Cycle of Excellence

49
The Cycle of Excellence: Using Deliberate Practice to Improve Supervision and Training,
First Edition. Edited by Tony Rousmaniere, Rodney K. Goodyear, Scott D. Miller, and Bruce E. Wampold.
© 2017 John Wiley & Sons, Ltd. Published 2017 by John Wiley & Sons, Ltd.
3
A basic tenet of deliberate practice is, of course, practice. But what should we practice?
Clearly, we should practice those skills that lead to better outcomes. But what are these
skills? Unfortunately, various theoretical perspectives emphasize particular therapeutic
actions that are thought to produce therapeutic benefits. Even within a theoretical orientation, supervisors may emphasize some skills over others or focus idiosyncratically on an
aspect of therapy that they think is important.
In every profession, practitioners need to develop and refine skills that lead to improved
performance and eschew spending time on skills that are irrelevant to performance. In psychotherapy, this is problematic for one of several reasons (Tracey, Wampold, Lichtenberg, &
Goodyear, 2014). First, the skills we discuss in our field are often therapy-specific—for example, a behavior therapist may be taught the skills necessary to conduct prolonged exposure
for posttraumatic stress disorder (PTSD) while another therapist may learn what is involved
in eye movement desensitization and reprocessing. The issue is that the specific ingredients
have not been shown to be what makes these treatments effective—when the ingredients are
removed from therapies, the treatments seem to remain as effective as they were with the
ingredient (Ahn & Wampold, 2001; Bell, Marcus, & Goodlad, 2013). Furthermore, as discussed in this chapter, adherence to the treatment protocol does not result in better outcomes (Webb, DeRubeis, & Barber, 2010), and the rated competence with which the specific
ingredients of the treatment are delivered is not related to outcome (Branson, Shafran, &
Myles, 2015; Webb et al., 2010). Moreover, a related problem is that there is variability in the
outcome of therapists within therapeutic orientations (Baldwin & Imel, 2013)—that is, some
therapists delivering Treatment A consistently achieve better outcomes than other therapists
delivering the very same treatment. This seems to be true in clinical trials as well as in practice and is unrelated to the degree to which the therapist adheres to the treatment protocol
(Wampold & Imel, 2015). Ergo, how one delivers a treatment is important, and one must
learn the skills that make various treatments effective—delivering a treatment that has been
designated as “evidence based” clearly is not sufficient to deliver the treatment effectively.
What is needed is a model that explains how psychotherapy works—that is, a model that
specifies the key components of effective practice that have been identified by research
What Should We Practice?
A Contextual Model for How Psychotherapy Works
Bruce E. Wampold
50 3 What Should We Practice?
evidence. In this chapter, I present a model for psychotherapy that is based on evidence
related to what is known about how psychotherapy works and what is known about effective therapists. This model, called the “Contextual Model,” is a meta‐model because it is
not an alternative to specific treatment models, such as cognitive behavioral therapy or
emotion‐focused therapy, but rather is a model that explains how all psychotherapies produce their benefits. This model is based on social science theory and research evidence
from randomized clinical trials of psychotherapy as well as psychotherapy process research
(Wampold & Imel, 2015). This model indicates a set of specific skills that should be the
focus of deliberate practice.
Contextual Model
The Contextual Model (Wampold & Budge, 2012; Wampold & Imel, 2015) is a meta‐model
of how psychotherapy works. Psychotherapy is a complex process that unfolds over time.
Thus, it is difficult to stipulate what makes psychotherapy work, yet there is theory and
compelling evidence that psychotherapy exerts its effects through multiple pathways. The
Contextual Model is not a model of how a particular therapy works but rather is a model of
how all psychotherapies work. Thus, this model serves the purpose of this volume sufficiently well in that it identifies the skills that therapists need to master to increase their
effectiveness. The model certainly is not the only one that could be adopted (e.g., Frank &
Frank, 1991; Orlinsky & Howard, 1986). And most certainly it is not absolutely true—that
is, aspects of it will change as evidence accumulates, and at some point the model may be
rejected in favor of another model. What is important to understand is that the Contextual
Model is a coherent way to organize what is known currently about psychotherapy and
identifies the skills that are necessary to practice psychotherapy effectively.
The Contextual Model is presented in Figure 3.1. The model contains three pathways
through which flows the power of psychotherapy. Some treatments emphasize one pathway
over another, but to be optimally effective, any psychotherapy must utilize all three pathways. In this chapter, various indicators of the quality of a therapy in each pathway are discussed. In the following section, therapist skills that are needed to enact each pathway
effectively are discussed. However, before we discuss the three pathways, the therapist must
develop an initial therapeutic bond.
Real relationship, belonging, social connection
Creation of expectation through explanation and
some form of treatment
Tasks/Goals Therapeutic
Actions
Healthy
Actions
Better Quality
of Life
Symptom
Reduction
Therapist
Patient
Trust,
Understanding,
Expertise
Figure 3.1 Contextual Model.
Contextual Model 51
Initial Therapeutic Bond
Patients come to therapy with distress—they are having difficulties in life and are discouraged about finding solutions to their problems. They feel demoralized, in Jerome Frank’s
term (Frank & Frank, 1991). Patients also come to therapy with personalities, racial/ethnic
backgrounds and identities, social networks (or lack of them), economic resources (or lack
of them), occupation/vocation/work histories and situations, histories, and current life
events (e.g., recent bereavement). Therapists also come to the initial meeting with personalities, racial/ethnic backgrounds and identities, histories, and current life events. It is a
meeting of strangers, embedded in a professional context.
Patients are seeking immediate answers to some questions: Can this therapist understand
me and my problems? Can I trust the therapist? Does the therapist have the capacity and
expertise to help me? Ed Bordin (1979), who developed the concept of the therapeutic alliance as a pantheoretical concept, noted that the initial bond was necessary before therapeutic work began: “Some basic level of trust surely marks all varieties of therapeutic
relationships, but when attention is directed toward the more protected recesses of inner
experience, deeper bonds of trust and attachment are required and developed” (p. 254).
The formation of the initial bond is a combination of top‐down and bottom‐up processing. The top‐down processing involves the belief that therapy will be effective and is based
on what patients know about therapy, past experience, stories from friends or family members, and the like. Indeed, patients seem to experience significant benefit from the time they
make the initial appointment to the time they present for the initial meeting with the therapist (Frank & Frank, 1991), as they are remoralized because they believe their involvement
in the impending psychotherapy will be helpful. Expectations about the particular therapist
may be present as well, because, for example, this therapist had been recommended by a
friend who had benefited from therapy.
Humans are evolved to make quick judgments (within 100 ms) about the trustworthiness
of another, based on facial features (Willis & Todorov, 2006). Of course, patients are also
making judgments about psychotherapy from the context—for example, the warmth
and efficiency of the clinic staff, the attractiveness and comfort of the waiting room, and
the therapy room itself, including diplomas and pictures hung on the wall. It is clear that the
initial interaction and patient engagement early in therapy are critical to the success of
therapy, if for no other reason than that most patients who drop out of therapy prematurely
do so after the first session; the second greatest number of patients drop out after the second
session, and so on (Connell, Grant, & Mullin, 2006; Simon & Ludman, 2010).
Real Relationship
Patient and therapist have distinct roles in therapy—patients have a problem, complaint, or
disorder that they want resolved, and therapists are the healers, providing something of
value to patients, based on their training and experience. However, despite these roles, psychotherapy involves a deep and intimate interpersonal relationship between two human
beings. This relationship can be described psychodynamically as the transference‐free genuine relationship based on realistic perceptions (Gelso, 2009), where genuineness was
defined by Gelso and Carter (1994) as “the ability and willingness to be what one truly is in
52 3 What Should We Practice?
the relationship—to be authentic, open and honest” and realistic perceptions as “those perceptions that are uncontained by transference distortions and other defenses . . . [the therapist and patient] see each other in an accurate, realistic way” (p. 297). In therapy, the real
relationship involves a therapist who is warm, caring, and empathic with a contract that this
relationship will continue regardless of the material discussed.1
The real relationship would appear to be fundamental to humanistic approaches, important for dynamic therapies, but generally not emphasized, or even ignored, by behavioral
and cognitive therapies. However, there is a compelling case to be made that the real relationship is critical to the benefits of psychotherapy of all types. Humans evolved as social
animals and attachment is fundamental to the survival of humans, as discussed by many
prominent theorists (Baumeister, 2005; Bowlby, 1980; Cacioppo & Cacioppo, 2012; Lieberman, 2013; Wilson, 2012). Indeed, there is strong evidence that perceived loneliness places
an individual at as great or greater risk for mortality than smoking, obesity, environmental
pollutants, and lack of exercise (for the general population or those at risk of cardiac
events) (Holt‐Lunstad, Smith, Baker, Harris, & Stephenson, 2015; Holt‐Lunstad, Smith, &
Layton, 2010; Luo, Hawkley, Waite, & Cacioppo, 2012). Indeed, holding the hand of a
beloved one, or even having a beloved person in the room, increases tolerance of pain, with
the expected concomitant neural processes (Benedetti, 2011), suggesting that individuals in
higher-quality relations benefit from greater regulatory effects on the neural system involved
in negative emotions, e.g., the affective components of pain (Benedetti, 2011, p. 149).
The healing power of an empathic relationship should not be underestimated. The evidence is strong that an empathic, caring, and understanding relationship will be beneficial
and will augment the effectiveness of treatments. The impact of empathy on healing in
medicine has been discussed extensively (e.g., Decety & Fotopoulou, 2015). Consider a
study of placebo effects on the symptoms, global improvement, adequate relief, and quality
of life of patients with irritable bowel syndrome (Kaptchuk et al., 2008; Kelley et al., 2009).
In this study, these patients were assigned to treatment as usual (TAU) by their physicians:
TAU with a sham acupuncture (acupuncture in which the needles do not pierce the skin
although patients believe they are receiving acupuncture) with limited interaction with the
acupuncturist; and an augmented interaction in which patients received TAU and sham
acupuncture, but the acupuncturist was warm, caring, and understanding. The results
showed that the both placebo conditions were superior to TAU, but the augmented condition was significantly better than simple delivery of the sham acupuncture. That is, when
the sham acupuncture involved a warm and caring practitioner, the benefits were greater,
sometimes with effects twice as large. Research on the real relationship indicate that is it
predictive of psychotherapy outcome (Gelso, 2014)
Some patients will benefit more from the real relationship than others. Those patients who
present with attachment difficulties, insecure attachment styles, poor social support, impoverished social networks, chaotic interpersonal relations, and features of borderline personality
disorder but find a relatively stable real relationship with their therapist will benefit more from
the real relationship than patients with relatively supportive interpersonal relationships.
1 There are limitations to the continuity of therapy, as would be the case if there were a risk of danger to self
or others, for example.
Contextual Model 53
Creation of Expectation through Explanation and Treatment
Patients come to therapy with a maladaptive conception of their distress. These maladaptive explanations, sometimes called folk psychology, are culturally influenced and often are
acquired from family, friends, and influential others as well as from the larger society (e.g.,
in advertisements for psychotropic medications). These explanations are not labeled maladaptive because they are unscientific, although surely many are, but because they fail to
lead patients to find solutions to what is distressing (Budge & Wampold, 2015; Wampold,
Imel, Bhati, & Johnson Jennings, 2006). An important aspect of healing practices, including Western medicine, is that patients are provided an explanation for their distress.
Indeed, patients presenting to a physician would be quite disoriented if no explanation
were provided—is the pain in my gut due to indigestion, an ulcer, or cancer? The explanation provides patients hope that there exists some treatment actions that will lead to
improvement—in that way, therapists are substituting an adaptive explanation for a maladaptive explanation. Notice that we are not saying that the adaptive explanation is more
scientific than the maladaptive one—what makes the explanation adaptive is that it allows
for ameliorative actions. (See the next section.) Cognitive behavioral therapists, interpersonal therapists, emotion‐focused therapists, eye movement desensitization and reprocessing, and dynamic therapists will offer their patients very different explanations of their
distress and plans for getting better. What is critical is that patients accept the explanation
and believe that it will lead, through the therapy process, to a reduction in distress. That is,
patients believe that participating in and successfully completing the therapeutic tasks will
be helpful in coping with their problems, which then further creates the expectation that
patients have “control” over their problems. These expectations and beliefs are central to
theories of how individuals change and behave, including theories involving mastery
(Frank & Frank, 1991; Liberman, 1978), self‐efficacy (Bandura, 1999), and response expectancies (Kirsch, 1985, 1999).
It is well known, scientifically as well as in our own experience, that expectations have a
large effect on what is experienced. Compelling evidence for the power of expectations is
found most profoundly in the placebo literature. Although there are several theories of
how placebos produce effects, expectations are central to understanding why placebos are
so powerful (see Benedetti, 2014; Kirsch, 1985; Price, Finniss, & Benedetti, 2008). It is
beyond the scope of this chapter to review the placebo research, but a few perspicuous
results will be convincing of the power of expectations. Placebos have been studied extensively for pain, including chronic pain, medically induced acute pain (e.g., postsurgical pain
and dental procedures), and experimentally induced pain (e.g, the cold pressor test) (see
Benedetti, 2009, 2014; Price et al., 2008, for a comprehensive review). It is well established
that taking a placebo analgesic with the expectation that the substance or procedure will
reduce pain reduces the experience of pain. Furthermore, it is also well established that
taking the placebo results in the release of endogenous opioids into the brain, indicating
that the placebo effect is not simply a subjective response but is mediated by a physiological process. Moreover, in an “open–hidden” paradigm, giving a postsurgical patient a given
dose of morphine administered surreptitiously (the hidden condition, e.g., by an intravenous infusion from a machine out of the patient’s awareness) is less effective (that is, the
patient reported more pain and requested more additional doses of analgesics) than when
54 3 What Should We Practice?
the patient is aware that the drug was being administered (open condition, e.g., a clinician
indicated to the patient that the drug was being delivered). Moreover, giving dental patients
a placebo in an open condition was equivalent to giving a patient 6 to 8 mg morphine in a
hidden condition for molar extraction. As a final example from pain, postoperative pain
patients after a course of opioid analgesics were randomly assigned to one of three conditions: (a) patients received no verbal instructions (a natural history condition); (b) patients
were told they would receive either a placebo or the painkiller they had previously received,
but they were all given only the placebo (the typical instruction given in double‐blind
placebo‐controlled randomized trial to test the efficacy of drugs); or (c) patients were told
they would receive the painkiller (deceptive condition). Patients in the double‐blind condition subsequently requested less medication than those in the natural history condition,
but patients who were told (deceptively) that they were receiving a painkiller requested
even less medication subsequently. What is clear from these studies (and hundreds of other
studies) is that patients’ expectation of pain relief results in pain relief and that these expectations are created by what is said to patients—that is, in verbal interactions with healers.
Demonstrable placebo effects are not limited to pain. Patients with Parkinson’s disease
benefit from placebos in terms of both symptoms (motoric activity) and levels of dopamine
in the brain (see Benedetti, 2014). Not surprisingly, patients with cardiac problems and diabetes have lower mortality rates if they adhere to protocols of beneficial drugs (i.e., take the
medication as instructed), but patients who are more adherent to the placebos in these trials
also have lower mortality than those who are not adherent (Simpson et al., 2006). Adherence to a protocol is a sign that patients believe the treatment will be effective. In this
instance, adhering to the placebo protocol (i.e., ingesting nothing medically active) can
reduce death. In another interesting study, female hotel room attendants were told that
their everyday work was good exercise. Compared to hotel workers who were not provided
any information, the informed workers reported that they got more exercise and they had
better health indicators (lower weight, lower blood pressure, and less body fat), even though
they did not do more exercise (Crum & Langer, 2007). Over 90% of the effect of antidepressants is due to the placebo effect (Kirsch, 2010). Patients in psychotherapy who attribute
their therapeutic gains to their own efforts rather than to a medication they had taken,
which was actually a placebo, were significantly less likely to relapse (Liberman, 1978;
Powers, Smits, Whitley, Bystritsky, & Telch, 2008).
Simply creating expectations through providing patients an explanation for their distress
and describing the treatment is not sufficient. Patients actually must enact the therapeutic
rituals—the explanation that a pill will decrease pain must be accompanied by the taking of
the pill. The explanation and the ritual work together, and patients must believe that therapeutic progress is a result of their own efforts, which provides a sense of their own control
over their distress. There is evidence that humans evolved to heal in a social context, such as
psychotherapy (Benedetti, 2011; Wampold & Imel, 2015). The importance of expectations
in psychotherapy has been well established (Constantino, Arnkoff, Glass, Ametrano, &
Smith, 2011).
Critical to the acceptance of the explanation and to the creation of expectations is the
therapeutic alliance. The alliance is defined as a pantheoretical construct that reflects
Contextual Model 55
collaborative and purposeful work and is composed of three components: (a) the bond
between therapist and patient, (b) agreement about the goals of therapy, and (c) agreement
about the tasks of therapy (Bordin, 1979; Hatcher & Barends, 2006; Horvath, 2006;
Horvath & Luborsky, 1993). The alliance is the most researched construct in psychotherapy process research. Nearly 200 studies have investigated the correlation of alliance with
outcome and have found meta‐analytically that there is a strong association of the alliance,
measured early in psychotherapy, and the final outcome, across all forms of psychotherapy
(Flückiger, Del Re, Wampold, Symonds, & Horvath, 2012; Horvath, Del Re, Flückiger, &
Symonds, 2011).
Enacting Health‐Promoting Actions
The power of therapeutic rituals is not limited to the expectations that are created. The
third pathway indicates an indirect effect of the relationship on outcome. A collaborative
working relationship involving agreement about the goals of therapy and the tasks needed
to achieve those goals will lead to the likelihood that patients will engage in therapeutic
tasks. Apart from the relationship, the actual tasks may well have therapeutic benefit.
An important point to keep in mind is that different treatments utilize very different therapeutic actions. Cognitive behavioral therapists ask patients to think more adaptively and to
change maladaptive cognitive schemas; behavioral therapists have patients approach previously avoided situations or people; interpersonal therapists work to improve the quality of
relationships; and dynamic therapists encourage the expression of avoided emotions. For
many disorders, a variety of treatments, utilizing very different treatment actions, have
been found to be effective (Wampold & Imel, 2015).
Of course, every approach to psychotherapy has a different explanatory system for disorders, as Laska, Gurman, and Wampold (2014) describe in reference to PTSD:
Each [treatment] posits a specific mechanism of change based on a given scientific
theory. For example, prolonged exposure (PE) for PTSD (Foa, Hembree, & Rothbaum,
2007) is conceptually derived from emotional processing theory (Foa & Kozak, 1986),
and the specific ingredients of PE (viz., imaginal and in vivo exposure) (a) activate the
“fear network,” (b) whereby clients habituate to their fears, and thus, (c) extinguish the
fear response. On the other hand, interpersonal therapy (IPT) for PTSD (Markowitz,
Milrod, Bleiberg, & Marshall, 2009) is derived from interpersonal and attachment
theory (Bowlby, 1973; Sullivan, 1953) and “focuses on current social and interpersonal functioning rather than exposure” (Bleiberg & Markowitz, 2005, p. 181). (p. 468)
Indeed, treatments used in research to control for specific effects have been found to be
effective. These treatments, which intentionally omitted specific ingredients thought to be
necessary to help patients with particular disorders, are as effective as evidence‐based treatments for the disorder when they are delivered by therapists who believe they are effective,
the rationale is convincing to the patients, and there are cogent and coherent treatment
actions. Indeed, these “control” treatments are so effective that they are now listed as
evidence‐based treatments, including behavioral activation for depression, interpersonal
therapy for depression, and present‐centered therapy for PTSD (Wampold & Imel, 2015).
56 3 What Should We Practice?
Lifestyle changes have large but underestimated effects on mental health (Walsh, 2011).
Improved mood and well‐being suggest to patients that the treatment is working and
augment the belief that the therapeutic components are efficacious. Again, patients
believe that their own hard work (i.e., engaging in the activities inherent in the treatment) is responsible for the benefits of therapy. What all effective treatments have in
common is that patients are persuaded to do something that promotes health and
well‐being.
Characteristics and Actions of Effective Therapists
In 2004, Beutler and colleagues reviewed what was known about the characteristics and
actions of effective therapists and concluded that not much was known in this regard. Fortunately, since then there has been a renewed interest in this topic as well as methodological
advances that can identify the therapist contribution to psychotherapy process and outcome. The characteristics and actions of effective therapists that have been identified are
briefly reviewed in the remainder of this chapter. Those characteristics and actions that are
not related to producing the benefits of psychotherapy will be discussed as well. These characteristics and actions are summarized in Table 3.1. This discussion is informative about
what therapists should deliberately practice.
Table 3.1 Effective therapists.
Characteristics and Actions of Effective Therapists Characteristics and Actions Not Related to Outcome
Formation of alliance across a range of patients Age
Facilitative interpersonal skills (as demonstrated
in response to difficult patient)
Gender
Verbal fluency Profession
Warmth and empathy Self‐reported social skills
Emotional expression Responses to interview questions about
clinical skills
Persuasiveness Theoretical orientation
Hopefulness Adherence to treatment protocol
Alliance‐bond capacity (see alliance) Rated competence delivering specific ingredients
of treatment
Problem focus
Delivery of a cogent treatment
Professional self‐doubt
Deliberate practice
Characteristics and Actions of Effective Therapists 57
Alliance
As discussed previously, the working alliance is a central construct in the contextual model.
The alliance is a vehicle used to create expectations and is necessary for patients to enact the
rituals of psychotherapy, which lead to the enactment of health‐promoting actions. Moreover, the bond in the alliance is quite similar to the real relationship. That is to say, the alliance seems to be central to therapeutic change, an observation strongly supported by the
research evidence.
As strong as the research is relative to alliance, it is not clear that it is the therapist’s contribution to the alliance that is important. Some patients come to therapy with strong social
support, secure attachment style, interpersonal skills, and motivation to change. Such
patients will form a relatively strong alliance with most therapists and have relatively good
outcomes. Thus, it might well be that it is the patient’s contribution to the alliance that is
important. However, just the opposite has been found. Baldwin, Wampold, and Imel (2007)
disentangled the therapist’s and the patient’s contributions to the alliance and found that
only the therapist’s contribution to the alliance predicted outcome, a result confirmed meta‐
analytically (Del Re, Flückiger, Horvath, Symonds, & Wampold, 2012). It is what therapists
offer patients in terms of forming the alliance that produces better outcomes. The conclusion from this research is unequivocal: Effective therapists form strong alliances across a
range of patients.
Facilitative Interpersonal Skills
Anderson and colleagues (Anderson, McClintock, Himawan, Song, & Patterson, 2015;
Anderson, Ogles, Patterson, Lambert, & Vermeersch, 2009) used an interesting method to
identify the characteristics and actions of effective therapists. Instead of using material
from therapy sessions or asking therapists to provide information, they presented a video of
a challenging patient (i.e., a stimulus that was constant across therapists) to 25 therapists at
a college counseling center, and the therapists recorded their responses to the patient at
various instances. The responses were then coded for what the authors called facilitative
interpersonal skills, which included verbal fluency, emotional expression, persuasiveness,
hopefulness, warmth, empathy, alliance‐bond capacity, and problem focus.
Facilitative interpersonal skill components are endemic to the contextual model. Empathy
is critical to the real relationship but, as discussed earlier, augments the effect of expectations and increases the likelihood that patients will form a collaborative working relationship and engage in therapy. Many believe that most therapists are empathic most of the
time, but there is variation between and within therapists in empathic responding, particularly in response to interpersonally aggressive and difficult patients.
Verbal fluency is critical for providing a believable, succinct, and adaptive explanation and
a cogent rationale for the therapeutic actions. Psychotherapy is, above all else, talk therapy.
That is, the delivery of psychotherapy is via verbal means and thus an effective therapist
must be able to communicate clearly and succinctly. Of course, some therapies emphasize
particular components that are expressed verbally, such as interpretations in dynamic therapy or psychoeducation in cognitive behavioral therapy.
58 3 What Should We Practice?
Emotion is central to the success of therapy (e.g., Diener, Hilsenroth, & Weinberger, 2007).
Again, some therapies are explicitly focused on emotion (e.g., emotion‐focused therapy
or affect phobia therapy), but emotion is central to all therapies, including cognitive and
behavioral therapies (see, e.g., Thoma, & McKay, 2015). Effective therapists are able to
modulate and express emotion. Often therapists need to activate avoided emotions, such
as sadness or anger, and must be able to appropriately model and express these emotions
for patients. In other instances, therapists will assist patients to reduce or inhibit emotions, such as fear, guilt, and shame. For example, a behavior therapist conducting a panic
induction with an extremely fearful patient will have to express calmness, even if the
therapist is anxious, as might likely be the case. And, of course, therapists need to mask
some of their affective reactions to patients, such as the disgust one might feel toward a
patient who does not bathe regularly or anger toward a patient who is insulting of the
therapist’s level of skill.
As discussed, a key component of the contextual model is that patients accept the explanation provided by therapists and believe that the treatment will be beneficial. Not surprisingly, Anderson and colleagues (2009) found that effective therapists are persuasive.
Moreover, effective therapists make it clear that patients’ progress toward achieving therapeutic goals is paramount—that is, the focus of the therapeutic encounter is on the patient’s
problems and their solution. And, of course, effective therapists communicate hopefulness
and optimism that patients can reach therapeutic goals, even if particular patients have
made many unsuccessful attempts, within and outside of therapy, to solve their problems,
(e.g., patients who abuse substances and have failed repeatedly to maintain sobriety for
significant periods of time).
Delivery of a Cogent Treatment
It is becoming increasingly clear that treatments without structure or a focus on the problems that motivated patients to seek help are less effective, particularly with focal symptoms, than are treatments than have a problem/solution focus (Wampold & Imel, 2015).
Unstructured treatments emphasize the real relationship as the change agent but ignore
expectations created by an explanation and a plan of action and eliciting health‐promoting
behavior change, the last two pathways of the contextual model. Effective therapists collaboratively develop a cogent treatment so that patients understand what needs to be
enacted in order to achieve their goals in therapy.
Professional Self‐Doubt and Deliberate Practice
In a series of studies, Nissen‐Lie and colleagues (Nissen‐Lie, Monsen, & Rønnestad, 2010;
Nissen‐Lie, Monsen, Ulleberg, & Rønnestad, 2013; Nissen‐Lie et al., 2015) found that
therapists’ self‐reported professional self‐doubt predicted outcome—that is, therapists
who had more doubt about their skill in helping patients (e.g, “lacking confidence that
you might have a beneficial effect on a patient” and “unsure about how best to deal effectively with a patient”) had better outcomes, particularly if they also had a positive sense
of self.
Characteristics and Actions of Effective Therapists 59
Perhaps therapists who doubted their effectiveness also were motivated to improve. Chow
et al. (2015) found that the amount of time therapists reported spending on improving targeted therapeutic skills outside of therapy predicted their outcomes with patients. This
practice meets the definition of deliberate practice (Ericsson & Lehmann, 1996) and is the
focus of this volume.
Characteristics and Actions of Therapists that Are Not Related to Outcome
It is informative to understand what characteristics and actions of therapists are not related
to outcome, as spending time and effort in those domains would not lead to improved outcomes. Generally, it has been found that the age of the therapist, the gender of the therapist,
and the profession of the therapist (e.g., psychology, psychiatry, social work, professional
counseling) do not predict outcome (Wampold & Imel, 2015)—of course, these are not variables that can be modified through practice, and they are of little relevance to the topics
discussed in this volume.
Anderson and colleagues (2009), in the study discussed earlier, used a challenge test to
assess facilitative interpersonal skills. Schöttke, Flückiger, Goldberg, Eversmann, and Lange
(2016) coded a discussion among trainees following a provoking video and found results
similar to those of Anderson and colleagues. It appears that therapists display important
skills in challenging situations. Interestingly, in these studies, self‐reported social skills
(Anderson et al., 2009) and responses in a structured interview designed to assess clinical
skills (Schöttke et al., 2016) did not predict outcomes. These studies suggest that, when
therapists make decisions about what skills to practice, therapist self‐report of skills is not
useful in identifying particular skills that need attention; rather, therapists must be observed
in challenging interpersonal situations.
Consistent with the more general literature on theoretical orientation (Wampold &
Imel, 2015), the studies examining characteristics and actions of effective therapists have
found that theoretical orientation did not predict a therapist’s outcomes (Anderson et
al., 2009; Chow et al., 2015; Schöttke et al., 2016). It is important to note that therapist
adherence to treatment protocols also does not predict outcome (Boswell et al., 2013; Webb
et al., 2010). That is to say, those therapists who more closely follow a treatment protocol do
not achieve better outcomes, and, indeed, flexibility in terms of adherence appears to be
more important (Owen & Hilsenroth, 2014). How a treatment is delivered is more important than the particular treatment that is offered to patients.
It also appears that competence in delivering a particular treatment, as rated by experts in
clinical trials, does not predict the outcomes of therapy (Boswell et al., 2013; Webb et
al., 2010). This is a curious finding because one would think that experts’ rating of competence must be related to how well therapists perform and to the outcomes achieved. The key
to understanding this finding is to emphasize that such competence measures are sensitive
to competence in a particular therapy and not to competence in many factors discussed in
this chapter, including alliance building, empathy, hopefulness, and persuasiveness. Indeed,
training therapists to be more competent in a particular therapy does not seem to improve
their outcomes (Branson et al., 2015).
60 3 What Should We Practice?
Conclusions
Deliberate practice leads to expertise, provided practitioners practice those skills necessary for
exemplary performance. It is possible to improve therapy performance if therapists practice
those skills that lead to better outcomes. In this chapter, an evidence‐based meta‐model for
how psychotherapy works was presented as well as the therapist skills required by the model.
Questions from the Editors
Question #1. In the chapter, you speak of the importance of providing a cogent rationale for
client difficulties and the treatment process. How can clinicians understand evidence that the
particular approach contributes little if anything to overall outcome with your claim that they
need to adhere to a treatment with a cogent rationale with allegiance and belief in that
treatment?
Answer from Author: Yes, at first glance, there is a dilemma here: Why should a clinician
have an allegiance to a particular type of therapy when the evidence is clear that which type
of therapy is used does not make a difference? To escape this dilemma, substitute the following belief: As a therapist, I believe that giving Treatment A will benefit my clients. Of
course, the therapist probably finds Treatment A to be appealing and consistent with his or
her values, attitudes, assumptions about the world, and so on. But such a statement demands
two corollaries. First, belief is not sufficient. The benefit to clients must be documented:
That is, there must be evidence that the treatment works well as delivered by the therapist—
and that is where routine outcome monitoring is important. Second, choice of the treatment approach should not be based solely on what the therapist finds appealing. Importantly,
the treatment needs to be compatible with the expectations, attitudes, values, and worldview of the client—some clients will find some treatments more acceptable than others. So,
therapists have to have a repertoire of treatments.
Question #2. Doesn’t embracing a contextual view of psychotherapy as described in the chapter risk exclusion from the broader medicalized healthcare system? If not, why?
Answer from Author: Navigating the world of healthcare delivery systems in various venues
is complicated business. Historically medicine has emphasized particular treatments for particular diseases or conditions. So, when psychotherapy is delivered within a medical context,
there is a strong inclination to follow the same road and ask which psychological treatment
is most effective for which particular disorder. Some venues have followed this course and
mandated that clinicians use only particular evidence‐based treatments. The answer is that
psychotherapy is remarkably effective, as effective as and longer-lasting than medications for
most mental disorders, and has fewer (or no) side effects; however, the specific ingredients
of particular treatments are not what makes psychotherapy work, as I discussed in this chapter. We need to continue to document the effectiveness of psychotherapy at a macro level
References 61
(i.e., via clinical trials and meta‐analyses) and at at the micro level—each therapist, each
agency, and each system must be accountable for the results of mental health services.
Question #3. Can you describe a few ways how graduate programs might integrate the contextual model into training of students?
Answer from Author: The model of expertise that we are discussing in this volume constitutes a dramatic shift of the standard practice. To accomplish change, we need to focus first
on training of therapists. Here are my suggestions:
● Graduate students/psychotherapy trainees need to be selected according to their potential to be effective therapists. The current criteria (exams, interviews, grades, personal
statements, and letters of recommendation) are poor predictors of therapy effectiveness;
challenge tests, such as the one devised by Tim Anderson, provide evidence for future
psychotherapy effectiveness.
● Trainees need to learn various treatment approaches (see my answer to question #2), but
strict adherence to protocols is not the goal.
● Trainees need to improve the skills discussed in this chapter, using deliberate practice
methods. An implication here is that supervisors and trainers need be skilled in using
deliberate practice procedures with their trainees.
● In all clinical work, trainees should use routine outcome monitoring to assess psychotherapy effectiveness.
● Recommendations for internship and clinical positions should be supported by evidence
of trainees effectiveness derived from routine outcome monitoring.
References
Ahn, H., & Wampold, B. E. (2001). A meta‐analysis of component studies: Where is the
evidence for the specificity of psychotherapy? Journal of Counseling Psychology, 48, 262–267.
Anderson, T., McClintock, A. S., Himawan, L., Song, X., & Patterson, C. L. (2015). A
prospective study of therapist facilitative interpersonal skills as a predictor of treatment
outcome. Journal of Consulting and Clinical Psychology. doi:10.1037/ccp0000060
Anderson, T., Ogles, B. M., Patterson, C. L., Lambert, M. J., & Vermeersch, D. A. (2009).
Therapist effects: Facilitative interpersonal skills as a predictor of therapist success. Journal
of Clinical Psychology, 65(7), 755–768. doi:10.1002/jclp.20583
Baldwin, S. A., & Imel, Z. E. (2013). Therapist effects: Finding and methods. In M. J. Lambert
(Ed.), Bergin and Garfield’s handbook of psychotherapy and behavior change (6th ed., pp.
258–297). Hoboken, NJ: Wiley.
Baldwin, S. A., Wampold, B. E., & Imel, Z. E. (2007). Untangling the alliance–outcome
correlation: Exploring the relative importance of therapist and patient variability in the
alliance. Journal of Consulting and Clinical Psychology, 75, 842–852.
Bandura, A. (1999). Self‐efficacy: Toward a unifying theory of behavioral change. In R. F.
Baumeister (Ed.), The self in social psychology (pp. 285–298). New York, NY: Psychology Press.
62 3 What Should We Practice?
Baumeister, R. F. (2005). The cultural animal: Human nature, meaning, and social life. New
York, NY: Oxford University Press.
Bell, E. C., Marcus, D. K., & Goodlad, J. K. (2013). Are the parts as good as the whole? A
meta‐analysis of component treatment studies. Journal of Consulting and Clinical
Psychology, 81(4), 722–736. doi:10.1037/a0033004
Benedetti, F. (2009). Placebo effects: Understanding the mechanisms in health and disease. New
York, NY: Oxford University Press.
Benedetti, F. (2011). The patient’s brain: The neuroscience behind the doctor–patient
relationship. New York, NY: Oxford University Press.
Benedetti, F. (2014). Placebo effects: Understanding the mechanisms in health and disease (2nd
ed.). New York, NY: Oxford University Press.
Beutler, L. E., Malik, M., Alimohamed, S., Harwood, T. M., Talebi, H., Noble, S., & Wong, E.
(2004). Therapist variables. In M. J. Lambert (Ed.), Bergin and Garfield’s handbook of
psychotherapy and behavior change (5th ed., pp. 227–306). Hoboken, NJ: Wiley.
Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working
alliance. Psychotherapy: Theory, Research & Practice, 16(3), 252–260. doi:10.1037/
h0085885
Boswell, J. F., Gallagher, M. W., Sauer‐Zavala, S. E., Bullis, J., Gorman, J. M., Shear, M. K., . . .
Barlow, D. H. (2013). Patient characteristics and variability in adherence and competence in
cognitive‐behavioral therapy for panic disorder. Journal of Consulting and Clinical
Psychology, 81(3), 443–454. doi:10.1037/a0031437
Bowlby, J. (1980). Attachment and loss. New York, NY: Basic Books.
Branson, A., Shafran, R., & Myles, P. (2015). Investigating the relationship between competence
and patient outcome with CBT. Behaviour Research and Therapy, 68, 19–26. doi:10.1016/
j.brat.2015.03.002
Budge, S. L., & Wampold, B. E. (2015). The relationship: How it works. In O.C.G. Gelo, A.
Pritz, & B. Rieken (Eds.), Psychotherapy research: Foundations, process, and outcome
(pp. 213–228). New York, NY: Springer‐Verlag.
Cacioppo, S., & Cacioppo, J. T. (2012). Decoding the invisible forces of social connections.
Frontiers in Integrative Neuroscience, 6. doi:10.3389/fnint.2012.00051
Chow, D. L., Miller, S. D., Seidel, J. A., Kane, R. T., Thornton, J. A., & Andrews, W. P. (2015).
The role of deliberate practice in the development of highly effective psychotherapists.
Psychotherapy, 52(3), 337–345. doi:10.1037/pst0000015
Connell, J., Grant, S., & Mullin, T. (2006). Client‐initiated termination of therapy at NHS
primary care counselling services. Counselling & Psychotherapy Research, 6(1), 60–67. doi:10
.1080/14733140600581507
Constantino, M. J., Arnkoff, D. B., Glass, C. R., Ametrano, R. M., & Smith, J. Z. (2011).
Expectations. Journal of Clinical Psychology, 67(2), 184–192. doi:10.1002/jclp.20754
Crum, A. J., & Langer, E. J. (2007). Mind‐set matters: Exercise and the placebo effect.
Psychological Science, 18(2), 165–171. doi:10.1111/j.1467-9280.2007.01867.x
Decety, J., & Fotopoulou, A. (2015). Why empathy has a beneficial impact on others in
medicine: Unifying theories. Frontiers in Behavioral Neuroscience, 8. doi:10.3389/
fnbeh.2014.00457
References 63
Del Re, A. C., Flückiger, C., Horvath, A. O., Symonds, D., & Wampold, B. E. (2012).
Therapist effects in the therapeutic alliance–outcome relationship: A restricted‐maximum
likelihood meta‐analysis. Clinical Psychology Review, 32(7), 642–649. doi:10.1016/j.
cpr.2012.07.002
Diener, M. J., Hilsenroth, M. J., & Weinberger, J. (2007). Therapist affect focus and patient
outcomes in psychodynamic psychotherapy: A meta‐analysis. American Journal of
Psychiatry, 164(6), 936–941. doi:http://doi.org/10.1176/appi.ajp.164.6.936
Ericsson, K. A., & Lehmann, A. C. (1996). Expert and exceptional performance: Evidence of
maximal adaptation to task constraints. Annual Review of Psychology, 47, 273–305.
Flückiger, C., Del Re, A. C., Wampold, B. E., Symonds, D., & Horvath, A. O. (2012). How
central is the alliance in psychotherapy? A multilevel longitudinal meta‐analysis. Journal of
Counseling Psychology, 59(1), 10–17. doi:10.1037/a0025749
Frank, J. D., & Frank, J. B. (1991). Persuasion and healing: A comparative study of
psychotherapy (3rd ed.). Baltimore, MD: Johns Hopkins University Press.
Gelso, C. J. (2009). The real relationship in a postmodern world: Theoretical and empirical
explorations. Psychotherapy Research, 19(3), 253–264. doi:10.1080/10503300802389242
Gelso, C. (2014). A tripartite model of the therapeutic relationship: Theory, research, and
practice. Psychotherapy Research, 24(2), 117–131.
Gelso, C. J., & Carter, J. A. (1994). Components of the psychotherapy relationship: Their
interaction and unfolding during treatment. Journal of Counseling Psychology, 41(3), 296–
306. doi:10.1037/0022-0167.41.3.296
Hatcher, R. L., & Barends, A. W. (2006). How a return to theory could help alliance research.
Psychotherapy: Theory, Research, Practice, Training, 43(3), 292–299. doi:10.1037/0033-
3204.43.3.292
Holt‐Lunstad, J., Smith, T. B., Baker, M., Harris, T., & Stephenson, D. (2015). Loneliness and
social isolation as risk factors for mortality: A meta‐analytic review. Perspectives on
Psychological Science, 10(2), 227–237. doi:10.1177/1745691614568352
Holt‐Lunstad, J., Smith, T. B., & Layton, J. B. (2010). Social relationships and mortality risk:
A meta‐analytic review. PLoS Medicine, 7(7), e1000316.
Horvath, A. O. (2006). The alliance in context: Accomplishments, challenges, and future
directions. Psychotherapy: Theory, Research, Practice, Training, 43(3), 258–263. doi:10.1037/
0033-3204.43.3.258
Horvath, A. O., Del Re, A. C., Flückiger, C., & Symonds, D. (2011). Alliance in individual
psychotherapy. Psychotherapy, 48(1), 9–16. doi:10.1037/a0022186
Horvath, A. O., & Luborsky, L. (1993). The role of the therapeutic alliance in psychotherapy.
Journal of Consulting and Clinical Psychology, 61, 561–573.
Kaptchuk, T. J., Kelley, J. M., Conboy, L. A., Davis, R. B., Kerr, C. E., Jacobson, E. E., . . . Lembo,
A. J. (2008). Components of placebo effect: Randomised controlled trial in patients with
irritable bowel syndrome. British Medical Journal, 336(7651), 999–1003. doi:10.1136/
bmj.39524.439618.25
Kelley, J. M., Lembo, A. J., Ablon, J. S., Villanueva, J. J., Conboy, L. A., Levy, R., . . . Kaptchuk,
T. J. (2009). Patient and practitioner influences on the placebo effect in irritable bowel
syndrome. Psychosomatic Medicine, 71(7), 789–797. doi:10.1097/PSY.0b013e3181acee12
64 3 What Should We Practice?
Kirsch, I. (1985). Response expectancy as a determinant of experience and behavior. American
Psychologist, 40, 1189–1202.
Kirsch, I. (1999). How expectancies shape experience. Washington, DC: American
Psychological Association.
Kirsch, I. (2010). The emperor’s new drugs: Exploding the antidepressant myth. New York, NY:
Basic Books.
Laska, K. M., Gurman, A. S., & Wampold, B. E. (2014). Expanding the lens of evidence‐based
practice in psychotherapy: A common factors perspective. Psychotherapy, 51(4), 467–481. doi:
10.1037/a0034332
Liberman, B. L. (1978). The role of mastery in psychotherapy: Maintenance of improvement
and prescriptive change. In J. D. Frank, R. Hoehn‐Saric, S. D. Imber, B. L. Liberman, & A. R.
Stone (Eds.), Effective ingredients of successful psychotherapy (pp. 35–72). Baltimore, MD:
Johns Hopkins University Press.
Lieberman, M. D. (2013). Social: Why our brains are wired to connect. New York, NY: Crown.
Luo, Y., Hawkley, L. C., Waite, L. J., & Cacioppo, J. T. (2012). Loneliness, health, and mortality
in old age: A national longitudinal study. Social Science & Medicine, 74(6), 907–914. doi:10
.1016/j.socscimed.2011.11.028
Nissen‐Lie, H. A., Monsen, J. T., & Rønnestad, M. H. (2010). Therapist predictors of early
patient‐rated working alliance: A multilevel approach. Psychotherapy Research, 20(6),
627–646. doi:10.1080/10503307.2010.497633
Nissen‐Lie, H. A., Monsen, J. T., Ulleberg, P., & Rønnestad, M. H. (2013). Psychotherapists’
self‐reports of their interpersonal functioning and difficulties in practice as predictors of
patient outcome. Psychotherapy Research, 23(1), 86–104. doi:10.1080/10503307.2012.735775
Nissen‐Lie, H. A., Rønnestad, M. H., Høglend, P. A., Havik, O. E., Solbakken, O. A., Stiles, T.
C., & Monsen, J. T. (2015). Love yourself as a person, doubt yourself as a therapist? Clinical
Psychology & Psychotherapy. doi:10.1002/cpp.1977
Orlinsky, D. E., & Howard, K. I. (1986). Process and outcome in psychotherapy. In S. L.
Garfield & A. E. Bergin (Eds.), Handbook of psychotherapy and behavior change (3rd ed., pp.
311–381). New York, NY: Wiley.
Owen, J., & Hilsenroth, M. J. (2014). Treatment adherence: The importance of therapist
flexibility in relation to therapy outcomes. Journal of Counseling Psychology, 61(2), 280–288.
Powers, M. B., Smits, J.A.J., Whitley, D., Bystritsky, A., & Telch, M. J. (2008). The effect of
attributional processes concerning medication taking on return of fear. Journal of Consulting
and Clinical Psychology, 76(3), 478–490.
Price, D. P., Finniss, D. G., & Benedetti, F. (2008). A comprehensive review of the placebo
effect: Recent advances and current thought. Annual Review of Psychology, 59, 565–590.
Schöttke, H., Flückiger, C., Goldberg, S. B., Eversmann, J., & Lange, J. (2016, January).
Predicting psychotherapy outcome based on therapist interpersonal skills: A five‐year
longitudinal study of a therapist assessment protocol. Psychotherapy Research.
10.1080/10503307.2015.1125546
Simon, G. E., & Ludman, E. J. (2010). Predictors of early dropout from psychotherapy for
depression in community practice. Psychiatric Services, 61(7), 684–689. doi:10.1176/appi.
ps.61.7.684
References 65
Simpson, S. H., Eurich, D. T., Majumdar, S. R., Padwal, R. S., Tsuyuki, S. T., Varney, J., &
Johnson, J. A. (2006, June). A meta‐analysis of the association between adherence to drug
therapy and mortality. British Medical Journal. doi:10.1136/bmj.38875.675486.55
Thoma, N. C., & McKay, D. (Eds.). (2015). Working with emotion in cognitive‐behavioral
therapy: Techniques for clinical practice. New York, NY: Guilford Press.
Tracey, T.J.G., Wampold, B. E., Lichtenberg, J. W., & Goodyear, R. K. (2014). Expertise in
psychotherapy: An elusive goal? American Psychologist, 69, 218–229. doi:10.1037/a0035099
Walsh, R. (2011). Lifestyle and mental health. American Psychologist, 66(7), 579–592. doi:10
.1037/a0021769
Wampold, B. E., & Budge, S. L. (2012). The 2011 Leona Tyler Award address: The
relationship—and its relationship to the common and specific factors of psychotherapy.
Counseling Psychologist, 40(4), 601–623. doi:10.1177/0011000011432709
Wampold, B. E., & Imel, Z. E. (2015). The great psychotherapy debate: The research evidence
for what works in psychotherapy (2nd ed.). New York, NY: Routledge.
Wampold, B. E., Imel, Z. E., Bhati, K. S., & Johnson Jennings, M. D. (2006). Insight as a
common factor. In L. G. Castonguay & C. E. Hill (Eds.), Insight in psychotherapy (pp.
119–139). Washington, DC: American Psychological Association.
Webb, C. A., DeRubeis, R. J., & Barber, J. P. (2010). Therapist adherence/competence and
treatment outcome: A meta‐analytic review. Journal of Consulting and Clinical Psychology,
78(2), 200–211. doi:10.1037/a0018912
Willis, J., & Todorov, A. (2006). First impressions: Making up your mind after a 100‐ms
exposure to a face. Psychological Science, 17(7), 592–598. doi:10.1111/j.1467-
9280.2006.01750.x
Wilson, E. O. (2012). The social conquest of earth. New York, NY: Liveright.

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