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 empathy, psychotherapeutic treatment for borderline personality disorder, and research on psychological treatment of depression.
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
Do Clinicians Agree on Transtheoretical Principles of Change?
Twomey, C., O’Reilly, G., & Goldfried, M. R. (2023, April 20). Consensus on the perceived presence of transtheoretical principles of change in routine psychotherapy practice: A survey of clinicians and researchers. Psychotherapy. Advance online publication. https://dx.doi.org/10.1037/pst0000489
Way back in 1982 Marvin Goldfried hypothesized that there were five transtheoretical principles of change that are part of every method of effective psychotherapies. However, for several decades since Goldfield’s hypothesis, the emphasis in training and research of psychotherapy has been on specific techniques and schools of psychotherapy. Despite the proliferation of therapy schools (there are now more than 500!), there is no evidence that any one bona fide therapeutic orientation is more effective than others, and patient outcomes over the decades have not improved. Recently, there has been a resurgence of interest in transtheoretical principles of change that might move the science and practice psychotherapy forward. Goldfried’s five transtheoretical principles are those strategies common to all theoretical orientations of therapy that since then have received substantial research support. First, fostering the patient’s hope, positive expectations, and motivation has been associated with positive outcomes in psychotherapy. Second, facilitating the therapeutic alliance is associated with positive outcomes, and unresolved alliance ruptures are associated with negative outcomes. Third, increasing patients’ insight is moderately associated with treatment outcomes across orientations. Fourth, encouraging patients to engage in corrective experiences is consistent with the importance of gradual exposure to feared situations and feelings. And fifth, ongoing reality testing corresponds to the long-established finding that adaptive behaviors can be strengthened through repetition and reinforcement. In this large survey of 1198 psychotherapists and researchers, Twomey and colleagues were interested to see if there was a consensus among psychotherapists on these five principles. Consensus was defined as survey respondents indicating that they agreed or strongly agreed that each principle was present in their own approach to psychotherapy. Ninety-three percent of respondents practiced psychotherapy, their average age in years was 50, 51% were women, 62% were psychologists, and they represented a wide range of theoretical orientations. Strong consensus (i.e., on average they strongly agreed) was found for the first three principles: fostering patients’ hope and expectations, facilitating a therapeutic alliance, and increasing patients’ insight. Good consensus (i.e., on average they agreed) was found for encouraging patients to engage in corrective experiences, and ongoing reality testing. There were no differences or associations noted with any of the demographic variables (age, profession, years of practice) nor for theoretical orientation.
Practice Implications
The results suggested that while some research continues to emphasize techniques specific to orientations of therapy, most clinicians agree on important principles of change that cut across orientations. These principles indicate that psychotherapists should (1) increase positive expectations by preparing patients for what will happen in therapy (duration, method, goals) and explaining why certain aspects of therapy are important, (2) foster the alliance by encouraging ongoing collaboration regarding the goals and methods of therapy, (3) encourage insight by collaboratively developing a case formulation that brings relevant issues into greater awareness for the patient, (4) provide patients with corrective experiences by encouraging exposure to difficult situations, interpersonal challenges, and working through alliance ruptures, and (5) help patients to be aware of and repeat corrective experiences over time as a means of fostering reality testing.
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.
April 2023
Preparing Patients for Psychotherapy
Swift, J. K., Penix, E. A., & Li, A. (2023). A meta-analysis of the effects of role induction in psychotherapy. Psychotherapy. Advance online publication.
Starting psychotherapy can be hard for some patients likely because they must face the unknown about themselves, the therapy process, and the therapist. Some patients might think that they must behave in a certain way, or they may have expectations of what might occur in therapy or about outcomes. Those expectations might be unrealistic, or they may be different from what their therapist intends. One road to success in therapy is for patients to know how to effectively engage with their psychotherapist. Role induction might be one means of preparing patients therapy and could include several activities. First, establishing rapport is key so that the patient and therapist experience an empathic bond. Second, providing an explanation of psychotherapy might include discussing why psychotherapy can be effective, what change the patient might experience, and how the therapy will work from session to session. Third, describing the roles of patient and therapist is key, including encouraging the patient to be open and honest, and discussing how the therapist might behave (directive/less directive, emotion/cognitive focused, and present/past focused). Fourth, anticipating challenges for the patient to complete therapy may also be useful to help patients deal with frustrations or thoughts of dropping out. In this meta-analysis, Swift and colleagues examined 17 studies in which patients who received a role induction were compared to those who were treated as usual. The overall effect of role induction on psychotherapy dropout was significant, OR = 1.64, 95% CI [1.06, 2.53], p = .03. Patients who were prepared were 1.64 times less likely to drop out than patients who were not prepared. The overall effect on posttreatment outcomes was also significantly in favor of role induction, d = 0.33, 95% CI [0.11, 0.55], p < .01, although the effect was small. In moderator analyses, preparing patients for therapy was more effective for older patients, when done by more experienced therapists, and when provided verbally as opposed to in writing.
Practice Implications
The research suggests that preparing patients for psychotherapy by establishing a relational bond, providing information on how therapy will proceed, and providing information on the roles of the patient and therapist can be useful to reduce dropouts and improve patient outcomes. It may be helpful for therapists to assess what a patient knows about psychotherapy and their expectations of theirs and therapists’ roles. Therapists can use this information to personalize the preparation for patients so that it helps them to understand patient and therapist roles, rationale for treatment, and how therapy works. The assessment may also help therapists to adapt therapy to patient preferences when feasible. Patient preparation works best if done verbally and personalized to a patient rather than giving the patient a generic written handout or directing them to a web page.
March 2023
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.
February 2023
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.
Practice Implications
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.
January 2023
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.