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.

September 2020

Mentalizing and Psychotherapy

Luyten, P., Campbell, C., Allisons, E., & Fonagy, P. (2020). The mentalizing approach to psychopathology: State of the art and future directions. Annual Review of Clinical Psychology, 16, 297-325.

Mentalizing (or reflective functioning) is important to the human ability to understand one’s self and others in terms of mental states like feelings, desires, wishes, attitudes, and goals. Without mentalizing we would not be able to adapt to complex situations including relationships that require high levels of collaboration and cooperation. Mentalizing underlies the capacity for empathy and improves functions like emotion regulation. Parental capacity to mentalize and to provide a secure attachment environment are requirements for children to develop mentalizing capacity. Without that capacity, children and adults are not able to trust that others are reliable sources of social information, which in turn fosters resilience to adversity. In this wide-ranging article, Luyten and colleagues review the research indicating that deficits in mentalizing underlies many mental health problems. For example, non-reflective assumptions about the self and others leads to problems with emotion regulation often seen in those who experienced childhood adversity. For these individuals, caretakers who were hostile and untrustworthy led the child to develop hypervigilant expectations of others as hurtful, critical, and threatening. This hypervigilant stance might have been useful early-on during the adversity, but hypervigilence represents a barrier to psychological and emotional development. Luyten and colleagues also argue that psychological interventions are forms of social learning that increase a patient’s trust in the self and others as sources of knowledge, improve the patient’s capacity to mentalize partly through the therapist’s modeling of mentalizing, and allow the patient to engage in their environment in more adaptive ways. The authors described mentalization-based treatment (MBT) as focused on increasing mentalizing capacity through improving patients’ mental states and emphasizing the active repair of ruptures in the patient-therapist therapeutic alliance. A recent meta-analysis found that MBT is an effective therapy for borderline personality disorder, and recent controlled trials found that patient improvement lasted from 3 years to 8 years post-treatment.

Practice Implications

Therapists who model mentalizing can encourage this capacity in their patients. Therapists can take a curious “not knowing” stance that allows patients to reflect on their own and others’ mental states (intentions, feelings, thoughts). As an important reparative experience, psychotherapists must be able to identify an alliance rupture (a subtle or obvious disagreement on goals or tasks of therapy, or a tension in the affective bond with the patient). Once identified, therapists must act to repair the rupture by renegotiating or re-explaining the goals or tasks of therapy, or discuss how the tension in the therapeutic relationship may represent a pattern of relationship problems for the patient.
The Reciprocal Relationship Between the Alliance and Outcomes

Flückiger, C., Rubel, J., Del Re, A. C., Horvath, A. O., Wampold, B. E., Crits-Christoph, P., Atzil-Slonim, D., . . . Barber, J. P. (2020). The reciprocal relationship between alliance and early treatment symptoms: A two-stage individual participant data meta-analysis. Journal of Consulting and Clinical Psychology, 88(9), 829–843.

The therapeutic alliance (patient and therapist agreement on tasks and goals of therapy and their emotional bond) is the most researched concept in psychotherapy. The research clearly indicates that a positive alliance reliably predicts patient outcomes in terms of reduced symptoms. However, researchers still debate whether the alliance is at all necessary. That is, some argue that the alliance is the result of patients feeling better early in therapy, and so the alliance is only an outcome of early symptom reduction. If that is the case, then the alliance is an artifact of symptom reduction, and clinicians need not pay much attention to it. In this meta-analysis, Fluckiger and colleagues collected 17 studies representing over 5000 patients that evaluated whether alliance in a previous session predicted outcomes in a subsequent therapy session, and vice versa. In other words, they looked at all studies that evaluated if change in alliance preceded change in symptoms and if change in symptoms preceded change in the alliance. What is unique about this meta-analysis is that they gathered patient-level data from the original studies. That allowed them to test the therapeutic alliance theory for each individual patient on a session by session basis for the first 7 sessions of therapy. (For the stats geeks out there, the authors analysed within-person [between-session] effects using multilevel time-lagged models). Their analyses found that high alliance at a preceding session was related to lower symptoms at the subsequent session (B adjusted = -.065 (95% CI [-.092, -.038]; p < .0001)), and higher symptoms at the start of a session was related to lower post session alliance (B adjusted = -.148 (95% CI [-.215, -.081]; p < .0001). They also found that patients who generally reported high alliance scores showed a stronger alliance – outcome relationship, and those with greater symptoms had a weaker alliance - outcome relationship.

Practice Implications

This meta-analysis is another indication of the importance of therapists and patients coming to a collaborative agreement on the tasks of therapy (what is done during sessions) and the goals of therapy (what issues to work on), and of their relational bond. The alliance is not always easy to establish – especially with regard to agreeing on goals. Also, the alliance should not be forgotten once established – alliance ruptures or tensions occur frequently and can have a negative effect on patients’ mental health outcomes. Patients of psychotherapists who repair alliance tensions generally have better mental health outcomes.
Supervision in Psychotherapy: The Impact of Attachment on Burnout

Hiebler-Rager, M., Nausner, L., Blaha, A., Grimmer, K., Korlath, S., Mernyi, M., & Unterrainer, H.F. (2020). The supervisory relationship from an attachment perspective: Connections to burnout and sense of coherence in health professionals. Clinical Psychology and Psychotherapy, Online First Publication: https://doi.org/10.1002/cpp.2494.

Health professionals including psychotherapists are susceptible to burnout due to the emotional challenges of the work. There is some research indicating that with good supervision trainees and experienced therapists might be less susceptible to burnout (i.e., exhaustion, inefficiency, cynicism) and might gain a greater sense of personal coherence (i.e., that stressful events encountered in life are predictable and manageable, and that managing these events is personally meaningful). Supervision involves a senior qualified practitioner providing an intensive relationship-based education and training focused on supporting, guiding, and teaching a trainee or colleague. One can argue that the supervisory relationship provides the supervisee with a secure base from which to learn and grow as a professional. This secure base functions similar to an attachment relationship, which means that the bond, trust, agreement, and clarity of supervisory goals are key. That is, when a critical incident occurs in the therapy, the supervisee experiences stressful emotions and seeks support and security from the supervisor. One factor that may affect this process is the pre-existing level of attachment insecurity in the trainee (i.e., being too preoccupied with relationships or being too dismissing of relationships). Greater attachment insecurity may make it more difficult for supervisees to experience supervision as a safe environment. In this study, Hiebler-Rager and colleagues assessed if the quality of the supervisory relationship reported by supervisees predicted their level of burnout and of cohesion, and also if supervisees’ level of attachment insecurity also predicted these outcomes over and above the effects of supervision. The sample included 346 supervisees with a wide range of experience (0 to 50 years), ages (23 to 80 years), and professions who completed questionnaires about the supervisory relationship, attachment, burnout, and cohesion. Even after controlling for number of supervision sessions and supervisees’ clinical experience, lower quality of the supervisory relationship was related higher levels of burnout (β = −.31) and a lower sense of coherence (β = .31; both p < .01) in the supervisee. Higher levels of insecure attachment of the supervisee also predicted higher burnout (attachment anxiety: β = .30, p < .01) and lower coherence (attachment anxiety: β = −.40, p < .01; attachment avoidance:β = −.17, p < .01), even after controlling for the effects of number of supervisions sessions, experience, and the quality of the supervisory relationship. Adding attachment insecurity was associated with a medium to large incremental effect over and above the quality of the supervisory experience (R-square change = 0.13 for burnout, and 0.24 for coherence).

Practice Implications

Supervision is a key manner in which psychotherapists are trained, and in which many participate in continuing education. A good quality supervisory relationship (secure and supportive) can help professionals mitigate the risk of burnout and to have a greater sense of personal coherence. However, some of the utility of supervision may depend to some extent on the supervisee’s own level of attachment insecurity. If a supervisee experiences an insecure attachment generally, they may require personal therapy to work on their sense of security in relationships and their ability to manage theirs and others’ emotions.

August 2020

Why Does Where a Patient Lives Affect Their Outcomes in Psychotherapy?

Firth, N., Saxon, D., Stiles, W. B., & Barkham, M. (2019). Therapist and clinic effects in psychotherapy: A three-level model of outcome variability. Journal of Consulting and Clinical Psychology, 87(4), 345–356.

Patients vary in their outcomes from receiving psychotherapy. That is some patients receive more benefit than others or receive benefit more quickly than others. Previous research indicates that factors like higher symptom severity and socioeconomic deprivation are factors that lead to poorer outcomes. There is also evidence that some therapists are more effective than others so that 5% to 10% of patient outcomes depend on which therapist the patient sees. There is also research showing that the location of the clinic may reflect systematic differences in patient outcomes. This may be due to differences in clinic patient populations, to therapist recruiting practices, resource allocation, and accessibility. Research in population health suggest that local neighborhoods affect physical health. In this large study of over 26,000 patients receiving psychological therapy in the United Kingdom (UK) health system, Firth and colleagues estimated how much of patient outcomes were due to differences among patients, differences among therapists, and difference among clinics. Patients received person-centred, psychodynamic, cognitive-behavioral, or supportive therapies. Drop-out rates from therapy was 33%. Average age of patients was 38.4 years (SD = 12.94) and 69.3% were women. Most patients experienced anxiety (71.8%) and/or depression (54%). There were 462 therapists in the study working at 30 clinics throughout the UK. Up to 58.4% of patients who provided post-treatment data (i.e., completed therapy) showed reliable and clinically meaningful improvement, but there were large differences in patient improvement rates across the clinics (range: 23.4% to 75.2%) and across therapists (6.7% to 100%). Patient severity explained a large proportion of therapist differences. That is, whereas many therapists were effective with less severely symptomatic patients, relatively fewer therapists were effective with more severely symptomatic patients. Patient unemployment, location of the clinic in a more economically deprived area, and the proportion non-White patients in the area explained most of the differences between clinics. Patients who were employed and living in an economically advantaged neighborhood composed of mostly White residents had better outcomes.

Practice Implications

We know from previous research that some therapists are more effective than others and these differences are more pronounced with more severely symptomatic patients. However, this study suggests that larger social factors like racism, systematic bias, and microaggressions also play a role in patient outcomes. Economic deprivation likely affects the level of funding and resources allocated to some clinics. Psychotherapists and funding sources need to take into account the broader socioeconomic, ethnic/racial, and geographic context in which the patient lives when planning and offering services to patients.
Countertransference: Patient Personality Affects Psychotherapist Reactions

Stefana, A., Bulgari, V., Youngstrom, E.A., Dakanalis, A., Bordin, C., & Hopwood, C. (2020). Patient personality and psychotherapist reactions in individual psychotherapy setting: A systematic review. Clinical Psychology and Psychotherapy.

Countertransference is one of the oldest concepts in psychotherapy. An over-inclusive definition refers to all of the therapist’s emotional reactions to a patient that is evoked by the patient’s behaviors, thoughts, or feelings in the therapy. However, a more contemporary and integrated definition defines countertransference as a subset of therapist reactions. In this view, countertransference is the internal and external reactions of a psychotherapist evoked by the patient, such that patient behaviors interact with unresolved issues of the therapist. In a previous meta-analysis, countertransference reactions of the therapist was associated with poorer patient outcomes, and therapists’ successful management of countertransference was associated with improved patient outcomes. The clinical literature often reports that patients with a personality disorder often evoke troublesome emotional reactions in therapists. In this systematic review, Stefana and colleagues provide a comprehensive evaluation of the relationship between patient personality problems and psychotherapists’ emotional, cognitive, and behavioral reactions in individual therapy. Seven studies were included in their review. Fifty-three percent of therapists were psychodynamically-oriented, most therapists had more than 3 years of experience, and all patients had a personality disorder or were assessed for problematic personality traits. Overall, the authors found that patients with Cluster A personality traits (paranoid, schizoid, schizotypal) tended to evoke therapist responses of feeling criticized, unappreciated, dismissed, or devalued by the patient. Patients with Cluster B personality traits (borderline, histrionic, narcissistic) tended to evoke therapist responses of feeling overwhelmed, helpless/inadequate, sexualized (experiences of sexual tension), and disengaged toward the patient. Patients with Cluster C personality traits (avoidant, dependent, obsessive-compulsive) tended to evoke parental/protective responses in the therapist. Looking at specific personality traits: paranoid personality traits evoked therapists feeling criticized, schizoid personality traits evoked therapists feeling inadequate, schizotypal or obsessive compulsive or narcissistic personality traits evoked therapists feeling disengaged, antisocial personality traits evoked therapists feeling devalued, borderline personality traits evoked therapists feeling overinvolved, avoidant or dependent personality traits evoked therapists feeling parental.

Practice Implications

The research appears to show that patients with certain personality traits, and thus certain ways of thinking, feeling, and reacting tend to evoke specific reactions in therapists. Therapists patterns of reactions appeared to be independent of theoretical orientation, suggesting that all therapists tend to have emotional reactions that may affect the therapeutic relationship and patient outcomes. Therapists can manage countertransference by remaining vigilant to their internal reactions, using self-awareness during sessions, consulting with colleagues and supervisors, and engaging in personal therapy.
Is Psychodynamic Therapy Effective for Treating Personality Disorders?

Keefe, J. R., McMain, S. F., McCarthy, K. S., Zilcha-Mano, S., Dinger, U., Sahin, Z., Graham, K., & Barber, J. P. (2019, December 5). A meta-analysis of psychodynamic treatments for borderline and Cluster C personality disorders. Personality Disorders: Theory, Research, and Treatment. Advance online publication.

Personality disorders are common mental conditions affecting between 6.1% and 9.1% of the population. Having a comorbid personality disorder predicts a number of negative outcomes from psychotherapy including lower remission rates, greater resistance to therapy, and greater relapse after therapy. Psychodynamic therapies are one of two classes of therapy that have been repeatedly tested in clinical trials for personality disorders (the other being cognitive-behavioral therapies). Psychodynamic therapies aim to help patients improve their personality functioning, including attachment, mentalization, and maturity of defense mechanisms. Dynamic therapies for personality disorders include transference-focused therapy, affect-phobia therapy, mentalization based treatment, and good psychiatric management. In this meta-analysis, Keefe and colleagues systematically assessed whether psychodynamic therapy was as effective as other active treatments and more effective than no treatment. They also evaluated the quality of the studies. They found 16 randomized controlled studies of over 1100 patients that directly compared psychodynamic therapy to another therapy or to a control condition. Outcomes included personality disorder symptoms, suicidality, general symptoms, and drop-out rates. Overall, psychodynamic therapy was as effective as other therapies when it came to all of these outcomes, and the drop-out rates were equivalent. Psychodynamic therapy was more effective than no treatment for personality disorder symptoms (g = 0.63; 95% CI [0.87, 0.41], SE = 0.08, p = .002), suicidality (g = 0.67; 95% CI [1.13, 0.20], SE = 0.15, p = .020), and general symptoms (g = 0.38;95% CI [0.68, 0.08], SE = 0.13, p = .019). Average study quality was high, suggesting that one could be confident in the overall findings of this meta analysis.

Practice Implications

For all outcomes, psychodynamic therapies were as effective as other active treatments and more effective than no-treatment controls for borderline personality disorder and for mixed Cluster C disorders (dependent, avoidant, and obsessive-compulsive personality disorders). The authors concluded that psychodynamic therapies are effective in treating personality disorders like borderline personality disorder and those with Cluster C personality disorders.

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September 2020

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August 2020

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Psychotherapy Practice Research Network (PPRNet)