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Lin, T., Stone, S. J., Heckman, T. G., & Anderson, T. (2021). Zoom-in to zone-out: Therapists report less therapeutic skill in telepsychology versus face-to-face therapy during the COVID-19 pandemic. Psychotherapy, 58, 449–459.

The COVID-19 pandemic has confronted psychotherapists with several challenges including rapidly switching their practice to using teletherapy (videoconferencing, phone, and other virtual media). The use of teletherapy in clinical work increased from 7.1% prior to the pandemic to 85.5% during the pandemic. And estimates suggest that at least one-third of clinical work will be performed by teletherapy post-pandemic. Over a third of psychologists reported that they lacked training in using teletherapy, and they believe that their skills in this domain are inadequate. Therapists have raised a number of concerns in past surveys including issues related to privacy, professional self-doubt, technological competence, challenges to the therapeutic relationship, and problems with implementing some interventions. In this survey of 440 therapists and trainees, Lin and colleagues were particularly interested in therapists’ perceptions of the impact of teletherapy relative to in person therapy on the therapeutic process and patient outcomes. Videoconferencing was the most frequently used modality by 73.56% of surveyed therapists. The survey asked if three broad areas of practice were affected by teletherapy compared to in person therapy. These areas included common therapeutic factors (level of therapist empathy, emotional expression, warmth, alliance bond), extra-therapeutic patient factors (the patient’s environment that impacted their ability to engage in homework or use prescribed resources), and perceived patient outcomes (therapist ratings of patient symptom reduction, satisfaction, clinical improvement). Therapists in the survey were representative of the population of therapists in the US, and 82% of them provided all their clinical work in recent months by teletherapy. Compared to in person therapy, therapists reported poorer skills related to common therapeutic factors (d = 0.86), somewhat greater impact of extra-therapeutic factors (d = 0.36), and perceived poorer patient outcomes (d = 0.68) in teletherapy. Therapists who were younger, preferred emotion-focused or relational therapies, and with no prior training reported a relatively greater decrease in therapeutic skills in teletherapy compared to in-person therapy.

Practice Implications

By far, most therapists believed that providing psychotherapy by virtual means reduced their capacity to use common therapeutic stances including empathy, warmth, and the therapeutic alliance. Some of this might be affected by the psychological distance caused by the virtual format and difficulties with reading body language and other non-verbal cues. Therapists perceived that patient outcomes suffered as a result. This was particularly true for younger therapists, possibly because of the impact of adopting the new modality on their professional self-confidence. Also, therapists who preferred experiential or interpersonally based therapies felt particularly challenged possibly because these therapies may be more reliant on emotional communication and discerning patient interpersonal behaviors. Training and support are needed for therapists and trainees to improve their confidence in providing teletherapy.

Firth, N., Saxon, D., Stiles, W. B., & Barkham, M. (2019). Therapist and clinic effects in psychotherapy: A three-level model of outcome variability. Journal of Consulting and Clinical Psychology, 87(4), 345–356.

Patients vary in their outcomes from receiving psychotherapy. That is some patients receive more benefit than others or receive benefit more quickly than others. Previous research indicates that factors like higher symptom severity and socioeconomic deprivation are factors that lead to poorer outcomes. There is also evidence that some therapists are more effective than others so that 5% to 10% of patient outcomes depend on which therapist the patient sees. There is also research showing that the location of the clinic may reflect systematic differences in patient outcomes. This may be due to differences in clinic patient populations, to therapist recruiting practices, resource allocation, and accessibility. Research in population health suggest that local neighborhoods affect physical health. In this large study of over 26,000 patients receiving psychological therapy in the United Kingdom (UK) health system, Firth and colleagues estimated how much of patient outcomes were due to differences among patients, differences among therapists, and difference among clinics. Patients received person-centred, psychodynamic, cognitive-behavioral, or supportive therapies. Drop-out rates from therapy was 33%. Average age of patients was 38.4 years (SD = 12.94) and 69.3% were women. Most patients experienced anxiety (71.8%) and/or depression (54%). There were 462 therapists in the study working at 30 clinics throughout the UK. Up to 58.4% of patients who provided post-treatment data (i.e., completed therapy) showed reliable and clinically meaningful improvement, but there were large differences in patient improvement rates across the clinics (range: 23.4% to 75.2%) and across therapists (6.7% to 100%). Patient severity explained a large proportion of therapist differences. That is, whereas many therapists were effective with less severely symptomatic patients, relatively fewer therapists were effective with more severely symptomatic patients. Patient unemployment, location of the clinic in a more economically deprived area, and the proportion non-White patients in the area explained most of the differences between clinics. Patients who were employed and living in an economically advantaged neighborhood composed of mostly White residents had better outcomes.

Practice Implications

We know from previous research that some therapists are more effective than others and these differences are more pronounced with more severely symptomatic patients. However, this study suggests that larger social factors like racism, systematic bias, and microaggressions also play a role in patient outcomes. Economic deprivation likely affects the level of funding and resources allocated to some clinics. Psychotherapists and funding sources need to take into account the broader socioeconomic, ethnic/racial, and geographic context in which the patient lives when planning and offering services to patients.

Hayes, J. A., Owen, J., & Bieschke, K. J. (2015). Therapist differences in symptom change with racial/ethnic minority clients. Psychotherapy, 52(3), 308-314.

There is ample research showing that therapists differ in their outcomes with clients. Some therapists consistently have better outcomes than others, and some therapists consistently have worse outcomes. One study estimated that as many as 5% of therapists are reliably harmful, with many more being neither harmful or helpful. Fortunately, there is evidence that some “super-shrink” therapists are reliably helpful. There is also research showing the existence of ethnic disparities in mental health problems and their treatment. The minority stress theory suggests that members of cultural minority groups face problems like discrimination, oppression, and prejudice that affect their mental health. When racial/ethnic minority (REM) individuals do experience mental health problems they may be reluctant to seek help from a therapist of European descent. This may be due to cultural mistrust or doubts about cultural sensitivity. Recently, writers have been discussing the importance of therapist cultural competence in treating REM clients. In this study by Hayes and colleagues, the authors looked at 36 therapists and 228 clients. Clients were students at a university counselling centre seen an average of 5.42 times, and about 65% of clients were of European descent. The therapists were in training in a doctoral counseling program, and they each treated at least 4 clients: two REM and two non-REM clients. Since each therapist had both REM and non-REM clients, the authors were able to estimate the effect of the therapist on client outcomes, and also to see if therapists differed in their ability to treat REM and non-REM clients. In this study, cultural competence was defined as differences in client outcomes within each therapist depending on client culture or race. Overall, about 39% of clients achieved reliable positive change in general symptom distress. Almost 9% of the variance in client outcome was attributable to therapists. Further, the client’s race/ethnicity explained 19% of the variance in treatment outcome attributed to therapists. In other words, which therapist a client saw had moderate impact on whether the client improved, and this was partly due to the client’s REM status.

Practice Implications

In this sample of training therapists and student clients, some therapists were more effective than others, and some of this difference was due to the client’s racial/ethnic heritage. The results suggest that therapists’ cultural competence is a component of overall competence. The findings speak to the need for multicultural training for therapists. Some authors discuss the importance of cultural humility among psychotherapists, which is an interpersonal stance that is other-oriented rather than self-focused, and characterized by respect and lack of superiority toward a client’s cultural background and experience. Client perception of their therapist as culturally humble will improve the therapeutic alliance and the client’s outcomes.

Author email: jxh34@psu.edu

Okiishi, J., Lambert, M. J., Nielsen, S. L., & Ogles, B. M. (2003). Waiting for supershrink: An empirical analysis of therapist effects. Clinical Psychology & Psychotherapy, 10(6), 361-373.

Much of psychotherapy research has focused on searching for effective psychotherapies rather than focusing on effective psychotherapists. Research on psychotherapies generally assumes that therapists are equally effective or relatively less important to patient outcomes than the interventions themselves. Therapists in clinical trials are trained to follow a manual in an attempt to reduce the therapists’ impact on patient outcomes, and to focus the study on the specific ingredients of the therapy itself. However, research indicates that the degree to which a therapist follows a manual has little bearing on patient outcomes, and that therapists do differ in terms of their patients’ outcomes. In one large study, between 33% and 65% of therapists was ineffective or harmful. Okiishi and colleagues asked if it is possible to identify highly effective therapists (“super-shrinks”) and highly ineffective therapists (“pseudo-shrinks”) based on their patients’ outcomes. The therapists were 56 men and women who treated 1779 clients in a university counselling centre. Each therapist saw at least 15 clients, so that there was a good sampling of therapists’ outcomes across a variety of clients. Therapists had a range of experience, training, and theoretical orientations. Clients were adults who had moderate to severe problems with anxiety, depression, or adjustment. Outcomes were measured after every session, and the average number of sessions was 5.16 (SD = 7.20). On average clients improved so that their level of distress significantly declined. Therapist characteristics (sex, experience, training background, theoretical orientation) did not predict patient outcomes. However, client change varied significantly, so that some clients improved at a faster rate than others, some did not change, and some got worse. There were no differences between therapists in their clients’ level of distress, so therapists had equivalent caseloads in terms of client initial distress. However, therapists significantly differed from each other in terms of their clients’ outcomes. For example, the top 3 therapists consistently had clients who got better (super-shrinks), and the bottom 3 therapists consistently had clients who got worse (pseudo-shrinks).

Practice Implications

One would hope that a loved one would get to see a “super-shrink” therapist, since these therapists seem to consistently have clients who do well in therapy. But what about the average or “pseudo-shrink” therapist– what can be done to elevate their skills and their patients’ outcomes? We’ve discussed in this blog several things therapists can do to improve their outcomes, including: using progress monitoring in their practice, receiving training focused on deliberate practice, and seeking out specific continuing education around developing, maintaining, and repairing the therapeutic alliance.

Schermuly-Haupt, M. L., Linden, M., & Rush, A. J. (2018). Unwanted events and side effects in cognitive behavior therapy. Cognitive Therapy and Research, 42(3), 219-229.

Unwanted events are negative consequences for clients that may or may not be related to treatment (i.e., events outside of therapy or inside of therapy that may negatively affect clients).  These might include: occupational problems, stigmatization, strains in personal relationships, changes in the social network, patients feeling overwhelmed, undermined self-efficacy, deterioration of symptoms, emergence of new symptoms, suicidality, and others. Side effects refer to negative reactions in clients directly related to appropriately delivered therapy. Research estimates that between 5% and 20% of patients report side effects of psychotherapy. One could argue that side effects may be inevitable even in well-delivered therapy, and therapists who are aware of the potential for side effects may be better equipped to help clients to manage. In this study, Schermuly-Haupt, interviewed 100 psychotherapists who provided CBT in outpatient clinics in Germany about side effects among their clients. All therapists were supervised as part of their work and so the authors assumed the therapy was appropriately delivered. Therapists had on average 5 years of experience and were trained to provide CBT. The interview asked therapists about their most recent treatment case in which the client attended at least 10 sessions. Clients typically had major depression, an anxiety disorder, or a personality disorder, and had attended 28 sessions of therapy on average. During the interview, therapists identified if an unwanted event occurred for a client from a standardized list, and then rated the duration and severity of the effects. They also rated the degree to which the unwanted event was directly related to therapy (i.e., a side effect). Prior to the interview, only 26% of therapists reported their client experienced side effects. However, the interview process found that almost all clients experienced an unwanted event (98%) that may or may have been related to therapy, and 43% experienced at least one side effect that was at least somewhat related to treatment. The most frequent side effects were: “negative wellbeing/distress” (27% of clients), “deterioration of symptoms” (9% of clients) and “strains in family relations” (6% of clients). Of the therapists, 46% rated the side effects as at least moderately severe, and 8.8% of side effects were rated as persistent (lasting more than a month).

Practice Implications

Unwanted events outside of therapy are very common among our clients, but so are side effects from appropriately delivered treatment. Psychotherapy is not always harmless, and it may be best to acknowledge and prepare both clients and therapists for side effects. These may represent ruptures in the alliance that can be managed through alliance-focused therapy, for example. That is, side effects may be caused a mismatch between the goals of a therapist and client, or a disagreement on how to proceed in therapy given what a client needs at the time. Goals and tasks of therapy may need to be renegotiated following the experience of a side effect.

Andrzej Werbart & Mo Wang (2012). Predictors of not starting and dropping out from psychotherapy in Swedish public service settings, Nordic Psychology, 64, 128-146.

There are few empirical studies looking at patients who are offered but who do not take up psychotherapy. This is a particularly important issue in publicly funded psychotherapy programs in which large numbers of patients who need mental health services to not access the service or leave before receiving adequate treatment. Evidence from the Improving Access to Psychotherapy (IAPT) program in the United Kingdom suggests that about half of patients who are offered psychotherapy either do not take it up or drop out prematurely and unilaterally. Knowledge about what determines treatment rejection or dropping out is critical in designing and developing publicly funded psychotherapy so that not only access but also patient outcomes are improved. In this study from the national Swedish psychotherapy program that is publicly funded, Werbart and colleagues looked at data from 13 clinics in which 189 therapists treated almost 1400 patients. Therapists were experienced (median experience = 5 years), and most received advanced psychotherapy training. Patients had a wide array of problems and severity. Of the patients, 13.6% never started therapy even though they were referred and assessed for treatment, and of those who started 17.4% dropped out of treatment. So a total of 31% never received adequate treatment and did not benefit for psychotherapy. Patients who never started therapy tended to be younger, unemployed, and with higher levels of mental illness. Patients who remained in therapy once they started tended to be older, had more problems with trauma or loss, and had more severe illness although they were not a danger to themselves or others. Never starting treatment and dropping out were both associated with clinics that had greater institutional instability. Clinic instability was defined as a clinic with: unclear treatment goals and guidelines, not well adapted to providing psychotherapy, unclear policies around who and how therapy is conducted, less cooperation among professionals, and financial problems.

Practice Implications

Jurisdictions around the world, including in Canada, are looking to offer publicly funded psychotherapy, yet there is little research to guide how to improve uptake and retention of patients within the system. Such systems might focus pre-therapy efforts to retain patients who are younger and with greater mental health problems. In particular, public systems need to pay attention to clinic and institutional stability. How patients experience the clinic environment (as welcoming and integrated), how treating professionals cooperate, the clarity and structure of treatment guidelines and goals, and the financial stability of a clinic all appear to have an impact on whether patients actually access and complete a course of psychotherapy.