Every year, thousands of students graduate from professional programs with degrees enabling them to work in the field of behavioral health. Many more who have already graduated and are working as a social worker, psychologist, counselor, or marriage and family therapist attend—often by legal mandate—continuing education events. The costs of such training in terms of time and money are not insignificant.
Most graduates enter the professional world in significant debt, taking years to pay back student loans and recoup income that was lost during the years they were out of the job market attending school. Continuing professional education is also costly for agencies and individuals in practice, having to arrange time off from work and pay for training.
To most, the need for training seems self-evident. And yet, in the field of behavioral health the evidence is at best discouraging. While in traveling in New Zealand this week, my long-time colleague and friend, Dr. Bob Bertolino forwarded an article on the subject appearing in the latest issue of the Journal of Counseling and Development (volume 88, number 2, pages 204-209). In it, researchers Nyman and Nafziger reported results of their study on the relationship between therapist effectiveness and level of training.
First, the good news: “clients who obtained services…experienced moderate symptom relief over the course of six sessions.” Now the bad news: it didn’t matter if the client was “seen by a licensed doctoral –level counselor, a pre-doctoral intern, or a practicum student” (p. 206, emphasis added). The authors conclude, “It may be that researchers are loathe to face the possibility that the extensive efforts involved in educating graduate students to become licensed professionals result in no observable differences in client outcome” (p. 208, emphasis added).
In case you were wondering, such findings are not an anomaly. Not long ago, Atkins and Christensen (2001) reviewed the available evidence in an article published in the Australian Psychologist and concluded much the same (volume 36, pages 122-130); to wit, professional training has little if any impact on outcome. As for continuing professional education, you know if you’ve been reading my blog that there is not a single supportive study in the literature.
“How,” you may wonder, “could this be?” The answer is: content and methods. First of all, training at both the graduate and professional level continues to focus on the weakest link in the outcome chain—that is, model and technique. Recall, available evidence indicates that the approach used accounts for 1% or less of the variance in treatment outcome (see Wampold’s chapter in the latest edition of the Heart and Soul of Change). As just one example, consider workshops being conduced around the United States using precious resources to train clinicians in the methods studied in the “Cannabis Youth Treatment” (CYT) project–a study which found that the treatment methods used contributed zero to the variance in treatment outcome. Let me just say, where I come from zero is really close to nothing!
Second, and even more important, traditional methods of training (i.e., classroom lecture, reading, attending conferences) simply do not work. And sadly, behavioral health is one of the few professions that continue to rely on such outdated and ineffective training methods.
The literature on expertise and expert performance provides clear, compelling, and evidence-based guidelines about the qualities of effective training. I’ve highlighted such data in a number of recent blogposts. The information has already had a profound impact on the way how the ICCE organizes and conducts trainings. Thanks to Cynthia Maeschalck, Rob Axsen, and Bob, the entire curriculum and methods used for the annual “Training of Trainers” event have been entirely revamped. Suffice it to say, agencies and individuals who invest precious time and resources attending the training will not only learn but be able to document the impact of the training on performance. More later.
This supports the primacy of the therapeutic relationship in effecting change as well as the importance of the ‘person’ of the therapist. How sad for all that money to be wasted on training in methods. I would add, however, that it may be possible that the student gains the confidence to become an effective therapist from all that training. What do others think?
I really enjoy reading your blog – it’s always interesting, entertaining and most of the time I learn something new from your posts.
This particular post and the article you reference are really interesting, provoking (it’s still so hard for me to accept that all my years in university haven’t improved my skills as a therapist) and also useful when we want to have debates with our collegues about professional training.
I’m also thinking that at some point I would like to take this information to my professional organization (Dansk Psykologforening) because their ideas about professional development are VERY different from what research tells us.
//Susanne
Charm,
The key here is that professional training is typically focused on the wrong factor accounting for change. Focusing on the right factors, or those that have more impact on change (i.e., the impact of the client and the therapist as the primary variables and their unique interactions rather than the therapist’s model or techniques applied generally) is what Dr. Miller is suggesting. We spend way too much time thinking that one type of technique is better than another, whereas other avenues of focus will pay off more for us to improve our helping skills.
Thanks.
Alan
Professional training is indeed a must. How could we develop our way of having additional knowledge if we see it as a waste of time. We don’t know all and through most training we could gather there. To be effective and efficient this is a must not just only through research and reading but also through training.
Charm Stevenson
Residential Treatment
Thank you Scott! Very interesting reading. Yes I think that we have to look at how training is done. During some months now my team and I are working together with reachersers and everytime we meet they are asking quetions about our work. A lot of things that we speak about as therapists has got new meaning for me. For example if the most important thing as a therapist is to know when letting the client be or stay with the client i ambivalence how do we train that skill? How do we know when to do what, and some time not to do anything?
Do you know if there has been research looking at longitudinal differences in client outcome between therapists according to how much and what kind of formal training, further education and supervision they have got?
That would really be interesting, and even more persuading evidence that personal traits and skills are important. Btw. in the program I used to teach in family therapy, we had a subject lasting for the whole program, and with a central position called Personal and Professional Development. As teachers we saw that the content of this subject was important, and influenced what we did in the other subjects.