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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.

Cologan, J., Schweiter, R.D., & Nolte, T. (2017). Therapist reflective functioning, therapist attachment style, and therapist effectiveness. Administration Policy and Mental Health, DOI: 10.1007/s10488-017-0790-5.

Differences between therapists account for about 8% of patient outcomes, which is a moderate effect and therefore an important factor. Constructs such as therapist personality characteristics and facilitative interpersonal skills may play a key role in how effective therapists can be with their clients. An important therapist quality might be reflective functioning, or mentalization. Reflective functioning refers to the ability to conceptualize, identify, and understand mental states in oneself and in others, and how mental states affect behaviour and functioning.  For example, reflective functioning is the basis for predicting others’ behaviors, understanding social nuances and others’ intentions, and also one’s own behaviors and internal experiences. Fundamentally for a therapist, reflective functioning is necessary for empathy, which is a key therapeutic quality. Another key issue for therapists might be their own attachment security, or their characteristic ways of relating to others in interpersonal relationships. Securely attached therapists (those who have a positive view of self and others in relationships) may be able to develop a better therapeutic alliance with clients. Insecurely attached therapists (those who are avoidant in relationships or who are preoccupied in relationships), may struggle to a greater extent with developing and maintaining an alliance. In this study, Cologan and colleagues assessed reflective functioning and attachment security in 25 therapists from different theoretical orientations who treated 1001 adult clients who mostly had problems with depression or anxiety. Client outcomes were measured pre and post treatment. On average clients experienced a reduction in their symptoms after psychotherapy. Clients of therapists with higher levels of reflective functioning experienced better outcomes. Therapist attachment insecurity did not have a direct effect on client outcomes.

Practice Implications

As with other studies, therapists in this study varied in their outcomes, so that some had better outcomes than others. Level of therapist reflective functioning (ability to mentalize) accounted for a large proportion of this difference. Therapists who had greater skills with understanding their own and clients’ behaviors in terms of mental states (intentions, motivations, psychological and emotional needs, internal conflicts) likely were better able to empathize and develop an alliance with their clients. These are skills that therapists can learn with practice, consultation, personal therapy, and training.

Love, M. & Farber, B.A. (2018). Honesty in psychotherapy: Results of an online survey comparing high vs. low self-concealers, Psychotherapy Research, DOI: 10.1080/10503307.2017.1417652.

An important task of psychotherapy is for therapists to provide a context within which clients feel comfortable disclosing difficult feelings, thoughts, and other experiences in their lives. Self-disclosure likely improves the therapeutic alliance (agreeing on tasks and goals, and an emotional bond between therapist and client), which is necessary for good outcomes. In fact, research indicates that client self-disclosure is generally associated with positive outcomes in therapy. And yet a number of surveys report that clients keep secrets or lie to their therapists. Clients appear to struggle between being honest and self-disclosing versus the fear or anxiety related to doing so. Research indicates that one can describe individuals as high self-concealers in most relationships in their lives. Such individuals consistently conceal negative aspects of themselves from others to help manage their anxiety in relationships in the short term. However, in the long term, high levels of self-concealment increases rumination and anxiety and reduces coping. In this study, Love and Farber conducted an online survey of 572 participants who were currently in therapy or were in therapy in the past year. The sample characteristics and the type of therapy they received were surprisingly similar to a nationally representative sample of clients who seek treatment, though this online survey sample was somewhat younger. Over 84% of clients in this survey reported being dishonest about at least one topic with their therapist. Most frequent topics for being dishonest included: details of sex life (33.9%), suicidal thoughts (21.9%), self-harm (14.5%), real reactions to therapist comments (18.9%), whether therapy was helping (15.7%), and family secrets (16.3%). The most predominant motive for dishonesty was embarrassment or shame (63.6%), followed by doubts that the therapist would understand (27.0%), fear of overwhelming emotions (18.1%), and disappointing or hurting the therapist (16.4%). Not surprisingly, clients who tended to conceal their experiences reported disclosing less distressful information and also reported a lower therapeutic alliance with their therapists. Almost half of high self-concealers reported that dishonesty hurt their therapeutic progress.

Practice Implications

Topics like suicidal ideation and sex are particularly difficult to speak about honestly in therapy, especially for those who are uncomfortable with disclosing in general. Most clients are willing to discuss difficult topics with therapists if the therapist inquires sensitively and directly. High self-concealers are highly attuned to how therapists might react, and these clients anticipate shame or judgement. Therapists need to monitor the state of the therapeutic relationship with each client, especially the client’s perception of therapist warmth and trustworthiness. This could include monitoring for any ruptures in the therapeutic alliance. Further, therapists may need to communicate that self-concealment serves a short term purpose to reduce anxiety, but has a long term cost in terms of amplifying distress.