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Therapy reflections: How to become a better therapist.



I used to think that therapists are like wine: the older they get the better they are. I was wrong. Research shows therapists do not improve over time (Goldberg et al. 2016) and at times are even worse than novice therapists. Experienced therapists reach a plateau and stop improving - whereas starting therapists are curious and show a big intention on improving (they think about their clients/patients more after work, prepare for sessions in a more dedicated manner, read up on material, etc.), probably because they have to by virtue of being more inexperienced. In fact, no major demographic variable (age, gender, qualification, experience, profession, case load, etc.) is linked to a better client outcome.

Often I ask myself how I can become a better therapist. Like most therapists I enjoy my work, especially when psychotherapy works. It can be frustrating when I am not able to help someone (or enable them to better help themselves). So how do we become more effective therapists?

Can Deliberate Practice make you a Supershrink? Scott Miller and others have dedicated their careers to studying therapist effectiveness. They found that most therapists are average in their performance, yet some outperform most therapists by both qualitative and quantitative measures. He likes to call such therapists “supershrinks”. What makes supershrinks more effective is their focus deliberate practice. Deliberate practice can be defined as “individualized training activities especially designed . . . to improve specific aspects of an individual’s performance through repetition and successive refinement” (Ericsson & Lehmann, 1996; pp. 278 –279)

Deliberate practice means (Ericsson et al., cited via Rousmaniere’s Psychotherapy talks):

  1. Observing your own work

  2. Getting feedback on your work

  3. Identifying specific microskills

  4. Repetitive practice of skills

  5. Accessing outcome

  6. Making it an engaging life-long learning experience

Superior psychotherapy outcomes are linked to being more engaged with your client, which happens not just during therapy but specifically how therapists mentally engage before and after sessions (Chow et al., 2015).

Breadth versus Depth How many therapists go to courses, learn new therapeutic approaches, go to conferences, and read to stay up to date? Many if not most of us. Our therapeutic toolbox is broad. How many of us commit to deepening our basic skillset? Hardly any. We're so driven by our novelty-seeking impulse, hearing about the latest therapy that might revolutionize the game, that we often don't focus on the basics that are essential for psychotherapy to work. When was the last time you brushed up on your listening skills? On your empathic atunement? How about a course on asking the right questions (isn't that what we do for a living?)? Or making a case conceptualisation? It's all basic skills therapist learn in their Masters and postgraduate training, that we don't try to refine and hone those skills.

Sharpening the Saw - Becoming a better therapist isn't easy. The more regularly you (deliberately) practice the better you get - this is a basic rule for any creative process. First you need to know how sharp your saw is before you can sharpen it. So it’s important to establish a baseline and measure how effectice you are as a therapist by getting feedback on the therapeutic relationship/working alliance (e.g. working alliance inventory, and routine measurements like the outcome rating scale (ORS) and session rating scale (SRS).

But it’s looking beyond numbers and takes time. Deliberately practicing means working with a practical intentionality. It means looking at your caseload and thinking about how to better support each client (or one at a time). It means reflecting on how your own story and personality might affect the therapeutic relationship, and also how it can be of value for the therapy. It means getting regular feedback on your therapeutic practice. How?

  • Regularly asking for feedback from your clients on the therapeutic relationship, yourself and the therapy as a whole.

  • Through routine outcome questionnaires filled out by clients (e.g. ORS and SRS).

  • Reflecting yourself (maybe even grading) how your session went.

  • Recording or videotaping sessions, transcripts, reviewing them personally and maybe sharing them in a trusted intervision group.

  • Getting a colleague to sit in one of your sessions.

  • Documenting useful and unuseful interventions.

  • Getting feedback from an expert or mentor.

  • Practicing specifici intervention skills

  • Monitoring the process of therapy

  • What values/personal philosophy do you hold dear and how does this inform your practice?

  • Are there other practical concerns outside of the therapy that need tending (note taking, admin, personal stress levels, self-care, etc.) that will have a positive effect on my craft?

  • What other ways can you think of or have been mentioned by experts that might be useful to your practice?

If these points seem daunting to you, it's because they are. And that's why we'd rather avoid doing them and why so few therapists actually get better. So if you want to improve your psychotherapy skills, ask yourself: How much time do you spend alone seriously engaging in activities related to improving your therapy skills? Is there on activity/skill you would like to work on? What can you do to kindly nudge yourself to reach that zone of proximal development? Getting more skilled in psychotherapy is alifelong mission, and selecting one specific goal to intentionally improve on will make it less daunting and more effective as well.

Conclusion - so where to go from here? As Chow (2017) points out clearly in his blog: relax, start small and focus on the right things:

”In our field of psychotherapy, with over 400 models therapy, there are so many aspects to learn and get distracted by. Again, here is the problem : We lose sight and remain vague, abstract, and overwhelmed in our definition on what to work on. Instead, we go broad, and sacrifice deep. And when we go deep, we go into rabbit holes that make us none the wiser. I worry we are barking up the wrong tree. We work on things that have suboptimal leverage on impacting our interpersonal therapeutic skills. Instead, we think that content knowledge will get us to there.

Here’s what Carl Rogers has to say about this, almost 78 years ago: “The experience of every clinic would bear out the viewpoint that a full knowledge of psychiatric and psychological information, with a brilliant intellect capable of applying this knowledge, is of itself no guarantee of therapeutic skill.” (Rogers, 1939, in The Clinical Treatment of the Problem Child)

NO GUARANTEE of therapeutic skill?? Good grief. Then what should I be working on? Here’s my best estimates at this point in time. It’s not in the domain of content or clinical knowledge. It’s got something more to do with process knowledge [moment-by-moment interaction between client & therapist] and conditional knowledge [what will help when]. […] [Ask yourself:] “At this point of my professional development, What is the one thing I can to work on to get better at my craft?””

So if most therapists don't age like a good wine and get better with time, what are they? Maybe therapists are more like cheeses: they come in different flavours as they ripen, and though some may get better; leave them unattended for too long and they get moldy. The important part is to focus and engage in the process, to more effectively help our clients.


References:

Chow, D. L., Miller, S. D., Seidel, J. A., Kane, R. T., Thornton, J. A., & Andrews, W. P. (2015). The role of deliberate practice in the development of highly effective psychotherapists. Psychotherapy , 52(3), 337. Pdf available via: https://clinica.ispa.pt/ficheiros/areas_utilizador/user11/21._the_role_of_deliberate_practice_in_the_development_of_highly_effective_psychotherapists.pdf

Chow, D. L. (2017, February 17). Mastery Learning for Therapists: Figure Out the What Before the How [web log]. Retrieved January 11, 2023, from http://darylchow.com/Daryl_Chow/Blog/wordpress/blog/2017/02/15/mastery-learning-for-therapists-figure-out-the-what-before-the-how/.

Ericsson, K. A., & Lehmann, A. C. (1996). Expert and exceptional performance: Evidence of maximal adaptation to task constraints. Annual Review of Psychology, 47, 273–305. http://dx.doi.org/10.1146/annurev.psych.47.1.273

Goldberg, S. B., Rousmaniere, T., Miller, S. D., Whipple, J., Nielsen, S. L., Hoyt, W. T., & Wampold, B. E. (2016). Do psychotherapists improve with time and experience? A longitudinal analysis of outcomes in a clinical setting. Journal of counseling psychology, 63(1), 1–11. https://doi.org/10.1037/cou0000131

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