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.

November 2021

Emotional Experiences of Psychotherapists

Chui, H., & Liu, F. (2021). Emotional experience of psychotherapists: A latent profile analysis. Psychotherapy, 58(3), 401–413.

Working with client emotional experiences in therapy is a core aspect of the psychotherapist’s work, regardless of their theoretical orientation. And so, therapists’ performance and their own well-being may be impacted by their capacity to experience and regulate their own emotions. Emotional reactivity refers to one’s sensitivity, intensity, and duration of emotional experience. Emotion regulation refers to the capacity to manage and express emotions and may be considered an interpersonal competency for therapists. Such competency likely involves flexible expression of emotion and a capacity for empathy. A better understanding of how therapists experience emotions might inform therapists’ use of empathy to facilitate their work with clients. In this study, Chui and Liu surveyed 314 English speaking and 589 Chinese speaking psychotherapists and asked them about their experiences of emotional reactivity, their emotion regulation, and empathy. Their data allowed them to develop profiles of psychotherapists along dimensions of emotional experience. Three latent profiles emerged in both the English and Chinese speaking samples of therapists. The highest proportion of English-speaking therapists (58%) were categorized as “Calm Regulators”, which indicated therapists with low emotional reactivity and few problems with emotion regulation. Next, 34.4% of English-speaking therapists were characterized as “Moderate Experiencers”, and 7.6% were “Emotional Feelers”. The latter profile included therapists who were emotionally over-reactive and who had greatest difficulty with regulating their emotions. As one might expect, those with the Calm Regulator profile had higher capacity for perspective taking, higher empathic concern, and lower personal distress than therapists in the other profiles. Also, therapists who were older, with more education, female, and with a psychodynamic orientation were more likely to have the Calm Regulator profile. Results were remarkably similar in the Chinese speaking sample, in which Calm Regulators also reported higher levels of counsellor self-efficacy.

Practice Implications

Therapists with the “Emotional Feelers” profile (i.e., that have higher levels of emotional reactivity and more difficulty regulating their emotions) may be at higher risk of burnout and of being less effective in their work. As a profession we often discuss clients’ individual differences in emotional experience and emotion regulation, but we spend less time considering these important interpersonal competencies in therapists. Recent surveys suggest that almost 50% of therapists may be at high risk of mental health problems. Psychotherapists, trainers, and supervisors need to pay more attention to therapists’ capacity to regulate their emotions, and its impact on their capacity to be emotionally flexible and empathic with clients. Therapists might consider personal therapy as a means of building this capacity.
Therapists are Not Equally Effective Across Sexual Orientations

Drinane, J. M., Roberts, T., Winderman, K., Freeman, V. F., & Wang, Y.-W. (2021, October 14). The myth of the safe space: Sexual orientation disparities in therapist effectiveness. Journal of Counselling Psychology. Advance online publication.

In general, differences between therapists account for 5% to 10% of the variance in client treatment outcomes. Some of these differences can be accounted for by therapists’ capacity to adjust to or to work with diverse client characteristics. For example, certain therapists more effectively espouse cultural humility and pursue opportunities for cultural conversations than other therapists, and this likely affects client outcomes. Most of the research on therapist effects related to diversity has focused on race/ethnicity. Very few studies to date have looked at therapist differences regarding sexual minority statuses. Therapists can engage in unhelpful practices including microaggressions toward sexual minority patients. Microaggressions can be unintended or subtle expressions of prejudice that are harmful to the recipient. Microaggressions that sexual minority patients experience may include communicating that one’s sexual orientation is a cause of distress, minimizing the importance of sexual orientation identity, and over-identification with LGBTQ clients. Further, patients with sexual minority statuses are at increased risk for adverse mental health outcomes possibly caused by the experience of minority stress related to stigma, prejudice, and discrimination. In this study, Drinane and colleagues a sample of 1,725 clients treated by 50 therapists in a university counselling center. About 17.7% of the client sample endorsed a sexual minority status. An unexpected finding was that sexual minority clients did not have worse mental outcomes than heterosexual clients. However, therapists varied in the extent to which their clients improved and how that improvement varied by sexual orientation status. Some therapists had queer clients who experienced more change than their heterosexual clients, whereas other therapists had heterosexual clients who experienced more change than their queer clients.

Practice Implications

The findings of this study indicate that therapists influence their clients outcomes differently based on the clients’ sexual orientation identity. Those therapists whose queer clients had worse outcomes than their heterosexual clients may be inadvertently engaging in microaggressions. Professional development that focuses on increasing the ability to consider sexual minority client experiences may lead psychotherapists to respond to sexual minority clients without prejudice. Therapists should consider how their own values shape their behaviors and interventions across client populations.
Psychological Treatments for Panic Disorder

Papola, D., Ostuzzi, G., Tedeschi, F., Gastaldon, C., Purgato, M., Del Giovane, C., . . . Barbui, C. (2021). Comparative efficacy and acceptability of psychotherapies for panic disorder with or without agoraphobia: Systematic review and network meta-analysis of randomised controlled trials. The British Journal of Psychiatry, 1-13. doi:10.1192/bjp.2021.148

Panic disorder affects between 1.1% and 3.7% of the population, and panic symptoms can occur in about 10% of patients in primary care. Panic disorder is characterized by recurrent and unexpected panic attacks including heart palpitations, sweating, and trembling. Often, the fear of panic attacks results in avoidance of places or situations that might cause another panic attack. Sometimes, panic attack co-occurs with agoraphobia, or anxiety related to being in certain places or situations. Panic disorder can be debilitating and can also co-occur with depression or substance use disorders. In this network meta-analysis, Papola and colleagues systematically reviewed 136 randomized controlled trials of psychological therapies for panic disorder that included over 7,300 patients. The therapies included CBT, psychodynamic therapy, behavior therapy, EMDR and others that were compared to each other and treatment as usual (which often included minimal intervention). The most effective treatments compared to treatment as usual were CBT (SMD = -0.67, 95%CI: -0.95 to -0.39) and short term psychodynamic therapy (SMD = -0.61, 95%CI: -1.15 to -0.07). All other psychotherapies (EMDR, IPT, behavior therapy, third wave CBT, cognitive therapy, psychoeducation) were not more effective than treatment as usual. The authors also evaluated acceptability of the treatment to patients, which they defined as the dropout rates from the therapies that were offered. Behavior therapy and cognitive therapy were less accepted by patients than short term psychodynamic therapy and CBT.

Practice Implications

The results of this large network meta-analysis indicates that CBT and short-term dynamic therapy are efficacious treatments for panic disorder. The authors suggest that these treatments should be considered as first line interventions. These findings confirm a growing trend indicating the efficacy of psychodynamic therapies for panic and as well as for other common mental disorders.

October 2021

Sustained Response to Antidepressants and Psychotherapy

Furukawa, T.A., Shinohara, K., Sahker, E., Karyotaki, E., Miguel, C., ….Cuijpers, P. (2021). Initial treatment choices to achieve sustained response in major depression: A systematic review and network meta-analysis. World Psychiatry, 20, 387-396.

Two common treatments for major depression are antidepressant medications and psychotherapy, both of which have been tested in randomized controlled trials. Antidepressants are among the most prescribed medications, and an increasing number of patients are on longer-term use of these medications. However, it is unclear as to whether choosing antidepressant medication or psychotherapy at the beginning or the acute phase of depression will lead to a sustained response in the longer term. In this network meta-analysis, Furukawa and colleagues examine the important question: “which therapies can get me well and keep me well?” The authors selected randomized controlled studies in which antidepressants or psychotherapy, or their combination were prescribed and compared to each other or to a control condition (treatment as usual or placebo pill). In these studies, adult participants with major depression remained in the treatment or control condition up to 12 months post-treatment. Psychotherapies included many known treatments like CBT, behavioral activation, psychodynamic therapy, and interpersonal psychotherapy. This network meta-analysis included 81 trials representing over 13,000 patient participants. Combined psychotherapy plus antidepressant medication resulted in a more sustained response to treatment (better outcomes) in the long run than control comparisons (OR: 2.52, 95% CI: 1.66, 3.85). Psychotherapy alone was more effective in the long run than pharmacotherapy alone (OR: 1.53, 95% CI: 1:00 – 2.35). The advantage of combined treatment over antidepressants alone was about 14% to 16%, whereas the advantage of psychotherapy over antidepressants was about 12%. There were no differences in longer term effectiveness among the different types of psychotherapy.

Practice Implications

This study shows that the effects of psychotherapy when initiated in the acute phase of major depression (at the outset of symptoms) are enduring over a longer time frame. Psychotherapies outperformed antidepressant medications, standard treatment, and pill placebo. The results also suggested that adding pharmacotherapy to psychotherapy did not interfere with the enduring effects of psychotherapy. The authors suggest that treatment guidelines for depression should be updated to emphasize psychotherapy as the preferred initial treatment option.
Therapist Dishonesty

Jackson, D., Farber, B.A., & Mandavia, A. (2021): The nature, motives, and perceived consequences of therapist dishonesty. Psychotherapy Research, DOI: 10.1080/10503307.2021.1933241

There is very little research or writing about therapist dishonesty with clients. Psychotherapy relies on clients to be honest to establish a therapeutic alliance – but what about therapists? Honesty is different from therapist self-disclosure. Self-disclosure refers to private information that therapists may or may not choose to share about themselves. Dishonesty, on the other hand are words or behaviors that are meant to deceive or mislead. Dishonesty can be covert (implying something that was not completely true) or overt (deliberately providing misleading information). Therapists might justify dishonesty as being carried out to protect their clients from harmful information, although some lying might be done by therapists to protect their own self esteem. In this survey of over 400 psychotherapists, Jackson and colleagues examined the topics, frequency, and some reasons why therapists were dishonest with clients. The therapists who responded to the survey had similar demographics to those practicing in the United States. They were on average 46.25 (SD = 15.59) years old, female (72.8%), mostly White (83.3%), working in private practice (62.6%), with an average of 16.48 (SD = 12.66) years of experience, and working from a range of theoretical orientations. The top reasons for therapist covert dishonesty included lying about feeling emotionally or physically unwell, feeling frustrated or bored with the client, or liking the client. The top reasons for therapist overt dishonesty included lying about feeling emotionally unwell, not remembering something a client said in a previous session, appointment availability, not having had conversations about the client with others, and not paying attention during a session. Over 91% of therapists indicated that they at least once gave the impression of paying attention when they were not, 88% implied they were not available for a session when they were, over 85% gave the impression that a client was making progress when they were not, 84% indicated they gave the false impression about a reason for being late to a session, and 65% at least once explicitly told a client something untrue about their own mental health history. Less than 1% of therapists reported that they were never dishonest with a client. Despite almost all therapists reporting being dishonest on occasion, therapist dishonesty tends to be relatively infrequent.

Practice Implications

Most of the time, if a therapist is dishonest with a client it is motivated by the consideration of a client’s best interest. On the one hand, therapists should be tactful by keeping in mind the needs and wellbeing of each client when considering what to disclose. However, research on therapist self-disclosure indicates that clients are more likely to disclose information if the therapist is honest about themselves. And some clinical writers suggest that therapists’ attempts to conceal negative feelings is an unproductive strategy that steers therapists and clients away from difficult conversations that might deepen the therapeutic relationship. As a general principle, therapists must consider whether the covert or overt dishonesty is truly in the service of the client or whether it is to protect the therapist’s self-esteem by not acknowledging their own missteps or limitations.
The Therapeutic Alliance in Treating Posttraumatic Stress Disorder

Howard, R., Berry, K., & Haddock, G. (2021). Therapeutic alliance in psychological therapy for posttraumatic stress disorder: A systematic review and meta-analysis. Clinical Psychology and Psychotherapy.

The therapeutic alliance is a key therapeutic factor with a lot of research support. The alliance is the collaborative agreement between patient and therapist on the goals and tasks of therapy, and their emotional bond. A meta-analysis of 295 studies reported that the alliance is moderately and reliably related to patient outcomes, and that this effect cuts across therapy modalities, orientations, and diagnoses. Some clinical writers expressed concern that the alliance is more difficult to develop with patients with posttraumatic stress disorder (PTSD) because of psychological consequences of PTSD like avoidance, mistrust, emotion regulation problems that pose a barrier to developing an alliance. Further, the disrupted interpersonal relationships that is part of the PTSD experience may also inhibit the development of an alliance with a therapist. However, one could also argue that a strong therapeutic alliance that is characterized by an emotional bond between client and therapist might be highly therapeutic for patients with PTSD. This meta-analysis by Howard and colleagues is the first to systematically review the research on the association between the therapeutic alliance and patient outcomes following PTSD treatment. The meta-analysis included 12 studies of adults receiving treatment for PTSD. The aggregated correlation effect size was r = -.339 (95% CI: -0.436, -0.234) with low levels of heterogeneity among the studies indicating that the findings are reliable. The average effect size was moderate in size, robust to effects of an outlier, and there was little evidence of publication bias. The authors also conducted a sub analysis that indirectly compared in-person therapy (k = 8; r = -.323) to remote therapy (k = 4; r = -.390) in which they found no significant differences (Q(1) = 0.41, p = .524) in the alliance-outcome association.

Practice Implications

The findings add support to the larger research literature in psychotherapy about the importance of the therapeutic alliance to patient outcomes. In particular, the findings suggest that clinicians should develop a good therapeutic alliance when treating patients with PTSD in order to promote better outcomes. That is, therapists and clients must come to a collaborative agreement on what the goals of the therapy are and how the therapy will be conducted. In addition, developing an interpersonal therapeutic bond will help the patient to weather the challenges that are associated some PTSD treatments. The findings also suggested that the effect of the alliance was as strong when therapy was in-person versus remote – but this finding is not as reliable given the indirect nature of the comparisons.

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November 2021

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October 2021

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Psychotherapy Practice Research Network (PPRNet)