Qualities of an Effective Therapist (1).pdf

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Unformatted text preview: enema ' Em“ macaw human: 931mm MSW Bounties macros”: QUALI'I'IES AND ACTIONS OF EFFECTIVE THERAPISTS . Rescind: suggests that certain pmhothmpirr characteristics are key to successjid (remain By Bruce E. Wampold Psychotherapy is generally viewed as a legitimate and beneficial treahnent for mental dismders in the United States. Of those who seek services for psychological distress in the United States, about 40 percent receive psychotherapy flour a psychologist, social worker. or counselor (Druss et 21.. 2007). In all, over 10 million Americans receive psychotherapy annually (Olfson et 11]., 2002; Wang ct al, 2005), st aycsrly cost of between $5.? and $9.6 billion (Lsngrcth, 2007; Minami & Wampoid, 2008; Olfson at 5.1., 2002). Clearly, psychotherapy is an established practice in the United States. Not only is psychotherapy widely practiced, it is effective: Those who receive psychotherapy achieve much better outcomes than they would have had they not received psychotherapy (Lambert dc Ogles, 2004; Wampold, 2001, 2007). In clinical trials, psychotherapy has been shown to be efi'ecfivo in heating depression, anxiety, marital dissatisthcfion, substance abuse, health problems (including making, pain and eating disorders) and sexual dysfimch‘on, and with various populations, including children, adolescents, adults, and elders (Chamhless et 8]., 1998). Indeed. psychotherapy is more cfiTective than many accepted, but expensive, medical practices, including interventions in cardiology treatments. geriatric medicine and asthma (Wcmpold, 2007). Psychomcrapy is as effective as or me cfi'ectivc than psychotropic medications for various mental disordeis, including my depression and anxiety disordem, and realms in lower relapse rates than medications (Helios, Stcwmt, & Sinmk. 2.1006; Imcl, Maltcrcr. McKay, Sc Wmnpold, 2008). In addition, outcomes in real world clinical panctice are comparable those psychotherapy clinical trials (Mound dc Weapold, 2008). To be sure, psychotherapy is remarkably effective. The more complex question is what factors melte- psychotherapy effective? The research evidence is not nlmgedrer clear, and there is much debate about some issues, but time cppcm to be suficient evidence to indicate that the psychotherapist is tremendously important to producing the benefits. The purpose of this mficle is to: a Briefly summarize the evidence related to effective psychotherapy. 9 Discuss the therapist's role in delivering continents I Detail the characteristics and actions cfefl‘cctive therapists. Effective psychotherapy In the decades since clinical scientists began using randomized clinical trials to test psychological treatments, my treatments have been identified as efiicsciocs.’ Indeed, in the 19903, APA's Div. 12, (Society ofClinical Psychology) identified mascots that met criteria to be classified as Empirically Supported Treatments (BSTs). Initially, 25 1138111161113 for particular 1 disorders were identified as having sufficient evidence to determined that they produce hencfihi in controlled research settings (Task Force on Promotion and Dissemination of Psychological Procedures, 1995). Although the term “Empirically Supported Treatment,” for a number of reasons, is no longer used, the identification of efficacious treatments by utilizing clinical trials is a major accomplish it the field, as it established that psychotherapy is indeed efi‘ecfive and led to the acceptance of psychotherapy as a treatment for mental disorders in the health delivery system of the United States (Barlow, 2004: Wampold, 2010). Treatments for which there is evidence to support their eficacy are often called Evidence-Based Treatments (EBTs), although there is no ofi'icial list of such troatrnents. Nevertheless, over 60 continents, for particular disorders, that might be termed EBTs are listed on the website of the Society of Clinical Psychology (see had/mdivl2.9rgfisycholog‘cale1cntslnesunentslmnl). Despite the strong evidence that some treatments are efiicacious for particular disorders, one issue remains hotly contested: Are some treatinent more effective than others? A nurnber of early meta— analyses seemed to indicate that no particular psychotherapy was more effective than any other psychotherapy (see Wampold, 2001 for a sunnnary). However, the point was raised by many whether this general conclusion applied to particular disorders. There is evidence, as well, that various treatments for particular disorders are approximately equally efiicaclous, including treatments for depression (Cuijpers, van Snatch, Andersson, &. van Oppcn, 2008; Wampold, Mlnami, Baskin, & Tierney, 2002), alcohol use disorders (Intel, Wampold, Miller, dc Fleming, 2008), PTSD (Banish, Imel, a Wampold, 2008; Powers, Halpem, Forenschak, Gillihan, & Foe, 2010), and childhood disorders (Miller, Wampold, d: Vaxlnely, 2008; Spielmsns, Peach, & McFall, 2007). It appears that this conclusion is as valid in routine care as it is clinical trials (Stiles, Baritham, Mallet-Clark, d: Council, 2008). However, some make difi’erent interpretations of the data and conclude that some continents are more reflective than others (Clark, Fairburn, & Wessely, 2007; Ehlers et ah, 2010; but see Wampold et al., 2010 also). ‘ Putting aside the debate about whether some treatrnents are more efi'ective than others, it is clear that if there are differences among trestrnents, the differences are quite small (Wampold, 2001, 2007, 2010). Thus, we are led with the question: Ifthe difi'erencci among treatments are nonexistent or are very small, are there other factors that do have an influence on the efi'ects of psychotherapy? The answer is yes—the therapist who is providing die psychotherapy is critically itnportant. In clinical trials as well as in practice, some therapists consistently achieve better outcomes than others, regardless of the treatment approach used (Wampold, 2006). For example, whether or not the therapist delivers cognitive behavioral treatment (CRT) or interpersonal psychotherapy (IPT) for depression matters not at all—m the other hand, some CBT therapists were more effective than other CBT therapists. and some ll’l‘ therapists were more efi'ective than other IPT therapists, even though the therapists in this clinical trial were experts, who received training and supervision, and were required to adhere to the treatment manual (Kim, Warnpold, dz. Bolt, 2006). In practice settings, the same phenomenon occurs: Some therapists, providing a wide variety oftreetments, consistently achieve better outcomes than others (Lutz, Lem], Martinovich, Lyons, & Stiles, 2007; Wampold dz Brovm, 2005), although the magnitude in practice does not seem to be greate- than it is in clinical trials. Interestingly, more cfl‘ective psychiatrists, meeting regularly with patients, achieve better outcomes administering a placebo than do less effective psychiatrists administering antidepressant medicationav‘chay, imel, dc Wempold, 2006)! The evidence that there are small or negligible difi'erences among treatments that are intended to be therapeutic for particulm' disorders and the evidence that some therapists consistently achieve better outcomes than other therapists, in clinical trials and in practice, raises the unmistakably important questions: What are the qualifies and action ofefiective therapists? Interestingly, as little as a decade ago, there was little convincing evidence to answer this question. Porttmsaely, the evidence is accumulating to be able to identify the qualities and actiom of efi’eotive therapists. In the next section, 14 qualities and actions of efi‘ectlve therapists are listed. This list is based 2 on the best available evidence (see e.g., Anderson, Oglet, Patterson, Lambert, a: Vermeersch, 2009; Baldwin, Wampold, & Intel, 2007; Duncan, Miller, Hubble, £5 Wempold, 2010; Lambert, Harmon, Slade, Whipple, & Hawkins. 2005: Norcross, 201]; Wampold, 2007) as well as theory and policy (e.g., APA Presidential Task Force on Evidence-Based Practice, 2006). Fourteen qualifies and actions of emotive therapists The 14 qualities and actions ofefi'ective therapist, based on theory, policy, and research evidence, can guide titerspists toward continual improvement. Various therapists, delivering various Treatments, in various contexts, will clearly emphasize some of these more than others. 1. Effective therapists have a sophisticated set of interpersonal skills, including a. Verbal fluency b. Interpersonal perception c. Afi'cctive modulation and expressiveness d. Warmth and acceptance e. Empathy fiFocusonothe-r 2. Clients of efi'ective therapists feel understood, trust the therapist, and believe the therapist can help him or her. The therapist creates these conditions in the first mountain of the interaction through verbal and impomantly non-verbal behavior. In the initial contacts, clients are very sensitive to cues of acceptance, undenstmding, and mpcrtise. Although these conditions are necessary throughout; titerspy, they are most critical in the initial interaction to enema engagement in thetlternpcutic process. 3. Effective therapists are able to form a working alliance with a broad range of clients. The working alliance involves me therapeutic bond, but also impomntly agreement about the task of goals of therapy. The working alliance is described as collaborative, purposeful work on the port of the client and the therapist. The effective therapist builds on the client's initial trust and belief to form this alliance and the alliance becomes solidly established early in therapy. ' 4. Efi‘ective therapists provide an acceptable and adaptive explanation for the client’s distress. Anyone who presents to a socially sanctioned healer, such as a physician or a psychotherapist, warns an explanation fin- his or her symptoms or problems. There are several cmnideratlom involved in providing the explanation. First, the animation must be consistent with the healing practice: in medicine, the explanation is biological “dramas in psychotherapy the explanation is psychological. Second, the explanation must be acceptable and accepted by the client, a process that involves compatibility with clients' attitndm, values, culture, and worldview. That is. treatments are adapted fior patients. Third, the explanation must be adaptive—that is, the explanation provides a means by which the client can overcome his or her difficulties. This induces positive expectations that the client can master what is needed to resolve difi‘iculties. Fourth, the “scientific truth" of the explanation is unimportant relative to its acceptance by the client. The therapist is aware of the context of the patient (e.g., issues of culture, SE5, race, e’dmicity) in the development and presentation of the explanation. Acceptance of the explanation leads to pinposefitl collaborative work. 5. The effective therapist provides a treatment plan that is consistent with the explanation provided to the client Once the client accepts the explanation, the treatment plan will nmke sense and client compliance will be increased. The nonlinear plan must involve healthy actions—the effective therapist ficilitates the client to do something that is in their best interest. Different continent approaches involve difl’etent actions, but the commonality is that all such actions are psychologically healthy. 3 6. The efl‘ective therapist is influential, persuasive, and convincing. The therapist presents the explanation and the tr-eaunent plan in a way that convinces the client that the explanation is conect end that compliance with the occupant will benefit the patient. This process leads to client hop-stillness, increased expectancy for mastery, and enactment of healthy actions. These characteristics are essential for forming a strong working alliance. 7. The effective therapist continually monitors client progress in an authentic way. This monitoring may involve the use of instruments or scale: or by checldng in with the patient regularly. Authenticity refers to communication to the client that the therapist truly wants to know how the client is doing. Administration of scales, for instance, without a discussion with the client, is insufficient; effective therapists will integrate progress evidence into treatment Therapists are particularly attentive to evidence that their cheats are deteriorating. 8. The effective therapist is flexible and will adjust therapy if resistance to the ueatment is apparent or the client is not melting adequate progress. Although the elfeofive therapist is persuasive, clients may not accept the eXplanetion and/or treatment or may not be making adequate progress given the untrue of the problem. The therapist is aware of verbal and nonverbal cues that the client is resistant to the explanation or the treatment, and uses the evidence gleaned from assessing therapeutic progress with outcome instnnnents. The effective therapist takes in new inforrmtion, test hypotheses about the client, and is willing to be "wrong." Adjustments might involve subtle difi‘erences in the manner in which the treatment is presented, use ofa difi‘ererrt theoretical approach, referral to another therapist, or use of adjunctive services (medication, acupuncture, etc). 9. The effective therapist does not avoid difiicult material in them)! and uses such difficulties therapemically. It is not unusual that the client will avoid material that is difficult. The effective therapist can infer when such avoidance is taking place and does not collude to avoid the material; rather the therapist will facilitate a discussion of the difficult material and in therapy will address core client problems. Such discussions are typically emotional and thus efi'ective therapists are comfortable with interactions with strong effect. When the difficult material involves the relationship between the therapist and the client, the efliective therapist addresses the interpersonal process in a therapeutic way (i.e., what is called by some the “tear and repair” of the alliance). 10. The efl'ecfive therapist communicates hope and optimism This communication is relatively easy for motivated clients who are making adequate therapeutic progress. However, those with severe mdfor chronic problems typically experience relapses, lack of consistent progress, or other difficulties. The effective therapists acknowledge these issues but continues to conununicate hope that the client will achieve realistic goals in the long run. This communication is not Pollyannaish optimism, but rather a firm belief that together the therapist and client will work successfully. This hopefhlness is about the client (i.e., the client can achieve the goals) and of the therapist him or herself (i.e., “i can work successfully with this client”). As a corollary, effective therapists mobilize client strengths and resources to facilitate the client's ability to solve his or her own problems. Moreover, the effective therapist creates client attributions that it is the client, through his or her work, who is responsible for therapeutic progress, creating a sense of mastery. l I. Efi‘ective therapists are aware of the client’s characteristics and context. Characteristics of the client referto the culture, race, ethnicity, spirituality, sexual orientation, age, physical health, motivation for change, and so form. The context involves available resources (e.g., 835 states), family and support networks, vocational status, cultural milieu, and concurrent services (c.g., psychiatric, case management, etc). The therapist works to coordinate care of the client with other psychological, psychiatric, physical, or social services. Frnthermore, the effective therapist is aware ofhow his or her oWn background, 4 personality, and status interacts with those of the patient, in terms of the clients reaction to the therapist, the therapist reaction to the client, and to their interaction. 12. The effective therapist is aware of his or her own myohological process and does not inject his or her own material into the therapy process unless such actions are deliberate and therapeutic. The cfl‘ective therapist reflects on his or her own reaction to the client (Le... counter transference) to determine if these reactions are reasonable given the patient presentation or are med on therapist issues. 13. The efi‘ective therapist is aware of the best research evidence related to the particular client, in terms of treatment. problems, social context, and so forth. Ofparticuler importance is understandiagthe biological, social, and psychological bases of the disorder or problem experienced by the patient. 14. The efi'ective therapist seeks to continually improve. Development of skill in an area involves intensive practice with model based feedback Feedback on the progress of clients is critical to improvement but the feedback is most useful if imbedded in a coherent model of therapy so that the therapist can make specific changes and determine the oumomes produced by sud: changes. Evidence that a client is not making satisfactory progress is useful but knowledge that the client is not making satisfactmy progress and that there is insufiicicnt agreemcm about the goals ofthmtpy provides information that the therapist can use in this particular case. Moreovm, the therapist can use such informafionemossclieotsto detect general patterns. The essential pointhere is thatthe cfi'ectivethempist, by definition, is the therapist who achieves expected or more than expected progress with his or her clients, generally, and who is continually improving. References Anderson, T., Ogles, B. M, Patterson, C. L., Inmbert, M. 1., 8r. Yenneersch, D. A. (2009). 'I'iterepist effects: Fecilitntive interpmonal skills as a predictor of therapist success. Jaw-ml of Clinical Psychology, 65, 755-768. APA Presidential Task Force on Bfidenoe-Based Practice. (2006). Evidence-based practice in psychology. American Psychologist, 61, 271-285. Baldwin, S. A, Wampold, B. E., «St Imel, Z. E. (2007). Untangling the alliance-outcome correlation: Exploring the relative importance of therapist and patient variability in the alliance. Journal of Consulting and Clinical tholo , 75, 842—852. Barlow, D. H. (2004). Psychological treatments. American Psychologitt, 59, 869-878. Benish, S., lmel, Z. E., & Wampold, B. E. (2008). The Relative efficacy ofbona fide psychothmpies of post-traumatic stress disorder: A meta-analysis of direct comparisons. Clinical thology Karim, 28, 746-758. Chomhless, D. L., Baker, M. 1., Baucom, D. H., Bender, L. E, Calhoun, K. 8., Daiuto, A, et al. (1998). Update on empirically validated therapies, II. The Clinical thologtlrt, 51', 3—16. Clark, D. M., Fairbum, C. G., 81. Wessely, S. (2007). Psychological treatment outcomes in routin NHS services: A commentary on Stiles et a1. (2007). Psychological Medicine. 38, 629-634. Cuijpers, P., van Staten, A, Anderssom (3., a: van Oppen, P. (2008). Psychomerapy for depression in adults: A meta-analysis of comparative omcome studies. Journal quonstdtt’ng and Clinical Psychology, 26, 909-922. Dress, B. G., Wang, P. S., Sampson, N. A, Olfson, M., Pincus, H. A, Wells, K. 13., ct el. (2007). Understanding mental health continent in persons without mental diagnoses: Results from the Nations! Comorbidity Survey Replication. Archives ofGenerol Prwhiarry, 64, 1196-1203. Dtmoen, 13., Miller, S. D., Hubble, M., & Wampoid, B. E. (Eds). (2010). The Woodrow of charge.- Delhrering what works (2nd ed). Washington DC: American Psychological Aesocietion. Bidets, A., Bissau, J., Clark, D. M, Creamer, M., Filling, 8., Richards, A, et a]. (2010). Do all psychological treatments really work the some in postnamnntic stress disorder. Clerical Pswhology Mew. 30, 269-276. Hollon, S. 1)., Stewart, M. 0., & Skunk, D. {2006). Enduring efi'eota for cognitive behavior therapy in the treatment of depression and anxiety. Annual Review quchology, 57, 285—3 15. lmel, Z. 13., Malterer, M....
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