Understanding the Therapist Contribution to Psychotherapy Outcome: A Meta-Analytic Approach

  • Robert J. King
  • Jayne A. Orr
  • Brooke Poulsen
  • S. Giac Giacomantonio
  • Catherine Haden
Original Paper

Abstract

Understanding the role that therapists play in psychotherapy outcome, and the contribution to outcome made by individual therapist differences has implications for service delivery and training of therapists. In this study we used a novel approach to estimate the magnitude of the therapist contribution overall and the effect of individual therapist differences. We conducted a meta-analysis of studies in which participants were randomised to receive the same treatment either through self-help or through a therapist. We identified a total of 15 studies (commencement N = 910; completion N = 723) meeting inclusion criteria. We found no difference in treatment completion rate and broad equivalence of treatment outcomes for participants treated through self-help and participants treated through a therapist. Also, contrary to our expectations, we found that the variability of outcomes was broadly equivalent, suggesting that differences in efficacy of individual therapists were not sufficient to make therapy outcomes more variable when a therapist was involved. Overall, the findings suggest that self-help, with minimal therapist input, has considerable potential as a first-line intervention. The findings did not suggest that individual differences between therapists play a major role in psychotherapy outcome.

Keywords

Therapist effects Self-help psychotherapy Cognitive behavior therapy Meta-analysis 

References

  1. American Psychological Association. (2012). Recognition of psychotherapy effectiveness. Retrieved from http://www.apa.org/about/policy/resolution-psychotherapy.aspx.
  2. Andrews, G., Cuijpers, P., Craske, M. G., McEvoy, P., & Titov, N. (2010). Computer therapy for the anxiety and depressive disorders is effective, acceptable and practical health care: A meta-analysis. PLoS One, 5(10), e13196. doi:10.1371/journal.pone.0013196.CrossRefPubMedPubMedCentralGoogle Scholar
  3. Baldwin, S., & Imel, Z. (2013). Therapist effects: Findings and methods. In M. Lambert (Ed.), Bergin and Garfield’s handbook of psychotherapy and behaviour change (6th edn.). Hoboken, NJ: Wiley.Google Scholar
  4. Barak, A., Hen, L., Boniel-Nissim, M., & Shapira, N. (2008). A comprehensive review and a meta-analysis of the effectiveness of internet-based psychotherapeutic interventions. Journal of Technology in Human Services, 2, 109–160. doi:10.1080/15228830802094429.CrossRefGoogle Scholar
  5. Berger, T., Boettcher, J., & Caspar, F. (2014). Internet-based guided self-help for several anxiety disorders: A randomized controlled trial comparing a tailored with a standardized disorder-specific approach. Psychotherapy, 51, 201–219. doi:10.1037/a0032527.CrossRefGoogle Scholar
  6. Bickman, L., Kelley, S. D., Breda, C., de Andrade, A. R., & Riemer, M. (2011). Effects of routine feedback to clinicians on mental health outcomes of youths: Results of a randomized trial. Psychiatric Services, 62, 1443–1449.CrossRefGoogle Scholar
  7. Borenstein, M., Hedges, L., Higgins, J., & Rothstein, H. (2005). Comprehensive meta-analysis: Version 2 (Version 2.2.021). Englewood, NJ: Biostat.Google Scholar
  8. Borenstein, M., Hedges, L. V., Higgins, J. P. T., & Rothstein, H. R. (2009). Introduction to meta-analysis. West Sussex: Wiley.CrossRefGoogle Scholar
  9. Botella, C., Gallego, M. J., Garcia-Palacios, A., Guillen, V., Baños, R. M., Quero, S., & Alcañiz, M. (2010). An Internet-based self-help treatment for fear of public speaking: A controlled trial. Cyberpsychology, Behavior and Social Networking, 13, 407–421. doi:10.1089/cyber.2009.0224.CrossRefPubMedGoogle Scholar
  10. Carlbring, P., Nilsson-Ihrfelt, E., Waara, J., Kollenstam, C., Buhrman, M., Kaldo, V., … Andersson, G (2005). Treatment of panic disorder: Live therapy vs. self-help via the Internet. Behaviour Research and Therapy, 43, 1321–1333. doi:10.1016/j.brat.2004.10.002.CrossRefPubMedGoogle Scholar
  11. Cobham, V. E. (2012). Do anxiety-disordered children need to come into the clinic for efficacious treatment? Journal of Consulting and Clinical Psychology, 80, 465–476. doi:10.1037/a0028205.CrossRefPubMedGoogle Scholar
  12. Cohen, J. (1992). A power primer. Psychological Bulletin, 112, 155–159. doi:10.1037/0033-2909.112.1.155.CrossRefPubMedGoogle Scholar
  13. Cuijpers, P., Driessen, E., Hollon, S., van Oppen, P., Barth, J., & Andersson, G. (2012). The efficacy of non-directive supportive therapy for depression: A meta-analysis. Clinical Psychology Review, 32, 280–291. doi:10.1016/j.cpr.2012.01.003.CrossRefPubMedGoogle Scholar
  14. Duval, S., & Tweedie, R. (2000). Trim and fill: A simple funnel-plot-based method of testing and adjusting for publication bias in meta-analysis. Biometrics, 56, 455–463. doi:10.1111/j.0006-341x.2000.00455.x.CrossRefPubMedGoogle Scholar
  15. Egger, M., Smith, D. G., Schneider, M., & Minder, C. (1997). Bias in meta-analysis detected by a simple, graphical test. British Medical Journal, 315, 629–634. doi:10.1136/bmj.315.7109.629.CrossRefPubMedPubMedCentralGoogle Scholar
  16. Ehlers, A., Clark, D. M., Hackmann, A., McManus, F., Fennell, M., Herbert, C., & Mayou, R. (2003). A randomized controlled trial of Cognitive Therapy, a self-help booklet, and repeated assessments as early interventions for Posttraumatic Stress Disorder. Archives of General Psychiatry, 60, 1024–1032. doi:10.1001/archpsyc.60.10.1024.CrossRefPubMedGoogle Scholar
  17. Elliott, R. (1985). Helpful and non-helpful events in brief counseling interviews: An empirical taxonomy. Journal of Counseling Psychology, 32, 307–322. doi:10.1037/0022-0167.32.3.307.CrossRefGoogle Scholar
  18. Floyd, M., Scogin, F., McKendree-Smith, N. L., Floyd, D. L., & Rokke, P. D. (2004). Cognitive therapy for depression: A comparison of individual psychotherapy and bibliotherapy for depressed older adults. Behavior Modification, 28, 297–318. doi:10.1177/0145445503259284.CrossRefPubMedGoogle Scholar
  19. Greist, J. H., Marks, I. M., Baer, L., Kobak, K. A., Wenzel, K. W., Hirsch, M. J., … Clary, C. M. (2002). Behavior therapy for obsessive–compulsive disorder guided by a computer or by a clinician compared with relaxation as a control. Journal of Clinical Psychiatry, 63, 138–145. doi:10.4088/JCP.v63n0209.CrossRefPubMedGoogle Scholar
  20. Henkelman, J., & Paulson, B. (2006). The client as expert: Researching hindering experiences in counselling. Counselling Psychology Quarterly, 19, 139–150. doi:10.1080/09515070600788303.CrossRefGoogle Scholar
  21. Higgins, J. P. T., & Altman, D. G. (2008). Assessing risk of bias in included studies. In J. P. T. Higgins & S. Green (Eds.), Cochrane handbook for systematic reviews of interventions (pp. 187–241). Chichester: Wiley.CrossRefGoogle Scholar
  22. Higgins, J. P. T., & Green, S. (2009). Cochrane handbook for systematic reviews of interventions version 5.0.2. Chichester: Wiley.Google Scholar
  23. Hofmann, S., & Smits, J. (2008). Cognitive-Behavioral Therapy for adult anxiety disorders: A meta-analysis of randomized placebo-controlled trials. Journal of Clinical Psychiatry, 69, 621–632. doi:10.4088/jcp.v69n0415.CrossRefPubMedPubMedCentralGoogle Scholar
  24. Horvath, A., & Symonds, B. (1991). Relationship between working alliance and outcome in psychotherapy: A meta-analysis. Journal of Counseling Psychology, 38, 139–149. doi:10.1037/0022-0167.38.2.139.CrossRefGoogle Scholar
  25. Kay-Lambkin, F. J., Baker, A. L., Lewin, T. J., & Carr, V. J. (2009). Computer-based psychological treatment for comorbid depression and problematic alcohol and/or cannabis use: A randomized controlled trial of clinical efficacy. Addiction (Abingdon, England), 104, 378–388. doi:10.1111/j.1360-0443.2008.02444.x.CrossRefGoogle Scholar
  26. Kilfedder, C., Power, K., Karatzias, T., McCafferty, A., Niven, K., Chouliara, Z., … Sharp, S. (2010). A randomized trial of face-to-face counselling versus telephone counselling versus bibliotherapy for occupational stress. Psychology and Psychotherapy, 83, 223–242. doi:10.1348/147608309X476348.CrossRefPubMedGoogle Scholar
  27. Kiropoulos, L. A., Klein, B., Austin, D. W., Gilson, K., Pier, C., Mitchell, J., & Ciechomski, L. (2008). Is internet-based CBT for panic disorder and agoraphobia as effective as face-to-face CBT? Journal of Anxiety Disorders, 22, 1273–1284. doi:10.1016/j.janxdis.2008.01.008.CrossRefPubMedGoogle Scholar
  28. Lambert, M. J., Harmon, C., Slade, K., Whipple, J. L., & Hawkins, E. J. (2005). Providing feedback to psychotherapists on their patients’ progress: Clinical results and practice suggestions. Journal of Clinical Psychology, 61, 165–174.CrossRefPubMedGoogle Scholar
  29. Leong, J., Cobham, V. E., de Groot, J., & McDermott, B. (2009). Comparing different modes of delivery: A pilot evaluation of a family-focused, cognitive-behavioral intervention for anxiety-disordered children. European Child & Adolescent Psychiatry, 18, 231–239. doi:10.1007/s00787-008-0723-7.CrossRefGoogle Scholar
  30. Levitt, H., Butler, M., & Hill, T. (2006). What clients find helpful in psychotherapy: Developing principles for facilitating moment-to-moment change. Journal of Counseling Psychology, 53, 314–324. doi:10.1037/0022-0167.53.3.314.CrossRefGoogle Scholar
  31. Lipsey, M., & Wilson, D. B. (2001). Practical meta-analysis. Thousand Oaks, CA: Sage.Google Scholar
  32. Lutz, W., Leon, S., Martinovich, A., Lyons, J., & Stiles, W. (2007). Therapist effects in outpatient psychotherapy: A three-level growth curve approach. Journal of Counseling Psychology, 54, 32–39. doi:10.1037/0022-0167.54.1.32.CrossRefGoogle Scholar
  33. Lutz, W., Rubei, J., Schiefele, A.-K., Bohnke, J., & Wittman, W. (2015). Feedback and therapist effects in the context of treatment outcome and treatment length. Psychotherapy Research, 25, 647–660. doi:10.1080/10503307.2015.1053553.CrossRefPubMedGoogle Scholar
  34. Marks, I. M., Kenwright, M., McDonough, M., Whittaker, M., & Mataix-Cols, D. (2004). Saving clinicians’ time by delegating routine aspects of therapy to a computer: A randomized controlled trial in phobia/panic disorder. Psychological Medicine, 34, 9–17. doi:10.1017/S003329170300878X.CrossRefPubMedGoogle Scholar
  35. Newman, M. G., Kenardy, J., Herman, S., & Taylor, C. B. (1997). Comparison of palmtop-computer-assisted brief cognitive-behavioral treatment to cognitive-behavioral treatment for Panic Disorder. Journal of Consulting and Clinical Psychology, 65, 178–183. doi:10.1037/0022-006X.65.1.178.CrossRefPubMedGoogle Scholar
  36. Okishi, J., Lambert, M., Eggett, D., Nielsen, L., Dayton, D., & Vermeerch, D. (2006). An analysis of therapist treatment effects: Toward providing feedback to individual therapists on their clients’ psychotherapy outcome. Journal of Clinical Psychology, 62, 1157–1172. doi:10.1002/jclp.20272.CrossRefGoogle Scholar
  37. Orwin, R. G., & Vevea, J. L. (2009). Evaluating coding decisions. In H. M. Cooper, L. V. Hedges & J. C. Valentine (Eds.), The handbook of research synthesis and meta-analysis (2nd edn., pp. 177–203). New York, NY: Russell Sage Foundation.Google Scholar
  38. Paulson, B., Truscott, D., & Stuart, J. (1999). Clients’ perceptions of helpful experiences in counseling. Journal of Counseling Psychology, 46, 317–324. doi:10.1037/0022-0167.46.3.317.CrossRefGoogle Scholar
  39. Rhodes, R., Hill, C., Thompson, B., & Elliott, R. (1994). Client retrospective recall of resolved and unresolved misunderstanding events. Journal of Counseling Psychology, 41, 473–483. doi:10.1037/0022-0167.41.4.473.CrossRefGoogle Scholar
  40. Safran, J. D., Muran, J. C., & Eubanks-Carter, C. (2011). Repairing alliance rupture. Psychotherapy, 48, 80–87. doi:10.1037/a0022140.CrossRefPubMedGoogle Scholar
  41. Saxon, D., & Barkham, M. (2012). Patterns of therapist variability: Therapist effects and the contribution of patient severity and risk. Journal of Consulting and Clinical Psychology, 80, 535–546. doi:10.1037/a0028898.CrossRefPubMedGoogle Scholar
  42. Selmi, P. M., Klein, M. H., Greist, J. H., Sorrell, S. P., & Erdman, H. P. (1990). Computer-administered cognitive-behavioral therapy for depression. The American Journal of Psychiatry, 147, 51–56. doi:10.1176/ajp.147.1.51.CrossRefPubMedGoogle Scholar
  43. Shapiro, D. A., & Firth, J. (1987). Prescriptive v. exploratory psychotherapy: Outcomes of the Sheffield Psychotherapy Project. British Journal of Psychiatry, 151, 790–799. doi:10.1192/bjp.151.6.790.CrossRefPubMedGoogle Scholar
  44. Shapiro, D. A., Firth-Cozens, J., & Stiles, W. B. (1989). The question of therapists’ differential effectiveness: A Sheffield Psychotherapy Project addendum. British Journal of Psychiatry, 154, 383–385. doi:10.1192/bjp.154.3.383.CrossRefPubMedGoogle Scholar
  45. Spek, V., Cuijpers, P. I. M., Nyklícek, I., Riper, H., Keyzer, J., & Pop, V. (2007). Internet-based cognitive behaviour therapy for symptoms of depression and anxiety: A meta-analysis. Psychological Medicine, 37, 319–328. doi:10.1017/s0033291706008944.CrossRefPubMedGoogle Scholar
  46. Spence, S. H., Donovan, C. L., March, S., Gamble, A., Anderson, R. E., Prosser, S., & Kenardy, J. (2011). A randomized controlled trial of online versus clinic-based CBT for adolescent anxiety. Journal of Consulting and Clinical Psychology, 79, 629–642. doi:10.1037/a0024512.CrossRefPubMedGoogle Scholar
  47. Tolin, D. F., Hannan, S., Maltby, N., Diefenbach, G. J., Worhunsky, P., & Brady, R. E. (2007). A randomized controlled trial of self-directed versus therapist-directed Cognitive-Behavioral Therapy for Obsessive–Compulsive Disorder patients with prior medication trials. Behavior Therapy, 38, 179–191. doi:10.1016/j.beth.2006.07.001.CrossRefPubMedGoogle Scholar
  48. Walwyn, R., & Roberts, C. (2010). Therapist variation within randomised trials of psychotherapy: Implications for precision, internal and external validity. Statistical Methods in Medical Research, 19, 291–315. doi:10.1177/0962280209105017.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2016

Authors and Affiliations

  • Robert J. King
    • 1
  • Jayne A. Orr
    • 1
  • Brooke Poulsen
    • 1
  • S. Giac Giacomantonio
    • 2
  • Catherine Haden
    • 1
  1. 1.Queensland University of TechnologyBrisbaneAustralia
  2. 2.BrisbaneAustralia

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