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Curran, J., Parry, G.D., Hardy, G.E., Darling, J., Mason, A-M., Chambers, E. (2019). How Does therapy harm? A model of adverse process using task analysis in the meta-synthesis of service users’ experience. Frontiers in Psychology, 10:347. doi: 10.3389/fpsyg.2019.00347

Forty to 60% of patients do not recover after a course of psychotherapy, and approximately 5% to 8.2% are worse off. In the National Health Service in the UK, 5% of patients reported lasting bad effects of therapy. Although these appear to be small percentages, they represent a large number of patients. In Canada for example, over 1 million Canadians use psychotherapy each year, so 5% would represent 50,000 individuals. Therapists, for their part are poor at identifying patients who deteriorate in therapy. In this meta-synthesis of qualitative research, Curren and colleagues aimed to derive a model based on patients’ experiences of the factors that lead to negative outcomes. They conducted a narrative review of qualitative research findings and of patients’ testimony from a number of sources. They noted eight domains identified by patients that are associated with adverse events in psychotherapy. First, contextual factors refer organizational issues that affect access to or choice of therapy, cultural validity of the therapy, and lack of information about services. Second, pre-therapy factors refer to poor pre-therapy contracting between therapist and patient, and therapists that focus on symptoms rather than the client as a person. Third, therapist factors refer to therapist inflexibility, and therapists’ financial interests that influence their decisions about therapy. Fourth, client factors refer to client lack of understanding of therapy, fear, and demoralization. Fifth, relationship factors refer to a poor relational fit between therapist and patient, therapists perceived as shaming, therapists misusing power, and clients not feeling heard or understood. Sixth, therapist behaviors refer to boundary violations, rigidly applying techniques, therapist acting out, and therapist passivity. Seventh, therapy process refers to the type of therapy offered not matching patient needs, and patients not agreeing with the techniques. Eighth, endings refer to short term therapies that “open a can of worms” without resolution, and the client feeling abandoned.

Practice Implications

Therapists would do well to ensure that the patient’s voice is heard when it comes to preferences and cultural validity of the treatment. In particular, therapists should not rigidly apply techniques focused exclusively on symptom reduction. Instead, therapists should see patients’ problems within their interpersonal and cultural context and focus on outcomes related to the quality of life of patients. Therapists must attend to developing and maintaining the therapeutic alliance (agreement on tasks and goals of the therapy, and the relational bond with patients). Any signs of disruptions or tensions in the alliance should be identified and repaired. Patients require information about the therapy, what it entails, and how it will end before signing on to a course of treatment. Organizations must remove barriers to accessing treatment and provide therapies that represent a range of orientations and foci to meet patients’ needs.

Hiebler-Rager, M., Nausner, L., Blaha, A., Grimmer, K., Korlath, S., Mernyi, M., & Unterrainer, H.F. (2020). The supervisory relationship from an attachment perspective: Connections to burnout and sense of coherence in health professionals. Clinical Psychology and Psychotherapy, Online First Publication: https://doi.org/10.1002/cpp.2494.

Health professionals including psychotherapists are susceptible to burnout due to the emotional challenges of the work. There is some research indicating that with good supervision trainees and experienced therapists might be less susceptible to burnout (i.e., exhaustion, inefficiency, cynicism) and might gain a greater sense of personal coherence (i.e., that stressful events encountered in life are predictable and manageable, and that managing these events is personally meaningful). Supervision involves a senior qualified practitioner providing an intensive relationship-based education and training focused on supporting, guiding, and teaching a trainee or colleague. One can argue that the supervisory relationship provides the supervisee with a secure base from which to learn and grow as a professional. This secure base functions similar to an attachment relationship, which means that the bond, trust, agreement, and clarity of supervisory goals are key. That is, when a critical incident occurs in the therapy, the supervisee experiences stressful emotions and seeks support and security from the supervisor. One factor that may affect this process is the pre-existing level of attachment insecurity in the trainee (i.e., being too preoccupied with relationships or being too dismissing of relationships). Greater attachment insecurity may make it more difficult for supervisees to experience supervision as a safe environment. In this study, Hiebler-Rager and colleagues assessed if the quality of the supervisory relationship reported by supervisees predicted their level of burnout and of cohesion, and also if supervisees’ level of attachment insecurity also predicted these outcomes over and above the effects of supervision. The sample included 346 supervisees with a wide range of experience (0 to 50 years), ages (23 to 80 years), and professions who completed questionnaires about the supervisory relationship, attachment, burnout, and cohesion. Even after controlling for number of supervision sessions and supervisees’ clinical experience, lower quality of the supervisory relationship was related higher levels of burnout (β = −.31) and a lower sense of coherence (β = .31; both p < .01) in the supervisee. Higher levels of insecure attachment of the supervisee also predicted higher burnout (attachment anxiety: β = .30, p < .01) and lower coherence (attachment anxiety: β = −.40, p < .01; attachment avoidance:β = −.17, p < .01), even after controlling for the effects of number of supervisions sessions, experience, and the quality of the supervisory relationship. Adding attachment insecurity was associated with a medium to large incremental effect over and above the quality of the supervisory experience (R-square change = 0.13 for burnout, and 0.24 for coherence).

Practice Implications

Supervision is a key manner in which psychotherapists are trained, and in which many participate in continuing education. A good quality supervisory relationship (secure and supportive) can help professionals mitigate the risk of burnout and to have a greater sense of personal coherence. However, some of the utility of supervision may depend to some extent on the supervisee’s own level of attachment insecurity. If a supervisee experiences an insecure attachment generally, they may require personal therapy to work on their sense of security in relationships and their ability to manage theirs and others’ emotions.

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.

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.