A new systematic review of the literature provides insight into why it is that some therapists tend to be more effective than others. Using a narrative approach, researchers Erkki Heinonen and Helen Nissen-Lie found that successful therapists have professionally cultivated specific skills—such as empathy, communication skills, and the capacity to form and repair successful relationships—but that these skills have roots in therapists’ personal lives and attachment histories. Their findings were recently published in the Psychotherapy Research journal.
“Psychotherapists are known to differ in their effectiveness,” the researchers write. “The present challenge is to provide content to this observation: What are the characteristics of the psychotherapist that actually contribute to these differences?”
Research has found that some therapists consistently achieve better therapy outcomes than others. This effect has been convincingly established within the literature. The idea that therapist characteristics influence therapy outcomes is referred to as “therapist effects” because they are not explained by other variables, such as client characteristics and presenting problems, therapeutic approach, manualized vs. nonmanualized therapy, and random error. Therefore, although contextual and client factors likely influence therapists, effective therapists are bringing something unique into the room.
Heinonen and Nissen-Lie conducted a systematic review to determine what it is about some therapists that lead to better or worse therapy outcomes. They write:
“A pressing task is, therefore, to understand the more or less stable characteristics of therapists that explain their differences in outcome. Besides helping to understand better how psychotherapy works, knowledge on the characteristics of effective therapists would have much other practical value.”
A better understanding of therapist effects, they point out could aid the process of selecting and training therapists. This depends upon whether therapist characteristics are innate dispositions or developmentally acquired, they write. Nevertheless, merely being aware of their contributions toward effective therapy may allow therapists to engage these aspects with greater intentionality and focus.
In this systematic review, studies published since the year 2000 were included, which examined both professional and personal characteristics of therapists. Professional characteristics are qualities that the therapist has explicitly developed toward their role as a therapist, such as their therapeutic philosophy and specific relational skills designed to work with clients.
Personal characteristics describe therapists in their non-professional lives, for instance, cultural orientation, personal values, and attachment style. Prior research has indicated that specific therapist characteristics—such as gender, particular profession, and competence and adherence to treatment manual—are not likely to be determining factors.
Heinonen and Nissen-Lie clarify the study’s aim to ultimately gain a clearer understanding of what it is that therapists contribute to therapeutic change:
“The aim here was to identify the skills, traits, and qualities that more effective therapists initially bring to each of their therapy sessions independent of the interaction with particular patients.”
Their overall goal was to “identify similarities and differences in therapist qualities conducive to better outcomes.” In this process, outcomes were measured by clients’ functioning and wellbeing after therapy or in follow up assessments.
The studies included in this review featured diverse methodologies, tools, and analytic procedures, which made conducting a quantitative analysis infeasible. Therefore, the researchers chose to utilize a narrative approach to synthesize findings across the 31 studies. Moreover, they took a critical approach to their interpretation of studies, choosing to emphasize results from ones that employed higher quality approaches and rigor.
The results of their synthesis indicate that therapists’ professional characteristics (e.g., philosophy, values, and attitudes about treatment) more directly influenced therapy outcome. However, personal characteristics, including personal values, attachment style, and descriptions of therapists’ non-professional lives interacted with the therapeutic work and the client-therapist relationship, even if they were not observed to influence the outcome directly.
Regarding therapists’ professional characteristics, some findings suggested that in long-term psychodynamic therapies, the therapists’ belief in insight and kindness as curative factors led to better outcomes. Additionally, in shorter-term treatments, when experienced therapists were confident in their professional skills, they had better results with clients.
However, in longer-term therapies, the therapist’s confidence could lead to worse outcomes, particularly with very distressed clients. In these instances, “professional self-doubt” was seen to be beneficial. For example, more effective therapists reported making more mistakes in therapy than less effective ones.
Therapists professional interpersonal skills were more predictive of outcome than therapists’ self-ratings of their occupational self-efficacy and confidence. The ability to professionally relate to clients with empathy, warmth, positive regard, clear and positive communication and the capacity to take critical feedback predicted better outcomes across all levels of therapist expertise.
Interestingly, the findings suggested that it may take an interpersonally challenging situation to arise in therapy for these therapist effects to emerge. In other words, how therapists respond when faced with challenging moments differentiate the effective therapists, who respond with empathy, self-control, and emotional containment, from the less effective ones.
Therapists’ personal attributes were not directly tied to their therapy outcomes, as with the therapists’ professional factors. For example, the influence of therapists’ attachment style and experiences of parental bonding on client outcome was not clearly detectable. However, even if these factors do not impact the outcome directly, they may still affect the outcome by interacting with other therapy ingredients, such as the client-therapist relationship. Moreover, it is difficult to sever aspects of therapists’ professional and personal lives, particularly when examining relational skills.
Although the findings did not indicate pronounced effects of therapists’ private intrapersonal and interpersonal lives, some patterns suggested that effective levels of therapist humility and self-doubt were related to their ability to be nurturing toward themselves (i.e., an intrapersonal aspect). This ability fostered a productive amount of self-doubt that in turn, led to better therapy outcome.
This may be because therapists’ personal, positive coping/psychological resources helped them to focus on the client and maintain greater flexibility. In some studies, personal qualities, such as mindfulness, “emotional intelligence,” and “reflective functioning,” compensated for therapists’ psychological vulnerabilities and bolstered outcome. Indeed, although the therapists’ attachment style was not distinctly related to outcome, one study found that therapists’ who were identified as securely attached were more effective in work with severely distressed clients.
More importantly, however, it appears that therapists’ capacity to access their own positive supports and psychological resources could compensate for vulnerabilities (e.g., the effects of weaker attachment bonds), enabling them to better differentiate between self and client. Therefore, therapists’ ability to exercise self-control, self-insight, and manage countertransference was deemed important, even if these aspects do not serve as direct measures of outcome.
After exploring the complexity of these findings, and the difficulty in distinguishing between therapists’ professional and personal presentations, the researchers noted how findings “point to the complexity of how therapists interact as professionals and people overall with the numerous variables linked to the outcome and contraindicate the study of therapists in a ‘vacuum.’”
As Heinonen and Nissen-Lie review study limitations, they note that these results reflect therapists’ traits rather than states. In other words, situational factors (e.g., illness in family, poor workplace environment) are not captured in this systematic review.
Overall, the professional skills exhibited by effective therapists, although developed and refined within a professional capacity, are considered to be connected to their personal lives and attachment. The researchers highlight several findings that underscore how “therapists’ self-rated skillfulness, difficulties in practice, and coping mechanisms, and attitudes toward therapy matter.”
There were no salient effects related to “personality style” (i.e., the Big Five traits), but basic relational skills around warmth were essential. Furthermore, the ability to stay focused on the client and manage reactions, capabilities that are connected to a secure attachment style, were influential.
Heinonen and Nissen-Lie conclude:
“According to the consistent findings of this review, more effective therapists are characterized by interpersonal capacities that are professionally cultivated but likely rooted in their personal lives and attachment histories—such as empathy, verbal and nonverbal communication skills and capacity to form and repair alliances—especially with interpersonally challenging clients.”
Erkki Heinonen & Helene A. Nissen-Lie (2019): The professional and personal characteristics of effective psychotherapists: a systematic review, Psychotherapy Research, DOI: 10.1080/10503307.2019.1620366 (Link)