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 CBT, negative effects of psychological interventions, and what people want from therapy.
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
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.
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.
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.
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.
The Impact of COVID-19 on Mental Health Workers’ Well-Being
Mittal, M., Morgan, A. A., Du, J., Jiang, J., Boekeloo, B., & Fish, J. N. (2022, December 19). “Each week feels like a mountain”: The impact of COVID-19 on mental health providers’ well-being and clinical work. Professional Psychology: Research and Practice. Advance online publication.
The COVID-19 pandemic has overwhelmed the health care system worldwide. Stressors on health care workers have included misinformation, rapidly changing knowledge of the virus, the politicization of mask wearing, high transmission rates, and high rates of patients requiring critical care. There has been much written about the impact of the pandemic on physicians and nurses caused by these factors. Much less attention has been paid to the experiences of mental health workers who had to rapidly transition to telehealth, which required immediate adaptations and learning with little training and preparation. In this qualitative study, Mittal and colleagues thematically analyzed text responses of 136 mental health professionals to questions about the impact of telehealth work during the pandemic on mental health and on clinical practice. The mental health professionals were from several disciplines (psychology, social work, counseling), most were women (84%), White (81%), with a mean age of 45.5 years. First, several themes emerged regarding providers’ mental health. Most indicated that their own experiences of exhaustion and stress were mirrored in their patients’ experiences, which made it harder to cope. Another common experience was “Zoom fatigue”, in which seeing clients online was more tiring, less enjoyable, and more isolating. Many also reported a decline in their physical health – that is, they experienced more headaches, trouble sleeping, poor appetite, and eye strain. Some reported a heightened sense of meaning in their work, such as a greater sense of pride and meaning derived from helping people during a particularly troubling time. Second, several themes were identified related to clinical practice. Practicing and living in the same space was particularly challenging for some - practicing from home while being responsible for other members of the household (children) was difficult and distracting. Many reported a decrease in work satisfaction and lower motivation, both of which impacted their level of empathy for and engagement with clients. Some reported positive effects especially related to having more time due to reduced commuting, and a greater sense of empathy for clients who felt isolated themselves.
The COVID-19 pandemic and using telehealth for work required a significant shift in practice for mental health professionals. The shift meant important changes in how we practice and how we live our lives. And so, it is not surprising that mental health professionals’ well-being has been impacted by this transition and the challenges it poses. It is important to recognize the stressors related to telehealth work and to try to mitigate their impact. Some authors have suggested ways of reducing the negative impact of increased screen time on mental health providers, such as: taking breaks whenever possible, including 5 to 10 minutes between sessions; using previous “commute time” for self-care (social connection, physical activity); increasing social and professional connections with planned gatherings; and prioritizing self-care even more, including physical exercise and personal therapy.
Working Alliance and Therapist Cultural Humility Reduce the Impact of Microaggressions
DeBlaere, C., Zelaya, D. G., Dean, J.-A. B., Chadwick, C. N., Davis, D. E., Hook, J. N., & Owen, J. (2022, December 8). Multiple microaggressions and therapy outcomes: The indirect effects of cultural humility and working alliance with Black, Indigenous, Women of Color clients. Professional Psychology: Research and Practice. Advance online publication.
A lack of culturally competent care can have negative impacts on therapy outcomes for Black, Indigenous, People of Color (BIPOC) and for women who experience discrimination based on gender. Often these negative outcomes occur because of microaggressions – which are a form of alliance rupture in the therapeutic relationship caused by subtle, intentional, or unintentional messages that degrade BIPOC, women, and other historically excluded groups. The majority of BIPOC clients (81%) and women (53%) report experiencing a therapist microaggression over the course of psychotherapy. A therapist’s cultural humility (valuing the importance of culture in their client’s experience) and the therapeutic alliance (client-therapist collaborative agreement on tasks and goals of therapy) may reduce the negative impact of microaggressions committed by the therapist. This study by DeBlaere and colleagues looked at the association between microaggressions experienced by BIPOC women and therapy outcomes, and whether this association was reduced by higher levels of therapist cultural humility and therapeutic alliance. The clients were 288 BIPOC women who were treated by a psychotherapist (81% had a female therapist, and 46% had a White therapist). Both racial and gender microaggressions were associated with worse outcomes. Using structural equation modeling to assess indirect effects, the authors found a significant indirect effect of racial microaggressions (−.12, 95% CI [−.35, −.07]) and gender microaggressions (−.10, 95% CI [−.36, −.05]) on positive therapy outcomes, through both cultural humility and working alliance, accounting for 24% of the variance in outcomes. That is, the effect of microaggressions on outcomes was partly explained by the level of therapist cultural humility and by the therapeutic alliance. The most common racial microaggression reported by clients was: “My counselor avoided discussing or addressing cultural issues in our sessions”, and the most common gender microaggression was: “My therapist encouraged me to be less assertive so that I do not present myself as being aggressive”.
Unfortunately, therapist racial and gender microaggressions are common. However, therapists who practice cultural humility and who work at developing a therapeutic alliance may commit fewer microaggressions and can more easily mitigate the negative effects of microaggressions should they occur. Taking steps to develop cultural humility, strengthening the alliance, and repairing alliance ruptures through professional development may be ways of improving therapy outcomes for BIPOC women.
Ways to Address Cultural Topics in Psychotherapy
Depauw, H., Van Hiel, A., De Clercq, B., Bracke, P., & Van De Putte, B. (2022). Addressing cultural topics during psychotherapy: Evidence based dos and dont's from an ethnic minority perspective. Psychotherapy Research.
When ethnic minority members receive psychotherapy, they tend to show higher premature drop-out rates. One of the factors associated with these negative outcomes may be that therapists may not know how to effectively address the cultural conversations that inevitably arise with some clients. To help therapists, some authors developed a Multicultural Orientation Framework (MCO) that consists of cultural humility (taking an other-oriented stance regarding culture while remaining non-defensive about one’s own limitations), cultural opportunities (discussing clients’ cultural identities when they emerge in therapy), and cultural comfort (a therapist’s genuine comfort in discussing cultural topics). Such a stance may also help therapists to address microaggressions (intentional or unintentional verbal or behavioral indignities based on cultural identity). One useful therapist stance is “broaching” of culturally sensitive topics – that is, therapists’ engaging in explicit dialogue with clients about culture. Previous research indicates that broaching culturally topics can benefit the therapeutic alliance and clients’ perception of therapist multicultural competence. In this survey study, Depauw and colleagues looked at three aspects of broaching – direct broaching in which a therapist explicitly raises cultural topics (“I noticed that we both have a different ethnic background…), indirect broaching in which a therapist is receptive to cultural topics but with less focused exploration (“…you mentioned your friend doesn’t understand your experiences, are there other situations in which that happened…?”), and avoiding broaching in which a therapist sidesteps cultural conversations even when a client brings them up. Depauw and colleagues surveyed 211 psychotherapy clients in the United Kingdom who identified as not being a member of the predominant social group (i.e., with regard to ethnicity, gender/sexual expression, religion, socioeconomic status, ability, and others). The researchers asked whether therapists broached cultural identity topics, what type of broaching approach a therapist took, and clients also rated their therapist’s level of MCO (cultural comfort, cultural humility, and missed opportunities) and therapist microaggressions. The results revealed that both therapist direct and indirect broaching of cultural topics were favorably associated with a client’s rating of the therapist’s MCO and with fewer microaggressions. Therapists’ avoidance of broaching of cultural topics was associated with negative ratings of therapist MCO and with more microaggressions. When only considering the clients’ most important self-identified cultural identity, the researchers found that indirect broaching was favorably related to all aspects of MCO and fewer microaggression, direct broaching was only associated with fewer missed opportunities, and avoidant broaching was unfavorably related to all aspects of MCO and microaggressions.
The results of this survey of clients suggest that therapists should not avoid cultural content in therapy. Broaching culturally sensitive topics is important for a good therapeutic experience for clients with diverse identities. In some cases, for clients’ primary cultural identity, indirect broaching of culturally sensitive topics may be more effective. Therapists should consider a client’s identity in terms of how the client experiences it and the importance of the identity to the client.
Brief Online DBT Was Not Effective to Reduce Self Harm
Simon, G.E., Shortreed, S.M., Rossom, R.C., Beck, A., Clarke, G.N. … Smith, J. (2022). Effect of offering care management or online dialectical behavior therapy shttps://pubmed.ncbi.nlm.nih.gov/35166800/kills training vs usual care on self-harm among adult outpatients with suicidal ideation: A randomized clinical trial. Journal of the American Medical Association, 327, 630-638. DOI:10.1001/jama.2022.0423
Self-harm or non-suicidal self-injury is a significant problem that might affect 6% of the population seeking medical attention. And so, health systems are considering ways of scaling up treatments to reduce incidences of self-harm behaviors. Previous research showed that traditionally delivered dialectical behavior therapy (DBT) may reduce the incidence of suicide attempts. In this very large study of over 18,000 patients, Simon and colleagues tested whether two low intensity (and therefore low cost) outreach programs in addition to usual care provided to outpatients could reduce self-harm. Patients who reported suicidal thoughts in the past two weeks from several large health systems in the U.S. were randomly assigned to receive (1) care as usual, or (2) care management which included regular messages to motivate patients to follow-up with usual care, or (3) an interactive online program based on DBT supported by a skills coach that focused on mindfulness, current emotions, opposite action, and paced breathing. Both care management and the DBT based online program were in addition to usual care. The main outcome was fatal or non-fatal self-harm within 18 months. The results indicated that 3.10% of those who only received usual care experienced self-harm, 3.27% of those who received care management experienced self-harm, and 3.98% of those who received the online DBT based skills program experienced self-harm. A statistical comparison found a significantly higher risk of self-harm in the DBT based skills training group compared to usual care alone (hazard ratio, 1.29; 97.5% CI, 1.02-1.64; p = .015). When the authors looked at uptake or participation in the programs over a 9-month period, 17% of those who were offered usual care remained engaged in the program but only 2% of those offered the DBT based skills program remained engaged.
This study is unusual in a couple of ways. First, it is very large and so it provides reliable findings that represent what might occur in actual practice. Second, the study reports a negative finding for a psychological intervention. The study indicates that trying to scale up a self-harm prevention program by providing it online even with live coaching resulted in significantly poorer outcomes than only usual care. Very few people (only 2%) continued with the online program after starting it. These results are similar to findings from previous research of online delivered therapy in which many people start but do not continue with such programs. Very few those who need mental health care want to interact with a program, and outcomes of such programs are modest at best.