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Owen, J., Tao, K. W., Imel, Z. E., Wampold, B. E., & Rodolfa, E. (2014). Addressing racial and ethnic microaggressions in therapy. Professional Psychology: Research and Practice, 45(4), 283–290.

Overt forms of racism and prejudice still occur in society, and less overt forms are likely more prevalent. Microaggression are those less overt forms of racism and prejudice that may include direct and indirect insults, slights, and discriminatory messages. Specific types of microaggression are: microinvalidations (e.g., denying that racism exists), microassaults (e.g., direct racism but done in private), and microinsults (e.g., believing a group’s cultural norms are pathological). Microaggression are by definition ambiguous and subtle, and they may target culture, race, gender, sexual orientation, and other group identities. Microaggressions are associated with psychological distress in the recipient. Microaggressions can also occur in therapy if a patient perceives a therapist’s dismissing or negating messages about the patient’s culture, or if a therapist engages in culturally inappropriate interventions. Microaggressions represent a special type of therapeutic alliance rupture that could lead to negative patient outcomes. It is also possible that therapists and clients who address microaggressions after they occur are capable of repairing the alliance rupture and moving forward with a stronger relationship. However, there is very little research of the impact of client perceived microaggressions on the therapeutic alliance. In this unique study, Owen and colleagues asked 120 racial and ethnic minority university counselling centre patients treated by 33 different therapists (23 of whom were White) to rate their experience microaggressions, to indicate if the microaggression was discussed, and to rate the therapeutic alliance. In total, 53.3% of patients experienced a microaggression in therapy, and of those patients, 68.4% were treated by a racial or ethnic minority therapist. Clients who reported fewer microaggressions also reported stronger therapeutic alliances (r = .28, p = .01). Of the patients who reported a microaggression, only 24% (13 patients) reported that the microaggression was discussed by the therapist. Of these 13 patients, almost all (12 patients) reported that the discussion was successful. Therapist and patient dyads who successfully discussed the microaggression: (1) had alliance scores comparable to patients who did not experience a microaggression, and (2) had alliance scores that were significantly higher than dyads who experienced but did not discuss the microaggression.

Practice Implications

Microaggressions appear to be ubiquitous in daily life and in psychotherapy – no therapist is immune. More than 53% of patients in this study reported a microaggression, despite what was likely their therapists’ good intentions. Microaggression are a special case of therapeutic alliance ruptures, which are known to be associated with poor patient outcomes. Therapists must develop a strong multicultural orientation and take a culturally humble stance with clients from a different culture or group. This involves therapists being attuned to the possibility of committing a microaggression, inviting patients to alert the therapist should a microaggression occur, and being open to clarifying misunderstandings and owning missteps.

Hill, C. E., Knox, S., & Pinto-Coelho, K. G. (2018). Therapist self-disclosure and immediacy: A qualitative meta-analysis. Psychotherapy, 55(4), 445-460.

Different writers and theorists in psychotherapy have disagreed on the need for or the wisdom of therapists disclosing about themselves during therapy. Recently, however, both humanistic therapists and some psychodynamic therapists tend to see therapist self-disclosure or immediate discussion of the therapeutic relationship more positively. Therapist self-disclosure is a therapist statement that reveals something personal about the therapist (“That makes me angry too”). On the other hand, immediacy refers to comments about and processing the therapeutic relationship by client and therapist in the here and now (“You said that people inevitably let you down, I wonder if you expect that I will let you down too”). Immediacy, also known as metacommunication, is particularly useful to address therapeutic alliance ruptures. In this qualitative meta-analysis, Hill and colleagues (2018) examined research that studied the effects of therapist disclosures and immediacy on subsequent client processes right after the disclosure or immediacy occurred. The authors included in their review 21 studies with a total sample of 184 cases. Five studies with 99 cases looked specifically at the effect of therapist disclosure. Therapist self-disclosure occurred relatively infrequently in 0% to 4% of all therapist responses. The most frequently occurring subsequent processes after therapist disclosure included an enhanced therapy relationship (reported in 64% of studies), greater client insight (reported in 46% of studies), and improved client mental health (reported in 45% of studies). Negative effects of therapist disclosure included negative client feelings or reactions (reported in 30% of studies) and impaired therapeutic relationship (reported in 16% of studies). Fifteen studies with 78 cases looked specifically at immediacy. Therapists used immediacy more extensively in between 12% to 38% of cases. The most frequently occurring subsequent processes following immediacy included an enhanced therapy relationship (reported in 40% of studies), and increased client self-disclosure (reported in 40% of studies). Negative effects of immediacy included a negative impact for the therapist (reported in 11% of studies) that referred to a heightened sense of therapist vulnerability.

Practice Implications

Reviews and theoretical guidelines stress that therapists should sparingly and deliberately use self-disclosure and immediacy. In fact, this review by Hill and colleagues indicated that therapist self-disclosure is relatively rare, whereas immediacy might be more common. Therapists might consider self-disclosure when the client is feeling alone and in need of support. But, as Hill and colleagues indicate, therapists must be thoughtful and strategic about self-disclosure, therapists should disclose only personally resolved material, and therapists must focus their disclosures exclusively on the client’s needs. On the other hand, immediacy may be a useful strategy to negotiate and address problems in the therapeutic relationship by talking about interactions and intentions in the relationship (i.e., metacommunicate about the relationship). Therapists have to consider that immediacy may require lengthy processing, and therapists should be attentive to the role of countertransference and seek consultation in order to be sure to act in the best interest of the client.

Author email: cehill@umd.edu

Fonagy, P., Lemma, A., Target, M., O'Keeffe, S., Constantinou, M., Ventura Wurman, T., . . . Pilling, S. (2019). Dynamic interpersonal therapy for moderate to severe depression: A pilot randomized controlled and feasibility trial. Psychological Medicine, 1-10. Online first publication. doi:10.1017/S0033291719000928

Most psychotherapies are equally effective when it comes to treating depression. However, no single therapy is uniformly effective, so that about 50% of patients might improve when it comes to symptom reduction. So, although there is a large evidence base for treatments like CBT, therapists and patients need access to a range of available treatments. There is less research on psychodynamic therapies, although a number of trials and meta-analyses indicate their effectiveness to treat depression. In the United Kingdom (UK), the health system may offer a stepped care program that provides patients with low intensity guided self-help based on a CBT model followed by more intensive treatment with CBT or IPT if patients did not benefit from self-help. The UK health system rarely offers Dynamic Interpersonal Therapy (DIT), and DIT has never been studied in a randomized controlled trial within the UK health system. Fonagy and colleagues designed this randomized controlled trial to test the efficacy of DIT when compared to the CBT-oriented self-help program as offered in the UK. The study also included a smaller randomized sample of those who received the intensive version of CBT for depression. In total, 147 participants with moderate to severe depression were randomly assigned to DIT, CBT guided self-help, or the intensive version of CBT. The DIT is informed by attachment theory and by mentalization theory, and it views depressive symptoms as responses to interpersonal difficulties or perceived attachment threats. The results of the trial showed a significantly greater effect of DIT compared to guided self-help with regard to depressive symptoms, overall symptom severity, social functioning, and quality of life at post-treatment. The patients receiving DIT maintained these gains up to 1-year post-treatment. Over half of DIT patients showed clinically significant improvements, but only 9% who received the CBT-based guided self-help achieved such improvement. There were no significant differences on any of the outcomes between DIT and the more intensive version of CBT.

Practice Implications

One of the benefits of DIT, according to the authors, is that it offers a treatment manual and curriculum that enables those without a lot of background in psychodynamic therapies to deliver it. This makes DIT potentially widely-applicable in publicly funded health systems like in the UK, Canada, and others. DIT may offer yet another effective option of psychotherapy to therapists and their patients who experience depressive symptoms. The study also points to the limits of offering only guided self-help to those with moderate to severe depression.

Author email: p.fonagy@ucl.ac.uk

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

Morales, K., Keum, B. T., Kivlighan, D. M., Jr., Hill, C. E., & Gelso, C. J. (2018). Therapist effects due to client racial/ethnic status when examining linear growth for client- and therapist-rated working alliance and real relationship. Psychotherapy, 55(1), 9-19.

Racial and ethnic minority (REM) clients tend to have less access to health care services, are less likely to seek services for mental illness, and may receive lower quality care. It is also possible that REM clients may be treated differently by psychotherapists, so that REM clients may have a different experience from non-REM clients of the therapeutic alliance (i.e., the collaborative agreement on tasks and goals of therapy, and the bond with the therapist). The alliance is a well-known factor that is related to client outcomes. If there is such a difference in how REM and non-REM clients experience the alliance, it is likely because of the therapist’s ability to establish and grow the alliance. Previous research showed that therapists and not clients are largely responsible for the alliance – outcome association. Research also demonstrated that some therapists are less effective with REM than with non-REM clients, possibly because of the differing experiences of and development of the therapeutic alliance. In this study, Morales and colleagues measured the therapeutic alliance after every session of therapy for 144 clients seen in a counselling center, almost half of whom were REM clients. The clients saw one of 19 therapists, so that each therapist (10 of whom were REM therapists) saw at least two REM and two non-REM clients. So, the researchers were able to see how each therapist developed a therapeutic alliance differently with REM and non-REM clients. The study found that higher therapeutic alliance between therapists and clients early in therapy was associated with clients remaining in therapy longer, and that the therapeutic alliance statistically significantly increased across sessions. However, therapists varied significantly in the alliance growth depending on whether they were treating REM or non-REM clients. Some therapists showed significant growth in the alliance with REM clients but not with non-REM clients, whereas other therapists showed significant growth in the alliance with non-REM but not with REM clients.

Practice Implications

There were significant differences between therapists in how they were able to develop a therapeutic alliance with racial and ethnic minority (REM) clients vs non-REM clients. The authors speculated that this difference might be due to the therapists’ level of multicultural orientation. A multicultural orientation is a way of being with clients that consists of cultural humility, using opportunities to examine culture, and cultural comfort. Having a multicultural orientation likely increases the level of therapeutic alliance and promotes its growth over time. Research shows that a client benefits when the therapist integrates the client’s cultural narrative into the psychotherapy.

Author email: kmorales@umd.edu

Laverdière, O., Kealy, D., Ogrodniczuk, J. S., & Morin, A. J. S. (2018). Psychological health profiles of Canadian psychotherapists: A wake up call on psychotherapists’ mental health. Canadian Psychology/Psychologie canadienne, 59(4), 315-322.

Patients prefer to work with psychotherapists whom they perceive as psychologically healthy and satisfied with their lives. Psychological health and satisfaction in therapists may be related to their ability to manage their own reactions to clients (countertransference), as well as to their ability to maintain personal and psychological well-being. However, the work circumstances on psychotherapists may compromise their psychological health. Patients often present in ways that may result in emotional reactions in therapists, such as self-doubt and frustration. Also, therapists may develop vicarious or secondary traumatic stress when exposed to patients with a history of trauma. Such emotional stressors may overwhelm therapists and contribute to burnout, distress, and lower quality of life. Previous research found that difficulties in therapist mental health may lead to emotional disengagement, patient early termination, and a lowered therapeutic alliance. Large-scale international surveys indicate that 87% of psychotherapists were involved in psychotherapy at some point in their careers. This suggests that many psychotherapists understand or have experienced the hazards of their work. In this survey of registered Canadian psychotherapists, Laverdière and colleagues were interested in the self-reported psychological health of psychotherapists. The sample included 240 psychotherapists who were mostly women (78%) and psychologists (84%), with a mean age of 42 years (SD = 11.66), practicing psychotherapy for an average of 13 years (SD = 9.42), and working primarily in independent practice (40%) or in an institutional setting (40%). Most identified their primary theoretical orientation as psychodynamic (31%), CBT (31%), integrative (22%), or humanistic (15%). Using a standardized measure of burnout, the authors found that 22% of psychotherapists were experiencing high levels of emotional exhaustion (with a further 20% in the moderate range), and 12% experienced a high level of depersonalization. Only 8% could be classified as having probable serious mental health issues and life dissatisfaction. The authors then developed statistical profiles of psychotherapists using latent class analysis. Using these profiles, 35% of psychotherapists were characterized by moderately high levels of burnout and distress and moderately low quality of life. A further 12% of psychotherapists had very high levels of burnout and distress and very low quality of life. Those with healthier profiles tended to be more experienced (B = .14, p = .008, OR = 1.15) and to have lower perceived workload (B = -1.10, p = .006, OR = .33).

Practice Implications

One in five psychotherapists in this survey were experiencing high levels of emotional exhaustion, and another 20% were in the moderately high range. Emotionally exhausted professionals are at higher risk of making errors, depersonalizing patients, and becoming emotionally exhausted. Psychotherapists at higher risk would benefit from organizational and therapeutic interventions. Peer support groups may help to alleviate some of the distress, as would regular consultation and supervision that partly focuses on countertransference and managing the stress of working with traumatized patients. Psychotherapists need to be aware of the risks involved in having a high workload, which is a well-known risk factor for poor mental health at work. On the positive side, greater experience as a psychotherapist may be a protective factor. Experience may bring with it more self-confidence, greater emotion regulation skills, and a better ability to manage countertransference.