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 transtheoretical principles of change, microaggressions and outcomes, interpretations and outcomes.
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
March 2023
Capacity to Mentalize Predicted Outcomes in Inpatient Therapy for Resistant Depression
Halstensen, K., Gjestad, R., Luyten, P., Wampold, B., Granqvist, P., Stålsett, G., & Johnson, S. U. (2021). Depression and mentalizing: A psychodynamic therapy process study. Journal of Counseling Psychology, 68(6), 705–718.
Mentalizing, or reflective functioning, refers to someone’s capacity to view themselves and others in terms of mental states (i.e., behaviors are interpreted in terms of feelings, wishes, desires, values, and goals). This capacity underlies skills like empathy, emotion regulation, and interpersonal functioning. Diminished mentalizing can aggravate depressed mood through negative biases in one’s perceptions of others and relationships and might prevent the reflection needed to regulate emotions. Individuals with mentalizing deficits might hypo mentalize so that they are very uncertain about the thoughts, feelings, or attitudes that underlie their own and others’ behaviors. Such individuals may experience apathy associated with depression. Others might hyper mentalize, that is they are too certain about what goes on in the minds of others, which means they may misinterpret or misunderstand the intentions and behaviors of others. Such individuals can experience chronic emptiness due to the lack of genuine connection with others. In this study, Halstensen and colleagues assessed if mentalizing predicted outcomes in 57 patients with treatment resistant depression who received inpatient therapy in Norway. This was a naturalistic study of intensive psychodynamic inpatient therapy. The average chronicity of depression was 11.7 years, all patients received previous unsuccessful psychological or medical treatment, and most had a comorbid diagnosis (e.g., panic disorder, social anxiety disorder). Measurements of mentalizing and depression were taken pre-treatment, during therapy, and up to one year post treatment. Depressive symptoms improved from pre-treatment to one year follow-up with a large effect (d = 1.47; α mean = −.09 per week, p = .001). The capacity to mentalize did not improve on average during that period, although there was a lot of individual variability in mentalizing scores. Interestingly, there was an increase in depressive symptoms at the outset of treatment that then declined significantly by post-treatment. Higher pre-treatment levels of mentalizing were associated with better depressive symptom outcomes (b = −16.80, p = .043), and those patients who improved their mentalizing capacity experienced stronger improvements in depressive symptoms.
Practice Implications
Although all patients were severely and chronically depressed, their capacities to mentalize varied significantly (some had higher and others lower levels). Patients in this study who had a high initial level of mentalizing capacity profited most from the intensive therapy. They seemed to be able to engage in the emotional work associated with the initial phase of intensive inpatient treatment for depression. On the other hand, patients in this study who had low levels mentalizing skills were likely to be non-responsive to intensive treatment. Patients with limited mentalizing capacity may require more support and more work to help them develop the reflective capacities necessary to understand their own and others’ behaviors in terms mental states.
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.
Practice Implications
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.
January 2023
The Impact of COVID-19 on Mental Health Workers’ Well-Being
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.
Practice Implications
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
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”.
Practice Implications
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
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.
Practice Implications
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.
December 2022
Can Psychotherapists be Trained to Maintain a Therapeutic Alliance?
Tasca, G. A., Ravitz, P., Hunter, J., Chyurlia, L., Baker, S., Balfour, L., Mcquaid, N., Pain, C., Compare, A., Brugnera, A., & Leszcz, M. (2022, November 10). Training community-based psychotherapists to maintain a therapeutic alliance: A Psychotherapy Practice Research Network study. Psychotherapy. Advance online publication.
The therapeutic alliance refers to a collaborative agreement between therapist and patient on the tasks and goals of therapy, and their relational bond. Research demonstrates that the alliance is one of the most reliable predictors of patient outcome. Much of the research on the alliance focused on asking either the patient or the therapist to rate the alliance. But the alliance is a dyadic concept, that is, it involves the shared perceptions of the therapeutic relationship by patient and therapist. More recent research has focused on patient-therapist congruence (degree of agreement or disagreement) of their perceptions of the alliance. The Psychotherapy Practice Research Network (PPRNet) recently completed a study in which community-based psychotherapists were trained to develop and maintain a therapeutic alliance. We examined if trained therapists were more congruent with their patients’ experience of the alliance than untrained therapists, and whether congruence in alliance ratings in one session of therapy was associated with better outcomes in the following session. Forty community-based psychotherapists were randomly assigned to be trained to develop and maintain the alliance or to receive no training. Patients were 117 adults who were seen in their therapists’ community-based practices. Training focused on helping therapists to understand and be responsive to their own and their patient’s mental states (intentions, feelings, thoughts) to be better attuned to their patient’s experience of the therapeutic relationship. The training included workshops and ongoing case consultations to help the clinician to strengthen the therapeutic relationship with the use of mentalizing, attachment theory, countertransference management, and metacommunication. Therapeutic alliance and well-being outcomes were measured at each of six consecutive early psychotherapy sessions. The results indicated that compared to untrained therapists, trained therapists and their patients were significantly more congruent in their alliance ratings. Patient well-being outcomes improved in a session when trained therapists and their patients agreed in their positive alliance ratings in a previous session. This association was not significant among untrained therapists and their patients.
Practice Implications
This study suggests that therapists can be trained to be more attuned to their patients’ experience of the therapeutic relationship, and that this congruence may make the alliance a more potent change agent. Training may make therapists more sensitive to their patients’ experience of the alliance across sessions. Therapists should be particularly attentive to the state of the therapeutic alliance from session to session and to track their patients’ experience of the alliance using skills like mentalizing. The PPRNet has converted this training program into a virtual self-paced platform, and we will test this new format in a study starting in 2023. We encourage community-based clinicians to receive the free training by participating in this new study. For more information about the training and new study, email pprnet@uottawa.ca.