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7/5/2019 1 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 difference between 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 0 10 20 30 40 50 60 70 80 90 100 -2 -1 0 4 5 6 7 8 9 10 11 12 13 14 15 CBT MET TSF 20 40 60 80 100 20 40 60 80 100 20 40 60 80 100 20 40 60 80 100 Treatments are not the same at all sites where they are delivered All Therapists Are Not the Same -20 0 20 40 60 80 100 Drug Use Employment Psychiatric Effect Size Percentage of Improvement Supportive-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 15 25 35 45 55 1 2 3 4 35 40 45 50 1 2 3 4 30 40 50 60 0 2 4 6 % Positive Urines Methadone Dose % Employed % Arrested McLellan et al. (1988). Journal of Nervous and Mental Disease, 176, 423-430.

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Page 1: In theory, Therapists Matter between theory and practiceIn theory, there is no difference between theory and practice In practice, there is. Dean Fixsen In practice, evidence-based

7/5/2019

1

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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-2 -1 0 4 5 6 7 8 9 10 11 12 13 14 15

CBT MET TSF

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Treatments are not the

same at all sites where

they are delivered

All Therapists Are Not the Same

-20

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Drug Use Employment Psychiatric Effect Size

Per

cen

tag

e of

Imp

rovem

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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

15

25

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45

55

1 2 3 4

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1 2 3 4

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% Positive Urines Methadone Dose

% Employed % Arrested

McLellan et al. (1988). Journal of Nervous and Mental Disease, 176, 423-430.

Page 2: In theory, Therapists Matter between theory and practiceIn theory, there is no difference between theory and practice In practice, there is. Dean Fixsen In practice, evidence-based

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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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60

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80

90

Intake 4 Months 16 Months

CBI + PlaceboNaltrexone, No CBIPlacebo, No CBICBI + Naltrexone

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-2 -1 0 4 5 6 7 8 9 10 11 12 13 14 15

CBT MET TSF

Project MATCH COMBINE Study

UK Alcohol Treatment Trial (UKATT)

29.5

42.345.4

29.5

43.246.6

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30

40

50

Baseline 3 Months 12 Months

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

120

100

80

60

40

20

0

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

Page 3: In theory, Therapists Matter between theory and practiceIn theory, there is no difference between theory and practice In practice, there is. Dean Fixsen In practice, evidence-based

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Evidence for Efficacy of Specific Treatments Top Eight in Cumulative Evidence Scores

314

189

116 110 10069 64 59

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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)

-94 -102 -108

-152

-183-207

-284

-443

-500

-450

-400

-350

-300

-250

-200

-150

-100

-50

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Mandated AA Milieu Therapy Video Self-

Confront

Relaxation Confrontation Insight

Psychotherapy

General

Counseling

Alcoholism

Education

It matters what you do . . .

15

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?

Page 4: In theory, Therapists Matter between theory and practiceIn theory, there is no difference between theory and practice In practice, there is. Dean Fixsen In practice, evidence-based

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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.

Page 5: In theory, Therapists Matter between theory and practiceIn theory, there is no difference between theory and practice In practice, there is. Dean Fixsen In practice, evidence-based

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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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1 2 3 4 5 6 7 8 9

100

75

100

75

33

75

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60

% P

osi

tive

Ou

tcom

es a

t 6

mon

ths

Therapist Empathy

Therapists Bibliotherapy

Client Drinking Outcomes Accounted for

by Therapist Empathy

28

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

56

6562 61

0

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20

30

40

50

60

70

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

Page 8: In theory, Therapists Matter between theory and practiceIn theory, there is no difference between theory and practice In practice, there is. Dean Fixsen In practice, evidence-based

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Small Compassionate Actions

100

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Systematic Encouragement Standard Procedures

% A

tten

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A

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

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

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

Page 10: In theory, Therapists Matter between theory and practiceIn theory, there is no difference between theory and practice In practice, there is. Dean Fixsen In practice, evidence-based

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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.

1.0

1.7

1.1

1.5

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)

66

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% Change Talk and Sustain Talk

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MI1 FA1 MI2 FA2

1.63

Glynn & Moyers (2010), Journal of Substance Abuse Treatment 39: 65-70

0.85 2.00 1.17

67 Client resistance responses per minute of counseling:

0.3

0.4

0.5

0.6

0.7

0.8

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?