Adm Policy Ment Health DOI 10.1007/s10488-017-0805-2

POINT OF VIEW

Growing Better Therapists: A New Opportunity for Mental Health Administrators Scott D. Miller1 · Mark A. Hubble1 · Bruce E. Wampold2 

© Springer Science+Business Media New York 2017

Thirty years have passed since Sol Garfield pointed out that efforts to understand both how psychotherapy worked and could be improved consistently neglected a critical variable: the therapist. “The variability in the performance and skill of the individual psychotherapist has for the most part been minimized or overlooked,” he asserted. Instead, he continued, the profession has, “appeared to support the uniformity hypothesis—all therapists…perform equally well” (p. 41). Subsequent research, including data reported in this special issue of Administration and Policy in Mental and Mental Health Services Research (Schiefele et  al. 2016), documents therapists do differ in their effectiveness, consistently accounting for between 3 and 9% of the variability in clinical outcomes. The question of whether such differences matter for managers and administrators requires an answer. Some of the contributions to the present volume could tempt one to conclude that the person of the therapist has little impact on the delivery and outcome of treatment. In fact, the results reported here suggest any differences are small, thus rendering therapists interchangeable, perhaps superfluous, even incorrigible. After all, neither training nor routinely providing performance feedback appear to enhance provider effectiveness. With regard to policy, the editors even wonder whether more promising returns will eventually be found in technology—delivery systems that entirely omit therapists or, in the interest of saving money * Scott D. Miller [email protected] 1

International Center for Clinical Excellence, Chicago, IL, USA

2

Modum Bad Psychiatric Center and University of Wisconsin, Madison, WI, USA



and resources, use algorithms to exclude those unlikely to benefit from therapy. Whether additional, including electronic, means for engaging people in psychological care should be developed, researched, and supported is not at issue. Epidemiological studies consistently show, for example, the majority of people who could benefit from seeing a therapist, do not go. And nowadays, fewer and fewer are turning to psychotherapy—33% less than did 20 years ago—and most never return after the first appointment (Guadiano and Miller 2012; Swift and Greenberg 2014). Clearly, the field needs to come up with more ways to attract and engage people in care. Given the widespread availability and popularity of mobile phones, computers, and tablets, it makes imminent sense to include applications within such devices aimed at improving mental health and well-being. On that score, researchers Mohr and Begale (2014) identified 40,000+ health apps, 500 of which are specific to mental health. Unfortunately, few if any have been systematically evaluated. More, nearly 90% are never used after installation. Finally, while research indicates they can work, it also conclusively shows the new technologies suffer from the very same problem as traditional mental health services: people do not engage. For example, a meta-analysis of computer-based therapies for depression found that without contact with a person, a staggering 74% of users stopped using the program (Richard and Richardson 2012)! In short, technology may be a useful adjunct, but is no replacement for human involvement and interaction.

No Matter Where We Go, There We Are Over 100 years ago, pioneering management expert, Frederick Winslow Taylor, author of the classic work Principles

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of Scientific Management, observed, “Our opportunity lies in systematically cooperating to train and to make [the] competent man (sic)” (p. 6). While this assertion is at odds with the editors’ position, and much of the research on the training and supervision of therapists, findings from the literature on expertise and expert performance indicate that Taylor was right (Miller et al. 2013; Tracey et al. 2014). When the focus moves from global comparisons of groups of therapists to the performance of individuals within groups, a very different picture emerges. First, differences between clinicians, it turns out, have a dramatic impact on client outcomes (Baldwin and Imel 2013; Saxon and Barkham 2012; Wampold and Brown 2005). To illustrate, in their analysis of therapist effects, Okiishi et al. (2006) found clients of the most effective practitioners improved significantly faster and were twice as likely to recover than those treated by the least effective. What is more, clients of the inferior performing therapists were twice as likely to deteriorate. In another study using a large sample of therapists (n = 119) in the National Health Service in England, Saxon and Barkham (2012) found that if the 1947 patients of the poorer therapists (viz., the 19 therapists they labelled as “below average”) were randomly assigned to the one of the other 100 therapists, an additional 265 patients would have recovered. Second, it is clear clinicians can improve their outcomes and help more people when exposed to the right process. Throughout the history of the profession, training and supervision have focused on factors that contribute little or nothing to client outcomes using methods for which there is no evidentiary justification. For example, massive time and effort is devoted to mastering treatment methods and promoting compliance with manualized protocols despite overwhelming evidence that neither significantly impact effectiveness (Wampold and Imel 2015; Laska et al. 2014). The same can be said of the field’s “tried and true” professional development initiatives. Despite often being mandated as part of certification or licensing, no consistent evidence exists that ongoing supervision, participation in guild-approved continuing education activities, and personal therapy, result in better therapists (Miller et al. 2015; Rousmaniere et al. 2017). Furthermore, while such activities may elicit confidence, the largest study in the history of psychotherapy research on the relationship between experience and effectiveness and one of the only longitudinal studies, documents that clinicians’ outcomes decline year after year (Goldberg et al. 2016). The “right process” we refer to is deliberate practice. Through extensive study of the development of expertise across a wide range of performance domains, researcher K. Anders Ericsson identified a series of distinct steps

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that, when followed, result in improved performance (Ericsson et al. 2006). Miller et al. (2017) outlined three for growing better therapists, including: (1) determining a baseline level of effectiveness; (2) obtaining systematic, ongoing feedback on actual performance; and (3) successive refinement through repetition targeted at objectives just beyond an individual’s current level of achievement (Miller et  al. 2017). Superior performers across a wide range of professions (e.g., medicine, computer programming, teaching, sports), including psychotherapy, devote at least twice as much time and effort to these steps than average performers, and 14 times more than the least able (Chow et al. 2015). Third, although the effects of deliberate practice are robust, abundant evidence from both research and real life makes clear few, absent strong encouragement and supportive structure, will incorporate it into their professional work. The culture at large at best expects proficiency, and proficiency is the enemy of excellence. The reason, according to the leading researcher on expertise, K. Anders Ericsson (1993), is simple, “Deliberate practice is not inherently motivating; and unlike work, it does not lead to immediate social and monetary rewards…and [actually] generates costs” (p.  368–369). Here exists a new opportunity for mental health managers and administrators: creating a work environment organized around deliberate practice. Goldberg et al. (2016) reported the results of a 7-year study on the implementation of deliberate practice at large mental health agency. Unlike any previous investigation of therapist training, a statistically significant, year-to-year increase in effectiveness was found among individual therapists, consistent with the magnitude of improvements seen in studies of deliberate practice in other professions. Importantly, managers and supervisors proved to be key, putting in place policies and procedures, building structures, holding people accountable, actively removing barriers, and making necessary resources available (Miller and Hubble 2011). Such findings make clear that the opportunity to train and make competent practitioners, as envisioned by Frederick Winslow Taylor in 1911, is within reach. It is no longer a matter of way. It’s a question of will. Funding  No fund was received from any source. Compliance with Ethical Standards  Conflict of interest  No conflicts of interest for any authors. Research Involving Human and Animal Participants  No animals or human participants were used in this report.

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