Maria Beckman

The therapist effect, i.e., the variation in psychotherapy outcomes attributable to individual therapists, is consistently estimated at 5-8%, yet a deeper understanding of the mechanisms remains poorly understood. This scoping review synthesizes systematic reviews and meta-analyses to clarify conceptualizations of therapist effects, assess methodological strengths and limitations, and summarize evidence in adult psychotherapy. Following PRISMA-ScR guidelines, searches were conducted in PubMed, Web of Science, and PsycINFO. Eligible studies were peer-reviewed systematic reviews or meta-analyses examining therapist-related factors and adult psychotherapy outcomes. Twenty-nine reviews met the inclusion criteria. Data on study aims, methods, main results, and conclusions were retrieved. Review quality was assessed using the AMSTAR 2. Two reviews estimated overall therapist effects without examining explanatory variables, while 27 focused on specific therapist traits or competencies. Methodological limitations were common, including limited preregistration, inadequate risk-of-bias assessment, and weak statistical approaches. Contextual moderators were rarely examined. Evidence for specific therapist characteristics was mixed, though moderate support emerged for interpersonal qualities and skills. Therapist effects appear multifaceted, involving therapist, patient, and contextual factors. Interpersonal skills show the most consistent associations with outcomes, but methodological weaknesses and limited contextual analysis constrain progress. Suggestions for future research include more rigorous study designs, including multi-level analyses.

Background: Major depression is a prevalent condition among patients with life-threatening illnesses, such as cancer, and recent findings suggest that psilocybin may hold promising treatment potential. Contemporary trials of psilocybin generally employ a model that includes psychotherapeutic support consisting of preparation and integration sessions surrounding the dosing. However, there is limited research on the psychotherapeutic component of treatment, including the skills, professional qualifications and training needed to provide it. Methods: In this study, nine nurses completed a 15-week online and on-site training program as facilitators in an ongoing randomized controlled trial of psilocybin treatment for depression. The training evaluation consisted of a subjective evaluation by the facilitators collected during and after completion of training, and an objective evaluation of the facilitators’ verbal relational skills assessed with standardized role-plays before and after completion of training. The recorded role-plays were assessed using the relational components of the Motivational Interviewing Treatment Integrity (MITI) code 4.2 and analyzed with the Wilcoxon Signed Rank Test. Results: The facilitators’ subjective evaluations indicated that the online and on-site training sessions had supported their knowledge- and skill acquisition. However, most facilitators reported that additional practical in-person training would have been necessary for them to feel adequately prepared to provide the treatment. The objective assessment of the facilitators’ verbal relational skills showed a significant increase in one of twelve MITI variables and medium to large effect sizes for six of the measures pre- to post-training. Conclusions: The training model used in this study showed potential to improve outcomes, though effects were modest and only demonstrated in role-play. The facilitators also indicated a need for additional training to feel adequately prepared. The exact requirements for the psychotherapeutic support surrounding the dosing in these treatments, including the specific skills and professional qualifications needed to provide it, remain unclear. Nonetheless, the results of this study suggest that different professionals may require distinct types of training to deliver these treatments effectively. Future studies should design training programs based on the facilitators’ baseline skills and provide clear descriptions and objective measures of both the training intervention and outcome, along with adherence measures throughout treatment. Trial registration: EudraCT: 2023-505532-35-00; Clinicaltrails.gov ID: NCT06319378. Registered 8 November 2023.

Effective training of mental health professionals is crucial for bridging the gap between research and practice when delivering cognitive behavioural therapy (CBT) and motivational interviewing (MI) within community settings. However, previous research has provided inconclusive evidence regarding the impact of training efforts. The current study aimed to systematically search, review and synthesize the literature on CBT and MI training to assess its effect on practitioner behavioural outcomes. Following prospective registration, a literature search was conducted for studies where mental health practitioners were exposed to training in face‐to‐face CBT or MI, reporting on at least one quantitative practitioner behavioural outcome. A total of 116 studies were eligible for the systematic review, and 20 studies were included in four meta‐analyses. The systematic review highlights the need to establish psychometrically valid outcome measures for practitioner behaviour. Results of the meta‐analyses suggest that training has a greater effect on practitioner behaviour change compared to receiving no training or reading a treatment manual. Training combined with consultation/supervision was found to be more effective than training alone, and no differences were found between face‐to‐face and online training. Results should be interpreted with caution due to methodological limitations in the primary studies, large heterogeneity, and small samples in the meta‐analyses. Future directions are discussed.

Editorial: The psychotherapeutic framing of psychedelic drug administration

Objective Access to effective treatments for adolescents with depression needs to improve. Few studies have evaluated behavioural activation (BA) for adolescent depression, and none remotely delivered BA. This study explored the feasibility and acceptability of therapist-guided and self-guided internet-delivered BA (I-BA) in preparation for a future randomised controlled trial (RCT). Design A single-blinded randomised controlled feasibility trial. Setting A specialist outpatient clinic in Sweden. Participants Thirty-two adolescents with mild-to-moderate major depression, aged 13–17 years. Interventions Ten weeks of therapist-guided I-BA or self-guided I-BA, or treatment as usual (TAU). Both versions of I-BA included parental support. TAU included referral to usual care within child and youth psychiatry or primary care. Outcomes Feasibility measures included study take-up, participant retention, acceptability, safety and satisfaction. The primary outcome measure was the blinded assessor-rated Children’s Depression Rating Scale, Revised. The primary endpoint was the 3-month follow-up. Results 154 adolescents were screened and 32 were randomised to therapist-guided I-BA (n=11), self-guided I-BA (n=10) or TAU (n=11). Participant retention was acceptable, with two drop-outs in TAU. Most participants in TAU had been offered interventions by the primary endpoint. The mean number of completed chapters (total of 8) for adolescents was 7.5 in therapist-guided I-BA and 5.4 in self-guided I-BA. No serious adverse events were recorded. Satisfaction was acceptable in both I-BA groups. Following an intent-to-treat approach, the linear mixed-effects model revealed that both therapist-guided and self-guided I-BA (Cohen’s d=2.43 and 2.23, respectively), but not TAU (Cohen’s d=0.95), showed statistically significant changes on the primary outcome measure with large within-group effect sizes. Conclusions Both therapist-guided and self-guided I-BA are acceptable and potentially efficacious treatments for adolescents with depression. It is feasible to conduct a large-scale RCT to establish the efficacy and cost-effectiveness of I-BA versus TAU. Trial registration number ClinicalTrials.gov Registry (NCT04117789).

As evaluation of practitioners’ competence is largely based on self-report, accuracy in practitioners’ self-assessment is essential for ensuring high quality treatment-delivery. The aim of this study was to assess the relationship between independent observers’ ratings and practitioners’ self-reported treatment integrity ratings of Motivational interviewing (MI). Practitioners (N = 134) were randomized to two types of supervision [i.e., regular institutional group supervision, or individual telephone supervision based on the MI Treatment Integrity (MITI) code]. The mean age was 43.2 years (SD = 10.2), and 62.7 percent were females. All sessions were recorded and evaluated with the MITI, and the MI skills were self-assessed with a questionnaire over a period of 12 months. The associations between self-reported and objectively assessed MI skills were overall weak, but increased slightly from baseline to the 12-months assessment. However, the self-ratings from the group that received monthly objective feedback were not more accurate than those participating in regular group supervision. These results expand findings from previous studies and have important implications for assessment of practitioners’ treatment fidelity: Practitioners may learn to improve the accuracy of self-assessment of competence, but to ensure that patients receive intended care, adherence and competence should be assessed objectively.

Supervision seems to be an essential part of therapist training and thus also of implementing evidence-based practices. However, there is a shortage of valid and reliable instruments for objective assessment of supervision competence that include both global measures and frequency counts of behaviour-two essential aspects of supervisory competence. This study tests the internal consistency and inter-rater reliability of an assessment tool that includes both these measures. Additionally, strategies and techniques used by 10 supervisors in 35 Motivational interviewing supervision sessions are described. Codings were conducted after two separate coding training sessions. The internal consistency across the global measures was acceptable (alpha = 0.70; 0.71). After the second training, the inter-rater reliabilities for all frequency counts were in the moderate to good range, except for two that were in the poor range; inter-rater reliability for one of the four global measures was in the moderate range, and three were in the poor range. A prerequisite for identifying specific supervisor skills central to the development of therapist skills, teaching these skills to supervisors and performing quality assurance of supervision, is to create instruments that can measure these behaviours. This study is a step in that direction.

Clinical supervision is a cornerstone in psychotherapist training, but research in this area is hampered by a lack of validated tools for assessing supervision quality. Short-SAGE (Supervision: Adherence and Guidance Evaluation) is an observational instrument designed for evaluating supervision in cognitive behavioural therapy. The aim of this study was to evaluate the inter-rater reliability of Short-SAGE. Four experienced clinical psychologists participated in three 3-hour Short-SAGE coding training sessions, followed by an additional meeting and coding instructions. In a cross-over design, codings of 20 supervision sessions were then assessed with intraclass correlations (ICC), for both the 3- and 7-point scales of the instrument. In the single measure analyses for both scales, only one item showed ICC in the good range, and the rest of the 14 item ICCs were in the poor to fair range. Moreover, on the 3-point scale, five of the 14 inter-rater correlations were non-significant. For research and training purposes, validated tools to assess supervision quality are highly needed. However, instruments for measuring adherence and/or competence are of little value if the coders do not attain inter-rater reliability. Whether quality of supervision is associated with improvements in supervisees' competencies is not yet clear. Short-SAGE provides a tool that may enable empirical research in this area. Further studies are needed to assess whether extensive training can improve the inter-rater reliability of Short-SAGE.

Background: The effects of the use of objective feedback in supervision on the supervisory relationship and skill acquisition is unknown. Aims: The objective of this study was to evaluate the effects of two different types of objective feedback provided during supervision in motivational interviewing (MI) on: (a) the supervisory relationship, including potential feelings of discomfort/distress, provoked by the supervision sessions, and (b) the supervisees' skill acquisition. Method: Data were obtained from a MI dissemination study conducted in five county councils across five county councils across Sweden. All 98 practitioners recorded sessions with standardized clients and were randomized to either systematic feedback based on only the behavioral component of a feedback protocol, or systematic feedback based on the entire protocol. Results: The two different ways to provide objective feedback did not negatively affect the supervisory relationship, or provoke discomfort/distress among the supervisees, and the group that received the behavioural component of the feedback protocol performed better on only two of the seven skill measures. Conclusions: Objective feedback does not seem to negatively affect either the supervisor-supervisee working alliance or the supervisees' supervision experience. The observed differences in MI skill acquisition were small, and constructive replications are needed to ascertain the mode and complexity of feedback that optimizes practitioners' learning, while minimizing the sense of discomfort and distress.