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.

October 2013

Do Psychotherapists with Different Orientations Stereotype Each Other?

Larsson, B. P., Broberg, A. G., & Kaldo, V. (2013). Do psychotherapists with different theoretical orientations stereotype or prejudge each other? Journal of Contemporary Psychotherapy, 1-10.

A remarkable difference between the field of psychotherapy and other health care or scientific areas is that psychotherapy is organized in different and somewhat competing theoretical orientations or schools. Leading thinkers of psychotherapy integration, have emphasized how this division presents an obstacle to integration and therefore to progress within the practice and science of psychotherapy. One of these obstacles could be persistent stereotypes that psychotherapists might have about other therapists who practice from a different theoretical orientation. Social psychologists have long known that people in one group (e.g., an in-group) may misjudge or stereotype people in other groups (e.g., out-groups). Stereotypes may be negative if members of an in-group hold a positive bias toward their in-group coupled with antagonism toward members of an out-group. Do psychotherapists stereotype other therapists who practice from a different theoretical orientation? A recent study by Larsson and colleagues addressed this question. They surveyed 416 therapists divided into four ‘pure’ self-reported schools: 161 psychodynamic therapists, 93 cognitive therapists, 95 behavioural therapists, and 67 integrative/eclectic therapists. Most were women (76%), mean age was in the mid 50s, mean experience was 5 to 10 years, and they represented a variety of disciplines including psychology, psychiatry, social work, and nursing. In the first section of the survey, therapists indicated what focus they deemed most important to their own psychotherapeutic work, including: (1) therapeutic relationship, (2) patient’s thoughts, (3) patient’s feelings, (4) patient’s behaviour, or (5) connection between the patient’s thoughts, feelings, and behaviors. Therapists then estimated how they thought psychotherapists from other orientations would rate each of these foci. In the second section of the survey, therapists completed scales about what they deemed were important aspects of psychodynamic, cognitive, behavioral, and eclectic/integrative therapy, respectively. Once again, they rated how they thought therapists from the other orientations would respond. Self-ratings of therapists within each orientation indicated the ‘true’ (i.e., prototypical) opinions of each orientation. The differences between ‘true’ opinions of the in-group versus the in-group’s ratings of therapists from other orientations (i.e. of the out-group) indicated the level of misjudgement or stereotyping. Of the 18 areas on which out-groups were rated, 11 were significantly misjudged by the in-group. Eclectic/integrative therapists were much less likely to stereotype therapists of cognitive or psychodynamic orientations, who were equally likely to stereotype others. The belief that one’s own orientation compared to others is better characterized as an applied science (a belief endorsed most often by cognitive therapists) was a statistically stronger predictor of stereotyping than orientation per se.

Practice Implications

Some researchers argue that different orientations are more similar in their practice of psychotherapy than theory would predict. Furthermore, research about common factors in psychotherapy suggests that these factors may be more important than techniques specific to a school of psychotherapy. However, as long as there are different therapeutic orientations there will likely remain a tendency among some psychotherapists to search for differences rather than to look for similarities between their own and other orientations. This may lead to stereotyping (i.e., an inaccurate opinion about therapists of other orientations), and perhaps negative stereotyping. Psychotherapists and researchers may want to keep in mind the tendency to stereotype clinicians from other orientations when talking to or about other psychotherapists. Such stereotyping is likely an impediment to good client care and research.

Author email: billy.larsson@psy.gu.se
Does Medicalization of Psychological Problems Reduce Stigma?

Kvaale, E. P., Haslam, N., & Gottdiener, W. H. (2013). The ‘side effects’ of medicalization: A meta-analytic review of how biogenetic explanations affect stigma. Clinical Psychology Review, 33, 782-794.

Psychotherapists may wonder how best to explain a psychological problem to their clients and their family members. Will their explanation help to reduce stigma and increase hope? Laypeople, clinicians, and researchers increasingly understand psychological problems in biomedical terms. Further, some anti-stigma campaigns describe mental health problems, including depression, as biological, medical illnesses. Reducing stigma is important to improve uptake of therapy, reduce an internalized sense of defectiveness, and increase hope and self esteem. Some argue that understanding psychological problems as biologically based will combat stigma by reducing blame and punitive treatment. Kvaale and colleagues asked whether there is a cost to medicalization of psychological problems by unwittingly promoting the stereotype that those with a mental illness have a deep seated, fixed, and defining essence. Proponents of medicalization hope that such an approach will reduce blame for a mental illness, and will result in less desire for social distance from the mentally ill. However, medicalization might also result in: an increased belief that those with psychological problems are dangerous; and greater pessimism and hopelessness about the prognosis (i.e., a belief that the problem can not be improved). A meta-analysis by Kvaale and colleagues looked at experimental studies of student and community based samples in which explanations for a psychological problem was manipulated to include biomedical explanations versus psychological explanations or no explanations. The meta-analysis aimed to examine the causal effects of biogenetic explanations for psychological problems on: blame, perceived dangerousness, social distance, and prognostic pessimism. Regarding blame, the authors reviewed 14 studies that included 2326 participants and found that biogenetic explanations were associated with a decreased tendency to blame individuals with psychological problems. Regarding perceived dangerousness, the authors reviewed 10 studies with 1207 participants, and found that biogenetic explanations were associated with an increase in perceiving those with psychological problems as dangerous. However this result is tentative because publication bias may have resulted in an over estimation of the association (see my May 2013 blog on publication bias [“Are the Effects of Psychotherapy for Depression Overestimated?”]). Regarding social distance, the authors reviewed 16 studies with 2692 participants, but found no relationship between biogenetic explanations and reduced social distance. Regarding prognostic pessimism, the authors reviewed 16 studies with 3469 participants, and found that biogenetic explanations were associated with greater pessimism about the prognosis of a psychological problem.

Practice Implications

The meta analysis by Kvaale and colleagues found that biomedical explanations for psychological problems typically decrease blame, but increase prognostic pessimism and perceptions of dangerousness, although the latter conclusion is somewhat tentative. The findings lead one to be skeptical of the view that stigma will be reduced by promoting an understanding of psychological problems as biogenetic diseases. Kvaale and colleagues suggest that the affected individual, family members and mental health professionals could be more pessimistic about change because of a biomedical explanation, thus impeding the patient’s recovery process. Psychotherapists should share information about the biogenetic factors of psychological problems. However, this must be done with caution. Kvaale and colleagues conclude that explanations that invoke biomedical factors may reduce blame but also may have unintended side-effects. Biogenetic explanations should not be promoted at the expense of psychosocial explanations, which may have more optimistic implications.

Author email: e.kvaale@student.unimelb.edu.au

August 2013

Does Focus on Retelling Trauma Increase Drop-out From Treatments For Posttraumatic Stress Disorder (PTSD)

Imel, Z. E., Laska, K., Jakupcak, M., & Simpson, T. L. (2013). Meta-analysis of dropout in treatments for posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 81, 394–404.

There are now a number of psychotherapies that the Society of Clinical Psychology list as effective psychotherapies available for posttraumatic stress disorder (PTSD). Approaches include prolonged exposure (PE), and cognitive processing therapy (CPT) among others (click here for examples). Therapies for PTSD also vary in how much they focus on retelling the trauma. Some treatments like trauma-focused CBT place a higher level of focus on retelling the trauma event, whereas Present Centred Therapy (PCT), which was originally conceived as a control condition, largely avoids the trauma. Patients may begin a treatment and find some aspect of it distressing resulting in discontinuation. There is ongoing debate regarding the belief that exposure-based treatments, which require the patient to retell traumatic events in detail to his or her therapist, are especially unacceptable or poorly tolerated by patients. Drop out rate is a common metric used to assess tolerability of a treatment. In the April 2013 blog I reported on a meta analysis that found that the average drop out rate in randomized controlled trials of adult psychotherapy was 19.7%. However drop out rates for PTSD in the community can be as high as 56%. Imel and colleagues conducted a meta analysis of drop out rates in randomized controlled trials of treatments for PTSD. They also assessed if drop out rates differed by the amount the therapy focused on retelling the trauma. In the meta analysis, 42 studies were included representing 1,850 patients; 17 of the studies directly compared two or more treatments. The aggregated drop out rates across all studies was 18.28%, which is not different from the rate in randomized trials of adult psychotherapy in general, but is much lower than reported in regular clinical practice. Group treatment was associated with a 12% increase in drop outs compared to individual treatment. In general, an increase in trauma focus was not associated with greater drop out rates. However, when trauma focused treatments were directly compared to PCT (a trauma avoidant intervention) in the same study, trauma-specific treatments were associated with a twofold increase in the odds of dropping out.

Practice Implications

Many have been concerned that exposure-based therapies can lead to symptom exacerbation and result in dropout. The findings of Imel and colleagues’ meta analysis suggest that dropout rates are not significantly different among active treatments. However, PCT may be an exception to this general pattern of no differences among active treatments. Perhaps PCT should be considered a first line treatment for those who do not prefer a trauma focused treatment. In addition, providing treatment for PTSD in groups was associated with greater drop out rates possibly due to shame related to public disclosure of the trauma. The authors suggest mimicking research trial procedures in community practice in order to reduce drop out rates, such as: providing therapist training, support, and supervision; careful patient screening; regular assessment of patient progress; and ongoing contact with assistants that may promote session attendance.

Author email: zac.imel@utah.edu
Helpful and Hindering Events in Psychotherapy

Castonguay, L.G., Boswell, J.F., Zack, S., Baker, S., Boutselis, M., Chiswick, N., Damer, D., Hemmelstein, N., Jackson, J., Morford, M., Ragusea, S., Roper, G., Spayd, C., Weiszer, T., Borkovec, T.D., & Grosse Holtforth,, M. (2010). Helpful and hindering events in psychotherapy: A practice research network study. Psychotherapy: Theory, Research, Practice, and Training, 47, 327-344.

There are many reasons why I like this paper, and one reason is that it is a psychotherapy practice research network study (most of the co-authors are independent practice clinicians). This group of clinicians and researchers met on a number of occasions to define the research questions, including: “what do psychotherapists and clients find most and least helpful in a psychotherapy session?”; and “do psychotherapists and clients agree on what was most and least helpful?” The clinicians and researchers also discussed and agreed on the method for collecting and analysing the data. Thirteen independent practice clinicians participated (6 CBT, 4 psychodynamic, and 3 experiental/humanistic). For a period of 18 months, all new clients were invited to participate so that 121 clients with a variety of disorders enrolled in the study. Clients and therapists filled out (on an index card) parts of the Helpful Aspects of Therapy (HAT) measure, which asked them to report, describe, and rate particularly helpful and hindering events from the session they had just completed. For example clients and therapists were asked: “Did anything particularly helpful happen during this session?”; and “Did anything happen during this session which might have been hindering?” When participants answered “Yes” to either of these questions, they were asked to briefly describe the event(s), and then rate them on a scale from 1 to 4 for level of helpfulness or level of hindrance. Both clients and therapists did so at the end of every therapy session. Close to 1500 therapeutic events were recorded by the clients and therapists. The events were then coded and categorized according to type of event by independent raters using an established coding system. Clients rated self-awareness, problem clarification, and problem solution as the most helpful type of events, although self-awareness was significantly the most identified of all helpful events by clients. Therapists rated self-awareness, alliance strengthening, and problem clarification as the most helpful type of events. Therapists identified self-awareness and alliance strengthening significantly more often than any other helpful events. Hindering events were identified much less frequently by clients and therapists. Client identified poor fit (e.g., therapist tried something that didn’t fit the client’s experience) as the most frequent hindering event category. Therapists identified therapist omissions (i.e., failure to provide support or an intervention) as the most frequent hindering event category. Overall, with the exception of self-awareness, therapists and clients did not agree on what were the most helpful or hindering events in therapy.

Practice Implications

Results regarding self awareness indicate that providing clients with opportunities to achieve a clearer sense of their experience (e.g., emotions, behaviors, and perceptions of self) is frequently reported as beneficial by both clients and therapists. The events that therapists most frequently reported as detrimental were those in which they failed to be attuned to their clients’ needs. This may reflect therapists’ concerns with potential alliance ruptures. The overall lack of agreement between therapists and clients on helpful and hindering events raises the question about whether therapists are not aware enough of clients’ experiences, or whether clients are not knowledgeable about what is in fact therapeutic. Perhaps client and therapist ratings of events represent complementary perspectives on what works or does not work in psychotherapy. Regarding participating in research, these independent practice therapists reported that the procedure of writing down helpful and harmful events and reading what their clients wrote after each session had a positive impact on their practice. That is, the process of data collection became immediately relevant to their clinical work.

Author email: lgc3@psu.edu

June 2013

Parallel Process in Psychotherapy Supervision

Tracey, T. J., Bludworth, J., & Glidden-Tracey, C. E. (2011). Are there parallel processes in psychotherapy supervision? An empirical examination. Psychotherapy, 49(3), 330-343.

Parallel process was first proposed in the psychodynamic literature as the replication of the therapeutic relationship in supervision. Parallel process is also recognized as an important aspect of supervision in developmental and interactional models of supervision, even though those models do not endorse the unconscious aspects of parallel process. Parallel processes in supervision occur when: (1) the trainee therapist brings the interaction pattern that occurs between the trainee therapist and client into supervision and enacts the same pattern but with the trainee therapist in the client’s role, or (2) the trainee therapist takes the interaction pattern in supervision back into the therapy session as the therapist, now enacting the supervisor’s role. For example, a client comes into therapy seeking guidance because things are not going well in his relationships. He desires structure and direction from the trainee therapist (client’s behaviour is submissive). The trainee therapist attempts to help the client by providing guidance (therapist’s behaviour is relatively dominant). The client then responds with “Yes, but…” to suggestions offered by the trainee therapist (client’s behaviour is non-affiliative). The trainee therapist over time starts to become subtly “critical” of the client (therapist matches the non-affiliative client behavior). The trainee therapist goes into supervision complaining about the client’s “resistence” and the trainee therapist asks for help and direction from the supervisor (trainee therapist increases his submissive behavior in a parallel enactment of the client’s submissive stance). As the supervisor provides some direction (supervisor increases her dominance), the trainee therapist responds with “Yes, but. . .” (trainee therapist increases his non-affiliative behavior). The supervisor engages in more “critical” comments than usual in response to the therapist (supervisor matches the non-affiliative trainee behavior). In this way, the supervision interaction becomes a relative replication of the therapy relationship, captured in the parallel amounts of dominance/submission and affiliation/non-affiliation exhibited by the participants in relation to each other. Tracey and colleagues (2012) studied this phenomenon by coding moment by moment interpersonal interactions using an interpersonal circumplex model (i.e. a model that assesses relative dominance and affiliation) among 17 triads of clients/trainee therapists/supervisors in a series of single case replications. The authors hypothesized that relative dominance and affiliation would be parallel between clients/trainee therapist pairs and corresponding trainee therapist/supervisor pairs in contiguous sessions. Significant results were found for each dyad within the 17 client/trainee therapist/supervisor triads. Therapists in the role of trainee altered their behavior away from their usual in supervision to act somewhat more like particular clients did in the previous therapy session. Supervisors tended to engage in complementary interpersonal responses in the subsequent supervision session. This provided evidence for parallel process at an interpersonal level of interactions. Further, positive client outcome was associated with increasing similarity of trainee therapist behavior to the supervisor over time on both dominance and affiliation. That is, the more therapists acted like their supervisors in the previous supervision meeting on both dominance and affiliation, the better the client outcome.

Practice Implications

This article provides intriguing evidence for an interpersonal model of parallel process. Supervisors may choose to communicate with the trainee about how the trainee therapist and client are interacting, as well as how the trainee and supervisor are interacting. In this way, the supervisor makes the implicit aspects of the parallel process more explicit for the trainee therapist. The trainee then can make choices about how best to proceed based on the new understanding of the interactional pattern at the process and content levels of interaction. For example, a therapist and supervisor can come to understand a block in the supervisory alliance as a parallel to a similar impediment in the trainee therapist-client relationship. A supervisor working through the block in supervision to create a more collegial and affiliative environment may model for the trainee therapist ways in which to effectively and collaboratively work with their client.

Author email: Terence.Tracey@asu.edu

May 2013

Are the Effects of Psychotherapy for Depression Overestimated?

Niemeyer, H., Musch, J., & Pietrowsky, R. (2013). Publication bias in meta-analyses of the efficacy of psychotherapeutic interventions for depression. Journal of Consulting and Clinical Psychology, 81, 58-74.

Meta-analyses are important ways of summarizing effects of medical and psychological interventions by aggregating effect sizes across a large number of studies. (Don’t stop reading, I promise this won’t get too statistical). The aggregated effect size from a meta analysis is more reliable than the findings of any individual study. That is why practice guidelines almost exclusively rely on meta analyses when making practice recommendations (see for example the Resources tab on this web site). However meta analyses are only as good as the data (i.e., studies) that go into them (hence, the old adage: “garbage in, garbage out”). For example, if the studies included in a meta analysis are a biased representation of all studies, then the meta analysis results will be unreliable leading to misleading practice guidelines. One problem that leads to unreliable meta analyses is called publication bias. Publication bias often refers to the tendency of peer reviewed journals not to publish studies with non-significant results (e.g., a study showing a treatment is no better than a control condition). Publication bias may also refer to active suppression of data by researchers or industry. Suppression of research results may occur because an intervention’s effects were not supported by the data, or the intervention was harmful to some study participants. In medical research, publication bias can have dire public health consequences (see this TED Talk). There is lots of evidence that publication bias has lead to a significant over-estimation of the effects of antidepressant medications (see Turner et al (2008) New England Journal of Medicine). Does publication bias exist in psychotherapy research, and if so does this mean that psychotherapy is not as effective as we think? A recent study by Niemeyer and colleagues (2013) addressed this question with the most up to date research and statistical techniques. They collected 31 data sets each of which included 6 or more studies of psychotherapeutic interventions (including published and unpublished studies) for depression. The majority of interventions tested were cognitive behavioral therapy, but interpersonal psychotherapy, and brief psychodynamic therapy were also included. The authors applied sophisticated statistical techniques to assess if publication bias existed. (Briefly, there are ways of assessing if the distribution of effect sizes across data sets fall in a predictable pattern called a “funnel plot” – specific significant deviations from this pattern indicate positive or negative publication bias). Niemeyer and colleagues found minimal evidence of publication bias in published research of psychotherapy for depression. This minimal bias had almost no impact on the size of the effect of psychotherapy for depression.

Practice Implications

This is a very important result indicating that despite a minor tendency toward a selective publication of positive results, the efficacy of all reviewed psychotherapy interventions for depression remained substantial, even after correcting for the publication bias. Niemeyer and colleagues’ findings demonstrate that publication bias alone cannot explain the considerable efficacy of psychotherapy for depression. Psychotherapeutic interventions can still be considered efficacious and recommended for the treatment of depression.

Author email address: helen.niemeyer@hhu.de

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October 2013

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August 2013

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June 2013

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May 2013

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Psychotherapy Practice Research Network (PPRNet)