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Sandford, D.M., Kirtley, O.J., Thwaites, R., & O’Connor, R.C. (2021). The impact on mental health practitioners of the death of a patient by suicide: A systematic review. Clinical Psychology and Psychotherapy, 28, 261-294.

In the UK, it is estimated that up to 27% of those who commit suicide have been in contact with a mental health professional in the past year. Even though suicide is a rare event, a mental health practitioner is likely to experience at least one instance of a patient suicide during their career. A psychotherapist who experiences a patient suicide could experience symptoms of burnout, PTSD, grief, and a sense of being overwhelmed. Sandford and colleagues conducted a systematic review of the existing research on the impact of a patient’s suicide, experiences of support by the practitioner, and factors that may minimize the negative impacts of patient suicide. They reviewed 54 quantitative and qualitative studies in order to synthesize the research. Professionals included psychiatrists, psychologists, psychotherapists, counsellors, and other mental health professionals. The most common responses of professionals to a patient suicide were guilt, blame, shock, anger, sadness, and grief. Over 20% of practitioners met criteria for PTSD in some studies. Many practitioners across all studies reported some negative impact on their personal life, with 24% identifying severe emotional impact (lower mood, poor sleep). Following a patient suicide, practitioners reported an increased focus on risk assessment, greater caution in their practices, and increased self-doubt about their own judgement. The average practitioner reported an impact that lasted about 4 weeks. A closer therapeutic relationship with the patient, patients who were younger, and the fear of blame and litigation were each associated with a higher level of distress in therapists. However, the impact was not related to therapist gender, age, or experience. Most practitioners felt inadequately prepared for dealing with a patient suicide. But protective factors included support from colleagues, friends and family, and supportive supervision.

Practice Implications

Even if suicide is a rare event in the population, an important minority of patients who commit suicide were in contact with a mental health professional in the preceding year. And so, one might expect to have a patient who commits suicide during one’s career that will have a negative impact on one’s own well-being and professional practice. Increased awareness of the incidence of suicide, informal social supports, and empathic supervision may mitigate the negative impacts. So will tailored training experiences on managing one’s own reactions to patients, as well as a professional work environment that is non-blaming and supportive.

Yang, Y., & Hayes, J. A. (2020). Causes and consequences of burnout among mental health professionals: A practice-oriented review of recent empirical literature. Psychotherapy, 57(3), 426–436.

Burnout is characterized by emotional exhaustion (feeling overextended and depleted), depersonalization (negative and cynical attitudes, and distance in relationships with clients and work), and reduced feelings of personal accomplishment (negative self-evaluation). Recent meta-analyses show that between 20% and 40% of mental health professionals are experiencing burnout. And so, this is a pervasive problem that could affect therapists’ physical and mental health as well as their clients’ outcomes. In this narrative review, Yang and Hayes looked at 44 studies published since 2009 to understand the individual predictors and consequences of burnout among psychotherapists across all professions. Based on the research, they categorized predictors of therapist burnout into three areas: work factors, psychotherapist factors, and client factors. Work factors that the research associated with psychotherapist burnout included: job control (less control over the nature and quantity of work and on work conditions) work setting (working in an institutional setting, organizational inefficiency), job demands (higher workload and hours), and support (little support from colleagues and supervisors). Psychotherapist factors that research indicated are related to clinician burnout included: therapist history of mental health problems and trauma, countertransference (an emotional reaction to clients affected by one’s own personal dynamics), psychological distress, and low professional self-efficacy (low professional self-confidence). Client factors related to therapist burnout included having a caseload of working with many clients who have complex difficulties. The research also indicated the effects of burnout on psychotherapists. Burnout adversely affects both physical (gastrointestinal problems, sleep deprivation, back pain) and psychological (low mood, anxiety, secondary trauma) well-being of therapists. The findings also indicated that burn-out increased job dissatisfaction and turnover in the workplace. The effect of therapist burn-out on clients included reduced client engagement in the therapy process, and reduced client mental health outcomes. Poorer client engagement and outcomes are likely caused by therapist exhaustion, reduced energy, and self-protective withdrawal.

Practice Implications

Psychotherapists would do well to monitor continually their level of burnout and to identify strategies to mitigate its effects. Looking for emotional support from colleagues, supervisors, friends, and family are good coping strategies. Therapists should also be mindful not to overwork, seek psychotherapy for oneself, and maintain appropriate boundaries with clients. Peer supervision and consultation may go a long way to achieving support, and to working through and managing problematic countertransference that inevitably arises in ones work as a psychotherapist.

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.

Markowitz, J.C., Milrod B., Heckman, T.G., Bergman, M., Amsalem, D., Zalman, H., Ballas, T., Neria, Y. (2020). Psychotherapy at a distance. American Journal of Psychiatry, doi: 10.1176/appi.ajp.2020.20050557.

Teletherapy was once seen as an adjunctive therapy mainly reserved for patients who lived in remote locations and who could not otherwise access psychotherapy. Now, due to public health restrictions related to COVID-19, teletherapy has become standard care. Conscientious psychotherapists who want to practice based on the best available evidence have looked to the research for some guidance. Previous PPRNet Blogs (see the May, June, and July 2020 Blogs at www.pprnet.ca) have highlighted some of the research related to teletherapy and videoconferencing psychotherapy. In this meta-review, Markowitz and colleagues in part assess the quality of some of these findings, that is – how good is this research. Quality of research often hinges on a number of factors: is the sample size large enough to make solid conclusions, are the methods used appropriate and robust (like randomized controlled trials), is there a sufficient quantity of research that can be summarized, and are patient samples in the studies similar to those typically see in clinical practice. There are thousands of studies of face to face psychotherapy for depression, but by comparison the number of studies of teletherapy are relatively sparse. Many studies of teletherapy are not randomized controlled trials in the typical sense, but rather they are a hodgepodge of studies of different interventions, patients, settings, and outcomes. Nevertheless, the outcomes are generally encouraging in terms of the efficacy of teletherapy. In a recent meta analysis, effects of videoconferenced psychotherapy appear to be equivalent to face to face therapy, but there were only 11 studies in all, only 5 of the studies were considered high quality, and 4 of the high quality studies were with military veterans with PTSD in the Veterans Administration System in the US. Regarding specific orientations, Markowitz and colleagues reported three rigorous trials showing CBT or interpersonal psychotherapy reduced depressive symptoms. There are six randomized trials of group therapy by videoconferencing or telephone, but most are of low quality and often specifically focused on patients with HIV.

Practice Implications

Videoconferenced and telephone delivered psychotherapy are likely here to stay in some form, even after the COVID-19 pandemic. Teletherapy greatly expands access for some, though some patients including homeless, poorer, or the elderly individuals still may not have adequate access. The research evidence for the efficacy of remote therapy is encouraging, but also problematic. Most research trials are too small to draw meaningful conclusions, and few studies focus on therapeutic factors. Anecdotal reports suggest that those who are socially anxious or avoidant may prefer remote care, however it is also possible that teletherapy may exacerbate problematic avoidance behaviors among some patients. At the moment, the research lags far behind the rapid transition to remote care that has occurred in the past months.

Simpson, S., Richardson, L., Pietrabissa, G., Castelnuovo, G., Reid, C. (2020). Videotherapy and therapeutic alliance in the age of COVID-19. Clinical Psychology and Psychotherapy, https://doi.org/10.1002/cpp.2521

The therapeutic alliance is one of the most robust predictors of patient outcomes in psychotherapy. The alliance refers to the patient’s and therapist’s agreement on the goals of therapy (what the patient wants for an outcome), the tasks of therapy (what to do in therapy to achieve these goals), and the relational bond between the patient and therapist. Despite the importance of the therapeutic alliance, psychotherapists tend to rate it lower in videoconferenced psychotherapy compared to face to face therapy. That is, psychotherapists are skeptical that one can develop and maintain the same quality of alliance in videoconferenced psychotherapy compared to face to face therapy. In this review, Simpson and colleagues evaluate the research on the alliance in videoconferenced psychotherapy. The authors argue that videoconference psychotherapy provides greater access for some patients, and also creates therapeutic opportunities that are not possible in face to face therapy. For example, those with PTSD, agoraphobia, social avoidance, and severe anxiety may find engaging in videoconferenced psychotherapy to be easier. Younger individuals who feel more at home with social interactions on a video screen may also engage better with videoconferenced psychotherapy. Simpson and colleagues reviewed 24 studies that examined the therapeutic alliance in the context of video therapy. There was a wide range of technologies and clinical groups, thus making meaningful comparisons difficult. Generally, both clients and therapists rated the alliance highly. There is some evidence that for a few patients, like those concerned with privacy and stigma, videoconferenced psychotherapy may be less threatening. However, it must be noted that most of these studies were surveys, analogue studies not including real therapeutic contexts, or single case reports. Currently, there appears to be no high quality randomized controlled trial comparing videoconferenced versus face to face therapy on the quality of the alliance.

Practice Implications

As is the case with treatment efficacy studies, high quality trials looking at the therapeutic alliance in videoconferenced psychotherapy lag far behind practice. As a result, the research provides little guidance to therapists. Small studies and anecdotal reports suggest that the alliance may be as good in videoconferenced psychotherapy as in face to face therapy, and that some patient, especially those with high levels of avoidance and anxiety, may find videotherapy to be less threatening. Given the ubiquitous nature of technology, and the likelihood that videoconferenced psychotherapy will continue well into the future, it is important that researchers turn to examining what works in videotherapy and for whom.

McPherson, S., Wicks, C. & Tercelli, I. (2020). Patient experiences of psychological therapy for depression: A qualitative metasynthesis. BMC Psychiatry, 20, 313. https://doi.org/10.1186/s12888-020-02682-1

Many times, researchers choose what to study in psychotherapy trials without really consulting patients who are receiving the care. For example, researchers are often primarily interested in how well psychotherapies reduce symptoms in patients with a particular disorder, or researchers might be interested in certain constructs that might affect patient outcomes (e.g., therapeutic alliance, therapist empathy). But are these the things that patients are really interested in when they seek psychological therapy? Although many treatment guidelines emphasize patient choice and experience, none of them take research of patient experiences into account to develop the guidelines. When presented with findings from randomized controlled trials of psychotherapy, patients reported that the research was of limited value in helping them make an informed choice about therapy. In this metasynthesis of qualitative studies, McPherson and colleagues aimed to bring together qualitative evidence concerning adult patients’ experiences of psychotherapy for depression. Qualitative research typically involves interviewing patients and systematically categorizing their responses into meaningful themes. The authors found 38 qualitative studies involving patient interviews of their experiences in receiving psychotherapy for depression. Several key themes emerged from the analysis. First, many people who receive remote therapy primarily from a computer program felt dissatisfied because of the lack of or limited contact with a real person therapist. Most patients did not feel connected to the computerized therapy and so their motivation waned quickly. Second, patients found psychological models and techniques to be less relevant than their need for help with their immediate family or social problems that likely triggered their depressive symptoms. This points to the primary importance of quality of life and of the social and cultural context for patients, despite that many psychological therapies tend to focus on symptoms almost exclusively. Third, this metasynthesis pointed to reports of negative effects of therapy, in which some therapeutic techniques like body scans induced flashbacks in some patients. Other patients had mixed or sometimes negative feelings about requirements for homework, which sometimes felt overwhelming, culturally out of step, or irrelevant.

Practice Implications

This metasynthesis of patient experiences in psychotherapy point to the importance of asking patients about their goals, expectations, and preferences in therapy. The findings highlight the importance of some common factors across therapies (e.g., therapist warmth and humanness, collaborative agreement on tasks and goals, and patient factors like culture and individual differences). Patients prefer human connection with therapists, and they tend to place less value on techniques of therapy. Patients also tend to value outcomes related to quality of life, social connection, and they want therapy consistent with their cultural values. Patients should be fully involved in a collaborative discussion about which therapy you offer them, how you provide the therapy, and what they want to achieve in therapy.