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Hayes, J. A., Owen, J., & Bieschke, K. J. (2015). Therapist differences in symptom change with racial/ethnic minority clients. Psychotherapy, 52(3), 308-314.

There is ample research showing that therapists differ in their outcomes with clients. Some therapists consistently have better outcomes than others, and some therapists consistently have worse outcomes. One study estimated that as many as 5% of therapists are reliably harmful, with many more being neither harmful or helpful. Fortunately, there is evidence that some “super-shrink” therapists are reliably helpful. There is also research showing the existence of ethnic disparities in mental health problems and their treatment. The minority stress theory suggests that members of cultural minority groups face problems like discrimination, oppression, and prejudice that affect their mental health. When racial/ethnic minority (REM) individuals do experience mental health problems they may be reluctant to seek help from a therapist of European descent. This may be due to cultural mistrust or doubts about cultural sensitivity. Recently, writers have been discussing the importance of therapist cultural competence in treating REM clients. In this study by Hayes and colleagues, the authors looked at 36 therapists and 228 clients. Clients were students at a university counselling centre seen an average of 5.42 times, and about 65% of clients were of European descent. The therapists were in training in a doctoral counseling program, and they each treated at least 4 clients: two REM and two non-REM clients. Since each therapist had both REM and non-REM clients, the authors were able to estimate the effect of the therapist on client outcomes, and also to see if therapists differed in their ability to treat REM and non-REM clients. In this study, cultural competence was defined as differences in client outcomes within each therapist depending on client culture or race. Overall, about 39% of clients achieved reliable positive change in general symptom distress. Almost 9% of the variance in client outcome was attributable to therapists. Further, the client’s race/ethnicity explained 19% of the variance in treatment outcome attributed to therapists. In other words, which therapist a client saw had moderate impact on whether the client improved, and this was partly due to the client’s REM status.

Practice Implications

In this sample of training therapists and student clients, some therapists were more effective than others, and some of this difference was due to the client’s racial/ethnic heritage. The results suggest that therapists’ cultural competence is a component of overall competence. The findings speak to the need for multicultural training for therapists. Some authors discuss the importance of cultural humility among psychotherapists, which is an interpersonal stance that is other-oriented rather than self-focused, and characterized by respect and lack of superiority toward a client’s cultural background and experience. Client perception of their therapist as culturally humble will improve the therapeutic alliance and the client’s outcomes.

Author email: jxh34@psu.edu

Simpson, S., Simionato, G., Smout, M., van Vresswijk, M.F., Hayes, C., Sougleris, C., & Reid, C. (2018). Burnout amongst clinical and counselling psychologist: The role of early maladaptive schemas and coping modes as vulnerability factors. Clinical Psychology and Psychotherapy, Online first DOI: 10.1002/cpp.2328.

Burnout in health professionals has become a global problem, with between 21% and 67% of mental health professionals reporting high levels. Researchers define burnout as including three components: emotional exhaustion (feeling emotionally exhausted from the work), depersonalization (feeling disconnected from patients), and reduced personal accomplishment in one’s work. Burnout is related to reduced capacity to perform professionally and to provide adequate care to patients. Much of the research has focused on institutional and workload factors as causes of burnout in health professionals. However, interpersonal factors like therapists’ early maladaptive schemas and coping mechanisms may also increase vulnerability to burnout. Early maladaptive schemas are self-defeating core beliefs and patterns that are repeated throughout one’s life and that have their origin in early life experiences. Maladaptive coping are thoughts and behaviors that one repeatedly engages in an unconscious or automatic way to minimize the activation of early maladaptive schemas. Maladaptive coping might include detachment, self-aggrandizement, attacking others, or over-compliance. In this study, Simpson and colleagues surveyed 443 clinical or counseling psychologists in Australia to assess if in fact early maladaptive schemas and maladaptive coping predicted burnout over and above job demands like workload. The mean age of the psychologists was 42.93 years (SD = 11.53), most were women (80.4%), who were married (52.8%), had attained a Masters degree (45.6%), and worked either in outpatient mental health centres (39.7%) or in private practice (33%). Most of the therapists (67%) indicated that over 50% of their client work involved trauma. Of the sample, 49.7% indicated at least a moderately high level of burnout on a standardized questionnaire, with emotional exhaustion as the highest type of burnout. The most common early maladaptive schemas among the psychologists were unrelenting standards and self-sacrifice. Detached coping was the most common coping mode. In terms of predicting burnout, job demands accounted for 10% of the variance in burnout, early maladaptive schemas accounted for an additional 18% of the variance in burnout over and above job demands, and maladaptive coping accounted for an additional 6% beyond maladaptive schemas and job demands.

Practice Implications

Work – life balance, managing clients with chronic and complex issues, and working with clients who experienced trauma can cause distress in mental health providers. Psychologists’ early maladaptive schemas like unrelenting standards and self-sacrifice in addition to maladaptive detached coping may represent the foundation of countertransference for some psychotherapists. These were significant predictors of therapist emotional exhaustion over and above workload. Psychotherapists would benefit from an increased awareness of their own early maladaptive schemas and coping mechanisms. Self-care, including professional development, consultations, peer support groups, and personal therapy throughout one’s career could reduce one’s susceptibility to burnout.

Okiishi, J., Lambert, M. J., Nielsen, S. L., & Ogles, B. M. (2003). Waiting for supershrink: An empirical analysis of therapist effects. Clinical Psychology & Psychotherapy, 10(6), 361-373.

Much of psychotherapy research has focused on searching for effective psychotherapies rather than focusing on effective psychotherapists. Research on psychotherapies generally assumes that therapists are equally effective or relatively less important to patient outcomes than the interventions themselves. Therapists in clinical trials are trained to follow a manual in an attempt to reduce the therapists’ impact on patient outcomes, and to focus the study on the specific ingredients of the therapy itself. However, research indicates that the degree to which a therapist follows a manual has little bearing on patient outcomes, and that therapists do differ in terms of their patients’ outcomes. In one large study, between 33% and 65% of therapists was ineffective or harmful. Okiishi and colleagues asked if it is possible to identify highly effective therapists (“super-shrinks”) and highly ineffective therapists (“pseudo-shrinks”) based on their patients’ outcomes. The therapists were 56 men and women who treated 1779 clients in a university counselling centre. Each therapist saw at least 15 clients, so that there was a good sampling of therapists’ outcomes across a variety of clients. Therapists had a range of experience, training, and theoretical orientations. Clients were adults who had moderate to severe problems with anxiety, depression, or adjustment. Outcomes were measured after every session, and the average number of sessions was 5.16 (SD = 7.20). On average clients improved so that their level of distress significantly declined. Therapist characteristics (sex, experience, training background, theoretical orientation) did not predict patient outcomes. However, client change varied significantly, so that some clients improved at a faster rate than others, some did not change, and some got worse. There were no differences between therapists in their clients’ level of distress, so therapists had equivalent caseloads in terms of client initial distress. However, therapists significantly differed from each other in terms of their clients’ outcomes. For example, the top 3 therapists consistently had clients who got better (super-shrinks), and the bottom 3 therapists consistently had clients who got worse (pseudo-shrinks).

Practice Implications

One would hope that a loved one would get to see a “super-shrink” therapist, since these therapists seem to consistently have clients who do well in therapy. But what about the average or “pseudo-shrink” therapist– what can be done to elevate their skills and their patients’ outcomes? We’ve discussed in this blog several things therapists can do to improve their outcomes, including: using progress monitoring in their practice, receiving training focused on deliberate practice, and seeking out specific continuing education around developing, maintaining, and repairing the therapeutic alliance.

Boswell, J. F., Constantino, M. J., Oswald, J. M., Bugatti, M., Goodwin, B., & Yucel, R. (2018). Mental health care consumers’ relative valuing of clinician performance information. Journal of Consulting and Clinical Psychology, 86(4), 301-308.

Research has shown that some therapists are more effective than others both in terms of their overall effectiveness and in terms of their effectiveness with specific patient problems. Further, despite advances in medicine on this topic, there is little or no information provided to patients about a therapist’s track record on overall effectiveness. In any case, little is known about what patients value in psychotherapists and how much they are willing to give up in order to get what they value. For example, do patients prefer therapists who are highly effective for most problems, and would they be willing to tolerate a poorer therapeutic relationship in order to work with such a highly effective therapist? In this study, Boswell and colleagues employed a relative valuing procedure often used in economics to assess the relative value to patients of different therapist characteristics and performance. Patients were asked how much they were willing to give up on one therapist characteristic (therapist’s overall effectiveness with clients [i.e., overall track record]) in order to receive more of some other characteristic (therapist specific effectiveness in a problem domain, a better therapeutic alliance, lower cost of therapy). The study included 403 patients treated in mental health clinics in the U.S. Patient characteristics were typical of those seen in such clinics – predominantly they had problems with depression or anxiety, were 41 years old on average, mostly women (68.5%), and receiving individual psychotherapy (89.3%). In general, patients highly valued a therapist with a track record of general overall effectiveness. However, patients were willing to give up more of their therapists overall effectiveness if the therapist had a track record of successfully treating their specific problem (e.g., therapist A has lower general efficacy but has demonstrated greater specific efficacy for depression). Patients were also willing to sacrifice therapist general effectiveness in order to pay less for therapy (vs paying a higher fee for a more effective therapist), and in order to work with a provider with whom they would have a better therapeutic alliance (vs a lower alliance with a more generally effective therapist). Surprisingly, patients placed a lower value on factors like therapist gender and race. Younger patients put greater value on therapist performance data (i.e., their track record data), suggesting a generational effect in which younger clients tend to prefer to make decisions based on available data.

Practice Implications

Patients were willing to give up some therapist general effectiveness in order to work with someone who has a track record of being effective for their specific problem, who costs less, and with whom they could have a better therapeutic alliance. Fortunately, therapist general efficacy and domain specific efficacy tend to be highly correlated, and so patients may not have to choose between these. The findings also suggest that patients may be willing to see a therapist who is less generally effective if it meant they could have a good relational experience with the therapist. Research indicates that therapists are able to improve their outcomes and therapeutic alliances with additional training and deliberate practice.

Pybis, J., Saxon, D., Hill, A., & Barkham, M. (2017). The comparative effectiveness and efficiency of cognitive behaviour therapy and generic counselling in the treatment of depression: Evidence from the 2nd UK National Audit of psychological therapies. BMC Psychiatry, 17, 215. DOI 10.1186/s12888-017-1370-7

Over a decade ago the United Kingdom (UK) invested large sums of public dollars to fund the Increasing Access to Psychotherapy (IAPT) program. In IAPT, most patients receive cognitive behavioral therapy (CBT) as first-line treatment for depression or anxiety, and may receive generic counseling as second line treatment. One of the admirable aspects of IAPT is that the program consistently assesses outcomes, makes its data available for analyses, and publishes yearly reports on their outcomes. In this very large study, Pybis and colleagues assess whether CBT and generic counseling have different outcomes for patients with depression or anxiety. Over 33,000 patients who received treatment at one of 103 sites were in the study. Most patients (about 23,000) receiving CBT, and the others (about 10,000) receiving generic counseling. Two-thirds of the patients were female, most (84%) were white British, and the mean age was 41 (SD = 13.86). CBT focused on changing negative thoughts and behaviors in order to improve depressive symptoms. Generic counselling was harder to define, though the authors described these therapists as practicing in an integrative manner by bringing skills from training in different forms of psychotherapy. Generic counseling therapists did not focus on giving advice or opinions, but rather on helping clients understand themselves better. Pre- to post-treatment effect sizes for CBT (0.94 [0.92, 0.95]) and generic counseling (0.95 [0.92, 0.98]) were equivalent for depression outcomes. In CBT 50.4% of patients reliably improved, whereas 49.6% reliably improved if they received generic counseling. The average number of sessions attended by patients in the two treatments (CBT = 8.9 [6.34]; counseling = 7.5 [5.54]) were also equivalent. However, there were significant site effects. That is, a moderate and significant amount of patient outcomes (15%) could be accounted for by the site at which they received treatment (i.e., some sites or clinics had better outcomes than others).

Practice Implications

Generic counseling as provided in the IAPT in the UK was as effective as structured CBT for reducing symptoms of depression. However, almost half of patients did not improve in either treatment. Generic counseling was likely a label used to describe integrative psychotherapy that followed principles from a variety of psychotherapies that were based on psychological principles. There were much larger site/clinic effects than treatment modality effects, so that clients in some clinics had better than clients who received treatment in other clinics. This is consistent with research on therapist effects that show that some therapists are more effective than others, regardless of their orientation. This research suggests that training therapists to be more effective by improving their facilitative interpersonal skills may yield better outcomes for clients.

Solomonov, N. & Barber, J.P. (2018). Patients’ perspectives on political self-disclosure, the therapeutic alliance, and the infiltration of politics into the therapy room in the Trump era. Journal of Clinical Psychology, DOI: 10.1002/jclp.22609.

Most studies of psychotherapy do not take into account the current political climate, and most therapists do not think about the impact of their politics on clients. Studies have focused on the effects of large historical-political events on therapy, but mainly in terms of client reactions to the events. Such studies typically assume that therapist and client shared or agreed on perspectives of the event. However, the 2016 U.S. presidential election was extremely polarizing and may represent one of those events in which clients and therapists do not agree. What if clients and therapists disagreed about the experience of the election and its aftermath – what might be the impact on their therapeutic alliance? To what extent are polarizing politics discussed in therapy, and how are these discussions experienced by clients? Solomonov and Barber conducted a national survey among 604 psychotherapy clients from the 50 U.S. states. The mean age of the sample was 33.82 years (SD = 11.10), 57% were women, 58% were Caucasian, 48% indicated that they voted for Hilary Clinton and 32% indicated that they voted for Donald Trump. Overall, 64% of patients indicated that they had spoken about politics with the therapist (66% of Trump supporters and 70% of Clinton supporters). Among Trump supporters, 38% of clients indicated that their therapist was a Republican, whereas 35% thought their therapist was a Democrat. Among Clinton supporters, only 14% said their therapist was a Republican and 64% perceived their therapist was a Democrat. Thirty percent of clients reported that their therapist explicitly disclosed their political views, and 38% of clients reported that even though their therapist did not explicitly disclose their political views the client could easily guess the therapist’s views. Clients who believed their therapist shared their political views reported significantly higher therapeutic alliance with the therapist than those who believed their therapist did not share their views. Clients who voted for Clinton reported significant increases in expression of negative feelings from before to after the election, whereas Trump supporters did not report a significant increase in negative feelings. Neither Trump nor Clinton supporters reported an increase in positive emotions pre and post election.

Practice Implications

About two thirds of clients in the U.S. have political discussions with their therapists, and almost half wanted to talk more about politics during sessions. Even though general self-disclosure among therapists is relatively infrequent, political self-disclosure among therapists about the 2016 U.S. election seemed to occur much more frequently. It is possible that political instability and the polarizing political climate in the U.S. may contribute to more self-disclosure of a political kind among therapists. This could have an impact on therapy. Clients who perceived their therapists to share political views reported a better therapeutic alliance than those who had divergent political views from their therapist. Similarities in values between therapist and client have long been known to be associated with the therapeutic alliance. The study demonstrates that in the current political climate in the U.S., client perceptions of shared or divergent values with therapists make their way into the therapeutic space.