Expertise In Psychotherapy Research Articles

The ongoing debate about expertise in psychotherapy – what would Bernie Neville say?

ABSTRACT In response to the ongoing and unresolved debate about expertise in psychotherapy, and in the context of this special issue, this article contends that Bernie Neville would argue that expertise in psychotherapy is more likely to be indicated by the quality of the therapeutic relationship than by the therapist’s specific methods or techniques. His teaching and research in education and psychotherapy was firmly grounded in humanistic-existential theory with a strong Rogerian orientation. Creativity was a hallmark of his work in education; for example, he deployed the myths of the ancient Greek gods to encourage students and practitioners to critically analyze and imaginatively understand being in the world. In this article, I also point to how the gods informed his thinking in relation to humanistic-existential themes concerning the precariousness of existence, to evidence-based psychotherapy relationships, and to the ‘Master Therapist’ model whereby the quest for expertise in psychotherapy is typically a dynamic process beset with paradox and ambiguity.

Developing expertise in psychotherapy: The case for process coding as clinical training.

Routine outcome monitoring (ROM) is a major development in the field since it offers likely outcome trajectories and is particularly helpful for failing cases. However, ROM has not led to improved skill development more generally, and it is debatable as to whether expertise is even possible to acquire in psychotherapy. What is missing but crucial to expertise is feedback on the outcome of one's actions in real time, which would enable responsive adjustments and improve outcomes. It is argued in this article that by identifying empirically validated moment-to-moment markers capable of differentiating later clinical outcomes, process researchers have uncovered the possibility of extracting prognostic information in real time, but one must develop the requisite observational skills. Multiple lines of research are reviewed to support the contention that real-time outcome information is available to guide responsivity and improve outcomes. And the typically hidden nature of these important signals further underscores the need for systematic training in process acuity. Given the pressing need to improve training methods, process coding training should not be restricted to research laboratories but should be exported to the clinical setting and tailored to the needs of clinicians for use in real time during therapy sessions. These are testable hypotheses that, if successful, hold the possibility of improving training and reversing the worrying trend of experience in psychotherapy being unrelated to outcome. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Developing process sensitivity: Reply to Wilcox (2024) and Boswell (2024).

Wilcox (2024) and Boswell (2024) make a number of important observations about facilitating process sensitivity training, and here, we respond to those suggestions. We postulate that cultivating process sensitivity is complementary, not antithetical, to traditional training in viewing therapy from a theoretical lens, and thus, can serve to enhance, rather than replace one's existing psychotherapy skills. Moreover, we argue that seeing the impact of process adjustments in real time can be a significant motivator for training in process sensitivity since the benefits are more immediately obvious. We further argue that the field can be more thoughtful about the use of simulations in training and the emerging interactive training platforms using video stimuli, since they facilitate exposure to clinical situations in a safe manner. Finally, while learning to identify process markers can play a valuable role in optimizing the timing of interventions, we argue that this pales in comparison to the value of process sensitization as a means of attending to outcome information in the moment ("little outcome"). If successful, this opens up the possibility of developing expertise in psychotherapy, which hitherto was considered not possible. However, these propositions require rigorous testing in studies on training and supervision. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

The Future of Psychotherapy Research and Neuroscience: Introducing the 4E/MoBI Approach to the Study of Patient–Therapist Interaction

The integration of neuroscience and psychotherapy research has long been a topic of interest in the field of mental health. A significant challenge in psychotherapy research is understanding the dyadic interaction between patient and therapist. This interaction is complex, emerging from a myriad of multi-level factors such as gestures, verbal communication, mentalization, and environmental influences. This article aims to present a roadmap for the future integration of neuroscience and psychotherapy research, addressing the complexities of human interaction. We introduce the 4E/MoBI approach, a framework that combines theoretical and methodological tools to study the dynamics of the brain, body, and environment in real-world settings. This approach emphasizes the use of physiological systems (e.g., heart and brain), behavioral interactions (e.g., conversations and eye-tracking), and environmental video recordings. Additionally, the scalable experimental design (SED) heuristic is discussed as a method to blend controlled experiments with real-world scenarios, allowing for the parametric testing of neurobehavioral markers. As a practical demonstration of the SED heuristic within the 4E/MoBI framework, a concrete experimental example using the N170 event-related potential (ERP) component is presented. While the N170 ERP component is not posited as the foundational marker in the field, it serves to illustrate the application of hypothesis-driven designs and analyses. The 4E/MoBI approach offers a promising avenue for the integration of neuroscience and psychotherapy research. By addressing existing gaps, such as the physiology and phenomenology of expertise in psychotherapy, this framework can foster a virtuous relationship between the two disciplines, paving the way for more comprehensive and nuanced understandings of therapeutic interactions.

Definition and Criteria for the Assessment of Expertise in Psychotherapy: Development of the Psychotherapy Expertise Questionnaire (PEQ).

Therapist expertise is a complex, multifaceted, and continually evolving concept. Defining this construct and its constituent components can yield a substantial contribution to the field of psychotherapy, consequently enhancing the comprehension of the fundamental factors that underlie its effectiveness. Within this framework, the present research aimed at developing and assessing the psychometric properties of the Psychotherapy Expertise Questionnaire (PEQ), a self-report measure to assess therapist expertise. A sample of 260 psychotherapists of various theoretical orientations were involved in this research. They completed a survey that included the PEQ as well as other self-reported measures aimed at evaluating personality traits, self-efficacy, self-esteem, and insight orientation. The analysis provided evidence of a good fit for both a correlational model with eight factors and a higher-order model, where the eight subdimensions were grouped into subjective (performance; cognitive functioning; personal and relational qualities of the therapist; therapist self-assessment) and objective (experience; reputation with clients and colleagues; training and professional updating; deontological ethics and setting rules) factors. The eight dimensions, two higher-order factors, and total score all showed excellent levels of internal consistency. Furthermore, significant associations were found between PEQ scores and insight orientation, general self-efficacy, self-esteem, personality traits, and time exercising clinical practice. To conclude, the Psychotherapy Expertise Questionnaire (PEQ) is a valuable, theoretically guided, and psychometrically robust self-report measure designed to assess therapist expertise and its constitutive dimensions. This measure can have practical applications in guiding tailored training and customised supervision.

Towards a taxonomy of mechanisms of change? Findings from an expert survey on the association between common factors and specific techniques in psychotherapy

ABSTRACT Objective In the present study, we used structural equation modeling (SEM) to investigate the complex relationship between common factors, i.e., mechanisms of change, and specific factors, i.e., therapeutic techniques. Method N = 256 psychotherapy experts were asked to rate the appropriateness of 14 techniques commonly used in psychotherapy to facilitate five different common factors – resource activation, motivational clarification, self-management & emotion regulation, social competence, and therapeutic relationship. Using SEM, we defined techniques as indicators and common factors as latent variables. Data were split randomly into two subsets. Indicators were selected if three a priori defined criteria were met based on training data (n = 128). Subsequently, the goodness of model fit was assessed in the test data (n = 128). Results The proposed model revealed adequate fit. All factor loadings were theoretically sound and significant in magnitude. Findings suggest that psychotherapy experts discriminate between common factors by their various associations with therapeutic techniques. Conclusion Suggestions are made, how therapeutic techniques are to be used to facilitate desirable change in the patient. Our model is a step towards a taxonomy of mechanisms of change that may help to improve research-informed decision-making.

Understanding the role of emotion and expertise in psychotherapy: An application of dynamical systems mathematical modeling to an entire course of therapy.

The therapeutic relationship continues to be one of the most important factors in therapeutic outcomes. Given the place of emotion in the definition of the therapeutic relationship, as well as the demonstrated positive impact that emotional expression has on therapeutic process and outcome, it stands to reason that studying the emotional exchange between the therapist and client further would be warranted. This study used a validated observational coding system--the Specific Affect Coding System (SPAFF) and a theoretical mathematical model to analyze behaviors which make up the therapeutic relationship. Specifically, the researchers used to codify relationship-building behaviors between an expert therapist and his client over the course of six sessions. Dynamical systems mathematical modeling was also employed to create "phase space portraits" depicting the relational dynamics between the master therapist and his client over six sessions. Statistical analysis was used to compare SPAFF codes and model parameters between the expert therapist and his client. The expert therapist showed stability in affect codes over six sessions while the client's affect codes appeared to be more flexible over time, though model parameters remained stable across the six sessions. Finally, phase space portraits depicted the evolution of the affective dynamics between the master therapist and his client as the relationship matured. The clinician's ability to stay emotionally positive and relatively stable across the six sessions (relative to the client) was noteworthy. It formed the basis for a stable base from which she could explore alternative methods to relate to others that she had allowed to dictate her actions, which is in keeping with previous research on the role of therapist facilitation of the therapeutic relationship, emotional expression within the therapeutic relationship, and influence of these on client outcomes. These results provide a valuable foundation for future research on emotional expression as a key component of the therapeutic relationship in psychotherapy.

Acceptance and commitment therapy (ACT) for people with dementia experiencing psychological distress: A hermeneutic single‐case efficacy design (HSCED) series

AbstractIntroductionPeople with dementia have a high prevalence of psychological distress but are underserved with evidence‐based psychological interventions. To promote choice and improve clinical outcomes, there is a necessity to test different psychological intervention options for this population.PurposeThis study aimed to investigate the effectiveness and acceptability of acceptance and commitment therapy (ACT) for people with dementia, considering carer‐supported, remote delivery and necessary therapy adaptations.MethodsA hermeneutic single‐case efficacy design series was used to analyse the therapy process and change for three clients with dementia and psychological distress. A matrix of quantitative and qualitative data was collated (“rich case records”) and subject to critical analyses by three independent psychotherapy experts (“judges”) who identified change processes and determined the outcome for each client.ResultsAdjudication concluded that one client made positive changes, specifically reliable reductions in psychological distress, which were largely attributable to ACT. Two clients remained unchanged.Discussion/ConclusionWhere change was achieved, the ACT‐specific processes of values, committed action and acceptance, in combination with non‐specific therapy factors, including a strong client–carer relationship, existing client interests and individualised therapy adaptations, were facilitative. Hence, ACT may be a feasible and effective vehicle for therapeutic change by helping carers to better meet the needs of their loved ones. Future research to optimise ACT delivery in this population may be beneficial. Furthermore, the assessment of carer factors (e.g., their psychological flexibility and the client–carer relationship) may strengthen the evidence base for systemic ACT use.

The Predicted Future of Psychotherapy: A Decennial e-Delphi Poll.

Whither psychotherapy in the 2030s? Following a decennial tradition, the authors conducted an e-Delphi poll on the future of psychotherapy in the United States. A panel of 56 psychotherapy experts participated in two rounds of predictions and achieved consensus on most items. The experts forecast multicultural, mindfulness, and cognitive-behavior therapies to increase the most, whereas classical psychoanalysis, reality therapy, and gestalt therapy to decrease the most. Technological, relationship-building, strength-oriented, skill-building, and self-change interventions were expected to rise. Master-level clinicians of multiple professions were projected to expand while psychiatrists to decline in the proportion of psychotherapy rendered. Therapy platforms with the highest likelihood of flourishing were videoconferencing, texting, smartphone applications, and multiple or flexible platforms. Short-term therapy, crisis intervention, and very short-term therapy were predicted to increase the most. Forecast scenarios with the highest likelihood were therapy personalization, treatment of health problems, requirement of evidence-based practices for insurance reimbursement, and integration of psychotherapy into primary care. Limitations of the Delphi methodology are elucidated, and practice implications for health-service psychologists are advanced.

Challenges related to the study of psychotherapy experts

Challenges related to the study of psychotherapy experts

Pandemic Allows Vast Natural Experiment in Socially Distant Psychotherapy

Pandemic Allows Vast Natural Experiment in Socially Distant Psychotherapy

A Mixed-Method Modified Delphi Study toward Identifying Key Elements of Psychotherapy in Iran.

Purpose: In Iran, psychotherapy is regarded as an effective treatment for psychiatric disorders. However, no previous research has identified the key elements of psychotherapy that may be specific to Iranian society. The current study was conducted in an attempt to identify these elements. Methods: A mixed-method modified Delphi approach was used, taking place over several stages during 2017–2018. The first stage involved interviewing 12 experts in psychotherapy to identify key elements of psychotherapy in Iran by thematic analysis. Then, successive Delphi rounds were conducted to obtain consensus (75% agreement) from 70 psychotherapy experts on these key elements. Results: Key elements of psychotherapy were grouped into the following themes: (1) systematic education/training; (2) psychotherapist competency; (3) psychotherapy reflective of Iranian societal needs; and (4) the substrate (scientific/ethical principles) of psychotherapy. Consensus was reached during two Delphi rounds. In Delphi round 1, 52.8% of the statements reached consensus, and all remaining statements reached consensus in round 2. Conclusions: The key elements of psychotherapy in Iran are a set of conditions for the education and training of competent psychotherapists who can perform psychiatric interventions appropriate to Iranian society under supervised rules. These should serve as a framework for improving the current delivery of psychotherapy in Iran.

'What should a woman do and imagine to have bulimia?': Co-constructing patient expertise in psychotherapy with bulimia patients.

One of the goals of psychotherapy with bulimia patients is identification of the functions of the eating disorder in their lives. Thus, as in any psychotherapeutic approach, the therapist should facilitate the patient's disclosure of his or her experience of living with bulimia. Talking about one's dysphoric experiences and, particularly in the case of bulimia, symptoms and experiences that commonly deprive people with bulimia of dignity, constitutes an emotional challenge for the patient and an equally challenging interactional task for the therapist. Using the example of one therapy session with a female bulimia patient, we examine how the therapist and the patient interactionally engage in co-constructing the patient's expertise - involving epistemics of experience as well as epistemics of expertise - concerning the illness in the interactional here-and-now. Applying tools and insights from discourse and conversation analysis, we examine the sequences in which the patient shifts the topical focus from a general observation concerning bulimia to her personal experience, to be further pursued interactionally by the therapist. We also discuss how the therapist downgrades her epistemic position and (concurrently) foregrounds and bolsters the patient's voice as expert to accomplish the session's therapeutic goals.

The Multitheoretical List of Therapeutic Interventions – 30 items (MULTI-30)

Objective: To develop a brief version of the Multitheoretical List of Therapeutic Interventions (MULTI-60) in order to decrease completion time burden by approximately half, while maintaining content coverage. Study 1 aimed to select 30 items. Study 2 aimed to examine the reliability and internal consistency of the MULTI-30. Study 3 aimed to validate the MULTI-30 and ensure content coverage. Method: In Study 1, the sample included 186 therapist and 255 patient MULTI ratings, and 164 ratings of sessions coded by trained observers. Internal consistency (Chronbach’s alpha and McDonald’s omega) was calculated and confirmatory factor analysis was conducted. Psychotherapy experts rated content relevance. Study 2 included a sample of 644 patient and 522 therapist ratings, and 793 codings of psychotherapy sessions. In Study 3, the sample included 33 codings of sessions. A series of regression analyses was conducted to examine replication of previously published findings using the MULTI-30. Results: The MULTI-30 was found valid, reliable, and internally consistent across 2564 ratings examined across the three studies presented. Conclusion: The MULTI-30 a brief and reliable process measure. Future studies are required for further validation. Clinical or methodological significance of this article: The MULTI-30, developed and validated in this study, is a valid, reliable, and cost-effective brief measure which could be used to assess patients, therapists, and observers’ perceptions of use of interventions from eight major therapeutic approaches. The MULTI-30 could be used to examine the role of use of specific interventions on process and outcome of different treatment modalities. It could also be used as a clinical tool in teaching, training, and supervision.

Working with traumatized immigrants with a ptsd diagnosis

Graef-Calliess Iris (Germany).Germany has always been an important host country for asylum seekers. Although recently an increasing number of investigations about mental health of specific migrant groups have been published in Germany, there is a paucity of research concerning mental health of traumatized asylum seekers. The aim of the presentation is to present study results which describe socio-demographics, types and frequency of traumatic experiences, psychiatric diagnoses, suicidality and time to access to mental health care in traumatized asylum seekers who applied to an outpatient department of a clinical center with high expertise in transcultural psychiatry and psychotherapy in Hannover, Germany. The study shows that most of the traumatized asylum seekers had experienced multiple pre-migratory traumatic events, had unfavorable post-migratory conditions, had PTSD and depressive disorders as diagnoses, and had high suicidality and late access to mental health care. This is indicative of the mental health situation of asylum seekers in Germany in general. Ways of dealing with this challenge for the mental health care system and options for clinical management will be presented.Disclosure of interestThe author has not supplied his declaration of competing interest.

Exploring the benefits of intersectional feminist social justice approaches in art psychotherapy

This paper charts a research and knowledge exchange project between a university and group of art psychotherapists who came together in a project aimed at better understanding the benefits of critical feminist social justice approaches to art psychotherapy. It outlines the impact of the partnership for art psychotherapy practice, practitioners’ continued professional development and patients’/service users’ benefit. Drawing on knowledges of critical feminisms held within the university and art psychotherapy expertise from local health services, the project evaluated the benefit of a practice enhancement activity and resource hub as consciousness raising training in intersectional feminism for developing critical feminist social justice approaches to art psychotherapy practice. The project was designed as a qualitative participatory study. The four main salient themes emerging from the data were that the enhancement activity and resource hub provided; patient/service user benefits, improved practitioner reflexive critical thinking; recognition from practitioners of the importance of being attentive to patient’s/service users’ situatedness; and acknowledgement by practitioners of the helpfulness of likeminded collectives for sustaining critical feminist social justice praxis. Project findings suggest that critical feminist social justice approaches are beneficial to art psychotherapy praxis and that continued engagement with current and re-emerging feminisms could continue to progressively reimagine and reshape that praxis.

The Promise and Challenge (and Reality) of Defining Therapist Expertise

This article is a commentary on Hill, Spiegel, Hoffman, Kivlighan, and Gelso’s interesting and thought-provoking article focused on defining psychotherapy expertise. I address Hill et al.’s inclusion of other criteria to evaluate expertise that counters Tracey, Wampold, Goodyear, and Lichtenberg’s conclusion that treatment outcome is the only criterion supported by the research to determine expertise. I also address Hill et al.’s discussion on the development of expertise with a focus on monitoring treatment outcome to promote therapist improvement. In sum, Hill et al. provide a way forward for psychotherapy researchers to address proposed dimensions of expertise that currently are based more on our clinical wisdom than empirical evidence and, in doing so, offer the promise of better understanding what makes an excellent psychotherapist.

Psychotherapy Expertise Should Mean Superior Outcomes and Demonstrable Improvement Over Time

How the field understands psychotherapy expertise is important. It affects how we practice and how we prepare others for practice. As in our other work, we argue that the most meaningful definition of expertise must involve steady improvement over time to achieve superior performance on some meaningful measure, which typically is client outcome. We also argue that the best means by which a therapist can achieve this is through ongoing deliberate practice. We contrast our position with not only Hill, Spiegel, Hoffman, Kivlighan, and Gelso’s preferred definition, in which they anchor expertise in therapist performance, but also with the various other possible definitions of expertise (e.g., therapist experience, therapist self-assessment of expertise) that they proffer as options.

Creating a climate for therapist improvement: A case study of an agency focused on outcomes and deliberate practice.

Recent evidence suggests that psychotherapists may not increase in effectiveness over accrued experience in naturalistic settings, even settings that provide access to patients' outcomes. The current study examined changes in psychotherapists' effectiveness within an agency making a concerted effort to improve outcomes through the use of routine outcome monitoring coupled with ongoing consultation and the planful application of feedback including the use of deliberate practice. Data were available for 7 years of implementation from 5,128 patients seen by 153 psychotherapists. Results indicate that outcomes indeed improved across time within the agency, with increases of d = 0.035 (p = .003) per year. In contrast with previous reports, psychotherapists in the current sample showed improvements within their own caseloads across time (d = 0.034, p = .042). It did not appear that the observed agency-level improvement was due to the agency simply hiring higher-performing psychotherapists or losing lower-performing psychotherapists. Implications of these findings are discussed in relation to routine outcome monitoring, expertise in psychotherapy, and quality improvement within mental health care. (PsycINFO Database Record

Do psychotherapists improve with time and experience? A longitudinal analysis of outcomes in a clinical setting.

Psychotherapy researchers have long questioned whether increased therapist experience is linked to improved outcomes. Despite numerous cross-sectional studies examining this question, no large-scale longitudinal study has assessed within-therapist changes in outcomes over time. The present study examined changes in psychotherapists' outcomes over time using a large, longitudinal, naturalistic psychotherapy data set. The sample included 6,591 patients seen in individual psychotherapy by 170 therapists who had on average 4.73 years of data in the data set (range = 0.44 to 17.93 years). Patient-level outcomes were examined using the Outcome Questionnaire-45 and a standardized metric of change (prepost d). Two-level multilevel models (patients nested within therapist) were used to examine the relationship between therapist experience and patient prepost d and early termination. Experience was examined both as chronological time and cumulative patients seen. Therapists achieved outcomes comparable with benchmarks from clinical trials. However, a very small but statistically significant change in outcome was detected indicating that on the whole, therapists' patient prepost d tended to diminish as experience (time or cases) increases. This small reduction remained when controlling for several patient-level, caseload-level, and therapist-level characteristics, as well as when excluding several types of outliers. Further, therapists were shown to vary significantly across time, with some therapists showing improvement despite the overall tendency for outcomes to decline. In contrast, therapists showed lower rates of early termination as experience increased. Implications of these findings for the development of expertise in psychotherapy are explored. (PsycINFO Database Record