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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.

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.

December 2020

Psychotherapy for Those Who Do Not Respond to Treatment

Gloster, A. T., Rinner, M. T., Ioannou, M., Villanueva, J., Block, V. J., Ferrari, G., ... & Karekla, M. (2020). Treating treatment non-responders: A meta-analysis of randomized controlled psychotherapy trials. Clinical Psychology Review, 75, https://doi.org/10.1016/j.cpr.2019.101810.

Generally, there are a number of effective treatments for mental disorders including psychotherapy and medications. However, by some estimates, about 40% of patients with mood or anxiety disorders do not respond to these treatments. Research shows that patients who do not respond to initial treatments tend to have lower quality of life and higher mortality. By definition, treatment non-response indicates a failure of the treatment to achieve symptom reduction for patients. There is a research literature looking at the impact of introducing a subsequent treatment like psychotherapy for patients who do not respond to a previous treatment (most often a medication). In this meta-analysis Gloster and colleagues examined the efficacy of adding psychotherapy for patients who were not responsive to a previous treatment. They only included randomized controlled trials of patients diagnosed with mood or anxiety disorders. The authors found 18 studies of this kind that had 1734 participants. Most of the studies (80%) used medications as an initial treatment. The psychotherapies that were given to non-responders were quite varied including CBT, psychodynamic therapies, and DBT. The authors adjusted effect sizes downward for publication bias – or the estimated effects of negative studies that were not published. Even with that downward adjustment, adding psychotherapy after previous treatment non-response resulted in significant positive effect for patients in terms of reduced symptoms (SMD = 0.45; 95% CI: 0.16, 0.75). Similar findings were noted for quality of life. However, there was a lot of variability in effects across studies. Better outcomes were not associated with a particular diagnosis or treatment type. The positive effects remained significant at follow up, but they did not hold up after adjusting for publication bias (SMD = 0.359; 95% CI -0.349, 1.068, p > .05).

Practice Implications

The findings of this meta-analysis are promising for using psychotherapy for those who do not respond to initial treatment, mostly with medication. Both symptoms and quality of life improved moderately with a second round of treatment. This is notable because treatment non-responders may experience frustration and demoralization, and these patients tend to have chronic conditions that cause significant impairment. An important caveat is that the evidence for longer term improvements may not be reliable, and so it is not clear whether the positive effects are sustained. Offering a patient a re-start of treatment may help them to establish new hope for recovery if the subsequent treatment is framed as something different from the previous interventions that did not work for them.
How Useful Are Smartphone Apps for Mental Health?

Weisel, K.K., Fuhrmann, L.M., Berking, M., Baumeister, H., Cuijpers, P., & Ebert, D.D. (2019). Stand alone smartphone apps for mental health: A systematic review and meta-analysis. NPJ Digital Medicine, 2, 118. https://doi.org/10.1038/s41746-019-0188-8

Mental health and lifestyle apps are very popular. There are more than 318,000 health related mobile apps on the market, 490 of which are specifically about mental health. Most of the apps do not provide information about their effectiveness, and only 11% appear valid on the face of it. Apps are potentially useful to increase access to mental health treatments since smartphones are ubiquitous in the population. However, past reports show that the drop-out rates of unguided internet interventions for mental health are very high, only 17% of clients actually complete all the modules, the average client only completes about 16% to 25% of modules, and any positive effects often disappeared when assessed in the longer term. In this meta-analysis, Weisel and colleagues assess if standalone psychological interventions delivered by smartphone apps are efficacious for mental disorders. Their systematic review found 19 randomized controlled trials that directly compared a smartphone app to a control group (e.g., no treatment) for a variety of disorders (depression, anxiety, PTSD, sleep problems, substance use, suicidal behavior). Almost half of the interventions were CBT-based. Only 1 of the 19 studies had a low risk of bias – that is only 5% of studies were high quality in terms of sampling, randomization, data analysis, and so on. More than half of studies were very low quality. The pooled effect size from six comparisons for depression showed a positive effect of smartphone apps at post-treatment to reduce depressive symptoms (g = 0.33; 95% CI: 0.10–0.57, p = .005). Similar positive findings were found for smoking cessation. These effects are considered small by most standards. However, the findings from four comparisons for anxiety disorders were not significant (g = 0.30, 95% CI: −0.1 to 0.7, p = 0.145). Similar non-significant results were found for most other disorders as well. There were not enough studies to assess the longer-term effects of apps beyond immediately post-treatment.

Practice Implications

The main problem with this research area is that the quality of the studies generally is very low. Researchers have known for some time that lower quality studies tend to result in inflated treatment effects. So even if the meta-analysis found small significant effects of mental health apps for depression and smoking cessation, these findings are not likely reliable. Further, there is almost no research on the longer-term outcomes to assess if any positive effects are lasting. The research does not support the use of apps and computerized interventions as standalone treatments. They may be useful as an adjunct to traditional therapy or when they are provided with sufficient guidance by a therapist.
How Does Therapy Harm?

Curran, J., Parry, G.D., Hardy, G.E., Darling, J., Mason, A-M., Chambers, E. (2019). How Does therapy harm? A model of adverse process using task analysis in the meta-synthesis of service users’ experience. Frontiers in Psychology, 10:347. doi: 10.3389/fpsyg.2019.00347

Forty to 60% of patients do not recover after a course of psychotherapy, and approximately 5% to 8.2% are worse off. In the National Health Service in the UK, 5% of patients reported lasting bad effects of therapy. Although these appear to be small percentages, they represent a large number of patients. In Canada for example, over 1 million Canadians use psychotherapy each year, so 5% would represent 50,000 individuals. Therapists, for their part are poor at identifying patients who deteriorate in therapy. In this meta-synthesis of qualitative research, Curren and colleagues aimed to derive a model based on patients’ experiences of the factors that lead to negative outcomes. They conducted a narrative review of qualitative research findings and of patients’ testimony from a number of sources. They noted eight domains identified by patients that are associated with adverse events in psychotherapy. First, contextual factors refer organizational issues that affect access to or choice of therapy, cultural validity of the therapy, and lack of information about services. Second, pre-therapy factors refer to poor pre-therapy contracting between therapist and patient, and therapists that focus on symptoms rather than the client as a person. Third, therapist factors refer to therapist inflexibility, and therapists’ financial interests that influence their decisions about therapy. Fourth, client factors refer to client lack of understanding of therapy, fear, and demoralization. Fifth, relationship factors refer to a poor relational fit between therapist and patient, therapists perceived as shaming, therapists misusing power, and clients not feeling heard or understood. Sixth, therapist behaviors refer to boundary violations, rigidly applying techniques, therapist acting out, and therapist passivity. Seventh, therapy process refers to the type of therapy offered not matching patient needs, and patients not agreeing with the techniques. Eighth, endings refer to short term therapies that “open a can of worms” without resolution, and the client feeling abandoned.

Practice Implications

Therapists would do well to ensure that the patient’s voice is heard when it comes to preferences and cultural validity of the treatment. In particular, therapists should not rigidly apply techniques focused exclusively on symptom reduction. Instead, therapists should see patients’ problems within their interpersonal and cultural context and focus on outcomes related to the quality of life of patients. Therapists must attend to developing and maintaining the therapeutic alliance (agreement on tasks and goals of the therapy, and the relational bond with patients). Any signs of disruptions or tensions in the alliance should be identified and repaired. Patients require information about the therapy, what it entails, and how it will end before signing on to a course of treatment. Organizations must remove barriers to accessing treatment and provide therapies that represent a range of orientations and foci to meet patients’ needs.

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January 2021

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December 2020

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Psychotherapy Practice Research Network (PPRNet)