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Constantino, M. J., Vîslă, A., Coyne, A. E., & Boswell, J. F. (2018). A meta-analysis of the association between patients’ early treatment outcome expectation and their posttreatment outcomes. Psychotherapy, 55(4), 473-485.

A concept similar to but distinct from client preferences is client expectations of outcomes. One of the first writers to discuss the importance of client expectations was Jerome Frank who argued that clients enter therapy demoralized, and that for therapy to be effective it must mobilize the client’s belief that treatment will work. Frank felt that outcome expectation is key to the process of remoralization for the client. Outcome expectations refer to clients’ personal predictions about how they will respond to treatment. Generally, problems may be signalled by clients who feel hopeless about the potential effectiveness of the therapy or therapist. But it is also possible for expectations to be unrealistically high, never met, and therefore disappointing. Clients may form outcome expectations before they start therapy, or the expectations may be shaped by early experiences in the therapy or with the therapist. Outcome expectations may develop, in part, based on how credible the therapy seems to the client, and or whether the therapist or therapy are consistent with the client’s preferences. Also, research indicates that higher realistic expectations likely leads to an improved therapeutic alliance, mainly because it facilitates collaboration of the client with the therapist. In this meta-analysis, Constantino and colleagues evaluated 72 studies (81 samples) of over 12,000 adult clients in which early outcome expectations were assessed and correlated with client outcomes at post-treatment. The overall effect of the meta-analysis was r = .18 (95% CI [.14, .22]), indicating a small, but statistically significant, positive effect. There were a few moderators of this relationship. The expectation – outcome correlation was larger for younger clients, and for therapies that used a treatment manual. Client diagnosis, treatment orientation, or treatment modality did not affect the correlation.

Practice Implications

Increasing a client’s expectation of a good outcome likely raises their hopes and goes some ways toward remoralizing the client. Therapists can assess their client’s outcome expectations early in therapy with a validated measure, and invite a discussion of these expectations. It may be useful to be aware of studies reviewed in the PPRNet blog, and to review with clients in a non-technical way the evidence for psychotherapy’s effectiveness. Although one should be inspiring about the potential outcomes of therapy for a client, therapists should not promise an unrealistic degree or speed of change. Therapists should express realistic confidence and competence in the psychotherapy that they are about to provide.

Author email: mconstantino@psych.umass.edu

Simpson, S., Simionato, G., Smout, M., van Vresswijk, M.F., Hayes, C., Sougleris, C., & Reid, C. (2018). Burnout amongst clinical and counselling psychologist: The role of early maladaptive schemas and coping modes as vulnerability factors. Clinical Psychology and Psychotherapy, Online first DOI: 10.1002/cpp.2328.

Burnout in health professionals has become a global problem, with between 21% and 67% of mental health professionals reporting high levels. Researchers define burnout as including three components: emotional exhaustion (feeling emotionally exhausted from the work), depersonalization (feeling disconnected from patients), and reduced personal accomplishment in one’s work. Burnout is related to reduced capacity to perform professionally and to provide adequate care to patients. Much of the research has focused on institutional and workload factors as causes of burnout in health professionals. However, interpersonal factors like therapists’ early maladaptive schemas and coping mechanisms may also increase vulnerability to burnout. Early maladaptive schemas are self-defeating core beliefs and patterns that are repeated throughout one’s life and that have their origin in early life experiences. Maladaptive coping are thoughts and behaviors that one repeatedly engages in an unconscious or automatic way to minimize the activation of early maladaptive schemas. Maladaptive coping might include detachment, self-aggrandizement, attacking others, or over-compliance. In this study, Simpson and colleagues surveyed 443 clinical or counseling psychologists in Australia to assess if in fact early maladaptive schemas and maladaptive coping predicted burnout over and above job demands like workload. The mean age of the psychologists was 42.93 years (SD = 11.53), most were women (80.4%), who were married (52.8%), had attained a Masters degree (45.6%), and worked either in outpatient mental health centres (39.7%) or in private practice (33%). Most of the therapists (67%) indicated that over 50% of their client work involved trauma. Of the sample, 49.7% indicated at least a moderately high level of burnout on a standardized questionnaire, with emotional exhaustion as the highest type of burnout. The most common early maladaptive schemas among the psychologists were unrelenting standards and self-sacrifice. Detached coping was the most common coping mode. In terms of predicting burnout, job demands accounted for 10% of the variance in burnout, early maladaptive schemas accounted for an additional 18% of the variance in burnout over and above job demands, and maladaptive coping accounted for an additional 6% beyond maladaptive schemas and job demands.

Practice Implications

Work – life balance, managing clients with chronic and complex issues, and working with clients who experienced trauma can cause distress in mental health providers. Psychologists’ early maladaptive schemas like unrelenting standards and self-sacrifice in addition to maladaptive detached coping may represent the foundation of countertransference for some psychotherapists. These were significant predictors of therapist emotional exhaustion over and above workload. Psychotherapists would benefit from an increased awareness of their own early maladaptive schemas and coping mechanisms. Self-care, including professional development, consultations, peer support groups, and personal therapy throughout one’s career could reduce one’s susceptibility to burnout.

Laverdière, O., Kealy, D., Ogrodniczuk, J. S., & Morin, A. J. S. (2018). Psychological health profiles of Canadian psychotherapists: A wake up call on psychotherapists’ mental health. Canadian Psychology/Psychologie canadienne, 59(4), 315-322.

Patients prefer to work with psychotherapists whom they perceive as psychologically healthy and satisfied with their lives. Psychological health and satisfaction in therapists may be related to their ability to manage their own reactions to clients (countertransference), as well as to their ability to maintain personal and psychological well-being. However, the work circumstances on psychotherapists may compromise their psychological health. Patients often present in ways that may result in emotional reactions in therapists, such as self-doubt and frustration. Also, therapists may develop vicarious or secondary traumatic stress when exposed to patients with a history of trauma. Such emotional stressors may overwhelm therapists and contribute to burnout, distress, and lower quality of life. Previous research found that difficulties in therapist mental health may lead to emotional disengagement, patient early termination, and a lowered therapeutic alliance. Large-scale international surveys indicate that 87% of psychotherapists were involved in psychotherapy at some point in their careers. This suggests that many psychotherapists understand or have experienced the hazards of their work. In this survey of registered Canadian psychotherapists, Laverdière and colleagues were interested in the self-reported psychological health of psychotherapists. The sample included 240 psychotherapists who were mostly women (78%) and psychologists (84%), with a mean age of 42 years (SD = 11.66), practicing psychotherapy for an average of 13 years (SD = 9.42), and working primarily in independent practice (40%) or in an institutional setting (40%). Most identified their primary theoretical orientation as psychodynamic (31%), CBT (31%), integrative (22%), or humanistic (15%). Using a standardized measure of burnout, the authors found that 22% of psychotherapists were experiencing high levels of emotional exhaustion (with a further 20% in the moderate range), and 12% experienced a high level of depersonalization. Only 8% could be classified as having probable serious mental health issues and life dissatisfaction. The authors then developed statistical profiles of psychotherapists using latent class analysis. Using these profiles, 35% of psychotherapists were characterized by moderately high levels of burnout and distress and moderately low quality of life. A further 12% of psychotherapists had very high levels of burnout and distress and very low quality of life. Those with healthier profiles tended to be more experienced (B = .14, p = .008, OR = 1.15) and to have lower perceived workload (B = -1.10, p = .006, OR = .33).

Practice Implications

One in five psychotherapists in this survey were experiencing high levels of emotional exhaustion, and another 20% were in the moderately high range. Emotionally exhausted professionals are at higher risk of making errors, depersonalizing patients, and becoming emotionally exhausted. Psychotherapists at higher risk would benefit from organizational and therapeutic interventions. Peer support groups may help to alleviate some of the distress, as would regular consultation and supervision that partly focuses on countertransference and managing the stress of working with traumatized patients. Psychotherapists need to be aware of the risks involved in having a high workload, which is a well-known risk factor for poor mental health at work. On the positive side, greater experience as a psychotherapist may be a protective factor. Experience may bring with it more self-confidence, greater emotion regulation skills, and a better ability to manage countertransference.

Solomonov, N. & Barber, J.P. (2018). Patients’ perspectives on political self-disclosure, the therapeutic alliance, and the infiltration of politics into the therapy room in the Trump era. Journal of Clinical Psychology, DOI: 10.1002/jclp.22609.

Most studies of psychotherapy do not take into account the current political climate, and most therapists do not think about the impact of their politics on clients. Studies have focused on the effects of large historical-political events on therapy, but mainly in terms of client reactions to the events. Such studies typically assume that therapist and client shared or agreed on perspectives of the event. However, the 2016 U.S. presidential election was extremely polarizing and may represent one of those events in which clients and therapists do not agree. What if clients and therapists disagreed about the experience of the election and its aftermath – what might be the impact on their therapeutic alliance? To what extent are polarizing politics discussed in therapy, and how are these discussions experienced by clients? Solomonov and Barber conducted a national survey among 604 psychotherapy clients from the 50 U.S. states. The mean age of the sample was 33.82 years (SD = 11.10), 57% were women, 58% were Caucasian, 48% indicated that they voted for Hilary Clinton and 32% indicated that they voted for Donald Trump. Overall, 64% of patients indicated that they had spoken about politics with the therapist (66% of Trump supporters and 70% of Clinton supporters). Among Trump supporters, 38% of clients indicated that their therapist was a Republican, whereas 35% thought their therapist was a Democrat. Among Clinton supporters, only 14% said their therapist was a Republican and 64% perceived their therapist was a Democrat. Thirty percent of clients reported that their therapist explicitly disclosed their political views, and 38% of clients reported that even though their therapist did not explicitly disclose their political views the client could easily guess the therapist’s views. Clients who believed their therapist shared their political views reported significantly higher therapeutic alliance with the therapist than those who believed their therapist did not share their views. Clients who voted for Clinton reported significant increases in expression of negative feelings from before to after the election, whereas Trump supporters did not report a significant increase in negative feelings. Neither Trump nor Clinton supporters reported an increase in positive emotions pre and post election.

Practice Implications

About two thirds of clients in the U.S. have political discussions with their therapists, and almost half wanted to talk more about politics during sessions. Even though general self-disclosure among therapists is relatively infrequent, political self-disclosure among therapists about the 2016 U.S. election seemed to occur much more frequently. It is possible that political instability and the polarizing political climate in the U.S. may contribute to more self-disclosure of a political kind among therapists. This could have an impact on therapy. Clients who perceived their therapists to share political views reported a better therapeutic alliance than those who had divergent political views from their therapist. Similarities in values between therapist and client have long been known to be associated with the therapeutic alliance. The study demonstrates that in the current political climate in the U.S., client perceptions of shared or divergent values with therapists make their way into the therapeutic space.

Blanchard, M. & Farber, B.A. (2016). Lying in psychotherapy: Why and what clients don’t tell their therapist about therapy and their relationship, Counselling Psychology Quarterly, 29, 90-112.

Clients’ disclosure of their thoughts and feelings are key aspects of psychotherapy, and trust is at the heart of the therapeutic relationship. However clients are not always honest with their therapist. Clients may keep secrets, hide negative reactions to interventions, minimize, spin, or tell outright lies. In this study, Blanchard and Farber asked: “what do clients lie about in therapy and why”. The authors used a broad definition of dishonesty that included: consciously twisting the facts, minimizing, exaggerating, omitting, and pretending to agree with the therapist. The authors excluded delusions, repression, denial, and other forms of unconscious deception. Blanchard and Farber were particularly interested in client dishonesty about therapy itself and about the therapist. The authors conducted an online survey of psychotherapy clients recruited from a community sample in a U.S. city, and 547 adult clients responded. The sample was surprisingly similar to a therapy-using population reported in the National Survey on Drug Use and Health. Most clients were women (78%), White (80%), saw a female therapist (71%), received CBT (35.4%) or psychodynamic therapy (18%), and were treated for depression (64%) and/or anxiety (49%) disorders. The survey asked about a wide range of possible topics for dishonesty such as use of drugs or alcohol, desire for revenge, pretending to agree with the therapist, etc. With this broad definition of conscious dishonesty, 93% of clients reported lying to their therapist, in which the average number of topics lied about per client was 8.4 (SD = 6.6). Those who lied more often also reported a general tendency in their lives to conceal negative personal information (r = .45). Only 6.8% of clients reported having told zero lies in therapy. Some topics were highly endorsed by clients – for example, 54% endorsed lying about “how badly I really feel – I minimized”, 25% did not disclose “my thoughts about suicide” and “my use of drugs or alcohol”. Other topics (endorsed by 5% to 25% of clients) included lies about eating habits, self-harm, infidelity, violent fantasies, experiences of physical or sexual abuse, and religious beliefs. About 72.6% of clients lied about at least one therapy-related topic, including: “pretending to like my therapist’s comments or suggestions” (29%), “reason for missing an appointment” (29%), “pretending to find therapy more effective than I do” (28%), “pretending to do the homework” (26%), “my real opinion of the therapist (19%), “not saying I want to end therapy (16%), and “my therapist makes me feel uncomfortable” (13%). Other items were relatively rare in the sample including “my romantic or sexual feeling about my therapist” (5%). Survey respondents were then asked why they were dishonest. Reasons why clients were dishonest included: “wanting to be polite”, “I didn’t want my therapist to feel he was bad at his job”, “I didn’t want to look bad or feel embarrassed”, “I would feel bad if I told her it really didn’t help me”, “wanting to avoid my therapist’s disapproval”, and “wanting to avoid upsetting my therapist”.

Practice Implications

Using a broad definition of dishonesty, this study found that 93% of clients did not tell the truth in one way or another to their therapist. Concern about self-judgments (i.e., embarrassment) or external judgments (i.e., avoiding therapist’s disapproval) may lead most clients to be less than honest at some times. Over 70% of clients reported lying about an aspect of therapy itself or of the therapeutic relationship. Clients appear to be particularly sensitive to upsetting or disappointing their therapist. This suggests the importance of therapists monitoring the level of emotional safety, trust, and alliance in the therapeutic relationship. Therapists may have to accept a certain level of dissimulation by clients in the therapy. Engaging in empathy, positive regard, and a focused attention on the therapeutic relationship may be important for therapists in order to overcome a level of fear or distrust among some clients about their self-judgement or the therapist`s judgment. These findings suggest that clients may benefit from therapists who receive training in identifying and resolving therapeutic alliance ruptures.

Hewison, D., Casey, P., & Mwamba, N. (2016). The effectiveness of couple therapy: Clinical outcomes in a naturalistic United Kingdom setting. Psychotherapy, 53, 377-387.

Current randomized controlled trials (RCTs) of couple therapy indicate that about 60% to 70% of couples improve to some degree, and that about 35% to 50% are no longer distressed by the end of therapy. But RCTs have been criticized for being somewhat artificial because their design is based on how pharmacological treatments are tested. Psychotherapy may be more complex than pharmacotherapy in its implementation, and compared to pharmacotherapy, psychotherapy relies more heavily on the qualities of the therapist and therapeutic relationship in order to achieve good outcomes. In an RCT, individuals often have to have a specific disorder to be included in the study, and those with co-morbid disorders may be excluded. This may limit what the findings have to say about real world applications of a particular treatment. Further, therapists in RCTs may receive unusual levels of supervision and support that is seldom seen in regular clinical practice. In this large study of over 435 couples, Hewison and colleagues assessed the effectiveness of a psychodynamically-oriented couple therapy as practiced in a large not-for-profit centre that provides psychological treatment (i.e., the Tavistock clinic in the United Kingdom). All participants received couple treatment and none were randomly assigned to a control group. The couple therapy focused on insight and emotional connection and expression within the context of a therapeutic relationship. The couple relationship rather than the individual partners were the object of the therapy. The unconscious meaning of couple communication was often discussed, and therapist countertransference was seen as a source of information about the couple. Most couples in the study identified as White (77.0%), heterosexual (93.9%), and married or living in a civil partnership (58.4%). More than half of the couples were in the relationship for over 5 years and had children. Therapists were qualified couple therapists or Masters level trainees, had a mean age of 50 (range: 26 – 71), tended to be White women (60%), and were all trained at the clinic. The average number of sessions that a couple attended was 23.3 (SD = 23.5), but with a wide range (2 to 150 sessions) as might be typical in a clinical setting. Overall, individual clients reported a large significant decrease in individual psychological distress (d = -1.04), and a moderate significant decrease in marital distress (d = -0.58). Half of individuals showed a reliable reduction in their individual distress, and over a quarter of couples reported a reliable decline in their couple distress.

Practice Implications

This is the largest study of couple therapy in a naturalistic setting. The psychodynamic couple therapy was effective in reducing individual distress for almost half of the participants although reliable change in couple distress was lower. The results of this field trial indicate that couple therapy that is offered in a functioning real-world clinic setting produces results similar to what is seen in highly controlled randomized trials.