Nissen-Lie, H.A., Heinonen, E., & Delgadillo, J. (2023). Therapist factors. In S. D. Miller, D. Chow, S. Malins, and M. A. Hubble (Eds.) The Field Guide to Better Results: Evidence-Based Exercises to Improve Therapeutic Effectiveness. American Psychological Association. https://doi.org/10.1037/0000358-005.
The thing about therapists that people in the profession do not like to talk about is that some therapists are more effective than others. Meta-analyses indicate that about 5% of patient outcome variance can be explained by differences between therapists. Although this seems small, it accounts for about one-third of the total difference in outcomes among patients. One study found that patient recovery rates for the most effective therapists were twice that achieved by their least effective counterparts. In another study, 15% more patients recovered when they saw an “average” therapist compared to one of the least effective clinicians. One key problem is that therapists consistently over-estimate their own effectiveness, and consistently under-estimate the percentage of their patients who get worse. This makes it difficult for therapists to correct course when necessary or to engage in targeted professional and personal development. In this chapter, Niessen-Lie and colleagues review the research that identifies key therapist qualities that are related to better patient outcomes. It turns out that demographics of the therapist (sex, gender, ethnicity, age), experience level, profession, and education level are all unrelated to patient outcomes. In fact, there is some evidence that more experienced older therapists have slightly poorer outcomes than their younger counterparts. However, some therapist factors are important and known to be related to patient outcomes. For example, therapists who are consistently effective across different types of patients, patient severity, and diagnoses have the best outcomes. Another key therapist factor or attribute is interpersonal skill. This includes therapist empathy, warmth, the capacity to express emotions verbally, the ability to develop a therapeutic alliance with a variety of patients, and the capacity to tolerate and manage strong negative emotions in therapy. A third therapist factor is flexibility. Therapists who can be flexible in using therapeutic techniques within a given treatment tend to have patients with better outcomes. Finally, therapists who can maintain an attitude of humility tend to have better outcomes. Humility refers to an openness to other’s points of view, accepting that there is room for growth, and for pushing beyond one’s current skill level while taking care of oneself. Without this attitude, there is little motivation for continued learning, personal growth, and professional development.
A therapist’s experience level, profession, experience, and other demographics have no bearing on their patients’ outcomes. However, we do know that being effective with a range of patients, interpersonal skills (empathy, verbal expression of emotions, and ability to tolerate strong emotions), flexibility in applying therapeutic interventions, and professional humility are related to patient outcomes. These therapist skills can be developed and improved during one’s career. Improving these skills require a therapist to be willing to examining when things do not go well in therapy (reviewing when patient outcomes are poor or a patient drops out), to reflect on one’s abilities, and to look for disconfirming evidence by asking “could I be wrong?” First, however, therapists must identify when therapy with a patient was ineffective. And for this, they may need the help of standardized assessments to monitor the state of the therapeutic relationship and patient progress.