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Here’s a quiz: Which of the following factors will make your therapist more likely to be effective in helping you with problems in your life?
An advanced degree — say, a PhD rather than a Masters. Better yet, several degrees in a variety of psychology disciplines.
Many years of experience as a therapist.
A focus in your particular area of distress, for example, eating disorders, substance abuse, anxiety, depression, etc.
A track record of keeping up to date with lots of training courses in the latest techniques.
If you answered “All of the above” you’d be in good company.
You’d also be entirely wrong. Here are the counterintuitive facts:
Multiple studies have shown that beginning trainees or even paraprofessionals have slightly better outcomes on average than fully trained and licensed therapists. Only a few studies (check out Chapter 1 of this book) have shown that psychotherapy training results in improved clinical outcomes. (I explain below why this seemingly crazy result actually makes sense.)
Studies show that the average therapist, as they gain more experience, does NOT get better client outcomes. In fact, over time, there is a small deterioration in the effectiveness of the average therapist. Of course, this doesn’t mean that ALL therapists fail to improve — some get much better. But, equally, some get worse with experience (think burnout), and on average, experience is a very slight negative.
There’s no evidence that specializing in a certain area of distress results in improved client outcomes.
Technique accounts for only 1% of client outcome. So if you went to see a therapist and then felt much better, only 1% of that ‘much better’ was because of the specific techniques that the therapist used. So although a therapist who does a lot of training courses can be very helpful, their skill in helping people doesn’t come from those courses.
This flies in the face of our experience. We know that doctors, lawyers, teachers, accountants and other professionals all improve with training and experience, and that we’re far better off going to a specialist in whatever issue we have. Why, alone among all these professionals, do psychotherapists fail to improve, either with time or specialization? Here are three major reasons:
Education is on techniques and theory, not common factors
With few exceptions, graduate schools and continuing education teach therapists everything except what they need to know. The evidence is clear: what makes people better is what’s called the common factors: a positive relationship with their therapist, a sense of hope, a sensible explanation for their troubles and a set of actions that they believe will alleviate those troubles. Yet universities and workshops teach primarily theories and techniques. It’s like teaching someone to play the piano by giving lectures on the construction of pianos and the physics of musical sounds.
People Are Unique
A surgeon who removes five appendixes a day year after year becomes very skilled, because there’s not much difference between one appendix operation and another. But people’s personalities and problems are unique. Two people who suffer from bulimia may look superficially the same — they binge eat and make themselves vomit — but their reasons for doing so may be wildly different. And the changes they will make on the way to recovery may also be wildly different. So what works with one person has no effect with another. Specialization doesn’t help, because a therapist is starting from ground zero with every client. What’s more, specialists can become attached to certain theories and techniques, leading clients to feel that their problems and treatment are being forced into a pre-set framework, rather than being viewed as unique and tailored for their specific situation.
Therapists Receive No Feedback
One survey of 129 mental health professionals found that every single therapist rated themselves as ‘above average’. A quarter of them felt that they were in the top 10% of therapists. On average they thought they were in the top 20%. Clearly, we therapists are a group of people that aren’t getting clear feedback, otherwise we’d have a more accurate assessment of how we’re doing.
It is this lack of feedback that results in our failure to improve with experience. Imagine being a pianist without the ability to hear the music that you produced? Or a lawyer arguing a case but never knowing the decision of the jury? Or a doctor treating a patient without knowing if the treatment worked?
Skeptics will say “But therapists get feedback all the time just by watching their clients.” Not exactly. Dissatisfied clients are reluctant to criticize, and prefer to simply not come back — some 1/3 of all clients don’t return for a second session and almost half don’t come back for a third session. And it’s human nature to attribute successes to our own skill and failures to the client’s unwillingness to change. So when people drop out of therapy, or fail to improve, it’s rare for a therapist to honestly look at themselves and find things they could have done better.
The psychotherapy profession has not been very good at figuring out what makes therapy work, and then training new therapists in it as well as giving experienced therapists the feedback needed to improve. That is, fortunately, starting to change. In my next article I’ll talk about the crucial issue of feedback.