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 CBT, negative effects of psychological interventions, and what people want from therapy.
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
Whose contribution (therapist or patient?) to the alliance mostly leads to change?
Wampold, B. E., & Flückiger, C. (2023). The alliance in mental health care: conceptualization, evidence and clinical applications. World Psychiatry, 22, 25–41. https://doi.org/10.1002/wps.21035
The therapeutic alliance is possibly the most researched concept in psychotherapy. The alliance consists to a collaborative agreement patient and therapist on the goals of therapy, a collaborative agreement on the tasks of therapy (how therapy should proceed), and the relational bond between therapist and patient (mutual liking and trust). The most recent meta-analysis of almost 300 studies showed that the correlation between the therapeutic alliance and patient outcomes was moderate in size (r = .29) and very stable across studies, treatment modalities, and patient populations. Another meta-analysis of studies that assessed outcomes and therapeutic alliance after every session showed that there is a reciprocal relationship between alliance and outcomes, demonstrating that the alliance is not simply a consequence of symptom improvement. In this sweeping review of the therapeutic alliance research and clinical literature, Wampold and Fluckiger asked “who is most responsible for the effects of the alliance – the patient or the therapist?”. The alliance is a dyadic construct about the interaction between therapist and patient. It could be that the patient contribution to the alliance is most important to their outcomes. A patient with insecure attachment, more symptoms, comorbid personality disorder, or low motivation might experience a poorer alliance with any therapist. Conversely, some therapists might be able to form a better alliance than other therapists across a wide range of patients, and this might be what results in better outcomes. Studies that disaggregate the total correlation of the alliance and outcome into patient and therapist contributions generally demonstrate that it is the therapist that is primarily responsible for the alliance-outcome association. That is, therapists who can form a stronger alliance with a wide range of patients also generally have better outcomes than other therapists. Even patients who tend to form a weaker alliance with therapists will develop a stronger alliance with therapists who generally have the skills to develop a strong alliance.
When it comes to the therapeutic alliance, the therapist matters even for patients who struggle to form an alliance. It turns out that gender, age, ethnicity, profession, and theoretical orientation of the therapist do not matter as much as their interpersonal skills. These interpersonal skills include a therapist’s capacity to communicate hope and positive expectations, persuasiveness, emotional expression, warmth, understanding, acceptance, empathy, and ability to repair alliance ruptures. If a therapist wants to make the most of the therapeutic alliance to help their patients, then the therapist should develop and nurture these interpersonal skills for themselves.
Quality of Life Outcomes in the Psychological Treatment of Persistent Depression
McPherson, S., & Senra, H. (2022). Psychological treatments for persistent depression: A systematic review and meta-analysis of quality of life and functioning outcomes. Psychotherapy, 59(3), 447–459.
The World Health Organization ranks depression as the largest cause of global disability accounting for 7.5% of all years lived with disability. Persistent forms of depression contribute to years lived with disability due to its chronic nature and its association with low levels of social and physical functioning, high rates of suicide, and high health care use. One way to look at disability as an outcome is to assess quality of life, which refers to performance in daily and social functioning and satisfaction with these activities. In this meta-analysis, McPherson and Senra examine 14 randomized controlled trials of psychological therapies for chronic or persistent depression in adults. The control condition included no treatment, waiting list, treatment as usual, or only antidepressant medication. The psychotherapies were mindfulness-based cognitive therapy (MBCT), CBT, interpersonal psychotherapy (IPT), long term psychoanalytic psychotherapy (LTPP), and DBT. Chronic depression was defined as a course of depression of at least 2 years and/or non-response to at least two treatments. The quality of life measure had to assess satisfaction with physical health, psychological state, level of independence, and social relationships. In general, the psychological treatments were associated with improvements in patients’ quality of life at the end of treatment (N=11; g=0.24; 95%CI: 0.13, 0.34). At follow up, the effect size was g=.21 (95%CI: 0.10, 0.32). That is, the effects were significant and positive, but small. The psychological interventions resulted in improvements in patient functioning at the end of treatment, g=.35 (95%CI: 0.21, 0.48), which is consistent with previous meta-analyses showing small to moderate effects of psychological treatments for persistent depression. Although there were too few studies to properly assess differences between therapy types, MBCT, IPT, and LTPP in combination with antidepressant medications had the largest effects among the therapies studied.
In international surveys, patients seeking treatment for depression, informal caregivers, and health professionals list quality of life and social functioning as just as important or as more important than symptom reduction. Yet, these outcomes related to quality of life are not often assessed in clinical trials. This meta-analysis of a modest number of studies, suggests that some psychological therapies (MBCT, IPT, LTPP), in combination with antidepressant medications have the largest positive effects on quality of life for those persistent depression.
Cognitive Behavior Therapy vs. Control Conditions and Other Treatments
Cuijpers, P., Miguel, C., Harrer, M., Plessen, C. Y., Ciharova, M., Ebert, D., & Karyotaki, E. (2023). Cognitive behavior therapy vs. control conditions, other psychotherapies, pharmacotherapies and combined treatment for depression: A comprehensive meta-analysis including 409 trials with 52,702 patients. World Psychiatry, 22, 105–115.
Depression is a highly prevalent mental disorder, with about 280 million people worldwide who have the disorder. Several evidence-based treatments are available for depression, including pharmacotherapies and psychotherapies. Cognitive behavior therapy (CBT) is the most researched type of psychotherapy for depression. To date there are 409 trials with over 52,00 patients. In this study, Cuijpers and colleagues conduct the largest meta-analysis of CBT versus control conditions (treatment as usual [TAU], no treatment, other active psychotherapies, and pharmacotherapy). Although early trials of CBT were of low quality (small sample sizes, high risk of bias), the quality of studies have improved over time. In this meta-analysis Cuijpers and colleagues found that CBT had a large to moderate effect compared to TAU or to no treatment (g=0.79; 95% CI: 0.70-0.89), suggesting that CBT is better than receiving no or limited treatment. These results were stable up to one year follow-up. One would have to treat 4.7 patients with CBT to see improvement in one patient relative to no or limited treatment. CBT was compared to other active treatments in 87 trials. CBT was no more effective than other psychotherapies such that the average difference was miniscule (g=0.06; 95% CI: 0-0.12). One would have to treat 63 patients with CBT for one patient to receive a better outcome relative to another psychotherapy. However, if differences did emerge between CBT and other psychotherapies, they were not reliable. The effects of CBT did not differ significantly from those of pharmacotherapies (anti-depressant medications) at the short term, but the effects of CBT were significantly larger than pharmacotherapies at 6–12-month follow-up (g=0.34; 95% CI: 0.09-0.58). However, these follow-up findings also were not reliable. Combined treatment of CBT plus anti-depressant medications was more effective than pharmacotherapies alone at the short (g=0.51; 95% CI: 0.19-0.84) and long term (g=0.32; 95% CI: 0.09-0.55), but combined treatment was not more effective than CBT alone at either time point.
The authors concluded that CBT is effective in the treatment of depression compared to no or limited treatment in the short and longer term. Although CBT gets the lion’s share of attention in the psychotherapy literature, there is no evidence that it is more effective than any other form of psychotherapy or antidepressant medication in the short term. There is evidence that combined CBT and medications may be more helpful than medications alone for depression.
The Impact of COVID-19 on Mental Health Workers’ Well-Being
Mittal, M., Morgan, A. A., Du, J., Jiang, J., Boekeloo, B., & Fish, J. N. (2022, December 19). “Each week feels like a mountain”: The impact of COVID-19 on mental health providers’ well-being and clinical work. Professional Psychology: Research and Practice. Advance online publication.
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.
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
DeBlaere, C., Zelaya, D. G., Dean, J.-A. B., Chadwick, C. N., Davis, D. E., Hook, J. N., & Owen, J. (2022, December 8). 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. Advance online publication.
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”.
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
Depauw, H., Van Hiel, A., De Clercq, B., Bracke, P., & Van De Putte, B. (2022). Addressing cultural topics during psychotherapy: Evidence based dos and dont's from an ethnic minority perspective. Psychotherapy Research.
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.
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.