Blog

Davis, D. E., DeBlaere, C., Owen, J., Hook, J. N., Rivera, D. P., Choe, E., Van Tongeren, D. R., Worthington, E. L., Jr., & Placeres, V. (2018). The multicultural orientation framework: A narrative review. Psychotherapy, 55(1), 89–100.

Studies have shown that many therapists have better outcomes with White clients than with racial and ethnic minority (REM) clients. Also the prevalence of racial/ethnic microaggressions in therapy is high, with as many as 81% of REM clients reporting at least one experience in which a therapist said or did something that was insensitive or offensive. Microaggressions can be understood as instances of therapeutic alliance ruptures that if unrepaired could lead to poor client outcomes. In this practice review of the existing research, Davis and colleagues consider the multicultural orientation framework to help therapists to be more sensitive and effective when working with REM clients. A key feature of the multicultural orientation framework is cultural humility, which refers to a therapist’s interpersonal stance that is open in relation to aspects of cultural identity that are important to the client. Another important concept is cultural opportunities, or the events in therapy in which the client’s cultural beliefs, values, and identity can be explored. Finally, cultural comfort refers to the therapist’s thoughts and feelings that emerge as a result of conversations about the client’s cultural identity. The review found two large and well-designed studies that looked at the association between a multicultural orientation and client outcomes. Therapist cultural humility predicted better therapy outcomes, and lower therapist cultural comfort resulted in client premature termination from therapy. In separate studies, cultural humility was associated with higher therapeutic alliance and fewer microaggressions by therapists. Finally, missed opportunities to discuss cultural identity was associated with more negative therapy outcomes for clients.

Practice Implications

Repairing alliance ruptures caused by microaggressions involves therapists: identifying the event, validating the client’s perspective, discussing the microaggression with appropriate humility, taking responsibility and making amends, and asking the client to inform the therapist about the best way forward. One study showed that the therapeutic alliance improved substantially after therapists and clients discussed and repaired a microaggression. A multicultural orientation involves therapists creating a culturally inclusive setting by overtly discussing the importance of culture and what might cause ruptures.

Aajes-van Doorn, K., Bekes, V., & Prout, T. (2020). Grappling with our therapeutic relationship and professional self-doubt during COVID-19: Will we use video therapy again? Counselling Psychology Quarterly, DOI: 10.1080/09515070.2020.1773404

Social restrictions caused by COVID-19 required many therapists to use video therapy to provide treatment to patients remotely. Video therapy offers many benefits like allowing for real-time (synchronous) interactions with patients who would otherwise not have access to mental health care. However most therapists have no training or experience in this modality, and previous surveys suggest that therapists believe video therapy to be less effective than face to face therapy. And some evidence suggests that the level of the working alliance in video therapy is lower than in face to face therapy. In this small survey of 141 therapists about video therapy, Aajes-van Doorn and colleagues examined psychotherapists’ view of the working alliance, therapists’ level of confidence in providing video therapy, and their intentions to use video therapy in the future. Psychotherapists were from the US, Canada, and Europe who treated adult patients in private practice. One third of therapists previously attended a webinar on how to use video conferencing for psychotherapy. The most frequently reported challenges for therapists concerned technical difficulties (61.0% of therapists), having a suitable space for therapy (48.2%), risk of patient or therapist getting distracted (41.1%), and difficulty feeling or expressing empathy to the client (20.6%). On a standardized scale, therapists responded feeling less connected to their patients during video therapy sessions, but they nevertheless reported a good therapeutic alliance compared to published norms. On two other measures, therapists providing video therapy felt more professional self-doubt, less competent, and less confident than levels reported in a previous study of therapists providing face to face therapy. Although therapists’ views of video therapy became more positive since the start of the pandemic, therapists still perceived video therapy to be less effective than face to face treatment. Therapists on average were undecided as to whether they would continue using video therapy in the future, and those who were more likely to continue using had prior experience with the modality.

Practice Implications

Although this is a small survey, it does provide a window into therapists’ experiences with video therapy. The study highlights the added stressors upon therapists in conducting video therapy including higher self-doubt and lower competence and confidence. Also, although the therapeutic alliance in video therapy was good, it seemed to be lower than reported in previous studies of face to face therapy.  Therapists may benefit from more clinical training and support in managing the various technical and clinical challenges of video therapy. With the permission of their patients and following appropriate ethical guidelines, therapists might consider video recording their sessions and reviewing these recordings in consultation/supervision to improve their work with clients in a virtual setting.

Norwood, C., Moghaddam, N.G., Malins, S., & Sabin-Farrell, R. (2018). Working alliance and outcome effectiveness in videoconferencing psychotherapy: A systematic review and noninferiority meta‐analysis. Clinical Psychology and Psychotherapy, 25, 797-808.

The working alliance is the collaboration between client and therapist on the tasks and goals of therapy, and it also includes the emotional bond. The alliance is the most researched concept in psychotherapy, and it is reliably related to good client outcomes. However, the alliance has been rarely studied in the context of videoconferencing psychotherapy (VCP). Delivering psychotherapy remotely was already gaining popularity prior to COVID-19 because of its potential to improve access to mental health care especially for people who live in remote areas. Some argue that face to face therapy might result in a higher therapeutic alliance because of the rich interpersonal cues, like eye contact and body posture that may facilitate collaboration and the bond. There is emerging evidence that VCP can be effective and that it may have comparable outcomes to face-to-face therapy. But what about the working alliance – does it develop in VCP similarly to face to face therapy?  In this meta-analysis, Norwood and colleagues conducted a systematic review of the existing research on the working alliance in VCP. They found only 4 direct comparison randomized controlled studies on the topic, and on average VCP resulted in a lower working alliance compared to face to face therapy, but the difference was not statistically significant (n = 4; SMD = -0.30; 95% CI: -0.67, 0.07; p = 0.11). People who received treatment via VCP had similar levels of symptom reduction compared to those who received face to face therapy (n = 4; SMD = −0.03; 95% CI [−0.45, 0.40], p = 0.90).

Practice Implications

With only four direct comparison randomized trials to draw from, the results of this meta-analysis remained ambiguous with regard to the therapeutic alliance. Although the difference between VCP and face to face therapy was not statistically significant, it was not ignorable – an effect size of SMD = -0.30 suggests a small advantage for face to face therapy when it comes to the alliance. However, symptom outcomes were comparable between face to face and VCP. The results suggest that therapists who use VCP during a pandemic, must pay particular attention to developing and maintaining a therapeutic alliance by collaboratively agreeing on goals and tasks of therapy, and by focusing on establishing an affective bond with patients despite the limited nonverbal cues available with online psychotherapy.

Stoll, J., Muller, J.A., Trachsel, M. (2020). Ethical issues in online psychotherapy: A narrative review. Frontiers in Psychiatry, 10, 993. doi: 10.3389/fpsyt.2019.00993

There is emerging evidence that videoconference delivered psychotherapy is as effective as face to face therapy. Providing psychotherapy by telecommunication technologies might be synchronous (real time) or asynchronous (email, chat, internet-based) in nature. During the current COVID-19 pandemic, many psychotherapists have moved to telehealth methods due to necessity rather than by choice. Based on previous survey findings, psychotherapists’ attitudes, and legal-ethical barriers have hampered a wider use of video conferencing methods for delivering psychological interventions. In this narrative review, Stoll and colleagues conduct a broad-based summary of 249 studies touching on the main ethical arguments for and against the provision of online psychotherapy. The top five ethical arguments in favor of online psychotherapy include the following. (1) Increased access and availability: online psychotherapy can improve access to health care services for those living in rural and remote areas. (2) Enhanced communication: online therapy is as effective as face to face therapy and allows for creative approaches to delivering therapy including integrating online materials, websites, and videos into therapy sessions. (3) Client characteristics: some clients who have problems with agoraphobia and severe anxiety may find online therapy a useful first step in treatment. (4) Convenience: research indicates that both patients and therapists judge online therapy to be convenient and comfortable. (5) Economic advantages: online therapy might be more cost-efficient due to reduced overhead and travel costs for therapists and clients. The top five ethical arguments against online psychotherapy include the following. (1) Privacy and confidentiality: related to the use of unsecured websites or unencrypted communication tools. (2) Therapist competence: some therapists may not have technology related competencies including specific ethical and legal requirements. (3) Communication issues: the absence of non-verbal cues may reduce the information that therapists have to work with in a session. (4) Research gaps: there is insufficient research to support online therapy, including no knowledge about which clients can benefit, and the impact on therapeutic processes. (5) Emergency issues: ethical issues may arise as to how to manage emergencies or crises of patients who are in different locations.

Practice Implications

The practice of videoconference delivered psychotherapy is here to stay and will be more widespread even after the pandemic. Therapists can take comfort in the many ethical reasons to provide such services, including reaching patients who might not otherwise have access to therapy or who might not be comfortable seeking out face to face therapy. Nevertheless, there are a number of ethical concenrs about the use of online therapy, not the least of which includes questions about privacy and confidentiality and therapist competence. Psychotherapists should follow practice guidelines of their regulatory colleges when considering online therapy.

Dickeson, E., Roberts, R., & Smout, M.F. (2020). Predicting boundary violation propensity among mental health professionals. Clinical Psychology and Psychotherapy, Online First Publication: https://doi.org/10.1002/cpp.2465.

Boundaries of the therapeutic relationship define the role and limits of therapist behaviors, and the limits of their relationship with clients. Violations of therapy boundaries might include sexual contact, which by some estimates occurs in 0.5% to 8.6% of therapists. Other boundary violations might include a broader range of behaviors such as therapists initiating hugs, forming a social relationship with a client, flirting, and consuming alcohol with a client. A number of years ago, Gabbard developed a typology of practitioners who committed boundary violations that included: the predatory therapist, the masochistic therapist, and the lovesick therapist. Despite the widespread use of this typology, there was little research on its validity or utility. Dickeson and colleagues conducted a survey of 275 Australian practitioners (psychologists, psychiatrists, psychotherapists, and social workers, 73% women) about their behaviors related to professional boundaries and also personality traits. The goal was to evaluate if therapist variables suggested by Gabbard were related to the likelihood of crossing a professional boundary. Over 30% of the therapists in their sample reported some kind of boundary violation with clients, with 0.7% indicating they had sex with a client. Male gender (r = .147–.255), experiential avoidance (r = .144–.230), narcissistic grandiosity (r = .334–.402), narcissistic vulnerability (r = .258–.331), and impulsivity (r = .196–.262) were the most consistent predictors of some propensity to commit a boundary violation among therapists. There was no evidence that age or working in a solo practice setting were related to propensity to professional boundary violations.

Practice Implications

Gabbard’s typology for therapists who engage in boundary violations were supported to some extent. The predatory therapist type was supported by findings related to narcissistic grandiosity and impulsivity. Such therapists may seek personal gratification by exploiting clients. There was also some evidence for the masochistic therapist type as seen by significant correlations with narcissistic vulnerability and experiential avoidance. Such practitioners might extend themselves beyond the limits of professional conduct in a misguided belief that only they can help the client. There is a general consensus in the profession that boundary violations are detrimental to clients. This research suggests that therapists with narcissistic issues might be more likely to transgress professional boundaries. Personal therapy, close supervision, and ongoing professional consultation may be helpful for therapists who feel that they at risk of a professional boundary transgression.

Predicting Which Psychotherapists Will Adopt Telepsychology

Pierce, B. S., Perrin, P. B., & McDonald, S. D. (2020). Demographic, organizational, and clinical practice predictors of U.S. psychologists’ use of telepsychology. Professional Psychology: Research and Practice, 51(2), 184–193.

Even prior to COVID-19, psychologists and psychotherapists were examining the use of telepsychology (telephone delivered psychotherapy and assessment). The interest arose from efforts to increase accessibility to psychological services for clients in rural and remote areas, and also for those for whom travelling to an urban centre was a significant barrier due to disability. However, there are barriers to psychotherapists’ use of telepsychology caused by: differing state and provincial laws and requirements, limits to working across state and provincial jurisdictions, issues related to insurance reimbursement, and concern that telepsychology and video conferencing platforms may not meet Health Insurance Portability and Accountability Act (HIPAA) or Personal Health Information Privacy and Access (PHIPA) requirements for confidentiality and privacy. In a previous study, close to 80% of psychologists felt that telepsychology could be effective, but 42% viewed telepsychology as less effective than face-to-face therapy, and 75% indicated that they would not likely refer to someone for telepsychology services. In this large survey of almost 1800 psychologists who practiced psychotherapy, Pierce and colleagues were interested in demographic, organizational, and clinical factors that predicted telepsychology-use by clinicians. The participants were 8.74 times more likely to use telepsychology if they worked in organizations that had policies supporting telepsychology-use compared to those who worked in organizations without such policies (p < .001). Nevertheless, psychologists in private practices were 2.86 times more likely to use telepsychology than those who worked in institutions. Also, psychologists who received training in telepsychology were 2.25 times more likely to use telepsychology than those who did not receive any training (p = .002). In terms of clinical practice areas, those who worked in sports performance, coaching, addictions, and parenting were more likely to use telepsychology. On the other hand, those who provided testing and evaluations were less likely to use telepsychology, likely because of practical limitations to psychometric testing online. Age and gender were not related to telepsychology use.

Practice Implications

Psychologists and psychotherapists who want to increase their comfort and satisfaction in working with telepsychology should consider getting professional development training and continuing education. In one study, over two thirds or psychologists perceived that they did not have sufficient training to use telepsychology. Organizations who want to encourage telepsychology should invest in training and provide clear policy guidelines to support professionals. The notion that older clinicians would be less likely to use telepsychology was not born out by these findings.