Things to pay attention to at the beginning

Today, I look at three studies of the beginning of therapy. First, Mitchell, Mitchell, Shannon, Dorahy & Hanna (2023) published “Effects of Baseline Psychological Symptom Severity on Dropout from Trauma-Focused Cognitive Behavior Therapy for Posttraumatic Stress Disorder: A meta-analysis” in Traumatology. Here is the edited abstract:

A meta-analysis was conducted to explore the effect of baseline psychological symptom severity on treatment dropout among adults administered trauma-focused cognitive behavior therapy (CBT) for posttraumatic stress disorder (PTSD). Searches were conducted of PsycINFO, Web of Science, and SCOPUS and resulted in the identification of 12 studies with data received for 902 adult participants with a primary diagnosis of PTSD. Nine randomized control trials and three non-randomized control trials were included. The interventions in the studies were guideline-recommended and evidence-based treatments of prolonged exposure, cognitive processing therapy, and cognitive behavioral therapy for PTSD. The average dropout rate across the included studies was 41.5%. Findings revealed participants dropping out of treatment had higher clinician-rated PTSD symptom severity at baseline than those who completed, with a significant and moderate effect size observed (g = −.50, 95% CI [−.95, −.04], p < .05). No other findings were significant. Clinicians should be aware that clients whom they rate to have more severe PTSD symptoms are at a higher risk of dropping out of standard cognitive and behavioral therapies for PTSD. 

I thought this study is important because of the high dropout rate. It seems to me that this is helpful though more work must be done to take the next step regarding trauma-focused therapy strategies.

Next, Miller-Matero et al. (2023) published “Association of Health Literacy with Chronic Pain and Pain-Related Distress” in Professional Psychology: Research and Practice. Here are the edited abstract and impact staements:

Research suggests health literacy should be considered when treating chronic pain. The purpose of this secondary analysis was to examine the relationship of health literacy with pain and psychological functioning and to determine whether health literacy status was associated with outcomes after a brief psychological intervention for chronic pain. Participants with chronic musculoskeletal pain (N = 60) were randomized to a five-session psychological intervention or control group between September 2018 and February 2020. Participants completed a baseline and postassessment, which included measures of health literacy status (i.e., adequate vs. lower level), pain severity, pain interference, pain catastrophizing, depression, anxiety, and pain acceptance. Participants were mostly female (78.3%) and Black (88.3%) with a mean age of 62.2 years. At baseline, lower levels of health literacy were associated with greater pain severity (p = .003), pain catastrophizing (p = .03), and depressive symptoms (p = .02). Among those randomized to the intervention group, health literacy status was not related to engagement in the intervention. However, those with adequate levels of health literacy were more likely to have lower depressive symptoms (p = .045) and higher acceptance of pain (p = .01) at postintervention compared to those with lower levels. Among individuals with chronic pain, those with lower levels of health literacy may have worse pain and psychological functioning. 

This study suggests that among individuals with chronic pain, those with lower levels of health literacy may have worse pain and psychological functioning and may not benefit as much from psychological interventions for pain management. Clinicians delivering psychological interventions for chronic pain may want to consider screening for health literacy status and adapt the intervention to ensure understanding. 

Although this is an older sample mostly female and Black, it seemed to me that more people with chronic pain are living to be older. It may be worth following this advice.

Finally, Dias, Rathenau, Sousa & Santos (2023) published “Therapeutic Presence, Working Alliance, and Clients’ Attitudes Toward Online Therapy” in Journal of Psychotherapy Integration. Here again the edited abstract and impact statements:

The pandemic forced changes that had to be implemented quickly. One of them was the shift from face-to-face to online psychological counseling. The sample consisted of 225 participants (117 therapists and 108 clients) aged between 18 and 75 years. Data collection took place entirely online. The results showed high values for the instruments of therapeutic presence and working alliance from both therapists’ and clients’ perspectives. Clients’ attitudes toward online interventions were neutral. Previous experience was not found to have a significant effect on attitudes, therapeutic presence, or working alliance. However, clients’ attitudes toward online interventions were associated with therapeutic presence and working alliance (clients’ perspective) and correlated with therapeutic presence (therapists’ perspective). Clients’ attitudes toward online therapy are an important aspect of the online therapeutic process and should be assessed and considered before the start of this process. 

With the pandemic, online therapy presented itself as a way to continue doing psychotherapy and as a tool to manage the increased feelings of anxiety, depression, and loneliness caused by the pandemic. Both therapists and clients were forced to switch their practice to the online context without most of them having any prior experience and training with it. The results of the present study suggest that therapeutic presence and working alliance can be established in an online context, and that clients’ attitudes toward online therapy, although neutral, are associated with therapeutic presence and working alliance according to clients’ perspective. It is suggested that before starting an online psychotherapy process, client’s attitudes, beliefs, and fears toward online therapy should be assessed, as a way to improve online psychological support and/or psychotherapeutic services so that the client can have a service that meets his needs and preferences. Research on how to improve online psychological support services is scarce, and thus a significant research effort is needed to obtain practical recommendations for its practice. 

We know that online therapy isn’t going away and that therapists’ time is valuable. Like the first two studies, this one emphasizes the value in taking extra time at the outset in order to ensure therapeutic engagement and reduce premature dropout.