Therapist factors associated with intent to use exposure therapy: a systematic review and meta-analysis.

Exposure therapy is effective but widely underused. Numerous studies indicate therapist factors that might explain this pattern of underuse. This systematic review and meta-analysis synthesised those previous research findings, to identify which therapist factors are clearly associated with their intent to use exposure therapy. A systematic review and six random-effects meta-analyses synthesised studies identified in three databases (Scopus, PsychINFO, Web of Science) and through reference lists and citation searches. Most studies relied on a survey design, resulting in weak quality of research. Twenty-six eligible studies were included in the narrative synthesis, (including 5557 participants), while 21 studies yielded sufficient data to enter the meta-analysis. Medium to large pooled effect sizes indicated that therapists with more positive beliefs, a CBT orientation, and training in exposure therapy were significantly more likely to use exposure. Small pooled effect sizes indicated that older and more anxious therapists were less likely to use exposure. Therapist years of experience was not significantly associated with exposure use. There was no evidence of publication bias. Therapist characteristics clearly play a role in the use of exposure therapy, and future clinical and research work is required to address this limitation in the delivery of this effective therapy.

Emotion regulation of the family therapist.

Outcome research highlights the importance of the therapeutic alliance for the outcome of therapy. Meta-analyses suggest that in family therapy, the therapeutic alliance is even more important than in individual therapy. In family therapy, however, the alliance is more complex than in individual therapy. Through empathy, authenticity and hopefulness the therapist can contribute to an effective alliance. Sometimes during the session, a therapist may experience strong emotions that are in tension with his/her therapeutic aspirations of empathetic listening, authenticity and hopefulness. A therapist might experience boredom instead of curiosity, irritation instead of acceptance, shame instead of authenticity. There is need for some kind of emotion regulation to protect the alliance. Furthermore, as some authors suggest, the therapist's emotions - even the emotions that are first glance seem harmful to the alliance - may also be useful for the therapist. Several case stories illustrate the different ways in which family therapists can deal with their emotions in the session.

Review: Therapist factors and their impact on therapeutic alliance and outcomes in child and adolescent mental health - a systematic review.

BACKGROUND: Young people's mental health is a significant concern globally. The evidence suggests that there is a strong relationship between therapeutic alliance and children's reported outcomes such as symptoms and dropout of services. There are indications that therapist characteristics - including static qualities and dynamic behaviours - can be associated with both alliance and outcomes. METHOD: The aim of this review was to systematically collate, summarise and critique studies reporting on therapist characteristics that might influence the therapeutic alliance or outcomes for young people accessing child and adolescent mental health services. The Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines were followed, and four databases (PsycINFO, PsycARTICLES, MEDLINE and CINAHL) were searched for 'therapist' and 'characteristic' combined with 'alliance' or 'outcome' and related terms associated with these topics. RESULTS: A review of 15 papers showed that therapists' in-session behaviours and interpersonal style have a significant impact on alliance or outcome. One study also indicated important associations with attachment style. Findings related to ethnicity, gender and level of experience were complex; highlighting differences between subgroups, ages, outcome measurement and diagnostic categories. Methodological issues such as secondary analysis on administrative data confounded the interpretation of results. CONCLUSIONS: There are indications that specific therapist factors can impact on alliance and outcomes in child and adolescent mental health services. Future research needs to adopt a prospective design and measure therapist characteristics and their relationship to alliance or outcome over time in a broad range of settings.

Trainee therapist personality and the rating of cognitive behavioural and dynamic interpersonal therapy processes.

Therapist factors are generally thought to be important predictors of the capacity to understand and respond to clinical material. The current study aims to identify which features of personality and clinical symptomatology predict a trainee therapist's rating of cognitive behavioural (CB) and psychodynamic interpersonal (PI) processes in video recordings of these therapies. Eighty psychology trainees completed the Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF) and watched two video recordings of therapy sessions showing prototypical examples of CB and PI psychotherapy, rating the processes they could identify using the Comparative Psychotherapy Process Scale (CPPS). Trainees accurately differentiated CB from PI process while viewing the CB session but rated the CB video higher in PI processes than the PI video itself. Bayesian regression models showed that the most consistent MMPI-2-RF scale that predicted variance in ratings was hypomanic activation (RC9) predicting higher ratings of all psychotherapy processes in both conditions, while clinical scale factors such as Aggressiveness-Revised (AGGR-r) and personality scale factors of Psychoticism-Revised (PSYC-r) and Negative Emotionality/Neuroticism-Revised (NEGE-r) showed some notable but less consistent predictions. The variances in psychotherapy process ratings accounted for by MMPI-2-RF scales ranged from 15% to 51%. The study suggests that some clinical symptoms and personality factors do influence the rating of psychotherapy processes by psychology trainees, but further studies would be required to substantiate such findings. These findings have relevance to therapist training and selection for clinical training and therapist mental health.

Clients' Perceptions of Changes in Their Therapists' Positive Regard in Transitioning from In-Person Therapy to Teletherapy.

OBJECTIVE: To investigate clients' perceptions of changes in their therapists' provision of positive regard (PR) following their transition from in-person therapy to teletherapy.Method A total of 2,118 clients, predominantly White, female, heterosexual, and in their mid-20s, who had been working with their therapist for an average of 20 months in-person and five months in teletherapy completed a Perceptions of Psychotherapy Process Scale (POPPS). This 42-item measure investigated, at a single time-point, the extent to which participants believed that specific therapist-related behaviors, statements, or attitudes changed since shifting to teletherapy. RESULTS: An exploratory factor analysis revealed, among other factors, a factor comprised of six items related to therapist-provided PR (e.g., "my therapist makes me feel cared about"). Clients' scores on this factor indicated a marginal but significant increase in therapists' provision of PR over teletherapy; these scores also significantly predicted scores on a factor reflecting clients' engagement in teletherapy. CONCLUSIONS: Despite the challenges of an abrupt shift to teletherapy, clients perceive their therapists as communicating PR to the same or even slightly higher degrees as compared to in-person therapy pre-pandemic; therapists and clients have seemingly adapted to the new demands of technology to preserve important elements of the therapeutic relationship.

Are we on the same page? A comparison of patients' and clinicians' opinions about the importance of CBT techniques.

Clinicians often omit or underuse several techniques while delivering therapy. These omissions can be due to unconscious factors (e.g., clinician's anxiety), or due to clinicians' deliberate decisions (e.g., modifying therapy believing that such modifications are on the patients' best interests). However, little is known about whether patients consider these modifications necessary. The main aim of this study was to explore the opinions about the important aspects of CBT according to both patients' and clinicians' perspectives. It also aimed to determine whether clinicians' anxiety influenced such preferences. To achieve these aims, two groups of participants were approached-CBT clinicians (n = 83) and CBT patients (n = 167). An online survey with a list of techniques commonly used in CBT was developed for each group, who indicated the importance they attributed to the techniques. Additionally, clinicians completed an anxiety measure. Results indicated that clinicians valued all "change-oriented" techniques and several "interpersonal engagement" techniques more than the patients. The only technique preferred by patients was "relaxation". Higher levels of clinician anxiety were associated with a lower preference for "behavioural experiments" and "exposure". In conclusion, clinicians are encouraged to plan therapy in collaboration with the patient, as well as to discuss the rationale for the implemented techniques.

Therapist Factors Matter: A Systematic Review of Parent Interventions Directed at Children's Behavior Problems.

The present review systematically explored research examining the relationship between therapist-related factors and the outcomes of parent interventions directed at children's behavior problems. A systematic search of the literature was conducted with online scientific databases, parenting programs, web sites, and bibliographic references of the selected articles, according to PRISMA guidelines. A total of 24 quantitative studies met the inclusion criteria. Although some methodological limitations were identified with respect to the measurement of therapist factors, the reviewed research strongly suggests that the therapist plays a critical role in parent interventions directed at behavior problems. In particular, many parent outcomes are found to be related to the parent-therapist alliance, the therapist's fidelity to the intervention, specific therapist's in-session actions, and the therapist's personal variables. The parent-therapist alliance and therapist fidelity to the intervention consistently relate to changes in parenting practices, and alliance additionally relates to fewer perceived barriers to participation in treatment, more treatment acceptability, and greater parenting satisfaction and self-efficacy. In addition, specific in-session therapist interpersonal actions relate to parents' engagement and satisfaction, while both the therapist's interpersonal actions and more active skills relate to parent change. Therapist's personal variables have been scarcely or poorly studied to date, but the results found justify the need to develop further research in this area. In conclusion, more attention should be given to the role of the therapist when implementing parenting programs directed at behavior problems, and more and better research is needed that can overcome the methodological limitations identified.

La presente revisión exploró de forma sistemática las investigaciones que examinam la relación entre los factores relacionados con el terapeuta y los resultados de intervenciones para padres de niños con problemas de conducta. Se realizó una búsqueda sistemática de la bibliografía con bases de datos científicas en línea, sitios web de programas de entrenamiento para padres y referencias bibliográficas de los artículos seleccionados, de acuerdo con las pautas de PRISMA. Un total de 24 estudios cuantitativos reunieron los criterios de inclusión. Aunque se identificaron algunas limitaciones metodológicas con respecto a la medición de los factores del terapeuta, la investigación analizada sugiere marcadamente que el terapeuta desempeña un papel crítico en las intervenciones dirigidas a padres de niños con problemas de conducta. En particular, muchos resultados de los padres se encuentran relacionados con la alianza entre los padres y el terapeuta, la fidelidad del terapeuta a la intervención, las acciones específicas del terapeuta dentro de la sesión y las variables personales del terapeuta. La alianza entre los padres y el terapeuta y la fidelidad del terapeuta a la intervención se relacionan constantemente con los cambios en las prácticas parentales, y la alianza además se relaciona con menos obstáculos percibidos para la participación en el tratamiento, una mayor aceptabilidad de lo mismo y una mayor satisfacción y autoeficacia de los padres. Además, las acciones interpersonales específicas del terapeuta dentro de la sesión se relacionan con la participación y la satisfacción de los padres, mientras que tanto las acciones interpersonales del terapeuta como las habilidades más activas se relacionan con el cambio de las praticas parentales. Hasta la fecha, las variables personales del terapeuta se han estudiado poco o deficientemente, pero los resultados encontrados justifican la necesidad de desarrollar la investigación en esta área. Para concluir, se debe prestar más atención al papel del terapeuta a la hora de implementar programas de entrenamiento para padres de niños con problemas de conducta, y se necesitan más y mejores investigaciones que puedan superar las limitaciones metodológicas identificadas.

Self-reported reflective functioning mediates the association between attachment insecurity and well-being among psychotherapists.

Objective: Subjective well-being is a crucial variable for mental health practitioners. This study examines the influence of therapists' attachment dimensions and self-reported reflective functioning on their perceived well-being. Further, it examines if reflective functioning mediates the association between attachment insecurity and well-being. Method: A total of 416 experienced psychotherapists were enrolled in this cross-sectional study, and completed self-report measures of attachment insecurity, reflective functioning, and well-being. We tested the hypothesized mediation model with path analysis that examined indirect effects. Results: Both attachment anxiety and avoidance dimensions had a significant negative association with perceived well-being with small to medium effects. "Certainty" in reflective functioning had a small positive effect on therapist well-being. Reflective functioning mediated the association between insecure attachment dimensions and well-being, suggesting that therapist's lower ability to mentalize may partially account for the effects of higher attachment insecurity on lower well-being. Conclusion: The well-being of psychotherapists with greater insecure attachment may deserve special attention, and therapists' mentalizing capacities may be targeted by researchers and trainers as a core ability to be cultivated in order to preserve therapists' professional and personal resources.

Mentalizing countertransference? A model for research on the elaboration of countertransference experience in psychotherapy.

As a construct, the elaboration of countertransference experience (ECE) is intended to depict the implicit and explicit psychological work to which therapists submit their experiences with clients. Through ECE, defined as a mentalizing process of a particular kind, therapists' experiences are presumed to acquire and increase in mental quality and become available for meaning-making and judicious clinical use. In this paper, we claim that such an ongoing process facilitates engagement with common therapeutic factors, such as the therapeutic alliance and countertransference management, enhancing therapist responsiveness in psychotherapy. We synthesize relevant literature on countertransference, mentalization, and, in particular, therapists' mentalization, informed by a systematic literature review. As a result, we propose a model for assessing ECE in psychotherapy, comprising 6 diversely mentalized countertransference positions (factual-concrete, abstract-rational, projective-impulsive, argumentative, contemplative-mindful, and mentalizing), 2 underlying primary dimensions (experiencing, reflective elaboration), and 5 complementary dimensions of elaboration. Strengths and limitations of the model are discussed.

Therapist Reflective Functioning, Therapist Attachment Style and Therapist Effectiveness.

This study investigated the relationship between two therapist attributes (reflective functioning and attachment style) and client outcome. Twenty-five therapists treated a total of 1001 clients. Therapists were assessed for reflective functioning and attachment style using the Adult Attachment Interview and the Experiences in Close Relationships Scale. Clinical outcome was measured using the Outcome Questionnaire (OQ-45). Data were analysed using hierarchical linear modelling. Results indicated that therapist reflective functioning predicted therapist effectiveness, whereas attachment style did not. However, there was evidence of an interaction between therapist attachment style and therapist reflective functioning. Secure attachment compensated somewhat for low reflective functioning and high reflective functioning compensated for insecure attachment. Possible implications for the selection of therapy training candidates and therapist training are discussed.

Perceived therapist genuineness predicts therapeutic alliance in cognitive behavioural therapy for psychosis.

OBJECTIVES: The quality of therapeutic alliance is a consistent and stable predictor of therapy outcome. Recent studies have shown therapist characteristics to be relevant predictors of the alliance in psychological therapies in general. However, little is known about the specific therapist characteristics that explain differences in therapeutic alliance in cognitive behavioural therapy for psychosis (CBTp). The aim of this study was to identify relevant therapist characteristics that predict early therapeutic alliance in CBTp. DESIGN AND METHODS: Forty-eight patients with a DSM-IV diagnosis of a psychotic disorder participating in a CBTp trial and 11 therapists were included in the analysis. Therapist characteristics as perceived by the patients (empathy, genuineness, positive regard, competence, and convincingness) were assessed at baseline. Alliance was assessed after the fifth therapy session. Data were analyzed using bivariate correlations and multivariate hierarchic regression analysis. RESULTS: All therapist characteristics were positively associated with patient-rated alliance. Patient characteristics were not significantly associated with alliance and did not predict alliance in the multivariate analysis. Regression analysis revealed therapist genuineness and competence to significantly predict higher patient-rated alliance. CONCLUSIONS: Our results suggest that perceived therapist genuineness is the most relevant predictor of patient-rated therapeutic alliance in CBTp. Future trials using control samples with other mental disorders could clarify whether this finding is specific to CBTp. Therapist training concepts for increasing beneficial therapist qualities are needed. PRACTITIONER POINTS: The patients' perception of the therapist as empathic, genuine, accepting, competent and convincing is associated with therapeutic alliance in CBTp. Perceived therapist genuineness and competence are the most relevant predictors of patient-rated therapeutic alliance. Training and supervision should focus on increasing basic therapist qualities. Limitations of this study include homogeneity of therapists, small sample size, and lack of a control group.

Patient and therapist perspectives on alliance development: therapists' practice experiences as predictors.

UNLABELLED: Research has shown that the therapist's contribution to the alliance is more important for the outcome than the patient's contribution (e.g., Baldwin, Wampold, & Imel, 2007); however, knowledge is lacking about which therapist characteristics are relevant for alliance building and development. The objective of this study was to explore the development of the working alliance (using the Working Alliance Inventory), rated by both patients and therapists as a function of therapist in-session experiences. The therapist experiences were gathered by means of the Development of Psychotherapists Common Core Questionnaire (Orlinsky & Rønnestad, 2005). Data from the Norwegian Multisite Study of the Process and Outcome of Psychotherapy (Havik et al., 1995) were used. Multilevel growth curve analyses of alliance scores from Sessions 3, 12, 20 and 40 showed that the therapist factors predicted working alliance levels or growths differently, depending on whether the alliance was rated by patients or by therapists. For example, it emerged that therapists' negative reactions to patients and their in-session anxiety affected patient-rated alliance but not therapist-rated alliance, whereas therapist experiences of flow (Csikszentmihalyi, 1990) during sessions impacted only the therapist-rated alliance. The patterns observed in this study imply that therapists should be particularly aware that their negative experiences of therapy are noticed by, and seem to influence, their clients when they evaluate the working alliance through the course of treatment. KEY PRACTITIONER MESSAGE: The findings of this study suggest that the working alliance is influenced by therapists' self-reported practice experiences, which presumably are communicated through the therapists' in-session behaviours. The study found a notable divergence between practice experiences that influenced the therapists and those that influenced the patients when evaluating the working alliance. Specifically, practitioners' self-reported difficulties in practice, such as their negative reactions to patients and their in-session anxiety, affected patient-rated alliance but not therapist-rated alliance, whereas therapist experiences of 'flow' during sessions impacted only the therapist-rated alliance. Practitioners should note that patient alliance ratings were more likely to be influenced by therapists' negative practice experiences than by positive ones. The divergence in the patient and therapist viewpoints has potential implications for therapist training and supervision and everyday self-reflection.

Therapist Factors and Outcomes in CBT for Anxiety in Youth.

This study examined the relationship between therapist factors and child outcomes in anxious youth who received cognitive-behavioral therapy (CBT) as part of the Child-Adolescent Anxiety Multimodal Study (CAMS). Of the 488 youth who participated in the CAMS project, 279 were randomly assigned to one of the CBT conditions (CBT only or CBT plus sertraline). Participants included youth (ages 7-17; M = 10.76) who met criteria for a principal anxiety disorder. Therapists included 38 cognitive-behavioral therapists. Therapist style, treatment integrity, and therapist experience were examined in relation to child outcome. Child outcome was measured via child, parent, and independent evaluator report. Therapists who were more collaborative and empathic, followed the treatment manual, and implemented it in a developmentally appropriate way had youth with better treatment outcomes. Therapist "coach" style was a significant predictor of child-reported outcome, with the collaborative "coach" style predicting fewer child-reported symptoms. Higher levels of therapist prior clinical experience and lower levels of prior anxiety-specific experience were significant predictors of better treatment outcome. Findings suggest that although all therapists used the same manual-guided treatment, therapist style, experience, and clinical skills were related to differences in child outcome. Clinical implications and recommendations for future research are discussed.

The forest and the trees: relational and specific factors in addiction treatment.

AIMS: Increased expectations for the use of evidence-based methods in addiction treatment have fueled a debate regarding the relative importance of 'specific' versus 'common' factors in treatment outcome. This review explores the influence of these factors on addiction treatment outcome. METHODS: The authors review and link findings from four decades of research on specific and general factors in addiction treatment outcome research. FINDINGS: Although few would argue that what one does in addiction treatment is immaterial, outcome studies tend to find small to no difference when specific treatment methods are compared with each other or with treatment as usual. In contrast, there are usually substantial differences among therapists in client outcomes, and relational factors such as therapist empathy and therapeutic alliance can be significant determinants of addiction treatment outcome. CONCLUSIONS: In addiction treatment, relational factors such as empathy, which are often described as common, non-specific factors, should not be dismissed as 'common' because they vary substantially across providers and it is unclear how common they actually are. Similarly they should not be relegated to 'non-specific' status, because such important relational influences can be specified and incorporated into clinical research and training.