Negative experiences in psychotherapy from clients’ perspective: A qualitative meta-analysis, Psychotherapy Research, DOI: 10.1080/10503307.2023.2226813
Psychotherapy research tends to focus on positive patient outcomes – or patients who get better. More recently, psychotherapy researchers have focused on negative outcomes and client experiences of negative events in psychotherapy. Approximately 5% of clients get worse, 20% of clients in clinical trials drop out, and about 66% of clients do not recover by the end of treatment. All of this suggests that some clients have negative experiences during therapy that may interfere with their progress. One can learn a lot from studying processes that do not go well. Potentially, therapists can learn what not to do, how to avoid pitfalls, how to recognize when the client has a negative experience, and how to repair an error. In this qualitative meta-analysis, Vybiral and colleagues reviewed 51 studies that recorded client statements from post-treatment interviews. Through qualitative analysis, the authors reported four major clusters representing clients' negative experiences, specific therapist behaviours within each cluster, and the percentage of studies in which clients noted these specific behaviors. The first cluster was Therapist Misbehaviors including therapists not listening (17% of studies), therapists not understanding (37%), therapists perceived incompetence (37%), therapists devaluing clients (56%), therapists judging (33%), and therapists using the client for their own benefit (27%). The second cluster was Hindering Aspects of the Therapeutic Relationship including therapists’ lack of empathy (44%), lack of trust in the therapist (21%), clients experiencing confusion (23%), and poor interpersonal match (25%). The third cluster was Poor Treatment Fit including negative evaluation of the procedures or practical aspects of treatment (33%), unmet client expectations about therapy (33%), lack of fit with the interventions (65%), and dissatisfaction with how therapy ended (50%). The fourth cluster was Negative Impacts of Treatment including that therapy was unhelpful (46%), that problems increased (37%), fearing the therapy process (50%), loss of hope (23%), unpleasant feelings during therapy (60%), negative thoughts caused by therapy (35%).
Practice Implications
This research indicates that the qualities of the therapist, the therapeutic relationship, the treatment provided, and the outcomes are key to clients’ perceptions of their therapy experience. A therapist's positive regard, genuineness, and empathy have long been considered necessary conditions for successful therapy. In addition, there is substantial research on the importance of the therapist and client developing a collaborative agreement on the goals of therapy and how therapy proceeds, that is – aspects of the therapeutic alliance. Therapists also must keep in mind that clients must develop realistic expectations of therapy like its duration, what gets discussed, and how therapy proceeds. Expectations are well-known predictors of client outcomes. Finally, therapists must monitor patient outcomes and processes, and modify what they are doing if the client experiences a precipitous increase in symptoms or a decrease in the alliance from one session to the next.
Preparing Patients for Psychotherapy
Swift, J. K., Penix, E. A., & Li, A. (2023, March 13). A meta-analysis of the effects of role induction in psychotherapy. Psychotherapy. Advance online publication. https://dx.doi.org/10.1037/pst0000475
Many patients struggle with the start of psychotherapy. In fact, many patients drop out of psychotherapy within the first few sessions likely because of anxiety or their expectations not being met. One way of helping patients start therapy on the right foot is to prepare them for what to expect and how therapy will proceed. Patient preparation, also known as role induction, is the process of providing patients with education for psychotherapy to ensure they have accurate expectations of their role, their therapist’s role, a rationale for treatment activities, and approximate treatment duration. This discussion with patients often occurs early in therapy and sometimes in the initial assessment session. Therapists might provide the information on their websites, on paper when the patient comes to the first session, or verbally during the session. In this meta-analysis, Swift and colleagues did a systematic review of the research on patient preparation and found 17 studies on the topic that met their criteria. Patients who received role induction had more positive behaviours during the subsequent session (accurate knowledge, appropriate expectations, higher satisfaction) compared to patients who did not get the preparation (d = 0.64, 95% CI [0.25, 1.03], p < .01, r = .31). Patients who received pre-therapy preparation were 1.64 times less likely to drop out of therapy than those who were not given the preparation (95% CI [1.06, 2.53], p = .03). The overall effect on post-treatment outcomes (symptom reduction) was statistically significant, such that those who received the role induction were more likely to have better outcomes than those who did not (d = 0.33, 95% CI [0.11, 0.55], p < .01, r = .16), although the effect was small. The largest effect occurred when role induction focused on the expected roles of the patient and therapist and on the duration of therapy. Also, larger effects occurred when therapists provided patients with the information in person and verbally rather than in a written format.
Practice Implications
It might be useful to assess the patient’s knowledge of psychotherapy, including what they expect their roles to be, what the therapist’s role is, how treatment will proceed, and the expected duration of treatment. This information might lead to a discussion about what to expect and what is realistic in therapy and this discussion should occur at the very start of therapy. A therapist might provide more information on those areas in which a patient may misunderstand or may have unrealistic expectations. Regardless, it is a good idea to discuss patient and therapist roles and to provide a rationale for the treatment. Preparing patients will have a greater impact if therapists provide the information as part of a verbal discussion that is personalized to the patient and is culturally appropriate.
April 2023
Preparing Patients for Psychotherapy
Swift, J. K., Penix, E. A., & Li, A. (2023). A meta-analysis of the effects of role induction in psychotherapy. Psychotherapy. Advance online publication.
Starting psychotherapy can be hard for some patients likely because they must face the unknown about themselves, the therapy process, and the therapist. Some patients might think that they must behave in a certain way, or they may have expectations of what might occur in therapy or about outcomes. Those expectations might be unrealistic, or they may be different from what their therapist intends. One road to success in therapy is for patients to know how to effectively engage with their psychotherapist. Role induction might be one means of preparing patients therapy and could include several activities. First, establishing rapport is key so that the patient and therapist experience an empathic bond. Second, providing an explanation of psychotherapy might include discussing why psychotherapy can be effective, what change the patient might experience, and how the therapy will work from session to session. Third, describing the roles of patient and therapist is key, including encouraging the patient to be open and honest, and discussing how the therapist might behave (directive/less directive, emotion/cognitive focused, and present/past focused). Fourth, anticipating challenges for the patient to complete therapy may also be useful to help patients deal with frustrations or thoughts of dropping out. In this meta-analysis, Swift and colleagues examined 17 studies in which patients who received a role induction were compared to those who were treated as usual. The overall effect of role induction on psychotherapy dropout was significant, OR = 1.64, 95% CI [1.06, 2.53], p = .03. Patients who were prepared were 1.64 times less likely to drop out than patients who were not prepared. The overall effect on posttreatment outcomes was also significantly in favor of role induction, d = 0.33, 95% CI [0.11, 0.55], p < .01, although the effect was small. In moderator analyses, preparing patients for therapy was more effective for older patients, when done by more experienced therapists, and when provided verbally as opposed to in writing.
Practice Implications
The research suggests that preparing patients for psychotherapy by establishing a relational bond, providing information on how therapy will proceed, and providing information on the roles of the patient and therapist can be useful to reduce dropouts and improve patient outcomes. It may be helpful for therapists to assess what a patient knows about psychotherapy and their expectations of theirs and therapists’ roles. Therapists can use this information to personalize the preparation for patients so that it helps them to understand patient and therapist roles, rationale for treatment, and how therapy works. The assessment may also help therapists to adapt therapy to patient preferences when feasible. Patient preparation works best if done verbally and personalized to a patient rather than giving the patient a generic written handout or directing them to a web page.
February 2023
Quality of Life Outcomes in the Psychological Treatment of Persistent Depression
McPherson, S., & Senra, H. (2022). Psychological treatments for persistent depression: A systematic review and meta-analysis of quality of life and functioning outcomes. Psychotherapy, 59(3), 447–459.
The World Health Organization ranks depression as the largest cause of global disability accounting for 7.5% of all years lived with disability. Persistent forms of depression contribute to years lived with disability due to its chronic nature and its association with low levels of social and physical functioning, high rates of suicide, and high health care use. One way to look at disability as an outcome is to assess quality of life, which refers to performance in daily and social functioning and satisfaction with these activities. In this meta-analysis, McPherson and Senra examine 14 randomized controlled trials of psychological therapies for chronic or persistent depression in adults. The control condition included no treatment, waiting list, treatment as usual, or only antidepressant medication. The psychotherapies were mindfulness-based cognitive therapy (MBCT), CBT, interpersonal psychotherapy (IPT), long term psychoanalytic psychotherapy (LTPP), and DBT. Chronic depression was defined as a course of depression of at least 2 years and/or non-response to at least two treatments. The quality of life measure had to assess satisfaction with physical health, psychological state, level of independence, and social relationships. In general, the psychological treatments were associated with improvements in patients’ quality of life at the end of treatment (N=11; g=0.24; 95%CI: 0.13, 0.34). At follow up, the effect size was g=.21 (95%CI: 0.10, 0.32). That is, the effects were significant and positive, but small. The psychological interventions resulted in improvements in patient functioning at the end of treatment, g=.35 (95%CI: 0.21, 0.48), which is consistent with previous meta-analyses showing small to moderate effects of psychological treatments for persistent depression. Although there were too few studies to properly assess differences between therapy types, MBCT, IPT, and LTPP in combination with antidepressant medications had the largest effects among the therapies studied.
Practice Implications
In international surveys, patients seeking treatment for depression, informal caregivers, and health professionals list quality of life and social functioning as just as important or as more important than symptom reduction. Yet, these outcomes related to quality of life are not often assessed in clinical trials. This meta-analysis of a modest number of studies, suggests that some psychological therapies (MBCT, IPT, LTPP), in combination with antidepressant medications have the largest positive effects on quality of life for those persistent depression.
August 2022
Is Psychotherapy Equally Effective Across Age Groups? Rethinking therapy for children and adolescents.
There are now hundreds of controlled studies showing the efficacy of psychotherapy for depression. Most of these studies have focused on specific age groups, so that psychotherapies were tested for children, adolescents, adults, and older adults separately. Few studies have looked at whether psychotherapy has different effects across age groups. This information might be important because it may indicate that some therapies might have to be altered or specifically designed for the age group. In this meta-analysis, Cuijpers and colleagues collected all randomized controlled trials of psychotherapy vs no treatment, usual care, or some other control group for depression across age groups. They found 366 studies representing over 36,000 patients. The studies included those of children, adolescents, young adults, middle-aged adults, older adults, and older old adults. The overall effect size across all age groups was g = 0.75 (95% CI, 0.67-0.82) suggesting a moderate effect of psychotherapy for depressive symptoms at post-treatment. The effect size for children was the lowest (g = 0.35, 95% CI: 0.15-0.55, k = 15), and the effect size for adolescents (g = 0.55, 95% CI: 0.34-0.75, k = 28) was also low. Effects for middle-aged adults (g = 0.77, 95% CI: 0.67-0.87, k = 304), older adults (g = 0.66, 95% CI: 0.51-0.82, k = 69), and older old adults (g = 0.97, 95% CI: 0.42-1.52, k = 10) were not significantly different. Young adults consistently had significantly better outcomes (g = 0.98, 95% CI: 0.79-1.16) than the other age groups except when compared to older old adults.
Practice Implications
It is possible that psychotherapies for depression as currently tested in the research literature are less effective for children and youth. This may be because the treatments that are most often used with children and adolescents are age adapted versions of therapy originally designed for adults. Psychotherapy for children and adolescents are affected by parental and family characteristics, and that these contexts may not be adequately accounted for by the therapies as currently tested and practiced. In any case, this meta-analysis suggests that current therapies for childhood and adolescent depression may need to be reconsidered given their relatively lower effects.
April 2022
Multicultural Competence and Orientation
Constantino, M.J., Boswell, J.F., & Coyne, A.E. (2021). Patient, therapist, and relational factors. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7th ed.). Wiley. Chapter 7.
Therapist multicultural competence is a commitment to increasing one’s knowledge of patient’s cultural background, tailoring interventions to a patient’s culture, and understanding the impact of one’s own cultural background. Multicultural competence research has looked at its impact on clinical interactions. In a meta-analysis of 15 studies, therapist multicultural competence was associated with lower levels of patient drop-out from therapy (r = 0.26) and with greater patient improvement (r = 0.24). An interesting finding of these meta-analyses is that whereas patient ratings of a therapist’s multicultural competence was significantly associated with better patient outcomes (r = 0.38), therapist ratings of their own multicultural competence was not significantly associated with outcomes (r = 0.06). In other words, if one is interested in a therapist’s multicultural competence then one should ask the patient, not the therapist. A related but broader concept is multicultural orientation. The multicultural orientation framework is not so much a theoretical approach but a “way of being” for a therapist. The three aspects of multicultural orientation include cultural humility (in which a therapist takes an open and curious stance towards the patient’s identities), cultural opportunities (in which the therapist actively explores a patient’s cultural beliefs and values), and cultural comfort (or the extent to which a therapist feels at ease working with cultural dynamics). A systematic review of multicultural orientation theory identified 9 articles that found that therapist cultural humility was associated with better therapeutic alliances, fewer in-session microaggressions, and greater patient improvement.
Practice Implications
The research on multicultural competence suggest that therapists should regularly assess a patient’s cultural identities for adapting the therapeutic approach. This assessment should focus on the patient’s, not the therapist’s, evaluation of the therapist’s multicultural competence. It is also important for therapists to build their knowledge of specific cultural groups when tailoring their treatments. Regarding a multicultural orientation, it appears that a therapist’s cultural humility is critically important. That is a therapist who is open, non-defensive, and curious regarding a patient’s identities will be most helpful to patients of various cultures.