Naturally, we all want to get better at the things that we do. Psychotherapists too may like to think that as they gain experience, they are continuing to develop their skills and improve the services they provide. Knowing that therapists contribute significantly to clients’ outcomes (explaining approximately 5% of variance in outcomes; Baldwin & Imel, 2013), therapists’ ability to improve directly impacts the populations that they serve. Research on the development of expertise suggests that there are indeed professions in which individuals tend to get better as they gain experience – astronomers, chess masters, mathematicians, and accountants all can expect to get better at what they do over time (Shanteau, 1992). Can psychotherapists look forward to the same?
The question of whether psychotherapists improve with experience has long intrigued the field (Bergin, 1971; Meltzoff & Kornreich, 1970; Myers & Auld, 1955). Research on expertise suggests that expertise can develop when: (a) the environment is predictable and outcomes are explicit, and (b) there are opportunities to learn from decisions, based on having access to quality information (Shanteau, 1992). Psychotherapy is not always, of course, a predictable environment. Nor do psychotherapists necessarily have access to feedback with which to assess decisions (Tracey, Wampold, Lichtenberg, & Goodyear, 2014).
Research on expertise in psychotherapy has relied heavily on cross-sectional designs (Stein & Lambert, 1995). These studies typically compare outcomes for therapists with varying degrees of experience (e.g., trainees versus licensed clinicians) or varying kinds of training (social workers versus psychologists). The major drawback with these cross-sectional studies is that the therapists measured at one point in time may differ from other therapists on many characteristics besides experience. The most direct test of whether psychotherapists improve over time requires a longitudinal design in which outcomes are measured for the same therapists across time.
Our study (Goldberg et al., 2016) aimed to provide a direct empirical test of whether psychotherapists improve over time using a longitudinal, naturalistic psychotherapy data set. We examined outcomes from n = 170 psychotherapists who treated n = 6,591 clients over the course of up to 18.43 years. Data were drawn from the counseling center at a large U.S. university. Clients at this center completed the Outcome Questionnaire – 45 (OQ; Lambert et al., 2004) prior to each session. Importantly, clinicians had access to this feedback about their patients’ progress as measured by the OQ. Using multilevel longitudinal modeling, we tested whether therapists’ outcomes improved as experience accrued, as assessed by the passage of time and the number of cases seen.
A large treatment effect was noted in these data (d = 0.94), consistent with evidence that psychotherapy is on average significantly effective at treating clients’ symptoms (Wampold & Imel, 2015). In longitudinal multilevel models, therapists were shown to vary significantly in changes in their outcomes across experience. However, overall a small but statistically significant decrease in client outcomes was also noted with experience—that is, therapists effectiveness was decreasing as they become more experienced. While some therapists had outcomes that improved over time, therapists on average did not, and most therapists saw declines. These small declines in outcomes over time remained even when controlling for a variety of potential confounds such as baseline severity, length of treatment, therapists’ initial level of experience, caseload size, rates of early termination, and when excluding several kinds of outliers.
Results from this study suggest that simply accruing experience, even when coupled with access to clients’ outcome data, does not guarantee that psychotherapists will improve. So what may be necessary for therapists to improve over time?
Another study from our group examined the same question – whether psychotherapists improve with increased experience – using data from a different mental health agency that focused on training and improving outcomes. This agency made a dedicated effort to assist therapists in improving their skills. Like the first sample (Goldberg et al., 2016), this second setting engaged in routine outcomes monitoring (Goldberg et al., in press). Unlike the first setting, however, the agency in this second study devoted a great deal of attention to incorporating outcome monitoring into all aspects of clinical work and training. Clients’ outcomes were routinely reviewed during supervision. In addition, agency staff and trainees had access an outside consultant well-versed in outcome monitoring through meeting that occurred every two weeks. These discussions focused on cases that were not progressing and specific therapeutic skills that clinicians could deliberately practice to improve (e.g., strengthening the therapeutic alliance). The agency worked hard to create a “culture of excellence” (Miller & Hubble, 2011, p. 25) in which clinicians felt encouraged to critically examine their practice.
In this second sample, a different picture emerged (Goldberg et al., in press). Small but statistically significant improvements in outcomes were noted – both within the agency overall across time and within-therapists across time. Further, it did not appear that the agency-level improvement was simply due to hiring more effective therapists (or to losing lower performing therapists). Although this agency is a single case study, it nonetheless provides evidence that improvement is possible and suggests some of the methods that may help bring about this change.
The two studies reviewed here address one therapist variable that may impact client outcomes – therapists’ accrued experience. The first study might be seen as treatment-as-usual; in the absence of devoted attention to utilizing outcome data and improving therapists’ practice, outcomes do not necessarily improve. The second study provides initial evidence that therapists can improve when provided sufficient support, challenge, and consultation.
Taken together, these studies suggest that therapists can improve over time. And, as with our clients, this improvement requires commitment and effort. These findings mirror research from the field of expertise, which has found that improved effectiveness across a wide range of professions comes from engaging in continual deliberate practice across the span of an entire career (Ericsson, 2006). By tracking outcomes, attending to cases that are not improving, and engaging in intentional practice of therapeutic skills, therapists can get better at what they do.
- What are lessons that can be learned from these studies for agencies seeking to improve their outcomes? What opportunities could be provided to clinicians in order to increase the chances that they can develop expertise?
- In what contexts might we expect therapists to improve, even in the absence of training focused on improving outcomes? Does providing training in specific treatment modalities lead to improved outcomes (i.e., within-therapist improvement)?
- What are barriers to psychotherapists improving? Which factors reside within the therapist (e.g., information-processing factors; Tracey et al., 2014) and which reside within the agency (e.g., creating a culture of excellence)? What may be some of the drawback of engaging in outcome monitoring for therapists? For agencies?
Simon B. Goldberg is a doctoral candidate in counseling psychology at the University of Wisconsin-Madison. His research interests include mindfulness-based interventions, psychotherapy, and research methods. He will be starting his clinical internship at the VA Puget Sound – Seattle Division in August 2016.
Tony Rousmaniere is a psychologist in private practice in Seattle, where he practices and teaches Intensive Short-Term Dynamic Psychotherapy. Dr. Rousmaniere’s research focus is clinical supervision and he is the co-editor of Using Technology to Enhance Counseling Training and Supervision: A Practical Handbook (American Counseling Association Press) and the forthcoming edited volume The Cycle of Expertise: Using Deliberate Practice in Supervision, Training, and Independent Practice (Wiley Press). Currently, Dr. Rousmaniere is a clinical faculty member at the University of Washington.
Bruce E. Wampold, Ph.D., ABPP, is the Patricia L. Wolleat Professor of Counseling Psychology at the University of Wisconsin—Madison and Director of the Research Institute, Modum Bad Psychiatric Center, Vikersund Norway. He has dedicated his career to identifying the factors that are responsible for the benefits of psychotherapy.
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