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Simionato, G. K., & Simpson, S. (2018). Personal risk factors associated with burnout among psychotherapists: A systematic review of the literature. Journal of Clinical Psychology. Advance online publication.

Burnout is an important factor in work-related problems for psychotherapists. Burnout is defined as a type of stress associated with feelings of exhaustion, disconnection, and self-doubt related to emotionally involved work in helping professions. Maslach described burnout as being composed of three factors: emotional exhaustion (personal and emotional fatigue at work), depersonalization (negative feelings about clients and the work), and a reduced sense of personal accomplishment (low personally related work successes). Psychotherapists are inclined to burnout because of the emotionally taxing work during which they must remain empathic. In order to protect themselves and conserve energy, psychotherapists may detach from clients, which may lead to a lower sense of work satisfaction and work accomplishments. High levels of burnout reduce a psychotherapist’s ability to take care of themselves and their clients. In this systematic literature review, Simionato and Simpson found 40 studies that empirically examined burnout among psychotherapists and the possible correlates or causes. Results of the 40 articles represented almost 9,000 therapists. Over 54% of therapists reported moderate to high levels of stress related to burnout. On average, therapists reported moderate to high levels of emotional exhaustion, depersonalization, and low personal accomplishment. Younger age was the most frequently identified risk factor for psychotherapist burnout, as was over-involvement with client problems. The authors suggested that the association between burnout and being younger may be due to being less experienced and to higher levels of unattainable standards for clinical practice and client outcomes. In addition, being female was associated with higher reported levels of burnout. This may be due to stress related to women having to juggle demands of both work and domestic responsibilities. Young clinicians are more likely to have young families, and women may be particularly prone to work-life conflict while managing the demands of both.

Practice Implications

Over half of psychotherapists reported moderate to high levels of burnout that could affect their work, their clients’ outcomes, and their personal well being. Training programs might facilitate self-awareness and the capacity for psychotherapists to reflect on their personal strengths, limitations, and maximum workload capacity in order to find the best fit between their personality, circumstances, and job demands. Practicing therapists might consider personal therapy to help cope better with demands of work and home life. Surveys of psychotherapists consistently showed that about 70% have sought psychotherapy at some point in their careers.

Davis, D. E., DeBlaere, C., Owen, J., Hook, J. N., Rivera, D. P., Choe, E., . . . Placeres, V. (2018). The multicultural orientation framework: A narrative review. Psychotherapy, 55(1), 89-100.

Many therapists have better outcomes with White or European clients than clients from diverse racial or ethnic minorities, and this might be due to racial and ethnic microaggressions that sometimes occur in therapy. Microaggression refer to intentional or unintentional brief commonplace verbal, behavioural, or environmental indignities that are experienced as derogatory or negative by racial and ethnic minority clients. A multicultural orientation refers to how the cultural worldviews, values, and beliefs of clients and therapists interact to co-create a relational experience in therapy. Therapist multicultural orientation has three elements. First, cultural humility, in which a therapist is able to maintain an interpersonal stance that is open to the client’s experience of cultural identity. Second, cultural opportunity, in which the therapist uses events in therapy to explore a client’s cultural identity in depth. Third, cultural comfort in which a therapist feels at ease, open, and calm with diverse clients. These elements are important in order to negotiate a therapeutic alliance (i.e. agreement on tasks and goals of therapy, and the emotional bond between client and therapist). In this narrative review, Davis and colleagues look at the small existing research on multicultural orientation and how that research can inform therapists’ practices. The authors found that in the two studies on the topic, greater therapist cultural humility was associated with better client outcomes. Several studies found that cultural humility was associated with a positive therapeutic alliance, and that therapist cultural humility was associated with fewer microaggressions as experienced by racial and ethnic minority clients. Finally, missed opportunities by therapists to explore the meaning of culture and identity were associated with negative client outcomes. Presumably, such missed opportunities meant that therapists did not recognize and repair cultural ruptures.

Practice Implications

The research on multicultural orientation suggests several practice implications. (1) Cultural humility requires therapists to explore their automatic cultural assumptions because if they remain unexplored they may be harmful to clients. (2) Therapists should overtly discuss the importance of cultural identities with clients in order to help both therapist and client develop a more complex understanding of the issues that bring the client to therapy. (3) A strong therapeutic alliance may require the therapist to incorporate their client’s cultural worldview and perspective when conceptualizing the client’s problems. (4) Depending on the client’s cultural worldview, therapists may consult with the client’s family and/or spiritual leaders when negotiating a culturally acceptable way of addressing the client’s problems. (5) Therapists need to identify for themselves when their values conflict with those of the client, and seek consultation or supervision when they do.

Steel, C., Macdonald, J., & Schroder, T. (2017). A systematic review of the effect of therapists’ internalized models of relationships on the quality of the therapeutic relationship. Journal of Clinical Psychology. Advance online publication.

Therapists likely respond differently to different clients, due to their own personal characteristics and unconscious processes.Relational theory suggests that the therapist’s particular qualities combine with the client’s particular qualities to form a unique interpersonal context. The interpersonal context of therapy may be influenced by client and therapist internalized patterns of relating which are likely formed in early childhood. The attachment theory concept of internal working models is one way to understand therapists’ internalized patterns of relating. Internal working models are like templates that help one to predict how relationships with others work. Internal working models of self indicate the quality of one’s self-concept. In this systematic review, Steel and colleagues examined a total 22 studies and asked: do therapists’ secure attachments and positive internal working models affect the quality of the therapeutic relationship with clients? There were too few studies on the specific concepts to conduct meta analyses to aggregate effect sizes, so the authors simply reviewed the literature. Eighteen of 22 studies showed an association between therapist internalized relational models/attachment security/self concept and the therapeutic relationship. Three of four studies that looked specifically at therapist attachment found that therapist secure attachment was associated with a more positive therapeutic relationship. Among these studies, all forms of therapist attachment insecurity were associated with poorer relationship quality with clients and with lower levels of therapist empathy. Four of five studies that examined the effects of internal working models of self indicated that greater therapist negative self-concepts (i.e., self-criticism, neglecting of self, hostility towards self) was associated with a poorer therapeutic alliance with clients. 

Practice Implications

Therapist effects (i.e., the differences between therapists) are emerging as important predictors of client outcomes. It is possible that therapists’ views of others and of self (i.e., internal working models) contribute to these differences. However, there are relatively few studies that examine psychotherapists’ views of self and of others and the impact on therapy. The research that does exist suggests important issues for therapists to consider. Therapists that are insecurely attached (i.e., are dismissive of the importance of relationships or are overly preoccupied with relationships) may have problems in developing positive therapeutic relationships and may be perceived as less empathic by clients. Therapists who have an overly negative view of their self (i.e., self critical, self neglecting) may struggle with developing a therapeutic alliance with clients. The findings suggest that clinicians need to be aware of their internalized relational models. The process of recognizing, reflecting on, and extricating from maladaptive interpersonal patterns and self-concepts may require supervision and/or personal therapy.

Author email: katiecatherinesteel@gmail.com

Hayes, J. A., Owen, J., Nissen-Lie, H. A. (2017). The contribution of client culture to differential therapist effectiveness. In L. G. Castonguay and C. E. Hill (Eds.) How and why are some therapists better than others? Understanding therapist effects (Ch. 9). Washington: American Psychological Association.

Some therapists may have better client outcomes because they are more adept at working with clients of different cultures. In this chapter, Hayes and colleagues define culture as referring to a group of people who share common history, values, beliefs, symbols, and rituals. The cultural groups to which one may belong include those based on: gender, religion, ethnicity, disability status, sexual orientation, race, and age, among others. Research suggests that culturally adapted therapy is more effective than unadapted therapy for racial minority clients. This may be due to more effective therapists being able to explain clients’ mental health problems and provide a rationale for specific therapy interventions that is congruent with the client’s beliefs. The most common model of multicultural therapy is multicultural competence, which is defined by having knowledge of various cultural groups, skills to navigate cultural processes, and self-awareness of personal bias. However, Hayes and colleagues argue for a multicultural orientation model in which a therapist is humble, respectful, and open to addressing culture in therapy. Whereas multicultural therapy is about acquiring knowledge, multicultural orientation refers to a way of being with clients. Hayes and colleagues review the research literature that indicates that therapists with cultural expertise are those who acknowledge when they do not have specific knowledge about a culture, have a high tolerance for not knowing, and at the same time recognize that cultural socialization affect clients’ mental health. A multicultural orientation is intended to bolster and support current therapeutic practices. For example, therapists may recognize that they need to better understand clients’ heritage when deciding whether or not to challenging a deeply held core belief related to the clients’ culture. In support of this, Hayes and colleagues review the research that indicates that: (1) client perception of therapist humility is related to client outcomes, especially for clients with a strong cultural identity; (2) clients who perceived that their therapist missed opportunities to discuss cultural issues in session had worse therapy outcomes; (3) clients who perceived therapists as culturally oriented experienced the therapy as more credible; and (4) therapist cultural comfort was related to better client outcomes.

Practice Implications

The authors suggest that therapists ask open-ended questions to clients regarding their cultural identity, such as asking the role that religion and spirituality play in their lives. This would allow therapists to learn about client cultural identity in the client’s own words. It is particularly important for therapists to maintain a stance of humility and cultural comfort, and to attend to opportunities to work productively with cultural issues in therapy in order to improve their clients’ outcomes.

Barkham, M., Lutz, W., Lambert, M., & Saxon, D. (2017). Therapist effects, effective therapists, and the law of variability. In L.G. Castonguay and C.E. Hill (Eds.) How and why are some therapists better than others? Understanding therapist effects. Washington, DC: American Psychological Association.

Psychotherapy research has often focused on the differences between treatment types (CBT, interpersonal psychotherapy, psychodynamic therapy), which has overshadowed research on what makes for an effective therapist. Psychotherapists represent the most costly important component of psychotherapy, and only recently has research begun to catch up to the importance of therapist effects. The term “therapist effects” refers to differences between therapists (i.e., variability) in their clients’ outcomes. In this chapter, Barkham and colleagues review some of the research on effective therapists. Best estimates of therapist effects suggest that differences between therapists account for about 8% of client outcomes – which is considered a medium effect and larger than the variance accounted for by the type of therapy that a client receives. Psychotherapy research often tries to control for therapist effects by training therapists to adhere to a manual, however adherence to a manual does not substantially reduce therapist effects, and adherence is not related to patient outcomes. The implication is that which therapist a client sees matters to the client’s mental health outcomes. The best research on the topic indicates that about 20% of therapists are substantially better than the average therapist, and 20% are substantially worse than the average. (The good news is that 60% of therapists [the average] are equally and positively effective). In that study of 119 therapists, the least effective therapists had about 40% of their clients recover, whereas the most effective therapists had about 76% of their clients recover. In other words, the better therapists were almost twice as effective as the worse therapists. In a re-examination of previous data, Barkham and colleagues looked at whether other variables, like client symptom severity, played a role in therapist effects. They found that differences among therapists was higher as client baseline severity increased. That is, the gap between better and worse therapists increased when client symptoms were more severe and complex. Good therapists were better equipped to handle more complex cases.

Practice Implications

There are important differences between therapists in their effectiveness, and this makes a difference to clients. It is particularly important for clients with more severe symptoms to be matched with more effective therapists. Previous research indicates that the level of therapist interpersonal skills (alliance, empathy, warmth, emotional expression, verbal skills) can account for significant proportion of therapist effects, and so training therapists in these interpersonal skills will improve client outcomes. Also, therapists who receive continuous reliable feedback throughout therapy about their client’s symptom levels can also drastically reduce client drop-outs and the number of clients who get worse during treatment.

Wampold, B. E. (2015). How important are the common factors in psychotherapy? An update. World Psychiatry, 14, 270-277.

What is the evidence for the common factors in psychotherapy and how important are they to patient outcomes? In their landmark book, The Great Psychotherapy Debate, Wampold and Imel cover this ground is some detail, and I reviewed a number of the issues raised in their book in the PPRNet blog over the past year. This article by Wampold provides a condensed summary of the research evidence for the common factors in psychotherapy, including: therapeutic alliance, therapist empathy, client expectations, cultural adaptation of treatments, and therapist effects. Therapeutic alliance refers to therapist and client agreement on tasks and goals of therapy, and the bond between therapist and client. A meta-analysis of the therapeutic alliance included over 200 studies of 14,000 patients and found a medium effect of alliance on patient outcomes (d = .57) across a variety of disorders and therapeutic orientations. A number of studies are also concluding that the alliance consistently predicts good outcomes, but that early good outcomes do not consistently predict a subsequent higher alliance. Further, therapists and not patients were primarily responsible for the alliance-outcome relationship. Another common factor, empathy, is thought to be necessary for cooperation, goal sharing, and social interactions. A meta-analysis of therapist empathy that included 59 studies and over 3,500 patients found that the relationship between empathy and patient outcome was moderately large (d = .63). Patient expectations that they will receive benefit from a structured therapy that explains their symptoms can be quite powerful in increasing hope for relief. A meta-analysis of 46 studies found a small but statistically significant relationship (d = .24) between client expectations and outcome. Cultural adaptation of treatments refers to providing an explanation of the symptoms and treatment that are acceptable to the client in the context of their culture. A meta analysis of 21 studies found that cultural adaptation of evidence-based treatments by using an explanation congruent with the client’s culture was more effective than unadapted evidence-based treatments, and the effect was modest (d = .32). Finally, therapist effects, refers to some therapists consistently achieving better outcomes than other therapists regardless of the patients’ characteristics or treatments delivered. A meta analysis of 17 studies of therapist effects in naturalistic settings found a moderately large effect of therapist differences (d = .55).

Practice Implications

These common factors of psychotherapy appear to be more important to patient outcomes than therapist adherence to a specific protocol and therapist competence in delivering the protocol. As Wampold argues, therapist competence should be redefined as the therapist’s ability to form stronger alliances across a variety of patients. Effective therapists tend to have certain qualities, including: a higher level of facilitative interpersonal skills, a tendency to express more professional self doubt, and they engage in more time outside of therapy practicing various psychotherapy skills.