Thursday, February 6, 2014

Treatment Providers: Born or Made?

On the listserv of the Association for the Treatment of Sexual Abusers (ATSA), a member recently observed that, in his experience, great therapists are born more than made. Indeed, many professionals who have worked in larger agencies have had the experience of working with someone who just didn’t seem to “get it.” The underlying assumption is that some of us are simply better than others. Is that true?

The stakes are high for professionals treating people who have sexually abused; don’t we all want to be the most effective we can be? Early pioneers stated that treatment must be confrontational (e.g., Salter, 1988, p. 93). More recently, Marshall (2005) summarized a number of studies showing that the most effective therapists are those who are warm, empathic, and rewarding, while providing clear direction. What seems to be the case is that no matter the therapy, agreement between therapist and client on the goals and tasks of treatment, as well as on the nature of the relationship itself (these factors being referred to as the therapeutic alliance), is vital (Wampold, 2001).

At first, Marshall’s findings seem encouraging. Warm, empathic, rewarding – that’s me, right? Until we ask others, including our clients. A major problem is that almost everyone considers themselves warm, empathic, and directive in one way or another. Do you know anyone who says they are cold and not particularly empathic? It’s now been 16 years since Beech and Fordham (1997) found that people treating men who had sexually abused believed themselves to be more helpful than their clients do. Have we gotten more effective since then? Or, does our faith in ourselves actually prevent us from becoming the best therapist we can be?

Research by Scott Baldwin and his colleagues (Baldwin, Imel, & Wampold, 2007) and by Bruce Wampold (2001) has found that there may be fewer differences between therapeutic approaches in psychotherapy, overall, than there are between therapists. Does this mean that who professionals are is more important than what we actually do?

A couple of recent publications should give us pause to consider our practice. The first is by Helene Nissen-Lie and her colleagues in Norway. The second is a review of research by Theresa Moyers and Bill Miller.

Helene Nissen-Lie and her colleagues (Nissen-Lie, Havik, Høglend, Monsen, & Rønnestad, 2013) examined an international sample of 70 therapists and 227 clients. The authors used measures that explored the personal satisfaction and personal burdens of each therapist. They next examined the therapist’s and the client’s experience of the alliance. They found that therapists with high levels of personal satisfaction rated their alliance to be higher than their clients did. The therapists’ self-reported level of personal burdens was strongly and inversely correlated with the client’s rating of the alliance. In other words, therapist’s experiences of their own problems seemed to have a greater effect on their alliance than their experiences of satisfaction. Important to recall is that it is the client’s experience of the alliance that predicts the success of treatment, and not the therapist’s.

Clearly, this was not a study of recidivism rates of sexual offenders, but instead yields important clues as to how therapists can build alliances that will help their methods become most effective. In this writer’s experience, many people who have sexually abused have described a sense of knowing when the time or situation was right to commit a crime. Why shouldn’t they also know when their therapist is on their game… and not?

In his early years, Bill Miller, then only beginning to develop motivational interviewing, decided to run a simple experiment. He looked at therapists providing substance abuse treatment, expecting to find that their clients relapsed less than people with addictions who read self-help books. He was wrong; there was no difference. Perplexed, he repeated the study and realized that those therapists who were judged by their peers to be more empathic did indeed produce clients who abused substances less. Therapists who demonstrated less empathy produced clients who would have done better with a good book. These findings are deeply frightening, but necessary to address if our field is ever to improve.

Since then, Theresa Moyers and Bill Miller (2013) have come to believe that although empathy levels differ between therapists, an important element of treatment provision is to screen for it during employment interviews and teach it to clinicians wherever possible. They also remind us of the body of research showing that it is the client’s perception of empathy that is more important than the therapist’s self-assessment. Further, they clarify that what is important is the actual demonstration and expression of “accurate empathy,” which they define as a:

… commitment to understanding the client's personal frame of reference and the ability to convey this heard meaning back to the client via reflective listening … the process encompasses the accurate understanding of both cognitive and emotional aspects of the client's experience as well as attunement to the unfolding experience of a client during a treatment session.

It can be a common refrain among treatment providers to say that people who have sexually abused are different or more challenging than other clients. Of course, Moyers and Miller are describing work with people who suffer from addictions – another population with a reputation for being deceptive and manipulative over time before entering treatment.

So where does this leave us?

Certainly, some therapists enter the field with higher levels of demonstrated empathy than others. Those of us committed to becoming better therapists can likely become more effective by deliberately practicing our skills in accurate empathy. However, our own self-assessment of our empathy – and for that matter our satisfaction with our lives – will probably predict very little of our actual effectiveness. Nissen-Lie and her colleagues have also shown that our personal burdens may have more of an effect on our clients than we realize. In the end, even if some of us have greater advantages in some areas, the best therapists may well be the ones who make themselves better… with the help of their clients.

David S. Prescott, LICSW


Baldwin, S. A., Wampold, B. E., & Imel, Z. E. (2007). Untangling the alliance-outcome correlation: Exploring the relative importance of therapist and patient variability in the alliance. Journal of Consulting and Clinical Psychology, 75(6), 842.

Marshall , W. L. (2005). Therapist style in sexual offender treatment: Influence on indices of change. Sexual Abuse:  A Journal of Research & Treatment, 17(2), 109-116.

Moyers, T.B., & Miller, W.R., (2012). Is low therapist empathy toxic? Psychology of Addictive Behaviors, 27, 878-884.

Nissen-Lie H.A., Havik, O.E, Høglend, P.A., Monsen, J.T., & Rønnestad, M.H. (2013). The contribution of the quality of therapists' personal lives to the development of the working alliance. Journal of Counseling Psychology, 60, 483-95.

Salter, A. (1988). Treating child sex offenders and their victims. Thousand Oaks, CA: Sage.

Wampold, B. E. (2001). The great psychotherapy debate: Models, methods, and findings.  Routledge.

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