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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 316 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; 66:791–802 317