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Solstad, S.M., Castonguay, L.G., & Moltu, C. (2018). Patients’ experiences with routine outcome monitoring and clinical feedback systems: A systematic review and synthesis of qualitative empirical literature. Psychotherapy Research. doi=10.1080/10503307.2017.1326645.

Routine outcome monitoring or progress monitoring involves assessing client outcomes or the therapeutic alliance on a weekly basis in psychotherapy, and then giving feedback to the therapist about how the client is doing relative to the previous week and relative to similar clients. Research on progress monitoring indicates that it improves outcomes and it reduces by half the number of clients who might get worse. Despite its benefits, many therapists are not aware of progress monitoring or are reluctant to use the procedure. Some have expressed concerns that progress monitoring could interfere with the therapeutic relationship. However, very few studies have asked clients about their experiences of progress monitoring. In this synthesis of qualitative studies, Solstad and colleagues reviewed 16 studies in which clients were interviewed about their experiences of progress monitoring. The authors used a procedure in which they identified common themes across the studies and categorized client statements within those themes (e.g., thematic analysis). The authors were interested in identifying what were the hindering and helpful processes in clients’ experiences of their therapists’ use of progress monitoring. Four main themes emerged from the research. First, some clients voiced suspicion of how the progress monitoring data was going to be used and why the procedure was implemented. That is, clients sometimes felt that filling out questionnaires weekly was mainly a bureaucratic exercise, or possibly a means to justify reducing services. Second, some clients felt the questionnaires were not flexible enough to capture the complexity of mental health and of client concerns. The questionnaires often focused on symptoms, but clients were also interested in the therapeutic relationship, family, and social functioning. Third, some clients wanted to be more fully informed about the rationale for progress monitoring so that they could feel more empowered to define their own outcomes and treatment plans. Fourth, some clients found progress monitoring to help them to see graphically their own progress, to become more engaged in treatment planning, and to participate in collaborative and reflective discussions with their therapist.

Practice Implications

If psychotherapists choose to use progress monitoring in their practices, they should make sure that clients know what the data will be used for and that the exercise is not just a bureaucratic process. The practice of outcome or progress monitoring can be used to stimulate reflection not only in the therapist but also in the client. Reviewing the client data together might enhance conversations about therapy, the therapeutic relationship, and help to establish realistic goals for therapy. Therapists might consider not only measuring symptom progress repeatedly, but also measuring the working alliance on a regular basis.

Jennissen, S., Huber, J., Ehrenthal, J.C., Schauenburg, H., & Dinger, U. (2018). Association between insight and outcome of psychotherapy: Systematic review and meta-analysis. The American Journal of Psychiatry. Published Online: https://doi.org/10.1176/appi.ajp.2018.17080847

For many authors, one of the purported mechanisms of change in psychotherapy is insight. In fact, the utility of insight for clients with mental health problems was first proposed over 120 years ago by Freud and Breuer. Briefly, insight refers to higher levels of self-understanding that might result in fewer negative automatic reactions to stress and other challenges, more positive emotions, and greater flexibility in cognitive and interpersonal functioning. Although insight is a key factor in some psychodynamic models, it also plays a role in other forms of psychotherapy. Experiential psychotherapy emphasises gaining a new perspective through experiencing, and for CBT insight relates to becoming more aware of automatic thoughts. Jennissen and colleagues defined insight as patients understanding: the relationship between past and present experiences, their typical relationship patterns, and the associations between interpersonal challenges, emotional experiences, and psychological symptoms. In this study, Jennissen and colleagues conducted a systematic review and meta analysis of the insight-outcome relationship, that is the relationship between client self-understanding and symptom reduction. They reviewed studies of adults seeking psychological treatment including individual or group therapy. The predictor variable was an empirical measure of insight assessed during treatment but prior to when final outcomes were evaluated. The outcome was some reliable and empirical measure related to symptom improvement, pre- to post- treatment. The review turned up 22 studies that included over 1100 patients mostly with anxiety or depressive disorders who attended a median of 20 sessions of therapy. The overall effect size of the association between insight and outcome was r = 0.31 (95% CI=0.22–0.40, p < 0.05), which represents a medium effect. Moderator analyses found no effect of type of therapy or diagnosis on this mean effect size, though the power of these analyses was low.

Practice Implications

The magnitude of the association between insight and outcome is similar to the effects of other therapeutic factors such as the therapeutic alliance. When gaining insight, patients may achieve a greater self-understanding, which allows them to reduce distorted perceptions of themselves, and better integrate unpleasant experiences into their conscious life. Symptoms may be improved by self-understanding because of the greater sense of control and master that it provides, and by the new solutions and adaptive ways of living that become available to clients.

Author email: Simone.Jennissen@med.uni-heidelberg.de

Simionato, G. K., & Simpson, S. (2018). Personal risk factors associated with burnout among psychotherapists: A systematic review of the literature. Journal of Clinical Psychology. Advance online publication.

Burnout is an important factor in work-related problems for psychotherapists. Burnout is defined as a type of stress associated with feelings of exhaustion, disconnection, and self-doubt related to emotionally involved work in helping professions. Maslach described burnout as being composed of three factors: emotional exhaustion (personal and emotional fatigue at work), depersonalization (negative feelings about clients and the work), and a reduced sense of personal accomplishment (low personally related work successes). Psychotherapists are inclined to burnout because of the emotionally taxing work during which they must remain empathic. In order to protect themselves and conserve energy, psychotherapists may detach from clients, which may lead to a lower sense of work satisfaction and work accomplishments. High levels of burnout reduce a psychotherapist’s ability to take care of themselves and their clients. In this systematic literature review, Simionato and Simpson found 40 studies that empirically examined burnout among psychotherapists and the possible correlates or causes. Results of the 40 articles represented almost 9,000 therapists. Over 54% of therapists reported moderate to high levels of stress related to burnout. On average, therapists reported moderate to high levels of emotional exhaustion, depersonalization, and low personal accomplishment. Younger age was the most frequently identified risk factor for psychotherapist burnout, as was over-involvement with client problems. The authors suggested that the association between burnout and being younger may be due to being less experienced and to higher levels of unattainable standards for clinical practice and client outcomes. In addition, being female was associated with higher reported levels of burnout. This may be due to stress related to women having to juggle demands of both work and domestic responsibilities. Young clinicians are more likely to have young families, and women may be particularly prone to work-life conflict while managing the demands of both.

Practice Implications

Over half of psychotherapists reported moderate to high levels of burnout that could affect their work, their clients’ outcomes, and their personal well being. Training programs might facilitate self-awareness and the capacity for psychotherapists to reflect on their personal strengths, limitations, and maximum workload capacity in order to find the best fit between their personality, circumstances, and job demands. Practicing therapists might consider personal therapy to help cope better with demands of work and home life. Surveys of psychotherapists consistently showed that about 70% have sought psychotherapy at some point in their careers.

Davis, D. E., DeBlaere, C., Owen, J., Hook, J. N., Rivera, D. P., Choe, E., . . . Placeres, V. (2018). The multicultural orientation framework: A narrative review. Psychotherapy, 55(1), 89-100.

Many therapists have better outcomes with White or European clients than clients from diverse racial or ethnic minorities, and this might be due to racial and ethnic microaggressions that sometimes occur in therapy. Microaggression refer to intentional or unintentional brief commonplace verbal, behavioural, or environmental indignities that are experienced as derogatory or negative by racial and ethnic minority clients. A multicultural orientation refers to how the cultural worldviews, values, and beliefs of clients and therapists interact to co-create a relational experience in therapy. Therapist multicultural orientation has three elements. First, cultural humility, in which a therapist is able to maintain an interpersonal stance that is open to the client’s experience of cultural identity. Second, cultural opportunity, in which the therapist uses events in therapy to explore a client’s cultural identity in depth. Third, cultural comfort in which a therapist feels at ease, open, and calm with diverse clients. These elements are important in order to negotiate a therapeutic alliance (i.e. agreement on tasks and goals of therapy, and the emotional bond between client and therapist). In this narrative review, Davis and colleagues look at the small existing research on multicultural orientation and how that research can inform therapists’ practices. The authors found that in the two studies on the topic, greater therapist cultural humility was associated with better client outcomes. Several studies found that cultural humility was associated with a positive therapeutic alliance, and that therapist cultural humility was associated with fewer microaggressions as experienced by racial and ethnic minority clients. Finally, missed opportunities by therapists to explore the meaning of culture and identity were associated with negative client outcomes. Presumably, such missed opportunities meant that therapists did not recognize and repair cultural ruptures.

Practice Implications

The research on multicultural orientation suggests several practice implications. (1) Cultural humility requires therapists to explore their automatic cultural assumptions because if they remain unexplored they may be harmful to clients. (2) Therapists should overtly discuss the importance of cultural identities with clients in order to help both therapist and client develop a more complex understanding of the issues that bring the client to therapy. (3) A strong therapeutic alliance may require the therapist to incorporate their client’s cultural worldview and perspective when conceptualizing the client’s problems. (4) Depending on the client’s cultural worldview, therapists may consult with the client’s family and/or spiritual leaders when negotiating a culturally acceptable way of addressing the client’s problems. (5) Therapists need to identify for themselves when their values conflict with those of the client, and seek consultation or supervision when they do.

Stiles, W. B. & Horvath, A. O. (2017). Appropriate responsiveness as a contribution to therapist effects. In L. Castonguay and C. Hill (Eds.). How and why some therapists are better than others?: Understanding therapist effects (Ch. 4). Washington: American Psychological Association.

Appropriate responsiveness refers to therapists’ ability to adapt their techniques to the client’s requirements and circumstances. This might include planning treatment based on how the client is responding, using the client’s evolving responses to treatment as a guide to interventions, and adjusting interventions already in progress in light of subtle signs of client uptake. Appropriate responsiveness may depend on a client’s diagnosis, education, personality, stage of life, values, stage of therapy, among others. Responsiveness also depends on therapists’ skills, personality, theoretical orientation, and history of the therapeutic relationship. In this chapter, Stiles and Horvath review the literature on relationship variables that predict therapy outcomes and interpret these findings in the context of therapist responsiveness. To illustrate, previous research showed that therapists’ rigid adherence to a treatment manual was associated with worse client outcomes – or to state it differently, therapist adherence flexibility was associated with better outcomes. This flexibility is an indication of appropriate responsiveness on the part of the therapist. Stiles and Horvath also argue that most of the relationship variables that predict client outcomes reflect whether therapists appropriately respond to the circumstances of the client at a particular point in therapy. That is, evidence-based relationship factors like alliance, cohesion, empathy, goal consensus, positive regard, and others evaluate whether the therapist successfully tailored interventions and behaviors to the client’s unique personality and circumstances. For example, therapeutic alliance (the affective bond, and agreement on tasks and goals of therapy) indicates that the therapist selected interventions that were appropriate to the client, introduced them at the right time, and was attentive to and interested in the client’s progress. In support of this, the authors cite research showing that the therapeutic alliance is largely a function of the therapists’ responsiveness and not the client’s characteristics. That is, therapists are largely responsible for the quality of the therapeutic alliance.

Practice Implications

Research is increasingly indicating that therapists’ ability to respond appropriately to clients on a moment-to-moment basis is a key therapeutic factor. In other words, therapists who can build strong alliances, repair alliance ruptures, work for goal consensus and collaboration, manage countertransference, and be empathic are those who respond to the changing nature of client characteristics and needs in therapy. Supervision that provides feedback to therapists on these therapeutic factors, mastering a framework to guide interventions, client progress monitoring and feedback, and acquiring knowledge of client personality and cultural factors can sensitise therapists to their client’s changing requirements and allow them to respond therapeutically.

Handbook of Psychotherapy and Behavior Change: Starting in March 2013 I will review one chapter a month from the Handbook of Psychotherapy and Behavior Change in addition to reviewing psychotherapy research articles. Book chapters have more restrictive copy right rules than journal articles, so I will not provide author email addresses for these chapters. If you are interested, the Handbook table of content and sections of the book can be read on Google Books.

Crits-Christoph, P., Connolly Gibbons, M.B., & Mukherjee, D. (2013). Psychotherapy process-outcome research. In M.E. Lambert (Ed.), Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change, 6^th Edition (pp. 298-340). New York: Wiley.

This month I consider the section in Crits-Christoph and colleagues’ chapter on the process of psychodynamic therapy (PDT). There are a number of PDT models, but they each share some fundamental aspects of treatment or purported mechanisms. One is insight or self understanding, in which patients learn about themselves and their relationships through interventions like interpretations. Self understanding is expected to help patients reduce symptoms by increasing adaptive responses in their important relationships. Transference interpretations may help patients understand their patterns within the therapy relationship, address or change these patterns, and generalize the changes to relationships outside of therapy. Another mechanism might be changes in defensive functioning. Defense mechanisms may be expressions and means of coping with unconscious conflict, needs, and motivations. Change in defensive functioning from less adaptive (e.g. acting out, passive aggression) to more adaptive (e.g., altruism, self observation) may be necessary to achieve improvement in symptoms. Crits-Christoph and colleagues addressed four questions in their review of research on the process of PDT. (1) Are the uses of PDT techniques like transference interpretations related to treatment outcomes?  A number of studies have associated the use of PDT interventions and outcomes, and the average effect size is moderate. In general, transference interpretations were associated with better treatment outcomes. However the findings for transference interpretations are complicated. For example, the use of too many transference interpretations may not be therapeutic and may result in poorer outcomes. A small number of studies looked at the quality or accuracy of transference interpretations and found a moderate relationship between accurate interpretations and good outcomes. Most of these studies did not control for previous improvement in outcomes, so an alternate explanation might be that patients whose symptoms improve facilitate therapists to provide more effective transference interpretations. (2) Is patient self-understanding or insight associated with positive outcomes in PDT? Crits-Christoph and colleagues concluded from their review that changes in self-understanding is an important part of the therapeutic process of PDT. The relationship between insight and outcomes were not evident in CBT or medication interventions, thus suggesting that self-understanding is a specific mechanism of PDT. (3) Is change in defensive functioning related to outcomes in PDT? Only four studies have looked at this question. The studies suggest that improved defensive functioning is related to good outcomes especially for those with more severe problems. However, it remains unclear whether change in defensive functioning causes change in symptoms or the other way around. (4) Is therapist competence in PDT related to treatment outcomes? There is some evidence that competence and adherence in delivering PDT were related to good patient outcomes. Some research also showed that competence and adherence to PDT protocols preceded or caused good outcomes.

Practice Implications

There is good evidence that transference interpretations are related to outcomes, but therapists need to use these judiciously. The research suggests that too many transference interpretations in those with lower levels of functioning, or inaccurate interpretations in general, can reduce outcomes or be related to poorer outcomes. There is also good evidence that patient self understanding of relationship patterns will result in positive outcomes. Self understanding or insight may be a specific mechanism by which PDT works that sets it apart from CBT and the effects of medications. The research also indicates some evidence for the positive effects of changes in defensive functioning, but it is not clear whether change in defenses is a cause of or caused by positive symptom outcomes. Therapist competence and adherence in delivering PDT is also related to good patient outcomes. This highlights the need for training and supervision in evidence based PDT interventions.