Should the Mental Health of Psychotherapists Be One of the Transtheoretical Principles of Change?

Often, psychotherapy researchers find that their contributions to psychotherapy get lost in the discussions of complex methodological issues that appear far removed from the real-life work of psychotherapists. Consequently, few psychotherapists regularly read research-based studies, and researchers communicate primarily with each other and less with psychotherapists. Fortunately, the pioneering work of Castonguay et al. (2019) has identified evidence-supported principles of change that improve patient outcomes, regardless of the psychotherapist’s theoretical orientation. They help bridge the researcher/practitioner gap by identifying, in succinct terms, evidence-supported findings related to improved patient outcomes. Psychotherapy scholars identified these principles after exhaustingly reviewing thousands of studies on psychotherapy.

Of course, none of the principles of change should be implemented in isolation. Nevertheless, together, they can guide psychotherapists on how to improve and personalize their treatment plans. Examples have been given of how psychotherapists can apply these change principles to improve the treatment of patients with suicidal thoughts (Knapp, 2022) and anxiety, depression, and other disorders (Castonguay et al., 2019).

Some of the principles appeared to support the conventional wisdom on what is effective in psychotherapy. For example, Principle 3 states, “Clients with more secure attachment may benefit more from psychotherapy than clients with less secure attachment” (McAleavey et al., 2019, p. 16). However, other principles conflict with some popular beliefs about the effectiveness of psychotherapy. For example, Principle 20 states, “Clients with substance use problems may be equally likely to benefit from psychotherapy delivered by a therapist with or without his or her own history of substance use problems” (McAleavey et al., 2019, p. 17).

The latest list updated in 2019 included 38 principles, which will likely change as more research on psychotherapy is conducted. Since the last review, emerging evidence suggests that the emotional well-being of the psychotherapist is another transtheoretical principle related to patient outcomes. Therefore, we propose a new principle of change, which could read, “Clients will be more likely to benefit from psychotherapy delivered by a psychotherapist with fewer symptoms of mental distress compared to psychotherapy delivered by a psychotherapist with more symptoms of mental distress.”

Identifying psychotherapists’ mental health as a principle of change will help alert psychotherapists to the importance of reflecting on and ensuring their emotional well-being and will encourage trainers to emphasize self-care within their psychotherapy training programs.

Background on the Emotional Well-Being of Psychotherapists

Psychotherapists, like everyone else, may already have and/or can develop mental health problems that could impact the quality of their work, even before they enter their professional field. In addition, they may experience personal events, such as family problems or personal illnesses, which could tax their emotional resources. In addition, working as a psychotherapist “is a mental health hazard” (Di Benedetto, 2015, p. 401) because it puts psychotherapists in situations likely to lead to distress. These stressors could include dealing with administrative or insurance problems, exposure to patient descriptions of their traumas, moral injury, the continual strain of dealing with the unhappy emotions of many patients, and, less frequently, stalking by patients, patient suicides, threats, or actual assaults by patients (Knapp & Fingerhut, 2024).

The impact of these stressors can be exacerbated if the psychotherapist has a trauma background, maladaptive schemas, or other vulnerabilities to stressors. Furthermore, the mental health of psychotherapists and other healthcare workers has declined substantially since the COVID-19 pandemic (Ruiz & Gibson, 2020). The increased demand for mental health services precipitated by the pandemic has led to larger caseloads and sicker patients.

Evidence Supporting the Mental Health of Psychotherapists as a Principle of Change

Below are some of the studies showing the relationship between patient outcomes and psychotherapist mental health:

• Psychotherapists who reported high levels of burnout had patients with poorer scores on outcome measures of depression and anxiety (Delgadillo et al., 2018).

• Psychotherapists who scored higher on personal resilience had better outcomes than psychotherapists who scored lower on personal resilience (Green et al., 2014).

• Graduate students in psychology who scored high on measures of psychological distress had worse performance on a measure of competence (Humphrey et al., 2017).

• According to Nissen-Lie et al. (2013), psychotherapists with significant personal burdens had more difficulty establishing a good working alliance with their patients. She concluded, “Patients are particularly sensitive to their therapist’s private life experiences of distress, which presumably is communicated through the therapist’s in-session behavior” (p. 483).

• Psychotherapists who scored high on psychological distress reported that their patients received a lower quality of services and had poorer outcomes (Salyers et al., 2015).

• Psychologists who scored high on burnout measures were poorer at showing empathy or identifying the emotions of their patients (Simionato et al., 2019), qualities linked to good professional relationships and outcomes.

• Psychotherapists who scored high on measures of insecure attachment had poorer patient outcomes (Heinonen & Nissen-Lie, 2020).

Practice Implications

Psychotherapists can use the existing principles of change to help them formulate good treatment plans for their patients. They can also improve their outcomes by ensuring their psychological well-being. Psychotherapists can do this by focusing on self-awareness, cultivating self-compassion, and creating supportive social environments.

Self-Awareness

Effective psychotherapists will strive to become aware of their thoughts and feelings through self-reflection (or thinking about what they have done) and mindfulness (being aware of what they are doing or feeling in the present moment; Epstein, 2020). They are aware of the emotions that arise when working with patients. Sometimes, they will feel frustrated or angry with patients and risk giving maladaptive responses. At other times, they will feel so much empathy or attraction that they may risk a boundary violation, even if it is subtle and not technically a violation of an ethical standard.

Unfortunately, psychotherapists are not always good at recognizing the extent to which their emotions could interfere with the quality of their work. Denial, rationalization, or other defensive mechanisms inhibit self-awareness, leading to unfinished business. Some personal and professional events are obviously upsetting and attention-grabbing (similar to getting a flat tire while driving). However, other professional events have a less obvious but equally significant impact on psychotherapist well-being (such as having tires that gradually lose their tread, making the risk of a sudden flat tire more likely). They may lead to a gradual deterioration in health, akin to developing a chronic health condition. Psychotherapists who have residual emotions that they have not recognized and processed may find that these emotions will leak into their patient interactions in an unhealthy manner and sometimes in ways that they do not recognize.

Psychotherapists can increase their self-awareness by soliciting feedback regularly from their patients, keeping journals, participating in consultation groups where they can share their feelings and reflect, receiving personal psychotherapy, or participating in interactive continuing education programs. Mindfulness exercises may also help psychologists become more attentive to their thoughts and feelings (Knapp et al., 2017; Sternlieb, 2013). Finally, just as hospitals have Morbidity and Mortality meetings to determine why a patient dies, psychotherapists may benefit from similar non-blaming meetings where they can reflect on why an intervention failed.

Self-Compassion

Self-compassion appears to improve the mental health of psychotherapists. For example, some psychotherapists may hold maladaptive beliefs or schemas, such as unrelenting standards (perfectionist) schema or excessive self-sacrifice (Kaeding et al., 2017; Simpson et al., 2018) that are linked to burnout. The unrelenting standards finding conjures up memories of the “L” (lie) scale in Gordon’s facetious Minnesota Multiphasic Personality Inventory scale for psychotherapists, which asked psychotherapists questions such as whether they have ever felt angry at a patient (Gordon, 1997). An answer of “no” (never) suggests that a failure to recognize or accept our all-too-human response may represent the unhealthy strategy of emotional suppression.

People can mitigate the detrimental effects of perfectionism by showing self-compassion and responding to their mistakes with kindness and forgiveness (Ong et al., 2020). The importance of self-compassion is accurately summarized in the title of an article by Nissen-Lie et al. (2017): “Love yourself as a person, doubt yourself as a therapist” (p. 48). Healthcare professionals who received mindfulness self-compassion training showed improved well-being (Neff et al., 2020), emphasizing the impact of this underutilized technique.

Creating a Supportive Environment

We all need social nutrition (Kornblith et al., 2022). Strong relationships are related to well-being and life satisfaction, while loneliness is related to poor health outcomes and an increased risk of death (Holt-Lunstad, 2021).

Social connections are especially important for psychotherapists. Psychotherapists with strong relationships with others are less likely to experience burnout (Yang & Hayes, 2020). Psychotherapists working in institutions may have treatment teams they can rely on, although they may need to nurture and promote good relationships with their team members. Those who work in solo practices may have to work harder to find those supportive relationships but may be able to do so by participating in consultation groups, journal clubs, or other interactive professional activities.

Social connections are part of a competent community (Johnson et al., 2012) in which psychotherapists have a network of people who help them sustain or improve the quality of their services. These social relationships allow psychotherapists to vent or express their emotions when angry or frustrated, provide material assistance when needed or consultation on a case if indicated, and give psychotherapists feedback if their colleagues notice that they seem overly burdened or distressed.

Conclusion

The principles of change literature describes empirical findings that can help psychotherapists improve the quality of their services regardless of their theoretical background. The evidence is sufficiently strong to suggest that psychotherapists’ emotional and psychological well-being could be included among these principles of change. Self-care, therefore, deserves to be an area of focus for all practicing psychotherapists and an integral part of training for all future psychotherapists.