Not every psychotherapist is equally effective, so determining what makes certain therapists more effective than others is essential to improving clients’ experience of psychotherapy. A recently published study in Counselling and Psychotherapy Research examined the behavior of a highly effective psychotherapist in the first few sessions with her clients. Qualitative analyses of the recorded sessions showed that this psychotherapist acted in ways with her clients to promote their sense of agency and collaboration between them, support their exploration of meaningful experiences, and create a climate of emotional security.
These findings support the central role of the therapeutic relationship and the importance of therapists’ responsiveness to clients’ needs and suggest competencies for training therapists.
The researchers, led by Sílvia Caçado from the University Institute in Lisbon, Portugal, described themselves as person-centered and existentialist in their therapy orientation, informed by common factors of effective therapy across orientations. They discussed various qualities of effective psychotherapists, as defined in the literature. This ranged from valuing their personal and professional development in continuous learning and feedback to improving clients’ motivation and hope for change by guiding clients to increase their self-awareness.
They note:
“However, to date, there is little empirical research focused on the study of the concrete clinical actions of highly effective therapists in the early stages of therapy. The literature identifies these very early stages as crucial moments in establishing good proximal outcomes, such as therapeutic alliance and the introduction of expectations about change.
The aim of this study was to identify the most salient aspects of conducting first psychotherapy sessions by a highly effective therapist. Specific questions were as follows: (a) What therapeutic activities are practiced by this highly successful therapist in the first three initial sessions with these good-outcome clients? (b) How do these therapeutic activities seem to contribute to the success of these psychological interventions?”
The researchers selected an expert psychotherapist from a British university counseling center based on her superior clinical outcomes compared to her colleagues rather than the reputation of other therapists, as is sometimes done in studies of expert therapists. The recordings of the first three sessions were taken from two clients who had the most successful outcomes in their caseload, both young male college students with depression.
To study the therapist’s in-session actions in an inductive and contextualized manner, the researchers employed a constructivist grounded theory method to analyze the session recordings qualitatively. The sessions were transcribed and coded to identify the therapist’s clinical strategies by analyzing her behaviors and therapeutic intentions. Coding started at a basic level by analyzing the transcripts line-by-line, and then, through constant comparison of these codes, it led to more focused, higher-order categories until they achieved saturation or when further data analysis produced no new categories.
To maintain reflexivity during the analysis, researchers tried to bracket their assumptions about therapy. Once the analysis was completed, the researchers ultimately came up with three overarching domains of the therapist’s clinical strategy, which included 12 categories. Quotes from the transcripts were included to highlight these categories. These included:
“Promoting clients’ sense of agency and the collaborative nature of the therapeutic process.”
The therapist used open questions and dialogue to encourage her clients to reflect on themselves, their worldviews, and their ambitions. She encouraged them to see themselves as competent in handling life’s challenges by reflecting on how they have coped well before and the psychological resources they have demonstrated. In sometimes subtle ways, she communicated her interest in how they understood their problems and centered her clients’ voices by ensuring that they ultimately directed treatment and that her perspectives were tentative to their agreement.
By continually attempting to clarify and re-evaluate clients’ goals for therapy, the therapist encouraged clients to express their needs and focus their sessions on them. When negotiating and co-formulating expectations for therapy with clients, the therapist seemed to foster a sense of mutuality between her and her clients. She often meta-communicated about her intentions for various behaviors and the relational difficulties experienced between them in sessions.
“Supporting clients’ exploration of meaningful contents, balancing responsively between following clients and introducing new dimensions.”
The therapist attempted to stay close to her clients’ narratives, focusing on their internal experiences of specific episodes and moving their focus away from abstractions about these narratives and what they might mean. Her clinical formulations were often open-ended. When clients had trouble staying with their experience, she guided them more directly, such as by asking them to pick a label for a feeling in a particular instance.
The therapist was sensitive to a variety of in-session cues from clients, both verbal and nonverbal, and pointed them out at times to highlight possible pertinent concerns that the client had not yet expressed directly. She attempted to clarify the various relevant patterns she observed in clients’ narratives, whether they were conflicts, interpersonal patterns, or coping styles. These tentative clarifications seemed to highlight problematic aspects of clients’ experiences, which could lead to more client processing. The therapist also responsively provided interpretations to her clients’ narratives, sometimes challenging them, but ultimately was attuned to her clients’ reactions to consider how they landed.
“Creating a climate of emotional security based on empathic presence, authenticity, and positive regard.”
The therapist used subtle cues to communicate her attentive presence to clients, either through short utterances (e.g., “mhmm”) or mirroring clients’ own words to validate their experiences. Occasionally, as a sign of her authentic presence, the therapist disclosed to the client her internal experience of the session to help interpret the client’s experiences that resonated with her.
Through reflections and inferences, she expressed empathy and validated clients’ experiences, which led to attunement between her and her clients, as shown by their confirmation of her clarifications and quick turn-taking in their dialogue. Such actions seemed to cultivate an emotionally secure setting that led clients to explore their problems in sessions with more depth.
The researchers then explored how these domains and categories relate to psychotherapy literature findings. They particularly focused on the importance of therapists promoting client agency, helping clients meaningfully explore their experiences, and being appropriately responsive in knowing whether to lead or follow during particular in-session moments. They discussed how therapeutic presence was noted in the therapist’s actions, sometimes nonverbally, as well as her embodied empathy, which, in attuning to her own internal experience, allowed her to empathize with clients and communicate this to them.
Based on these findings, the researchers suggested:
“…The three major dimensions and their subcategories be considered as a checklist for therapists in training. That is, trainees can watch (or listen to) their therapy sessions, to assess whether these competencies are present in their therapeutic intervention with clients. This specific part of the training is focused on the first sessions. The same procedure can be applied by more experienced therapists.”
The findings of this study reflect other research on effective therapists. This is especially true of the importance of cultivating a good therapeutic relationship with clients, who find this relationship to be a meaningful part of their treatment experience.
Effective therapists develop interpersonal skills in their profession, often rooted in their personal relational development. In recent meta-analytic studies, therapists’ ability to form positive working alliances with their clients was found to be related to more successful treatment outcomes. Empathic therapists, especially when rated by their clients, were more likely to achieve better clinical outcomes.
Research on existential concerns and therapist effectiveness shows that therapists with clients who developed more meaning in life through a strong therapeutic bond demonstrated better clinical outcomes. Additionally, therapists reported that the more in touch they were with their own existential concerns, the more able they were to appropriately respond to clients’ existential concerns.
There are clear limitations in analyzing one therapist and two of her cases, including the generalizability of such findings to therapeutic dyads (therapist-client) that differ in diagnostic presentations and with major differences in social positioning. However, this research suggests that therapists across orientations could learn about being more collaborative with their clients and provide the conditions necessary for them to do the difficult work of therapy.
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Caçador, S., Sousa, D., & Cooper, M. (2024). Inside the consulting room of a highly effective therapist: An analysis of first sessions. Counselling and Psychotherapy Research, 24(2), 681–691. https://doi.org/10.1002/capr.12705 (Link)
Dear Javier, I deeply respect your intelligence, tenacity, and courage for publishing the articles you publish in Mad in America. I don’t understand much of the invective that has been sent your way these last few years. Keep doing what you’re doing. There are many mental health therapists like myself who value the perspective you are sharing. Michael Robin
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Thank you Michael!
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Dear Javier, Your article provides an excellent background for what I tried to describe in my piece in Mad in America, Healing My Broken Story: The Power of Compassionate Relationships (Sept 8, 2023). I hope we can continue to communicate and share ideas.
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William M Epstein’s three key books are useful here – the illusion of psychotherapy, psychotherapy as religion and psychotherapy and the social clinic in the united states, soothing fictions. Across these books he takes apart the best of the evidence base for psychotherapy and dismantles it on methodological grounds. In the process demonstrates none of it has any robust evidence supporting it and it can be harmful – he’s routinely ignored – some of his critique is as follows:
Publication Bias: Epstein highlights the prevalence of publication bias in psychotherapy research, where studies with positive outcomes are more likely to be published, leading to an incomplete and potentially biased understanding of the effectiveness of various therapeutic approaches.
Lack of Rigor: He criticizes the methodological rigor of many studies in the field, noting flaws such as small sample sizes, inadequate control groups, and reliance on self-report measures, which undermine the validity and generalizability of findings.
Inconsistent Definitions and Measures: Epstein points out the lack of consistency in how terms are defined and measured across studies, making it difficult to compare results or draw meaningful conclusions about the effectiveness of different therapeutic interventions.
Overemphasis on Quantitative Research: He suggests that the dominance of quantitative research in the field may overshadow qualitative insights and fail to capture the complexities of human experience and the therapeutic process.
Subjectivity of Diagnosis: Epstein argues that psychiatric diagnoses are often based on subjective interpretations of symptoms rather than objective criteria, leading to inconsistency and variability in diagnosis across clinicians.
Lack of Validity: He suggests that many psychiatric diagnoses lack validity, meaning they do not accurately represent distinct, biologically-based disorders. This undermines the scientific basis of psychotherapy research that relies on these diagnoses as a framework for understanding and treating mental health issues.
Reliability Concerns: Epstein raises concerns about the reliability of psychiatric diagnoses, noting that different clinicians may reach different diagnoses for the same individual. This inconsistency undermines the reliability of research findings based on these diagnoses.
Impact on Treatment Efficacy: The reliance on questionable psychiatric diagnoses may also affect the efficacy of psychotherapy treatments, as interventions based on flawed diagnostic frameworks may not effectively address the underlying issues experienced by individuals seeking therapy.
There are other critics – again mostly ignored by the field – its a house of cards, profitable and useful to power as it helps to obfuscate a range of cultural disorders, that are magically turned into personal disorders and therefore helps to maintain a toxic status quo.
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Yours is an excellent summary of the numerous fallacies and self-serving rationalizations of the so-called mental health industry.
I would also recommend Dr. Jeffrey Masson’s book “Against Therapy: The Myth of Emotional Healing.”
There can be no such thing as psychotherapy in the literal sense, inasmuch as except for clearly verifiable neurological disorders, states of emotional distress labeled as mental disorders or illnesses have nothing to do with brain pathology, despite the many efforts undertaken over many decades to identify genetic defects, chemical imbalances, or damaged neural circuits. Without a body of credible findings obtained through careful, long-term, and repeatable experiments and testing (the various iterations of the ever-expanding DSM lack all scientific legitimacy in this regard), any criteria for assessing the effectiveness of a particular school of therapy (from among the several hundreds that currently exist) are necessarily wholly subjective and purely hypothetical.
As I once mentioned in a previous post, for several decades after the Second World War Freudian therapy was considered the gold standard of treatment for neuroses. Then Arthur Janov came on the scene in 1970 with his claim that Primal Therapy superseded all previous, supposedly ineffective modalities. And now CBT is lauded as the optimum panacea for those with problems in living (Thomas Szasz’s term). What can be the universally valid basis for evaluating the efficacy of these or any other treatments?
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I’ve worked as a psychotherapist for about 5 years now, and as with most therapists my initial training was heavy on CBT, DSM, and medical-model thinking. For years, I was puzzled by the repeated experience that the clients who completely stumped me and whose problems I felt totally incompetent to “solve” or “cure” were often the ones whose lives improved most dramatically during “treatment”. Whenever I asked them for feedback, they insisted that the therapy was very helpful and they kept coming back, even though neither they nor I could explain what I was “doing” to contribute to their progress. I have come to believe more and more that “relational wounds are healed in relationship”, that the reason I was so effective with those clients was BECAUSE I was forced to abandon my manuals and put all my energy into the relationship itself. So I like seeing more and more of this kind of “common factors” research, and I’ve heard that some therapist training programs are starting to incorporate it as well.
Psychotherapy is just as absurd and potentially harmful as psychiatry, IF its practitioners think of themselves as medical providers treating brain diseases or personal problems. It is potentially transformational if practiced by folks who know themselves as professional relationship builders providing an artificial secure attachment “pit stop” where already whole but temporarily injured humans can heal their relational wounds before heading out to build the more interconnected world that we all need and deserve.
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I certainly favor the development of meaningful relationships, but I don’t accept the notion that self-styled therapists are better able to accomplish this worthwhile goal than non-judgmental, non-hierarchical support groups bringing together people who confront similar problems in living. For without universally applicable, verifiable criteria for judging the efficacy of one form of treatment over another, whence do mental health professionals derive their supposedly superior insight, wisdom, and interpersonal skills? What gives them the right to pass judgment on the emotional well-being of their clients and to pin degrading psychiatric labels upon them (for insurance billing purposes)? The entire mental health industry is based on nothing but self-arrogated authority and false premises.
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