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
January 2023
The Impact of COVID-19 on Mental Health Workers’ Well-Being
The COVID-19 pandemic has overwhelmed the health care system worldwide. Stressors on health care workers have included misinformation, rapidly changing knowledge of the virus, the politicization of mask wearing, high transmission rates, and high rates of patients requiring critical care. There has been much written about the impact of the pandemic on physicians and nurses caused by these factors. Much less attention has been paid to the experiences of mental health workers who had to rapidly transition to telehealth, which required immediate adaptations and learning with little training and preparation. In this qualitative study, Mittal and colleagues thematically analyzed text responses of 136 mental health professionals to questions about the impact of telehealth work during the pandemic on mental health and on clinical practice. The mental health professionals were from several disciplines (psychology, social work, counseling), most were women (84%), White (81%), with a mean age of 45.5 years. First, several themes emerged regarding providers’ mental health. Most indicated that their own experiences of exhaustion and stress were mirrored in their patients’ experiences, which made it harder to cope. Another common experience was “Zoom fatigue”, in which seeing clients online was more tiring, less enjoyable, and more isolating. Many also reported a decline in their physical health – that is, they experienced more headaches, trouble sleeping, poor appetite, and eye strain. Some reported a heightened sense of meaning in their work, such as a greater sense of pride and meaning derived from helping people during a particularly troubling time. Second, several themes were identified related to clinical practice. Practicing and living in the same space was particularly challenging for some - practicing from home while being responsible for other members of the household (children) was difficult and distracting. Many reported a decrease in work satisfaction and lower motivation, both of which impacted their level of empathy for and engagement with clients. Some reported positive effects especially related to having more time due to reduced commuting, and a greater sense of empathy for clients who felt isolated themselves.
Practice Implications
The COVID-19 pandemic and using telehealth for work required a significant shift in practice for mental health professionals. The shift meant important changes in how we practice and how we live our lives. And so, it is not surprising that mental health professionals’ well-being has been impacted by this transition and the challenges it poses. It is important to recognize the stressors related to telehealth work and to try to mitigate their impact. Some authors have suggested ways of reducing the negative impact of increased screen time on mental health providers, such as: taking breaks whenever possible, including 5 to 10 minutes between sessions; using previous “commute time” for self-care (social connection, physical activity); increasing social and professional connections with planned gatherings; and prioritizing self-care even more, including physical exercise and personal therapy.
Working Alliance and Therapist Cultural Humility Reduce the Impact of Microaggressions
A lack of culturally competent care can have negative impacts on therapy outcomes for Black, Indigenous, People of Color (BIPOC) and for women who experience discrimination based on gender. Often these negative outcomes occur because of microaggressions – which are a form of alliance rupture in the therapeutic relationship caused by subtle, intentional, or unintentional messages that degrade BIPOC, women, and other historically excluded groups. The majority of BIPOC clients (81%) and women (53%) report experiencing a therapist microaggression over the course of psychotherapy. A therapist’s cultural humility (valuing the importance of culture in their client’s experience) and the therapeutic alliance (client-therapist collaborative agreement on tasks and goals of therapy) may reduce the negative impact of microaggressions committed by the therapist. This study by DeBlaere and colleagues looked at the association between microaggressions experienced by BIPOC women and therapy outcomes, and whether this association was reduced by higher levels of therapist cultural humility and therapeutic alliance. The clients were 288 BIPOC women who were treated by a psychotherapist (81% had a female therapist, and 46% had a White therapist). Both racial and gender microaggressions were associated with worse outcomes. Using structural equation modeling to assess indirect effects, the authors found a significant indirect effect of racial microaggressions (−.12, 95% CI [−.35, −.07]) and gender microaggressions (−.10, 95% CI [−.36, −.05]) on positive therapy outcomes, through both cultural humility and working alliance, accounting for 24% of the variance in outcomes. That is, the effect of microaggressions on outcomes was partly explained by the level of therapist cultural humility and by the therapeutic alliance. The most common racial microaggression reported by clients was: “My counselor avoided discussing or addressing cultural issues in our sessions”, and the most common gender microaggression was: “My therapist encouraged me to be less assertive so that I do not present myself as being aggressive”.
Practice Implications
Unfortunately, therapist racial and gender microaggressions are common. However, therapists who practice cultural humility and who work at developing a therapeutic alliance may commit fewer microaggressions and can more easily mitigate the negative effects of microaggressions should they occur. Taking steps to develop cultural humility, strengthening the alliance, and repairing alliance ruptures through professional development may be ways of improving therapy outcomes for BIPOC women.
Ways to Address Cultural Topics in Psychotherapy
When ethnic minority members receive psychotherapy, they tend to show higher premature drop-out rates. One of the factors associated with these negative outcomes may be that therapists may not know how to effectively address the cultural conversations that inevitably arise with some clients. To help therapists, some authors developed a Multicultural Orientation Framework (MCO) that consists of cultural humility (taking an other-oriented stance regarding culture while remaining non-defensive about one’s own limitations), cultural opportunities (discussing clients’ cultural identities when they emerge in therapy), and cultural comfort (a therapist’s genuine comfort in discussing cultural topics). Such a stance may also help therapists to address microaggressions (intentional or unintentional verbal or behavioral indignities based on cultural identity). One useful therapist stance is “broaching” of culturally sensitive topics – that is, therapists’ engaging in explicit dialogue with clients about culture. Previous research indicates that broaching culturally topics can benefit the therapeutic alliance and clients’ perception of therapist multicultural competence. In this survey study, Depauw and colleagues looked at three aspects of broaching – direct broaching in which a therapist explicitly raises cultural topics (“I noticed that we both have a different ethnic background…), indirect broaching in which a therapist is receptive to cultural topics but with less focused exploration (“…you mentioned your friend doesn’t understand your experiences, are there other situations in which that happened…?”), and avoiding broaching in which a therapist sidesteps cultural conversations even when a client brings them up. Depauw and colleagues surveyed 211 psychotherapy clients in the United Kingdom who identified as not being a member of the predominant social group (i.e., with regard to ethnicity, gender/sexual expression, religion, socioeconomic status, ability, and others). The researchers asked whether therapists broached cultural identity topics, what type of broaching approach a therapist took, and clients also rated their therapist’s level of MCO (cultural comfort, cultural humility, and missed opportunities) and therapist microaggressions. The results revealed that both therapist direct and indirect broaching of cultural topics were favorably associated with a client’s rating of the therapist’s MCO and with fewer microaggressions. Therapists’ avoidance of broaching of cultural topics was associated with negative ratings of therapist MCO and with more microaggressions. When only considering the clients’ most important self-identified cultural identity, the researchers found that indirect broaching was favorably related to all aspects of MCO and fewer microaggression, direct broaching was only associated with fewer missed opportunities, and avoidant broaching was unfavorably related to all aspects of MCO and microaggressions.
Practice Implications
The results of this survey of clients suggest that therapists should not avoid cultural content in therapy. Broaching culturally sensitive topics is important for a good therapeutic experience for clients with diverse identities. In some cases, for clients’ primary cultural identity, indirect broaching of culturally sensitive topics may be more effective. Therapists should consider a client’s identity in terms of how the client experiences it and the importance of the identity to the client.
December 2022
Can Psychotherapists be Trained to Maintain a Therapeutic Alliance?
Tasca, G. A., Ravitz, P., Hunter, J., Chyurlia, L., Baker, S., Balfour, L., Mcquaid, N., Pain, C., Compare, A., Brugnera, A., & Leszcz, M. (2022, November 10). Training community-based psychotherapists to maintain a therapeutic alliance: A Psychotherapy Practice Research Network study. Psychotherapy. Advance online publication.
The therapeutic alliance refers to a collaborative agreement between therapist and patient on the tasks and goals of therapy, and their relational bond. Research demonstrates that the alliance is one of the most reliable predictors of patient outcome. Much of the research on the alliance focused on asking either the patient or the therapist to rate the alliance. But the alliance is a dyadic concept, that is, it involves the shared perceptions of the therapeutic relationship by patient and therapist. More recent research has focused on patient-therapist congruence (degree of agreement or disagreement) of their perceptions of the alliance. The Psychotherapy Practice Research Network (PPRNet) recently completed a study in which community-based psychotherapists were trained to develop and maintain a therapeutic alliance. We examined if trained therapists were more congruent with their patients’ experience of the alliance than untrained therapists, and whether congruence in alliance ratings in one session of therapy was associated with better outcomes in the following session. Forty community-based psychotherapists were randomly assigned to be trained to develop and maintain the alliance or to receive no training. Patients were 117 adults who were seen in their therapists’ community-based practices. Training focused on helping therapists to understand and be responsive to their own and their patient’s mental states (intentions, feelings, thoughts) to be better attuned to their patient’s experience of the therapeutic relationship. The training included workshops and ongoing case consultations to help the clinician to strengthen the therapeutic relationship with the use of mentalizing, attachment theory, countertransference management, and metacommunication. Therapeutic alliance and well-being outcomes were measured at each of six consecutive early psychotherapy sessions. The results indicated that compared to untrained therapists, trained therapists and their patients were significantly more congruent in their alliance ratings. Patient well-being outcomes improved in a session when trained therapists and their patients agreed in their positive alliance ratings in a previous session. This association was not significant among untrained therapists and their patients.
Practice Implications
This study suggests that therapists can be trained to be more attuned to their patients’ experience of the therapeutic relationship, and that this congruence may make the alliance a more potent change agent. Training may make therapists more sensitive to their patients’ experience of the alliance across sessions. Therapists should be particularly attentive to the state of the therapeutic alliance from session to session and to track their patients’ experience of the alliance using skills like mentalizing. The PPRNet has converted this training program into a virtual self-paced platform, and we will test this new format in a study starting in 2023. We encourage community-based clinicians to receive the free training by participating in this new study. For more information about the training and new study, email pprnet@uottawa.ca.
The Therapeutic Alliance in Child and Adolescent Psychotherapy
Roest, J.J., Welmers-Van de Poll, M.J., Van der Helm, G.H.P., Stams, G.J.J.M., & Hoeve, M. (2022). A three-level meta-analysis on the alliance-outcome association in child and adolescent psychotherapy. Research on Child and Adolescent Psychopathology.
Much of the research and writing about the therapeutic alliance has focused on adult individual psychotherapy. However, there have been several recent meta-analyses of the alliance-outcome association in child populations. In one meta-analysis of 28 studies, for example, the mean alliance-outcome correlation was r = .19, which represents a small but positive effect. Most of these previous meta-analyses only looked at alliance rated at one time point (usually early in therapy) rather than focusing on the growth in the alliance across sessions. These previous meta-analyses also did not investigate the effect of alliance agreement on treatment outcomes (i.e., whether therapist and child were congruent in their ratings of the alliance). In this meta-analysis by Roest and colleagues, the authors tried to parse out these various factors that might affect the alliance-outcome association in studies of child and adolescent psychotherapy. The authors included 99 studies representing 8,496 children and 3,442 parents. They found that associations between child-therapist alliance and child outcomes (r = .17), growth in child-therapist alliance across sessions and child outcomes (r = .19), and parent-therapist alliance and child outcomes (r = 0.13) tended to be positive but small. However, associations between child-therapist alliance agreement (i.e., their congruence in alliance ratings) and child outcomes (r = .21) and the association between parent-therapist alliance and parent outcomes (r = 0.24) were positive and moderately large.
Practice Implications
It appears that the therapeutic alliance plays a role in positive outcomes for child and adolescent patients. Overall, the effects seem to be small, indicating that developing a good alliance may have a modest effect on a child’s outcomes. A more important effect might be noted in the agreement or congruence between therapist and child or adolescent client on their experience of the alliance. That is, a therapist who is more attuned to their patient’s experience of the therapeutic relationship might promote better outcomes. Attunement might require therapists to accurately reflect on the child’s experience of the relationship and of the therapist. Mentalizing (understanding oneself and others in terms of intentions and mental states) may be a key skill to develop for a therapist who works with children and adolescents.
Adding Short-Term Psychodynamic Psychotherapy to Antidepressants
Driessen, E., Fokkema, M., Dekker, J.J.M., Peen, J., Van, H.L…. Cuijpers, P. (2022). Which patients benefit from adding short-term psychodynamic psychotherapy to antidepressants in the treatment of depression? A systematic review and meta-analysis of individual participant data. Psychological Medicine.
Short-term psychodynamic psychotherapy (STPP) and anti-depressant medications are both considered empirically supported treatments for depression. And there have been several trials demonstrating the efficacy of long-term psychoanalytic psychotherapy for treatment-resistant depression. Despite this research, it remains unclear which patient might benefit from anti-depressant medication alone and which patient might benefit from adding STPP to the antidepressants. The best use of scarce resources makes this an important question. There are challenges to doing a meta-analysis of patient characteristics that predict different outcomes in antidepressants alone versus antidepressants plus STPP. A key challenge is that common meta-analyses use study-level data (an overall summary of the effect size found in a study), and so statistical power often is limited by the small number of studies. The unique aspect of this study by Driessen and colleagues is that they conducted a meta-analysis of patient-level data. That is, they got individual patient data from the authors of the seven studies that specifically tested the effects of antidepressants alone vs antidepressants plus STPP. So instead of being limited by seven summary effect size statistics, the authors had a sample of 482 patient effect sizes to work with. The effect of adding STPP to antidepressants was larger for participants with high rather than low baseline depression scores [B = −0.49, 95% CI: −0.61 to −0.37, p < 0.0001], for participants with ⩽8 rather than more years of education (B = −0.66, 95% CI −1.05 to −0.27, p < 0.0009), and for participants with a depressive episode duration of >2 years rather than <1 year (B = −0.68, 95% CI −1.31 to −0.05, p = 0.03) or less than 1–2 years (B = −0.86, 95% CI −1.66 to −0.06, p = 0.04). At follow-up, higher baseline depression scores and longer depressive episode duration were still associated with better outcomes for those receiving a combination of antidepressants plus STPP.
Practice Implications
The results of this patient-level meta-analysis suggests that adding short-term psychodynamic psychotherapy to antidepressant medication might be particularly efficacious for patients with higher initial levels of depression and/or with longer duration of depressive symptoms. It is possible that the addition of a psychological treatment like STPP may tackle some of the underlying psychological vulnerabilities whose treatment is necessary for those who have more persistent and severe depressive symptoms.