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
Emotional Experiences of Psychotherapists
Chui, H., & Liu, F. (2021). Emotional experience of psychotherapists: A latent profile analysis. Psychotherapy, 58(3), 401–413.
Working with client emotional experiences in therapy is a core aspect of the psychotherapist’s work, regardless of their theoretical orientation. And so, therapists’ performance and their own well-being may be impacted by their capacity to experience and regulate their own emotions. Emotional reactivity refers to one’s sensitivity, intensity, and duration of emotional experience. Emotion regulation refers to the capacity to manage and express emotions and may be considered an interpersonal competency for therapists. Such competency likely involves flexible expression of emotion and a capacity for empathy. A better understanding of how therapists experience emotions might inform therapists’ use of empathy to facilitate their work with clients. In this study, Chui and Liu surveyed 314 English speaking and 589 Chinese speaking psychotherapists and asked them about their experiences of emotional reactivity, their emotion regulation, and empathy. Their data allowed them to develop profiles of psychotherapists along dimensions of emotional experience. Three latent profiles emerged in both the English and Chinese speaking samples of therapists. The highest proportion of English-speaking therapists (58%) were categorized as “Calm Regulators”, which indicated therapists with low emotional reactivity and few problems with emotion regulation. Next, 34.4% of English-speaking therapists were characterized as “Moderate Experiencers”, and 7.6% were “Emotional Feelers”. The latter profile included therapists who were emotionally over-reactive and who had greatest difficulty with regulating their emotions. As one might expect, those with the Calm Regulator profile had higher capacity for perspective taking, higher empathic concern, and lower personal distress than therapists in the other profiles. Also, therapists who were older, with more education, female, and with a psychodynamic orientation were more likely to have the Calm Regulator profile. Results were remarkably similar in the Chinese speaking sample, in which Calm Regulators also reported higher levels of counsellor self-efficacy.
Therapists with the “Emotional Feelers” profile (i.e., that have higher levels of emotional reactivity and more difficulty regulating their emotions) may be at higher risk of burnout and of being less effective in their work. As a profession we often discuss clients’ individual differences in emotional experience and emotion regulation, but we spend less time considering these important interpersonal competencies in therapists. Recent surveys suggest that almost 50% of therapists may be at high risk of mental health problems. Psychotherapists, trainers, and supervisors need to pay more attention to therapists’ capacity to regulate their emotions, and its impact on their capacity to be emotionally flexible and empathic with clients. Therapists might consider personal therapy as a means of building this capacity.
Jackson, D., Farber, B.A., & Mandavia, A. (2021): The nature, motives, and perceived consequences of therapist dishonesty. Psychotherapy Research, DOI: 10.1080/10503307.2021.1933241
There is very little research or writing about therapist dishonesty with clients. Psychotherapy relies on clients to be honest to establish a therapeutic alliance – but what about therapists? Honesty is different from therapist self-disclosure. Self-disclosure refers to private information that therapists may or may not choose to share about themselves. Dishonesty, on the other hand are words or behaviors that are meant to deceive or mislead. Dishonesty can be covert (implying something that was not completely true) or overt (deliberately providing misleading information). Therapists might justify dishonesty as being carried out to protect their clients from harmful information, although some lying might be done by therapists to protect their own self esteem. In this survey of over 400 psychotherapists, Jackson and colleagues examined the topics, frequency, and some reasons why therapists were dishonest with clients. The therapists who responded to the survey had similar demographics to those practicing in the United States. They were on average 46.25 (SD = 15.59) years old, female (72.8%), mostly White (83.3%), working in private practice (62.6%), with an average of 16.48 (SD = 12.66) years of experience, and working from a range of theoretical orientations. The top reasons for therapist covert dishonesty included lying about feeling emotionally or physically unwell, feeling frustrated or bored with the client, or liking the client. The top reasons for therapist overt dishonesty included lying about feeling emotionally unwell, not remembering something a client said in a previous session, appointment availability, not having had conversations about the client with others, and not paying attention during a session. Over 91% of therapists indicated that they at least once gave the impression of paying attention when they were not, 88% implied they were not available for a session when they were, over 85% gave the impression that a client was making progress when they were not, 84% indicated they gave the false impression about a reason for being late to a session, and 65% at least once explicitly told a client something untrue about their own mental health history. Less than 1% of therapists reported that they were never dishonest with a client. Despite almost all therapists reporting being dishonest on occasion, therapist dishonesty tends to be relatively infrequent.
Most of the time, if a therapist is dishonest with a client it is motivated by the consideration of a client’s best interest. On the one hand, therapists should be tactful by keeping in mind the needs and wellbeing of each client when considering what to disclose. However, research on therapist self-disclosure indicates that clients are more likely to disclose information if the therapist is honest about themselves. And some clinical writers suggest that therapists’ attempts to conceal negative feelings is an unproductive strategy that steers therapists and clients away from difficult conversations that might deepen the therapeutic relationship. As a general principle, therapists must consider whether the covert or overt dishonesty is truly in the service of the client or whether it is to protect the therapist’s self-esteem by not acknowledging their own missteps or limitations.
Psychotherapies are Less Effective for Black Youth Who Live in Communities with Higher Anti-Black Racism.
Price, M.A., Weisz, J.R., McKetta, S., Hollinsaid, N.L., Lattanner, M.R., Reid, A.E., Hatzenbuehler, M.L. (2021). Meta-analysis: Are psychotherapies less effective for Black youth in communities with higher levels of anti-Black racism? Journal of the American Academy of Child & Adolescent Psychiatry.
Racism is a system in which racial groups are ranked, devalued, and provided limited opportunities and resources. Individual racism refers to how individuals of stigmatized groups respond to racism (self-devaluation, hopelessness), interpersonal racism refers to how people discriminate or mistreat others based on race, and structural or cultural racism refers to collective beliefs regarding racial groups that become enacted by larger social systems and institutions. Historically, health research on the negative effects of racism has focused on interpersonal racism. More recently, research has studied the association between structural or cultural racism and adverse health outcomes. Few studies have examined the effects of cultural racism on mental health outcomes especially among Black youth. In this meta-analysis, Price and colleagues identified 194 studies across 34 US states. They measured anti-Black cultural racism by analyzing publicly available surveys that tapped into racism. The authors statistically aggregated the scores for each US state thus providing a cultural racism score for each state. The authors categorized the 194 studies according to the composition of race of its participants, such that studies had either majority-White samples (k = 158) or majority-Black samples (k = 36). To examine the independent effect of state-level cultural racism, the authors also controlled for several confounding variables in their analyses (state-level White or Black population density, state poverty rate). Higher anti-Black racism at the state level was associated with lower effects of psychotherapy in studies in which most of the youth were Black (β = -0.20, 95% CI: -0.35, -0.04, p = .02). However, the effect of cultural racism was unrelated to the effects of psychotherapy in studies in which most of the youth were White (β = 0.0004, 95% CI: -0.03, 0.03, p = .98). The standardized effect sizes in states with the highest anti-Black racism (g = 0.19) were significantly lower than in states with the lowest racism (g = .60). A concerning finding was that the differences between low and high racism states widened at follow-up, indicating that cultural racism eroded some of the gains made by Black youth in high racism states.
Researchers have long known the negative health disparities related to racism, but this is the first study to evaluate the effects of cultural racism on the effects of psychotherapy. This meta-analysis indicates that anti-Black cultural racism reduced psychotherapy effectiveness for Black youth, and some gains tended to decline at follow up. Psychotherapists should consider modifying their treatments for Black youth to derive most benefit and to adopt a multicultural orientation. Nevertheless, stigma and racism have negative effects at multiple levels that require structural and community interventions to target racism at its source.
Can Therapists Identify Racial Microaggressions?
Owen, J., Drinane, J. M., Tao, K. W., DasGupta, D. R., Zhang, Y. S. D., & Adelson, J. (2018). An experimental test of microaggression detection in psychotherapy: Therapist multicultural orientation. Professional Psychology: Research and Practice, 49(1), 9–21.
Microaggressions are covert or subtle expressions of racist actions that include micro-insults (pathologizing cultural values), micro-invalidations (assuming that patients from a racial-ethnic minority [REM] are too sensitive about race), and micro-assaults (blatant racism not in the presence of someone of that race). Previous research showed that 53% to 81% of patients from a REM experienced at least one microaggression from their therapist. Most commonly therapists might minimize cultural issues or subtly express a racial stereotype. Those same studies found that microaggressions were related to worse therapeutic alliance and patient outcomes. Microaggressions are a form of therapeutic alliance rupture that is common in psychotherapy. Of the patients who experienced a microaggression, only 24% indicated that the microaggression was addressed by the therapist. However almost all of those for whom the microaggression was addressed felt that the microaggression was resolved. For therapists to resolve a rupture caused by a microaggression, they first must identify a microaggression. In this study, Owen and colleagues recruited 68 psychotherapists (mostly White women of about 30 years of age) and divided them into two groups. One group viewed a simulated therapy video with three types of microaggressions committed by the therapist. The other group saw a video of a therapy session in which there were no microaggressions. In both videos the therapist was a White woman in her late 30s and the patient was a Hispanic man in his late 20s. Therapist participants who viewed the microaggression video reported significantly more insensitive comments by the therapist in the video than those who viewed the neutral video. However, only 38% to 51% of therapist participants identified a microaggression in the video, and less than 25% identified 2 or 3 microaggressions that occurred.
The study suggests that therapists can identify when a session includes culturally insensitive interactions. However, therapists were not able to identify almost half of microaggressions when they occurred. This in part may explain why microaggressions often go undetected and unrepaired. The authors admitted that we know very little about what goes on for therapists in these moments – are they anxious about what happened, are they unsure of how to repair the microaggression? The results of this and other studies indicate that therapists should take on a multicultural orientation that includes cultural humility (curiosity and a non-superior approach), responding to cultural opportunities (explore when cultural content is presented), and cultural comfort (ease and calmness related to another’s culture and race).
Patients Crying in Psychotherapy
Genova, F., Zingaretti, P., Gazzillo, F., Tanzilli, A., Lingiardi, V., Katz, M., & Hilsenroth, M. (2021). Patients’ crying experiences in psychotherapy and relationship with working alliance, therapeutic change and attachment styles. Psychotherapy, 58(1), 160–171.
Crying often reflects deep feeling and may play a role in the expression of these feelings. In psychotherapy, crying may be an important experience in helping patients to experience and express their emotions. In previous research, patients who had a strong therapeutic alliance with their therapist also felt that crying allowed them to communicate feelings that they could not express verbally. Researchers also report that patients cry in 14% to 21% of sessions, and that crying may be an indicator of healing when it is assisted by therapist interventions. In this study, Genova and colleagues explored the association between patients’ crying during therapy and the therapeutic alliance and therapeutic change. In a survey, 106 adult patients (mean age = 30.94 years, SD = 8.74) were asked to complete several questionnaires about crying in therapy, crying in their lives in general, the therapeutic alliance, and their outcomes in therapy. Of all patients, 83% reported crying at least once in therapy, suggesting that patient crying during therapy is a common event. Most patients (67.4%) talked to their therapist about crying. Many patients reported negative feelings like sadness (53.5%), frustration (38.4%), or powerlessness (28.2%) after crying in therapy. However, other patients also reported positive feels after crying like relief (45.3%), feeling emotionally touched (34.1%), or a sense of warmth (24.7%). Some patients (41.9%) reported that crying in therapy improved their relationship with their therapist, and no patient reported that crying worsened their therapeutic relationship. There was a significant positive correlation between feeling relieved after crying and the therapeutic alliance (r = .29), but a significant negative correlation between feeling depressed after crying and the therapeutic alliance (r = -.30). Positive feelings after crying were also associated with patient rated improvement in therapy (r = .29 to r = .34). However, negative feelings, such as more tension after crying, were related to poorer outcomes (r = -.27).
When patients and therapists have a strong therapeutic alliance (collaborative agreement on the goals and tasks of therapy, and a relational bond), patients experience their crying as a useful event to resolve negative feelings. This is especially true when crying leads to greater awareness and new realizations and when the therapist is supportive. It is critical for therapists to explore their patients’ crying in therapy as it represents an opportunity to deepen the therapeutic relationship and the patient’s self-awareness and self-efficacy.
Disclosure of Suicidal Thoughts and Behaviors in Psychotherapy
Love, H. A., & Morgan, P. C. (2021, March 18). You Can Tell Me Anything: Disclosure of Suicidal Thoughts and Behaviors in Psychotherapy. Psychotherapy. Advance online publication.
Only about half of people who die by suicide each year disclose their thoughts or behaviors to another person before their death. And many times, those with suicidal ideation do not disclose to their therapist. There is very little known about why patients do or do not disclose their suicidal thoughts or behaviors to their therapists. This qualitative study by Love and Morgan takes a unique approach to identifying themes that lead to patient disclosure or non-disclosure of suicidal thoughts and behaviors to psychotherapists. The authors distributed a survey online to those currently in psychotherapy and who have had suicidal thoughts. Sixty-eight current patients with suicidal thoughts responded to questions about their experience with disclosing or not disclosing to their therapists. On average, participants were 26.78 years old (SD = 7.25), mostly white and female. Half of the patients disclosed, and half did not disclose to their therapist, and most of those who did not disclose to their therapist (77.4%) also did not disclose to others in their lives. The authors did a qualitative analysis of the text responses to identify major themes. The main theme for not disclosing was the fear of negative outcomes. This included involuntary hospitalization, fear of their therapist’s judgment, and overall lack of trust in the therapist. The main themes for disclosing included a desire to receive the best possible care, trust in the therapist, and perception that the therapist was honest about policies regarding suicidal thoughts and behaviors including reporting procedures. Patients’ experience of the disclosure event itself was affected by several factors. Patients experienced the therapist as supportive of the disclosure when the therapist was empathic, nonjudgmental, and normalized suicidal thoughts. Supportive therapists did not minimize suicidal thoughts, but they did address it directly. A positive and supportive therapist response played a large role in the experience of the disclosure process. Not surprisingly, patients who perceived greater therapist support indicated greater satisfaction in the therapist’s response.
A strong therapeutic alliance that includes a collaborative approach to determining safety planning and crisis management is key to promoting disclosure of suicidal thoughts and behaviors and to a positive experience for clients. Patients who can describe what influences their suicidal thoughts in a safe and empathic therapeutic environment are in a good position to deal with the suicidal urges. Involuntary hospitalization emerged as an important fear because of the loss of autonomy, loss of connection, and hopelessness that it might create. And so, such action, when necessary, should be done as carefully as possible to avoid creating a lack of trust in future care and disclosures. A clear, straightforward, and empathic discussion of the circumstances around suicidal thoughts, and an open discussion of safety and contingency plans is critical to conserve the patient’s trust in the therapist and therapeutic relationship.