Thursday, September 27, 2018

Psychotherapy: Rigorous training, supervision, trying the different methods, yield no improvement in more than forty years

The question of expertise in psychotherapy. Daryl Chow, Scott D. Miller, Mark A. Hubble. Journal of Expertise 2018. Vol. 1(2),

Abstract: Although it is well established that, on average, psychotherapy is effective, outcomes have remained flat for more than five decades. Since the 1990s, the effort to identify "empirically supported treatment" approaches has done little to alter this fact. Even more sobering, studies either fail to show therapists improve with specialized training or their outcomes steadily decline with time and experience. The aim of this paper is to illuminate how findings from the literature on expertise and expert performance illuminate new paths for the field of psychotherapy. Results to date point to new possibilities for helping practitioners realize improvements in the quality and outcome of their work.


In particular, the belief that “rigorous training” currently required for entering the field makes a difference in the quality and outcome of care practitioners provide. In the United States, doctoral training programs in psychology take between four and six years to complete [...] And yet, study after study reveals degreed professionals perform no better than students (Boswell, Castonguay, & Wasserman, 2010; Christensen & Jacobson,1994; Lambert & Ogles, 2004; Miller, Hubble, & Chow, in press). Millions are also spent annually on continuing education, including workshops, books, journals, instructional videos, and the like. Although mandatory for maintaining a license to practice, no evidence exists of any effect on results (Neimeyer, Taylor, & Wear, 2009; Webb, DeRubies, & Barber, 2010).

Another requirement for entering the field is working under the supervision of a senior clinician. While varying somewhat from jurisdiction to jurisdiction, and discipline to discipline, approximately 3,000 hours of supervision is the norm (Caldwell, 2015). Nevertheless, after reviewing research spanning a century, Watkins (2011) writes: “We do not seem any more able to say now (as opposed to 30-years ago) that psychotherapy supervision contributes to patient outcome”

In hundreds of randomized controlled trials pitting one method against another, none proves superior [...] cognitive behavior therapy is compared with other bona fide approaches, such as interpersonal therapy, emotion-focused therapy, psychodynamic therapy, etc. Bona fide psychotherapies are treatments that are designed to be therapeutic, delivered by a trained therapists based on psychological principles, considered to be a viable form of treatment that has been presented to the psychotherapy community (i.e., via dedicated treatment manuals or books [Wampold et al., 1997]). Yet, training clinicians to use these approaches makes no difference in client outcomes (Rousmaniere, Goodyear, Miller, & Wampold, 2017).

As so much of conventional wisdom regarding what matters most for a good result has been shown to be immaterial, irrelevant, and inconsequential, it should come as no surprise that the overall outcome of psychotherapy has not improved in more than 40 years (Miller, Hubble, Chow, & Seidel, 2013). In their comprehensive review of the literature, Wampold and Imel (2015) report, “From the various meta‐analyses conducted . . . the aggregate effect size related to absolute efficacy is remarkably consistent” (p. 94).

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