email page print pageAll Topic Reviews
Maximizing Effectiveness in Dynamic Psychotherapy Self-Compassion in Psychotherapy101 Healing StoriesA Clinician's Guide to Legal Issues in PsychotherapyA Map of the MindA Primer for Beginning PsychotherapyACT With LoveActive Treatment of DepressionAffect Regulation, Mentalization, and the Development of SelfAlready FreeBad TherapyBecoming an Effective PsychotherapistBecoming MyselfBefore ForgivingBeing a Brain-Wise TherapistBetrayed as BoysBeyond Evidence-Based PsychotherapyBeyond MadnessBeyond PostmodernismBinge No MoreBiofeedback for the BrainBipolar DisorderBody PsychotherapyBoundaries and Boundary Violations in PsychoanalysisBrain Change TherapyBrain Science and Psychological DisordersBrain-Based Therapy with AdultsBrain-Based Therapy with Children and AdolescentsBrief Adolescent Therapy Homework PlannerBrief Child Therapy Homework PlannerBrief Therapy Homework PlannerBuffy the Vampire Slayer and PhilosophyBuilding on BionCare of the PsycheCase Studies in DepressionCaught in the NetChild and Adolescent Treatment for Social Work PracticeChoosing an Online TherapistChronic DepressionClinical Dilemmas in PsychotherapyClinical Handbook of Psychological DisordersClinical Intuition in PsychotherapyClinical Pearls of WisdomCo-Creating ChangeCognitive Therapy for Challenging ProblemsCompassionConfessions of a Former ChildConfidential RelationshipsConfidentiality and Mental HealthConfidingContemplative Psychotherapy EssentialsControlConversations About Psychology and Sexual OrientationCoping with BPDCouch FictionCounseling in GenderlandCounseling with Choice TheoryCouple SkillsCrazy for YouCreating a Life of Meaning and CompassionCreating HysteriaCritical Issues in PsychotherapyCrucial Choices, Crucial ChangesDeafness In MindDecoding the Ethics CodeDeconstructing PsychotherapyDeep Brain StimulationDemystifying TherapyDepression 101Depression in ContextDialogues on DifferenceDissociative ChildrenDo-It-Yourself Eye Movement Techniques for Emotional HealingDoing CBTE-TherapyEarly WarningEncountering the Sacred in PsychotherapyEnergy Psychology InteractiveErrant SelvesEssays on Philosophical CounselingEssentials of Wais-III AssessmentEthically Challenged ProfessionsEthics and Values in PsychotherapyEthics in Plain EnglishEthics in Psychotherapy and CounselingExercise-Based Interventions for Mental IllnessExistential PsychotherapyExpectationExploring the Self through PhotographyExpressing EmotionFacing Human SufferingFairbairn's Object Relations Theory in the Clinical SettingFamily TherapyFavorite Counseling and Therapy Homework AssignmentsFear of IntimacyFlourishingFolie a DeuxForms of Intersubjectivity in Infant Reasearch and Adult TreatmentFoundations of Ethical Practice, Research, and Teaching in PsychologyFreud and the Question of PseudoscienceFrom Morality to Mental HealthFundamentals of Psychoanalytic TechniqueGenes on the CouchGod & TherapyHalf Empty, Half FullHandbook of Clinical Psychopharmacology for TherapistsHandbook of Counseling and Psychotherapy with Lesbian, Gay, and Bisexual ClientsHandbook of Evidence-Based Therapies for Children and AdolescentsHealing the Heart and Mind with MindfulnessHeinz KohutHelping Children Cope With Disasters and TerrorismHigh RiskHistory of PsychotherapyHow and Why Are Some Therapists Better Than Others?How Clients Make Therapy WorkHow People ChangeHow Psychotherapists DevelopHow to Fail As a TherapistHow to Go to TherapyHypnosis for Inner Conflict ResolutionHypnosis for Smoking CessationI Never Promised You a Rose GardenIf Only I Had KnownIn Others' EyesIn SessionIn Therapy We TrustIn Treatment: Season 1Incorporating Spirituality in Counseling and PsychotherapyInside the SessionInside TherapyIs Long-Term Therapy Unethical?Issues in Philosophical CounselingIt's Not as Bad as It SeemsItís Your HourLearning ACTLearning from Our MistakesLearning Supportive PsychotherapyLetters to a Young TherapistLife CoachingLogotherapy and Existential AnalysisLove's ExecutionerMadness and DemocracyMaking the Big LeapMan's Search for MeaningMaybe You Should Talk to SomeoneMetaphoria: Metaphor and Guided Metaphor for Psychotherapy and HealingMind GamesMindfulnessMindfulness and AcceptanceMindfulness-Based Cognitive Therapy for DepressionMindworks: An Introduction to NLPMockingbird YearsMoments of EngagementMomma and the Meaning of LifeMotivational Interviewing: Preparing People For ChangeMulticulturalism and the Therapeutic ProcessMultifamily Groups in the Treatment of Severe Psychiatric DisordersNarrative PracticeNietzsche and PsychotherapyOn the CouchOne Nation Under TherapyOur Inner WorldOur Last Great IllusionOutsider ArtOutsider Art and Art TherapyOvercoming Destructive Beliefs, Feelings, and BehaviorsOverexposedPathways to SpiritualityPersonality and PsychotherapyPhilosophical CounselingPhilosophical Counselling and the UnconsciousPhilosophical Issues in Counseling and PsychotherapyPhilosophical PracticePhilosophy and PsychotherapyPhilosophy for Counselling and PsychotherapyPhilosophy PracticePhilosophy's Role in Counseling and PsychotherapyPillar of SaltPlan BPlato, Not Prozac!Polarities of ExperiencesPower GamesPractical Psychoanalysis for Therapists and PatientsPrinciples and Practice of Sex TherapyProcess-Based CBTPromoting Healthy AttachmentsPsychologists Defying the CrowdPsychology, Psychotherapy, Psychoanalysis, and the Politics of Human RelationshipsPsychosis in the FamilyPsychotherapyPsychotherapyPsychotherapy and ConfidentialityPsychotherapy As PraxisPsychotherapy East and WestPsychotherapy for Children and AdolescentsPsychotherapy for Personality DisordersPsychotherapy Is Worth ItPsychotherapy Isn't What You ThinkPsychotherapy with Adolescent Girls and Young WomenPsychotherapy with Children and AdolescentsPsychotherapy without the SelfPsychotherapy, American Culture, and Social PolicyRapid Cognitive TherapyRational Emotive Behavior TherapyRational Emotive Behavior TherapyRationality and the Pursuit of HappinessRebuilding Shattered LivesReclaiming Our ChildrenRecovery OptionsRelationalityRent Two Films and Let's Talk in the MorningSaving the Modern SoulScience and Pseudoscience in Clinical PsychologySecond-order Change in PsychotherapySelf-Compassion in PsychotherapySelf-Determination Theory in the ClinicSelf-Disclosure in Psychotherapy and RecoverySerious ShoppingSex, Therapy, and KidsSexual Orientation and Psychodynamic PsychotherapySigns of SafetySoul Murder RevisitedStaring at the SunStraight to JesusStrangers to OurselvesSubjective Experience and the Logic of the OtherTaking America Off DrugsTales of PsychotherapyTales of UnknowingTalk is Not EnoughTalking Cures and Placebo EffectsTelling SecretsThe Behavioral Medicine Treatment PlannerThe Body in PsychotherapyThe Brief Couples Therapy Homework Planner with DiskThe Case Formulation Approach to Cognitive-Behavior TherapyThe Challenge for Psychoanalysis and PsychotherapyThe Child and Adolescent Psychotherapy Treatment PlannerThe Clinical Child Documentation SourcebookThe Clinical Documentation SourcebookThe Complete Adult Psychotherapy Treatment PlannerThe Couch and the TreeThe Couples Psychotherapy Treatment PlannerThe Crucible of ExperienceThe Cure of SoulsThe Death of PsychotherapyThe Education of Mrs. BemisThe Ethical Treatment of DepressionThe Ethics of PsychoanalysisThe Gay and Lesbian Psychotherapy Treatment PlannerThe Gift of TherapyThe Great Psychotherapy Debate: The Evidence for What Makes Psychotherapy Work The Healing JourneyThe Heart & Soul of ChangeThe Heroic ClientThe Husbands and Wives ClubThe Incurable RomanticThe Love CureThe Making of a TherapistThe Mindful TherapistThe Mirror Crack'dThe Mummy at the Dining Room TableThe Neuroscience of PsychotherapyThe Neuroscience of Psychotherapy: Healing the Social BrainThe New Rational TherapyThe Older Adult Psychotherapy Treatment PlannerThe Other Side of DesireThe Pastoral Counseling Treatment PlannerThe Philosopher's Autobiography The Pornographer's GriefThe Portable CoachThe Portable Ethicist for Mental Health Professionals The Present Moment in Psychotherapy and Everyday LifeThe Problem of EvilThe Problem with Cognitive Behavioural TherapyThe Psychodynamics of Gender and Gender RoleThe Psychotherapy Documentation PrimerThe Psychotherapy Documentation PrimerThe Psychotherapy of HopeThe Real World Guide to Psychotherapy PracticeThe Schopenhauer CureThe Sex Lives of TeenagersThe Talking CureThe Therapeutic "Aha!"The Therapist's Guide to PsychopharmacologyThe Therapist's Guide to Psychopharmacology, Revised EditionThe Therapist's Ultimate Solution BookThe Trauma of Everyday LifeThe Trouble with IllnessThe UnsayableThe Way of the JournalTheory and Practice of Brief TherapyTherapy with ChildrenTherapy's DelusionsTheraScribe 3.0 for WindowsTheraScribe 4.0Thinking about ThinkingThinking for CliniciansThinking for CliniciansThoughts Without a ThinkerThriveToward a Psychology of AwakeningTracking Mental Health OutcomesTrauma, Truth and ReconciliationTreating Attachment DisordersTreatment for Chronic DepressionTreatment Plans and Interventions for Depression and Anxiety DisordersUnderstanding Child MolestersUnspeakable Truths and Happy EndingsWhat the Buddha FeltWhat Works for Whom?What Works for Whom? Second EditionWhen the Body SpeaksWhispers from the EastWise TherapyWittgenstein and PsychotherapyWorking MindsWoulda, Coulda, ShouldaWriting About PatientsYoga Skills for Therapists:Yoga Therapy
In essence, How and why are some therapists better than others? Understanding therapist effects, a book edited by Louis G. Castonguay and Clara E. Hill, is a review of how little scholars and practitioners know about the contribution made by therapists to the effectiveness of psychological interventions. The term therapist effects has been specifically coined to label the impact of clinicians' individual characteristics, competencies, and actions on client outcomes, which can be statistically separated from the impact of type of treatment and clients' symptomatology (encompassing needs and severity). Although therapist effects have been often ignored and treated as error variance in studies on the effectiveness of treatment interventions (outcome research), and their estimated size is rather small (i.e., approximately between 5% and 8% of the variance), they are currently being treated as a relevant, but still obscure entity in investigations of clinical trials, general practice, and specialty clinics.
Of course, the critical question to be asked concerns the ingredients that make some therapists more effective than others. Yet, before answering this question, it is necessary to clarify the criteria by which the outcomes of psychotherapy can be measured. Can change be estimated objectively by taking into account the assessment of therapists and the self-assessment of clients before, during, and after psychotherapy? Does the opinion of familiar others, such as family members, friends, and coworkers, need to be included so as to noticeably increase the validity and reliability of clinicians' estimates of clients' behavioral, cognitive, and emotional change? If clients' views were the only measuring instruments, biases in the evaluation of the effectiveness of the treatment received may stem from clients' need to justify their decision to undergo treatment, as well as their investment of money and time. Furthermore, clients, who generally enter psychotherapy during a crisis, may get better as the crisis subdues and the passage of time puts things in perspective. If therapists' were the only measuring instruments, the evaluation of the effectiveness of the psychological treatment administered may be biased by self-justifications as well as by the justifications that clients use to enter therapy or interrupt it (which emphasize negative emotions), leave it (which emphasize well-being and positive emotions), and stay in touch if they are satisfied. Furthermore, comparisons of the individual characteristics, competencies, and behaviors of therapists are challenging. For instance, dropout rates may not only have a variety of sources, but also be defined differently. Records of the effects of psychotherapy in outcome research may be shaped by the conceptual models adopted. They also may be plagued by the size of the samples of therapists used as well as by the limited or incomplete records obtained. Thus, it is not surprising that the portion of outcome research explicitly devoted to therapist effects has brought to the surface more questions than answers.
How can effectiveness be objectively (i.e., fairly) measured? Is there a well-articulated, consensus-based operational definition of therapists' competence that encompasses the diversity of clients' needs and therapists' conceptual models? If competence is a matter of identifiable skills, what are the skills that therapists can acquire from training? Alternatively, is it a matter of being able to follow the protocol linked to a specific type of treatment that is the critical skill of effective therapists? The colorful assortment of conceptual models of therapies that exist on the market of psychological treatments, each emphasizing different aspects of human existence, leads to substantial differences in the way the needs of clients are conceptualized, addressed, and even measured during treatment. Can outliers, such as exceptionally successful and exceptionally mediocre clinicians, help scholars identify the cluster of factors that likely propel therapist effects across clients' needs as well as the properties that may modulate such effects? If so, the issue of how to define success concretely, comprehensively, and consensually emerges as a sore thumb. Undeniably, outcome research focused on therapist effects remains a commendable but challenging enterprise that has yet to harvest mature fruits.
As the reader approaches the end of this well-written book, a series of themes start to take shape. First and foremost, evidence from a variety of investigations seems to point to a set of factors that may define the effectiveness of individuals who have been trained to offer psychological treatment. Rather than specific demographic characteristics, effective therapists seem to possess a cluster of abilities, such as handling negative reactions, superior processing of information, communicating empathy, respect and genuineness, embodying cultural competence and self-analysis, and establishing an effective working relationship with their clients. All abilities are said to be in the service of one key goal of treatment, namely, fostering the process of change. This array of abilities and the umbrella under which they serve are not surprising. In fact, it is not difficult to envision each suggested ability as having been generated by a layperson's common sense, which, propelled by an elementary understanding of psychological treatment, is guided by his/her use of critical thinking skills. In this context, formalized data collection and complex statistical analysis seem more reassuring afterthoughts than the pillars upon which the identification of factors relies. It is not easy, however, to understand how each factor can be concretely represented in the day-to-day operations of therapists subscribing to different conceptual models and treating clients whose psychological distress varies in severity. Furthermore, statistical assessment of the magnitude of the contribution of each factor remains challenging in the complex environment of clinical work where several factors can independently or interactively contribute to client outcomes. Second, it is undeniable that the variability due to the therapist accounts for a small portion of the treatment outcome variance. Nevertheless, therapist effects play a role in the effectiveness of the treatment administered either alone or by interacting with the treatment administered and the needs of the client who received it. The extent of their contribution may be magnified or reduced as measurement instruments of data collection and statistical analysis are improved and new ones are developed. Third, if the amount of desirable change fostered in clients is the selected measure of effectiveness, most therapists cannot be classified as either unequivocally effective or ineffective. The existence of this amorphous group along with the fact that therapist effects increase in magnitude with the severity of the client's symptomatology suggest that the ideal ingredients for therapeutic success (even if simply measured as magnitude of fostered change relative to target) may not only differ across clients' needs, but also be hidden in the heterogeneity of the available data.
The themes discussed above bring about unanswered questions which tickle the reader's curiosity. Althougheach chapter of How and why are some therapists better than others? Understanding therapist effects, leads the reader to think of more questions than answers, it is an enlightening and engaging read. The reason is that it offers not only a panoramic view of a largely neglected field for which interest is now growing, but also an honest record of its struggles to produce findings that are valid, reliable, and helpful to practitioners. As a field of clinical psychological science, the literature on therapist effects offers scholars and practitioners alike opportunities to examine clinical work through the unbiased lenses of the scientific method, thereby not only increasing their understanding of psychotherapy, but also making clients' investment in psychotherapeutic treatments smarter. Opportunities are palpable since fruits of outcome research have shed light on the relative effectiveness of different types of treatment in reference to clients' needs and symptoms, and on the necessity to examine clinical work through the tools of the scientific method.
© 2017 Maura Pilotti
Maura Pilotti, PhD