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
September 2021
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.
Practice Implications
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.
August 2021
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).
Practice Implications
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.
Practice Implications
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.
July 2021
Adverse Effects of Psychotherapy in Patients with Depression
Moritz, S., Nestoriuc, Y., Rief, W., Klein, J.P., Jelinek, L., Peth, J. (2019). It can’t hurt, right? Adverse effects of psychotherapy in patients with depression. European Archives of Psychiatry and Clinical Neuroscience, 269, 577–586.
Only recently have psychotherapy researchers begun to document adverse events or negative outcomes in treatment trials. Research demonstrates that in everyday clinical practice, clinicians generally are unable to identify patients who get worse because of therapy. Unfortunately, the field remains unclear as to what constitutes an adverse event in psychotherapy. Moritz and colleagues refined and shortened a questionnaire filled out by patients about adverse events that they may have experienced in a recent psychotherapy. The authors defined an adverse event as consisting of three aspects. First, side effects were defined as the patient experiencing an unintended negative effect including stigma, relationships deteriorating, and greater symptoms. Second, malpractice was defined as the patient judging that the therapist provided a treatment that was not appropriate to the problem at hand. Third, unethical conduct was defined as a therapist abusing a patient in some manner. In addition, the authors also had a scale of positive effects experienced by patients due to the therapy. For this study, Moritz and colleagues recruited 135 patients who were diagnosed with depression and asked them to fill out the questionnaire about adverse events in their most recent psychotherapy. Most patients (95.6%) reported at least one positive effect of the psychotherapy that they received. However, at least one adverse event was reported by 52.5% of patients. Side effects were endorsed most frequently by 38.5% of patients. Malpractice was endorsed second most frequently by 26.7% of patients. Finally, unethical conduct was endorsed by 8.1% of patients. Not surprisingly, adverse events in therapy were negatively correlated with positive effects of therapy (r = -.24). Adverse events were not associated with patient factors like gender, or therapy factors like type of therapy or profession of the therapist.
Practice Implications
This study by Moritz and colleagues is far from perfect, but it does begin a conversation about acknowledging that psychotherapy is not necessarily a benign event for some patients. In a previous study for example, 42% of patients with obsessive compulsive disorder experienced more or worsening symptoms due to exposure techniques used in CBT. Psychotherapists are notoriously poor at identifying patients who get worse from therapy, and so some therapists use aids like continuous progress monitoring to track patient progress and identify when therapy may be harmful.
June 2021
The Emotionally Burdened Psychotherapist
Nissen-Lie, H. A., Orlinsky, D. E., & Rønnestad, M. H. (2021). The emotionally burdened psychotherapist: Personal and situational risk factors. Professional Psychology: Research and Practice. Advance online publication.
To provide good treatment, a psychotherapist must have enough mental and emotional energy to be attuned to the different states of their patients. However, sometimes emotional reserves of therapists can dwindle because of personal or professional burdens. As a result, many therapists report the experience of burnout that inevitably has a negative effect on their patients. Therapists’ personal burdens can be defined as stress in one’s personal life, feeling worry or concern, experiencing conflict within one’s family, or loss of a loved one. These therapist personal burdens could be enduring vulnerabilities or short-lived stressors, but they nevertheless have an impact on the therapist’s effectiveness. Higher stress in a therapist’s personal life is related to more avoidant coping, and lower capacity to stay focused, engaged, and empathic with patients. In this large-scale survey of over 12,000 psychotherapists worldwide (e.g., Norway, US, Canada, UK, Australia, Denmark, China), Nissen-Lie and colleagues looked to identify past and current personal and situational factors that were linked to the experience of personal burden among psychotherapists. The therapists were mostly married or in a committed relationship (72%), half were psychologists, the average length of clinical practice was 12 years (SD = 9.2), and therapists worked almost evenly across the major theoretical orientations (including CBT, psychodynamic, systemic, and behavioral). The most salient predictors of personal burden among psychotherapists were: current health and financial worries, early trauma or abuse, attachment anxiety (i.e., concern about abandonment and difficulty regulating negative emotions), dominant and demanding behavior in relationships, lower work satisfaction, and younger age. Cumulatively, these variables accounted for a substantial amount (30%) of the variance in personal burden.
Practice Implications
Increasingly, research is pointing to negative life events and work experiences that may limit a therapists’ capacity to be engaged and empathic with patients. Focus on therapist well-being should be an important part of clinical training and supervision. Previous research found that receiving personal therapy, obtaining clinical supervision, working shorter hours, and lower caseloads improved empathy and wellbeing among psychotherapists.
May 2021
Does Clinical Training Lead to Greater Therapist Interpersonal Skills?
Wolfer, C., Visla, A., Held, J., Hilpert, P., & Fluckiger, C. (2021). Assessing interpersonal skills—A comparison of trainee therapists' and students' interpersonal skills assessed with two established assessments for interpersonal skills. Clinical Psychology and Psychotherapy, 28, 226-232.
Differences between therapists may account for 2% to 8% of the variance in patient mental health outcomes. This seems like a small amount, but the effect is as large as the specific effects caused by interventions of any therapeutic orientation. One of the factors that accounts for differences between therapists is therapist interpersonal skills such as empathy, respectfulness, warmth, openness, and willingness to collaborate. These skills can be learned and likely allow some individuals to be more effective when encountering challenging or complex interpersonal situations. One might think that such skills would be a pre-requisite for entering psychotherapy training, but that may not be the case. A study of training therapists found that more than half of novices were unhelpful to their patients. In this study by Wolfer and colleagues, the authors were interested in seeing if therapists at different stages of training had different levels of these important interpersonal skills. That is, do trainees as a higher level of training acquire more of these skills than those prior to receiving training. This was a small study comparing 19 therapists in clinical training versus 17 students in psychology but with no clinical training. Clinical trainees were in the program for at least 2 years, and received many hours of supervision. All participants watched a video recording of difficult patient statements. Participants’ reactions to the patient video were recorded and then trained raters coded the responses for level of interpersonal skills. Trainee therapists scored significantly higher than students on two scales of interpersonal skills, even after controlling for age. In fact, trainee therapists were over 13 times more likely to demonstrate facilitative interpersonal skills than untrained students. Although being in a clinical training program was associated with greater interpersonal skills, level of experience of clinical trainees (range 2 to 5 years of training) was not related to the level of interpersonal skills.
Practice Implications
This is a relatively small study, so one should consider the findings quite cautiously. Nevertheless, it is one of the few studies to assess interpersonal skills in therapists. It is possible that only those with more interpersonal skills choose to be trained as clinicians – that is, only especially skilled students may go on to receive clinical training. However, the trainees’ substantial amount of clinical training (observing clinicians handle complex situations, receiving supervision to enhance self-reflection) may have facilitated growth in their interpersonal skills. As in previous research, clinical experience alone was not related to therapist interpersonal skill.