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.

July 2018

Placebo Response in Transcranial Magnetic Stimulation for Depression

Razza, L. B., Moffa, A. H., Moreno, M. L., Carvalho, A. F., Padberg, F., Fregni, F., & Brunoni, A. R. (2018). A systematic review and meta-analysis on placebo response to repetitive transcranial magnetic stimulation for depression trials. Progress in Neuro-Psychopharmacology & Biological Psychiatry, 81, 105-113.

Transcranial magnetic stimulation (TMS) is a new treatment for depression thought to modulate brain activity through electromagnetic pulses delivered by a coil placed over the patient’s scalp. A meta analysis shows that TMS may be effective in treating depressive disorders when compared to a placebo control, although only 18.6% of those receiving TMS were no longer depressed at the end of treatment. The placebo control condition usually involves a sham version of TMS in which the coil is placed over the scalp but no magnetic stimulation is applied. In antidepressant trials, the placebo response is quite high such that approximately 40% of patients respond to the placebo condition (in antidepressant trials, the placebo condition includes an identical pill that is inert). In this meta analysis, Razza and colleagues assess the placebo response in TMS. They included only double blind randomized controlled trials (i.e., trials in which both the patient and physician were not aware if the treatment was real or a sham). The authors estimated the placebo response based on pre- to post-sham TMS scores of common measures of depression. The meta analysis included 61 studies of over 1300 patients. The main result showed that sham response was large (g = 0.80; 95%CI = 0.65–0.95). Trials including patients with only one episode of depression or who were not treatment resistant (g =0.67, 95%CI = 0.06–1.28, p= 0.03) had higher placebo responses than those trials in which patients previously had two or more failed antidepressant treatments (g = 0.5, 95%CI = 0.03–0.99, p = 0.048).

Practice Implications

The results of this meta analysis demonstrates a high placebo response in trials testing TMS. This is similar to the high level of placebo response commonly seen in patients in antidepressant medication trials. It appears that psychological factors like attention, instillation of hope, patient expectations of receiving benefit, and perhaps working alliance may account for an important portion of why pharmacological and other medical interventions appear to work for those with depressive disorders. This is particularly true for patients who are receiving treatment for the first time or for whom previous medical treatment was successful.
Are E-Health Interventions Useful for Weight Loss?

Podina, I. R., & Fodor, L. A. (2018). Critical review and meta-analysis of multicomponent behavioral e-health interventions for weight loss. Health Psychology, 37(6), 501-515.

Over 35% of Americans are overweight or obese, and this poses significant health-related challenges. Obesity likely contributes to heart disease, Type II diabetes, and some forms of cancer. Also, obesity is often co-morbid with mental health conditions including depression and binge-eating disorder. Practice guidelines list multicomponent behavioural interventions as state of the art treatment for weight loss. These include dietary counselling, increased physical activity, and behavioural methods to support behaviour change. However, such interventions often require direct in-person contact with a health or mental health professional, which can be expensive and create a barrier to accessing treatment for some. An option to increase access is to deliver the multicomponent behavioural intervention by internet or by another electronic format such as DVD. In this meta analysis, Podina and Fodor reviewed 47 randomized controlled studies representing over 1500 participants in which e-health interventions for weight loss in overweight or obese individuals were tested against in-person treatment or a control condition (no treatment or treatment as usual). E-health interventions were more effective than control conditions for weight loss outcomes at post-treatment, g = 0.34 (95% CI [0.24 to 0.44]). Similar results were found at follow-up. However, e-health interventions were significantly less effective than active in-person treatments, g = -0.31 (95% CI [-0.43 to -0.20]) for weight loss in overweight or obese individuals.

Practice Implications

E-health interventions (mostly internet delivered treatment) of multicomponent behavioral treatment for weight loss was more effective than no treatment or treatment as usual. However, e-health was significantly less effective than traditional face to face behavioral interventions to help people reduce their body weight. The authors raised concerns about the use of e-health interventions for weight loss as the first line treatment as the effects were small and the approach was less effective than in-person interventions.

May 2018

Burnout in Psychotherapists

Simionato, G. K., & Simpson, S. (2018). Personal risk factors associated with burnout among psychotherapists: A systematic review of the literature. Journal of Clinical Psychology. Advance online publication.

Burnout is an important factor in work-related problems for psychotherapists. Burnout is defined as a type of stress associated with feelings of exhaustion, disconnection, and self-doubt related to emotionally involved work in helping professions. Maslach described burnout as being composed of three factors: emotional exhaustion (personal and emotional fatigue at work), depersonalization (negative feelings about clients and the work), and a reduced sense of personal accomplishment (low personally related work successes). Psychotherapists are inclined to burnout because of the emotionally taxing work during which they must remain empathic. In order to protect themselves and conserve energy, psychotherapists may detach from clients, which may lead to a lower sense of work satisfaction and work accomplishments. High levels of burnout reduce a psychotherapist’s ability to take care of themselves and their clients. In this systematic literature review, Simionato and Simpson found 40 studies that empirically examined burnout among psychotherapists and the possible correlates or causes. Results of the 40 articles represented almost 9,000 therapists. Over 54% of therapists reported moderate to high levels of stress related to burnout. On average, therapists reported moderate to high levels of emotional exhaustion, depersonalization, and low personal accomplishment. Younger age was the most frequently identified risk factor for psychotherapist burnout, as was over-involvement with client problems. The authors suggested that the association between burnout and being younger may be due to being less experienced and to higher levels of unattainable standards for clinical practice and client outcomes. In addition, being female was associated with higher reported levels of burnout. This may be due to stress related to women having to juggle demands of both work and domestic responsibilities. Young clinicians are more likely to have young families, and women may be particularly prone to work-life conflict while managing the demands of both.

Practice Implications

Over half of psychotherapists reported moderate to high levels of burnout that could affect their work, their clients’ outcomes, and their personal well being. Training programs might facilitate self-awareness and the capacity for psychotherapists to reflect on their personal strengths, limitations, and maximum workload capacity in order to find the best fit between their personality, circumstances, and job demands. Practicing therapists might consider personal therapy to help cope better with demands of work and home life. Surveys of psychotherapists consistently showed that about 70% have sought psychotherapy at some point in their careers.
Therapist Characteristics That Affect Client Outcomes

Lingiardi, V., Muzi, L., Tanzilli, A., & Carone, N. (2017). Do therapists' subjective variables impact on psychodynamic psychotherapy outcomes? A systematic literature review. Clinical Psychology & Psychotherapy. Advance online publication.

Psychotherapists differ in their effectiveness such that some therapists are more effective than others, and these differences account for up to 9% of client outcomes. Despite this, not many studies have looked at therapist personal characteristics that might be associated with better or worse outcomes. In this systematic literature review, Lingiardi and colleagues focus on empirical studies of psychodynamic therapists and their personal characteristics that might affect therapeutic processes and client outcomes. The authors included only quantitative studies. Thirty studies representing nearly 1,400 therapists and 6,000 clients were included in the review. Most studies occurred in a naturalistic setting, and most therapists were female (66%) with an average of over 9 years of experience. The studies looked at various therapist personal characteristics and their association with therapeutic processes and client outcomes. Therapist attachment security (ability to engage in meaningful loving relationships and adaptively manage emotions) was associated with better client outcomes. Similarly, therapists who reported better experiences of parental care and better quality relationships with attachment figures tended to have clients who rated a more positive therapeutic alliance. In addition, therapist interpersonal functioning was evaluated in several studies. Therapists who were rated as more affiliative (warm, friendly) and less hostile (cold, rejecting) tended to have clients who achieved better outcomes. Further, therapist facilitative interpersonal skills (emotional expressiveness, verbal fluency, warmth, empathy) were associated with better client outcomes in short-term therapy. Finally, several studies assessed therapist self-concept (stable means by which one treats oneself). Therapists who were more hostile or negative toward the self tended to be more critical or ignoring of clients, which lead to poorer client outcomes.

Practice Implications

Therapist personal characteristics (attachment security), interpersonal skills (warmth, friendliness, empathy), and self concept (how one treats oneself) may account for why some therapists are more effective than others. Problems in these areas might lead to problematic countertransference (emotional reactions on the part of therapists triggered by client issues) or therapeutic alliance ruptures, both of which are related to poorer client outcomes. Therapists can learn methods of managing countertransference and repairing alliance ruptures. If the personal characteristics are persistent and problematic, therapists might consider personal therapy.

April 2018

Therapist Multicultural Orientation Improves Client Outcomes

Davis, D. E., DeBlaere, C., Owen, J., Hook, J. N., Rivera, D. P., Choe, E., . . . Placeres, V. (2018). The multicultural orientation framework: A narrative review. Psychotherapy, 55(1), 89-100.

Many therapists have better outcomes with White or European clients than clients from diverse racial or ethnic minorities, and this might be due to racial and ethnic microaggressions that sometimes occur in therapy. Microaggression refer to intentional or unintentional brief commonplace verbal, behavioural, or environmental indignities that are experienced as derogatory or negative by racial and ethnic minority clients. A multicultural orientation refers to how the cultural worldviews, values, and beliefs of clients and therapists interact to co-create a relational experience in therapy. Therapist multicultural orientation has three elements. First, cultural humility, in which a therapist is able to maintain an interpersonal stance that is open to the client’s experience of cultural identity. Second, cultural opportunity, in which the therapist uses events in therapy to explore a client’s cultural identity in depth. Third, cultural comfort in which a therapist feels at ease, open, and calm with diverse clients. These elements are important in order to negotiate a therapeutic alliance (i.e. agreement on tasks and goals of therapy, and the emotional bond between client and therapist). In this narrative review, Davis and colleagues look at the small existing research on multicultural orientation and how that research can inform therapists’ practices. The authors found that in the two studies on the topic, greater therapist cultural humility was associated with better client outcomes. Several studies found that cultural humility was associated with a positive therapeutic alliance, and that therapist cultural humility was associated with fewer microaggressions as experienced by racial and ethnic minority clients. Finally, missed opportunities by therapists to explore the meaning of culture and identity were associated with negative client outcomes. Presumably, such missed opportunities meant that therapists did not recognize and repair cultural ruptures.

Practice Implications

The research on multicultural orientation suggests several practice implications. (1) Cultural humility requires therapists to explore their automatic cultural assumptions because if they remain unexplored they may be harmful to clients. (2) Therapists should overtly discuss the importance of cultural identities with clients in order to help both therapist and client develop a more complex understanding of the issues that bring the client to therapy. (3) A strong therapeutic alliance may require the therapist to incorporate their client’s cultural worldview and perspective when conceptualizing the client’s problems. (4) Depending on the client’s cultural worldview, therapists may consult with the client’s family and/or spiritual leaders when negotiating a culturally acceptable way of addressing the client’s problems. (5) Therapists need to identify for themselves when their values conflict with those of the client, and seek consultation or supervision when they do.

February 2018

Therapeutic Relationship Predicts Pharmacological Treatment Outcomes

Totura, C.M.W., Fields, S.A., & Kraver, M.S. (2018). The role of the therapeutic relationship in psychopharmacological treatment outcomes: A meta-analytic review. Psychiatric Services, 69, 41-47.

There is evidence to suggest that pharmacological treatments are effective for a wide range of disorders. However, a high level of adherence to taking psychotropic medications is necessary in order for them to have a chance of working. Medical interventions in general do not work well when patients are non-adherent to the regimen, and non-adherence is a significant problem in medicine. Treatment adherence is particularly problematic in those with a mental health condition. Low adherence may have to do with problems with the medications themselves, like unpleasant side effects. And low adherence also may be due to issues related to mental health impairment, like low motivation and problems with reasoning. A particular issue in mental health treatment is the manner in which patients receive the medication. Unlike some medical interventions, psychotropic medications are often taken by patients on their own and away from the clinic or hospital. In psychotherapy, we know that a good therapeutic alliance improves outcomes partly because a good alliance provides a context within which psychological interventions can work (i.e., clients may be more adherent to the treatment recommendations) and partly because the alliance itself may be therapeutic. In this meta analysis, Totura and colleagues examine if there is an association between the therapeutic alliance and mental health outcomes for patients who receive pharmacological interventions for their mental illness symptoms. Eight studies of 59 samples representing over 1,000 patients were included. Four studies were of pharmacological treatment for affective disorders, two for schizophrenia, and two for mixed diagnoses. The results indicated a statistically significant and moderate effect: z = .30 (CI=.20, .39, SE=.048, z=6.192, p=.05), such that greater therapeutic alliance predicted better mental health outcomes among patients receiving pharmacotherapy.

Practice Implications

Higher quality of the physician-patient relationship was related to better mental health treatment outcomes for patients taking pharmacotherapy. The therapeutic alliance appears to be just as import in pharmacological treatment as it is in psychotherapy. It is possible that a good alliance with the provider may increase patient adherence, which may lead to better outcomes. It is also possible, however, that the alliance itself is therapeutic. That is, negotiating an alliance and repairing alliance tensions may lead to positive changes in patients’ ability to cope with emotions and to make the most of their social supports. The results also suggest the importance of training physicians in communication skills to improve therapeutic relationships.

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July 2018

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May 2018

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April 2018

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February 2018

Practice Implications

Psychotherapy Practice Research Network (PPRNet)