The effect that therapist factors can have on treatment outcomes has been studied previously (Castonguay & Hill, 2017; Norcross & Lambert, 2019; Wampold & Imel, 2015). Findings are contradictory on the role of therapist factors such as age, gender and theoretical orientation on the effectiveness of delivering psychological interventions. For example, therapist factors have been shown to reduce symptoms in depression (Strunk et al., 2010) and improve outcomes for patients with social anxiety disorder (Ginzburg et al., 2012). However, other research indicates that there is no relationship between therapist factors and treatment outcome (Webb et al., 2010).
Previous research has indicated that therapists feel that they lack confidence to deliver evidence-based trauma focused cognitive behavioural therapy (TF-CBT) (Finch, Ford, Grainger & Meister-Stedman, 2020).
There are a few studies that have focused on child and adolescent populations for receiving TF-CBT. Pfeiffer et al (2020) examined the effectiveness of TF-CBT in children and adolescents finding that there was no significance between a therapist’s background and experience on a patients treatment outcome.
The aim of this study was to explore whether therapist characteristics such as gender, clinical experience and theoretical background reduced symptoms of PTSD within children and adolescents (Grainger et al, 2022).
The authors conducted a systematic review. The systematic review included studies of TF-CBT interventions that had used a randomised controlled trial (RCT) methodology. The following inclusion criteria were outlined:
- Random allocation of participants
- TF-CBT intervention for child/adolescent PTSD, in comparison with a passive or active control group
- Average participant age below 18 years of age in the total sample size
- At least 10 participants per group at post treatment/follow up
Each study underwent a thorough quality assessment criteria (Cuijpers et al., 2010) whereby a study was considered to be high quality when:
- Participants met the diagnostic criteria of PTSD
- A treatment manual was utilised
- Practitioners who delivered the therapy were appropriately trained
- Treatment integrity was reviewed
- Data was analysed with intent to treat
- At least 50 participants were compared with the treatment and control outcome
- Randomisation was conducted by an independent party
- Outcome assessments were blinded to treatment condition
Overall, the studies were scored with a ‘moderate quality’, receiving a mean score of 5.8. None of the studies included in the meta-analysis received a score of between 0 and 2, with three studies receiving a score of 3 and seventeen studies were rated as high quality. The remainder of the studies received a quality rating between 4 and 6.
A total of 40 trials were included in the systematic review, exploring the effect of the therapist’s professional background on treatment outcomes.
A significant moderating effect was found when comparing treatment outcomes of clinical psychologists and psychiatrists versus other professionals (p = .044). However, the majority of these studies included a passive control group, and when these were removed, the effect no longer remained.
There were no significant relationships found between therapist’s educational attainment (e.g. masters level or above vs other / lay vs professional) and treatment outcomes.
The data shows that therapist level of professional training and experience has no effect on the outcomes of trauma-focussed CBT in children and young people.
Strengths and limitations
- The review has identified an undervalued area of research, where therapist factors have not been identified in the treatment of PTSD
- The paper addressed a clearly focused question about the significance of the therapist in delivering TF-CBT
- There was a good amount of research included in the review with results from 40 RCTs being synthesised
- A thorough quality assessment was used for the research papers, with an 8 stage process
- The results can be applied to practitioners delivering TF-CBT to children and adolescents.
- There was a limited evidence base shown in the reviews and an inconsistency in the therapist data reported to researchers
- It appears it was difficult to distinguish the educational abilities of professionals involved in the studies as this was not often declared during the study. Therefore it may be difficult to ascertain the educational attainments for all participants.
- Cultural differences were not explored due to there being various training routes in different countries.
Implications for practice
The meta-analysis has shown that professionals with minimal professional training can reduce PTSD symptoms, as effectively as doctoral trained clinicians. This indicates a potential future workforce development with the ability to appropriately train professionals in TF-CBT. Future exploration of specific therapist factors such as therapeutic techniques and therapeutic relationships would be greatly beneficial to understand the significance in reducing PTSD symptoms within the child and adolescent population.
With the current evidence indicating that therapists lack confidence and competence in delivering this intervention, a workshop on Cognitive Therapy for PTSD organised by Bespoke Mental Health aimed to explore these factors in further detail. The workshop was delivered by Professor Richard Meister-Stedman and is available in the event archive on the Bespoke Mental Health website.
Statement of interests
Grainger, L., Thompson, Z., Morina, N., Hoppen, T., & Meiser‐Stedman, R. (2022). Associations between therapist factors and treatment efficacy in randomized controlled trials of trauma‐focused cognitive behavioral therapy for children and youth: A systematic review and meta‐analysis. Journal of Traumatic Stress.
Castonguay, L. G., & Hill, C. E. (Eds.). (2017). How and why are some therapists better than others?: Understanding therapist effects (pp. xv-356). Washington, DC: American Psychological Association.
Cuijpers, P., van Straten, A., Bohlmeijer, E., Hollon, S. D., & Andersson, G. (2010). The effects of psychotherapy for adult depression are overestimated: a meta-analysis of study quality and effect size. Psychological medicine, 40(2), 211-223.
Finch, J., Ford, C., Grainger, L., & Meiser-Stedman, R. (2020). A systematic review of the clinician related barriers and facilitators to the use of evidence-informed interventions for post traumatic stress. Journal of Affective Disorders, 263, 175-186.
Ginzburg, D. M., Bohn, C., Höfling, V., Weck, F., Clark, D. M., & Stangier, U. (2012). Treatment specific competence predicts outcome in cognitive therapy for social anxiety disorder. Behaviour Research and Therapy, 50(12), 747-752.
Norcross, J. C., & Lambert, M. J. (Eds.). (2019). Psychotherapy relationships that work: Volume 1: Evidence-based therapist contributions. Oxford University Press.
Pfeiffer, E., Ormhaug, S. M., Tutus, D., Holt, T., Rosner, R., Wentzel Larsen, T., & Jensen, T. K. (2020). Does the therapist matter? Therapist characteristics and their relation to outcome in trauma-focused cognitive behavioral therapy for children and adolescents. European journal of psychotraumatology, 11(1), 1776048.
Strunk, D. R., Brotman, M. A., DeRubeis, R. J., & Hollon, S. D. (2010). Therapist competence in cognitive therapy for depression: predicting subsequent symptom change. Journal of consulting and clinical psychology, 78(3), 429.
Wampold, B. E., & Imel, Z. E. (2015). The great psychotherapy debate: The research evidence for what works in psychotherapy (2nd ed.). Routledge.
Webb, C. A., DeRubeis, R. J., & Barber, J. P. (2010). Therapist adherence/competence and treatment outcome: A meta-analytic review. Journal of consulting and clinical psychology, 78(2), 200.