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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

Swift, J. K., Callahan, J. L., Cooper, M., & Parkin, S. R. (2018). The impact of accommodating client preference in psychotherapy: A meta‐analysis. Journal of Clinical Psychology, 74(11), 1924-1937.

Here is another in a series of meta analyses looking at client factors that predict psychotherapy outcomes. In 2006 the American Psychological Association defined evidence-based practice in psychology as composed of 3 pillars: (1) the integration of the best available research combined with (2) clinical expertise in the context of (3) client characteristics including client preferences. Client preferences can be grouped into three broad categories. First, activity preferences refer to activities that a client hopes they and their therapists will engage in during treatment. For example, some clients may prefer homework between sessions, or therapists who interpret, or may prefer a type of therapy modality like group, couple, or individual treatment. Second, treatment preferences include client’s wishes for certain types of therapy approach like CBT, psychodynamic, interpersonal psychotherapy, peer-support, or others. Third, therapist preferences include a client’s desire for the type of therapist with which they would like to work. This might include preferences based on demographics, therapist personality, interpersonal style, culture, and so on. Studies that measure the impact of clients receiving their preferences may simply ask clients what they prefer, or might use a questionnaire of preferences. Some research found that clients are willing to give-up up to 40% in the treatment’s efficacy in order to ensure that they worked with a therapist with whom they would have a good relationship. In this meta-analysis, Swift and colleagues reviewed 53 studies that examined the association between client preferences and psychotherapy outcomes. In 28 studies that included data from 3,237 clients, the overall effect of client preference on psychotherapy drop out was statistically significant, such that clients who were not matched or not given a choice of treatment preference were 1.79 times more likely to drop out compared to those who did get their preference (95% CI: 1.44, 2.22; p < .001). In 53 studies of over 16,000 clients, the overall effect of clients receiving their preference on outcomes was also statistically significant (d = 0.28, 95% CI [0.17, 0.38], p < .001). Receiving a preferred treatment or therapist was associated with better client outcomes.

Practice Implications

The results of this body of research suggests that therapists will do well to attempt to accommodate client preferences in psychotherapy, unless they are impractical, or therapeutically or ethically counter-indicated. One can ask clients about their preferences for activities of therapy, therapist style and characteristics, and treatment type.  Some of these decisions may require clients to be educated about their options, and so agencies may consider adopting decision aids. At the very least therapists should initiate a discussion with clients about what the client wants and what they can reasonably expect to receive. These discussions may occur at the beginning of treatment and revisited part way through as well. Therapists may also consider using more structured valid assessments of client preferences to help with this task.

Author email: Joshua.Keith.Swift@gmail.com

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.

Duncan, B. L., & Reese, R. J. (2015). The Partners for Change Outcome Management System (PCOMS): Revisiting the client’s frame of reference. Psychotherapy, 52(4), 391-401.

Generally, psychotherapy is effective for a wide variety of disorders, but regardless, many clients do not benefit. Further, the research shows that some therapists are more effective than others, but therapists tend to grossly over-estimate their effectiveness. In one large survey, therapists reported that their outcomes were better than 75% of their peers, no therapist rated themselves as below average, and therapists tended to over-estimate their effectiveness and under-estimate client deterioration. One way to evaluate patient outcomes and processes is to engage in progress monitoring and feedback. This involves repeated brief assessments of client outcomes followed by real-time feedback to therapists to gauge client progress and signal potential problems. Several such systems exist including the Outcome Questionnaire-45.2 and the Partners for Change Outcome Management System (PCOMS). The PCOMS is made up of the Outcome Rating Scale (ORS) and the Session Rating Scale (SRS). The ORS measures distress in 3 atheoretical domains (personal, family, social) not based on diagnosis. The SRS is a measure of therapeutic alliance. Both the ORS and SRS are very short 4-item scales that can be administered before (ORS) and after (SRS) each session of therapy. In this paper, Duncan and Reese review the research supporting the use of the PCOMS. A meta analysis found that clients whose therapists received feedback with the PCOMS were 3.5 times more likely to experience reliable change and had less than half the chance of experiencing deterioration. Five randomized controlled trials demonstrated the advantage of the PCOMS over treatment as usual, including by reducing drop outs and achieving reliable change in fewer sessions.

Practice Implications

A lot of research has demonstrated that most therapists over-estimate their effectiveness and that many are not able to identify clients who are getting worse. It is time for therapists to acknowledge this positive bias of their effectiveness and their need for quality information in order to make good clinical decisions. Progress monitoring and feedback systems are one means by which therapists can receive quality information. The repeated use of the PCOMS for example, can help to identify when clients begin to deteriorate and/or when problems emerge with the therapeutic alliance. Being able to identify these issues early may allow therapists to act quickly to avert client deterioration or drop out.

Miller, S. D., Hubble, M. A., Chow, D., & Seidel, J. (2015). Beyond measures and monitoring: Realizing the potential of feedback-informed treatment. Psychotherapy, 52(4), 449-457.

Progress monitoring is the process of repeatedly assessing client functioning with validated measures and providing feedback to therapists. The feedback is designed to identify problems with the therapeutic relationship or with client deterioration by comparing client progress to similar clients. This allows therapists to change what they are doing, renegotiate aspects of therapy, or directly address the issues. Research is clear that progress monitoring significantly increases the proportion of clients who improve, reduces drop outs by a third, shortens the length of therapy, and reduces costs. Yet the research also indicates that only 12% of psychologists are using progress monitoring in their practice. If progress monitoring is so useful, then why aren`t more therapists using it? In this review, Miller and colleagues discuss some of the barriers and problems with using or adopting progress monitoring in clinical practice. They describe that even in the most favorable circumstances, it takes about two decades for new treatments to be integrated into routine care. Another issue is that recent surveys indicate that only about 33% of psychologists and 66% of training directors are aware of progress monitoring. Even for those who are aware, a common barrier might be cost and time to implement the procedures. Despite the brevity and low cost of the tools, like the PCOMS, they all place an additional burden on clinicians’ busy schedule. There is also the issue of staff turnover. As staff come and go, organizations may lose those who lead, train, and support the use of progress monitoring. Probably the biggest barrier is skepticism on the part of clinicians who might see the tools as too superficial, or who might be concerned that repeated measurement may somehow negatively affect the therapeutic relationship. However, research indicates that clients generally report positive experiences – they like being a more integral part of the assessment process, and they appreciate the ability to track their own progress. Finally, whereas clinicians may use progress monitoring to improve clinical decision-making, administrators may see it as a means of conducting performance reviews.

Practice Implications

In most health care fields, it can take 20 years for an innovation to make it into routine practice. That might be the case for progress monitoring. More clinicians need to know about it, be trained in its use, and see for themselves that the information is valid, of high quality, and that it can supplement their work in identifying clients who are not doing well. In particular, progress monitoring may be a means of enhancing the therapeutic alliance as it provides therapists and clients a vehicle to discuss how the therapy is going, what needs focus, and what to do if things go awry. Organizations need to treat progress monitoring as a means of helping therapists to improve their skills, and not as a means of auditing performance. Therapists need quality information upon which to make sound clinical decisions, and progress monitoring is one way of receiving this information.