The impact of alliance-focused and facilitative interpersonal relationship training on therapist skills: An RCT of brief training

[Measuring and training of therapeutic competencies]

This article provides an overview of our research concepts on therapeutic competencies with regard to three main questions. The first research question deals with therapists' competencies to succesfully handle transference and countertransference in the cotext of Alliance Ruptures. Research on the Alliance-Focused Training and on subjective countertransference is presented. The second research question deals with therapists' general interpersonal skills. The research approaches outlined here concern the construct of Facilitative Interpersonal Skills (FIS) and the measurement of these skills using the FIS-task. In further studies on this topic, we are focusing on the question of which therapist characteristics are associated with higher interpersonal skills and which linguistic and phonetic features characterise therapist responses that are rated as interpersonally competent. Another study concerns the tendency of therapists to overestimate their interpersonal skills (self-assessment bias). The third main research question deals with the competence to apply therapeutic techniques and to create helpful change processes. An instrument to assess verbal techniques (Psychodynamic Intervention List) and research approaches focusing on the description and the assessment of mediators of change are presented.

Listening quality leads to greater working alliance and well-being: Testing a social identity model of working alliance

OBJECTIVES

Characterization of psychotherapy as the "talking cure" de-emphasizes the importance of an active listener on the curative effect of talking. We test whether the working alliance and its benefits emerge from expression of voice, per se, or whether active listening is needed. We examine the role of listening in a social identity model of working alliance.

METHODS

University student participants in a laboratory experiment spoke about stress management to another person (a confederate student) who either did or did not engage in active listening. Participants reported their perceptions of alliance, key social-psychological variables, and well-being.

RESULTS

Active listening led to significantly higher ratings of alliance, procedural justice, social identification, and identity leadership, compared to no active listening. Active listening also led to greater positive affect and satisfaction. Ultimately, an explanatory path model was supported in which active listening predicted working alliance through social identification, identity leadership, and procedural justice.

CONCLUSIONS

Listening quality enhances alliance and well-being in a manner consistent with a social identity model of working alliance, and is a strategy for facilitating alliance in therapy.

Routine Outcome Monitoring and Clinical Feedback in Psychotherapy: Recent Advances and Future Directions

In the past decade, there has been an increase in research related to the routine collection and active use of standardized patient data in psychotherapy. Research has increasingly focused on personalization of care to patients, clinical skills and interventions that modulate treatment outcomes, and implementation strategies, all of which appear to enhance the beneficial effects of ROM and feedback. In this article, we summarize trends and recent advances in the research on this topic and identify several essential directions for the field in the short to medium term. We anticipate a broadening of research from the focus on average effects to greater specificity around what kinds of feedback, provided at what time, to which individuals, in what settings, are most beneficial. We also propose that the field needs to focus on issues of health equity, ensuring that ROM can be a vehicle for increased wellbeing for those who need it most. The complexity of mental healthcare systems means that there may be multiple viable measurement solutions with varying costs and benefits to diverse stakeholders in different treatment contexts, and research is needed to identify the most influential components in each of these contexts.

A 21st Century Principle-Based Training Approach to Psychotherapy: A Contribution to the Momentum of Transtheoretical Work

Background

Despite the finding that the majority of psychotherapists adopt a rather process-oriented and integrative stance, it is uncommon that psychotherapy trainings are transtheoretical and transdiagnostic. Considering principles of change that cut across different schools of therapy holds promise for developing truly research-informed psychotherapy trainings. Common principles of change may answer the question what should be trained. Another important question is how to train. In current psychotherapy training programs, transfer of theory into practice relies mainly on role-playing exercises and supervised practice, both of which have their limitations.

Aims

A fantasy for the future would be the development, implementation, and evaluation of a complementary 21st century online principle-based and marker-led psychotherapy training: incorporating the concepts of deliberate practice as well as expert training, the huge potential of technologies, and considering the importance of (context) responsiveness.

Conclusion

To illustrate this idea, we present a training that we are currently developing, an online Alliance-Focused Training.

The influence of deliberate practice on skill performance in therapeutic practice: A systematic review of early studies

OBJECTIVE

Deliberate practice (DP) is recommended as a new approach to facilitate the acquisition of discrete therapeutic skills, however, its implementation and effectiveness in psychotherapy remains unclear.

METHOD

A systematic search on DP for therapeutic skills among psychotherapy trainees and psychotherapists yielded eleven studies for inclusion. Nine were randomized controlled studies (RCTs), including seven unique RCTs, and two were within-group studies.

RESULTS

Risk of bias was assessed as "high" for one RCT, "some concerns" for the remaining RCTs, and "serious" for within-group studies. All RCTs found the DP group performed better than the control group. All studies involved efforts to improve performance based on learning objectives and iterative practice but varied in the source of expert guidance and feedback. The included studies provide limited insight into best practice for delivering DP.

CONCLUSION

The results highlight the paucity of research in this field; however they offer insight into current applications of DP and provide preliminary empirical support DP for as a model for promoting the development of discrete therapeutic skills. Given the rapid dissemination of DP publications and manuals in psychotherapy, future research is strongly encouraged.

A re-introduction of the psychodynamic approach to the standard clinical psychology curriculum

OBJECTIVE

There is a strong evidence-base for a psychodynamic approach, supporting primary theoretical tenets as well as the treatment effectiveness. Additionally, there are increasing calls from the field for more individualized treatment for clients, and the lack of training in multiple orientations limits the ability of students in clinical psychology Ph.D. programs in the United States to personalize their treatments. The accumulated evidence-base for contemporary relational psychodynamic theory and therapy places it in good standing to return to the standard clinical psychology curriculum, along with other evidence-based approaches.

METHODS

We use data from the Insider's Guide (which describes clinical Ph.D. programs in the United States) from three time points over 20 years to document the waning psychodynamic approach in clinical psychology programs. We review the scientific evidence for four primary tenets of a contemporary psychodynamic approach: three related to development-from healthy to psychopathological: (1) unconscious processes; (2) internal representations of self and other; (3) dimensional model of psychopathology, and a fourth tenet that builds on these three and is the foundation for a contemporary psychodynamic approach to psychotherapy: (4) therapeutic relationship as a primary mechanism of change.

RESULTS/CONCLUSIONS

Based on the review of the evidence, we make specific recommendations for clinical psychology training programs about how to include a psychodynamic approach in the curriculum.

Therapists who foster social identification build stronger therapeutic working alliance and have better client outcomes

BACKGROUND

For decades we have known that therapeutic working alliance is a key contributor to client engagement and positive outcomes in therapy. However, we have made little progress in narrowing down its determinants, which is critical in supporting trainees to optimize such alliance. We make a case for the value of incorporating social psychological frameworks into models of alliance and explore the role of social identity processes in the development of therapeutic alliance.

METHOD

Across two studies, over 500 psychotherapy clients completed validated measures of alliance, social identification with their therapist, positive therapy outcomes, and a range of client and therapist characteristics.

FINDINGS

Social identification strongly predicted alliance in both samples, whereas client and therapist characteristics showed few such associations. Alliance mediated the relationship between social identification and positive therapy outcomes. In addition, we found evidence that (a) personal control is a key psychological resource in therapy that arises from social identification, and (b) therapists who engage in identity leadership (i.e., who represent and build a social identity that they share with clients) are more likely to foster social identification and its downstream benefits.

INTERPRETATION

These data show that social identity processes are key to the emergence of working alliance. We conclude with a discussion of how recent social identity and identity leadership interventions might be adapted to train therapists in relevant identity-building skills.

Therapists' self-assessment of time spent on learning activities and its relationship to treatment outcomes: A replication study

OBJECTIVES

This study investigated whether therapists' self-assessed time spent on learning activities was associated with treatment outcomes. The study was a replication of Chow et al.'s (2015) study, which showed that the most effective therapists spent more total time on solitary learning activities than less effective therapists. The present study sought to replicate this finding, and it explored the association between 25 specific activities of therapists and clients' treatment outcomes. Also, this study explored which learning activities therapists found most relevant for improving their performance.

METHODS

In this naturalistic longitudinal study, data from 2424 outpatients who were being treated by 40 different therapists were analyzed using multilevel analyses. Posttreatment scores on the OQ-45 (controlled for pretreatment client variables) were used to measure treatment outcome. The RAPID Practice-D was used to measure therapists' learning and other activities spent with the aim of improving their therapeutic skills.

RESULTS

The results showed that the total amount of time that therapists indicated they spent on learning activities did not predict clients' treatment outcomes. Also, no specific learning activities were related to clients' outcomes. Nevertheless, therapists indicated that they perceived several specific activities to be highly relevant for improving their skills.

CONCLUSION

The results showed that therapists' perceptions of how much time they spent on learning activities was not related to their performance. This might suggest that therapists' perceptions of their activities is inaccurate or that they attach value to the wrong activities. It also indicates the importance of not relying solely on the self-assessments of therapists to evaluate a therapist's training and its relationship with outcome.

Evaluating Dialectical Behavior Therapy Training With Mental Health Clinicians

A substantial body of research supports dialectical behavior therapy (DBT) as an evidence-based treatment for those with borderline personality disorder (BPD); however, there remains a lack of mental health clinicians trained in this modality, resulting in limited clinician competencies and skills. Furthermore, the effectiveness of DBT trainings with mental health clinicians remains understudied. The present study evaluated a comprehensive 5-day DBT-Linehan Board of Certification training program. Informed by the Theory of Planned Behavior, this study assessed changes in clinician knowledge, attitudes, perceived behavioral control (PBC), intentions, and behaviors relevant to DBT at baseline, posttraining, and 6-month follow-up. Results showed large, significant pre-to-post training improvements in clinicians' knowledge, attitudes, PBC, and intentions related to DBT implementation. Large improvements in knowledge, attitudes, and PBC were sustained at follow-up. A significant improvement in actual behaviors was also found at follow-up. Implications of the present study and directions for future research are discussed.

Effect of deliberate practice training of graduate students in general psychotherapeutic skills compared with theoretical teaching: protocol for the randomised controlled TRIPS trial

INTRODUCTION

Psychology students at universities in Denmark and worldwide often receive relatively little clinical training, even though such training is crucial to job performance after graduation. Training common psychotherapeutic skills, such as being empathic and facilitating the therapeutic alliance, is critical since these skills are related to psychotherapy outcomes. In this study, a deliberate practice-based approach to student training will be compared with theoretical teaching. The main hypothesis is that deliberate practice training will result in a larger improvement in students' observer-rated interpersonal skills.

METHODS AND ANALYSIS

The TRaining of graduate students In general Psychotherapeutic Skills study has a double-centre, randomised, assessor-blinded, two-way crossover study design. About 200 graduate students from two Danish universities will be randomised into two groups, (a) deliberate practice training of common psychotherapeutic skills using role-play and Skillsetter, an online skill-building system with therapy videos or (b) theoretical teaching. Group a will first receive the experimental condition, followed by the control condition, while group b will receive the conditions in reverse order. Each condition consists of 15 hours of classroom participation and homework. The primary outcome is facilitative interpersonal skills-observer. Secondary outcomes include the facilitative interpersonal skills-self-report, the Counselor Activity Self-Efficacy Scales and the Interpersonal Reactivity Index. Outcomes will be measured at baseline (week 0), after the first condition (week 5; before the crossover, reflecting true randomisation) and after both conditions (week 10). Main outcome analyses will be performed at week 5. Several predictors of the effect of deliberate practice will be explored.

ETHICS AND DISSEMINATION

Ethical approval from university ethics boards has been obtained. All participants will be asked to provide informed consent before participation. Once completed, the study can potentially transform the training of psychotherapy in graduate education, which, ultimately, may positively influence psychotherapy outcomes (IP-IRB / 03092021).

TRIAL REGISTRATION NUMBER

NCT05164497.

An apprenticeship model in the training of psychotherapy students. Study protocol for a randomized controlled trial and qualitative investigation

Background

One approach towards advancing the quality of mental health care is to improve psychotherapists’ skills through education and training. Recently, psychotherapy training has benefitted from adapting training methods from other professions (e.g., deliberate practice). The apprenticeship model has a long history in skill trades and medicine, but has yet to be adopted in training mental health professionals. This study aims to investigate the impact of apprenticeship training on clinical psychology students’ skills.

Methods

In a pragmatic mixed-methods trial, 120 first year students in a Master’s degree clinical psychology program will be randomized to either training-as-usual or training-as-usual plus psychotherapy apprenticeship. In the intervention group, students will participate, over a period of 10 weeks, in weekly treatment sessions together with licensed therapists at outpatient mental health and substance use treatment clinics. Outcomes are assessed post-intervention and at two-year follow-up. The main outcome measure is the Facilitative Interpersonal Skills (FIS) performance test. Additional self-report measures tap self-efficacy, self-compassion, worry, rumination, and stress. Weekly reflection log entries written by the students will be qualitatively analyzed in order to gain an in-depth understanding of the learning process. Students’ and therapists’ experiences with the intervention will be explored in focus group interviews.

Discussion

To the best of our knowledge, this is the first controlled study to investigate the impact of apprenticeship as an isolated training component in the education of clinical psychologists. The study is designed so as to yield a comprehensive understanding of an approach which could prove to be a valuable supplement to the existing educational methods in this field and ultimately, contribute to improve the quality of mental health care.

Facilitative interpersonal skills are relevant in child therapy too, so why don’t we measure them?

One of the consistent findings from psychotherapy process research has been the impact of therapist effects on patient change and the therapeutic alliance. The Facilitative Interpersonal Skills (FIS) paradigm is a task in which participants respond to standardized videos of actors playing patients in interpersonally challenging moments as if they were the therapist, which was designed to assess therapist effects. Participants’ video recorded responses are coded for eight skills: verbal fluency, emotional expressiveness, warmth/acceptance/understanding, empathy, persuasiveness, hope/positive expectations, alliance-bond capacity, and rupture-repair responsiveness. Performance-based procedures like the FIS minimize self-report bias and systematically control for client-related variability while maintaining strong clinical relevance. Research has shown that therapist FIS predicts the quality of the therapeutic alliance and outcome in adult psychotherapy. This paper describes the development and first adaptation of the FIS task using child and adolescent patients as the stimuli, and reports findings from a pilot study testing the reliability. The FIS-Child (FIS-C) task was administered to 10 therapists with a range of clinical backgrounds. Participants also completed the original FIS task and self-report measures of their empathy, social skills, and playfulness. Adequate interrater reliability was achieved on the FIS-C. There were no significant differences between participants’ ratings on the FIS-C compared to the original FIS, although there were minor differences in the correlations between the FISC and self-report measures compared to the original FIS. Findings support moving forward with utilizing the FIS-C to empirically study therapist effects that may be common factors across treatment models.