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 CBT, negative effects of psychological interventions, and what people want from therapy.
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
December 2021
How Much Psychotherapy is Necessary?
Lutz, W., de Jong, K., Rubel, J.A., & Delgadillo, J. (2021). Measuring, predicting, and tracking change in psychotherapy. In M. Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7th ed.). Wiley. Chapter 4.
The question of how many psychotherapy sessions are necessary to achieve good patient outcomes, or how frequently sessions should occur has been on the minds of practitioners and researchers for over a century. In this part of the chapter, Lutz and colleagues review some of the research related to how many sessions of psychotherapy is necessary to achieve positive outcomes for patients. A meta-analysis of 70 randomized controlled trials (RCT) of psychotherapy did not demonstrate any correlation between the number of sessions a patient receives and their outcomes. Other research indicates that receiving psychotherapy twice a week is more effective than receiving treatment once a week for depression. The findings of these two lines of research suggest that treatment length may not matter as much as treatment frequency. However, RCTs of psychotherapy tend to test only time limited therapies and they may not reflect exactly what happens in the real world with diverse patients who have complex problems. Perhaps the most relevant research for clinicians may be what is called the dose-response studies. These are studies that indicate how many sessions it takes for patients to get better regardless of treatment length. The dose-response research showed that 50% of patients starting treatment in the dysfunctional range required 21 sessions to achieve clinically significant change. That also means that half of patients did not change meaningfully with 21 sessions of therapy. More than 35 sessions were necessary for 70% of patients to achieve clinically meaningful change (and still, 30% of patients did not benefit). It is likely that some patients get better with a few sessions, but as severity or complexity of problems increase so does the number of required sessions. To add to the complexity, optimal duration of therapy varies according to practice settings. For example, for CBT in controlled studies the average patient needed about 17 sessions to get better, while 35 sessions of CBT was necessary in real world settings for the average patient to improve (again, that means that 50% did not yet improve).
Practice Implications
The findings from this line of research of the optimal number of sessions suggest that it is difficult to translate findings from controlled trials to real world practice. Most RCTs limit therapy to a brief number of sessions whether patients get better or not. Some patients do improve with a few sessions but over half of patients require more than 21 sessions to achieve clinically meaningful change, and about 30% of patients require more than 35 sessions. There is some evidence that more sessions per week leads to better outcomes as well.
Dropping Out From Psychotherapy
Lutz, W., de Jong, K., Rubel, J.A., & Delgadillo, J. (2021). Measuring, predicting, and tracking change in psychotherapy. In M. Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7th ed.). Wiley. Chapter 4.
In this part of the chapter, Lutz and colleagues review research methods related to patients dropping out of psychotherapy. Drop outs represent an important problem. For the clinician, a patient who drops out may represent loss of income due to missed appointments, extra work, administrative costs, and a lower sense of professional self-efficacy. Not all patients who terminate therapy early have a poorer outcome. But the research indicates that overall, patients who drop out of treatment do have poorer outcomes, higher hospitalization rates, lower work productivity, and higher social costs than patients who complete treatment. Hence, when a patient drops out of therapy it should be defined as a failure of the treatment that could lead to further demoralization of the patient. Defining a drop out is tricky in that some studies indicate that if a patient does not attend a minimum number of sessions, then they have dropped out. However, a more realistic definition might be that if a patient unilaterally decides to end therapy against a therapist’s advice, then the patient can be considered to have dropped out. Estimates of patient drop out from therapy vary widely depending on the treatment context and patient characteristics. For example, highly controlled studies report dropout rates of about 19.7%, but less controlled studies that might be closer to real world practice report average dropout rates of 26%. But the range of dropout rates across studies was very wide from 0% to 74.2%. Patient characteristics that led to higher dropout rates included higher initial impairment, younger age, lower level of education, a personality disorder diagnosis, and negative expectations about treatment. Therapists had a significant impact on dropping out as well. Therapist effects accounted for 12.6% of the variance in dropping out – that is a moderate but important effect. That is, some therapists have higher dropout rates than others, and this is likely independent of patient characteristics. This is like therapist effects on patient outcomes, in which it is estimated that about 10.1% of patient deterioration is predicted by the therapist’s effect.
Practice Implications
Patients dropping out from psychotherapy is an important problem that negatively affects the patient, the therapist, and that has broader social, health, and economic consequences as well. Aligning the patient’s and therapist goals for the therapy, coming to a collaborative agreement on how therapy will work, and developing an emotional and empathic bond with the patient may be ways of reducing the number of dropouts from therapy. These are all elements of the therapeutic alliance that must be negotiated very early in therapy to forestall a negative outcome such as the patient dropping out.
Routine Outcome Monitoring
Lutz, W., de Jong, K., Rubel, J.A., & Delgadillo, J. (2021). Measuring, predicting, and tracking change in psychotherapy. In M. Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7th ed.). Wiley. Chapter 4.
Routine outcome monitoring is also known as progress monitoring and feedback. This involves regularly assessing patients with a psychometrically reliable scale before a therapy session and providing the therapist with feedback on the patient’s progress. The feedback includes how the patient is doing relative to the average patient, and how the patient is doing in this session relative to their own scores in previous sessions. By doing this, therapists can get regular and reliable information about their patient’s progress and be alerted to when the patient is not on track to improve or is getting worse. Decisions about patient improvement on a session-to-session basis are complex because they involve knowing how the patient is doing regarding symptoms, quality of life, and relationship functioning relative to other patients and relative to their own functioning in the past. No wonder therapists often mis-judge when a patient is getting worse. Routine outcome monitoring involves decision-making tools to enhance a clinician’s decisions – like the way a physician uses a blood test or x-ray to enhance their clinical observations. In this part of the chapter, Lutz and colleagues review the research over the past 50 years on outcome monitoring and feedback. The effects of psychotherapy with feedback compared to psychotherapy without feedback ranges from small (g = .07) to medium (d = .40) in size. These effects seem small, but the authors remind us that feedback is a relatively simple clinical tool provided in addition to psychotherapy, and so these positive effects occur are over and above the general effectiveness of psychotherapy. Highest effect sizes are achieved for clients who are not on track (likely to get worse) such that feedback compared to no feedback in these not-on-track patients result in effect sizes ranging from 0.36 to 0.53, indicating a moderate to large effect. Further, when feedback was provided, patient dropout was reduced by 20% compared to when feedback was not provided.
Practice Implications
Although routine outcome monitoring is relatively easy to use, there are barriers to their implementation. Organizational cultures are difficult to change, and resources must be assigned to implement these strategies. Clinicians must have the technology, some training, and funds to purchase the psychometric scales which may be a challenge for some. And attitudinal barriers are a problem if managers or clinicians do not value outcome measurement. Nevertheless, patient reported outcomes with psychometrically valid scales should be central to ensure good patient-centered care. Psychotherapists can benefit from quality information to help their clinical decision making, especially when it comes to identifying patients who might not be benefitting. Such feedback about patients who are at risk of getting worse may help clinicians to adjusting treatment and their interpersonal stances to these patients.
November 2021
Emotional Experiences of Psychotherapists
Chui, H., & Liu, F. (2021). Emotional experience of psychotherapists: A latent profile analysis. Psychotherapy, 58(3), 401–413.
Working with client emotional experiences in therapy is a core aspect of the psychotherapist’s work, regardless of their theoretical orientation. And so, therapists’ performance and their own well-being may be impacted by their capacity to experience and regulate their own emotions. Emotional reactivity refers to one’s sensitivity, intensity, and duration of emotional experience. Emotion regulation refers to the capacity to manage and express emotions and may be considered an interpersonal competency for therapists. Such competency likely involves flexible expression of emotion and a capacity for empathy. A better understanding of how therapists experience emotions might inform therapists’ use of empathy to facilitate their work with clients. In this study, Chui and Liu surveyed 314 English speaking and 589 Chinese speaking psychotherapists and asked them about their experiences of emotional reactivity, their emotion regulation, and empathy. Their data allowed them to develop profiles of psychotherapists along dimensions of emotional experience. Three latent profiles emerged in both the English and Chinese speaking samples of therapists. The highest proportion of English-speaking therapists (58%) were categorized as “Calm Regulators”, which indicated therapists with low emotional reactivity and few problems with emotion regulation. Next, 34.4% of English-speaking therapists were characterized as “Moderate Experiencers”, and 7.6% were “Emotional Feelers”. The latter profile included therapists who were emotionally over-reactive and who had greatest difficulty with regulating their emotions. As one might expect, those with the Calm Regulator profile had higher capacity for perspective taking, higher empathic concern, and lower personal distress than therapists in the other profiles. Also, therapists who were older, with more education, female, and with a psychodynamic orientation were more likely to have the Calm Regulator profile. Results were remarkably similar in the Chinese speaking sample, in which Calm Regulators also reported higher levels of counsellor self-efficacy.
Practice Implications
Therapists with the “Emotional Feelers” profile (i.e., that have higher levels of emotional reactivity and more difficulty regulating their emotions) may be at higher risk of burnout and of being less effective in their work. As a profession we often discuss clients’ individual differences in emotional experience and emotion regulation, but we spend less time considering these important interpersonal competencies in therapists. Recent surveys suggest that almost 50% of therapists may be at high risk of mental health problems. Psychotherapists, trainers, and supervisors need to pay more attention to therapists’ capacity to regulate their emotions, and its impact on their capacity to be emotionally flexible and empathic with clients. Therapists might consider personal therapy as a means of building this capacity.
Therapists are Not Equally Effective Across Sexual Orientations
Drinane, J. M., Roberts, T., Winderman, K., Freeman, V. F., & Wang, Y.-W. (2021, October 14). The myth of the safe space: Sexual orientation disparities in therapist effectiveness. Journal of Counselling Psychology. Advance online publication.
In general, differences between therapists account for 5% to 10% of the variance in client treatment outcomes. Some of these differences can be accounted for by therapists’ capacity to adjust to or to work with diverse client characteristics. For example, certain therapists more effectively espouse cultural humility and pursue opportunities for cultural conversations than other therapists, and this likely affects client outcomes. Most of the research on therapist effects related to diversity has focused on race/ethnicity. Very few studies to date have looked at therapist differences regarding sexual minority statuses. Therapists can engage in unhelpful practices including microaggressions toward sexual minority patients. Microaggressions can be unintended or subtle expressions of prejudice that are harmful to the recipient. Microaggressions that sexual minority patients experience may include communicating that one’s sexual orientation is a cause of distress, minimizing the importance of sexual orientation identity, and over-identification with LGBTQ clients. Further, patients with sexual minority statuses are at increased risk for adverse mental health outcomes possibly caused by the experience of minority stress related to stigma, prejudice, and discrimination. In this study, Drinane and colleagues a sample of 1,725 clients treated by 50 therapists in a university counselling center. About 17.7% of the client sample endorsed a sexual minority status. An unexpected finding was that sexual minority clients did not have worse mental outcomes than heterosexual clients. However, therapists varied in the extent to which their clients improved and how that improvement varied by sexual orientation status. Some therapists had queer clients who experienced more change than their heterosexual clients, whereas other therapists had heterosexual clients who experienced more change than their queer clients.
Practice Implications
The findings of this study indicate that therapists influence their clients outcomes differently based on the clients’ sexual orientation identity. Those therapists whose queer clients had worse outcomes than their heterosexual clients may be inadvertently engaging in microaggressions. Professional development that focuses on increasing the ability to consider sexual minority client experiences may lead psychotherapists to respond to sexual minority clients without prejudice. Therapists should consider how their own values shape their behaviors and interventions across client populations.
Psychological Treatments for Panic Disorder
Papola, D., Ostuzzi, G., Tedeschi, F., Gastaldon, C., Purgato, M., Del Giovane, C., . . . Barbui, C. (2021). Comparative efficacy and acceptability of psychotherapies for panic disorder with or without agoraphobia: Systematic review and network meta-analysis of randomised controlled trials. The British Journal of Psychiatry, 1-13. doi:10.1192/bjp.2021.148
Panic disorder affects between 1.1% and 3.7% of the population, and panic symptoms can occur in about 10% of patients in primary care. Panic disorder is characterized by recurrent and unexpected panic attacks including heart palpitations, sweating, and trembling. Often, the fear of panic attacks results in avoidance of places or situations that might cause another panic attack. Sometimes, panic attack co-occurs with agoraphobia, or anxiety related to being in certain places or situations. Panic disorder can be debilitating and can also co-occur with depression or substance use disorders. In this network meta-analysis, Papola and colleagues systematically reviewed 136 randomized controlled trials of psychological therapies for panic disorder that included over 7,300 patients. The therapies included CBT, psychodynamic therapy, behavior therapy, EMDR and others that were compared to each other and treatment as usual (which often included minimal intervention). The most effective treatments compared to treatment as usual were CBT (SMD = -0.67, 95%CI: -0.95 to -0.39) and short term psychodynamic therapy (SMD = -0.61, 95%CI: -1.15 to -0.07). All other psychotherapies (EMDR, IPT, behavior therapy, third wave CBT, cognitive therapy, psychoeducation) were not more effective than treatment as usual. The authors also evaluated acceptability of the treatment to patients, which they defined as the dropout rates from the therapies that were offered. Behavior therapy and cognitive therapy were less accepted by patients than short term psychodynamic therapy and CBT.
Practice Implications
The results of this large network meta-analysis indicates that CBT and short-term dynamic therapy are efficacious treatments for panic disorder. The authors suggest that these treatments should be considered as first line interventions. These findings confirm a growing trend indicating the efficacy of psychodynamic therapies for panic and as well as for other common mental disorders.