The Psychotherapy Practice Research Network (PPRNet) blog began in 2013 in response to psychotherapy clinicians, researchers, and educators who expressed interest in receiving regular information about current practice-oriented psychotherapy research. It offers a monthly summary of two or three published psychotherapy research articles. Each summary is authored by Dr. Tasca and highlights practice implications of selected articles. Past blogs are available in the archives. This content is only available in English.
…I blog about transtheoretical principles of change, microaggressions and outcomes, interpretations and outcomes.
Type of Research
- ALL Topics (clear)
- Alliance and Therapeutic Relationship
- Anxiety Disorders
- Attendance, Attrition, and Drop-Out
- Client Factors
- Client Preferences
- Cognitive Therapy (CT) and Cognitive-Behavioural Therapy (CBT)
- Combination Therapy
- Common Factors
- Depression and Depressive Symptoms
- Efficacy of Treatments
- Feedback and Progress Monitoring
- Group Psychotherapy
- Illness and Medical Comorbidities
- Interpersonal Psychotherapy (IPT)
- Long-term Outcomes
- Neuroscience and Brain
- Outcomes and Deterioration
- Personality Disorders
- Placebo Effect
- Practice-Based Research and Practice Research Networks
- Psychodynamic Therapy (PDT)
- Resistance and Reactance
- Self-Reflection and Awareness
- Suicide and Crisis Intervention
- Therapist Factors
- Transference and Countertransference
- Trauma and/or PTSD
- Treatment Length and Frequency
Some Therapists are Reliably Effective and a Few are Reliably Harmful
Kraus, D. R., Castonguay, L., Boswell, J. F., Nordberg, S. S., & Hayes, J. A. (2011). Therapist effectiveness: Implications for accountability and patient care. Psychotherapy Research, 21, 267-276.
Some patients benefit from psychotherapy, some do not, and a few get worse. Research has indicated that patient motivation, client-therapist match, and client characteristics might be associated with better or worse client outcomes. What about the contribution of the therapist? Do some therapists consistently have patients with better outcomes or with worse outcomes? Are consistently effective therapists effective for most patient problem areas or only some? Answers to these questions have important public health, funding, continuing education, and training implications. In a large study conducted in the U.S., Kraus and colleagues assessed 12 patient domains (sexual functioning, work functioning, violence, social functioning, anxiety, substance abuse, psychosis, quality of life, sleep, suicidality, depression, and mania) with a standardized reliable measure (the Treatment Outcome Package). The measure was used in a variety of public and private clinics and practices. Almost 700 therapists were sampled (including social workers 43%, mental health counsellors 35%, psychologists 10%, others 12%), with an average of 11 years experience. Ten cases were selected from each therapist caseload, so almost 7000 patients were included that received at least 16 sessions of therapy (16 sessions is an adequate dose for 50% of patients to improve – see my August, 2013 blog). The patients were, for the most part, representative of a typical caseload with regard to age, sex, and problem area as compared to previous national (U.S.) research. The authors used a reliable change index to classify patients as reliably improved, unchanged, or reliably worsened. The reliable change index is a way of assessing if change from session 1 to 16 on average exceeded the scale’s measurement error so that the change was considered reliable (i.e., not due to error). Reliable change for each therapist’s 10 patients was calculated so that a therapist could be classified as “effective” (i.e., on average their patients reliably improved), “ineffective” (i.e., on average their patients did not change), or “harmful” (i.e., on average their patients reliably worsened). The frequency of effective therapists ranged from a low of 29% in treating symptoms of sexual dysfunction to a high of 67% in treating symptoms of depression. Harmful therapists ranged from a low of 3% in treating depressive symptoms to a high of 16% in treating symptoms of substance abuse and violence. When looking at competency areas (i.e., areas of reliable effectiveness), the median number of areas of therapist competence was 5 out of 12 problem areas. Only 1 therapist of the approximately 700 therapists was competent in 11 of 12 domains, and none were competent in all 12 domains. Being effective in one domain was not correlated with effectiveness in another domain. So, one cannot infer that if a therapist was effective in treating depression he or she would also be effective in treating social dysfunction, for example.
There was tremendous variability in therapist skill and areas of competence in this very large sample of therapists. Between 3% and 16% of therapists were classified as reliably harmful to their patients, and between 29% and 67% were reliably effective depending on the problem area they were treating. Therapists who were effective in one domain could be harmful in another. Most therapists had some areas in which they were consistently effective, usually around 5. However, as indicated by previous research, without routine measurement, therapists may not be aware of clients for whom they are consistently helpful or harmful. Routine monitoring of outcomes could guide the matching of client problems to therapists, and could direct therapists to areas for continuing education, training, or personal therapy.
Author email: email@example.com
What Are The Characteristics of More Effective Therapists?
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