Helene Amundsen Nissen-Lie
The rationale behind the current studies was the need to better understand the therapist effect (i.e. variability in processes and outcomes of therapy due to therapists), which has been established in numerous studies (e.g. Dinger, Strack, Leicsenring, Wilmers, & Schauenburg, 2008; Kim & Wampold, 2006; Lutz, Leon, Martinovich, Lyons, & Stiles, 2007; Okiishi, Lambert, Nielsen, & Ogles, 2003). Three empirical studies were conducted to address this topic investigating associations between therapists’ self-perceptions, based on concepts evolved within the International Study of the Development of Psychotherapists (ISDP) (Orlinsky et al., 1999; Orlinsky & Rønnestad, 2005), and psychotherapy process and outcome data obtained from different observational perspectives (i.e. patients, therapists, external clinical experts). The studies used data from the Norwegian Multisite Study of Process and Outcome of Psychotherapy (NMSPOP) (Havik et al., 1995) which is a large-scale multi-site project of naturalistic psychotherapeutic treatments conducted within the Norwegian public health care services. The data were collected at 15 outpatient clinics from patients (N = 370) prior to their treatment, throughout treatment and during a 2-year follow-up period.
The current project investigated the nature of therapist differences from the point of view of therapists’ self-perceptions as described by their ‘Work involvement styles’ and subscales (Orlinsky & Rønnestad, 2005). The magnitude of therapist effects was calculated for early alliance, alliance over time, and for outcome, and showed that the therapist effect was larger in alliance scores compared to outcome, and largest when rated by the therapists. In outcomes, the therapist variability in patient change was much larger in observer-rated functioning (GAF) and interpersonal distress (IIP), compared to symptom distress (GSI). All in all the studies reported notable therapist effects in alliance and outcome.
A number of systematic relationships between the therapists’ self-perceptions and alliance as well as outcome were revealed in the studies. The global ‘Work involvement styles’ were unrelated to most measures rated by patients or external raters, but these factors were strongly related to therapist-rated alliance in consistent ways: ‘Healing involvement’ was a positive predictor while ‘Stressful involvement’ was a negative predictor of therapist-rated alliance. The influence of therapists’ experiences of difficulties called ‘Professional self doubt’ (PSD) and ‘Negative personal reaction’ (NPR) was strong for both patient-rated early alliance and one type of outcome (i.e. decrease in interpersonal problems). The effect of NPR and PSD ran in opposing directions: NPR was negatively related to alliance quality and outcome (level of interpersonal problems), while PSD on the other hand was positively associated with early alliance and change in interpersonal problems, but had a negative effect on alliance growth as rated by patients.
Therapists’ ‘in-session anxiety’ demonstrated a convergent, negative influence on alliance, as observed by both patients and therapists. Therapists’ self-reported ‘Warm interpersonal style’ (WIS) exerted a clear positive effect on alliance as observed by both patients and therapists, but had a less important impact on outcome. The therapists’ self-estimated ‘Advanced relational skills’ (ARS), referring to the capacity to utilize one’s own emotional reactions towards the patients and the patients’ emotional reactions towards oneself as therapist (or countertransference and transference reactions), were unexpectedly associated with lower early alliance , less reduction in interpersonal problems and less growth in global functioning (GAF) as rated by clinical expert observers. Finally, patients’ interpersonal distress before treatment was a strong moderator of the effect of ARS on change in symptom distress and interpersonal problems. Higher ARS in therapists was less constructive for more disturbed patients.
To summarize, the three studies demonstrated complex but meaningful links between the therapists’ perceptions of themselves on the one hand, and the working alliance and patient improvement from therapy on the other, which have important implications for the self-reflection, clinical practice, as well as for training and supervision, of psychotherapists.