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Psychotherapy Training: Is it Worth the Bother?

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Big bucks.  That’s what training in psychotherapy costs.  Take graduate school in psychology as an example.  According to the US Department of Education’s National Center (NCES), a typical doctoral program takes five years to complete and costs between US$ 240,000-300,000.00.

Who has that kind of money laying around after completing four years of college?  The solution? Why, borrow the money, of course!  And students do.  In 2009, the average amount of debt of those doctoral students in psychology who borrowed was a whopping US$ 88,000–an amount nearly double that of the prior decade.  Well, the training must be pretty darn good to warrent such expenditures–especially when one considers that entry level salaries are on the decline and not terribly high to start!

Oh well, so much for high hopes.

Here are the facts, as recounted in a recent, concisely written summary of the evidence by John Malouff:

1. Studies comparing treatments delivered by professionals and paraprofessionals either show that paraprofessionals have better outcomes or that there is no difference between the two groups;

2. There is virtually no evidence that supervision of students by professionals leads to better client outcomes (you should have guessed this after reading the first point);

3. There is no evidence that required coursework in graduate programs leads to better client outcomes.

If you are hoping that post doctoral experience will make up for the shortcomings of professional training, well, keep hoping.  In truth, professional experience does not correlate often or significantly with client therapy outcomes.

What can you do?  As Malouf points out, “For accrediting agencies to operate in the realm of principles of evidence-based practice, they must produce evidence…and this evidence needs to show that…training…contribute(s) to psychotherapy outcomes…[and] has positive benefits for future clients of the students” (p. 31).

In my workshops, I often advise therapists to forgo additional training until they determine just how effective they are right now.  Doing otherwise, risks perceiving progress where, in fact, none exists.  What golfer would buy new clubs or pursue expensive lessions without first knowing their current handicap?  How will you know if the training you attend is “worth the bother” if you can’t accurately measure the impact of it on your performance?

Determining one’s baseline rate of effectiveness is not as hard as it might seem.  Simply download the Outcome Rating Scale and begin using it with your clients.  It’s free.  You can then aggregate and analyze the data yourself or use one of the existing web-based systems (www.fit-outcomes.com or www.myoutcomes.com) to get data regarding your effectiveness in real time.

After that, join your colleagues at the upcoming Advanced Intensive Training in Feedback Informed Treatment.   This is an “evidence-based” training event.  You learn:

• How to use outcome management tools (e.g., the ORS) to inform and improve the treatment services you provide;

• Specific skills for determining your overall clinical success rate;

• How to develop an individualized, evidence-based professional development plan for improving your outcome and retention rate.

There’s a special “early bird” rate available for a few more weeks.  Last year, the event filled up several months ahead of time, so don’t wait.

On another note, just received the schedule for the 2013 Evolution of Psychotherapy conference.  I’m very excited to have been invited once again to the pretigious event and will be bring the latest information and research on acheiving excellence as a behavioral health practitioner.  On that note, the German artist and psychologist, Andreas Steiner has created a really cool poster and card game for the event, featuring all of the various presenters.  Here’s the poster.  Next to it is the “Three of Hearts.”  I’m pictured there with two of my colleagues, mentors, and friends, Michael Yapko and Stephen Gilligan:

Why is this man laughing?

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May 4th, 2011
Copenhagen, Denmark

Just finished my first day of a two week trip covering spots in Denmark and Holland.  Yesterday, I traveled to Copenhagen from Hilo, Hawaii where I was presenting for the Hawaiian Association of Marriage and Family Therapy.  Dr. Gay Barflied (pictured on the far left above) spent years lobbying to bring me to the “Big Island” for the conference, where I spoke about the latest research on expertise and excellence in the field of behavioral health.  I met so many dedicated and talented clinicians in Hilo, including marriage and family therapist, Makela Bruno-Kidani (pictured in the middle photo above) who started the day off with a traditional Hawaiian chant and then presented me with two beautiful lei to wear during the event.

On a break, Gay mentioned an article that appeared in the May/June 1995 issue of AHP Perspective.  In it, she said, Maureen O’Hara, president of the Association for Humanistic Psychology, quoted one of the first articles me and my colleagues wrote on the common factors, “No More Bells and Whistles” (I’ll upload a copy to the “publications and handouts” section of the website as soon as I’m back in the States).  Carl Rogers, she said, would have been laughing (happily, that is) had he read the findings we cited documented the lack of differential efficacy of competing treatment approaches.  We had, in essence, proved him right!

“It turns out,” OHara wrote, “that Miller, Hubble, and Duncan come to similar conclusions.  Carl Rogers was right.  After all our forays into the dizzing arcana of paradoxical interventions, inner children, narrative therapy, EMDR, behaviorism, psychopharmacology, bioenergetics, TA, Jungian analysis, psychodrama, Gestalt, and so on down the entire list of hundred brand named therapies, what actually creates change is the…creation of a relationship between client and therapist…”.

I’d never seen the article before.  It brought back very positive memories about the journey that has led most recently to the study of excellence.  Indeed, as we point out in the lead article in the upcoming May/June 2011 issue of the Psychotherapy Networker, relationships are not only the “sine qua non” of healing for clients but are responsible for the professional growth for therapists.

Hope Transcends: Learning from our Clients

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“Hope Transcends” was the theme of the 39th Annual Summer Institute on Substance Abuse and Mental Health held in Newark, Delaware this last week.  I had the honor of working with 60+ clinicians, agency managers, peer supports, and consumers of mental health services presenting a two-day, intensive training on “feedback-informed clinical work.”  I met so many talented and dedicated people over the two days and even had a chance to reconnect with a number of folks I’d met at previous trainings– both at the Institute and elsewhere.

One person I knew but never had the privilege of meeting before was psychologist Ronald Bassman.  A few years back, he’d written a chapter that was included in my book, The Heroic Client.  His topic at the Summer Institute was similar to what he’d written for the book: harmful treatment.  Research dating back decades documents that approximately 10% of people deteriorate while in psychotherapy.  The same body of evidence shows that clinicians are not adept at identifying: (a) people who are likely to drop out of care; or (b) people who are deteriorating while in care.

Anyway, you can read about Ron on his website or pick up his gripping book A Fight to Be.  Briefly, at age 22 Ron was committed to a psychiatric hospital.  Over the next several years, he was diagnosed with paranoid schizophrenia and forcefully subjected to a series of humiliating, painful, degrading and ultimately unhelpful “treatments.”  Eventually, he escaped his own and the systems’ madness and became a passionate advocate for improving mental health services.  His message is simple: “we can and must do better.”  And, he argues persuasively, the process begins with building better partnerships with consumers.

One way to build bridges with consumers is routinely seeking their feedback regarding the status of the therapeutic relationship and progress of any services offered.  Indeed, the definition of “evidence-based practice” formally adopted by the American Psychological Association mandates that the clinician “monitor…progress…[and] If progress is not proceeding adequately…alters or addresses problematic aspects of the treatment (e.g., problems in the therapeutic relationship or the implementation of the goals of treatment)” (pp. 276-277, APA, 2006).  Research reviewed in detail on this blog documents significant improvement in both retention and outcome when clinicians use the Outcome and Session Rating Scales to solicit feedback from consumers.  Hope really does transcend.  Thank you Ron and thank you clinicians and organizers at the Institute.

And now, just for fun.  Check out these two new videos:


The Impact of Mentors

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Brendan Madden   Scott D. Miller   Jeffrey K. Zeig

A little over month ago, I blogged about how the outcome and session rating scales were originally conceived of and developed.  A few days prior to that, I wrote about where the whole idea of using measures to solicit feedback had started.  In both instances, my teachers and supervisors played a significant role. Immediately following a two day workshop I’d given in Israel, psychologist Haim Omer suggested developing a visual analog scale that could be used in lieu of the longer Outcome Questionnaire 45.2–an idea that literally changed the entire arc of my professional career.  Drs. Lynn Johnson and Michael Lambert–a supervisor and professor I met and worked with as a graduate student–were the first to pioneer feedback-informed treatment (FIT).  Some twenty plus years into my career, I remain in contact with both, calling, seeking input, discussing ideas, and soliciting feedback.

“Professional coaches,” says the noted “expert on experts” K. Anders Erickson, “…play an essential role in guiding…future experts in a safe and effective manner” (p. 698).   Needless to say, I’ve been very fortunate to have such visionary mentors.  One more story.

In 1984, I wrote a letter to Dr. Jeffrey K. Zeig, the director of the Milton H. Erickson Institute.  I was in my second year of a Ph.D. program in psychology and, like many graduate students, dead broke.  While taking a course on hypnosis as part of my studies, I’d become interested in the work of Milton Erickson.

“I’d like to learn more,” I wrote at the time, “Would it be possible for me to visit the Institute, watch some videos and have a chance to talk with you?”  I wasn’t too far away.  I could drive to Phoenix where the Institute was located.  I could even arrange to stay with friends to save money.  “Dr. Zeig,” I continued, “I’m a graduate student and don’t have much money, but I’d be willing to do some work in kind.”  I’d pasted mailing labels on thousands of brochures for the local hypnosis and therapy organizations, for example, in exchange for being able to attend professional continuing education events.  “I’ll vacuum and clean the office, wash vehicles, do filing.  Whatever might be helpful to you or the Institute.”

Within a couple of weeks, an envelop from the Milton H. Erickson Institute arrived.  In it was a letter that was brief and to the point.  “Please call me,” it said, and was signed Jeffrey K. Zeig, Ph.D.  Needless to say, I called straight away.  We chatted for a few minutes.  He told me that I was welcome to visit the Institute, watch videos, talk with some of the staff and even spend some time with him.  And then he asked, “Do you think you could afford five dollars?”  I was floored.

Ever since meeting him on that hot summer day in Phoenix, he’s been an important teacher and mentor.  It’s particularly noteworthy that whenever we talk–by phone, email, or in chance meetings on airplanes while criss-crossing the globe–he invariably asks, “What are you learning?”  And then he listens, intently.

Last week, we were catching up on the phone and Jeff told me that his long-held desire to open an international psychotherapy training and research facility had finally been fulfilled.  Briefly, The Institute for Applied Therapeutic Change is a real clinic where professionals and students can learn the latest in behavioral healthcare from leading experts in the field and while working with real clients (click on the text above for the complete press release).

“I can hardly wait to attend some of the events,” I said.  “And when are you available to teach?” he responded.   Stunned again.  I’m so fortunate and can hardly wait to participate in the Institute activities as both a presenter and student.  Stay tuned to the Foundation website for more details!

Deliberate Practice, Expertise, & Excellence

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Later today, I board United flight 908 on my way to workshops scheduled in Holland and Belgium.  My routine in the days leading up to an international trip is always the same.  I slowly gather together the items I’ll need while away: computer (check); european electric adapter (check); presentation materials (check); clothes (check).   And, oh yeah, two decks of playing cards and close up performance mat.

That’s me (pictured above) practicing a “ribbon spread” in my hotel room following a day of training in Marion, Ohio.  It’s a basic skill in magic and I’ve been working hard on this (and other moves using cards) since last summer.  Along the way, I’ve felt both hopeful and discouraged.  But I’ve kept on nonetheless taking heart from what I’m reading about skill acquisition.

Research on expertise indicates that the best performers (in chess, medicine, music, sports, etc.) practice every day of the week (including weekends) for up to four hours a day.  Sounds tiring for sure.  And yet, the same body of evidence shows that world class performers are able to sustain such high levels of practice because they view the acquisition of expertise as a long-term process.  Indeed, in a study of children, researcher Gary McPherson found that the answer to a simple question determined the musical ability of kids a year later: “how long do you think you’ll play your instrument?”  The factors that were shown to be irrelevant to performance level were: initial musical ability, IQ, aural sensitivity, math skills, sense of rhythm, income level, and sensorimotor skills.

The type of practice also matters.  When researchers Kitsantas and Zimmerman studied the skill acquisition of experts, they found that 90% of the variation in ability could be accounted for by how the performers described their practice; the types of goals they set, how they planned and executed strategies, self-monitored, and adapted their performance in response to feedback.

So, I take my playing cards and close-up mat with me on all of my trips (both domestic and international).  I don’t practice on planes.  Gave that up after getting some strange stares from fellow passengers as they watched me repeat, in obsessive fashion, the same small segment of my performance over, and over, and over again.  It only made matters worse if they found out I was a psychologist.  I’d get that “knowing look,” that seemed to say, “Oh yeah.”  Anyway, I also managed to lose a fair number of cards when the deck–because of my inept handling while trying to master some particular move–went flying all over the cabin (You can imagine why I’ve been less successful in keeping last year’s New Year resolution to learn to play the ukelele).

Once I’m comfortably situated in my room, the mat and cards come out and I work, practice a specific handling for up to 30 minutes followed by a 15-20 minute break.  Believe it or not, learning–or perhaps better said, attempting to learn–magic has really been helpful in understanding the acquisition of expertise in my chosen field: psychology and psychotherapy.  Together with my colleagues, we are translating our experience and the latest research on expertise into steps for improving the performance and outcome of behavioral health services.  This is, in fact, the focus of the newest workshop I’m teaching, “Achieving Clinical Excellence.”   It’s also the organizing theme of the ICCE Achieving Clinical Excellence conference that will be held in Kansas City, Kansas in October 2010.  Click on the photo below for more information.

In the meantime, check out the two videos I’ve uploaded to ICCETV featuring two fun magic effects.  And yes, of course, feedback is always appreciated!

Magical Moments in Kansas

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Registrations are already coming in for the first International Conference on “Achieving Clinical Excellence.”

Not too long ago, I announced that internationally known researcher K. Anders Erickson, Ph.D.–the “expert on experts”–had agreed to present at the event.  At that time, I also indicated that a number of internationally accomplished performers from a variety of professions (including psychology, business, medicine, science, music, entertainment, and sports) would be with us in Kansas City to teach and inspire.  Attendees will learn the science and skills for achieving their personal best as a behavioral health practitioner by literally learning from the best.

Practice, as anyone who has been reading my recent blogosts and publications knows, is key for achieving excellence–and not just any old kind will do.  To be effective, it must be deliberate, reflective, and ongoing.   What’s more, it must be accompanied with high levels of support and detailed instruction from exceptional teachers.

michael ammart

No performer embodies these two principles–dedicated practice and exceptional teaching–better than FISM gold-medial winning magician, Michael Ammar.  Magic magazine named him one of the 100 most influential magicians of the century.

Michael will open the second day of the the conference.  First, he’ll perform. What can I say?  You’ll be astonished and amazed.  After that, Michael will talk about the role of practice in achieving excellence.  He’s a master teacher who has spent years studying the elements of successful practice.  He’ll not only inspire you, he will provide you with the means to excel.

Join us for three action packed days of fun, science and skill building.  In the meantime, if you have a spare moment, watch Michael Ammar perform one of the classics of magic: the cups and balls.

 

Common versus Specific Factors and the Future of Psychotherapy: A Response to Siev and Chambless

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Early last summer, I received an email from my long time friend and colleague Don Meichenbaum alerting me to an article published in the April 2009 edition of the Behavior Therapist–the official “newsletter” of the Association for Behavioral and Cognitive Therapies–critical of the work that I and others have done on the common factors.

Briefly, the article, written by two proponents of the “specific treatments for specific disorders” approach to “evidence-based practice” in psychology, argued that the common factors position–the idea that the efficacy of psychotherapy is largely due to shared rather than unique or model-specific factors–was growing in popularity despite being based on “fallacious reasoning” and a misinterpretation of the research.

Although the article claimed to provide an update on research bearing directly on the validity of the “dodo verdict”–the idea that all treatment approaches work equally well–it simply repeated old criticisms and ignored contradictory, and at times, vast evidence.  Said another way, rather than seizing the opportunity they were given to educate clinicians and address the complex issues involved in questions surrounding evidence-based practice, Siev and Chambless instead wrote to “shore up the faithful.”  “Do not doubt,” authors Siev and Chambless were counseling their adherents, “science is on our side.”

That differences and tensions exist in the interpretation of the evidence is clear and important.  At the same time, more should be expected from those who lead the field.  You read the articles and decide.  The issues at stake are critical to the future of psychotherapy.  As I will blog about next week, there are forces at work in the United States and abroad that are currently working to limit the types of approaches clinicians can employ when working with clients.  While well-intentioned, available evidence indicates they are horribly misguided.  Once again, the question clinicians and consumers face is not “which treatment is best for that problem,” but rather “which approach “fits with, engages, and helps” the particular consumer at this moment in time?”

How NOT to Achieve Clinical Excellence: The Sorry State of Continuing Professional Education

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Greg Neimeyer, Ph.D., is causing quite a stir in continuing education circles.  What has he done?  In several scholarly publications, he’s reviewed the existing empirical literature and found that continuing professional education in heavioral health is not particularly, well, …educational.  Indeed, in a soon-to-be published piece in the APA journal, Professional Psychology, he notes, “While the majority of studies report high levels of participants’ satisfaction with their CE experiences, little attention has been paid to assessing actual levels of learning, the translation of learning into practice, or the impact of CE on actual professional service delivery outcomes.”   Neimeyer then goes on to cite a scholarly review published in 2002 by Daniels and Walter which pointed out that “a search [of the research literature] revealed no controlled studies of the impact of continuing education in the…behavioral health disciplines” (p. 368).  Said another way, the near ubiguitous mandate that clinicians attend so many hours per year of approved “CE” events in order to further their knowledge and skill base has no empirical support.

Personally, my guess is that any study that might be done on CE in Behavioral Health would show little or no impact on performance anyway.  Why?  Studies in other fields (i.e., medicine, flight training) have long documented that traditional CE activities (i.e., attending conferences, lectures, reading articles) have no demonstrable effect.  So, what does work?  The same research that calls the efficacy of current CE activities into questions provide clear guidance: namely, brief, circumscribed, skill-based training, followed by observed practice, real-time feedback, and performance measurement. Such characteristics are, in fact, part and parcel of expert performance in any field.  And yet, it is virutally non-existent in behavioral health.

Let me give you an example of a CE offering that arrived in my box just this week.  The oversized, multi-color, tri-fold brochure boldly asserts a workshop on CBT featuring the “top evidence-based techniques.”  Momentarily setting aside the absolute lack of evidence in support of such trainings, consider the promised content–and I’m not kidding: clinical applications of cognitive behavior therapy, motivational interviewing, cognitive therapy, mindfulness and acceptance based therapies, and behavior therapy.  As if that were not enough, the outline for the training indicates that participants will learn 52 other bulleted points, including but not limited to: why CBT, integration of skills intro practice, identifying brain-based CBT strategies, the latest research on CBT, the stages of change, open-ended and reflective listening, behavioral activiation, acceptance and commitment, emotional regulation and distrss tolerance skills, the ABC technique to promote rational beliefs, homework assignments that test core beliefs, rescripting techniques for disturbing memories and images…and so on…AND ALL IN A SINGLE 6 HOUR DAY!  You say you have no money? Your agency has suffered budget cuts?  No worries, the ad states in giant print, as the same content is available via CD, web and podcast.

Such an agenda defies not only the evidence but strains credulity to the breaking point.  Could anyone accomplish so much in so little time?  Clinicians deserve and should demand more from the CE events they register for and, in many instances, are mandated to attend in order to maintain licensure and certification.  The International Center for Clinical Excellence web platform will soon be launched.  The mission of the site, as indicated in my blog post of August 25th, is to “support clinical excellence through creating virtual clinical networks, groups and clinical communities where clinicians can be supported in the key behavior changes required for developing clinical excellence.”  Members of the site will use a variety of social networking and collaborative tools to learn skills, obtain real-time feedback, and measure their performance.    Anyway, kudos to Dr. Greg Neimeyer for confronting the ugly truth about CE in behavioral health and saying it out loud!

Superior Performance as a Psychotherapist: First Steps

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So what is the first step to improving your performance?  Simply put, knowing your baseline.  Whatever the endeavor, you have to keep score.  All great performers do.  As a result, the performance in most fields has been improving steadily over the last 100 years.

Consider, for instance, the Olympics. Over the last century, the best performance for every event has improved–in some cases by 50%!  The Gold Medal winning time for the marathon in the 1896 Olympics was just one minute faster than the entry time currently required just to participate in the Chicago and Boston marathons.

By contrast, the effectiveness of psychological therapies has not improved a single percentage point over the last 30 years.  How, you may wonder, could that be?  During the same time period: (1) more than 10,000 how-to books on psychotherapy have been published; (2) the number of treatment approaches has mushroomed from 60 to 400; and (3) there are presently 145 officially approved, evidenced-based, manualized treatments for 51 of the 397 possible DSM IV diagnostic groups.  Certainly, given such “growth,” we therapists must be more effective with more people than ever before.  Unfortunately, however, instead of advancing, we’ve stagnated, mistaking our feverish peddling for real progress in the Tour de Therapy.

Truth is, no one has been keeping score, least of all we individual practitioners. True, volumes of research now prove beyond any doubt that psychotherapy works.  Relying on such evidence to substantiate the effectiveness of one’s own work, however, is a bit like Tiger Woods telling you the par for a particular hole rather than how many strokes it took him to sink the ball.  The result on outcome, research indicates, is that effectiveness rates plateau very early in most therapists careers while confidence level continue to grow.

In one study, for example, when clinicians were asked to rate their job performance from A+ to F, fully two-thirds considered themselves A or better. No one, not a single person in the lot, rated him or herself as below average. As researchers Sapyta, Riemer, and Bickman (2005) conclude, “most clinicians believe that they produce patient outcomes that are well above average” (p. 146). In another study, Deirdre Hiatt and George Hargrave used peer and provider ratings, as well as a standardized outcome measure, to assess the success rates of therapists in a sample of mental health professionals. As one would expect, providers were found to vary significantly in their effectiveness. What was disturbing is that the least effective therapists in the sample rated themselves on par with the most effective!

The reason for stagnant success rates in psychotherapy should be clear to all: why try to improve when you already think your the best or, barring that, at least above average?

Here again, expanding our search for excellence beyond the narrow field of psychotherapy to the subject of expertise and expert performance in general can provide some helpful insights. In virtually every profession, from carpentry to policework, medicine to mathematics, average performers overestimate their abilities, confidently assigning themselves to the top tier. Therapists are simply doing what everyone else does. Alas, they are average among the average.

Our own work and research proves that clinicians can break away from the crowd of average achievers by using a couple of simple, valid, and reliable tools for assessing outcome. As hard as it may be to believe, the empirical evidence indicates that performance increases between 65-300% (click here to read the studies). Next time, I’ll review these simple tools as well as a few basic methods for determining exactly how effective you are. Subscribe now so you’ll be the first to know.

One more note, after posting last time, I heard from several readers who had difficulty subscribing. After doing some research, we learned that you must use IE 7 or Firefox 3.0.7 or later for the subscribe function to work properly.  Look forward to hearing from you!

In the meantime, the transcript below is of a recent interview I did for Shrinkrap radio.  It’s focused on our current work: