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Wampold, B. & Owen, J. (2021). Therapist effects: History, methods, magnitude, and characteristics of effective therapists. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7^th ed.). Wiley. Chapter 9.

Is therapist interpersonal skill a therapeutic “competence”? Past research on this important topic has been hampered by a couple of methodological challenges. First, asking therapists to self-report on their own social skills and empathy may result in a self-serving bias and is not related to patient outcomes. A second challenge is that therapists’ competence may be influenced by patient characteristics. For example, a therapist seeing an angry patient with low motivation to change might appear less competent than the same therapist seeing an agreeable patient who is highly motivated. Until recently these issues have limited the research on therapist characteristics that indicate therapeutic competence. In this part of the chapter, Wampold and Owen review some of the research that overcomes this limitation. Some researchers conducted a series of studies in which therapists watched videos of standardized patients with different characteristics, and the therapists’ responses to the videos were recorded. In this way, all therapists “saw” the same patients. Therapists’ responses to the videos were coded for facilitative interpersonal skills; that is, for therapist verbal fluency, hope, emotional expression, warmth, empathy, and alliance capacity. In one study, therapist facilitative interpersonal skills assessed with these standardized patient videos predicted outcomes of real patients seen by the therapists in their practices. In another study, student therapists completed the therapist facilitative interpersonal skills assessment at the very beginning of their training. These facilitative skills predicted outcomes obtained when the trainees began seeing patients later in their training. In an interpersonally challenging situation, like some therapeutic encounters where affect is strong, the interpersonal skills of therapists were robust predictors of patient outcome.

Practice Implications

The research showing that therapist interpersonal skills predict patient outcomes is beginning to redefine what it means to be a competent therapist. Research reviewed elsewhere in this blog indicated that adhering to a treatment manual or protocol is not related to patient outcomes. Instead, therapists’ capacity to use verbal skills to express emotions, to be empathic, to develop a therapeutic alliance with a variety of patients, and to repair therapeutic alliance ruptures appear to be much more reliable predictors of patient outcomes. Training programs and professional development should focus on these important skills.

Wampold, B. & Owen, J. (2021). Therapist effects: History, methods, magnitude, and characteristics of effective therapists. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7^th ed.). Wiley. Chapter 9.

The early days of psychotherapy research treated psychotherapists in a clinical trial as largely interchangeable. That is, it was assumed that therapists were more alike than different and so their impact to patient outcomes were ignored. Some of this was thought to be achieved by training therapists to be highly adherent to a treatment protocol. The thinking was that if every therapist followed the manual faithfully, then any differences among therapists would disappear. Never mind that research indicates that therapist adherence to or competence in delivering a manualized treatment is largely unrelated to patient outcomes. In this part of the chapter, Wampold and Owen examine the question of “does the therapist matter to the patient’s outcomes.” In other words, are there differences between therapists when it comes to patient outcomes? It turns out that between 3% and 15% of patient outcomes in highly controlled randomized trials is attributable to differences between therapists. This might seem like a small percentage, but it is larger than outcomes associated with differences between treatment orientations or the effects of specific interventions. And these are highly controlled trials partly designed to reduce therapist differences. In everyday clinical practice in which there is less control over therapists, the lowest estimate of therapist effects is about 6% but could be as high as 12%. The effect of the therapist is probably higher for more severely symptomatic patients.

Practice Implications

Which therapist a patient sees matters, and this is particularly true for patients who have more severe symptoms. That is more severe patients may do much worse or much better in therapy depending on which therapist they see. A therapist’s capacity to follow a treatment manual does not predict patient outcomes, but other factors like interpersonal skills, openness to lifelong learning, and getting reliable feedback about patient outcomes may be those skills and practices that matter to patient outcomes.

Constantino, M.J., Boswell, J.F., & Coyne, A.E. (2021). Patient, therapist, and relational factors. In Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7^th ed.). Wiley. Chapter 7.

Interpersonal behaviors can be characterized by the level of affiliation (i.e., friendliness vs hostility) and of interdependence (i.e., dominance vs submissiveness). Interpersonal complementarity refers to two people in an interaction whose behaviors are matched on affiliation (friendliness evokes friendliness in the other) and reciprocity in terms of interdependence (dominance evokes submission or submission evokes dominance in the other). So friendly-dominant behaviors in one person tends to evoke friendly-submissive behavior in another and vice versa, and similarly, hostile-dominant behaviors in one person tend to evoke hostile-submission in the other and vice versa. Complementary interactions are comfortable and do not cause anxiety, they reinforce the interactional styles of the participants, and they tend to continue unchanged. Non-complementary interactions do cause anxiety, and they either change or they terminate. In this part of the chapter, Constantino and colleagues review the research on the role of complementarity between therapists and patients. Therapists on average tend to behave in a friendly-dominant style and many but not all patients tend to respond in a friendly-submissive style. The most interesting findings of this line of research is that the number of complementarity interactions between therapists and patients tend to change across stages of successful therapy. In early sessions, patient-therapist interactions tend to be highly complementary. Interactions in the middle of therapy tend to be lower in complementarity. And at the end of therapy, patients and therapists tend to return to higher levels of complementarity. Hostile therapist interactions are rare, and when they occur it is almost exclusively in unsuccessful therapy cases.

Practice Implications

This research has a lot to say about how therapists should respond to patients’ interpersonal behaviors and styles. Therapists should always remain affiliative or friendly (or at least neutral) and avoid hostile interactions with patients. The research indicates even a small number of hostile responses from therapists may lead to negative outcomes or dropping out. The research seems to indicate that (a) higher therapist-patient interpersonal complementarity early in therapy is related to establishing rapport and a therapeutic alliance, (b) lower complementarity in the mid stage of therapy might indicate that therapists are engaging patients differently in order to help change patient patterns of interpersonal relating, and (c) a return to higher complementarity at the end of therapy may indicate therapists reinforcing changes and patients experiencing a new sense of self within the therapeutic relationship.

Curran, J., Parry, G.D., Hardy, G.E., Darling, J., Mason, A-M., Chambers, E. (2019). How Does therapy harm? A model of adverse process using task analysis in the meta-synthesis of service users’ experience. Frontiers in Psychology, 10:347. doi: 10.3389/fpsyg.2019.00347

Forty to 60% of patients do not recover after a course of psychotherapy, and approximately 5% to 8.2% are worse off. In the National Health Service in the UK, 5% of patients reported lasting bad effects of therapy. Although these appear to be small percentages, they represent a large number of patients. In Canada for example, over 1 million Canadians use psychotherapy each year, so 5% would represent 50,000 individuals. Therapists, for their part are poor at identifying patients who deteriorate in therapy. In this meta-synthesis of qualitative research, Curren and colleagues aimed to derive a model based on patients’ experiences of the factors that lead to negative outcomes. They conducted a narrative review of qualitative research findings and of patients’ testimony from a number of sources. They noted eight domains identified by patients that are associated with adverse events in psychotherapy. First, contextual factors refer organizational issues that affect access to or choice of therapy, cultural validity of the therapy, and lack of information about services. Second, pre-therapy factors refer to poor pre-therapy contracting between therapist and patient, and therapists that focus on symptoms rather than the client as a person. Third, therapist factors refer to therapist inflexibility, and therapists’ financial interests that influence their decisions about therapy. Fourth, client factors refer to client lack of understanding of therapy, fear, and demoralization. Fifth, relationship factors refer to a poor relational fit between therapist and patient, therapists perceived as shaming, therapists misusing power, and clients not feeling heard or understood. Sixth, therapist behaviors refer to boundary violations, rigidly applying techniques, therapist acting out, and therapist passivity. Seventh, therapy process refers to the type of therapy offered not matching patient needs, and patients not agreeing with the techniques. Eighth, endings refer to short term therapies that “open a can of worms” without resolution, and the client feeling abandoned.

Practice Implications

Therapists would do well to ensure that the patient’s voice is heard when it comes to preferences and cultural validity of the treatment. In particular, therapists should not rigidly apply techniques focused exclusively on symptom reduction. Instead, therapists should see patients’ problems within their interpersonal and cultural context and focus on outcomes related to the quality of life of patients. Therapists must attend to developing and maintaining the therapeutic alliance (agreement on tasks and goals of the therapy, and the relational bond with patients). Any signs of disruptions or tensions in the alliance should be identified and repaired. Patients require information about the therapy, what it entails, and how it will end before signing on to a course of treatment. Organizations must remove barriers to accessing treatment and provide therapies that represent a range of orientations and foci to meet patients’ needs.

Timuluk, L. & Keogh, D. (2017). The client’s perspective on (experiences of) psychotherapy: A practice-friendly review. Journal of Clinical Psychology, 73, 1556-1567.

Psychotherapy studies that ask clients for their perspective on the treatment or therapist are surprisingly rare. Researchers have conducted such studies over many decades, but there exist very few of them. This is curious given that respecting clients’ preferences for types of therapy or for therapists’ behaviors is predictive of good mental health outcomes. Giving voice to clients’ perspectives is consistent with the notion that psychotherapy is a co-constructed endeavour rather than something that a therapist does to a client (as is the case for a medical intervention). In this review, Timuluk and Keogh review the research in which patients were interviewed for their perspective on a wide range of aspects of psychotherapy. The research indicates a number of things that clients value, that help, and that hinder their progress in therapy. Clients value a number of therapist traits like friendliness, warmth, respect, offering appropriate guidance, and understanding. This research showed that clients recognize that the relationship (i.e., the alliance) has therapeutic effects. Clients report that many forms of therapist behaviors help to develop a therapeutic alliance including eye contact, smiling, warm personalized greetings, paraphrasing, identifying client feelings, and referring to material from previous sessions. Clients find some events in therapy to be unhelpful or that hinder their progress, like feeling exposed and unprotected, being emotionally overwhelmed, and feeling misunderstood by the therapist.

Practice Implications

Although clients do value therapist expertise in applying therapeutic techniques, they hold therapist personal qualities like warmth, authenticity, honesty, and dedication as necessary prerequisites for therapy. Clients view the therapist’s interpersonal manner as key to forming a therapeutic relationship. It is important that therapists are aware of how they feel towards a client (countertransference), and how these feelings might impact the way in which they communicate through body language, tone of voice, and behaviors. Effective therapists are willing to seek their client’s perspectives, and are open and non-defensive about what a client has to say about the therapy or therapist, even if negative. Therapist openness to feedback will inevitably lead to a stronger relationship and collaboration with the client, and to better outcomes for the client.

Norcross, J. C., & Wampold, B. E. (2019). Relationships and responsiveness in the psychological treatment of trauma: The tragedy of the APA Clinical Practice Guideline. Psychotherapy, 56(3), 391-399.

The American Psychological Association’s (APA) Clinical Practice Guideline for Posttraumatic Stress Disorder in Adults published in 2017 was met with a great deal of concern and criticism by the community of scholars and practitioners working with patients with PTSD. A key concern was that the APA used a biomedical model and not a psychological or contextual model in guiding their understanding of PTSD, their approach to what constitutes evidence, and to decisions about recommended treatments. In particular, the biomedical approach focuses almost exclusively on treatment methods, and down-plays the context of treatment (i.e., the relationship, patient factors, and therapist responsiveness). In this critique, Norcross and Wampold highlight the flaws in the APA Clinical Practice Guideline for PTSD, and the authors focus specifically on those variables that are known to predict patient outcomes but that were ignored by the Guideline. Norcross and Wampold highlighted that there exists numerous meta analyses that demonstrate that all bona fide psychotherapies work about equally well for trauma, and that the particular treatment method has little impact on PTSD outcomes. Yet, the restrictive review process undertaken by APA all but ignored this well-established finding. Also ignored was the research on the importance of the therapeutic relationship in the treatment of trauma. One review outlined nineteen studies that found that the therapeutic alliance was associated with or predicted reduction in PTSD symptoms. This is consistent with the general psychotherapy research literature, in which the alliance is the most researched and most reliable factor related to patient outcomes. Also missing from the PTSD Guideline was reference to a large body of research on therapist responsiveness to patient characteristics. Patients are more likely to improve if their therapists can adapt to the patient’s coping style, culture, preferences, level of resistance, and stage of change. In one study of cognitive-processing therapy (CPT; a treatment recommended by the APA Guideline), there were substantial differences between therapists in their patient’s PTSD symptom outcomes. That is, some therapists reliably were more effective than others, even though all therapists were trained in and supervised in providing the same manualized evidence-based treatment. Among the identified skills of the most effective CPT therapists were: a flexible interpersonal style, and an ability to develop and maintain a good therapeutic alliance across patients.

Practice Implications

There is growing consensus that the APA Clinical Practice Guideline for PTSD are based on dubious methodology and are of limited use to therapists and their patients with PTSD. Psychotherapists should practice a bona-fide therapy for PTSD, but should do so by taking into account the treatment context. In other words, more effective therapists are good at developing, maintaining, and repairing the therapeutic alliance across a range of patients. Effective therapists can also respond and adapt to patient characteristics such as level of resistance, coping style, culture, and stage of change. And so, even when providing a treatment based on the APA Guideline, therapists should nurture trust in the therapeutic relationship and be adaptive to their patients’ characteristics.