For my Presidential Initiative, I have chosen a topic dear to my heart, that of what therapists DO in sessions that help clients change. I assert that while client factors (e.g., personality, diagnoses, motivation), therapist factors (e.g., personality, training, theoretical orientation) and the therapeutic relationship (e.g., working alliance) are incredibly important, what therapists do is also important. Therapists do not just sit there passively but rather are actively formulating case conceptualizations and planning and implementing interventions to move clients along the change process because of course we all want to help clients function more effectively in life.
It is important here to distinguish skills (e.g., microinterventions, such as questions or interpretations) and methods (sequences of skills intended to target a specific activity (e.g., dream work, cognitive restructuring) from the larger treatment packages (e.g., CBT, psychodynamic therapy). Indeed, the larger treatment packages are composed of methods which are composed of skills. Much of our research has been aimed at comparing the different treatment packages but relatively little has aimed at examining the effects of different skills (which are used across treatments).
This assertion that therapist skills and methods make a difference probably seems obvious to psychotherapists. Of course, we do something to help clients change. It’s not just a nice relationship, it’s not just client expectations, we actually have to do something to help clients change. And yet, we have not been able to show empirically that therapist techniques (skills, interventions, methods) make much difference.
How could that be?
Well, to start with, our research is very blunt and we have yet to have research methods that help us understand the complexity of the psychotherapy endeavor (I say this after 50 some years of trying to do psychotherapy research).
Second, a big factor is that every therapist and client are different. What works for one therapist with one client does not necessarily work for that therapist with another client or for other therapists and clients because other factors need to be accounted for (e.g., timing, personality factors, needs in the moment, transference, countertransference). During training, trainees can learn basic and advanced skills but what to do in therapy with an individual client cannot be predicted by statistics that average across all clients.
My Personal Story
When I started graduate school, I was introverted and lacked confidence about helping others. I took a course in helping skills and gradually learned that helping skills could be learned. By practicing, I became better. I started teaching helping skills, and then I started doing research on therapist techniques. I got incredibly frustrated trying to study therapist techniques because the typical research paradigm of correlating frequency of occurrence of different skills in relation to treatment outcome yielded mixed results and just dd not pass the common sense test (e.g., why should more be better?).
I have been lucky during my career to have a teaching track, a therapist track, and a researcher track. As a teacher, I continued the tradition of helping skills that I learned in graduate school (Carkhuff, 1969) and kept modifying it based on my continued learning about theories, practice, and feedback from students who challenged every idea, resulting in a text about helping skills (Hill, 2020). As a researcher, I spent considerable time trying to operationalize what I was teaching so that I could study it in psychotherapy…that resulted in a lot of false starts, but I feel like we’re getting closer to the clinical phenomena in some of our recent research (e.g., Anvari et al., 2020, in press; Hill et al., 2020; Prass et al., 2021). As a clinician, I realized that what I preached (i.e., taught) did not always work and I did not always do what I said should be done (e.g., use mostly reflections of feelings). So, yes, my clients and students taught me a lot. I would say that what has been difficult is having a different opinion than the “received view” (e.g., that the therapeutic relationship is the all-important mechanism of change and that techniques do not matter).
The Task Force
John Norcross headed up three task forces highlighting the crucial importance of the therapeutic relationship (Norcross, 2002, 2011; Norcross & Lambert, 2018). We extend the work of these previous task forces by highlighting the importance of therapist skills and methods. John Norcross and I are co-heading this task force co-sponsored by the Society for the Advancement of Psychotherapy, Society for Counseling Psychology, Society for Psychotherapy Research, and Society for the Exploration of Psychotherapy Integration. We have an international steering committee with well-known psychotherapy clinicians and researchers.
We have now commissioned about 30 chapters in a book to be published by Oxford University Press and subsequently to be published in condensed form in journals. In one major section of the book, we focus on psychotherapy skills, which we define as more discrete interventions (e.g., nonverbal behaviors, silences, questions, reflection responses, challenges, interpretations, direct guidance, metaphors, and Socratic dialogue). In the other major section of the book, we focus on psychotherapy methods, which we define as broader sequences of skills (e.g., providing a treatment rationale, assessment as an intervention, teaching emotion regulation, chair work, dream work, between session homework, exposure, mindfulness/acceptance/meditation methods, routine outcome monitoring, working with cultural diversity, strengths-oriented methods, mentalization, behavioral activation, cognitive restructuring). We are very fortunate to have some of the best researchers writing chapters, and we expect the book to come out in 2023.
As an example, with Sarah Knox and Changming Duan I am co-authoring of one of the chapters on the outcomes of advice, suggestions, and recommendations in psychotherapy (not including homework assignment and process advisement). This skill is controversial across theoretical orientations (advocated by CBT, advised against by psychodynamic and humanistic), and yet it can be argued that advice, suggestions, and recommendations are used at least somewhat by many therapists. In fact, one could argue that encouraging clients to express feelings, take responsibility, or gain self-awareness implicitly suggest and promote these activities. Reviewing the literature has enabled me to think more deeply about our assumptions about what works in psychotherapy.
Meanwhile, I challenge all of you to think about how therapist skills and methods work in psychotherapy and how we can study them in a more clinically relevant way. As I tell my helping skills students, all the skills and methods are potentially helpful and harmful, so we need to know more about when and how to use them and how to assess the effects. I hope that this project stimulates more researchers to study the effects of therapist skills and methods and innovative clinically-relevant ways.
And of course, a major goal is to improve our training of psychotherapists and our treatment of clients (patients). We need more of an evidence base about how skills and methods work to improve our training and practice.
I’ll be keeping you informed about our progress.
Cite This Article
Hill, C. (2021). 2021 president’s column 56(4): Therapists’ skills and methods that work. Psychotherapy Bulletin, 56(4), 2-4.
Anvari, M., Dua, V., Lima Rosas, J., Hill, C. E., & Kivlighan, D. M. Jr. (in press). Facilitating exploration in psychodynamic psychotherapy: Therapist skills and client attachment. Journal of Counseling Psychology,
Anvari, M., Hill, C. E., & Kivlighan, D. M. Jr. (2020). Therapist skills associated with client emotional expression in psychodynamic psychotherapy. Psychotherapy Research, 30(7),900-911. https://dx.doi.org/10.1080/10503307.2019.1680901
Carkhuff, R. R. (1969). Human and helping relations (Vols. 1 and 2). New York: Holt, Rinehart, & Winston.
Hill, C. E. (2020). Helping skills: Facilitating exploration, insight, and action (5th ed). Washington DC: American Psychological Association.
Hill, C. E., Lu., Y., Gerstenblith, J., Kline, K., Wang, J., Lu, Y, & Zhu, Xu (2020). Facilitating client collaboration and insight through interpretations and probes for insight in
psychodynamic psychotherapy: A case study of one client with three successive therapists. Psychotherapy, 57(2), 263-272. https://doi.org/10.1037/pst0000242
Norcross, J. C. (Ed.) (2002). Psychotherapy relationships that work: Therapist contributions and responsiveness to patient needs. New York, NY: Oxford University Press.
Norcross, J. C. (Ed.) (2011). Psychotherapy relationships that work: Evidence-based responsiveness. New York, NY: Oxford University Press.
Norcross, J. C. (Ed.) (2019). Psychotherapy relationships that work: Volume 1: Evidence-based therapist contributions. New York, NY: Oxford University Press.
Prass, M., Ewell, A., Hill, C. E., & Kivlighan, D. M. Jr (2021). Solicited and unsolicited advice-giving in psychotherapy: Is it advised? Counselling Psychology Quarterly,34(2), 253-274. https://dx.doi.org/10.1080/09515070.2020.1723492