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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

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

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.

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.

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.

Hewison, D., Casey, P., & Mwamba, N. (2016). The effectiveness of couple therapy: Clinical outcomes in a naturalistic United Kingdom setting. Psychotherapy, 53, 377-387.

Current randomized controlled trials (RCTs) of couple therapy indicate that about 60% to 70% of couples improve to some degree, and that about 35% to 50% are no longer distressed by the end of therapy. But RCTs have been criticized for being somewhat artificial because their design is based on how pharmacological treatments are tested. Psychotherapy may be more complex than pharmacotherapy in its implementation, and compared to pharmacotherapy, psychotherapy relies more heavily on the qualities of the therapist and therapeutic relationship in order to achieve good outcomes. In an RCT, individuals often have to have a specific disorder to be included in the study, and those with co-morbid disorders may be excluded. This may limit what the findings have to say about real world applications of a particular treatment. Further, therapists in RCTs may receive unusual levels of supervision and support that is seldom seen in regular clinical practice. In this large study of over 435 couples, Hewison and colleagues assessed the effectiveness of a psychodynamically-oriented couple therapy as practiced in a large not-for-profit centre that provides psychological treatment (i.e., the Tavistock clinic in the United Kingdom). All participants received couple treatment and none were randomly assigned to a control group. The couple therapy focused on insight and emotional connection and expression within the context of a therapeutic relationship. The couple relationship rather than the individual partners were the object of the therapy. The unconscious meaning of couple communication was often discussed, and therapist countertransference was seen as a source of information about the couple. Most couples in the study identified as White (77.0%), heterosexual (93.9%), and married or living in a civil partnership (58.4%). More than half of the couples were in the relationship for over 5 years and had children. Therapists were qualified couple therapists or Masters level trainees, had a mean age of 50 (range: 26 – 71), tended to be White women (60%), and were all trained at the clinic. The average number of sessions that a couple attended was 23.3 (SD = 23.5), but with a wide range (2 to 150 sessions) as might be typical in a clinical setting. Overall, individual clients reported a large significant decrease in individual psychological distress (d = -1.04), and a moderate significant decrease in marital distress (d = -0.58). Half of individuals showed a reliable reduction in their individual distress, and over a quarter of couples reported a reliable decline in their couple distress.

Practice Implications

This is the largest study of couple therapy in a naturalistic setting. The psychodynamic couple therapy was effective in reducing individual distress for almost half of the participants although reliable change in couple distress was lower. The results of this field trial indicate that couple therapy that is offered in a functioning real-world clinic setting produces results similar to what is seen in highly controlled randomized trials.