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 adult depression, efficacy of CBT for perfectionism, and a measure of ruptures in the therapeutic alliance.
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
June 2023
What People Want From Therapy
Delboy, S. & Michaels, L. (2021). Going beneath the surface: What people want from therapy. Psychoanalytic Inquiry, 41:8, 603-623. DOI: 10.1080/07351690.2021.1992232
There has been an increased interest in and demand for mental health care, and so one can imagine that the public might have questions or opinions about psychotherapy. Moreover, research has shown that patients who get the type of treatment that they expect or want are more likely to have better outcomes. However, it is rare that researchers ask the public what they want from therapy. In this unique study, Delboy and Michaels conducted a survey of US citizens about their perceptions and preferences for psychotherapy. Their sample of 1,535 respondents were deliberately selected to be representative of US census data for age, gender, ethnicity, socioeconomic status, and geographic region. The survey asked what people what they wanted from therapy: 70% indicated that they wanted to “learning skills and coping strategies”, which is like what is offered in manualized treatment modalities. However, 70% also wanted to “better understand oneself and the root of one’s issues”, which is like what is offered in depth, insight, and relational therapies. When forced to choose between a “therapy that takes fewer sessions and helps manage symptoms” and a “therapy that takes longer but addresses the root causes of problems”, 91% chose a longer therapy focused on root causes. Over 60% of the sample indicated that they wanted to “share feelings without judgement” and to “feel heard and understood by someone who cares”, which suggests that people value these qualities in the therapist and the therapeutic relationship. Interestingly, two thirds of the sample recognized that therapy takes time “to understand and resolve” one’s issues and problems. And less than 10% did not want to understand their problems or examine issues from childhood. Regarding the reasons of their mental health issues, 50% reported that relationship patterns are an important source of their distress, whereas only 10% attributed mental health problems to a “chemical imbalance” in the brain.
Practice Implications
Patients tend to do better when they get the treatment that they prefer. A similar percentage of the public (70%) wanted to “learn coping strategies” and to “better understand” themselves. However, when asked to choose, the vast majority (91%) preferred to better understand themselves and to address the root causes of problems. In addition, most people recognized that therapy takes more time than is often offered in time limited treatments. This is consistent with large surveys of patients that indicated that it took over 50 sessions before significant symptom relief was achieved. It is time for insurance providers, clinicians, and training programs to begin to take stock of client preferences when paying for, providing, and training for psychotherapy.
Patient Experience of Lasting Negative Effects of Psychotherapy
McQuaid, A., Sanatinia, R., Farquharson, L. et al. (2021). Patient experience of lasting negative effects of psychological interventions for anxiety and depression in secondary mental health care services: A national cross-sectional study. BMC Psychiatry, 21, 578. https://doi.org/10.1186/s12888-021-03588-2
One in six adults experience either depression or anxiety that affect their social functioning or quality of life. Most treatment guidelines indicate psychotherapy as a first line treatment for these common mental health problems because of the positive effects of therapy documented by research. Despite the effectiveness of psychotherapies, researchers pay little attention to potential negative impacts of psychological treatments. Negative effects might include worsening of symptoms, emergence of new symptoms, loss of self-esteem, among others. National surveys in the U.K. noted that 5% of patients reported lasting negative effects from psychological treatment. People who had preferences for therapy that were not met tended to have more negative effects, and service policy constraints may also influence patients’ experiences of negative effects. In this analysis of national survey data, McQuaid and colleagues considered all patients who completed therapy during a one-year period in the National Health Service (NHS) in the U.K. These patients received treatment in a secondary care service – that is, a service for those with moderate to severe symptoms. The survey asked whether patients experienced lasting “bad” effects from the treatment, and the authors assessed several service policies and procedures as correlates of these negative experiences. Of those patients who received service, 662 (14.8%) responded to the survey. Overall, 14.1% reported “agreeing” that they experienced a lasting bad effect, and another 13.7% reported a “neutral” response to this item. The likelihood of reporting a neutral or lasting negative effect was greater among those who felt that they did not receive timely therapy (they waited too long, or it was too difficult to access services), who did not receive enough sessions of treatment (most of the therapy in the NHS is short-term), and whose therapists did not discuss the patient’s progress in therapy.
Practice Implications
This study is not perfect by any means, but it does highlight system and service issues that may result in worsening of symptoms among patients, especially those with moderate to severe symptoms. Remaining on a wait list for too long may lead to worsening symptoms – which indicates that it might be best for some patients to be referred elsewhere if it is feasible. Not providing a sufficient dose of therapy (enough sessions) may also lead patient symptoms to be worse at the end of treatment. The disappointment and frustration associated with ending therapy too early may impact patients’ self-esteem, mood, and hopes for recovery. Clinicians might consider how much therapy they can offer before proceeding with someone who has moderate to severe symptoms. Finally, therapists should have regular discussions with patients about their progress and perhaps use progress monitoring as a tool to facilitate these discussions.
March 2023
Capacity to Mentalize Predicted Outcomes in Inpatient Therapy for Resistant Depression
Halstensen, K., Gjestad, R., Luyten, P., Wampold, B., Granqvist, P., Stålsett, G., & Johnson, S. U. (2021). Depression and mentalizing: A psychodynamic therapy process study. Journal of Counseling Psychology, 68(6), 705–718.
Mentalizing, or reflective functioning, refers to someone’s capacity to view themselves and others in terms of mental states (i.e., behaviors are interpreted in terms of feelings, wishes, desires, values, and goals). This capacity underlies skills like empathy, emotion regulation, and interpersonal functioning. Diminished mentalizing can aggravate depressed mood through negative biases in one’s perceptions of others and relationships and might prevent the reflection needed to regulate emotions. Individuals with mentalizing deficits might hypo mentalize so that they are very uncertain about the thoughts, feelings, or attitudes that underlie their own and others’ behaviors. Such individuals may experience apathy associated with depression. Others might hyper mentalize, that is they are too certain about what goes on in the minds of others, which means they may misinterpret or misunderstand the intentions and behaviors of others. Such individuals can experience chronic emptiness due to the lack of genuine connection with others. In this study, Halstensen and colleagues assessed if mentalizing predicted outcomes in 57 patients with treatment resistant depression who received inpatient therapy in Norway. This was a naturalistic study of intensive psychodynamic inpatient therapy. The average chronicity of depression was 11.7 years, all patients received previous unsuccessful psychological or medical treatment, and most had a comorbid diagnosis (e.g., panic disorder, social anxiety disorder). Measurements of mentalizing and depression were taken pre-treatment, during therapy, and up to one year post treatment. Depressive symptoms improved from pre-treatment to one year follow-up with a large effect (d = 1.47; α mean = −.09 per week, p = .001). The capacity to mentalize did not improve on average during that period, although there was a lot of individual variability in mentalizing scores. Interestingly, there was an increase in depressive symptoms at the outset of treatment that then declined significantly by post-treatment. Higher pre-treatment levels of mentalizing were associated with better depressive symptom outcomes (b = −16.80, p = .043), and those patients who improved their mentalizing capacity experienced stronger improvements in depressive symptoms.
Practice Implications
Although all patients were severely and chronically depressed, their capacities to mentalize varied significantly (some had higher and others lower levels). Patients in this study who had a high initial level of mentalizing capacity profited most from the intensive therapy. They seemed to be able to engage in the emotional work associated with the initial phase of intensive inpatient treatment for depression. On the other hand, patients in this study who had low levels mentalizing skills were likely to be non-responsive to intensive treatment. Patients with limited mentalizing capacity may require more support and more work to help them develop the reflective capacities necessary to understand their own and others’ behaviors in terms mental states.
Negative Effects of Psychotherapy
Strauss, B., Gawlytta, R., Schleu, A., & Frenzl, D. (2021). Negative effects of psychotherapy: Estimating the prevalence in a random national sample. BJPsych Open, 7(6), E186.
The focus of psychotherapy research tends to be on establishing the effectiveness of psychotherapies for various disorders. Rarely do psychotherapy studies report negative effects or negative outcomes. Some researchers estimate that about 5% of patients experience worsening of symptoms by the end of psychotherapy. However, there are very few investigations of clients’ experiences of the negative impact of therapy and fewer still that ask clients in the general population who had a course of therapy. In this national survey of the general population, Strauss and colleagues asked 5562 individuals if they received psychotherapy in the past 6 years. Of the total sample, 244 indicated that they had or are currently in treatment. These individuals had characteristics similar to patients seen in treatment. The mean age was 55.1 years (SD = 15/2), 63.4% had shorter term therapy of less than a year, 41% reported an anxiety disorder and 77% had a mood disorder, 63.1% saw a female therapist, and 69.2% saw a psychologist. These individuals were asked a series of questions regarding their experiences as clients in therapy. Rates of positive change due to therapy varied by the problems that they noted. For example, 26.6% indicated that they had a better relationship with their parents due to therapy, whereas 67.7% experienced improved mood. On average 88.6% agreed that they had a positive working relationship with the therapist. However, about 19% dropped out of therapy and an additional 13.1% changed therapist during treatment, indicating negative experiences or outcomes. Patient problems that had the highest deterioration rates (i.e., worsened) were physical well-being (13.1%), ability to work (13.1%), vitality (11.1%), sexual problems (10.6%) and problems with self-esteem (10.3%). The most common negative effect attributed to specifically to the treatment was the resurfacing of unpleasant memories (57.8% in the total sample). Other such problems like sleep problems, stress, and unpleasant feelings were reported 27.9% to 36.9% of the time. Of the total sample, 56.6% reported having had at least one negative effect caused by their experience in psychotherapy. Boundary violations and malpractice were very rarely reported by this sample of patients.
Practice Implications
Much of the research and clinical writing of psychotherapy tends to focus on whether it is effective and to document its positive effects. However, an important minority of patients experience worsening of symptoms and/or unpleasant or negative effects of psychotherapy. Some might argue that painful feelings that emerge in some clients is a necessary process when the client works through conflicting feelings or perceptions of themselves and others. A collaborative agreement between therapist and client on how therapy might proceed, how it works, or the goals of therapy will go a long way to limit the negative impact of working through unpleasant feelings in therapy. Nevertheless, therapists should monitor dropout rates in their practice and worsening symptoms in their clients and adjust their therapy and interpersonal stances accordingly.
January 2023
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.