What are the most pressing problems in the practice of psychotherapy?

What are the most pressing problems in the practice of psychotherapy?

There are several issues at hand. For example, it’s a bit of a scandal that, on average, therapists do not get better with experience.1

**For more about this, see** **6 Visuals About Our Progress**

So what do we do? We invest time, effort and money in getting certified, trained and endorsed in various schools of thought.

However, formal training has little to no impact on actually improving client outcomes.

Let me briefly point out 4 relevant studies that has surfaced in the last couple of years.

First, one prospective study by Tim Anderson and colleagues noted that a trainee’s interpersonal ability influenced results. However, it was their ability measured prior to receiving any training, that predicted actual client outcomes. The 2 years of doctoral training had no significant effect.2

Second, in a recent 2022 study by Chris Edmondstone and colleagues, they took a step further and asked if there were truly differences from the get-go, before training took place?3

Here’s what Edmondstone et al. found:

Differences between therapists exists even before training took place.

Take a look.

Third, David Erekson and colleagues conducted a longitudinal investigation on the impact of psychotherapist training. In essence, there were asking a similar question, “Does training improve client outcome?”4

Here’s what Erekson et al. found:

Therapists were found to achieve the same amount of change on average in their later stages of training
Findings suggest that as therapists progress through formal stages of training, they do not improve in their ability to effect change in their client.
Granted, some do improve with training. But in essence, psychotherapy training does not have a universal effect.

Finally, Jesse Owen and colleagues studied if trainees in the US improved in their clients’ therapy outcomes over time, or, if it is “As good as it gets?”5

Here’s what Owen et al. found:

Trainees improved over time, but only with clients who are less distressed.
There were no change over time when working with more distressed clients.

Take a look.

Changes in client outcomes over 50 months

The Most Pressing Issue

What do we make of these findings?

It’s clearly not because of a lack of trying.

It might not seem like the most pressing issue, but I believe that if we re-imagine how we conduct clinical supervision, we stand a chance to turn things around.

At the heart of our work, it is people passing on to people. This apprentice-model is quite a gift. Many of you reading this are clinical supervisors and you are doing your best to guide other therapists.

You care about this.

This is why one of the first online courses I’ve created back in 2018 was Reigniting Clinical Supervision (RCS). I didn’t want RCS to be like a poor substitute for live training, or a webinar-recording. So I decided to build this course from the ground up, specifically for someone to learn at their own pace, one bite-sized idea at a time, while journeying with a community of like-minded people.

The first sketches of the course design… and the ambient nerves of putting myself in front of a camera for hours on end.

13 cohort of clinical supervisors from around the globe have gone through RCS so far. And the doors are now open for registration for the 14th cohort. (More details below).

Wait, But Why?

Perhaps there are more pressing issues like burnout, lack of clinicians to deliver treatment, access to services and so on. But I would argue if we tweak the way we conduct clinical supervision, this would have a significant ripple on effect.

People passing on to people. Clinical supervisors passing on to therapists, therapists passing on to clients…

But first, our default ways of clinical supervision is not without issues. There are some pitfalls to our default ways of conducting clinical supervision.

Tapping Into Native Wisdom

Given what we know so far from the four studies we’ve highlighted about the impact of training (or the lack of), as well as the differences that is apparent between therapists from the get-go, instead of hyper-fixating on the “common-core” skills we need to acquire, it behooves us to tap into what each therapist has to offer, and bring that to the table from the very beginning.

Let’s call this native wisdom.6

Native wisdom is located in our prior knowledge, experiences and relational encounters that consist of both edifying and adverse histories.

Educational psychologist David Ausubel said,

If I had to reduce all of educational psychology to just one principle, I would say this. The most important single factor influencing learning is what the learner already knows. Ascertain this and teach him accordingly. (emphasis mine).

This is relevant to clinical supervisors. Our role is to tap into the existing knowledge of each supervisee, and then, help to cultivate this further.

Much like a gardener.

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