After a recent keynote I did, I was approached by a very thoughtful therapist who wondered about the characteristics/behaviors that I liked to see in therapists. Before I get to the list, though, let’s explore therapist factors. Therapist effects represent the amount of variance attributable not to the model wielded, but rather to whom the therapist is. Recent meta-analysis suggested that 5-8% of the overall variance is accounted for by therapist effects. This translates to 36-57% of the variance attributed to treatment, so therefore, the impact of therapist factors is about five to eight times more than that of model differences.
Although we know that some therapists are better than others, there is not a lot of research about what specifically distinguishes the best from the rest. Demographics don’t seem to matter much, and although a variety of therapist interpersonal variables seem intuitively important, there is not much empirical support for any particular quality or attribute. So what does matter? There’s a couple of possibilities, and one absolute certainty.
One possibility is that therapists who spend more time in what is called “resource activation” (harvesting client abilities to address goals) as opposed to “problem activation” (discussing the problem and its causes) tend to get better outcomes. Of course this makes perfect sense in the context of how much of the variance of change that clients bring to endeavor. Up to 86% of change is accounted for by client/life variables, everything about the client that has nothing to do with us or the therapy.
Another possibility is experience, but not the generic kind that we were often told that would make us better. A criticism often leveled at research investigating therapist experience is that it is not operationally defined and that a more sophisticated look may yield more positive findings. Our study of couple therapists (see it here) revealed that similar to other studies, demographics were not significant but specific experience in couple therapy explained 25% of the variance accounted for by therapists. So, experienced therapists can take some solace that getting older does have its advantages—as long as it is specific to task at hand.
And the absolute certainty: The alliance has consistently been shown to account for most of therapist differences. In general, research strongly suggests that clients seen by therapists with higher average alliance ratings have better outcomes. Our study confirmed this. We found that therapist average alliance quality accounted for 50% of the variability in outcomes attributed to therapists. So the answer to the oft heard question about why some therapists are better than others is that tried and true but taken for granted old friend, the therapeutic alliance.
There are many other characteristics that could be mentioned and this is certainly not the truth with a capital T. This is just my opinion based on what I say above as well as my firm, research supported belief that PCOMS improves outcome. Here is a list of characteristics/behaviors I most like to see in therapists:
1. Believe that the client is the source of wisdom, ideas, theories, and solutions. Can showcase client talent and maximize client resources. (Doesn’t mean that they can’t have wisdom, ideas, theories, and solutions too.)
2. Believe that clients know what’s best for their own lives and have the motivation and ability to reach their goals….even in dire circumstances.
3. Privilege the client’s perspective regarding the benefit of services and systematically monitor it. Provides a structured space at the top of each hour to discuss progress and alter therapy if change is not happening.
4. Skilled at forming alliances with those that others find difficult, and structuring the work around client goals and expectations. Are “people persons,” possessing a natural way of connecting, showing appreciation, and expressing understanding…they like people and it shows.
5. Don’t leave the alliance to chance; provide a structured space in each session to discuss how things are really going with the client and alter accordingly. Understand that some clients are better served by others.
6. Skilled at focusing the conversation on what the client would like to see happen and channeling the complexities of topics and client experiences toward something tangible that will make a difference.
7. Are “dyed in the wool” optimists and convey it without cheerleading or being Pollyannaish. While resonating with client despair, they refuse to succumb to it as the only way to understand the client.
8. Believe that therapy is about change and are not satisfied with doing work that doesn’t benefit clients. Do not believe “supportive therapy” is enough or that the continual processing of client lives is a good long term strategy. Understand that benefiting all clients is not possible.
9. Don’t leave their own development to chance; monitor their outcomes over time and take proactive steps to improve. Are not afraid to do things for the first time or learn from clients who don’t benefit.
10. Accountable first to their clients, and to those who make services possible. Know that services are precious and must be used wisely—that for services to continue there must be proof of value and return on investment for funders.
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