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Pybis, J., Saxon, D., Hill, A., & Barkham, M. (2017). The comparative effectiveness and efficiency of cognitive behaviour therapy and generic counselling in the treatment of depression: Evidence from the 2nd UK National Audit of psychological therapies. BMC Psychiatry, 17, 215. DOI 10.1186/s12888-017-1370-7

Over a decade ago the United Kingdom (UK) invested large sums of public dollars to fund the Increasing Access to Psychotherapy (IAPT) program. In IAPT, most patients receive cognitive behavioral therapy (CBT) as first-line treatment for depression or anxiety, and may receive generic counseling as second line treatment. One of the admirable aspects of IAPT is that the program consistently assesses outcomes, makes its data available for analyses, and publishes yearly reports on their outcomes. In this very large study, Pybis and colleagues assess whether CBT and generic counseling have different outcomes for patients with depression or anxiety. Over 33,000 patients who received treatment at one of 103 sites were in the study. Most patients (about 23,000) receiving CBT, and the others (about 10,000) receiving generic counseling. Two-thirds of the patients were female, most (84%) were white British, and the mean age was 41 (SD = 13.86). CBT focused on changing negative thoughts and behaviors in order to improve depressive symptoms. Generic counselling was harder to define, though the authors described these therapists as practicing in an integrative manner by bringing skills from training in different forms of psychotherapy. Generic counseling therapists did not focus on giving advice or opinions, but rather on helping clients understand themselves better. Pre- to post-treatment effect sizes for CBT (0.94 [0.92, 0.95]) and generic counseling (0.95 [0.92, 0.98]) were equivalent for depression outcomes. In CBT 50.4% of patients reliably improved, whereas 49.6% reliably improved if they received generic counseling. The average number of sessions attended by patients in the two treatments (CBT = 8.9 [6.34]; counseling = 7.5 [5.54]) were also equivalent. However, there were significant site effects. That is, a moderate and significant amount of patient outcomes (15%) could be accounted for by the site at which they received treatment (i.e., some sites or clinics had better outcomes than others).

Practice Implications

Generic counseling as provided in the IAPT in the UK was as effective as structured CBT for reducing symptoms of depression. However, almost half of patients did not improve in either treatment. Generic counseling was likely a label used to describe integrative psychotherapy that followed principles from a variety of psychotherapies that were based on psychological principles. There were much larger site/clinic effects than treatment modality effects, so that clients in some clinics had better than clients who received treatment in other clinics. This is consistent with research on therapist effects that show that some therapists are more effective than others, regardless of their orientation. This research suggests that training therapists to be more effective by improving their facilitative interpersonal skills may yield better outcomes for clients.

Cologan, J., Schweiter, R.D., & Nolte, T. (2017). Therapist reflective functioning, therapist attachment style, and therapist effectiveness. Administration Policy and Mental Health, DOI: 10.1007/s10488-017-0790-5.

Differences between therapists account for about 8% of patient outcomes, which is a moderate effect and therefore an important factor. Constructs such as therapist personality characteristics and facilitative interpersonal skills may play a key role in how effective therapists can be with their clients. An important therapist quality might be reflective functioning, or mentalization. Reflective functioning refers to the ability to conceptualize, identify, and understand mental states in oneself and in others, and how mental states affect behaviour and functioning.  For example, reflective functioning is the basis for predicting others’ behaviors, understanding social nuances and others’ intentions, and also one’s own behaviors and internal experiences. Fundamentally for a therapist, reflective functioning is necessary for empathy, which is a key therapeutic quality. Another key issue for therapists might be their own attachment security, or their characteristic ways of relating to others in interpersonal relationships. Securely attached therapists (those who have a positive view of self and others in relationships) may be able to develop a better therapeutic alliance with clients. Insecurely attached therapists (those who are avoidant in relationships or who are preoccupied in relationships), may struggle to a greater extent with developing and maintaining an alliance. In this study, Cologan and colleagues assessed reflective functioning and attachment security in 25 therapists from different theoretical orientations who treated 1001 adult clients who mostly had problems with depression or anxiety. Client outcomes were measured pre and post treatment. On average clients experienced a reduction in their symptoms after psychotherapy. Clients of therapists with higher levels of reflective functioning experienced better outcomes. Therapist attachment insecurity did not have a direct effect on client outcomes.

Practice Implications

As with other studies, therapists in this study varied in their outcomes, so that some had better outcomes than others. Level of therapist reflective functioning (ability to mentalize) accounted for a large proportion of this difference. Therapists who had greater skills with understanding their own and clients’ behaviors in terms of mental states (intentions, motivations, psychological and emotional needs, internal conflicts) likely were better able to empathize and develop an alliance with their clients. These are skills that therapists can learn with practice, consultation, personal therapy, and training.

Anderson, T., Crowley, M. E. J., Himawan, L., Holmberg, J. K., & Uhlin, B. D. (2016). Therapist facilitative interpersonal skills and training status: A randomized clinical trial on alliance and outcome. Psychotherapy Research, 26(5), 511-529.

Research on therapist effects indicates that there are differences between therapists so that some therapists are more effective than others. Therapist effects account for about 9% of client outcomes, which represents a moderate and therefore important effect. Differences between therapists do not seem to be accounted for by differing levels of adherence to or competence in delivering a manualized treatment. However, some researchers argue that therapist effects can be accounted for by differing level of facilitative interpersonal skills. That is, therapists vary in the level of interpersonal skills, and this difference accounts for a significant proportion of client outcomes. Therapist facilitative interpersonal skills might include: empathy, positive regard, warmth, ability to establish and repair therapeutic alliances, verbal fluency, emotional expression, and the ability to enhance client expectations of improvement. In this unique analogue study, Anderson and colleagues selected 23 “therapists” who were rated as very high or as very low on facilitative interpersonal skills. For example, highly skilled “therapists” scored high on a self-report measure of social skills and also demonstrated high interpersonal skills in their responses to video vignettes of therapy. Therapists also differed on their training status: half of the “therapists” were advanced clinical psychology graduate students, and the other half were graduate students from other programs (social sciences, humanities) who had no clinical training at all. The 66 clients were volunteers from a large undergraduate student research pool who met diagnostic criteria for a mental disorder (anxiety or depression) and were moderately to highly distressed. Clients were randomly assigned to receive treatment or to a wait-list control condition, so that 46 clients (2 per therapist) received treatment and 22 received no treatment. Compared to those in the control condition, clients who received treatment on average improved in terms of level of distress, regardless of which “therapist” they were assigned to. The training status of “therapists” (those with clinical training versus those without clinical training) had no effect on client outcomes or on the therapeutic alliance. Compared to “therapists” with low facilitative interpersonal skills, those with high interpersonal skills (regardless of training status) had significantly better client outcomes and significantly higher levels of the alliance.

Practice Implications

This was an analogue study in which some “therapists” were non-clinicians, so one must take the results with a grain of salt. Nevertheless, clients started out distressed, had a diagnosable disorder, and on average they achieved significant reduction in distress if they received therapy. Whether “therapists” had any clinical training did not affect outcomes, that is, non-clinical “therapists” did just as well as clinical trainees. However, higher “therapist” facilitative interpersonal skills regardless of training status lead to better client outcomes. These findings provide support for the notion that a therapist who is: empathic, warm, able to establish and repair therapeutic alliances, verbally fluent, emotionally expressive, and able to enhance client expectations of improvement will be more effective in reducing their clients’ levels of distress.

Author email: andersot@ohio.edu

Steel, C., Macdonald, J., & Schroder, T. (2017). A systematic review of the effect of therapists’ internalized models of relationships on the quality of the therapeutic relationship. Journal of Clinical Psychology. Advance online publication.

Therapists likely respond differently to different clients, due to their own personal characteristics and unconscious processes.Relational theory suggests that the therapist’s particular qualities combine with the client’s particular qualities to form a unique interpersonal context. The interpersonal context of therapy may be influenced by client and therapist internalized patterns of relating which are likely formed in early childhood. The attachment theory concept of internal working models is one way to understand therapists’ internalized patterns of relating. Internal working models are like templates that help one to predict how relationships with others work. Internal working models of self indicate the quality of one’s self-concept. In this systematic review, Steel and colleagues examined a total 22 studies and asked: do therapists’ secure attachments and positive internal working models affect the quality of the therapeutic relationship with clients? There were too few studies on the specific concepts to conduct meta analyses to aggregate effect sizes, so the authors simply reviewed the literature. Eighteen of 22 studies showed an association between therapist internalized relational models/attachment security/self concept and the therapeutic relationship. Three of four studies that looked specifically at therapist attachment found that therapist secure attachment was associated with a more positive therapeutic relationship. Among these studies, all forms of therapist attachment insecurity were associated with poorer relationship quality with clients and with lower levels of therapist empathy. Four of five studies that examined the effects of internal working models of self indicated that greater therapist negative self-concepts (i.e., self-criticism, neglecting of self, hostility towards self) was associated with a poorer therapeutic alliance with clients. 

Practice Implications

Therapist effects (i.e., the differences between therapists) are emerging as important predictors of client outcomes. It is possible that therapists’ views of others and of self (i.e., internal working models) contribute to these differences. However, there are relatively few studies that examine psychotherapists’ views of self and of others and the impact on therapy. The research that does exist suggests important issues for therapists to consider. Therapists that are insecurely attached (i.e., are dismissive of the importance of relationships or are overly preoccupied with relationships) may have problems in developing positive therapeutic relationships and may be perceived as less empathic by clients. Therapists who have an overly negative view of their self (i.e., self critical, self neglecting) may struggle with developing a therapeutic alliance with clients. The findings suggest that clinicians need to be aware of their internalized relational models. The process of recognizing, reflecting on, and extricating from maladaptive interpersonal patterns and self-concepts may require supervision and/or personal therapy.

Author email: katiecatherinesteel@gmail.com

Hayes, J. A., Owen, J., Nissen-Lie, H. A. (2017). The contribution of client culture to differential therapist effectiveness. In L. G. Castonguay and C. E. Hill (Eds.) How and why are some therapists better than others? Understanding therapist effects (Ch. 9). Washington: American Psychological Association.

Some therapists may have better client outcomes because they are more adept at working with clients of different cultures. In this chapter, Hayes and colleagues define culture as referring to a group of people who share common history, values, beliefs, symbols, and rituals. The cultural groups to which one may belong include those based on: gender, religion, ethnicity, disability status, sexual orientation, race, and age, among others. Research suggests that culturally adapted therapy is more effective than unadapted therapy for racial minority clients. This may be due to more effective therapists being able to explain clients’ mental health problems and provide a rationale for specific therapy interventions that is congruent with the client’s beliefs. The most common model of multicultural therapy is multicultural competence, which is defined by having knowledge of various cultural groups, skills to navigate cultural processes, and self-awareness of personal bias. However, Hayes and colleagues argue for a multicultural orientation model in which a therapist is humble, respectful, and open to addressing culture in therapy. Whereas multicultural therapy is about acquiring knowledge, multicultural orientation refers to a way of being with clients. Hayes and colleagues review the research literature that indicates that therapists with cultural expertise are those who acknowledge when they do not have specific knowledge about a culture, have a high tolerance for not knowing, and at the same time recognize that cultural socialization affect clients’ mental health. A multicultural orientation is intended to bolster and support current therapeutic practices. For example, therapists may recognize that they need to better understand clients’ heritage when deciding whether or not to challenging a deeply held core belief related to the clients’ culture. In support of this, Hayes and colleagues review the research that indicates that: (1) client perception of therapist humility is related to client outcomes, especially for clients with a strong cultural identity; (2) clients who perceived that their therapist missed opportunities to discuss cultural issues in session had worse therapy outcomes; (3) clients who perceived therapists as culturally oriented experienced the therapy as more credible; and (4) therapist cultural comfort was related to better client outcomes.

Practice Implications

The authors suggest that therapists ask open-ended questions to clients regarding their cultural identity, such as asking the role that religion and spirituality play in their lives. This would allow therapists to learn about client cultural identity in the client’s own words. It is particularly important for therapists to maintain a stance of humility and cultural comfort, and to attend to opportunities to work productively with cultural issues in therapy in order to improve their clients’ outcomes.

Westmacott, R. & Hunsley, J. (2017). Psychologists’ perspectives on therapy termination and the use of therapy engagement/retention strategies. Clinical Psychology and Psychotherapy, 24, 687–696.

The average psychotherapy client attends a median of about 3 to 5 sessions, which is substantially less than the number of sessions the average client needs to realize a clinically significant decline in symptoms. Premature termination (clients ending therapy unilaterally) occurs in 19% of cases in research trials and in as many as 38% of clients in community practices. And so premature termination is mental health problem for clients and an economic problem for therapists and agencies. Clients terminate therapy prematurely for a variety of reasons including: dissatisfaction with therapy or the therapist, achieving their goals, and practical barriers (appointment times, travel, cost). Therapists tend to underestimate the proportion of unilateral terminations from their practice, and underestimate negative outcomes and client negative perceptions of therapy and therapists. In this study, Westmacott and Hunsley, surveyed psychologists who provide psychotherapy (N=269) on their perspectives on their clients’ reasons for termination and the strategies they use to retain their clients in therapy. Therapists reported that 33.3% of their clients terminated prematurely, which is somewhat lower than the percentage reported in previous research. Most psychologists (65.7%) tended to attribute the most important reasons for premature termination before the third session to clients’ lack of motivation to change (rated as very important or important on a scale). A much smaller percentage (15.8%) attributed waiting too long for services as the most important reason for premature termination before session 3. The most important reason for premature termination after the third session was most often attributed to clients reaching their treatment goals (54.8%). Regarding strategies to retain clients - almost all psychologists (96.8%) indicated that they fostered a strong alliance, 74.3% indicated that they negotiated at treatment plan, 58.0% prepared clients for therapy, 38.7% used motivational enhancement strategies, 33.0% used client outcome monitoring, and 17.8% used appointment reminders.

Practice Implications

This survey of psychologists suggests that psychotherapists may somewhat underestimate the number of clients who prematurely terminate therapy. Psychotherapists may also overly attribute dropping out to client-focused factors (low motivation, achieving outcomes), rather than therapist-focused factors (dissatisfaction with therapist or therapy), setting-focused factors (negative impression of the office and staff), or practically-focused factors (appointment times, cost). Many therapists reported using alliance-building and negotiating a treatment plan to retain clients. However, few therapists used other evidence-based methods like systematic outcome monitoring, and fewer still used appointment reminders. Therapists should consider therapist-focused and setting-focused reasons for client termination, and to use outcome monitoring and appointment reminders to reduce drop-outs from their practices.