Why are some psychologists better at providing therapy than others?
"It's quite surprising how little research has been devoted to [answering this question], particularly given its importance in psychotherapy training," says Bruce Wampold, PhD, of the University of Wisconsin–Madison.
But that dearth of knowledge is about to change, thanks to a six-year effort involving Wampold and other internationally recognized psychotherapy researchers. In April, the 32-person group — led by Pennsylvania State University psychology professor Louis Castonguay, PhD, and University of Maryland psychology professor Clara Hill, PhD — held the first of three conferences at Penn State to delineate the characteristics of "good therapists."
The group seeks to identify the characteristics associated with successful therapists, establish what therapists are doing, thinking and feeling (and not doing, thinking and feeling) when they are conducting effective sessions, and pinpoint factors that assist in or interfere with effective treatments.
It's a process the group is already familiar with: They've been meeting since 2001 to discuss the process of change and have published two APA books on provocative topics in psychotherapy — insight and corrective experiences.
And psychotherapy effectiveness is a timely topic, given the growing body of research that shows that for many psychological problems psychotherapy works better in the long term and is more cost-effective and long-lasting than medication, says Katherine C. Nordal, PhD, APA's executive director for professional practice.
"Hundreds of studies have found that psychotherapy is an effective way to help people make positive changes in their lives," Nordal says. "Compared with medication, psychotherapy has fewer side effects and lower instances of relapse when discontinued."
The brainstorming process
The original idea for a series of meetings on timely topics in psychotherapy was conceived in October 2000, says Castonguay. He had just attended a symposium at the Mid-Atlantic Society for Psychotherapy Research. He, Hill and several other attendee approached the speakers to talk about their findings. In the discussion that followed, Hill commented that informal gatherings like this one were often what she looked forward to most when attending a conference because the open-minded and spontaneous nature of such get-togethers typically led to new ideas about what is going on in therapy and what facilitates positive outcomes.
From that comment, Castonguay and Hill began to discuss how exciting it might be to do away with prepared papers, panels and posters and instead host an informal, open discussion about the process of change in therapy.
"Conferences are great, but all of us need the stimulation of our colleagues to really advance things and discover new ways of looking at things," Hill says.
Armed with that idea, Castonguay returned to his department and pooled resources to cover some of the costs to host 25 experts from an array of theoretical perspectives and with research expertise in psychotherapy to meet every two years for an invitation-only, two-day discussion at Penn State. The group would focus on a specific aspect of the process of change; for this first set of conferences, the topic was insight — a client's acquisition of a new understanding during psychotherapy — and how the therapist can help foster this.
"There was just this tremendous synergy that took place when we all came together, and an unbelievable number of creative ideas that stemmed from our discussions," Castonguay says.
After that first conference, each attendee agreed to conduct an in-depth exploration of issues related to insight to discuss at the next meeting held two years later. Some of the attendees embarked on ambitious theoretical projects, either by reviewing the literature on insight or by clarifying this concept from the point of view of different therapeutic approaches. Others decided to conduct extensive case studies — both qualitative and quantitative — on the attainment of insight in psychotherapy. Still other attendees set out to examine such clinical issues as the link between insight and action or to explore how social psychology, cognitive psychology, developmental psychology and philosophy can enhance understanding of insight.
At a third and final conference two years later, the group drafted a chapter on their findings for the APA book "Insight in Psychotherapy," published in 2005. Essentially, says Castonguay, the chapter is a statement by recognized scholars saying, "Here's what we agree on and what the future direction of this issue will be."
Using a similar process, the group held a second series of Penn State conferences, this time on the topic of corrective experiences — events that challenge one's fear or expectations and lead to new outcomes. "Corrective experiences are only one part of therapy, but they're a huge part that often leads to transformation, making them an important psychotherapy process to examine," Hill says.
APA published the resulting book on the conference, "Transformation in Psychotherapy," in June.
Characteristics of effective therapists
While the chapters on the therapist effect are still several years away from being written, the book that will eventually emerge will include discussion and research that can delineate personal features distinguishing effective therapists from less effective ones as well as identify ways of acting in therapy that trainers, supervisors and therapists themselves can focus on to help improve the outcome of individual clinicians.
For example, research led by Wampold suggests that effective therapists have a sophisticated set of interpersonal skills, including verbal fluency, warmth, acceptance, empathy and an ability to identify how a patient is feeling. Successful therapists can also form strong therapeutic alliances with a range of patients and are able to induce them to accept the treatment and work with them, he says.
Effective therapists are also highly tuned in to patient progress, either informally or through the use of outcome measures, according to research by Michael Lambert, PhD, a psychology professor at Brigham Young University and another participant in this latest series of Penn State conferences. He summarizes his research on the importance of client feedback in psychotherapy in his 2010 APA book "Prevention of Treatment Failure." He says that therapists must take the time to track patient progress — ideally through client self-reporting — and take action to address issues that impede it.
"We know that psychotherapy works — research shows that a substantial number of people who come to see therapists will not only benefit from therapy but will also demonstrate clinically meaningful change," Castonguay says. Other experts point out, however, that while therapist factors are clearly important, they are not exclusive of the models that therapists practice. It's imperative that providers make sure the treatments they are using are based on solid science, says Thomas Sexton, PhD, a psychology professor at Indiana University and a member of APA's Div. 43 (Society for Family Psychology) Task Force for Evidence-Based Practices.
"There's evidence to suggest that certain intervention programs also make a difference with specific client problems," Sexton says. "The work of the task force centered around the position that effective therapists need good interpersonal skills, a systematic model with good likelihood of success, and the ability to implement those models with fidelity and clinical complexity — or with high competence — in ways that match to the clients."
And more clients may soon be able to experience meaningful therapeutic gains if this group can identify the therapist characteristics and actions that most help — as well as those that undermine — psychotherapy.
Amy Novotney is a writer in Chicago.
- Castonguay, L.G., & Hill, C.H. (Eds.). (2007). Insight in Psychotherapy. Washington, DC: APA.
- Castonguay, L.G., & Hill, C.H. (Eds.). (2012). Transformation in Psychotherapy: Corrective Experiences Across Cognitive Behavioral, Humanistic, and Psychodynamic Approaches. Washington, DC: APA.
- Duncan, B.L., et al. (Eds.). (2009). The Heart and Soul of Change: Delivering What Works in Therapy (2nd ed.). Washington, DC: APA.
- Duncan, B.L. (2010). On Becoming a Better Therapist. Washington, DC: APA.
- Lambert, M.J. (2010). Prevention of Treatment Failure: The Use of Measuring, Monitoring, and Feedback in Clinical Practice. Washington, DC: APA.
- Sexton, T.L., & van Dam, A. (2010). Creativity within the Structure: Clinical Expertise and Evidence-based Treatments. Journal of Contemporary Psychotherapy, 40, 175–180.
- Sexton, T.L., & Kelly, S.D. (2010). Finding the Common Core: Evidence-Based Practices, Clinically Relevant Evidence, and Core Mechanisms of Change. Administration and Policy in Mental Health and Mental Health Services Research, 37, 81–88.
- Truscott, D. (2009) Becoming an Effective Psychotherapist: Adopting a Theory of Psychotherapy That's Right for You and Your Client. Washington, DC: APA.