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 who is most responsible for the effects of the alliance, quality of life outcomes for psychological treatment of persistent depression, and cognitive behvaviour therapy for 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
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.
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.
How Much Psychotherapy is Really Necessary for Clients to Improve?
Findings form psychotherapy research studies have tested a dose-response relationship that shows that after a certain number of sessions the rate of client improvement diminishes. That research tends to show a range of 4 to 12 sessions is necessary in order for the average client to improve (half of clients get better by this point, but half do not yet get better). The key limitation of this research is that the vast majority of it was conducted in student counselling centres offering brief treatments. That is, the clients in this research domain tend to be students with mildly to moderately severe problems, and the counselling centres often had a policy (not based on client need) that limited the number of treatment sessions. There is actually very little psychotherapy dose-response research of clients with moderate to severe problems who receive treatment in naturalistic settings that do not arbitrarily impose a session limit. In such settings, it would be the client’s optimal response to treatment and not externally imposed limits that determine when therapy is terminated. This study by Nordmo and colleagues was conducted in several psychotherapy outpatient clinics in Norway. The 362 adult clients had moderate to severe levels of mental health problems, and about half had a personality disorder. The 88 therapists had about 10 years of experience and used several major orientations of psychotherapy practice (psychodynamic, CBT, behavioral, humanistic). Clinicians and clients came to an agreement about when to terminate therapy, and so no limit on sessions was externally imposed. Outcomes were assessed regularly and were evaluated for reliable change and clinical recovery in symptoms and interpersonal problems. Clients attended an average of 52 sessions (SD = 59, Mdn = 36), and improvements were maintained up to 2 years post-treatment. The results indicated that the more sessions a client received the greater their improvement. This was particularly true for those clients with more severe problems. Clients with less severe problems needed fewer sessions to improve. The average client needed 57 sessions to show clinically significant improvement.
Practice Implications
The psychotherapy dose-response research to date is limited because it is primarily based on clients with mild to moderate problems treated in student counselling centres. In real-world contexts, client rate and magnitude of change are related to the length of treatment. That is, clients with moderate to severe problems will require more than 4 to 12 sessions in order to improve. As the authors argued, the one-size-fits-all approach to treatment length in everyday practice is not supported by the research, and does not provide adequate treatment to those clients with moderate to severe problems, or those with complex comorbidities.
February 2021
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.