These are the therapist behaviours that are helpful or harmful, according to clients

GettyImages-594373291.jpgBy Christian Jarrett

Although psychotherapy is effective for many people, it doesn’t help everyone. In fact, in some cases it can do more harm than good. And while clinical researchers publish many studies into the outcomes of different therapeutic approaches, such as CBT or psychoanalytic psychotherapy, we actually know relatively little about the specific therapist behaviours that clients find beneficial or unwelcome.

A new study in the Journal of Clinical Psychology, although it involves only a small sample, has broken new ground by asking clients to provide detailed feedback on a second-by-second basis of their experience of a recent therapy session, and to explain their perspective on what took place. Intriguingly, the very same therapist behaviours were sometimes identified as helpful and at other times as a hindrance, showing just what a challenge it is to be a therapist.

“It is important to recognise that all therapists are going to make mistakes,” write Joshua Swift at Idaho State University, and his colleagues. “Perhaps the success of the session does not depend on whether errors are made but on the frequency of mistakes and how quickly therapists are able to repair them.”

Swift and his colleagues recruited 16 individuals, most of them women, attending therapy sessions at a training centre for clinical psychologists. They were seeking help for various problems including depression, anxiety and a history of trauma or abuse. The clients each saw one of ten therapists at the clinic (eight were women), who between them either endorsed CBT, person-centred therapy or integrative therapy.

The researchers asked the clients to watch back a video recording of their most recent therapy session and equipped them with a dial-rating device, which they could rotate clockwise or counter-clockwise to indicate how helpful or hindering they found each stage of the session on a second-by-second basis (the researchers call this a “micro-process approach”).

There was a lot of up and down variability through a session, which the researchers said shows the limitation of client feedback approaches which involve them filling out questionnaires at the end of each session, and which therefore might miss this variability.

Using the dial ratings, the researchers identified the three most helpful and three most hindering therapy segments for each client and then asked them to explain what was happening in those moments, and then why they found each moment helpful or hindering.

The most helpful therapy moments involved specific treatment techniques, such as times the therapist gave the client a concrete strategy they could use in everyday life; instances when the therapist made connections for the client (such as identifying events that affected their depression symptoms); or helped them process their emotions. Other helpful moments involved fundamental therapist skills, such as listening and expressing empathy, offering support or praise, or when the therapist discussed the process of therapy, including what the client wants from it.

The clients said they found these moments helpful because they learned a new skill, felt heard or understood, gained insight and/or were better able to process their emotions.

In terms of hindering therapist behaviours, these often seemed the same, superficially at least, as the helpful behaviours, including instances when the therapist listened, attempted to express empathy, or attempted to structure the session. The difference seemed to be in the execution or timing of these behaviours. The clients said they found these moments unhelpful when they were off-topic (for instance, their therapist listened to them “rambling” on about irrelevant details without intervening); when they felt like they were being judged; or they felt it was too soon for them to confront a particular issue.

Other unhelpful moments involved the client perceiving that their therapist was giving a perspective that they considered unwelcome (in one case, for example, the therapist suggested it was not a good idea to make long-term decisions when drunk), or their therapist revealed their own perspective through their body language, such as stretching and seeming frazzled.

The fact that the same therapist behaviours can be seen as helpful or harmful in different contexts shows, the researchers said, “the delicate balance that therapists must obtain while conducting therapy.”

Understanding the client’s perspective of helpful and hindering events in psychotherapy sessions: A micro-process approach

Christian Jarrett (@Psych_Writer) is Editor of BPS Research Digest

32 thoughts on “These are the therapist behaviours that are helpful or harmful, according to clients”

  1. Effective for many people? Mmmmm, when I was studying Psychology, the literature generally agreed that Psychotherapy was either completely ineffective or actually worse than no intervention at all. Have things changed, or have therapist’s become so rich and powerful that they’ve created their own lobby group:)

    1. Several decades of research suggest that about 80 per cent of clients are in a better state following therapy (compared with no therapy). Around 5 to 10 per cent get worse following therapy (compared with no therapy).

      1. I seem to remember, though I could be wrong, that it was a study cited in Gross, the A level recommended text during the late 90’s.

      2. I’d love to see a copy of this meta-analysis (esp. since psychotherapy is such a broad church, what do you include/not include?) – but those are seriously impressive numbers if they are RCTs. Less so if we’re just talking pre-post clinically significant changes, and not at all if there is neither an active or placebo control…

    2. You need to get your money back from that psychology course, that is certainly not what the literature states.

    3. Not questioning the research variables of this so called study and publishing your biased and unfounded beliefs is a concern for me. This study in my opinion is flawed before it’s even started. I believe it’s unethical to use clients in this way. The therapists involved were not experienced. Who where the people asking the clients the questions. How did they carry that out. What where the questions. How can you measure how a client feels now or in two months time. What personality types were the clients in this study. That’s just for starters. As someone who professes to be interested in psychology I would have imagined you would have been more interested in the application of the study instead of using your biased beliefs to degrade other psychotherapeutic disciplines. It has also been proved that the relationship between client and therapist is more beneficial in the outcome of therapy than the actual therapeutic discipline. Read Patrick Casement.

    4. It has also been proved that the relationship between client and therapist is more beneficial in the outcome of therapy than the actual therapeutic discipline. Read Patrick Casement. Your decision not to question the research variables of this so called study as well as publishing your biased and unfounded beliefs without intelligent question is a concern for me. The picture used to market this study is totally inappporpriate, presenting an emotive and inaccurate representation of a client and therapist relationship. This drawing really needs addressing and questions asked around why anyone would use such a visual image to market their study. An inaccurate and emotive representation doesn’t bode well as to the content. Taking my questioning deeper, are there issues in the content of this study that are driven by scrupulous motives and therefore creating inaccurate representation. This study in my opinion is flawed before it’s even started. I believe it’s unethical to use clients in this way, first and foremost – my major concern. The therapists involved were not experienced. Who where the people asking the clients the questions? How did they carry that out? What where all the questions? How can you measure how a client feels now, in two months time, in a years time? What personality types were the clients in this study? How long had the clients been in therapy? How many times had the clients had therapy before? That’s just for starters. As someone who professes to be interested in psychology I would have imagined you would have been more interested in the research method and application of the study instead of using your biased beliefs to degrade other psychotherapeutic disciplines.

  2. I agree Tom….Nick there are lots of papers on the efficacy of Psychotherapy…..but then again, Psychology is not necessarily a “lover” of Psychotherapy, they are seperate disciplines with their own supporters and detractors….on both sides…

  3. This research is as “valuable” as focus groups in advertising testsing… They are asking people about things that they cannnot know – since many of the processes are beyond consciousness. Whi gives credid to such research?!

  4. The subjective emotional experience of the client, while useful information, it does not necessarily correlate with beneficial outcomes. Physical exercise can be most unpleasant at times, but the effects of the difficult and unpleasant workout may considerable benefits. A relaxing, comfortable workout might feel subjectively better, but not have the desired outcome of physical health and longevity. I believe the same is true about psychotherapy. Watching your therapist stretch or seem frazzled may be uncomfortable and unhelpful, but having your therapist suggest you not make decisions while drunk may be uncomfortable but have longer term benefits. A comfortable, pleasurable therapy may feel good, but may not offer much in the way of long term change.

    1. I agree with the first part of your statement, but the latter part I disagree with. The client can be made to feel judged and controlled very easily, since this is a hierarchical relationship from the beginning, not one of peers. Thus, to unwelcomingly suggest what one should to shouldn’t do with one’s decisions can very well seem to come from a controlling attitude, thus sparking a problematic disconnection and lack of trust between client and therapist- especially with clients who are sensitive to being controlled.

  5. It seems likely that the findings of this study are at best, specific to training therapists behaviour : hopefully skillled and experienced therapists behaviours are very different and much more attuned to the client …and for example, less likely to be ‘frazzled’.

    1. I would suspect that the more experienced the therapist is, the less that they would believe it was in ideal environment to showcase their feelings of being frazzled to the client. This is not unlike a therapist who would openly become angry in the client’s presence.

  6. For me this study focuses attention on attunement to the client and being able to activate or compensate at the right time for them – this is why I find Video Interaction Guidance a really helpful intervention because of its determined focus on these areas.

    1. I believe what the client wants besides attunement is validation, not invalidation. For example, “their therapist listened to them “rambling” on about irrelevant details without intervening); ” is a type of invalidating the boundaries and concerns of the client, specifically, the time and money spent is being wasted on babbling abotu irrelevant topics, and the therapist isn’t setting a boundary on it. This is invalidating to the client’s time and money and efforts. The authors of this study dont seem to understand these simple circumstances enough to surmise this.

  7. I was shocked to hear that at least one therapist had been stretching or seeming frazzled during a therapy session. I cannot imagine many faster ways to lose rapport, which has been clearly demonstrated to be the number one factor in successful therapy, regardless of therapy type. The only excuse I can think of for stretching, is if one was actually getting a full blown muscular cramp, in which case I would tell the client, so they would know I was in immediate physical pain, and not bored by them or their issues. I cannot for the life of me, see how showing frazzlement in session, could ever be appropriate behaviour for a therapist, and for me, it calls their therapy skills into serious question, and as for some clients feeling judged, words fail me on that one! It was interesting that timing appeared the critical factor, and that a similar question/suggestion posed at different times could have a perceived beneficial vs non beneficial outcome. No-one or thing can be perfect, and therapists and sessions are no exception. Surely when in session however, sometimes it is noting the client’s reaction to a question/suggestion they feel uncomfortable with, that is what guides the therapist in the right direction for the following questions/suggestions/discussion which will hit the spot? Is that not just client led therapy in action?

    1. I wouldn’t be too quick to assume that a therapist was in fact “frazzled”. This may have been projection by the client. I recently heard that a family member of a patient I was supporting in a social work capacity, say that the first time she saw me I was really lovely. Then after she made a complaint to the hospital about something that had occurred I became nasty. This was news to me as I wasn’t aware of her complaint and if I had been, it is my job to support her in presenting such a complaint to management. My second meeting with her was in a Family consult with the doctors and nurses involved with her father and all I did was ensure everybody in the family had their concerns expressed, acknowledged and answered by the team. People can be uncomfortable when being heard as they are often expressing things that in the past may have been suppressed or punished by others. They may have an expectation of antagonism and project onto actions and comments by therapists and doctors.
      I agree about explaining if you have to stretch due to a cramp. I often use silence in my therapy but explain to the person what I am doing. If I am feeling a bit frazzled I might acknowledge to the client that their situation is indeed challenging and tell them I will take time being quiet for a minute to collect my thoughts and provide the best possible response. In my experience the client appreciates such thoughtfulness.

      1. Yes, I have had a therapist who told me she was frazzled in my sessions and couldn’t figure out what to do with me and had to ask her supervisor what to do with me. Yes, they do exist. She also reprimanded me for taking a few seconds to think after she asked me a question. She told me that it made her feel bad, and to not do it anymore. DO what? I asked her. Look to the side and think for a few seconds. She told me that that bothered her. Who was the client, me or her? Lol.

  8. I applaud this kind of research asking clients (yet I think it needs to be complemented with overall outcome). Please note, this kind of research is not new. Greenberg et al. have done a lot of research on therapy process (i.e. micro skills) and incorporated this into Emotion-Focused Therapy. Unfortunately this very well researched approach is little known in the UK.

    See eg this article for an overview:

  9. Does a client ever truly understand the reasons why we do things in therapy with them. I guess the superficiality of their responses in this research study is useful to know about given their roles as ‘consumers’. I’ll add my credence to client benefits being out of awareness.

  10. Shows “just what a challenge it is to be a therapist”? Sure. But in most instances therapists are adequately remunerated, and if they’re not, it’s within their sphere of influence to do something about it.

    What about the mental, emotional, and spiritual challenges an abused, anxious, depressed or traumatised person must face every day? The economic and social impact of having such experiences? The unrealised potential that lays forever dormant – often because of the lack of insight, empathy, attention, or skill of the expert therapist?

    Therapists forget that their job is a relatively simple one – to help a person heal, or gain perspective that lead a person to take empowering action. They also regularly forget that a client’s efforts to heal or take empowering action are not that of a 9 to 5 job; they are, for the most part, lifelong – and life threatening strides for clients.

    I say keep some perspective in articles like this one.

  11. Due to the variability of human beings, the complexities presented by Traumatised clients and the falliability of therapists, therapy will always be an inexact science. There is so much early experience and emotion stirred, particularly for clients, that much of this is not necessarily within their awareness. We all utiise ways of protecting ourselves from the pain of our truth and so are not always ready or able to take in the compassionate presence of the therapist. There are therapists however, who do harm clients, usually because they have not done enough work to face their own pain and understand their motives in using the client to gratify and gain care themselves.

  12. This is silly without putting it into context. Clients don’t like therapists make “unwelcome statements”, or give unwelcome perspectives. Well, if I was in the business of only saying what clients want to hear, a lot of my patients would never get better (through my help anyway). Whether clients liked us doing that or not is maybe good to be aware for for statements that don’t have to be made on our part, but other than that I will say exactly what is needed for you to get better. Sometimes that involves a grand reality check for you and trust me, I actually don’t like giving you one and it takes me quite a bit to say something I know you will not like me for. But I do it as I consider it part of my duty and job.

  13. I dont get the trouble here. As long as the therapist says thing with empathy and validation, the client will welcome the therapist to tell them any truth. The problem with this study is that they left out 2 things- the empathy and the validation that the therapist had and displayed. One could add compassion also. These are the skills/traits that are not talked about in traditional psychotherapy, because psychotherapy is still a male dominated field. If a therapist wanted to switch to a new topic, or move the client’s story along to it’s conclusion, or do whatever, it wouldn’t actually matter, as long as it was done with a bit of empathy and validation, compassion for the client. you would not hear any of those clients complaining about a sense of feeling disappointed, disconnected from the therapist, or a loss of confidence in the therapist! It’ called “human skills”. Off a therapist lacks these human skills, nothing- not even “therapist skills”, can save the relationship. I suppose this is the reason why this study was confusing and failed to delineate the reasons why the very same behaviors incited one person and then satisfied the same person. It is because one behavior by the therapist was done with consideration, empathy, and validation, whereas the next time the the therapist did it , it was done with impatience, lack of understanding, and too many assumptions )in other words, no empathy for the client.) This study does not quantify the lack or existence of empathy.

  14. I agree with pretty much all the responses here. There are also certain clients who are only interested in having their actions validated (for eg. when talking about interactions with a spouse), and don’t want to hear that there may be something that they could have done differently, or how their words may have been interpreted by the other person; or that maybe the other person wasn’t responsible for everything that was wrong in the relationship. Do you just tell them what they want to hear?

Comments are closed.