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Chow, D. L., Miller, S. D., Seidel, J. A., Kane, R. T., Thornton, J. A., & Andrews, W. P. (2015). The role of deliberate practice in the development of highly effective psychotherapists. Psychotherapy, 52(3), 337.

In 2014, Tracey and colleagues caused a stir when they claimed that there was no evidence of expertise in psychotherapy (see my July, 2014 blog). They defined expertise as increased quality of performance that is gained with additional experience – and they concluded that psychotherapy research has not provided evidence that therapist performance improves with experience. The issue is important because differences between therapists account for over 5% of patient outcomes. This seems small, but it is larger than variance in outcomes accounted for by the use of empirically supported treatments (0% - 4%), and almost as large as the variance accounted for by client-rated alliance (5% - 15%). Across a wide variety of professions (e.g., music, medicine, chess, sports), professionals’ engagement in deliberate practice results in improvement and superior performance. However, there is little evidence of this in psychotherapy. In this article by Chow and colleagues, the authors look specifically at “deliberate practice” defined as individualized training activities to improve one’s performance through repetition and refinement. To be effective, deliberate practice has to be focused on achieving specific targets and guided by conscious monitoring of outcomes over a long period of time. The authors collected a sample of 69 therapists who worked across a number of organizations and practice areas, and these therapists provided data related to 4,850 patients. Seventeen of the 69 therapists who treated 1,632 clients also provided data on professional development activities. Therapists were multidisciplinary (i.e., counsellors, psychologists, marital therapists, social workers, psychotherapists) with an average of over 8 years of experience, who worked mainly in private practice or within the national health service in the U.K., and who primarily treated adult patients with depression or anxiety disorders. Patient outcomes were measured repeatedly with a valid standardized scale, and deliberate practice was self reported by therapists using a measure that asked about the frequency and time therapists engaged in 25 activities outside of work aimed at improving therapeutic skills. On average, clients improved by the end of treatment and the effect was large (d = 1.22). As expected therapists differed in their patient outcomes (i.e., some therapists were reliably more effective than others). Therapist demographic variables, theoretical orientation, years of experience, and practice setting were not related to patient outcomes. However, the amount of time in deliberate practice activities was associated with a reduction in client distress. Compared to the less effective therapists (2.62 hrs/wk in deliberate practice), the best performing therapists (7.39 hrs/wk in deliberate practice) spent about 2.81 times more time on deliberate practice. Therapists rated the following deliberate practice activities as the most relevant to their patients’ outcomes: reviewing challenging cases, attending training workshops, reflecting on past sessions, and reflecting on what to do in future sessions.

Practice Implications

Although this is a single study with a relatively small sample of therapists, it is one of those rare studies to assess the effects of therapist deliberate practice on patient outcomes. As is the case with other professions, reviewing one’s performance can play an important role in identifying errors, altering course, and remediating problems. As Tracey and colleagues indicated, therapists need good quality information in order to learn from their errors and make adjustments so that clients can improve. Quality information might be available from progress monitoring (i.e., continuous feedback to therapists about client outcomes), which has been shown to improve client outcomes especially for at-risk cases. Chow and colleagues go further to suggest targeted learning by using standardized clients within training and supervision contexts. Deliberate practice is not only for newer or less experienced therapists, since experienced therapists also vary in their ability to engage and help clients. Highly effective therapists spend more time engaging in activities outside of their practice specifically aimed at improving their performance.

Abbass, A., Kisely, S., Rasic, D., Town, J.M., & Johansson, R. (2015). Long-term healthcare cost reduction with Intensive Short-term Psychodynamic Psychotherapy in tertiary psychiatric care. Journal of Psychiatric Research, http://dx.doi.org/10.1016/j.jpsychires.2015.03.001

Several years ago Lazar (2010) published a book detailing the cost-effectiveness of psychotherapy for a variety of disorders. That is, her systematic review found that on most economic indicators (lost income, decreased disability, decreased health utilization) psychotherapy resulted in an immediate cost reduction over and above the cost of the treatment. In this study from Halifax, Canada, Abbass and colleagues looked at the effects of psychotherapy, specifically of Intensive Short-term Dynamic Psychotherapy (ISTDP), on the long-term reduction in hospital costs and physician visits. Abass and colleagues argue that adverse childhood events are an important determinant of adult mental health problems and of increased costs to the health system likely because of the consequence of problems with emotion regulation. Psychotherapies like ISTDP specifically address issues that are a consequence of childhood maltreatment and so might reduce some of the consequent health care costs. Abbass and colleagues provided ISTDP to 890 patients in the Halifax health care system who were referred to the psychotherapy service from emergency departments, physicians, and mental health providers. These patients’ outcomes were compared to 192 patients not seen by the clinic for various reasons. Most common diagnoses of the total sample were: somatoform disorder, anxiety disorder, personality disorder, and depressive disorder. Participant completed measures of psychological distress, and the research team were able to access provincial health usage data tracked over 3 years. Fifty eight therapists of various skill levels (psychiatrists, psychologists, family physicians, trainees) provided ISTDP. The average patient attended 7.3 sessions which cost $708 (estimated by salaries in 2006). Patients receiving psychotherapy had physician and hospital costs that decreased from $3,224 to $4759 in Canadian dollars per year over three years (again in 2006 dollars). Patients in the control condition not receiving ISTDP showed health care costs that increased from $368 to $2,663 per year. These trajectories of health care costs were significantly different. Yearly physician and health care costs for patients prior to being treated with ISTDP were greater than those of the general Canadian population, but 3 years post ISTDP their health care costs were less than the general Canadian population. In addition, compared to control patients those treated with psychotherapy showed a significant reduction in psychological distress.

Practice Implications

This study by Abbass and colleagues demonstrates that short term psychotherapy provided to a broad range of patients and targeting health and illness behaviors related to problems with emotion regulation can reduce health care costs. These reductions in hospital and physician visits occurred in the short term and were sustained over several years. Some patients may require longer treatment, but the evidence suggests that short term interventions should be tried first.

Author email: allan.abbass@dal.ca

Ehring, T., Welboren, R., Morina, N., Wicherts, J.M., Freitag, J., & Emmelkamp, P.M.G (2014). Meta-analysis of psychological treatments for posttraumatic stress disorder in adult survivors of childhood abuse. Clinical Psychology Review, 34, 645-657.

Post-traumatic stress disorder (PTSD) occurs at a very high frequency among those who experienced childhood physical and/or sexual abuse. As adults these individuals often request mental health services. Previous meta analyses of psychotherapies for PTSD have combined samples of those with PTSD due to childhood maltreatment and those due to trauma in adulthood. This meta analysis by Ehring and colleagues is the first specifically to look at treatment of PTSD in those with childhood abuse. Some argue that PTSD due to childhood abuse is different because of the high level of complex symptoms like emotion regulation problems, impulsivity, depression, dissociation, substance abuse, and others. And so treatments for PTSD related to childhood abuse may require different characteristics and may have different outcomes. Further, there is a long standing debate about whether trauma-focused treatments are appropriate for those with PTSD who have high levels of complex symptoms. There is concern for example that the focus on trauma memories may exacerbate symptoms like dissociation. Previous reviews showed that treatments targeting the trauma memory (i.e., focus on processing the memory and its meaning) had the largest effect on PTSD outcomes. This is likely because of the impact that memory processes (i.e., re-accessing memories, maladaptive attributions of memories) have on the maintenance of the disorder. Would these large treatment effects also be found in PTSD that resulted specifically from childhood abuse? (A note about meta analyses: meta analyses are the best way to synthesize a research area because this method combines the effect sizes from multiple studies into a single effect size. The findings of meta analyses are much more reliable than findings from any single study. See my November 2013 blog). Ehrling and colleagues conducted a meta analysis of 16 studies that included over 1200 participants with PTSD due to childhood abuse. Treatments included: trauma-focused cognitive behavioral therapy (CBT), non-trauma-focused CBT, eye movement desensitization and reprocessing (EMDR), and others. Psychological interventions were effective for PTSD related to childhood abuse, and the effects were large for both PTSD symptom severity and for other symptoms (i.e., depression, anxiety, dissociation). Psychological interventions were more effective that control conditions (i.e., wait lists or treatments as usual), and these effects were moderate. Effects remained large or moderate well into post-treatment follow-ups. Trauma focused treatments were more effective than non-trauma-focused treatments, and individual interventions were more effective than group-based interventions.

Practice Implications

Psychological interventions for PTSD in adults who experienced childhood abuse are effective in reducing symptom severity with moderate to large effects. Other symptoms like anxiety, depression, and dissociation also showed large positive changes in these individuals. Research shows that trauma-focused treatments are under-used in routine practice. This may be due to the concern that trauma-focused treatments may not be safe in some individuals with complex symptoms. Trauma-focused treatments may lead to higher effects than non-trauma focused treatments, indicating the potential importance of processing the trauma memory.

Mackenzie, C. S., Erickson, J., Deane, F. P., & Wright, M. (2014). Changes in attitudes toward seeking mental health services: A 40-year cross-temporal meta-analysis. Clinical Psychology Review, 34(2), 99-106.

Rates of treatment for mental disorders in developed countries have increased over time and this is largely due to the dramatic rise in the use of medications, such as antidepressants over the past 30 years. Concurrently the proportion of people receiving outpatient psychotherapy has declined. Despite the increase of pharmacological interventions, many mental health services in the US do not meet evidence based guidelines, and most people with mental disorders in the US and Canada are not receiving care. Barriers to accessing care include: lack of knowledge (not knowing where to get help); structural barriers (financial costs), and attitudes (stigma, belief that one should handle the problem oneself, and belief that treatment will not help). There is a great deal of evidence that negative attitudes about seeking and receiving help are the most consistent reasons related to low service utilization in Canada and the US. Efforts to reduce stigma, in part, have attempted to define mental illness as a medical or biological disorder likely with the intent of reducing blame of the individual for his or her problems. As Mackenzie and colleagues indicate, this coincided with an aggressive direct-to-consumer advertising of psychotropic medications for mental disorders. And so the perception that mental disorders are biological and that require biological treatments became entrenched in the population. However, as I summarized in the PPRNet October 2013 Blog endorsing neurobiological causes of mental illness is associated with seeing the disorder as persistent, unchangeable, and serious. This increases social distance, which is an aspect of stigma. In their meta analysis, Mackenzie and colleagues reviewed all published studies over the past 40 years that used the Attitudes Toward Seeking Professional Help Scale. They analysed 22 studies with a total sample size of 6,796. They used cross-temporal meta-analysis to correlate year of the study with total scores on the scale. The correlation was large and negative (r = -.53) indicating that participants’ help-seeking attitudes have become significantly more negative over time.

Practice Implications

Attitudes toward seeking mental health services have become increasingly negative over the past four decades, which is consistent with worsening public stigma about mental health. This has coincided with an increase in the use of psychotropic medications and a decline in psychotherapy during the same period, despite evidence that psychotherapy is as effective as medications and preferred by patients. As Mackenzie and colleagues suggest, it is possible that attitudes toward mental health care have become increasingly negative due to efforts to convince the public that mental disorders have a neurobiolobic etiology and require biological treatments. When appropriate, clinicians should not promote biological explanations at the expense of psychosocial explanations for mental disorders. Psychological explanations and treatments may result in patients experiencing a greater sense of optimism about change, and greater personal control over the treatments they receive.

Puig, A., Yoon, E., Callueng, C., An, S., & Lee, S. M. (2014). Burnout syndrome in psychotherapists: A comparative analysis of five nations. Psychological Services, 11(1), 87-96.

Psychotherapists can experience severe stress when working with some clients. The stress can be the result of work conditions like budget cuts and increased therapy caseloads, and from characteristics of the work itself like remaining compassionate with clients who experience significant emotional pain and trauma. In the May 2014 blog, I reported on research on secondary trauma experienced by therapists as an occupational hazard of working with traumatized patients. Although secondary trauma is distinct from burnout, the accumulation of these experiences by therapists coupled with other demands of the work can lead to burnout. Burnout syndrome is often defined as the failure to perform clinical tasks well because of discouragement, apathy, and the experience of emotional or physical drain. Burnout can affect both the therapist’s well being and patient outcomes. In this study by Puig and colleagues, the Counsellor Burnout Inventory (CBI) was given to therapists in five countries. The CBI measures therapist Exhaustion, sense of Incompetence, Negative Work Environment, and Deterioration in Personal Life. The samples of therapists were from countries that included the United States (n = 750), Korea (n = 382), Japan (n = 257), Philippines (n = 218), and Hong Kong (n = 222). Puig and colleagues argue that countries like the US may be characterized by a more individualistic cultural context, whereas other countries in Asia may have more collectivistic values. These cultural values and differing professional practice contexts may affect the experience of burnout by psychotherapists. The majority of therapists were female (67.3% to 85.3%) with average experience ranging from 5.34 years in Korea to 12.33 years in the US. Puig and colleagues translated the CBI from English and then conducted a confirmatory factor analysis that showed that the CBI is reliable and valid within each of these samples of therapists from different countries. Therapists in Hong Kong and the US had the highest scores on the Exhaustion scale. Puig and colleagues suggested that burnout in Hong Kong and US may be most affected by demands of the work that psychotherapists do in those countries. Psychotherapists from Japan reported highest levels on the Incompetence scale, suggesting that burnout in Japanese therapists might be most affected by a sense of low self efficacy and efficiency. Of all the nations, US therapists perceived their working environments most negatively. Deterioation in Personal Life scores were highest in Korea suggesting that burnout may contribute to low personal quality of life for Korean psychotherapists. All therapists reported low mean scores on the Devaluing Client scale, but those in the US and Philippines had the lowest mean scores. It appears that burnout is least affected by negative relationships with clients for all therapist groups.

Practice Implications

Therapists, policymakers, and administrators need to attend to increased stress related to psychotherapists’ work, the environment, and characteristics of clients who experience trauma. The impact of stress and burnout can be seen in therapists’ performance their personal lives and well-being. In addition, burnout can affect patient outcomes. Puig and colleagues suggest that psychotherapists can participate in professional development activities (e.g., workshops) to enhance their knowledge and skills in managing stress and maintaining a healthy and balanced work and personal life. Organizations should consider restructuring the social and work environment (e.g., workload), and clarifying and reassessing their expectations of therapists in order to prevent conflict and ambiguity. On his web site, Ken Pope provides a list of resources for therapist well-being and preventing burnout, and he discusses the ethics of therapist self-care.

Afifi, T. O., MacMillan, H. L., Boyle, M., Taillieu, T., Cheung, K., & Sareen, J. (2014). Child abuse and mental disorders in Canada. Canadian Medical Association Journal, cmaj-131792.

Childhood adversity, including physical abuse, sexual abuse, neglect, witnessing violence, and loss of an attachment figure early in life is well known to result in a number of health and mental health problems later in life. Afifi and colleagues refer to child abuse at a significant public health problem worldwide. Despite the well known effects of child abuse, until recently there has been little research on the estimates of abuse and its outcomes in Canada. In their study, Afifi and colleagues looked at three types of child abuse (physical abuse, sexual abuse, and intimate partner violence) and its effects on 14 mental conditions including suicide and substance abuse. The authors used data from the 2012 Canadian Community Health Survey that included a representative sample of respondents aged 15 years and older living in the 10 provinces representing over 25,000 Canadians. The household survey response rate was close to 80%, and those over the age of 18 (N = 23,395) were asked about child abuse that occurred before the age of 16. Physical abuse was defined as any instances of being slapped, punched, kicked, burned etc. Sexual abuse was defined as being forced into any unwanted sexual activity by being threatened. Exposure to partner violence was classified as having seen or heard parents, step-parents, or guardians hitting each other. The prevalence of any of these 3 types of child abuse was 32.1%, with physical abuse being most common (26.1%), followed by sexual abuse (10.1%) and exposure to intimate partner violence (7.9%). Women were more likely than men to have experienced childhood sexual abuse (14.4% versus 5.8%) and exposure to intimate partner violence (8.9% versus 6.9%) as children. Men were more likely than women to have experienced child physical abuse (31.0% versus 21.3%). All forms of child abuse were associated with an increase in later mental illness, such that those who experienced any form of child abuse were over 3 times more likely to have a later mental illness. Obsessive–compulsive disorder was associated specifically with sexual abuse, eating disorders were specifically associated with physical abuse, post traumatic stress disorder was specifically associated with sexual abuse and certain types of physical abuse. All 3 types of abuse were associated with drug abuse/dependence, suicidal ideation, and suicide attempts. Exposure to a higher number of abuse types (i.e., sexual abuse, physical abuse, and intimate partner violence) was associated with more mental illnesses, and the effect was worse for women.

Practice Implications

Child abuse is an important public health problem in Canada and is associated with a number of mental health problems in adulthood. Health care providers should be aware of the relation between specific types of child abuse and certain mental conditions. Clinicians working in the mental health field should acquire skills in assessing patients for exposure to abuse, and should understand the implications for treatment.