Psychotherapy is remarkably effective but we should not be too complacent about this conclusion. Psychotherapy results in a better outcome than would otherwise be the case in about one out of three clients, which compared to many medical treatments is actually very good. But we can do better, of course. Some therapists achieve better outcomes than others—that is, some therapists consistently help clients, while others do not. This raises a truly important question: What are the characteristics and actions of effective therapists?
The question about effective therapists is obviously important, is it not? If we know what the most effective therapists do, then we can:
- learn how to be more effective
- efficiently train students to be good therapists
- and improve the quality of mental health services.
Unfortunately, the answer to what characterizes effective therapists has been elusive. Psychotherapy is a transactional event—what happens in therapy is due to both the therapist and the client and their interaction. A difficult client—say one with features of borderline personality, a poor attachment history, chaotic interpersonal reactions, difficult history with other therapists, and an angry presentation—will tend to make us all look like we are having a “bad therapy day.” The challenge is to identify the actions of effective therapists across a range of clients.
| Characteristics and Actions of Effective Therapists | Characteristics and Actions Not Related to Outcome |
|---|---|
| Formation of alliance across a range of patients and the ability to repair alliance ruptures | Age |
| Verbal fluency | Gender |
| Warmth and empathy | Profession or degree |
| Emotional expression | Self-reported social skills |
| Persuasiveness | Responses to interview questions about clinical skills |
| Hopefulness | Theoretical orientation |
| Problem focus | Adherence to treatment protocols |
| Delivery of a cogent treatment | Rated competence delivering specific ingredients of treatment |
| Professional self-doubt and time spent improving |
Timothy Anderson, a professor of psychology at Ohio University, designed an ingenious study to identify what effective therapists do. In 2009 he and colleagues published a study that examined the outcomes of 25 therapists who had treated 1,141 clients. The therapists completed a social skills inventory and then watched several videos of challenging clients, after which they recorded their therapeutic response. The responses were then coded for what Anderson and colleagues called Facilitative Interpersonal Skills (FIS), and which included verbal fluency, emotional expression, persuasiveness, hopefulness, warmth, empathy, alliance and problem focus. It turned out that FIS ratings predicted the outcomes of the therapists—the clients of therapists who had higher FIS scores in this challenge test benefited more from therapy than clients of therapists with lower FIS scores. This was the first time that a characteristic of therapists assessed outside of therapy predicted the outcomes achieved by the therapists.
Interestingly therapists self-reported social skills did not predict therapist effectiveness. It appears that to identify effective therapists, they must respond to a challenging interpersonal task, a result that was replicated in a German study. In this study, an interview designed to assess clinical skills did not predict therapist outcomes but skills in a stressful group interaction did.
What Characteristics Do Effective Therapists Have?
Since Anderson’s study, several additional studies have examined affective therapists, using a variety of sophisticated designs and advanced statistics, the results of which are found in the table above. It is clear that effective therapists have a set of therapeutic skills that they use with clients, particularly challenging clients. It has also been found that effective therapists question their skill level (labelled as professional self-doubt) and spend time outside of therapy trying to improve (e.g., reading therapy books, attending workshops, practicing skills).
There are also characteristics and actions of therapists that do not appear to be related to their effectiveness, including age, gender, profession or degree (psychologist, counselor, social worker, etc.), theoretical orientation, degree of adherence to a treatment manual, or the rated competence delivering a particular treatment with a particular client (this is a more difficult one to understand, so I will come back to this point in a later blog post.
Where does this leave the field? We have known for a long time that some therapists are more effective than others (well, I think we all—therapists and clients—from our experience). We are now finding out what characterizes the more effective therapists. The next step is to determine if we can use this information to improve services and to train more effective therapists.
References:
- Anderson, T., Ogles, B. M., Patterson, C. L., Lambert, M. J., & Vermeersch, D. A. (2009). Therapist Effects: Facilitative Interpersonal Skills as a Predictor of Therapist Success. Journal of Clinical Psychology, 65(7), 755-768. doi:10.1002/jclp.20583
- Schöttke, H., Flückiger, C., Goldberg, S. B., Eversmann, J., & Lange, J. (2016). Predicting psychotherapy outcome based on therapist interpersonal skills: A five-year longitudinal study of a therapist assessment protocol. Psychotherapy Research.
- Wampold, B. E., Baldwin, S. A., Holtforth, M. g., & Imel, Z. E. (2017). How and why are some therapists better than others: Understanding therapist effects. In L. G. Castonguay & C. E. Hill (Eds.), Therapist Effects. Washington DC: American Psychological Association.
