Sleepy Psychotherapists: How Clinicians’ Biological Factors May Affect the Conduct of Psychotherapy
Publication: American Journal of Psychotherapy
Abstract
Objective:
Numerous therapist variables and cognitive biases can affect the quality of the therapeutic alliance and the conduct and outcomes of psychotherapy. This article aims to examine factors that potentially affect clinician performance, including chronobiological variables of clinicians and patients.
Methods:
The author reviewed literature pertaining to biological influences on human cognitive performance and considered how these factors may apply to the practice of psychotherapy.
Results:
Biological factors potentially affecting the conduct and quality of psychotherapy were identified. These factors include decision fatigue, hunger, sleep deficit, shift work, and several chronobiological issues related to circadian rhythms and episodic ultradian rhythms. In addition, misaligned scheduling of psychotherapy sessions in relation to therapist and patient evening-morning chronotypes may impede the effectiveness of psychotherapy.
Conclusions:
The practice of psychotherapy is cognitively demanding, requiring that clinicians remain constantly alert and in command of their executive functions. Decreases in clinician alertness resulting from homeostatic depletion, chronobiologically misaligned schedules, and illness-associated factors may reduce the quality and benefit of psychotherapy sessions. Mitigation strategies are available. Investigations of these factors are needed.
Highlights
•
Biological factors, including physiological homeostatic, chronobiological, and illness-related factors, can affect psychotherapists’ cognitive functioning and thus their conduct of psychotherapy.
•
Scheduling misalignments related to psychotherapist and patient morning-evening chronotype characteristics may affect the quality of psychotherapy sessions.
•
Mitigation of potentially modifiable factors requires clinician self-appraisal and self-care and institutional attention to optimize clinician alertness and diminish cognitive sluggishness at times of direct patient care.
The practice of psychotherapy demands top cognitive performance by clinicians. Psychotherapists are expected to maintain high degrees of alertness and focused attention, to listen carefully, and to use everything they know about their patients to rapidly reflect on and respond to patients’ verbal and nonverbal communications. Nevertheless, anecdotes abound concerning clinicians who doze off, pinch their legs, or bite the inside of their cheeks to stay awake during some psychotherapy sessions.
As a central tenet of psychodynamic psychotherapy, countertransference results from a mixture of psychological and social influences. Biological factors may play a role as well. Psychotherapists practicing psychodynamic therapy sometimes ascribe clinician sleepiness during psychotherapy to countertransference reactions, specifically clinicians’ responses to patients who use obsessional defenses and who are boring. However, many other factors contributing to drowsiness and cognitive sluggishness during psychotherapy sessions may reside in clinicians themselves. The aim of this article is to call attention to the numerous biological factors that can adversely affect clinicians’ cognitive processes and their conduct of psychotherapy. These factors include depletion of physiologic processes necessary for maintaining homeostasis, chronobiological misalignments, and additional aggravating processes related to illness among clinicians. Interventions that may mitigate these adverse effects and areas for further study are also discussed.
These inquiries were motivated by the following intriguing findings. In a classic study (1) of 1,125 judicial rulings on prisoner parole requests rendered by 65 Israeli judges over a 50-day period, prisoners had a better chance of favorable rulings if they were seen at the beginning of the day rather than later in the day. With the day divided into three sessions (early morning, after a midmorning snack, and after lunch), rulings were more favorable at the beginning than toward the end of each session and were more favorable earlier in the day than later in the day, especially after lunch. The authors postulated that fatigue and hunger affected the judges’ decision making. In the field of general medicine, a study of 33 primary care practices involving nearly 20,000 patients (2) found that patients with appointments later in the day were less likely to receive orders for guideline-recommended cancer screenings. In another study of 1,220 patients matched for numerous clinical variables and types of surgery (3), cardiothoracic surgeons were found to order more blood transfusions during surgeries that were conducted later in the day. To explain these phenomena, the authors (4) invoked mental fatigue, hunger, and decision fatigue as potential contributors.
In addition, a substantial literature (5) addresses the deleterious effects of chronic sleep deprivation and fatigue on clinical performance, patient safety, and clinical outcomes. Increasing attention has also been directed to burnout and clinician sleep deprivation and fatigue in medical settings (6). Concerns about the effects of sleep deprivation on performance spurred the Accreditation Council for Graduate Medical Education (7) to develop work hour standards for house officers.
On the basis of these leads, literature was reviewed on biological variables related to cognitive performance, including the studies mentioned above as well as several associated with sleep and wakefulness issues, such as circadian and episodic ultradian cycles. The review focused on how these factors might alter therapist performance related to cognition and the conduct and outcomes of psychotherapy.
Methods
A PubMed literature search was conducted for studies that addressed biological factors having an impact on the cognitive functioning of psychotherapists and the conduct of psychotherapy, specifically those addressing homeostatic, chronobiological, and illness-related factors. Literature more broadly concerning the impact of these factors on human cognitive performance was also selectively examined.
Results
No studies specifically related to the effects of biological factors on the performance of psychotherapy were found in PubMed. However, several articles indicated that various biological factors, including homeostatic depletion, chronobiological influences, and illness-related issues and their treatment can influence the cognitive performance of various populations. Consideration was given to how these factors might also have an impact on clinicians’ performance in the conduct of psychotherapy.
Cognitive Functions
Research in the area of cognitive functioning has considered differing aspects of cognitive performance, which in one scholarly review (8), were separated into attention, memory, and executive functioning. These categories, in turn, can be subdivided, both conceptually and on the basis of experimental methods and scales designed to measure each component separately. Accordingly, studies of attention have addressed alertness and arousal, selective attention flexibility, divided attention, sustained attention or vigilance, and sleepiness and fatigue. Studies of memory have addressed working memory, episodic memory, semantic memory, procedural memory, and the perceptual representation system. Studies of executive functioning (8) have addressed inhibition, set shifting, rule deduction and categorization, and planning. Although laboratory studies (9) have operationally defined, measured, and attempted to unpack the influence of each of these variables, in our daily experience the variables closely intertwine with one another to produce varying levels of competent or sluggish cognitive functioning.
Biological Factors
A range of biological factors work in concert to augment or diminish the quality of clinicians’ cognitive performance during psychotherapy. These include factors that can be grouped as homeostatic (depletion models), chronobiological (circadian and episodic ultradian models), and illnesses and their treatments.
Homeostatic factors.
Homeostatic factors are best represented by sleep deprivation and hunger. First, chronic sleep deprivation caused by personal habits of poor sleep hygiene and undersleeping, disturbed sleep (e.g., insomnias, sleep interruptions because of exogenous factors ranging from baby care to urinary frequency), shift work (e.g., nighttime calls interrupting sleep), or other causes of insomnia can all contribute to progressive sleep deficits. These deficits increase the need for sleep, which is more likely to occur in settings of low sensory stimulation, such as dimly lit offices and during soft-toned conversations. Discrepancies between individual preferences for sleep-wake periods and work demands have been called “social jetlag” (10), as occurs in individuals who chronically go to sleep late during the work week and attempt to compensate for their sleep deficits on the weekends. Notably, in a study of health care workers performing shift work (11), those who recognized they were fatigued and whose cognitive testing showed objective decrements did not view their performance as any worse than before. For caffeine-dependent individuals, caffeine deficiency may contribute to daytime sluggishness (12). Furthermore, hunger, especially glucose deprivation, may contribute to diminished cognitive performance. Intense cognitive work is glucose dependent, and several studies (13, 14) have suggested that cognitive sharpness is likely to fall in direct relation to cognitive effort expended and time since the last meal or snack. At the same time, daytime sleepiness, especially in the early afternoon, can follow large meals (15). Suggested mechanisms of this effect, which remain speculative, are based on observations that high fat intake elevates blood cholecystokinin levels, which increase lassitude, and that foods and drinks with high glycemic indices also promote sleepiness (15).
Chronobiological factors.
Chronobiological factors include circadian and episodic ultradian rhythms. Circadian (approximately 24-hour rhythms) occur in numerous physiological functions, including a range of hormonal and cellular rhythms, such as body temperature and alertness. Notably, better and worse cognitive performance has been shown to generally correspond to higher and lower core body temperatures, respectively, although the relationship is complex (16, 17).
Episodic ultradian rhythms, which ordinarily last 90–120 minutes but can take place over up to 6 hours, are readily observed on electroencephalographic measures (18). These include the classic 90- to 120-minute basic rest-activity cycles (BRACs) initially described decades ago by Kleitman (19). Daytime BRACs appear to be continuations of the rapid eye movement cycle periodicity during sleep, occurring at roughly 90-minute intervals. Daytime ultradian cycles occurring roughly every 90–120 minutes have been described as influencing daytime vigilance (20) and waking fantasies (21). Dopaminergic networks are thought to mediate ultradian oscillators, and it has been suggested that these rhythms play a role in optimizing and restoring energy throughout the day (22). Several ultradian oscillators may operate concomitantly (23). For example, evidence shows that verbal and spatial performance are affected by 90-minute daytime cycles that are approximately 180 out of phase with one another, suggesting that ultradian rhythms can affect cognitive style and that separate ultradian oscillators may be operating in each cerebral hemisphere (24).
Fluctuations in performance of two or more individuals working together, as in psychotherapy, are also influenced by interindividual differences in chronotype, reflecting circadian preference, and by the synchronicity between individuals’ peak periods of arousal and the time of the day at which optimum performance is required. Accordingly, some individuals are at their peak during early mornings (“larks”) and prefer early bedtimes, others are sluggish in the morning but wake up during evening hours and prefer late bedtimes (“owls”), and many other individuals are somewhere in the middle (25, 26).
Whereas roughly 50% of the variance in chronotype preference appears to be genetic (27), these patterns are also influenced by environmental forces (e.g., work and school schedules) and may shift with age. Early morning preference occurs more commonly among elderly populations (up to 75%), whereas early morning preference occurs among only 7% of younger individuals (28). Furthermore, over the course of the day, cognitive performance deteriorates among elderly persons but often improves among young adults (29).
Overall, these time-of-day modulations affect performance on a wide range of cognitive tasks measuring attentional capacities, executive functioning, and memory (8, 9). These performance fluctuations are also contingent on the chronotype, which reflects interindividual differences in circadian preference, and particularly depend on the synchronicity between individuals’ peak periods of circadian arousal and the time of the day at which testing occurs. When juxtaposed, the effects of homeostatic and chronobiological factors are sometimes counterbalanced but at times their effects may be superimposed. For example, a confluence of circadian and episodic ultradian troughs in conjunction with homeostatic depletion can assure periods of low mental alertness and cognitive sluggishness.
Illnesses and their Treatments.
Illnesses and their treatments that affect clinicians and potentially impair their cognitive sharpness are plentiful. These include numerous chronic medical illnesses contributing to fatigue (30) or pain (31); depression; early neurocognitive decline; excessive alcohol or substance use; and adverse cognitive effects of medications, such as analgesics, muscle relaxants, psychotropics, anticholinergics, steroids and other hormones, and immune suppressors. Decreased visual and auditory acuity can also contribute to problems in attending and ascertaining shifts during psychotherapy sessions.
Discussion and Conclusions
Implications for the Conduct of Psychotherapy
Although biological factors influencing clinician performance, including the homeostatic, chronobiological, and illness-related factors discussed above, are of great concern to health care clinician performance in general, they have not previously been considered specifically with respect to the performance of psychotherapy. Are sleepy psychotherapists sloppy psychotherapists? Do patients get their psychotherapists’ best efforts? Are all a clinician’s psychotherapy hours worth the same amount? Should clinicians attempt to conduct psychotherapy after a sleepless night of being on call? Although no specific studies address these questions, the types of cognitive functions enumerated earlier in this article offer reasonable entry points to consider how diminished cognitive functioning may adversely affect psychotherapy.
Impairments affecting attention (e.g., alertness, selective attention flexibility, and divided attention) may decrease the chances that psychotherapists hear or see something important being communicated (or omitted) verbally or nonverbally. Inattentive psychotherapists may miss important but subtle shifts in topic or emphasis and are less likely to be attuned to patients.
Impairments affecting memory, including working memory, episodic memory, semantic memory, procedural memory, and the perceptual representation system, may decrease psychotherapists’ recall of important aspects of patients’ histories that are necessary to fully understand patients’ current issues. Important connections might more easily slip their minds.
Impairments in executive functioning affecting inhibition, set shifting, rule deduction and categorization, and planning may decrease psychotherapists’ fidelity to treatment models. Psychotherapists with subtly diminished executive functioning may show increased impulsivity in thought, disinhibition in speech, and greater reliance on fast-thinking heuristic shortcuts, including cognitive biases, rather than on deliberate, slow thoughtfulness. This view is consistent with data suggesting that prefrontal cortical executive functions inhibit and evaluate incorrect hunches and intuitions, all of which commonly occur among clinicians and may adversely affect psychotherapy.
Although a full discussion is beyond the scope of this article, psychotherapists’ mood states, which are likely to have an impact on the conduct of psychotherapy, are also affected by biological factors, including chronobiological factors. States of happiness, sadness, motivation, irritability, anxiety, and pessimism have been described as shifting in circadian patterns and linked to circadian rhythms (32–34). Concurrently, irritability and other mood states are clearly affected by hunger, sleepiness, pain, sensitivity to sounds, and other physiological stimuli (35). In addition, biological contributions to psychotherapist temperament (36) and attachment style (37) also have an impact on countertransference reactions.
Additional considerations stem from the fact that patients, as well as psychotherapists, are subject to these factors and that their respective biologies interact. How homeostatic, chronobiologic, and illness-associated factors of psychotherapists and patients align and misalign to influence how psychotherapies are processed is unstudied. Consider how psychotherapists who are bright and eager early in the morning might work with patients who are mentally sluggish—“still asleep”—at those times. Compare these psychotherapy sessions to those in which psychotherapists who are sluggish in the midafternoon might work with patients who are by then fully present and expectant. How might these factors affect alliance and attunement? Studies of functional near-infrared spectroscopy-based hyperscanning using paired fitted skull caps have already demonstrated how teachers and students, basketball players, and other dyads and small groups synchronize neurally around mutual tasks (38–40). Similar approaches might be applied to psychotherapy studies as well.
Mitigating Strategies
Several approaches are available to mitigate the above biological factors that may contribute to impeded performance by clinicians. Most obvious is reflection on the part of clinicians to honestly self-assess patterns of shifting alertness during their scheduled psychotherapy hours. Such appraisals require examination of one’s own health, including illnesses and treatments; eating, sleeping, and substance use patterns; personal biorhythms; self-care; and health habits. When in doubt, simple self-assessment tools, such as the Epworth Sleepiness Scale for daytime sleepiness (41–43), may reveal otherwise unrecognized difficulties, especially if conducted at multiple times throughout the day. Web-based apps integrated into smartphones and smartwatches are available (44). When problems are identified, clinicians should engage in self-care, obtain supervision to examine how their own psychological contributions interact with biological ones, and seek professional consultation for their own health issues as indicated.
Regarding self-care, psychotherapists may become more aware of the need to keep physically and psychologically fit. They may be able to identify certain hours during the day that should not be scheduled for psychotherapy (or for other demanding work, for that matter), because they are unlikely to be mentally sharp at those times. No doubt, clinicians themselves would not want to be seen by a psychotherapist who felt mentally sluggish, nor would they be willing to accept services provided by mentally sluggish surgeons or other physicians. In addition to attending to their own health needs, psychotherapists may want to respect their personal biorhythms by scheduling brief nap times or “siesta hours” for refreshment (45), assuring availability of snacks for when they are prone to hunger or blood sugar nadirs, taking walks outside the building to recharge, or engaging in other activities that restore mental energy (46).
Finally, to foster clinician well-being and better patient care, health care systems should consider how they might attend to individual clinician’s variable alertness and fatigue rhythms and accommodate schedules accordingly. Some difficulties might be identified via patient satisfaction surveys and patient or peer complaints, by comparing practice patterns across individuals and time of day in electronic records, or via innovative quality improvement initiatives that use self-report (47), smartwatches, and other forms of monitoring (43, 44, 48). Institutions scrutinizing potential performance problems must assure that clinicians are treated with respect and dignity (49). Everyone benefits when clinicians work when they are fresh and refreshed and avoid direct patient care when they are likely to be sluggish.
Implications for Research
These considerations raise numerous questions for further study. To what extent can differences in the quality of psychotherapy (fidelity, patient satisfaction, therapeutic alliance, and outcomes) be associated with clinicians’ cognitive functioning? To what extent can differences in clinicians’ cognitive functioning be linked to the various biological factors enumerated above? What are the best approaches for studying these relationships and teasing apart specific contributing factors? How can individual clinicians and health care systems optimally assure clinician well-being and mitigate possible adverse effects of these factors on psychotherapy outcomes?
Whereas the questions raised in this article invite systematic investigation, numerous anecdotal observations already suggest that biological effects can detract from the quality of psychotherapy. They also suggest that clinicians and health care systems should do what they can to mitigate modifiable adverse influences.
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Information & Authors
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History
Received: 3 July 2020
Revision received: 8 August 2020
Revision received: 12 September 2020
Accepted: 5 October 2020
Published in print: March 01, 2021
Published online: 15 March 2021
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The author reports no financial relationships with commercial interests.
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