Blog

The Psychotherapy Practice Research Network (PPRNet) blog began in 2013 in response to psychotherapy clinicians, researchers, and educators who expressed interest in receiving regular information about current practice-oriented psychotherapy research. It offers a monthly summary of two or three published psychotherapy research articles. Each summary is authored by Dr. Tasca and highlights practice implications of selected articles. Past blogs are available in the archives. This content is only available in English.

May 2022

The Therapist Effect: Or Does the Therapist Matter?

Wampold, B. & Owen, J. (2021). Therapist effects: History, methods, magnitude, and characteristics of effective therapists. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7^th ed.). Wiley. Chapter 9.

The early days of psychotherapy research treated psychotherapists in a clinical trial as largely interchangeable. That is, it was assumed that therapists were more alike than different and so their impact to patient outcomes were ignored. Some of this was thought to be achieved by training therapists to be highly adherent to a treatment protocol. The thinking was that if every therapist followed the manual faithfully, then any differences among therapists would disappear. Never mind that research indicates that therapist adherence to or competence in delivering a manualized treatment is largely unrelated to patient outcomes. In this part of the chapter, Wampold and Owen examine the question of “does the therapist matter to the patient’s outcomes.” In other words, are there differences between therapists when it comes to patient outcomes? It turns out that between 3% and 15% of patient outcomes in highly controlled randomized trials is attributable to differences between therapists. This might seem like a small percentage, but it is larger than outcomes associated with differences between treatment orientations or the effects of specific interventions. And these are highly controlled trials partly designed to reduce therapist differences. In everyday clinical practice in which there is less control over therapists, the lowest estimate of therapist effects is about 6% but could be as high as 12%. The effect of the therapist is probably higher for more severely symptomatic patients.

Practice Implications

Which therapist a patient sees matters, and this is particularly true for patients who have more severe symptoms. That is more severe patients may do much worse or much better in therapy depending on which therapist they see. A therapist’s capacity to follow a treatment manual does not predict patient outcomes, but other factors like interpersonal skills, openness to lifelong learning, and getting reliable feedback about patient outcomes may be those skills and practices that matter to patient outcomes.

November 2021

Emotional Experiences of Psychotherapists

Chui, H., & Liu, F. (2021). Emotional experience of psychotherapists: A latent profile analysis. Psychotherapy, 58(3), 401–413.

Working with client emotional experiences in therapy is a core aspect of the psychotherapist’s work, regardless of their theoretical orientation. And so, therapists’ performance and their own well-being may be impacted by their capacity to experience and regulate their own emotions. Emotional reactivity refers to one’s sensitivity, intensity, and duration of emotional experience. Emotion regulation refers to the capacity to manage and express emotions and may be considered an interpersonal competency for therapists. Such competency likely involves flexible expression of emotion and a capacity for empathy. A better understanding of how therapists experience emotions might inform therapists’ use of empathy to facilitate their work with clients. In this study, Chui and Liu surveyed 314 English speaking and 589 Chinese speaking psychotherapists and asked them about their experiences of emotional reactivity, their emotion regulation, and empathy. Their data allowed them to develop profiles of psychotherapists along dimensions of emotional experience. Three latent profiles emerged in both the English and Chinese speaking samples of therapists. The highest proportion of English-speaking therapists (58%) were categorized as “Calm Regulators”, which indicated therapists with low emotional reactivity and few problems with emotion regulation. Next, 34.4% of English-speaking therapists were characterized as “Moderate Experiencers”, and 7.6% were “Emotional Feelers”. The latter profile included therapists who were emotionally over-reactive and who had greatest difficulty with regulating their emotions. As one might expect, those with the Calm Regulator profile had higher capacity for perspective taking, higher empathic concern, and lower personal distress than therapists in the other profiles. Also, therapists who were older, with more education, female, and with a psychodynamic orientation were more likely to have the Calm Regulator profile. Results were remarkably similar in the Chinese speaking sample, in which Calm Regulators also reported higher levels of counsellor self-efficacy.

Practice Implications

Therapists with the “Emotional Feelers” profile (i.e., that have higher levels of emotional reactivity and more difficulty regulating their emotions) may be at higher risk of burnout and of being less effective in their work. As a profession we often discuss clients’ individual differences in emotional experience and emotion regulation, but we spend less time considering these important interpersonal competencies in therapists. Recent surveys suggest that almost 50% of therapists may be at high risk of mental health problems. Psychotherapists, trainers, and supervisors need to pay more attention to therapists’ capacity to regulate their emotions, and its impact on their capacity to be emotionally flexible and empathic with clients. Therapists might consider personal therapy as a means of building this capacity.

July 2021

Matching Patients to Therapists’ Strengths

Constantino, M.J., Boswell, J.F., Coyne, A.E., Swales, T.P., & Kraus, D.R. (2021). Effect of matching therapists to patients vs assignment as usual on adult psychotherapy outcomes: A randomized clinical trial. JAMA Psychiatry, doi: 10:1001/jamapsychiatry.2021.1221.

We know that about 60% of patients do not benefit fully from the psychotherapy they receive and that therapists differ in their effectiveness. In one study, above average therapists were twice as effective as below average therapists. In fact, most therapists are reliably effective for some presenting problems, but not for all. What if we could match a patient to a therapist based on what the therapist is good at? In this unique study in a large mental health treatment network, Constantino and colleagues evaluated the past effectiveness of 48 therapists who treated at least 5 patients each across a variety of patient problem domains. The authors identified those patient problem domains for which each therapist was reliably effective or ineffective using valid psychometric measures. Then the researchers randomly assigned 218 patients in the mental health treatment network to receive care as usual (patients were assigned to therapists based on which therapist was available at the time of referral), or to receive treatment from a therapist who was reliably effective for the patient’s problems. Out of 9 possible patient problem domains, therapists had an average of 1.56 (SD = 1.66) patient domains for which they were reliably effective and an average of 0.96 (SD = 1.65) patient problem domains for which they were reliably ineffective. Over 87% of therapists had at least one strength on which they could be matched to a patient, and 10.4% were reliably ineffective for all patient problem domains. To a moderate degree, patients treated by a therapist matched to their problem domain experienced greater weekly reductions in their general impairment compared with patients in the care as usual group (d = 0.75). Relative to their own average outcomes, a therapist achieved better patient outcomes when treating a matched patient than when treating a care as usual patient.

Practice Implications

This is the first study of its kind and so it needs to be replicated. Most therapists had a few patient domains for which they were effective. About 10% of therapists were ineffective across all patient domains. The results of the trial suggested that therapists are likely more effective with some patients than others, depending on the patient’s problems. Therapists should assess their outcomes with a range of patient problems and evaluate their effectiveness using valid psychometric instruments. If a therapist finds that they are less effective with some patients, then the therapist should receive more training and supervision for treating that patient problem.
Psychotherapist burnout affects patient outcomes

Delgadillo, J., Saxon, D., & Barkham, M. (2018). Associations between therapists’ occupational burnout and their patients’ depression and anxiety treatment outcomes. Depression and Anxiety, 35, 844-850.

Providing psychotherapy can be challenging for the therapist. Vicarious trauma, secondary traumatic stress, and compassion fatigue among psychotherapists are well documented. In addition, organizational conditions in publicly funded mental health programs like workload, safety issues, and lack of supervision and support can lead to higher rates of therapist burnout. Surveys document that between 21% and 67% of mental health workers experience burnout. Occupational burnout can take many forms, but it is typically defined as emotional exhaustion and disengagement that lead to lower levels of therapist empathy, engagement, and depersonalization. One could speculate that burnout among therapists leads to worse patient outcomes because of the impact of disengagement on the therapeutic alliance. However few if any studies examined the association between therapist burnout and patient mental health outcomes. In this study, Dalgillo and colleagues assessed therapist burnout and job satisfaction in 49 therapists, and they assessed depression and anxiety outcomes in 2223 of their patients. The therapists provided treatment as part of the UK’s Increasing Access to Psychotherapy (IAPT) program. The analyses controlled for therapist case mix. That means that differences between therapists’ caseload (patient level of impairment, social economic status, and severity of symptoms) were controlled so that the findings were unique to the effect of therapist burnout and job satisfaction on patient mental health outcomes. Higher therapist disengagement (an index of burnout) and lower therapist job satisfaction were significantly associated with poorer treatment outcomes for patients. In addition, higher burnout was related to lower job satisfaction among therapists.

Practice Implications

This is one of the first studies to show a direct association between therapist burnout and low job satisfaction with patient mental health outcomes. It is possible that these findings are specific to the UK’s IAPT program, in which therapists might feel a lower sense of control over their work. Nevertheless, organizations need to design mental health delivery in such a manner as to enhance psychotherapist autonomy, coping, and resilience, as these are likely related to therapist burnout and poorer patient mental health outcomes.

June 2021

The Emotionally Burdened Psychotherapist

Nissen-Lie, H. A., Orlinsky, D. E., & Rønnestad, M. H. (2021). The emotionally burdened psychotherapist: Personal and situational risk factors. Professional Psychology: Research and Practice. Advance online publication.

To provide good treatment, a psychotherapist must have enough mental and emotional energy to be attuned to the different states of their patients. However, sometimes emotional reserves of therapists can dwindle because of personal or professional burdens. As a result, many therapists report the experience of burnout that inevitably has a negative effect on their patients. Therapists’ personal burdens can be defined as stress in one’s personal life, feeling worry or concern, experiencing conflict within one’s family, or loss of a loved one. These therapist personal burdens could be enduring vulnerabilities or short-lived stressors, but they nevertheless have an impact on the therapist’s effectiveness. Higher stress in a therapist’s personal life is related to more avoidant coping, and lower capacity to stay focused, engaged, and empathic with patients. In this large-scale survey of over 12,000 psychotherapists worldwide (e.g., Norway, US, Canada, UK, Australia, Denmark, China), Nissen-Lie and colleagues looked to identify past and current personal and situational factors that were linked to the experience of personal burden among psychotherapists. The therapists were mostly married or in a committed relationship (72%), half were psychologists, the average length of clinical practice was 12 years (SD = 9.2), and therapists worked almost evenly across the major theoretical orientations (including CBT, psychodynamic, systemic, and behavioral). The most salient predictors of personal burden among psychotherapists were: current health and financial worries, early trauma or abuse, attachment anxiety (i.e., concern about abandonment and difficulty regulating negative emotions), dominant and demanding behavior in relationships, lower work satisfaction, and younger age. Cumulatively, these variables accounted for a substantial amount (30%) of the variance in personal burden.

Practice Implications

Increasingly, research is pointing to negative life events and work experiences that may limit a therapists’ capacity to be engaged and empathic with patients. Focus on therapist well-being should be an important part of clinical training and supervision. Previous research found that receiving personal therapy, obtaining clinical supervision, working shorter hours, and lower caseloads improved empathy and wellbeing among psychotherapists.

May 2021

Does Clinical Training Lead to Greater Therapist Interpersonal Skills?

Wolfer, C., Visla, A., Held, J., Hilpert, P., & Fluckiger, C. (2021). Assessing interpersonal skills—A comparison of trainee therapists' and students' interpersonal skills assessed with two established assessments for interpersonal skills. Clinical Psychology and Psychotherapy, 28, 226-232.

Differences between therapists may account for 2% to 8% of the variance in patient mental health outcomes. This seems like a small amount, but the effect is as large as the specific effects caused by interventions of any therapeutic orientation. One of the factors that accounts for differences between therapists is therapist interpersonal skills such as empathy, respectfulness, warmth, openness, and willingness to collaborate. These skills can be learned and likely allow some individuals to be more effective when encountering challenging or complex interpersonal situations. One might think that such skills would be a pre-requisite for entering psychotherapy training, but that may not be the case. A study of training therapists found that more than half of novices were unhelpful to their patients. In this study by Wolfer and colleagues, the authors were interested in seeing if therapists at different stages of training had different levels of these important interpersonal skills. That is, do trainees as a higher level of training acquire more of these skills than those prior to receiving training. This was a small study comparing 19 therapists in clinical training versus 17 students in psychology but with no clinical training. Clinical trainees were in the program for at least 2 years, and received many hours of supervision. All participants watched a video recording of difficult patient statements. Participants’ reactions to the patient video were recorded and then trained raters coded the responses for level of interpersonal skills. Trainee therapists scored significantly higher than students on two scales of interpersonal skills, even after controlling for age. In fact, trainee therapists were over 13 times more likely to demonstrate facilitative interpersonal skills than untrained students. Although being in a clinical training program was associated with greater interpersonal skills, level of experience of clinical trainees (range 2 to 5 years of training) was not related to the level of interpersonal skills.

Practice Implications

This is a relatively small study, so one should consider the findings quite cautiously. Nevertheless, it is one of the few studies to assess interpersonal skills in therapists. It is possible that only those with more interpersonal skills choose to be trained as clinicians – that is, only especially skilled students may go on to receive clinical training. However, the trainees’ substantial amount of clinical training (observing clinicians handle complex situations, receiving supervision to enhance self-reflection) may have facilitated growth in their interpersonal skills. As in previous research, clinical experience alone was not related to therapist interpersonal skill.

This month...

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May 2022

Practice Implications

November 2021

Practice Implications

July 2021

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June 2021

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May 2021

Practice Implications

Psychotherapy Practice Research Network (PPRNet)