what works in psychotherapy randy walton, ph.d. licensed clinical psychologist williamsburg,...

What Works in What Works in PsychotherapyPsychotherapy

Randy Walton, Ph.D.Randy Walton, Ph.D.

Licensed Clinical PsychologistLicensed Clinical Psychologist

Williamsburg, Virginia, USAWilliamsburg, Virginia, USA

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Psychology education and Psychology education and trainingtraining

Helps organize, develop, and skillfully use Helps organize, develop, and skillfully use abilities we already have:abilities we already have:

EmpathyEmpathy CommunicationCommunication SupportSupport UnderstandingUnderstanding RespectRespect TrustTrust

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Psychotherapy ResearchPsychotherapy Research

Thousands of research studies of Thousands of research studies of psychotherapypsychotherapy

Increase Increase understanding of understanding of what workswhat works

Increase confusion Increase confusion about what works about what works due to conflicting due to conflicting resultsresults

Meta-analytic research studies: studies of studies

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QuizQuiz

Question 1: Question 1:

Does Does psychotherapy psychotherapy work?work?

YESYES

40-70% of clients who 40-70% of clients who receive psychotherapy receive psychotherapy show substantial benefitshow substantial benefit

At the end of therapy At the end of therapy the average treated the average treated person is better off than person is better off than the average untreated the average untreated person.person.

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Conclusions from Meta-analytic Conclusions from Meta-analytic StudiesStudies

Common Factors associated with Common Factors associated with Psychotherapy OutcomePsychotherapy Outcome

““Extra-therapeutic” Factors (87%)Extra-therapeutic” Factors (87%) Therapeutic Factors (13%)Therapeutic Factors (13%)

Therapeutic Alliance (8%)Therapeutic Alliance (8%) Therapeutic Allegiance (4%)Therapeutic Allegiance (4%) Therapy model or technique (1%)Therapy model or technique (1%)

Wampold, B.E. 2001. Wampold, B.E. 2001. The Great Psychotherapy Debate: Models, The Great Psychotherapy Debate: Models, Methods, and “FindingsMethods, and “Findings. Erlbaum.. Erlbaum.

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Conclusions from Meta-analytic Conclusions from Meta-analytic StudiesStudies

Common Factors associated with Common Factors associated with Psychotherapy OutcomePsychotherapy Outcome

““Extra-therapeutic” Factors (40%)Extra-therapeutic” Factors (40%) Therapeutic Alliance (30%)Therapeutic Alliance (30%) Therapy Model or Technique (15%)Therapy Model or Technique (15%) Placebo Effect (15%)Placebo Effect (15%)

Hubble, Duncan, Miller 1999. Hubble, Duncan, Miller 1999. The Heart and Soul of Change: What The Heart and Soul of Change: What Works in Therapy. APAWorks in Therapy. APA

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Psychotherapy Models or Psychotherapy Models or TechniquesTechniques

Account for a small amount of the variance Account for a small amount of the variance in psychotherapy outcomesin psychotherapy outcomes

Virtually all psychotherapy models and Virtually all psychotherapy models and techniques are effective with some people, some techniques are effective with some people, some of the timeof the time

Differences in outcome between models is Differences in outcome between models is consistently small or negligibleconsistently small or negligible

Outcome differences between therapists using Outcome differences between therapists using the same model have been found to be 2-3 times the same model have been found to be 2-3 times greater than the differences between modelsgreater than the differences between models

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Therapeutic Relationship and Therapeutic Relationship and AllianceAlliance

Therapeutic RelationshipTherapeutic Relationship

TrustTrust WarmthWarmth EmpathyEmpathy UnderstandingUnderstanding AcceptanceAcceptance GenuinenessGenuineness KindnessKindness

Therapeutic AllianceTherapeutic Alliance

Client’s emotional Client’s emotional relationship to the relationship to the therapisttherapist

Client’ capacity to work in Client’ capacity to work in therapytherapy

Therapist’s empathic Therapist’s empathic understanding & understanding & involvementinvolvement

Client-therapist agreement Client-therapist agreement on therapy tasks and goalson therapy tasks and goals

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The most important therapeutic factors The most important therapeutic factors in a positive psychotherapy outcomein a positive psychotherapy outcome

A positive therapeutic relationship is A positive therapeutic relationship is considered crucial for a successful outcome considered crucial for a successful outcome in any type of psychotherapyin any type of psychotherapy

A strong therapeutic alliance is considered A strong therapeutic alliance is considered a necessary condition for therapeutic a necessary condition for therapeutic change to occurchange to occur

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Dynamic not static: relationship and Dynamic not static: relationship and alliance change over time alliance change over time

More predictive of psychotherapy More predictive of psychotherapy outcome than diagnosisoutcome than diagnosis

More predictive of psychotherapy More predictive of psychotherapy outcome than model or techniqueoutcome than model or technique

Predictive of client dropoutPredictive of client dropout

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The conclusion for therapists:The conclusion for therapists:

No matter what therapeutic No matter what therapeutic technique or model is used, it technique or model is used, it is not likely to be effective if is not likely to be effective if there is not a strong client-there is not a strong client-

therapist relationshiptherapist relationship..

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Therapeutic Therapeutic Relationship/Alliance and Relationship/Alliance and Therapy Model/TechniqueTherapy Model/Technique

The therapeutic model or technique The therapeutic model or technique used by a therapist is primarily used by a therapist is primarily effective if it matches the client’s effective if it matches the client’s “theory of change”:“theory of change”: The The client’sclient’s

View of the problemView of the problem View of the change processView of the change process Goals and expectationsGoals and expectations Desired pace for treatmentDesired pace for treatment

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The more therapy models and techniques The more therapy models and techniques a therapist can understand and use, the a therapist can understand and use, the more options the therapist has for helping more options the therapist has for helping a wider range of clients.a wider range of clients.

An effective therapist should be able to An effective therapist should be able to use a variety of therapeutic models and use a variety of therapeutic models and techniques instead of assuming that each techniques instead of assuming that each client will respond equally well to a client will respond equally well to a particular model or technique.particular model or technique.

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A psychotherapist A psychotherapist should use a should use a

psychotherapy psychotherapy model or technique model or technique

to fit the client, to fit the client, rather than trying to rather than trying to make the client fit a make the client fit a particular model or particular model or

technique.technique.

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Building a strong therapeutic Building a strong therapeutic relationshiprelationship

Active Listening – Effective, powerfulActive Listening – Effective, powerful Active Listening involves three main Active Listening involves three main

components:components:1.1. Listening to another personListening to another person

2.2. Communicating to that person that we Communicating to that person that we are interested in what they have to sayare interested in what they have to say

3.3. Communicating to that person that we Communicating to that person that we understand what they have to sayunderstand what they have to say

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Passive Listening – less effectivePassive Listening – less effective Listening to another personListening to another person Being interested in what that person has Being interested in what that person has

to sayto say Trying to understand what that person Trying to understand what that person

has to sayhas to say NOTNOT communicating to that person that communicating to that person that

we are interested and understandwe are interested and understand

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Competitive or Combative Listening – Competitive or Combative Listening –

Least effectiveLeast effective Not really listeningNot really listening Thinking about what we want to say nextThinking about what we want to say next More interested in expressing our point of More interested in expressing our point of

view than in understanding the other view than in understanding the other personperson

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Active Listening TechniquesActive Listening Techniques Stop talkingStop talking Let the client relax, take their time, explain things in their own Let the client relax, take their time, explain things in their own

wayway Physically show that you are interestedPhysically show that you are interested

Face the client Face the client Open posture, e.g., don’t fold armsOpen posture, e.g., don’t fold arms Maintain eye contactMaintain eye contact Reflect their body position (mirroring)Reflect their body position (mirroring)

Remove distractions, stop whatever else you are doingRemove distractions, stop whatever else you are doing Empathize: consider their point of view, “stand in their shoes”Empathize: consider their point of view, “stand in their shoes” Don’t let you own emotions interfere or distract youDon’t let you own emotions interfere or distract you Be cautious about disagreeing, criticizing, or arguingBe cautious about disagreeing, criticizing, or arguing Ask questions to clarify, or encourage the client to say more or Ask questions to clarify, or encourage the client to say more or

give an examplegive an example Don’t try to problem-solve (that may come later)Don’t try to problem-solve (that may come later)

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Active Listening TechniquesActive Listening Techniques ParaphrasingParaphrasing

Summarize or repeat the facts of Summarize or repeat the facts of the situationthe situation

State your understanding of the State your understanding of the thoughts, beliefs, feelings and thoughts, beliefs, feelings and emotions you heardemotions you heard

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Active Listening TechniquesActive Listening Techniques Paraphrasing example:Paraphrasing example:

ClientClient: “It seems like I cry all day. I don’t : “It seems like I cry all day. I don’t want to talk to anyone, even my friends. want to talk to anyone, even my friends. I don’t want to do anything, all I want to I don’t want to do anything, all I want to do is stay in my bed and sleep.”do is stay in my bed and sleep.”TherapistTherapist: “So you’re crying all the time, : “So you’re crying all the time, you don’t want to do anything or talk to you don’t want to do anything or talk to anyone, and all you want to do is sleep. anyone, and all you want to do is sleep. It sounds like you are feeling It sounds like you are feeling __________.”__________.”

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Active Listening TechniquesActive Listening Techniques If you are not sure you understand, express that If you are not sure you understand, express that

to the client: “I’m not sure I understand”, and ask to the client: “I’m not sure I understand”, and ask for clarification: “could you tell me more?”, or for clarification: “could you tell me more?”, or “could you give me an example?”“could you give me an example?”

OROR If you are not sure you understand, try If you are not sure you understand, try

paraphrasing anyway; if we are genuinely paraphrasing anyway; if we are genuinely interested and trying to understand, clients will interested and trying to understand, clients will usually appreciate the effort and clarify for us: usually appreciate the effort and clarify for us: “No, I’m not really feeling sad. I just feel empty.”“No, I’m not really feeling sad. I just feel empty.”

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Active Listening TechniquesActive Listening Techniques If you disagree or disapprove of what If you disagree or disapprove of what

the client is sayingthe client is saying Try to be nonjudgmentalTry to be nonjudgmental Try to be acceptingTry to be accepting Try to be respectfulTry to be respectful Try to understand their point of viewTry to understand their point of view Don’t try to shame or embarrass the Don’t try to shame or embarrass the

other personother person

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Active Listening TechniquesActive Listening Techniques

Don’t begin to problem-solve too soonDon’t begin to problem-solve too soon

Often, if you continue to practice active listening, Often, if you continue to practice active listening, the client will develop their own solution to their the client will develop their own solution to their problemsproblems

In psychotherapy it is almost always preferable to In psychotherapy it is almost always preferable to help clients develop their own solutions to problemshelp clients develop their own solutions to problems Helps clients feel better about themselvesHelps clients feel better about themselves Helps clients feel more confident in managing future Helps clients feel more confident in managing future

problemsproblems

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Active Listening TechniquesActive Listening Techniques It is okay to not have the solution to every It is okay to not have the solution to every

problem or a perfect understanding of the problem or a perfect understanding of the client.client.

Clients are the experts on themselvesClients are the experts on themselves

Let the client teach you and guide youLet the client teach you and guide you

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Extra-therapeutic FactorsExtra-therapeutic FactorsAccount for major portion of improvement that occurs during Account for major portion of improvement that occurs during

psychotherapypsychotherapy

How can a therapist use these factors in How can a therapist use these factors in psychotherapy?psychotherapy?

Listen for , invite, and use information about extra-Listen for , invite, and use information about extra-therapeutic factorstherapeutic factors

What is different about better or worse daysWhat is different about better or worse days Ask about any between session improvementAsk about any between session improvement Help clients see any changes, and maintenance of changes, Help clients see any changes, and maintenance of changes,

as a consequence of their own effortsas a consequence of their own efforts Even if clients attribute changes to luck, therapist skill, Even if clients attribute changes to luck, therapist skill,

medication, or some other factor, ask:medication, or some other factor, ask: How they adopted the changes in their livesHow they adopted the changes in their lives What they did to use the changes to their own benefitWhat they did to use the changes to their own benefit What they will do in the future to maintain the changesWhat they will do in the future to maintain the changes

Ask about what happens in the client’s life that is helpfulAsk about what happens in the client’s life that is helpful Encourage clients to explore and use resources in their life Encourage clients to explore and use resources in their life

and communityand community

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The Client is CentralThe Client is Central

The capacity for self understanding, The capacity for self understanding, problem-solving, and growth, resides problem-solving, and growth, resides primarily in the clientprimarily in the client

The most effective therapists are ones The most effective therapists are ones who allow or help their clients develop who allow or help their clients develop their own understanding and solutions to their own understanding and solutions to problemsproblems

(It’s a relief to know that I don’t have to have all the (It’s a relief to know that I don’t have to have all the answers)answers)

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QuizQuizQuestion 2Question 2

Who is better at identifying Who is better at identifying whether a client is making whether a client is making progress in psychotherapy, progress in psychotherapy, the therapist or the client?the therapist or the client?

THE CLIENTTHE CLIENT

Research shows that Research shows that therapists are remarkably therapists are remarkably bad at judging whether a bad at judging whether a client is making progress in client is making progress in psychotherapy.psychotherapy.

The client’s experience of The client’s experience of meaningful change , meaningful change , especially early in therapy especially early in therapy (first 4-5 sessions) is one of (first 4-5 sessions) is one of the best predictors of a the best predictors of a positive therapy outcome.positive therapy outcome.

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QuizQuizQuestion 3Question 3

Who is better at accurately Who is better at accurately rating the quality of the rating the quality of the therapeutic relationship therapeutic relationship and therapeutic alliance, and therapeutic alliance, the therapist or the client?the therapist or the client?

THE CLIENTTHE CLIENT

Research shows that the Research shows that the client’s rating is clearly client’s rating is clearly superior to the therapist’s superior to the therapist’s in predicting in predicting psychotherapy outcomes.psychotherapy outcomes.

Research shows that the Research shows that the client’s rating is clearly client’s rating is clearly superior to the therapist’s superior to the therapist’s in predicting in predicting psychotherapy dropouts.psychotherapy dropouts.

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Assessing and Tracking Assessing and Tracking Psychotherapy Progress and the Psychotherapy Progress and the

Therapeutic Relationship/AllianceTherapeutic Relationship/Alliance

Psychotherapy Effects: Progress in Psychotherapy Effects: Progress in psychotherapypsychotherapy Continuously changing over the course of treatmentContinuously changing over the course of treatment

Faster or slowerFaster or slower Better or worseBetter or worse

Psychotherapy Fit: The quality of the Psychotherapy Fit: The quality of the therapeutic relationship and therapeutic alliancetherapeutic relationship and therapeutic alliance Continuously changing over the course of treatmentContinuously changing over the course of treatment

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Assessing and Tracking Assessing and Tracking Psychotherapy Progress and the Psychotherapy Progress and the Therapeutic Relationship/AllianceTherapeutic Relationship/Alliance

Psychotherapeutic processes, models, and Psychotherapeutic processes, models, and techniques are best informed and directed by techniques are best informed and directed by systematic and ongoing assessment of the “fit” systematic and ongoing assessment of the “fit” and the “effect” of any given therapeutic and the “effect” of any given therapeutic relationship.relationship.

Therapeutic processes, models, and techniques Therapeutic processes, models, and techniques are not well informed and directed by:are not well informed and directed by: Static concepts such as diagnosisStatic concepts such as diagnosis Unreliable or inaccurate theories and impressions of the Unreliable or inaccurate theories and impressions of the

therapisttherapist

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Routinely check with clients about whether Routinely check with clients about whether they believe progress is being made:they believe progress is being made:

Therapist:Therapist: “How do you feel we’re doing?” “How do you feel we’re doing?”OROR

Therapist:Therapist: “Let’s look at your goals. Do “Let’s look at your goals. Do you feel like we are making progress?”you feel like we are making progress?”

OROR Therapist:Therapist: “You look less overwhelmed. “You look less overwhelmed.

Are you feeling that way?”Are you feeling that way?”

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Routinely check with clients about Routinely check with clients about the relationship and alliancethe relationship and alliance Is the therapist's approach helpful?Is the therapist's approach helpful? Do they talk about what they want to Do they talk about what they want to

talk about?talk about? Do they feel heard, understood, and Do they feel heard, understood, and

respected?respected?

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Use of rating scales (example)Use of rating scales (example)

Outcomes Rating Scale (ORS)Outcomes Rating Scale (ORS) Measures “Effect”Measures “Effect” Four rating scale items, 1-2 minutes to administer and scoreFour rating scale items, 1-2 minutes to administer and score Administered, scored, and graphed at beginning of every sessionAdministered, scored, and graphed at beginning of every session Discuss and use improvement, decline, or no changeDiscuss and use improvement, decline, or no change

Session Rating Scale (SRS)Session Rating Scale (SRS) Measures “Fit”Measures “Fit” Four rating scale items, 1-2 minutes to administer and scoreFour rating scale items, 1-2 minutes to administer and score Administered, scored, and graphed at end of every sessionAdministered, scored, and graphed at end of every session Discuss any low scoresDiscuss any low scores

These scales, along with the administration and scoring manual, are available for free These scales, along with the administration and scoring manual, are available for free download and printing: http://www.talkingcure.com/download and printing: http://www.talkingcure.com/

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Outcome Rating Scale (ORS)

Looking back over the last week, including today, help us understand how you have been feeling by rating how well you have been doing in the following areas of your life, where marks to the left

represent low levels and marks to the right indicate high levels. If you are filling out this form for another person, please fill out according to how you think he or she is doing.

Individually

(Personal well-being)

I----------------------------------------------------------------------I

Interpersonally

(Family, close relationships)

I----------------------------------------------------------------------I

Socially

(Work, school, friendships)

I----------------------------------------------------------------------I

Overall

(General sense of well-being)

I----------------------------------------------------------------------I

Institute for the Study of Therapeutic Change

_______________________________________

www.talkingcure.com

© 2000, Scott D. Miller and Barry L. Duncan

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Session Rating Scale (SRS V.3.0)

Please rate today’s session by placing a mark on the line nearest to the descriptions that best fits your experience.

I did not feel heard, understood, and respected.

Relationship

I-------------------------------------------------------------I

I felt heard, understood, and respected.

We did not work on or talk about what I wanted to work on or talk about.

Goals and Topics

I-------------------------------------------------------------I

We worked on and talked about what I wanted to work on and talk about.

The therapist's approach is not a good fit for me.

Approach or Method

I------------------------------------------------------------I The therapist’s approach is a good fit for me.

There was something missing in the session today.

Overall

I------------------------------------------------------------I

Overall, today’s session was right for me.

Institute for the Study of Therapeutic Change

www.talkingcure.com

© 2002, Scott D. Miller, Barry L. Duncan, & Lynn Johnsaon

http://www.talkingcure.com/

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Chart # Client Name Therapist Date of Intake 1 2 3 4 5 6

1 220321RH Walton 1/12/2007 17.8 18.1 22 23.6 24.6 26.8

2 DAH Walton 1/23/2007 30.1 28.6 27.8

3 219632 Walton 2/4/2007 24.1 24.9 23.9 24.8

4 220012 FAL Walton 2/10/2007 5.4 7.9

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ConclusionConclusion Therapeutic Relationship and AllianceTherapeutic Relationship and Alliance

o Of all therapeutic factors, it is the single best predictor of Of all therapeutic factors, it is the single best predictor of therapeutic outcometherapeutic outcome

Client is CentralClient is Centralo Therapist follows the client’s leadTherapist follows the client’s leado Client’s theory of change is crucialClient’s theory of change is crucialo Active listeningActive listening

Ongoing, systematic assessment of client’s rating of Ongoing, systematic assessment of client’s rating of “effect” and “fit”“effect” and “fit”

o Client-directed, outcome informed treatment is the best guide Client-directed, outcome informed treatment is the best guide to treatment decisionsto treatment decisions

You already have the basic abilities needed to be a good You already have the basic abilities needed to be a good psychotherapistpsychotherapist

o Relax and enjoy your workRelax and enjoy your work

what works in psychotherapy randy walton, ph.d. licensed clinical psychologist williamsburg,...

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