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

17 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:)

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      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.

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      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…

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  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…

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  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?!

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  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.

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  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’.

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  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.

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  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?

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  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: https://focus.psychiatryonline.org/doi/abs/10.1176/foc.8.1.foc32.

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  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.

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