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Some counsellors & psychotherapists are more effective than others

This is the third in a sequence of blog posts - "Therapist drift: black heresy or red herring - maybe not so important?", "Psychotherapy is helpful but has developed shockingly poorly over the last 30 yearsand now this one "Some counsellors & psychotherapists are more effective than others."  As you can see from the slide below, identification and study of highly successful therapists' methods and characteristics is an obvious area to explore much more fully, as it is almost certain to give leads on how we might make general improvements in psychotherapy's helpfulness.

In the earlier post "Psychotherapy is helpful but has developed shockingly poorlyI introduced the extensive research literature showing that over thirty years' of attempts to develop more effective forms of psychotherapy have, by and large, been stunningly ineffective.  Despite this, a whole series of studies have shown that some counsellors & psychotherapists are more effective than others:

But to add insult to injury, therapists seem very poor at knowing how effective they themselves are:

This situation ... that some therapists are more effective than others ... cries out for research studies to identify more and less effective therapists, and then to carefully monitor what they do so that we can learn what kinds of qualities, skills, and behaviours tend to produce better outcomes.  It's not rocket science, but it could have major implications for improvements in how we select, train, monitor & supervise counsellors & psychotherapists. There are already some emerging findings in this fascinating, and potentially very fruitful, area:

Jo-Ann Pereira's finding that more effective therapists seem to be more resilient & mindful than less effective therapists is intriguing.  I attended Jo-Ann's presentation of her results at last year's BABCP summer conference and wrote a good deal about it in the post "Warwick BABCP conference: 3rd day - what personal qualities distinguish more & less effective therapists?"  This more recent interest in therapists' mindfulness overlaps into the longer term interest in the effects of therapists' attachment style on their outcomes with clients - see for example the 2003 paper "Respective contributions of therapist and client adult attachment orientations to the development of the early working alliance" and more recently "The therapist's attachment representation and the patient's attachment to the therapist" & "The relationships between adult attachment, theoretical orientation, and therapist-reported alliance quality among licensed psychologists".  And there is overlap.  Pepping & colleagues in particular have studied this - see for example their 2016 paper "The origins of individual differences in dispositional mindfulness" with their finding "In brief, both retrospective reports (Study 1) and current reports (Study 2) of the quality of parenting received were associated with individual differences in mindfulness via attachment processes".  From earlier research - see "Individual differences in attachment and dispositional mindfulness: The mediating role of emotion regulation" - they propose that "the mechanism by which attachment and mindfulness are related is through emotion regulation difficulties".  Now this area of investigation starts to look potentially fascinating.  It tumbles us into so many deeply interesting questions, for example - should we be assessing & selecting would-be therapists on qualities like mindfulness, attachment security, emotion regulation, resilience & compassion?  Should our therapy trainings teach trainee therapists to develop these qualities more fully?  Does this have implications for supervision?  Does it have implications for who we should be selecting to supervise and to teach these disciplines?  So interesting ... and so important.  

And this first of my four suggestions for ways out of our impasse - "Identification and study of highly successful therapists' methods and characteristics" - overlaps into the third suggestion - "Teaching & specific training in 'facilitative interpersonal skills'".  I say these two suggestions overlap because qualities like emotion regulation, attachment security, resilience, mindfulness & compassion are very much inter-personal as well as intra-personal. Note though - and this seems important - that interpersonal skills in the four important studies listed on the following slide were all assessed by external observers scoring therapists on how they actually behaved when under a degree of challenge:  

For more on the implications of the Schottke study, see the post "Using involvement in group discussions for (self-) assessment and learning".  For more on Anderson's work, see "Truly excellent therapists have "grace under interpersonal pressure" - Fascinating new research" and "Truly excellent therapists have "grace under interpersonal pressure" - How can we assess ourselves?".  While for the suggestion"Routine outcome monitoring to encourage alerts and problem-solving if one is going off track", see several posts on this website including "Psychotherapists & counsellors who don't monitor their outcomes are at risk of being both incompetent & potentially dangerous".

So we've looked a bit more deeply at three of the four suggestions I've made for "ways out of our impasse" (see slide below).  Now for the last of this sequence of blog posts - "Lessons (for therapists) from emerging research on how people develop excellence".

 

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