The Outcome of Psychotherapy: Yesterday, Today and Tomorrow

Te outcome of psychotherapy: Yesterday, today and tomorrow

SCOTT D. MILLER, MARK A. HUBBLE, DARYL L. CHOW and JASON A. SEIDEL

In 1963, the first issue of the journal Psychotherapy appeared. Responding to findings reported in a previous publication by Eysenck (1952), Strupp wrote of the ‘staggering research problems’ confronting the field and the necessity of conducting ‘properly planned and executed studies’ to resolve questions about the process and outcome of psychotherapy. Today, both the efficacy and effectiveness of psychotherapy has been well established. Despite the consistent findings substantiating the field’s worth, a significant question remains the subject of debate: How does psychotherapy work? On this subject, debate continues to divide the profession. In this paper, a ‘way out’ is proposed informed by research on the therapist’s contribution to treatment outcome and findings from studies on the acquisition of expertise.

‘If we want to solve a problem that we have never solved before, we must leave the door to the unknown ajar.’ Richard P. Feynman

n 1963, the population of the states granting licenses to practice scientifc basis of Freudian theories United States was approaching 190 psychology was on the rise. In August, and concepts. Hans Eysenck (1952) million.I Te average worker earned just the same month that Reverend Martin published a review of 24 studies under $6000 per annum. A frst class Luther King delivered his, ‘I Have a which concluded that psychotherapy stamp cost 4 cents, a gallon of gas, 29. Dream’ speech from the steps of the was not only inefective, but Te national debt stood at $310 billion. Lincoln Memorial, the inaugural potentially harmful. Te conclusions Around the country, Americans were issue of Psychotherapy was published. provoked considerable public and tuning into Te Beverly Hillbillies, Tree months later, in Dallas, Texas, professional attention, and were the nation’s number one rated TV President John F. Kennedy was immediately disputed by proponents program. ZIP codes were introduced assassinated. In the tumultuous years of psychotherapy (Luborsky, 1954; by the U.S. Postal Service and the that followed, the American experience Rosenzweig, 1954). Beatles released their frst album, Please and identity would be transformed. So, Strupp’s (1963) article in the frst Please Me. A war in Vietnam was on, too, would the feld of psychotherapy. issue of Psychotherapy, and Eysenck’s but few knew where the country was or In the decades preceding the (1964) response, revisited the still what the fghting was all about. appearance of Psychotherapy, practice unsettled debate. Although the efcacy In that year, membership of the was mostly limited to physicians, and of psychotherapy would remain in American Psychological Association psychoanalysis and psychodynamic doubt for some time to come, the stood at 17,000 (Hilgard, 1987). Te approaches predominated (Frank, back and forth between the two sides Diagnostic and Statistical Manual 1992; VandenBos, Cummings, & served to highlight both the ‘staggering (DSM) was 130 pages in length, and DeLeon, 1992). Beginning in the research problems’ (Strupp, 1963, p. listed 106 mental disorders. Treatment 1950s, the prevailing paradigm came 2) confronting investigators and the models numbered fewer than forty under scrutiny. Researchers within ‘necessity of properly planned and executed (Miller, Duncan, & Hubble, 1997; the emerging behavioural school experimental studies into this important Wampold, 2001). Te number of were harshly critical, challenging the ﬁeld’ (Eysenck, 1964, p. 97).

64 PSYCHOTHERAPY IN AUSTRALIA s VOL 20 NO 3 s MAY 2014 Fifty years later, much has changed. have long argued that psychotherapy 1999; Miller, Duncan, & Hubble, Te U.S. population has increased by is analogous to medicine. From this 2004). Instead of focusing on specifc 40 percent. Owing to the frequent point of view, psychologically informed methods, they insist that mechanisms change in the cost of a frst class stamp, interventions work in much the same common to all approaches, no the printed price has been replaced way as penicillin treats infection. matter the theory or technique, are with the word, ‘Forever’. At the time Te hallmark of their position is that responsible for change. In addition to of writing this article, a gallon of gas efective treatments must contain the instillation of hope, provision of fetches $4.50, and the national debt is specifc ingredients remedial to the a therapeutic rationale and strategies quickly approaching $17 trillion. Only two members of the Fab Four are still alive. Vietnam, once an implacable Despite the consistent fndings substantiating enemy, is now a trading partner of the United States, and the two countries the feld’s worth, a signifcant question remains conduct joint naval training exercises. Today, the American Psychological unanswered: How does psychotherapy work? Association has 137,000 members. Licenses are required to practice condition being treated. For this for achieving change, the therapeutic independently as a psychologist group, randomised clinical trials relationship is most often cited as one, in every state. Over 800,000 (RCTs) are the principal means of if not the most potent transtheoretical professionals are able to bill third investigation, the fndings of which are ingredient of psychotherapy (Bachelor party payers for mental health used to generate treatment guidelines, & Horvath, 1999; Grencavage & services (Brown & Minami, 2010). manuals, and lists of ‘empirically Norcross, 1990; Norcross, 2010). Tree Te Substance Abuse and Mental supported’ or ‘validated’ therapies converging lines of research are cited Health Service Administration’s (e.g., Barlow, 2004; Chambless & in support of these nonspecifc factors (SAMHSA) website lists 145 Hollon, 1998). Tey contend that for as the most signifcant independent manualised treatments for 51 of the psychotherapy to advance as a science, variables responsible for client 365 mental disorders now contained psychologists must operationalise change: (1) the absence of diferential in the DSM. Tis volume, in its ffth falsifable hypotheses using specifc efectiveness when specifc approaches edition, has reached an astonishing methods (discrete independent are directly compared and when 947 pages. Many psychologists, variables), test those hypotheses, and researcher allegiance and other biasing including the APA president, are teach students those methods that variables are controlled (Wampold, calling for the abandonment of the stand up to rigour and replication 2001); (2) dismantling studies which DSM and transition to the World (Gambrill, 1990; Zurif, 1985). Te show that the contribution of specifc Health Organization’s International critical argument supporting this techniques to treatment outcome is Classifcation of Diseases (Bradshaw, approach is that diferent therapies are negligible (Duncan et al., 2010); and 2012; Clay, 2012). diferentially efective, and specifc (3) research showing consistently Te principle disagreement between therapies are more efective than greater variance in outcomes between Strupp and Eysenck recorded in the nonspecifc treatment-as-usual (TAU). psychotherapists in a given study frst volume of Psychotherapy has been Exponents for the other side insist than between the types of therapy resolved. Not only is the efcacy of that any suggestion psychotherapy is they are practicing (Bemish, Imel, psychotherapy well established, but so comparable to a medical intervention & Wampold, 2008; Beutler et al., is its efectiveness in real world clinical is grossly inaccurate (Frank & Frank, 2004; Crits-Christoph & Mintz, settings (American Psychological Association, 2012; Duncan, Miller, Wampold, & Hubble, 2010; Wampold, 2001). Despite the consistent fndings substantiating the feld’s worth, a signifcant question remains unanswered: How does psychotherapy work? In Strupp’s words (1963, p. 2), the feld would ‘not be satisﬁed with studies of therapeutic outcomes until [it] succeed[ed] in becoming more explicit about the independent variable’ — in particular, the contributions made by the client, the therapist, the treatment method, and commerce between the participants. Here, debate continues to divide the profession. Gathered on one side are those who Illustration: © IStock, Getty Images, 2014.

PSYCHOTHERAPY IN AUSTRALIA s VOL 20 NO 3 s MAY 2014 65 1991; Crits-Christoph et al., 1991; understandable. Economic pressures that 90% of states were implementing Imel, Wampold, Miller, & Fleming, on practitioners are powerful and real. strategies to support the use of 2008; Kim, Wampold, & Bolt, 2006; Without a doubt, debate does not put ‘evidence-based practices’ (EBPs). Luborksy et al., 1986; Lutz, Leon, food on the table. With few exceptions, such eforts have Martinovich, Lyons, & Stiles, 2007; For all that, an equally passionate equated EBP with lists of specifc Okiishi, Lambert, Eggett, Nielsen, & call comes from the other side. treatments for specifc disorders (e.g., Dayton, 2006; Shapiro, Firth-Cozens, ‘Te medicalisation of psychotherapy’, Addiction and Mental Health Services, & Stiles, 1989; Wampold & Bolt, Wampold (2001, p. 2) protests, ‘might 2011). In turn, reimbursement has 2006; Wampold, Mondin, Moody, & well destroy talk therapy as a beneﬁcial been made contingent on an adherence Ahn, 1997). treatment of psychological and social to ofcially sanctioned therapies. At Te failure to reach agreement problems’. On the face of it, the premise present, one looks in vain for evidence about how psychotherapy works is not has merit. Terapy is a fuid, dynamic that these policies have ended divisions without consequence. To begin, how process, one involving a complex among researchers and clinicians will the outcome of psychotherapy ever and nuanced series of interchanges. regarding what constitutes a ‘best improve if the two major explanatory Forcing clinicians to adopt ‘truncated practice’, improved either outcome or paradigms are in continuous dispute and prescriptive’ treatments may well access to care (Bohanske & Franczak, and the causal variables defy strip therapy of the very interpersonal 2010), bolstered consumer confdence, consensus? On that score, meta- processes critical to its success. or secured fnancial stability for analytic evidence shows outcome To resolve the predicament in which clinicians. As for the latter, in the same has changed little over the past 40 the profession remains mired, three period, psychologists’ incomes have years despite overwhelming support possible solutions are immediately been in decline (APA Monitor, 2010; of psychotherapy and a dramatic apparent. First, both sides can continue Cummings & O’Donohue, 2008). increase in the number of diagnoses to conduct more of the same type of Finally, what of the hope for and treatment approaches (c.f., APA, research in the hope that new fndings fnding a middle way? If the success 2012; Smith & Glass, 1977; Wampold, will emerge vindicating one, while of an integrative movement could be Mondin, Moody, & Ahn, 1997; forcing the other to capitulate. Second, measured by the number of books Wampold, Mondin, Moody, Stich et end the problem by legislative fat. In and articles published, professional al., 1997). efect, owing to the pressing fnancial meetings held, or rhetorical eloquence Te polarisation among researchers and political considerations, declare a of the advocates, then it would be and inability to answer basic questions winner, of necessity placing expedience reasonable to conclude a new age of about the internal workings of above science. Tird, fnd a middle cooperation and unity has already psychotherapy also undermine the way. In this scenario, the two warring arrived. Of course, this has not standing of the profession within the camps fnally move to the center, happened, at all. Far from unifying the world of healthcare, especially among integrating their beliefs and best profession, an entire new movement consumers. Nationwide surveys of practices. has come on the scene, burdened by potential users of psychotherapy fnd On review, each of these approaches its own disagreements about what that a clear majority (77%) doubt is empirically plausible. It is the case integration actually means and, its efcacy (APA, 2004; Terapy in though that, if having not already at street level, how to put it into America, 2004). Moreover, while 90% failed, they seem destined to do so. practice (Miller, Duncan, & Hubble, of people report they would prefer to Taking each of the three solutions 2004; Norcross, 1997). Outside talk about their problems rather than in order, the hope that with the of the laboratory and the halls of take medication, use of psychotropic right research design or line of academia, theories and techniques are drugs has continued to rise while investigation, a clear victor will come accumulated rather than integrated visits to psychotherapists have steadily forth is — to put it bluntly — akin to on any level but that of the individual declined (Hubble, Duncan, Miller, & an alchemist’s optimism. After 50 clinician, employed idiosyncratically Wampold, 2010) years, and a massive expenditure of rather than systematically. Like it or Some contend that the threat to time, efort, and money, had one side not, that is the reality on the ground. the feld’s survival is so grave the or the other been right, lead would The way out profession’s interest would best be have been transformed into empirical served by setting the scientifc issues gold long ago (Duncan et al., 2010). After 50 years, and little success in aside and acting as though the medical Numerous replications, meta-analyses, deciding how psychotherapy works, we model applies (Nathan, 1997). ‘Moving and critiques supporting both sides return to Strupp’s (1963) proposition. aggressively in the direction of developing have been hailed as high truth on one Once more, ‘It seems to me that we shall and implementing empirically-validated side, and so much sound and fury on not be satisﬁed with studies of therapeutic treatment methods’, Wilson (1995) the other. Few have been sufciently outcomes until we succeed in becoming argues, ‘would seem imperative in swayed to give up their claims or view more explicit about the independent securing the place of psychological therapy of the evidence. variable’ (p. 2). Hands down, for in future health care policy’ (p. 163). Te second solution of defning all concerned, the independent Doing otherwise, it is claimed, risks practice by statute is well underway. variable of consuming interest has exclusion. Such assertions are entirely In 2009, Cooper and Aratani found been psychotherapy — the treatment

66 PSYCHOTHERAPY IN AUSTRALIA s VOL 20 NO 3 s MAY 2014 philosophy, theoretical constructions core conditions shared by all healing reveal a single, underlying trait shared regarding etiology and cure, and practices (c.f., Duncan, 2010). Simply by top performers: deep domain- associated procedures and techniques. put, one cannot remove the efect of specifc knowledge. In short, the Of lesser interest have been the the therapist without undermining the best know more, perceive more, and recipients of care; in particular, their therapy. remember more than their average diagnosis or pathology, personality formation and malformations, life situation, socioeconomic status, environmental supports and stressors No matter the client’s presenting problem or and, in more recent years, gender and ethnicity. style of relating, top performers were able Although identifed by Strupp to respond collaboratively and empathically, (1963), far less attention has been paid to the contribution of the therapist and far less likely to make remarks or (Beutler et al., 2004; Kim, Wampold, & Bolt, 2006; Wampold, 2010). comments that distanced or ofended a client. Doing, performing, and delivering has consistently overshadowed the doer, performer, and deliverer. Looking Strupp (1963) foresaw the variability counterparts. Te same research past the therapist’s contribution has between therapists prior to the identifes a universal set of processes been and continues to be an egregious collection of the evidence which that both account for how domain- error. Available evidence documents confrmed it: ‘Let us stay, however, with specifc knowledge is acquired and that the therapist is one of the most the method of treatment and consider furnish step-by-step directions robust predictors of outcome among further its relation to outcomes. For this anyone can follow to improve their factors studied. Indeed, the variance of purpose let us disregard (what in reality performance within a particular outcomes attributable to therapists (5– cannot be disregarded) therapist variables discipline (Ericsson, Charness, 9%) is larger than the variability among and socio-environmental factors’ (p. 2). Feltovich, & Hofman, 2006). treatments (0–1%), the alliance (5%), While Eysenck (1964) emphasised In summary, no matter one’s and the superiority of an empirically the need for clarity and precision in allegiance, the hope has been that supported treatment to a placebo methods and measurement, Strupp knowing how psychotherapy works treatment (0–4%) (Duncan et al., 2010; (1963) grappled with the importance of would give rise to a universally Lutz, Leon, Martinovich, Lyons, & the contextual nuances unfortunately accepted standard of care which, in Stiles, 2007; Wampold, 2005). refected in ‘crude…quasi documentation turn, would yield more efective and Beginning in 1997, Garfeld and which has hopelessly befogged the issue’ (p. efcient treatment. However, if the other notable researchers, including 2). outcome of psychotherapy is in the Strupp (Strupp & Anderson, 1997; Fortunately, a large body of hands of the person who delivers Luborsky, McClellan, Woody, research outside of psychotherapy it, then attempts to reach accord O’Brien, & Auerbach, 1985; Luborsky, now provides a new, clearer direction regarding the essential nature, qualities Mclellan, Diguer, Woody, & that takes into account both the or characteristics of the enterprise are Seligman, 1997; Okiishi, Lambert, need for clear measurement and the much less important than knowing Nielsen, & Ogles, 2003) brought importance of contextual infuences how the best accomplish what they do. the therapist back to the table, in an on methodology that drive better Looking to the future, the emphatic critique of the profession’s outcomes (Colvin, 2008; Ericsson, application of research methods and focus on treatment models and 2009a; Ericsson, charness, Feltovich, fndings from the feld of expertise and techniques. Not surprisingly, for & Hofman, 2006). Tese fndings expert performance provides the way those who believe that psychotherapy are less concerned with the particulars out of the feld’s current balkanisation is analogous to medicine, therapist of a given area of performance than and stalemate. Such research is already diferences are considered a ‘nuisance how mastery of any human endeavour underway, and the initial results are variable’, noise to be fltered out via is acquired. Across a variety of felds, informative and provocative (Miller strict adherence to the treatment including sports, music, medicine, & Hubble, 2011; Miller, Hubble, protocol. On the other side, the mathematics, teaching, computer & Duncan, 2007; Miller, Hubble, therapist is not only an interventionist, programming, and more, the subject of Duncan, & Wampold, 2010). but also an intrinsic part of the these studies has been the individual The road best travelled: Improving intervention; not just the delivery performer, and the question of interest outcomes one therapist at a time mechanism, but an important part of has been, ‘Why are some better than what is delivered. Efectiveness, it is others?’ A fundamental fnding of the believed, results from a combination of In sharp contrast to the feld research on superior performance is therapists’ ‘desirable personal requisites’ of psychotherapy — with its rival that talent is not a function of genetics, (Garfeld, 1997, p. 41) and their ability paradigms, competing schools, and degrees earned, title, privilege, or to use whatever methods empower the disparate conclusions — investigations experience. In short, talent is made. It

PSYCHOTHERAPY IN AUSTRALIA s VOL 20 NO 3 s MAY 2014 67 results from a process of an altogether interpretations of 50 years ago (Strupp, usage rates among therapists has been diferent nature, beyond traditional 1963). shown to be dramatically higher (89%) professional preparation and the mere Nevertheless, though measures as compared to other assessment tools investment of time. and norms are now widely available, ([20–25%] Miller, Duncan, Brown, Informed by fndings reported by surveys indicate that few clinicians Sorrell, & Chalk, 2006; Miller et al., researchers (Ericsson, 1996; Ericsson, actually employ them in their day- 2003). 2009a; Ericsson, 2009b; Ericsson et to-day work (Phelps, Eisman, & Te second element in fostering al., 2006; Ericsson, Krampe, & Tesch- Kohout, 1998). Indeed, the collection superior performance is obtaining Romer, 1993) and writers (Colvin, of outcome data of any sort is rare. feedback. Howard, Moras, Brill, 2008; Coyle, 2009; Shenk, 2010; Curiously, despite the low utilisation, Martinovich, and Lutz (1996) were Syed, 2010) on the subject of expertise, Bickman and associates (Bickman et among the frst to suggest that formal, Miller, Hubble, and Duncan (2007) al., 2000) found in their own survey, routine measurement of client progress identifed three components critical that a large percentage of therapists could be used for optimising treatment. for superior performance. Working in hold interest in receiving regular In 2001, Lambert and colleagues tandem to create a ‘cycle of excellence’, reports of client progress. Later, reported results demonstrating that these include: (1) determining a Hatfeld and Ogles (2004) conducted providing feedback to clinicians baseline level of efectiveness; (2) obtaining systematic, ongoing, formal feedback; and (3) engaging in deliberate practice. Each is discussed … no matter how the curative elements in turn. To be the best requires knowing of psychotherapy have been construed or how one fares in a given practice taught … the feld has not created new domain. Interestingly enough, the exact methods by which top performers generations of superior clinicians. determine their baseline are highly variable, defying any simple attempt at classifcation and replication a survey with a national sample of about client progress doubled the rate (Miller et al., 2007). What can be licensed psychologists to investigate of clinically signifcant and reliable said with certainty is that the best this discontinuity. As before, clinicians change, decreased deterioration by are constantly comparing what they expressed interest in having reliable 33%, and reduced the overall number do to their own ‘personal best’, the outcome information. Among the of treatment sessions. Over the past performance of others, and existing reasons given by those choosing not decade, research has continued and standards or baselines (Ericsson, to use outcome measures, the top two accelerated. For example, studies 2006). Fortunately, in the realm were, ‘practical (e.g., cost and time) and involving the ORS and SRS have of psychotherapy, numerous well- philosophical (e.g., relevance) barriers’ (p. shown that exposure to feedback as established outcome measures are 485). much as triples the rate of reliable available to clinicians for assessing Fully aware of the realities of change while cutting deteriorations their baseline (c.f., Froyd & Lambert, clinical practice, and in an efort to rates in half (Anker, Duncan, & 1989; Ogles, Lambert, & Masters, overcome the obstacles to routine Sparks, 2009; Lambert & Shimokawa, 1996). Additionally, computerised data outcome measurement, Miller and 2011; Reese, Norsworthy, & bases exist which allow therapists to Duncan (2000) developed, tested, Rowlands, 2009; Reese, Toland, Slone, make real time comparisons of their and disseminated two brief, four- & Norsworthy, 2010). According results with national and international item measures (Duncan et al., 2003; to Lambert (2010), ‘it is time [for norms (Lambert, 2012; Miller, Miller, Duncan, Brown, Sparks, & clinicians] to routinely track client Duncan, Sorrell, & Brown, 2005). Claud, 2003)1. Te frst, the Outcome outcome’ (p. 260). It is also worth noting that since the Rating Scale (ORS) assesses client Lambert’s proprietary, outcome time of the debate between Strupp progress and, when aggregated, can be management system, has been (1963, 1964) and Eysenck (1964), used to determine a therapist’s overall approved as evidence-based by the several methods have emerged for efectiveness. Te second, the Session Substance and Mental Health Services operationalising and standardising Rating Scale (SRS), measures the Administration National Registry the concepts of clinical improvement quality of the therapeutic relationship, of Evidence-based Programs and and treatment failure (c.f., Hedges & a key element of efective therapy Practices (SAMHSA NREPP). Olkin, 1985; Jacobson & Truax, 1991; (Bachelor & Horvath, 1999; Norcross, Te ORS and SRS, interpretive Ogles, Lambert, & Fields, 2002). 2010). Written and oral forms are algorithms, and normative database, While each conceptualisation and available at no cost and have been collectively known as ‘Feedback measurement scheme has both benefts translated into 20 diferent languages. Informed Treatment’ (FIT), were and drawbacks, these techniques show Both scales take less than a minute to carefully reviewed and listed on a considerable improvement beyond complete and score. Owing to their SAMHSA’s registry in February the ‘befogged’ understandings and brevity and simplicity, adoption and 2013 (see www.nrepp.samhsa.gov/

68 PSYCHOTHERAPY IN AUSTRALIA s VOL 20 NO 3 s MAY 2014 ViewIntervention.aspx?id=249). elite performers across many diferent interaction. Diferences in client Implementation materials developed by domains devote the same amount outcomes between therapists were the International Center for Clinical of time to this process, on average, found to be unrelated to therapist Excellence (ICCE), including six ‘how every day. In a study of violinists, for gender, theoretical orientation, to’ manuals, received perfect scores example, Ericsson and colleagues professional experience, and overall for training and support resources, (1993) found that the top performers social skills. Instead, the best results and quality assurance procedures. Te had devoted two times as many hours were obtained by those who exhibited process summarised in the manuals (10,000) to deliberate practice as deeper, broader, more accessible, conforms to the American Psychological the next best players and 10 times interpersonally nuanced knowledge Association’s (APA) defnition of as many as the average musician. In as measured on the FIS task. No evidence-based practice. Of note, the addition to helping refne and extend matter the client’s presenting problem defnition combines ‘the integration of specifc skills, engaging in prolonged or style of relating, top performers the best available research’ with clinical periods of refection, planning, and were able to respond collaboratively expertise in ‘the monitoring of patient practice engenders the development of and empathically, and far less likely progress (and of changes in the patient’s mechanisms enabling top performers to to make remarks or comments that circumstances, e.g., job loss, major illness) use their knowledge in more efcient, distanced or ofended a client. that may suggest the need to adjust the nuanced, and novel ways than their Acquiring such understanding, treatment (e.g., problems in the therapeutic more average counterparts (Ericsson & perception, and sensitivity is a common relationship or in the implementation Stasewski, 1989). goal for clinicians. Researchers have of the goals of the treatment)’ (APA Turning to psychotherapy, research found that ‘healing involvement’ — a Presidential Task Force on Evidence- on the alliance is illustrative. Studies practitioner’s experience of engaging, Based Practice, 2006, p. 273, 276– have consistently found a moderate, yet afrming, being highly empathic, 277). robust, correlation between the quality staying fexible, and dealing As powerful an efect as feedback of the therapeutic relationship and constructively with difculties exerts on outcome, it is not enough outcome (Baldwin Wampold, & Imel, encountered in the therapeutic for the development of expertise. As 2007; Horvath, Del Re, Fluckiger, interaction — is the pinnacle of the literature on superior performance & Symonds, 2011). At the same therapists’ aspirations (Orlinksky & shows in other felds, more is needed time, neither training in the alliance Ronnestad, 2005). And yet, the study to enable clinicians to learn from the nor experience conducting therapy by Anderson et al. (2009) suggests that information provided. De Jong, van has proven particularly predictive of some end up having such knowledge Sluis, Nugter, Heiser, and Spinhoven clinician efectiveness (Horvath, 2001; while others, of equal experience and (2012) found, for instance, that not Anderson et al., 2009) In attempting to social ability, do not. all therapists beneft from feedback. ‘untangle the alliance-outcome correlation’, Two research projects are underway In addition, Lambert reports that Baldwin, Wampold, and Imel (2007) by members of the ICCE community. practitioners do not get better at examined a group of 81 clinicians and One is a randomised clinical trial of detecting when they are of track or found that 97% of the diference in deliberate practice applied to training their cases are at risk for drop out or outcome between the practitioners therapists — a longitudinal study deterioration, despite being exposed was attributable to therapist variability being conducted at the University to ‘ feedback on half their cases for over in the alliance. By contrast, client of North Carolina Wilmington three years’ (Miller et al., 2004, p. 16). variability was unrelated to outcome. School of Social Work. Upon entry In efect, feedback functions like a Te results show that some therapists to the two-year program, beginning GPS, pointing out when the driver is are consistently better at establishing students are being given a battery of track and even suggesting alternate and maintaining helpful relationships of assessments, including: (a) the routes, while not necessarily improving than others. Evidence that the FIS inventory, a video-interactive overall navigation skills or knowledge diference is attributable to their tool designed to measure alliance of the territory and, at times, being possession of deeper, domain-specifc building, (b) the Values in Action completely ignored. knowledge can be found in a related Inventory of Strengths (VIA-IS), which Learning from feedback requires study by Anderson, Ogles, Patterson, measures character strengths, and (c) an additional step: engaging in Lambert and Vermeersch (2009). a demographic questionnaire. During deliberate practice (Ericsson, 1996; In brief, Anderson et al. (2009) their frst year, all students receive Ericsson, 2006, Ericsson, 2009b; examined therapist efects using a the traditional training curriculum. Ericsson, Krampe, & Tesch-Romer, sample of 25 providers treating clients In year two, students are randomly 1993). Deliberate practice means in a university counseling center. Te split into two groups, with group one setting aside time for refecting on clinicians were asked to respond to a continuing the traditional training, feedback received, identifying where series of video simulations to test for and the other, experimental group one’s performance falls short, seeking ‘ facilitative interpersonal skills’ (FIS). receiving the traditional training guidance from recognised experts, Each simulation presented a difcult plus a program of deliberate practice and then developing, rehearsing, clinical situation, complicated by a aimed at improving trainees’ skills in executing, and evaluating a plan for client’s anger, dependency, passivity, alliance formation and maintenance improvement. Research indicates that confusion, or need to control the (i.e., ongoing measurement, feedback,

PSYCHOTHERAPY IN AUSTRALIA s VOL 20 NO 3 s MAY 2014 69 and practice opportunities under trying to improve outcomes merely Consistent with both the research on varying conditions). Te hypothesis through the study of psychotherapies psychotherapy and the literature on the of the study is that hours spent in in general (i.e., premises, models, and acquisition of expertise, no particular deliberate practice activities will be associated procedures), the future of personal qualities or talents are more predictive of outcome than the profession may be better served by required for entry (Ericsson, Krampe, participation in traditional training, working to improve the outcome of & Tesch-Romer, 1993). Anyone, clinician character strengths, and other each and every therapist. with a modicum of instruction, can demographic variables. It is hoped that Summary conclusions learn how to do the basic tasks and this RCT will address, in part, Strupp’s achieve outcomes commensurate (1963) question regarding the ‘variance Te question that gave rise to the with professionals already practicing introduced by the person of the therapist exchange between Strupp (1963) and (Atkins & Christensen, 2001; practicing them — his degree of expertness, Eysenck (1964) in the inaugural issue Nyman, Nafzinger, & Smith, 2010). his personality, and attitudes’ (pp. 1–2). of this journal has been settled by No amount of theory, coursework, Results are not yet available. the accumulation of fve decades of continuing education, or on-the-job Te second research project evidence, including a correction of experience will lead to the development examines the relationship between what Eysenck criticised as a lack of ‘a of the ‘experienced judgment’ required outcome and practitioner demographic set of reasonable criteria which have a for superior performance. For that, it variables, work practices, participation certain degree of reliability and objectivity’ would appear that practitioners must in professional development activities, (p. 99). Te efcacy and efectiveness be engaged in the process outlined beliefs regarding learning and personal of psychotherapy are well established, above — in essence, continuously appraisals of therapeutic efectiveness. based on ‘standards stated and follow- reaching for objectives just beyond Although preliminary, results from ups carried out’ (Eysenck, 1964, p. their current ability (Miller, Duncan, this study are in line with earlier 99), and benefting from continual & Hubble, 2007). research on the factors that account refnements of what constitutes Te implications for the future of for expertise. Similar to Anderson efectiveness, whether in the research, professional preparation et al. (2009) and others (Wampold behavioural terms preferred by Eysenck and development, licensure and & Brown, 2005), therapist gender, or the intrapsychic judgments of clients certifcation, are nothing less than qualifcations, professional discipline, preferred by Strupp (Eid & Larsen, major. From a craft perspective, years of experience, and time spent 2008). Te second question of how it professional training would emphasise conducting therapy are unrelated to works — in particular, the independent the development of evidence-based outcome or therapist standing within variable of importance — far from therapists at least as much as, if not the study sample. Similar to fndings moving the profession forward, has more than, the dissemination of the reported by Walfsh, McAllister, fragmented the feld leaving outcomes evidence base for specifc therapies, O’Donnell, and Lambert (2012), unchanged for just as many decades. what Strupp (1963) called ‘the person therapist self-appraisal is not a reliable In point of fact, no matter how the of the therapist practicing them’ (p. 1). measure of efectiveness. Te fndings curative elements of psychotherapy In practice, this could translate into also provide the frst evidentiary have been construed or taught, be easing admission criteria so that a support for the key role deliberate they specifc technical operations, larger number of candidates may practice plays in the development transtheoretical healing factors, or enter training programs. Prospective of expertise among highly efective some combination thereof, the feld has matriculants into graduate programs clinicians; specifcally, the amount not created new generations of superior focused on producing the best of time therapists reported spending clinicians. clinicians that psychology has to engaged in solitary activities intended Te way out as proposed in this ofer might learn that graduation to improve their skills was a signifcant paper necessitates setting aside depends not only on learning about predictor of outcome (Chow, Miller, historical perspectives, traditions, psychotherapy, but also on being Kane, Torton, & Andrews, in and even biases — and embracing a capable of reliably producing positive preparation). diferent view of psychotherapy. As results. To that end, trainees would In all, the evidence at hand Norcross (1999) has observed, the be exposed to clients early in their indicates that the fndings from ‘ideological cold war may have been a training, routinely measured, and given the expertise literature likely apply necessary developmental state, [but] its ample opportunity to practice basic to the domain of psychotherapy. days have come and passed’ (p. xvii). skills (e.g., alliance formation) under Furthermore, the three activities— Indeed, once attention is turned to varying conditions (e.g., Anderson et knowing one’s baseline, obtaining the performance of the individual al., 2009). feedback, and engaging in deliberate practitioner, as the weight of the In addition, educators may improve practice—likely provide the means for research on expertise is directing, then the readiness of their incoming achieving the gains in outcome that it would make eminent sense to regard graduate students by experimenting have for so long eluded the feld. If the therapeutic practice as craft. with undergraduate psychology results reported here hold up to further A craft is defned as ‘a collection of curricula oriented to elements of investigation, it would suggest that a learned skills accompanied by experienced clinical quality beyond the learning of shift in focus is required. Instead of judgment’ (Moore, 1994, p. 1). facts and methods; perhaps including

70 PSYCHOTHERAPY IN AUSTRALIA s VOL 20 NO 3 s MAY 2014 opportunities for clinical volunteer such training has been successful, it is in behavioural health. Members can experiences (e.g., crisis hotlines, safe especially important that these eforts choose to participate in any of the houses, residential treatment) for those are systematically tracked and clinician 100-plus forums, create their own who express interest in clinical training data pooled together develop better discussion groups, immerse themselves and who want to begin assessing their methods for assessing and improving in a library of documents and how- performance as budding clinicians and the impact of these activities. to videos, access outcome tools, and most important, request and receive performance-oriented feedback from their peers. …efective therapists report making more Te following year a task force within the organisation created and mistakes and being more self-critical published a document detailing four ‘core competencies’ for applying the than their less efective counterparts. fndings from the expertise literature to the practice of psychotherapy learning the discipline of continually With regard to research, the (Miller, Maeschalck, Axsen, & Seidel, assessing and fnding ways to improve application of fndings from the feld 2011). Te frst core competency their clinical outcomes. of expertise to psychotherapy is in its is in the research foundations of Similarly, licensure to practice infancy. As a result, the potential areas FIT, including: familiarity with psychotherapy or quality certifcations for investigation are numerous. For research on the therapeutic alliance; could be granted, in part, on achieving example, available evidence makes clear behavioural healthcare outcomes; and maintaining a baseline level of that superior performance does not expert performance and its application performance equal to established occur in a vacuum. Te best fourish to clinical practice; and the properties outcome benchmarks. Postgraduate in supportive communities — what of valid, reliable, and feasible alliance training would also change. As has been termed, ‘cultures of excellence’ and outcome measures. Te second Niemeyer, Taylor, and Wear (2009) or ‘communities of practice’ (Miller competency is in FIT implementation: point out, ‘If continuing education is a & Hubble, 2011). Although some integrating consumer-reported natural expression of a profession’s ongoing aspects (e.g., error-centric learning outcome and alliance data into clinical evolution, then professional psychology environment, opportunities for work; collaborating with consumers can be viewed as suﬀering a signiﬁcant refection and deliberate practice built about collecting feedback regarding developmental delay’ (p. 617). Although into daily workfow) are known, more alliance and outcome; and ensuring most states, for example, mandate research is needed to identify the that the course and outcome of a number of CE hours to maintain characteristics of settings that prove behavioural healthcare services are licensure to practice independently, the optimal for the development and informed by consumer preferences. Te process is largely self-regulated. With maintenance of expert performance. third competency, measurement and a few notable exceptions (e.g., ethics), Another potentially promising reporting, focuses on measuring and practitioners select the events they line of research would explore the documenting the therapeutic alliance attend. Direct measures of learning are practice patterns of top performing and outcome of clinical services on an uncommon and performance measures therapists. A study by Najavits and ongoing basis with consumers; and on for the participants completely absent. Strupp (1994) found, for instance, that providing details in reporting outcomes No process is in place for identifying efective therapists report making more sufcient to assess the accuracy and skill or knowledge defcits in need of mistakes and being more self-critical generalisability of the results. Te remediation and no concrete plan is than their less efective counterparts. fourth competency is continuous required for continual professional Other research shows that clinicians’ professional improvement: determining development or the assessment of experience of difculties in practice one’s baseline level of performance; whether such a plan results in any accounts for most therapist variance comparing one’s baseline level of change in clinical outcomes. From in alliance ratings (Nissen-Lie, performance to the best available an expertise perspective, the current Monsen, & Ronnestad, 2010). Results norms, standards, or benchmarks; system is at best inefective and, at such as these immediately suggest developing and executing a plan for worst, perilous. It reinforces clinicians’ the possibility of studies exploring improving baseline performance; well-documented propensity to infate methods for helping practitioners and seeking performance excellence their efectiveness and see themselves develop an open, even welcoming, by developing and executing a plan as developing professionally when, attitude towards errors. of deliberate practice for improving in fact, they are not (Walfsh et al., In December 2009, the performance to levels superior to 2012; Orlinsky & Ronnestad, 2005). ICCE was launched (www. national norms, standards, and Considering the potential lag (likely centerforclinicalexcellence.com). benchmarks. Researchers are already a year or more for many full-time Similar to sermo.com for physicians, using the site to formulate research psychotherapists) between clinical the site provides a free, international, questions, solicit participants for training and the accumulation of web-based community for clinicians studies on expertise in psychotherapy, sufcient data to determine whether and researchers dedicated to excellence and using software to investigate

PSYCHOTHERAPY IN AUSTRALIA s VOL 20 NO 3 s MAY 2014 71 interesting outcome patterns as well as training on client outcome. Australian Psychologist, 36(2), 122–130. empirically supported therapies. Journal of the conversational data generated by Consulting and clinical Psychology, 66(1), Bachelor, A., & Horvath, A. (1999). The clinicians interacting on the site. 7–18. Strupp and Eysenck began a pointed therapeutic relationship. In M.A. Hubble, B.L. Duncan, & S.D. Miller (Eds.). The heart Chow, D., Miller, S. D., Kane, R., debate 50 years ago on matters of and soul of change: What works in therapy. Thornton, J., & Andrews, W. (n.d.). The consequence facing the feld. Teir (pp. 133–178). Washington, DC: American study of supershrinks: Development and pointed exchange revealed important Psychological Association. deliberate practices of highly effective psychotherapists. Manuscript in preparation. weaknesses in need of redress. Baldwin, S., Wampold, B., & Imel, Z. (2007). 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74 PSYCHOTHERAPY IN AUSTRALIA s VOL 20 NO 3 s MAY 2014 (1997). A meta-analysis of outcome studies he mentioned the time the measure took the SRS (Miller, 2010b). Once again, a mentor and supervisor, Lynn Johnson, Empirically, ‘all must have prizes’. of his clients experienced completing Ph.D., developed a 10-item likert scale for Psychological Bulletin, 122(3), 203–215. the tool due to its required literacy level. assessing the quality of the therapeutic A psychologist in attendance, Haim interaction (including alliance [Johnson, Wilson, G. T. (1995). Empirically validated Omer, Ph.D., suggested bypassing the 1995]). The author had used the scale but treatments as a basis for clinical practice: language dependent items and using Problems and prospects. In S. C. Hayes, a visual analogue scale to capture the demands of an inner city clinic. The V. M. Follette, R. M. Dawes, & K. E. Grady the major domains assessed by the measure was shortened and converted (Eds.), Scientiﬁc standards of psychological longer tool. Miller’s experience with the into a visual analogue scale capturing practice: Issues and recommendations (pp. Line Bissection Test (Schenkenberg, the major elements of a good therapeutic 163–196). Reno, NV: Context Press. Bradford, and Ajax, 1980) during Zuriff, G. E. (1985). Behaviorism: A his neuropsychology internship and (1979). Together with Barry Duncan, Psy.D. conceptual reconstruction. New York, NY: subsequent work on the development and others, measures for children, young Columbia University Press. of scaling questions at the Brief Family children, and groups were added and Therapy Center (Berg and Miller, 1992; tested for reliability, validity, and feasibility. Endnotes Miller and Berg, 1995) led him to suggest to his colleague, Barry Duncan, Psy.D. that Acknowledgements 1. The ORS was developed following the a measure be created with four lines, each 10 centimeters in length, representing Questionnaire 45 (OQ), a tool developed Psychotherapy, 2013, Vol. 50, No. 1, 88–97. the four domains of client functioning by his professor, Michael J. Lambert, Copyright permission received through assessed by the OQ 45 (Miller, 2010a). Ph.D. At a workshop Miller was teaching Copyright Clearance Centre RightsLink. A similar process led to the creation of on routine outcome measurement in Israel, License No. 3244060373371.

AUTHOR NOTES

SCOTT D. MILLER, MARK A. HUBBLE, DARYL L. CHOW and JASON A. SEIDEL are all senior members of the International Center for Clinical Excellence (Chicago, USA), an international consortium of clinicians, researchers, and educators dedicated to promoting excellence in behavioural health services. Scott Miller, PhD, founder of the International Center for Clinical Excellence, conducts workshops and training internationally, helping hundreds of agencies and organisations, both public and private, to achieve superior results. He is the author of numerous articles and books, including Escape from Babel: Toward a Unifying Language for Psychotherapy Practice (with Barry Duncan & Mark Hubble, 1997), The Heart and Soul of Change (with Mark Hubble & Barry Duncan, 1999, 2010), The Heroic Client (with Barry Duncan, 2000, & Jacqueline Sparks, 2004). Mark Hubble is co-author/editor of numerous articles and books (with Scott Miller and Barry Duncan). Daryl Chow is a registered psychologist with the Specialist Psychological Outreach Team (SPOT) in Western Australia. He is currently working in Singapore as a senior psychologist with the Institute of Mental Health (IMH) and Early Psychosis Intervention Program (EPIP), conducting psychotherapy and psychotherapy research. Jason Seidel is a psychologist in private practice at the Colorado Centre for Clinical Excellence (Denver, USA), and has worked in psychological and counselling services for over 20 years. Jason is one of the ﬁrst psychotherapists to report his outcomes in rigorous detail on the Internet. For more information visit www.centerforclinicalexcellence.com. Comments: [email protected]

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