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Textbook How and Why Are Some Therapists Better Than Others Understanding Therapist Effects 1St Edition Louis G Castonguay Ebook All Chapter PDF
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HOW
A ND
WHY
A RE
SOME
THER A PIST S
BE T TER
THAN
OTHER S?
HOW
AND
WHY
ARE
SOME
THER APIST S
BE T TER
THAN
OTHERS?
Understanding
Therapist Effects
Published by To order
American Psychological Association APA Order Department
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The opinions and statements published are the responsibility of the authors, and such
opinions and statements do not necessarily represent the policies of the American
Psychological Association.
Names: Castonguay, Louis Georges, editor. | Hill, Clara E., 1948- editor.
Title: How and why are some therapists better than others? : understanding
therapist effects / edited by Louis G. Castonguay and Clara E. Hill.
Description: First Edition. | Washington, DC : American Psychological
Association, [2017] | Includes bibliographical references and index.
Identifiers: LCCN 2016052063| ISBN 9781433827716 | ISBN 1433827719
Subjects: LCSH: Psychotherapy—Research. | Psychotherapists—Training
of—Research.
Classification: LCC RC337 .H69 2017 | DDC 616.89/14072—dc23 LC record
available at https://lccn.loc.gov/2016052063
http://dx.doi.org/10.1037/0000034-000
À la memoire de mon père, Roméo, qui aurait pu être un grand thérapeute,
mais qui fut bien plus.
(To the memory of my father, Roméo, who could have been a great therapist,
but who was much more.)
—Louis G. Castonguay
To all the therapists I’ve had and trained, because I know that who the
therapist is makes a big difference.
—Clara E. Hill
CONTENTS
Contributors................................................................................................. xi
Preface........................................................................................................ xiii
Introduction.................................................................................................. 3
Louis G. Castonguay and Clara E. Hill
I. Empirical Foundations......................................................................... 11
Chapter 1. Therapist Effects, Effective Therapists,
and the Law of Variability............................................... 13
Michael Barkham, Wolfgang Lutz, Michael J. Lambert,
and David Saxon
Chapter 2. What Characterizes Effective Therapists?...................... 37
Bruce E. Wampold, Scott A. Baldwin,
Martin grosse Holtforth, and Zac E. Imel
vii
Chapter 3. Who Works for Whom and Why? Integrating
Therapist Effects Analysis Into Psychotherapy
Outcome and Process Research...................................... 55
Michael J. Constantino, James F. Boswell,
Alice E. Coyne, David R. Kraus,
and Louis G. Castonguay
II. Conceptual Contributions.................................................................. 69
Chapter 4. Appropriate Responsiveness as a Contribution
to Therapist Effects......................................................... 71
William B. Stiles and Adam O. Horvath
Chapter 5. Therapist Presence, Absence,
and Extraordinary Presence............................................. 85
Jeffrey A. Hayes and Maria Vinca
Chapter 6. Inner Experience and the Good Therapist................... 101
Charles J. Gelso and Andres E. Perez-Rojas
Chapter 7. The Role of the Therapist’s Attachment
in the Process and Outcome of Psychotherapy............. 117
Bernhard M. Strauss and Katja Petrowski
Chapter 8. The Role of Therapist Skills
in Therapist Effectiveness............................................. 139
Timothy Anderson and Clara E. Hill
Chapter 9. The Contributions of Client Culture
to Differential Therapist Effectiveness.......................... 159
Jeffrey A. Hayes, Jesse Owen,
and Helene A. Nissen-Lie
Chapter 10. Therapist Negative Reactions:
How to Transform Toxic Experiences........................... 175
Abraham W. Wolf, Marvin R. Goldfried,
and J. Christopher Muran
Chapter 11. Professional Expertise in Psychotherapy....................... 193
Franz Caspar
contents ix
CONTRIBUTORS
xi
Adam O. Horvath, EdD, Simon Frasier University, Vancouver, British
Columbia, Canada, and University Catolica, Santiago, Chile
Zac E. Imel, PhD, University of Utah, Salt Lake City
Dakota J. Kaiser, MS, Marquette University, Milwaukee, WI
Hanjoo Kim, MS, Pennsylvania State University, University Park
Graham Knowlton, MS, Marquette University, Milwaukee, WI
Sarah Knox, PhD, Marquette University, Milwaukee, WI
David R. Kraus, PhD, Outcome Referrals, Framingham, MA
Nadia Kuprian, MA, Adelphi University, Garden City, NY
Michael J. Lambert, PhD, Brigham Young University, Provo, UT
Wolfgang Lutz, PhD, University of Trier, Trier, Germany
Andrew A. McAleavey, PhD, Weill-Cornell Medical School, New York, NY
J. Christopher Muran, PhD, Derner Institute, Adelphi University, Garden
City, NY
Michelle G. Newman, PhD, Pennsylvania State University, University Park
Helene A. Nissen-Lie, PhD, University of Oslo, Oslo, Norway
Jesse Owen, PhD, University of Denver, Denver, CO
Andres E. Perez-Rojas, PhD, New Mexico State University, Las Cruces
Katja Petrowski, PhD, University Hospital Carl Gustav Carus, Dresden,
Germany
Jeremy D. Safran, PhD, New School for Social Research, New York, NY
David Saxon, MSc, University of Sheffield, Sheffield, United Kingdom
William B. Stiles, PhD, Miami University, Oxford, OH, and Appalachian
State University, Boone, NC
Bernhard M. Strauss, PhD, Institute of Psychosocial Medicine and Psycho-
therapy, Jena, Germany
Maria Vinca, PhD, Independent Practice, State College, PA
Bruce E. Wampold, PhD, University of Wisconsin, Madison, and Modum
Bad Psychiatric Center, Vikersund, Norway
Abraham W. Wolf, PhD, Case Western Reserve University, Cleveland, OH
Henry Xiao, MS, Pennsylvania State University, University Park
Soo Jeong Youn, MS, Pennsylvania State University, University Park
xiii
described as a “think tank” of psychotherapy.1 The first two sets of confer-
ences focused on insight and corrective experiences, each of them leading to
a book.2, 3 This current book is the result of the third set of conferences, which
involved a total of three meetings.
As with the past two sets of conferences, the meetings on therapist
effects involved a large contingent of scholars from eastern North America
(participants were originally selected based on their expertise and, for eco-
nomic reasons, driving distance of their academic institution from Penn
State!). Because of the current worldwide attention to the topic of therapist
effects, however, contributors to this book include highly respected and influ-
ential researchers from North America and Europe.
We invited these scholars to focus on several questions aimed at better
understanding and maximizing the effectiveness of therapists: How have ther-
apist effects been studied? What are the personal features of good therapists?
What are therapists doing, thinking, and feeling (or not doing, thinking, or
feeling) when they are conducting a good session or a good treatment? What
factors facilitate or interfere with effective performance during a session or
treatment? And what are the best ways to identify good therapists and assess
their performance?
This book is not a compilation of conference proceedings, or a transcrip-
tion of exchanges that took place during meetings. Rather, the conferences
served as opportunities to stimulate and exchange ideas, clarify and sharpen
thoughts, generate new ways of thinking, and debate alternative views with
the ultimate aim of setting up, building, and receiving feedback about con-
ceptual and empirical projects conducted by members between meetings. In
this book, we showcase these innovative projects, and then present the con-
sensus reached by the group in terms of defining therapist effects and clarify-
ing the factors that explain these effects.
We are grateful to all of our contributors who have provided knowl-
edge and creative insights to our collaborative efforts to shed light on
the intriguing, but largely unexplained phenomenon, of therapist effects.
We also owe tremendous gratitude to Brian Rabian, who, on behalf of the
Psychology Clinic at Penn State, provided us with most of the funding for
the conferences. We also want to thank Susan Reynolds for her support
and guidance as senior acquisitions editor at the American Psychological
1Hatcher, S. L. (2007). Epiphanies on insight: A review of Castonguay and Hill (2006). PsycCritiques,
52(13), 1–5. Retrieved from https://www.apa.org/pubs/books/4317122c.pdf
2Castonguay, L. G., & Hill, C. E. (Eds.). (2006). Insight in psychotherapy. Washington, DC: American
Psychological Association.
3Castonguay, L. G., & Hill, C. E. (Eds.). (2012). Transformation in psychotherapy: Corrective Experiences
across cognitive behavioral, humanistic, and psychodynamic approaches. Washington, DC: American
Psychological Association.
preface xv
HOW
A ND
WHY
A RE
SOME
THER A PIST S
BE T TER
THAN
OTHER S?
INTRODUCTION
LOUIS G. CASTONGUAY AND CLARA E. HILL
http://dx.doi.org/10.1037/0000034-001
How and Why Are Some Therapists Better Than Others? Understanding Therapist Effects, L. G. Castonguay
and C. E. Hill (Eds.)
Copyright © 2017 by the American Psychological Association. All rights reserved.
3
change, whereas, unfortunately, other clinicians have produced less benefi-
cial change in their clients. At this point in time, however, it is mostly unclear
how and/or why this happens.
We know that therapists vary in terms of their therapeutic intentions.
For example, Fuller and Hill (1985) found that when working with the same
clients, some experienced therapists strived to give more information to their
clients, whereas other therapists were more intent on getting information
from their clients. Particular therapists, within and across different theoreti-
cal orientations, might also be focusing more on some processes or techniques
than others (e.g., exploring what is taking place in the therapeutic relation-
ship, facilitating a more positive view of self, helping clients to think about
meaning in life and death anxiety, fostering the resolution of painful feelings
toward parents). However, we can only rely on a paucity of empirical findings
to show whether or not these intentions and interventions, as well as several
other ways of being, thinking, and acting, are responsible for the fact that not
all therapists are equal in their outcomes.
The goal of this book is to address this gap in knowledge by relying on the
expertise and collaboration among highly influential scholars and researchers
from different theoretical orientations (e.g., cognitive–behavioral, humanis-
tic, psychodynamic) and research traditions (e.g., quantitative, qualitative,
randomized clinical trials, naturalistic investigations, cases studies). All of
the chapters in this book are designed to address one or two fundamental
questions: What might explain, at least in part, why some therapists are bet-
ter or worse than others? What are the ways by which therapists might get
more positive and less negative outcomes? All chapters have been written
to be clinically relevant and meaningful because we want this book to be a
source of innovative and creative strategies to help clinicians examine and
improve their practice.
We believe that the clinical insights and guidelines that can be derived
from these chapters are relevant to the practice of clinicians, irrespective of
their professional background and level of experience. Similarly, this book was
written to be helpful to early and well-seasoned researchers interested in clari-
fying how, with whom, and under what circumstances individual therapists
make a difference in the outcome of psychotherapy.
The book is composed of four sections. Part I includes introductory chap-
ters about the empirical foundations of our current knowledge. The next two
sections focus on general characteristics, ways of being, and clinical compe-
tencies of effective therapists. The chapters included in Part II examine these
issues from a conceptual perspective, whereas the chapters in Part III show
how clinically relevant studies can delineate factors that may explain thera-
pist effects and help clinicians to become more effective. Finally, implications
and conclusions are presented in the chapters of Part IV.
The first three chapters of the book include reviews of the empirical
literature about therapist effects.
In Chapter 1, Michael Barkham, Wolfgang Lutz, Michael J. Lambert,
and David Saxon first define key concepts in this line of research. They then
summarize the evidence that some therapists are more effective than others,
and some are more harmful than others. On the basis of six major conclu-
sions that they derived from current research, Barkham et al. provide recom-
mendations for future investigations, as well as suggestions for the clinical
applications of our scientific knowledge.
Chapter 2, by Bruce E. Wampold, Scott A. Baldwin, Martin grosse
Holtforth, and Zac E. Imel, begins with the assumption that there are thera-
pist effects, and then goes on to address the next obvious question of who
the best therapists are and what they are doing in therapy. After describing
conceptual and methodological difficulties related to understanding what sets
these therapists apart, Wampold et al. review the characteristics and com-
petencies that have currently been shown to contribute or not contribute
to therapist effects (a number of these characteristics and competencies are
examined in detail in later chapters of the book).
Building on Chapter 2, Michael J. Constantino, James F. Boswell,
Alice E. Coyne, David R. Kraus, and Louis G. Castonguay discuss various
complexities of between-therapist effects on client outcomes in Chapter 3.
They outline two categories of promising determinants of these effects and
provide a detailed map (and numerous examples) for investigating therapist
effects and their determinants. Specifically, this chapter offers a conceptual
(rather than a technical) description of design and statistical strategies for
future research on therapist effects.
introduction 5
appropriately doing the right thing at the right time by choosing and imple-
menting interventions on the basis of a range of contextual variables. With the
goal of expanding previous conceptual and research work, they propose that
the therapeutic effect of such responsiveness is mediated by good therapeutic
processes, such as the formation of a strong and positive working alliance.
Closely related to the notion of responsiveness is the concept of pres-
ence, or the capacity of therapists to be aware of and open to their experience
and the client’s experience in the here-and-now of the therapeutic inter
action. The role of presence, especially as a precondition of empathy, as well
as factors that occur before and during sessions that can influence therapist
presence, is described in Chapter 5 by Jeffrey A. Hayes and Maria Vinca.
Hayes and Vinca also boldly suggest that a state of “extraordinary presence”
may distinguish the most effective therapists from others.
Chapter 6, by Charles J. Gelso and Andres E. Perez-Rojas, focuses on
specific types of inner experience (especially affective experience) that thera-
pists, irrespective of their conceptual allegiance, have when working with
clients. Gelso and Perez-Rojas argue that therapist effects can be explained in
part by therapists’ ability to experience and communicate attitudes of empa-
thy, positive regard, and authenticity. They also suggest that effective thera-
pists are able to accept “taboo” feelings of hate and love toward their clients,
and understand and regulate these emotions as they occur in the therapeutic
relationship. Gelso and Perez-Rojas then describe specific strategies to thera-
peutically manage countertransference and provide suggestions for how to
investigate these phenomena.
Therapists’ regulation of emotions and their interaction with clients
are also explored in Chapter 7 by Bernhard M. Strauss and Katja Petrowski.
On the basis of their review of the emerging research on this topic, Strauss
and Petrowski propose that differential attachment (secure or insecure) may
explain one important aspect of therapist effects: Therapist effects are stronger
for highly impaired and distressed clients than for highly functioning clients.
With these distressed clients, secure therapists (who are less prone to react
defensively and with negative countertransference) may foster more positive
alliance and outcome.
Timothy Anderson and Clara E. Hill describe four sets of intertwined
therapeutic skills in Chapter 8: technical, relational, conceptualization, and
cultural. Although each of these skill sets is important for novice and expe-
rienced therapists to develop, Anderson and Hill argue that highly success-
ful treatment requires a combination of these skills. They further suggest
that therapeutic mastery is reflected by a personalized integration of highly
advanced and nuanced skills. They illustrate how the different skill sets can
be integrated using a conceptual model.
introduction 7
PART III: EMPIRICAL CONTRIBUTIONS
The fourth and final section is devoted to the effort of having a broader
impact on psychotherapy practice. In Chapter 16, James F. Boswell, David R.
Kraus, Michael J. Constantino, Matteo Bugatti, and Louis G. Castonguay
discuss a wide range of implications raised by the collection of process and
outcome data on therapist effects in day-to-day clinical practice. Boswell
REFERENCES
Castonguay, L. G., & Beutler, L. E. (Eds.). (2006). Principles of therapeutic change that
work. New York, NY: Oxford University Press.
Chambless, D. L., & Ollendick, T. H. (2001). Empirically supported psychological
interventions: Controversies and evidence. Annual Review of Psychology, 52,
685–716. http://dx.doi.org/10.1146/annurev.psych.52.1.685
Fuller, F., & Hill, C. E. (1985). Counselor and helpee perceptions of counselor inten-
tions in relationship to outcome in a single counseling session. Journal of Coun-
seling Psychology, 32, 329–338. http://dx.doi.org/10.1037/0022-0167.32.3.329
Norcross, J. C. (2011). Psychotherapeutic relationships that work: Evidence-based
responsiveness (2nd ed.). New York, NY: Oxford University Press. http://dx.doi.
org/10.1093/acprof:oso/9780199737208.001.0001
introduction 9
1
THERAPIST EFFECTS, EFFECTIVE
THERAPISTS, AND THE LAW
OF VARIABILITY
MICHAEL BARKHAM, WOLFGANG LUTZ,
MICHAEL J. LAMBERT, AND DAVID SAXON
During the past 50 years, clinicians and researchers have made huge steps
toward devising and testing more effective psychological therapies, with their
implementation into practice settings supported by national policy bodies
(e.g., the Substance Abuse and Mental Health Services Administration in
the United States, the National Institute for Health and Care Excellence
in the United Kingdom, the Agency for Healthcare Research and Quality
in Australia). However, the focus on treatment models and interventions
has masked a focus on the role and contribution of therapists, a result that is
surprising given that they are the most valuable and costly component in the
delivery of psychological therapies. Accordingly, the focus of this chapter is
on therapist effects, the contribution made by therapists to client outcomes as
opposed to the effects of specific treatments or client factors.
As the chapter title suggests, there are two key components that are
related but subtly different to therapist effects. The first is effective therapists,
http://dx.doi.org/10.1037/0000034-002
How and Why Are Some Therapists Better Than Others? Understanding Therapist Effects, L. G. Castonguay
and C. E. Hill (Eds.)
Copyright © 2017 by the American Psychological Association. All rights reserved.
13
which refers to the finding that some therapists are more effective than others,
and the second is variability, which refers to the natural phenomenon that
pervades almost all human endeavors, such that achieving similar levels of
skills within a profession is nigh on impossible. In this chapter, we first
set out more fully the central definitions and concepts relating to therapist
effects, effective therapists, and variability. We then provide a brief history
of research in this field, focus on how research studies are moving toward
placing therapists at the center of research—what we term therapist-focused
research—and identify one situation where therapist effects appear most
apparent. We draw together six substantive conclusions concerning our cur-
rent view of therapist effects and flag key directions for improving research
before concluding with a section on applying research in this field to key
areas of practice.
Our aim is to introduce readers to the conceptual issues that underpin
implications for practitioners, policymakers, and researchers. However, this
chapter focuses primarily on therapist effects and is, therefore, only a starting
point. For specific perspectives, we direct interested readers to more detailed
accounts within this volume (e.g., Chapters 2 and 3 address characteristics
and behaviors of effective therapists, as well as statistical and methodologi-
cal strategies to identify these therapist factors; Chapter 16 discusses what
to do with data related to therapist effects in terms of practice, training, and
policymaking).
Ja kun saatiin tietää sekin, että kissat aikoivat ajaa heitä vastaan
komeasti kärryillä, päättivät he ottaa auton, että näyttäisi
komeammalta.
Mentiin paikalle, mutta voi ilkeys! kirkosta ei ollut muuta jälellä kuin
pahainen hyhmätönkkö ja sekin romahti näkymättömiin ja suli
auringon paisteessa vedeksi.
— No karhupa tietenkin.
— Ei se nouse sinultakaan!
— Kontio kuninkaaksi!
Nallen jouluyö.
Ka, mikäs sieltä nyt tuli kelkkansa kanssa? Ihminen taisi olla, mikä
lienee partaniekka. Heh, eiköhän liene ihan vanha joulu-ukko
liikkeellä. Olipas vain!
Siinähän Riitta jo toikin ruuan tähteitä. Kun nyt menisi vain pois.
Kas, eikös ollut leipäkorissa tuoretta leipääkin, ja miten herkullisen
näköistä oli liha paistiastiassa! Ei muuta kuin käsiksi vain!
Mutta voi ilkeys! Riitta oli tullut niin hiljaa ruokakonttoriin, ettei
kukaan heistä huomannut, ennenkuin tämä löi käsiään yhteen ja
hihkasi.: