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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.

Saxon, D., Barkham, M., Foster, A., & Parry, G. (2016). The contribution of therapist effects to patient dropout and deterioration in the psychological therapies. Clinical Psychology and Psychotherapy, DOI: 10.1002/cpp.2028.

Sometimes patients experience negative outcomes in psychotherapy. For example, some patients drop out of therapy (i.e., they unilaterally decide to leave therapy before making any progress or before the endpoint planned with the therapist). In a previous meta-analysis of 669 studies, dropout rates ranged from 17% to 26% in psychotherapy trials. In this study, Saxon and colleagues were interested in the therapist effect on drop out. In other words, what is the impact of the individual therapist on negative outcomes like patients unilaterally terminating treatment? To examine the therapist effect one can look at differences between therapists in the average number of patients who drop out within their caseload. The authors looked at over 10,000 patients seen by 85 therapists from 14 sites in the United Kingdom initiative for Improving Access to Psychological Therapies. Therapists were selected if they saw more than 30 patients, and patients were included if they attended more than one session of therapy. Patient mean age was 40.3 (SD = 13.0), 71.2% were women, most were White (95%) and employed (76%). Of all the patients, 76.8% had some level of depression and 82.7% had some level of anxiety. Over 90% of the patients scored in the clinical range for symptom severity at pre-treatment. Patient symptom severity seen by a particular therapist was controlled in this study so that therapists who tended to treat severe cases were not penalized (i.e., case mix was controlled). Patients who dropped out represented 33.8% of the sample, with over half of these patients unilaterally terminating before the third session. The mean number of sessions for treatment completers was 6.1 (SD = 2.68). Therapist differences (i.e., the therapist effect) accounted for 12.6% (CI = 9.1, 17.4) of the patient drop out variance. In other words, about a quarter of therapists had a significantly greater number of drop outs compared to the average therapist. The mean dropout rate for the average therapist was 29.7% (SD = 6.4), the mean dropout rate for the above average therapist was 12.0% (SD = 7.3), whereas the mean dropout rate for the below average therapist was 49.0% (SD = 10.4).

Practice Implications

Who a patient gets as a therapist appears to have an important impact on whether the patient remains in therapy. Almost half of clients dropped out if they saw a poorly performing therapist (and nearly a quarter of therapists were poorly performing). By contrast, highly performing therapists only had a 12% drop out rate. Therapist variables that are known to be related to negative outcomes like dropping out include: lack of empathy, negative countertransference, and disagreements with patients about the therapy process. Previous research showed that therapeutic orientation is not related to negative outcomes. Therapists who are perform below average on when it comes to patient dropout might be able to use progress monitoring or some other means of measuring their patients’ outcomes to their advantage. These therapists may require more support, supervision, or training to improve their patients’ 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.

Dalgadilo, J., Dawson, A., Gilbody, S., & Bohnke, J.R. (2017). Impact of long-term medical conditions on the outcomes of psychological therapy for depression and anxiety. British Journal of Psychiatry, 210, 47-53.

Twenty percent of people have long-term medical conditions, and this percentage rises to 58% for people over 60. These long-term conditions account for approximately 70% of health care costs in the UK. The most prevalent long-term conditions in the population include: hypertension, chronic pain, gastrointestinal disorders, asthma, diabetes, heart disease, and chronic obstructive pulmonary disease. Do these conditions reduce the outcomes of psychological therapies? Dalgadilo and colleagues conducted a large study in the UK of patients who accessed publicly funded psychological services. The authors looked at what impact long-medical problems had on psychological intervention outcomes. Patients accessing the public system in the UK received stepped care - so that they were first given self help followed by a second step of intensive psychotherapy, if they needed it. The sample for the study included over 28,000 patients with a mean age of just over 38 years. About 23.2% had a long-term condition. Sixty-eight percent only received the low intensity self help, and 32% required the intensive psychotherapy. Those with long-term conditions, compared to those without long-term conditions, tended to report higher levels of distress and lower quality of life at the outset. Long-term conditions that were associated with poorer psychological intervention outcomes included: chronic pain, chronic obstructive pulmonary disorder, severe mental health problems, and diabetes. The effects were small (d = .20) to medium (d = .50) sized (confidence intervals not reported). Those with long-term conditions were more likely to receive high intensity psychotherapy after the self help. However, poorer outcomes for those with long-term conditions, compared to those without long-term conditions, were still apparent after they received the intensive psychotherapy.

Practice Implications

Compared to those without long-term medical conditions, those with long-term conditions have a higher level of impairment to start with and tend to finish therapy with greater depression and anxiety. The study points to the need to integrate psychological therapies in medical practices - especially for those with long-term medical conditions. Certain conditions like chronic pain, and having multiple conditions increase psychological distress and likely reduce patient mental health outcomes.