Do Psychotherapists Improve with Time and Experience?

October 27, 2015 By scottdm 14 Comments

The practice known as “routine outcome measurement,” or ROM, is resulting in the publication of some of the biggest and most clinically relevant psychotherapy studies in history. Freed from the limits of the randomized clinical trial, and accompanying obsession with manuals and methods, researchers are finally able to examine what happens in real world clinical practice.

A few weeks ago, I blogged about the largest study of psychotherapy ever published. More than 1,400 therapists participated. The progress of over 26,000 people (aged 16-95) treated over a 12 year period in primary care settings in the UK was tracked on an ongoing basis via ROM. The results? In an average of 8 visits, 60% of those treated by this diverse group of practitioners achieved both reliable and clinically significant change—results on par with tightly controlled RCT’s. The study is a stunning confirmation of the effectiveness of psychotherapy.

This week, another mega-study was accepted for publication in the Journal of Counseling Psychology. Once more,
ROM was involved. In this one, researchers Goldberg, Rousemanier, Miller, Whipple, Nielsen, Hoyt, and Wampold examined a large, naturalistic data set that included outcomes of 6500 clients treated by 170 practitioners whose results had been tracked an average of 5 years.

Their question?

Do therapists become more effective with time and experience?

Their answer? No.

For readers of this blog, such findings will not be particularly newsworthy. As I’ve frequently pointed out, experience has never proven to be a significant predictor of effectiveness.

What might be a bit surprising is that the study found clinicians’ outcomes actually worsened with time and experience. That’s right. On average, the longer a therapist practiced, the less effective they became! Importantly, this finding remained even when controlling for several patient-level, caseload-level, and therapist-level characteristics, as well as when excluding several types of outliers.

Such findings are noteworthy for a number of reasons but chiefly because they contrast sharply with results from other, equally-large studies documenting that therapists see themselves as continuously developing in both knowledge and ability over the course of their careers. To be sure, the drop in performance reported by Goldberg and colleagues wasn’t steep. Rather, the pattern was a slow, inexorable decline from year to year.

Where, one can wonder, does the disconnect come from? How can therapists’ assessments of themselves and their work be so at odds with the facts? Especially considering, in the study by Goldberg and colleagues, participating clinicians had ongoing access to data regarding their effectiveness (or lack thereof) on real-time basis! Even the study I blogged about previously—the largest in history where outcomes of psychotherapy were shown to be quite positive—a staggering 40% of people treated experienced little or no change whatsoever. How can such findings be reconciled with others indicating that clinicians routinely overestimate their effectiveness by 65%?

Turns out, the boundary between “belief in the process” and “denial of reality” is remarkably fuzzy. Hope is a significant contributor to outcome—accounting for as much as 30% of the variance in results. At the same time, it becomes toxic when actual outcomes are distorted in a manner that causes practitioners to miss important opportunities to grow and develop—not to mention help more clients. Recall studies documenting that top performing therapists evince more of what researchers term, “professional self-doubt.” Said another way, they are less likely to see progress where none exists and more likely to values outcomes over therapeutic process.

What’s more, unlike their more average counterparts, highly effective practitioners actually become more effective with time and experience. In the article below, my colleagues and I at the International Center for Clinical Excellence identify several evidence-based steps any practitioner follow to match such results.

Let me know your thoughts.

Until next time,

Scott

Scott D. Miller, Ph.D.
Registration is now open for our March Intensives in Chicago. Join colleagues from around the world for the FIT Advanced and the FIT Supervision workshops.

Do therapists improve (preprint)

The outcome of psychotherapy yesterday, today, and tomorrow (psychotherapy miller, hubble, chow, seidal, 2013)

Public Attitudes Toward Mental Health Services: A Change for the Worse

July 3, 2014 By scottdm 1 Comment

The results are not encouraging. A recent meta-analysis found that public attitudes toward psychotherapy have become progressively more negative over the last 40 years. The impact on practitioners is staggering. Between 1997 and 2007, use of psychotherapy declined by 35%. Not surprisingly, clinicians’ incomes also suffered, dropping 15-20% over the last decade.

So, if not psychotherapy, what do consumers of mental health services really want?

Well, if you trust the study I’ve cited, the answer seems clear: drugs. During the same time period that talking fell out of favor, use of pharmaceuticals increased a whopping 75%! Some blame society’s short attention span and desire for a “quick fix.” Such an argument hardly seems credible, however, given that psychotherapy works to alleviate distress as fast or faster than most psychotropics.

Others, including the authors of the meta-analysis, blame public education campaigns and pharmacological marketing aimed at “convincing the public that mental disorders have a neurobiological etiology that require biological treatments” (p. 103). At first glance, this idea is compelling. After all, every year, the pharmaceutical industry spends $5 billion dollars on direct-to-consumer advertising.

And yet, what is it the drug companies are really selling in those ads? In one of the most well-known TV commercials for a popular antidepressant, less than 7 seconds is spent on the supposed neurobiological cause. Instead, the majority of the time is spent depicting the positive results one can expect from the product. It’s marketing 101: focus on the benefits not the features of whatever you’re selling.

What do consumers want? The answer is: results. Your training, degree, certification, and treatment approach are irrelevant, mere features most consumers could care less about. Your rate of effectiveness is another matter entirely–its the benefit people are looking for from working with you.

So, how effective are you? Do you know? Not a guess or a hunch, but the actual number of people you treat that are measurably improved? If not, its easy to get started. Start by downloading two, simple, free, SAMHSA-approved scales for measuring progress and quality of mental health services. Next, visit www.whatispcoms.com to learn how individual practitioners and agencies can use these tools to monitor and improve outcome and retention in treatment, as well as communicate results effectively to consumers.

To see how outcomes attract consumers, just take a look at the Colorado Center for Clinical Excellence website. This Denver-based group of practitioners is a model for the future of clinical practice.

Is your therapy making your clients worse? The Guardian Strikes Again

June 12, 2014 By scottdm 1 Comment

Last week, an article appeared in The Guardian, one of the U.K.’s largest daily newspapers. “Counselling and Therapy can be Harmful,” the headline boldly asserted, citing results of a study yet to be published. It certainly got my attention.

Do some people in therapy get worse? The answer is, most assuredly, “Yes.” Research dating back several decades puts the figure at about 10% (Lambert, 2010). Said another way, at termination, roughly one out of ten people are functioning more poorly than they were at the beginning of treatment.

The cause? Here’s what we know. Despite claims to the contrary (e.g., Lilenfeld, 2007), no psychotherapy approach tested in a clinical trial has ever been shown to reliably lead to or increase the chances of deterioration. NONE. Scary stories about dangerous psychological treatments are limited to a handful of fringe therapies–approaches that have been never vetted scientifically and which all practitioners, but a few, avoid.

So, if it’s not about the method, then how to account for deterioration? As the article points out, “some therapists had a lot more clients [who] deteriorated than others.” And yet, while that statement is true–lots of prior research shows that some do more harm than others–there are too few such clinicians to account for the total number of clients who worsen. Moreover, beyond that 10%, between 30 and 50% of people in treatment experience no benefit whatsoever!

Here is where the old adage, “an ounce of prevention is worth a pound of cure,” applies. Whatever the cause, lack of progress and risk of deterioration are issues for all clinicians. A growing body of research makes clear, the key to addressing the problem is tracking the progress of clients from visit to visit so that those not improving, or getting worse, can be identified and offered alternatives.

It’s not hard to get started. You can learn a simple, evidence-based method for tracking progress and the quality of the relationship at: www.whatispcoms.com. Best of all, practitioners can access the tools for free!

After that, join fellow practitioners from the US, Canada, Europe, and Australia for one of our intensive trainings coming up this August in Chicago. I promise you’ll leave prepared to address the issue of deterioration directly and successfully.