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.

May 2016

Organizational Factors That Reduce Suicide Rates in the Population

Kapur, N., Ibrahim, S., While, D., Baird, A.,... Appleby, L. (2016). Mental health service changes, organisational factors, and patient suicide in England in 1997–2012: a before-and-after study. The Lancet Psychiatry.

Suicide is a major cause of death worldwide, and many recent public health efforts have focused on suicide prevention. Many studies have looked at social, psychological, and biological factors that may cause suicide, but few studies have examined the effects of health service contexts on suicide rates. In this large retrospective population-based study, Kapur and colleagues looked at over 19,000 suicides that occurred within England’s health services from 1997 to 2012. This represented 26% of all suicides in England. The researchers: evaluated economic climate, surveyed the clinic administrators and clinicians involved, and they reviewed policy, service, and staffing changes at each time point. Health care in England is organized nationally through the National Health Service, and the government also collected confidential survey data on deaths by suicide between 1997 and 2012. The researchers examined if specific policy changes and organizational factors affected suicide rates. Health system changes such as: (a) implementing the National Institute for Health and Care Excellence depression guidelines, (b) making available crisis and home treatment teams, (c) implementing policies on transfer from youth to adult care and (d) new procedures for managing patients with dual diagnosis were all associated with reduced suicide rates during the study period. One of the most interesting findings was that these changes to the treatment and management of depression, youth, crises, and dual diagnoses were much more effective in reducing suicide rates under two organizational contexts: (1) when non-medical staff turnover was low, and (2) when there was greater reporting of patient safety incidents. Lower staff turnover likely means that patients in those organizations received greater continuity of care and that suicidal or depressed patients were more likely to receive treatment from highly trained and experienced professionals. Greater reporting of patient safety incidents tend to occur in organizations in which the staff feels sufficiently safe and secure to report and discuss negative clinical events without fear of reprisal or punishment. Such reflective practice is likely critical to increasing staff expertise in providing psychological treatment.

Practice Implications

Psychotherapists often do not think about the organizational context within which they work when considering the treatment they provide to those with mental health issues including people who may attempt suicide. Yet many psychotherapists work within an organizational context (e.g., hospitals, group practices, clinics, community health care centers, etc.). The findings from this study indicate that stability in staffing (i.e. low turnover) and working within a system that encourages reporting and discussing negative events likely has a positive impact on mental health outcomes like suicide.

April 2016

Patient Experience of Negative Effects of Psychotherapy

Crawford, M.J., Thana, L., Farquharson, L., Palmer, L., Hancock, E.... Parry, G.D. (2016). Patient experience of negative effects of psychological treatment: results of a national survey. British Journal of Psychiatry, 208, 260-265.

There is lots of evidence that psychotherapy is effective for a wide variety of disorders. However, a number of studies report that between 5% and 10% of patients report higher levels of symptoms following treatment compared to when they started. Although the side effects and negative outcomes in pharmacological treatment studies are routinely reported, negative outcomes in psychological treatment studies are rarely reported and investigated. In this very large survey, Crawford and colleagues analysed data from an audit of state funded psychological therapies for depression and anxiety in England and Wales. Adult patients from 220 centers were invited to complete an anonymous service-user questionnaire that asked about their experiences of the processes and outcomes of psychotherapy. Some of the questions asked if clients experienced a “lasting bad effect” from the treatment. Nearly 15,000 individuals responded to the survey. More than half (51%) were treated with cognitive behavioral therapy, and most clients received only one treatment, which was predominantly individual therapy. Most (74.35%) received fewer than 10 sessions. Of the respondents, 763 (5.23%) reported that therapy had a “lasting bad effect”, and an additional 7.70% were “unsure” whether they experienced a lasting bad effect. People over 65 years old were less likely to have a lasting negative effect, and those from minority ethnic groups and non-heterosexuals were more likely to report lasting bad effects. In addition, those who did not know what type of therapy they received were more likely to have lasting bad effects.

Practice Implications

A substantial minority of patients reported lasting negative effects from their psychological treatment. With approximately a million Canadians receiving outpatient psychological treatment of one form or another each year, these findings imply that thousands of patients could have experienced a lasting negative effect. The findings suggest that psychotherapists need to be highly sensitive to cultural and ethnic minority issues and acquire cultural competence. The same is true when treating non-heterosexuals. Clinicians should also make sure to provide sufficient information to patients about the type of treatment they are receiving as part of the informed consent process. Attending to these issues may reduce the likelihood of therapeutic alliance ruptures that may be related to lasting negative effects.
Nonimproved Patients View Their Psychotherapy

Werbart, A., Von Below, C., Brun, J., & Gunnarsdottir, H. (2015). “Spinning one’s wheels”: Nonimproved patients view their psychotherapy. Psychotherapy Research, 25, 546-564.

The rate of patients who experience no change after receiving psychotherapy is about 35% to 40% in clinical trials. Further, about 5% to 10% get worse after treatment. So, in spite of the fact that psychotherapy is effective in general, a sizeable minority of patients do not benefit. There is also evidence that patients’ perception of therapy differs greatly from their therapists’. Therapists are often inaccurate in identifying or predicting patient outcomes, and patients’ judgements tend to better correspond with treatment outcomes. In this study, Werbart and colleagues evaluated outcomes of 134 patients who had elevated symptoms. The average age of patients was 22.4 years (range 18 – 26), so many were young adults. Almost all received a diagnosis ranging from depressive disorders, anxiety disorders, or personality disorders. The predominant treatment was psychoanalytic. Of the 134 patients, many experienced large improvements by the end of treatment. However, 20 patients remained clinically distressed and did not improve or deteriorated after receiving psychotherapy. The authors interviewed these 20 patients at termination and at three-year follow-up using a semi-structured interview. The interview asked patients for their experiences of therapy. The researchers transcribed the interviews and coded the transcripts using a known method of qualitative analysis called “grounded theory”. Three main themes related to poor outcomes were identified by these patients. (1) The therapy or therapist – in which: therapists were perceived by patients as passive or reticent, patients felt distant from the therapist, and patients did not understand the therapy method. (2) Outcomes of therapy – in which: the patient expected more from therapy, and symptoms and emotional problems remained in the “impaired” range at the end of treatment. (3) The impact of life circumstances – referring to negative impacts of events outside of the therapy.

Practice Implications

This is a small but unique study that interviewed patients who did not benefit from psychotherapy about their experiences of the treatment and therapist. Nonimproved patients described their therapist generally as too passive, distant, and uninvolved in the work of therapy. These patients described difficulty understanding the therapeutic method and the nature of the therapeutic relationship. The findings highlight the importance of the therapeutic alliance. To have a good alliance, patients and therapists have to agree on the tasks of therapy, agree on the goals that the therapy should achieve for the patient, and there should be a mutual liking or bond between patient and therapist. Those patients whose therapists pay attention to and foster a good alliance are more likely to experience good outcomes.

March 2016

Do Psychotherapists Improve with Experience?

Goldberg, S.B., Rousmaniere, T., Miller, S.D., Whipple, J., Nielsen, S.L., Hoyt, W.T., & Wampold, B.E. (2016). Do psychotherapists improve with time and experience? A longitudinal analysis of outcomes in a clinical setting. Journal of Counseling Psychology, 63, 1-11.

Do therapists get better in providing psychotherapy as they gain more experience? This is a long standing question in psychotherapy, and most studies that compare therapists of different experience levels have not provided encouraging findings. This large longitudinal study in a practice setting by Goldberg and colleagues is unique because they follow therapists over a number of years during their careers. That is, the authors do not focus on outcome differences between therapists with different levels of experience, but rather they see if a therapist improves over time as the therapist accrues experience. Data were collected on 170 therapists and 6,591 patients over 18 years in a large practice in the U.S. Patients were distressed adults who attended an average of 8 sessions (range = 3 to 153) across 13 weeks. Over the 18 years of the study, on average therapists saw 39 patients, saw their first patient of the study after their 5^th year post graduate school, and had been working at the practice for about 5 years. On average patients got better, so that their psychological symptoms declined significantly over the course of treatment (i.e., 50% reliably improved). These rates of improvement are similar to benchmarks set in clinical trials. Contrary to expectations, therapists tended to have slightly poorer patient outcomes as the therapists gained experience. This result remained significant even when patient baseline severity, therapist caseload size, and other factors were controlled. However, more experienced therapists tended to have fewer early unplanned terminations (< 2 sessions) than less experienced therapists.

Practice Implications

This is the first large longitudinal study that followed therapists over several years of their career. Therapists became less effective over time, although the magnitude of the deterioration was very small. At the very least, one can say that patients did not achieve better outcomes as their therapists became more experienced. The authors note that the results of this study are in contrast to a large therapist survey in which most practitioners reported that their skills improved with passing time, and in contrast to another study in which therapists tended to over-estimate their effectiveness and under-recognize failing cases. Ways for therapists to improve their skills and patient outcomes might include: engaging in regular progress monitoring, targeted learning of fundamental therapeutic skills, training with standardized patients, and setting aside time for reflection and clinical consultation.

February 2016

Patients’ Experiences of Clinicians’ Crying During Psychotherapy

Tritt, A., Kelly, J., & Waller, G. (2015). Patients’ experiences of clinicians’ crying during psychotherapy for eating disorders. Psychotherapy, 52(3), 373-380.

Psychotherapy can be an emotionally intensive experience for both patients and therapists. In a large survey, more than 70% of therapists reported having cried in therapy, and 30% cried during the past month. Therapists who cried almost always saw the experience as positive or neutral (99.2%) for the patient and the therapeutic relationship. Do clients feel the same way about therapists who cry? In this study, Tritt and colleagues surveyed 188 adult patients with an eating disorder who were recently in psychotherapy. Of those, 107 (56.9%) reported that their therapist had cried during therapy. There was no association between frequency of therapist crying and therapist age, patient diagnosis, or type of psychotherapy (i.e., manual-based or not). Therapists who cried a moderate amount were seen by clients as having a positive demeanor (i.e., happy, firm, consistent), whereas therapists who cried more extremely were rated by clients as having a more negative demeanor (i.e., anxious, angry, bored). If therapists who cried were generally perceived by clients to have a positive demeanor, then therapist crying had a positive impact on therapy. That is, clients reported a greater respect for the therapist, greater willingness to express emotions, and higher willingness to undertake therapy in the future. However, if therapists who cried were generally perceived by clients to have a negative demeanor, then therapist crying had a negative impact on therapy. That is, clients were less willing to express emotions in therapy and to undertake therapy in the future. Further, if the therapist who cried was rated as having a negative demeanor, the client experienced more self blame, assumed that there was something wrong in the therapist’s life, and that the therapist and client did not share the same perspective on the client’s life and treatment.

Practice Implications

This small but unique and interesting survey sheds some light on clients’ experiences of therapists who cry during therapy. More than half of clients experienced their therapist crying during therapy. In contrast to surveys of therapists who tend to evaluate therapist crying as exclusively positive or neutral, this survey found that many but not all clients experienced therapist crying as positive. It depends on how the client perceives the therapist as a person. Therapists who are seen by clients as happy, firm, and consistent may assume that patients will experience their crying as a positive indicator of the therapeutic relationship. However, therapists who are seen by clients as anxious, bored, or angry cannot assume that clients will see their tears as being positive for therapy.

January 2016

Deliberate Practice in Highly Effective Therapists

Chow, D. L., Miller, S. D., Seidel, J. A., Kane, R. T., Thornton, J. A., & Andrews, W. P. (2015). The role of deliberate practice in the development of highly effective psychotherapists. Psychotherapy, 52(3), 337.

In 2014, Tracey and colleagues caused a stir when they claimed that there was no evidence of expertise in psychotherapy (see my July, 2014 blog). They defined expertise as increased quality of performance that is gained with additional experience – and they concluded that psychotherapy research has not provided evidence that therapist performance improves with experience. The issue is important because differences between therapists account for over 5% of patient outcomes. This seems small, but it is larger than variance in outcomes accounted for by the use of empirically supported treatments (0% - 4%), and almost as large as the variance accounted for by client-rated alliance (5% - 15%). Across a wide variety of professions (e.g., music, medicine, chess, sports), professionals’ engagement in deliberate practice results in improvement and superior performance. However, there is little evidence of this in psychotherapy. In this article by Chow and colleagues, the authors look specifically at “deliberate practice” defined as individualized training activities to improve one’s performance through repetition and refinement. To be effective, deliberate practice has to be focused on achieving specific targets and guided by conscious monitoring of outcomes over a long period of time. The authors collected a sample of 69 therapists who worked across a number of organizations and practice areas, and these therapists provided data related to 4,850 patients. Seventeen of the 69 therapists who treated 1,632 clients also provided data on professional development activities. Therapists were multidisciplinary (i.e., counsellors, psychologists, marital therapists, social workers, psychotherapists) with an average of over 8 years of experience, who worked mainly in private practice or within the national health service in the U.K., and who primarily treated adult patients with depression or anxiety disorders. Patient outcomes were measured repeatedly with a valid standardized scale, and deliberate practice was self reported by therapists using a measure that asked about the frequency and time therapists engaged in 25 activities outside of work aimed at improving therapeutic skills. On average, clients improved by the end of treatment and the effect was large (d = 1.22). As expected therapists differed in their patient outcomes (i.e., some therapists were reliably more effective than others). Therapist demographic variables, theoretical orientation, years of experience, and practice setting were not related to patient outcomes. However, the amount of time in deliberate practice activities was associated with a reduction in client distress. Compared to the less effective therapists (2.62 hrs/wk in deliberate practice), the best performing therapists (7.39 hrs/wk in deliberate practice) spent about 2.81 times more time on deliberate practice. Therapists rated the following deliberate practice activities as the most relevant to their patients’ outcomes: reviewing challenging cases, attending training workshops, reflecting on past sessions, and reflecting on what to do in future sessions.

Practice Implications

Although this is a single study with a relatively small sample of therapists, it is one of those rare studies to assess the effects of therapist deliberate practice on patient outcomes. As is the case with other professions, reviewing one’s performance can play an important role in identifying errors, altering course, and remediating problems. As Tracey and colleagues indicated, therapists need good quality information in order to learn from their errors and make adjustments so that clients can improve. Quality information might be available from progress monitoring (i.e., continuous feedback to therapists about client outcomes), which has been shown to improve client outcomes especially for at-risk cases. Chow and colleagues go further to suggest targeted learning by using standardized clients within training and supervision contexts. Deliberate practice is not only for newer or less experienced therapists, since experienced therapists also vary in their ability to engage and help clients. Highly effective therapists spend more time engaging in activities outside of their practice specifically aimed at improving their performance.

This month...

Type of Research

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May 2016

Practice Implications

April 2016

Practice Implications

Practice Implications

March 2016

Practice Implications

February 2016

Practice Implications

January 2016

Practice Implications

Psychotherapy Practice Research Network (PPRNet)