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Barkham, M., Lutz, W., Lambert, M., & Saxon, D. (2017). Therapist effects, effective therapists, and the law of variability. In L.G. Castonguay and C.E. Hill (Eds.) How and why are some therapists better than others? Understanding therapist effects. Washington, DC: American Psychological Association.

Psychotherapy research has often focused on the differences between treatment types (CBT, interpersonal psychotherapy, psychodynamic therapy), which has overshadowed research on what makes for an effective therapist. Psychotherapists represent the most costly important component of psychotherapy, and only recently has research begun to catch up to the importance of therapist effects. The term “therapist effects” refers to differences between therapists (i.e., variability) in their clients’ outcomes. In this chapter, Barkham and colleagues review some of the research on effective therapists. Best estimates of therapist effects suggest that differences between therapists account for about 8% of client outcomes – which is considered a medium effect and larger than the variance accounted for by the type of therapy that a client receives. Psychotherapy research often tries to control for therapist effects by training therapists to adhere to a manual, however adherence to a manual does not substantially reduce therapist effects, and adherence is not related to patient outcomes. The implication is that which therapist a client sees matters to the client’s mental health outcomes. The best research on the topic indicates that about 20% of therapists are substantially better than the average therapist, and 20% are substantially worse than the average. (The good news is that 60% of therapists [the average] are equally and positively effective). In that study of 119 therapists, the least effective therapists had about 40% of their clients recover, whereas the most effective therapists had about 76% of their clients recover. In other words, the better therapists were almost twice as effective as the worse therapists. In a re-examination of previous data, Barkham and colleagues looked at whether other variables, like client symptom severity, played a role in therapist effects. They found that differences among therapists was higher as client baseline severity increased. That is, the gap between better and worse therapists increased when client symptoms were more severe and complex. Good therapists were better equipped to handle more complex cases.

Practice Implications

There are important differences between therapists in their effectiveness, and this makes a difference to clients. It is particularly important for clients with more severe symptoms to be matched with more effective therapists. Previous research indicates that the level of therapist interpersonal skills (alliance, empathy, warmth, emotional expression, verbal skills) can account for significant proportion of therapist effects, and so training therapists in these interpersonal skills will improve client outcomes. Also, therapists who receive continuous reliable feedback throughout therapy about their client’s symptom levels can also drastically reduce client drop-outs and the number of clients who get worse during treatment.

Pomerville, A., Burrage, R.L., & Gone, J.P. (2016). Empirical findings from psychotherapy research with indigenous populations: A systematic review. Journal of Consulting and Clinical Psychology, 84, 1023-1038.

Indigenous people around the world have a higher incidence of mental illness compared to other ethnic or racial groups. These higher rates may be related to the historical effects of colonization and to current discrimination. Despite this, there is very little empirical research on psychotherapy provided to Indigenous peoples. Psychotherapy, as commonly practiced, has Eurocentric values by emphasizing individuality, independence, rationality, assertiveness, and by sometimes taking an ahistorical present-centered focus. These values may conflict with some Indigenous cultures that emphasize community, interdependence, mysticism, modesty, and the historical context of current functioning. Hence, psychotherapy as typically defined may require adaptations when used with Indigenous groups. In their review, Pomerville and colleagues examine what is currently known about psychotherapy with Indigenous populations. The populations studied in the existing research includes Indigenous peoples of the US, Australia, Canada, Pacific Islands, and New Zealand. There were no psychotherapy studies prior to 1986, and only 23 studies since then. Most studies emphasized some form of cultural adaptation of the treatment. The majority of studies focused on substance abuse, with only a few on anxiety and depression. Only two studies were controlled outcomes studies (i.e., randomized controlled trials considered by many to provide the best evidence from a single study). Research on individual therapy for Indigenous adolescents is completely lacking. The authors concluded that the efficacy of novel or adapted treatments or the generalizability of existing empirically supported treatments to Indigenous people are currently unknown.

Practice Implications

The virtual absence of controlled outcome trials of psychotherapies for Indigenous populations is serious gap in the practice of mental health interventions. This state of the research is particularly problematic given the high rates of mental illness and alarming rates of suicide among adolescents in Indigenous populations. Some studies found discontent among Indigenous communities with the current application of empirically supported treatments, and others argue that Indigenous healing be given the same legitimacy despite no controlled outcome research. On the other hand some authors favour training cultural competence among clinicians who practice standard empirically supported treatments. Pomerville and colleagues suggest that in the absence of evidence, tailoring psychotherapy to address the needs of Indigenous clients by taking into account specific practices of their communities may improve retention and outcomes.

Fried, E.I. (2016). The 52 symptoms of major depression: Lack of content overlap among seven common depression scales. Journal of Affective Disorders.

Depression is a leading cause of disability in the world and an important reason why people seek psychotherapy. Depression is also the most commonly studied disorder in psychological treatment studies. Measuring depression with self-report or clinician rating scales seems straight forward, but it turns out that it is not. This is important for clinicians because we assume that scales assess depressive symptoms in a reliable way, and that this measurement gives a valid indicator of a patient’s level of depression and improvements in the depressive symptoms. In this review Fried examined the content of the seven of the most common measures of depression including: the Beck Depression Inventory (BDI), the Centre for Epidemiological Studies Depression Scale (CESD), and the Hamilton Rating Scale for Depression (HRDS). Many might assume depression to represent a single construct – meaning depression is sometimes thought to represent one unitary thing that is consistent across individuals. Because of that assumption, some might consider depression scales to be interchangeable. But according to Fried, these seven scales listed a total of 52 different symptoms. Using a statistical approach called a Jaccard Index, Fried found that the overlap in symptoms among the different depression scales was low (i.e., different scales seemed to be tapping into different symptoms). When he reviewed the content of each scale, this low overlap seemed clear. For example, the BDI (developed by the founder of CBT) emphasizes cognitive symptoms of depression, the CESD has a number of items that are only indirectly related to depressive symptoms (like interpersonal sensitivity), and the HRDS (often used in medication trials to evaluate side effects) emphasizes somatic symptoms like insomnia, fatigue, and sexual dysfunction. Perhaps this lack of overlap is not so surprising given that the concept of depression is likely multidimensional and not representative of a single uniform construct.

Practice Implications

So what does this mean for clinical practice? Many clinicians use a depression scale to assess their patients and monitor their outcomes. Which scale one uses seems to make a difference in terms of what is being measured and what outcomes are monitored. Using the BDI will emphasize the cognitive aspects of depression, whereas ratings with the HRDS may emphasize the somatic aspects of depression. Fried recommends that researchers use more than one scale, and if the findings differ across scales, then that provides more nuanced information about the effects and outcomes of depression and its treatment. Perhaps the same can be said for clinical practice – if clinicians use only one depression scale, then they should be aware of what aspects of depression or what kind of information about their patent’s depression that the scale is providing.

Wampold, B.E. & Imel, Z.E. (2015). The great psychotherapy debate (2^nd ed.). New York: Routledge.

The Great Psychotherapy Debate: Starting in April, 2015 I review parts of The Great Psychotherapy Debate (Wampold & Imel, 2015) in the PPRNet Blog. This is the second edition of a landmark, and sometimes controversial, book that surveys the evidence for what makes psychotherapy work. You can view parts of the book in Google Books

In the concluding chapter of their book, Wampold and Imel discuss the evidence and strategies that therapists can use to improve patient outcomes. As indicated in previous PPRNet Blogs, Wampold and Imel concluded that the differences between specific treatment approaches is small. In other words, Wampold and Imel argue that there is no good evidence that one bona fide psychotherapy is more effective than another for most disorders. By “bona fide” treatments, they mean psychotherapy that: provides the client with a plausible theory/explanation of the disorder, delivers a structured intervention based on the plausible theory, and is offered by an effective therapist. The authors also found that contextual factors (e.g., therapeutic alliance, therapist empathy, client expectations) accounted for a sizeable proportion of patient outcomes. A key element in this understanding of effective therapy is the role of the therapist. The authors reviewed various studies and meta analyses that showed that therapists differ widely in their outcomes and in their ability to establish a therapeutic alliance. Unfortunately, therapists tend to be overly-optimistic about their clients’ outcomes. Therapists often do not have quality data on their clients’ progress, and the complexities of the therapeutic work makes it difficult for therapists to keep in mind all aspects of the therapy that is helpful or not helpful to clients. For example, some therapists may be good at establishing an alliance, but they may not be so good at providing a viable treatment structure. Other therapists may be highly empathic with clients who have moderately severe symptoms, but the same therapists may not respond as empathically with more difficult clients. Outcome or process monitoring (i.e., providing therapists with reliable information about the ongoing status of patient symptoms or about the quality of the therapeutic relationship) provides an evidence-based aid in helping therapists to improve their clients’ outcomes.

Practice Implications

Regardless of the type of psychotherapy they use, therapists are responsible for achieving good outcomes for their clients. This includes continually developing therapeutic skills over time. There is some evidence that a reflective attitude towards one’s psychotherapy practice is helpful. Unfortunately, therapists may not be continually improving or reflecting on their practice. This is indicated by research showing that trainees and interns appear to be as competent as experienced clinicians. Therapists need quality information about their clients in order to improve their own practice and clients’ outcomes. But psychotherapy practice is complex, the therapeutic relationship is multifaceted, and clients are variable in their presenting issues and life experiences. All of these make it difficult for any therapist to make accurate decisions in therapy. Progress or process monitoring (i.e., continually measuring outcomes and relationship processes with a psychometrically valid instrument), may be one way for therapists to receive high quality feedback about patient progress in order to improve their psychotherapy practice.

Boswell, J.F., Kraus, D.R., Miller, S.D., & Lambert, M.J. (2015). Implementing routine outcome monitoring in clinical practice: Benefits, challenges, and solutions. Psychotherapy Research, 25, 6-19.

Routine outcome monitoring (ROM) refers to: (1) systematically assessing patient outcomes at every session, (2) comparing patient scores and progress to a database of similar patients, (3) using algorithms or decision tools to identify patients who are not improving or deteriorating, (4) providing regular and immediate feedback to therapists about the patient, and (5) in some cases providing clinical decision aids to help therapists improve outcomes for patients who are not improving or who are deteriorating. Boswell and colleagues review the research related to ROM. Generally, about 30% to 50% of patients do not respond to treatment, and 8% of patients tend to get worse during treatment. Therapists tend to overestimate their patients’ improvement, and so therapists may not always identify patients who do not respond or get worse. Therapists may need assessment aids to help them make decisions about patient progress and treatment. Boswell and colleagues point out that ROM have a proven ability to predict treatment failure and other negative outcomes. In a meta analysis of over 6,000 patients, the patients at risk of a negative outcome whose therapist received ROM feedback prior to every session were better off than 70% of at-risk patients whose therapist received no feedback. When therapists are provided feedback and suggestions for interventions, their patients had almost four times higher odds of achieving clinically significant improvement. Boswell and colleagues list a number of barriers that psychotherapists and agencies experience to implementing ROM in their practices. Many therapists are not aware of or have no experience with ROM, and so they may not be aware of its benefits to their practice and patients. Time and money are two practical issues that may arise. This type of assessment is not always reimbursed and the average clinician may feel that they do not have enough time to reflect on routine assessment and feedback so as to reconsider their interventions. Agencies may not understand the value of allocating resources to this type of testing (although medically oriented agencies would not hesitate to order a blood test or an x-ray). Finally, some therapists might experience ROM as intrusive, as impeding the therapeutic relationship, and as a means for an agency to control therapist decisions.

Practice Implications

Routine outcome monitoring (ROM) has clear benefits to patients, therapists, and agencies. To overcome barriers, therapists and agencies could implement ROM as part of routine clinical care, and advertise this as an evidence-based practice that will benefit prospective patients. Clients generally appreciate knowing that they will receive the best possible care. ROM can enhance the therapeutic relationship if it is presented to clients as a collaborative endeavor. For example, if a patient is not improving or is deteriorating, therapists can discuss this with patients as well as a plan to alter aspects of the treatment in order to improve the prospects for a better outcome. Therapists can choose from a number of possible ROM options to best tailor the approach to their clients based on cost, time, and relevance. Currently, there are several outcome monitoring systems available to clinicians including: the Partners for Change Outcome Management System (PCOMS), the Treatment Outcome Package (TOPS), the Clinical Outcomes in Routine Evaluation (CORE), and the Outcome Questionnaire (OQ) system.

Laska, K. M., Gurman, A. S., & Wampold, B. E. (2014). Expanding the lens of evidence-based practice in psychotherapy: A common factors perspective. Psychotherapy, 51(4), 467-481.

In this wide ranging review of the Common Factors (CF) perspective in psychotherapy, Laska and colleagues tackle the complex issues of defining CF and describing the evidence. The authors argue that CF in psychotherapy are not a vague set of ideas that fit under the label of “non-specific factors” or “relationship factors”. They also state that there is an unnecessary dichotomy between the concepts of empirically supported treatments (EST) and CF. In EST, specific and brief manualized therapies for specific disorders are tested in highly controlled randomized trials. ESTs purport that efficacious psychotherapies contain specific techniques based on an articulated theory of the disorder, and a specific mechanism of change for that disorder (e.g., depression is partly caused by depressogenic beliefs and so CBT for depression specifically targets cognitive distortions). There are published lists of ESTs for many disorders. However, Laska and colleagues argue that there is little evidence of the specificity of these treatments. For example, in dismantling studies an intervention like CBT for depression is compared to a dismantled version that removes an “active ingredient” [e.g., by providing only behavioral activation as an intervention], with little difference in patient outcomes between the full and dismantled versions. Further, for a number of disorders, several therapies based on very different theories of the disorder and of change are equally effective. In contrast to the EST approach, Laska and colleagues describe the CF approach which focuses on factors that are necessary and sufficient for patient change across psychotherapies, such as: (1) an emotional bond between client and therapist, (2) a healing setting for therapy, (3) a therapist who provides a theoretically and culturally relevant explanation for emotional distress, (4) an adaptive explanation that is acceptable to clients, and (5) procedures that lead clients to do something that is positive and helpful. Nevertheless, CF does not provide therapists with a license to do whatever they want without considering the evidence of a therapy’s efficacy. Rather CF does encourage therapists to make use of specific factors found in ESTs and to practice with a purpose. In support of the importance of CF, Laska and colleagues review the evidence from a number of meta analyses that show that CF (i.e., alliance, empathy, collaboration, positive regard, genuineness, therapist effects) each account for 5% to 11.5% of patient outcomes. These are moderate effects. Specific ingredients of psychotherapies or differences between ESTs account for 0% to 1% of patient outcomes, which represent small effects.

Practice Implications

An excessive focus or reliance on empirically supported therapies (EST) may unnecessarily limit what the profession and funders consider to be evidence-based practice. A common factors (CF) approach provides scientific evidence for effective therapeutic practices that are necessary in addition to the specific treatments found in lists of ESTs. To be effective, therapists should be able to: (1) develop a therapeutic alliance and repair ruptures to the alliance, (2) provide a safe context for the therapy, (3) be able to communicate sound psychological theory for the client’s distress based on evidence, (4) suggest a course of action that is based on evidence, and (5) conduct therapy based on established theories of distress and healing. Laska and colleagues argue that systematic patient progress monitoring and ongoing monitoring of the therapeutic alliance may be an effective method of quality improvement of therapists’ outcomes. Progress monitoring may provide therapists with information about areas for continuing education to improve their patients’ outcomes.