Most Therapists Overestimate Their Clients’ Progress

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During a workshop called, simply, “Training Psychotherapists” at The Evolution of Psychotherapy conference in Anaheim, California, in 2017, CBT pioneer Don Meichenbaum said, “Love yourself as a person, and doubt yourself as a therapist.”

Meichenbaum described a modern field with no humility in selling psychotherapy services—marketing filled with psychobabble and neurobabble. He quipped that many modern therapists are insulated from criticism and lack a sense of humor. He said, “When people advertise that their approach is 'revolutionary’ or a ‘breakthrough’ or their approach makes a difference to ‘effectiveness,’ let me tell you, that’s bullsh*t.”

Scott Miller, director of the International Center for Clinical Excellence and one of Meichenbaum’s co-presenters, jumped in and contrasted graduate school with “gradual school." Miller claimed that there is very little evidence supporting the common, nearly universal training that therapists receive in graduate school. He said, “Thirty years of data finds no outcome shows improvement in pre-doctoral and postdoctoral practice and that students often do better than supervisors.” He continued, “Outcomes of therapists decline year in and year out, yet all the while, the confidence of the clinician in themselves and their work goes up at a much faster rate.”

The fact of the matter is that we therapists tend to be more confident about our skills than outcome data supports. Humility about our knowledge and our skills is valuable, especially in our line of work, yet it is rare. The Dunning-Kruger effect is a phenomenon that can be summed up, according to David Dunning himself, as, “Our ignorance is invisible to us.”

Maybe more training is the answer?

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Jeffrey Zeig, the third co-presenter, offered, “There’s no evidence that continuing education credit trainings help therapists, yet we’re required to get them. We must find better ways.”

In a separate speech given at the conference, Miller spoke at length about a study conducted in the UK known as Improving Access to Psychological Therapies (IAPT). It is the greatest investment of time and funds ever spent by a country in improving access to psychological care. Impressively, the program increased the percentage of people who received treatment. Miller pointed out, however, that the vast majority (up to 85 percent) of people in need did not. The point? Other studies indicate that potential consumers cite “lack of confidence in the outcome of care” as a barrier. Clearly, training is important—particularly, training that improves therapist effectiveness.

What about more training in "evidence-based practices?"

Meichenbaum: "One research study trained therapists in 300 hours of CBT, and therapists were no more effective, in spite of those therapists’ demonstration of fidelity."

Zeig tagged on, “John Gottman says the effect size is no different for empirically validated treatments.”

So what is the answer, dear experts?

Meichenbaum stepped in, “When clinicians tailor therapy and diverge from manuals and are sensitive to individualize based on their read of the client, outcomes go up.”

Miller mused, “This is the third rail of our field: Why are some therapists better than others? Deliberate practice. Which is about what you do before and after you meet with clients—better therapists do more of it, two and a half times more than average therapists. The best do it fourteen times more. The worst therapists report being as good as the best therapists. Most therapists overestimate their clients’ progress by 65 percent.”

Meichenbaum invited Miller to talk about the APA's then-recent posting of PTSD treatment guidelines.

Miller's response was that in head-to-head comparisons of different approaches, no difference in outcome is found. One side argues for a formulary, another for other factors, while those on the panel agree: training must improve outcomes, or it's not worth therapist time and investment.

Meichenbaum added, “The only factor predictive of outcome: the degree to which the therapist provides for channels of client feedback. Watch videotape, but do not watch it alone. You’ll just think you did good.”

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Any last expertise to share?

Meichenbaum riffed, “So go home, figure out your own way, and work on your own deliberate practice.”

Miller closed, “People settling into their practice is exactly what causes burnout and a decrease in their effectiveness of practice. Routinization is bad. You must constantly face your errors… Burnout is being forced to continue to work with people that you are not helping.”