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 psychotherapy for borderline personality disorder, capacity to metnalize and therapy resistant depression, and negative effects of psychotherapy
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
March 2021
Identifying Outcomes for Depression That Matter to Patients
One of the criticisms of mental health treatment research is that the outcomes measured in these studies are those that matter to researchers but may not matter as much to patients. Common outcome measures of depression like the Beck Depression Inventory (BDI), the Patient Health Questionnaire (PHQ-9) or the Hamilton Depression Rating Scale (HDRS) were developed by researchers because of their relative ease of use, and their sensitivity to change following treatment. But these measures provide a narrow view of what it is like to experience depression because they focus only on a limited set of symptoms. But is symptom reduction the only thing that matters to patients and their loved ones? In this large-scale study by Chevance and colleagues, the authors surveyed over 1900 patients with a mood disorder, 464 informal caregivers (family members), and 627 health care providers from a wide range of mental health disciplines. The survey extended across dozens of countries and sampled a range of age groups. The authors asked patients open ended questions about what outcomes are important to them in the treatment of their depression, and then the responses were analyzed using a qualitative method. Chevance and colleagues identified two broad categories important to patients: symptoms and functioning. Regarding symptoms, patients identified several domains in which they wanted to experience improvements. These included: their perception of their self (e.g., self-esteem, self-confidence), physical symptoms (e.g., sleep, energy level), cognitive symptoms (e.g., social interest, cognitive distortions, motivation), emotional symptoms (e.g., mental pain, anxiety, sadness), and symptoms related to burden of suicidal thoughts. Regarding functioning, patients identified four domains in which they wished to see improvements. These included: elementary functioning (e.g., self-care, coping with daily tasks, autonomy), social functioning (e.g., social isolation, interpersonal relationships, family life), professional functioning (e.g., loss of job/studies, professional responsibilities), and complex functioning (e.g., coping with daily life, financial issues, personal growth).
Practice Implications
Clearly, patients, their loved ones, and those who provide treatment have a much broader view than researchers of what constitutes important outcomes to their mental health treatment for depression. The two most common symptom outcomes identified by patients were psychic pain and the burden imposed by suicidal ideation, yet these rarely assessed as primary outcomes in psychotherapy studies. And outcomes like social functioning, family relationships, and personal growth are not primary outcomes, and often they are not assessed at all in research studies. Clinicians would do well to take a broader view of what is important to patients, and to keep in mind their patients wishes as they develop collaborative goals for treatment with patients. It may be useful not only to use standardized scales to aid in developing treatment plans, but also to ask patients what they hope to gain from therapy should the treatment be successful.
How Much Psychotherapy is Really Necessary for Clients to Improve?
Findings form psychotherapy research studies have tested a dose-response relationship that shows that after a certain number of sessions the rate of client improvement diminishes. That research tends to show a range of 4 to 12 sessions is necessary in order for the average client to improve (half of clients get better by this point, but half do not yet get better). The key limitation of this research is that the vast majority of it was conducted in student counselling centres offering brief treatments. That is, the clients in this research domain tend to be students with mildly to moderately severe problems, and the counselling centres often had a policy (not based on client need) that limited the number of treatment sessions. There is actually very little psychotherapy dose-response research of clients with moderate to severe problems who receive treatment in naturalistic settings that do not arbitrarily impose a session limit. In such settings, it would be the client’s optimal response to treatment and not externally imposed limits that determine when therapy is terminated. This study by Nordmo and colleagues was conducted in several psychotherapy outpatient clinics in Norway. The 362 adult clients had moderate to severe levels of mental health problems, and about half had a personality disorder. The 88 therapists had about 10 years of experience and used several major orientations of psychotherapy practice (psychodynamic, CBT, behavioral, humanistic). Clinicians and clients came to an agreement about when to terminate therapy, and so no limit on sessions was externally imposed. Outcomes were assessed regularly and were evaluated for reliable change and clinical recovery in symptoms and interpersonal problems. Clients attended an average of 52 sessions (SD = 59, Mdn = 36), and improvements were maintained up to 2 years post-treatment. The results indicated that the more sessions a client received the greater their improvement. This was particularly true for those clients with more severe problems. Clients with less severe problems needed fewer sessions to improve. The average client needed 57 sessions to show clinically significant improvement.
Practice Implications
The psychotherapy dose-response research to date is limited because it is primarily based on clients with mild to moderate problems treated in student counselling centres. In real-world contexts, client rate and magnitude of change are related to the length of treatment. That is, clients with moderate to severe problems will require more than 4 to 12 sessions in order to improve. As the authors argued, the one-size-fits-all approach to treatment length in everyday practice is not supported by the research, and does not provide adequate treatment to those clients with moderate to severe problems, or those with complex comorbidities.
Adding Psychodynamic Therapy to Antidepressant Medications
Depression is the single largest contributor to disability worldwide. There are a number of established treatments for depression including antidepressant medications and psychotherapies. One of the psychological treatments that is evidence-based is short-term psychodynamic psychotherapy (STPP). There is evidence in the general psychotherapy research literature that combining psychotherapy with antidepressant medications is more efficacious than providing medications alone. However, no meta-analysis has looked specifically at adding STPP to antidepressant medication. In this meta-analysis Driessen and colleagues analysed data from 7 studies that compare STPP plus medications versus antidepressant medications alone, or that compare STPP plus medications versus supportive therapy plus medications. Although the number of studies was small, the unique aspect of this meta-analysis is that Driessen and colleagues were able to get all of the individual level data from each study, so they were able to analyse data from 482 participants. Typical meta analyses only look at study level data (effects reported from the study as a whole) and not individual level data (effects for each individual who participant in each study). So, the results from Driessen and colleagues’ study provides a more precise and specific analysis of the findings. Combined treatment of STPP and antidepressant medications was significantly more efficacious than antidepressants with and without supportive therapy at post-treatment, but the effects were small (d = 0.26, SE = 0.01, p = .01). At follow up, combined treatment of STPP and antidepressant medications was again more efficacious than antidepressant medications and supportive therapy, but the effects were moderately large (d = 0.50, SE = 0.10). Other findings also suggested that STPP’s specific interventions provided significant added benefit over and above the non-specific effects of supportive therapy. The findings were consistent whether or not analyses were done on studies with complete versus incomplete data, controlling for baseline depression scores, and use or not of a treatment manual. Overall, the quality of the studies was good, and the findings were stable across studies.
Practice Implications
People with depression and their clinicians might expect better outcomes in terms of depressive symptoms if they combine STPP and antidepressant medications, rather than receiving medications alone. The benefits might be related to the specific interventions of STPP, which suggests that therapists may need specific training and supervision in order to make the most of STPP’s effectiveness.
February 2021
The COVID-19 Telepsychology Revolution
The COVID-19 pandemic has changed many things in our lives – how we connect with loved ones, how we play, and how we work. The pandemic has also affected typical coping strategies like seeking social support to improve or maintain mental health. Not surprisingly then, COVID-19 and the public health measures enacted to reduce its transmission has altered how therapists and patients engage in psychotherapy. On the positive side, this revolution in how psychotherapy is provided could lead to increased access for some patients living in rural and remote areas, those with severe anxiety, or those with physical disabilities that impede their mobility. In addition, some regulatory bodies in American states have relaxed rules that restrict inter-state practice and strict privacy requirements so that psychotherapy may remain accessible to patients during these times. Prior to the pandemic only about 21% of psychologists ever used telepsychology in their clinical practices, and many reported significant challenges to using telepsychology in their workplaces. Clinicians were also skeptical of the utility of telepsychology and its potential to negatively impact the therapeutic relationship. In one pre-pandemic survey, 75% of psychologists were not willing to refer their patients to telepsychology. Has the pandemic changed current perceptions and future expectations of psychotherapists’ use of telepsychology? In this large survey of over 2100 American psychologists, Pierce and colleagues documented past, current, and future use of telepsychology. Before the pandemic, on average only 7.07% (SD = 14.86) of psychologists’ practices involved telepsychology. During the pandemic 85.53% (SD = 29.24) of psychologists’ practice was made up of telepsychology. This represents nearly a 12-fold increase. Psychologists projected that in the future, after the pandemic, 34.96% (SD = 28.35) of their practice would consist of telepsychology. That is, after the pandemic, almost all psychologists who responded (89.19%) plan to use some form of telepsychology in at least in one third of their clinical work.
Practice Implications
These survey results suggest that telepsychology may be here to stay, even after the pandemic. Psychotherapists however require training to use telepsychology effectively and to feel more effective in their use of the technology. This trend will increase access for some marginalized patients, and some therapists will likely want to maintain the convenience afforded by telepsychology (reduced overhead, less travel). Psychological providers and regulatory bodies will have to adapt to the new reality. With more use and experience may come more self-confidence and perhaps more relaxed regulatory restrictions on the use of telepsychology.
Causes and Consequences of Burnout in Mental Health Professionals
Burnout is characterized by emotional exhaustion (feeling overextended and depleted), depersonalization (negative and cynical attitudes, and distance in relationships with clients and work), and reduced feelings of personal accomplishment (negative self-evaluation). Recent meta-analyses show that between 20% and 40% of mental health professionals are experiencing burnout. And so, this is a pervasive problem that could affect therapists’ physical and mental health as well as their clients’ outcomes. In this narrative review, Yang and Hayes looked at 44 studies published since 2009 to understand the individual predictors and consequences of burnout among psychotherapists across all professions. Based on the research, they categorized predictors of therapist burnout into three areas: work factors, psychotherapist factors, and client factors. Work factors that the research associated with psychotherapist burnout included: job control (less control over the nature and quantity of work and on work conditions) work setting (working in an institutional setting, organizational inefficiency), job demands (higher workload and hours), and support (little support from colleagues and supervisors). Psychotherapist factors that research indicated are related to clinician burnout included: therapist history of mental health problems and trauma, countertransference (an emotional reaction to clients affected by one’s own personal dynamics), psychological distress, and low professional self-efficacy (low professional self-confidence). Client factors related to therapist burnout included having a caseload of working with many clients who have complex difficulties. The research also indicated the effects of burnout on psychotherapists. Burnout adversely affects both physical (gastrointestinal problems, sleep deprivation, back pain) and psychological (low mood, anxiety, secondary trauma) well-being of therapists. The findings also indicated that burn-out increased job dissatisfaction and turnover in the workplace. The effect of therapist burn-out on clients included reduced client engagement in the therapy process, and reduced client mental health outcomes. Poorer client engagement and outcomes are likely caused by therapist exhaustion, reduced energy, and self-protective withdrawal.
Practice Implications
Psychotherapists would do well to monitor continually their level of burnout and to identify strategies to mitigate its effects. Looking for emotional support from colleagues, supervisors, friends, and family are good coping strategies. Therapists should also be mindful not to overwork, seek psychotherapy for oneself, and maintain appropriate boundaries with clients. Peer supervision and consultation may go a long way to achieving support, and to working through and managing problematic countertransference that inevitably arises in ones work as a psychotherapist.
Social Support and Therapeutic Bond Interact to Predict Client Outcomes
Researchers have known for many years that the number of social supports and the size of a patient’s social network have a positive impact on patient outcomes in psychotherapy. Social supports reduce loneliness, and higher loneliness is an important cause of distress. Research has also demonstrated quite convincingly that the relationship in psychotherapy plays an important role in patient mental health outcomes. The therapeutic alliance, for example, is one of the most researched concepts in psychotherapy and shows a clear and positive association with client improvement across a number of theoretical orientations and client problems. The therapeutic alliance is the collaborative agreement between client and therapist on the tasks and goals of therapy, and also their relational bond. The bond includes trust, respect, and confidence in the therapist. This is important because aspects of mental health, like emotion regulation, develop partly in social and intimate relationships, including in the therapeutic relationship. If the therapeutic relationship works to reduce loneliness and improve emotion regulation, then a positive therapeutic relationship will be particularly important for clients with less social support. In this study, Zimmerman and colleagues examined if an extra-therapeutic factor (social support) interacted with an intra-therapeutic factor (therapeutic alliance) to predict client outcomes. Over 1200 adult clients were treated by 164 experienced therapists who were guided by CBT manuals. Patients received 42.77 sessions on average (SD = 19.97), social support was assessed at the start of treatment, and alliance and outcomes were monitored after every session. On average, clients improved throughout treatment. Clients who had more social supports and who reported a better bond with their therapist improved the most. Of particular interest was the interaction between social support and bond. Those clients with lower social supports benefitted more if they also had a good therapeutic bond, and clients with a good therapeutic bond did well regardless of their level of social support.
Practice Implications
Both extra-therapeutic social support and intra-therapeutic bond with the therapist uniquely contributed to better outcomes for clients. However, a good therapeutic bond with the therapist appears to be particularly important for all clients, especially those with low levels of social supports. Psychotherapists would do well to assess the level and quality of their clients’ social support. And in all cases, especially for clients with low social support, therapists should work to develop and maintain a supportive and trusting therapeutic bond with their clients.