in theory, therapists matter between theory and practicein theory, there is no difference between...
TRANSCRIPT
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Therapists Matter
Eight skills that make you better at what you do
William R. Miller, Ph.D.
The University of New Mexico
In theory, there is no differencebetween theory and practice
In practice, there is.
Dean Fixsen
In practice, evidence-based treatments are not homogeneous
Same Treatments at Different Sites in Project MATCH
Milwaukee West Haven Albuquerque Farmington
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Treatments are not the
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they are delivered
All Therapists Are Not the Same
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Drug Use Employment Psychiatric Effect Size
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Imp
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tSupportive-Expressive Therapy: 3 Counselors
Luborsky, McLellan, Woody, O’Brien & Auerbach, 1985
Archives of General Psychiatry 42:602-611
A Natural Experiment
� Two drug treatment counselors resigned
� Their 62 cases were assigned randomly to the four
remaining counselors
� There were dramatic differences in client outcomes.
McLellan et al., 1988 Journal of Nervous and Mental Disease, 176, 423-430.
Client Outcomes Before vs. After Random Transfer to 4 Counselors
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% Employed % Arrested
McLellan et al. (1988). Journal of Nervous and Mental Disease, 176, 423-430.
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Evidence-Based Treatment or Common Factors?Evidence-Based Treatment
� When different bona fide psychotherapies are compared with
each other, client outcomes are usually the same on average
Percent Days AbstinentNIAAA Multisite Trials
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Intake 4 Months 16 Months
CBI + PlaceboNaltrexone, No CBIPlacebo, No CBICBI + Naltrexone
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CBT MET TSF
Project MATCH COMBINE Study
UK Alcohol Treatment Trial (UKATT)
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MI SBNT
Percent Days Abstinent
MI = 3 Sessions vs. SBNT = 8 Sessions
Evidence-Based Treatment
� Within a clinic or kind of therapy, client outcomes usually
vary widely depending on who provided the treatment
� Therapists typically account for far more variance in
outcome than do the specific treatment methods being used
� Evidence-based treatments are inseparable from the
therapists who provide them
Therapists’ Outcomes in Manual-Guided CBT
Mean PDA Week 68Mean PDA Week 52Mean PDA Week 26Mean PDA Week 4Mean PDA Baseline
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All Clients got “the same” manual-guided cognitive-
behavior therapy in the NIAAA COMBINE Study
Percent Days Abstinent (PDA)
Outcomes by 19 therapists
with >10 clients
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Evidence for Efficacy of Specific Treatments Top Eight in Cumulative Evidence Scores
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Miller, W. R., Wilbourne, P. L., & Hettema, J. E. (2003). What works? A summary of alcohol treatment outcome research. In R. K. Hester & W. R.
Miller (Eds.), Handbook ofAlcoholism Treatment Approaches: Effective Alternatives (3rd ed., pp. 13-63). Boston, MA: Allyn & Bacon.
Yet all treatments are not the same
Evidence for Efficacy of Specific TreatmentsBottom Eight in Cumulative Evidence Scores)
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Mandated AA Milieu Therapy Video Self-
Confront
Relaxation Confrontation Insight
Psychotherapy
General
Counseling
Alcoholism
Education
It matters what you do . . .
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and it matters how you do it
Relational Factors in Therapy
� How “common” are they? Certainly not universal
� Calling them “non-specific” just means that we haven’t
done our homework
� They are specifiable, measurable, and variable
� They matter
Therapist Skills that Affect Client Outcomes
1.Accurate Empathy
What is Empathy?
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Perspective taking?
A developmental prerequisite for empathy
Is empathy something that you feel: Feeling for?
Is it literally feeling what the other feels?
Sympathy or co-feeling may happen, but is not essential
Or is empathy something that you do?
A specifiable, learnable, observable skill
The art of empathic
Listening and understanding
Carl Rogers
Truax, C. B., & Carkhuff, R. R. (1967). Toward effective counseling and psychotherapy. Chicago: Aldine.
Accurate Empathy:
� is reliably measurable from observable practice behavior
� is learnable: quality can improve with training and practice
� It matters: observed counselor skill predicts client outcome
� Its absence (low counselor empathy) is harmful
� Baseline skill predicts in-session practice and client outcome
Moyers, T. B., Houck, J. M., Rice, S. L., Longabaugh, R., & Miller, W. R. (2016). Therapist empathy, Combined Behavioral Intervention, and alcohol outcomes in the COMBINE research project. Journal of Consulting and Clinical Psychology, 84(3), 221-229.
Moyers, T. B., & Miller, W. R. (2013). Is low therapist empathy toxic? Psychology of Addictive Behaviors, 27(3), 878-884.
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And we’ve known for a long time that it matters
One
example
1978
Miller, Taylor & West, 1980Journal of Consulting and Clinical Psychology 48:590-601
� Problem drinkers were randomly assigned to self-help “bibliotherapy” or to one of nine outpatient counselors, all delivering the same manual-guided treatment: behavioral self-control training
� 3 supervisors rated counselors’ levels of accurate empathy (Truax & Carkhuff scale) with high inter-rater reliability
Counselor Empathy and Client Outcomes
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Therapist Empathy
Therapists Bibliotherapy
Client Drinking Outcomes Accounted for
by Therapist Empathy
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6 months 1 year 2 years
r = .82 r = .71 r = .51
Miller & Baca (1983) Behavior Therapy 14: 441-448
67% 52%26%
Accurate Empathy in Counseling
� Clients of counselors with high levels of empathic skill are:
�Less “resistant” and more likely to remain in treatment
�More likely to change, less likely to “relapse”
� Higher counselor levels of accurate empathy predict better outcomes in client-centered counseling, psychotherapy, behavior therapy, health promotion, and motivational interviewing
Meta-analyses
Empathy is a moderately strong predictor of treatment outcome: Mean effect size (d = .58, p < .001) across 82
independent samples with 6,138 clients
Relationship held across different theoretical orientations and presenting problems
Elliott, R., Bohart, A. C., Watson, J. C., & Greenberg, L. S. (2011). Empathy. Psychotherapy, 48(1), 43-49.
Elliott, R., Bohart, A. C., Watson, J. C., & Murphy, D. (2018). Therapist empathy and client outcome: An updated meta-analysis. Psychotherapy, 55(4), 399-410.
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So . . Accurate Empathy
� Is observable and reliably measurable behavior
� Can improve with training and coaching
� Is highly variable across counselors and therapists
� Pre-measured skill (for example, when screening candidates) predicts actual accurate empathy in later observed practice
� High accurate empathy predicts better client outcomes
� Low accurate empathy predicts poorer outcomes or harm
A Modest Proposal
Hire Empathic Therapists!
It is an evidence-based practice to hire staff
based on the skill of accurate empathy
Therapist Skills that Affect Client Outcomes
1. Accurate Empathy
2.Acceptance
These skills have an internal experiential element and an
external communication component.
One without the other is incomplete.
The ancient discipline of mindfulness
� Mindfulness involves attentive observation of one’s immediate
experience without needing to judge or evaluate, approve or
disapprove. It is an accepting appreciation of what is, without
critique or demand for what ought to be.
� Mindful acceptance is now widely studied as therapeutic to teach to
clients, including in the treatment of substance use disorders.
� Mindful acceptance is also a therapeutic attitude for providers.
Nonjudgmental Acceptance
� “It involves as much feeling of acceptance for the client’s expression of negative, “bad”, painful, fearful, defensive, abnormal feelings as for his expression of “good,” positive, mature, confident, social feelings.” Carl Rogers
� When people experience themselves as unacceptable, they are immobilized and unable to change.
� Paradoxically, it is when people experience acceptance of themselves as they are -be it from parents, a loved one, a therapist, or from God – that they are enabled to change.
� This runs contrary to a belief that people will change if we can just make them feel bad enough about themselves, or punish them enough.
Language in Addiction Treatment
� Stigma is communicated in widely accepted moralistic language:
�Addict Alcoholic (labeling the person, not the condition)
�Clean and Dirty
�Substance “Abuse” and “Abuser”
�“Denial” and inaccurate beliefs about personality disorder
�Relapsed
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Labels and Perception
� In case descriptions, a person was described as either a “substance abuser”
or as “having a substance use disorder.” This was the only change.
� When described as a “substance abuser,” both lay public and health
professionals were far more likely to perceive the person as blameworthy,
threatening, and deserving of punishment.
Kelly, J. F., Dow, S. J., & Westerhoff, C. (2010). Does our choice of substance-related terms influence perceptions of treatment need? An empirical investigation with two commonly used terms. Journal of Drug Issues, 10(4), 805-818.Kelly, J. F., & Westerhoff, C. M. (2010). Does it matter how we refer to individuals with substance-related conditions? A randomized study of two commonly used terms. International Journal of
Drug Policy, 21(3), 202-207.
Acceptance and Client Outcomes
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All Studies Client Report Observer Rating Warmth
Percent Finding Significant Positive Relationship (154 studies)
Orlinsky, D. E., Grawe, K., & Parks, B. K. (1994). Process and outcome in psychotherapy: Noch einmal. In A. E. Bergin & S. L. Garfield (Eds.), Handbook of psychotherapy and behavior change (pp. 270-376). New York: John Wiley & Sons.
Acceptance with “Minority” Clients
� Positive impact of acceptance increased with the proportion of
racial/ethnic minorities in the sample (Orlinsky, et al., 1994).
� Effect size of motivational interviewing tripled in samples
predominantly from racial-ethnic minority groups (Hettema et al.
2005).
Hettema, J., Steele, J., & Miller, W. R. (2005). Motivational interviewing. Annual Review of Clinical Psychology, 1, 91-111.
Therapist Skills that Affect Client Outcomes
1. Accurate Empathy
2. Acceptance
3.Positive Regard
Unconditional Positive Regard
� Unconditional Positive Regard: Clients are not required to meet certain
conditions in order to be respected by the counselor.
� An attitude of “warmth, liking, respect, [and] sympathy” (Rogers, 1959)
� In the most general sense, this disposition is a stance of respect and benevolence
toward your clients, a commitment to their well-being and best interests.
� Average effect size of PR on outcome: g = .36.
Farber, B. A., Suzuki, J. Y., & Lynch, D. A. (2018). Positive regard and psychotherapy outcome: A meta-analytic review. Psychotherapy, 55(4), 411-423.
Communicating Acceptance
� Absence of judgmental responses like disapproving, criticizing,
disagreeing, labeling, warning, or shaming
� Compassionate concern expressed in action
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Small Compassionate Actions
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Systematic Encouragement Standard Procedures
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20 Minutes in the E.R. One Handwritten Letter
One Telephone Call. Systematic Encouragement to Attend AA
Therapist Skills that Affect Client Outcomes
1. Accurate Empathy
2. Acceptance
3. Positive Regard
4.Genuineness
Should a helper be:
� Detached, aloof, opaque, and emotionally unresponsive?
� That may be good for judges, soldiers, detectives,
dentists, and poker players
� If personal relationships are non-essential or even a
hindrance to the job
Or is your humanity important in your work?
� Some other terms for genuineness: Presence, congruence, real relationship, openness, honesty, non-phoniness
� All have to do with not hiding yourself at your clients’ expense
� . In practice this means being:
� (a) aware of your own inner experiences with clients
� (b) emotionally engaged as the client’s story unfolds, and
� (c) willing to reveal your own experiences, thoughts, emotions, and values when they benefit your client
Research on Genuineness and Client Outcomes
� Meta-analysis of 21 studies: d = .46
� Counselor self-disclosure is associated with better therapeutic
relationship and client outcomes, particularly when disclosure
reveals the therapist’s humanity or similarity to the client
{Kolden, G. G., Wang, C.-C., Austin, S. B., Chang, Y., & Klein, M. H. (2018). Congruence/genuineness: A meta-analysis. Psychotherapy, 55(4), 424-433.
Hill, C. E., Knox, S., & Pinto-Coelho, K. G. (2018). Therapist self-disclosure and immediacy: A qualitative meta-analysis. Psychotherapy, 55(4), 445-460.
Rogerian Skill and Client Outcomes
Valle (1981) J Studies on Alcohol 42: 783-790
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Effect sizes of Rogers’ therapeutic factors(from meta-analyses)
0.58
0.36
0.46
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Accurate Empathy Positive Regard Genuineness
Average Effect Size (Cohen’s d)
Medium ->
Small ->
Effects Smaller than 0.2:
Preventive effect of aspirin
Average differences between specific
bona-fide treatments or “schools”
Therapist Skills that Affect Client Outcomes
1. Accurate Empathy
2. Acceptance
3. Positive Regard
4. Genuineness
5.Focus
Focus and Coherence
If you don’t know where you’re going, any road can take you there.
Lewis Carroll
If you don’t know where you’re going, you might wind up somewhere else.
Yogi Berra
Focus and Coherence
� More effective therapists have clear goals for treatment and a coherent
plan for reaching them.
� Shared goals of therapist and client is a key component of a good
working alliance, which in turn predicts better treatment outcomes.
� informal “chat” unrelated to clients’ treatment needs was inversely
related to client motivation for change and retention in treatment.
Imel, Z. E., & Wampold, B. (2008). The importance of treatment and the science of common factors in psychotherapy. In S. D. Brown & R. W. Lent (Eds.), Handbook of counseling psychology (pp. 249-
266). New York: Wiley. Bamatter, W. et al. (2010). Informal discussions in substance abuse treatment sessions with Spanish-speaking clients. Journal of Substance Abuse Treatment, 39(4), 353-363.
Therapist Skills that Affect Client Outcomes
1. Accurate Empathy
2. Acceptance
3. Positive Regard
4. Genuineness
5. Focus
6.Hope and Expectancy
Therapist Belief Matters – A Lot
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Azrin 1973 Azrin 1976 Azrin 1982
Traditional
CRA
% DaysAbstinent
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Therapist Belief and Treatment Outcome
% DaysAbstinent
Leake & King (1977)
� Psychologists tested patients in three different
treatment programs
� They identified patients with particularly high
alcoholism recovery potential (HARP)
� HARP vs. non-HARP patients did not differ
from each other on prior treatment history or
severity of alcoholism
Counselor Ratings During Treatment Showed HARPS to be:
�More motivated for counseling
�More punctual in meeting appointments
� Showing greater self-control
� Neater and more attractive in appearance
�More cooperative
� Trying harder to stay sober
� Showing better recovery
And throughout 12 months of Follow-up HARP Patients Showed:
� Higher rates of abstinence
� Longer spans of abstinence
� Fewer slips
�More employment
The Psychologist’s Secret:
“HARPS” HAD BEEN SELECTED AT RANDOM
How do we look at our patients?
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Therapist Skills that Affect Client Outcomes
1. Accurate Empathy
2. Acceptance
3. Positive Regard
4. Genuineness
5. Focus
6. Hope and Expectancy
7.Evocation
It matters what clients say, and aware
or not, you influence it
� Therapists differentially reinforce specific kinds of client speech
� Even Carl Rogers did - What do you ask and reflect?
� Mood induction by elicited speech
� “Resistance” predicts poorer outcome, and is interactive
Truax, C. B. (1966). Reinforcement and non-reinforcement in Rogerian psychotherapy. Journal of Abnormal Psychology, 71, 1-9.
Therapist Style and Client ResistancePatterson & Forgatch (1985)
Journal of Consulting & Clinical Psychology, 1985, 53: 846-851.
Imagine this:
Counselors were trained to switch their counseling style
every 12 minutes within sessions, between
E: an empathic/listening style and
D: a directive/teaching style
E - D - E - D
Therapist Style and Client ResistancePatterson & Forgatch, Journal of Consulting & Clinical Psychology, 1985, 53: 846-851.
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Empathic Teach/Direct Empathic Teach/Direct1 1 2 2
Resistance Responses per Minute of Family Therapy
Bottom line: When you tell clients what to do, they tend to get defensive
Client Change Talk and Sustain Talk(Research on Motivational Interviewing)
� The ratio of client change talk to sustain talk shifts with stages of
change and predicts whether change will occur
� Motivational interviewing is designed to evoke change talk and
soften sustain talk
� Solid evidence base for efficacy, but . . .
Can Counselors Influence Change Talk?Glynn & Moyers (2010), Journal of Substance Abuse Treatment 39: 65-70
� 9 counselors switched every 12 minutes between:
�MI: Seeking to evoke change talk and
�FA: Functional analysis of drinking
� in conversations with 47 people about their drinking concerns
� Coded client change talk (CT) and sustain talk (ST)
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% Change Talk and Sustain Talk
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E1 D1 E2 D2
Therapist Skills that Affect Client Outcomes
1. Accurate Empathy
2. Acceptance
3. Positive Regard
4. Genuineness
5. Focus
6. Hope and Expectancy
7. Evocation
8.Offering Information and Advice
Using Your Expertise:
Directing, Guiding, and Following
� Directing tends to evoke reactance and resistance
� Yet a good guide doesn’t just follow you around
� Giving information and advice can change behavior
� Guiding is is a middle ground, with both directing and following
� Honoring client autonomy is a key in guiding
� Ask – Provide - Ask
� Offering clients choice among options
Ryan, R. M., & Deci, E. L. (2017). Self-determination theory: Basic psychological needs in motivation,
development, and wellness. New York: Guilford Press.
Accurate Empathy
Acceptance
Positive Regard
Genuineness
Focus
Hope and Expectancy
Evocation
Offering Information and Advice
So which is more important?