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
January 2023
The Impact of COVID-19 on Mental Health Workers’ Well-Being
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.
Practice Implications
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
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”.
Practice Implications
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.
November 2022
What are Best Practices for Psychotherapy with Indigenous Peoples
In 2016 2.8% of the Canadian population identified as First Nations, 1.7% as Metis, and 0.2% as Inuit. In Canada there are 634 First Nations each with their own traditions, governance structures, and land claims. Colonial violence and land dispossession has led to Indigenous Peoples suffering from many mental health inequities. Indigenous samples are rarely evaluated in clinical trials of psychotherapy. And psychotherapy, as typically delivered, is a practice that is embedded in European cultural values which may not be appropriate for Indigenous Peoples. Defining best practices in psychotherapy with Indigenous Peoples may indeed be thorny given the historical context and values inherent in psychotherapy practice. In this article, Wendt and colleagues review four paths to providing psychotherapy to Indigenous clients, but each path has their challenges. The first path is to offer on empirically supported therapies for specific identifiable disorders. However, out of the hundreds of clinical trials available, only six were conducted that specifically focused on American Indian clients and all for alcohol use problems. Most empirically supported therapies were not validated for use with Indigenous clients, and some argue that this may make these treatments potentially harmful. The second path is to culturally adapt interventions so that the original therapies are maintained but adapted to the needs and culture of the Indigenous population. Some research suggests that cultural adaptations result in moderately better outcomes. Deeper adaptations incorporate cultural beliefs and promote cultural identity and connections to the Indigenous community. However, cultural adaptations tend to preserve a disorder-centric approach to problems rather than seeing problems in terms of a balance between mental, emotional, and spiritual health. The third path involves emphasizing the psychotherapy relationship, the working alliance, and promotion of hope – also known as the common factors approach to psychotherapy. This is highly collaborative approach to how therapy progresses and to maintaining a reciprocal balance in the therapeutic relationship. However, this approach does not necessarily address the European cultural values inherent in most psychotherapies. The fourth path involves efforts to strengthen and revitalize traditional Indigenous practices and cultural education as a means of healing. These might include integrating sweat lodges, the Medicine Wheel, and talking circles. This path embodies a “culture as treatment” approach in which problems are seen within historical losses of identity, purpose, and place. A report from the Canadian Psychological Association and the Psychology Foundation of Canada calls for psychologists to “view themselves as facilitators and supporters of the healing wisdom and knowledge that is already present in Indigenous communities”. However, as Wendt and colleagues note, there are practical barriers to this approach, and even if “culture as treatment” is seen by some as self-evidently effective, it has rarely been researched.
Practice Implications
Mental health professionals should avoid being unwitting agents of assimilation when providing clinical care to Indigenous clients. Primarily, clinicians should maintain a stance of cultural humility. Traditional indigenous approaches to mental health are important as a long-term strategy, including traditional understandings of problems, traditional healing, and Indigenous-led cultural interventions. All of this, however, is limited by inadequately addressed colonial harms, poverty, and legal obstacles to Indigenous Nations’ sovereignty.
August 2022
Brief Online DBT Was Not Effective to Reduce Self Harm
Self-harm or non-suicidal self-injury is a significant problem that might affect 6% of the population seeking medical attention. And so, health systems are considering ways of scaling up treatments to reduce incidences of self-harm behaviors. Previous research showed that traditionally delivered dialectical behavior therapy (DBT) may reduce the incidence of suicide attempts. In this very large study of over 18,000 patients, Simon and colleagues tested whether two low intensity (and therefore low cost) outreach programs in addition to usual care provided to outpatients could reduce self-harm. Patients who reported suicidal thoughts in the past two weeks from several large health systems in the U.S. were randomly assigned to receive (1) care as usual, or (2) care management which included regular messages to motivate patients to follow-up with usual care, or (3) an interactive online program based on DBT supported by a skills coach that focused on mindfulness, current emotions, opposite action, and paced breathing. Both care management and the DBT based online program were in addition to usual care. The main outcome was fatal or non-fatal self-harm within 18 months. The results indicated that 3.10% of those who only received usual care experienced self-harm, 3.27% of those who received care management experienced self-harm, and 3.98% of those who received the online DBT based skills program experienced self-harm. A statistical comparison found a significantly higher risk of self-harm in the DBT based skills training group compared to usual care alone (hazard ratio, 1.29; 97.5% CI, 1.02-1.64; p = .015). When the authors looked at uptake or participation in the programs over a 9-month period, 17% of those who were offered usual care remained engaged in the program but only 2% of those offered the DBT based skills program remained engaged.
Practice Implications
This study is unusual in a couple of ways. First, it is very large and so it provides reliable findings that represent what might occur in actual practice. Second, the study reports a negative finding for a psychological intervention. The study indicates that trying to scale up a self-harm prevention program by providing it online even with live coaching resulted in significantly poorer outcomes than only usual care. Very few people (only 2%) continued with the online program after starting it. These results are similar to findings from previous research of online delivered therapy in which many people start but do not continue with such programs. Very few those who need mental health care want to interact with a program, and outcomes of such programs are modest at best.
Is Psychotherapy Equally Effective Across Age Groups? Rethinking therapy for children and adolescents.
There are now hundreds of controlled studies showing the efficacy of psychotherapy for depression. Most of these studies have focused on specific age groups, so that psychotherapies were tested for children, adolescents, adults, and older adults separately. Few studies have looked at whether psychotherapy has different effects across age groups. This information might be important because it may indicate that some therapies might have to be altered or specifically designed for the age group. In this meta-analysis, Cuijpers and colleagues collected all randomized controlled trials of psychotherapy vs no treatment, usual care, or some other control group for depression across age groups. They found 366 studies representing over 36,000 patients. The studies included those of children, adolescents, young adults, middle-aged adults, older adults, and older old adults. The overall effect size across all age groups was g = 0.75 (95% CI, 0.67-0.82) suggesting a moderate effect of psychotherapy for depressive symptoms at post-treatment. The effect size for children was the lowest (g = 0.35, 95% CI: 0.15-0.55, k = 15), and the effect size for adolescents (g = 0.55, 95% CI: 0.34-0.75, k = 28) was also low. Effects for middle-aged adults (g = 0.77, 95% CI: 0.67-0.87, k = 304), older adults (g = 0.66, 95% CI: 0.51-0.82, k = 69), and older old adults (g = 0.97, 95% CI: 0.42-1.52, k = 10) were not significantly different. Young adults consistently had significantly better outcomes (g = 0.98, 95% CI: 0.79-1.16) than the other age groups except when compared to older old adults.
Practice Implications
It is possible that psychotherapies for depression as currently tested in the research literature are less effective for children and youth. This may be because the treatments that are most often used with children and adolescents are age adapted versions of therapy originally designed for adults. Psychotherapy for children and adolescents are affected by parental and family characteristics, and that these contexts may not be adequately accounted for by the therapies as currently tested and practiced. In any case, this meta-analysis suggests that current therapies for childhood and adolescent depression may need to be reconsidered given their relatively lower effects.
July 2022
Are Humanistic Psychotherapies Effective?
Elliot, R., Watson, J., Timulak, L., & Sharbanee, J. (2021). Research on humanistic-experiential psychotherapies: Updated review. In Barkham, W., Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield's Handbook of Psychotherapy and Behavior Change (7th ed.). Wiley. Chapter 13.
Humanistic or experiential psychotherapies have a long history going back to the work of Carl Rogers and Fritz Pearls in the 1960s. This is a broad umbrella of therapies that include person-centred therapy, gestalt, emotion-focused, psychodrama, and existential therapies. Most of these therapies see the therapeutic relationship as central and curative. The therapist tries to enter the client’s subjective world with empathy to understand the client’s experience and to provide a validating and corrective emotional experience. The goals of humanistic-experiential therapy include self-awareness, personal growth, and meaning-making in clients’ lives. In this chapter, Elliott and colleagues review and update the meta-analytic evidence for the effectiveness and efficacy of humanistic-experiential therapy. The uncontrolled pre- to post-treatment change from receiving humanistic-experiential therapy estimated from 97 studies was .86 (k = 94; 95% CI [.74, .97]), representing a large effect. Clients maintained their immediate post-treatment gains during the year following therapy (ESw = .88; k = 41; 95% CI [.67, 1.1]) and beyond (ESw = .92; k = 15; 95% CI [.52, 1.31]). Compared to no-treatment control groups in 15 randomized studies, humanistic-experiential therapy showed a large pre-post effect ESwc= .98 (95% CI [.55, 1.20]). Compared to all other therapies in 56 randomized trials, humanistic-experiential therapy produced equivalent outcomes, (ESwc = –.07; 95% CI [–.21, .07]). The outcomes compared specifically to CBT in which only bona-fide humanistic-experiential therapies were included (i.e., only studies in which the humanistic-experiential therapies were meant to be effective) also indicated a non-significant difference, (ES = –.15; k = 9; 95% CI [–.27, .03]).
Practice Implications
Dating back to the work of Carl Rogers, humanistic-experiential therapies have had an important impact on how many types of therapy is offered today. The emphasis of many therapies on empathy, the therapeutic relationship, and corrective emotional experience are hallmarks of humanistic-experiential therapies. The results of these updated meta-analyses indicate that humanistic-experiential therapies are effective in the short and longer term and are as effective as other forms of well-research psychotherapies.