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 therapeutic skill in telepsychology versus face-to-face therapy, patient confidence and symptom improvement, and progress feedback.
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
March 2021
Identifying Outcomes for Depression That Matter to Patients
One of the criticisms of mental health treatment research is that the outcomes measured in these studies are those that matter to researchers but may not matter as much to patients. Common outcome measures of depression like the Beck Depression Inventory (BDI), the Patient Health Questionnaire (PHQ-9) or the Hamilton Depression Rating Scale (HDRS) were developed by researchers because of their relative ease of use, and their sensitivity to change following treatment. But these measures provide a narrow view of what it is like to experience depression because they focus only on a limited set of symptoms. But is symptom reduction the only thing that matters to patients and their loved ones? In this large-scale study by Chevance and colleagues, the authors surveyed over 1900 patients with a mood disorder, 464 informal caregivers (family members), and 627 health care providers from a wide range of mental health disciplines. The survey extended across dozens of countries and sampled a range of age groups. The authors asked patients open ended questions about what outcomes are important to them in the treatment of their depression, and then the responses were analyzed using a qualitative method. Chevance and colleagues identified two broad categories important to patients: symptoms and functioning. Regarding symptoms, patients identified several domains in which they wanted to experience improvements. These included: their perception of their self (e.g., self-esteem, self-confidence), physical symptoms (e.g., sleep, energy level), cognitive symptoms (e.g., social interest, cognitive distortions, motivation), emotional symptoms (e.g., mental pain, anxiety, sadness), and symptoms related to burden of suicidal thoughts. Regarding functioning, patients identified four domains in which they wished to see improvements. These included: elementary functioning (e.g., self-care, coping with daily tasks, autonomy), social functioning (e.g., social isolation, interpersonal relationships, family life), professional functioning (e.g., loss of job/studies, professional responsibilities), and complex functioning (e.g., coping with daily life, financial issues, personal growth).
Practice Implications
Clearly, patients, their loved ones, and those who provide treatment have a much broader view than researchers of what constitutes important outcomes to their mental health treatment for depression. The two most common symptom outcomes identified by patients were psychic pain and the burden imposed by suicidal ideation, yet these rarely assessed as primary outcomes in psychotherapy studies. And outcomes like social functioning, family relationships, and personal growth are not primary outcomes, and often they are not assessed at all in research studies. Clinicians would do well to take a broader view of what is important to patients, and to keep in mind their patients wishes as they develop collaborative goals for treatment with patients. It may be useful not only to use standardized scales to aid in developing treatment plans, but also to ask patients what they hope to gain from therapy should the treatment be successful.
February 2021
The COVID-19 Telepsychology Revolution
The COVID-19 pandemic has changed many things in our lives – how we connect with loved ones, how we play, and how we work. The pandemic has also affected typical coping strategies like seeking social support to improve or maintain mental health. Not surprisingly then, COVID-19 and the public health measures enacted to reduce its transmission has altered how therapists and patients engage in psychotherapy. On the positive side, this revolution in how psychotherapy is provided could lead to increased access for some patients living in rural and remote areas, those with severe anxiety, or those with physical disabilities that impede their mobility. In addition, some regulatory bodies in American states have relaxed rules that restrict inter-state practice and strict privacy requirements so that psychotherapy may remain accessible to patients during these times. Prior to the pandemic only about 21% of psychologists ever used telepsychology in their clinical practices, and many reported significant challenges to using telepsychology in their workplaces. Clinicians were also skeptical of the utility of telepsychology and its potential to negatively impact the therapeutic relationship. In one pre-pandemic survey, 75% of psychologists were not willing to refer their patients to telepsychology. Has the pandemic changed current perceptions and future expectations of psychotherapists’ use of telepsychology? In this large survey of over 2100 American psychologists, Pierce and colleagues documented past, current, and future use of telepsychology. Before the pandemic, on average only 7.07% (SD = 14.86) of psychologists’ practices involved telepsychology. During the pandemic 85.53% (SD = 29.24) of psychologists’ practice was made up of telepsychology. This represents nearly a 12-fold increase. Psychologists projected that in the future, after the pandemic, 34.96% (SD = 28.35) of their practice would consist of telepsychology. That is, after the pandemic, almost all psychologists who responded (89.19%) plan to use some form of telepsychology in at least in one third of their clinical work.
Practice Implications
These survey results suggest that telepsychology may be here to stay, even after the pandemic. Psychotherapists however require training to use telepsychology effectively and to feel more effective in their use of the technology. This trend will increase access for some marginalized patients, and some therapists will likely want to maintain the convenience afforded by telepsychology (reduced overhead, less travel). Psychological providers and regulatory bodies will have to adapt to the new reality. With more use and experience may come more self-confidence and perhaps more relaxed regulatory restrictions on the use of telepsychology.
Social Support and Therapeutic Bond Interact to Predict Client Outcomes
Researchers have known for many years that the number of social supports and the size of a patient’s social network have a positive impact on patient outcomes in psychotherapy. Social supports reduce loneliness, and higher loneliness is an important cause of distress. Research has also demonstrated quite convincingly that the relationship in psychotherapy plays an important role in patient mental health outcomes. The therapeutic alliance, for example, is one of the most researched concepts in psychotherapy and shows a clear and positive association with client improvement across a number of theoretical orientations and client problems. The therapeutic alliance is the collaborative agreement between client and therapist on the tasks and goals of therapy, and also their relational bond. The bond includes trust, respect, and confidence in the therapist. This is important because aspects of mental health, like emotion regulation, develop partly in social and intimate relationships, including in the therapeutic relationship. If the therapeutic relationship works to reduce loneliness and improve emotion regulation, then a positive therapeutic relationship will be particularly important for clients with less social support. In this study, Zimmerman and colleagues examined if an extra-therapeutic factor (social support) interacted with an intra-therapeutic factor (therapeutic alliance) to predict client outcomes. Over 1200 adult clients were treated by 164 experienced therapists who were guided by CBT manuals. Patients received 42.77 sessions on average (SD = 19.97), social support was assessed at the start of treatment, and alliance and outcomes were monitored after every session. On average, clients improved throughout treatment. Clients who had more social supports and who reported a better bond with their therapist improved the most. Of particular interest was the interaction between social support and bond. Those clients with lower social supports benefitted more if they also had a good therapeutic bond, and clients with a good therapeutic bond did well regardless of their level of social support.
Practice Implications
Both extra-therapeutic social support and intra-therapeutic bond with the therapist uniquely contributed to better outcomes for clients. However, a good therapeutic bond with the therapist appears to be particularly important for all clients, especially those with low levels of social supports. Psychotherapists would do well to assess the level and quality of their clients’ social support. And in all cases, especially for clients with low social support, therapists should work to develop and maintain a supportive and trusting therapeutic bond with their clients.
January 2021
Psychological Practitioner Workplace Well-Being
Summers, E.M., Morris, R.C., Bhutani, G.E., Rao, A.S., & Clarke, J.C. (2020). A survey of psychological practitioner workplace well-being. Clinical Psychology and Psychotherapy. Online first publication: https://doi.org/10.1002/cpp.2509
Burnout is a specific form of workplace psychological stress characterized by emotional exhaustion (loss of energy), depersonalization (cynicism towards patients), and lack of personal accomplishment (dissatisfaction). Research has shown higher than average levels of burnout in psychological practitioners. The National Health Service (NHS) in the United Kingdom (UK) employs a large workforce of psychological practitioners (psychologists, counsellors, assistant psychologists, social workers, and others) to provide mental health care. In surveys among UK practitioners, 48% felt depressed, almost 50% felt like a failure, and 92% felt that their job was stressful. Unfortunately, many providers tend not to seek help when they feel burned out, anxious, or depressed. Summers and colleagues conducted a large-scale survey of psychological practitioners that provide mental health care in the UK’s NHS system. Over 1,600 practitioners responded to questionnaires about professional and personal well-being, and about workplace conditions. Results showed a high correlation (r = .61) between workplace well-being and general personal well-being, suggesting that experiences in the workplace affect experiences outside of the workplace and vice versa. Scores of professional and general well-being were significantly below the national average, indicating poorer well-being among psychological providers compared to the general population. There were no differences among genders, and among most ethnic groups, and higher pay was not associated with higher well-being. Noteworthy factors that correlated with poorer professional well-being included workplace harassment/bullying by managers, feeling depressed, and having a physical disability. Being on contract with the NHS, working only part-time for the NHS, or working in private practice were each related to somewhat better well-being.
Practice Implications
There is ongoing concern about professional well-being and burnout among psychological practitioners as suggested by international surveys. Many NHS employees in the UK and mental health professionals around the world report high levels of burnout. Protective factors for psychological practitioners might include: having more control over one’s work, a supportive organizational culture, and taking care of one’s own psychological and physical health. Personal therapy, peer supervision, and consultation may be means by which therapists manage emerging dissatisfaction and depersonalization that may affect their work with patients and their own well-being.
Mentalizing May be a Protective Factor for Therapist’s Well-Being
Brugnera, A., Zarbo, C., Compare, A., Talia, A., Tasca, G.A., … & Lo Coco, G. (2020). Self-reported reflective functioning mediates the association between attachment insecurity and well-being among psychotherapists, Psychotherapy Research, https://doi.org/10.1080/10503307.2020.1762946.
Therapeutic work can be emotionally demanding for the therapist and can affect levels of personal well-being. But little is known about what can foster greater well-being among psychotherapists. Therapist well-being affects their relationships and effectiveness with clients. In recent research, therapists who reported a more satisfying personal life tended to rate higher therapeutic alliances to their clients, and therapeutic alliance is associated with better client outcomes. Two factors that affect therapist well-being include attachment insecurity and mentalizing. Attachment insecurity can be characterized as attachment avoidance (over self-reliance and downregulation of emotions) and attachment anxiety (preoccupation with relationship loss and up-regulation of emotions). High attachment anxiety and avoidance are related to interpersonal problems, maladaptive emotion regulation, and lower self-esteem. Mentalizing is the capacity to understand one’s own and other’s behaviors in terms of mental states (intentions, feelings, thoughts, desires), and so it forms the basis for humans’ capacity for empathy, cooperation, and social learning. In this survey of 416 psychotherapists in Italy, Brugnera and colleagues asked therapists to complete questionnaires that assessed their own attachment insecurity, reflective functioning (or mentalizing), and subjective well-being. Not surprisingly, greater attachment insecurity and lower reflective functioning were associated with lower well-being among therapists. Using a statistical mediation model, their study tested a theory in which mentalizing explained why attachment insecurity led to lower well-being. They found a significant indirect effect of both attachment avoidance and attachment anxiety on well-being that was explained by reduced reflective functioning. That is, higher attachment insecurity led to lower capacity to mentalize, which in turn led to lower well-being.
Practice Implications
Previous research showed a well-documented link between attachment insecurity and lower well-being among psychotherapists. This study is unique in that it helps to explain why this is the case. Even for those therapists who have higher attachment insecurity, a greater capacity to mentalize may buffer them from the negative impact on well-being. Recent research shows that novice therapists who receive specific training can improve their capacity to mentalize by: learning to identify their own reactions that distract them from understanding the client, distinguishing reactions they have that might provide useful information to understand the client, and taking a reflective stance to better understand the client based on their own personal reactions.
Can Therapists Train to Improve their Capacity to Mentalize?
Ensink, K., Maheux, J., Normandin, L., Sabourin, S., … & Parent, K. (2013). The impact of mentalization training on the reflective function of novice therapists: A randomized controlled trial, Psychotherapy Research, 23, 526-538, DOI: 10.1080/10503307.2013.800950
Recently, researchers and clinicians have been discussing the importance of therapists’ capacity to mentalize. That is, the capacity of therapists to be aware of mental states within themselves and clients, to identify and reflect upon emotional experiences of clients, and to understand the impact of client emotions and life experiences on the therapist’s capacity to be present, empathic, and effective. Most training programs in psychology and psychiatry focus almost exclusively on techniques – the rational application of psychological theory to diagnose and treat. These programs rarely, if ever, focus on training student therapists to mentalize. And yet, much of effective therapy also involves active listening, empathic understanding, developing a therapeutic bond, and consciously and deliberately imagining clients’ mental states. Without such skills, therapists may be susceptible to engage in anti-therapeutic acts (acting out, disengaging, verbalizing anger and frustration, feeling ineffective, burning out) born out of un-reflected personal reactions to clients and their experiences. In their study, Ensink and colleagues tested a training program designed to improve the capacity to mentalize in student therapists compared to therapists who only received traditional training in identifying psychopathology and applying therapeutic techniques. Mentalizing training involved 30 hours of experiential workshops that provided feedback to students on identifying their own reactions that might interfere with understanding the client, reflecting on their reactions, and considering how this reflection might help to understand the patient better. Capacity to mentalize was assessed by rating responses and reactions of student therapists in both conditions (mentalizing training vs traditional didactic training) to videos of clients in therapy. All novice therapists (in both training conditions) started at relatively low levels of reflectivity (an index of mentalizing), suggesting that students did not start the training program with these skills. Trainees in the mentalizing training group showed significant improvement in their capacity to mentalize, whereas students in the traditional didactic training showed a significant decline in their reflective capacity to mentalize.
Practice Implications
Psychotherapists do not start their training with high capacities to mentalize and so they may require training to hone this skill. Also, therapists who receive no such training do not spontaneously acquire these skills. Clients often have experiences that are perceived as foreign to trainee therapists, and so therapists may feel ill equipped to empathize, understand, and respond emotionally to such challenging client experiences. Therapists can be trained to identify their internal experiences (negative or positive emotional reactions that may be related to the client’s and/or therapist’s unresolved issues) that may interfere with establishing a productive therapeutic relationship. Increasing the capacity to mentalize may reduce therapists work-related stress as it affords therapists a greater measure of control and mastery over challenging encounters with some clients.