The #1 thing we miss about new therapists.

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I once heard Sue Johnson, the creator of Emotionally Focused Therapy (EFT), say, “We have good research that even novice therapists who use our model do well. They have a higher dropout rate, but their outcomes are still good.” She was talking about Wayne Denton and colleagues article on teaching EFT to psychiatry students.

In that study Denton took a small group of psychiatry trainees who had never before worked with couples, trained them in 12 hours of EFT, and then had them see couples for eight 50-minute sessions.

Denton made up for the lack of training by giving the trainees continued supervision in EFT.

I invite you to read the article yourself, but sufficient to say these novice therapists helped their clients, and did so in less time then EFT therapists in other studies.

Quite impressive! So when Johnson says even novice therapists get good results the implied message is, "EFT really is the golden model which will finally restore mental health to the masses through loving connection. I mean the model is so powerful that even novice therapists can get good results!"

But what if Johnson's interpretation of the research is wrong? What if she's missing a crucial piece of information?

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The power hierarchy of therapy

There is an unofficial hierarchy in therapy. It's based on power, and it goes something like this:

Model developers and professors have power over what's taught ...

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which influences what supervisors and fully licensed professionals believe...

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and how they supervise interns and trainees.

Because this hierarchy is in place, when we read about how well trainees do, we obviously assume the model must be what's generating such outstanding results.

The problem is the therapy hierarchy is bunk.

The research is pretty clear more experienced therapists do NOT do better than new therapists. In fact, if anything, the research points in the other direction, with interns doing slightly better than licensed professionals simply because they are trying harder [1].

The fact that our hierarchy doesn't relate to client outcomes is kind of an open secret in the field.

We've known this since 1978 when Drs Strupp and Hadley conducted their landmark study [2]. They got a bunch of university professors together, had them provide counseling to university students, and compared the professors outcome scores to professional mental health providers. To everyone's surprise the professors did just as well as the professionals.

This idea, that the present hierarchy doesn't relate to results, is fueled by the research on models like Multisystemic Therapy (MST) and Functional Family Therapy (FFT) which use paraprofessionals [3]. Both of these models hit the "gold standard" requirements for being evidenced based, and they are the go too models for agencies doing in home community based therapy.

These models show that you can take someone with no therapy training, run them through a week long course, let them see at risk teens, and they actually do pretty well! These MST and FFT therapists help a lot of kids.

So how it is that Sue Johnson makes this implied claim, when the research says otherwise?

I don't think Sue Johnson is evil, or dumb, or anything else. I think she's just so focused on developing and popularizing her model she's not had time (or the incentive) to look at the broader field and see what the research says on trainee outcomes or typical therapist skill development [4].

I happens to many model developers [5]. It's a mistake made not of malice, but busyness.

All of which begs the questions: So what does typical therapists development look like?

Tony Rousmaniere from Super Shrink to Deliberate Practice.

Tony Rousmaniere was the typical wayward teen struggling with depression, mad at his parents, and flirting with drug addiction — until he got referred to a local therapist [6]. The therapist’ unconditional positive regard and non-judgemental approach struck such a cord with young Tony that, years later, Tony himself decided to become a therapist.

During his psychology internship Tony worked in a school and, a rebel at heart, easily connected with his school-aged clients. In fact when he checked his outcomes he found 25% of his clients responded quite quickly. Another 25% took a little longer to get started, but also eventually experienced change.

As a trainee he was easily helping half his clients. He was surprised and delighted, especially given the fact that the average licensed therapist helps half their clients [7].

Still he wanted to help the other half. So he got a supervisor who was insightful, and gave Tony the sort of wizened advice you’d expect.

After months of clinical supervision, Tony looked at his outcomes and again was surprised, but this time not delighted.

Nothing had changed. Half of his clients continued to do well, and the other half saw no change.

Tony was undeterred.

He started going to trainings and got personalized supervision from model developers. He trained for years and even became a trainer in a model. Then, when he finally tabulated his outcomes, well he was surprised. Half of his clients did well. The other half was full of dropouts and client deteriorations. He hadn't really improved at all.

***

After reading this in his book Deliberate Practice for Psychotherapists I reached out to Tony via email:

Me: One of the things I’m picking up from your story, and I want to be as sensitive as possible because it’s your story, is that you trained with the best for years and it improved your dropout rate, but your overall success rate is still slightly above average [around 50%]… I’m just asking because I’ve also heard you say that it is probably easy to move up the floor of therapy, but probably very hard to raise the ceiling.

Tony: Yeah that pretty much summarizes it. My interpretation of this is that I am roughly pretty average, so my “floor” wasn’t very low, and I couldn’t get much higher…This is how I make sense of it: my clients had fewer aversive experiences but I wasn’t able to consistently provide much better help to them.

Tony Rousmaniere, Founder of Sentio Counseling Center and Pioneer in Deliberate Practice for Counselors — Tony Rousmaniere, Pioneer in Deliberate Practice for Counselors

Typical therapist' development.

Tony Rousmaniere provides us with an example of typical therapist' development.

With a little of bit of training many people see a huge initial boost in their therapy skills. But after that, despite more schools and more trainings, therapists don't typically improve.

A little training helps a lot. Then we plateau, and more education doesn't help.

This is an uncomfortable finding. It means the years of schooling don't make us better therapists. Getting a Ph.D won't make us better. Heck, if we're strictly concerned about client outcomes, most of our masters degree probably isn't helpful.

This is also a really good thing.

If you look at the current system it appears to take 2 years minimum to create a new counselor. When it takes that long to create new counselors, it can be really hard to keep up with the need for our services.

But it doesn't have to take that long.

You can place a rebel like Tony in a school he'd help just as many kids as his fully licensed peers.

You can give a psychiatry student a little training and get a pretty good couples counselor.

You can give a person off the street a week of training and change a delinquents life.

New counselors and therapists do better than you'd expect.

Part of why you need a masters degree to become a counselor is we want highly trained and effective counselors.

We want a counselors to be better than average. We want them to help more than 50% of their clients.

If we actually want to fulfill that promise we need to ditch the power hierarchy and design a hierarchy based on ability. If we focus on ability, then we can design a hierarchy where we can learn from the very best.

Think about it this way. Basketball is going through a revolution right now. Players like Steph Curry have shown that is possible to make way more 3 point shots than anyone thought was possible. And because he's on display, hoards of kids are practicing and improve the skills necessary to make 3 pointers with high consistency.

It's changing how basketball is played so much that there's debate about moving the 3 point line back.

Basketball has a hierarchy which showcases the very best talent, so the whole field improves.

I think we need the same thing in therapy.

This, of course, is fraught with loads of problems. Ability hierarchies aren't perfect. Still, I think the benefits of this outway the cost.

If we took this seriously we would simultaneously help more teens and couples, and develop methods which are actually superior, and stop underestimating new therapists.

Which is the kind of world Sue Johnson and others are actually trying to create.

Best, Jordan (the Counselor)

-Fin-

[Notes]

[1] 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

[2] Strupp HH, Hadley SW. Specific vs nonspecific factors in psychotherapy. A controlled study of outcome. Arch Gen Psychiatry. 1979 Sep;36(10):1125-36. doi: 10.1001/archpsyc.1979.01780100095009. PMID: 475546.

[3] My wife, who ran an MST program for about 3 years, has told me stories of lawyers, teachers, pastors, and others going through MST training. Even in the research, their MST therapists don't always have clinical degrees. For example in the article sited below one person was had divinity training, one had a bachelors in psychology, and another had a masters in psychiatric nursing. Typically these are not clinical degrees.

Weiss, B., Han, S., Harris, V., Catron, T., Ngo, V. K., Caron, A., Gallop, R., & Guth, C. (2013). An independent randomized clinical trial of multisystemic therapy with non-court-referred adolescents with serious conduct problems. Journal of Consulting and Clinical Psychology, 81, 1027–1039. doi:10.1037/a0036200

[4] Of course, this video where I heard Johnson say this only reflects her view at that point in time. She may believe otherwise now.

[5] "The ultimate example of this is what happened with the original Solution Focused Brief Therapy team. In the 90s the SFBT team had a group of independent researchers research their effectiveness. Turns out SFBT was no more effective and no more brief than any other model. Furthermore, Insoo Kim Berg, the model creator was not the most effective therapist, rather one of the interns was." - Maybe we're trying to Hard. Jordan Harris

[6] Tony describes his journey is his various books on deliberate practice. The main source for this segment comes from his book Deliberate Practice for Psychotherapists.

[7] In truth, it maybe worse than this. There's some research that therapist abilities before therapy training are correlated with their abilities after therapy training. The implication is we think, "oh we've helped this person improve" but in actually they would have performed well without the training.

This is consistent with the Strupp and Hadley article where the professors were chose because of their increased social skills. They weren't just random academics.

I think it's a mute point in some ways. It would be unethical to ever allow someone to do therapy with zero training, and there are certain things you'd have to review, like basic ethics, handling suicidal clients, and working abreactions/trauma responses. So the starting conditions would be the same, a person with minimal training doing well, but ultimately not improving over time, hence the need for an actual ability hierarchy.

[Selected Additional Resources]

Owen, J., Wampold, B. E., Kopta, M., Rousmaniere, T., & Miller, S. D. (2016). As good as it gets? Therapy outcomes of trainees over time. Journal of Counseling Psychology, 63(1), 12–19. https://doi.org/10.1037/cou0000112

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), 337–345. https://doi.org/10.1037/pst0000015

Also, watch this video. If you have limited time, I recommend watching from 21:01- 28:21.