How Master Therapists Work

Effecting Change from the First through the Last Session and Beyond

Len Sperry, Jon Carlson

• Publisher: Routledge
• Year: 2013
• eBook ISBN: 9781135093532
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

How Master Therapists Work engages the reader in experiencing what really happens in therapy with master therapists: who they are, what they do, and how they bring about significant change in clients. It examines one master therapist's actual six-session therapy (also available on DVD) that transformed a client's life, resulting in changes that have been sustained for more than seven years. Session transcriptions directly involve the reader in every aspect of the therapeutic change process. This is followed by the commentary of a master therapist-psychotherapy researcher who explains how these changes were effected from a psychotherapy research perspective. Next, the master therapist who effected these changes explains what he was thinking and why he did what he did at key points in the therapy process. Then, the client shares her thoughts on this life changing therapeutic experience. This is a must have, one-of-a-kind book that will greatly enhance the therapeutic understanding and skills of both practicing therapists and therapists-in-training.

1
Effecting Change: Master Therapists in Action

In the past decade, magazine articles and New York Times best sellers like Outliers (Gladwell, 2008) and Talent Is Overrated (Colvin, 2008) have popularized research on expertise across various professions (Ericsson, Charness, Feltovich, & Hoffman, 2006; Ericsson & Lehmann, 1996). This focus on expertise is beginning to affect the profession and practice of psychotherapy. In the past few years, there is increasing interest about expertise and mastery in psychotherapy among therapists, researchers, academics, supervisors, students, and trainees. Commonly asked questions about expertise and mastery in psychotherapy abound: What is a master therapist? How do master therapists work (i.e., perform therapy)? How does one become a master therapist? This book addresses all three questions. This chapter begins the discussion of the first two questions, and Chapter 9 addresses the third question. More specifically, this chapter starts by discussing the context in which psychotherapy is currently practiced, which has sparked an interest in psychotherapy expertise and master therapists. Next, a description and a profile of master therapists are given. Then, the chapter begins the discussion of how master therapists work, continuing in subsequent chapters.

The Context of Psychotherapy Practice Today

Why is there such an interest in psychotherapy expertise and master therapists? One needs some knowledge of the context of psychotherapy practice today to more fully understand and appreciate the answer to this question. The past decade has witnessed a remarkable evolution in psychotherapy research and practice. A number of factors explain this evolution, with accountability being the most important. In the current era of accountability, the practice of psychotherapy has become increasingly focused, clinically effective, cost-effective, monitored, and evidence based. Evidence-based practice (EBP) is defined as “the integration of best research evidence with clinical expertise and patient values” (Institute of Medicine, 2001, p. 147). EBP is broader than the concept of empirically supported treatment (described below) in that it explicitly considers client values and clinical expertise (i.e., using clinical skills and past experience to rapidly identify the client’s health status, diagnosis, risks and benefits, and personal values and expectations). Presumably, then, competent and well-informed therapists would develop and maintain enhanced therapeutic alliances; use best practices information; implement treatment tailored to match client diagnoses, need, and preferences; and monitor clinical outcomes (DeLeon, 2003).

This section overviews five elements that reflect current psychotherapy theory, research, and practice, and their evolution: outcomes, treatments, therapeutic alliance, and client and therapist factors. Competency and expertise are key therapist factors.

Outcomes

Therapeutic or treatment outcomes have become the coin of the realm in psychotherapy today. While therapeutic processes remain important, the culture of accountability and the related EBP movement have made treatment outcomes the central consideration in psychotherapy practice. Outcomes refer to the effects or end points of specific interventions or therapeutic processes. Two types of outcomes can be distinguished: immediate or formative outcomes and final or posttreatment outcomes. Outcomes can be assessed in a pretreatment and post-treatment manner or in an ongoing manner (i.e., by monitoring outcomes at each session). Research points to better outcomes when therapists engage in ongoing monitoring than with pre-post assessment or no formal assessment of outcomes (Duncan, 2012; Lambert et al., 2003; Lambert & Shimokawa, 2011).

Treatment

Empirically supported treatments (ESTs) are interventions for which empirical research has provided evidence of their effectiveness. Often, these are manual-based treatments. As health care costs were spiraling upward, clinician practice patterns were portrayed as the basic cause of waste, inefficiency, and escalating costs. As a result, health care systems and managed care plans moved to standardize care and specify guidelines for the provision of that care. The expectation was that clinicians—including psychotherapists—would provide only encounter-based, as opposed to relationship-based, services and be able to demonstrate that these services were evidence based and cost-effective. This was the beginning of what has been called the EST movement in psychotherapy (Reed, McLauglin, & Newman, 2002). While there is controversy about the use of ESTs, particularly those that are manual based, there is a growing consensus that EBP treatments are useful and necessary.

Therapeutic Alliance

The therapeutic relationship remains the single most important variable in psychotherapy outcome research. An early meta-analysis by Lambert (1992) found that specific treatments or techniques accounted for no more than 15% of the variance in therapy outcomes. On the other hand, the therapy relationship and factors common to different therapies accounted for 30% of the variance in therapy outcomes. Therapeutic alliance is a type of therapeutic relationship that encompasses three factors: the therapeutic bond between client and therapist, the agreed-on goals of treatment, and an agreement about methods to achieve that goal or goals. It is described in more detail in Chapter 2. The Lambert meta-analysis and other data became a rallying cry for proponents of the therapeutic relationship against proponents of ESTs. For years, this “either-or” battle raged until an increasing acceptance emerged that both treatments and relationships are operative in treatment outcomes.

Client

However, this “both-and” understanding would soon be found to be shortsighted. Another meta-analysis of the elements accounting for psychotherapy change (Lambert & Barley, 2001) found that the largest element accounting for change (40%) was due to extratherapeutic factors, also referred to as “client resources” or “client.” While this finding was essentially the same as previously reported (Lambert, 1992), its significance had been underplayed. The client element includes several factors such as motivation and readiness for change, capacity for establishing and maintaining relationships, access to treatment, social support system, and other nondiagnostic factors. Chapter 2 describes client resources in detail.

Therapist

As useful as the Lambert research (1992) has been in understanding the elements contributing to psychotherapy outcomes, there was no direct consideration of the role of the therapist. It has long been observed that some therapists are much more effective than others (Orlinsky et al., 1999). For years, terms like “master therapist” and “supershrink” have been used to describe the expertise of such therapists. Increasingly, research demonstrates that therapist factors positively affect the client, the therapeutic alliance, and the implementation of treatment interventions, resulting in improved clinical outcomes. This and the remaining chapters of this book continue this discussion of therapist factors, also called the “therapist effect.”

There has also been a growing awareness among therapists throughout the world (Orlinsky, Botermans, & Ronnestad, 2001) that psychotherapy outcomes are influenced as much or more by the therapist providing the therapy as by the therapeutic approach. Outcomes research has likewise demonstrated the influence of therapist effects on treatment outcomes (Crits-Christoph et al., 1991; Teyber & McClure, 2000; Wampold, 2001). In commenting on the results of his meta-analysis, Wampold (2001) concluded that “the particular treatment that the therapist delivers does not affect outcomes… therapists within treatment account for a large proportion of the variance” (p. 202). In other words, it is the therapist and not the treatment that influences the amount of therapeutic change that occurs. Research also finds that master therapists are better at effecting change than are less proficient therapists (Orlinsky et al., 2001; Orlinsky & Ronnestad, 2005). In short, this interest in expertise and the emphasis on psychotherapy outcomes is reflected in the increasing number of research studies, articles, books, and workshops on master therapists. This book clearly reflects this trend.

In addition to the focus on these five factors is the role of competencies. Competency is the current zeitgeist in psychotherapy training. Competency represents a paradigm shift in psychotherapy training, and, not surprisingly, has affected and will continue to affect psychotherapy practice. Requirement standards are beginning to be replaced with competency standards, core competencies are replacing core curriculums, and competency-based licensure is on the horizon. The shift to psychotherapy competency has also become an accreditation standard in psychiatry training programs that now requires that trainees demonstrate competency in three psychotherapy approaches. Training programs in clinical psychology programs have solidly embraced competencies, and marital and family therapy and professional counseling programs are poised to follow suit. Because competencies involve knowledge, skill, and attitudinal components, competency-based education is quite different from how psychotherapy previously had been taught, learned, and evaluated.

Six core psychotherapy competencies have been described: (a) articulate a conceptual framework for psychotherapy practice, (b) develop and maintain an effective therapeutic alliance, (c) develop an integrative case conceptualization and treatment plan based on an integrative assessment, (d) implement tailored interventions, (e) monitor treatment progress and outcomes and plan for termination process, and (f) practice in a culturally sensitive and ethically sensitive manner (Sperry, 2010a, 2010b). In our experience, master therapists demonstrate high levels of these competencies.

Profile of the Master Therapist

The designation “master” refers to one who teaches or practices with a high level of expertise or proficiency. Such expertise reflects mastery in practice that involves “an encompassing, inventive, procedural kind of knowledge that can be modeled impressively for others or used as a basis for supervisory shaping of the practice of others” (Orlinsky, 1999, p. 13). The term “master therapist” is used in the psychotherapy literature to describe therapists who are considered to be “the best of the best” among fellow therapists with regard to psychotherapeutic expertise (Jennings & Skovholt, 1999). Psychotherapeutic expertise can be defined as knowing “what happens moment-by-moment during therapy sessions… precision, subtlety, and finesse in therapeutic work… ability to guide the development of other therapists” (Orlinsky et al., 1999, p. 211).

Because the study of expertise in psychotherapists is a relatively recent undertaking, there are few profiles of master therapists. Jennings and Skovholt (1999) have proposed a model of expertise for master therapists that specifically addresses three domains of knowledge—cognitive, emotional, and relational— vital to the success or failure of therapists. This model assumes that one must develop expertise in all three areas to reach the level of master therapist. Whereas other expertise models emphasize the cognitive domain, the three-domains model is one of the first therapist expertise models to highlight the role of the emotional or relational domains in the development of expertise. As such, it represents a necessary first step in identifying the characteristics of master therapists and the developmental pathways by which psychotherapists can achieve mastery.

Key Characteristics

Over the past three decades, seminal qualitative research has been undertaken to identify the characteristics and developmental journey of master therapists. Several studies were done in the United States, Canada, Korea, Singapore, and Japan (Jennings & Skovholt, 1999; Jennings, Skovholt, Goh, & Lian, 2013; Skovholt & Jennings, 2004). The initial research project identified nine key personality characteristics (cognitive, emotional, and relational) among the 10 peer-nominated master therapists studied (Jennings & Skovholt, 1999). It found that therapeutic mastery involves considerably more than accumulated experience doing therapy. Rather, mastery involves an ongoing effort in improving skills and competencies, gaining new knowledge, and remaining open to experience and others’ feedback. This study provides further support for the notion that relationship skills and therapeutic alliance form the cornerstone for therapeutic excellence. Unfortunately, the study did not compare master therapists with a sample of beginning and lesser experienced therapists.

The following 11 characteristics represent a prototype of the ideal therapist (Jennings & Skovholt, 1999; Jennings et al., 2013). “Each therapist possesses his or her own unique constellation of gifts, characteristics, and skills that need to be cultivated and leveraged in order for that individual to become the best therapist possible” (Jennings et al., p. 237). These studies suggest that master therapists possess many, if not all, of these characteristics.

Master Therapists Are Voracious Learners

Continuous professional development is a hallmark of these therapists. To say they are committed to lifelong learning is an understatement. They are enthusiastic learners who not only want to fully understand their clients but also want to know as much as they can about their craft. So, they continually read new literature in the field, are curious about the history of the field, and stay current with the newest developments, techniques, and studies.

Master Therapists Use Their Accumulated Experiences

These therapists, with a average of 29.5 years of professional experience, draw on their rich experience with similar problems These experiences seem to have increased their depth and competence as persons and psychotherapists. Like others, they have experienced personal and family problems and professional doubts. Unlike some, these therapists have learned to resolve them. Furthermore, they are not afraid to acknowledge these personal experiences and draw from them to better understand and assist their clients.

Master Therapists Value Cognitive Complexity and Ambiguity

These therapists do not simply tolerate complexity and ambiguity; they seek it. They understand that not everything in the human realm follows linear thinking and logic. Rather, they can understand and appreciate the complexity and ambiguity of subjective emotional experiences. From this deep and broadened understanding, they are able to more effectively help their clients. Cognitive complexity is described in detail later in this chapter.

Master Therapists Have Emotional Receptivity

These therapists are emotionally open, self-aware, reflective, nondefensive and seek feedback. This openness includes the capacity to accept any feelings that the client brings up, as well as the capacity to recognize and share the...

Table of contents

• Cover
• Title
• Copyright
• Dedication
• CONTENTS
• Foreword
• Preface
• 1 Effecting Change: Master Therapists in Action
• 2 Effecting Change: The First Session
• 3 Effecting Change: The Second Session
• 4 Effecting Change: The Centrality of the Case Conceptualizations
• 5 Effecting Change: Incorporating Second Order Change
• 6 Effecting Change: Incorporating First Order Change
• 7 Effecting Change: Incorporating Third Order Change
• 8 Effecting Change: Monitoring, Evaluation, and Termination
• 9 Effecting Change: Becoming a Master Therapist
• Bibliography
• Index