Magic Potions, Snake Oil, and Getting Better at Psychotherapy
Most therapists aspire to become better at what they do. But how do you get better? How do you make sense of all the noise—the fads and fashions, our love affair with models, and the persuasions of snake oil marketeers?
Snake Oil 1: The Holy Grail
Our quest for the ‘Holy Grail’ does nothing for us—that “right approach,” be it crafted by masters of the field, or a meticulously researched evidence-based treatment, or the everyday garden variety, doesn’t matter much to outcome.
Not one approach has ever shown it is better than any other. The famous dodo bird verdict, “All have won and all must have prizes,” invoked by Saul Rosenzweig in 1936 to illustrate the equivalence of outcome among approaches, is the most replicated finding in the psychological literature (Duncan, 2014).
Snake Oil 2: Personal Therapy and Self Awareness
We are often told that to develop ourselves as psychotherapists requires us to become more self-aware through personal therapy. This makes a lot of intuitive sense and to gain an appreciation of what it is like to sit in the client’s chair seems invaluable.
But a look at probably the best source, The Psychotherapist’s Own Psychotherapy (Geller et al., 2005), reveals that the cold hard truth is that while therapists rave about its benefits personal therapy has nothing to do with outcome.
Snake Oil 3: Experience
Surely, years of clinical encounters make a difference. But are we getting better, or are we having the same experience year after year? More bad news here—experience just doesn’t seem. to matter much. In large measure, experienced and inexperienced therapists achieve about the same outcomes.
Although it defies commonsense, experience does not improve outcomes either. For example, Nyman et al. (2010) reported that it did not matter to outcome if the client was seen by a licensed doctoral–level counsellor, a pre-doctoral intern, or a practicum student.
Snake Oil 4: Deliberate Practice
Deliberate practice downplays the complexity of the therapeutic process. Psychotherapy is inherently idiosyncratic to the individuals involved and relationally unique, not a disembodied set of interpersonal skills practiced by repetition. Psychotherapy is an in-the-moment process defined more by uncertainty and discovery than a series of skills practiced like multiplication tables.
Psychotherapy is dynamic and interactive as well as relationally and culturally idiosyncratic—a far different endeavor than shooting a basketball or playing an instrument. Deliberate practice also ignores the massive research about therapist development and what therapists say about improving over the course of their careers.
What Research and Therapists Say about How to Get Better
Does this mean that you should forget the whole thing? No. Contrary to my cynical portrayal of the state of the field’s efforts to help you get better, an empirically-based method has arisen from the most extensive investigation of therapist development ever conducted.
An ongoing 20+ year, multinational study of over 11,000 therapists (Orlinsky & Rønnestad, 2005) reports that getting better is intimately connected to therapists’ experiences with clients and what they learn from them. Almost 97% of the therapists studied reported that learning from clients was the most significant influence on their development, It appears therapists genuinely believe that clients are the best teachers.
Clients provide the opportunity for constant learning about the human condition, different cultures, and worldviews, as well as the myriad ways that people transcend adversity. Tracking outcomes, however, via the Partners for Change Outcome Management System or any measurement or monitoring process, takes the notion that “the client is the best teacher” to a different, higher, and more immediately practical level.
Tracking outcomes not only focuses us more precisely on the here-and-now of sessions, it takes us beyond mere intuition and subjective impressions to quantifiable feedback about how the client is doing. We get unambiguous data about whether clients are benefiting and whether our services are a good fit for them. From their reactions and reflections, we receive information that we can use in figuring out the next step to take in therapy.
In short, tracking outcomes enables your clients—especially those who aren’t responding well to your therapeutic business-as-usual—to teach you how to work better. In fact, clients who aren’t benefiting offer us the most opportunity for learning by helping us to step outside our comfort zones.
PCOMS Delivers Results
Tracking outcomes allows you to continually assess your development, challenge your assumptions, adjust to client preferences, and master new tools. Measuring outcomes allows you to cut through the ambiguity of therapy, using objective evidence from your practice to help you discern your clinical development without falling prey to that perennial bugaboo of the therapeutic endeavor: wishful thinking.
Barry’s Recipe for getting better: 1. Stop chasing magic potions and snake oil salesmen 2. Keep development on the front burner; 3. Measure outcomes to identify non-responding clients and track effectiveness; and 4. Learn from clients, especially those not benefitting that make you step outside your comfort zones.