Practice-Based Psychotherapy Research
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PPRNet Blog: December 2018

Giorgio A. TascaAt the PPRNet conference in November 2012 over 100 psychotherapy clinicians, researchers, and educators were very keen to receive ongoing information about psychotherapy research that is practice-oriented and presented in an easily readable format. And so the PPRNet Blog was born.

About once a month I will review and summarize two or three published psychotherapy research articles. As part of the summary, I will highlight the practice implications of the research.

Because of copyright issues, we cannot post the full text of the articles, but we will provide a link to the abstract on the publisher's web site. I will also post the author's email address. Most authors are very happy to share their work. So if you want a copy of the article send the author an email with a request for a pdf or reprint.

At the bottom of each review you can post a comment, and comment on your colleagues' comments. I will update these as frequently as possible.

If you have ideas for an article to review or a topic you would like to see covered, please send me an email at

Giorgio A. Tasca

blogThe Evidence for Countertransference Management

Hayes, J. A., Gelso, C. J., Goldberg, S., & Kivlighan, D. M. (2018). Countertransference management and effective psychotherapy: Meta-analytic findings. Psychotherapy, 55(4), 496-507.

This is another meta analysis from the Psychotherapy Relationship That Work series that will be published in a book by Norcross and Wampold in 2019. Psychotherapists’ unresolved personal conflicts and the cognitive, emotional, or behavioural manifestations of these conflicts in therapy are called countertransference. Countertransference can result in reactions within the therapist that negatively affect their relationship with patients and patient outcomes. Successfully managing these reactions may be an important aspect of positive outcomes in psychotherapy. The old view of countertransference, dating back to Freud, was that countertransference was detrimental to therapy, and therapists had to work to keep their personal reactions out of therapy. More contemporary views see therapist countertransference as inevitable and as providing potentially important information about the patient. In their model of countertransference management, Hayes and Gelso identified five aspects managing countertransference. 1) Origins of countertransference refer to therapists gaining an understanding of their unresolved issues from their past that can interact with patient characteristics in therapy (therapist unresolved family issues, low professional self esteem). 2) Triggers refer to specific issues within the patient that stimulate a specific unresolved issue in the therapist (the patient is competitive and the therapist has a fragile professional self esteem). 3) Manifestations refer to therapist cognitive, behavioural, or affective reactions to triggers and origins (the therapist puts the competitive client in his or her place). 4) Effects refer to the impact of countertransference manifestations on the therapy process or outcome (patient who is put in his or her place drops out or goes silent). 5) Management refers to therapists’ strategies to manage countertransference, including self awareness, self care, consultation and supervision, or personal therapy. In this series of meta analyses, Hayes and colleagues found that: (1) countertransference reactions are associated with poorer therapy outcomes (r = -.16, p = .02, 95% CI [-.30, -.03], d = -0.33, k = 14 studies, N = 973); (2) therapists’ management of countertransference reduces countertransference reactions (r = -.27, p = .001, 95% CI [-.43, -.10], d = -0.55, k = 13 studies, N = 1,065); and (3) successful countertransference management is related to better therapy outcomes (r = .39, p = .001, 95% CI [.17, .60], d = 0.84, k = 9 studies, N = 392 participants).

Practice Implications
The research on countertransference management is still in its early stages but results are promising. Therapists’ ability to identify unresolved issues within themselves, how these issues interact with specific patient behaviors and clinical presentations, and management of therapist reactions are important to their work. The work of psychotherapy is fraught with emotional challenges and potential pitfalls for the therapist. Every therapist will experience confusing or challenging emotional reactions to a client. Better understanding and management of these reactions and their manifestations will not only lead to better patient outcomes, but also to greater therapist personal well-being and work satisfaction.

For a copy of the abstract, click this link: .
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blogA Wake up Call on Psychotherapists’ Mental Health

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.

For a copy of the abstract, click this link:
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blogEarly Maladaptive Schemas and Coping Make Psychotherapists Vulnerable to Burnout

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.

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