Blog

Crawford, M.J., Thana, L., Farquharson, L., Palmer, L., Hancock, E.... Parry, G.D. (2016). Patient experience of negative effects of psychological treatment: results of a national survey. British Journal of Psychiatry, 208, 260-265.

There is lots of evidence that psychotherapy is effective for a wide variety of disorders. However, a number of studies report that between 5% and 10% of patients report higher levels of symptoms following treatment compared to when they started. Although the side effects and negative outcomes in pharmacological treatment studies are routinely reported, negative outcomes in psychological treatment studies are rarely reported and investigated. In this very large survey, Crawford and colleagues analysed data from an audit of state funded psychological therapies for depression and anxiety in England and Wales. Adult patients from 220 centers were invited to complete an anonymous service-user questionnaire that asked about their experiences of the processes and outcomes of psychotherapy. Some of the questions asked if clients experienced a “lasting bad effect” from the treatment. Nearly 15,000 individuals responded to the survey. More than half (51%) were treated with cognitive behavioral therapy, and most clients received only one treatment, which was predominantly individual therapy. Most (74.35%) received fewer than 10 sessions. Of the respondents, 763 (5.23%) reported that therapy had a “lasting bad effect”, and an additional 7.70% were “unsure” whether they experienced a lasting bad effect. People over 65 years old were less likely to have a lasting negative effect, and those from minority ethnic groups and non-heterosexuals were more likely to report lasting bad effects. In addition, those who did not know what type of therapy they received were more likely to have lasting bad effects.

Practice Implications

A substantial minority of patients reported lasting negative effects from their psychological treatment. With approximately a million Canadians receiving outpatient psychological treatment of one form or another each year, these findings imply that thousands of patients could have experienced a lasting negative effect. The findings suggest that psychotherapists need to be highly sensitive to cultural and ethnic minority issues and acquire cultural competence. The same is true when treating non-heterosexuals. Clinicians should also make sure to provide sufficient information to patients about the type of treatment they are receiving as part of the informed consent process. Attending to these issues may reduce the likelihood of therapeutic alliance ruptures that may be related to lasting negative effects.

Tritt, A., Kelly, J., & Waller, G. (2015). Patients’ experiences of clinicians’ crying during psychotherapy for eating disorders. Psychotherapy, 52(3), 373-380.

Psychotherapy can be an emotionally intensive experience for both patients and therapists. In a large survey, more than 70% of therapists reported having cried in therapy, and 30% cried during the past month. Therapists who cried almost always saw the experience as positive or neutral (99.2%) for the patient and the therapeutic relationship. Do clients feel the same way about therapists who cry? In this study, Tritt and colleagues surveyed 188 adult patients with an eating disorder who were recently in psychotherapy. Of those, 107 (56.9%) reported that their therapist had cried during therapy. There was no association between frequency of therapist crying and therapist age, patient diagnosis, or type of psychotherapy (i.e., manual-based or not). Therapists who cried a moderate amount were seen by clients as having a positive demeanor (i.e., happy, firm, consistent), whereas therapists who cried more extremely were rated by clients as having a more negative demeanor (i.e., anxious, angry, bored). If therapists who cried were generally perceived by clients to have a positive demeanor, then therapist crying had a positive impact on therapy. That is, clients reported a greater respect for the therapist, greater willingness to express emotions, and higher willingness to undertake therapy in the future. However, if therapists who cried were generally perceived by clients to have a negative demeanor, then therapist crying had a negative impact on therapy. That is, clients were less willing to express emotions in therapy and to undertake therapy in the future. Further, if the therapist who cried was rated as having a negative demeanor, the client experienced more self blame, assumed that there was something wrong in the therapist’s life, and that the therapist and client did not share the same perspective on the client’s life and treatment.

Practice Implications

This small but unique and interesting survey sheds some light on clients’ experiences of therapists who cry during therapy. More than half of clients experienced their therapist crying during therapy. In contrast to surveys of therapists who tend to evaluate therapist crying as exclusively positive or neutral, this survey found that many but not all clients experienced therapist crying as positive. It depends on how the client perceives the therapist as a person. Therapists who are seen by clients as happy, firm, and consistent may assume that patients will experience their crying as a positive indicator of the therapeutic relationship. However, therapists who are seen by clients as anxious, bored, or angry cannot assume that clients will see their tears as being positive for therapy.

Erekson, D.M., Lambert, M.J., & Egget, D.L. (2015). The relationship between session frequency and psychotherapy outcome in a naturalistic setting. Journal of Consulting and Clinical Psychology.

The dose-response model of psychotherapy suggests that a single session is like a “dose” of therapy, and that each session adds to a cumulative response by the client. For example, research indicates that between 13 and 18 sessions are required for 50% of patients to improve significantly, but with diminishing returns for clients after 18 sessions. In this very large study in a naturalistic setting, Erekson and colleagues studied the question of the effects of the “dose” or quantity of therapy a little differently. What if the spacing or frequency of sessions rather than the total number of sessions was important to patient outcomes? That is, if psychotherapy reinforces adaptive behaviors, then less learning might occur if time between sessions increases. With greater time between sessions clients may miss timely support from a therapist, and the therapeutic alliance may not be as solid. Erekson examined the impact of session frequency in a very large sample of university students (N = 21,488) seen by therapists (N = 303) for individual therapy lasting about 50 minutes per session. Clients typically received between 6 and 21 weeks of therapy. The data were collected at a counselling center over a 17-year period. Therapist orientations included CBT, psychodynamic, existential, and integrative. Patient outcomes were measured after each session with a reliable measure that allows one to evaluate if a client recovered from symptoms, reliably improved but did not recover, or reliably deteriorated. The authors found that compared to less frequent sessions (approximately every 2 weeks), more frequent sessions (approximately weekly) was associated with faster improvement and faster recovery. The statistical models predicted that 50% of individuals being seen weekly would reliably improve in 8 sessions, whereas 50% those seen every 2 weeks would reliably improve in 12 sessions. That is, clients seen every two weeks required 50% more sessions to achieve the same level of improvement as clients seen every week.

Practice Implications

Clients that are seen weekly may have a better therapeutic experience and develop a better therapeutic alliance with their therapists, which may in turn result in faster improvements. More frequent meetings may suggest to clients that their needs are important to the therapist. Institutions may have the opinion that lower session frequency is a way of saving resources, but in the end patients seen less frequently may require more therapy to achieve outcomes at the same rate as patients seen more frequently. Higher frequency of sessions may increase the efficiency of the psychotherapy and possibly reduce the amount of resources invested by the institution to improve patient mental health outcomes.

Stiles, W.B., Barkham, M., & Wheeler, S. (2015). Duration of psychological therapy: Relation to recover and improvement rates in UK routine practice. British Journal of Psychiatry, 207, 115-122.

In this very large study from the UK National Health Service (NHS), Stiles and colleagues assessed whether more therapy is better. That is, do people continue to get better with more sessions or do patients reach a certain level of improvement and terminate therapy regardless of number of sessions. The “dose-effect model” of psychotherapy suggests that patients continue to improve with more sessions, although the rate of improvement slows down after 18 sessions. However, large naturalistic studies from the UK health system show that patients have similar rates of recovery regardless of the number of sessions they attend (i.e., up to 20 sessions). These findings suggest that patient improvement may follow a good-enough or “responsive regulation model” of improvement, in which patients responsively regulate the number of sessions that they need. This could have implications for policies regarding how many sessions are prescribed to patients. In this study, Stiles and colleagues drew data from the NHS data base of over 26,000 adult patients who were seen by 1,450 therapists. These were patients who provided enough reliable outcome data, who attended 40 or fewer sessions, and who had a planned ending. Many patients had multiple problems including anxiety, depression, bereavement, and trauma and abuse. Patients who were selected for the study had initial symptom scores in the clinical range. The most common therapy approaches included integrative, psychodynamic, CBT, and supportive. Patient “recovery” was defined as no longer scoring in the clinical range at the end of therapy. Patient “improvement” was defined as a reliable drop in symptom scores on a psychometric measure. Patients received an average of 8.3 sessions, 60% recovered, and an additional 19% improved but did not recover. Rates of reliable improvement were negatively correlated (r = -.58) with number of sessions, and the effect was large. That is, patients who stayed in therapy longer had lower rates of recovery. These patients were more symptomatic at the outset.

Practical Implications

The results of this very large naturalistic study suggest that therapists and clients should regularly monitor improvement and adjust the treatment duration based on whether clients improve to a satisfactory level. The authors refer to this as “responsive regulation” of treatment duration. In practice, this means that therapists and clients end treatment when patients have improved to a “good-enough” level, which is likely balanced against costs and alternatives. These findings should encourage therapists and agencies to shift their attention away from prescribing a pre-specified length of treatment at the beginning of therapy towards evaluating on an ongoing basis what constitutes good-enough gains for each client.

Owen, J., Adelson, J., Budge, S., Wampold, B., Kopta, M., Minami, T., & Miller, S. (2015). Trajectories of change in psychotherapy. Journal of Clinical Psychology, 71(9), 817–827.

Knowing the rate, or the trajectory, or the shape of client change across sessions of therapy can inform our understanding of how patients change, our policies of how many sessions to provide clients, and our clinical decisions if clients are no longer improving. The most popular models of client change across sessions include the “dose-effect model” and the “good-enough level model”. The dose-effect suggests that the more therapy patients receive the more they improve but, at a certain point, more sessions result in diminishing returns. In the August, 2013 PPRNet blog, I reviewed a chapter suggesting that 17% to 50% partially improve after about 7 sessions, and 50% patients fully recover after receiving about 21 sessions of therapy. Dose effect models might encourage some agencies to provide only the average number of sessions so that most patients will improve. The good-enough level model, on the other hand suggests that patients stay in therapy for varying lengths of time, and the number of sessions is determined by the point at which they feel better. In this study by Owen and colleagues, the authors take a different approach by looking at the patterns or trajectories of change that represent how and at what rate patients improve over time. In this very large study, they gathered session-by-session outcome data for over 10,000 clients seen at 47 treatment centres by over 500 different therapists. Client presenting problems and therapy orientations varied. Owen and colleagues identified 3 classes of patient change trajectories by using advanced statistical modeling of general distress outcomes across 5 to 25 sessions of therapy (average = 9.4 sessions). The largest class, representing 75% of clients, typified those who rapidly improved to session 5 and whose improvement plateaued to session 11, after which they improved again. This was called the “early and late change” class. The second largest class of patients, representing almost 20% of the sample, showed consistent linear change across the sessions. This was called the “slow and steady change” class. The third class of clients, representing about 5% of the sample, showed an initial decline in functioning up to session 5, followed by a steady improvement up to session 9, and then a plateau in improvement after session 9. This was called the “got worse before they got better” class.  This last group of clients had the most severe symptoms at the outset.

Practice Implications

This study indicates that one size does not fit all when it comes to how rapidly and in what manner patients change. “Early and late change” patients improve early on and then show another round of improvement later on in therapy. “Slow and steady” change patients show mild but consistent improvement across sessions of therapy. And those whose symptoms are more severe at the outset may “get worse before they get better”. This means that it may not be feasible to set an average fixed number of sessions for all patients, but rather therapists and agencies must rely on indices of reliable or good-enough change to determine optimal therapy length for each client. For example, “early and late change” patients may be working on different issues at different stages of therapy. Whereas clients who “show slow and steady” change may need to be in therapy longer before they realize sufficient improvement. For those patients with more severe symptoms who “get worse before they get better”, the therapy initially may be difficult but may ultimately induce change in the long run. In this case, therapists may need to provide enough of the current therapeutic approach before considering a change in the course of therapy.

Author email: Jesse.owen@louisville.edu

Puig, A., Yoon, E., Callueng, C., An, S., & Lee, S. M. (2014). Burnout syndrome in psychotherapists: A comparative analysis of five nations. Psychological Services, 11(1), 87-96.

Psychotherapists can experience severe stress when working with some clients. The stress can be the result of work conditions like budget cuts and increased therapy caseloads, and from characteristics of the work itself like remaining compassionate with clients who experience significant emotional pain and trauma. In the May 2014 blog, I reported on research on secondary trauma experienced by therapists as an occupational hazard of working with traumatized patients. Although secondary trauma is distinct from burnout, the accumulation of these experiences by therapists coupled with other demands of the work can lead to burnout. Burnout syndrome is often defined as the failure to perform clinical tasks well because of discouragement, apathy, and the experience of emotional or physical drain. Burnout can affect both the therapist’s well being and patient outcomes. In this study by Puig and colleagues, the Counsellor Burnout Inventory (CBI) was given to therapists in five countries. The CBI measures therapist Exhaustion, sense of Incompetence, Negative Work Environment, and Deterioration in Personal Life. The samples of therapists were from countries that included the United States (n = 750), Korea (n = 382), Japan (n = 257), Philippines (n = 218), and Hong Kong (n = 222). Puig and colleagues argue that countries like the US may be characterized by a more individualistic cultural context, whereas other countries in Asia may have more collectivistic values. These cultural values and differing professional practice contexts may affect the experience of burnout by psychotherapists. The majority of therapists were female (67.3% to 85.3%) with average experience ranging from 5.34 years in Korea to 12.33 years in the US. Puig and colleagues translated the CBI from English and then conducted a confirmatory factor analysis that showed that the CBI is reliable and valid within each of these samples of therapists from different countries. Therapists in Hong Kong and the US had the highest scores on the Exhaustion scale. Puig and colleagues suggested that burnout in Hong Kong and US may be most affected by demands of the work that psychotherapists do in those countries. Psychotherapists from Japan reported highest levels on the Incompetence scale, suggesting that burnout in Japanese therapists might be most affected by a sense of low self efficacy and efficiency. Of all the nations, US therapists perceived their working environments most negatively. Deterioation in Personal Life scores were highest in Korea suggesting that burnout may contribute to low personal quality of life for Korean psychotherapists. All therapists reported low mean scores on the Devaluing Client scale, but those in the US and Philippines had the lowest mean scores. It appears that burnout is least affected by negative relationships with clients for all therapist groups.

Practice Implications

Therapists, policymakers, and administrators need to attend to increased stress related to psychotherapists’ work, the environment, and characteristics of clients who experience trauma. The impact of stress and burnout can be seen in therapists’ performance their personal lives and well-being. In addition, burnout can affect patient outcomes. Puig and colleagues suggest that psychotherapists can participate in professional development activities (e.g., workshops) to enhance their knowledge and skills in managing stress and maintaining a healthy and balanced work and personal life. Organizations should consider restructuring the social and work environment (e.g., workload), and clarifying and reassessing their expectations of therapists in order to prevent conflict and ambiguity. On his web site, Ken Pope provides a list of resources for therapist well-being and preventing burnout, and he discusses the ethics of therapist self-care.