Laska, K. M., Smith, T. L., Wislocki, A. P., Minami, T., & Wampold, B. E. (2013). Uniformity of evidence-based treatments in practice? Therapist effects in the delivery of cognitive processing therapy for PTSD. Journal of Counseling Psychology, 60(1), 31-41.
Some therapists are more effective than others. Why, and how can we improve therapist effectiveness? Previous researchers estimates that differences among therapists account for 8% of the outcome variance, which is as big or a bigger effect than differences between treatment types. Some argue that training and supervising therapists in evidence-based treatments (EBTs) can reduce differences between therapists. But if training in EBTs does not reduce differences, what are the therapist factors we should be focusing on to improve outcomes? A study by Laska and colleagues (2013) addresses some of these issues. In their study, 25 therapists (psychologists and social workers) in Veterans Administration (VA) hospitals were trained by a nationally recognized trainer in cognitive processing therapy (CPT) for post traumatic stress disorder (PTSD), and they treated 192 veterans. Therapists were trained to a standard level of competence in CPT, and they were supervised weekly by a certified expert in CPT. Differences between therapists’ effectiveness accounted for 12% of the outcome variance. In other words training and supervision in CPT did not appear to reduce differences between therapists, so that some therapists remained significantly more (or less) effective than others. The CPT expert supervisor was able to identify the more effective therapists even though she was blind to patient outcomes. She was also asked to list the qualities of these more successful therapists. Four areas emerged from the qualitative analysis of the supervisor interviews. (1) Reducing Avoidance – i.e., therapists’ ability to skilfully address patient avoidance of difficult areas or avoidance of therapy assignments, and not to collude with client avoidance; (2) Language in Supervision – i.e., therapists’ willingness to discuss struggles with cases, openness to discussing their contribution to impasses, and non-defensiveness in response to supervisor feedback; (3) Flexible Interpersonal Style – i.e., therapists’ ability both to join with and to challenge patients, to flexibly apply the manual so that they did not miss important interpersonal events in the therapy, but at the same time not to stray too far from the manual; and (4) Strong Therapeutic Alliance –i.e., therapists’ genuineness with patients, ability to develop a bond, and to agree with patients on tasks and goals of therapy.
Creating a culture within a practice setting in which therapists are routinely provided feedback about their clients’ ongoing progress and about the therapeutic relationship has the potential to improve patient care. Therapists’ ability to handle interpersonally challenging encounters with patients is what distinguishes the most competent therapists from others. Training and supervision of therapists should focus on facilitative interpersonal skills as well as on the specific treatment protocol.
Author email: Kevin.Laska2@va.gov