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Aajes-van Doorn, K., Bekes, V., & Prout, T. (2020). Grappling with our therapeutic relationship and professional self-doubt during COVID-19: Will we use video therapy again? Counselling Psychology Quarterly, DOI: 10.1080/09515070.2020.1773404

Social restrictions caused by COVID-19 required many therapists to use video therapy to provide treatment to patients remotely. Video therapy offers many benefits like allowing for real-time (synchronous) interactions with patients who would otherwise not have access to mental health care. However most therapists have no training or experience in this modality, and previous surveys suggest that therapists believe video therapy to be less effective than face to face therapy. And some evidence suggests that the level of the working alliance in video therapy is lower than in face to face therapy. In this small survey of 141 therapists about video therapy, Aajes-van Doorn and colleagues examined psychotherapists’ view of the working alliance, therapists’ level of confidence in providing video therapy, and their intentions to use video therapy in the future. Psychotherapists were from the US, Canada, and Europe who treated adult patients in private practice. One third of therapists previously attended a webinar on how to use video conferencing for psychotherapy. The most frequently reported challenges for therapists concerned technical difficulties (61.0% of therapists), having a suitable space for therapy (48.2%), risk of patient or therapist getting distracted (41.1%), and difficulty feeling or expressing empathy to the client (20.6%). On a standardized scale, therapists responded feeling less connected to their patients during video therapy sessions, but they nevertheless reported a good therapeutic alliance compared to published norms. On two other measures, therapists providing video therapy felt more professional self-doubt, less competent, and less confident than levels reported in a previous study of therapists providing face to face therapy. Although therapists’ views of video therapy became more positive since the start of the pandemic, therapists still perceived video therapy to be less effective than face to face treatment. Therapists on average were undecided as to whether they would continue using video therapy in the future, and those who were more likely to continue using had prior experience with the modality.

Practice Implications

Although this is a small survey, it does provide a window into therapists’ experiences with video therapy. The study highlights the added stressors upon therapists in conducting video therapy including higher self-doubt and lower competence and confidence. Also, although the therapeutic alliance in video therapy was good, it seemed to be lower than reported in previous studies of face to face therapy.  Therapists may benefit from more clinical training and support in managing the various technical and clinical challenges of video therapy. With the permission of their patients and following appropriate ethical guidelines, therapists might consider video recording their sessions and reviewing these recordings in consultation/supervision to improve their work with clients in a virtual setting.

Dickeson, E., Roberts, R., & Smout, M.F. (2020). Predicting boundary violation propensity among mental health professionals. Clinical Psychology and Psychotherapy, Online First Publication: https://doi.org/10.1002/cpp.2465.

Boundaries of the therapeutic relationship define the role and limits of therapist behaviors, and the limits of their relationship with clients. Violations of therapy boundaries might include sexual contact, which by some estimates occurs in 0.5% to 8.6% of therapists. Other boundary violations might include a broader range of behaviors such as therapists initiating hugs, forming a social relationship with a client, flirting, and consuming alcohol with a client. A number of years ago, Gabbard developed a typology of practitioners who committed boundary violations that included: the predatory therapist, the masochistic therapist, and the lovesick therapist. Despite the widespread use of this typology, there was little research on its validity or utility. Dickeson and colleagues conducted a survey of 275 Australian practitioners (psychologists, psychiatrists, psychotherapists, and social workers, 73% women) about their behaviors related to professional boundaries and also personality traits. The goal was to evaluate if therapist variables suggested by Gabbard were related to the likelihood of crossing a professional boundary. Over 30% of the therapists in their sample reported some kind of boundary violation with clients, with 0.7% indicating they had sex with a client. Male gender (r = .147–.255), experiential avoidance (r = .144–.230), narcissistic grandiosity (r = .334–.402), narcissistic vulnerability (r = .258–.331), and impulsivity (r = .196–.262) were the most consistent predictors of some propensity to commit a boundary violation among therapists. There was no evidence that age or working in a solo practice setting were related to propensity to professional boundary violations.

Practice Implications

Gabbard’s typology for therapists who engage in boundary violations were supported to some extent. The predatory therapist type was supported by findings related to narcissistic grandiosity and impulsivity. Such therapists may seek personal gratification by exploiting clients. There was also some evidence for the masochistic therapist type as seen by significant correlations with narcissistic vulnerability and experiential avoidance. Such practitioners might extend themselves beyond the limits of professional conduct in a misguided belief that only they can help the client. There is a general consensus in the profession that boundary violations are detrimental to clients. This research suggests that therapists with narcissistic issues might be more likely to transgress professional boundaries. Personal therapy, close supervision, and ongoing professional consultation may be helpful for therapists who feel that they at risk of a professional boundary transgression.

Clients of Therapists Who Are Flexible Have Better Outcomes

Katz, M., Hilsenroth, M. J., Gold, J. R., Moore, M., Pitman, S. R., Levy, S. R., & Owen, J. (2019). Adherence, flexibility, and outcome in psychodynamic treatment of depression. Journal of Counseling Psychology, 66(1), 94–103.

Psychodynamic and cognitive-behavioral (CB) treatments are quite different in how therapy is delivered, but both are equally effective for depression. Such findings suggest that various types of specific interventions can positively impact client outcomes. A possible mechanisms of therapeutic action is that effective therapists may be particularly responsive to their clients’ behaviors and needs. That is, effective therapists may be flexible in how adherent they are to the techniques of a therapeutic orientation. Therapists who are flexible in their adherence to a therapeutic technique may promote a better therapeutic alliance (i.e., a therapist’s and client’s collaborative agreement on the goals of therapy and what to do in therapy). In this study, Katz and colleagues examined whether the flexible use of some CB techniques by psychodynamic therapists was related to better client outcomes in terms of depressive symptoms. Forty six patients diagnosed with depression were treated by 26 advanced graduate student therapists who were trained to practice psychodynamic therapy. Psychodynamic therapy techniques included: a focus on affect and affect expression, identifying relational patterns and patterns of thoughts and feelings, emphasizing past experiences and interpersonal relationships, working on the therapeutic alliance, and restructuring defense mechanisms. The researchers video recorded two early sessions of therapy which were independently rated to assess the degree to which therapists adhered to psychodynamic therapy principles or to CB therapy principles. Client depression outcomes were assessed pre- and post-therapy. Higher ratings of psychodynamic therapy adherence were related to better patient depression outcomes at post-treatment. In addition, the clients of psychodynamic therapists who used some CB techniques early in therapy had the best outcomes. In other words, the use of psychodynamic techniques was sufficient for clients to improve, but flexible use of some CB techniques by psychodynamic therapists provided added benefit. The CB techniques that were most often integrated by the therapists included: actively initiating topics and therapeutic activities, explaining the rationale of an intervention, focusing on the future, and providing psychoeducation about symptoms.

Practice Implications

Clients in this study improved on average from psychodynamic therapy, and psychodynamic interventions were related to better outcomes. However, clients of therapists who flexibly integrated a small amount of CB techniques benefitted more from the psychodynamic techniques. Research is increasingly showing that therapist flexibility in treatment adherence is related to better patient outcomes. For psychodynamic therapists, flexibility in treatment adherence leads to clients being more responsive to the interventions and having better outcomes.

The Interactive Nature of Countertransference

Connery, A. L., & Murdock, N. L. (2019). An interactive view of countertransference: Differentiation of self and client presentation. Psychotherapy, 56(2), 181–192.

Countertransference in psychotherapy is ubiquitous – it is experienced by every therapist with many clients. An early supervisor of mine once quipped, “You might not be interested in countertransference, but it is certainly interested in you.” Countertransference refers to a therapist’s emotional, cognitive, behavioral responses that are triggered by a client, and that are caused in part by the therapist’s unresolved conflicts, sensitivities, or vulnerabilities. So, it is useful to consider countertransference as a result of an interaction between client factors and therapist factors. Research indicates that therapists’ experience of countertransference is related to negative outcomes in their clients, and that identification and management of countertransference results in better client outcomes. In this study, Connery and Murdoch posited that therapists who had lower levels of differentiation of self would experience higher countertransference reactions. That is, those therapists with lower ability to balance the inherent pulls of separateness and togetherness in interpersonal relations, and who had more difficulty maintaining a sense of self in intimate relationships would be more susceptible to the interpersonal pressures inherent in some psychotherapy relationships. The authors conducted a clever study in which 262 practicing psychotherapists of varying professions, orientations, experience, and ages completed some questionnaires. Then the researchers randomly assigned the therapists either to watch 10 video clips simulating a hostile and dominant patient (i.e., with features of narcissism or paranoia) or to watch 10 video clips simulating a hostile and submissive patient (i.e., with features of passive-aggression). After viewing the videos, researchers asked the therapists to describe their own emotional reactions to the client they viewed using a questionnaire that rates countertransference. In general, therapists tended to respond with over-involvement to the videos of hostile and submissive clients. However, those therapists with more problems with maintaining their sense of self in close relationships were particularly susceptible to feelings of over-involvement with these clients. On the other hand, therapists in general tended to respond with more under-involvement to the videos of hostile and dominant clients. However, those therapists who had more problems with maintaining a sense of self in relationships were not any more susceptible to these countertransference reactions compared to therapists with better differentiation of self.

Practice Implications

Differentiation of self indicates the capacity to develop a healthy balance of interpersonal relatedness and self-differentiation that allows one to balance emotional reactions and rational thought when under stress. This study suggests that therapists’ ability to manage closeness and distance in relationships affects the intensity with which they experience countertransference reactions towards clients who have passive-aggressive qualities. This provide further evidence that not only client characteristics, but also some therapist vulnerabilities play a role in determining countertransference reactions. The findings point to the importance of continued peer supervision and of personal therapy for psychotherapists so that they may be less susceptible to the stress inherent in their work, and so that their clients can achieve optimal outcomes.

Timuluk, L. & Keogh, D. (2017). The client’s perspective on (experiences of) psychotherapy: A practice-friendly review. Journal of Clinical Psychology, 73, 1556-1567.

Psychotherapy studies that ask clients for their perspective on the treatment or therapist are surprisingly rare. Researchers have conducted such studies over many decades, but there exist very few of them. This is curious given that respecting clients’ preferences for types of therapy or for therapists’ behaviors is predictive of good mental health outcomes. Giving voice to clients’ perspectives is consistent with the notion that psychotherapy is a co-constructed endeavour rather than something that a therapist does to a client (as is the case for a medical intervention). In this review, Timuluk and Keogh review the research in which patients were interviewed for their perspective on a wide range of aspects of psychotherapy. The research indicates a number of things that clients value, that help, and that hinder their progress in therapy. Clients value a number of therapist traits like friendliness, warmth, respect, offering appropriate guidance, and understanding. This research showed that clients recognize that the relationship (i.e., the alliance) has therapeutic effects. Clients report that many forms of therapist behaviors help to develop a therapeutic alliance including eye contact, smiling, warm personalized greetings, paraphrasing, identifying client feelings, and referring to material from previous sessions. Clients find some events in therapy to be unhelpful or that hinder their progress, like feeling exposed and unprotected, being emotionally overwhelmed, and feeling misunderstood by the therapist.

Practice Implications

Although clients do value therapist expertise in applying therapeutic techniques, they hold therapist personal qualities like warmth, authenticity, honesty, and dedication as necessary prerequisites for therapy. Clients view the therapist’s interpersonal manner as key to forming a therapeutic relationship. It is important that therapists are aware of how they feel towards a client (countertransference), and how these feelings might impact the way in which they communicate through body language, tone of voice, and behaviors. Effective therapists are willing to seek their client’s perspectives, and are open and non-defensive about what a client has to say about the therapy or therapist, even if negative. Therapist openness to feedback will inevitably lead to a stronger relationship and collaboration with the client, and to better outcomes for the client.

Kolden, G.G., Austin, S.A., Wang, C-C., Chang, Y., & Klein, M. (2018). Congurence/genuineness: A meta-analysis. Psychotherapy, 55, 424-433.

More than 60 years ago Carl Rogers first described congruence or genuineness in the psychotherapy relationship as one of the necessary conditions for patients to improve. Congruence has two components. The intrapersonal component refers to mindful genuineness, personal awareness, and authenticity in relationships. The interpersonal component refers to the capacity to express ones’ internal experiences to another person. Rogers argued that patients often experience incongruence with regard to their internal states (they may avoid or fear the experience or expression of what they think or feel). He also stated that therapists’ congruence in the relationship with a patient is a pre-requisite for positive regard and empathy toward the patient. In this meta-analysis, Kolden and colleagues do a systematic review of the relationship between therapist congruence and patient outcomes. The review included 21 studies representing 1,192 patients. The weighted effect size for congruence and psychotherapy outcome was r = .23 (95% CI: .13, .32), representing on average a moderately large effect. Theoretical orientation did not affect the congruence – outcome association. However older therapists with more experience showed a significantly stronger congruence – outcome relationship. Also, therapy with younger patients was associated with a larger congruence – outcome relationship.

Practice Implications

Research continues to support fundamental therapeutic factors defined by Rogers many decades ago. In this case, congruence/genuineness (or the therapist’s ability to know their internal experience and communicate it respectfully to patients) is positively related to patient outcomes. This is especially true for older therapists (who may have a greater capacity for genuineness) and for younger patients – (for whom therapist genuineness may be particularly important). Patients who may have a greater need for and expectation of genuineness are likely to develop a stronger therapeutic alliance with a highly congruent therapist. Patients in a congruent therapeutic relationship learn that it is a safe space, that they matter as a person, and that the therapist is committed and accepting. All of which are precursors to a successful therapy.