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Aajes-van Doorn, K., Bekes, V., & Prout, T. (2020). Grappling with our therapeutic relationship and professional self-doubt during COVID-19: Will we use video therapy again? Counselling Psychology Quarterly, DOI: 10.1080/09515070.2020.1773404

Social restrictions caused by COVID-19 required many therapists to use video therapy to provide treatment to patients remotely. Video therapy offers many benefits like allowing for real-time (synchronous) interactions with patients who would otherwise not have access to mental health care. However most therapists have no training or experience in this modality, and previous surveys suggest that therapists believe video therapy to be less effective than face to face therapy. And some evidence suggests that the level of the working alliance in video therapy is lower than in face to face therapy. In this small survey of 141 therapists about video therapy, Aajes-van Doorn and colleagues examined psychotherapists’ view of the working alliance, therapists’ level of confidence in providing video therapy, and their intentions to use video therapy in the future. Psychotherapists were from the US, Canada, and Europe who treated adult patients in private practice. One third of therapists previously attended a webinar on how to use video conferencing for psychotherapy. The most frequently reported challenges for therapists concerned technical difficulties (61.0% of therapists), having a suitable space for therapy (48.2%), risk of patient or therapist getting distracted (41.1%), and difficulty feeling or expressing empathy to the client (20.6%). On a standardized scale, therapists responded feeling less connected to their patients during video therapy sessions, but they nevertheless reported a good therapeutic alliance compared to published norms. On two other measures, therapists providing video therapy felt more professional self-doubt, less competent, and less confident than levels reported in a previous study of therapists providing face to face therapy. Although therapists’ views of video therapy became more positive since the start of the pandemic, therapists still perceived video therapy to be less effective than face to face treatment. Therapists on average were undecided as to whether they would continue using video therapy in the future, and those who were more likely to continue using had prior experience with the modality.

Practice Implications

Although this is a small survey, it does provide a window into therapists’ experiences with video therapy. The study highlights the added stressors upon therapists in conducting video therapy including higher self-doubt and lower competence and confidence. Also, although the therapeutic alliance in video therapy was good, it seemed to be lower than reported in previous studies of face to face therapy.  Therapists may benefit from more clinical training and support in managing the various technical and clinical challenges of video therapy. With the permission of their patients and following appropriate ethical guidelines, therapists might consider video recording their sessions and reviewing these recordings in consultation/supervision to improve their work with clients in a virtual setting.

Dickeson, E., Roberts, R., & Smout, M.F. (2020). Predicting boundary violation propensity among mental health professionals. Clinical Psychology and Psychotherapy, Online First Publication: https://doi.org/10.1002/cpp.2465.

Boundaries of the therapeutic relationship define the role and limits of therapist behaviors, and the limits of their relationship with clients. Violations of therapy boundaries might include sexual contact, which by some estimates occurs in 0.5% to 8.6% of therapists. Other boundary violations might include a broader range of behaviors such as therapists initiating hugs, forming a social relationship with a client, flirting, and consuming alcohol with a client. A number of years ago, Gabbard developed a typology of practitioners who committed boundary violations that included: the predatory therapist, the masochistic therapist, and the lovesick therapist. Despite the widespread use of this typology, there was little research on its validity or utility. Dickeson and colleagues conducted a survey of 275 Australian practitioners (psychologists, psychiatrists, psychotherapists, and social workers, 73% women) about their behaviors related to professional boundaries and also personality traits. The goal was to evaluate if therapist variables suggested by Gabbard were related to the likelihood of crossing a professional boundary. Over 30% of the therapists in their sample reported some kind of boundary violation with clients, with 0.7% indicating they had sex with a client. Male gender (r = .147–.255), experiential avoidance (r = .144–.230), narcissistic grandiosity (r = .334–.402), narcissistic vulnerability (r = .258–.331), and impulsivity (r = .196–.262) were the most consistent predictors of some propensity to commit a boundary violation among therapists. There was no evidence that age or working in a solo practice setting were related to propensity to professional boundary violations.

Practice Implications

Gabbard’s typology for therapists who engage in boundary violations were supported to some extent. The predatory therapist type was supported by findings related to narcissistic grandiosity and impulsivity. Such therapists may seek personal gratification by exploiting clients. There was also some evidence for the masochistic therapist type as seen by significant correlations with narcissistic vulnerability and experiential avoidance. Such practitioners might extend themselves beyond the limits of professional conduct in a misguided belief that only they can help the client. There is a general consensus in the profession that boundary violations are detrimental to clients. This research suggests that therapists with narcissistic issues might be more likely to transgress professional boundaries. Personal therapy, close supervision, and ongoing professional consultation may be helpful for therapists who feel that they at risk of a professional boundary transgression.

Clients of Therapists Who Are Flexible Have Better Outcomes

Katz, M., Hilsenroth, M. J., Gold, J. R., Moore, M., Pitman, S. R., Levy, S. R., & Owen, J. (2019). Adherence, flexibility, and outcome in psychodynamic treatment of depression. Journal of Counseling Psychology, 66(1), 94–103.

Psychodynamic and cognitive-behavioral (CB) treatments are quite different in how therapy is delivered, but both are equally effective for depression. Such findings suggest that various types of specific interventions can positively impact client outcomes. A possible mechanisms of therapeutic action is that effective therapists may be particularly responsive to their clients’ behaviors and needs. That is, effective therapists may be flexible in how adherent they are to the techniques of a therapeutic orientation. Therapists who are flexible in their adherence to a therapeutic technique may promote a better therapeutic alliance (i.e., a therapist’s and client’s collaborative agreement on the goals of therapy and what to do in therapy). In this study, Katz and colleagues examined whether the flexible use of some CB techniques by psychodynamic therapists was related to better client outcomes in terms of depressive symptoms. Forty six patients diagnosed with depression were treated by 26 advanced graduate student therapists who were trained to practice psychodynamic therapy. Psychodynamic therapy techniques included: a focus on affect and affect expression, identifying relational patterns and patterns of thoughts and feelings, emphasizing past experiences and interpersonal relationships, working on the therapeutic alliance, and restructuring defense mechanisms. The researchers video recorded two early sessions of therapy which were independently rated to assess the degree to which therapists adhered to psychodynamic therapy principles or to CB therapy principles. Client depression outcomes were assessed pre- and post-therapy. Higher ratings of psychodynamic therapy adherence were related to better patient depression outcomes at post-treatment. In addition, the clients of psychodynamic therapists who used some CB techniques early in therapy had the best outcomes. In other words, the use of psychodynamic techniques was sufficient for clients to improve, but flexible use of some CB techniques by psychodynamic therapists provided added benefit. The CB techniques that were most often integrated by the therapists included: actively initiating topics and therapeutic activities, explaining the rationale of an intervention, focusing on the future, and providing psychoeducation about symptoms.

Practice Implications

Clients in this study improved on average from psychodynamic therapy, and psychodynamic interventions were related to better outcomes. However, clients of therapists who flexibly integrated a small amount of CB techniques benefitted more from the psychodynamic techniques. Research is increasingly showing that therapist flexibility in treatment adherence is related to better patient outcomes. For psychodynamic therapists, flexibility in treatment adherence leads to clients being more responsive to the interventions and having better outcomes.

The Interactive Nature of Countertransference

Connery, A. L., & Murdock, N. L. (2019). An interactive view of countertransference: Differentiation of self and client presentation. Psychotherapy, 56(2), 181–192.

Countertransference in psychotherapy is ubiquitous – it is experienced by every therapist with many clients. An early supervisor of mine once quipped, “You might not be interested in countertransference, but it is certainly interested in you.” Countertransference refers to a therapist’s emotional, cognitive, behavioral responses that are triggered by a client, and that are caused in part by the therapist’s unresolved conflicts, sensitivities, or vulnerabilities. So, it is useful to consider countertransference as a result of an interaction between client factors and therapist factors. Research indicates that therapists’ experience of countertransference is related to negative outcomes in their clients, and that identification and management of countertransference results in better client outcomes. In this study, Connery and Murdoch posited that therapists who had lower levels of differentiation of self would experience higher countertransference reactions. That is, those therapists with lower ability to balance the inherent pulls of separateness and togetherness in interpersonal relations, and who had more difficulty maintaining a sense of self in intimate relationships would be more susceptible to the interpersonal pressures inherent in some psychotherapy relationships. The authors conducted a clever study in which 262 practicing psychotherapists of varying professions, orientations, experience, and ages completed some questionnaires. Then the researchers randomly assigned the therapists either to watch 10 video clips simulating a hostile and dominant patient (i.e., with features of narcissism or paranoia) or to watch 10 video clips simulating a hostile and submissive patient (i.e., with features of passive-aggression). After viewing the videos, researchers asked the therapists to describe their own emotional reactions to the client they viewed using a questionnaire that rates countertransference. In general, therapists tended to respond with over-involvement to the videos of hostile and submissive clients. However, those therapists with more problems with maintaining their sense of self in close relationships were particularly susceptible to feelings of over-involvement with these clients. On the other hand, therapists in general tended to respond with more under-involvement to the videos of hostile and dominant clients. However, those therapists who had more problems with maintaining a sense of self in relationships were not any more susceptible to these countertransference reactions compared to therapists with better differentiation of self.

Practice Implications

Differentiation of self indicates the capacity to develop a healthy balance of interpersonal relatedness and self-differentiation that allows one to balance emotional reactions and rational thought when under stress. This study suggests that therapists’ ability to manage closeness and distance in relationships affects the intensity with which they experience countertransference reactions towards clients who have passive-aggressive qualities. This provide further evidence that not only client characteristics, but also some therapist vulnerabilities play a role in determining countertransference reactions. The findings point to the importance of continued peer supervision and of personal therapy for psychotherapists so that they may be less susceptible to the stress inherent in their work, and so that their clients can achieve optimal outcomes.

Orlinsky, D.E., Ronnestad, M.H., Hartmann, A., Heinonen, E., & Willutzki, U. (2019). The personal self of psychotherapists: Dimensions, correlates, and relations with patients. Journal of Clinical Psychology. Online first: DOI: 10.1002/jclp.22876

What role does the psychotherapist’s personal self play in determining their interpersonal stances with patients? It is an intriguing question about the intersection between the personal self and the professional self of psychotherapists. Are we different in our personal lives compared to our professional lives? In this large survey of over 10,000 psychotherapists from Europe and North America, Orlinsky and colleagues examine the convergence of the personal and professional self of psychotherapists. The personal self was defined as therapists’ view of the self when engaging in personal relationships. This can include behaviors in close relationships, and also one’s temperament defined as innate sensitivities or proclivities in relationships. Previous research indicated that when relationships are satisfying, life typically feels rich and meaningful – but if personal relationships are limited or non-existent, life can feel empty and meaningless. The survey asked therapists a number of questions, including about how they describe themselves in close personal relationships, what their general proclivities are around affect expression, cognitive style, and expectations of relationships, and how they rated their life satisfaction. Half of the sample of psychotherapists were psychologists, and there was also a large representation of psychiatrists, counsellors, and social workers. Major theoretical orientations were represented (psychodynamic, CBT, humanistic), and therapists came from a number of countries mainly in Europe and North America. Most psychotherapists identified themselves as caring (friendly and warm: 85%) in close relationships, but some also reported being more forceful (authoritative: 37%) and reclusive (guarded: 27.6%). In terms of temperament most therapists were optimistic and intuitive (84% each), but some also indicated more pragmatic (72%) or skeptical (25%). Therapists who more caring and expressive also reported higher levels of personal life satisfaction. In general, therapists who were more caring in their personal relationships reported being more affirming with patients (r = .52), those who were more forceful in personal relationships tended to be more directive with patients (r = .48), and those who were more reclusive in personal relationships were more reserved with patients (r = .20).

Practice Implications

Not surprisingly, most therapists saw themselves as warm, affiliative, optimistic, and receptive in personal relationships. But, many therapists (35%) also described themselves in negative terms (reserved, guarded, skeptical) in close relationship. Although psychotherapists may see their personal relationships and their professional relationships as independent, this large multinational survey indicates otherwise. Personal relationship style and temperament has a moderate to large association with professional interpersonal style with patients. This may indicate that therapists generally are genuine (consistent with themselves) in their relationship with patients. But other therapists may have to reign in more negative aspects of their selves and social behaviors in order to be empathic and caring towards 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