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Lutz, W., de Jong, K., Rubel, J.A., & Delgadillo, J. (2021). Measuring, predicting, and tracking change in psychotherapy. In M. Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7^th ed.). Wiley. Chapter 4.

The question of how many psychotherapy sessions are necessary to achieve good patient outcomes, or how frequently sessions should occur has been on the minds of practitioners and researchers for over a century. In this part of the chapter, Lutz and colleagues review some of the research related to how many sessions of psychotherapy is necessary to achieve positive outcomes for patients. A meta-analysis of 70 randomized controlled trials (RCT) of psychotherapy did not demonstrate any correlation between the number of sessions a patient receives and their outcomes. Other research indicates that receiving psychotherapy twice a week is more effective than receiving treatment once a week for depression. The findings of these two lines of research suggest that treatment length may not matter as much as treatment frequency. However, RCTs of psychotherapy tend to test only time limited therapies and they may not reflect exactly what happens in the real world with diverse patients who have complex problems. Perhaps the most relevant research for clinicians may be what is called the dose-response studies. These are studies that indicate how many sessions it takes for patients to get better regardless of treatment length. The dose-response research showed that 50% of patients starting treatment in the dysfunctional range required 21 sessions to achieve clinically significant change. That also means that half of patients did not change meaningfully with 21 sessions of therapy. More than 35 sessions were necessary for 70% of patients to achieve clinically meaningful change (and still, 30% of patients did not benefit). It is likely that some patients get better with a few sessions, but as severity or complexity of problems increase so does the number of required sessions. To add to the complexity, optimal duration of therapy varies according to practice settings. For example, for CBT in controlled studies the average patient needed about 17 sessions to get better, while 35 sessions of CBT was necessary in real world settings for the average patient to improve (again, that means that 50% did not yet improve).

Practice Implications

The findings from this line of research of the optimal number of sessions suggest that it is difficult to translate findings from controlled trials to real world practice. Most RCTs limit therapy to a brief number of sessions whether patients get better or not. Some patients do improve with a few sessions but over half of patients require more than 21 sessions to achieve clinically meaningful change, and about 30% of patients require more than 35 sessions. There is some evidence that more sessions per week leads to better outcomes as well.

Furukawa, T.A., Shinohara, K., Sahker, E., Karyotaki, E., Miguel, C., ….Cuijpers, P. (2021). Initial treatment choices to achieve sustained response in major depression: A systematic review and network meta-analysis. World Psychiatry, 20, 387-396.

Two common treatments for major depression are antidepressant medications and psychotherapy, both of which have been tested in randomized controlled trials. Antidepressants are among the most prescribed medications, and an increasing number of patients are on longer-term use of these medications. However, it is unclear as to whether choosing antidepressant medication or psychotherapy at the beginning or the acute phase of depression will lead to a sustained response in the longer term. In this network meta-analysis, Furukawa and colleagues examine the important question: “which therapies can get me well and keep me well?” The authors selected randomized controlled studies in which antidepressants or psychotherapy, or their combination were prescribed and compared to each other or to a control condition (treatment as usual or placebo pill). In these studies, adult participants with major depression remained in the treatment or control condition up to 12 months post-treatment. Psychotherapies included many known treatments like CBT, behavioral activation, psychodynamic therapy, and interpersonal psychotherapy. This network meta-analysis included 81 trials representing over 13,000 patient participants. Combined psychotherapy plus antidepressant medication resulted in a more sustained response to treatment (better outcomes) in the long run than control comparisons (OR: 2.52, 95% CI: 1.66, 3.85). Psychotherapy alone was more effective in the long run than pharmacotherapy alone (OR: 1.53, 95% CI: 1:00 – 2.35). The advantage of combined treatment over antidepressants alone was about 14% to 16%, whereas the advantage of psychotherapy over antidepressants was about 12%. There were no differences in longer term effectiveness among the different types of psychotherapy.

Practice Implications

This study shows that the effects of psychotherapy when initiated in the acute phase of major depression (at the outset of symptoms) are enduring over a longer time frame. Psychotherapies outperformed antidepressant medications, standard treatment, and pill placebo. The results also suggested that adding pharmacotherapy to psychotherapy did not interfere with the enduring effects of psychotherapy. The authors suggest that treatment guidelines for depression should be updated to emphasize psychotherapy as the preferred initial treatment option.

Sandford, D.M., Kirtley, O.J., Thwaites, R., & O’Connor, R.C. (2021). The impact on mental health practitioners of the death of a patient by suicide: A systematic review. Clinical Psychology and Psychotherapy, 28, 261-294.

In the UK, it is estimated that up to 27% of those who commit suicide have been in contact with a mental health professional in the past year. Even though suicide is a rare event, a mental health practitioner is likely to experience at least one instance of a patient suicide during their career. A psychotherapist who experiences a patient suicide could experience symptoms of burnout, PTSD, grief, and a sense of being overwhelmed. Sandford and colleagues conducted a systematic review of the existing research on the impact of a patient’s suicide, experiences of support by the practitioner, and factors that may minimize the negative impacts of patient suicide. They reviewed 54 quantitative and qualitative studies in order to synthesize the research. Professionals included psychiatrists, psychologists, psychotherapists, counsellors, and other mental health professionals. The most common responses of professionals to a patient suicide were guilt, blame, shock, anger, sadness, and grief. Over 20% of practitioners met criteria for PTSD in some studies. Many practitioners across all studies reported some negative impact on their personal life, with 24% identifying severe emotional impact (lower mood, poor sleep). Following a patient suicide, practitioners reported an increased focus on risk assessment, greater caution in their practices, and increased self-doubt about their own judgement. The average practitioner reported an impact that lasted about 4 weeks. A closer therapeutic relationship with the patient, patients who were younger, and the fear of blame and litigation were each associated with a higher level of distress in therapists. However, the impact was not related to therapist gender, age, or experience. Most practitioners felt inadequately prepared for dealing with a patient suicide. But protective factors included support from colleagues, friends and family, and supportive supervision.

Practice Implications

Even if suicide is a rare event in the population, an important minority of patients who commit suicide were in contact with a mental health professional in the preceding year. And so, one might expect to have a patient who commits suicide during one’s career that will have a negative impact on one’s own well-being and professional practice. Increased awareness of the incidence of suicide, informal social supports, and empathic supervision may mitigate the negative impacts. So will tailored training experiences on managing one’s own reactions to patients, as well as a professional work environment that is non-blaming and supportive.

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.

Curran, J., Parry, G.D., Hardy, G.E., Darling, J., Mason, A-M., Chambers, E. (2019). How Does therapy harm? A model of adverse process using task analysis in the meta-synthesis of service users’ experience. Frontiers in Psychology, 10:347. doi: 10.3389/fpsyg.2019.00347

Forty to 60% of patients do not recover after a course of psychotherapy, and approximately 5% to 8.2% are worse off. In the National Health Service in the UK, 5% of patients reported lasting bad effects of therapy. Although these appear to be small percentages, they represent a large number of patients. In Canada for example, over 1 million Canadians use psychotherapy each year, so 5% would represent 50,000 individuals. Therapists, for their part are poor at identifying patients who deteriorate in therapy. In this meta-synthesis of qualitative research, Curren and colleagues aimed to derive a model based on patients’ experiences of the factors that lead to negative outcomes. They conducted a narrative review of qualitative research findings and of patients’ testimony from a number of sources. They noted eight domains identified by patients that are associated with adverse events in psychotherapy. First, contextual factors refer organizational issues that affect access to or choice of therapy, cultural validity of the therapy, and lack of information about services. Second, pre-therapy factors refer to poor pre-therapy contracting between therapist and patient, and therapists that focus on symptoms rather than the client as a person. Third, therapist factors refer to therapist inflexibility, and therapists’ financial interests that influence their decisions about therapy. Fourth, client factors refer to client lack of understanding of therapy, fear, and demoralization. Fifth, relationship factors refer to a poor relational fit between therapist and patient, therapists perceived as shaming, therapists misusing power, and clients not feeling heard or understood. Sixth, therapist behaviors refer to boundary violations, rigidly applying techniques, therapist acting out, and therapist passivity. Seventh, therapy process refers to the type of therapy offered not matching patient needs, and patients not agreeing with the techniques. Eighth, endings refer to short term therapies that “open a can of worms” without resolution, and the client feeling abandoned.

Practice Implications

Therapists would do well to ensure that the patient’s voice is heard when it comes to preferences and cultural validity of the treatment. In particular, therapists should not rigidly apply techniques focused exclusively on symptom reduction. Instead, therapists should see patients’ problems within their interpersonal and cultural context and focus on outcomes related to the quality of life of patients. Therapists must attend to developing and maintaining the therapeutic alliance (agreement on tasks and goals of the therapy, and the relational bond with patients). Any signs of disruptions or tensions in the alliance should be identified and repaired. Patients require information about the therapy, what it entails, and how it will end before signing on to a course of treatment. Organizations must remove barriers to accessing treatment and provide therapies that represent a range of orientations and foci to meet patients’ needs.

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.