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.
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25 October 2017
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References
American Psychological Association. (2012). Recognition of psychotherapy effectiveness. Retrieved from http://www.apa.org/about/policy/resolution-psychotherapy.aspx.
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.
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.
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.
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.
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.
Borenstein, M., Hedges, L., Higgins, J., & Rothstein, H. (2005). Comprehensive meta-analysis: Version 2 (Version 2.2.021). Englewood, NJ: Biostat.
Borenstein, M., Hedges, L. V., Higgins, J. P. T., & Rothstein, H. R. (2009). Introduction to meta-analysis. West Sussex: Wiley.
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.
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.
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.
Cohen, J. (1992). A power primer. Psychological Bulletin, 112, 155–159. doi:10.1037/0033-2909.112.1.155.
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.
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.
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.
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.
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.
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.
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.
Henkelman, J., & Paulson, B. (2006). The client as expert: Researching hindering experiences in counselling. Counselling Psychology Quarterly, 19, 139–150. doi:10.1080/09515070600788303.
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.
Higgins, J. P. T., & Green, S. (2009). Cochrane handbook for systematic reviews of interventions version 5.0.2. Chichester: Wiley.
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.
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.
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.
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.
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.
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.
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.
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.
Lipsey, M., & Wilson, D. B. (2001). Practical meta-analysis. Thousand Oaks, CA: Sage.
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.
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.
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.
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.
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.
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.
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.
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.
Safran, J. D., Muran, J. C., & Eubanks-Carter, C. (2011). Repairing alliance rupture. Psychotherapy, 48, 80–87. doi:10.1037/a0022140.
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.
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.
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.
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.
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.
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.
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.
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.
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This study was financed by Queensland University of Technology. No external funding was involved.
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This article relies entirely on analysis of secondary data. It does not contain any studies with human participants performed by any of the authors. References marked with an asterisk indicate studies included in the meta-analysis.
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King, R.J., Orr, J.A., Poulsen, B. et al. Understanding the Therapist Contribution to Psychotherapy Outcome: A Meta-Analytic Approach. Adm Policy Ment Health 44, 664–680 (2017). https://doi.org/10.1007/s10488-016-0783-9
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DOI: https://doi.org/10.1007/s10488-016-0783-9