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Research Abstracts
What Do We Know About Master Therapists?
Tracy D. Eells, Ph.D.
U
ntil recently, the study of therapist skill has been
relatively neglected in psychotherapy research.
Researchers have instead focused on comparative outcome research, have examined many process variables
other than therapist skill, and have developed treatment
manuals and scales that measure therapist adherence to
the manualized techniques. In outcome research, the
aim is to keep therapist adherence to a therapy model
high and skill level constant. Recently, however, a number of studies have addressed the characteristics and
skills of master therapists. I will summarize and comment on five of these studies.
ABSTRACTS
Ablon JS, Jones EE: How expert clinicians’ prototypes of an ideal treatment correlate with outcome
in psychodynamic and cognitive-behavioral therapy. Psychotherapy Research 1998; 8:71–83
Summary: A panel of internationally known experts in psychodynamic (PD) and cognitive-behavioral
(CB) therapy used the Psychotherapy Process Q-set
(PQS) to produce prototypes of an ideal treatment in
each of these therapy modalities. Experts rated each of
the 100 PQS items (e.g., “patient’s dreams or fantasies
are discussed”) according to how well it described an
ideally conducted course of therapy that adheres to that
therapy’s theoretical principles. The prototypes were
then correlated with process and outcome variables in
three archived treatment samples, of which two were
psychodynamic and one was cognitive-behavioral. The
psychodynamic treatments correlated positively and
significantly with both the ideal psychodynamic and the
ideal cognitive-behavioral prototypes. The cognitivebehavioral treatments correlated highly with the cog314
nitive-behavioral prototype but not with the psychodynamic prototype. The psychodynamic prototype
constructed by experts was consistently and positively
correlated with outcome in both the psychodynamic
and cognitive-behavioral treatment samples. The cognitive-behavioral prototype was not consistently positively correlated with outcome.
Comment: This study addresses ideal expert technique in psychodynamic and cognitive-behavioral therapy more than it does the behavior of therapists identified as experts. The most remarkable finding is that
the ideal psychodynamic prototype correlated positively with outcome in psychodynamic as well as cognitive-behavioral treatments, whereas the cognitivebehavioral prototype did not correlate consistently with
outcome in any of the treatment samples. Although a
high degree of adherence to the cognitive-behavioral
prototype was demonstrated by the CB therapists, these
results suggest that psychodynamic techniques may be
more associated with outcome than are CB techniques,
even in the CB sample. The results also indicate that
PD therapists use a broader range of techniques than
do CB therapists. PD therapists appear to be comfortable addressing cognitive themes, treatment goals, extratherapy activities, and new behaviors that patients
might try. As the authors note, these findings demonstrate the importance of studying therapy process in addition to outcome. Without investigation into therapy
process, we cannot know whether a presumptive cognitive-behavioral treatment actually contains significant
psychodynamic ingredients or vice versa. The psychodynamic ingredients may be those most associated with
outcome.
Copyright q 1999 American Psychiatric Association
J Psychother Pract Res, 8:4, Fall 1999
Research Abstracts
Blatt SJ, Sanislow CA, Zuroff DC, Pilkonis PA:
Characteristics of effective therapists: further analysis of data from the National Institute of Mental
Health Treatment of Depression Collaborative Research Program. Journal of Consulting and Clinical
Psychology 1996; 64:1276–1284
Summary: Data from the National Institute of Mental Health–sponsored Treatment of Depression Collaborative Research Program (TDCRP) were reanalyzed
to investigate characteristics of therapists who were
more or less effective in helping patients. The TDCRP
involved 239 depressed patients and focused on three
treatment conditions: cognitive-behavioral therapy
(CBT), interpersonal therapy (IPT), and imipramine
plus clinical management. The study took place at four
treatment sites. Generally, the findings were that all
treatments were effective in treating depression. These
authors developed an aggregate measure of residualized
therapeutic change scores for each patient at termination. These scores served as a measure of therapeutic
effectiveness. The therapists were then rank ordered according to effectiveness and categorized into one of
three groups: less effective, moderately effective, and
more effective. Comparisons indicated that the more
effective therapists, as compared with the less and moderately effective therapists, avoided somatic interventions in their usual practice, devoted relatively more of
their professional time to psychotherapy, were less
likely to believe that medications were a necessary component of successful treatment for depression, and expected that more sessions would be necessary before a
depressed patient began to show significant therapeutic
change. The more effective therapists did not differ
from their less effective colleagues on the basis of beliefs
about etiology of depression.
Comment: This study supports the idea that effective therapists differ from less effective therapists in systematic ways. Perhaps most important, effective therapists appear to be strong believers in the psychotherapy
process. In addition, they express more skepticism
about the necessity of medication for the treatment of
depression, and psychotherapy is a larger part of their
professional practice as compared with the less effective
therapists. It could be that the more successful therapists
communicated their confidence in the therapeutic process to their patients, thereby instilling more hope. Recent research has shown that confidence in one’s therapist is a strong component of the therapeutic bond.1 A
J Psychother Pract Res, 8:4, Fall 1999
strength of this study is that it relates therapist characteristics to actual treatment success. However, many factors influence treatment outcome beyond those attributable to therapist behaviors.
Wiser S, Goldfried MR: Therapist interventions
and client emotional experiencing in expert psychodynamic-interpersonal and cognitive-behavioral therapies. Journal of Consulting and Clinical
Psychology 1998; 66:634–640
Summary: Thirty-one peer-nominated expert cognitive-behavioral or psychodynamic interpersonal therapists provided audiotapes of sessions in which those
therapists judged a significant change event to have occurred. These sessions were then investigated to determine which therapeutic interventions were associated
with high and low emotional experiencing. Affirming
and understanding communications from therapists
were associated with maintaining a high level of experiencing, as were reflections and acknowledgments.
Shifting down to a lower level of emotional experiencing was associated with a protecting and nurturing
stance combined with moderately high interpersonal
control. Verbally lengthy interventions were also associated with shifts to lower levels of affective experiencing. None of the intervention approaches studied were
systematically associated with shifts to a higher level of
emotional experiencing.
Comment: The assumption underlying this study is
that a high level of affective experience produces more
meaningful and enduring change than interventions
conducted solely at an intellectual level. The findings
show that expert psychotherapy technique transcends
orientation. These findings can be useful to therapists
seeking strategies for maintaining a high level of affective experiencing in their patients. The authors explain
that the interpersonal control associated with shifts to
lower levels of affective experience included highly affiliative but gently guiding or challenging interventions
such as, “You’re sad, yes, but perhaps you’re angry,
too?” Comments such as these shifted patients into
more intellectualized and less affect-laden states of
mind. It is interesting that no systematic relationship
was found between intervention style and shifts to
higher levels of affective experiencing. The authors note
that therapists chose among numerous different interventions to produce shifts toward greater levels of experiencing. These included single confrontations; se315
Research Abstracts
quences of gentle, non-direct statements; periods of
silence; and affectively focused questions. In sum, these
results point toward specific interventions used by expert clinicians across therapy modalities that appear associated with positive therapeutic change.
Goldfried MR, Raue PJ, Castonguay LG: The therapeutic focus in significant sessions of master therapists: a comparison of cognitive-behavioral and
psychodynamic-interpersonal interventions. Journal of Consulting and Clinical Psychology 1998;
66:803–810
Summary: Clinically significant sessions obtained
from 36 peer-nominated master cognitive-behavioral
(CB) or psychodynamic-interpersonal (PD) therapists
were analyzed. The patients were treated in a naturalistic setting for problems with anxiety, depression, or
both. “Clinically significant” sessions were defined as
those in which an interpersonal issue central to the patient’s problems was addressed, the therapist observed
an in-session impact on the patient, and the therapist
noted a change in the client (not due to external factors)
within 1 or 2 weeks of the session. Few overall differences in therapeutic focus based on therapy orientation
were found. Several differences were observed, however, when comparing clinically significant segments of
these sessions with less meaningful segments. Within
the significant segments, therapists of both orientations
were more likely to encourage patients to view things
more realistically, provide factual information, or indicate how a specific thought, feeling, intention, or behavior was part of a larger theme. Therapists of both
orientations placed a greater focus on clients’ selfobservations, self-evaluations, expectations, general
thoughts, and emotions during the clinically significant
portion of the session. In addition, more connections or
links were made during the significant portion of the
session, such as how one aspect of a patient’s functioning affected other aspects of functioning or how other
people affected the patient’s behavior. A number of orientation-by-session-portion interactions were observed.
For example, PD therapists were more likely to highlight emotion during the significant portion of their sessions than they were during the nonsignificant portion,
or than CB therapists were during the significant portion of the CB sessions.
Comment: These results provide further support for
the idea that master therapists are similar in their focus
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during the most emotionally significant moments of
therapy, regardless of CB or PD orientation. Unfortunately, this data set does not include outcome variables,
and thus process-outcome links cannot be determined.
Note also that generalizations from this study should be
restricted to problems in which anxiety or depression
are linked to interpersonal issues in the patient’s life.
Thus, as the authors point out, these findings may not
extrapolate to cases with more circumscribed problems
such as panic or obsessive-compulsive behavior.
Jennings L, Skovholt TM: The cognitive, emotional, and relational characteristics of master therapists. Journal of Counseling Psychology 1999;
46:3–11
Summary: Cognitive, emotional, and relational
characteristics of 10 peer-nominated master therapists
were identified through qualitative research methods.
Each therapist had been nominated by at least four
peers within a major metropolitan area. Seven were
women and three men. Six were Ph.D. psychologists,
three were master’s-level social workers, and one was a
psychiatrist. Their ages ranged from 50 to 72 years, and
their level of experience practicing psychotherapy
ranged from 21 to 41 years. Four theoretical orientations were represented: psychodynamic (n44), family
systems (n42), integrative (n42), and existentialhumanistic (n42). All of the therapists worked full-time
in private practice. A systematic qualitative analysis was
conducted and preliminary findings were checked for
accuracy with the therapist sample. Results indicate that
master therapists are voracious learners; draw extensively from accumulated experience; value cognitive
complexity; are emotionally receptive and nondefensive; are mentally healthy and mature individuals who
attend to their own emotional well-being; are aware of
how their emotional health affects work quality; possess
strong relationship skills and are experts at using those
skills in therapy; and believe that the foundation for
therapeutic change is a strong working alliance.
Comment: Rather than focusing on specific skills,
this article identifies key personality characteristics of
peer-nominated master therapists. As other studies have
shown, the key characteristics of master therapists appear not to be unique to a specific therapeutic orientation, but go beyond orientation. The views of these therapists suggest that therapeutic mastery is not simply a
matter of accumulated experience doing therapy, but
J Psychother Pract Res, 8:4, Fall 1999
Research Abstracts
involves constant engagement in improving skills, gaining new knowledge, and remaining open to experience
and feedback from others. This study provides further
support for the notion that relationship skills and therapeutic alliance form the cornerstone for therapeutic excellence. The study would have been much stronger
had it contrasted the master therapists with a sample of
novice or journeyman therapists.
CONCLUSIONS
Taken as a whole, these five studies suggest that expertise in psychotherapy transcends orientation. Master
therapists appear to behave in quite similar ways re-
J Psychother Pract Res, 8:4, Fall 1999
gardless of orientation, particularly during key moments in therapy. They have confidence in psychotherapy as a treatment tool; are pragmatically focused; link
patient experiences to broader themes; and view the
therapy relationship as the foundation of treatment.
Dr. Eells is a clinical psychologist and Associate Professor in
the Department of Psychiatry and Behavioral Sciences, University of Louisville, Louisville, KY.
REFERENCE
1. Stiles WB, Agnew-Davies R, Hardy GE, et al: Relations of the
alliance with psychotherapy outcome: findings in the second
Sheffield Psychotherapy Project. J Consult Clin Psychol 1998;
66:791–802
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