THE Integrative Therapist

Transcription

1 Society for the Exploratio SEPI of Psychotherapy Itegratio Volume 4, Issue 1 Jauary 2018 ISSN # Missio Statemet The Society for the Exploratio of Psychotherapy Itegratio (SEPI) is a iteratioal, iterdiscipliary orgaizatio whose aim is to promote the exploratio ad developmet of approaches to psychotherapy that itegrate across theoretical orietatios, cliical practices, ad diverse methods of iquiry. Jeffery Smith Editor Alexadre Vaz Associate Editor I This Issue From Our New Associate Editor Youg Therapist s Corer Structured Iterviews o Research: Michael Costatio Hector Ferádez Alvarez Steve C. Hayes Scott D. Miller Ja Roubal William B. Stiles Ladislav Timulak Toy Roussmaiere SEPI Questioaire o Research SEPI XXXIV Aual Meetig THE Itegrative Therapist A R T I C L E S I N T E R V I E W S C O M M E N T A R I E S A Word From the Editor Dear Readers, Research Issue Jeffery Smith First I wat to welcome Alexadre Vaz, Associate Editor to our staff. As a researcher ad cliicia, he brigs to this issue a emphasis o therapist factors i the success of psychotherapy. With questios slated i that directio, simply readig this issue is a educatio o the fermet goig o i thikig about psychotherapy ad psychotherapy research. Staely Messer, i his Presidetial Letter brigs up the promise of carefully doe sigle case studies, especially i their ability to Caadia Rockies i Witer focus o the subtleties of what therapists ca ad do brig to the iteractio. Toy Roussmaiere talks about Deliberate Practice, ivolvig serious self-examiatio ad traiig aki to that of a athlete. Ad Steve Hayes highlights the cocept of improvemet i psychological flexibility as a measurable abstractio relevat to successful psychotherapy. Takig the time to click o the lik to our survey resposes, ow escoced i the SEPI Archives, will take you o a tour of subjects like trauma, emotio, eurobiology ad especially the importace of commo factors ad the therapeutic relatioship. Clearly, i our thikig, we are beyod the RCT horserace, ad are ready to pursue the quest for improvemet i results by uderstadig how therapists ad patiets iteract. Ad the there are the politics ad ecoomics of research. How will the field fid the support eeded to pursue the directios so well highlighted i this issue? So we ll put out a call for articles for comig issues o how to meet the challege of gettig the kid of research support we so clearly eed. Jeffery Smith Presidet s Colum Dear SEPI Members, Staley Messer As this issue of the SEPI Newsletter is devoted to research, my letter will describe what I view as importat developmets i furtherig SEPI s aim of itegratig research ad practice. Those of us who have bee i the field for some time grew up with the idea that the radomized cliical trial or RCT was the gold stadard i coductig psychotherapy research. While it still retais preemiece because it allows oe to maximize iteral validity ad make causal ifereces about the value of a particular approach, it is ow recogized that it falls short i beig maximally useful to the practitioer. Amog other drawbacks, it is subject to researcher allegiace effects, which refers to the strog associatio betwee a researcher s preferred therapy model ad the therapy that was judged to be more successful. I additio, may patiets are excluded from RCTs, such as those who are dually diagosed, so that they typically iclude rather select patiet samples, makig them less applicable to ormal practice. May patiets drop out of RCTs ad oly about 40% gai from them. Cotiued o page 4

2 The Itegrative Therapist Volume 4, Issue 1 Jauary 2018 Suddely, I was surrouded by my bookshelf protagoists i the flesh. SEPI is just startig. As a commuity, it has all the potetial to be at the vaguard of psychotherapy practice ad research. From Our New Associate Editor Alexadre Vaz Dear SEPI colleagues, Maybe disappoitmet is the fear of o loger belogig to a system. So I could put it like this: he is very happy because he was fially disappoited. Clarice Lispector, i The Passio Accordig to G.H. A itroductio is i order, or so I was told! My ame is Alexadre Vaz ad I m a youg cliical psychologist ad researcher from Lisbo, Portugal. My very early psychotherapy heroes were Carl Rogers ad Albert Ellis. Try to itegrate that, SEPIas! Soo after, bige readig led me to stumble upo Jerome Frak s Persuasio ad Healig whe I was 21 years old. A card-carryig itegratioist was bor. My first SEPI meetig experiece was absolutely memorable. Suddely, I was surrouded by my bookshelf protagoists i the flesh. It s a amazig feelig whe the people you grew up with itellectually are actually kid, friedly humas. From that meetig, oe experiece stads out: doig a live roleplay sessio with Rhoda Goldma. I d be embarrassig her if I told her how much that experiece shook me up. So, let s let her kow i the safe space of a iteratioally available ewsletter. I oe 40-miute uscripted sessio, I probably felt more I ad Thou-ed tha durig most of the 5 years I was i psychoaalytic psychotherapy. What a way to start a adveture. I feel strogly that psychotherapy itervetios, models, studies ad commuities are oly as ambitious as the people behid them. As Paul Wachtel oted i a past issue, blad ecumeical platitudes, tamely itegrative thikig, ca dull the cuttig edge of our movemet. While SEPI is defiitely a safe space for may of us, I doubt itegratio should feel too safe. Which leads me to aother poit I hoestly believe SEPI is just startig. As a commuity, it has all the potetial to be at the vaguard of psychotherapy practice ad research i the 21 st cetury. Besides tryig my best to provide valuable cotet, I am sesitive to the importace of creatig yet aother itegrative bridge withi SEPI, amely, a geeratioal oe. I a era where I see may of my peers ot so tured o by readig, SEPI ca either remiisce o the past glory of literate studets (if that was ever a thig), or adapt i such as a way as to make youger professioals itrisically excited to fid out more, debate more ad cotribute more. I see this ewsletter as a absolutely ecessary meas to that ed, as well as a ogoig ivestmet i ew audiovisual cotet, social media presece, ad the like. Carl Saga, i his amazig The Demo-Hauted World, wrote: Not explaiig sciece seems to me perverse. Whe you re i love, you wat to tell the world. That s how I feel about SEPI. So, thak you to Jeff Smith ad the Executive Board for appoitig me associate editor of The Itegrative Therapist. Our work is just startig full speed ahead! Society for the Exploratio of Psychotherapy Itegratio 2

3 The Itegrative Therapist Volume 4, Issue 1 Jauary 2018 Youg Therapist s Corer Sofia Macedo, Uiversity of Lisbo, Portugal I realized that itegratio i psychotherapy was still just a good theoretical idea ad much eeded to be leared about how to be itegrative i practice. I fid myself sailig through a deep ocea of effective ad sigificat therapeutic optios / approaches, without kowig for certai whe ad how I should cosider each. Startig as a Youg Itegrative Therapist First of all, I would like to thak SEPI for the iitiative to liste to youg therapists that are startig their practice without a sigle theoretical ad practical orietatio. I hope this ca ispire future research ad discussio to atted to our preset growth pais ad eeds. I would also like to thak all the cotributios that have allowed me to grow as a itegrative therapist sice such a early stage. Early i my life, I felt curious about huma beig s mid ad behavior. While beig a psychology studet ad future therapist, I wodered how psychotherapy could respectfully embrace its richess ad complexity. At the begiig of my academic years, this questio did t seem to be totally aswered by the theoretical ad practical orietatios that were exclusively preseted. Separately, they seemed just pieces of a complex puzzle that did t allow me to see ad play with the whole picture. Therefore, the perspective of havig more tha a uique istrumet i my therapist toolbox brought me comfort ad relief, through my adquataice with experieced Portuguese itegrative psychotherapists ad itegrative literature (e.g., routes to itegratio, commo factors, itegrative models). The idea of beig able to otice, focus, ad work with differet psychological levels ad dimesios made me believe, as a future therapist, that I would be more prepared to resposively aswer to patiets sigularity ad to differet istaces of a sigle self. However, as soo as I started my cliical practice I realized that itegratio i psychotherapy was still just a good theoretical idea ad much eeded to be leared about how to be itegrative i practice. Beig a begier is, per se, a frighteig situatio marked by iexperiece, disorietatio ad a low sese of competece. However, I believe that part of the axiety I ofte experiece at this startig poit is also triggered by the apparet icompatibility betwee the desire to develope a itegrative practice ad the simultaeous eed for structure ad its uderlyig perceptio of orgaizatio ad guidace. It s at a decisio cliical makig level that I fid most of the challeges as a waabe itegrative. Frequetly I fid myself sailig through a deep ocea of effective ad sigificat therapeutic optios/approaches, without kowig for certai whe ad how I should cosider each -where should my attetio lie o? Is there ay priority work? Which situatios, phases of the therapeutic process or momets of a psychotherapy sessio, will beefit from the use of a specific approach?. Sometimes the desire for a structure makes me woder if it d be easier to start with a sigle approach ad progressively assimilate other psychotherapies. At the same time ad for these same reasos, I coclude this would be takig the risk of startig biased or create the habit of puttig the my eed for secureess i frot of the patiet. Although I believe restrictive structures i psychotherapy might decrease the opportuity to develop uique therapeutic processes cetered o the perso ad collaborative therapeutic relatioships, I miss havig specific guidelies towards a itegrative psychotherapy (early) practice. The itegrative models that I ve bee i cotact with ispire my thikig ad practice. Nevertheless, I woder sometimes if, cotroversially, these ted to develop as ew sigle models. It would be iterestig to highlight o a sigle map which situatios, phases ad momets of the therapeutic process might beefit from the specific approaches already developed ad its respective literature, audiovisual support, ad traiig. Startig as a itegrative psychotherapist presupposes a lot of autoomy but also the resposibility of usig the huge amout of the available kowledge. I truly believe that a itegrative thikig ad practice ca ideed icrease resposiveess i psychotherapy ad promote structural ad lastig chages. However, I ackowledge that more empirical evidece is eeded i order to guide cliical decisio makig of youg itegrative therapists that are startig this log ad challegig psychotherapeutic path. Society for the Exploratio of Psychotherapy Itegratio 3

4 The Itegrative Therapist Volume 4, Issue 1 Jauary 2018 Presidet s Colum, cotiued from page 1 I would argue that case study research has come of age ad provides a excellet bridge betwee research ad practice. Typically ot cosidered are patiet characteristics such as cultural backgroud, psychological midedess ad motivatio for treatmet, as well as life cotext, the therapeutic alliace ad therapist factors or their iteractio with patiet variables. All of this ad more limit the usefuless of RCTs as guides to practice (Messer, 2016). What is there to replace or augmet the results of RCTs? I would argue that case study research has come of age ad provides a excellet bridge betwee research ad practice, supplemetig what we lear from traditioal RCTs. Research has show that practitioers are more iflueced by cases tha by data from RCTs, regardless of their theoretical orietatio (Stewart & Chambless, 2010). There are also mixed methods that icorporate RCTs ad sigle case comparisos, which iclude quatitative ad qualitative data. Oe of our keyote speakers for the upcomig SEPI coferece i NYC (May 31-Jue 2, 2018) is Joh McLeod (2010) who has published a forward-lookig book focusig o the various ways to coduct rigorous case study research. He shows how cases ca be preseted i such a way as to provide reliable ad valid evidece rather tha beig purely aecdotal or illustrative. He emphasizes four factors that make case studies relevat for buildig a solid psychotherapy kowledge base: (1) a arrative way of kowig, (2) complexity or thick descriptio, (3) a fuller cotext for the variables of iterest, ad (d) beig able to observe practical expertise i actio. What are some of the ways that have bee developed to coduct rigorous case study research? These are kow as the pragmatic case study method (Fishma), =1 time series case aalysis (Kazdi; Morga & Morga), the hermeeutic (or adjudicatioal) sigle case efficacy desig (Bohart; Elliott), theory buildig case study (Stiles), arrative case research (Etherigto), ad team-based case study method to eable practitioers ad studets to coduct systematic case studies (McLeod). This is ot the place to elaborate o these approaches but suffice it to say that they are works i progress, each with their ow advatages ad drawbacks. I a recet book edited by Fishma, Messer, Edwards ad Datillio (2017), four RCTs of differet kids of therapy are preseted ad, alog with each, two or three cases from the RCTs usually a success ad a failure case. Each case is preseted i arrative form but is ehaced by the quatitative data that were collected as part of the RCT. Whereas the RCT group results are ot able to describe how or explai why some cliets are successful ad others ot, the case comparisos do exactly that. This is kow as the mixed methods model as it makes use of both quatitative ad qualitative data. What do case studies add to what is leared from a RCT? I a review of the Fishma et al. volume i PsycCRITIQUES, Art Bohart summarized some relevat poits oted by the editors, chapter authors ad commetators: SEPI... has a importat role to play i arrowig the gap betwee research ad practice. Idetifyig therapist ad cliet factors that may help determie success or failure Idetifyig extra-therapeutic factors such as the role of parets Examiig how mismatches betwee cliet ad therapy ca affect outcome Determiig the role of culture Examiig how the process of a specific therapy works I additio to SEPI s traditioal role of studyig commoalities ad differeces amog theoretical ad cliical positios, I believe that it has a importat role to play i arrowig the gap betwee research ad practice. Systematic ad rigorous sigle case studies are oe very promisig vehicle for achievig this goal. Refereces: Fishma, D. B., Messer, S. B., Edwards, D. J. A., & Dattilio, F. M. (Eds.) (2017). Case studies withi psychotherapy trials: Itegratig qualitative ad quatitative methods. New York, NY: Oxford. McLeod, J. (2010). Case study research i i couselig ad psychotherapy. Los Ageles: Sage. Messer, S. B. (2016). Evidece-based practice. I H. Friedma (Ed.), Ecyclopedia of metal health, 2 d ed., Vol. 2 (pp ). Waltham, MA: Academic Press Stewart, R. E., & Chambless, D. L. (2010). Iterestig practitioers i traiig i empirically supported treatmets: Research reviews versus case studies. Joural of Cliical Psychology, 66, Society for the Exploratio of Psychotherapy Itegratio 4

5 The Itegrative Therapist Volume 4, Issue 1 Jauary 2018 Structured Iterviews o Research Homig i o key issues i research, the Itegrative Therapist has asked a group of leaders i the research field to respod to five questios desiged to brig out treds, opiios ad questios at the cuttig edge of the psychotherapy research. Nie members of SEPI (ad beyod) have kidly offered the resposes that follow. Cliicias eed to first ackowledge the existece of this global therapist effect, which may ot be easy give that most therapists report beig more geerally effective tha the average cliicia. Michael Costatio 1. Psychotherapy research seems to poit towards a greater variability i outcomes betwee therapists tha therapies. How ca this research o therapist effects iform cliicias ad their real-world practice? It s probably ow safe to say: research robustly idicates, vs. seems to suggest, that psychotherapists vary i their efficacy, thus rederig a pressig eed to thik less i terms of what itervetios work best for whom, but more i terms of what therapists ad therapist-level characteristics/behaviors work best for whom... ad whe/how? To be practically useful, cliicias eed to first ackowledge the existece of this global therapist effect, which may ot be easy give that most therapists report beig more geerally effective tha the average cliicia. Despite these self-perceptios, clearly ot all therapists are highly effective geeralists. Moreover, research idicates that therapists possess relative stregths ad weakesses withi their ow practice depedig o their patiets presetig problems; that is, may cliicias may have ukow specialist tedecies. To make therapist effects kowledge actioable, therapists also eed to work toward kowig thyself by measurig their ow variable efficacy i treatig differet types of patiets ad problems. Oly the ca this iformatio be haressed; for example, by treatig oly the patiets that they are reliably good at treatig, or by gettig additioal traiig i treatig the types of patiets for whom they are less effective. This focus o the therapist, I would argue, is iheretly itegrative, as it crosses theoretical orietatios. 2. How ca the field of psychotherapy itegratio, specifically, beefit from recogitio of the importace of therapist effects? Psychotherapy itegratioists would beefit from uderstadig that to explai betwee-therapist differeces i patiet outcomes iheretly requires kowig somethig about the perso of the therapist ad/or therapists differetial abilities to facilitate importat i-sessio processes. To do this requires disaggregatig the total correlatio ito its betwee-patiet ad betwee-therapist compoets, ad appreciatig how failig to do so ca result i false empirical ad cliical coclusios. To me, routiely icorporatig therapist-level aalysis ito our research ca go log a log way toward defiig far more precisely cliicia expertise. This focus o the therapist, I would argue, is iheretly itegrative, as it crosses theoretical orietatios. Moreover, delvig ito the therapist as a research participat ca also cross scietific disciplies. Ad ot oly ca the field of psychotherapy itegratio beefit from recogizig the importace of the therapist effect, but perhaps itegratioists, with their ope-mided approach to treatmet delivery, are best situated to coduct this type of research ad model its traslatio to the therapy room. As oe example, we kow that routie outcome measuremet ad related feedback, both iheretly itegrative practices, ca facilitate patiet improvemet. However, although such feedback improves outcomes for a give case, research has show that receivig such feedback does ot, over time, improve overall therapist-level effectiveess. This may be because we are givig therapists valuable patiet-level feedback, which improves patiet-level outcomes, but we are almost ever givig therapists true therapist-level feedback, which could, theoretically at least, impact therapist-level outcomes. To me, this level of feedback is a importat focus of future itegrative research. Cotiued o page 6 Society for the Exploratio of Psychotherapy Itegratio 5

6 The Itegrative Therapist Volume 4, Issue 1 Jauary traiig all therapists to do similar thigs to deliver treatmet competetly would be traiig them to do somethig that patiets will ultimately see very differetly. Ay research that parses ad provides appropriate therapistlevel implicatios is very importat for practitioers. 3. Fudig for psychotherapy research has geerally goe for the study of particular models applied to the treatmet of specific disorders. Meawhile, much of the research suggests that who provides the treatmet is more importat tha which treatmet is provided. Goig forward, what ca research programs do to deal with this tesio? The optimist i me believes that if the reality of therapist variability is accepted, there eed ot be a tesio. The realist i me, though, uderstads that may persos will remai loyal to the faithful delivery of treatmet brads. Cosider, though, the otio of competece i deliverig a treatmet maual it may be somethig o which we ca trai therapists to the poit of seeig o betwee-therapist differece i performace idices. However, if you ask patiets to rate their therapists o perceived competece, there could be immese variability, which would suggest it is somethig about the patiet or the uique dyad that affects perceptios of competece. I this case, traiig all therapists to do similar thigs to deliver treatmet competetly would be traiig them to do somethig that patiets will ultimately see very differetly; thus, it would be a attempt to affect a therapist-level predictor of a patiet-level process, which is a iheretly flawed coceptual ad statistical assumptio, though still the basis of may studies/traiigs o empirically-supported treatmets. To me, parsig efficacy effects at differetial levels holds the most promise for addressig this tesio, especially if we ca articulate the clear traiig ad practice implicatios that derive from parsed effects. For example, if you have a fully betwee-patiet effect o a treatmet process, the uderstadig determiats of that effect is most promisig i helpig you to persoalize treatmet for a give patiet/dyad. As a example of this extreme, it would be like learig that patiet comfort relates to outcome, ad all variability i comfort is betwee patiets. We may the lear via research that (a) oe betwee-patiet predictor of low comfort is beig a ma, ad (b) what predicts more comfort for me is sports memorabilia o the walls. The implicatio for therapists is that to best affect comfort (irrespective of potetial brad loyalty) would mea seeig their male patiets i a room with sports memorabilia. As there were o betwee-therapist effects, the key to improvig comfort would ot be i chagig somethig about therapists themselves, or how they deliver treatmet. But, at the other extreme, if we foud a wholly betwee-therapist effect o a process, the uderstadig determiats of that effect ca help haress it ad teach therapists to cosistetly foster it across their patiets. For example, we might fid that warmth is a betwee-therapist predictor of betwee-therapist patiet comfort levels. The implicatio here would be for therapists to try to be warm with all of their patiets. This type of result is the most likely path to discoverig a true therapist-level competece, ad it eed ot create tesio, especially whe the determiat (like warmth) represets somethig that ca be applied to ay type of itervetio. 4. Speakig of fudig, would you rather be doig psychotherapy research i Europe or i the US, ad why? Havig oly ever lived ad coducted research i the US, I have o direct basis for compariso. So, I will simply say that research o therapist effects, wherever coducted, should hoe i o determiats of such effects. I applaud early work o this topic, which has revealed therapist facilitative iterpersoal skill ad deliberative practice as promisig determiats of why some therapists cosistetly outperform others. We eed to keep up this type of discovery i all coutries, as idetifyig traiable therapist-level behaviors should become a focal poit for evidece-based traiig. 5. I your opiio, of relatively recet research fidigs, what are the most importat for cliicias? Ay research that parses ad provides appropriate therapist-level implicatios is very importat for practitioers. Agai, if a betwee-patiet variable (say therapist empathy perceptios) fully explaied betwee-patiet variability o a outcome, it would be ear impossible to base our cliical traiigs o the geeric idea of improvig therapist empathy, as such differeces i empathy perceptios would have everythig to do with the patiet or dyad. However, we might also lear that while there could still be variability withi a therapists caseload o ratigs of their empathy, it could simultaeously be the case that Therapist B is cosistetly better across all of her patiets tha Therapist A at promotig empathy, which may also relate to more improvemet for Therapist B s patiets. We would the wat to uderstad determiats of these empathy perceptios that systematically differ betwee therapists caseloads. Let s say that therapist verbal fluecy explaied much of the variability i patiet empathy ratigs, with more verbally fluet therapists beig perceived, o average across all of their patiets, as more empathic tha less verbally fluet therapists. I this case, haressig this determiat by helpig cliicias become more verbally fluet across patiets could become a traiig ceterpiece. However, if we foud somethig like therapist iterpersoal trauma to be a strog therapist-level predictor of betwee-therapist differeces i treatmet process ad outcome, this might have to be the basis of therapist selectio (give that traiig caot udo trauma). As should be clear, the cliical implicatios are quite differet based o the results of these differet levels of aalysis. Society for the Exploratio of Psychotherapy Itegratio 6

7 The Itegrative Therapist Volume 4, Issue 1 Jauary 2018 Structured Iterviews o Research, cotiued Research ca help cliicias develop a more refied persoal care ad persoal preparatio strategies for the task. We have may years of work i Lati America ad the coditios i our regio are ot those of USA ad Europe. Hector Ferádez Alvarez 1. Psychotherapy research seems to poit towards a greater variability i outcomes betwee therapists tha therapies. How ca this research o therapist effects iform cliicias ad their realworld practice? Research o therapist effects ca be useful for cliicias i several ways give the strog persoal ivolvemet that the role of therapist implies. Research ca help cliicias develop a more refied persoal care ad persoal preparatio strategies for the task. I this sese, the proposals to apply self-reflectio ad self-practice (Beett-Levy) ca be very useful. O the other had, this research ca help practice i the real world to the extet that it helps kowig the way i which the role of therapist modulates the potetial scope of settigs ad therapeutic techiques. 2. How ca the field of psychotherapy itegratio, specifically, beefit from recogitio of the importace of therapist effects? Udoubtedly, kowig better the effects of therapists ca be very useful for the field of itegratio i psychotherapy, isofar as this may allow formulatig more idividualized therapeutic treatmet plas ad more idiographic itervetios. However I thik this ca be applied to the whole field of psychotherapy. 3. Fudig for psychotherapy research has geerally goe for the study of particular models applied to the treatmet of specific disorders. Meawhile, much of the research suggests that who provides the treatmet is more importat tha which treatmet is provided. Goig forward, what ca research programs do to deal with this tesio? The research programs that ca deal with this tesio will be desigs that ca cross a great diversity of treatmets x therapists i order to overcome the dissociated estimatio of both compoets. 4. Speakig of fudig, would you rather be doig psychotherapy research i Europe or i the US, ad why? We have may years of work i Lati America ad the coditios i our regio are ot those of USA ad Europe, therefore we have o argumets to respod, but the iterestig thig about the questio is that it restricts research to these regios sice there are other regios where research is coducted. We uderstad that a good alterative would be to iclude the cotributios of Lati America, ad the developmet of iteratioal collaboratio programs. 5. I your opiio, of relatively recet research fidigs, what are the most importat for cliicias? These are: a) idetificatio of the sources of failure i psychotherapy (drop outs, harmful effects, etc.), b) empirical studies liked to supervisio i psychotherapy (especially liked to the effects of supervisio o the therapeutic outcome of patiets), c) the use of ew techologies (ethical issues, cross-cultural issues, implemetatio stadards, comparative outcomes). Society for the Exploratio of Psychotherapy Itegratio 7

8 The Itegrative Therapist Volume 4, Issue 1 Jauary 2018 Structured Iterviews o Research, cotiued Steve C. Hayes We all kow that half of the cliicias are below average but we all secretly believe that we are i the top half. That s a delusio. I thik you ca brig these two ideas (therapists matter; methods matter) together by cosiderig what the actual processes are that mediate outcomes amog our various therapies. 1. Psychotherapy research seems to poit towards a greater variability i outcomes betwee therapists tha therapies. How ca this research o therapist effects iform cliicias ad their real-world practice? If you look at the literature o commo core processes that have to do with therapist s characteristics, a weakess is that the literature does t tell you eough about what you ca do as a therapist i order to be amog those who are particularly effective. There s a small literature of that kid, but I do t thik it s very powerful ad the head to head experimetal tests are ot there to my kowledge. I will propose a good way to do it later. Whe I m discussig this with cliicias, I usually ask how may people thik that therapist factors ad the therapeutic relatioship are critical to outcomes i psychotherapy. About 99% of the people i the audiece raise their hads. I the ask them whether or ot they thik they ca do a reasoably good job of producig powerful workig alliaces. About 95% of the people i the audiece the raise their had. I the ask how may people thik that they live i therapeutic Lake Woebego, where all the therapists are above average, ad a ervous laughter goes through the room. We all kow that half of the cliicias are below average but we all secretly believe that we are i the top half. That s a delusio. If you ask cliets to idicate characteristics of their therapists, or features of their relatioship with their therapists, they see thigs that are useful ad helpful, but that should ot be take to substitute for a adequate scietific aalysis. There could well be (actually, I thik there are I will describe some i a momet) third variables accoutig for the empirical relatioships ad the lay public would ot kow what those are. Just tryig to produce characteristics that cliets poit to, may ot be effective. It takes experimetal sciece (ot just correlatioal sciece) to explai the features of therapists ad the relatioship that matter, to give them theoretical meaig, ad to develop meas of teachig practitioers methods for producig the critical features that matter. I ve see this questio balloo ito the idea that techiques ad methods do ot matter, ad that is to my mid is a bit bizarre. It is just so obviously utrue. Take the etire literature ow o itervetios based o books, website, apps, ad so o. You ca readily show effects without ay therapist ivolvemet, i ad you ca show differetial outcomes based o the methods that are icluded. ii We kow methods matter, at least sometimes. I sometimes hear the most extreme versios of this lie of thikig from some of the very folks who claim to be the most iterested i the professio of psychotherapy, but they do ot seem to realize that the ed poit could well be to de-professioalize psychotherapy. If oly therapist factors matter, why all of these traiig programs? Why pay therapists like professioals? Why ot just scree for socially supportive ad credible people ad call them therapists? A weakess i the literature that is udereath your questio, i my opiio, is that the ways that we have characterized therapies are ot very useful. Techiques ca be applied competetly or icompetetly, of course, but the much more importat part of techiques ad methods are the processes of chage that they egage. Labelig somethig by a techological or protocol ame is a very shallow way to categorize thigs. If the method does ot move the iteded chage process, what good is that techological label? It would be like categorizig heart valve replacemet uder the label movig a scalpel ad the claimig that how you do heart valve surgery does ot matter to health outcomes, citig evidece from a study that icluded surgeos who claimed to be doig heart valve replacemet but ever replaced the valve: they just moved the scalpel. I thik you ca brig these two ideas (therapists matter; methods matter) together by cosiderig what the actual processes are that mediate outcomes amog our various therapies, ad the focusig o what best produces those Cotiued o page 9 Society for the Exploratio of Psychotherapy Itegratio 8

9 The Itegrative Therapist Volume 4, Issue 1 Jauary 2018 processes. Therapist factors move processes that matter±ad sometimes they are the same processes targeted by methods. For example, I thik you ca do a pretty good job of characterizig the workig alliace by focusig o the degree to which the therapeutic relatioship models, istigates, ad supports psychological flexibility, as that term is thought of from a Acceptace ad Commitmet Therapy (ACT) poit of view. iii I thik the future of therapy is ot therapies cosidered solely as a set of techiques, but therapies as itervetio strategies that move the mediators of chage. You ca do a quick persoal assessmet of this idea by thikig of somebody who was profoudly empowerig to you i your life, ad the askig yourself these questios: did you feel accepted for who you really were by this perso? Did you feel costatly judged by this perso, or was judgmet ad criticism far away? Whe the perso was with you, did they seem to be preset, or were they costatly lookig at their watch, or talkig about thigs that did t have to do with this momet of beig together? Whe you look that perso i the eye, did you see cosciousess there, ad could you see that you yourself were beig see as a coscious huma beig? Or did you see dead eyes, the eyes of a perso who is oly half preset? Whe you were together with that perso, did what you care about matter to them, or would they easily ride over your deepest cocers without a secod thought? Could you be together i a way that fit the situatio ad fit the possibilities ad what you cared about, or was it always oe way, my way, or the highway? Those six questios ask about acceptace, defusio, flexible attetio i the ow, a perspective takig sese of self, values, ad actios liked to values, which are the six defiig features of psychological flexibility. If you aswered the way I would guess you did, the this summary might make ituitive sese to you: empowerig relatioships are psychologically flexible. I d persoally be happy to call ACT ay therapeutic method that is focused o ad has bee show to move psychological flexibility. It s the model ad processes that matter, ot the techiques ad protocol. We ve tested this idea by the way. If you put i the workig alliace it mediates outcomes i ACT, but so too does psychological flexibility. If you let the two compete i a multiple mediator model, the workig alliace is weakeed, ad is sometimes o loger sigificat. iv That is ot because the relatioship is ot importat. I thik it is because if the cliet does ot iteralize what the therapeutic relatioship is modelig, it does ot matter that much. Said i aother way, the relatioship is a meas to a ed a chage i importat psychological processes. But those same processes ca also be targeted by techiques ad methods: the relatioship ad therapist factors are oly oe way to do so. It s a both ad situatio, ot a either or. I thik the future of therapy is ot therapies cosidered solely as a set of techiques, but therapies as itervetio strategies that move the mediators of chage. v If you had to pick a sigle set of processes that mediate outcomes across a wide rage of huma problem areas, ad eve therapeutic methods, I thik you could ot do much better tha to omiate psychological flexibility as such a target. It ca be moved by may methods. Thus, if you take a more process-based focus, you ca use a lot of differet therapeutic techiques, whether aalytic, humaistic, existetial, cogitive, behavioral, systems, or what have you, but always be doig evidece-based therapy i the sese that the processes of chage beig moved are evidece-based. 2. How ca the field of psychotherapy itegratio, specifically, beefit from recogitio of the importace of therapist effects? There s o mature sciece or professio that divides itself ito such silly divisios as psychotherapy does. We eed to rethik what psychotherapy itegratio really meas i the cotext of a more process-based approach. It seems to me that we should be usig evideced-based procedures to chage evidece-based processes, for the purposes of fosterig the prosperity ad solvig the problems of people. That does mea that we re itegratig methods, but it does ot ecessary mea that we re itegratig theories. Of course, we eed to get o with the busiess of softeig the divisio betwee broad traditios. There s o mature sciece or professio that divides itself ito such silly divisios as psychotherapy does, or ideed much of the psychological ad behavioral sciece. The aalytic wig; the behavioral wig; the existetial wig; the cogitive wig; ad so o. Oh please. That s obviously just a temporary trasitio i the developmet of our field ad evetually will pass away. We ca fid what s useful iside our various psychotherapy traditios by subjectig them to careful examiatio of the moderators ad mediators of chage for both positive aspiratios ad the amelioratio of egative problems; that is, both for people who eed metal ad behavioral health assistace, as well as assistace i the areas of work, or relatioships, or sport, or what have you. Therapist s effects, whe scietifically uderstood, ca poit to maipulable processes of importace. I emphasized psychological flexibility i that aswer above, but I could have talked about the importace of social support, or attachmet issues, or learig good relatioship skills, ad so o ad these differet models ca be tested ad compared. I thik i the mature era we ll evetually get to, we will let go of our attachmets Cotiued o page 10 Society for the Exploratio of Psychotherapy Itegratio 9

10 The Itegrative Therapist Volume 4, Issue 1 Jauary 2018 to schools, ad istead hold o to the best that Wester sciece ca give you i the developmet of coheret model of processes of chage, both i diagosig complex huma problems ad issues ad i alterig their trajectories. I thik the model that very likely will evetually uderlie psychotherapy research is the same model that uderlies all the rest of the life scieces: evolutio sciece. We have goe through a era i which we have focused o sigs ad symptoms, which gives us very poor feedback o true progress, ad o the success of our practice. 3. Fudig for psychotherapy research has geerally goe for the study of particular models applied to the treatmet of specific disorders. Meawhile, much of the research suggests that who provides the treatmet is more importat tha which treatmet is provided. Goig forward, what ca research programs do to deal with this tesio? I m ot sure I agree with your characterizatio, especially i the cotext of the chages iside the Uited States fudig system, i which the NIMH is greatly reducig fudig for psychotherapy research as it applies to metal health problems. Meawhile medicatio use is soarig. Thikig of it as a matter of who provides the treatmet versus which treatmet is provided is a very limited way to thik about it, ad frakly is ulikely to chage these treds i fudig or use. I do t mea that there s ot a issue iside that distictio, I simply mea that that distictio is ot the right way to thik about that issue, as I ve argued above. The correct way, i my opiio, is to focus o the process of chage, ad the processes that moderate them. If you did that, you could iclude therapist effects, as log as you had good meas of alterig them, alog with other processes ad we could get beyod this sad era of protocols for sydromes. That era is already passig. We eed to move toward a view of evidece-based psychotherapy that is iheretly itegrative i the sese that we will take whatever processes are available that moderate or mediate chage. We eed models to help brig order to the myriad chage processes. I thik the model that very likely will evetually uderlie psychotherapy research is the same model that uderlies all the rest of the life scieces: evolutio sciece. My guess is that you will see over time that the mediators of chage i psychotherapy will lie up pretty well with processes that ecourage healthy variatio, that fit variatio to cotext, that allow people to select ad retai variatios i psychological adjustmets that are successful while lettig go of those that are ot, ad that focus o the right dimesio (e.g., emotioal, cogitive, over behavioral) ad level of selectio (e.g., sub-orgaismic, orgaismic, social). 4. Speakig of fudig, would you rather be doig psychotherapy research i Europe or i the US, ad why? I ve mostly doe research i the Uited States, so I do t have a strog opiio o that beyod a appreciatio for a greater iterest i the theories ad processes of research i certai parts of Europe. It has always seemed to me that uderstadig basic processes, eve if it required that cliicias do the basic sciece work that allow us to have effective processes i had that ca apply to huma complexity, is by far the most progressive empirical approach, as opposed to simply radomized cotrol trials liked to protocols for sydromes, which I always thought was ulikely to be very importat, eve though I felt forced to do it i order to put importat ideas ito the coversatio. My ow research has always icluded laboratory ad basic sciece elemets as a result. You see that breadth of focus i the Cotextual Behavioral Sciece commuity the group that has arise to guide the developmet of ACT ad related parts of the research program. vi CBS folks are about as iterested i evolutio sciece or a basic sciece of cogitio (especially, Relatioal Frame Theory) as they are ACT. vii 5. I your opiio, of relatively recet research fidigs, what are the most importat for cliicias? The most importat research fidigs by far, i my opiio, are mediatioal data. Mediators are ot causes, but they are fuctioally importat targets of chage that are more proximal tha the targets of chage that will emerge without guidace by sciece. If you wet out to your backyard ad shoot baskets for a hour a day, you d get better, but ot if you wore blidfolds. You ca go to your cliic ad see six cliets a day for years o ed ad ot get ay better. Most cliicias do t believe that, but the data are clear. viii Psychotherapy is oe of the few areas of huma fuctioig i which experiece does t correlate very well with competece. That oly happes whe feedback is poor. We have goe through a era i which we have focused o sigs ad symptoms, which gives us very poor feedback o true progress, ad o the success of our practice. We also focus o the degree to which our cliets are pleased with us, which is also is a very poor substitute for idicatios of real chage. If you focus o mediators, you have a chace. Cotiued o page 11 Society for the Exploratio of Psychotherapy Itegratio 10

11 The Itegrative Therapist Volume 4, Issue 1 Jauary 2018 If you ca see major progress i therapy sessios i those areas, you re very likely witessig a life beig liberated. If you ca forgive a bit of self-focus, let me use the mediatioal evidece o psychological flexibility i ACT ad allied methods as a example of what I mea. The data o the mediatioal role of psychological flexibility is oe of the strogest sets of mediatioal data available i the psychotherapies, i terms of the breadth of applicatio ad the cosistecy of the result. ix Those data allow me to tell practitioers to take psychological flexibility very seriously. Whe they see their cliets becomig more emotioally ad cogitively ope, more cetered i the preset momet, with more flexible attetio to the ow; ad more able to alig their behavior with their chose values. If you ca see major progress i therapy sessios i those areas, you re very likely witessig a life beig liberated. Metaphorically, whe you see trasformatios like that you are seeig a ball that wet through the hoop. Chase that effect let that feedback shape you as a cliicia ad it seems likely you will have a better chace to get better over time as defied both by beig able to move the mediator ad also by cliet outcomes produced. It s a very testable hypothesis i ay case, ad there we come full circle back to your origially questio. The same should be true of ay broad ad flexible set of mediatioal results. You should be able to the same experimetal study with well-crafted measures of the workig alliace for example, ad it would allow feedback systems to be tested head to head from various models. That would be a progressive step i fosterig a sciece ad practice of itegrative therapy. Foototes ad Refereces i Foudatio Professor, Departmet of Psychology, Behavior Aalysis Program, Mail Stop 296, Uiversity of Nevada, Reo, NV ii Here is a recet example withi the ACT literature: Hofer, P. D., Waadt, M., Aschwade, R., Milidou, M., Acker, J., Meyer, A. H., Lieb R. & Gloster, A. T. (i press). Self-help for stress ad burout without therapist cotact: A olie radomised cotrolled trial. Work & Stress. doi: / iii A example liked to a popular CBT self-help book showed that icludig or removig elemets of it made a uexpected differece: Haeffel, G. (2010). Whe self-help is o help: Traditioal cogitive skills traiig does ot prevet depressive symptoms i people who rumiate. Behaviour Research ad Therapy, 48, iv Hayes, S. C., Strosahl, K., & Wilso, K. G. (2012). Acceptace ad Commitmet Therapy: The process ad practice of midful chage (2 d editio). New York: Guilford Press. v A study that shows that result is Gifford, E. V., Kohleberg, B., Hayes, S. C., Pierso, H., Piasecki, M., Atouccio, D., & Palm, K. (2011). Does acceptace ad relatioship focused behavior therapy cotribute to bupropio outcomes? A radomized cotrolled trial of FAP ad ACT for smokig cessatio. Behavior Therapy, 42(4), DOI: /j.beth vi A short form of that argumet ca be foud here: Hayes, S. C. & Hofma, S. G. (2017). The third wave of cogitive behavioral therapy ad the rise of process-based care. World Psychiatry, 16, doi: /wps My colleague Stefa Hofma ad I have a text comig out that shows how CBT ca be thought of as a form of processbased therapy: Hayes, S. C. & Hofma, S. G. (2018). (Eds.), Process-based CBT: The Sciece ad core cliical competecies of cogitive behavioral therapy. Oaklad, CA: Cotext Press / New Harbiger Publicatios. vii You ca see what that commuity is up to at viii For book legth descriptios of these two areas from a CBS poit of view see Wilso, D. S. & Hayes, S. C. (Eds.). (i press; 2018). Evolutio ad cotextual behavioral sciece: A reuificato. Oaklad, CA: Cotext Press / New Harbiger Publicatios; ad Hayes, S. C., Bares-Holmes, D., & Roche, B. (2001). Relatioal Frame Theory: A Post-Skieria accout of huma laguage ad cogitio. New York: Pleum Press. ix Christese, A. & Jacobso, N. S. (1994). Who (or what) ca do psychotherapy: The status ad challege of oprofessioal therapies. Psychological Sciece, 5, x You ca see a list of some of the ACT mediatioal studies here: Society for the Exploratio of Psychotherapy Itegratio 11

12 The Itegrative Therapist Volume 4, Issue 1 Jauary 2018 Structured Iterviews o Research, cotiued O average, top performers sped two to four times as much time egagig i activities related to improvig their outcomes, outside of performig psychotherapy....oe chief itegrative variable should be the professioal developmet of cliicias. Scott D. Miller 1. Psychotherapy research seems to poit towards a greater variability i outcomes betwee therapists tha therapies. How ca this research o therapist effects iform cliicias ad their real-world practice? For me, at least i two ways. The first is that, give the variability of performace, we eed to be moitorig our work o a ogoig basis, both i our ability to coect with the idividual cliet but also our outcomes. The secod oe is how we determie whether or ot we are developig professioally. There s overwhelmig evidece that therapists value professioal developmet activities, as well as a idetity cosistet with the idea that they are gettig better with time ad experiece. The data idicates that they do t get better with time ad experiece. Ad so, the variability of idividual performace gives us a widow to look through to uderstad why some are better tha others, cosistetly so. Ad, it turs out, some evidece exists that the differeces are attributable to the amout of time spet i a activity called deliberate practice. I 2007, our team itroduced this cocept to the broader psychotherapy audiece, ad bega lookig at how therapists who were better spet their time. O average, top performers sped two to four times as much time egagig i activities related to improvig their outcomes, outside of performig psychotherapy meaig, they re egagig i deliberate practice. I thik those are really the two areas. 2. How ca the field of psychotherapy itegratio, specifically, beefit from recogitio of the importace of therapist effects? Well, I thik oe of the chief itegrative variables is the therapist. Sol Garfield was poitig this out early two decades ago, suggestig the field look ito the cotributio made by the cliicia to outcome. Istead, our professio, i my opiio, took a detour developig treatmet models ad approaches, believig that traiig therapists i those approaches would lead to superior outcomes ad superior performig therapists. I thik the outcome of that choice has prove uhelpful, the opposite directio of what was predicted. So, oe chief itegrative variable should be the professioal developmet of cliicias. To me, the variability betwee providers gives us evidece o what we might focus o. 3. Fudig for psychotherapy research has geerally goe for the study of particular models applied to the treatmet of specific disorders. Meawhile, much of the research suggests that who provides the treatmet is more importat tha which treatmet is provided. Goig forward, what ca research programs do to deal with this tesio? I thik there are so may thigs that could be doe. Whether or ot they will happe is a ope questio. The curret way research is thought about ad fuded has bee mastered ad drive by those i uiversity settigs. Chagig the domiat approach to thikig ad researchig is likely, as is true of chage i geeral, to prove difficult. So, I m ot particularly saguie about the prospects of researchers chagig their view ad adoptig a differet way of thikig about the field ad how we do research. I also thik that much of the research cotiues to be fuded by orgaizatios led by physicias ad the medical model. Sorry to be pessimistic, but I thik it s very ulikely that those orgaizatios (e.g., NIMH, NICE) are goig to foster chage i a ew directio. What s more likely to happe is what s bee happeig for the last 30 years: psychology will try to emulate medicie, ad if it wats moey to do research it will have to treat psychotherapy as a aalogue to prescriptio drugs. Cotiued o page 13 Society for the Exploratio of Psychotherapy Itegratio 12

13 The Itegrative Therapist Volume 4, Issue 1 Jauary 2018 If the questio is where I d rather be practicig psychotherapy, I would say i Europe six ways til Suday. I thik some of the most itriguig results are about idividual therapist s differeces. 4. Speakig of fudig, would you rather be doig psychotherapy research i Europe or i the US, ad why? If the questio is where I d rather be practicig psychotherapy, I would say i Europe six ways til Suday. The reaso is I thik Europe has a much larger social cosciousess ad safety et. The US has a distictly differet culture. More, much of the practice is drive by reimbursemet ecoomics. I do t kow eough about how psychotherapy research i fuded i Europe to commet about research there to argue covicigly oe way or the other. For the reasos I stated i the previous questios, research fudig is very difficult for someoe comig from a cotextual rather tha medical paradigm. 5. I your opiio, of relatively recet research fidigs, what are the most importat for cliicias? I terms of effectiveess ad professioal developmet, I thik some of the most itriguig results are about idividual therapist s differeces. It is also, at preset, the Wild West. We do t really have a good defiitio of what therapists eed to practice i order to get better. Eve those of us hailig from a cotextual paradigm are uclear at this momet about what might be the best protocol for professioal developmet. At the same time, I thik there is emergig evidece that deliberate practice icludes a umber of essetial elemets. The first is, moitorig the outcome as well as egagemet level of cliets i your therapy practice. Doig so will aid i idetifyig performace improvemet opportuities where we show deficits i our outcomes, for example. The Itegrative Therapist: Call for Cotet The Itegrative Therapist wats you to be a author. We are seekig brief, iformal, iterestig ad actioable articles with a persoal touch. Thik of the way you would talk to a colleague over luch. Please limit refereces to those that are absolutely essetial. Our bias is towards articles relevat to SEPI s three missios: itegratio betwee researchers ad cliicias, itegratio across cultures, ad further developmet of psychotherapy itegratio. Each issue has a theme. The April 15 issue will focus o Theoretical Covergece, the issue of movemet away from distict, competig schools ad towards a uified way of lookig at our subject. Cotributors are ivited to sed articles, iterviews, commetaries, letters to the editor, photos, ad aoucemets to Jeffery Smith, MD, Editor, The Itegrative Therapist. Submissio Deadlies ad Publicatio Dates December 1 deadlie for Jauary 15 Issue March 1 deadlie for May 15 Issue Jue 20 deadlie for July 15 Issue September 15 deadlie for October 15 Issue Society for the Exploratio SEPI of Psychotherapy Itegratio Specificatios The preferred legth of submissios is 1,250 words or less Block style, sigle spaced with a extra space betwee paragraphs No paragraph idetatios, page umberig, headers or footers Use subheadigs ad bullet poits freely Bare Miimum refereces should be sigle spaced, i approved APA-style format lease iclude a photo of the author or authors, miimum 50K file size each. Photos should be submitted as separate JPEG, TIFF, GIF, or BITMAP files. All submissios should be set i the body of a to jsmd@howtherapyworks.com with the subject lie Cotributio to Itegrative Therapist. Society for the Exploratio of Psychotherapy Itegratio 13

14 The Itegrative Therapist Volume 4, Issue 1 Jauary 2018 Structured Iterviews o Research, cotiued Ja Roubal The key psychotherapist s competecy would be the the ability to cope with their ow experieces while beig at the same time available to the meetig with cliet. Agai ad agai, I am astoished by how little the psychotherapy chage process is cosciously cotrolled by the therapist. 1. Psychotherapy research seems to poit towards a greater variability i outcomes betwee therapists tha therapies. How ca this research o therapist effects iform cliicias ad their real-world practice? The recetly growig, research based emphasis o the psychotherapy relatioship role i the chage process ca support psychotherapists i explorig, how to be with the cliet i a effective way. It seems to me that it is ot so much importat what we do with our cliets, rather how we are with them. Attuig well i a specific way to every idividual cliet, moreover i every specific momet of our meetig, seems to be oe of the key poits for the psychotherapy effectiveess. Psychotherapy ad eurosciece research ca help practitioers to reflect ad cultivate this competecy. 2. How ca the field of psychotherapy itegratio, specifically, beefit from recogitio of the importace of therapist effects? It seems to me that may itervetios, which therapists do with the itetio to help their cliets, work to a great extet for therapists themselves to cope with their ow experieces of axiety, ucertaity, or helplessess. The key psychotherapist s competecy would be the the ability to cope with their ow experieces while beig at the same time available to the meetig with cliet. Such a competecy is iheretly itegrative, because it is geuiely huma. Our huma experieces ad abilities to meet the other huma beig do ot differ accordig to the differet psychotherapy approaches we were traied i. 3. Fudig for psychotherapy research has geerally goe for the study of particular models applied to the treatmet of specific disorders. Meawhile, much of the research suggests that who provides the treatmet is more importat tha which treatmet is provided. Goig forward, what ca research programs do to deal with this tesio? I fid it very promisig to focus o explorig psychotherapists ow experieces, together with their strategies for copig with such experieces, with differet specific populatios: with cliets who experiece psychosis, depressio, borderlie pheomea, paics, etc. 4. Speakig of fudig, would you rather be doig psychotherapy research i Europe or i the US, ad why? I am lucky that I ca be more focused o the topic of my research tha o the fudig resources. 5. I your opiio, of relatively recet research fidigs, what are the most importat for cliicias? I recetly foud very ispirig to study research o psychotherapists coutertrasferece (i the broad meaig, icely summarized ad itroduced by e.g. Gelso & Hayes, 2007; or Wolf, Goldfried, & Mura, 2013) i the light of the eurocogitive mirrorig cocept, ad of the eurosciece research i geeral (aptly liked to psychotherapy by e.g. Siegel, 2012; or Cozolio, 2016). Agai ad agai, I am astoished by how little the psychotherapy chage process is cosciously cotrolled by the therapist, ad so how importat is that therapists humbly do ot get i the way of the healig potetial of huma meetig with its ow, ofte hidde, dyamics ad wisdom. Refereces: Cozolio, L. (2016). Why therapy works. Usig our mids to chage our brais. New York, N.Y.: W.W. Norto & Compay. Cotiued o page 19 Society for the Exploratio of Psychotherapy Itegratio 14

15 The Itegrative Therapist Volume 4, Issue 1 Jauary 2018 Structured Iterviews o Research, cotiued William B. Stiles...to me, the scietific headlie is ot the modest therapist effects but the lack of treatmet approach effects. Cliets ted to have similar positive outcomes because all treatmets offer a wide rage of tools ad therapists have leared how to use them appropriately. 1. Psychotherapy research seems to poit towards a greater variability i outcomes betwee therapists tha therapies. How ca this research o therapist effects iform cliicias ad their real-world practice? Differeces i effectiveess amog therapists are ot large, except at the extremes, but they are bigger tha othig, which is roughly the differece amog therapies. I suppose a implicatio for idividual cliicias is: to be effective, cocetrate o doig a good job of what you do ad do t worry about which treatmet approach you use. 2. How ca the field of psychotherapy itegratio, specifically, beefit from recogitio of the importace of therapist effects? As I said, to me, the scietific headlie is ot the modest therapist effects but the lack of treatmet approach effects. This is the familiar Dodo verdict: everybody has wo ad all must have prizes. If we uderstood this, we might have start o uderstadig what does make a differece. How ca so may demostrably differet treatmets all be about equally effective? To come at this questio a bit sideways, I thik a clue is that i routie practice, treatmet duratio does t predict outcome either. Usig several large practice-based datasets gathered i the British Natioal Health Service, we foud that cliets averaged similar amouts of pre-post chage regardless of how may sessios they atteded. Those who atteded two or three sessios did as well as those who atteded twety or thirty sessios. Others have replicated this fidig too. Fidig that short ad log treatmets have similar outcomes may seem surprisig if you thik of treatmet duratio as a experimetal maipulatio. But it is more plausible if cliets ad therapists are cosidered as resposively regulatig treatmet duratio. That is, we speculated, participats regulate how much therapy they get i respose to their eeds ad circumstaces. Cliets have varied requiremets ad resources; therapists do too. They moitor beefits ad costs as treatmet proceeds, make progress at differet rates, ad ed treatmet whe they ve had eough, however may sessios that is. So the cliets ted to have similar outcomes because they all get about as much therapy as they eed or ca afford. The Dodo results could have a similar explaatio. Perhaps cliets ad therapists resposively make the best use they ca of whatever type of treatmet is beig offered. They use the tools of the offered treatmet to address emergig requiremets. Cliets ted to have similar positive outcomes because all treatmets offer a wide rage of tools ad therapists have leared how to use them appropriately. This sort of appropriate resposiveess (doig the right thig as eeds ad circumstaces chage) is characteristic of ay huma iteractio, ad of course it is emphasized i cliical traiig, but it is overlooked i the simple causal models that get tested i experimetal paradigms like radomized trials. So how does all this bear o therapist effects? Perhaps therapists differ i appropriate resposiveess. That is, perhaps they vary i their ability or tedecy to do the right thig. Of course, the right thig to do is differet i differet circumstaces, so appropriate resposiveess is ot easy to measure. Choosig the right itervetio at ay momet depeds o just about every treatmet variable you ca thik of: diagosis, severity, age, geder, ethicity, itelligece, laguage, culture, type of treatmet, stage of treatmet, cliet persoality, therapist persoality, history of the relatioship, ad so o ad so o. Perhaps the more effective therapists are better at makig these complex choices. As a result, they may show better empathy, form stroger alliaces, ad have more positive outcomes. Cotiued o page 16 Society for the Exploratio of Psychotherapy Itegratio 15

16 The Itegrative Therapist Volume 4, Issue 1 Jauary Fudig for psychotherapy research has geerally goe for the study of particular models applied to the treatmet of specific disorders. Meawhile, much of the research suggests that who provides the treatmet is more importat tha which treatmet is provided. Goig forward, what ca research programs do to deal with this tesio? This looks pretty hopeless to me, at least i the short to medium term. Fuders are fixed o the questio of what works, or which is the best treatmet. The received wisdom is that radomizatio is ecessary to establish causality, ad hece for secure kowledge about whether a treatmet works, or works better tha a alterative. To put it aother way, high quality research is uderstood to require a coditio that ca be maipulated as a idepedet variable, ad treatmet approach is about all we ve got....quality research is uderstood to require a coditio that ca be maipulated as a idepedet variable, ad treatmet approach is about all we ve got. It would be possible, of course, to radomize cliets to therapists, ad this could establish therapist effects more firmly i a particular istace. But it would be hard to covice fuders to pay the huge costs ivolved for a radomized cliical trial that, at best, could show oe particular therapist was more effective tha aother. 4. Speakig of fudig, would you rather be doig psychotherapy research i Europe or i the US, ad why? Europea fuders have bee relatively more friedly toward a wider variety of types psychotherapy research, icludig process research ad qualitative research. It s hard to kow if that will cotiue. 5. I your opiio, of relatively recet research fidigs, what are the most importat for cliicias? I lie with the foregoig discussio, I thik a importat recet fidig is the Pybis et al. (2017) report that outcomes for CBT ad geeric couselig for the treatmet of depressio were comparable i a very large (N > 33,000) British sample. (Couselig i the UK is usually a itegrative treatmet approach.) I this study, the familiar observatio that differet treatmet approaches had equivalet outcomes occurred i the cotext of a highly-publicized ad well-fuded program called Improvig Access to Psychological Therapies, or IAPT, which ivolved special traiig for the CBT therapists aimed at improvig efficiecy ad outcomes i these practice-based NHS settigs. To exted the earlier lie of thikig, it appears that the resposive regulatio that yields equivalet outcomes across differet treatmet types ad duratios may be robust to specialized traiig of therapists. Outcomes may still deped o participats makig appropriate resposive use of what is offered. Refereces Pybis, J., Saxo, D., Hill, A., & Barkham, M. (2017). The comparative effectiveess ad efficiecy of cogitive behaviour therapy ad geeric cousellig i the treatmet of depressio: evidece from the 2d UK Natioal Audit of psychological therapies. BMC Psychiatry, 17:215. DOI /s Stiles, W. B., Barkham, M., & Wheeler, S. (2015). Duratio of psychological therapy: Relatio to recovery ad improvemet rates i UK routie practice. British Joural of Psychiatry, 207, doi: /bjp.bp Stiles, W. B., & Horvath, A. O. (2017). Appropriate resposiveess as a cotributio to therapist effects. I L. Castoguay & C. E. Hill (Eds.), How ad why are some therapists better tha others? Uderstadig therapist effects (pp ). Washigto, DC: APA Books. SEPI Aouces: UPDATED LISTING OF INTEGRATIVE TRAINING PROGRAMS WORLDWIDE The SEPI leadership has completed a survey to idetify itegrative traiig programs ad gather pertiet data about each. The list, ow coverig over 60 programs is available o the SEPI website at the followig address: Society for the Exploratio SEPI of Psychotherapy Itegratio Society for the Exploratio of Psychotherapy Itegratio 16

17 The Itegrative Therapist Volume 4, Issue 1 Jauary 2018 Structured Iterviews o Research, cotiued Ladislav Timulak If we kew what therapist qualities might be resposible for those outcomes, we could see whether we could foster those qualities more. I live i Irelad ad my sese is that Irelad is friedly to psychotherapy research. 1. Psychotherapy research seems to poit towards a greater variability i outcomes betwee therapists tha therapies. How ca this research o therapist effects iform cliicias ad their real-world practice? First of all, while we kow that some therapists cliets have better outcomes tha others, we do ot kow that much about what qualities i those therapists might be resposible for those outcomes. If we kew what therapist qualities might be resposible for those outcomes, we could see whether we could foster those qualities more. 2. How ca the field of psychotherapy itegratio, specifically, beefit from recogitio of the importace of therapist effects? I am ot sure. We oly kow that cliets of some therapists have better outcomes. We oly idirectly ifer the qualities of those therapists that may be resposible for those differeces. I thik we eed more theoretical work doe that would frame what we kow about the therapist qualities that may be importat for therapists effects. Oce we had a clear lie of research supported by a plausible theoretical framework, the we could start to get more clarity o this pheomeo. Oly the could we thik of applicatios for traiig ad/or practice. 3. Fudig for psychotherapy research has geerally goe for the study of particular models applied to the treatmet of specific disorders. Meawhile, much of the research suggests that who provides the treatmet is more importat tha which treatmet is provided. Goig forward, what ca research programs do to deal with this tesio? I am ot sure whether the claim i this questio is actually true. We oly kow that the cliets of some therapists have better or worse outcomes (as opposed to beig i the maistream average therapist effect). We actually do ot kow much about who are those therapists whose cliets do exceptioally well (or badly for that matter). Therefore I would be careful i makig such a claim. As outlied above, I believe we eed more theoretically drive research ito the qualities resposible for better outcomes with particular therapists cliets. 4. Speakig of fudig, would you rather be doig psychotherapy research i Europe or i the US, ad why? I live i Irelad ad my sese is that Irelad is friedly to psychotherapy research (I m basig this judgmet o my lie of successful bids). I am ot that familiar with the situatio more broadly i Europe, UK, or US. My sese is that metal health is more ad more recogized by govermetal bodies, which is reflected i opportuities for obtaiig fudig. It is possible, however, that my view is over-optimistic, aecdotal ad based o my local experiece. 5. I your opiio, of relatively recet research fidigs, what are the most importat for cliicias? I was particularly iflueced by studies o emotioal processig sequeces stemmig from the work of Atoio Pascual-Leoe ad others i various theoretical orietatios. I appreciate that the work is theoretically elegat, predictive ad applicable to a variety of cotexts, approaches, ad cliet presetatios. I thik we do ot have that may sequetial theories of chage ad correspodig multi-step sequeces of therapist strategies/itervetios. It is iterestig to see, for istace, that hopelessess ca be differetiated ito a sese of beig uloved/ulovable ad that through the articulatio of a umet eed (e.g., to be loved/accepted), the cliet may access adaptive experieces of feelig loved or deservig whilst also grievig for the times whe that coectio was ot available. Society for the Exploratio of Psychotherapy Itegratio 17

18 The Itegrative Therapist Volume 4, Issue 1 Jauary 2018 Structured Iterviews o Research, cotiued While traditioal cotiuig educatio is focused o models, ad cliical cosultatio is usually focused o cliets, Deliberate Practice is focused squarely o the uique developmetal path of each therapist. Researchers coductig cliical trials of models should assess therapist effectiveess before doig their cliical trials. Toy Roussmaiere 1. Psychotherapy research seems to poit towards a greater variability i outcomes betwee therapists tha therapies. How ca this research o therapist effects iform cliicias ad their real-world practice? This research could help guide cliicias towards more effective cliical traiig. Traditioally, cliical traiig has focused largely o learig ew treatmet models, without much cosideratio for first assessig each therapists idividual stregths ad weakesses. While treatmet models are valuable, they are best leared i the cotext of each therapist s persoal growth edge: iterpersoal skills ad psychological capacity just beyod the therapist s curret ability. For example, ca you imagie puttig 20 radom people through a maratho traiig without first assessig each perso s fitess? The focus o the idividuality of the therapist ca build o the fidig of therapist effects ad add a importat dimesio to cliical traiig. While traditioal cotiuig educatio is focused o models, ad cliical cosultatio is usually focused o cliets, Deliberate Practice is focused squarely o the uique developmetal path of each therapist. 2. How ca the field of psychotherapy itegratio, specifically, beefit from recogitio of the importace of therapist effects? The field of psychotherapy itegratio ca beefit by icreasig the research focus o what leads some therapists to be more or less effective tha others. Which cliical skills or persoal attributes impact cliical outcome the most? Whe these are idetified, we ca the do research more precisely targeted cliical traiig. This same pla could also be doe for supervisors. 3. Fudig for psychotherapy research has geerally goe for the study of particular models applied to the treatmet of specific disorders. Meawhile, much of the research suggests that who provides the treatmet is more importat tha which treatmet is provided. Goig forward, what ca research programs do to deal with this tesio? Researchers coductig cliical trials of models should assess therapist effectiveess before doig their cliical trials, ad this data should be used to scree which therapist to iclude i cliical trials. For example, there could be a cliical trial for CBT or psychodyamic therapy for therapists who have bee foud to have low, medium, or high cliical effectiveess. Screeig therapists will help researchers customize the cliical traiig provided i trials, ad also lead to more valid ad geeralizable fidigs regardig which practicig cliicias will beefit from those models. I persoally thik we should aim for more effective cliical traiig for therapists at the lower ad mid-rage of the effectiveess curve, as that could beefit cliets the most. 4. Speakig of fudig, would you rather be doig psychotherapy research i Europe or i the US, ad why? I have t bee ivolved i grats yet. Cotiued o page 19 Society for the Exploratio of Psychotherapy Itegratio 18

19 The Itegrative Therapist Volume 4, Issue 1 Jauary I your opiio, of relatively recet research fidigs, what are the most importat for cliicias?...a few recet studies have suggested that traiees ad therapists iterpersoal skills ad self-reflective fuctioig are associated with better cliical outcomes. Oe promisig ew tred i research is studies that examie tras-modal therapist characteristics. For example, a few recet studies have suggested that traiees ad therapists iterpersoal skills ad self-reflective fuctioig are associated with better cliical outcomes (e.g., Aderso, McClitock, Himawa, Sog, & Patterso, 2015; Cologo, Schweitzer, Kig, & Notle, 2017; Schottke, Fluckiger, Goldberg, Eversma, & Lage, 2016). This raises the excitig possibility that traiees ad therapists may be able to improve their iterpersoal skills ad self-reflective fuctioig through the use of Deliberate Practice. This would be a therapist-focused method of cliical traiig, ad may more reliably improve cliical outcomes, whe compared to a model of traiig that focuses primarily o treatmet models. Refereces Aderso, T., McClitock, A. S., Himawa, L., Sog, X., & Patterso, C. L. (2015). A Prospective Study of Therapist Facilitative Iterpersoal Skills as a Predictor of Treatmet Outcome. Joural of Cosultig ad Cliical Psychology, 84(1), Cologo, J., Schweitzer, R. D., Kig, R., & Nolte, T. (2017). Therapist Reflective Fuctioig, Therapist Attachmet Style ad Therapist Effectiveess. Admiistratio ad Policy i Metal Health ad Metal Health Services Research, 44(5), Schöttke, H., Flückiger, C., Goldberg, S. B., Eversma, J., & Lage, J. (2016). Predictig psychotherapy outcome based o therapist iterpersoal skills: A five-year logitudial study of a therapist assessmet protocol. Psychotherapy Research, 3307(February), Ja Roubal ~ Structured Iterview, cotiued from page 14 Gelso, C. J., & Hayes, J. A. (2007). Coutertrasferece ad the therapist s ier experiece: Perils ad possibilities. Mahwah, NJ: Lawrece Erlbaum Associates. Siegel, D. J. (2012). The developig mid: How the relatioships ad the brai iteract to shape who we are (2d ed.). New York, NY: The Guilford Press. Wolf, A. W., Goldfried, M. R., & Mura, J. C. (2013). Trasformig egative reactios to cliets: From frustratio to compassio. Washigto, DC: America Psychological Associatio. Society for the Exploratio SEPI of Psychotherapy Itegratio Society for the Exploratio of Psychotherapy Itegratio 19

20 The Itegrative Therapist Volume 4, Issue 1 Jauary 2018 SEPI Questioaire o Research Alexadre Vaz...aswers we got from SEPIas from all over the world truly highlight what a diverse buch our dear commuity is. Ladies ad getlema, it s time for us to cotiue our (very recet) traditio here at the Newsletter ad preset our ewest Survey results! The may aswers we got from SEPIas from all over the world truly highlight what a diverse buch our dear commuity is. We asked you o psychotherapy research ad its impact, ad we got practically every psychotherapy topic represeted plus the kitche sik! You ca ow browse through all the survey aswers i our archive. [Research Survey Lik] To ope your itegrative appetite, feast your pluralistic mid o the aswers provided by SEPI s most seior member, the iimitable Zolta Gross: Q1 What research fidigs, if ay, have made you rethik or sigificatly recosider previous ideas you held o psychotherapy practice? Research o the importace of the therapeutic alliace ad o the fact that some therapists are better tha others. Both of these have had a impact o psychotherapy ad more research o these variables should be doe. Q2 What research fidigs have most iflueced your thikig o how to improve as a therapist? Noe that I kow of. Q3 What researchable questio o psychotherapy would you most like to see addressed (or be addressed more thoroughly)? Much more research o the emotioal itelligece of therapists is eeded. Q4 If you are a researcher, what is your top priority or suggestio i order to make the research field more relevat for real-world cliical practice? The differet metatheoretical laguages of research ad cliical practice eeds itegratio. Q5 Please idetify yourself ad year of graduatio (uless you wish to remai aoymous). Zolta Gross, Ph.D Society for the Exploratio SEPI of Psychotherapy Itegratio Society for the Exploratio of Psychotherapy Itegratio 20

21 The Itegrative Therapist Volume 4, Issue 1 Jauary 2018 Society for the Exploratio of Psychotherapy Itegratio 21