Therapists' professional and personal characteristics as predictors of outcome in long-term psychodynamic psychotherapy and psychoanalysis

Therapeutic stance towards persons with psychosis - a Grounded Theory study

OBJECTIVE

Over the last decades, psychotherapy of psychosis has increasingly gained attention. The quality of the therapeutic alliance has been shown to have an impact on therapy outcome. Yet, little is know about the influence of the therapeutic stance on the alliance. In this study, we explore psychotherapists' stance towards persons with psychosis with the aim of better understanding its characteristic-hindering and helpful-aspects.

METHOD

6 semi-structured interviews with psychotherapists from three different schools (CBT, PD, ST) were analysed with Grounded Theory. Credibility was checked through external and peer-researcher-supported debriefing.

RESULTS

4 core categories were generated and interrelated in a theoretical model. Therapists' stance was initially characterized by insecurity. Diffent ways of dealing with insecurity yielded different stances: a monological and an open one. A helpful stance was conceived as stemming from openness and was characterized by a dialogical structure. A co-presence (or "dosing") of you and I was conceived as its core aspect.

CONCLUSION

These findings specify the interpersonal dynamics arising from different stances and their impact on the therapeutic alliance and process. Research is still needed to further understand the characteristics of helpful and hindering therapeutic stances, which should also inform the training of psychotherapists.

Measuring psychotherapist functioning with the Therapist Work Involvement Scales (TWIS): reliability, factor structure, and measurement invariance

OBJECTIVES

The Therapist Work Involvement Scales (TWIS) is a self-report research instrument that enables a multilayered description of psychotherapists' experiences when treating clients. The TWIS was created in a comprehensive study of close to 5,000 psychotherapists, and has been used in multiple studies. The aim of the current paper is to clarify the organization and statistical characteristics of the TWIS, and to present an updated version for longitudinal and cross-sectional research.

METHODS

Collection of a large sample of psychotherapy trainees made possible the use of confirmatory factor analysis (CFA) to evaluate the dimensions and structure of therapists' process experiences, assessing reliabilities, measurement invariance over gender, item statistics, and correlations with other measures to show concurrent and predictive validity.

RESULTS

The CFAs largely confirmed the factor structure of four of the five facets, and of the global super-factors. The global factors of Healing Involvement and Stressful Involvement each showed substantial correlations with therapists' attachment style and professional growth, and were used to describe four practice patterns that typify the experiences of therapists.

CONCLUSION

The results have shown the TWIS to be a statistically sound, multidimensional research instrument enabling therapists to describe their experience in current therapeutic work.

Development of the Psychotherapist Character Virtues (PCV) Interview

OBJECTIVE

To develop an interview-based rating method for assessing therapists' beneficial character traits and evaluate its reliability and validity.

METHOD

The semi-structured Psychotherapist Character Virtues (PCV) interview and evaluation method, based on Erik Erikson's and Heinz Kohut's writings on 16 virtues or abilities and achievements of an adult self, was administered to 68 psychodynamic and solution-focused therapists. Inter-rater reliability was assessed based on 20 videorecorded interviews, rated by two evaluators. In a mixed-methods design, validity was investigated against (i) therapist's questionnaire-based self-reported professional and personal background characteristics and (ii) a qualitative content analysis of emotional atmosphere in the interview.

RESULTS

Interrater reliability for individual 16 virtues was acceptable (median correlation .72). From individual virtues, three principal components (Creative Will, Empathy, and Love/Care) emerged with good/excellent internal consistency (component determinacies .95, .85, and .90, respectively) and criterion validity with self-reported professional and personal characteristics. Cluster analysis of therapists' component scores yielded six different therapist character profiles. In qualitative analysis, character profiles meaningfully differed in their impact on the interview's emotional atmosphere.

CONCLUSION

PCV appears promising for evaluating therapists' character virtues, posited to undergird therapists' sensitive attunement and responsiveness. Further research is needed on PCV's predictive validity for therapeutic relationships and outcomes.

The Therapist's Intuition and Responsiveness: What Makes the Difference between Expert and in Training Gestalt Psychotherapists

This study aims to investigate the presence of intuition and responsiveness in early students and in experienced students and psychotherapists, which is understood as the ability to integrate bodily sensitivity and cognition of what is experienced with the patient (aesthetic relational knowing-ARK). The study compares how the therapist's felt sense of the phenomenological intersubjective field and aesthetic relational competence differs between a group of experienced students and psychotherapists and a group of beginners. The sample consisted of 128 participants (20 M; 108 F), finally divided into two groups: "experienced students and psychotherapists" and "beginners". The Aesthetic Relational Knowledge Scale (ARKS), a questionnaire consisting of 58 items targeting three factors (empathy, body awareness, and resonance), was administered. Statistical analyses were conducted to assess (i) differences between the two groups (through Student's t and Cohen's d for effect sizes), (ii) the influence of the level of training for each ARK factor using analyses of covariance for testing the possible influence of demographic variables, and (iii) logistic regressions to compare the influence of the three factors of the ARK model on the group variable with groups as a categorical variable. Significant differences between the two groups were found in body awareness and resonance. Body awareness was found to be the variable best discriminating between the beginners and the experienced students and psychotherapists. Despite being non-significant, there is a tendency suggesting that empathy appears more relevant at the beginning of training. The study shows the importance of training for the development of the therapist's intuition and responsiveness, especially in the factors of body awareness and resonance. The results indicate the importance of assessing and supporting the aesthetic and field resonance of therapists in training, increasing quality and depth of the therapist's responsiveness. This study is limited by a correlational design using self-report and on a limited sample, but it shows that the ARKS can monitor the effectiveness of training related to Gestalt therapeutic competencies.

From Idea Cults to Clinical Chameleons: Moving Physical Therapists' Professional Identity Beyond Interventions

The components of clinical practice are complex, often ambiguous, and influenced by a wide variety of interrelated contextual factors. As appreciation grows for the impact of individuality, complexity, and uncertainty in health processes, effective translation into widespread clinical practice remains limited. In attempts to bring patients effective solutions, well-meaning physical therapists can get trapped in "idea cults," in which a favored idea is supported and others are disparaged. We recommend that physical therapists develop a practice of self-reflection marked by openness and humility to more successfully adapt to the unique needs, values, and preferences of each person. We highlight 4 ways physical therapists can cultivate a more mindful and adaptable clinical approach that can help recognize and navigate the complexities of everyday clinical practice. J Orthop Sports Phys Ther 2022;52(4):170-174. doi:10.2519/jospt.2022.10976.

Person-Centered Psychiatry as Dialogical Psychiatry: The Significance of the Therapeutic Stance

In this article, we present holistic and person-centered perspectives in psychiatry, with the aim of better understanding what a focus on personhood might really mean and what clinical implications it might have. We first introduce classical and philosophical concepts of personhood, in order to then outline person-centered approaches in psychiatry, which mainly focus on the person of the patient. We then argue that, for it to really be person-centered, psychiatry must necessarily also focus on the person of professionals. We thus explore the notion of stance, as the expression of the therapist's personhood. By unpacking the effects that a professional's stance can have on patients, we finally turn to a consideration of the interpersonal sphere. More specifically, we propose clinical considerations on a therapeutic stance that strives to support and to help the person of the patient unfold. Such a stance must - we argue - necessarily be a dialogical one. Drawing on these considerations, we thus claim that a truly person-centered approach in psychiatry must necessarily and automatically be interperson-centered and dialogical. In the concluding remarks, we finally discuss broader societal implications and outline future research perspectives.

How Does It Feel to Be Online? Psychotherapists' Self-Perceptions in Telepsychotherapy Sessions During the COVID-19 Pandemic in Italy

Aims: The COVID-19 pandemic and consequent extreme restrictions imposed by governments across the world forced psychotherapists to abruptly change their working modality. The first aim of the current study was to assess psychotherapists’ self-perceptions (i.e., affective and cognitive perceptions about their self and their self in relation to clients) when providing telepsychotherapy during the first peak of the COVID-19 pandemic in Italy. The second aim was to explore the associations between psychotherapists’ self-perceptions, characteristics, and clinical practices.

Method: An online survey was administered to 281 Italian licensed psychotherapists (M_age=45.15; SD=10.2; 83.6% female) between April 5 and May 10, 2020. The survey comprised ad-hoc questions that were designed to collect sociodemographic details and information related to working practices. Moreover, a semantic differential (SD) scale was developed to assess psychotherapists’ self-perceptions, and a factor analysis was performed from the SD items.

Results: The SD scale showed an overall trend of positive psychotherapist self-perception during telepsychotherapy, despite reports of greater fatigue and directive and talkative behavior during sessions. Four SD factors accounted for 45% of the variance: “Affective Availability,” “Attitude Predisposition,” “Well-being,” and “Interventionism.” Scores on the first three factors were indicative of psychotherapists’ Positive vs. Negative self-perception. A comparison of the Positive and Negative attitudinal profiles using the chi-squared test with Yates’s correction and a Monte Carlo simulation found that psychotherapists with a Positive profile reported greater satisfaction with the telematic modality and were more likely to perceive that their clients were able to maintain privacy during sessions.

Conclusion: The results suggest that Italian psychotherapists have been able to promptly adapt to the imposed telematic modality during the COVID-19 pandemic. However, they may have attempted to compensate for their physical distance from clients by intervening more during sessions. These findings may support psychotherapists who are currently practicing and inform future practitioners who are considering the use of telematic treatment as a routine component of psychotherapeutic care.

Psychotherapists' perception of their clinical skills and in-session feelings in live therapy versus online therapy during the COVID-19 pandemic: a pilot study

During the coronavirus disease 2019 (COVID-19) pandemic, many psychotherapists who were used to seeing their patients in face-toface setting adapted to providing therapies online. In the present pilot study, we investigated therapist current experiences of online therapy compared to live therapy. Twenty-nine therapists completed Clinical Skills, Difficulties in Practice, and in-sessions feelings of Flow, Boredom and Anxiety of the Trainee Current Progress Report, giving a score for each item in two different conditions: Live Therapy and Online Therapy. Compared to Live Therapy, in Online Therapy therapists reported significantly less Clinical Skills, whereas Difficulties in Practice did not differ in the considered conditions. With regard to in-sessions feeling, therapists reported significantly lower scores of Boring and higher scores of Flow in Live Therapy compared to Online Therapy, whereas Anxiety did not differed in the considered conditions.

Personality Assessment and Psychotherapy Preferences: Congruence between Client Personality and Therapist Personality Preferences

Consideration of client preferences has been emphasized as important to therapeutic outcomes, such as treatment engagement and retention. Although studies have investigated several client and therapist characteristics associated with client preferences, few have considered whether people have preferences regarding a potential therapist's personality. The current study extended prior research on client preferences by examining the influence of participants' Big Five personality traits on preferences for therapist personality characteristics utilizing latent profile analysis. We expected congruence between client personality traits and preferred psychotherapist personality traits. In both undergraduate and community samples, results indicated that participants generally prefer a psychotherapist with personality characteristics similar to their own. Our findings establish the presence of preferences based on personality factors and have implications for future research directions and the role of personality assessment in routine clinical practice.

The professional and personal characteristics of effective psychotherapists: a systematic review

Objective: Psychotherapists differ notably in the outcomes their patients achieve, and the characteristics that may explain these differences have attracted increasing interest. We systematically review studies on therapist pre-treatment characteristics predicting patient outcomes. Method: Systematic searches on databases for psychotherapy research, clinical psychology, and medical science for the years 2000-2018 identified published research examining therapist characteristics and psychotherapy outcomes. Of 2041 studies, 31 met inclusion criteria. Results: Findings show a few direct effects of therapist intrapersonal variables (e.g., self-relatedness, attachment) and several interaction effects with other constructs (e.g., patient pathology) on outcome. There is little support for the relevance of self-rated social skills. However, more consistent evidence has recently emerged for performance-based measurements of professional interpersonal skills, especially when elicited in challenging situations. Patient outcomes were also predicted by therapists' self-rated professional characteristics, such as their experienced difficulties in practice, coping mechanisms, and attitudes towards therapeutic work, indicating that therapist self-perception also matters, although not always in the direction expected. Conclusions: More effective therapists seem characterized by professionally cultivated interpersonal capacities, which are likely rooted in their personal lives and attachment history. Research guidelines are proposed for moving this field forward (including larger samples, multilevel modeling, and in-depth qualitative work).

Effectiveness of psychoanalysis and long-term psychodynamic psychotherapy on personality and social functioning 10 years after start of treatment

The evidence on potentially greater benefits of psychoanalysis (PA) vs. long-term psychodynamic psychotherapy (LPP) is scarce. This study compared the effectiveness of PA and LPP on personality and social functioning during a 10-year follow-up from the beginning of the treatments. The eligible patients, 41 self-selected for PA and 128 assigned to LPP, were 20-45 years of age and had anxiety or mood disorder. Outcomes were analyzed using ten standard measures of personality and social functioning, carried out 5-9 times during the follow-up. Different change patterns by time in PA and LPP emerged, suggesting less benefit of PA during the first years of follow-up and more benefit in most outcomes thereafter. Greater post-treatment improvement in PA than in LPP was seen up to 1-2 years after PA had ended in more mature defense style (DSQ), level of personality organization (LPO), more positive self-concept (SASB), more improved social adjustment (SAS-SR) and sense of coherence (SOC). However, at the 10-year follow-up the differences were non-significant. In conclusion, PA may give some additional benefits when long-term aims are linked to personality and social functioning. The relatively small differences and higher costs in comparison to LPP may restrict the feasibility of PA.

"It's both a strength and a drawback." How therapists' personal qualities are experienced in their professional work

Objective: The aim of this study was to gain knowledge about how the integration of personal and professional experiences affects therapeutic work. Method: Therapists (N = 14) who had been recommended by their leaders at their individual workplaces were interviewed twice with semi-structured qualitative interviews, which were then subjected to thematic and Interpretative Phenomenological Analysis. Results: All the therapists in the sample described their personal qualities as an experienced tension between their personal strengths and vulnerabilities in the therapeutic setting. This tension came to expression through four subordinate themes: (a) The tension between perceiving oneself as a helper while dealing with one's own needs for attention and care; (b) The tension between the ability for embodied listening to the patient while tuning into oneself; (c) The tension between staying present while handling aggression and rejection from clients; and (d) The tension in striving for a constructive balance between closeness and distance. Conclusion: The results point to ways in which the personal selves of the therapists may affect their professional role performance. Drawing upon previous research and literature on the topic, the paper discusses how therapists' personal qualities are experienced as affecting their work and suggests several implications for psychotherapy training and practice.

A proposed conceptualization of therapeutic competence: the three level model

A model of therapeutic competence that equally satisfies the requirements of practice and research is still lacking. The existing models are not widely accepted, at least partially because the postulated competences can often not be operationalized in a satisfactory manner. Yet, in order to be measurable, therapeutic competences need to be operationalized. We present the Three Level Model of Therapeutic Competence as a working model for studying therapeutic competence. The model proposes that therapeutic competence develops based on rather stable individual Dispositions, which promote the acquisition of therapeutic competences. We further distinguish between Basic Competences, which are mostly independent of the theoretical orientation of the therapeutic approach, and Specific Competences, which are defined based on the theoretical underpinnings of a therapeutic orientation (e.g. Cognitive Behavioral Therapy). We describe this model and outline how it can be used to operationalize and assess therapeutic competence.

Do therapists' subjective variables impact on psychodynamic psychotherapy outcomes? A systematic literature review

BACKGROUND

Despite growing attention to the general therapist effects in a wide range of clinical settings, little is known about the individual, cross-situational, and therapy-nonspecific variables that impact on the differential effectiveness of clinicians. The current study is a systematic review of the evidence relating to the influence of therapist's subjective characteristics on outcomes of psychodynamic psychotherapies.

METHOD

A multistage and systematic search of articles published between 1987 and 2017 identified 30 relevant studies, which were organized into 6 areas according to the specific therapist's variable considered.

RESULTS

Therapists' interpersonal functioning and skills showed the strongest evidence of a direct effect on treatment outcomes. Furthermore, there were preliminary evidence that therapists' attachment styles, their interpersonal history with caregivers, and their self-concept might affect outcomes through interaction effects with other constructs, such as technical interventions, patient's pathology, and therapeutic alliance. The high variability between studies on therapists' overall reflective or introspective abilities and personality characteristics suggested the need for more systematic research in these areas, whereas therapists' values and attitudes showed small effects on therapeutic outcome.

CONCLUSIONS

The present review clarifies how a deep examination of the contribution of therapists' subjective characteristics can help elucidate the complex association between relational and technical factors related to the outcome of psychodynamic treatments.

Factors related to psychotherapists' self-assessment when treating anxiety and other disorders

The aim of the study was to replicate and extend recent findings regarding therapists' self-assessment biases. This study examined clinicians' estimates of their abilities when working with general clinical groups and with anxious patients, and of the recovery/improvement rates of their clients. It also considered what clinician personality traits and clinical practice elements were associated with such estimates. A total of 195 out 801 clinicians completed a survey regarding self-ratings, team ratings, therapy outcomes for their clients, and their own personality traits. The great majority of clinicians rated themselves and their teams as being better clinicians than their peers, though not to as extreme a level as in the previous study. They also reported exceptionally positive therapy outcomes. Due to the large proportion of non-responders, it is possible that these findings do not reflect actual self-assessment bias, but a greater willingness to participate among clinicians who are more skilled and with particular personality styles. However, the data suggest that perceptions of skill and therapy outcome might be associated with clinician personality characteristics, though not with other clinical practice variables. These interpretations should be treated with caution due to the limited response rate. Different possible explanations for these patterns of self-assessment are outlined, including conscious and unconscious processes. Methods for enhancing accurate skill perception are discussed, including self-monitoring and supervision.