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Research in counselling and psychotherapy Post‐COVID‐19

Chance a. bell.

1 Department of Family Science, University of Nebraska Kearney, Kearney NE, USA

Sarah A. Crabtree

2 Albert & Jessie Danielsen Institute, Boston University, Boston MA, USA

Eugene L. Hall

Steven j. sandage.

3 MF Norwegian School of Theology (Oslo), Oslo Norway

The COVID‐19 pandemic brings to light many areas the field of counselling and psychotherapy may need to address in future research. We outline several issues stemming from or exacerbated by the pandemic and offer suggestions for future research to address the mental health needs of those impacted. Our suggestions focus on five domains: (a) the health and well‐being of helping professionals, (b) the infodemic, (c) discrimination and minority stress, (d) spiritual and existential dynamics in mental health and (e) couple and family stress and resilience. We aim to provide a multi‐systemic perspective of mental health and well‐being in the time of COVID‐19, as well as encourage current and future studies to incorporate these suggestions to advance the health and well‐being of our communities through evidence‐based treatment approaches.

Counselling and psychotherapy transformed almost overnight after most countries around the world imposed restrictions on public gatherings to reduce the transmission of COVID‐19. Many clinicians have moved their practices to a telemental health format and have worked with clients on unique issues arising from the COVID‐19 pandemic. News outlets and public health agencies reporting on the widespread mental health impact cite concerns of heightened stress, fear and loneliness (Lynch,  2020 ) as well as increased alcohol consumption (Cramer, 2020 ). The surge in mental health issues impacting nearly every domain of lived experience will require research addressing the unique issues stemming from COVID‐19. The current paper utilises a systemic framework on mental health based on the assumption of reciprocal influence between individuals and their multi‐dimensional relational and socio‐cultural contexts. We offer suggestions for future psychotherapy research in five inter‐related areas profoundly impacted by COVID‐19: (a) the health and well‐being of helping professionals, (b) the infodemic, (c) discrimination and minority stress, (d) spiritual and existential dynamics in mental health and (e) couple and family stress and resilience.

1. HELPING PROFESSIONALS

Frontline healthcare workers face unique challenges: increased infection risk, serving as the sole caretaker for many COVID‐19 patients or the last person with the dying, rationing resources to patients in need, balancing personal and patients’ health and well‐being and navigating duty to patients and family members (Greenberg, Docherty, & Wessely,  2020 ; Zheng, Lee, & Bloomer, 2018 ). These challenges existed prior to COVID‐19, but their frequency and intensity have increased dramatically. Such burdens may lead to moral injury or mental strain originating from actions, or lack thereof, that run counter to personal values (e.g., morals, ethics), increasing the risk of mental health challenges such as depression, anxiety, post‐traumatic stress, guilt and suicidal thoughts (Greenberg et al.,  2020 ). The potential for these evidenced effects to be amplified as a result of COVID‐19 warrants empirical attention. Although researchers have begun to indicate factors important in treating healthcare workers’ mental health (Kisely et al., 2020 ), more studies are needed to ensure clinicians are equipped to address their specific needs. Industries, including hospitals, may even consider adding mental health services for employees, similar to university counselling centres, which have become integral to student success and functioning (Vostanis & Bell,  2020 ). The interest, viability and sustainability of such programmes deserve further investigation, however.

Clinicians have also faced a number of challenges due to COVID‐19. Of specific interest should be continuity of care and clinician well‐being. The impact of telemental health on client–clinician relationships has received attention previously (Irvine et al.,  2020 ; Reese et al.,  2016 ); however, COVID‐19 forced psychotherapists to abruptly adopt telemental health modalities with little or no training, and the effects of this on clients and clinicians merit examination. Potential areas include effects on client–clinician relationships, effectiveness of overall and telemental health services, client types/issues most suited for telemental health services, altered safety of the shared therapy room, fluctuation of crises on clinicians’ caseloads (e.g., domestic violence has increased during the pandemic; Bradbury‐Jones & Isham,  2020 ) and therapeutic modalities appropriate for telemental health services. Such information will be critical for continued care and preparation for future crises, with priority given to the hardest‐hit regions.

If clinicians are indeed their best tool in therapy, their personal well‐being also warrants examination (Aponte & Ingram,  2018 ). COVID‐19 has increased demand on clinicians. Crises can increase the severity of clients’ symptoms, which require more of a clinician's time, attention and energy, and caring for others’ crises may feel especially challenging if clinicians struggle to cope with the effects of the pandemic. They have been equally exposed to the effects of the pandemic and experienced adversity. Understanding clinicians’ approaches to coping during COVID‐19 may inform practice, client outcomes and clinician self‐care in the future.

2. THE INFODEMIC

The effects of the infodemic, a phenomenon impacting public health efforts during COVID‐19, are salient to clinicians and deserve empirical attention. The World Health Organization defines an infodemic as “an over‐abundance of information—some accurate and some not—that makes it hard for people to find trustworthy sources and reliable guidance when they need it” (WHO, 2020 , p. 7). Waves of misinformation about COVID‐19 have been associated with a lack of proper social distancing behaviour, strained mental health, increased hate crimes and even the unnecessary loss of lives (Jones,  2020 ). Indeed, future research should assess the holistic impact of misinformation on mental health and overall well‐being.

The current infodemic raises concern about clients who irregularly access or are resistant to accurate and current recommendations, which may put themselves and their families at risk. Some resistance to safety practices may be rooted in religious and/or political beliefs. However, one study demonstrated that a functional fear of developing COVID‐19 predicted safety recommendation adherence (e.g., social distancing, increased hand washing) while moral and political beliefs did not (Harper, Satchell, Fido, & Latzman,  2020 ). Future studies should identify reasons for perceived resistance to recommended safety measures and potential strategies to balance individual and community needs. Conversely, information about safety practices may contribute to the development of extreme safety behaviours (e.g., excessive hand washing) stemming from obsessive/compulsive tendencies, especially when re‐entering social life. However, we agree with Harper et al.'s ( 2020 ) suggestion to “consider the context within which negative emotional states are experienced before considering whether such emotional states are necessarily pathological” (Conclusion, para. 2). We recommend researchers investigate the beneficial role of functional fears and identify promising practices to promote emotional self‐regulation and address existential fears. Research should also address the importance of accurate health information for how safety guidelines are internalised or on individuals’ capacities to think critically about recommendations from unreliable sources. Studies might also focus on treatment strategies for clients who become dysregulated by conflicting views on health practices in ways that intensify interpersonal difficulties.

3. DISCRIMINATION AND MINORITY STRESS

Misinformation has also contributed to increases in hate crimes, particularly for Asian and Pacific Islander (API) communities, in part since U.S. President Donald Trump began using the term “Chinese virus” instead of “coronavirus” (Kim,  2020 ). The U.S. state of Oregon indicated hate crimes increased by 366% in the spring of 2020 with about 20% of all reported incidents involving Asian and Pacific Islanders (Wilson,  2020 ). The UK has also seen an approximate 20% increase in hate crimes against API communities since COVID‐19 began (Grierson,  2020 ). The Federal Bureau of Investigations warned law enforcement agencies around the United States of the potential for increased hate crimes against groups associated with the spread of the coronavirus (Campbell,  2020 ).

The extensive and negative impact of minority stress on marginalised groups (e.g., overt discrimination like hate crimes) is well evidenced and deteriorates health and well‐being at individual, couple/family and community levels (Meyer,  2003 ). Researchers will likely see an increase in racial minority stress and related physical and mental health impacts. Carter, Lau, Johnson, and Kirkinis ( 2017 ) noted racial discrimination likely affects health, and over and above physical health or cultural outcomes, mental health warrants particular attention. Other minority groups have experienced unique stressors stemming from COVID‐19 as well. Lower‐income families, disproportionately families of colour, have had to navigate online learning without proper Internet service necessary for children's education. One in five Boston public school students have not logged in to their school accounts since March, and many are expected to be from lower‐income communities (Toness,  2020 ). Persons experiencing homelessness face constant exposure and increased safety concerns as many homeless shelters and resource centres have closed. A disproportionate number of homeless youths are LGBTQ, many of whom are considered extremely vulnerable in this pandemic (HRC, 2020 ). Other LGBTQ youth have been forced to quarantine in homophobic environments without reprieve through school or social activities (HRC, 2020 ). Research on specific clinical strategies to treat minority stress‐induced mental health issues remains limited, and future investigations should focus on the translation of this research into practice. Further, evidence‐based community interventions are needed to eliminate stigmatisation and discrimination towards minority groups (including youth) and to provide needed information that can simultaneously inform needed policy changes and mental health interventions.

4. SPIRITUAL AND EXISTENTIAL DYNAMICS IN PSYCHOTHERAPY

The COVID‐19 pandemic is generating massive and complicated dynamics of suffering and loss that may intensify the need for clinicians to address spiritual and existential dynamics in psychotherapy, as clients struggle with tragedy and uncertainty that can challenge prior belief systems or prompt stronger seeking within their meaning systems. Captari et al. ( 2018 ) conducted a meta‐analysis showing spiritually and religiously adapted psychotherapies tend to be as effective as other secular psychotherapies and more effective for spiritual outcomes. However, psychotherapy researchers might explore ways spiritual and existential dynamics uniquely emerge in this context of global destabilisation and loss. For example, there is growing evidence that spiritual and religious (SR) struggles with the sacred (e.g., doubt, anger at God or the Sacred, absence of meaning) are relatively common but can be linked with mental health problems (Pargament & Exline, 2020 ) and predict difficulties in psychosocial functioning (Sandage, Rupert, Stavros, & Devor,  2020 ). Future studies might track SR struggles during the course of psychotherapy to see whether (a) reducing these struggles predicts unique variance in treatment outcomes and (b) certain intervention strategies might be particularly efficacious with clients who score high in SR struggles.

Existential struggles include a diverse set of anxieties about existence and human finitude that can apply to clients with or without SR commitments. Death anxiety is the ultimate existential struggle, and traumatic events such as COVID‐19 can activate ongoing fears about mortality. Symptoms of PTSD and other anxiety disorders can be associated with a variety of existential concerns, including anxieties about death, fate, control, contamination, loss, estrangement and others (Sandage et al.,  2020 ; Weems, Russell, Neill, Berman, & Scott,  2016 ). Psychotherapy researchers might seek to understand the effects of differing forms of existential anxiety on clients’ specific symptom profiles, as well as client strengths or coping strategies that can mitigate these effects. For example, Kesebir ( 2014 ) found support for the hypothesis that humility represents a virtuous form of “quiet ego” (p. 610) that can buffer the impact of death anxiety. Steele ( 2020 ) noted the importance of attachment and reflective functioning research for the current pandemic and called for interventions that serve to “mentalize fear” (p. 97).

Strengths and virtues like humility, gratitude, forgiveness, mindfulness, hope and other widely studied constructs in positive psychology might be important predictors of client resilience and well‐being in this COVID‐19 context (Polizzi, Lynn, & Perry,  2020 ). Jankowski et al. ( 2020 ) argued to move psychotherapy research towards a dual focus on outcomes of symptom alleviation (the traditional focus of mental health care) and enhanced virtue and well‐being. COVID‐19’s differing impacts appear to be resulting in a variety of trajectories for different clients, including increased symptomatology, increased well‐being and a combination of the two. We recommend psychotherapy researchers include measures of both symptoms and well‐being and seek to understand therapeutic processes and interventions that not only reduce symptoms but also facilitate the up‐regulation of positive affect, virtue and well‐being. This will also require research that attends to systemic, socio‐economic and other contextual factors of privilege and oppression that can impact client well‐being, as well as sensitivity to diverse definitions of well‐being across cultural and SR traditions.

Relational disconnections around pandemic suffering also point to the need for psychotherapy research on complicated and traumatic forms of grief. Many people have suffered death in isolation with limited or no direct family contact, and this lack of physical connection is often compounded by complications to death rituals such as funerals and burial. These unique challenges to social connection in grieving processes may contribute to higher prevalence rates of prolonged or complicated grief disorders, and further research is needed on psychotherapies for those disorders. While communities of ritual (e.g., religious congregations) face new limitations for “hands on” involvement in the grief process, it will be useful to investigate the therapeutic role of technology‐assisted community supports and other emerging forms of adapted ritual process to facilitate healing and meaning‐making in the face of grief.

5. COUPLES AND FAMILIES

Social distancing guidelines and shelter‐in‐place advisories have affected families in extraordinary and unprecedented ways. One of the most salient challenges has been the pandemic's deleterious toll on the economy. Alarming rates of job loss and reduced wages have left families feeling the strain of economic hardship with uncertainty about when or whether they will recover, and those who were already financially disadvantaged seem especially at risk (Parker et al., 2020 ). Previous research has documented the detrimental effects of financial stress on family relational processes, for example parental emotional distress and couple conflict leading to harsher parenting styles and more externalising behaviours in children (Neppl, Senia, & Donnellan,  2016 ), as well as financial distress impacting marital quality through couple demand/withdraw patterns (Barton, Futris, & Nielsen,  2015 ). Research on the impact of COVID‐19’s economic toll should examine how family relational processes are affected and subsequently contribute to individual and relational outcomes.

Families have also been affected by the loss of structured support found in extrafamilial systems, such as schools, childcare facilities or physical workplaces, leaving families with the responsibility to cover their functions alone. While families have likely struggled as a result of these losses, we also suspect many families have found creative solutions and urge researchers to examine indicators of resilience and coping alongside indicators of stress. Families have also spent considerably more time together, and researchers should investigate how extended periods of confinement have contributed to changes in family stability and functioning. While some families may be flourishing, seclusion from others and seldomly leaving home might also strain relationships or create safety concerns. China has reported rising divorce rates following stay‐at‐home orders (Landsverk,  2020 ), suggesting time together in isolation may exacerbate pre‐existing issues or create new problems. Reports of domestic and sexual violence are also on the rise (Bradbury‐Jones & Isham,  2020 ). Family violence is known to increase during times when access to others (e.g., teachers, friends), who might notice signs of abuse or help victims access services, is limited (Boutilier, Jadidzadeh, Esina, Wells, & Kneebone,  2017 ).

Families have been affected in countless other ways. Loved ones in nursing homes or hospitals have been unable to receive visitors. Families have remained connected through video calls. Fertility clinics have closed, disrupting couples’ attempts to conceive children. As the pandemic unfolds, we urge clinicians and researchers to seek nuanced understanding of the ways families have been affected by various forms of loss, interruption of goals and ambiguity in decision‐making. In addition to what families have experienced, investigating how families have responded to the changes imposed upon them will be important. Family stress and resilience scholars have found family coping largely depends on a family's perception of a stressful event and their awareness of and access to resources available to meet its demands (Price, Price, & McKenry, 2014 ). Others suggest that flexibility in family roles and rules (as opposed to rigidity or chaos) and cohesion (as opposed to disengagement or enmeshment) is most conducive to successfully navigating periods of change (Olson,  2011 ). While there may be fewer opportunities to directly intervene in the ways the pandemic has affected families, researchers are well positioned to examine the meanings families have created about their experiences, resources they have identified and accessed, and how relational functioning has been affected or contributes to individual and familial outcomes.

6. CONCLUSION

We have offered a perspective on some key directions for the research on counselling and psychotherapy in response to COVID‐19. These suggestions include increased attention to frontline healthcare workers, clinicians and the therapeutic process, the effects of information about COVID‐19 and associated risks, discrimination and minority stress, engagement of spiritual and existential dynamics in psychotherapy and the impact on families. Clinicians may feel overwhelmed given the uncertainty and uncontrollable factors related to COVID‐19, but research from previous crises or on adapting to stressful situations can inform clinical practice until research offers more pointed suggestions. While we urge the field to move forward with such endeavours, we recognise other areas of research may be warranted and exhort researchers to use their ingenuity and creativity to address the challenges created by the pandemic.

ACKNOWLEDGEMENTS

This project was supported by a grant (#61603) from the John Templeton Foundation on Mental Healthcare, Virtue, and Human Flourishing.

Biographies

Chance A. Bell has published on the quantitative analysis of couple relational and mental health, and psychotherapy effectiveness in North America, Europe and Southern Asia. He is a member of the International Advisory Board of Counselling and Psychotherapy Research.

Sarah A. Crabtree ’s clinical and research interests include the intersections of religion and spirituality, couple relationships, intercultural competence, systems of power and inequality, positive psychology and substance use.

Eugene L. Hall concentrates his research and clinical work on LGBTQ issues, minority health, couple and family therapy, positive psychology and resilience.

Steven J. Sandage focuses his research and clinical practice in the areas of spirituality and psychotherapy, positive psychology, couple and family therapy, personality disorders, and intercultural competence and social justice.

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All authors have an equal authorship.

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• March 15, 2024 | VOL. 77, NO. 1 CURRENT ISSUE pp.1-42

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Recent Developments in Group Psychotherapy Research

• Jenny Rosendahl , Ph.D. ,
• Cameron T. Alldredge , M.S. ,
• Gary M. Burlingame , Ph.D. ,
• Bernhard Strauss , Ph.D.

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This article reviews group psychotherapy research published within the past 30 years, predominantly focusing on outcomes of group treatments for patients with various mental disorders. Additionally, meta-analyses on the efficacy of group treatments for patients with cancer or chronic pain are summarized. Results strongly support the use of group therapy and demonstrate outcomes equivalent to those of individual psychotherapy. The research also appears to emphasize the effect of feedback on outcomes in group treatments and an association between treatment outcomes and group cohesion and alliance. Other promising developments in the field of group therapy are discussed.

Research on group therapy over the past 30 years has been summarized in 11 meta-analyses, including 329 randomized controlled trials and 370 comparisons between group therapy and various control groups, together involving over 27,000 patients.

Meta-analytic results demonstrate that group therapy is effective compared with nonactive treatment and is equivalent to other active treatments for various mental disorders.

Group therapy treatments have recently been applied to patients with a variety of medical conditions, such as neurological diseases, cancer, and chronic pain.

Increasing emphasis is being placed on conducting studies that use feedback measures to help therapists identify patients likely to experience failure in treatment and/or in the therapeutic relationship.

Editor’s Note: This article is part of a special issue on group psychotherapy with Guest Editor Fran Weiss, L.C.S.W.-R., B.C.D. Although authors were invited to submit manuscripts for the themed issue, all articles underwent peer review as per journal policies.

In 2018, after a lengthy effort, the American Psychological Association decided to recognize group psychotherapy as a specialty, thus making it a defined area of practice requiring specific knowledge and skills gained through organized education and training. This decision was based on evaluation of the empirical, theoretical, and clinical literature on group treatments. The findings were so convincing that group psychotherapy was posited as an area for further education equivalent to those of clinical or counseling psychology. Indeed, the American Psychological Association group specialty petition referenced specific training programs in North America that emphasized group psychotherapy and the longstanding efforts of the American Group Psychotherapy Association to train clinicians at pre- and postdegree levels.

Since 1971, research in all areas of psychotherapy has been regularly summarized in the Handbook of Psychotherapy and Behavior Change , originally written by Allen Bergin and Sol Garfield ( 1 ). In 2021, the 50th anniversary year, the seventh edition ( 2 ) of this book will be published, and most of the chapters for this new edition are already available. We discuss some elements of the chapter on group psychotherapy ( 3 ) in this review.

Two authors of this review (G.M.B., B.S.) summarized the research on group therapy for the Handbook ’s fifth and sixth editions ( 4 , 5 ). The forthcoming edition continues a long history of research cooperation and has refined the methods used to produce the summaries of evidence. In the early years of research on group psychotherapy, studies tended to focus on smaller samples, usually without much control of potential influencing factors. The past 20 years have seen a shift in the general standard of group psychotherapy research, as evidenced by many controlled, carefully planned studies with larger samples and rigorous methodology. These developments in the research have contributed to advancement beyond narrative summaries (as was the case in previous editions of the Handbook ’s chapters on group psychotherapy) ( 4 , 5 ) and have led to the more reliable meta-analytical summaries about various disorders.

Research on Group Psychotherapy Outcomes

The Handbook ’s previous chapters on group psychotherapy ( 4 , 5 ) were based on a simple model that identified potential variables influencing group treatment outcomes. The “five influencing factors model” served as the ordering principle for the literature reviews and is still considered useful in reflecting on group therapy in practice and supervision. The five factors include formal change theory, group dynamics, structural aspects of groups, characteristics of group participants, and characteristics of the group leader. Together, these variables work to define the group process and provide information regarding the form and function of groups.

Following a model by Barlow ( 6 ), the latest group therapy chapter is built on a conceptual model in which different types of therapeutic groups are distinguished from each other ( Figure 1 ). This model outlines three main types of therapeutic groups: leaderless groups (which mainly play a role in self-help and addiction treatment), psychoeducational groups (which are important in psychiatric settings and increasingly within day hospitals), and therapeutic groups that are either manual or model based. Manual-based groups are typically short term and are primarily designed according to specific therapy orientations or formal change theories (e.g., group analysis or cognitive-behavioral therapy [CBT]). For example, in short-term group analysis, techniques focus on a specific conflictual theme, and CBT techniques, such as exposure or cognitive restructuring, are applied. Model-based groups are less structured and focus on principle-based interventions tailored to the developmental stage of the group as a whole in addition to those of individual members.

FIGURE 1. Conceptual framework for organizing group therapy treatments a

a Adapted from Burlingame and Strauss ( 3 ).

Meta-Analyses on the Efficacy of Group Therapy in Treating Mental Disorders

Because of the long tradition of research on group psychotherapy and the growing importance of evidence-based standards, a large number of randomized controlled studies (RCTs) on the efficacy of group psychotherapy are available. Since 2013, numerous meta-analyses have been published through international cooperation among colleagues from the United States (Gary Burlingame, Brigham Young University), Germany (Bernhard Strauss and Jenny Rosendahl, University of Jena), Canada (Giorgio Tasca, University of Ottawa), and Italy (Gianluca Lo Coco, University of Palermo). In a joint effort, 11 meta-analyses have been conducted, including 329 RCTs (370 comparisons between group therapy and various control groups) and more than 27,000 patients. In the new edition of the Handbook ( 2 ), the evidence on group therapy is summarized according to the highest level of evidence-based research, allowing for specification of direction and strength of differences between treatment conditions ( 7 ), calculation of overall effect, and estimation of heterogeneity on individual study effects ( 8 ). Figure 2 provides an overview of the disorder-specific findings of the individual meta-analyses.

FIGURE 2. Meta-analyses results, by disorder and control condition a

a Effect sizes of 0.2 were interpreted as small, 0.5 as medium, and 0.8 as large ( 7 ). Heterogeneity was considered nonexistent if I 2 =0% and was quantified as low, moderate, and high with upper limits of 25%, 50%, and 75% for I 2 , respectively ( 8 ).

*p<0.05, **p<0.01, ***p<0.001.

To date, 11 different meta-analytic summaries ( 9 – 19 ) have been based on RCTs examining the efficacy of group psychotherapy for patients with mental disorders. In comparison to untreated control groups (e.g., waitlist control groups, minimal contact conditions), group psychotherapy has demonstrated large effects on the reduction of disorder-specific symptoms associated with anxiety, obsessive-compulsive disorders, and depression. For eating disorders (e.g., bulimia, binge eating disorder) and posttraumatic stress disorder (PTSD), medium effects have been found ( 12 , 14 ). Additionally, small effects have been shown for substance use disorders and schizophrenia ( 16 , 17 ).

Comparisons to active treatment conditions (e.g., individual psychotherapy, pharmacotherapy, inpatient or outpatient treatment as usual) have yielded a more complex picture. Compared with inpatient or outpatient treatment as usual, group psychotherapy has demonstrated significant advantages with medium to large effect sizes on disorder-specific symptoms for patients with depression, bipolar disorder, and borderline personality disorder ( 15 , 19 ). Specific comparison with pharmacotherapy ( 11 , 19 ) has been available only in the context of obsessive-compulsive disorders and depression, with no significant differences found.

In comparisons between group psychotherapy and individual psychotherapy, disorder-specific findings have been identified for obsessive-compulsive disorders (no differences) and substance-induced disorders (small effect in favor of group therapy). In a meta-analytic summary comparing group and individual therapy across various disorders ( 10 ), 46 studies with equivalent treatments (treatment protocol, patients, dosage) across formats demonstrated similar effectiveness (effect size g=–0.01), in addition to 21 studies with nonequivalent treatment approaches (g=–0.06). Furthermore, in all comparisons of individual and group therapy, there were no differences in the rates of acceptance (i.e., patients in groups expressed the same level of satisfaction as those in individual therapy), remission, improvement, or premature termination. In sum, meta-analytic results demonstrate that treatment in small groups is effective compared with nonactive treatment and is equivalent to other active treatments.

A majority of studies in these meta-analyses examined group CBT approaches in the broadest sense, which included third-wave methods such as mindfulness-based therapies. Exceptions were mostly found in the efficacy research on treatments for borderline personality disorder ( 15 ), eating disorders ( 12 ), and PTSD ( 14 ), which included the use of interaction-focused and psychodynamic approaches. In addition, systemic approaches were found in studies involving multifamily groups for schizophrenia. Psychoeducational groups were also widespread and were found effective in treating schizophrenia and affective disorders (particularly bipolar disorders). A majority of studies on the efficacy of group treatments have been conducted in outpatient settings and have mainly focused on short-term groups.

Aside from the group CBT approaches, psychodynamic and group analytic approaches have the longest tradition. Nevertheless, the most recent systematic review of psychodynamic group studies ( 20 ) showed that, despite important theoretical contributions in the field, only a small number of studies reached the standards of outcome research. On the other hand, promising trends have emerged during the past decade, such as conceptual clarifications of group analytic work ( 21 ). In addition, efforts to improve research have been made. For example, Lorentzen ( 22 ) developed a transdiagnostic manual for short- and long-term group analysis that has provided the basis for studies comparing the two approaches and for detecting several moderators ( 23 , 24 ). In addition, new approaches have been developed on the basis of interpersonal and psychodynamic assumptions, such as Whittingham’s ( 25 ) eight-session, manualized focused brief group therapy, which combines elements derived from process groups and attachment theory. Furthermore, Tasca et al.’s ( 26 ) integrative approach combining psychodynamic, interpersonal, and attachment theory (group psychodynamic-interpersonal psychotherapy) has led to empirical studies. Both of these approaches demonstrate that brief focused groups can be useful in the psychodynamic field and may be interpreted as a response to the overwhelming evidence for short-term group CBT. Promising psychodynamic group research can be found for mentalization-based approaches in different treatment settings and for various patient groups ( 27 ).

All studies included in the meta-analyses were RCTs implementing rigorous research designs. Although such trials generally provide less biased estimates of psychotherapy outcomes and generate substantially more replicable results than do other designs, they have been criticized for their limited external validity and absence of information on treatment mechanisms ( 28 , 29 ).

Moderators of Group Treatment Outcomes

An increasing number of studies have implemented rigorous study designs to test moderators of treatment efficacy in the various meta-analyses. However, no clear trends have emerged, and single moderators have proven relevant for different disorders. For example, “allegiance,” defined as the researcher’s belief in the superiority of a treatment (risk of allegiance bias lowers the effects of head-to-head comparisons in anxiety disorders) ( 18 ), group size (larger groups lead to lower effects when working with patients with borderline personality disorder) ( 15 ), and specific diagnosis (larger effects on binge eating frequency seen in binge eating disorders compared with bulimia) ( 12 ) are significant moderators. In group therapy for schizophrenia, two moderators explained variance in effect size: a higher treatment dose (i.e., increased frequency × length of sessions) produced larger effects, and advanced (i.e., doctoral-level) training of group leaders led to larger effect sizes ( 17 ). In patients with PTSD ( 14 ), gender (larger effects in women) and trauma type (smaller effects for military-sector trauma) were found to be moderators. For the other disorders, either no significant moderators were found or they were not systematically investigated (affective disorders, social anxiety, panic disorder, obsessive-compulsive disorder, substance abuse disorder) ( 9 , 11 , 13 , 16 , 19 ).

Group Therapy for Medical Conditions

The scope of application of small group treatments has been expanded to patients with a variety of medical conditions (e.g., neurological diseases such as epilepsy and dementia). Research on group treatments for oncological patients (with a focus on breast cancer) has continued. In the 2013 chapter ( 5 ), 23 studies examining group therapy for cancer patients were summarized. These studies primarily included supportive-expressive therapy ( 30 ), CBT, and psychoeducation groups. Since then, this area of research has expanded considerably, with the largest number of group therapy studies still focusing on patients with breast cancer. Several of these studies now have long-term (up to 11 years) follow-up data available ( 31 ). Results from these studies suggest that the effects of group therapy, as demonstrated by reduced cortisol and depression, are maintained over the long term compared with outcomes among patients assigned to control conditions ( 31 ).

The predominant therapeutic approach among groups for those with general medical conditions has been CBT with a focus on stress and stress management ( 32 ), although some studies have examined psychoeducational approaches, and even fewer have focused on supportive group therapies ( 33 ). Similar to research on group therapy for mental disorders, the oncology literature shows a trend toward testing group treatments that can be classified as third-wave CBT (i.e., mindfulness-based stress reduction) ( 34 ). It has been observed that the primary outcome criteria have expanded considerably, with resilience, optimism, and posttraumatic growth investigated more often. Overall, the effects of group therapies have been relatively positive, although some studies have yielded contradictory results. The supportive-expressive groups in the tradition of Spiegel or Yalom ( 30 , 35 ) have almost completely disappeared from the literature and have been replaced by third-wave approaches (e.g., mindfulness-based or acceptance and commitment treatments), which diverge from traditional CBT in that they focus more on one’s relationship with thoughts and emotions rather than on their content.

A second general medical issue that has been examined in the context of group therapies is pain. A majority of these studies have focused on chronic pain and fibromyalgia, although a minority have dealt with specific pain conditions. Nine studies on fibromyalgia published since 2013 were included in the Handbook’s most recent review ( 3 ), which tested a variety of group approaches and found relatively good effects in terms of physical function, pain-related disability, pain severity, anxiety, depression, and self-efficiency ( 36 ). Studies on chronic pain have primarily focused on coping with and reducing pain-related disability.

Overall, group studies on pain only partially confirmed the effectiveness of CBT approaches (the gold standard treatment) for pain. In any case, there are enough studies on group treatment in oncology and pain therapy to warrant a more differentiated meta-analytical consideration of the results.

General Conclusions Regarding Group Psychotherapy Outcomes

The 2013 chapter on group therapy ( 5 ) summarized 250 studies concerning 12 different disorders in a systematic narrative review, despite the studies’ increasing methodological quality. In contrast, the updated review ( 3 ) refers to a total of 11 new meta-analyses, with group therapy compared with active or nonactive control conditions. All considered meta-analyses used a rigorous methodology, included RCTs only, and considered the risk of bias in the studies. In addition to the 329 studies in the meta-analyses, 40 studies on group treatments for patients with cancer or pain were included. Results from this most current review demonstrate that group treatments achieve large effects compared with nonactive treatment conditions and that the differences from other treatments, such as individual therapy, are negligible in terms of effect size. In a majority of comparisons (75%), the heterogeneity of single study effects was small, suggesting that these can be considered reliable estimates of treatment effect.

Despite these findings, existing treatment guidelines of international organizations (e.g., American Psychological Association, National Institute for Health and Care Excellence), and guidelines in German-speaking countries (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften), recommend group therapies only in exceptional cases ( 37 ), which is both surprising and demands an explanation. One possible explanation is that group therapies have been excluded from the work of researchers who systematically summarize the evidence regarding the effects of psychotherapy.

Taken together, our current review covering about 30 years suggests that group therapy can be recommended for treating a wide range of issues. This finding is based on past comparisons of group therapy with nonactive control groups and with active treatments ( Figure 2 ). These results need to be acknowledged and conveyed in current treatment guidelines. As Yalom and Leszcz ( 30 ) have argued, group therapy is a “triple E treatment,” meaning that it is effective compared with nonactive treatments; equivalent to other active treatments, including individual therapy; and efficient in terms of time and cost. Thus, it is worthy of being promoted by health policies.

Limitations of Studies on Group Psychotherapy Outcomes

A limitation regarding interpretation of the research findings refers to their validity for a wider range of treatments. Specifically, there is a gap between clinical-theoretical considerations of psychodynamic or group analytical approaches and specific studies in the group therapy literature. One notable exception is a Norwegian study on the empirical comparison of short- (20 sessions) and long-term (80 sessions) groups in an RCT ( 23 ). This study, based on an exemplary group analysis manual ( 22 ), suggested that the mere presence of personality pathology justifies longer-term groups ( 24 ). Presumably, the development of manuals in psychodynamic group therapy is important to stimulate further empirical research in the group-analytic context.

In addition to the development of mindfulness-based group therapies, two promising approaches have recently emerged in the interpersonal and psychodynamic context, respectively. These approaches, however, require more empirical support. Specifically, Whittingham ( 25 ) developed a manualized “ultra-short group therapy” (eight sessions of focused brief group therapy), which combines elements of process-oriented groups as defined by Yalom and Leszcz ( 30 ) and concepts of attachment theory. Tasca and colleagues ( 26 , 38 ) have described group psychodynamic-interpersonal psychotherapy as an integrative group concept drawing from psychodynamic, interpersonal, and attachment-oriented approaches. The effectiveness of this therapy has been demonstrated in several studies of patients diagnosed as having disorders such as binge eating.

Another limitation relates to treatment setting, because a majority of studies on evidence-based groups have been conducted in outpatient settings with short-term groups. Controlled studies of true long-term groups are not available, except for those of the previously mentioned studies ( 23 , 24 ). The last systematic summary on inpatient therapy groups was a meta-analysis published several years ago ( 39 ), which included 24 controlled studies and 46 pre-post comparisons. Results yielded a small effect for controlled studies (d=0.31) and a large effect (d=0.59) for pre-post comparisons. The largest effects were found for patients with affective disorders.

Other Relevant Research Topics

Feedback systems in group therapy.

Numerous recent studies have been conducted in individual therapy to monitor the course of therapy and to help therapists identify problematic developments early in treatment. Lambert and colleagues ( 40 ) started this research, which is now widespread in many countries and shows that feedback systems can effectively detect and prevent negative developments early in treatment. In the group context, progress monitoring has been tested even less, despite its obvious use, given that group leaders are consistently tasked with monitoring the progress of several (usually eight to 10) people simultaneously.

Despite this paucity in the group literature, a wide range of methods is available to continuously and economically monitor the effects of group treatment on individuals’ symptomatology and other changes, as well as on group-specific elements (e.g., the quality of relationships between group members and member-leader). Studies ( 41 ) have tested the effects of feedback systems used to report the progress of individual group members to the group leader. In 2015, the journal Psychotherapy ( 42 ) published a special issue on progress monitoring and feedback that outlined the empirical evidence on feedback systems. Altogether, the evidence has indicated that feedback systems not only reduce problematic progressions in treatment but also can improve therapeutic outcome. This finding was reinforced by a review ( 43 ) that summarized 25 studies on feedback from patient-reported outcome measures in individual therapy.

Interest in conducting studies on using feedback in group therapy started with the findings of Chapman et al. ( 44 ), which showed that the accuracy of therapists’ prediction of change in groups corresponded little with change-related data from patients. For example, Newnham et al. ( 45 ) described the effects of feedback on treatment progress 5 days into a short-term, daily treatment. When feedback was provided, significant improvement was observed among patients whose development did not match original predictions. Additional studies ( 46 , 47 ) have since shown positive effects of feedback in group therapy. In a cluster-randomized study ( 41 ) of 432 members of 58 groups at university counseling centers, progress feedback alone was tested against progress feedback plus therapeutic relationship feedback. A surprising 35% of participants produced an alert for not being on track for successful treatment outcome at least once during therapy, a result that was observed again in an archival replication study ( 48 ). The quality of the therapeutic relationship predicted improvement in outcome, and feedback appeared to reverse the course of relationship deterioration and reduce rates of treatment failure. In groups where leaders received relationship and progress feedback, there was a reduction in cases of outcome deterioration and an overall increase in outcome improvement.

Cohesion and Alliance

Two recent meta-analyses studied the two relationship variables most frequently investigated within the group context: alliance and cohesion. Cohesion, which refers to the sense of connection or closeness among group members, is related to therapeutic outcome to the same extent reported for the therapeutic alliance in individual therapy (r=0.28) ( 49 ). In a meta-analysis ( 50 ) of 55 studies and more than 6,000 group members, a mean correlation (r=0.26) between cohesion and outcome measures was found, which can be interpreted as the mean effect. Single study results on the cohesion-outcome correlation in group therapy, however, were heterogeneous. A moderating effect was found for theoretical orientation, with the highest correlation observed for interpersonal groups, followed by psychodynamic, cognitive, supportive, and eclectic therapy groups. The cohesion-outcome association was stronger when group leaders emphasized member interaction and when groups were long lasting.

The relationship between member-leader alliance and outcomes of group therapy has been summarized in a recent meta-analysis ( 51 ). The 29 studies in this meta-analysis included 3,628 patients and yielded a significant weighted average correlation between alliance and outcome (r=0.17), which was lower compared with the correlation observed for individual treatment (r=0.28) ( 49 ). A possible explanation for this is the fact that the relationship between a patient and therapist is only one part of group therapy, but it makes up the entirety of the therapeutic relationship in individual therapy. Some moderators were observed; heterogeneity of study results could have been explained by treatment orientation (lower correlation for CBT than for other group treatments) and the reporting perspective (higher correlation for patient-reported than for mixed or observer-reported alliance).

Promising Developments

In addition to cohesion and alliance, patient characteristics may influence group therapy outcomes. Specifically, the influence of attachment characteristics on treatment effects has been examined ( 52 ). Over the past decade, numerous studies have shown that positive changes in attachment characteristics do indeed contribute to improvements in interpersonal problems and in other psychological symptoms ( 53 ). Analogous findings have been reported from social and organizational psychology. Based on these results, it has been postulated that “repeated interactions with responsive and supportive leaders and cohesive groups beneficially alter a person’s attachment patterns and psychological functioning” ( 54 ). In the context of attachment research, other methodological approaches have been tested, such as the actor-partner independence model ( 55 ) and attachment heterogeneity in groups ( 56 ). Overall, the research shows high relevance for attachment characteristics in group treatment, a finding that should encourage group leaders to attend to the influence of attachment goals on group members’ behavior and the impact of attachment characteristics on members’ willingness to engage with and stay in the group. Attachment characteristics may also moderate the relationship between group cohesion and member outcomes and should therefore be considered during group composition and selection of members. Another area for future development, consistent with those occurring in individual psychotherapy, includes development of Internet-based group treatments relying on both asynchronous (i.e., Internet forum providing contact to a therapist) and synchronous (i.e., real time) online contact. In this regard, the field has made considerable progress in the last years, reflecting new technologies that allow such interventions to reach a wider range of patients than face-to-face settings.

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Psychedelic Therapy—A New Paradigm of Care for Mental Health

• 1 Department of Mental Health, James J. Peters VA Medical Center, Bronx, New York
• 2 Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York
• Original Investigation Single-Dose Psilocybin Treatment for Major Depressive Disorder Charles L. Raison, MD; Gerard Sanacora, MD, PhD; Joshua Woolley, MD, PhD; Keith Heinzerling, MD; Boadie W. Dunlop, MD, MS; Randall T. Brown, MD, PhD; Rishi Kakar, MD; Michael Hassman, DO; Rupal P. Trivedi, MD; Reid Robison, MD; Natalie Gukasyan, MD; Sandeep M. Nayak, MD; Xiaojue Hu, MD; Kelley C. O’Donnell, MD, PhD; Benjamin Kelmendi, MD; Jordan Sloshower, MD, MSc; Andrew D. Penn, RN, MS, NP; Ellen Bradley, MD; Daniel F. Kelly, MD; Tanja Mletzko, MA; Christopher R. Nicholas, PhD; Paul R. Hutson, PharmD; Gary Tarpley, PhD; Malynn Utzinger, MD; Kelsey Lenoch, BS; Kasia Warchol, BS; Theraysa Gapasin, MS, aMFT; Mike C. Davis, MD, PhD; Courtney Nelson-Douthit, BS; Steffanie Wilson, PhD; Carrie Brown, MA; William Linton, BS; Matthew W. Johnson, PhD; Stephen Ross, MD; Roland R. Griffiths, PhD JAMA

An increasing number of clinicians and researchers have become interested in the potential of psychedelic drugs for the treatment of mental health disorders, including depression, anxiety, posttraumatic stress disorder, eating disorders, and addictions. 1 , 2

Currently, most psychedelic compounds are illegal under federal law. They were placed on the most restrictive class of drugs, Schedule I, in the 1970s as part of the “war on drugs,” meaning that they were considered to have high potential for abuse with no accepted medical use. 2 However, the ever-growing global mental health crisis, coupled with the shortage of effective therapeutic strategies, has given rise to a reconsideration of the therapeutic potential of these compounds in recent years.

Classic psychedelics have rapid and profound effects on perception, cognition, and consciousness that result in part from their actions at serotonin 5-HT2 A receptors. 1 This can result in heightened awareness of one’s internal states and feelings of connectedness that last for several hours. Psychedelics can also induce challenging and difficult experiences and need to be used carefully and in the presence of facilitators or therapists who are trained to work with people experiencing nonordinary states of consciousness. But these compounds offer unique therapeutic possibilities in their ability to promote openness to engage with things that are often avoided and suppressed. In fact, before they were determined to be Schedule I drugs, psychedelics were used therapeutically to help patients open up and identify and discuss emotionally triggering material in psychotherapy. 2

The study by Raison et al provides an excellent example of the promise of this new approach using psilocybin therapy for patients with major depressive disorder. 3 Although the trial was relatively small, it demonstrated that a single dose of psilocybin in the context of a 6-week period that included active psychotherapy resulted in a rapid, robust, and sustained reduction in depressive symptoms.

Psilocybin is a naturally occurring compound belonging to a class of compounds known as tryptamines, similar to lysergic acid diethylamide (LSD), dimethyltryptamine (DMT), and mescaline. Understanding its therapeutic efficacy requires an appreciation of the context in which it is used, and not just its pharmacological profile or biological mechanism of action. The psychotherapy that occurs with the psychedelic medication is a critical component of this approach. 4

When a psychedelic is taken with the proper preparation, intention, facilitation, and therapeutic environment, the patient can use the experience to gain new insights that can catalyze healing and recovery. The psychedelic allows feelings such as self-compassion, forgiveness, understanding, and self-acceptance to surface that can be powerful antidotes to shame, guilt, anger, isolation, disconnection, or other negative emotions that patients find difficult to discuss in therapy and that do not seem to be mitigated by traditional antidepressants. 1 Furthermore, a sense of boundlessness or ego dissolution may be felt as a mystical or spiritual experience, helping people find meaning, perspective, and connection with others and the world. These experiences have been associated with symptom reduction and may represent an important mechanism of action. 4

The psychedelic approach Is radically different from traditional approaches that seek to suppress depressive symptoms by targeting presumptive underlying pathophysiology or biological dysregulation. Dysphoria, irritability, anxiety, and sleep problems can respond to classic antidepressants and help patients manage symptoms and improve functioning. But the benefits of psychopharmacotherapy and psychotherapy are often small and incremental, and true remission is generally not obtained for months or years. 5 , 6 Furthermore, psychotropic medications require chronic use, can be difficult to discontinue, and cause a variety of adverse effects, including weight gain, sexual dysfunction, and feelings of sedation or emotional numbing. Symptoms can reappear, even in stabilized patients, when the medications are discontinued, creating a heartbreaking dilemma for patients.

In contrast, psychedelic therapies address the cause of symptoms rather than merely suppressing them. Here, a medication is administered acutely for only a few sessions—sometimes even a single medication session—in the context of a therapeutic framework that provides the opportunity to integrate and synthesize the revelations that occur during the medication session. The acute pharmacological effects of the medicine, including potential adverse effects, resolve quickly and the safety profile is good. Clinically significant response rates are robust and can be maintained for weeks or months.

However, it is clear that despite the enthusiasm, psychedelic therapies do not represent a panacea for every patient. There are no silver bullets in psychiatry. In the study by Raison et al, similar to all other reports, there are a significant number of patients who did not respond to therapy. 3 , 7 It is important to analyze and understand adverse outcomes in psychedelic trials and conduct longitudinal studies to determine how sustained the effects will be and what may initiate a recrudescence of symptoms. Future studies will help identify who is most likely to benefit from psychedelics, whether booster or repeated treatment is safe and beneficial, and what the optimal dose and therapeutic frameworks are.

Nonetheless, psychedelic therapy represents a novel way of approaching mental health treatment that may benefit many people. It will also bring new knowledge regarding molecular bases of mental illness and how they relate to consciousness. Inquiries into the mechanisms of action of psychedelics will open new windows of understanding regarding neuronal plasticity and brain functioning. 1

Psychedelic therapies necessitate a rethinking of mental health care delivery in which medication is integrally paired with psychotherapy and delivered in a novel setting and framework. This will require an investment of time and resources, and it is not likely that these approaches will be broadly available to psychiatric patients except in clinical trials for the next few years. However, if the gains are strong and enduring and patients report symptom reduction and existential and spiritual transformation, the investment may be warranted. Meanwhile, clinicians should be knowledgeable about these new treatments as public interest and the empirical base grow.

The social, economic, and public health impacts of untreated mental disorders demand solutions. If psychedelic therapies do prove to have enduring effects after just a single or a few administrations in the context of a few sessions for preparation and integration, they have the potential to offer not just a new approach to mental health care, but an entirely new paradigm of care.

Corresponding Author: Rachel Yehuda, PhD, James J. Peters VA Medical Center, 130 W Kingsbridge Rd, 526 OOMH, Bronx, NY 10468 ( [email protected] ).

Published Online: August 31, 2023. doi:10.1001/jama.2023.12900

Conflict of Interest Disclosures: Dr Yehuda reported receiving nonfinancial support from MAPS PBC (Multidisciplinary Association for Psychedelic Studies Public Benefit); grants from COMPASS Pathways, Steven and Alexandra Cohen Foundation, and The Bob and Renee Parsons Foundation; and honoraria for talks at the National Institute for the Clinical Application of Behavioral Medicine, Danish Psychiatric Society, Boston Trauma Conference, and UPenn Nursing School outside the submitted work and reported consulting for TeraMind, Wesana, and the Noetic Fund. Dr. Lehrner is an investigator on a trial sponsored by MAPS PBC financially supported by the Steven and Alexandra Cohen Foundation and a trial sponsored by COMPASS Pathways and reported receiving honoraria for talks at Psychedelic Science 2023 and Philadelic 2023.

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Yehuda R , Lehrner A. Psychedelic Therapy—A New Paradigm of Care for Mental Health. JAMA. 2023;330(9):813–814. doi:10.1001/jama.2023.12900

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• Published: 08 April 2024

Climate change-related concerns in psychotherapy: therapists’ experiences and views on addressing this topic in therapy

• Katharina Trost   ORCID: orcid.org/0009-0005-1865-1199 1 ,
• Verena Ertl 1 ,
• Julia König   ORCID: orcid.org/0000-0002-6267-337X 1 ,
• Rita Rosner   ORCID: orcid.org/0000-0002-7960-8398 1 &
• Hannah Comtesse   ORCID: orcid.org/0000-0003-4150-6107 1  

BMC Psychology volume  12 , Article number:  192 ( 2024 ) Cite this article

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While adverse impacts of climate change on physical health are well-known, research on its effects on mental health is still scarce. Thus, it is unclear whether potential impacts have already reached treatment practice. Our study aimed to quantify psychotherapists’ experiences with patients reporting climate change-related concerns and their views on dealing with this topic in psychotherapy.

In a nationwide online survey, responses were collected from 573 psychotherapists from Germany. Therapists reported on the presence of such patients, their socio-demographic characteristics, and climate change-related reactions. Psychotherapists’ views on dealing with this topic in psychotherapy were also assessed. Descriptive statistics were used to analyse the responses.

About 72% (410/573) of psychotherapists indicated having had patients expressing concerns about climate change during treatment. Out of these therapists, 41% (166/410) stated that at least one patient sought treatment deliberately because of such concerns. Patients were mainly young adults with higher education. Most frequent primary diagnoses were depression, adjustment disorder, and generalized anxiety disorder. Psychotherapists having encountered such patients differed from those without such encounters in their views on potential functional impairment and the necessity to target the concerns in treatment. Although 79% (326/415) of all respondents felt adequately prepared by their current therapeutic skills, 50% (209/414) reported a lack of information on how to deal with such concerns in therapy.

Conclusions

Results indicate that psychotherapists are frequently confronted with climate change-related concerns and regard the mental health impact of climate change on their patients as meaningful to psychotherapeutic care. Regular care could be improved by a continuous refinement of the conceptualization and knowledge of the mental health influences of climate change. This would allow providing tailored methods of assessing and addressing climate change-related concerns in practice.

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Introduction

Consequences of climate change are affecting an increasing number of people around the world [ 1 ]. While the ways in which climate change impacts physical health have been recognized for some time (e.g., 2), mental health outcomes have become a focus in recent years [ 3 ]. Results show that both acute and chronic (anticipated) consequences of climate change can affect mental health via diverse pathways [ 4 , 5 , 6 ]. Recent reviews on climate change impacts on mental health have highlighted a potential relation between acute climate change consequences and mental disorders [ 6 , 7 , 8 , 9 ]. It is well established that acute events, such as floods or wildfires, are associated with traumatic stress. For example, Kessler, Aguilar-Gaxiola [ 10 ] showed in a review that single event natural disasters were one of the 29 trauma event types with an increased risk of posttraumatic stress disorder (PTSD). Furthermore, Neria, Nandi [ 11 ] reported in a systematic review PTSD prevalence rates between 4% and 60% after natural disasters such as earthquakes, floods, hurricanes, and wildfires around the world from 1963 to 2005, depending on degree of exposure (e.g., proximity to epicenter, extent of disruption) and sample characteristics. While the association between acute events and PTSD is well established, reviews also proposed a relationship between acute weather events and an increase in anxiety disorders and depression [ 5 , 6 , 7 , 8 , 12 ]. Although not every weather extreme or disaster is caused by climate change, it is an established fact that natural disasters are becoming more frequent with climate change progressing [ 13 ]. Consequently, the possible negative effects of climate change on mental health are likely to increase.

The chronic effects of climate change (e.g., drought) on mental health are more difficult to operationalize, because impacts are mostly indirect and delayed, and factors interact in multiple ways (e.g., [ 14 ], for drought, [ 15 ]). However, recent (narrative) reviews on climate change impacts on mental health did focus on chronic influences (e.g., drought, increase in temperature and sea-level, deforestation) on mental health [ 5 , 6 , 7 , 12 , 16 ]. The review conducted by Palinkas and Wong [ 6 ], for example, assumed that subacute consequences of climate change (e.g., heat waves) can exacerbate existing mental disorders (e.g., substance abuse disorders due to diminished thermoregulation). Additionally, this review found that experiencing drought episodes (primarily studied in Australia) is associated with generalized anxiety disorder and depression, among other symptoms, due to factors such as economic effects and migration.

Furthermore, besides the exposure to climate change-related disasters and the perception of chronic climate change hazards, research has suggested that the awareness of the existential threat of climate change (e.g., ecological losses), evokes emotional reactions and may affect mental health (e.g., [ 5 ]). To capture these reactions, new concepts of climate/eco-emotions such as climate change anxiety [ 17 ] and ecological grief [ 18 ] have been introduced. However, these concepts have only recently been quantified [ 17 , 19 ], with first results indicating associations of severe levels of these concepts with functional impacts in daily life (e.g., [ 20 ]). At the general population level, several large-scale studies have shown that significant numbers of people in different countries are emotionally affected by worries, fears and sadness about environmental changes attributed to climate change [ 20 , 21 , 22 ]. For example, in a representative German survey conducted in 2022 more than a half of the participants (55%) indicated to be sad about natural destruction, around a quarter (23%) fully agreed with the statement “I am afraid of the consequences of climate change”, and almost a quarter of people (22%) felt psychologically stressed by climate change and environmental destruction, 5% of whom felt very stressed [ 22 ].

Taken together, these findings suggest that concerns about climate change seem to be widespread and may also become evident in clinical groups [ 23 , 24 , 25 ]. A recent study conducted in the USA investigated the experience, attitude, and knowledge of mental health professionals (MHP, N  = 517) with regard to the impact of climate change on mental health and its effect on treatment [ 24 ]. The majority of participants (57%) strongly agreed that the consequences of climate change influence mental health. Additionally, 54% of MHPs indicated that they had already seen clients who raised climate change-related concerns during treatment. MHPs reported that these concerns were related to symptoms of generalized anxiety, depression, grief reactions, and post-traumatic stress in these clients. Further, the majority of MHPs stated that they lacked tools for assessment and treatment as well as information on referral possibilities for these clients. Similar results were yielded in a sample of physicians and nurses in the USA [ 25 ]. However, it remains unclear whether and to what extent this is also the case in psychotherapeutic care in Europe.

The current study aimed at examining whether German psychotherapists are currently already encountering patients with climate change-related concerns in their practice. Therefore, we recruited a nationwide sample of psychotherapists working in different settings in Germany as possible for an online survey and queried them about these concerns as well as gathering information on patients’ demographics and clinical status. Further, we explored cognitive, emotional, physiological, and behavioral reactions of their patients regarding the respective climate change concerns. Finally, we examined psychotherapists’ views on dealing with climate change-related concerns during treatment. In this regard, we investigated whether psychotherapists who had encountered patients with concerns (therapists with experience) differed in their views from those who had not yet encountered such patients (therapists without experience).

Participants and procedure

The study was conducted as a nationwide cross-sectional online survey among psychotherapists, both licensed and in training, across all therapeutic approaches recognized in Germany. The therapeutic approaches in Germany are: cognitive behavioral therapy (CBT), psychoanalysis (PA), depth psychology (DP), systemic therapy (ST). Inclusion criteria were (a) being a licensed psychotherapist or psychotherapist in training and (b) giving informed consent to participate in the survey. The study was approved by the ethics committee of the Catholic University Eichstätt-Ingolstadt (number: 122–2022). Data collection took place between February and April 2023.

Our recruitment approach aimed to reflect the reality of the German psychotherapeutic care system as accurately as possible. Therefore, all regional Psychotherapists’ Chambers (“Psychotherapeutenkammern”), in which licensed psychotherapists need to be registered, were asked to forward the online survey link to their members. After a follow-up, commitments from eight out of 12 chambers were received. To include psychotherapists in training we used a random sampling approach. Training institutions in each of the 16 federal states were asked to forward the survey to their trainees. Given the absence of an official comprehensive list of all registered training institutions in Germany, we made a concerted effort to compile a thorough inventory of training institutes across the federal states (up to January 2023). This was achieved by utilizing the websites of psychotherapist chambers (Bavaria, Berlin, Bremen, Hessen, Niedersachsen, Nordrhein-Westfalen, Saarland, Schleswig-Holstein). In cases where lists were outdated or unavailable, additional searches were conducted on the official websites of states (Baden-Württemberg, Brandenburg, Hamburg, Mecklenburg-Vorpommern, Rheinland-Pfalz, Sachsen) as well as the German Association of Psychotherapists (DPtV, Sachsen-Anhalt. Thüringen). The final list comprised 271 institutions across all federal states and therapeutic approaches.

In each of the federal states, a random selection of 10% (in total, n  = 33) of the institutions was contacted to forward the survey to their trainees. In case an institution denied distributing the survey to their trainees, another institution for this federal state was randomly selected. At the end of the recruitment process, a sum of 45 training institutions was contacted, of which 27 distributed the survey link to their trainees. The 10% target could not be achieved in 5 federal states (Bavaria, Bremen, Hessen, Nordrhein-Westfalen, Rheinland-Pfalz). In addition, all regional associations of statutory health insurance physicians (“Kassenärztliche Vereinigungen”) and three professional associations of psychotherapists that operate across therapeutic approaches and throughout Germany (“Berufsverbände”, Association of Psychological Psychotherapists in the professional association of German psychologists, BDP-VPP; Federal Association of Contract Psychotherapists, BVVP; German Association of Psychotherapists, DPtV) were requested to distribute the survey. Two out of three requested professional associations published the survey link on their homepage and five out of 17 regional associations of statutory health insurance physicians (Bremen, Hamburg, Niedersachsen, Westfalen-Lippe, Thüringen) forwarded the survey to their members. Members of the national bodies could be licensed psychotherapists and psychotherapists in training. Members of associations of statutory health insurance physicians were licensed.

All contacted institutions received detailed information about the study by phone and e-mail and distributed the survey information, link, and QR-Code electronically via e-mail, internal newsletter, and/or a notice on their homepage and intranet. Four training institutions placed an announcement (printed version of the tender text) on their bulletin board.

A total of 624 psychotherapists clicked on the survey link, of whom 51 denied consent or did agree and dropped out before answering to the items for experience regarding patients with climate change-related concerns. Thus, we analyzed the responses of the remaining participants ( N  = 573). Dropouts after the consent page were not excluded from subsequent analyses as participants dropped out at different stages of the survey, and itemwise analyses were conducted (see 24, for a similar approach). To ensure the robustness of this approach, we contrasted participants with more and less than 10% missing values across the survey on all items. This yielded no significant differences in terms of therapists' characteristics, experiences with patients with climate change-related concerns, or views on the topic.

The survey comprised 37 items, of which 24 items administered to all participants and 13 items (focusing on climate change-specific reactions) presented only to those reporting that they had already treated patients with climate change-related concerns (i.e., therapists with experience). Items were newly developed for this study and based on a large-scale survey on experience, attitude, and knowledge of MHPs with climate change topics raised by their clients [ 24 ]. To ensure comprehensibility and relevance of all items, the survey was piloted by five psychotherapists in training before circulation. The survey was provided online using the survey tool Qualtrics. The complete survey is presented in Appendix A .

At the beginning of the survey, socio-demographic and work-related information about the participants was collected in ten items about: age (year of birth), gender (female/male/diverse), level of training (trainee vs. licensed), therapeutic approach (CBT, PA, DP, ST, other), work experience (number of years working as a therapist including time as trainee, number of weekly treatment sessions), and practice setting (private practice, hospital, outpatient clinic, other). Additionally, engagement in climate or pro-environmental advocacy groups was assessed dichotomously. The degree of pro-environmental behavior in everyday life was assessed on a 4-point scale (1 =  in no area of everyday life , 4 =  in almost all areas of everyday life). Thereafter, participants were assigned to one of two paths, depending on whether they had already encountered patients expressing climate change-related concerns. Path A (for therapists with experience) collected information about the number of such patients (seen in the last 12 months), the patients’ socio-demographic characteristics as well as their cognitive, emotional, physiological, and behavioral reactions. Predefined answer options for cognitive styles (e.g., rumination), physiological (e.g., racing heart) and behavioral reactions (e.g., crying) were formulated according to our current knowledge of human stress response and the recent literature on climate change-related emotions [ 17 , 19 , 26 ]. In addition, their expression of feelings related to climate change-related concerns were collected in free-text format. In path B, therapists without experience were asked whether they expected to encounter patients with climate change-related concerns in the future. In the first two parts, for most items multiple responses were allowed (therapists’ practice setting and therapeutic approach; patients’ age in years, educational degree, assumed family status, most frequent assigned diagnoses, cognitive styles, feelings, physiological and behavioral reactions). In the last part of the survey, all participants (therapists with and without experience) answered 12 questions regarding their views on climate change-related concerns (a) in relation to mental health, (b) on how to deal with them in therapy and (c) whether they felt well equipped or wished for additional training and resources on the topic. Therapists answered on a 4-point scale (1 =  I do not agree at all , 4 =  I fully agree).

Statistical analysis

All analyses were performed itemwise because the survey did not employ a forced choice format and participants dropped out at different stages of the survey. This means that we included the number of participants who had answered the respective items (indicated by n/N for all frequencies reported; see 24, for a similiar approach).

Descriptive statistics were used to describe items presented in the three parts of the survey, using frequencies or mean values. The free text answers related to the patients’ feelings were mostly given in one word per option (e.g., anxiety, fear, anger). The answers were categorized inductively [ 27 ] and analyzed descriptively.

For contrasting therapists with and without experience with regard to their views on climate change-related concerns in therapy, all items presented in the last part of the survey were dichotomized in 0 =  disagreement (on the 4-point scale: 1 =  I do not agree at all , 2 =  I rather disagree ) and 1 =  agreement (on the 4-point scale: 3 =  I rather agree , 4 =  I fully agree ). Group differences were computed using chi-square test, t-tests, and Mann-Whitney-U-test, depending on the type of data. All tests were two-tailed with α = 0.05. Bonferroni-Holm correction was performed within each thematic group of items asking about therapists’ views (i.e., views on consequences of climate change-related concerns for mental health, views on how to address climate change-related concerns in therapy and views on required resources for addressing climate change-related concerns in therapy). Data were analyzed using SPSS statistics, version 28.

Therapists’ socio-demographic information

Psychotherapists’ socio-demographic and work-related information is shown in Table  1 . Therapists were on average 49 years old and mostly female (75.6%, 433/571). The sample consisted predominantly of licensed therapists (87.1%, 499/573), who had been working with patients for an average of 15.2 years. Most therapists worked in private practices (79.0%, 453/573), while 11.0% (63/573) were employed in hospitals. Specialized on treating adults (73.6%, 422/573), therapists worked with an average of 19.1 treatment sessions per week over the last year. The most frequent approaches were CBT (56.5%, 324/573) and DP (40.7%, 233/573). Around 80% (450/570) of participants reported behaving climate change-conscious in many to almost all areas of everyday life . About 17% (99/568) reported being actively involved in “for future-” movements (e.g., “fridays for future”), or other climate or pro-environmental advocacy groups.

Therapists’ experience with patients with climate change-related concerns

Experience with patients with climate change-related concerns was reported by 71.6% (410/573) of the participants. Of the therapists without experience, 58.6% (95/163) expected to encounter more patients with climate change-related concerns in the future.

Of the therapists with experience ( n  = 410), 84.9% (348/410) reported having encountered a range of one to 30 of such patients, with 66.6% (273/410) indicating between one and 10 patients expressing climate change-related concerns. Of the therapists with experience ( n  = 410) 364 replied to the question whether. Around 40.5% (166/410) reported that at least one patient with climate change-related concerns had stated that such concerns were the explicit reason for seeking therapy.

Table  2 displays information provided by therapists with experience about socio-demographic characteristics of their patients with climate change-related concerns. Patients with such concerns were described as mainly young (19 to 24 years, 64.0%, 210/328) and early middle aged (25 to 34 years, 57.6%, 189/328) adults, as well as higher educated (higher education entrance qualification, 77.2%, 251/325; university degree, 66.8%, 217/325). Mostly, these patients were living in a relationship (62.3%, 197/316) and without children (53.4%, 171/320). Therapists indicated having diagnosed these patients with mostly depression (53.0%, 167/315), adjustment disorder (12.4%, 39/315), and generalized anxiety disorder (11.1%, 35/315) as the primary diagnoses for seeking treatment.

Therapists with experience reported a range of cognitive, emotional, physiological, and behavioral reactions of patients with climate change-related concerns. For the detailed list of patients’ reactions see Table A in Appendix B . Rumination was indicated as the most common cognitive style (73.1%, 231/316), besides catastrophic thoughts/ disaster thoughts (59.2%, 187/316). Within the “Other” category, 3.8% (12/316) of the therapists with experience reported effective solution- and action-oriented styles.

Furthermore, therapists with experience indicated that anxiety (88.6%, 194/219) with manifestations from worrying to panic, helplessness (60.7%, 133/219) with hopelessness and feelings of despair, anger (60.3%, 132/219) and grief (35.2%, 77/219) including disconsolateness and the feeling of senselessness were the four most frequent reported feelings in their patients.

More than two thirds of the therapists with experience who answered to the questions concerning physiological and behavioral reactions noticed physiological (68.2%, 176/258) and behavioral reactions (83.6%, 219/262). Around 60% (155/258) reported sleep disorders in their patients. Therapists indicated that avoidance (57.3%, 150/262), aggression (44.7%, 117/262), and crying (34.0%, 89/262) were the three most common behavioral reactions in their patients when climate change-related concerns were addressed in therapy.

Comparison of therapists with and without experience

Results of comparisons on socio-demographic and work-related characteristics between therapists with and without experience are summarized in Table  3 . Therapists with experience were significantly more often female and reported more climate friendly everyday behavior and engagement in climate change-related advocacy groups. They also indicated a significantly higher patient-load in the last 12 months. There were no differences in age and therapeutic approach.

Table  4 shows responses of therapists with and without experience regarding their views on (a) consequences of climate change-related concerns for mental health, (b) how to address climate change-related concerns in therapy and (c) required resources for addressing climate change-related concerns in therapy. For the full range of responses on the original 4-point scale (from 1 =  I do not agree at all to 4 =  I fully agree ) see Table B in Appendix B .

Therapists with experience approved significantly more often of all four statements regarding the potential consequences of climate change-related concerns to mental health. Around 80% (217/268) were convinced that climate change-related concerns can lead to serious functional impairment in everyday life. Whereby also more than half of the therapists without experience (58.0%, 91/157) agreed to this view. Therapists with experience (87.6%, 234/267) saw significantly more often relevant negative consequences to mental health, apart from traumatization e.g., due to extreme weather events. This opinion was also frequent in therapists without experience (64.5%, 100/155).

Regarding the views on how to address the topic in therapy, therapists with experience significantly more often agreed to the statement that climate change-related concerns should be taken up in a validating way (81.8%, 216/264). Additionally, therapists with experience are significantly more likely to approve of the statements that stress caused by climate change-related concerns (88.0%, 234/266) as well as motivation caused by climate change-related concerns (89.9%, 240/267) should be addressed in therapy. Both groups, therapists with (79.2%, 210/265) and without (77.3%, 116/150) experience reported having acquired adequate therapeutic skills to address climate change-related concerns in therapy and did not differ significantly in this regard. Around 30% (82/265) of therapists with experience stated concerns about their own potential overload from dealing with this topic in therapy. Also, nearly 20% (27/150) of therapists without experience stated the same concerns. There was a significant difference between the groups.

Regarding the views on required resources, therapists with experience significantly more often express an interest in educating and informing themselves. However, both groups of therapists reported difficulties in finding information or training on how to deal with patients expressing climate change-related concerns in therapy. Finally, therapists without experience significantly more frequently denied the importance of addressing the topic in therapy.

The current study investigated in a nationwide sample of psychotherapists in Germany whether they see patients with climate change-related concerns in their practice. We further examined characteristics of patients with such concerns and the therapists’ views on the topic of climate change in therapy. The results showed that the majority of therapists is already confronted with this topic in therapy. Although close to 80% of the therapists felt adequately prepared by applying their current therapeutic skills, half of them wished for more information and training on how to deal with such concerns in therapy.

The number of therapists (72%) indicating to see patients with climate change-related concerns in treatment found in this study is even higher than the number in the survey conducted with MHPs in the USA [ 24 ]. Hoppe, Prussia [ 24 ] reported that around 54% of MHPs stated to see clients with such concerns. However, since we exclusively sampled psychotherapists (opposed to the broader group of MHPs) who reported on their patients, it is likely that the patients discussed by the therapists in this study were heavily burdened. A review by Woodland, Ratwatte [ 9 ], comprising 31 studies, revealed an association between pre-existing mental health impacts and the exacerbation of mental health problems due to consequences of climate change (i.e., acute weather events). These findings may elucidate the higher proportion of therapists treating such patients, in contrast to the observations of Hoppe Hoppe, Prussia [ 24 ]. Furthermore, there is evidence suggestion an increased awareness of climate change in Germany in recent years [ 22 ] and compared to other nations [ 28 ]. The biennial Special Eurobarometer surveys on Climate Change conducted from 2009 to 2021 evaluated European perceptions of climate change, involving over 26,000 participants from the 27 EU member states and the UK. The results from 2019 indicated that more than eight out of ten respondents in Germany regarded climate change as a ‘very serious’ issue (81%), surpassing the EU average of 79% [ 28 ].

Further, 41% of the 410 therapists with experience stated that at least one patient with such concerns explicitly sought treatment because of these. This suggests that some patients seem to relate their functional impairment and distress to climate change and its consequences and seek treatment for this reason . This finding aligns with causal process diagram of Berry, Waite [ 4 ] to conceptualize relations between climate change and mental health. Climate change could influence mental health via various (in)direct paths. For example, the “loss of personal mental health resources” can be caused by an impaired capacity to cope with adversities and thus directly increase the risk of mental illness. Correspondingly, therapists in this study reported that their patients often experienced feelings of helplessness and frustration, which could be indicative of a reduced capacity to cope. In addition, climate change and its consequences could function as an additional stressor, increasing the mental health burden of patients. Together with other currently salient threats to the basis of existence, like the Ukraine war or sustained consequences of the Covid-19 pandemic [ 29 ] climate change-related concerns could add to pathology in a dose-effect manner.

The most frequently reported diagnoses of patients raising climate change-related concerns in this study were depression, adjustment disorder, and general anxiety disorder. According to available data of a Germany-wide research data platform (KODAP, short for the coordination of data collection and evaluation at research and training outpatient clinics for psychotherapy ) containing the diagnoses of 4266 adult patients treated in 2016, the most frequent diagnoses defined as treatment causes were affective disorders (39.4%), of these 36% were depressive episode/disorder diagnoses. Anxiety disorders accounted for 14.2% of the index diagnoses, whereby generalized anxiety disorder took 14th place under the 50 most frequent diagnoses with 2.3%. Frequent index diagnoses were also adjustment disorder with 4.5% (6th most frequent given diagnosis) [ 30 , 31 ]. Comparing the KODAP composition of diagnoses to our results implies that the three most frequent reported diagnoses are overrepresented in the present study. This could be related to differences in the settings. As KODAP provided data from patients in training outpatient clinics, we primarily surveyed psychotherapists about their patients in private practices. The current study cannot definitively determine whether these diagnoses occur more frequently in patients raising climate change-related concerns compared to other patients treated by the participants in their respective settings. Given the absence of comparative data, it is important to interpret these results with caution. Thus, it remains uncertain whether overrepresentation of these diagnoses in our study can be in any way linked to the presence of climate change-related concerns. Also, it needs to be stated that even strong emotional responses are part of an adequate reactions to the threat of climate change and can initiate an adaptive process [ 26 , 32 , 33 ]. However, climate change awareness could lead to extreme worrying, as several large-scale surveys have indicated [ 20 , 21 , 22 ]. The core symptom of generalized anxiety disorder is characterized by severe and persistent worrying [ 34 ] and thus concerns about consequences of climate change could act as such a core symptom. This is consistent with the results of the present study, as well as the survey of Hoppe, Prussia [ 24 ]. Both indicated that generalized anxiety disorder is frequently reported in relation to climate change mental health impacts. Yet, there is an ongoing debate about whether climate change-related symptoms are linked with established diagnoses (e.g., generalized anxiety disorder, as we considered above) or whether the broad range of climate change-related reactions indicates a need for an additional diagnostic category [ 4 , 8 , 32 ].

Furthermore, this study examined psychotherapists’ views on dealing with climate change-related concerns during treatment. Overall, both therapists with and without experience were convinced in the majority that climate change-related concerns have the potential to lead to serious functional impairment in patients and need to be taken up in a validating way in therapy. Therapists considered climate change-related concerns relevant for mental health, even when concerns were not related to traumatic experiences associated with climate change. This seems to indicate that psychotherapists have already consulted the currently existing literature on the acute and chronic effects of climate change consequences on mental health and is in line with our finding that more than the half of the participating psychotherapists undertake further information or training on these topics.

In addition, Budziszewska and Jonsson [ 23 ] conducted a qualitative study interviewing ten Swedish patients, who addressed climate change-related concerns within treatment. Results showed that an effective treatment (from the patients’ perspective) required psychotherapists’ knowledge about climate change and the competence to use this knowledge. This demands therapists to confront this topic themselves. In our study in more than 20% of the participating psychotherapists (more often with experience) worries occurred about a potential overload caused by treating patients with climate change-related concerns. This worry should be taken seriously in training and dissemination endeavors and indicates the need for self-care strategies and adequate supervision [ 8 , 35 , 36 ]. Nevertheless, almost 80% of respondents in this study felt well prepared to work with patients with climate change-related concerns using the therapeutic skills they had already acquired. The survey of Hoppe, Prussia [ 24 ] reported that less than a third of MHPs felt adequately prepared for this topic in treatment. As our study exclusively surveyed psychotherapists, our sample was likely to be trained more homogenously and specifically than the broad profession group (social workers, family and marriage counselors, psychologists) recruited by Hoppe, Prussia [ 24 ], which could explain the higher rate of preparedness found in our study. Nonetheless, our results are in line with findings of Gossmann, Rosner [ 37 ], who outlined in a German study surveying psychotherapists ( N  = 1358) about their work satisfaction, that psychotherapists in Germany felt efficacious, skillful, and able to deal with stressful situations in general.

There are several implications of the present findings for research and practice. Future studies are required to assess whether severe emotional reactions and high levels of functional impairment due to climate change-related concerns are related to specific established diagnoses or form climate change-specific pathologies. There is an increasing amount of literature seeking to comprehend psychological reactions to climate change consequences. More and more researchers aim to define and evaluate constructs and develop measures to get an exhaustive picture of climate change-related reactions and consequences for mental health [ 17 , 19 , 26 , 38 , 39 , 40 , 41 ]. Moreover, our results indicate a lack of information about how to address climate change-related concerns in psychotherapy. There is already some guideline literature that covers tasks and challenges in the areas of research and practice and provides initial therapeutic considerations [ 8 , 35 , 36 , 42 , 43 ]. However, material for psychoeducation, guidelines, and components for treatment of climate change-related concerns as well as strategies for psychotherapists’ self-care could be improved by a continuous refinement of the conceptualization and knowledge of mental health impacts of climate change.

Strengths and limitations

This study is - to the best of our knowledge - the first study assessing psychotherapists’ observations of patients raising climate change-related concerns and their views on dealing with this topic in therapy. A notable strength of this study lies in the composition of our sample of psychotherapists regarding the distribution of age, gender, practice setting and therapeutic approaches which was similar to the general population of psychotherapists practicing in Germany [ 44 ]. In the present study, approximately 60% of participating therapists fell within the age range of 36 to 61 years, with three-quarters being female. Official data for Germany indicated that 58% of employed psychotherapists fell within the age range of 35 to 60 years, with a female majority of 76.7% [ 44 ]. Furthermore, in our study, 79% of the psychotherapists practiced in private practice, while 11% were employed in hospital settings. Comparatively, official data reported that 71% worked in private practice and 15% were employed in hospitals [ 44 ]. Regarding therapeutic approaches, CBT was the most prevalent at 56.5%, followed by DP at 40.7%. PA at 16.3% and ST at 3.3%. Data from psychotherapists working with both adults and children/adolescents showed a similar distribution [ 45 ].”

However, there are several limitations. First, the presence of a self-selection bias cannot be discounted. It is plausible that therapists with a specific interest in climate change might have been more likely to participate in this study. Around 17% of respondents indicated involvement in advocacy groups, but the general level of involvement of German psychotherapists remains indeterminate due to a lack of comparative numbers. Secondly, the data on therapists’ diagnoses regarding climate change-related concerns are aggregated and retrospective estimates provided promptly during survey completion. The validity of these data needs to be treated with caution. Third, psychotherapists with the focus on adult patients were overrepresented in our study. This means that, this survey does not cover children and adolescents seeking treatment adequately. Further, it is important to note that the insights regarding patients’ and therapists’ awareness of climate change may not be generalized to other EU countries as Germany exhibits notably higher levels of climate change awareness compared to the EU average [ 46 ]. Final, the items were specifically developed for this study with no prior validation. Yet, the items were adapted from a large-scale survey with MHPs in the US [ 24 ] as we also aimed at descriptive results on the status quo on this topic in Europe.

This study provides first findings on the presence of patients with climate change-related concerns in therapy in Europe. Psychotherapists generally considered the impact of climate change on their patients’ mental health to be significant to psychotherapeutic care. Further research is needed to explore the associations between these concerns and psychological symptoms as well as to develop effective interventions to address these concerns.

Data availability

No datasets were generated or analysed during the current study.

Abbreviations

Cognitive behavioral therapy

Depth psychology

Intergovernmental panel on climate change

Coordination of data collection and evaluation at research and training outpatient clinics for psychotherapy

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Acknowledgements

This research was funded by a doctoral scholarship of the Cusanuswerk foundation granted to Katharina Trost. The authors want to thank all those involved in the recruitment process (especially Theresa Neumann), including associations and institution distributing the online link, and all the therapists who took the time to complete the survey.

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KT, VE, and HC designed the study. KT collected the data and carried out the data analysis under supervision of HC. KT wrote the first draft of the manuscript. JK and RR critically reviewed the manuscript. All authors read and approved the final manuscript.

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Correspondence to Katharina Trost .

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The study was approved by the ethics committee of the Catholic University Eichstätt-Ingolstadt in December 2022 (ethics approval number: 122–2022). All participants gave digital informed consent to participate in the study and received no financial compensation. All methods were carried out in accordance with declaration of Helsinki.

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Supplementary Material 1: The complete survey is presented in Appendix A. The list of patients’ reaction is provided in Table A in appendix B and the full range responses of therapists’ views on the original 4-point scale (from 1 =  I do not agree at all to 4 =  I fully agree ) is provided in Table B in Appendix B

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Trost, K., Ertl, V., König, J. et al. Climate change-related concerns in psychotherapy: therapists’ experiences and views on addressing this topic in therapy. BMC Psychol 12 , 192 (2024). https://doi.org/10.1186/s40359-024-01677-x

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Received : 29 November 2023

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DOI : https://doi.org/10.1186/s40359-024-01677-x

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Study of the behavior of vver and pwr fuel irradiated in the hbwr reactor (halden, norway)

• Published: 23 March 2012
• Volume 111 , pages 413–421, ( 2012 )

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• B. Yu. Volkov 1 ,
• E. P. Ryazantsev 1 ,
• V. V. Yakovlev 1 ,
• A. K. Panyushkin 2 ,
• A. V. Ivanov 2 ,
• O. V. Kryukov 2 ,
• P. I. Lavrenyuk 3 ,
• Yu. V. Pimenov 3 &
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The methods, techniques, and results of comparative studies of VVER and PWR fuel tested in the HBWR reactor (Norway) are presented. Experimental VVER fuel elements with uranium dioxide fuel were fabricated at the Machine Building Plant (MSZ) (in Elektrostal) using standard technology; the experimental PWR fuel elements were fabricated according to the model specifications. The results obtained made possible a comparative evaluation of the changes in the thermophysical parameters and the heat and radiation resistance of the two types of fuel as well as the kinetics of the gaseous fission products as a function of the heat load and burnup.

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National Research Center Kurchatov Institute, Moscow, Russia

B. Yu. Volkov, E. P. Ryazantsev & V. V. Yakovlev

Machine Building Plant (MSZ), Elektrostal, Moscow Oblast, Russia

A. K. Panyushkin, A. V. Ivanov & O. V. Kryukov

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Translated from Atomnaya Énergiya, Vol. 111, No. 6, pp. 342–348, December, 2011.

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Volkov, B.Y., Ryazantsev, E.P., Yakovlev, V.V. et al. Study of the behavior of vver and pwr fuel irradiated in the hbwr reactor (halden, norway). At Energy 111 , 413–421 (2012). https://doi.org/10.1007/s10512-012-9512-y

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Received : 25 March 2011

Published : 23 March 2012

Issue Date : April 2012

DOI : https://doi.org/10.1007/s10512-012-9512-y

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