Therapist Personality Characteristics That Impede Client Progress
Most of us have thought about the kind of personality characteristics in clients that we prefer not to work with, but what effect might our own personality characteristics have on therapy outcomes? This week’s study by Jaime Delgadillo and colleagues (2020) represents one of the best attempts to explore this question.
They looked at the outcomes of 69 UK therapists in their first 3 years of practice in the IAPT program; 36 were low-intensity personal wellbeing program (PWP) workers and 33 were CBT therapists. PWP involved < 8 sessions of guided self-help. CBT involved up to 20 sessions of manualised disorder-specific structured therapy. There were 3 stages of training: 1) the 1-year training program; 2) first 6 months post-training; 3) 6-24 months after training. They measured therapists’ personality using the 240-item NEO PI-R, allowing them to look not only at the effects of the ‘big 5’ personality traits but also at the more specific facets within those traits. They measured therapists’ competence using Observed Structured Clinical Examinations (OSCEs) for the PWP and the Cognitive Therapy Rating Scale-Revised (CTR-S) for the CBT group. They measured therapists’ “reflective ability” via every PWP and CBT therapist completing three 1000-word reflective analyses of their practice and the relationship of CBT theory to it, which were rated by experts. Although no validity data was presented for the reflective ability measure or the OSCE, the authors are to be commended for going beyond purely self-report measures in investigating therapist characteristics associated with client outcomes. They also looked at demographic characteristics such as therapist age, gender, years of experience, and stage of training.
The authors estimated therapist effects in two ways: 1) as accounting for 1-3% of variance in client outcomes; and 2) as 6% of the variation between therapists in the average effect size of symptom reduction they achieve across their clients. The authors found that after adjusting for baseline client symptom severity, neither competence, reflective ability nor years of experience were associated with client outcomes. However, clients receiving therapy from a therapist in their third stage of training (i.e., 6-24 months post—training) achieved better outcomes than those who received therapy from a therapist in their first stage (i.e., during the 1-year training program). Then, for PWP workers, above-average agreeableness was associated with poorer treatment outcomes. For CBT therapists, above-average openness to experience was associated with poorer treatment outcomes. Interestingly, removing therapists from the analysis who scored above average on these personality traits eliminated between-therapist variance in average effect sizes achieved.
The authors then used machine learning analyses to identify therapist personality facets associated with client outcomes. For PWP workers, only the compliance facet was associated with poorer client outcomes. For CBT therapists, openness to ideas was associated with poorer anxiety and depression outcomes and openness to feelings was also associated with poorer outcomes for anxiety symptom scores.
The authors interpreted their findings primarily as evidence of therapist drift; agreeable PWP workers were thought to deviate from protocols to accommodate client wishes and CBT therapists deviate because they’re too interested in either abstract or eccentric intellectual ideas which are beside the therapeutic point.
This study was exploratory, and it would be quite fun to pick lots of holes in it but the main caution I’ll highlight to anyone who might read it is that it says in a couple of places that there were no differences between PWP and CBT. It’s important to remember that clients were not randomly assigned to PWP vs CBT, and the analyses that found no effect of service type first adjusted for client baseline severity, which is confounded with intervention type in a stepped-care model, so to take the ‘no difference’ message out of context would be irresponsibly misleading.
Although the effect sizes are small and the interpretations speculative, it is a useful stimulus for therapist self-reflection. Anecdotally, many of us have undoubtedly experienced boredom executing empirically-supported interventions and fascination with exotic, less well-tested ideas. Part of my ambition in my trainings and research is to try to re-ignite clinician enthusiasm for the less exotic: the tried-and-true practices that make a bigger difference to client outcomes and are easily overlooked as we become desensitised to teaching about them. This study suggests we check our personalities for hidden vulnerabilities. Above-average agreeableness and compliance manifests as self-sacrifice and subjugation. Although average agreeableness is heavily socially reinforced and would widely be considered a virtue, we do need to self-monitor for when we kill clients with kindness. Above-average openness to ideas may lead us to be directed by what is most interesting rather than what is most effective. Above-average openness to emotions may lead us to engage in prolonged immersion in emotive experiences, again, at the expense of what the client stands to learn.
Take home: Clinical Implications
6% of the variation between therapists’ average effect size of symptom reduction across their clients was systematic (i.e., rather than due to random error)
Better outcomes were associated with being 6-24 months post-training rather than in the 1-year training program
For guided self-help workers, above-average agreeableness (specifically, compliance) was associated with poorer client outcomes
For CBT therapists, above-average openness to experience (specifically, openness to ideas) was associated with poorer client outcomes
Go to https://www.tandfonline.com/doi/abs/10.1080/10503307.2020.1731927?journalCode=tpsr20 for the original article.
References
Delgadillo, J., Branson, A., Kellett, S., Myles-Hooton, P., Hardy, G. E., & Shafran, R. (2020). Therapist personality traits as predictors of psychological treatment outcomes. Psychotherapy Research, 1-14. doi:10.1080/10503307.2020.1731927