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 psychotherapy for borderline personality disorder, capacity to metnalize and therapy resistant depression, and negative effects of psychotherapy
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
November 2022
What are Best Practices for Psychotherapy with Indigenous Peoples
In 2016 2.8% of the Canadian population identified as First Nations, 1.7% as Metis, and 0.2% as Inuit. In Canada there are 634 First Nations each with their own traditions, governance structures, and land claims. Colonial violence and land dispossession has led to Indigenous Peoples suffering from many mental health inequities. Indigenous samples are rarely evaluated in clinical trials of psychotherapy. And psychotherapy, as typically delivered, is a practice that is embedded in European cultural values which may not be appropriate for Indigenous Peoples. Defining best practices in psychotherapy with Indigenous Peoples may indeed be thorny given the historical context and values inherent in psychotherapy practice. In this article, Wendt and colleagues review four paths to providing psychotherapy to Indigenous clients, but each path has their challenges. The first path is to offer on empirically supported therapies for specific identifiable disorders. However, out of the hundreds of clinical trials available, only six were conducted that specifically focused on American Indian clients and all for alcohol use problems. Most empirically supported therapies were not validated for use with Indigenous clients, and some argue that this may make these treatments potentially harmful. The second path is to culturally adapt interventions so that the original therapies are maintained but adapted to the needs and culture of the Indigenous population. Some research suggests that cultural adaptations result in moderately better outcomes. Deeper adaptations incorporate cultural beliefs and promote cultural identity and connections to the Indigenous community. However, cultural adaptations tend to preserve a disorder-centric approach to problems rather than seeing problems in terms of a balance between mental, emotional, and spiritual health. The third path involves emphasizing the psychotherapy relationship, the working alliance, and promotion of hope – also known as the common factors approach to psychotherapy. This is highly collaborative approach to how therapy progresses and to maintaining a reciprocal balance in the therapeutic relationship. However, this approach does not necessarily address the European cultural values inherent in most psychotherapies. The fourth path involves efforts to strengthen and revitalize traditional Indigenous practices and cultural education as a means of healing. These might include integrating sweat lodges, the Medicine Wheel, and talking circles. This path embodies a “culture as treatment” approach in which problems are seen within historical losses of identity, purpose, and place. A report from the Canadian Psychological Association and the Psychology Foundation of Canada calls for psychologists to “view themselves as facilitators and supporters of the healing wisdom and knowledge that is already present in Indigenous communities”. However, as Wendt and colleagues note, there are practical barriers to this approach, and even if “culture as treatment” is seen by some as self-evidently effective, it has rarely been researched.
Practice Implications
Mental health professionals should avoid being unwitting agents of assimilation when providing clinical care to Indigenous clients. Primarily, clinicians should maintain a stance of cultural humility. Traditional indigenous approaches to mental health are important as a long-term strategy, including traditional understandings of problems, traditional healing, and Indigenous-led cultural interventions. All of this, however, is limited by inadequately addressed colonial harms, poverty, and legal obstacles to Indigenous Nations’ sovereignty.
July 2022
Are Humanistic Psychotherapies Effective?
Elliot, R., Watson, J., Timulak, L., & Sharbanee, J. (2021). Research on humanistic-experiential psychotherapies: Updated review. In Barkham, W., Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield's Handbook of Psychotherapy and Behavior Change (7th ed.). Wiley. Chapter 13.
Humanistic or experiential psychotherapies have a long history going back to the work of Carl Rogers and Fritz Pearls in the 1960s. This is a broad umbrella of therapies that include person-centred therapy, gestalt, emotion-focused, psychodrama, and existential therapies. Most of these therapies see the therapeutic relationship as central and curative. The therapist tries to enter the client’s subjective world with empathy to understand the client’s experience and to provide a validating and corrective emotional experience. The goals of humanistic-experiential therapy include self-awareness, personal growth, and meaning-making in clients’ lives. In this chapter, Elliott and colleagues review and update the meta-analytic evidence for the effectiveness and efficacy of humanistic-experiential therapy. The uncontrolled pre- to post-treatment change from receiving humanistic-experiential therapy estimated from 97 studies was .86 (k = 94; 95% CI [.74, .97]), representing a large effect. Clients maintained their immediate post-treatment gains during the year following therapy (ESw = .88; k = 41; 95% CI [.67, 1.1]) and beyond (ESw = .92; k = 15; 95% CI [.52, 1.31]). Compared to no-treatment control groups in 15 randomized studies, humanistic-experiential therapy showed a large pre-post effect ESwc= .98 (95% CI [.55, 1.20]). Compared to all other therapies in 56 randomized trials, humanistic-experiential therapy produced equivalent outcomes, (ESwc = –.07; 95% CI [–.21, .07]). The outcomes compared specifically to CBT in which only bona-fide humanistic-experiential therapies were included (i.e., only studies in which the humanistic-experiential therapies were meant to be effective) also indicated a non-significant difference, (ES = –.15; k = 9; 95% CI [–.27, .03]).
Practice Implications
Dating back to the work of Carl Rogers, humanistic-experiential therapies have had an important impact on how many types of therapy is offered today. The emphasis of many therapies on empathy, the therapeutic relationship, and corrective emotional experience are hallmarks of humanistic-experiential therapies. The results of these updated meta-analyses indicate that humanistic-experiential therapies are effective in the short and longer term and are as effective as other forms of well-research psychotherapies.
April 2022
Countertransference and its Management
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.
Countertransference is one of the oldest concepts in psychotherapy dating back more than 100 years. More recently, some writers view countertransference as a pantheoretical concept, in other words it affects all therapists and occurring in all therapies. One definition of countertransference is that it is the “internal and external reactions in which unresolved conflicts of the therapist, usually but not always unconscious, are implicated”. Countertransference may provide important information about a patient’s interpersonal patterns, but it may also be an impediment to the therapist’s effectiveness. One prominent model of countertransference identifies its component parts to include: origins within the therapist (i.e., unresolved issues within the therapist that may interact with patient qualities); triggers caused by the patient’s transference (i.e., patient maladaptive interpersonal patterns) and other patient behaviors that may interact with the therapist’s unresolved issues; manifestations – or how the countertransference affects the therapist’s behaviors and responses toward the patient; the effects of these behaviors on the therapeutic relationship or the patient; and the therapist’s management of countertransference responses – or what the therapist does to maintain an equilibrium. In this part of the chapter, Constantino and colleagues review two meta-analyses of the impact of countertransference and its management on the patient. A meta-analysis of 14 studies indicated a small but significant correlation between therapist countertransference and poor patient outcomes (r = -0.16), and a second meta-analysis of 9 studies indicated a moderate and significant association between successful countertransference management and patient improvement (r = 0.39).
Practice Implications
Despite countertransference being a well-established topic in psychotherapy, the research is relatively new. The findings suggest that regardless of what type of therapy is practiced, therapists should be mindful of their countertransference reactions. It is important for therapists to monitor their internal mental and emotional states during a therapy session, and to note when they feel something that is not typical for them (bored, annoyed, attracted, overwhelmed, disgusted, distracted). A therapist’s management of these feelings may include remaining calm in the moment, self-reflection about the origins and triggers of their reactions, seeking consultation with a trusted colleague, and personal therapy to work on unresolved issue
Therapist Flexibility and Responsiveness
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.
One of the most intriguing findings from psychotherapy research is that adherence or competence to manual-prescribed techniques has almost no impact on patient mental health outcomes. That means that efforts to get therapists to follow a manual has no bearing on whether their patients get better. In fact, there is sufficient research to suggest that rigid adherence to a treatment model may be harmful to patients. Research suggests that purposefully moving away from protocols at times in therapy can be more validating, collaborative, and autonomy granting that sticking with the protocol. Thus, the over-zealous delivery of a treatment, despite good intentions, can be ineffective or harmful to patients. Some of the specific research in this area found that the patients of therapists who varied in their use of theory-prescribed interventions had better outcomes. Similarly, when psychodynamic therapists integrated cognitive and behavioral interventions, patients had better outcomes than when the therapists were less flexible. A similar concept to flexibility is therapist responsiveness, or their ability to respond to the specific therapeutic context. This might include therapists’ ability to develop a case formulation specific to the patient, and flexibly tailoring their interventions to that formulation. Therapist responsiveness and tailoring interventions to the patient may result in better outcomes.
Practice Implications
That the level of adherence to treatment manuals bears no relation to patient outcomes speaks to the speaks to problems associated with persistent and rigid adherence. Rigidity in applying a treatment model may lead to negative processes in therapy and poor patient outcomes. It is important for therapists to be responsive and attuned to their patients’ needs, progress, and treatment goals. That is, it likely more important to tailor treatment to the patient and their characteristics rather than trying to get the patient to adapt to the treatment.
March 2022
Patient Expectations and Preferences
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.
In this chapter, Constantino and colleagues review the effects of patient expectations of benefit and patient preferences for treatment. Patient outcome expectations is broadly related to the placebo effect. That is, there is a commonly known positive effect when patients expect that a treatment will help them get better. This effect occurs across all psychotherapies and is also seen in medical and pharmacological interventions. A meta-analysis of almost 13,00 patients in 81 studies found a small to moderate relationship (r = .18) between patient expectations of positive outcomes and the extent to which they improved. There is also evidence that outcome expectations improve the therapeutic alliance. The more optimistic patients are about getting better, the more they are likely to engage in a collaborative working relationship with their therapist. A related line of research addresses patient preferences for treatment. This refers to what is done in therapy, the characteristics of the therapist, and the length of therapy among others. Preferences can be grouped into three categories: activity preferences are the patient's desire for the psychotherapy to include specific therapist behaviors or interventions; treatment preferences are the patient's desire for a specific type of intervention to be used, such as psychotherapy vs. medication, or CBT vs. person-centered therapy; and therapist preferences are the patient's desire to work with a therapist who possesses specific characteristics (e.g., a certain gender, race, or interpersonal style). In a meta-analysis of 28 studies, patients who received their preferences were 1.79 times less likely to drop out of therapy compared to those who did not get their preference. The effect on patient outcomes were statistically significant but small (d = .28). The beneficial effect of preferences was stronger for those with anxiety or depressive disorders.
Practice Implications
Patients who have higher expectations of getting better are on their way to feeling remoralized, they are more likely to engage in a therapeutic relationship, and they are more likely to be collaborative in the therapy. Therapists can improve patient expectations by providing patients with a clear rationale for the interventions, a realistic sense of how long therapy will take, and a non-technical summary of the research evidence for the therapy they are providing. Patients who get what they prefer in a therapy or therapist also may experience better outcomes, especially if they have an anxiety or depressive disorder. Listening to what patients expect and want from therapy may help therapists to tailor the treatment to the patient’s wishes. Providing patients with more than one treatment option when possible may be one means of meeting patient expectations.
February 2022
What Have We Learned from Practice-Research Networks?
Castonguay, L.G., Barkham, M., Youn, S.J., & Page, A. (2021). Practice-based evidence: Findings from routine clinical settings. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7th ed.). Wiley. Chapter 6.
Practice-based evidence refers to research that is conducted as part of routine clinical practice. Often these studies do not impose strict research conditions like randomization of patients, and so they produce findings that are more relevant to psychotherapy as practiced real-world. In studies from practice-research networks, clinicians are often involved in the design and implementation of the study. Our Psychotherapy Practice-Research Network (PPRNet) is an example of a collaboration between researchers and clinicians to produce practice-based evidence. In a large survey, we found that most clinicians regardless of theoretical orientation wanted more research on the therapeutic relationship and on professional development. And so PPRNet developed a research program on training psychotherapists to identify and repair therapeutic alliance ruptures and microaggressions. In this chapter, Castonguay and colleagues review some of the key findings from practice research networks. First, White patients report better outcomes than Black patients in routine care, and these differences were linked back to the clinicians. That is, therapists varied in their effectiveness with racial and ethnic minority patients. Second, patients benefit when clinicians monitor the therapeutic alliance and outcomes on a session-to-session basis using reliable and valid measures. Noticing when a patient’s ratings of the alliance decline from one session to the next, might indicate a problem in the therapeutic relationship. Third, when monitoring the alliance, therapists should also rate the alliance. If a therapist’s ratings of the alliance are higher than their patients, then this may be a sign that the therapist is not paying attention to problems in the alliance. Fourth, developing and maintaining a strong therapeutic alliance likely will improve patient outcomes. Fifth, a reliable and valid assessment of client’s past and current interpersonal difficulties is likely to improve a therapist’s treatment plan for that patient.
Practice Implications
Doing research in clinical practices is not as well controlled as clinical trials research. But practice-based evidence is more relevant to how psychotherapy is done in the real world with real patients. The research is not so clear about why some therapists are more effective with racial and ethnic minority (REM) patients. However, complementary research suggests that some therapists who have a previously high level of multicultural orientation (cultural humility, open to conversations about culture, and cultural comfort) are more effective with REM patients. Also monitoring the therapeutic alliance with a valid scale on a session-to-session basis leads to better outcomes. Such monitoring will alert the therapist to resolve an alliance rupture if a patient’s ratings decrease from one session to the next. If therapists also rate the alliance and find that their scores are higher than their patient’s, then this may alert the therapist to a potential problem. Finally, knowing if a patient has current and past interpersonal problems can inform a therapist to focus on how those problems affect current symptoms and to talk about how those problems manifest themselves in the therapeutic relationship.