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Clients of Therapists Who Are Flexible Have Better Outcomes

Katz, M., Hilsenroth, M. J., Gold, J. R., Moore, M., Pitman, S. R., Levy, S. R., & Owen, J. (2019). Adherence, flexibility, and outcome in psychodynamic treatment of depression. Journal of Counseling Psychology, 66(1), 94–103.

Psychodynamic and cognitive-behavioral (CB) treatments are quite different in how therapy is delivered, but both are equally effective for depression. Such findings suggest that various types of specific interventions can positively impact client outcomes. A possible mechanisms of therapeutic action is that effective therapists may be particularly responsive to their clients’ behaviors and needs. That is, effective therapists may be flexible in how adherent they are to the techniques of a therapeutic orientation. Therapists who are flexible in their adherence to a therapeutic technique may promote a better therapeutic alliance (i.e., a therapist’s and client’s collaborative agreement on the goals of therapy and what to do in therapy). In this study, Katz and colleagues examined whether the flexible use of some CB techniques by psychodynamic therapists was related to better client outcomes in terms of depressive symptoms. Forty six patients diagnosed with depression were treated by 26 advanced graduate student therapists who were trained to practice psychodynamic therapy. Psychodynamic therapy techniques included: a focus on affect and affect expression, identifying relational patterns and patterns of thoughts and feelings, emphasizing past experiences and interpersonal relationships, working on the therapeutic alliance, and restructuring defense mechanisms. The researchers video recorded two early sessions of therapy which were independently rated to assess the degree to which therapists adhered to psychodynamic therapy principles or to CB therapy principles. Client depression outcomes were assessed pre- and post-therapy. Higher ratings of psychodynamic therapy adherence were related to better patient depression outcomes at post-treatment. In addition, the clients of psychodynamic therapists who used some CB techniques early in therapy had the best outcomes. In other words, the use of psychodynamic techniques was sufficient for clients to improve, but flexible use of some CB techniques by psychodynamic therapists provided added benefit. The CB techniques that were most often integrated by the therapists included: actively initiating topics and therapeutic activities, explaining the rationale of an intervention, focusing on the future, and providing psychoeducation about symptoms.

Practice Implications

Clients in this study improved on average from psychodynamic therapy, and psychodynamic interventions were related to better outcomes. However, clients of therapists who flexibly integrated a small amount of CB techniques benefitted more from the psychodynamic techniques. Research is increasingly showing that therapist flexibility in treatment adherence is related to better patient outcomes. For psychodynamic therapists, flexibility in treatment adherence leads to clients being more responsive to the interventions and having better outcomes.

The Interactive Nature of Countertransference

Connery, A. L., & Murdock, N. L. (2019). An interactive view of countertransference: Differentiation of self and client presentation. Psychotherapy, 56(2), 181–192.

Countertransference in psychotherapy is ubiquitous – it is experienced by every therapist with many clients. An early supervisor of mine once quipped, “You might not be interested in countertransference, but it is certainly interested in you.” Countertransference refers to a therapist’s emotional, cognitive, behavioral responses that are triggered by a client, and that are caused in part by the therapist’s unresolved conflicts, sensitivities, or vulnerabilities. So, it is useful to consider countertransference as a result of an interaction between client factors and therapist factors. Research indicates that therapists’ experience of countertransference is related to negative outcomes in their clients, and that identification and management of countertransference results in better client outcomes. In this study, Connery and Murdoch posited that therapists who had lower levels of differentiation of self would experience higher countertransference reactions. That is, those therapists with lower ability to balance the inherent pulls of separateness and togetherness in interpersonal relations, and who had more difficulty maintaining a sense of self in intimate relationships would be more susceptible to the interpersonal pressures inherent in some psychotherapy relationships. The authors conducted a clever study in which 262 practicing psychotherapists of varying professions, orientations, experience, and ages completed some questionnaires. Then the researchers randomly assigned the therapists either to watch 10 video clips simulating a hostile and dominant patient (i.e., with features of narcissism or paranoia) or to watch 10 video clips simulating a hostile and submissive patient (i.e., with features of passive-aggression). After viewing the videos, researchers asked the therapists to describe their own emotional reactions to the client they viewed using a questionnaire that rates countertransference. In general, therapists tended to respond with over-involvement to the videos of hostile and submissive clients. However, those therapists with more problems with maintaining their sense of self in close relationships were particularly susceptible to feelings of over-involvement with these clients. On the other hand, therapists in general tended to respond with more under-involvement to the videos of hostile and dominant clients. However, those therapists who had more problems with maintaining a sense of self in relationships were not any more susceptible to these countertransference reactions compared to therapists with better differentiation of self.

Practice Implications

Differentiation of self indicates the capacity to develop a healthy balance of interpersonal relatedness and self-differentiation that allows one to balance emotional reactions and rational thought when under stress. This study suggests that therapists’ ability to manage closeness and distance in relationships affects the intensity with which they experience countertransference reactions towards clients who have passive-aggressive qualities. This provide further evidence that not only client characteristics, but also some therapist vulnerabilities play a role in determining countertransference reactions. The findings point to the importance of continued peer supervision and of personal therapy for psychotherapists so that they may be less susceptible to the stress inherent in their work, and so that their clients can achieve optimal outcomes.

Imel, Z. E., Pace, B. T., Soma, C. S., Tanana, M., Hirsch, T., Gibson, J., Georgiou, P., Narayanan, S., & Atkins, D. C. (2019). Design feasibility of an automated, machine-learning based feedback system for motivational interviewing. Psychotherapy, 56(2), 318–328.

I do not mean to conjure up the image of a dystopian future, but I could not resist the pithy title for this blog. Ideally, psychotherapists in training or those who seek professional development would receive high quality accurate feedback about their behavior (e.g., about interpersonal skills, empathy, vocal tone, body language) and competence (e.g., regarding specific interventions) in real time. This would allow psychotherapists and trainees can make fine-tuned adjustments to their behaviors and interventions that match or complement the specific patient with which they are working. But, given the current technology, this is impossible. Instead psychotherapy training and feedback to practicing clinicians is slow, cumbersome, and imprecise. Current supervision and consultation practices rely on giving feedback based on the clinician’s verbal case report or, at best, based on viewing video recordings. There are systems that provide feedback on patient outcomes that may alert psychotherapists to something going amiss in for the patient. But such feedback occurs post-session, is based on patient self-report, and does not inform immediate in-session therapist behaviors. In this study, Imel and colleagues evaluated an initial proof of concept of an automated feedback system that generated quality metrics about specific therapist interventions and about therapist skills like empathy. They used computer technology based on natural language processing to take conversational data from video of psychotherapy sessions in order to answer questions like: “what did the therapist and patient talk about during the session?”, “how empathic was the therapist?”, and “how often did the therapist use reflections versus closed questions in the session?” The authors developed a machine learning tool to transcribe, code, and rapidly generate feedback to 21 experienced and novice therapists who recorded a 10-minute session with a standardized patient (a standardized patient is an actor who loosely follows a script). The machine learning technology was accurate at defining or coding a “closed question” by a therapist (e.g., a question with a yes/no answer; inter rater agreement with a human coder ICC = .80), but not as accurate at defining or coding a therapist empathic statement (inter rater agreement with a human coder ICC = .23). The system provided immediate feedback the therapists about their behaviors during the session using graphics and text (fidelity to specific interventions, counseling style, empathy, percent open/closed questions, percent reflections). All therapists rated the tool as “easy to use”, 86% strongly agreed that the feedback was representative of their performance, 90% agreed that if the tool was available, they would use it in their clinical practice.

Practice Implications

Typically, professional consultation or supervision involves a consultant giving the therapist feedback based on imprecise descriptions of events in a therapy session that occurred at some point in the recent past. This method of training and consultation in psychotherapy has not changed much in the past 60 years. One key drawback of current methods of training and consultation is that they do not make use of real-time feedback to help therapist adjust behaviors to the specific patient or context. It is possible that in the near future with rapid advances in artificial intelligence and machine learning a therapist will be able to finish a session with a patient and receive an immediate feedback report about the previous hour. The feedback might include metrics on empathy, the percent of questions vs reflections, competence in specific interventions, among other personalize ratings. This future might also have novice trainees receive immediate real-time in-session feedback about behaviors of interest that need to be adjusted, or for which more training is necessary. For some, this might be a vision of a dystopian future, for others it may represent a way forward in which therapists achieve more refined skills and better patient outcomes.

Orlinsky, D.E., Ronnestad, M.H., Hartmann, A., Heinonen, E., & Willutzki, U. (2019). The personal self of psychotherapists: Dimensions, correlates, and relations with patients. Journal of Clinical Psychology. Online first: DOI: 10.1002/jclp.22876

What role does the psychotherapist’s personal self play in determining their interpersonal stances with patients? It is an intriguing question about the intersection between the personal self and the professional self of psychotherapists. Are we different in our personal lives compared to our professional lives? In this large survey of over 10,000 psychotherapists from Europe and North America, Orlinsky and colleagues examine the convergence of the personal and professional self of psychotherapists. The personal self was defined as therapists’ view of the self when engaging in personal relationships. This can include behaviors in close relationships, and also one’s temperament defined as innate sensitivities or proclivities in relationships. Previous research indicated that when relationships are satisfying, life typically feels rich and meaningful – but if personal relationships are limited or non-existent, life can feel empty and meaningless. The survey asked therapists a number of questions, including about how they describe themselves in close personal relationships, what their general proclivities are around affect expression, cognitive style, and expectations of relationships, and how they rated their life satisfaction. Half of the sample of psychotherapists were psychologists, and there was also a large representation of psychiatrists, counsellors, and social workers. Major theoretical orientations were represented (psychodynamic, CBT, humanistic), and therapists came from a number of countries mainly in Europe and North America. Most psychotherapists identified themselves as caring (friendly and warm: 85%) in close relationships, but some also reported being more forceful (authoritative: 37%) and reclusive (guarded: 27.6%). In terms of temperament most therapists were optimistic and intuitive (84% each), but some also indicated more pragmatic (72%) or skeptical (25%). Therapists who more caring and expressive also reported higher levels of personal life satisfaction. In general, therapists who were more caring in their personal relationships reported being more affirming with patients (r = .52), those who were more forceful in personal relationships tended to be more directive with patients (r = .48), and those who were more reclusive in personal relationships were more reserved with patients (r = .20).

Practice Implications

Not surprisingly, most therapists saw themselves as warm, affiliative, optimistic, and receptive in personal relationships. But, many therapists (35%) also described themselves in negative terms (reserved, guarded, skeptical) in close relationship. Although psychotherapists may see their personal relationships and their professional relationships as independent, this large multinational survey indicates otherwise. Personal relationship style and temperament has a moderate to large association with professional interpersonal style with patients. This may indicate that therapists generally are genuine (consistent with themselves) in their relationship with patients. But other therapists may have to reign in more negative aspects of their selves and social behaviors in order to be empathic and caring towards patients.

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.

Mental Health Disorders Increase Health Care Utilization in Adults with Chronic Disease

Sporinova B, Manns B, Tonelli M, et al. (2019). Association of mental health disorders with health care utilization and costs among adults with chronic cisease. JAMA Network Open. Published online: 2(8):e199910. doi:10.1001/jamanetworkopen.2019.9910

Chronic diseases like diabetes, heart disease, chronic obstructive pulmonary disease (COPD), chronic kidney disease are common and represent a major burden on the individual and on society. So much so that chronic diseases represent about 60% of global disease burden. There is also a documented association between mental and physical health, such that mortality in cancer, diabetes, and following a heart attack is significantly higher in those with depression. The cost of chronic disease to the Canadian economy represents about 60% of the annual health care budget, and depression alone has a $32.3 billion impact on the Canadian economy. In this economic study, Sporinova and colleagues sought to quantify the impact of having a mental disorder on health care utilization and cost for those with chronic diseases. The study used a large data base of adults from Alberta, Canada who had at least one chronic disease including asthma, COPD, heart failure, myocardial infarction, diabetes, epilepsy, and chronic kidney disease. Mental disorders were defined as a concurrent diagnosis of depression, schizophrenia, or substance use disorder. Factors like sex, income, and rural residency were controlled in the analyses. Of the cohort with a chronic illness, 15.8% had a mental disorder, with depression as the most common mental disorder at 11.2%. People with chronic illness and a mental disorder tended to be younger, women, with a lower socio-economic status, and they tended to die at a higher rate during the study period. The mean total 3-year health costs of those with a chronic illness was $20,210 (95% CI: $19,674, $20,750) Canadian dollars, whereas for those with a concurrent mental disorder the cost was significantly higher at $38,250 (95% CI: $36,476, $39,935). Higher costs were driven by greater hospitalizations, prescription drug use, and physician visits. Costs were higher for older people, and for those with more than one mental disorder.

Practice Implications

The results clearly indicated that an important proportion of those with chronic illnesses were also diagnosed with a mental disorder. Further, a diagnosis of a mental disorder drove up the burden of the chronic illness significantly, both for the individual and for the health care system. Past research indicated improved medical outcomes when treating depression in medical patients. And so, although the physical symptoms of chronic illness may appear prominent, clinicians must treat mental health problems when they exist concurrently, if they want to improve patient medical and mental health outcomes.