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 therapist variables leading to poor outcomes, aspects of the therapeutic relationship and outcomes, and psychological therapies and patient quality of life.
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
May 2023
Multiple Microaggressions and Therapy Outcomes
DeBlaere, C., Zelaya, D. G., Dean, J.-A. B., Chadwick, C. N., Davis, D. E., Hook, J. N., & Owen, J. (2023). Multiple microaggressions and therapy outcomes: The indirect effects of cultural humility and working alliance with Black, Indigenous, women of color clients. Professional Psychology: Research and Practice, 54(2), 115–124. https://doi.org/10.1037/pro0000497
Many Black, Indigenous, Women of Color (BIWOC) underutilize mental health care partly because of lack of culturally competent care, and the anticipation of bias and discrimination often experienced by Black, Indigenous, People of Color (BIPOC). One way that such bias and discrimination is expressed in a therapy context is through racial microaggressions which are subtle, intentional, or unintentional messages that degrade BIPOC. Another way that bias and discrimination is expressed is through gender microaggressions which are intentional or unintentional behaviors that exclude, demean, oppress, or express indifference towards women. Research indicates that up to 89% of BIPOC clients and 53% of women experienced a microaggression from their therapist. Both racial and gender microaggressions committed by therapists are related to poorer therapeutic alliance and client outcomes. One might also consider BIWOC clients to be doubly susceptible to microaggressions due the intersecting nature of their identities as a person of color and as a woman. One way to limit the effects of microaggressions is for therapists to take a stance of cultural humility and to foster a therapeutic alliance. Cultural humility refers to a therapist’s way of being with a client that values the importance of culture in the client’s experience. In this study by DeBlaere and colleagues, the authors surveyed 288 BIWOC clients who were currently or recently in psychotherapy to assess the association between microaggressions and outcomes, and whether cultural humility and a therapeutic alliance might reduce the impact of microaggressions. The clients saw a female therapist 81% of the time and a White therapist 46% of the time. DeBlaere and colleagues found that 89% of the sample reported at least one instance of a racial microaggression by their therapist, and 43% reported some form of gender microaggression. White and male therapists were more likely to commit these microaggressions. The most common racial microaggression involved therapists avoiding discussing or addressing cultural issues, and the most common gender microaggression involved therapists encouraging female clients to be less assertive so that the client might not appear aggressive. Racial and gender microaggressions were both negatively related to therapy outcomes. The authors also found that cultural humility and therapeutic alliance both mediated and helped to explain the effects of microaggressions on outcomes. That is, the negative effects of a racial or gender microaggression on outcomes were reduced when the client experienced the therapist as having a higher level of cultural humility, which then led to a stronger therapeutic alliance, that in turn led to a better outcome.
Practice Implications
This study points to the potential of therapist cultural humility and their capacity to maintain a therapeutic alliance as key to reducing the impact of racial and gender microaggressions on client outcomes. The findings reinforce the importance of therapists examining their own cultural biases and making discussions of culture and racism explicit in therapy. This is especially important for White male therapists. Such a process might cultivate cultural humility in the therapist that will mitigate the negative impact of a microaggression should it occur.
Interpretations and Outcomes: A Systematic Review
Zilcha-Mano, S., Fisher, H., Dolev-Amit, T., Keefe, J. R., & Barber, J. P. (2023). A systematic review of the association between interpretations and immediate, intermediate, and distal outcomes. Psychotherapy. Advance online publication. https://doi.org/10.1037/pst0000479
Interpretation is a therapeutic technique that refers to a psychotherapist who recognizes and seeks to raise the patient’s awareness and understanding of recurrent maladaptive patterns. An interpretation goes beyond what the patient says or recognizes consciously and gives a new meaning or explanation for behaviours, thoughts, or feelings so that the patient sees their problems in a new way. In other words, the effect of an interpretation is to raise a patient’s insight into their problems. Interpretation is a transtheoretical technique, although it is often associated with psychodynamic therapies. Some interpretations are interpersonal in nature (focused on maladaptive relationship patterns inside and outside of the therapeutic relationship), and some are intrapersonal in nature (e.g., focused on the conflict between ones wishes/desires and how one ideally sees oneself). In this systematic review of the research on interpretation, Zilcha-Mano and colleagues included 18 studies that tested the association between interpretation and outcomes. Previous reviews found a mixed association between interpretation and outcomes possibly because of the different methods of assessing interpretation and different way of conceptualizing outcomes. What is unique about this review is that it categorized outcomes as immediate (e.g., in-session alliance, disclosure, emotional expression), intermediate (e.g., next-session alliance strength, session depth), and distal (e.g., change in symptoms from pre- to post-treatment). Since there were so few studies in each of these outcome categories (6 studies of immediate, 4 studies of intermediate, and 12 studies of distal outcomes), the authors did not conduct a meta-analysis, but rather counted studies that supported or did not support the use of interpretation for each of these categories of outcomes. For immediate outcomes, half of the studies reported a positive association with interpretation (whereas half of studies showed a neutral or negative association). That is, on average patients in those studies tended to react positively to therapist interpretations during the session with increased therapeutic alliance or emotional processing. For intermediate outcomes, half the studies reported a positive association with interpretation (as opposed to neutral or negative association). That is, on average the results suggested that interpretation in in a previous session was associated with patients experiencing a better alliance and session depth in the subsequent session. For distal outcomes, there was mixed evidence with most studies reporting a neutral effect of interpretation on pre- to post-symptom change.
Practice Implications
It is challenging to draw explicit practice implications from a research area that is complex and not yet large enough to allow for a meta-analysis. However, using a mixture of these research findings and clinical experience, Zilcha-Mano and colleagues suggest some therapeutic practices that may be helpful. They suggest, for example that therapists (1) observe the immediate and intermediate outcomes of an interpretation (i.e., does the patient rejected it or does it deepen the therapeutic work?), (2) check with patients about how they feel about the interpretation, (3) prioritize accurate and experience-near interpretation (those that the patient can immediately recognize and understand), (4) monitor the strength of the alliance before, during, and after an interpretation, (5) consider that an interpretation may be more beneficial for patients with poorer quality of relationships and self-concepts than for those with better relationship and self-functioning, and (6) be aware that interpretations may not be beneficial and could be harmful if delivered at the wrong time or if not attuned to the patient’s needs and capacities
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.
October 2022
Therapists Report Less Therapeutic Skill in Telepsychology vs In Person Therapy
Lin, T., Stone, S. J., Heckman, T. G., & Anderson, T. (2021). Zoom-in to zone-out: Therapists report less therapeutic skill in telepsychology versus face-to-face therapy during the COVID-19 pandemic. Psychotherapy, 58, 449–459.
The COVID-19 pandemic has confronted psychotherapists with several challenges including rapidly switching their practice to using teletherapy (videoconferencing, phone, and other virtual media). The use of teletherapy in clinical work increased from 7.1% prior to the pandemic to 85.5% during the pandemic. And estimates suggest that at least one-third of clinical work will be performed by teletherapy post-pandemic. Over a third of psychologists reported that they lacked training in using teletherapy, and they believe that their skills in this domain are inadequate. Therapists have raised a number of concerns in past surveys including issues related to privacy, professional self-doubt, technological competence, challenges to the therapeutic relationship, and problems with implementing some interventions. In this survey of 440 therapists and trainees, Lin and colleagues were particularly interested in therapists’ perceptions of the impact of teletherapy relative to in person therapy on the therapeutic process and patient outcomes. Videoconferencing was the most frequently used modality by 73.56% of surveyed therapists. The survey asked if three broad areas of practice were affected by teletherapy compared to in person therapy. These areas included common therapeutic factors (level of therapist empathy, emotional expression, warmth, alliance bond), extra-therapeutic patient factors (the patient’s environment that impacted their ability to engage in homework or use prescribed resources), and perceived patient outcomes (therapist ratings of patient symptom reduction, satisfaction, clinical improvement). Therapists in the survey were representative of the population of therapists in the US, and 82% of them provided all their clinical work in recent months by teletherapy. Compared to in person therapy, therapists reported poorer skills related to common therapeutic factors (d = 0.86), somewhat greater impact of extra-therapeutic factors (d = 0.36), and perceived poorer patient outcomes (d = 0.68) in teletherapy. Therapists who were younger, preferred emotion-focused or relational therapies, and with no prior training reported a relatively greater decrease in therapeutic skills in teletherapy compared to in-person therapy.
Practice Implications
By far, most therapists believed that providing psychotherapy by virtual means reduced their capacity to use common therapeutic stances including empathy, warmth, and the therapeutic alliance. Some of this might be affected by the psychological distance caused by the virtual format and difficulties with reading body language and other non-verbal cues. Therapists perceived that patient outcomes suffered as a result. This was particularly true for younger therapists, possibly because of the impact of adopting the new modality on their professional self-confidence. Also, therapists who preferred experiential or interpersonally based therapies felt particularly challenged possibly because these therapies may be more reliant on emotional communication and discerning patient interpersonal behaviors. Training and support are needed for therapists and trainees to improve their confidence in providing teletherapy.
May 2022
Do Psychotherapists Get Better with Experience and Training?
Wampold, B. & Owen, J. (2021). Therapist effects: History, methods, magnitude, and characteristics of effective therapists. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7th ed.). Wiley. Chapter 9.
One of the defining characteristics of expertise is the overall improvement in skills and performance over the course of one’s career. We can identify, for example, that there are experts in chess, tennis, surgery, and musical performance based on performance. Expertise in these areas is explicitly developed partly because there is clear and immediate feedback regarding performance (i.e., a tennis player knows immediately that they missed a serve, and so they make an adjustment on the next serve). In psychotherapy, this is not so easy. Therapists rarely receive immediate feedback about their specific interventions or interpersonal responsiveness to a patient. In this part of the chapter, Wampold and Owen review the research on the relationship between therapist experience and training and patient outcomes. They focus on high quality studies that disentangled therapist from patient effects. Overall, the evidence does not support the notion that the more experience that a therapist accumulates the better their patients’ outcomes. In fact, one study that tracked therapists over time (up to 18 years) found that patients’ outcomes got slightly worse with more experience. Similar findings occur for training of student therapists. For the most part, more training that student therapists received over a 12-to-42-month period was not associated with better patient outcomes. There is some evidence that trainees can improve their capacity to develop a therapeutic alliance, and that with more deliberate practice (focused, immediate attention and feedback on specific skills) therapists can realize better outcomes with their patients.
Practice Implications
As a senior therapist who is very involved in training, I find these results discouraging. Nevertheless, the solutions offered by the research do provide a ray of hope. Providing therapists with specific and immediate feedback about patient outcomes and therapeutic processes (e.g., ratings of patient distress and of the alliance after every session), has the potential for helping therapists to inform their practice, make adjustments, and develop expertise. Deliberate practice of specific skills in psychotherapy (e.g., ways of addressing an alliance rupture or of responding to intense emotion) may also improve therapist expertise and patient outcomes. It is also quite possible that the focus on learning specific manualized protocols, which is often the goal of graduate and post-graduate training, may not be the most effective training and professional development.
July 2021
Psychotherapist burnout affects patient outcomes
Delgadillo, J., Saxon, D., & Barkham, M. (2018). Associations between therapists’ occupational burnout and their patients’ depression and anxiety treatment outcomes. Depression and Anxiety, 35, 844-850.
Providing psychotherapy can be challenging for the therapist. Vicarious trauma, secondary traumatic stress, and compassion fatigue among psychotherapists are well documented. In addition, organizational conditions in publicly funded mental health programs like workload, safety issues, and lack of supervision and support can lead to higher rates of therapist burnout. Surveys document that between 21% and 67% of mental health workers experience burnout. Occupational burnout can take many forms, but it is typically defined as emotional exhaustion and disengagement that lead to lower levels of therapist empathy, engagement, and depersonalization. One could speculate that burnout among therapists leads to worse patient outcomes because of the impact of disengagement on the therapeutic alliance. However few if any studies examined the association between therapist burnout and patient mental health outcomes. In this study, Dalgillo and colleagues assessed therapist burnout and job satisfaction in 49 therapists, and they assessed depression and anxiety outcomes in 2223 of their patients. The therapists provided treatment as part of the UK’s Increasing Access to Psychotherapy (IAPT) program. The analyses controlled for therapist case mix. That means that differences between therapists’ caseload (patient level of impairment, social economic status, and severity of symptoms) were controlled so that the findings were unique to the effect of therapist burnout and job satisfaction on patient mental health outcomes. Higher therapist disengagement (an index of burnout) and lower therapist job satisfaction were significantly associated with poorer treatment outcomes for patients. In addition, higher burnout was related to lower job satisfaction among therapists.
Practice Implications
This is one of the first studies to show a direct association between therapist burnout and low job satisfaction with patient mental health outcomes. It is possible that these findings are specific to the UK’s IAPT program, in which therapists might feel a lower sense of control over their work. Nevertheless, organizations need to design mental health delivery in such a manner as to enhance psychotherapist autonomy, coping, and resilience, as these are likely related to therapist burnout and poorer patient mental health outcomes.