Ignoring Self-of-the-Therapist Makes Treatment Less Effective

Until recently, the study of psychotherapy has been preferred over the study of the psychotherapist (Orlinsky & Ronnestad, 2005). It is a mistake to assume that all therapists are equal. Therapists differ in effectiveness (Baldwin & Imel, 2012). In fact, 15-20 percent of therapists are consistently more effective, while 15-20 percent are consistently less effective (Barkham, Lutz, Lambert, & Saxon, 2017). Provided that clinicians don’t violate any ethical and legal mandates, many practice as they see fit (Baldwin & Imel, 2013) and often operate without any oversight. The fact that therapists themselves impact clients’ outcomes is consequential (Goldberg & Sachter, 2018). This can substantially affect the mental health of many people. We must also train empirically supported therapists. What if each of us published our couple and family therapy outcomes?  What if our training programs considered academic performance and supervisor subjective evaluations as well as client performance?

Attention on the Therapist 

Psychotherapists exert significant influence on treatment outcomes (Baldwin & Imel, 2013). The effect is more pronounced with challenging clients, especially couples and families (Castonguay & Hill, 2017). This impact is separate from the model they use as well as the therapeutic alliance they establish.

Therapists’ personal characteristics impact treatment (Heinonen, Lindfors, Laaksonen, & Knekt, 2012). APA’s Div. 29 task force, which focused on empirically supported relationships, identified “the person of the therapist” as an important area of focus (Norcross & Wampold, 2011). Late in life, Minuchin (2017) wrote that the therapists themselves were the instruments of change and the techniques by themselves weren’t that useful.

No matter how skilled we are, our personal issues color our thinking and shape our behaviors with clients, sometimes to the clients’ detriment. Who we are as people impacts the quality of our relationships with our clients, our understanding of our clients and their problems as well as how we implement our technical interventions. Our personal issues are demonstrated when (a) we are overinvolved with particular clients, (b) we avoid difficult conversations, (c) we become reactive and judgmental, (d) we are allergic to conflict, (e) we are more concerned with being liked than being effective or (f) we suggest a quick fix.

Training and Supervision

Even though it is directly linked to therapist efficacy, training of psychotherapists rarely includes a focus on the intrapersonal or what is going on inside the therapist. We often believe that is too personal. In addition, we often assume that graduate students and trainees automatically become more emotionally mature or differentiated (self-aware, better able to soothe their own anxiety and less reactive) as a result of their time in academics and supervised practice. However, using the Crucible® Differentiation Scale (CDS; Schnarch & Regas, 2012), we found that there was no difference in the level of emotional maturity between first year and graduating clinical psychology students studying in universities on the west coast (Mothner & Regas, 2010).

In order to influence clients positively, trainees and clinicians must be encouraged to know evidence-based treatments and to engage in self-reflection regarding their personal and professional functioning. They need to be aware of and be able to regulate their own emotions and anxiety. Furthermore, they must be mindful of their own reactivity and make sure they are not driven by their instincts (Regas, Kostick, Bakaly, & Doonan, 2017). Clinicians must confront with their own issues so that they can have a high level of presence with clients. These skills must be a well-developed aspect of training.

Bakaly, Doonan, Hernández and I have developed a training model that we use at the California School of Professional Psychology and at the Ronald McDonald House training program (Regas et al., 2017). This training model takes into account the importance of self-of-the-therapist as well as utilizing evidence-based approaches. Personal growth and differentiation/emotional maturity are encouraged as a means of promoting professional development. When trainees and clinicians are free from the grip of unresolved issues and work to enhance their level of differentiation, they become more effective and confident therapists. There is informed consent and a well-defined policy about the treatment of personal information. This training program is therapeutic without being therapy. The goal is to make better therapists. The more aware we are of how our unresolved issues and level of differentiation impact our treatment, the more able we are to resolve them or not let them impact the therapy in a counterproductive way. This makes our therapy more effective.

References

Baldwin, S., & Imel, Z. (2013). Therapist effects: Findings and methods.In M. J. Lambert  (Ed.), Bergin and Garfield’s handbook of psychotherapy and behavior change (5th ed.) (pp. 258-297). New York NY: Wiley.

Barkham, M., Lutz, W., Lambert, M. J., & Saxon, D. (2017). Therapist effects, effective therapists, and the law of variability. In L. G. Castonguay & C. E. Hill (Eds.), How and why are some therapists better than others?: Understanding therapist effects (pp. 13-36). Washington, DC: American Psychological Association.

Castonguay, L. G., & Hill, C. E. (Eds.). (2017). How and why are some therapists better than others?: Understanding therapist effects. Washington, DC: American Psychological Association.

Goldberg, S. B., & Sachter, L. D. (2018). The zentensive: A psychodynamically oriented meditation retreat for psychotherapists. Practice Innovations, 3(1), 18-31.

Heinonen, E., Lindfors, O.,  Laaksonen, M., & Knekt, P. (2012).Therapists' professional and personal characteristics as predictors of outcome in short- and long-term psychotherapy. Journal of Affective Disorders,138(3),  301-312.

Minuchin, S. (2017, January/February). The art of creating uncertainty. Psychotherapy Networker.

Mothner, K., & Regas, S. (2010, October). The therapist-in-training: Level of emotional maturity among clinical psychology doctoral students. Poster session presented at the annual convention of Los Angeles County Psychological Association, Culver City, CA.

Norcross, J. C., & Wampold, B. E. (2011, March). Evidence-based therapy relationships: Research conclusions and clinical practices. Psychotherapy, 98-102. doi: 10.1037 /a0022161

Orlinsky, D., & Rønnestad, M. (2005). (Eds.) How psychotherapists develop: A study of therapeutic work and professional growth. Washington, DC: American Psychological Association.

Regas, S. J., Kostick, K. M., Bakaly, J. W., & Doonan, R. L. (2017). Including the self-of-the-therapist in clinical training. Couple and Family Psychology: Research and Practice, 6(1), 18-31.

Schnarch, D., & Regas, S. (2012). Crucible Differentiation Scale (CDS): Assessing    differentiation in human relationships. Journal of Marital and Family Therapy,38(4), 639-652.

Sexton, T. L., Ridley, C. R., & Kleiner, A. J. (2004). Beyond common factors: Multilevel-process models of therapeutic change in marriage and family therapy. Journal of Marital and Family Therapy, 30, 131–149.