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.
…I blog about psychotherapy for borderline personality disorder, capacity to metnalize and therapy resistant depression, and negative effects of psychotherapy
Type of Research
- ALL Topics (clear)
- Alliance and Therapeutic Relationship
- Anxiety Disorders
- Attendance, Attrition, and Drop-Out
- Client Factors
- Client Preferences
- Cognitive Therapy (CT) and Cognitive-Behavioural Therapy (CBT)
- Combination Therapy
- Common Factors
- Depression and Depressive Symptoms
- Efficacy of Treatments
- Feedback and Progress Monitoring
- Group Psychotherapy
- Illness and Medical Comorbidities
- Interpersonal Psychotherapy (IPT)
- Long-term Outcomes
- 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
- Therapist Factors
- Transference and Countertransference
- Trauma and/or PTSD
- Treatment Length and Frequency
Early Maladaptive Schemas and Coping Make Psychotherapists Vulnerable to Burnout
Simpson, S., Simionato, G., Smout, M., van Vresswijk, M.F., Hayes, C., Sougleris, C., & Reid, C. (2018). Burnout amongst clinical and counselling psychologist: The role of early maladaptive schemas and coping modes as vulnerability factors. Clinical Psychology and Psychotherapy, Online first DOI: 10.1002/cpp.2328.
Burnout in health professionals has become a global problem, with between 21% and 67% of mental health professionals reporting high levels. Researchers define burnout as including three components: emotional exhaustion (feeling emotionally exhausted from the work), depersonalization (feeling disconnected from patients), and reduced personal accomplishment in one’s work. Burnout is related to reduced capacity to perform professionally and to provide adequate care to patients. Much of the research has focused on institutional and workload factors as causes of burnout in health professionals. However, interpersonal factors like therapists’ early maladaptive schemas and coping mechanisms may also increase vulnerability to burnout. Early maladaptive schemas are self-defeating core beliefs and patterns that are repeated throughout one’s life and that have their origin in early life experiences. Maladaptive coping are thoughts and behaviors that one repeatedly engages in an unconscious or automatic way to minimize the activation of early maladaptive schemas. Maladaptive coping might include detachment, self-aggrandizement, attacking others, or over-compliance. In this study, Simpson and colleagues surveyed 443 clinical or counseling psychologists in Australia to assess if in fact early maladaptive schemas and maladaptive coping predicted burnout over and above job demands like workload. The mean age of the psychologists was 42.93 years (SD = 11.53), most were women (80.4%), who were married (52.8%), had attained a Masters degree (45.6%), and worked either in outpatient mental health centres (39.7%) or in private practice (33%). Most of the therapists (67%) indicated that over 50% of their client work involved trauma. Of the sample, 49.7% indicated at least a moderately high level of burnout on a standardized questionnaire, with emotional exhaustion as the highest type of burnout. The most common early maladaptive schemas among the psychologists were unrelenting standards and self-sacrifice. Detached coping was the most common coping mode. In terms of predicting burnout, job demands accounted for 10% of the variance in burnout, early maladaptive schemas accounted for an additional 18% of the variance in burnout over and above job demands, and maladaptive coping accounted for an additional 6% beyond maladaptive schemas and job demands.
Work – life balance, managing clients with chronic and complex issues, and working with clients who experienced trauma can cause distress in mental health providers. Psychologists’ early maladaptive schemas like unrelenting standards and self-sacrifice in addition to maladaptive detached coping may represent the foundation of countertransference for some psychotherapists. These were significant predictors of therapist emotional exhaustion over and above workload. Psychotherapists would benefit from an increased awareness of their own early maladaptive schemas and coping mechanisms. Self-care, including professional development, consultations, peer support groups, and personal therapy throughout one’s career could reduce one’s susceptibility to burnout.
Politics in the Therapy Room during the Trump Era
Solomonov, N. & Barber, J.P. (2018). Patients’ perspectives on political self-disclosure, the therapeutic alliance, and the infiltration of politics into the therapy room in the Trump era. Journal of Clinical Psychology, DOI: 10.1002/jclp.22609.
Most studies of psychotherapy do not take into account the current political climate, and most therapists do not think about the impact of their politics on clients. Studies have focused on the effects of large historical-political events on therapy, but mainly in terms of client reactions to the events. Such studies typically assume that therapist and client shared or agreed on perspectives of the event. However, the 2016 U.S. presidential election was extremely polarizing and may represent one of those events in which clients and therapists do not agree. What if clients and therapists disagreed about the experience of the election and its aftermath – what might be the impact on their therapeutic alliance? To what extent are polarizing politics discussed in therapy, and how are these discussions experienced by clients? Solomonov and Barber conducted a national survey among 604 psychotherapy clients from the 50 U.S. states. The mean age of the sample was 33.82 years (SD = 11.10), 57% were women, 58% were Caucasian, 48% indicated that they voted for Hilary Clinton and 32% indicated that they voted for Donald Trump. Overall, 64% of patients indicated that they had spoken about politics with the therapist (66% of Trump supporters and 70% of Clinton supporters). Among Trump supporters, 38% of clients indicated that their therapist was a Republican, whereas 35% thought their therapist was a Democrat. Among Clinton supporters, only 14% said their therapist was a Republican and 64% perceived their therapist was a Democrat. Thirty percent of clients reported that their therapist explicitly disclosed their political views, and 38% of clients reported that even though their therapist did not explicitly disclose their political views the client could easily guess the therapist’s views. Clients who believed their therapist shared their political views reported significantly higher therapeutic alliance with the therapist than those who believed their therapist did not share their views. Clients who voted for Clinton reported significant increases in expression of negative feelings from before to after the election, whereas Trump supporters did not report a significant increase in negative feelings. Neither Trump nor Clinton supporters reported an increase in positive emotions pre and post election.
About two thirds of clients in the U.S. have political discussions with their therapists, and almost half wanted to talk more about politics during sessions. Even though general self-disclosure among therapists is relatively infrequent, political self-disclosure among therapists about the 2016 U.S. election seemed to occur much more frequently. It is possible that political instability and the polarizing political climate in the U.S. may contribute to more self-disclosure of a political kind among therapists. This could have an impact on therapy. Clients who perceived their therapists to share political views reported a better therapeutic alliance than those who had divergent political views from their therapist. Similarities in values between therapist and client have long been known to be associated with the therapeutic alliance. The study demonstrates that in the current political climate in the U.S., client perceptions of shared or divergent values with therapists make their way into the therapeutic space.
Lying in Psychotherapy: What Clients Don’t Tell Their Therapist
Blanchard, M. & Farber, B.A. (2016). Lying in psychotherapy: Why and what clients don’t tell their therapist about therapy and their relationship, Counselling Psychology Quarterly, 29, 90-112.
Clients’ disclosure of their thoughts and feelings are key aspects of psychotherapy, and trust is at the heart of the therapeutic relationship. However clients are not always honest with their therapist. Clients may keep secrets, hide negative reactions to interventions, minimize, spin, or tell outright lies. In this study, Blanchard and Farber asked: “what do clients lie about in therapy and why”. The authors used a broad definition of dishonesty that included: consciously twisting the facts, minimizing, exaggerating, omitting, and pretending to agree with the therapist. The authors excluded delusions, repression, denial, and other forms of unconscious deception. Blanchard and Farber were particularly interested in client dishonesty about therapy itself and about the therapist. The authors conducted an online survey of psychotherapy clients recruited from a community sample in a U.S. city, and 547 adult clients responded. The sample was surprisingly similar to a therapy-using population reported in the National Survey on Drug Use and Health. Most clients were women (78%), White (80%), saw a female therapist (71%), received CBT (35.4%) or psychodynamic therapy (18%), and were treated for depression (64%) and/or anxiety (49%) disorders. The survey asked about a wide range of possible topics for dishonesty such as use of drugs or alcohol, desire for revenge, pretending to agree with the therapist, etc. With this broad definition of conscious dishonesty, 93% of clients reported lying to their therapist, in which the average number of topics lied about per client was 8.4 (SD = 6.6). Those who lied more often also reported a general tendency in their lives to conceal negative personal information (r = .45). Only 6.8% of clients reported having told zero lies in therapy. Some topics were highly endorsed by clients – for example, 54% endorsed lying about “how badly I really feel – I minimized”, 25% did not disclose “my thoughts about suicide” and “my use of drugs or alcohol”. Other topics (endorsed by 5% to 25% of clients) included lies about eating habits, self-harm, infidelity, violent fantasies, experiences of physical or sexual abuse, and religious beliefs. About 72.6% of clients lied about at least one therapy-related topic, including: “pretending to like my therapist’s comments or suggestions” (29%), “reason for missing an appointment” (29%), “pretending to find therapy more effective than I do” (28%), “pretending to do the homework” (26%), “my real opinion of the therapist (19%), “not saying I want to end therapy (16%), and “my therapist makes me feel uncomfortable” (13%). Other items were relatively rare in the sample including “my romantic or sexual feeling about my therapist” (5%). Survey respondents were then asked why they were dishonest. Reasons why clients were dishonest included: “wanting to be polite”, “I didn’t want my therapist to feel he was bad at his job”, “I didn’t want to look bad or feel embarrassed”, “I would feel bad if I told her it really didn’t help me”, “wanting to avoid my therapist’s disapproval”, and “wanting to avoid upsetting my therapist”.
Using a broad definition of dishonesty, this study found that 93% of clients did not tell the truth in one way or another to their therapist. Concern about self-judgments (i.e., embarrassment) or external judgments (i.e., avoiding therapist’s disapproval) may lead most clients to be less than honest at some times. Over 70% of clients reported lying about an aspect of therapy itself or of the therapeutic relationship. Clients appear to be particularly sensitive to upsetting or disappointing their therapist. This suggests the importance of therapists monitoring the level of emotional safety, trust, and alliance in the therapeutic relationship. Therapists may have to accept a certain level of dissimulation by clients in the therapy. Engaging in empathy, positive regard, and a focused attention on the therapeutic relationship may be important for therapists in order to overcome a level of fear or distrust among some clients about their self-judgement or the therapist`s judgment. These findings suggest that clients may benefit from therapists who receive training in identifying and resolving therapeutic alliance ruptures.
Effectiveness of Psychodynamic Couple Therapy in a Naturalistic Setting
Hewison, D., Casey, P., & Mwamba, N. (2016). The effectiveness of couple therapy: Clinical outcomes in a naturalistic United Kingdom setting. Psychotherapy, 53, 377-387.
Current randomized controlled trials (RCTs) of couple therapy indicate that about 60% to 70% of couples improve to some degree, and that about 35% to 50% are no longer distressed by the end of therapy. But RCTs have been criticized for being somewhat artificial because their design is based on how pharmacological treatments are tested. Psychotherapy may be more complex than pharmacotherapy in its implementation, and compared to pharmacotherapy, psychotherapy relies more heavily on the qualities of the therapist and therapeutic relationship in order to achieve good outcomes. In an RCT, individuals often have to have a specific disorder to be included in the study, and those with co-morbid disorders may be excluded. This may limit what the findings have to say about real world applications of a particular treatment. Further, therapists in RCTs may receive unusual levels of supervision and support that is seldom seen in regular clinical practice. In this large study of over 435 couples, Hewison and colleagues assessed the effectiveness of a psychodynamically-oriented couple therapy as practiced in a large not-for-profit centre that provides psychological treatment (i.e., the Tavistock clinic in the United Kingdom). All participants received couple treatment and none were randomly assigned to a control group. The couple therapy focused on insight and emotional connection and expression within the context of a therapeutic relationship. The couple relationship rather than the individual partners were the object of the therapy. The unconscious meaning of couple communication was often discussed, and therapist countertransference was seen as a source of information about the couple. Most couples in the study identified as White (77.0%), heterosexual (93.9%), and married or living in a civil partnership (58.4%). More than half of the couples were in the relationship for over 5 years and had children. Therapists were qualified couple therapists or Masters level trainees, had a mean age of 50 (range: 26 – 71), tended to be White women (60%), and were all trained at the clinic. The average number of sessions that a couple attended was 23.3 (SD = 23.5), but with a wide range (2 to 150 sessions) as might be typical in a clinical setting. Overall, individual clients reported a large significant decrease in individual psychological distress (d = -1.04), and a moderate significant decrease in marital distress (d = -0.58). Half of individuals showed a reliable reduction in their individual distress, and over a quarter of couples reported a reliable decline in their couple distress.
This is the largest study of couple therapy in a naturalistic setting. The psychodynamic couple therapy was effective in reducing individual distress for almost half of the participants although reliable change in couple distress was lower. The results of this field trial indicate that couple therapy that is offered in a functioning real-world clinic setting produces results similar to what is seen in highly controlled randomized trials.
The Long Reach of Nurturing Family Environments
Waldinger, R.J. & Schulz, M.S. (2016). The long reach of nurturing family environments: Links with midlife emotion-regulatory styles and late-life security in intimate relationships. Psychological Science. DOI: 10.1177/0956797616661556.
Although, not a psychotherapy study, this research has important implications for psychological treatment of adults, including older adults. This research, drawn from the original Grant study, is extraordinary because the sample is from a 78-year long study of 81 men. The original cohort of over 200 men were first assessed as adolescents and young adults between 1939 and 1942. At that time, the original authors conducted intensive interviews of the adolescents` family experiences and current life situations. These men were re-interviewed in mid-life in the 1960s (aged between 45 and 50 years), which included interviews and assessments of challenges in relationships, work functioning, and physical health. Waldinger and Schulz recently re-interviewed these men and their current partner in late-life (aged between 75 and 85 years), with interviews focusing on their current partner relationship. Raters reviewed audio recordings and notes from all the interviews and coded for: (a) quality of family environment in childhood (distant, hostile vs cohesive, warm) - taken from the first interview; (b) style of regulating emotions (suppressive, maladaptive vs engaged, adaptive) – taken from the midlife interview; and (c) security of attachment with their current partner (secure, comforting vs insecure, anxious) – taken from the late-life interview. The authors found that more nurturing early family environments were significantly linked with late-life attachment security with a partner (r = .23, 95% CI = .01, .45), and early family environment was significantly related to midlife adaptive emotion regulation strategies (r = .29, 95% CI = .06, .50). Also, adaptive emotion regulation strategies in midlife were significantly correlated with greater late-life attachment security (r = .23, 95% CI = .05, .51). These are medium-sized correlations, but they are remarkable because they represent associations between variables that were assessed decades apart. Through a statistical mediation analysis, the authors also reported that adaptiveness of emotion-regulation strategies partially explained why positive childhood family environments may lead to late-life attachment security (accounting for 6% of the variance).
This compelling study adds to the argument that early family environment shapes the way adults regulate their emotions, which in turn affects how they experience relationships in old age. More securely attached adults were better able to meet two challenges associated with aging: accepting vulnerability in depending on a partner, and accepting the responsibility of being depended upon by that partner. The early family environment indeed has a long reach. Psychotherapy directed at reducing the effects of childhood adversity takes on a heightened meaning in the context of these findings. Treatment for adults who struggle with the consequences of non-nurturing early environments should include improving emotion regulation strategies.
Organizational Factors That Reduce Suicide Rates in the Population
Kapur, N., Ibrahim, S., While, D., Baird, A.,... Appleby, L. (2016). Mental health service changes, organisational factors, and patient suicide in England in 1997–2012: a before-and-after study. The Lancet Psychiatry.
Suicide is a major cause of death worldwide, and many recent public health efforts have focused on suicide prevention. Many studies have looked at social, psychological, and biological factors that may cause suicide, but few studies have examined the effects of health service contexts on suicide rates. In this large retrospective population-based study, Kapur and colleagues looked at over 19,000 suicides that occurred within England’s health services from 1997 to 2012. This represented 26% of all suicides in England. The researchers: evaluated economic climate, surveyed the clinic administrators and clinicians involved, and they reviewed policy, service, and staffing changes at each time point. Health care in England is organized nationally through the National Health Service, and the government also collected confidential survey data on deaths by suicide between 1997 and 2012. The researchers examined if specific policy changes and organizational factors affected suicide rates. Health system changes such as: (a) implementing the National Institute for Health and Care Excellence depression guidelines, (b) making available crisis and home treatment teams, (c) implementing policies on transfer from youth to adult care and (d) new procedures for managing patients with dual diagnosis were all associated with reduced suicide rates during the study period. One of the most interesting findings was that these changes to the treatment and management of depression, youth, crises, and dual diagnoses were much more effective in reducing suicide rates under two organizational contexts: (1) when non-medical staff turnover was low, and (2) when there was greater reporting of patient safety incidents. Lower staff turnover likely means that patients in those organizations received greater continuity of care and that suicidal or depressed patients were more likely to receive treatment from highly trained and experienced professionals. Greater reporting of patient safety incidents tend to occur in organizations in which the staff feels sufficiently safe and secure to report and discuss negative clinical events without fear of reprisal or punishment. Such reflective practice is likely critical to increasing staff expertise in providing psychological treatment.
Psychotherapists often do not think about the organizational context within which they work when considering the treatment they provide to those with mental health issues including people who may attempt suicide. Yet many psychotherapists work within an organizational context (e.g., hospitals, group practices, clinics, community health care centers, etc.). The findings from this study indicate that stability in staffing (i.e. low turnover) and working within a system that encourages reporting and discussing negative events likely has a positive impact on mental health outcomes like suicide.