Practice-Based Psychotherapy Research
To Improve The Wellbeing Of Our Community
PPRNet Blog: May 2014
At the PPRNet conference in November 2012 over 100 psychotherapy clinicians, researchers, and educators were very keen to receive ongoing information about psychotherapy research that is practice-oriented and presented in an easily readable format. And so the PPRNet Blog was born.
About once a month I will review and summarize two or three published psychotherapy research articles. As part of the summary, I will highlight the practice implications of the research.
Because of copyright issues, we cannot post the full text of the articles, but we will provide a link to the abstract on the publisher's web site. I will also post the author's email address. Most authors are very happy to share their work. So if you want a copy of the article send the author an email with a request for a pdf or reprint.
At the bottom of each review you can post a comment, and comment on your colleagues' comments. I will update these as frequently as possible.
If you have ideas for an article to review or a topic you would like to see covered, please send me an email at firstname.lastname@example.org.
Giorgio A. Tasca
Handbook of Psychotherapy and Behavior Change
Starting in March 2013 I will review one chapter a month from the Handbook of Psychotherapy and Behavior Change in addition to reviewing psychotherapy research articles. Book chapters have more restrictive copy right rules than journal articles, so I will not provide author email addresses for these chapters. If you are interested, the Handbook table of content and sections of the book can be read on Google Books: Handbook on Google Books.
Practice Research Networks
Castonguay, L., Barkham, M., Lutz, W., & McAleavey, A. (2013). Practice-oriented research: Approaches and applications. In M.E. Lambert (Ed.), Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change, 6th Edition (pp. 85-133). New York: Wiley.
In this chapter of the Handbook, Castonguay and colleagues (2013) review research methods and results associated with practice research networks (PRN). There is substantial evidence to show that psychotherapists often are not influenced by research findings when they prepare their case formulations and conduct interventions. As a result, clients may not be benefitting fully from nearly 60 years of research in psychotherapy methods and processes. There may be several explanations for this divide. Clinicians may perceive psychotherapy research, especially the emphasis on empirically supported treatments, as limited in its clinical relevance. Researchers may pay limited attention to concerns of clinicians when developing research strategies and treatment manuals. The end result is that clinicians feel disenfranchised from the research field, and therefore unaffected by the findings. Clinicians may pay more attention to psychotherapy research if they were more involved and “owned” the research and findings. One solution is to develop PRN based on a partnership of practitioners and researchers in which they collaborate on all aspects of a study; i.e., generation of ideas, implementation, and publication. Castonguay and colleagues (2013) report on the research generated by several PRNs in the U.S. The American Psychiatric Institute for Research and Education’s PRN (APIRE-PRN) conducted several studies including: one study that found that compared to White patients, African Americans were less likely to be prescribed second generation antipsychotic medications, which are considered to be the treatment of choice by psychiatrists; and a second study that reported that presence of a personality disorder, low Global Assessment of Functioning scores, and seeing a psychiatrist at a discounted fee was associated with treatment non-compliance. The Pennsylvania Psychological Association PRN (PPA-PRN) conducted several studies, including one study that found that better patient outcomes were associated with: higher expectancy for change among clients, lower client interpersonal problems, greater number of therapy sessions, and lower therapist case load. A second PPA-PRN study that I reported in my August 2013 Blog found that therapists’ efforts to foster clients’ awareness of their emotions, thoughts, and feelings were perceived as particularly helpful by both clients and therapists. Finally, the National Drug Abuse Treatment Clinical Trials Network (CTN) conducted several studies with the intent of bringing drug abuse researchers into the real world and creating opportunities for clinicians to participate in research. This network completed over 50 trials. For example, in one trial, researchers found evidence for better retention, treatment engagement, and family functioning for brief strategic family therapy compared to treatment as usual.
A qualitative study reported by Castonguay and colleagues (2010) indicated that clinician involvement in a PRN study fostered new learning as well as a sense of community with other professionals with shared goals. Therapists also indicated that their clients perceived their research participation as intrinsically meaningful and an opportunity to contribute to scientific knowledge. However, participating in a PRN had its challenges as well. Clinicians had to remember detailed procedures, at times practitioners had to depart from their clinical routine, and clinicians had to find time to complete questionnaires and other procedures. Castonguay and colleagues (2010) recommended that practice based research procedures in a PRN remain simple and clear, that clinicians have to have ready access to research staff for consultations, and that incentives have to be built in for clients and clinicians to participate. Studies in which research goals and clinical goals are indistinguishable are most likely to succeed.
Indirect Exposure to Trauma Can Lead to Job Burnout and Secondary Traumatic Stress Among Mental Health Providers
Cieslak, R., Shoji, K., Douglas, A., Melville, E., Luszczynska, A., & Benight, C.C. (2014). A meta-analysis of the relationship between job burnout and secondary traumatic stress among workers with indirect exposure to trauma. Psychological Services, 11, 75-86.
The concept of job burnout was originally developed to document negative consequences of work related exposure to stressful situations experienced by various professionals such as police officers, paramedic first responders, emergency room clinicians, etc. Job burnout can be defined as emotional exhaustion and disengagement. However, recent research on mental health providers has extended the focus beyond job burnout caused by direct exposure, to investigate the consequences of indirect exposure through contact with people who have experienced traumatic events, exposure to graphic trauma content reported by the survivor, or exposure to people’s cruelty to one another. These are sometimes referred to as secondary exposure or indirect exposure to trauma. Professionals indirectly exposed to trauma through their work could experience consequences or symptoms that have been conceptualized as secondary post-traumatic stress, vicarious traumatization, and compassion fatigue, which can collectively be called secondary traumatic stress (STS). STS may include three clusters of symptoms: intrusive re-experiencing of the traumatic material, avoidance of trauma triggers and emotions, and increased physical arousal. Compassion fatigue was defined as a substantial reduction in the mental health providers’ empathic capacity. Cieslak and colleagues (2014) conducted a meta-analysis to assess the strength of associations between job burnout and other psychosocial consequences of work-related indirect exposure to trauma in professionals working with trauma survivors. They reviewed 41 studies that included 8,256 workers. The association between secondary traumatic stress (STS) and job burnout in professionals was significant and large. Workers were more likely to experience compassion fatigue and emotional exhaustion compared to PTSD-like symptoms and depersonalization, however, even the association with PTSD-like symptoms and depersonalization was moderate and significant. Both women and men were susceptible to STS, but the effect was larger in women.
Burnout and other consequences of indirect exposure to trauma are likely to be high among mental health professionals. Burnout will affect professionals’ well being and quality of life, and will diminish their effectiveness with patients through reduced empathy and increased disengagement. Mental health professionals who are exposed to secondary trauma should be aware of the potential for negative personal consequences, and assess their own level of emotional exhaustion, empathic capacity, and engagement. Mental health professionals should seek help if they re-experience the events, engage in avoidance of trauma triggers and emotions, and experience heightened arousal. Taking care of oneself through consultation with trusted colleagues, change in work contexts, social supports, and personal therapy could help to forestall compassion fatigue and burnout. Educational programs to improve self awareness and mindful communication may reduce burnout in mental health professionals.
Beutler, L.E., Harwood, T.M., Michelson, A., Song, X., & Holman, J. (2011). Resistance/Reactance level. Journal of Clinical Psychology, 67, 133-142.
Patient resistance to psychotherapy is a persistent and perplexing problem. Resistance can be defined as patient behavior that is directly or indirectly contrary to therapist recommendations or to the health of the patient. However, the label “resistance” implies that the problem lies entirely within the patient, i.e., that the patient is the problem. Beutler and colleagues (2011) argue that it is more accurate to define the problem as “reactance”, which refers to the relational or co-constructed nature of psychotherapy. The notion of reactance (instead of resistance) suggests that the therapist also plays a role in the resistance, since the therapist is also responsible to create a context within which highly ambivalent clients do or do not thrive. Failure to thrive could be viewed as a poor fit between patient and therapy. Using social psychological theory, Beutler and colleagues conceptualized reactance as a state of mind aroused in the patients when he or she perceives their freedom to be limited by the therapy. A therapist may elicit resistant behavior from a patient by assuming more control of the patient’s behavior within and outside of the therapy sessions than is tolerable, by using confrontational techniques, and by creating and failing to repair alliance ruptures. Beutler and colleagues argued that therapist directiveness was a key factor in determining reactance in the therapy. Therapist directiveness refers to the extent to which a therapist dictates the pace and direction of therapy. Beutler and colleagues conducted a meta-analysis to assess if therapist directiveness was associated with poorer outcome in patients who were more resistant in therapy. The meta-analysis included 12 studies with 1,103 patients. They found that higher patient resistance was related to poorer outcomes, and the effect was moderate. The interaction between therapist directiveness and patient level of resistance directly affected outcomes, and this effect was significant and large. That is, greater therapist directiveness with patients who were more resistant resulted in poorer outcomes. Conversely, patients who were low in resistance responded well to more directive therapy.
Therapists should view some manifestations of client resistance as a signal that they are using ineffective methods. A therapist’s response to resistant states in a patient requires: acknowledgement and reflection of the patient’s concerns; discussion of the therapeutic relationship; and renegotiation of the therapeutic contract regarding goals and therapeutic roles. These therapist responses are designed to provide the patient with a greater sense of control over the process. High reactance indicates that a treatment should: de-emphasize therapist authority and guidance, employ tasks that are designed to provide the patient with control and self-direction, and de-emphasize the use of rigid homework assignments. As Beutler and colleagues indicate, resistance is best characterized as a problem of the therapy relationship (not of the patient) and as such, becomes a problem for the therapist and patient to solve. The skilled therapist can find a way to stimulate change and reduce a patient’s fear of losing control or freedom.