The commonalities of psychotherapy Therapy, therapist, and client variables

If the Dodo lives: why does psychotherapy work? (Wampold, 2001)

Common Factors of Psychotherapy (Tracey, 2003) Relationship Factors Client forms an alliance with therapist Client receives warmth and positive regard Client is a partner in therapeutic interaction Other Common Factors Client experiences tension reduction Client is persuaded that change is necessary Client is provided with information and education Client receives feedback to gain a more realistic perspective Client experiences therapeutic techniques and rituals

Relationship Factors (groundwork for change) Therapeutic rapport Therapeutic alliance Therapist warmth, respect, empathy, acceptance, and genuineness

Other Common Factors Anxiety reduction/arousal Changing expectations Affective experiencing Cognitive learning/insight Focus on what is adaptive

Other Common Factors (cont.) Listening, questioning, advising, interpreting, etc. (see next slide) Mastery efforts Facing fears Practicing Taking risks Working through

Estimate of % of Time Spent in Various Activities Process Counseling Psychotherapy Listening 20 60 Questioning 15 10 Evaluating 5 Interpreting 1 3 Supporting Explaining Informing Advising Ordering 9

Do therapist characteristics influence therapy outcomes?

Why do people become counselors/therapists? Many reasons are positive Some have a desire to help others less fortunate Some want to help prevent people from having difficulties in the first place Some want to help people reach their full potential Some are potentially problematic When the person needs to make a difference but has unrealistic expectations for helping When the person has a need to care for others, he/she may undermine the client’s autonomy by doing for the client When the person has a need to solve his or her own problems When the person has a need to be powerful or influential

Therapist variables: What matters and what doesn’t? Some things don’t matter Therapist’s demographics are unrelated to outcomes (but important to clients) Therapist’s modality (theoretical orientation) Therapist’s specific degree (Ph.D. vs Psy.D. vs MSW) But some things do…

Therapist variables that matter (competence and confidence) Expertise in specific presenting problems Acknowledgement of limitations Commitment to self improvement and staying current Experience

More therapist variables that matter (interpersonal dimensions) So-called “cultural competence” Respects the client’s worldview, personal experience, spirituality, and culture Has self-awareness: Knows own biases or prejudices (good or bad) and is able to analyze own feelings Has ability to model appropriate behaviors Social intimacy Emotional expression Genuineness Self-care Has ability to be altruistic (put client’s needs first) Is ethical

More therapist variables that matter (personality) Few therapist personality traits have been studied, but some have High levels of dominance in a therapist result in better outcomes when the client and therapist were culturally similar, but low-dominance therapists were more effective with culturally dissimilar client Tolerance for ambiguity [quiz yourself]

More therapist variables that matter (empathy) What empathy is not Sympathy: “I'm sorry you’re sad.” Emotional Contagion: “I feel sad too.” Apathy: “I don't care how you feel.” Telepathy: “I read your sadness without you expressing it to me either verbally or non-verbally. Just listening Barter video: Empathy: part 1

More therapist variables that matter (empathy continued) What empathy is Ability to be present Barter video: Part 3 Ability to recognize, perceive and, to some degree, directly experientially feel the emotion of another Ability to convey understanding without judgment Ability to remove blocks to connection and action Barter video: Part 2

More therapist variables that matter (empathy continued) Similar across different treatment modalities Modest support for Rogers’s contention that they are necessary and sufficient for therapeutic change Good support for the idea that it is necessary but NOT sufficient (less successful therapists tend to score lower) Recently became regarded as teachable learnable “skills” Evidence for an empathic civilization “I see myself in your eyes”

More therapist variables that matter (emotional health) Freedom from personal problems Survey of 749 APA therapists 44% experienced personal problems in the past 3 years almost 37% said it decreased the quality of therapy In study of 562 licensed psychologists, more than a third reported emotional exhaustion or “burnout” Important to recognize tender areas of one’s life.  Clients pick up anger, defensiveness, and anxiety Therapists need to avoid getting entangled in client’s dynamics Therapy is for the client not the therapist, so the therapist’s emotional needs must be met elsewhere

Client variables Motivation (lightbulb joke) Degree of patient’s distress (mixed findings; may be curvilinear) Intelligence: > IQ = better outcomes Willingness to see problems as psychological Optimism about therapy

Client variables (continued) Gender, age, race/ethnicity, and social class Gender of client is not related to outcome, but sexism sometimes an issue Younger clients have a better prognosis (but avoid ageism!) Ethnic/racial minorities have similar outcomes in therapy (maybe! – see next slide), but are less likely to seek it and more likely to drop out of it     No relationship between social class and outcome

Data from Christopher R. Larrison, Susan L Data from Christopher R. Larrison, Susan L. Schoppelrey, and Samantha Hack-Ritzo Average patient change over time for white patients Average change over time for minority patients

Client-Therapist Fit Psychotherapy is an Art …as well as a science Theories, techniques and methods of psychotherapy are secondary to the clinician knowing what to do for whom. The Who-How-Whom Factor Who does it? (Demographic characteristics, personality, experience) How is it done? (Individual vs family vs group, Theoretical orientation) Whom is it being done to? (Demographic characteristics, Personality)