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
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.
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.
Psychotherapist burnout affects patient outcomes
Delgadillo, J., Saxon, D., & Barkham, M. (2018). Associations between therapists’ occupational burnout and their patients’ depression and anxiety treatment outcomes. Depression and Anxiety, 35, 844-850.
Providing psychotherapy can be challenging for the therapist. Vicarious trauma, secondary traumatic stress, and compassion fatigue among psychotherapists are well documented. In addition, organizational conditions in publicly funded mental health programs like workload, safety issues, and lack of supervision and support can lead to higher rates of therapist burnout. Surveys document that between 21% and 67% of mental health workers experience burnout. Occupational burnout can take many forms, but it is typically defined as emotional exhaustion and disengagement that lead to lower levels of therapist empathy, engagement, and depersonalization. One could speculate that burnout among therapists leads to worse patient outcomes because of the impact of disengagement on the therapeutic alliance. However few if any studies examined the association between therapist burnout and patient mental health outcomes. In this study, Dalgillo and colleagues assessed therapist burnout and job satisfaction in 49 therapists, and they assessed depression and anxiety outcomes in 2223 of their patients. The therapists provided treatment as part of the UK’s Increasing Access to Psychotherapy (IAPT) program. The analyses controlled for therapist case mix. That means that differences between therapists’ caseload (patient level of impairment, social economic status, and severity of symptoms) were controlled so that the findings were unique to the effect of therapist burnout and job satisfaction on patient mental health outcomes. Higher therapist disengagement (an index of burnout) and lower therapist job satisfaction were significantly associated with poorer treatment outcomes for patients. In addition, higher burnout was related to lower job satisfaction among therapists.
Practice Implications
This is one of the first studies to show a direct association between therapist burnout and low job satisfaction with patient mental health outcomes. It is possible that these findings are specific to the UK’s IAPT program, in which therapists might feel a lower sense of control over their work. Nevertheless, organizations need to design mental health delivery in such a manner as to enhance psychotherapist autonomy, coping, and resilience, as these are likely related to therapist burnout and poorer patient mental health outcomes.
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
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.