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OBJECTIVE Although higher quality patient-therapist alliance and more positive patient outcome expectation (OE) consistently predict symptomatic/functional improvement in psychotherapy, most research has failed to capture the nuance in these process-outcome relations by parsing them into within-therapist (i.e., differences between patients treated by the same therapist) and between-therapist (i.e., differences between therapists' average process/outcome ratings across all patients in their caseloads) components. Moreover, the few studies that have done so have produced mixed results, suggesting the possibility of systematic variability in these associations (i.e., moderators). One potential source of such variability could be providers themselves; that is, different therapists could use these processes to differing therapeutic benefit. This study tested the alliance- and OE-outcome associations at both the within- and between-therapist levels and explored therapist-level moderators of them. METHOD Data derived from 212 adult outpatients treated naturalistically by 42 psychotherapists as part of a randomized trial that compared different case-assignment methods. Patients completed measures of alliance, OE, and outcome repeatedly throughout treatment. Therapist characteristics were assessed at baseline. RESULTS Multilevel structural equation models revealed that, at the between-therapist level, only higher alliance quality, but not more optimistic OE, was associated with greater caseload-level improvement. At the within-therapist level, only more optimistic OE, but not higher alliance quality, was associated with patient improvement. Finally, therapists' self-perceived alliance-fostering effectiveness and cognitive-behavioral orientation moderated the within- and between-therapist alliance-outcome associations, respectively. CONCLUSION Results indicate that different therapists use common treatment processes to differing therapeutic benefit, which can inform more personalized clinical practices and trainings. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Contains fulltext : 215261.pdf (Publisher’s version ) (Open Access) In this study, we investigated the relationship between fidelity of pivotal response treatment implementation and therapist characteristics, such as therapist personality, therapist-child relationship, therapist attitude toward evidence-based practices, and therapist experience. We also explored whether child age and autism symptom severity were related to pivotal response treatment fidelity. Participants were 41 level III certified pivotal response treatment therapists who recorded three 10-min pivotal response treatment sessions and completed four questionnaires to measure therapist characteristics. Results indicated that therapists' attitude toward evidence-based practices, specifically openness to innovation, and therapists; experience with pivotal response treatment significantly predicted fidelity of pivotal response treatment implementation. Cross-validation methods largely confirmed these findings. Therapist personality, therapist- child relationship, and child characteristics were not significantly related to pivotal response treatment fidelity. Implications for clinical practice and directions for future research are discussed. Lay abstract: Pivotal response treatment is a naturalistic behavioral intervention that teaches pivotal skills to children with autism spectrum disorder to produce widespread gains in other skills. Although most children with autism spectrum disorder benefit from pivotal response treatment, intervention outcomes vary considerably among children. Fidelity of intervention implementation (i.e. the extent to which an intervention is implemented as intended) may affect intervention outcomes. In this study, we studied the relationship between fidelity of pivotal response treatment implementation and therapist characteristics, such as therapist personality, therapist- child relationship, therapist attitude toward evidence-based practices, and therapist experience. We also explored whether a child's age and autism symptom severity were related to pivotal response treatment fidelity. Participants were 41 pivotal response treatment therapists who videotaped three pivotal response treatment sessions and completed four questionnaires to measure therapist characteristics. This study found that therapists' openness to innovation and their experience with pivotal response treatment predicted fidelity of implementation. Therapist personality, therapist-child relationship, and child characteristics were not related to pivotal response treatment fidelity. The results of this study emphasize that it is important (1) to target therapists' attitudes toward innovation prior to or during training in pivotal response treatment and (2) to provide therapists with ongoing supervision and feedback after training to increase fidelity of implementation and thus to improve intervention outcomes for children with autism spectrum disorder. 16 p.

Conventional psychotherapy approaches are currently contending with a prospective client market that is increasingly receptive to intuitive healers, tarot card readers, and extrasensory perception ...

Client engagement in substance misuse treatment programs is directly associated with positive treatment outcomes. The nature of these programs means there are often difficulties engaging and retaining clients, but authors have consistently found a strong therapeutic alliance is associated with client engagement. While research has focused on the association between the alliance and engagement, the factors that influence the therapeutic alliance have received less attention.To examine therapists' characteristics, namely therapists' stress and empathy levels, as potential predictors of client engagement and the therapeutic alliance, within an adolescent substance misuse group treatment program.The sample included 84 adolescent clients and 14 therapists from a Secure Training Centre in England. Client engagement in the treatment program was observed, while self-reporting measures assessed the therapeutic alliance (client and therapist-rated), and therapists' stress and empathy levels.Multiple regression analysis revealed that therapists' stress levels negatively influenced the therapeutic alliance and had a curvilinear relationship with client engagement, indicating that stress is not exclusively negatively related to engagement. Although stress was found to negatively impact both cognitive and affective empathy, neither cognitive nor affective empathy were significantly related to client engagement or the therapeutic alliance.This study demonstrates the importance of therapist characteristics on client engagement and the therapeutic alliance. Within practice stress can have a positive impact on clients' engagement. Nevertheless, therapists may need additional support to deal with stress effectively. Therapists' empathy may too be fundamental to client engagement, but only it if is perceived by clients.

Compared with mainstream medicine and complementary and alternative therapies, the practice of psychotherapy has enjoyed a relative pass when it comes to ethical evaluation. Therefore, contributions to the, although slowly growing, body of literature on psychotherapy ethics are to be welcomed. In his paper ‘Psychotherapy, placebos, and informed consent’, Garson Leder takes issue with what he calls the ‘go open’ project in psychotherapy ethics—the idea that the so-called ‘common factors’ in therapy should be disclosed to prospective patients. Although Leder does not give a detailed list, the common factors include therapist characteristics (empathy, positive regard, positive expectations that therapy will succeed), patient characteristics (expectations about therapy including its plausibility, confidence in the therapist), and the working alliance (how well both therapist and patient work well together during sessions). He argues that the project advocating disclosure of these factors is flawed on two grounds: (1) that information about common factors is not necessary for informed consent; and (2) clarity about specific mechanisms of change in therapy is consistent with ‘many theory-specific forms of psychotherapy’. There are multiple serious problems with Leder’s critique of the recent literature, including how he represents the contours of the debate, which I list, and address in this response.

Alliance may impact psychotherapy outcomes both as a precondition that enables therapeutic work and an evolving process that is therapeutic in itself. This study examined the participation of the elaboration of countertransference experience (ECE) in alliance variation between therapist-client dyads early in therapy and within dyads over time. A total of 44 session assessments nested within 12 dyads were modeled through longitudinal multilevel analyses and utilized to examine the associations between the ECE dimensions of Immersion and Reflection and alliance components across 4 time points within the first 10 sessions of psychotherapy. Results supported the importance of initial ECE to explain differences in alliance between dyads, the particular relevance of ECE with clients presenting lower levels of personality organization, and the effect of personality difficulties on alliance change. Unexpected results were found concerning the correlations between ECE and alliance and their covariation over time. In conclusion, ECE dimensions appear to be involved in alliance formation, both in initial differences between dyads and in changes over time within the same case. ECE seems particularly important with more personality-disturbed clients. Future research should disentangle therapist and client contributions and examine the participation of ECE in the resolution of alliance ruptures. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

This study examined the professional development of psychotherapy trainees over three years of training. The first objective was to investigate the long-term change of work involvement (Healing and Stressful Involvement) during psychotherapy training. The second objective was to investigate possible predictors of professional development from the areas of training context as well as professional and personal attributes of trainees. A total of 184 psychotherapy trainees with psychodynamic, psychoanalytic and cognitive behavioral orientation participated in the study. The development of work involvement was assessed over three years of training using the Work Involvement Scales. The set of possible predictors for work involvement included training context variables (training orientation, supervision), professional attributes of trainees (theoretical breadth, work satisfaction), and personal attributes of trainees (introject affiliation, attachment strategies, personality traits). Hierarchical Linear Modeling was conducted to investigate the change over time and the individual predictors of work involvement. Over three years of training Healing Involvement improved whereas Stressful Involvement did not change over time. Healing Involvement was mostly predicted by training context variables and professional attributes (therapeutic orientation, job satisfaction) as well as extraversion. Stressful Involvement was only predicted by personal attributes of trainees (age, neuroticism, conscientiousness, introject affiliation). The results imply two distinct sets of predictors for Healing and Stressful Involvement that will be discussed with regard to their implications for psychotherapy training and trainee selection.

Accurate alliance rupture detection is a prerequisite to any successful repair process. Despite its importance, however, rupture detection remains a struggle for most therapists. Supporting the existence of a therapist effect on therapy outcomes, rupture detection skills may rely on certain therapists’ personal characteristics. The aim of this study was to verify whether alliance rupture detection performance is related to therapists’ personal characteristics. One hundred and eight undergraduates, trainees and mental health professionals participated in an experimental task assessing their alliance rupture detection ability. Participants also completed attachment, empathy and countertransference management self-reported measures. Participants with clinical experience (trainees and professionals) reported more alliance ruptures, accurate or not, than those with no clinical experience (undergraduates). Trainees reported more accurate ruptures and less inaccurate ones than the two other groups. Attachment anxiety was positively associated with accurate ruptures detection for undergraduates, while this association proved negative for trainees and therapists. Perspective-taking, a cognitive dimension of empathy, was negatively associated with accurate rupture detection, whereas personal distress, an affective dimension of empathy, was negatively associated with accurate ruptures detection for trainees, and positively associated for undergraduates. Self-insight, a component of countertransference management, revealed a negative association with accurate rupture detection for trainees. These findings suggest that therapists vary as to their rupture detection ability and that this ability is related to certain personal characteristics. They also highlight the importance of specific training and clinical supervision for both trainees and experienced therapists in order to improve their detection ability.

Laypeople and psychotherapists alike tend to assume that psychotherapists are more effective than the average population in regulating negative emotions. Being receptive to patients’ distress and being able to downregulate negative emotions are important skills for psychotherapists to provide effective help and sustain their own well-being. We investigated whether psychotherapists react to negative material differently and downregulate emotions more effectively than individuals working in other, nontherapeutic, professions. Practicing psychotherapists (n = 21) and a control group of nontherapists (n = 18) were exposed to pictures designed to elicit negative emotions in varying intensities and were asked to rate their emotional response, first after viewing them naturally and then after choosing and applying one of two given regulation strategies (i.e., distraction and reappraisal). Both groups responded similarly in terms of emotional reactivity and strategy choices, but psychotherapists were more effective than nontherapists in reducing their emotional response after applying emotion regulation strategies. We suggest that psychotherapists’ comparable emotional reactivity and more effective emotion regulation make them well prepared to provide effective help to patients and safeguard their own well-being. (PsycINFO Database Record (c) 2016 APA, all rights reserved)

Background Despite growing attention to the general therapist effects in a wide range of clinical settings, little is known about the individual, cross-situational, and therapy–nonspecific variables that impact on the differential effectiveness of clinicians. The current study is a systematic review of the evidence relating to the influence of therapist's subjective characteristics on outcomes of psychodynamic psychotherapies. Method A multistage and systematic search of articles published between 1987 and 2017 identified 30 relevant studies, which were organized into 6 areas according to the specific therapist's variable considered. Results Therapists' interpersonal functioning and skills showed the strongest evidence of a direct effect on treatment outcomes. Furthermore, there were preliminary evidence that therapists' attachment styles, their interpersonal history with caregivers, and their self-concept might affect outcomes through interaction effects with other constructs, such as technical interventions, patient's pathology, and therapeutic alliance. The high variability between studies on therapists' overall reflective or introspective abilities and personality characteristics suggested the need for more systematic research in these areas, whereas therapists' values and attitudes showed small effects on therapeutic outcome. Conclusions The present review clarifies how a deep examination of the contribution of therapists' subjective characteristics can help elucidate the complex association between relational and technical factors related to the outcome of psychodynamic treatments.

Multicultural sensitivity is important in clinical practice, yet we know little about how the physical environment projects this quality. Objects displayed in the therapy office are one possible source of multicultural expression. This study examined the display of art objects in a therapy office on judgments of the therapist’s characteristics, including openness to multiculturalism. In a 2 (cultural emphasis of art objects) 2 (number of art objects displayed) 2 (student vs. community sample) between-subjects design, 154 undergraduate participants from a small liberal arts college in the Northeast and 57 adults, most of whom were Latino residents of the surrounding community, rated a therapist based on 1 of 4 photos of a room arranged as a therapist’s office. Participants’ ratings of 43 therapist characteristics were grouped through factor analysis into 4 factors: Competence, Multiculturalism, Welcomeness, and Direct Style. In general the students gave more favorable ratings than did the community sample. The community sample was more favorable toward the therapist when more of the objects on display could be characterized as multicultural. Practice recommendations for psychologists regarding office decor and art are discussed.

Therapeutic alliance has been acknowledged as one of the catalysts for change within a therapeutic relationship. The contributions of therapists' characteristics to alliance are not often studied. From a Bowen System's Theory perspective, the therapist's level of differentiation would be highly relevant to the development of a therapeutic alliance. The hypothesis for this study was that therapists who are able to take a more differentiated stance in therapy will build a stronger therapeutic alliance. To test this hypothesis, multilevel modeling procedures were performed, using data from nine therapists and 93 couple cases collected at a large, Midwestern university. Therapist differentiation of self was found to be weakly associated with the clients' perception of therapeutic alliance across the early sessions of therapy, but not in the expected direction. Although the results were unexpected, this study provides an example of the potential of examining therapist characteristics from within one model of therapy, that can be applied across various clients and various models of therapy.

Psychotherapy research suggests that therapists contribute to the process of therapeutic change. Research into sex offender treatment has tended to focus on the content rather than the process of therapeutic change. This paper reviews the evidence for the role of therapist characteristics in relation to therapeutic change in sex offender treatment. A literature search of a number of electronic databases and additional manual searches identified a total of 15 relevant articles. Studies were carried out in different treatment contexts and with a variety of methodological approaches. A number of therapist characteristics were identified in relation to the process of therapeutic change in sex offender treatment. Due to the methodological limitations of the studies, no conclusive evidence was found for the contribution of therapist characteristics to treatment efficacy. Nevertheless, the findings may have some clinical utility in relation to improving the therapeutic effectiveness of sex offender trea...

Despite the importance of the working alliance in therapeutic outcome, little is known about the factors associated with its formation. We advance that personality similarity between client and therapist is one such factor pertinent to the working alliance. In this study, personality similarity in 32 client-therapist dyads was examined for its relations to the bond, task, and goal elements of the working alliance (Bordin, 1979, Psychotherapy: Theory, Research, and Practice, 16, 252-260) and therapeutic outcome. Personality similarity was conceptualized using Holland's (1997, Making vocational choices [3rd ed.]) congruence construct. Therapists completed the Self-Directed Search pretreatment and clients completed the Working Alliance Inventory-Short Revised and Self-Directed Search after the third session. Results indicated that (a) client-therapist personality congruence was associated with the bond, (b) bond was associated with task and goal, and (c) task and goal were associated with therapeutic outcome. Congruence was not associated with task, goal, or therapeutic outcome. Holland's theory provides a framework for adapting to clients of varying personality types. By understanding how client-therapist personalities relate to each other in therapy, client-therapist bonds may be more efficiently realized.

AIMS To explore the effects of client and therapist characteristics along with percentage of days abstinent before admission on retention and effectiveness of outpatient substance abuse treatment. DESIGN The study was implemented with naturalistic principles and prospective design. The clients (N = 327) and the therapists (N = 33) were recruited from Finnish outpatient treatment units (N = 7). Results The client's low readiness to change, the therapist's low directiveness and low empathy predicted short duration of treatment. Client's past substance use frequency was likewise a significant predictor of retention in treatment; clients with low percentage of days abstinent at baseline dropped out much more easily. The client's high anger and low percentage of days abstinent at baseline was found to predict low percentage of days abstinent at follow-up. Greater satisfaction with support from therapist was predicted by client's high readiness to change and lower substance use frequency at baseline. Conclusions Retention in treatment was predicted by both client's and therapist's characteristics, while effectiveness in outpatient substance abuse treatment was more dependent on client's characteristics and earlier substance use.

This study sought to describe a brief review of studies conducted on the therapeutic alliance, taking into consideration therapeutic process and outcomes. We seek to reflect about the need to encourage the communities who engage in and conduct research on clinical practice not only to implement surveys of empirically validated measures of therapeutic outcomes, but also make them a regular practice among all clinical mental health psychotherapists. We therefore suggest the following paradigm – the Practice Based on Evidence of Results (PBER) – as a way to improve the quality of technical and tactical interventions of psychotherapists

The focus of this study is the investiga-tion of the relation between patients’interpersonal problems, therapists’ at-tachment representations, and the de-velopment of the therapeutic allianceover time. The authors investigatedweekly alliance ratings of 281 psycho-therapy inpatients, treated by 12 psy-chotherapists. Alliance quality wasmeasured with the Inpatient ExperienceScale. Multilevel regression modelsshowed that patients’ interpersonalproblems were associated with the levelof alliance quality. Therapists’ attach-ment security was not related to alli-ance development, but higher attach-ment preoccupation of therapists wasassociated with lower levels of alliancequality. In addition, an interaction ef-fect between therapists’ degree of at-tachment preoccupation and patients’interpersonal problems explained varia-tions of the alliance development curveover time. Limitations of the study arediscussed.Keywords: therapeutic alliance, attach-ment theory, interpersonal theory, thera-pist factors

This study explored therapist characteristics associated with the development of working alliance in long-term therapies, up to 120 sessions. The quality of working alliance was rated by both patients (n = 201) and therapists (n = 61) at sessions 3, 12, 20 and every 20th successive session. Therapists' self-reported scores on the 'cold/detached' dimension of Inventory of Interpersonal Problems-64 tapping therapists' interpersonal style, such as being distanced, disconnected or indifferent, had a negative impact on the working alliance as rated both by patients and therapists. More professional training was associated with poorer quality of working alliance, as rated by patients. A trend indicated that more experienced therapists rated the alliance lower at all sessions. Therapists' report of better maternal care up to their adolescence had a positive impact on patients' rating of alliance. Clinical implications are discussed.

Not only do treatment, therapist, client, and contextual variables depend partly on each other—confounding effects supposedly assessed in randomized clinical trials (RCTs) of psychotherapy, as Krause and Lutz (2009) explained—but the independent variables depend partly on the dependent variables. Therapists and clients can use emerging information about outcome to modify their activity in therapy and so optimize outcome, a phenomenon described as appropriate responsiveness. As a result of appropriate responsiveness, not only are RCTs uninterpretable in terms of experimental effects, but also the hypothesized effects (i.e., differential effectiveness of treatments) tend to be specifically defeated, yielding frequent findings of equivalent effectiveness for theoretically and technically diverse treatments.

A number of studies have evaluated counselling interventions for people with myalgic encephalitis, but few report client perceptions in any detail. This study seeks to explore client perceptions using a qualitative methodology. A sample of 25 individuals with myalgic encephalitis were interviewed about their experiences in counselling. The interviews were transcribed and subjected to thematic analysis using grounded theory principles. The analysis showed that people with myalgic encephalitis endure significant changes to their lives, often involving great loss and trauma. After seeking help through counselling, participants had experienced a wide variety of approaches and there were positive and negative perceptions of each. Other perceptions related to therapist characteristics and the way in which interventions were carried out. Recommendations for practitioners are given.

Transition from high school to college can be particularly difficult and stressful for Chinese college students because of parent expectations.The purpose of this study was to examine therapist variables influencing Chinese college students' preferences for mental health professionals using conjoint analysis.Two hundred fifty-eight community college students in Hong Kong were asked to rate the profile of 55 mental health professionals representing a combination of therapist characteristics (i.e., gender, age, race/ethnicity, professional background, and training institutions) from the most to least preferred therapist from whom to seek psychological counselling.Results indicated that students' preference formation was based largely on professional background and training institution of the mental health professionals. Clinical psychologists and clinical social workers were preferred over educational psychologists (school psychologists), counsellors, and psychiatrists. Mental health professionals who received training from more prestigious schools were preferred over those trained at less prestigious schools.Understanding clients' preference formation for choosing mental health professionals could be the first step to gain insights for developing effective educational and outreach strategies to promote help seeking behavior and mental health service utilization among Chinese college students.

Psychotherapists aim to benefit others, especially clients. The corresponding ethical principle, beneficence, is found in the aspirational, not enforceable, section of the American Psychological Association (2002) ethics code, is central to the idea of a professional, and is a crucial component of ethical excellence. Beneficence and related controversies (e.g., varying ideas about what it means to benefit others) are described, then linked to psychotherapy's goals and outcomes (which are, in part, the ethical ends toward which therapy aims and by which it is evaluated), especially through ideas about the good life. I conclude by discussing ways in which therapists can--through careful reflection and action aimed at benefiting others--move toward ethical excellence regarding beneficence. (PsycINFO Database Record (c) 2010 APA, all rights reserved).

Therapy is usually described from the therapist's point of view. It is often portrayed as a process of interventions operating on clients to produce changes in structures and processes. Even Carl Rogers has been portrayed as a directive, interventionist therapist. Despite statements that it is clients who make therapy work there are virtually no descriptions of how clients do this. In this study 2 researchers used a vicarious empathic ethnographic method to try to enter into clients' experience of Carl Rogers through transcripts of his work with 3 clients. The goal was to explore how clients actively construed the therapy encounter and used it in terms of their own purposes. Of particular interest were 3 questions: Do different clients construe "the same" therapeutic stimulus differently? (Answer: yes.) How did the 2 vicarious clients experience Carl Rogers? (1 construed him as more empathically on-target than the other, but both construed him as significantly missing with 2 out of the 3 clients.) Was Car...

In this pilot study, concept mapping, a methodological approach combining qualitative and quantitative analytic strategies, was used to identify the therapist qualities, competencies, and skills necessary for effective play therapy outcomes as perceived by a sub-sample of 28 experienced play therapists who are members of the Association for Play Therapy (APT). The clusters associated with the therapeutic relationship and facilitative skills (e.g., empathy, warmth, and genuineness) were rated as the most essential skills to possess and also as the most difficult to develop. In contrast, the clusters associated with play therapy interventions and theories were rated as the least important skills to possess but as the easiest to acquire. The findings are discussed, with implications for therapeutic practice, research, and policy.

The present review is a comprehensive examination of the therapist's personal attributes and in-session activities that positively influence the therapeutic alliance from a broad range of psychotherapy perspectives. Therapist's personal attributes such as being flexible, honest, respectful, trustworthy, confident, warm, interested, and open were found to contribute positively to the alliance. Therapist techniques such as exploration, reflection, noting past therapy success, accurate interpretation, facilitating the expression of affect, and attending to the patient's experience were also found to contribute positively to the alliance. This review reveals how these therapist personal qualities and techniques have a positive influence on the identification or repair of ruptures in the alliance.

Background:Evidence exists for a relationship between individual characteristics and both job and training performance; however relationships may not be generalizable. Little is known about the impact of therapist characteristics on performance in postgraduate therapist training programmes.Aims:The aim of this study was to investigate associations between the grades of trainee Low-Intensity and High-Intensity cognitive behavioural therapists and individual characteristics.Method:Trainee Low-Intensity (n= 81) and High-Intensity (n= 59) therapists completed measures of personality and cognitive ability; demographic and course grade data for participants were collected.Results:Degree classification emerged as the only variable to be significantly associated with performance across assessments and courses. Higher undergraduate degree classifications were associated with superior academic and clinical performance. Agreeableness was the only dimension of personality to be associated (positively) with clinical skill. Age was weakly and negatively associated with performance.Conclusions:Relationships between individual characteristics and training outcomes are complex and may be context specific. These results could have important implications for the selection and development of therapists for Low or High-Intensity cognitive behavioural therapy (CBT) training.

This paper presents a conceptualisation of the therapeutic alliance from the adolescent perspective and discusses implications for practitioners. The main aim of the study was to focus on the factors that participants identified as important in relationship formation and maintenance. Eighteen individuals were interviewed using a semi-structured format. Three major themes were identified: therapeutic environment, uniqueness of the therapeutic relationship, and therapist characteristics. Participants identified both positive and negative aspects of the therapeutic relationship. A strong alliance was found to be necessary in that the perception of the therapist as accepting, supportive and trustworthy influenced the adolescent's evaluation of the appropriateness of therapeutic tasks and goals. Participants stressed the importance of the supportive nature of the relationship in their willingness to collaborate in therapeutic interventions.

This article reviews a body of research, empirical and speculative, describing variables thought to determine a psychotherapist's choice of theoretical orientation. The review finds two types of variables (1) the influences of training, colleagues, supervisors, initial clinical experience and (2) the effects of personality traits and epistemological values, beliefs and philosophy. The weight of evidence from the reviewed studies of cognitive behavioural/behavioural and psychodynamic psychotherapists, and an analysis of the data, suggests that personality and epistemic traits are significantly involved in orientation choice. This has implications for training, practitioner and client outcome satisfaction, and understanding the poor communication that exists between these two major orientations.

Factors that influence client outcome can be divided into four areas: extratherapeutic factors, expectancy effects, specific therapy techniques, and common factors. Common factors such as empathy, warmth, and the therapeutic relationship have been shown to correlate more highly with client outcome t

This qualitative study explores empathic listening from the vantage point of 5 female clients engaged in consecutive therapeutic relationships with two different therapists, a male and a female. Previous experiences of being “misunderstood” or “not heard” stood in stark contrast to experiences of being empathically understood in their relationships with the two therapists. Participants experienced being heard when therapists created a safe space for selfexploration, were actively and genuinely engaged in the therapeutic dialogue (paraphrasing, clarifying, questioning, and remembering details), and did not flinch when painful material was brought to the therapeutic process. Each participant’s experience of being heard was idiosyncratic and reflected something of what she had been missing in previous interpersonal encounters. Empathic listening emerges as a relational, interactional variable unique to each therapeutic encounter examined and not reducible to a technique or skill.

This study examined the occurrence of therapist recommendations and client implementation of recommendations based on client perceptions of (a) fit, (b) difficulties of implementation, and (c) therapist influence. Therapists (N = 27) volunteered to list any recommendations that occurred in a single session, and clients (N = 102) agreed to complete 2 measures of acceptability and 1 measure of implementation concerning the primary recommendation. Results indicated a high frequency of recommendations, with most sessions containing multiple recommendations. Therapists provided 8 types of recommendations; validation of internal experiences, reframing meanings, decision making, and social interactions were most frequent. Clients who returned tended to report a high level of implementation. Client perceptions of difficulties and therapist influence were predictive of client-reported implementation.

L. Jennings and T. M. Skovholt's (1999) study constitutes a useful step toward deepening scientific understanding of what therapists at their best are capable of offering to their clients. Both the study's strengths and limitations stimulate questions, which this commentary attempts to consider. These questions mainly concern the lack of a clear initial definition of master therapist, the lack of meaningful comparison groups needed to infer the distinctive characteristics of master therapists, the incomplete communication of data-analytic procedures, and the formulation of results as a uniform ideal-typical pattern that precludes recognition of individual differences. Despite this, the clinical richness of the findings is well appreciated, and the questions stimulated by the study indicate its high heuristic value.

The experiences of prepracticum trainees were explored with a combination of qualitative and quantitative methodologies. Specifically, changes in trainees' anxiety, self-efficacy, counter-transference management, and therapeutic skills were investigated over the course of a semester. Trainees', clients', and supervisors' perceptions of trainees' reactions during counseling were also examined as well as the strategies that trainees used to manage their reactions. Quantitative analyses indicated that trainees became less anxious and developed greater skills over the semester. Qualitative results suggested that trainees experienced a range of reactions during sessions, some of which interfered with their ability to provide maximally effective counseling, and that trainees most often managed their reactions by focusing on the client, using self-awareness, and suppressing their feelings.

Randomly selected samples of practicing couple therapists who were members of the American Psychological Association's Division 43 or the Association for Marriage and Family Therapy completed a survey of couple problem areas and therapeutic issues encountered in couple therapy. Therapists rated problem areas in terms of occurrence, treatment difficulty, and damaging impact. A composite of these 3 dimensions suggested that the most important problems were lack of loving feelings, power struggles, communication, extramarital affairs, and unrealistic expectations. Comparison of the findings with therapist ratings obtained by S. K. Geiss and K. D. O'Leary (1981) suggests considerable stability in presenting problems in couple therapy over the past 15 years. Therapist-generated characteristics associated with negative outcome were also identified, the most common being partners' inability or unwillingness to change and lack of commitment.

Levels of supervisory activity and confidence were investigated in relation to a number of therapist characteristics. Analyses of data from more than 1600 therapists of various professions, orientations, and career levels in several countries, two-thirds of whom were resident in Europe, showed that: (1) supervising the work of other therapists becomes a normal part of the professional development of psychotherapists as therapist experience levels increase; (2) supervisory confidence increases noticeably with the initial supervisory experiences, and thereafter increases progressively and slowly; (3) some therapists with little supervisory experience claim high levels of supervisory confidence; and (4) supervisors' confidence about guiding the development of others can not be predicted by the amount of supervision received, or by duration or type of therapist experience, but can be predicted on the basis of self-assessed therapeutic skill and, to some extent, by amount of experience as a supervisor. The results are discussed in the light of existing models of supervisor development.

Research on psychotherapy has increased in both quantity and quality over the past 30 years and has tended to focus on the evaluation of outcome. The major emphasis has been on studies comparing different forms of psychotherapy. The recent emphasis on training manuals has reinforced this pattern. On the other hand, the importance of the therapist's contribution to outcome and the related matter of therapist variability have been given inadequate attention. These issues are discussed and evaluated in the articles that follow.

Background and aims: Therapist characteristics may be associated with variation in consistency, quality and effectiveness of treatment delivery. We examined associations between treatment fidelity and therapist education, experience, treatment orientation and perceived skills in a randomized, multi-site trial of Twelve Step Facilitation (TSF). Methods: Raters scored audio-recorded, TSF sessions (n = 966; 97% of TSF sessions) from 32 community-based, trained therapists for adherence, competence, empathy and global session performance. Results: Therapists with graduate degrees had significantly higher adherence and global performance fidelity ratings. Therapists reporting more positive attitudes toward 12-Step groups had lower adherence ratings. Being in recovery was associated with lower fidelity in univariate tests, but higher adherence in multivariate analysis. Fidelity was higher for therapists reporting self-efficacy in basic counseling skills and lower for self-efficacy in addiction-specific counseling skills. Fidelity was also superior in group relative to individual TSF sessions. Conclusions: Results have implications for therapist selection, training and supervision in community-based, effectiveness trials and community implementation of evidence-based treatments. To obtain high fidelity and improve outcomes, it may be preferable to choose masters level therapists who are open to learning new treatments and have good, general counseling skills. © 2013 Informa Healthcare USA, Inc.