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Psychotherapy and Applied Psychology
Psychotherapy and Applied Psychology is hosted by Dr. Dan Cox, a professor at the University of British Columbia.
This show delivers engaging discussions with the world's foremost research experts for listeners interested in or practicing psychotherapy or counseling to provide expert insights and practical advice into mental health, psychotherapy practice, and clinical training.
This podcast provides valuable insights whether you are interested in psychotherapy, an applied psychology discipline such as clinical psychology, counseling psychology, or school psychology; or a related discipline such as psychiatry, social work, nursing, or marriage and family therapy.
If you want to learn about cutting edge research, improve your psychotherapy/counseling practice, explore innovative therapeutic techniques, or expand your mental health knowledge, you are in the right place.
This show will provide answers to questions like:
*How will technology influence psychotherapy?
*How effective is teletherapy (online psychotherapy) compared to in-person psychotherapy?
*How can psychotherapists better support clients from diverse cultural backgrounds?
*How can we measure client outcomes in psychotherapy?
*What are the latest evidence-based practices?
*What are the implications of attachment on psychotherapy?
*How can therapists modify treatment to a specific client?
*How can we use technology to improve psychotherapy training?
*What are the most critical skills to develop during psychotherapy training?
*How can psychotherapists improve their interpersonal and communication skills?
Psychotherapy and Applied Psychology
Personalizing Psychotherapy and Patient Empowerment with Dr. Michael Constantino
Dan welcomes back Dr. Michael Constantino, a professor of clinical psychology and director of the Psychotherapy Research Lab at the University of Massachusetts Amherst.
In part 2, Dan and Dr. Constantino explore the intersection of technology, therapist effectiveness, and patient empowerment in therapy. Dr. Constantino shares on his development of an app that allows patients to match with therapists based on their preferences and effectiveness profiles. Then, Dr. Constantino emphasizes deliberate practice for therapists, the role of humility in enhancing therapist effectiveness, and the significance of cultural humility in therapeutic relationships.
Special Guest: Dr. Michael Constantino
https://www.pcori.org/research-results/2015/matching-patients-therapists-improve-mental-health-care
Constantino, M. J., Coyne, A. E., Boswell, J. F., Goldfried, M. R., & Castonguay, L. G. (2023). Training on context-responsive psychotherapy integration: An evidence-informed framework. In L. G. Castonguay & C. E. Hill (Eds.), Becoming better psychotherapists: Advancing training and supervision (pp. 85–105). American Psychological Association. https://doi.org/10.1037/0000364-005
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[Music] From alliance ruptures to therapist humility, certain moments in therapy can make or break the work, yet most of us have little training on these pivotal moments. In this conversation, Dr. Michael Constantino lays out his vision for a new era of therapist training, one that's evidence-based, responsive, and highly personalized. I'm your host, Dr. Dan Cox, professor of counseling psychology at the University of British Columbia. Welcome to psychotherapy and applied psychology, where I dive deep with leading researchers to uncover practical insight, pull back the curtain, and hopefully have a little bit of fun along the way. If you find this show valuable, consider sharing it. It's one of the best ways to keep these conversations going. So without further ado, here's my conversation with Dr. Michael Constantino.[Music] So we're also working on an app that allows patients to sort of drive their own matching right on their phone, where it sort of populates in a given area. Here are all the therapists that, you know, once a baseline has established their effectiveness profiles. These are all the therapists that show up for you in your filter. And depending on what else is important to you, preference-wise, you can start clicking on other boxes like I want them to be within five miles, or I need it to be virtual or whatever. And that short list will shrink, but eventually, here are the people that are well matched to you, meet your preferences, and you can get on all of their weight lists simultaneously, and you'll get a pain when the first one has an availability. Right? So that we have some funding from NIH now for a small business innovation research grant to test this app, which puts the patient right in the driver's seat as opposed to an intake coordinator or an administrator. Right. So I want to get back, so many things I want to hit, but because I think it sort of feeds into what we were just talking about, I want to bring in sort of the deliberate practice idea here, and particularly what you brought up, which is you have a center and network, whatever, and there isn't anybody who's particularly stellar in this area. So I'm imagining where you have one or two or three therapists who are like,"Good, not great," and I'm thinking, "Is that potentially a place where one could bring in deliberate practice to try to help get a person into that great category?" Yeah. I think it's a great question and a testable one, and one that we want to pursue. I mean, I think the, as you likely know, the connection between deliberate practice and therapist effects has been that there is at least one study out there that said one thing that predicts higher performing therapists, this is on the global between therapists effect. One of the things that predicts that is that they are more likely to engage in deliberately practicing their craft. You know, whether that's watching videos, working with peer consultants, you know, they really try, and especially between sessions and between work with patients, they really try to sort of work on their craft. And so that made this connection between deliberate practice and therapist effects, sort of be more high profile. For us, there's also, I mean, deliberate practice is really just a method of learning. And I would say overall, the research is promising, but still mixed. I think sometimes the effective deliberate practice as a method can be overstated. But certainly there are studies that exist that say, and we did one. For example, we did a deliberate practice workshop for helping therapists become better at addressing resistance in the room. And it turns out that after this workshop, when you measure things like therapist ability to use empathy and to roll with resistance and to be validating. All things that research tells us will help you better resolve patient resistance to a treatment or provider. Therapists can learn those things in a relatively sort of effective way. And so we would like to take that teaching and learning technology of a deliberate practice type workshop, and those become continuing education experiences that at least connected to our trial focus more on the type of presenting problem a patient has. And that gets challenging, right? Because it's probably not going to just be you have to learn a manualized treatment for that disorder. But it could be that there are nuances of the research for treating people with depression or anxiety or substance misuse. And so that practice workshop can focus on and for a therapist whose early profile said, you are kind of ineffective or weak in this area. And they're just like, you know, but I don't want to give up on that on treating patients who have that concern. Maybe after a series of deliberate practice workshops and targeted continuing education. Maybe their next profile will get will will show that they're up to average. And they can even work it into a strength, right? But it all it all takes sort of intentionality that comes from learning in an evidence based way what your strengths and weaknesses are. And I think with what might help that I think what's really interesting about that study we talked about a while back, where we showed therapists weren't particularly good at predicting their own effectiveness strengths and weaknesses. And the thing that one of the things that predicted actual therapist performance was the therapist who underestimated their abilities were actually the therapist who overall on the global top score their average patients did better than other therapists. So there is a certain level of humility that we also know if you are a humble therapist, you are probably more likely to be an effective therapist. Why do you think that that is? Yeah, I think part of it is a willingness to the connection I wanted to make was that if you knew of that finding, then you might be signing up for or going into these deliberate practice workshops with an attitude of like, I have a lot more to learn. It is a lifelong learning career, you know, it isn't that I've, you know, somehow learn how to do these three treatments and I'm just going to do them over and over again, right? I think humility breeds flexibility. It breeds openness to learning. So you can plug that into another factor like deliberate practice that is also predicted between therapist effectiveness differences. If you combine the virtue of humility with the openness to engage in deliberate practice, maybe this is where we could really see a training effect in a field where I think we unfortunately know there are very few types of training methods if any where we continuously see that they have an effect on therapist improvement. We have ways of training that are long established, but there are very few manipulated training studies or at least ones that have been replicated that said if you teach in this way, you will see that a therapist gets significantly better on the thing you're teaching. Right, we just haven't been a field that has done that has matured all that much in testing our training ideas. And so this would at least be one way to take what you learn. So first of all, there's a certain level of humility you have to have to allow your performance to be measured and to get the feedback. Right. And if you do that and then your training becomes more targeted or your decision making about what patients you see becomes more pointed, maybe we will see an overall bump in the field in terms of how to train, how to practice, how to get our patients to the right providers. And because we know the provider matters, but we know the provider doesn't explain still doesn't explain 95% of other variants, right. So it doesn't mean that it's not it's unimportant to learn treatment types or it's unimportant to learn. And so that's a common factor processes, all of those things are still really vital, right, because you know therapist still do things in the room that you know we can learn about, oh, this is what makes you effective. Right, that's the other where that's the other area this research has to take us is it's one thing to say a therapist is really good in this area. And they say, how do they do it? And is it is it generalizable or is it specific to their style and their charisma and their attitude and their personality. And that's another thing that we want to think about in terms of training is how do you bottle the things that we learn that therapist use or parlay into exceptional effectiveness. One of the things when it comes to humility that you were talking about the person who's more humble is more likely to seek out training get feedback. But I was also thinking about the effect of sort of you know Jesse Owens work former guest of the show that that that also in session if I more humble I might be more willing to listen to my client and be more flexible and learn from them. That right so like that that you could see that could be happening at both levels right in session if I'm more humble, then I'm going to be just taking I'm probably going to be more responsive. And I think responsiveness is the perfect term for it right yeah cultural humility within Jesse's multicultural orientation model being one of the pillars of that orientation I think is a it's a perfect way to think about it right it's like if I'm if I'm humble I don't presume I have the answer. I'm not surprised that you and I might have attention or a disagreement and I'm open to hearing your take your perspective and I'm open to working with you to collaborate on a solution. I think that becomes just a meta facilitative interpersonal skill right which is just like a willingness to listen a willingness to learn from the patient to see it as a two person by directional psychology. And then you start we're all the way back to square one for me which is like how do you take self concept and interpersonal relationship and negotiate it for good and I think you know anybody who's talked about Alliance and Alliance ruptures you know you constantly think of the therapeutic relationship is having to be negotiated because it's two sets of people with unique needs histories talents shortcomings. And those will come together and create diatic indices right indices of hopefully often attunement but sometimes misatument right right and misatument could be I didn't listen or the misatument could be cultural you know or the misatument you know could be I offered this but you told me you really didn't need that you needed something else. And the humility I think sort of opens us up to see moments of misatument so getting back to what you said a while ago about in your match study that people of color that this matching seem to matter a lot so that was still matching on that like primary domain exactly it was still matching to problem and they still didn't know they got matched. So for people of color matching with a therapist who has particular effectiveness in that primary problematic domain at least their primary problematic domain that really mattered regardless of those patient severity exactly it double the size of the match as an independent moderator separate from severity yeah right so there seems to be something about. The experience of working with a clinician who is historically effective at treating your problem you don't know it but you're but still they met with that therapist that therapist we knew was very effective there was something about that experience that helped those people in particular people with those identities in particularly because they must have had some you know challenge they probably had some challenges in finding a therapist working with a good fitting therapist perceiving a therapist is meeting their needs. And it was it was helpful. Yeah so I I I wanted to but I think that you know there's lots of work on people of different like looking at socio demographic variables and matching with therapist and it's mostly a dud right so that. And it's a really non-signific effects of matching to identity right so right so and I think it's an interesting thing is like when I'm teaching like one of the undergrad courses that I teach oftentimes this comes up and people are just like I'm sure that this is like this must matter and it's sort of like well the data don't really support that but yeah this is doing so like I just think this is really interesting. And we want to take it further and we have so we've now basically done sort of a rinse and repeat of our entire sequence of learning about therapist strengths and weaknesses finding out if patients and therapists and administrators who want to hear about that information for treatment decision making purposes and testing whether matching matters we are doing that now with identity so in two different ways first we'll talk about race and ethnicity right we are basically. Saying if you the only thing it takes for a therapist to have strengths and weaknesses is at least two domains of measuring on something so instead of looking at the 12 problem domains we are now looking at whether therapists differ if if a therapist average patients outcomes differ depending on the race and ethnicity they identify with and so it turns out that therapist can also have strengths and we're going to talk about that. And also have strengths and weaknesses not only in what they treat but who they treat so for some therapist their average person of patient who identifies as a person of color gets significantly better than when they treat their average patient who's white and vice versa and so that too can become a match variable and we have now shown preliminarily this is with retrospective matching just did it happen not did we intentionally manipulate it. But we have shown that when a patient got matched by chance to a therapist who their historical data told us they were better at working with people of color than with white individuals when that happened or in the other direction did they have significantly better outcomes it turns out that they did and so we're getting ready to publish those data with again Alice coin James Boswell David Kraus in myself but this is just it's inspired by learning. It's inspired by learning that matching to problems was was very relevant in fact stronger for people of color it's inspired by that but then we thought why not just directly test whether some therapists do better with certain identity groups and have that be not only a reaction to our own matching work but an antidote or another way of thinking about matching on identity that is different than the findings that you mentioned that are non significant right so it's not about matching just because we both share an identity it may be matching in a way that pertains to identity but it's because the patient identifies a certain way and you as the therapist historically do really well at treating patients who identify that way right yes Yeah, so I think that's the point to emphasize which is these are not necessarily therapists of color or not matching right right they could be but they don't have to be right so you can certainly imagine a case where you'd have therapists of color who actually have worse outcomes with some reason for some color right so that's so it's just right okay it's and then we of course want to see if we double if we double match based on problems and identity will get even bigger effects so these are the this is the sort of things that are coming we we've we've gotten most advanced on the race and ethnicity question but my graduate student Avery gains her dissertation is also focused on doing a very similar thing for sexual orientation and so and we've already established that once again therapists can have within caseload differences so relative to themselves they can have strengths and weaknesses depending on the sexual orientation that their patients identify with yeah yeah so other I was not bad no I was just going to say that's just a different way of tethering evidence based matching to identity that isn't the the thing that a lot of people are disappointed in hearing my students as well that if you you know if you just put people with the same identity together you they must get you know they must prefer that they must get better and you're just like they might prefer it but they don't necessarily benefit from it right but that also tells us there's so much more to that than just we share an identity right in terms of like cultural connection and and and so forth and his you know personal experience connection we maybe we should have never expected that this sort of just identity match would be you know a boon to to patients improvement right right and so are there any other because I'm thinking about so like what what are the what would be the remote most robust match variables right match characteristics and so you know I'm you know one of the things that pops into mind is is is personality or you know even it could be interpersonal problems or something in that sort of world are there other sort of characteristics that you would think about matching that you're sort of like maybe you know that are sort of like oh I think that could be something that where there's a lot of value yeah it's it's really interesting you know there's been this question of like patient aptitude by treatment interaction that's been around for a long time like the first way to think about personalization was like who are the patients who would respond best to CBT versus IPT or medication versus psychodynamic or something like that and I think you know that that hasn't led to many replicated findings you know there are some that are certain attachment styles would do better in cognitive behavioral therapy certain others would do better in interpersonal therapy or dynamic but nothing that has really sort of stood out and become a replicable finding that that people start to implement but I do think Rob Derivis is work on having a personalized advantage index so basically using machine learning and predictive analytics to say if you have this constellation of presenting characteristics then you know it is much more likely that this type of treatment would you that you be better suited and more likely to respond to this type of treatment than this type of treatment or to a medication versus this I really like the predictive algorithm or analytic method because it takes a constellation of patient symptoms into account versus saying is there one patient factor that we can match to treatment type and so inspired by that I get to work in here one of the newest things that we're doing is we are creating a patient treatment fit variable to try to leverage clinically the between therapist effect and I'll try to be brief on this one but basically we're trying to think of this as an efficient simple match system that clinics might be well positioned to use immediately that can capitalize on just learning which of your therapists are highly effective overall and which are sort of less effective and if you knew that then it becomes a question of resource allocation meaning who are for whom for which patient should you most preserve openings on a caseload of your most effective therapist which patients need to see those highest overall general performing clinicians I'm not talking about the 12 domains now which are the patients who most need those therapists to get better and we are developing this predictive analytic again calling it inspired by Rob Derby's work on the personalized advantage index for treatment types we are doing it for provider type and we have some really interesting preliminary data that basically will tell us there are certain constellations of presenting characteristics for patients that would make them statistically more likely to improve if they saw a therapist in sort of the top therapist and sort of the top third of the sample and we're doing this in a really efficient way so we only have sort of two categories at the moment you're either a patient who needs a high performing therapist or you're a patient who would get better or who would improve to the same degree hopefully get better whether you saw a high performing therapist or any other therapist and again it's another version of like first of all if you wanted to do this now you wouldn't need to have a multi-dimensional outcome measure you could just have one measure that says you are highly distressed or not and as long as you're collecting some data on patients in that way then we could find out at baseline which of those patients should you be preserving your highest performing therapist for and which patients could see any of your therapist it's not based on within therapist strengths and weaknesses it's simply based on who are the overall most effective therapist in a given network or sample and so you know we think of this as sort of a way of doing like a day one type matching before a clinic might be willing to also consider learning about therapist strengths and weaknesses based on problems or identities at least this way from a resource allocation point you could you could help say you know I know that these are the top therapists in my network and I don't want all of their openings to get taken up by patients who would do just as well with any of our therapists we really want to preserve that space so to your question to us that's another match idea that we're really excited about that again takes constellations of patient characteristics into account as opposed to just looking at individual variables in interaction with treatment packages or something else so I hope that has a lot of bang for the buck as well. So one of the things that stands out is that you know at the beginning when we were talking about how much what is the between therapist effect and I know we're talking more about within therapist effects now but you know we said 5% right so what seems like a small percentage of the variance but the effects of your match study you know the effect size of whatever it was 0.75 did you say? Well the between group effect points on that yeah it's huge so I think that that I just sort of want to bang that home because I think that sometimes we see this you know these effect sizes 5% 7% whatever it is and we think oh well who cares right it doesn't really matter but to an extent what your study is saying is like there's a tremendous amount of bang for the buck in that that in a way that that 5% it's not intuitive in terms of what that actually means. No exactly I think I think a way that helps me and hopefully when I talk to students it's like you know the idea of like what percent of variance and outcome is explained by variable that comes from correlational predictor research right and you know hopefully if I say the therapist explains 5% and you're like oh well what does that matter hopefully if I say well the therapeutic alliance do you think that's important and somebody's like well yeah it's like well that explains about 7% right it's like and the best we can do is usually like empathy and therapist empathy and goal alignment those are like 10 and 11% meta analytically right so it's just if you just if people can just appreciate that the best we can do is explain somewhere between 5% and 10% of variability the only thing that tells us is that that variable matters to try and do something with it then doing something with it like leveraging it in a match intervention that can explain far more variability right because you've taken a meaningful variable you've created a type of intervention although in this case the intervention is simply who do you assign a patient to and then you try to sort of capitalize on that effect purposely pointedly and then you see a bigger amount of variance explained by the intervention and so I think that's that's the that's the process of taking a predictor or process outcome study that says okay it's explaining a small but meaningful amount of variance but it's like can I leverage it intentionally and do something with it that makes it more potent with it I often explain it or talk to folks about it is like is sort of between teacher effects so because we've all been in years of schooling right and so that the between teacher effects are about the same as the between therapist effects yeah and that like just you know have you ever you know that think back to your time in classrooms have you had some teachers that were awesome and some teachers that were terrible you know and a whole bunch of kind of average right it's sort of about the same thing with therapists and what you guys are doing which is super cool because with teachers I mean when you get to university you can pick and choose somewhat but you know jet most of the way through you just get assigned to them it is what it is but what you're doing which is very cool is saying let's find the best teacher for you right and let's match you your style of learning your challenges your so whatever it is and let's match you to that best teacher and that if you I mean you know if you actually think about that autobiographically that man if I had you know the class that you struggled and you struggled in geometry but if I found the best geometry teacher for you specifically and put you in there you probably do pretty well and learn a lot right and I love that I mean thank you and I love that summary because it you know part of what we talk about is you know like 180 degrees of personalizations for so long when we think of personalizing we think of getting a patient to the right treatment or the right intervention right but there's also ways in which we can personalize not only the patient to the right provider but also the provider to the right patient or the right training experience right like like we yeah like whether it's a teacher or a therapist it's like after training we tend to just think you can do what you do right but just like with our patients we should we should be thinking about everybody needs some level of personalization in their training or their experience or their professional development and so that's been what we've been trying to talk about is like expanding the notion of personalization to the provider as well. So that so are you okay with time I know I get so yeah yeah okay great I have about like 30 questions that I'm not going to get to because I just this is just sort of gone on there's been great I wanted to talk about training so you know I just did a podcast with Tony Ruminier who's the big liver practice guy in his work and all that sort of stuff yeah of course of course and so we happen to be in the middle my home program we happen to be in the middle of re accreditation and all that stuff and so these sort of things are are hitting simultaneously and I'm sort of like man I sort of think we really need to rethink how we do training. So for you where do you sit on that if you were the czar of training even just in your particular program what would what do you think training would look like yeah it's a great question and it would take a really long answer that I saw try to give a brief answer but I mean I would combine a lot of things but we actually just wrote a chapter for a book on training that was edited by Louis Castingay and Clara Hill. And our chapter focused on a model or a framework that I've been developing for a while now over a decade called context responsive psychotherapy integration and this model essentially tells us you know that it's sort of an if then way of thinking about psychotherapy right it's like if you know that we all need to have some level of first step responsiveness to a patient right and it could be based on therapist strengths that these are the patients you see or patients get assigned to you but it could also be on like offering a rationale for the work and how one might change right and the idea is that this first step responsiveness is to try and find a way for you and your patient to get off on the right foot and part of what what I think you would need to do to train in that to facilitate that is to learn multiple theoretical approaches at at least a conversational level right so that you have the ability to offer treatments and rationales and principles to to meet a patient's need to have a patient say that one sounds good that one doesn't or like oh I want to explore that a little bit more and so I would spend a lot of our time training. One part of training would be to get people to be more conversational on a variety of overarching theoretical models of change that doesn't mean you try to teach people 20 manuals in graduate school right but it does mean you don't only teach people CBT for five or six years and so that's one part and then the other idea of context responsive into responsiveness that would come later is that we know empirically that when certain things happen in therapy that they will predict a worse outcome for a patient right so when there's an alliance rupture when there is resistance when there when somebody's expectancies for improvement when when there are cultural misatunements these are big ones right and if we know that those occurrences happen that they pose a risk for poor outcome and that they're relatively common occurrences we can have we've already established some evidence based based ways to depart from what you're currently doing and instead use these pointed strategies that are useful and empirically supported for improving repairing ruptures restoring hope getting more culturally back on track and aligned addressing and resolving resistance and I think we should be spending a lot of time in our training in addition to getting conversational on a variety of theoretical approaches we should be training people to learn what are these key markers that are risk factors for poor outcome and what are evidence based strategies for addressing them and so these these sort of modular if then trainings I think so actually James Boswell and I wrote about these in our deliberate practice for cognitive behavioral therapy where it's like it's you know when do you have to take your CBT and put it on the shelf at least momentarily because these other things data will tell you are more likely to be effective in resolving the rupture resolving the resistance etc and I just don't think we spend a lot of time in training on these sort of modular if this then that if this then that even though a lot of times in supervision students are coming to us saying this thing happened and oh shit I don't know what to do with it and so I just would want we have a database and it's growing and it should always evolve the context responsive psychotherapy integration model should always evolve as we learn more if markers and then responses but those are the two components that I would want to put that we wrote about as sort of training in a new key train people to get off on the right foot by being able to be conversational and thinking about a variety of ways people change and find one that suits the patient and getting off on the first step could just be seeing the patients that you already know you're good at treating the therapist affects them but really this idea of ongoing responsiveness to the moment or to the context is like learning perhaps through deliberate practice how to be more effective at addressing negative process if you will or disruptive process when I so when I did the podcast with Catherine on alliance ruptures and repairs and sort of you know I was familiar with literature but I you know in prepping you really do these deep dyes then you have this long conversation with this person sort of through that experience I sort of walked away saying why the hell is this like this should be a part of every training program because because one of the things you know in her work that becomes clear is alliance ruptures these are not outlier things that happen every once in a while these are normal parts of the process like it just is going to happen more I mean you know very frequently and that as therapists when you're in training or even practice they're scary right it's sort of like oh God what do I do now we're not on the same page and I don't know how to handle it and I feel like my clients being defensive or maybe I'm being defend right all these things are happening and it becomes this oh shit moment when but it's normal so instead if we train it as this is a normal like expect this to happen and this is a normal thing that happens and this is actually therapeutic in and of itself this is one of the values of the opportunity yeah just like you said at the beginning this is at this interpersonal relationship you're having and so part of our training being to instead of trying to do this I mean don't be a jerk but don't try to avoid this except when it's there and let's see it as an opportunity and we can actually there's really nice training that can help you to work through this so it actually improves the relationship improves outcomes yeah and I was sort of in reading that they're sort of like doing that deep dive and actually when I teach this fall I'm going to I'm teaching it and sort of going to dig into it because I was really you know convinced and you but anyway so it just really strikes me and that's exactly what you're talking about and you're more sophisticated about it and you're saying here are a handful of places that are just normal challenging parts of any therapeutic experience trans trans theoretically yes that we need to train folks to be able to respond adaptively to these and it'll help in all sorts of ways all exactly and and the yes so part of the CRPI model is like trying to think of common factors a little differently they're not just trans theoretical principles but rather their things that happen commonly right right these things will come up in your work and it's not it's not because you made a mistake it's not because you induced them it's because two human beings are having an interaction that has to be constantly monitored and negotiated and and experiences checked on and discussed and so yeah part of that you know oh shit moment I think is often this was pulling me away from what I think I need to do is a clinician which is stick to the treatment and what I would want training to do is to really underlying sort of the interpersonal principles it doesn't mean you have to be an interpersonal therapist but just understanding that one of the things that's always available to you as a clinician and it's empirically supported as being helpful is metacommunication right talking about what's unfolding between you and the patient right now and I would just want to teach people that early so that they don't think I have to show you this video it was terrible it was the worst session I didn't know what to do it's like you always have something available which is to say I'm sensing right now that we're having some tension and I'm not quite sure what to do with that maybe it's worth talking like you always have available to you the ability to medic communicate like as a therapist you should never feel like you don't have anything to say or do because you can always say I'm experiencing right now that I'm not quite sure what to say or do my experience of us right now is leaving it so that I'm not sure how to proceed and I would love to talk to you about that because you know I want to get your take and get on the same side. Yeah and that was one of when I when I did one of these with with James Boswell one of the major takeaways that I had in that was sort of just like the bring whatever is going you just bring it into the room right bring it as part of the process bring it in bring it up with the client have be part of the conversation that there's so much power in that yeah if like if a if a super supervisor can tell me I was feeling stuck my first response is going to be what did you tell the patient that you were feeling stuck in that moment it's not that it didn't have to be like you know you were you were chewing your nails and and couldn't wait to talk to your supervisor because you didn't know what to do in that moment it could just be you shared your experience in the service of relationship ruptures being corrective experience opportunities and if we just are able to sort of get that in the vernacular of people without having to you know necessarily disparage treatment packages or names of orientations because I don't think that's going to do us any good either to me it's really about learning to speak different languages with your patient and then understanding these core common principles and risk factors and ways to address them I think if you are equipped with that if we did a manipulated training study I would think that if we train that way I'd like to believe or at least I'd hypothesize that that would outperform our typical approach of just spending a year in a certain person's team who does act or this or that or CBT or IPT or PV whatever you can collect those experiences and I think those will help you become more conversational about theory and about change processes but I think if that's all we're doing then people start to believe that that treatments treat people as opposed to people treating people and in therapy it really is people who treat people we use strategies we use techniques but we're not just prescribing something and hoping that those skills stick I mean some people do some people believe in that approach and that's okay I'm not even putting that down because part of our research on therapist effects is also showing us that some therapist will use cognitive behavioral therapy really effectively and they and others won't and vice versa some therapist will be really good at using more open ended exploratory dynamic supportive therapies but you try to get them to do a CBT protocol for example and they'll be clumsy right and so also through training I think what we can be learning is what do we personally use well not only what do we who do we treat well but what do we use well I don't like you I think if I was asked to do certain things I would just be clumsy at it right but if you asked me to do other things I might be more verbally fluent more hope inspiring things that go into the FIS construct that might just be more natural for me if I'm if I'm asked to be more call Rogers like that you know more back like you know to be to be overly simplistic about it yeah so before we wrap up let me take a real quick left turn you did a little bit of work or some work looking at different like the different mechanisms of change for different therapeutic approaches yeah so like this idea of like that outcome so for you know for if we're doing cognitive therapy and in a personal or something like that that the mechanisms of change like they might be equally as effective but if the mechanisms of change are different could you yeah yeah we did that was a really cool study with Alice coin where we did these competing competing mediator study and it was basically born out of a trial where we compared CBT alone versus CBT integrated with motivational interviewing so very client centered like and and at post treatment there was no difference right so there wasn't an additive effect of integrating motivational interviewing into cognitive therapy there was a cross follow up but will leave that to the side for now just for the idea post treatment we thought well that's normally the point at which people will stop looking for mediators or mechanisms right there was no main effective treatment to mediate statistically though you don't need a main effect to find mediators and it turns out that in that trial the CBT clinicians were very good at promoting patients trusting reliance on the therapist direction so they were just being really good teachers like CBT clinicians often are friendly and more dominant in in the approach of teaching or nurturing or taking care of or giving skill and they promoted more patient trusting following or reliance on that and that transmitted or that that was then translated into better outcome in CBT where is the M.I. therapist they engendered in their patients more than the CBT group greater sort of client agency which is what the M.I. was intended to do for those patients and that translated into significantly better outcome in that condition relative to the other so it was basically both groups were promoting something in a really effective way that that treatment was supposed to and that significantly led to better outcomes when it was higher versus when that process was lower but it also wiped out any main effect of treatment right so we have different paths to getting to the same place and if we can align the therapist delivering the treatment with the mechanism of that treatment and that goes well that's one way to get a patient to better outcome but you can see a totally different path for a different patient and then it becomes about getting patients on the path that they're most likely to respond to but I but it was so interesting and I wish that paper was read and cited more because it was really meant to be like a statistical showing of like just because you don't have a main effect doesn't mean you can't find different ways in which a treatment promoted better outcome and then we showed it and we showed how those two past suppressed the main effect and so whereas most people stop and they just say well we didn't really learn anything unique we just learn that two bona fide therapies are equally effective so what we knew that but as it turns out if we still do mediator analyses we actually found out the way or at least one way in which CBT alone helped and one way in which CBT integrated with M.I. helped and so you have these nice sort of theory specific mechanisms that were supported. Well so it might I don't know how much it gets cited but when I learned about that work several years ago like it really like it had I had a light bulb moment and that's why I brought it up because I just sort of was like this explains so much right this whole sort of dodo bird verdict of like sort of the gently speaking what treat the different orientations aren't really differences in terms of outcomes. It's sort of like well the different approaches are sort of working on the way I think about it is like they're working on different systems right and so they're all going so all of these systems matter because we are sort of all these systems are part of a whole person and so that you can impact these different systems within a person by these different ways and get sort of the equal outcome and when I was talking to Bill styles on this podcast even he was talking about sort of a similar and I'm going to butcher. And I'm going to butcher this but you know sort of this idea of that yeah if you just look at symptom reduction or quality of life improvement or whatever they're all about equal but the actual experience of the human being and what changes in the human being probably differs between the different approaches. I think that you know when you look at these other characteristics sort of like what what you guys were right so like and I just think that that's a really you know nice and more sophisticated way of thinking about these different approaches that we use and sort of you know the they're all the same it doesn't matter I sort of think like I mean sort of but that just seems too simplistic you know I just sort of like and I think you guys sort of cracked the egg open a little bit and it really at least influenced. How I think about the different approaches and their impact on people in people's experience of them and really made it much more three dimensional yeah and that's really well said right because part of it was just like. We maybe we can move out of the trial as mentality is like we're looking for comparative effects if they're not there there's no reason to go looking for mechanisms because there was no effect to explain and it's like no we can still say but but what was helpful in CBT that made it comparably effective to this or what was how. What was helpful in CBT slash am I that made it comparably effective to CBT and then it does allow us to continue to unpack add nuance think about ways that if I'm going to choose this path well then this is a variable I want to as a clinician to cultivate but if I'm doing CBT alone this is a different type of variable I want to measure and cultivate and it gives you an option as a therapist it gives you more insight into theory specific pathways to change all that can then can then sit aside alongside more common factor research that says irrespective of what you're doing these variables will matter like the alliance in both of those conditions was predictive of outcome right of course and so then yeah becomes more three dimensional becomes more nuance and it's just like all in the service of understanding sort of how people change and knowing that there are multiple ways to arrive and as you put it at different outcomes even right certainly at change but it also depends on what outcome is most important to the patient right you know if they really want to improve their self esteem that is different than reducing their symptoms and you might choose to do CBT am I because you know am I is really focused on self efficacy and self esteem but if somebody's just like I just want these symptoms to go away I just have to stop panicking you might be like well CBT I know if I can get them to like if I can get them to sort of trust me and rely on my you know rationale and follow the techniques because they believe in them then that will be the most effective way to go which brings us right back to sort of personalization in what we choose to do and responsiveness when it gets off track and I think these are just the two the two big constructs that go hand in hand when we think about individualizing therapy in an evidence-based way. So one thing I ask everyone when I chat with them is if they've had any pushback to any of their work. Yeah I mean it's it's a great question and I think the the you know not really in terms of like these you know going back and forth in journal articles with with commentaries and her bottles not really and not even with with sort of audience members and a lot of what we're presenting I think the biggest. The biggest potential pushback I think has been from the therapist who worries that the kind of narrative that could come out of the match work or the therapist performance profiles were is that it could affect their livelihood right is that it really could you know that in some ways they they could lose their job or lose their ability to have enough patience on their case load and. We have been aware of that from the beginning because we did a lot of qualitative research interviews focus groups with therapists and so from the beginning we have said we don't want that message to come out that's not the intention of our work. And so help us understand the messaging help us understand how this has to be contextualized and not oversimplified to just say well if you get a strength you should do that and if you if you don't you should stop. And we never intended it for to be that so I hope we've been because we've been been involving therapist stakeholders from beginning I think for the most part we've mitigated ahead of time the potential pushback that would would be there. And we also have all we've tried to be very clear about right now we're just talking about problem based matching it's not the only thing and we and we aren't trying to overstate the findings right there are moderators there are shortcomings there are limitations and and so hopefully that you know haven't really had a lot of pushback you know on on the ideas. So what do we do with the 4% of therapists or so that suck yeah I mean that that's that's a yeah and it's like first of all I think we'd have to be we'd have to parse the research more carefully than we currently do because again we have 4% of people who are either ineffective or harmful or some combination across the 12 domains so the ones who really suck would be or the ones who are harmful would be the real ones. So that's less than 4% that would be less than if you're okay with just this person is kind of ineffective or more average if you're okay with that you know at least not be at least do know harm kind of thing that's that's a different subset of that 4% but yeah you're right there's probably 2% of people who are actually harming their patients and so early regularly and we and that is a tough that is a tough thing to answer but if we really wanted to face the same thing. So we wanted to face that problem and we really wanted to live up to the do no harm oath I think we'd we'd have to be willing systems would have to be willing to act on that it doesn't necessarily mean well I guess it depends on the the time that which you found that out getting back to training like how long do we need in training to learn that somebody's becoming pretty regularly harmful and then you know that's an open question because it's quite possible there are some people that should just continue on in the next one. Continue on into research or teaching or another field but I'm sure many people would push back on that idea to say that it takes time and you know 5 years of graduate training isn't enough to trust that somebody's harmful right so but but even if we learned it later in a career we might have to think about how do people their interest and what they do professionally if they start to learn that they consistently produce harm and maybe even after they go through trainings it doesn't change. Yeah I mean the answer is like it would be great to help those people change direction in their career but that would be pushed back on for sure. Honestly your number is very low generally when I have conversations with people about this I'm trying to think of the there's been work done sort of on these things and usually the numbers higher than 2% so I think it's when people sort of talk about the concerning therapist so this this is a really low number and right I always sort of think about isn't again go back to teaching right like we all had teachers who were terrible. Yeah and that it just makes sense that you're going to get people in any field who aren't going to be good at it right and if we go back to the difference between between and within right at a between therapist level yes there are just some therapists whose average patient is going to get worse or or is not going to get much better right which is I just want to be clear that what I was talking about with the 4% is just the people who had no strength across any of the 12 domains right so 4% of people never had a strength. And then we were saying sub percentage some sub percentage of those might have multiple or many areas where they're harmful right that's why it's getting lower but you're right if you just think of it in terms of overall performance the number is probably higher that there are therapists out there that we might say suck right yeah but I mean I think though that your your approach to it is a more in some I mean it's more nuanced it so because of that it's actually a little more generous. Maybe even a lot more generous and that's okay opening gives you an opening to capitalize on on a strength or at least an area where your average yeah and why shouldn't we right like these people are in the field wouldn't it be nice to be able to reduce the amount of deterioration increased the amount of improvement and then there's only you know two out of a hundred and we're all parking these numbers you know two out of a hundred and if there's only two people out of a hundred that are that we really need to like try to help and or if that doesn't that that's a that's pretty optimistic I feel like yeah council out of the practice area professional yeah so so you sent me a few links that I will include are there other resources or other places where for folks who are listening who you think who would want to learn more about what we're talking about that you want to direct people towards well what I'll say is the two links are two are the they're the project pages both for the trial we talked about and the implementation follow up to that and part of the reason I sent you those is those pages also have links to any articles that have come out related to those data sets and so for the trial we've actually done a fair amount of follow up studies as well some of which we talked about so it's kind of a one stop shop for clicking on to get to articles but because you brought it up I might suggest for those who are interested reading that chapter we have on context responsive psychotherapy integration so training from that perspective and again that that came out recently in a book an edited book by Casting and Hill and I'd be happy to send you a link to that or the reference and you know for anybody who is interested in that part of our chat about training it would flesh out some of the ideas that I brought up at an overview level yeah that's perfect yeah I will link to the to to all of that so Mike I can't tell you how much I appreciate this it's been wonderful I thank you for all the kind words and for for having me ladies and gentlemen Dr. Michael Constantino that's a wrap on our conversation as I noted at the top of the show be much appreciated if you spread the word to anyone else who you think might enjoy it until next time(upbeat music)[Music]
