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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

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.

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.