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.
…I blog about psychotherapy for borderline personality disorder, capacity to metnalize and therapy resistant depression, and negative effects of psychotherapy
Type of Research
- ALL Topics (clear)
- Alliance and Therapeutic Relationship
- Anxiety Disorders
- Attendance, Attrition, and Drop-Out
- Client Factors
- Client Preferences
- Cognitive Therapy (CT) and Cognitive-Behavioural Therapy (CBT)
- Combination Therapy
- Common Factors
- Depression and Depressive Symptoms
- Efficacy of Treatments
- Feedback and Progress Monitoring
- Group Psychotherapy
- Illness and Medical Comorbidities
- Interpersonal Psychotherapy (IPT)
- Long-term Outcomes
- 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
- Therapist Factors
- Transference and Countertransference
- Trauma and/or PTSD
- Treatment Length and Frequency
How to Reduce Premature Termination in Your Psychotherapy Practice
Swift, J.K., Greenberg, R.P., Whipple, J.L., & Kominiak, N. (2012). Practice recommendations for reducing premature termination in therapy. Professional Psychology, 43, 379-387.
As discussed in a previous blog entry, Swift and Greenberg (2012) found that almost 20% of adult individual therapy patients drop out of therapy. Dropping out is generally defined as clients unilaterally terminating psychotherapy prior to benefitting fully and against their therapist recommendation. In this paper, Swift and colleagues review five methods with the best research evidence to reduce premature termination. (1) Providing education about duration and course of therapy. Research indicates that 25% of clients expect to recover after only two sessions of therapy, 44% after four sessions, and 62% expect to recover after 8 sessions. However the research literature indicates that it takes 13 to 18 sessions for 50% of clients to recover. Further, although some clients improve quickly and maintain that, some clients may feel worse before they get better, especially if the symptoms are related to painful feelings or events. So aligning client expectations about the length of treatment and the course of treatment may reduce dropping out. This education should be research based to increase the credibility of the information. (2) Providing role induction. Clients who are naıve to therapy may start not knowing what behaviors or roles are most appropriate on their part and could feel lost or like they are doing things wrong. Role induction refers to providing clients with some pre-treatment education or orientation about appropriate therapy behaviors. This could be done by video, verbally, or in writing. A meta analysis found that pre-therapy role induction increases attendance and reduces drop outs. (3) Incorporating client preferences. Client preferences include wants or desires concerning the type of treatment that is to be used, the type of therapist one would like to work with, and the roles and behaviors that are to take place in therapy. A recent meta analysis found that clients who had their preferences accommodated were almost half as likely to drop out of treatment prematurely compared with clients whose preferences were not taken into account. (4) Strengthening early hope. Although it is important that clients do not hold unrealistic expectations (i.e., recovery after only two sessions), it is also important that they have a general hope that therapy can help them get better. Research evidence shows that expectations for change explain as much as 15% of the variance in therapy outcomes. (5) Fostering the therapeutic alliance. The therapeutic alliance involves agreeing on goals and tasks of therapy, and a positive bond between client and therapist. A rupture in the alliance has been associated with dropping out of therapy, and a previous meta analysis found that a stronger alliance was associated with fewer drop outs.
Therapists can do 5 things that are research supported to reduce patient drop outs. (1) Provide education about duration and course of therapy. Practicing clinicians can help their clients to develop realistic expectations about duration and recovery prior to the start of therapy. Clinicians working with a more severely disturbed population or working from an orientation that espouses longer treatment durations may want to alter the education they provide to better fit their clients. (2) Provide role induction. Clinicians can provide education about the “jobs” of both the client and the therapist, such as who is expected to do most of the talking and who will be responsible for structuring or directing sessions. This type of induction should also include a discussion of the rationale for the approach that will be used. (3) Incorporate client preferences. Accommodating client preferences does not mean the therapist should automatically use the client’s preferred methods. Often clients are unaware of what treatment options are available or best suited for their particular problems. Instead, therapists should consider sharing their knowledge about the particular disorder and the nature of different approaches to the treatment of those problems with clients. Clients can then share their preferences regarding those treatment options with the therapist and work collaboratively toward a decision about which approach might be best. (4) Strengthen early hope. Therapists should express confidence that the therapy will work for their patient. Knowing the research evidence on the efficacy of psychotherapy will increase the therapist’s credibility in making such statements. (5) Foster a therapeutic alliance. Efforts to foster the therapeutic alliance should occur early on in therapy when the risk of premature termination is high, and as also therapy progresses. Early efforts should focus on making sure there is an agreement on the goals and tasks before jumping to treatment interventions.
Author email: Joshua.Keith.Swift@gmail.com
Do Therapists Cry in Psychotherapy?
Blume-Marcovici, A. C., Stolberg, R. A., & Khademi, M. (2013). Do therapists cry in therapy? The role of experience and other factors in therapists' tears. Psychotherapy. Advance online publication. doi:10.1037/a0031384
There is almost no research on therapists crying during psychotherapy, and on its correlates and impact. A survey of therapists’ ethical behavior conducted 25 years ago asked a single question about crying, and 56.5% of respondents indicated that they cried in the presence of a client. By contrast there are several such surveys in medicine. Notably, a study of medical students and interns found that 68% medical students and 74% of medical interns had cried with patients. A recent survey by Blume-Marcovici and colleagues is the first of its kind since it was devoted to therapists crying in therapy and associated factors. They defined crying as: “tears in one’s eyes due to emotional reasons”. The authors surveyed U.S. psychologists and had 541 respondents. The sample included 59% graduate students, and 41% licensed clinicians who had an average of 9.6 years experience. Seventy six percent were women, mean age was 36 years, 35% had a cognitive behavioural therapy (CBT) orientation, and 33% had some psychodynamic orientation (PDT). Respondents reported that 72% had cried in therapy. Those who cried reported crying in 6.6% of their sessions in the past 4 weeks. There were no differences between men and women, and there was no association between therapist crying and therapist personality traits or level of empathy. Therapists who cried more often in their daily life tended to cry more in therapy. PDT and CBT therapists did not differ in the amount they cried in their daily lives, however PDT therapists (88.9%) reported crying more often than CBT therapists (50.1%) in therapy. Further, older and more experienced therapists reported crying more often in therapy in the past month than younger and less experienced therapists. It is possible that older therapists may become more comfortable in using their clinical judgment, and so have fewer restrictions on their own affective displays. Of therapists who cried, 45.7% felt that the therapeutic relationship improved, and 1% reported that the relationship deteriorated due to crying. Patients, however, were not surveyed for their opinion about their therapist’s crying.
Crying among therapists may happen relatively frequently. Although this study is novel, it is the only one of its kind so one should be cautious about drawing practice implication. The challenge of therapists crying in therapy is that it can bend or break the therapeutic frame (e.g., is the therapist crying because of being overwhelmed and acting on his or her own needs, or is the therapist genuinely responding for and with the patient?). The survey suggests that therapist crying can strengthen the therapeutic relationship. This is more likely true when the therapist is attuned to the patient’s needs, and when the crying signals a moment of positive emotional connection in the midst of painful feelings in the client. As with any event in therapy, a genuine and skilful exploration by the therapist and patient of the therapist’s crying has the potential to strengthen the relationship.
Author email: email@example.com