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 2021

Psychotherapies are Less Effective for Black Youth Who Live in Communities with Higher Anti-Black Racism.

Price, M.A., Weisz, J.R., McKetta, S., Hollinsaid, N.L., Lattanner, M.R., Reid, A.E., Hatzenbuehler, M.L. (2021). Meta-analysis: Are psychotherapies less effective for Black youth in communities with higher levels of anti-Black racism? Journal of the American Academy of Child & Adolescent Psychiatry.

Racism is a system in which racial groups are ranked, devalued, and provided limited opportunities and resources. Individual racism refers to how individuals of stigmatized groups respond to racism (self-devaluation, hopelessness), interpersonal racism refers to how people discriminate or mistreat others based on race, and structural or cultural racism refers to collective beliefs regarding racial groups that become enacted by larger social systems and institutions. Historically, health research on the negative effects of racism has focused on interpersonal racism. More recently, research has studied the association between structural or cultural racism and adverse health outcomes. Few studies have examined the effects of cultural racism on mental health outcomes especially among Black youth. In this meta-analysis, Price and colleagues identified 194 studies across 34 US states. They measured anti-Black cultural racism by analyzing publicly available surveys that tapped into racism. The authors statistically aggregated the scores for each US state thus providing a cultural racism score for each state. The authors categorized the 194 studies according to the composition of race of its participants, such that studies had either majority-White samples (k = 158) or majority-Black samples (k = 36). To examine the independent effect of state-level cultural racism, the authors also controlled for several confounding variables in their analyses (state-level White or Black population density, state poverty rate). Higher anti-Black racism at the state level was associated with lower effects of psychotherapy in studies in which most of the youth were Black (β = -0.20, 95% CI: -0.35, -0.04, p = .02). However, the effect of cultural racism was unrelated to the effects of psychotherapy in studies in which most of the youth were White (β = 0.0004, 95% CI: -0.03, 0.03, p = .98). The standardized effect sizes in states with the highest anti-Black racism (g = 0.19) were significantly lower than in states with the lowest racism (g = .60). A concerning finding was that the differences between low and high racism states widened at follow-up, indicating that cultural racism eroded some of the gains made by Black youth in high racism states.

Practice Implications

Researchers have long known the negative health disparities related to racism, but this is the first study to evaluate the effects of cultural racism on the effects of psychotherapy. This meta-analysis indicates that anti-Black cultural racism reduced psychotherapy effectiveness for Black youth, and some gains tended to decline at follow up. Psychotherapists should consider modifying their treatments for Black youth to derive most benefit and to adopt a multicultural orientation. Nevertheless, stigma and racism have negative effects at multiple levels that require structural and community interventions to target racism at its source.
Can Therapists Identify Racial Microaggressions?

Owen, J., Drinane, J. M., Tao, K. W., DasGupta, D. R., Zhang, Y. S. D., & Adelson, J. (2018). An experimental test of microaggression detection in psychotherapy: Therapist multicultural orientation. Professional Psychology: Research and Practice, 49(1), 9–21.

Microaggressions are covert or subtle expressions of racist actions that include micro-insults (pathologizing cultural values), micro-invalidations (assuming that patients from a racial-ethnic minority [REM] are too sensitive about race), and micro-assaults (blatant racism not in the presence of someone of that race). Previous research showed that 53% to 81% of patients from a REM experienced at least one microaggression from their therapist. Most commonly therapists might minimize cultural issues or subtly express a racial stereotype. Those same studies found that microaggressions were related to worse therapeutic alliance and patient outcomes. Microaggressions are a form of therapeutic alliance rupture that is common in psychotherapy. Of the patients who experienced a microaggression, only 24% indicated that the microaggression was addressed by the therapist. However almost all of those for whom the microaggression was addressed felt that the microaggression was resolved. For therapists to resolve a rupture caused by a microaggression, they first must identify a microaggression. In this study, Owen and colleagues recruited 68 psychotherapists (mostly White women of about 30 years of age) and divided them into two groups. One group viewed a simulated therapy video with three types of microaggressions committed by the therapist. The other group saw a video of a therapy session in which there were no microaggressions. In both videos the therapist was a White woman in her late 30s and the patient was a Hispanic man in his late 20s. Therapist participants who viewed the microaggression video reported significantly more insensitive comments by the therapist in the video than those who viewed the neutral video. However, only 38% to 51% of therapist participants identified a microaggression in the video, and less than 25% identified 2 or 3 microaggressions that occurred.

Practice Implications

The study suggests that therapists can identify when a session includes culturally insensitive interactions. However, therapists were not able to identify almost half of microaggressions when they occurred. This in part may explain why microaggressions often go undetected and unrepaired. The authors admitted that we know very little about what goes on for therapists in these moments – are they anxious about what happened, are they unsure of how to repair the microaggression? The results of this and other studies indicate that therapists should take on a multicultural orientation that includes cultural humility (curiosity and a non-superior approach), responding to cultural opportunities (explore when cultural content is presented), and cultural comfort (ease and calmness related to another’s culture and race).
Mindfulness-Based Interventions Among People of Color

Sun, S., Goldberg, S.B., Loucks, E.B., & Brewer, J.A. (2021). Mindfulness-based interventions among people of color: A systematic review and meta-analysis, Psychotherapy Research, DOI: 10.1080/10503307.2021.1937369.

In the United States, people of color (POC) are disproportionately affected by structural inequalities related to racism such as high rates of incarceration, poor housing, and economic difficulties. Racial disparities also exist in health care such that POC are less likely to use health services thus resulting in more persistent health problems. Research has shown that mindfulness-based interventions (MBIs) may be effective in improving health outcomes of conditions that are prevalent among POC like psychiatric symptoms and cardiovascular disease. Some argue that MBIs are especially culturally relevant to POC because of the focus on overall well-being, the emphasis on resilience, and communally delivered formats. In this meta-analysis, Sun and colleagues systematically reviewed 24 randomized controlled trials with a total of over 2000 participants in which MBI was compared to no treatment or to an active control (a control group that was meant to be therapeutic). Only trials in which the study sample was predominantly (>75%) POC were included. At post-treatment, MBIs showed small but statistically significant outcomes compared to active controls (k = 16, g = 0.11, 95% CI = [0.04, 0.18], p = .002) and to no treatment (k=8, g = 0.26, 95%CI = [0.07, 0.45], p = .007). These are smaller effects than reported in other populations. Drop-out rates for POC receiving MBI was about 22%, which is similar to what is reported in the general psychotherapy outcome literature.

Practice Implications

The results suggest a modest effect of MBI for POC, and that the effects may be smaller than reported in studies with other populations. Only two of the studies reported culturally adapting MBI for POC. Psychotherapists might consider cultural adaptation of MBI or providing MBI from a multi-cultural orientation framework that includes therapists’ cultural humility, making the best of cultural opportunities in therapy, and developing cultural comfort and competence.

August 2021

What Proportion of Patients Benefit from Short-Term Psychotherapy?

Cuijpers, P., Karyotaki, E., Ciharova, M., Miguel, C., Hisashi, N., &Furukawa, T.A. (2021). The effects of psychotherapies for depression on response, remission, reliable change, and deterioration: A meta-analysis. Acta Psychiatrica Scandinavica, 10.1111/acps.13335. Advance online publication.

Many meta-analyses report that psychological therapies are effective to treat depression, that there are no differences between types or orientations of therapy in their outcomes, and that psychotherapy is as effective as medications in the short term and perhaps more effective in the longer term. But what do these findings mean for everyday practice? Many meta-analyses report a standardized mean effect size between treatment and control conditions. However, the effect size is an abstraction that may be difficult to interpret unless you understand the statistic. Clinicians may ask a more practical question: what is the proportion of patients that improve (have meaningful reductions in depression scores) and recover (improved and no longer are depressed)? This meta-analysis by Cuijpers and colleagues of 228 studies representing over 23,000 adult patients looked at the proportion of patients who improved and recovered after psychotherapy relative to those in control conditions (no treatment, care as usual, pill placebo). The psychotherapies were short term manualized treatments like CBT, behavioral activation, interpersonal psychotherapy delivered in individual, group, and self-help formats. About 41% of patients improved with psychotherapy for depression compared to 17% that improved with usual care and 31% for pill placebo. However, after statistically controlling for publication bias (i.e., the likelihood that some unflattering studies were never published), the improvement rate for psychotherapy was 38%. Recovery rates for psychotherapy ranged from 26% to 34%, and recovery in the control conditions ranged from 9% to 17%. There were no differences between therapy orientations. Highest rates of recovery or improvement were achieved by individual therapy and the lowest rates were seen in guided self-help. Deterioration rates were just below 5% in psychotherapy and about 7% to 13% in control conditions.

Practice Implications

The effects of time-limited manualized psychotherapies tested in randomized controlled trials were modest. About 40% of patients improved and about 30% recovered. On the positive side, psychotherapies resulted in only about 5% of patients getting worse. The authors argued that clinicians must consider more effective strategies beyond these approaches to improve outcomes for depression. Some have focused on improving psychotherapist effectiveness, rather than on specific interventions. Methods like progress monitoring, managing countertransference, and repairing therapeutic alliance ruptures are means of improving psychotherapists’ effectiveness.
Patients Crying in Psychotherapy

Genova, F., Zingaretti, P., Gazzillo, F., Tanzilli, A., Lingiardi, V., Katz, M., & Hilsenroth, M. (2021). Patients’ crying experiences in psychotherapy and relationship with working alliance, therapeutic change and attachment styles. Psychotherapy, 58(1), 160–171.

Crying often reflects deep feeling and may play a role in the expression of these feelings. In psychotherapy, crying may be an important experience in helping patients to experience and express their emotions. In previous research, patients who had a strong therapeutic alliance with their therapist also felt that crying allowed them to communicate feelings that they could not express verbally. Researchers also report that patients cry in 14% to 21% of sessions, and that crying may be an indicator of healing when it is assisted by therapist interventions. In this study, Genova and colleagues explored the association between patients’ crying during therapy and the therapeutic alliance and therapeutic change. In a survey, 106 adult patients (mean age = 30.94 years, SD = 8.74) were asked to complete several questionnaires about crying in therapy, crying in their lives in general, the therapeutic alliance, and their outcomes in therapy. Of all patients, 83% reported crying at least once in therapy, suggesting that patient crying during therapy is a common event. Most patients (67.4%) talked to their therapist about crying. Many patients reported negative feelings like sadness (53.5%), frustration (38.4%), or powerlessness (28.2%) after crying in therapy. However, other patients also reported positive feels after crying like relief (45.3%), feeling emotionally touched (34.1%), or a sense of warmth (24.7%). Some patients (41.9%) reported that crying in therapy improved their relationship with their therapist, and no patient reported that crying worsened their therapeutic relationship. There was a significant positive correlation between feeling relieved after crying and the therapeutic alliance (r = .29), but a significant negative correlation between feeling depressed after crying and the therapeutic alliance (r = -.30). Positive feelings after crying were also associated with patient rated improvement in therapy (r = .29 to r = .34). However, negative feelings, such as more tension after crying, were related to poorer outcomes (r = -.27).

Practice Implications

When patients and therapists have a strong therapeutic alliance (collaborative agreement on the goals and tasks of therapy, and a relational bond), patients experience their crying as a useful event to resolve negative feelings. This is especially true when crying leads to greater awareness and new realizations and when the therapist is supportive. It is critical for therapists to explore their patients’ crying in therapy as it represents an opportunity to deepen the therapeutic relationship and the patient’s self-awareness and self-efficacy.
Disclosure of Suicidal Thoughts and Behaviors in Psychotherapy

Love, H. A., & Morgan, P. C. (2021, March 18). You Can Tell Me Anything: Disclosure of Suicidal Thoughts and Behaviors in Psychotherapy. Psychotherapy. Advance online publication.

Only about half of people who die by suicide each year disclose their thoughts or behaviors to another person before their death. And many times, those with suicidal ideation do not disclose to their therapist. There is very little known about why patients do or do not disclose their suicidal thoughts or behaviors to their therapists. This qualitative study by Love and Morgan takes a unique approach to identifying themes that lead to patient disclosure or non-disclosure of suicidal thoughts and behaviors to psychotherapists. The authors distributed a survey online to those currently in psychotherapy and who have had suicidal thoughts. Sixty-eight current patients with suicidal thoughts responded to questions about their experience with disclosing or not disclosing to their therapists. On average, participants were 26.78 years old (SD = 7.25), mostly white and female. Half of the patients disclosed, and half did not disclose to their therapist, and most of those who did not disclose to their therapist (77.4%) also did not disclose to others in their lives. The authors did a qualitative analysis of the text responses to identify major themes. The main theme for not disclosing was the fear of negative outcomes. This included involuntary hospitalization, fear of their therapist’s judgment, and overall lack of trust in the therapist. The main themes for disclosing included a desire to receive the best possible care, trust in the therapist, and perception that the therapist was honest about policies regarding suicidal thoughts and behaviors including reporting procedures. Patients’ experience of the disclosure event itself was affected by several factors. Patients experienced the therapist as supportive of the disclosure when the therapist was empathic, nonjudgmental, and normalized suicidal thoughts. Supportive therapists did not minimize suicidal thoughts, but they did address it directly. A positive and supportive therapist response played a large role in the experience of the disclosure process. Not surprisingly, patients who perceived greater therapist support indicated greater satisfaction in the therapist’s response.

Practice Implications

A strong therapeutic alliance that includes a collaborative approach to determining safety planning and crisis management is key to promoting disclosure of suicidal thoughts and behaviors and to a positive experience for clients. Patients who can describe what influences their suicidal thoughts in a safe and empathic therapeutic environment are in a good position to deal with the suicidal urges. Involuntary hospitalization emerged as an important fear because of the loss of autonomy, loss of connection, and hopelessness that it might create. And so, such action, when necessary, should be done as carefully as possible to avoid creating a lack of trust in future care and disclosures. A clear, straightforward, and empathic discussion of the circumstances around suicidal thoughts, and an open discussion of safety and contingency plans is critical to conserve the patient’s trust in the therapist and therapeutic relationship.

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September 2021

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August 2021

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Psychotherapy Practice Research Network (PPRNet)