Last updated on 16th June 2021
Hemingway wrote "Courage is grace under pressure". New research underlines that "grace under interpersonal pressure" is a key ability of truly excellent therapists. Study after study has shown that psychotherapists vary considerably in how helpful they are for their clients. The slide below shows a typical set of findings:
But what on earth distinguishes more effective from less effective psychotherapists? Research suggests that qualifications, professional discipline, type of therapy, overall experience, and gender don't seem to contribute much to effectiveness. Specific experience with particular types of problem may help a bit in relevant situations (Kraus et al, 2011). At least years of experience don't seem to make psychotherapists less effective, unlike the medical profession - see "Systematic review: the relationship between clinical experience and quality of health care." I have written a series of blog posts about this huge elephant-in-the-room issue; see for example "What shall we do about the fact that there are supershrinks and pseudoshrinks?" and "Five recent research studies on the worrying variability both in psychotherapist effectiveness and also in willingness to change". One suggestion that emerged from the work of Timothy Anderson and colleagues is that master therapists are distinguished by how they react under interpersonal pressure - see the 2009 paper "Therapist effects: facilitative interpersonal skills as a predictor of therapist success" with its abstract reading "This study examined sources of therapist effects in a sample of 25 therapists who saw 1,141 clients at a university counseling center. Clients completed the Outcome Questionnaire-45 (OQ-45) at each session. Therapists' facilitative interpersonal skills (FIS) were assessed with a performance task that measures therapists' interpersonal skills by rating therapist responses to video simulations of challenging client–therapist interactions. Therapists completed the Social Skills Inventory (SSI) and therapist demographic data (e.g., age, theoretical orientation) were available. To test for the presence of therapist effects and to examine the source(s) of these effects, data were analyzed with multilevel modeling. Of demographic predictor variables, only age accounted for therapist effects. The analysis with age, FIS, and SSI as predictors indicated that only FIS accounted for variance in outcomes suggesting that a portion of the variance in outcome between therapists is due to their ability to handle interpersonally challenging encounters with clients."
Since first coming across this very interesting paper I have been drumming my fingers waiting to see if it can be replicated. A few days ago, a dear Australian friend told me at a peer supervision (thank you Skype) about the online publication of Anderson's new research - "Therapist facilitative interpersonal skills and training status: A randomized clinical trial on alliance and outcome". The abstract reads "Objectives: Therapist effects, independent of the treatment provided, have emerged as a contributor to psychotherapy outcomes. However, past research largely has not identified which therapist factors might be contributing to these effects, though research on psychotherapy implicates relational characteristics. The present Randomized Clinical Trial tested the efficacy of therapists who were selected by their facilitative interpersonal skills (FIS) and training status. Method: Sixty-five clients were selected from 2713 undergraduates using a screening and clinical interview procedure. Twenty-three therapists met with 2 clients for 7 sessions and 20 participants served in a no-treatment control group. Results: Outcome and alliance differences for Training Status were negligible. High FIS therapists had greater pre–post client outcome, and higher rates of change across sessions, than low FIS therapists. All clients treated by therapists improved more than the silent control, but effects were greater with high FIS than low FIS therapists. From the first session, high FIS therapists also had higher alliances than low FIS therapists as well as significant improvements on client-rated alliance. Conclusions: Results were consistent with the hypothesis that therapists’ common relational skills are independent contributors to therapeutic alliance and outcome."
We're on a roll. You wait an age for one bus and then three come by. I checked for other recent Timothy Anderson work and bingo, up comes the 2016 paper "A prospective study of therapist facilitative interpersonal skills as a predictor of treatment outcome" stating "Objective: This study examined whether therapists' facilitative interpersonal skills (FIS) would prospectively predict the outcomes of therapies that occurred more than one year later. Method: Therapists were 44 clinical psychology trainees who completed the FIS performance task and a self-reported measure of social skills in the initial weeks of their training. In the FIS task, prospective therapists were presented with a standard set of videos portraying clients in therapy. Verbal responses to these therapeutic simulations were recorded and then rated by trained coders. More than one year later, the therapists began providing psychotherapy to clients in a psychology clinic. Clients completed a symptom measure before each therapy session. Results: Using multilevel modeling, it was found that therapist FIS significantly predicted client symptom change. That is, higher FIS therapists were more effective than lower FIS therapists. However, subsequent analyses showed that this FIS effect was not uniform across all therapy durations; specifically, higher FIS therapists were more effective than lower FIS therapists over shorter durations (e.g., </=8 sessions) but did not differ from lower FIS therapists in effectiveness for the small percentage of therapies that were longer-term (e.g., >16 sessions). Conclusions: Therapists' interpersonal characteristics may influence client progress in therapy." Note the suggestion that more effective therapists may typically only demonstrate better outcomes with shorter cases is contradicted by another recent & bigger study - "Unpacking the therapist effect: Impact of treatment length differs for high- and low-performing therapists" - which reported the opposite findng "The discrepancy in outcomes between high- & low-performing therapists increased as treatment duration increased"!
And along came a further "bus". Browsing through linked research studies, I found Schöttke et al's"Predicting psychotherapy outcome based on therapist interpersonal skills: A five-year longitudinal study of a therapist assessment protocol" just published online this January. The abstract reads "Objective: In the past decade, variation in outcomes between therapists (i.e., therapist effects) have become increasingly recognized as an important factor in psychotherapy. Less is known, however, about what accounts for differences between therapists. The present study investigates the possibility that therapists' basic therapy-related interpersonal skills may impact outcomes. Method: To examine this, psychotherapy postgraduate trainees completed both an observer- and an expert-rated behavioral assessment: the Therapy-Related Interpersonal Behaviors (TRIB). TRIB scores were used to predict trainees' outcomes over the course of the subsequent five years. Results: Results indicate that trainees' with more positively rated interpersonal behaviors assessed in the observer-rated group format but not in a single expert-rated format showed superior outcomes over the five-year period. This effect remained controlling for therapist characteristics (therapist gender, theoretical orientation [cognitive behavioral or psychodynamic], amount of supervision, patient's order within therapist's caseload), and patient characteristics (patient age, gender, number of comorbid diagnoses, global severity, and personality disorder diagnosis). Conclusions: These findings underscore the importance of therapists' interpersonal skills as a predictor of outcome and source of therapist effects. The potential utility of assessing therapists' and therapists-in-training interpersonal skills are discussed."
So all three of these new studies highlight the importance of therapist interpersonal skills specifically in confronting situations. This might involve assessing responses to standard film clips of actors playing challenging clients or assessing behavior in charged group discussions. There are parallels here with supervision that uses the results of routine outcome monitoring (of both progress & alliance) in standard clinical work to focus on recordings of therapy sessions where there has been lack of progress and/or alliance ruptures. And all these kinds of interpersonal scenarios have obvious training potential as well. Exciting times ... this new research signposts ways that we can better select for, train, monitor & improve psychotherapist effectiveness. For more on the implications of the Schöttke study, see the post "Using involvement in group discussions for (self-) assessment and learning". For more on implications of Anderson's work, see the next post in this series -"Truly excellent therapists have 'grace under interpersonal pressure' - How can we assess ourselves?"