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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.

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.

Kleinbub, J. R., Talia, A., & Palmieri, A. (2020). Physiological synchronization in the clinical process: A research primer. Journal of Counseling Psychology, 67(4), 420–437.

When two people interact, their hearts tend to beat at a coordinated rate and breathing rhythms become similar. In addition, people tend to engage in nonverbal behavior synchronization (harmonized facial expression, body posture, vocal tone, etc.). Due to technological developments in video software and in physiological measurement devices, research into synchronization between psychotherapists and patients may soon become common and may begin to inform clinical practice. In this article, Kleinbub and colleagues review the existing research on physiological synchronization and its implications for research and psychotherapy practice. One important finding in the field is that physiological synchronization is related to positive qualities of the therapist, like empathy. That is, therapists whose skin conductance levels (an index of physiological arousal) matched those of their patients, were perceived by their patients as more empathic. In other studies, physiological synchronization between patient and therapist was associated with higher levels of the therapeutic alliance. There is also interesting research showing that therapists with higher attachment security showed greater physiological synchronization in simulated role-plays of clinical interviews. That is, a greater experience of attachment security and a capacity to mentalize appeared to translate into therapists’ capacity to synchronize with their patients at a physiological level. Although one might expect that more physiological synchronization between patients and therapists is better, various studies point to a more nuanced view. Research in romantic couples and with mother-infant dyads suggest that there is an optimal balance between moments of rupture and synchronization. Reporting on their own research, Kelenbub and colleagues suggested that changes in topic and expressions of disagreement between patient and therapist (an indication of a therapeutic alliance rupture) were associated with lower physiological synchronization. Although not yet formally tested, the authors speculated that when therapists and patients repair alliance ruptures, they might return to a heightened state of physiological synchronization.

Practice Implications

Research and interest in patient-therapist synchronization has been around since the late 1950s. However, with recent technological advances, researchers now have the capacity to unobtrusively and inexpensively assess physiological markers in patients and therapists on a moment to moment basis and correlate these with psychotherapy processes. There are no direct practice implications yet from this research. However, the research does point to the need for therapists to improve their capacity to mentalize (i.e., capacity to understand one’s own and others’ mental states) and to empathize, and to acquire skills to develop a therapeutic alliance and repair alliance ruptures when they occur.

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.

Luyten, P., Campbell, C., Allisons, E., & Fonagy, P. (2020). The mentalizing approach to psychopathology: State of the art and future directions. Annual Review of Clinical Psychology, 16, 297-325.

Mentalizing (or reflective functioning) is important to the human ability to understand one’s self and others in terms of mental states like feelings, desires, wishes, attitudes, and goals. Without mentalizing we would not be able to adapt to complex situations including relationships that require high levels of collaboration and cooperation. Mentalizing underlies the capacity for empathy and improves functions like emotion regulation. Parental capacity to mentalize and to provide a secure attachment environment are requirements for children to develop mentalizing capacity. Without that capacity, children and adults are not able to trust that others are reliable sources of social information, which in turn fosters resilience to adversity. In this wide-ranging article, Luyten and colleagues review the research indicating that deficits in mentalizing underlies many mental health problems. For example, non-reflective assumptions about the self and others leads to problems with emotion regulation often seen in those who experienced childhood adversity. For these individuals, caretakers who were hostile and untrustworthy led the child to develop hypervigilant expectations of others as hurtful, critical, and threatening. This hypervigilant stance might have been useful early-on during the adversity, but hypervigilence represents a barrier to psychological and emotional development. Luyten and colleagues also argue that psychological interventions are forms of social learning that increase a patient’s trust in the self and others as sources of knowledge, improve the patient’s capacity to mentalize partly through the therapist’s modeling of mentalizing, and allow the patient to engage in their environment in more adaptive ways. The authors described mentalization-based treatment (MBT) as focused on increasing mentalizing capacity through improving patients’ mental states and emphasizing the active repair of ruptures in the patient-therapist therapeutic alliance. A recent meta-analysis found that MBT is an effective therapy for borderline personality disorder, and recent controlled trials found that patient improvement lasted from 3 years to 8 years post-treatment.

Practice Implications

Therapists who model mentalizing can encourage this capacity in their patients. Therapists can take a curious “not knowing” stance that allows patients to reflect on their own and others’ mental states (intentions, feelings, thoughts). As an important reparative experience, psychotherapists must be able to identify an alliance rupture (a subtle or obvious disagreement on goals or tasks of therapy, or a tension in the affective bond with the patient). Once identified, therapists must act to repair the rupture by renegotiating or re-explaining the goals or tasks of therapy, or discuss how the tension in the therapeutic relationship may represent a pattern of relationship problems for the patient.