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.

Case report: A dual case study of how clinical feedback can be a communication aide and influence therapeutic work

Background

While routine outcome monitoring and clinical feedback may improve outcomes after psychotherapy, results from efficiency studies have been mixed. Moreover, how clinical feedback is implemented influences how it works for patients and clinicians, and working mechanisms are hitherto not thoroughly explored. Researchers have argued that inviting and using feedback from patients is best conceived of as a clinical skill. In this paper, we use case study methodology to explore and describe feedback's functions within three clinical skill themes: actualizing alliance work, concretizing change and stagnation and verbalizing the non-verbal.

Case presentation

Sonja is a young adult patient with a trauma background. She has a history of serious suicide attempts and distrust in relationships. She attended psychotherapy for eight months. Harald is a middle-aged man with a stable family. Traumatic events in his past has made him conceal own needs and developing depression. He attended psychotherapy for 19 months. Case material include the patient's clinical feedback over a range of life areas, medical health notes and the therapist's process notes.

Conclusion

Clinical feedback can be a positive supplement to the therapeutic work and process. The importance of making this as a joint tool between the client and the therapist is significant.

Definition and Criteria for the Assessment of Expertise in Psychotherapy: Development of the Psychotherapy Expertise Questionnaire (PEQ)

Therapist expertise is a complex, multifaceted, and continually evolving concept. Defining this construct and its constituent components can yield a substantial contribution to the field of psychotherapy, consequently enhancing the comprehension of the fundamental factors that underlie its effectiveness. Within this framework, the present research aimed at developing and assessing the psychometric properties of the Psychotherapy Expertise Questionnaire (PEQ), a self-report measure to assess therapist expertise. A sample of 260 psychotherapists of various theoretical orientations were involved in this research. They completed a survey that included the PEQ as well as other self-reported measures aimed at evaluating personality traits, self-efficacy, self-esteem, and insight orientation. The analysis provided evidence of a good fit for both a correlational model with eight factors and a higher-order model, where the eight subdimensions were grouped into subjective (performance; cognitive functioning; personal and relational qualities of the therapist; therapist self-assessment) and objective (experience; reputation with clients and colleagues; training and professional updating; deontological ethics and setting rules) factors. The eight dimensions, two higher-order factors, and total score all showed excellent levels of internal consistency. Furthermore, significant associations were found between PEQ scores and insight orientation, general self-efficacy, self-esteem, personality traits, and time exercising clinical practice. To conclude, the Psychotherapy Expertise Questionnaire (PEQ) is a valuable, theoretically guided, and psychometrically robust self-report measure designed to assess therapist expertise and its constitutive dimensions. This measure can have practical applications in guiding tailored training and customised supervision.

Psychopharmacology attitudes, beliefs, and practices among systemic family therapists and supervisors

Many aspects of systemic family therapist (SFT) training and competence play a vital role in effective treatment and professional satisfaction. One area that has been significantly overlooked by many SFTs is the role of psychotropic medication (PM) in conjunction with talk therapy for optimal mental health outcomes. This study explores the current status of PM in SFT training and clinical practice. Our findings highlight the continued struggle of SFTs in their comfort level with addressing the PM needs of their clients. We identified a perceived inadequacy of SFT training and supervision regarding PM use. SFTs around the world need to find educational opportunities to improve their competence in working with their clients and their prescribed medications. Additional studies need to be conducted on strategies and mechanisms to improve client care. If SFTs are ignorant of PM, their treatment of clients-who often use PM-will be compromised.

Common Elements Approaches to Implementation Research and Practice: Methods and Integration with Intervention Science

We propose that common elements approaches can advance implementation research and practice and facilitate pragmatic use of intervention and implementation evidence. Common elements are practices or processes frequently shared by interventions or implementations. Traditional common elements methodologies use synthesis, distillation, and statistics to describe and evaluate the merit of common ingredients in effective interventions. Recent developments include identifying and testing common configurations of elements, processes, and context variables across the literature of effective interventions and implementations. While common elements thinking has grown popular in intervention science, it has rarely been utilized in implementation science, and specifically, combined with the intervention literature. The goals of this conceptual methodology paper are to (1) provide an overview of the common elements concept and how it may advance implementation research and usability for practice, (2) give a step-by-step guide to systematic common elements reviews that synthesizes and distills the intervention and implementation literature together, and (3) offer recommendations for advancing element-level evidence in implementation science. A narrative review of the common elements literature was conducted with attention to applications to implementation research. A six-step guide to using an advanced common elements methodology was provided. Examples of potential results are presented, along with a review of the implications for implementation research and practice. Finally, we reviewed methodological limitations in current common elements approaches, and identified steps towards realizing their potential. Common elements methodologies can (a) synthesize and distill the implementation science literature into practical applications, (b) generate evidence-informed hypotheses about key elements and determinants in implementation and intervention processes and mechanisms, and (c) promote evidence-informed precision tailoring of intervention and implementation to context. To realize this potential, common elements approaches need improved reporting of details from both successful and unsuccessful intervention and implementation research, more data availability, and more testing and investigation of causal processes and mechanisms of change from diverse theories.

Supplementary Information

The online version contains supplementary material available at 10.1007/s43477-023-00077-4.

Understanding the role of emotion and expertise in psychotherapy: An application of dynamical systems mathematical modeling to an entire course of therapy

Introduction

The therapeutic relationship continues to be one of the most important factors in therapeutic outcomes. Given the place of emotion in the definition of the therapeutic relationship, as well as the demonstrated positive impact that emotional expression has on therapeutic process and outcome, it stands to reason that studying the emotional exchange between the therapist and client further would be warranted.

Methods

This study used a validated observational coding system--the Specific Affect Coding System (SPAFF) and a theoretical mathematical model to analyze behaviors which make up the therapeutic relationship. Specifically, the researchers used to codify relationship-building behaviors between an expert therapist and his client over the course of six sessions. Dynamical systems mathematical modeling was also employed to create "phase space portraits" depicting the relational dynamics between the master therapist and his client over six sessions.

Results

Statistical analysis was used to compare SPAFF codes and model parameters between the expert therapist and his client. The expert therapist showed stability in affect codes over six sessions while the client's affect codes appeared to be more flexible over time, though model parameters remained stable across the six sessions. Finally, phase space portraits depicted the evolution of the affective dynamics between the master therapist and his client as the relationship matured.

Discussion

The clinician's ability to stay emotionally positive and relatively stable across the six sessions (relative to the client) was noteworthy. It formed the basis for a stable base from which she could explore alternative methods to relate to others that she had allowed to dictate her actions, which is in keeping with previous research on the role of therapist facilitation of the therapeutic relationship, emotional expression within the therapeutic relationship, and influence of these on client outcomes. These results provide a valuable foundation for future research on emotional expression as a key component of the therapeutic relationship in psychotherapy.

Right brain-to-right brain psychotherapy: recent scientific and clinical advances

This article overviews my recent acceptance of a Lifetime Achievement Award from Sapienza University of Rome, in which I discussed three decades of my work on the right brain in development, psychopathogenesis, and psychotherapy. In the following, I offer current brain laterality and hemispheric asymmetry research indicating that right brain emotional and relational processes operate beneath conscious awareness not only in early human development, but over the lifespan. I discuss recent interdisciplinary studies on the central role of ultrarapid right brain-to-right brain intersubjective communications of face, voice, and gesture and the implicit regulation of emotion in nonverbal attachment dynamics. Special emphasis is on the fundamental psychobiological process of interpersonal synchrony, and on the evolutionary mechanism of attachment, the interactive regulation of biological synchrony within and between organisms. I then present some clinical applications, suggesting that effective therapeutic work with "primitive" nonverbal emotional attachment dynamics focuses not on conscious verbal insight but on the formation of an unconscious emotion-communicating and regulating bond within the therapeutic relationship. Lastly, I review recent hyperscanning research of the patient's and therapist's brains during a face-to-face, emotionally focused psychotherapy session that supports the right brain-to-right brain communication model. I end suggesting that the right brain is dominant in both short-term symptom-reducing and long-term growth-promoting deep psychotherapy.

Assessment of professional self-efficacy in psychological interventions and psychotherapy sessions: Development of the Therapist Self-Efficacy Scale (T-SES) and its application for eTherapy

OBJECTIVE

This study aimed to develop the Therapist Self-Efficacy Scale (T-SES), and test its validity in a sample of Italian mental health therapists, to assess their professional self-efficacy concerning their practice of eTherapy in a synchronous video-based setting.

METHODS

A sample of 322 Italian mental health professionals (37.6% psychologists, 62.4% psychotherapists; M_age  = 38.48, SD = 8.509) completed an online survey.

RESULTS

The T-SES showed a clear, one-factor structure with good psychometric properties. Significant associations were found with insight orientation, general self-efficacy, self-esteem, and personality traits of openness, conscientiousness, and agreeableness. The results showed no differences between psychologists and psychotherapists, or differences based on years of experience.

CONCLUSION

The T-SES is an agile and versatile self-report measure for mental health professionals to assess their self-efficacy concerning their therapeutic activity, which can provide information for tailoring training for eTherapy.

The concise measurement of clinical communication skills: Validation of a short scale

OBJECTIVE

There is a lack of brief rating scales for the reliable assessment of psychotherapeutic skills, which do not require intensive rater training and/or a high level of expertise. Thus, the objective is to validate a 14-item version of the Clinical Communication Skills Scale (CCSS-S).

METHODS

Using a sample of N = 690 video-based ratings of role-plays with simulated patients, we calculated a confirmatory factor analysis and an exploratory structural equation modeling (ESEM), assessed convergent validities, determined inter-rater reliabilities and compared these with those who were either psychology students, advanced psychotherapy trainees, or experts.

RESULTS

Correlations with other competence rating scales were high (rs > 0.86-0.89). The intraclass correlations ranged between moderate and good [ICC_(2,2) = 0.65-0.80], with student raters yielding the lowest scores. The one-factor model only marginally replicated the data, but the internal consistencies were excellent (α = 0.91-95). The ESEM yielded a two-factor solution (Collaboration and Structuring and Exploration Skills).

CONCLUSION

The CCSS-S is a brief and valid rating scale that reliably assesses basic communication skills, which is particularly useful for psychotherapy training using standardized role-plays. To ensure good inter-rater reliabilities, it is still advisable to employ raters with at least some clinical experience. Future studies should further investigate the one- or two-factor structure of the instrument.

Improving Mental Health Services: A 50-Year Journey from Randomized Experiments to Artificial Intelligence and Precision Mental Health

This conceptual paper describes the current state of mental health services, identifies critical problems, and suggests how to solve them. I focus on the potential contributions of artificial intelligence and precision mental health to improving mental health services. Toward that end, I draw upon my own research, which has changed over the last half century, to highlight the need to transform the way we conduct mental health services research. I identify exemplars from the emerging literature on artificial intelligence and precision approaches to treatment in which there is an attempt to personalize or fit the treatment to the client in order to produce more effective interventions.

Learning the subtle dance: The experience of therapists who deliver mentalisation-based therapy for borderline personality disorder

OBJECTIVES

This study aimed to understand therapists' lived experiences of delivering mentalisation-based therapy (MBT), including their experiences of service user change.

METHOD

One-to-one semi-structured interviews or focus groups were conducted with 14 MBT therapists and analysed using interpretative phenomenological analysis (IPA).

RESULTS

Four superordinate themes were identified: (1) experiencing the challenges and complexities of being with service users during MBT; (2) being on a journey of discovery and change; (3) being an MBT therapist: a new way of working and developing a new therapeutic identity; and (4) being a therapist in the group: seeing it all come together.

CONCLUSION

Our findings highlight the complexity, challenges and individualised experience of working therapeutically with service users with a diagnosis of BPD. The study provides a perspective of service use change that is enriched by idiosyncrasies within the therapeutic encounter. We conclude with a consideration of implications for MBT research and clinical practice.

Experience-Based Competency Training in Child and Adolescent Psychotherapy

Abstract. Background: Compared to adult psychotherapy training, there is little knowledge about the use of standardized actor-patients (SPs) for the development of professional competencies for younger patient populations. Objective: We assessed the effectiveness of two university-based training programs for diagnostic as well as intervention skills in child and adolescent psychotherapy. Methods: Psychology students took part in two courses on the development of diagnostic competencies ( N = 59) and on intervention skills ( N = 51). We applied active and experience-based learning strategies, including exercises on self-awareness, mindfulness, peer role-play, and the use of SPs. Competence gain as well as a general evaluation of the seminars were assessed by self-report. Results: For both seminars, self-reported competence increased significantly with a large effect. The retrospective evaluation of learning success and acceptance ratings of the didactic formats were high. Conclusions: Experience-based trainings that include SPs are a feasible option for child and adolescent psychotherapy. The findings are discussed from a conceptual as well as a practical perspective.

On what do therapists agree? Assessing therapist evaluations of emotion regulation strategy effectiveness

OBJECTIVE

To develop more unified, process-based, and disseminable psychotherapy treatments, it is important to determine whether there is consensus among therapists regarding intervention strategies.

DESIGN

Because emotion regulation is a cornerstone of modern treatments and a thriving area of clinical research, we assessed therapists' ratings of the effectiveness of commonly studied emotion regulation strategies.

METHODS

Therapists (n = 582) read eleven vignettes describing stressful scenarios and rated the effectiveness of ten emotion regulation strategies in each scenario.

RESULTS

Across therapists, we found general consensus regarding the most (i.e., problem-solving) and least (i.e., concealing emotions) effective strategies. Cognitive/behavioural/third-wave therapists rated acceptance and distraction as more effective, and emotional expression and gathering information as less effective, than other therapists, Fs> 4.20, ps < .05, whereas hours of clinical experience were generally unrelated to strategy effectiveness ratings.

CONCLUSIONS

We discuss what these points of agreement and relative disagreement among therapists reveal about a more unified, process-based treatment approach and how these results can guide emotion regulation research.

PRACTITIONER POINTS

There is general consensus among practising therapists that problem-solving is the most effective emotion regulation strategy and expressive suppression is the least effective. However, CBT-oriented therapists rated acceptance and distraction as more effective than non-CBT-oriented therapists. Non-CBT-oriented therapists rated emotional expression and gathering information as more effective than CBT-oriented therapists. Years of experience were unrelated to ratings of emotion regulation strategy effectiveness.

The Interpersonal Neurobiology of Intersubjectivity

In 1975, Colwyn Trevarthen first presented his groundbreaking explorations into the early origins of human intersubjectivity. His influential model dictates that, during intimate and playful spontaneous face-to-face protoconversations, the emotions of both the 2-3-month-old infant and mother are nonverbally communicated, perceived, mutually regulated, and intersubjectively shared. This primordial basic interpersonal interaction is expressed in synchronized rhythmic-turn-taking transactions that promote the intercoordination and awareness of positive brain states in both. In this work, I offer an interpersonal neurobiological model of Trevarthen's intersubjective protoconversations as rapid, reciprocal, bidirectional visual-facial, auditory-prosodic, and tactile-gestural right brain-to-right brain implicit nonverbal communications between the psychobiologically attuned mother and the developing infant. These co-constructed positive emotional interactions facilitate the experience-dependent maturation of the infant's right brain, which is in an early critical period of growth. I then address the central role of interpersonal synchrony in intersubjectivity, expressed in a mutual alignment or coupling between the minds and bodies of the mother and infant in face-to-face protoconversations, as well as how these right brain-to-right brain emotional transmissions generate bioenergetic positively charged interbrain synchrony within the dyad. Following this, I offer recent brain laterality research on the essential functions of the right temporoparietal junction, a central node of the social brain, in face-to-face nonverbal communications. In the next section, I describe the ongoing development of the protoconversation over the 1st year and beyond, and the co-creation of a fundamental energy-dependent, growth-promoting social emotional matrix that facilitates the emergence of the highly adaptive human functions of mutual play and mutual love. In the final section, I discuss the clinical applications of this interpersonal neurobiological model of intersubjectivity, which has a long history in the psychotherapy literature. Toward that end, I offer very recent paradigm-shifting hyperscanning research that simultaneously measures both the patient and therapist during a psychotherapeutic interaction. Using the Trevarthen's two-person intersubjective model, this research demonstrates changes in both brains of the therapeutic dyad and the critical role of nonverbal communications in an emotionally-focused psychotherapy session. These studies specifically document interbrain synchronization between the right temporoparietal junction of the patient and the right temporoparietal junction of the clinician, a right brain-to-right brain nonverbal communication system in the co-constructed therapeutic alliance. Lastly, I discuss the relationship between the affect communicating functions of the intersubjective motivational system and the affect regulating functions of the attachment motivational system.

Perceptions of Therapeutic Intervention in Suicide Crisis Counseling in Experienced Korean Counselors: A Concept Mapping Study

Within Organization for Economic Cooperation and Development (OECD) nations, South Korea has the highest suicide rate for which immediate prevention measures are sought including effective therapeutic counseling interventions. As such, the present study explored and examined experienced South Korean counselors' perception of therapeutic interventions for the prevention or delaying of completed suicide, using concept mapping methodology. The semi-structured interviews were provided to 15 study participants of experienced counselors having a minimum of 5 years of professional counseling career and at least 10 suicide crisis counseling sessions. A total of 77 statements were extracted with 8 major clusters: "Securing Safety," "Active Advocacy for Client," "Coping Skills Training," "Conceptualization of Suicide Crisis," "Emotional Identification and Validation," "Empowerment," "Counselor Self-Disclosure," "Counselor Self-Awareness and Regulation." From the results, the present study described unique findings in Korean counselors' perceptions of suicide crisis therapeutic intervention. Study limitations and future implications are further discussed.

Assessing interpersonal skills-A comparison of trainee therapists' and students' interpersonal skills assessed with two established assessments for interpersonal skills

Therapist differences in psychotherapy outcomes have been consistently found. Therefore, therapists' characteristics such as interpersonal skills are of particular interest. Two assessments of interpersonal skills for the selection of trainees have recently been developed. To extend current knowledge, this study compares trainee therapist's and psychology student's interpersonal skills in both assessments simultaneously and also investigates the potential influence of clinical experience and age on interpersonal skills. Furthermore, the psychometric properties of these assessments are examined. A total of 19 trainee therapists and 17 undergraduate students (N = 36) participated in both assessments and provided information on their prior clinical experience. Trainee therapists had significantly better interpersonal skills than the students in both assessments. However, different indicators of clinical experience (e.g., years in practice, patients treated, and supervision) did not influence their performance in either assessment. The good psychometric properties of both assessments could be replicated. Conceptual and practical considerations on the assessment of interpersonal skills are discussed.

In-session interactive dynamics of the psychotherapy process between therapeutic alliance, therapist expertise, therapist technical intervention, patient metacognition and functioning

Empirical research has explored different dimensions of the therapy process and their associations, often showing bidirectional links: for example, metacognition may be favoured by a positive alliance with the clinician; on the other hand, metacognitive difficulties may be an obstacle for the alliance. However, little is still known about the overall relationship between multiple dimensions during the psychotherapy process. The aim of this study is to further explore the in-session interaction of therapeutic process variables, focusing on patient metacognition, therapeutic alliance, technical intervention, therapist expertise, and patient functioning. Participants included 45 patients involved in a psychodynamic weekly treatment in two clinical centres. Therapists were both in-training and experienced clinicians. Four instruments were applied on four psychotherapy sessions (178 verbatim transcripts): Metacognition Assessment Scale-Revised (MAS-R) assessing metacognition, Collaborative Interaction Scale (CIS) assessing therapeutic alliance, Psychodynamic Intervention Rating Scale (PIRS) assessing therapist technical interventions, and Shedler-Westen Assessment Procedure (SWAP)-200 assessing patient functioning. Sequential analyses revealed that specific therapist interventions co-occurred with three different levels of therapeutic alliance: a first one characterized by positive collaboration, the second one by neutral collaboration, and the third one by ruptures. Moreover, and critically, the patient metacognition, patient functioning, and therapist expertise were found to exert different effects in the three alliance levels. These findings suggest the existence of a specific interdependence between the variables involved in the research. These results further indicate that the therapist expertise is a key element in the therapeutic process, as it can drastically affect the in-session interactive dynamic.

Training lay counsellors in public health: Considerations for social workers, professional counsellors and psychologists

Many non-governmental organisations (NGOs) in resource-constrained communities who provide psychosocial services employ lay and paraprofessional counsellors to dispense these services to clients. Yet, selection criteria for such lay persons are highly variable. In the context of low levels of formal education in many communities, education-based criteria are not easily applied. The eligibility of individuals for counsellor training is a matter of considerable importance even though NGO staff may not differentiate between those volunteers or employees who are and are not eligible for training. Also, no screening instruments have been developed to reliably discriminate between individuals who do and do not become effective counsellors. Indeed, decisions about which applicants are and are not trainable are of considerable consequence in sustaining high quality work. A research programme is needed to identify attitudinal and personality markers that may predict success as lay counsellors. In this article specific suggestions are made, including suggestions for practice so that the administrative and human resource needs of NGO's can be balanced with the professional and ethical imperative of recruiting lay counsellors who are trainable and capable of performing counselling tasks with the highest level of professionalism possible despite their lay status.

An exploratory study of patients' sudden losses during outpatient CBT and therapists' experience of difficulties

OBJECTIVE

Patients' sudden deterioration in symptomatology, also called sudden losses, is a rarely explored phenomenon.

METHOD

Psychological distress of 1,763 patients treated by 140 therapists was monitored after every therapy session. Patient-reported outcome measures and patients' therapy satisfaction was assessed. Therapists rated their experience of difficulties for every patient repeatedly over the course of therapy.

RESULTS

More than one-quarter of patients (26.5%) experienced at least one sudden loss during therapy. Patients with sudden losses did not differ significantly in psychotherapy outcome and therapy satisfaction from patients without sudden shifts. Therapists did not experience professional self-doubt more often when working with sudden loss patients.

CONCLUSION

Sudden losses were not necessarily harmful for the outcome of psychotherapy and patients' global therapy satisfaction. The results suggest that sudden losses can be compensated over the course of treatment.

Modest, yet progressive: Effective therapists tend to rate therapeutic change less positively than their patients

Objective: Empirical findings on self-serving biases amongst psychotherapists are inconsistent. We tested in a large naturalistic data set, if therapists are prone to illusory superiority when estimating their patients' outcome and whether this effect is buffered by therapists' effectiveness. Method: A post-hoc analysis with N = 69 therapists, who treated N = 1080 patients, was conducted. Therapists' and patients' mean ratings for therapeutic improvement in the Clinical Global Impression Scale (CGI) were compared. Using a multilevel modelling approach, we further investigated the relation between the patient-therapist divergence in the CGI and actual therapeutic change in the Global Severity Index (GSI) of the Brief Symptom Inventory and in the Satisfaction With Life Scale (SWLS). Results: Ratings in the CGI did not show significant differences between patients' and therapists' assessment of therapeutic change. Lower estimations by therapists, compared to patients' self-report, were associated with greater therapeutic change in GSI and SWLS. Conclusions: Therapists, on a whole, did not seem to be prone to illusory superiority when assessing therapeutic outcome. Contrary, the more modest the therapists' estimation of therapeutic outcome was, the greater the actual therapeutic change.

Assessing therapist development: Reliability and validity of the Supervisee Levels Questionnaire (SLQ-R)

BACKGROUND

Therapist development is a crucial target for clinical training in order to ensure high-quality psychotherapy. A major challenge in examining therapeutic development is the assessment of developmental processes. The Supervisee Levels Questionnaire (SLQ-R) was analyzed in this study to examine its validity, reliability, and underlying dimensional structure.

METHOD

Seven hundred and sixty therapists participated in an online survey concerning their current psychotherapy training. The factor structure as well as the validity of the SLQ-R were investigated using exploratory and confirmatory factor analysis.

RESULTS

In line with the results of the exploratory factor analyses, a Bifactor ESEM (exploratory structural equation modeling) model with two factors and one global factor provided the best fit to the data. The two factors were labeled professional self-confidence and professional insecurity.

CONCLUSION

Empirical support for reliability and validity of the new factor structure of the SLQ-R was found. The instrument is useful for assessing the therapist's developmental level.

Successful and Less Successful Psychotherapies Compared: Three Therapists and Their Six Contrasting Cases

Despite the general effectiveness of bona fide psychotherapies, the number of patients who deteriorate or fail to improve is still problematic. Furthermore, there is an increased awareness in the field that the therapists’ individual skills make a significant contribution to the variance in outcome. While some therapists are generally more successful than others, most therapists have experienced both therapeutic success and failure in different cases. The aim of this case-series study was to deepen our understanding of what matters for the therapists’ success in some cases, whereas other patients do not improve. How do the patients and their therapists make sense of and reflect on their therapy experiences in most successful and unsuccessful cases? Are there any distinctive features experienced by the participants at the outset of treatment? To explore these issues, we applied a mixed-method design. Trying to keep the therapist factor constant, we selected contrasting cases from the caseloads of three therapists, following the criterion of reliable and clinically significant symptom reduction or non-improvement at termination. Transcripts of 12 patient interviews and 12 therapist interviews (at baseline and at termination) were analyzed, applying inductive thematic analysis and the multiple-case comparison method. The comparisons within the three therapists’ caseloads revealed that in the successful cases the patient and the therapist shared a common understanding of the presenting problems and the goals of therapy and experienced the therapeutic relationship as both supportive and challenging. Furthermore, the therapists adjusted their way of working to their patients’ needs. In non-improved cases, the participants presented diverging views of the therapeutic process and outcome. The therapists described difficulties in the therapeutic collaboration but not how they dealt with obstacles. They tended to disregard their own role in the interactions and to explain difficulties as being caused by the nature of their patients’ problems. This could indicate that the therapists had difficulty in reflecting on their own contributions, accepting feedback from their patients, and adjusting their work accordingly. These within-therapist differences indicate that taking a “third position” is most needed and seems to be most difficult, when early signs of a lack of therapeutic progress appear.

Discursive Psychology: Implications for Counseling Psychology

In this article, we present discursive psychology (DP), a qualitative approach that focuses on the study of conversational and textual materials, including everyday interactions. Although DP is well-established methodologically and theoretically, and is used widely in Europe and in the Commonwealth countries, it is relatively unknown in counseling psychology in the United States. As such, the purpose of this article is to provide a general overview of DP and offer guidance for researchers who may be interested in studying and using DP. We thus discuss practical considerations for utilizing DP, including the development of research questions, carrying out data collection, and conducting DP-informed analyses. We also provide a general overview of the history of DP and key resources for those interested in studying it further, while noting the usefulness of DP for counseling psychology.

Provider-Associated Measurement Error in Routine Outcome Monitoring in Community Mental Health

Despite the strengths of routine outcome monitoring (ROM) in community mental health settings, there are a number of barriers to effective implementation of ROM, including measurement error due to provider factors (e.g., training level) and non-target client factors (i.e., client characteristics which have no meaningful relationship to the outcome of interest). In this study, ROM data from 80 client-provider dyads were examined for sources of variance due to provider factors and non-target client factors. Results indicated that provider factors and non-target client factors accounted for between 9.6 and 54% of the variance in the ROM measures. Our findings supported past research that provider characteristics impact ROM, and added the novel finding that client gender, age, diagnosis, and cognition also impact ROM. Methods to increase accuracy and utility of ROM in community mental health are discussed.

"It was hard work every session": Therapists' view of successful psychoanalytic treatments

OBJECTIVE

To explore therapists' experiences of the therapeutic process in successful cases of psychoanalytic psychotherapy.

METHOD

A two-stage, mixed-method design was used. Sixteen successful cases were drawn from a sample of 92 young adults in psychoanalytic psychotherapy according to Jacobson's criteria for reliable and clinically significant improvement. Therapist interviews at baseline and termination were analyzed applying Inductive Thematic Analysis.

RESULTS

Three core themes emerged: Being Particularly Motivated to be This Patient's Therapist, Maintaining a Safe and Attentive Therapeutic Position, and Assiduous Work Every Session. The therapists experienced positive feelings towards the patient from the outset of treatment and described active, relational work that included paying attention to incongruities in the patient's self-presentation and being mindful of patient's avoidant behavior. The therapist's motivation and attentive position made it possible to balance support and challenge in the therapeutic relationship.

CONCLUSIONS

Successful therapeutic work presupposes positive expectations, an active therapeutic stance and assiduous work session-by-session. Therapist expertise may involve the ability to mobilize and work effectively with patient-specific resources and obstacles from the beginning of treatment. In addition to identifying the characteristics and actions of effective therapists, research should also focus on processes emerging within effective therapeutic dyads. Clinical or methodological significance of this article: Our study indicates several factors that seem to characterize therapist expertise and can inform psychotherapy training. Successful therapeutic work presupposes positive expectations, an active therapeutic stance, courage to challenge the patient, and assiduous work session-by-session. Therapist expertise may involve the ability to mobilize and work effectively with patient-specific resources and obstacles from the beginning of treatment. In addition to identifying the characteristics and actions of effective therapists, research should also focus on processes emerging within effective therapeutic dyads.

The Promise and Challenge (and Reality) of Defining Therapist Expertise

This article is a commentary on Hill, Spiegel, Hoffman, Kivlighan, and Gelso’s interesting and thought-provoking article focused on defining psychotherapy expertise. I address Hill et al.’s inclusion of other criteria to evaluate expertise that counters Tracey, Wampold, Goodyear, and Lichtenberg’s conclusion that treatment outcome is the only criterion supported by the research to determine expertise. I also address Hill et al.’s discussion on the development of expertise with a focus on monitoring treatment outcome to promote therapist improvement. In sum, Hill et al. provide a way forward for psychotherapy researchers to address proposed dimensions of expertise that currently are based more on our clinical wisdom than empirical evidence and, in doing so, offer the promise of better understanding what makes an excellent psychotherapist.

Reflections on the Power to Define Psychotherapy Expertise

The field of psychology has struggled to define what it is that makes an expert therapist expert. Just as elusive has been the ability to know and articulate how one achieves expertise as a therapist. In their major contribution, Hill, Spiegel, Hoffman, Kivlighan, and Gelso identify a number of constructs that researchers interested in assessing expertise can consider and evaluate. In this reaction to their article, we share where we are in agreement with the authors and where our thoughts diverge. We conclude with what we deem to be missing from this discussion regarding therapist expertise—power and privilege as it relates to who decides what makes an expert.

Our Best Selves

Psychotherapist expertise proves an urgent topic for practice and training, but insufficient research and conflicting definitions confound efforts to enhance expertise. In an ambitious article, Hill, Spiegel, Hoffman, Kivlighan, and Gelso offer a clear definition of expertise and propose broad indicators. In this reaction, we (a) laud the prominent psychologists for undertaking the Herculean task, (b) highlight points of convergence on relationships and responsiveness between their conclusions and those of others and ourselves, (c) take some collegial exceptions to their proposals and advance alternatives, and (d) underscore the probability that expertise resides far more in the person of the therapist than in specific methods. In particular, distinguishing expertise from experience, and separating expertise about psychotherapy from expertise demonstrated in session, will help to operationalize and cultivate it. The title of this commentary—“Our Best Selves”—embodies the conviction that developing the person of the therapist will most likely actualize expertise.

Psychotherapy Expertise Should Mean Superior Outcomes and Demonstrable Improvement Over Time

How the field understands psychotherapy expertise is important. It affects how we practice and how we prepare others for practice. As in our other work, we argue that the most meaningful definition of expertise must involve steady improvement over time to achieve superior performance on some meaningful measure, which typically is client outcome. We also argue that the best means by which a therapist can achieve this is through ongoing deliberate practice. We contrast our position with not only Hill, Spiegel, Hoffman, Kivlighan, and Gelso’s preferred definition, in which they anchor expertise in therapist performance, but also with the various other possible definitions of expertise (e.g., therapist experience, therapist self-assessment of expertise) that they proffer as options.

Therapist Expertise

In this rejoinder, we respond to comments raised by Goodyear, Wampold, Tracey, and Lichtenberg; Norcross and Karpiak; Reese; and O’Shaughnessy, Du, and Davis about the definition of expertise and methods for increasing expertise. The most consensus among these authors was found for client outcomes as a criterion of expertise and practice as a mechanism for increasing expertise. Until we have better empirical evidence, however, we suggest keeping the eight criteria that we originally proposed to measure expertise (performance, cognitive processing, client outcomes, experience, personal qualities, self-assessment, reputation, credentials), as well as the four mechanisms for increasing expertise (training, practice, feedback, and personal therapy). We challenge future researchers to hone the list and determine how to weight the various criteria and mechanisms based on empirical evidence.