When the Therapists Need Therapy

The cartoon stereotype of a psychotherapy session sees the client lying on the therapist’s couch, sharing their soul. But do we have a clear mental picture of the person taking the notes?

We should, as the work of Prof. Harold Chui shows. The mood of the owner of that couch can have an impact on the outcome of a psychotherapy session. Counselling is a two-way dialogue, not a one-person stream of consciousness.

‘Emotions have an impact on our cognitive processes,’ Professor Chui says. ‘My studies look at session behaviour, to teach therapists to be mindful of what mood you go into the session with, and do something to regulate that.’

To date, most studies of the effectiveness of therapy focus on the method of the therapy itself. Is cognitive-behavioural therapy or psychodynamic therapy better to tackle depression, for instance? (The answer is that both can work).

Professor Chui’s work shows that the manner and the delivery of the therapy can also have a significant impact on its effectiveness. His is ‘process research,’ studying the actual counselling itself, rather than the ‘outcome research’ that results-based studies of therapy examine.

At CUHK, he has studied more than 600 sessions since 2018, from at least 40 dyads, or therapist-client pairs. By the time the data collection is complete in May 2020, he will have captured more than 800 sessions.

He surveys both the therapist and the patient before the session, and after it. They indicate, on a scale of 1 to 5, how happy, sad or anxious they are, for instance. Of the 28 questions, 10 relate to positive emotions, 10 to negative emotions, 4 to calmness, and 4 to fatigue. After the sessions, they indicate how effective they think the sessions were.

Although some people may be generally more optimistic or pessimistic, studying the same therapist-client pairs helps track fluctuations in mood in the same people over time. It also allows examination of the relationship between mood fluctuations and the counselling process. The sessions are offered to the public at a heavily discounted rate of HK$100 per hour, one-tenth the price of a private-practice session.

Besides the surveys, people who are trained to analyse therapist behaviour also review videotapes or transcripts of the session. They provide their own independent assessment of the performance of the therapist. Since transcriptions are very time-consuming, particularly in Chinese, Professor Chui is working with Prof. Tan Lee in the Department of Electronic Engineering to build a Cantonese software dictionary of counselling that could be used for automatic transcription. For now, sessions require manual checking and transcription.

Professor Chui first began this line of inquiry at the University of Maryland, while studying for his doctorate. Analysis there showed that a positive mood for the therapist resulted in a better session. Although this may be what we would intuitively expect, it wasn’t guaranteed. There was also the chance that an overly happy therapist would be less empathic, or struggle to relate to a client who is expressing their deepest fears or worst emotions.

‘If I’m happy, I may have a positive bias when I hear a story, and I may underestimate a client’s negative mood,’ Professor Chui explains. ‘That may have a huge impact. You may miss something, like a client who may be at risk of suicide, and that can be devastating.’

Chui, an assistant professor in the Department of Educational Psychology, has practical experience on the topic: he is also a licensed psychologist in New York, and registered in Hong Kong. His focus at CUHK is on teaching counselling techniques and processes to trainee and working schoolteachers, as well as other ‘helping professionals’ such as social workers and speech therapists.

Now in Hong Kong, Professor Chui is examining why mood matters, and what a happy therapist does differently that influences the outcome. Is it verbal behaviour? Do they establish a better rapport with the patient?

‘People are generally aware that my mood will influence my judgment and decisions, but this is not really evidence-based,’ Professor Chui says. ‘I want to make it an evidence-based thing, where you show that mood can affect a session, and what you say in the session.’

His early research shows that an upbeat therapist demonstrates greater empathy, while the patient experiences some emotional contagion. It is not that simple, however.

A therapist who is empathic becomes more empathic when they’re in a better mood. So they would benefit from listening to upbeat music or even reading sentences that reinforce a positive mood. A therapist who is less empathic, though, actually sees a decline in empathic behaviour when they’re in a good mood. Inducing a happier mood makes them less able to empathize with clients.

A calm therapist translates to a better session. But a tired therapist can still deliver good performance if they can perk themselves up during the session, by talking to a client.

This knowledge will then be used in therapist training. First, therapists should start to assess their own mood prior to a session. Even if they are not in the best frame of mind, there may be techniques they can deploy that would improve a session. For someone who is not particularly good at regulating their own emotions, becoming aware of how they feel themselves is important before they try to counsel others.

‘Part of counsellor training is to make students aware that everyone has different ways of experiencing and expressing emotions, and that’s OK. That’s human diversity,’ Professor Chui says. ‘If emotional self-awareness is a shortcoming of yours, perhaps we need some more work on what we call counsellor self-care before they can work with patients more effectively.’

By Alex Frew McMillan
Photos by Eric Sin

This article was originally published on CUHK Homepage in Feb 2020.

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Harold Chui psychologist psychotherapy Department of Educational Psychology Cantonese software dictionary Tan Lee Department of Electronic Engineering professors