Frontiers Friday #59. Therapist Effects (Part I)

Frontiers of Psychotherapist Development

Frontiers Friday #59. Therapist Effects   

I was so obsessed about this week's topic on Frontiers Friday that in 2010, I left my job in Singapore, packed our bags, and my wife and I headed to Australia where I did my doctoral in this area. No regrets, but I got to hand it to my wife for being up for an adventure.

The topic that got me hooked into the study of development and practices of highly effective therapists, was about therapist effects.

In gist, therapist effect is the reliable differences found between therapists based on client outcomes, above and beyond modality differences. 

Though I did this table back in 2014, I believe this would give you an overview on the factors that contribute to outcome in psychotherapy.
Note the difference between Specific Model Effects and Therapist Effects in terms of the proportion of variance in outcomes.

I'd do my best to give each of these recommendations key grafs. But for those of you who are keen to get into the weeds, I've added links to my private archive. (Note: Not for distribution, but for private use only.)

Here's the first five recommendations on this topic of therapist effects. 
 

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1. 🔑 Seminal Study by David F Ricks (1974) 
   This seminal study was probably the first to coin the term "Supershrink." It is also the first study to explore results obtained by therapists with different competency levels. 
   David Ricks compared the long-term outcomes of ‘highly disturbed’ adolescents, when the participants were later reviewed as adults, the results dramatically differed between the two therapists who provided the treatment.
   For example, 27% of the first therapist’s cases received the diagnosis of schizophrenia as adults, while 84% of the second therapist’s cases received that diagnosis.
   A significant amount of the adults who had seen the first therapist were more socially well-adjusted, compared to those who saw the second therapist, despite the fact that, at commencement of therapy, both therapists’ caseloads were equal in level of disturbance and other variables (gender, IQ level, socio- economic status, age, ethnicity, period seen, and frequency of psychotic disturbances found in the parents). Even though both therapists were trained in the psychoanalytic tradition, Ricks found that they differed in five major ways in which psychotherapeutic methods were employed:  

   i. Compared to the other therapist, the “Supershrink” allotted more of his effort to help the more disturbed adolescents, instead of those easier to treat.
   ii. He also used resources external to the therapy context, and was more competent in supporting the youths’ development of autonomy, while helping parents to recognise the importance of their adolescent’s individuation.
   iii. The “Supershrink” was firmer and more direct with the families and employed fewer intrapsychic interventions.
   iv. He was more skilled than the “Pseudoshrink” in developing a deeper and more lasting therapeutic relationship, and
   v. The “Supershrink” was keen to elicit the patient’s feedback of each session.

   Of course there was severe limitation by comparing with only two therapists. But this gave birth to an important research area decades later.  
    

2. ✋ Waiting for Supershrink
   This 2003 study based on John Okiishi's 200 doctoral study found that 4.1% of outcomes in a university counselling centre setting was attributable to therapist effects. Okiishi and colleagues found that "The therapists whose clients showed the fastest rate of improvement had an average rate of change 10 times greater than the mean for the sample." Conversely, "the therapists whose clients showed the slowest rate of improvement actually showed an average increase in symptoms among their clients."
    

3. ⚠️  Consequence of Ignoring Therapist Effects
   In this study published in Psychological Methods titled, "The Consequence of Ignoring a Nested Factor on Measures of Effect Size in Analysis of Variance" (Wampold & Serlin, 2000), the researchers stressed that ignoring therapist effects in the investigation would falsely inflate the estimates of treatment effects. 
   That's because many outcome studies ignore the "nesting" nature of the statistical analysis. In other words, analyses that do not take into account the dependency of "who" the treatment provider is, is not actually representing the actual reality of treatment delivery.
   
   

   

   
   Wampold and Serlin concluded that there are "serious consequence" for ignoring who the treatment provider is.
   (Sidenote: This study probably contributed to a rise in multi-leveling modeling analysis in our field). 
    

4. 😱 Psychiatrist effects in the psychopharmacological treatment of depression 
   This study blew my mind. Taking the advice of "nesting factor" in the data, the researchers reanalysed the famous Treatment of Depression Collaborative Research Program (TDCRP) dataset by accounting for who the psychiatrist was in the prescription of antidepressants.
   What did they find?
   "The proportion of variance in the BDI scores due to medication was 3.4%, while the proportion of variance in BDI scores due to psychiatrists was 9.1%." In other words, "the psychiatrist effects were greater than the treatment effects." 
   What about the difference between active drug and placebo? One-third of the psychiatrists demonstrated superior outcomes with placebo than one-third of the psychiatrists demonstrated with imipramine hydrochloride."
   In other words, "effective psychiatrists augment the effects of the active ingredients of imipramine hydrochloride as well as produce benefits with a placebo."
   Isn't that fascinating? 
    

5. ⏸ Words Worth Contemplating: 
   
   "We all want progress, but if you’re on the wrong road, progress means doing an about-turn and walking back to the right road; in that case, the man who turns back soonest is the most progressive.” ~ C. S. Lewis 

Reflection:  

How do we turn clinical research into me-search? Based on the above findings, what are the implications of on how we engage in professional development?   

 

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