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 content from the updated edition of the Handbook of Psychotherapy and Behavior Change, published in 2021:therapist interpersonal skills, clinical supervision, and psychodynamic therapy.
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 2013
Do Therapists Cry in Psychotherapy?
Blume-Marcovici, A. C., Stolberg, R. A., & Khademi, M. (2013). Do therapists cry in therapy? The role of experience and other factors in therapists' tears. Psychotherapy. Advance online publication. doi:10.1037/a0031384
There is almost no research on therapists crying during psychotherapy, and on its correlates and impact. A survey of therapists’ ethical behavior conducted 25 years ago asked a single question about crying, and 56.5% of respondents indicated that they cried in the presence of a client. By contrast there are several such surveys in medicine. Notably, a study of medical students and interns found that 68% medical students and 74% of medical interns had cried with patients. A recent survey by Blume-Marcovici and colleagues is the first of its kind since it was devoted to therapists crying in therapy and associated factors. They defined crying as: “tears in one’s eyes due to emotional reasons”. The authors surveyed U.S. psychologists and had 541 respondents. The sample included 59% graduate students, and 41% licensed clinicians who had an average of 9.6 years experience. Seventy six percent were women, mean age was 36 years, 35% had a cognitive behavioural therapy (CBT) orientation, and 33% had some psychodynamic orientation (PDT). Respondents reported that 72% had cried in therapy. Those who cried reported crying in 6.6% of their sessions in the past 4 weeks. There were no differences between men and women, and there was no association between therapist crying and therapist personality traits or level of empathy. Therapists who cried more often in their daily life tended to cry more in therapy. PDT and CBT therapists did not differ in the amount they cried in their daily lives, however PDT therapists (88.9%) reported crying more often than CBT therapists (50.1%) in therapy. Further, older and more experienced therapists reported crying more often in therapy in the past month than younger and less experienced therapists. It is possible that older therapists may become more comfortable in using their clinical judgment, and so have fewer restrictions on their own affective displays. Of therapists who cried, 45.7% felt that the therapeutic relationship improved, and 1% reported that the relationship deteriorated due to crying. Patients, however, were not surveyed for their opinion about their therapist’s crying.
Practice Implication
Crying among therapists may happen relatively frequently. Although this study is novel, it is the only one of its kind so one should be cautious about drawing practice implication. The challenge of therapists crying in therapy is that it can bend or break the therapeutic frame (e.g., is the therapist crying because of being overwhelmed and acting on his or her own needs, or is the therapist genuinely responding for and with the patient?). The survey suggests that therapist crying can strengthen the therapeutic relationship. This is more likely true when the therapist is attuned to the patient’s needs, and when the crying signals a moment of positive emotional connection in the midst of painful feelings in the client. As with any event in therapy, a genuine and skilful exploration by the therapist and patient of the therapist’s crying has the potential to strengthen the relationship.
Author email: ablume@alliant.edu
February 2013
What To Do When a Patient Might be Suicidal
Fowler, J.C. (2012). Suicide risk assessment in clinical practice: Pragmatic guidelines for imperfect assessments. Psychotherapy, 49, 81-89.
The journal Psychotherapy regularly publishes Practice Reviews, which are clinician-friendly practical articles that are based on the best current evidence. Recently, James Fowler published a Practice Review on suicide risk assessment. The assessment, management, and treatment of suicidal patients are some of the most stressful events in clinical practice. However, there is very little that is clear in the evidence base to help clinicians to make accurate assessments about suicide risk. Assessing suicide risk factors tends to result in making an inordinate number of false-positive predictions (i.e., deciding that a patient will attempt suicide when in fact the patient will not attempt suicide). Making false positive suicide predictions might be seen by some as desirable because doing so represents a conservative course of action. However, a clinician acting as if a patient will suicide when he or she will not can lead to unintended negative consequences for the therapeutic alliance and for the patient’s future trust in health professionals. Fowler suggests an assessment approach in which efforts are made to enhance therapeutic alliance by negotiating a collaborative approach to assessing risk and understanding why thoughts of suicide are so compelling. The list of protective factors (e.g., supportive social contacts, religious beliefs, therapeutic contacts) and risk factors (e.g., past suicide attempts) based on the most current evidence are presented in the article in easy to read tables. Fowler also presents a list of clinician resources for suicide assessment and facts with handy web site addresses. For example, Fowler suggests the Suicide Assessment Five-step Evaluation and Triage (SAFE-T) that incorporates the risk and protective factors with the best evidence base.
Practice Implications
Most methods of predicting suicide risk result in false positives (i.e., predicting suicide when suicide will not occur). Though conservative, a false positive prediction of suicide risk can have a negative impact on therapeutic alliance and patients’ future trust in health care providers. Evidence-based assessments of risk and protective factors may help. A free SAFE-T pocket guide is available to download at the Substance Abuse and Mental Health Services Administration (SAMHSA) web site: http://store.samhsa.gov/product/SMA09-4432.
Author email: cfowler@menninger.edu
Does Participating in Research Have a Negative Effect on Psychotherapy?
Town, J. M., Diener, M. J., Abbass, A., Leichsenring, F., Driessen, E., & Rabung, S. (2012). A meta-analysis of psychodynamic psychotherapy outcomes: Evaluating the effects of research-specific procedures. Psychotherapy, 49, 276-290.
One of the main reasons that some clinicians do not participate in research is that they argue that doing so will have a negative impact on the therapeutic relationship, the therapy process, and patient outcomes. Although I have heard this from clinicians of many theoretical orientations, this opinion is perhaps most strongly held by some colleagues with a psychodynamic orientation. I identify with psychodynamic theory and practice, so this opinion about research held by some of my colleagues has been very disconcerting to me. Up to now, the best I could say in defense of practice-based research of psychodynamic therapy was to talk about my own experiences, which have been highly positive and rewarding. A recent meta analysis by Town and colleagues from Dalhousie University changes all that. (First, a note about meta analysis. Meta analysis is a statistical way of combining the effects of many studies, each of which has a number of participants, into a common metric called an effect size. By combining studies, the end result is more meaningful and more reliable than the results of any single study on its own.). The meta analysis by Town and colleagues had 45 independent samples and over 1600 patients. Results indicated that psychodynamic treatments for a variety of disorders (e.g., depression, anxiety, personality disorders) showed a significant large positive treatment effect – this is not new. What is new is that compared to conditions in which no research-specific protocols were introduced, conditions that did use research protocols were no different in terms of patient outcomes up to one year post treatment. There was even a significant small positive effect of these research protocols on outcomes from post treatment to one year post treatment. Research-specific protocols included video recordings of therapy sessions, therapists following treatment manuals, fidelity checks to make sure therapists were accurately doing psychodynamic therapy, and psychometric measurements of processes and outcomes
Practice Implications
Research protocols do not have a negative impact on psychodynamic therapy outcomes. Perhaps research protocols should be introduced into all therapies to improve longer term outcomes in addition to studying therapy procedures and processes that work.
Author email: joel.town@dal.ca
Increasing Attendance in Psychotherapy
Oldham, M., Kellett, S., Miles, E., & Sheeran, P. (2012). Interventions to increase attendance at psychotherapy: A meta-analysis of randomized controlled trials. Journal of Consulting and Clinical Psychology, 80, 928-939.
A great deal of clinical time can be wasted because of patient nonattendance at scheduled psychotherapy appointments. The financial costs of nonattendance are also high, and patients who need help but do not attend are not receiving help. Premature termination from psychotherapy is associated with poor outcomes. Previous reviews reported that premature termination rates in regular clinical practice ranged from 40% to 46.8%. Clearly this is a big problem for many psychotherapists and patients. Oldham and colleagues (2012) conducted a meta analysis of interventions to increase psychotherapy attendance. Their meta analysis included 33 randomized controlled trials (RCTs) representing 4422 patients. Interventions had a significant moderate effect on reducing premature termination and increasing attendance. Effective interventions included: giving patients a choice of appointment times, giving patients a choice of therapists, motivational enhancement interventions, preparing patients prior to psychotherapy on what to expect, attendance reminders, and providing information on how to make the best use of therapy. Participants with single diagnoses made better use of interventions than those with multiple diagnoses.
Practice Implications
Psychotherapists can improve attendance in psychotherapy by providing patients with choice of appointment times and therapists, by taking the time to prepare patients prior to therapy for what to expect in treatment and how to best make use of therapy, using motivational interventions, and by providing appointment reminders.
Author email: s.kellett@sheffield.ac.uk or p.sheeran@sheffield.ac.uk