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Ensink, K., Maheux, J., Normandin, L., Sabourin, S., … & Parent, K. (2013). The impact of mentalization training on the reflective function of novice therapists: A randomized controlled trial, Psychotherapy Research, 23, 526-538, DOI: 10.1080/10503307.2013.800950

Recently, researchers and clinicians have been discussing the importance of therapists’ capacity to mentalize. That is, the capacity of therapists to be aware of mental states within themselves and clients, to identify and reflect upon emotional experiences of clients, and to understand the impact of client emotions and life experiences on the therapist’s capacity to be present, empathic, and effective. Most training programs in psychology and psychiatry focus almost exclusively on techniques – the rational application of psychological theory to diagnose and treat. These programs rarely, if ever, focus on training student therapists to mentalize. And yet, much of effective therapy also involves active listening, empathic understanding, developing a therapeutic bond, and consciously and deliberately imagining clients’ mental states. Without such skills, therapists may be susceptible to engage in anti-therapeutic acts (acting out, disengaging, verbalizing anger and frustration, feeling ineffective, burning out) born out of un-reflected personal reactions to clients and their experiences. In their study, Ensink and colleagues tested a training program designed to improve the capacity to mentalize in student therapists compared to therapists who only received traditional training in identifying psychopathology and applying therapeutic techniques. Mentalizing training involved 30 hours of experiential workshops that provided feedback to students on identifying their own reactions that might interfere with understanding the client, reflecting on their reactions, and considering how this reflection might help to understand the patient better. Capacity to mentalize was assessed by rating responses and reactions of student therapists in both conditions (mentalizing training vs traditional didactic training) to videos of clients in therapy. All novice therapists (in both training conditions) started at relatively low levels of reflectivity (an index of mentalizing), suggesting that students did not start the training program with these skills. Trainees in the mentalizing training group showed significant improvement in their capacity to mentalize, whereas students in the traditional didactic training showed a significant decline in their reflective capacity to mentalize.

Practice Implications

Psychotherapists do not start their training with high capacities to mentalize and so they may require training to hone this skill. Also, therapists who receive no such training do not spontaneously acquire these skills. Clients often have experiences that are perceived as foreign to trainee therapists, and so therapists may feel ill equipped to empathize, understand, and respond emotionally to such challenging client experiences. Therapists can be trained to identify their internal experiences (negative or positive emotional reactions that may be related to the client’s and/or therapist’s unresolved issues) that may interfere with establishing a productive therapeutic relationship. Increasing the capacity to mentalize may reduce therapists work-related stress as it affords therapists a greater measure of control and mastery over challenging encounters with some clients.

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.

Imel, Z. E., Pace, B. T., Soma, C. S., Tanana, M., Hirsch, T., Gibson, J., Georgiou, P., Narayanan, S., & Atkins, D. C. (2019). Design feasibility of an automated, machine-learning based feedback system for motivational interviewing. Psychotherapy, 56(2), 318–328.

I do not mean to conjure up the image of a dystopian future, but I could not resist the pithy title for this blog. Ideally, psychotherapists in training or those who seek professional development would receive high quality accurate feedback about their behavior (e.g., about interpersonal skills, empathy, vocal tone, body language) and competence (e.g., regarding specific interventions) in real time. This would allow psychotherapists and trainees can make fine-tuned adjustments to their behaviors and interventions that match or complement the specific patient with which they are working. But, given the current technology, this is impossible. Instead psychotherapy training and feedback to practicing clinicians is slow, cumbersome, and imprecise. Current supervision and consultation practices rely on giving feedback based on the clinician’s verbal case report or, at best, based on viewing video recordings. There are systems that provide feedback on patient outcomes that may alert psychotherapists to something going amiss in for the patient. But such feedback occurs post-session, is based on patient self-report, and does not inform immediate in-session therapist behaviors. In this study, Imel and colleagues evaluated an initial proof of concept of an automated feedback system that generated quality metrics about specific therapist interventions and about therapist skills like empathy. They used computer technology based on natural language processing to take conversational data from video of psychotherapy sessions in order to answer questions like: “what did the therapist and patient talk about during the session?”, “how empathic was the therapist?”, and “how often did the therapist use reflections versus closed questions in the session?” The authors developed a machine learning tool to transcribe, code, and rapidly generate feedback to 21 experienced and novice therapists who recorded a 10-minute session with a standardized patient (a standardized patient is an actor who loosely follows a script). The machine learning technology was accurate at defining or coding a “closed question” by a therapist (e.g., a question with a yes/no answer; inter rater agreement with a human coder ICC = .80), but not as accurate at defining or coding a therapist empathic statement (inter rater agreement with a human coder ICC = .23). The system provided immediate feedback the therapists about their behaviors during the session using graphics and text (fidelity to specific interventions, counseling style, empathy, percent open/closed questions, percent reflections). All therapists rated the tool as “easy to use”, 86% strongly agreed that the feedback was representative of their performance, 90% agreed that if the tool was available, they would use it in their clinical practice.

Practice Implications

Typically, professional consultation or supervision involves a consultant giving the therapist feedback based on imprecise descriptions of events in a therapy session that occurred at some point in the recent past. This method of training and consultation in psychotherapy has not changed much in the past 60 years. One key drawback of current methods of training and consultation is that they do not make use of real-time feedback to help therapist adjust behaviors to the specific patient or context. It is possible that in the near future with rapid advances in artificial intelligence and machine learning a therapist will be able to finish a session with a patient and receive an immediate feedback report about the previous hour. The feedback might include metrics on empathy, the percent of questions vs reflections, competence in specific interventions, among other personalize ratings. This future might also have novice trainees receive immediate real-time in-session feedback about behaviors of interest that need to be adjusted, or for which more training is necessary. For some, this might be a vision of a dystopian future, for others it may represent a way forward in which therapists achieve more refined skills and better patient outcomes.

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.

Pybis, J., Saxon, D., Hill, A., & Barkham, M. (2017). The comparative effectiveness and efficiency of cognitive behaviour therapy and generic counselling in the treatment of depression: Evidence from the 2nd UK National Audit of psychological therapies. BMC Psychiatry, 17, 215. DOI 10.1186/s12888-017-1370-7

Over a decade ago the United Kingdom (UK) invested large sums of public dollars to fund the Increasing Access to Psychotherapy (IAPT) program. In IAPT, most patients receive cognitive behavioral therapy (CBT) as first-line treatment for depression or anxiety, and may receive generic counseling as second line treatment. One of the admirable aspects of IAPT is that the program consistently assesses outcomes, makes its data available for analyses, and publishes yearly reports on their outcomes. In this very large study, Pybis and colleagues assess whether CBT and generic counseling have different outcomes for patients with depression or anxiety. Over 33,000 patients who received treatment at one of 103 sites were in the study. Most patients (about 23,000) receiving CBT, and the others (about 10,000) receiving generic counseling. Two-thirds of the patients were female, most (84%) were white British, and the mean age was 41 (SD = 13.86). CBT focused on changing negative thoughts and behaviors in order to improve depressive symptoms. Generic counselling was harder to define, though the authors described these therapists as practicing in an integrative manner by bringing skills from training in different forms of psychotherapy. Generic counseling therapists did not focus on giving advice or opinions, but rather on helping clients understand themselves better. Pre- to post-treatment effect sizes for CBT (0.94 [0.92, 0.95]) and generic counseling (0.95 [0.92, 0.98]) were equivalent for depression outcomes. In CBT 50.4% of patients reliably improved, whereas 49.6% reliably improved if they received generic counseling. The average number of sessions attended by patients in the two treatments (CBT = 8.9 [6.34]; counseling = 7.5 [5.54]) were also equivalent. However, there were significant site effects. That is, a moderate and significant amount of patient outcomes (15%) could be accounted for by the site at which they received treatment (i.e., some sites or clinics had better outcomes than others).

Practice Implications

Generic counseling as provided in the IAPT in the UK was as effective as structured CBT for reducing symptoms of depression. However, almost half of patients did not improve in either treatment. Generic counseling was likely a label used to describe integrative psychotherapy that followed principles from a variety of psychotherapies that were based on psychological principles. There were much larger site/clinic effects than treatment modality effects, so that clients in some clinics had better than clients who received treatment in other clinics. This is consistent with research on therapist effects that show that some therapists are more effective than others, regardless of their orientation. This research suggests that training therapists to be more effective by improving their facilitative interpersonal skills may yield better outcomes for clients.

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.