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Erekson, D. M., Janis, R., Bailey, R. J., Cattani, K., & Pedersen, T. R. (2017). A longitudinal investigation of the impact of psychotherapist training: Does training improve client outcomes? Journal of Counseling Psychology, 64(5), 514-524.

The research on the effects of therapist training on client outcomes has not been very encouraging. Most studies indicate that more therapist training, better adherence to and competence in a treatment manual, and greater experience are not related to improved client outcomes. The profession would like to think that therapists affect client outcomes so that more training and experience might be related to better outcomes. One could argue that the research in this area is hampered by many studies not following the same therapists across time over stages of training. That is, many studies compare client outcomes between novices and licensed professionals – but these studies do not really address the question “does an individual therapist get better as he or she accumulates more years of training and experience?” In this unique study, Erekson and colleagues track client outcomes of 22 therapists over a 10 year period starting from the therapists’ early training in a doctoral program in psychology to their first years as licensed psychologists working in a counselling centre. On average, the psychotherapists saw 183.95 (SD = 103.23) student clients during that time (range: 62 to 449 clients). The clients primarily had clinically impairing problems with anxiety and depression. Stages of training were defined as: graduate trainee, intern, post-doctoral fellow, and licensed professional. The average client moderately improved (d = .72) in terms of symptoms from the start to the end of their therapy. When looking at therapists’ effects across stages of training, the authors controlled for client initial severity and size of therapist caseload. The results indicated that 4 of the 22 therapists improved in their client outcomes over stages of training, 10 remained the same, and 8 therapists worsened over time. On average, client outcomes remained the same across a therapist’s stage of training. However, average client rate of change (i.e., how quickly a therapist’s client improved) became slower as therapists achieved more training and experience.

Practice Implications

This study adds to the weight of evidence that therapist training and experience as currently conceptualized do not result in better outcomes among clients. One possible explanation for why psychotherapist trainees do as well or better than when they are licensed professionals may lie in the structure of training programs. Trainees in graduate school and internships typically receive a high level of supervision and learning experiences, and must deliberately report client progress on an ongoing basis. Therapists who are licensed professionals are not required to maintain these practices, and so they may not be practicing deliberately. Researchers and clinical writers identify deliberate practice as an important means by which practicing psychotherapists can maintain and improve their skills in interpersonal effectiveness and therapeutic alliance.

Author email: david_erekson@byu.edu

Owen, J., Wampold, B. E., Kopta, M., Rousmaniere, T., & Miller, S. D. (2016). As good as it gets? Therapy outcomes of trainees over time. Journal of Counseling Psychology, 63, 12-19.

Does psychotherapy training improve trainees’ knowledge and skills? Do trainees improve in their ability to produce positive client outcomes over time? The research on training psychotherapists is mostly inconclusive. Some studies show little or no difference between trainees and experienced therapists, and others found no association between level of experience and client outcomes. On the other hand, some researchers have found a relationship between training and competence in delivering a particular type of treatment. Overall, the research seems to show that there is a lot of variability between therapists in their outcomes and on how training affects their practice and their clients’ outcomes. However, rarely do these studies assess outcomes within the same trainee over time as they accumulate more training. In this study, Owen and colleagues evaluate if psychotherapy trainees’ client outcomes improved with training over time. They assessed 114 psychology trainees at different levels of training in 47 clinics across the U.S. These training therapists saw over 1100 clients over at least a 12-month period, and many therapists were followed for three years. The average client improved, but with small effects (d = .31, CIs not reported). Therapists were more effective with clients who were more distressed (d = .66) than clients who were less distressed (d = .10), probably because more distressed clients had more room to improve. Trainees’ outcomes improved significantly over time, although their average improvement over time was small. Most importantly, trainees’ improvements over time varied so that the researchers were able to identify four patterns of change over a three year period of training: (1) one group of trainees started out with moderately good outcomes and their outcomes remained moderately good over time; (2) a second group started out with small positive effects in their client outcomes and they improved to achieve moderately good outcomes by their third year; (3) a third group of trainees started out with small positive client outcomes but their outcomes got worse by their third year; and (4) a fourth group started out with poor outcomes and improved to achieve small positive outcomes by year 3 of their training.

Practice Implications

Trainees appear to have various trajectories in their ability to foster positive client outcomes over time, and, at times, that trajectory is negative. Trainees whose outcomes get worse over time (group 3) or who do not achieve at least moderately good outcomes (group 4) may need specific training to foster better interpersonal effectiveness, empathy, management of countertransference, and humility. In general, therapists should assess their clients’ outcomes with progress monitoring tools in order to use the feedback to improve their outcomes over time. If outcomes are not positive on average, then therapists should consider remediation, further training, or consultation.

Wampold, B. E., Baldwin, S. A., Holtforth, M. G., & Imel, Z. E. (2017). What characterizes effective therapists. In L.G. Castonguay and C.E. Hill (Eds.) How and why are some therapists better than others? Understanding therapist effects. Washington, DC: American Psychological Association.

The research on therapist effects indicates that some therapists are more effective than others. Previous research showed that therapist characteristics like age, race, ethnicity, gender, and experience are not consistently related to patient outcomes. Neither is therapist competence and adherence to a treatment approach. In this chapter, Wampold and colleagues ask the question: what characterizes effective therapists? The research is complicated because it is difficult to disentangle therapist effects from patient factors. That is, it is possible that some clients (i.e., those who are more motivated, likeable, and psychologically minded) might create favorable conditions for some therapists to be more effective. However, recent advances in statistical methods have allowed researchers to isolate the effects of therapist characteristics from patient factors. Based on this new research, Wampold and colleagues identified four characteristics of effective therapists. (1) The ability to form an alliance across a range of patients. The therapeutic alliance is defined as the agreement on tasks and goals of therapy, and the affective bond between therapist and patient. Alliance is reliably associated with good patient outcomes. Research shows that therapists and not clients are primarily responsible for the alliance-outcome relationship. (2) Facilitative interpersonal skills – which includes verbal fluency, warmth, empathy, and emotional expression. These skills in a therapist are a strong predictor of patient outcomes. (3) Professional self doubt – or healthy skepticism about one’s abilities and skills leading to self-reflective practice has also been found to predict positive patient outcome. (4) Deliberate practice - defined as individualized training activities especially designed to improve specific aspects of an individual’s performance through repetition and successive refinement. The amount of time outside of therapy that therapists engage in improving targeted therapeutic skills predicted patient outcomes.

Practice Implications

Some therapists are better than others - and demographics, professional affiliation, training, and adherence to a manual do not differentiate better therapists. Four factors are emerging as indicators of better therapists. Ability to develop, maintain, and repair a therapeutic alliance is well known to predict patient outcomes and it appears that therapists are largely responsible for the condition of the alliance. Therapists’ ability to be verbal, warm, and empathic is also key to patient outcomes. Professional skepticism about one’s abilities that lead to reflective practice is also an important characteristic in order to continually improve one’s abilities and monitor one’s outcomes. And, finally therapists who spend time outside of therapy deliberately and repetitively practicing skills will achieve better patient outcomes.

Goldberg, S.B., Babins-Wagner, R., Rousmaniere, T., Berzins, S., Hoyt, W.T., Whipple, J.L., Miller, S.D., & Wampold, B.E. (2016). Creating a climate for therapist improvement: A case study of an agency focused on outcomes and deliberate practice. Psychotherapy, 53, 367-375.

There is a lot of evidence that psychotherapy is effective – a result that has been demonstrated in randomized trials and in naturalistic setting. As I have noted numerous times in this Blog, psychotherapy is as effective as medications but without the side effects and with longer lasting results. However, there is room for improvement, especially in the effectiveness of individual therapists. Health care organizations are increasingly interested in quality improvement, which refers to efforts to make changes in practice that will lead to better patient outcomes, better care, and better professional development. One approach to quality improvement in medicine has been through audit and feedback – which involves measuring a clinician’s practice, comparing the clinician’s outcomes to professional standards, and giving the clinician feedback. In psychotherapy, the analogue is routine outcome monitoring in which patient progress is monitored with standardized measures throughout therapy, and therapists receive ongoing feedback on each patient’s progress relative to the average patient with that disorder. We know that therapists tend not to improve in terms of patient outcomes with experience alone, and some authors argue that one of the things that therapists are missing is good quality information about their clients’ progress. What would happen if an agency or organization decided to make it a priority to provide therapists with quality information about client progress? This paper by Goldberg and colleagues is a case study in which an agency deliberately created a culture of quality feedback and professional development to improve therapist expertise, therapist intentional practice, and client outcomes. The case study is of a community mental health agency in Alberta. Over 5,000 clients were seen by 153 therapists over a 7 year period (2008 to 2015) as part of the study. Clients received at least three sessions of therapy (mean = 6.53 sessions, SD = 5.02), and had a range of disorders typically seen in a mental health clinic. Therapists included 49.7% licensed or provisionally licensed professionals at the masters or doctoral level from different professions (e.g., social work, psychology, pastoral counselling), and 50.3% practicum students. Throughout the 7 years of the study, therapists saw an average of 33.52 clients (SD = 26.24). In 2008, the agency required the staff to collect outcome measures of all clients before each session (although patient scores were not tied to staff performance evaluations). This policy change caused a 40% turnover in clinical staff within 4 months (clearly a large minority of therapists did not want to participate in this new clinic directive)! These staff positions were replaced and staffing was stable after that point. In addition to requiring clinicians to provide measures on all patients (although patients could decline to participate), the agency provided monthly clinical consultations with an external consultant as a means of professional development. During these consultation, clinicians were encouraged to bring cases that were not progressing well in order to get feedback on their most challenging patients. Discussions were organized around therapeutic alliance, i.e., clarifying goals and preferences, and ways of facilitating engagement. The overall results showed a significant decline in distress among patients over the course of treatment. Of most interest was that therapists on average showed a significant improvement in their outcomes over time. That is, contrary to research showing that therapists do not improve over time when left to their own devices, therapists in this agency that received feedback and professional education around difficult cases did improve significantly.

Practice Implications

The findings of this study indicate that psychotherapists can improve over time if they receive quality information about client progress, and if they receive professional development that is tied to this information (i.e., concrete suggestions for ways of working with difficult clients). In other words, it is possible for therapist to develop expertise over time under some conditions. A significant challenge in this case study was that a number of therapists left the agency due to the quality improvement efforts. Some therapists are sensitive to or feel threatened by outcome monitoring. However, therapists who remained or who were subsequently hired by the agency showed a reliable increase in their expertise and client outcomes as a result of deliberate intentional practice, quality feedback about client progress, and concrete professional development focused on the therapeutic alliance.

Goldberg, S.B., Rousmaniere, T., Miller, S.D., Whipple, J., Nielsen, S.L., Hoyt, W.T., & Wampold, B.E. (2016). Do psychotherapists improve with time and experience? A longitudinal analysis of outcomes in a clinical setting. Journal of Counseling Psychology, 63, 1-11.

Do therapists get better in providing psychotherapy as they gain more experience? This is a long standing question in psychotherapy, and most studies that compare therapists of different experience levels have not provided encouraging findings. This large longitudinal study in a practice setting by Goldberg and colleagues is unique because they follow therapists over a number of years during their careers. That is, the authors do not focus on outcome differences between therapists with different levels of experience, but rather they see if a therapist improves over time as the therapist accrues experience. Data were collected on 170 therapists and 6,591 patients over 18 years in a large practice in the U.S. Patients were distressed adults who attended an average of 8 sessions (range = 3 to 153) across 13 weeks. Over the 18 years of the study, on average therapists saw 39 patients, saw their first patient of the study after their 5^th year post graduate school, and had been working at the practice for about 5 years. On average patients got better, so that their psychological symptoms declined significantly over the course of treatment (i.e., 50% reliably improved). These rates of improvement are similar to benchmarks set in clinical trials. Contrary to expectations, therapists tended to have slightly poorer patient outcomes as the therapists gained experience. This result remained significant even when patient baseline severity, therapist caseload size, and other factors were controlled. However, more experienced therapists tended to have fewer early unplanned terminations (< 2 sessions) than less experienced therapists.

Practice Implications

This is the first large longitudinal study that followed therapists over several years of their career. Therapists became less effective over time, although the magnitude of the deterioration was very small. At the very least, one can say that patients did not achieve better outcomes as their therapists became more experienced. The authors note that the results of this study are in contrast to a large therapist survey in which most practitioners reported that their skills improved with passing time, and in contrast to another study in which therapists tended to over-estimate their effectiveness and under-recognize failing cases. Ways for therapists to improve their skills and patient outcomes might include: engaging in regular progress monitoring, targeted learning of fundamental therapeutic skills, training with standardized patients, and setting aside time for reflection and clinical consultation.

Chow, D. L., Miller, S. D., Seidel, J. A., Kane, R. T., Thornton, J. A., & Andrews, W. P. (2015). The role of deliberate practice in the development of highly effective psychotherapists. Psychotherapy, 52(3), 337.

In 2014, Tracey and colleagues caused a stir when they claimed that there was no evidence of expertise in psychotherapy (see my July, 2014 blog). They defined expertise as increased quality of performance that is gained with additional experience – and they concluded that psychotherapy research has not provided evidence that therapist performance improves with experience. The issue is important because differences between therapists account for over 5% of patient outcomes. This seems small, but it is larger than variance in outcomes accounted for by the use of empirically supported treatments (0% - 4%), and almost as large as the variance accounted for by client-rated alliance (5% - 15%). Across a wide variety of professions (e.g., music, medicine, chess, sports), professionals’ engagement in deliberate practice results in improvement and superior performance. However, there is little evidence of this in psychotherapy. In this article by Chow and colleagues, the authors look specifically at “deliberate practice” defined as individualized training activities to improve one’s performance through repetition and refinement. To be effective, deliberate practice has to be focused on achieving specific targets and guided by conscious monitoring of outcomes over a long period of time. The authors collected a sample of 69 therapists who worked across a number of organizations and practice areas, and these therapists provided data related to 4,850 patients. Seventeen of the 69 therapists who treated 1,632 clients also provided data on professional development activities. Therapists were multidisciplinary (i.e., counsellors, psychologists, marital therapists, social workers, psychotherapists) with an average of over 8 years of experience, who worked mainly in private practice or within the national health service in the U.K., and who primarily treated adult patients with depression or anxiety disorders. Patient outcomes were measured repeatedly with a valid standardized scale, and deliberate practice was self reported by therapists using a measure that asked about the frequency and time therapists engaged in 25 activities outside of work aimed at improving therapeutic skills. On average, clients improved by the end of treatment and the effect was large (d = 1.22). As expected therapists differed in their patient outcomes (i.e., some therapists were reliably more effective than others). Therapist demographic variables, theoretical orientation, years of experience, and practice setting were not related to patient outcomes. However, the amount of time in deliberate practice activities was associated with a reduction in client distress. Compared to the less effective therapists (2.62 hrs/wk in deliberate practice), the best performing therapists (7.39 hrs/wk in deliberate practice) spent about 2.81 times more time on deliberate practice. Therapists rated the following deliberate practice activities as the most relevant to their patients’ outcomes: reviewing challenging cases, attending training workshops, reflecting on past sessions, and reflecting on what to do in future sessions.

Practice Implications

Although this is a single study with a relatively small sample of therapists, it is one of those rare studies to assess the effects of therapist deliberate practice on patient outcomes. As is the case with other professions, reviewing one’s performance can play an important role in identifying errors, altering course, and remediating problems. As Tracey and colleagues indicated, therapists need good quality information in order to learn from their errors and make adjustments so that clients can improve. Quality information might be available from progress monitoring (i.e., continuous feedback to therapists about client outcomes), which has been shown to improve client outcomes especially for at-risk cases. Chow and colleagues go further to suggest targeted learning by using standardized clients within training and supervision contexts. Deliberate practice is not only for newer or less experienced therapists, since experienced therapists also vary in their ability to engage and help clients. Highly effective therapists spend more time engaging in activities outside of their practice specifically aimed at improving their performance.