Practice-Based Psychotherapy Research
To Improve The Wellbeing Of Our Community

PPRNet Blog: June 2016


Giorgio A. TascaAt the PPRNet conference in November 2012 over 100 psychotherapy clinicians, researchers, and educators were very keen to receive ongoing information about psychotherapy research that is practice-oriented and presented in an easily readable format. And so the PPRNet Blog was born.

About once a month I will review and summarize two or three published psychotherapy research articles. As part of the summary, I will highlight the practice implications of the research.

Because of copyright issues, we cannot post the full text of the articles, but we will provide a link to the abstract on the publisher's web site. I will also post the author's email address. Most authors are very happy to share their work. So if you want a copy of the article send the author an email with a request for a pdf or reprint.

At the bottom of each review you can post a comment, and comment on your colleagues' comments. I will update these as frequently as possible.

If you have ideas for an article to review or a topic you would like to see covered, please send me an email at pprnet@toh.on.ca.

Giorgio A. Tasca


blogIs Therapist Effectiveness a Stable Characteristic?

Kraus, D. R., Bentley, J. H., Alexander, P. C., Boswell, J. F., Constantino, M. J., Baxter, E. E., & Castonguay, L. G. (2016). Predicting therapist effectiveness from their own practice-based evidence. Journal of Consulting and Clinical Psychology, 84(6), 473-483.

There is lots of evidence that there are differences between therapists in their patients' outcomes. Some studies estimate that 5% to 7% of patient outcomes can be attributed to differences between therapists' abilities and style of delivering treatment. But most of these studies measured outcomes only once, and so they could not estimate if therapist effects are stable across time. Further, many of these studies used only a global measure of patient distress as an outcome and did not measure domain-specific outcomes (e.g., depression, anxiety, mania, alcohol dependence, etc.). In this study by Krauss and colleagues, 59 therapists who treated 3,540 patients were included. Therapists had on average 10 years of experience and were from a variety of professions (psychologists, psychiatrists, social workers, counsellors etc.). The settings included mental health clinics, independent practice, hospitals, and others. The authors went to some effort to control for case-mix variables such as client problem difficulty, length of treatment, caseload size, and other variables. Client outcomes were measured for 12 different domains ranging from depression to sexual dysfunction to substance abuse. First, outcomes were assessed for 30 patients of each therapist, and then these were compared to outcomes of the same therapist's next 30 patients. Therapists were classified as “exceptional”, “average”, or “below average” based on their patients' outcomes. Fifty-seven percent of therapists who were rated as exceptional with the first 30 patients were likely to remain exceptional or above average with the next 30 patients. In other words, effective therapists tended to remain effective over time. Therapists had better patient outcomes when it came to depression, suicidality, and substance abuse, but therapists tended not to have as good outcomes when it came to mania, and sexual functioning.

Practice Implications

Effective therapists tend to remain effective over time for particular client problem areas. However, therapists are seldom effective for more than 4 or 5 client presenting problems, and less than 10 % of therapists are effective with all client problem areas. Therefore patients with differing problems are likely to achieve better or worse outcomes depending on the particular therapist and his or her strengths. Therapists can regularly assess patient outcomes and use that information to help with continuing education to improve their practice for a particular problem area.

View a copy of the Is Therapist Effectiveness a Stable Characteristic? abstract.

Author email: dkraus@outcomereferrals.com

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blogAre Therapists Uniformly Effective Across Patient Outcomes?

Nissen-Lie, H. A., Goldberg, S. B., Hoyt, W. T., Falkenström, F., Holmqvist, R., Nielsen, S. L., & Wampold, B. E. (2016). Are therapists uniformly effective across patient outcome domains? A study of therapist effectiveness in two different treatment contexts. Journal of Counseling Psychology. Advance online publication. http://dx.doi.org/10.1037/cou0000151

What characterizes more or less effective therapists? Are some therapists more effective for certain types of client mental health problems? In this study by Nissen-Lie and colleagues the authors look at whether therapists are skilled across patient problem domains. They conducted two studies with over 6000 patients and almost 200 therapists. Patients were assessed with common outcome measures of mental health domains that included: social functioning, work functioning, relationship functioning and symptom distress. Therapists included psychologists and social work professionals (70%) and trainees (30%) who saw at least 10 patients each. Theoretical orientations ranged from CBT, psychodynamic, and supportive psychotherapy. Patients were symptomatic at the start of therapy and primarily had problems with anxiety and depression. Patient symptoms on average improved so that psychotherapy had a moderate to large effect. Therapists did not differ in caseload mix regarding client severity. The authors reported that the client mental health domains (i.e., symptom severity, work functioning, social functioning, and interpersonal functioning) were relatively distinct or unrelated areas (i.e., the domains were largely uncorrelated). The authors then calculated change scores for each client domain area and used these change scores in a multilevel factor analysis. They wanted to see if a therapist’s clients achieved greater change in one client domain versus in another client domain. The results showed that if clients of a therapist changed in one domain (e.g., depression) then that outcome was highly related to change in another domain (e.g., interpersonal functioning). In other words, if a therapist was effective (or ineffective) in reducing client symptoms, then that therapist was also likely effective (or ineffective) in reducing, work, social, and relationship problems.

Practice Implications

The results support the notion of therapist uniformity in terms of client outcome domains. In other words effective therapists tend to be effective with many types of client problems (but perhaps not all client problems – see my blog this month of the Kraus et al. (2016) study). The authors argue that effective therapists have three key qualities: flexibility in adapting treatments to clients, sensitivity to differences between clients, and responsiveness to clients’ reactions to therapeutic interventions. That is, effective therapists are willing and able to self correct when required.

View a copy of the Are Therapists Uniformly Effective Across Patient Outcomes? abstract.

Author email: h.a.nissen-lie@psykologi.uio.no

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blogTherapist Interpersonal Skills Account for Patient Outcomes

Schottke, H., Fluckiger, C., Goldberg, S.B., Eversmann, & Lange, J. (2016). Predicting psychotherapy outcome based on therapist interpersonal skills: A five-year longitudinal study of a therapist assessment protocol. Psychotherapy Research, DOI: 0.1080/10503307.2015.1125546

Therapist effects, or differences between therapists, account for an important amount of patient outcomes (i.e., 5% to 7%). Two therapist characteristics most consistently proposed as predictors of patient outcomes are: therapist competence/adherence to a treatment manual, and therapist interpersonal skills. A recent meta analysis found that therapist adherence or competence were not significantly related to patient outcomes. However, there has been very little research on therapists’ interpersonal capacities. These capacities might include factors like: empathy, warmth, ability to respond well to patient hostility, sensitivity to interpersonal process in therapy, and ability to address alliance ruptures. In this paper, Schottke and colleagues (2016) conducted a five year study with 41 therapists and 264 patients in which they assessed the impact of therapist interpersonal skills on patient outcomes. The therapists were all post-graduate trainees and who practiced a manual oriented cognitive behavioral therapy (CBT) or psychodynamic therapy (PDT). The patients were adults mainly treated for depression, and many had co-morbid problems. What was unique about the study is that the therapist interpersonal skill was rated before they received formal training, and the rating were done by trained reliable judges. The judges rated the therapist trainees on interpersonal skills including: clear and positive communication, empathy, warmth, managing criticism, and willingness to cooperate. Patients were assessed pre- and post-treatment on general symptom outcomes. Higher therapist interpersonal skills were reliably associated with better patient outcomes, even after controlling for symptoms severity and number of comorbid diagnoses. In this study, therapist interpersonal capacities measured before receiving formal training and supervision was a significant predictor of patient outcomes after training was initiated.

Practice Implications

The findings of this study indicate that therapists’ talent should in part be characterized by interpersonal competencies that include clear communication, empathy, respectful management of criticism, warmth, and willingness to cooperate. It could be that therapist trainees with high interpersonal skills engage in an extensive degree of deliberate practice that may account for better patient outcomes.

View a copy of the Therapist Interpersonal Skills Account for Patient Outcomes
abstract
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Author email: henning.schoettke@uni-osnabrueck.de

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