3.0 The effective therapist

The effective therapist

Does it matter which therapy?”

• no → treatment modality explains roughly 1-2% of the variation in outcome

Does it matter which therapist?

• therapist differences explain around 5%

Clients seen by therapists in the top quartile are on average likely to benefit

• about twice as much as those seen by therapists in the bottom quartile.

Personal characteristics → of a therapist

• Has a sense of identity → respects & appreciates others, is open to change.

• Makes life-oriented choices → is authentic, sincere & honest.

• Has a sense of humour → makes mistakes and is willing to admit them.

• Lives in the present → is deeply involved in their work.

• Appreciates the influence of culture → maintains healthy boundaries

Issues experienced by beginning therapists → IN THE ROOM

• Anxiety, being yourself, & self-disclosure.

• Avoiding perfectionism → being honest about your limitations.

• Understanding silence.

• Dealing with demands from clients, & with clients who lack commitment.

• Declining to give advice.

Issues experienced by beginning therapists → IN YOURSELF

• Tolerating ambiguity.

• Developing a sense of humour.

• Defining your role as a therapist.

• Learning to use techniques properly & developing your own style.

• Maintaining your own vitality.

Why is it difficult to determine what makes an effective therapist?

• Many different therapeutic approaches can be effective for the same disorder, despite having incompatible theories

• Knowing that a treatment package works does not tell us which components make it work

“Effective therapist” → has no single definition

• Effectiveness may refer to client compliance, therapeutic alliance, or successful outcomes.

  • Therefore, different research programs may study different meanings of therapist effectiveness.

Outcome research

• Research that asks whether a treatment PRODUCES CHANGE

  • by measuring clients before & after, & comparing one condition against another.

  • names the package

What is the difference between outcome research & process research in psychotherapy?

• Outcome research = DOES therapy work? → examines the results of treatment, such as symptom improvement, remission & dropout.

• Process research = HOW does therapy work? → examines what happens during therapy & which therapist/client processes produce change, e.g. therapeutic alliance and therapist responses.

The main limitations found in what is the difference between outcome research & process research in psychotherapy

• Outcome research → tells us whether treatment worked, but not what happened inside the sessions that made it work

• Process research → identifies processes associated with change, but this does not automatically prove that the process caused the outcome

Process research

• Research that asks WHAT HAPPENS INSIDE the sessions, & which of it produces the change

  • by observing & coding recorded therapy moment by moment.

  • describes the interaction

Two perspectives of the therapist´s instrument

• The behavioural perspective

• The experiential perspective

The behavioural perspective

• The instrument: your behaviour — what you actually do & say, moment by moment.

• What you develop: a repertoire of effective behaviours & the ability to recognise their function & impact on the client.

• The focus: What did my response do to the client’s behaviour? Did it evoke, reinforce, or inhibit the behaviour I was aiming for?

• Core principle: interpersonal contact always changes behaviour. The therapist’s task is to make that influence intentional & goal-directed.

The experiential perspective

• The instrument: your person — your capacity to use yourself in the service of emotional change.

• What you develop: the ability to recognise the client’s active emotion, its level of arousal & productivity, & what the client needs next to move forward.

• The focus: What is happening in the client’s emotional process, moment by moment?

• Core principle: emotional change follows identifiable processes & sequences. The therapist’s task is to facilitate the next step in that process.

Similarities found in Behavioural perspective & experiential perspective

• Both rely on recorded sessions, deliberate practice, & observer-rated coding.

• Your behaviour matters in both

• 
  

The key difference is what is being observed & trained:

• Behavioural: the function & impact of the therapist’s behaviour.

• Experiential: the client’s emotional process & the therapist’s ability to facilitate change

  • difference is whether the primary target of training is what the therapist does or what the client is experiencing & how it changes

Classical — the stimulus comes first & ELICITS

• BEFORE:

  • US (the assault) → UR (fear).

  • NS (the lift) → nothing

• PAIRING: the neutral stimulus occurs together with the unconditioned one.

• AFTER:

  • CS (the lift) → CR (fear).

• The lift did nothing to her before. Now her heart races at the sight of one, & nothing about her decided to learn it — the pairing did it.

Classical conditioning is a form of

• Associative learning in which an organism learns to associate two stimuli, such that a previously neutral stimulus comes to elicit a response after being repeatedly paired with a stimulus that naturally produces that response 

  • Explains phobias & trauma reactions.

  • Explains why a client can react to your tone of voice for reasons that have nothing to do with you.

Operant Conditioning

• Response → Consequence

Operant Conditioning: Response → Consequence

• The response is the behaviour the person emits (e.g., leaving the supermarket).

• The consequence is what follows (e.g., the panic drops).

Unlike classical conditioning, the behaviour in Operant Conditioning is

• Emitted rather than elicited.

• The consequence does not trigger the behaviour; it changes how likely it is to occur again.

Operant conditioning is a form of

• associative learning in which the likelihood of a behaviour changes as a result of its consequences, particularly through reinforcement or punishment 

Behaviour INCREASES →Reinforcement

• Positive reinforcement (R+) → Something is ADDED

• Negative Reinforcement (R-) → Something is REMOVED

Behaviour DECREASES → Punishment

• Positive punishment (P+) → Something is ADDED

• Negative punishment (P-) → Something is REMOVED

Behaviour analytic ABC model

• A → B → C

  • A = Antecedent: what happens before the behaviour.

  • B = Behaviour: what the person does. (For Ellis B is beliefs).

  • C = Consequence: what happens after the behaviour.

Behaviour-analytic notation → Three term contingency

Sᴰ → R → Sᴿ

Sᴰ 

• discriminative stimulus → a cue that signals that reinforcement is available for a particular response

• (Situation where the behaviour will be reinforces if it occurs)

R

• Response of behaviour of interest (target of intervention)

Sᴿ

• Reinforcing stimulus → the consequence that increases the future probability of that behaviour.

The role a consequence

• plays in maintaining or changing a behaviour

  • A consequence is not necessarily a reinforcer simply because it follows a behaviour

  • It functions as reinforcement if it increases the future probability of that behaviour.

 Functional analysis → Example

Functional analysis: How consequences shape behaviour → Example

Functional Analysis → example of a table

Clinical Time Course → example of a table

Functional analysis helps us understand 

• what maintains a pattern

Emotional change in Emotion-Focused Therapy

• How emotional experience can change & transform

From an EFT perspective, emotional change involves moving from

• problematic emotional states towards new emotional experiences, meanings & responses.

Antonio Pascual-Leone's model describing Emotional change in Emotion-Focused Therapy

• An initial emotional state is accessed & processed until a new, more adaptive emotional response becomes possible

• The goal is therefore not simply to reduce the emotion, but to transform the emotional process.