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 therapeutic alliance, clinical training and interpersonal skills, and the impact of patient suicide on therapists.
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
May 2020
Effectiveness and Adherence of Telephone-Administered Psychotherapy
Effectiveness and Adherence of Telephone-Administered Psychotherapy
Castro, A., Gili, M., Ricci-Cagello, I., Roca, M., Gilbody, S., Perez-Ara, A., Segui, A., & McMillan, D. (2020). Effectiveness and adherence of telephone-administered psychotherapy for depression: A systematic review and meta-analysis. Journal of Affective Disorders, 260, 514-526.
The COVID-19 pandemic has resulted in psychotherapy providers moving to online and telephone-delivered interventions. But questions remain about the efficacy of delivering psychotherapy in these formats to patients with depression. Depression is highly prevalent as it affects about 320 million people around the world and causes serious disability and lowered quality of life. Psychotherapy is effective in treating depression, however there are significant barriers to people accessing face-to-face psychotherapy including cost, stigma, distance, and disability. Telephone-delivered psychotherapy may minimize these barriers. One potential question that may arise is whether patients will adhere to telephone-delivered psychotherapy. That is, will patients find telephone sessions acceptable as indicted by the rate of starting therapy and of attending sessions? In this systematic review and meta-analysis, Castro and colleagues evaluated whether telephone-delivered psychotherapy for depression is as effective as other active treatments and more effective than no-treatment. The authors also examined the level of adherence/acceptability to telephone administered treatment, determined by the percent of scheduled sessions actually attended by a patient. The sample of studies was small such the authors only found a total of 11 direct comparison randomized controlled trials. These trials represented almost 1400 patients. The only treatment tested in these trials were CBT-oriented. Four studies found that telephone-delivered therapy produced significantly larger reductions in depressive symptoms when compared to no treatment controls (mean SMD = -0.48; 95% CI: -0.82 to -0.14). In four other studies telephone-administered therapy was just as effective as an active control (e.g., medication or self-help). The weighted average percentage of scheduled telephone sessions that patients attended was 73%, and the percent of patients who started telephone therapy after the initial referral was about 90%. These percentages indicating adherence and acceptability are similar to findings reported from individual psychotherapy studies.
Practice Implications
There are few randomized controlled trials that assess the efficacy of telephone-administered psychotherapy, and these studies were limited to only one type of intervention. However, the findings from this meta-analysis suggested that telephone-delivered psychotherapy may be efficacious and as effective as some other active treatments. Further, telephone therapy may be acceptable to patients in that they start and attend sessions at a rate similar to face-to-face therapy. These preliminary findings provide clinicians who provide telephone psychotherapy during this period of physical distancing due to COVID-19 with some evidence for the utility of telephone delivered treatment.
Predicting Which Psychotherapists Will Adopt Telepsychology
Predicting Which Psychotherapists Will Adopt Telepsychology
Even prior to COVID-19, psychologists and psychotherapists were examining the use of telepsychology (telephone delivered psychotherapy and assessment). The interest arose from efforts to increase accessibility to psychological services for clients in rural and remote areas, and also for those for whom travelling to an urban centre was a significant barrier due to disability. However, there are barriers to psychotherapists’ use of telepsychology caused by: differing state and provincial laws and requirements, limits to working across state and provincial jurisdictions, issues related to insurance reimbursement, and concern that telepsychology and video conferencing platforms may not meet Health Insurance Portability and Accountability Act (HIPAA) or Personal Health Information Privacy and Access (PHIPA) requirements for confidentiality and privacy. In a previous study, close to 80% of psychologists felt that telepsychology could be effective, but 42% viewed telepsychology as less effective than face-to-face therapy, and 75% indicated that they would not likely refer to someone for telepsychology services. In this large survey of almost 1800 psychologists who practiced psychotherapy, Pierce and colleagues were interested in demographic, organizational, and clinical factors that predicted telepsychology-use by clinicians. The participants were 8.74 times more likely to use telepsychology if they worked in organizations that had policies supporting telepsychology-use compared to those who worked in organizations without such policies (p < .001). Nevertheless, psychologists in private practices were 2.86 times more likely to use telepsychology than those who worked in institutions. Also, psychologists who received training in telepsychology were 2.25 times more likely to use telepsychology than those who did not receive any training (p = .002). In terms of clinical practice areas, those who worked in sports performance, coaching, addictions, and parenting were more likely to use telepsychology. On the other hand, those who provided testing and evaluations were less likely to use telepsychology, likely because of practical limitations to psychometric testing online. Age and gender were not related to telepsychology use.
Practice Implications
Psychologists and psychotherapists who want to increase their comfort and satisfaction in working with telepsychology should consider getting professional development training and continuing education. In one study, over two thirds or psychologists perceived that they did not have sufficient training to use telepsychology. Organizations who want to encourage telepsychology should invest in training and provide clear policy guidelines to support professionals. The notion that older clinicians would be less likely to use telepsychology was not born out by these findings.
Once-Weekly or Twice-Weekly Sessions of Psychotherapy?
Once-Weekly or Twice-Weekly Sessions of Psychotherapy?
Some research has suggested that the number of sessions per week, not the total number of sessions received, is correlated with patient outcomes. It is possible that higher session frequency per week might lead clients to better recall the content of sessions, which in turn may lead to better treatment outcomes. Or perhaps, higher frequency of sessions might lead to a better therapeutic alliance and higher client motivation thus leading to better outcomes. Although previous research has suggested that more sessions per week is better, no study has ever directly assessed this issue until now. Bruijniks and colleagues conducted a large randomized controlled trial of 200 adults with depression seen across nine specialized clinics in the Netherlands. Researchers randomly assigned clients to receive either cognitive-behavioral therapy (CBT) or interpersonal psychotherapy (IPT) for a maximum of 20 sessions. Half of the clients in either type of therapy received the 20 sessions on a twice a week basis, and half of clients in each type of therapy received the 20 sessions on a once a week basis. The therapies were manualized, therapists were trained and supervised, and clients were carefully selected to meet criteria for depression. More patients dropped out of weekly (31%) compared to twice weekly (17%) therapy. There were no differences between CBT and IPT in depression outcomes. However, there was a significant effect of session frequency on patient outcomes in favor of twice weekly sessions (d = 0.55). Using a strict criteria of “recovery” from depression at 6 months post treatment, 19.6% of patients receiving once weekly therapy “recovered” compared to 29.5% of patients receiving twice weekly therapy.
Practice Implications
This large multi-site study has intriguing implications for practice. More frequent sessions per week may result in significantly better patient outcomes regardless of the type of therapy offered. Not surprisingly, IPT and CBT were equally effective. However, their effectiveness was limited in that only between 20% to 30% of patients recovered from depression. This finding is similar to the results previous trials, and speaks to the limitations of time-limited manual-based therapies for depression. Nevertheless, it appears that more frequent therapy per week may be a better option for some clients.
April 2020
Clients of Therapists Who Are Flexible Have Better Outcomes
Clients of Therapists Who Are Flexible Have Better Outcomes
Katz, M., Hilsenroth, M. J., Gold, J. R., Moore, M., Pitman, S. R., Levy, S. R., & Owen, J. (2019). Adherence, flexibility, and outcome in psychodynamic treatment of depression. Journal of Counseling Psychology, 66(1), 94–103.
Psychodynamic and cognitive-behavioral (CB) treatments are quite different in how therapy is delivered, but both are equally effective for depression. Such findings suggest that various types of specific interventions can positively impact client outcomes. A possible mechanisms of therapeutic action is that effective therapists may be particularly responsive to their clients’ behaviors and needs. That is, effective therapists may be flexible in how adherent they are to the techniques of a therapeutic orientation. Therapists who are flexible in their adherence to a therapeutic technique may promote a better therapeutic alliance (i.e., a therapist’s and client’s collaborative agreement on the goals of therapy and what to do in therapy). In this study, Katz and colleagues examined whether the flexible use of some CB techniques by psychodynamic therapists was related to better client outcomes in terms of depressive symptoms. Forty six patients diagnosed with depression were treated by 26 advanced graduate student therapists who were trained to practice psychodynamic therapy. Psychodynamic therapy techniques included: a focus on affect and affect expression, identifying relational patterns and patterns of thoughts and feelings, emphasizing past experiences and interpersonal relationships, working on the therapeutic alliance, and restructuring defense mechanisms. The researchers video recorded two early sessions of therapy which were independently rated to assess the degree to which therapists adhered to psychodynamic therapy principles or to CB therapy principles. Client depression outcomes were assessed pre- and post-therapy. Higher ratings of psychodynamic therapy adherence were related to better patient depression outcomes at post-treatment. In addition, the clients of psychodynamic therapists who used some CB techniques early in therapy had the best outcomes. In other words, the use of psychodynamic techniques was sufficient for clients to improve, but flexible use of some CB techniques by psychodynamic therapists provided added benefit. The CB techniques that were most often integrated by the therapists included: actively initiating topics and therapeutic activities, explaining the rationale of an intervention, focusing on the future, and providing psychoeducation about symptoms.
Practice Implications
Clients in this study improved on average from psychodynamic therapy, and psychodynamic interventions were related to better outcomes. However, clients of therapists who flexibly integrated a small amount of CB techniques benefitted more from the psychodynamic techniques. Research is increasingly showing that therapist flexibility in treatment adherence is related to better patient outcomes. For psychodynamic therapists, flexibility in treatment adherence leads to clients being more responsive to the interventions and having better outcomes.
The Effectiveness of Telepsychology Interventions
The Effectiveness of Telepsychology Interventions
Varker, T., Brand, R. M., Ward, J., Terhaag, S., & Phelps, A. (2019). Efficacy of synchronous telepsychology interventions for people with anxiety, depression, posttraumatic stress disorder, and adjustment disorder: A rapid evidence assessment. Psychological Services, 16(4), 621–635.
The arrival of COVID-19 as a global pandemic has led to public health authorities encouraging physical distancing, including in the context of psychotherapy. Many professional organizations and regulatory colleges have made similar calls, so that psychotherapists and mental health providers have had to come up with creative ways of continuing to provide care to their clients. Many therapists have turned to telepsychology – the provision of psychotherapy through telephone, video conferencing technologies, or internet based chat rooms. But what is the evidence for these modalities of care, is there adequate research to support their use, are they as effective as care as usual? In this rapid evidence assessment, Varker and colleagues review the existing empirical research on the efficacy of telepsychology programs. They only looked at synchronous telepsychology interventions (i.e., those interventions during which therapist and client are interacting in real time), and not asynchronous use of technology (smartphone apps and chat technologies in which therapist and client are not interacting in real time or are not interacting at all). Synchronous telepsychology is most similar to face to face psychotherapy, and likely the option adopted by most therapists during these times. Health care providers initially adopted telepsychology and telehealth to overcome barriers to access to health care and psychotherapy like distance, stigma, and transportation needs. With the global pandemic related to COVID-19, psychotherapists are increasingly using telepsychology to manage physical distancing requirements while providing services. Varker and colleagues focused their review on randomized controlled trials and meta-analyses, which researchers consider to be the highest level of evidence for an intervention. The authors found 24 studies that evaluated telepsychology interventions with clinical populations of adults who had depression, anxiety, or PTSD. They found good quality evidence for telephone-delivered therapy (11 studies) and video teleconference-delivered interventions (12 studies). That means that the studies of these modalities were high quality and so results were likely reliable. The evidence indicated that both of these modes of delivering psychotherapy were as effective as face-to-face or treatment as usual. The evidence for internet delivered text-based treatments was not of high quality (3 studies). There were too few studies of this modality, and their quality was low. And so, the authors determined that the evidence for text-based therapy was unknown.
Practice Implications
Research on telepsychology interventions is still quite new with a limited number of quality studies attesting to their efficacy. Nevertheless, the findings were promising for telephone delivered psychotherapy and videoconferencing telepsychology, such that psychotherapists can be reasonably confident in using these methods with clients. Text-based delivery of interventions had limited and poor-quality evidence. Psychotherapists should: first and foremost follow their regulatory college requirements for using telepsychology, check with their liability insurance providers, assess if their telepsychology platform is HIPPA compliant, assess if their clients are suitable for this modality, and follow best practices when using telepsychology.
The Interactive Nature of Countertransference
The Interactive Nature of Countertransference
Connery, A. L., & Murdock, N. L. (2019). An interactive view of countertransference: Differentiation of self and client presentation. Psychotherapy, 56(2), 181–192.
Countertransference in psychotherapy is ubiquitous – it is experienced by every therapist with many clients. An early supervisor of mine once quipped, “You might not be interested in countertransference, but it is certainly interested in you.” Countertransference refers to a therapist’s emotional, cognitive, behavioral responses that are triggered by a client, and that are caused in part by the therapist’s unresolved conflicts, sensitivities, or vulnerabilities. So, it is useful to consider countertransference as a result of an interaction between client factors and therapist factors. Research indicates that therapists’ experience of countertransference is related to negative outcomes in their clients, and that identification and management of countertransference results in better client outcomes. In this study, Connery and Murdoch posited that therapists who had lower levels of differentiation of self would experience higher countertransference reactions. That is, those therapists with lower ability to balance the inherent pulls of separateness and togetherness in interpersonal relations, and who had more difficulty maintaining a sense of self in intimate relationships would be more susceptible to the interpersonal pressures inherent in some psychotherapy relationships. The authors conducted a clever study in which 262 practicing psychotherapists of varying professions, orientations, experience, and ages completed some questionnaires. Then the researchers randomly assigned the therapists either to watch 10 video clips simulating a hostile and dominant patient (i.e., with features of narcissism or paranoia) or to watch 10 video clips simulating a hostile and submissive patient (i.e., with features of passive-aggression). After viewing the videos, researchers asked the therapists to describe their own emotional reactions to the client they viewed using a questionnaire that rates countertransference. In general, therapists tended to respond with over-involvement to the videos of hostile and submissive clients. However, those therapists with more problems with maintaining their sense of self in close relationships were particularly susceptible to feelings of over-involvement with these clients. On the other hand, therapists in general tended to respond with more under-involvement to the videos of hostile and dominant clients. However, those therapists who had more problems with maintaining a sense of self in relationships were not any more susceptible to these countertransference reactions compared to therapists with better differentiation of self.
Practice Implications
Differentiation of self indicates the capacity to develop a healthy balance of interpersonal relatedness and self-differentiation that allows one to balance emotional reactions and rational thought when under stress. This study suggests that therapists’ ability to manage closeness and distance in relationships affects the intensity with which they experience countertransference reactions towards clients who have passive-aggressive qualities. This provide further evidence that not only client characteristics, but also some therapist vulnerabilities play a role in determining countertransference reactions. The findings point to the importance of continued peer supervision and of personal therapy for psychotherapists so that they may be less susceptible to the stress inherent in their work, and so that their clients can achieve optimal outcomes.