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8

THE ROLE OF THERAPIST SKILLS


IN THERAPIST EFFECTIVENESS
TIMOTHY ANDERSON AND CLARA E. HILL

The English word skill is derived from Old Norse skilja, meaning, “to
separate, divide.” In this chapter, we separate or divide therapist skills into
technical, relational, conceptualization, and cultural aspects.
! Technical skills are defined by the delivery of interventions, spe-
cific strategies, and techniques.
! Relational skills refer to emotional and interpersonal commu-
nication.
! Conceptual skills refer to cognitive and organizational ability to
understand the client.
! Cultural skills are defined by the therapist’s awareness of cultural
context.
After discussing each of these skills separately, we integrate them into a con-
textual model for explaining therapist effectiveness. Our overarching goal is

http://dx.doi.org/10.1037/0000034-009
How and Why Are Some Therapists Better Than Others? Understanding Therapist Effects, L. G. Castonguay
and C. E. Hill (Eds.)
Copyright © 2017 by the American Psychological Association. All rights reserved.

139
to derive an explanation for the finding that some therapists are better (or
worse) than others.

TECHNICAL SKILLS

Technical skills are the interventions the therapist uses to help clients.
In other words, these skills refer to what the therapist does in sessions. In this
section, we describe the three levels at which techniques can be conceptual-
ized and assessed, according to Stiles, Hill, and Elliott (2015): treatment,
session, and sentence.

Techniques Conceptualized and Assessed at the Treatment Level

At the treatment level, techniques are most often thought of as the


treatment itself (e.g., psychodynamic, cognitive–behavioral). They are mea-
sured either by judgments of adherence to and competence with a particular
treatment manual or by naturalistically observing behaviors and determin-
ing the approach with which the therapist is most closely aligned.
Therapists differ in how much they adhere to manuals (Webb, DeRubeis,
& Barber, 2010), although most studies have found that this variance among
therapist adherence does not predict treatment outcomes (see also Chap-
ter 3, this volume). Furthermore, it is not clear whether therapist differences
in adherence to technical skills are due to the techniques themselves, to
individual therapist or client characteristics, or even perhaps to the pro-
cesses by which techniques unfold. It is possible that competent delivery of
techniques ultimately predicts outcomes (e.g., Barber, Crits-Christoph, &
Luborsky, 1996; Sharpless & Barber, 2009) and that therapist characteris-
tics influence how techniques are differentially expressed among therapists;
one therapist may adhere to using techniques as appropriated, whereas
another may use them with expertise or mastery. Therapists may also differ
in their identification, enthusiasm, and beliefs in the treatment approach.
For example, therapist adherence has been found to be conflated with ther-
apist allegiance effects (Hollon, 1999), and there is reason to believe that
therapist allegiance, enthusiasm, and involvement may be implicated in
client outcomes. Further complicating matters, there is evidence that treat-
ment adherence is irrelevant to outcomes when the therapeutic alliance is
high, but is relevant when the therapeutic alliance is low (Barber et al., 2006).
Although a good argument can be made for the lack of a direct relationship
between technical adherence and therapist effects, it may be that there
is an indirect effect with a mediating variable that links therapist tech-
nical adherence with outcome. For example, findings that therapists who

140 ANDERSON AND HILL


were higher in adherence were also higher in internalized hostility (Henry,
Schacht, Strupp, Butler, & Binder, 1993) suggest that other therapist vari-
ables need to be controlled to understand the relationship between technical
adherence and therapist effects.

Techniques Conceptualized and Assessed at the Session Level

At the session level, skills may involve such things as analyzing transfer-
ence or addressing cultural issues. Judges typically observe an entire research
or training session and determine how much of each skill is used.
Ackerman and Hilsenroth (2001, 2003) reviewed the literature on
in-session activities and techniques associated with good and poor therapeu-
tic alliance. Their reviews indicated that the quality of specific techniques
or technical activity matters most. Sometimes the overuse of certain tech-
niques (e.g., interpretation of client resistance, therapist silence, disclosure of
personal conflicts) had deleterious effects. In contrast, several studies found
positive influences for the accuracy and appropriateness of several techniques
(e.g., reflection, exploration, other techniques designed to encourage client
expression of emotion, and transference interpretations).

Techniques Conceptualized and Assessed at the Sentence Level

At the sentence level, the therapist delivers verbal response modes


(VRMs), which include techniques such as reflections of feelings and inter-
pretations (e.g., Hill, 1978; Stiles, 1992).
Considerable controversy exists over how to best examine the effects of
specific VRMs. Stiles and Horvath (see Chapter 4) argue compellingly that
the traditional paradigm of correlating the proportion of VRMs with session
and treatment outcomes is inadequate because it does not account for therapist
responsiveness to client needs (e.g., one well-timed interpretation will have
more effect than 10 poorly timed interpretations). However, when they inves-
tigated the immediate effects of VRMS (e.g., client reactions and behaviors
in the subsequent speaking turn), Hill et al. (1988) found minimal effects.
Relationships among techniques, timing, quality, and client involvement all
seem to be important moderators of therapist techniques.
Furthermore, examining the influence of all therapist techniques seems
too global when individual techniques can have very different outcomes
depending on the context. More recent research, investigating specific well-
defined techniques (e.g., therapist self-disclosure, therapist immediacy) within
the context of specific sessions within cases using a qualitative methodology
has proven to be a more effective way of examining the influence of therapist
techniques (e.g., Hill et al., 2014; Pinto-Coelho, Hill, & Kivlighan, 2016).

THE ROLE OF THERAPIST SKILLS IN THERAPIST EFFECTIVENESS 141


Excellent examples of how skills can be investigated and linked with outcome
are provided elsewhere in this volume (see Chapters 13, 14, and 15).

RELATIONAL SKILLS

Relational skills involve the therapist’s ability to express, receive, and


interpret emotional and interpersonal exchanges with the client. These skills
focus on how the therapist interacts with the client and responds to the cli-
ent’s needs (see Chapter 4). Relational skills have been defined as using inter-
nal experiences to process interpersonal information, including emotional
and personality characteristics of others (Ackerman & Hilsenroth, 2003;
Anderson & Strupp, 2015).
Therapist inner experiences of empathy, positive regard (warmth),
and genuineness have been found to be strong predictors of therapy out-
come (Elliott, Bohart, Watson, & Greenberg, 2011; Farber & Doolin, 2011;
Kolden, Klein, Wang, & Austin, 2011). Some research has even shown a
causal influence for empathy on outcome (e.g., Burns & Nolen-Hoeksema,
1992). Empathy, positive regard, and genuineness variables have theoretical
roots in Rogers (1957), who considered them to be necessary and sufficient
conditions, although later research found them to be necessary but not suffi-
cient in terms of client outcomes (Elliott et al., 2011; Farber & Doolin, 2011).
Part of what defines empathy (and also positive regard and genuineness) as
relational is that it involves the therapist feeling the empathy and then com-
municating the empathy, and the client perceiving the empathy (Barrett-
Lennard, 1962, 1981).
Although relational skills are usually assessed at the session level, these
skills can also be conceptualized as occurring in the therapist’s momentary
reactions and internal processes. Benjamin’s (1979) Structural Analysis of
Social Behavior, where each therapist’s unit of speech is rated within circular
interpersonal space (e.g., friendliness, agency, focus), is one example of how
a therapist’s momentary reactions to a client can be empirically judged. For
example, the presence of subtle expressions of interpersonal hostility using
Structural Analysis of Social Behavior was associated with communication
patterns in which therapists were “telling” versus “listening” to their clients
(Anderson, Knobloch-Fedders, Stiles, Ordoñez, & Heckman, 2012).

CONCEPTUALIZATION SKILLS

Conceptualization skills involve cognitive processes whereby the


therapist uses an organizing scheme (i.e., theory) to understand the client’s
problems or dynamics (Eells, 2010; see also Chapter 11, this volume). As a

142 ANDERSON AND HILL


profession, therapists believe that good theory explains the client’s suffering
as well as suggests appropriate therapeutic actions in the form of techniques
and/or relational engagement.
Mostly, we think of conceptualization skills as occurring at the treatment
level. For example, an entire case tends to be understood using a cognitive–
behavioral, humanistic, or psychodynamic approach. But we can also think of
conceptualization at a session level in that therapists develop general strate-
gies of intervention for how to approach sessions (Goldfried, 1980), and at a
sentence level in that therapists develop intentions for how to intervene in
specific instances (Fuller & Hill, 1985). We suggest that the following concep-
tualization skills are important at the session/sentence level: (a) awareness of
what the client is experiencing and needs in the moment, (b) awareness of the
therapist’s own experience (e.g., feelings, thoughts), and (c) awareness of goals
for the next intervention within the context of goals and for treatment more
globally. Therefore, case conceptualization is not only an overall understand-
ing of the client’s dynamics but also a moment-to-moment skill.
It should be noted that, other than formal intake or assessment reports,
it is not easy to observe conceptualization skills because they mostly occur
within the therapist’s head (see Chapter 11). Attention to the therapist’s
more momentary mentation of the client, however, may facilitate under-
standing about how theoretical thinking can be integrated with in-session
therapeutic processes. It is important to note that conceptual skills are not
traits or something that a therapist possesses in the abstract, but rather they
are situational expressions. A therapist might generally be able to concep-
tualize cases, but she or he might have difficulty with a particular case in a
particular moment because clients are complex or because the therapist’s own
personal issues get triggered.

CULTURAL SKILLS

The therapist’s cultural skills involve an understanding of research about


cultural identity and how mental disorders might be differentially expressed
cross-culturally. Use of cultural skills is related to conceptualization skills in
that heightened awareness is involved. However, cultural skills involve an
awareness of the cultural context for both the client and the therapist.
Frank and Frank’s (1993) contextual model of psychotherapy was
groundbreaking by describing how psychological practices vary across cul-
tures. In addition to techniques, the therapeutic relationship, and theory,
Frank and Frank focused on the healing power of the setting as one of four
common factors. Not only is the setting a recognition of a protected space,
but it was specifically emphasized as the cultural influences of this distinctive

THE ROLE OF THERAPIST SKILLS IN THERAPIST EFFECTIVENESS 143


use of space, “Both secular and religious healing sites are distinguished from
the rest of the patients’ surroundings by special attributes, including sharply
delineated spatial and temporal boundaries” (Frank & Frank, 1993, p. 41).
Although cross-cultural differences exist in the setting of those designated to
provide therapy or religious healing, the meanings attributed to these socially
sanctioned spaces lend psychological power to the therapist’s role as a healer.
Whereas the setting may provide healing power to the roles of therapist
and client, it does not speak to the rich history of cultural identities that
each participant brings when entering a healing setting. Sue, Arredondo, and
McDavis (1992) suggested that therapists take a multicultural perspective by
becoming adept in cultural competencies needed to practice in a complex,
diversified society: “Although all of us are racial, ethnic, and cultural beings,
belonging to a particular group does not endow a person with the competen-
cies and skills necessary to be a cultural skilled counselor” (p. 478).
Ivey, D’Andrea, Ivey, and Simek-Morgan (2002) described the aware-
ness of the client’s and the therapist’s cultural contexts in multicultural coun-
seling as more of a “meta-theory” than the conventional use of theory in
psychological treatments. However, we believe that it is important not to
relegate cultural skills as another layer of abstraction to the treatment level.
Cultural skill involves the therapist’s well-attuned awareness of his or her
own cultural identity and that of his or her client, as well as how these iden-
tities are (or are not) dynamically intertwined within the cultural context.
Ideally, cultural skills at the treatment level also influence the session and
sentence levels. However, it is one thing to have attained awareness and cross-
cultural experiences about cultures, systems, and families, but it is another skill
to be able to implement this awareness as a session-relevant focus or within
a momentary interaction. For example, when conducting emotion-focused
therapy, cultural skill involves having not only the awareness of how different
cultures process emotional experience but also a practical and even visceral
experience of how culture might influence emotional schemes and problem-
solving. Given that many Asian cultures rely on subtle forms of emotional
expression, therapists might explore these modes of expression within the ses-
sion before assuming that more evocative exploration of client emotions is
warranted. Furthermore, when cultural differences exist, they are likely to be
complex, and there is danger in oversimplification. For example, although
emotional expression may be subtler within some Asian cultures (relative to
many Western cultures), there also tends to be a greater emphasis on internal
experiencing in which identifying separate entities of experience (e.g., cogni-
tions) might be more unfamiliar (relative to Western cultures; Tseng, Chang,
& Nishozono, 2005). The discussion and use of discrete and separate aspects of
a client’s experience within a “clinical” context might have marked implica-
tions for cultural adaptation of many Western psychotherapies.

144 ANDERSON AND HILL


Similarly, cultural skill involves an ability to understand that men and
women may have different modes of understanding that may link to the
therapist’s (and client’s) cultural identity and personhood (e.g., Belenky,
Clinchy, Goldberger, & Tarule, 1997). For example, a culturally skilled older
male therapist would understand that a younger female client might remain
silent because of the interpersonal power dynamic. This female client may
not believe that her subjective knowledge will be acknowledged as valid and
legitimate, especially if the male therapist emphasizes objectivity and ratio-
nality within the treatment. Therefore, a culturally aware therapist remains
attuned to how a client expresses self-knowledge in unique and gendered ways.
More recently, greater attention has been given to how therapist cultural
skills are expressed at a sentence/momentary level. Sue et al. (2007) intro-
duced the notion of microaggressions, in which subtle expressions of inter-
personal hostility are expressed that involve an individual’s cultural identity.
Microaggressions can have a profound and long-lasting effect on the client. As
Owen et al. (2014) demonstrated, the amount of microaggressions in therapy
is negatively associated with the alliance, and the failure to address microag-
gressions is associated with an even lower alliance.
Hayes, Owen, and Nissen-Lie (Chapter 9, this volume) effectively point
out the perils for “therapists who become ‘culturally encapsulated,’ defin-
ing reality according to one set of cultural assumptions, acting insensitively
toward cultural variations, and judging others from their own self-referent
criteria” (p. 165). Hence, failure to gain cultural competency can wreak
havoc across a therapist’s set of technical, relational, and conceptual skills.
It is easy to imagine how the unaddressed microaggression would contribute
to an alliance rupture.

A CONTEXTUAL MODEL FOR INTEGRATING THE SKILLS

Prior attempts to isolate effective therapist skills have yielded dis-


appointing results or have been limited in generalizability across therapists
and therapies (Wampold & Imel, 2015). The most effective therapist skills
are likely to be identified by taking a broader approach that integrates across
the four skills that have been identified in this chapter (technical, relational,
conceptualization, and cultural).

The Contextual Model

Anderson, Lunnen, and Ogles’s (2010) contextual model integrated


several similar models and processes, including Frank and Frank’s (1993)
original contextual model of psychotherapy, Orlinsky and Howard’s (1986)

THE ROLE OF THERAPIST SKILLS IN THERAPIST EFFECTIVENESS 145


sequentially arranged generic model of psychotherapy, Goldfried’s (1980)
psychotherapy principles, and Castonguay and Beutler’s (2006) empirically
supported principles of change. Anderson et al. clarified the use of the treat-
ment setting as a common factor that extends beyond the therapist’s office
to include broader cultural influences such as the client’s and the therapist’s
cultural identity.
Our visual representation of this model is presented in Figure 8.1. The
four common factors are in the boxes on the outer perimeter of the figure.
However, the factors have been replaced by the skills reviewed in this chap-
ter. Examples of more specific therapist skills are provided within the circles
of the figures. This figure illustrates that skills are interrelated. The linking of
these skills can be thought of as integrative skills, or skill sets, analogous to
Goldfried’s (1980) principles of change. In fact, it would be rationally consis-
tent to assume that consistently integrated skill sets would be effective in the
same way that empirically supported techniques and relationship factors have

Cultural
skills
Level of Abstraction (Specific vs. Broad)

e.g., Cultural e.g., Cultural


awareness competency

Conceptual e.g., Case e.g., Empathy Relational


skills formulation and warmth skills

e.g., Behavioral e.g., Immediacy


exposure

Technical
skills

Figure 8.1. An integrated contextual model of therapist skill. Each of the boxes rep-
resents one of the four skill sets described in this chapter. Circles provide examples
of skills (many other examples are possible). Arrows illustrate that the optimal use
of any specific skill involves integration with skills from other skill sets.

146 ANDERSON AND HILL


been linked (Castonguay & Beutler, 2006). Using behavioral exposure in
anxiety provides an example of this point. As seen in Figure 8.1, behavioral
exposure can be implemented within a fairly narrow and somewhat mechani-
cal manner, but the same behavioral intervention can be integrated with
other common skills as a part of a sophisticated and broad set of skills. The
technical skill of behavioral exposure can be linked to the therapist’s con-
sistent overarching cultural beliefs, psychological theory (behavior change
induces psychological changes), and relationships (therapist immediacy with
the client, which might convey that the therapist is earnest and genuinely
believes the theory).
One value in integrating technical, relational, conceptual, and cultural
skills is that it allows for recognition of how a therapist adapts treatments to
be responsive to multiple factors. For example, it is now commonly recognized
that competent practice involves deviations from treatment manuals because
of the emergence of various “real life” events and that a therapist makes cul-
tural adaptations to treatments as needed (Wampold & Imel, 2015; Whaley
& Davis, 2007). It is sometimes easy for a therapist to fall into focusing on
just one of these factors (e.g., implementing techniques) and lose sight of
the fact that a client and his or her problems are experientially multifaceted.
It is also sometimes easy for a therapist to become absorbed in maintaining
a warm relationship, lost in theoretical abstractions, or focused on cultural
contributions without considering how all of these factors can be integrated.
Coming from a slightly different model, Hill (2014) described how some
of these components work together. She suggested that at any given moment
in the therapy session, a therapist must have a conceptual awareness of the
client dynamics, including some treatment-level knowledge of the client
history, attachment style, psychodynamics, and culture, as well as an under-
standing of the therapeutic relationship (the dynamics between client and
therapist). The therapist also needs to have a very specific sense of what the
client is thinking and feeling in the current moment. In addition, the thera-
pist needs to be aware of his or her own issues and reactions in the moment,
and how these reactions might help or hinder the therapeutic work. Because
of the therapist’s conceptualization of the client, awareness of the client’s
dynamics, sense of what the client is thinking and feeling at the moment,
and awareness of own motives, the therapist formulates intentions for what
she or he wants to accomplish in the next intervention. These intentions
are determined by the therapist’s theoretical orientation, and might include
such things as wanting the client to explore, to gain insight, or to act in some
way. The therapist then selects an intervention that seems likely to accomplish
the goals for the client in the moment. With empathy, respect, and genu-
ineness, the therapist delivers the intervention and carefully observes how
the client responds, modifying subsequent responses accordingly. Obviously,

THE ROLE OF THERAPIST SKILLS IN THERAPIST EFFECTIVENESS 147


the therapist must have these skills in his or her repertoire, and it is hoped
that these skills were acquired after practicing them extensively until they
were simply part of his or her being and could be called forth when needed.
Typically, several skills can be used to accomplish the same goals depending
on how they are implemented, whereas other skills might be very unlikely to
accomplish the goals.

Case Example1

The following clinical example illustrates how the integration of these


four contextual skill sets likely contributes to therapist effects. Alice, a 62-year-
old office worker, had a successful treatment outcome after 25 sessions of psy-
chotherapy. Her therapist, Dr. A, was a highly regarded therapist with extensive
clinical experience; she had demonstrated positive outcomes in a small sample
of previous cases. Alice presented with depression and complicated grief,
which included loss of appetite, sleep, and a persistent gloomy outlook. Dr. A’s
early interventions were exploratory reflections and restatements that
focused on Alice’s continued despair about the death of her husband 2 years
before the beginning of therapy. In addition, Dr. A’s use of technical skills
involved cognitive restructuring around Alice’s beliefs that she could not
recover from her loss because she perceived herself as empty and worthless
without the presence of her husband. Dr. A’s early use of cognitive interven-
tions quickly became integrated with a conceptualization of Alice on the
basis of interpersonal and psychodynamic theory. Dr. A’s cultural skills were
apparent as she carefully asked Alice about her family of origin. They were
ardent members of a fundamentalist Christian religion and believed in strict
discipline and corporal punishment enforced by a demanding father, whom
Alice described as mean-spirited. Dr. A connected Alice’s cognitive beliefs
about low self-regard to Alice’s perception of not being valued as a woman
within this fundamentalist culture. Alice was already aware of her negative
feelings around fundamentalism and her family, given that as a teenager she
had bolted from her family after meeting her husband, a man of a markedly
different faith whom she viewed as her “savior.” Her family and religious com-
munity severed social ties with her for having married a perceived infidel to
her faith, so she was adrift.
As therapy progressed, Dr. A increasingly communicated to Alice that
her beliefs about her lack of value were linked to cultural origins. Alice’s
dominating and cruel father came to represent what she had escaped from,

1
Client identifiers have been disguised to protect patient confidentiality.

148 ANDERSON AND HILL


interpersonally and culturally. As a dynamic conceptualization, these early
experiences were less easy to leave behind. Alice presented in a highly con-
trolled and emotionally constricted manner; however, she became tearful as
Dr. A increasingly focused on her self-hatred, which then developed into
attention toward her anger at her father and all that this larger fundamental-
ist culture had meant to her, including a devalued identity as a woman. For
example, Dr. A had noticed that Alice had been nervously swinging her leg
when describing the dominance and discipline of her father, which included
how Alice believed that he ultimately despised his daughters because they
were a burden on him. At one point, Dr. A interrupted Alice in mid-sentence
and disclosed that she had noticed Alice’s foot “kicking” and that Dr. A had a
fantasy that it was Alice’s father’s kicking, but really, Alice had been kicking
herself throughout her life. The kicking foot became an emotionally infused
metaphor for future sessions, and Alice frequently commented on how much
she felt that Dr. A understood her as a person.
The relationship was highly positive as these technical, conceptual, and
cultural elements appeared to merge. For example, a discussion about Dr. A’s
and Alice’s clothing, which started as a seemingly simple woman-to-woman
aside about fashion, led to a series of rich, transference-based interventions
about the socioeconomic and class differences between them. Dr. A was per-
sistent in asking about the differences, which Alice initially attributed merely
to financial differences. Dr. A persisted and asked what Alice thought Dr. A
had thought about her, because she had noticed Alice withdrawing during the
initial discussion about the cost of their apparel (which had been brought up
by Alice). Alice became more forthcoming, however, as Dr. A continued to
ask her how she (Dr A) would be able to know if Alice had negative feelings
toward her. Dr. A was particularly attentive to Alice’s silence about vocalizing
her experiences that involved such differences, especially those that might
evoke judgments. The cultural attentiveness of Dr. A was integrated within a
conceptual framework; her technical interventions (this time for transference
exploration) were grounded within a highly positive, emotionally charged
therapeutic relationship. Her skill sets of technical, relational, conceptual,
and cultural skills were seamlessly integrated.

Implications of the Contextual Model

We propose that the use of any one of the therapy skills discussed here
will be more effective when consistently combined with the other three ther-
apy skills. Using the example of the therapist who implements behavioral
exposure to treat social anxiety, it is important that this technical skill be
integrated with relational, conceptual, and cultural skills. In other words, to
be effective, this therapist must responsively apply behavioral exposure in

THE ROLE OF THERAPIST SKILLS IN THERAPIST EFFECTIVENESS 149


an interpersonally warm manner, on the basis of a good conceptualization
of the client, which is integrated into an understanding of the client’s cul-
tural identity and background. A therapist may unwittingly express a lack of
understanding of the client’s distress when using behavioral exposure in the
context of a weak therapeutic bond, when the client has other more press-
ing problems than social anxiety, or when the client does not understand
the rationale for the behavioral exposure because it conflicts with his or her
cultural beliefs.
A second implication is that the contextual integration of skills has
additive benefits that extend beyond the skills themselves. Similar to the
notion that the gestalt is greater than the sum of its parts, it could also be said
that contextual skills are greater than the sum of the four skills. Therefore,
the use of any skill is strengthened when combined with other contextual
skills in a competent manner.
Third, therapists who are attuned to the full context of skills might
be more likely to have their skill set extend into a more advanced and
personalized development of novel nuanced skills, leading to the attain-
ment of therapeutic mastery. It has been said that therapists often begin
practice by following skills from a particular theory, but by the time they
attain expertise, the expression of theory is personalized and automatic and
becomes indistinguishable from the person of the therapist (Hill, 2014).
Recent research on expertise and mastery has addressed how masters of a
discipline can appear to have natural talents of intuition (see Chapter 11,
this volume); however, what may not be apparent to the casual observer is
that this effortless talent may be the effects of considerable practice of more
basic skills (Gladwell, 2007).
Using a lifetime of decision-making research, Kahneman (2011) described
how many master firefighters, for example, can skillfully identify dangerous
zones within a building through what might, at first glance, appear to be natu-
ral and intuitive talent. However, as Kahneman described, these abilities may
be best characterized as complex sets of skills, developed through extensive
practice of more primordial skills, which serve as building blocks for more
complex and advanced skill sets. Similarly, master therapists have a capacity
for intuitive understanding of others (“mind reading”), which may appear to
the casual observer as something of a natural, inborn talent (see also Hill,
Spiegel, Hoffman, Kivlighan, & Gelso, in press).
Future research may facilitate our understanding of how therapists
develop these advanced skills. Psychotherapy may benefit from recent obser-
vations in other fields of sociology about how advanced skills develop, or
what Coyle (2009) referred to as “talent hotbeds.” Models for identifying
broader skill sets are needed so that we can begin to understand how basic
skill sets develop into more advanced expertise (Kahneman, 2011).

150 ANDERSON AND HILL


THE CONTEXTUAL MODEL AND THERAPIST EFFECTS

How might a more contextual approach to skills advance the effort to


identify the source of therapist effects? Both authors of this chapter have
conducted studies of therapist skills that, although different, shared an inte-
grative theme.

Hill’s Research on Helping Skills

Hill’s (2014) helping skills model serves as a good example for under-
standing how specifically defined interventions can be conceived narrowly
(as specific techniques that can be operationalized at the sentence level) and
applied broadly at session and treatment levels. Helping skills integrate these
operationalized techniques by organizing them within sequenced sets via which
many treatments are commonly organized: (a) exploratory skills (e.g., reflec-
tions), (b) insight skills (e.g., interpretations), and (c) action skills (e.g., giving
homework). Helping skills have clear definitions, but are not taught in a cook-
book approach or with an orthodoxy about which skills must always be used.
Skills are specifically taught within the context that they must be implemented
with empathy, compassion, self-awareness, and cultural awareness.
Furthermore, part of what makes helping skills useful within the contex-
tual model is that the skills can be combined in nearly unlimited combinations
and can be practically implemented within a wide variety of contexts. For
example, it is recognized that not all clients respond to empathy in the same
way, and, furthermore, clients have different needs (e.g., some like to focus
on feelings, others do not). This flexibility provides the building blocks for
therapists to gain expertise by flexibly combining helping skills in the inte-
grative manner that we have recommended in this chapter. As Ridley, Kelly,
and Mollen (2011) stated, Hill’s (2014) helping skills model, relative to other
models, has the most comprehensive coverage of skills, culture, theory, rela-
tionship of skills to therapeutic change, and integration of skills.
Research has shown that helping skills can be effectively taught (Hill
& Kellems, 2002; Hill et al., 2008; Hill, Spangler, Jackson, & Chui, 2014).
Use of helping skills not only increased after helping skills training, but were
judged as being associated with higher posttraining ratings of the therapeutic
relationship, and higher evaluations of the session quality (Hill et al., 2008).
Hill, Sullivan, Knox, and Schlosser (2007) found that as a result of train-
ing, master’s level trainees were better able to use exploration and insight
skills, felt better about themselves as therapists, were less anxious, had more
self-efficacy, were more comfortable in the role of therapist, were less self-
critical, and felt themselves better able to connect with clients. Furthermore,
self-efficacy ratings in application of helping skills progressively increased

THE ROLE OF THERAPIST SKILLS IN THERAPIST EFFECTIVENESS 151


throughout training until completion (Hill et al., 2008). Hill et al. (2015)
recently reported that advanced doctoral students continued learning and
applying the more advanced skills as a result of increased practice and
experience.

Anderson’s Research on Facilitative Interpersonal Skills

Another research program that is compatible with a contextual model is


Anderson’s research on facilitative interpersonal skills (FIS; Anderson, Ogles,
Patterson, Lambert, & Vermeersch, 2009). FIS is based on a broader defini-
tion of skills and is grounded by assessing therapist responses to a standard
set of realistic therapy situations. Observational ratings of responses are built
from therapist relational abilities, inferred from therapy processes that have
been strongly linked to outcome (e.g., empathy, alliance, warmth/positive
regard) and items inspired by Frank and Frank’s (1993) contextual model
(e.g., persuasiveness, hope). On the basis of these contextual items, raters are
encouraged to not weigh assumptions about technical models and assump-
tions, and to consider psychological healing principles that may appear
unorthodox. For example, it is possible that therapists can have successful
outcomes but appear unorthodox and even somewhat questionable in terms
of contemporary standards of psychotherapy (Anderson & Strupp, 2015).
FIS and outcome have been evaluated in various settings using differ-
ent research designs. First, in a randomized controlled trial that categorized
“therapists” (master’s level therapists and novices) by interpersonal skills,
Anderson, Crowley, Himawan, Holmberg, and Uhlin (2016) found that
clients treated by therapists with high interpersonal skills had better out-
comes and alliances than did clients whose therapists had low interpersonal
skills. Anderson et al. (2009) assessed therapist FIS at the Brigham Young
Counseling Center, where prior analysis had identified the presence of thera-
pist effects in a large sample of clients. Using hierarchical linear modeling,
they found that therapists with higher FIS had clients who reported better
outcomes (on a symptom measure) relative to therapists with lower FIS. Most
recently, when FIS was administered to entering graduate students at Ohio
University, Anderson, McClintock, Himawan, Song, and Patterson (2016)
found that FIS predicted therapist effectiveness when trainees began seeing
clients within an in-house clinic. In contrast, FIS was not correlated with
measures of empathy and helping skills in undergraduate students prior to
or after training in helping skills (Hill et al., 2016). Although training was
effective and trait empathy was correlated with helping skills near the begin-
ning of training, FIS was not correlated with helping skills. Interestingly,
FIS predicted posttraining gains in the student’s reported self-efficacy in
providing helping skills even though none of the variables (including FIS)

152 ANDERSON AND HILL


were significant in predicting the implementation of actual helping skills.
Apparently, FIS predicted helpers who gained confidence in their helping
skills without being able to predict demonstrated learning of helping skills.

CONCLUSION

We suggest that the contextual model could be used to investigate


whether therapist skills help to explain therapist effects. We argue that skills
should have the greatest efficacy when combined and used in context.
Our research programs in helping skills and FIS provide examples of how
this model can be investigated. Specific skill sets from within these approaches
(e.g., empathy, alliance building, friendly forms of persuasiveness, insight,
building hope and positive expectations, and finally, skillful use of homework
and other action-oriented skills) seem to be effective when used appropriately
(i.e., within the context of a good relationship and with cultural awareness).
We hope that future research, using newer methods, will allow empirical
investigation of whether such integration can account for therapist effects.
Stiles et al. (2015) described how examining technical skills can be examined
within context by using qualitative and case study approaches. At the other
extreme, recent advances in statistical methodology (see Chapter 3, this vol-
ume) have been developed for analyzing large, nested data sets making it
possible to investigate which of these skills independently explains outcome
variance because of the therapist (although we must be careful because often
this research relies on quantity rather than quality of interventions).

REFERENCES

Ackerman, S. J., & Hilsenroth, M. J. (2001). A review of therapist characteristics


and techniques negatively impacting the therapist alliance. Psychotherapy: The-
ory, Research, Practice, Training, 38, 171–185. http://dx.doi.org/10.1037/0033-
3204.38.2.171
Ackerman, S. J., & Hilsenroth, M. J. (2003). A review of therapist characteristics
and techniques positively impacting the therapeutic alliance. Clinical Psychology
Review, 23, 1–33. http://dx.doi.org/10.1016/S0272-7358(02)00146-0
Anderson, T., Crowley, M. J., Himawan, L., Holmberg, J., & Uhlin, B. (2016). Ther-
apist facilitative interpersonal skills and training status: A randomized clini-
cal trial on alliance and outcome. Psychotherapy Research, 26, 511–529. http://
dx.doi.org/10.1080/10503307.2015.1049671
Anderson, T., Knobloch-Fedders, L. M., Stiles, W. B., Ordoñez, T., & Heckman,
B. D. (2012). The power of subtle interpersonal hostility in psychodynamic

THE ROLE OF THERAPIST SKILLS IN THERAPIST EFFECTIVENESS 153


psychotherapy: A speech acts analysis. Psychotherapy Research, 22, 348–362.
http://dx.doi.org/10.1080/10503307.2012.658097
Anderson, T., Lunnen, K. M., & Ogles, B. (2010). Putting models and techniques
in context. In B. Duncan, S. Miller, & B. Wampold (Eds.), The heart and soul of
change (pp. 143–166). Washington, DC: American Psychological Association.
http://dx.doi.org/10.1037/12075-005
Anderson, T., McClintock, A. S., Himawan, L., Song, X., & Patterson, C. L. (2016).
A prospective study of therapist facilitative interpersonal skills as a predictor
of treatment outcome. Journal of Consulting and Clinical Psychology, 84, 57–66.
http://dx.doi.org/10.1037/ccp0000060
Anderson, T., Ogles, B. M., Patterson, C. L., Lambert, M. J., & Vermeersch, D. A.
(2009). Therapist effects: Facilitative interpersonal skills as a predictor of
therapist success. Journal of Clinical Psychology, 65, 755–768. http://dx.doi.org/
10.1002/jclp.20583
Anderson, T., & Strupp, H. H. (2015). Training in time-limited dynamic psycho-
therapy: A systematic comparison of pre- and post-training cases treated by
one therapist. Psychotherapy Research, 25, 595–611. http://dx.doi.org/10.1080/
10503307.2014.935517
Barber, J. P., Crits-Christoph, P., & Luborsky, L. (1996). Effects of therapist adher-
ence and competence on patient outcome in brief dynamic therapy. Journal
of Consulting and Clinical Psychology, 64, 619–622. http://dx.doi.org/10.1037/
0022-006X.64.3.619
Barber, J. P., Gallop, R., Crits-Christoph, P., Frank, A., Thase, M. E., Weiss, R. D.,
& Gibbons, M. B. C. (2006). The role of therapist adherence, therapist com-
petence, and alliance in predicting outcome of individual drug counseling:
Results from the National Institute Drug Abuse Collaborative Cocaine Treat-
ment Study. Psychotherapy Research, 16, 229–240. http://dx.doi.org/10.1080/
10503300500288951
Barrett-Lennard, G. T. (1962). Dimensions of therapist response as causal factors
in therapeutic change. Psychological Monographs: General and Applied, 76(43),
1–36. http://dx.doi.org/10.1037/h0093918
Barrett-Lennard, G. T. (1981). The empathy cycle: Refinement of a nuclear con-
cept. Journal of Counseling Psychology, 28, 91–100. http://dx.doi.org/10.1037/
0022-0167.28.2.91
Belenky, M. F., Clinchy, B. M., Goldberger, N. R., & Tarule, J. M. (1997). Women’s
ways of knowing: The development of self, voice, and mind (10th ed.). New York,
NY: Basic Books.
Benjamin, L. S. (1979). Structural analysis of differentiation failure. Psychiatry: Jour-
nal for the Study of Interpersonal Processes, 42, 1–23. http://dx.doi.org/10.1080/
00332747.1979.11024003
Burns, D. D., & Nolen-Hoeksema, S. (1992). Therapeutic empathy and recovery
from depression in cognitive–behavioral therapy: A structural equation model.

154 ANDERSON AND HILL


Journal of Consulting and Clinical Psychology, 60, 441–449. http://dx.doi.org/
10.1037/0022-006X.60.3.441
Castonguay, L. G., & Beutler, L. E. (2006). Principles of therapeutic change that work.
Oxford, England: Oxford University Press.
Coyle, D. (2009). The talent code: Greatness isn’t born. It’s grown. Here’s how. New
York, NY: Bantam Books.
Eells, T. D. (2010). Handbook of psychotherapy case formulation (2nd ed.). New York,
NY: Guilford Press.
Elliott, R., Bohart, A. G., Watson, J. C., & Greenberg, L. S. (2011). Empathy. In
J. C. Norcross (Ed.), Psychotherapy relationships that work: Evidence-based respon-
siveness (2nd ed., pp. 132–152). Oxford, England: Oxford University Press.
http://dx.doi.org/10.1093/acprof:oso/9780199737208.003.0006
Farber, B. A., & Doolin, E. M. (2011). Positive regard and affirmation. In J. C. Norcross
(Ed.), Psychotherapy relationships that work: Evidence-based responsiveness (2nd ed.,
pp. 168–186). Oxford, England: Oxford University Press. http://dx.doi.org/
10.1093/acprof:oso/9780199737208.003.0008
Frank, J. D., & Frank, J. B. (1993). Persuasion and healing: A comparative study of psy-
chotherapy (3rd ed.). Baltimore, MD: Johns Hopkins University Press.
Fuller, F., & Hill, C. E. (1985). Counselor and helpee perceptions of counselor inten-
tions in relation to outcome in a single counseling session. Journal of Counseling
Psychology, 32, 329–338. http://dx.doi.org/10.1037/0022-0167.32.3.329
Gladwell, M. (2007). Blink: The power of thinking without thinking. New York, NY:
Little, Brown and Company.
Goldfried, M. R. (1980). Toward the delineation of therapeutic change prin-
ciples. American Psychologist, 35, 991–999. http://dx.doi.org/10.1037/
0003-066X.35.11.991
Henry, W. P., Schacht, T. E., Strupp, H. H., Butler, S. F., & Binder, J. L. (1993).
Effects of training in time-limited dynamic psychotherapy: Mediators of ther-
apists’ responses to training. Journal of Consulting and Clinical Psychology, 61,
441–447. http://dx.doi.org/10.1037/0022-006X.61.3.441
Hill, C. E. (1978). Development of a counselor verbal response category. Jour-
nal of Counseling Psychology, 25, 461–468. http://dx.doi.org/10.1037/0022-
0167.25.5.461
Hill, C. E. (2014). Helping skills: Facilitating exploration, insight, and action (4th ed.).
Washington, DC: American Psychological Association. http://dx.doi.org/
10.1037/14345-000
Hill, C. E., Anderson, T., Kline, K., McClintock, A. S., Cranston, S. M., McCarrick,
S. M., . . . Gregor, M. (2016). Helping skills training for undergraduate students:
Who should we select and train? The Counseling Psychologist, 44, 50–77. http://
dx.doi.org/10.1177/0011000015613142
Hill, C. E., Baumann, E., Shafran, N., Gupta, S., Morrison, A., Rojas, A. E., . . .
Gelso, C. J. (2015). Is training effective? A study of counseling psychology

THE ROLE OF THERAPIST SKILLS IN THERAPIST EFFECTIVENESS 155


doctoral trainees in a psychodynamic/interpersonal training clinic. Journal of
Counseling Psychology, 62, 184–201. http://dx.doi.org/10.1037/cou0000053
Hill, C. E., Helms, J. E., Tichenor, V., Spiegel, S. B., O’Grady, K. E., & Perry,
E. S. (1988). The effects of therapist response modes in brief psychotherapy.
Journal of Counseling Psychology, 35, 222–233. http://dx.doi.org/10.1037/
0022-0167.35.3.222
Hill, C. E., & Kellems, I. S. (2002). Development and use of the Helping Skills
Measure to assess client perceptions of the effects of training and of helping skills
in sessions. Journal of Counseling Psychology, 49, 264–272. http://dx.doi.org/
10.1037/0022-0167.49.2.264
Hill, C. E., Roffman, M., Stahl, J., Friedman, S., Hummel, A., & Wallace, C. (2008).
Helping skills training for undergraduates: Outcomes and predictors of out-
comes. Journal of Counseling Psychology, 55, 359–370. http://dx.doi.org/10.1037/
0022-0167.55.3.359
Hill, C. E., Spangler, P. T., Jackson, J., & Chui, H. (2014). Training undergraduate
students to use insight skills: Integrating results across three studies. The Coun-
seling Psychologist, 42, 800–820. http://dx.doi.org/10.1177/0011000014542602
Hill, C. E., Spiegel, S. B., Hoffman, M. A., Kivlighan, D. M., Jr., & Gelso, C. J. (in press).
Therapist expertise in psychotherapy revisited. The Counseling Psychologist.
Hill, C. E., Sullivan, C., Knox, S., & Schlosser, L. (2007). Becoming therapists:
Experiences of novice trainees in a beginning graduate class. Psychotherapy:
Theory, Research, Practice, Training, 44, 434–449. http://dx.doi.org/10.1037/
0033-3204.44.4.434
Hollon, S. D. (1999). Allegiance effects in treatment research: A commentary.
Clinical Psychology: Science and Practice, 6, 107–112. http://dx.doi.org/10.1093/
clipsy.6.1.107
Ivey, A. E., D’Andrea, M. Ivey, M. B., & Simek-Morgan, L. (2002). Theories of coun-
seling and psychotherapy: A multicultural perspective (5th ed.). Boston, MA: Allyn
and Bacon.
Kahneman, D. (2011). Thinking, fast and slow. New York: Farrar, Straus and Giroux.
Kolden, G. G., Klein, M. H., Wang, C., & Austin, S. B. (2011). Congruence/
Genuineness. In J. C. Norcross (Ed.), Psychotherapy relationships that work:
Evidence-Based Responsiveness (2nd ed., pp. 187–202). Oxford, England: Oxford
University Press.
Orlinsky, D. E., & Howard, K. I. (1986). Process and outcome in psychotherapy.
In S. L. Garfield & A. E. Bergin (Eds.), Handbook of psychotherapy and behavior
change (3rd ed., pp. 311–381). New York, NY: Wiley.
Owen, J., Tao, K. W., Imel, Z., Wampold, B. E., & Rodolfa, E. (2014). Addressing
racial and ethnic micro-aggressions in therapy. Professional Psychology: Research
and Practice, 45, 283–290. http://dx.doi.org/10.1037/a0037420
Pinto-Coelho, K., Hill, C. E., & Kivlighan, D. M. (2016). Therapist self-disclosure in
psychodynamic psychotherapy: A mixed-methods investigation. Counselling Psy-
chology Quarterly, 29, 29–52. http://dx.doi.org/10.1080/09515070.2015.1072496

156 ANDERSON AND HILL


Ridley, C. R., Kelly, S. M., & Mollen, D. (2011). Microskills training: Evolution,
reexamination, and call for reform. The Counseling Psychologist, 39, 800–824.
http://dx.doi.org/10.1177/0011000010378438
Rogers, C. R. (1957). The necessary and sufficient conditions of therapeutic personal-
ity change. Journal of Consulting Psychology, 21, 95–103. http://dx.doi.org/10.1037/
h0045357
Sharpless, B. A., & Barber, J. P. (2009). A conceptual and empirical review of the
meaning, measurement, development, and teaching of intervention competence
in clinical psychology. Clinical Psychology Review, 29, 47–56. http://dx.doi.org/
10.1016/j.cpr.2008.09.008
Stiles, W. B. (1992). Describing talk. Newbury Park, CA: Sage.
Stiles, W. B., Hill, C. E., & Elliott, R. (2015). Looking both ways. Psychotherapy
Research, 25, 282–293. http://dx.doi.org/10.1080/10503307.2014.981681
Sue, D. W., Arredondo, P., & McDavis, R. (1992). Multicultural counseling competen-
cies and standards: A call to the profession. Journal of Counseling & Development,
70, 477–486. http://dx.doi.org/10.1002/j.1556-6676.1992.tb01642.x
Sue, D. W., Capodilupo, C. M., Torino, G. C., Bucceri, J. M., Holder, A. M., Nadal,
K. L., & Esquilin, M. (2007). Racial microaggressions in everyday life: Implica-
tions for clinical practice. American Psychologist, 62, 271–286. http://dx.doi.org/
10.1037/0003-066X.62.4.271
Tseng, W., Chang, S. C., & Nishozono, M. (2005). Asian culture and psychotherapy:
Implications for East and West. Honolulu: University of Hawaii Press.
Wampold, B. E., & Imel, Z. E. (2015). The great psychotherapy debate: The evidence for
what makes psychotherapy work. New York, NY: Routledge.
Webb, C. A., DeRubeis, R. J., & Barber, J. P. (2010). Therapist adherence/competence
and treatment outcome: A meta-analytic review. Journal of Consulting and Clinical
Psychology, 78, 200–211. http://dx.doi.org/10.1037/a0018912
Whaley, A. L., & Davis, K. E. (2007). Cultural competence and evidence-based
practice in mental health services. American Psychologist, 62, 563–574.

THE ROLE OF THERAPIST SKILLS IN THERAPIST EFFECTIVENESS 157

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