Gaining Therapist Expertise: Why? and How?
Is expertise significant when compared with the other factors involved in psychotherapy outcomes? If so, how do psychotherapists gain expertise? Before answering that question, expertise as it relates to psychotherapy must be defined. If a therapist does not understand all of the activities that are required to perform psychotherapy, then they can’t understand how to cultivate the requisite skills. Once a therapist accounts for the behaviors, attitudes, and personal characteristics that contribute to expertise, then a more thorough exploration of cultivating it can take place. Because of the complexity of the process, the attempt to navigate the domain of psychotherapy expertise must be done with humility.
Expertise in Psychotherapy
Reese (2017) writes that psychology research advanced after the field of psychology acknowledged that the qualities of the therapist impacted the outcome of therapy more than the treatment model used. In light of this conclusion, understanding how the psychotherapist can cultivate more expertise to better influence outcomes becomes more worthwhile. Moving away from older debates around orientation and modality, a new debate has emerged around what expertise means when applied to counseling and psychotherapy.
Tracey, Wampold, Lichtenberg, and Goodyear (2014) say that expertise is more than competence. Through experience, they say that those with expertise should have more organized and broader knowledge that leads to better decision-making. Goodyear, Wampold, Tracey, and Lichtenberg (2017) write that therapist expertise must be measurable and show superior performance to peers mainly regarding client outcomes. However, Spengler et al. (2009) found in a meta-analysis of n=4,607 clinicians, that therapists with specializations performed no better than generalists at clinical judgment. They also found that experienced therapists performed only modestly better that novices when applying this broader knowledge and experience.
Compounding the problem, when it comes to self-assessment of therapy skills, researchers consistently find highly suspect judgments. Goodyear et al. (2017) in their review of the literature on therapist self-assessment conclude that therapists do poorly at judging their own competency. Similarly, Walfish, McAlister, O’Donnell, and Lambert (2012), while examining therapists’ self-appraisal of expertise, found that the average therapist rated themselves compared to their peers as performing at the 80th percentile and that one in four therapists believe themselves to be above the 90th percentile in the field. They warn that there is no reason to believe that therapists’ own performance and their clients’ well-being are at risk because of an overly positive self-assessment. Nevertheless, they postulate therapists may need this emotional leverage to not burn out while dealing with cases whose outcomes are largely out of their control.
Following this trend, a stark realization from recent research on therapist expertise is that therapists might not improve with experience. The most comprehensive studies conducted on therapist outcomes yield results that imply that years of experience and time in sessions don’t automatically lead to superior outcomes. In fact, years of experience and clinical hours may have a corrosive effect on outcomes for some practitioners that offset any benefits from gained expertise. O’Shaughnessy, Du, and Davis (2017) indicate that therapist burnout may explain some of these differences. They also say that it is clear over time, that all therapists gain experience, but not all therapists gain expertise.
While only examining patient outcomes at a single clinic, a longitudinal study by Goldberg et al. (2016) found that not only do patient outcomes not improve with experience, they actually decline when looked at in aggregate. The study followed 170 therapists over several years as they treated over 6,500 patients. When examining therapist outcomes individually, Goldberg et al. (2016) found that some therapists did improve with experience (39.41%) even though the overall trend was downward, implying that at least with some therapists, cultivating better outcomes is possible. But what about the other 60%? Critically, this study looked at measure of outcomes, not skills. Cultural and environmental factors at the clinic could certainly contribute more to outcomes than any increases in therapist expertise, which was not directly measured.
In another study that included (n=281) therapists treating (n = 10,812) patients, Brown, Lambert, Jones, and Minami (2005) found that there are significant differences in outcomes between therapists. Brown et al. (2005) could not explain the differences in outcomes by therapists’ prior experience. While this study could not conclude why some therapists were better than others, they could only conclude that some therapists were highly effective compared to their peers.
Thirdly, Chow et al. (2015) studied n = 69 therapists and n = 4,580 clients seeking the characteristics of highly effective psychotherapists. Years of experience did not significantly predict outcomes. Many other therapist characteristics such as gender, degrees conferred, and theoretical orientation also had no significant impact on outcomes.
While a popular argument holds that the strongest predictor of therapist expertise should be client outcomes in aggregate, it is important not to conflate outcomes with expertise. Chow et al. (2015) found that therapist effects account for roughly 5% of the variance in outcomes. Baldwin and Imel (2013) conducted a meta-analysis of therapist effects on therapy. While they concluded that in clinical research settings, 3% of outcomes could be attributed to therapist effects, in regular practice, approximately 7% could be attributed to therapist effects (it is worth noting the range of therapist effect was 0% to 55%). While these findings may discourage a therapist from feeling like a high-level of expertise can have little impact on a single case, greater expertise has a larger impact on a greater number of cases. Since therapist factors do impact case outcomes, a therapist with higher levels of expertise should have a career that results in better overall outcomes compared with peers with less expertise but the same amount of experience and with similar cases.
How much does it matter if therapists perform in the low-range compared with those of higher expertise? As Tracey et al. (2014) state, therapy outcomes primarily are the result of factors outside the control of the therapist. But even if therapist factors are small, what happens to patients when they are treated by practitioners with more expertise? Imel, Sheng, Baldwin, and Atkins (2015) simulated performance outcomes when low-performing therapists were removed. They used models that attributed case outcomes to varying amounts of attribution to therapist expertise from 5% to 20% in increments of 5 percentage points per simulation. They randomly sampled 50 therapists from three simulated populations of 1,000 therapists. Even at the lowest amount of therapist influence (5%), by removing the bottom 5% of therapists from the simulation 40 times within a ten year simulation, 4,266 additional patients responded to treatment. While this simulation has many limitations, it is evidence that if providers can only marginally improve their expertise over the course of their careers, substantially more patients will likely respond to treatment.
Characteristics and skills
Assuming that gaining expertise as a therapist is seen as beneficial (i.e. leading to more successful outcomes over a career and across the field), and that it can be cultivated, there are many pitfalls when defining expertise as it relates to conducting psychotherapy. Some conflate reputation and skills in a related area of expertise with expertise as a therapist. There is danger there. A brilliant physics researcher may not be an effective physics teacher. Someone who shines in a consult group as a conceptualizer and orator of the human psyche may fail to help the client being discussed when actually conducting therapy.
Hill, Spiegel, Hoffman, Kivlighan, and Gelso (2017) blame the lack of research into developing therapist expertise on poor definitions of the specific skills and therapist characteristics that would need to be operationalized. They rebuke current graduate clinical training and post-degree supervision as a model lacking proof that it improves therapist skills. To practice the art of psychotherapy, the practitioner requires not only an educational background, but also certain personal characteristics and the ability to perform a specific set of skills unique to conducting psychotherapy. To gain expertise as a therapist is to improve on those personal characteristics and the ability to perform that set of skills. But the challenge is in defining them.
Several researchers have taken on the challenge. Hill et al. (2017) attempt to enumerate a set of operationalizable criteria that can be researched so that models of training can be improved to show evidence of increased expertise in each domain. Prior to Hill et al. (2017), Tracey, Wampold, Goodyear, and Lichtenberg (2015) set out to accomplish a similar task. Tracey et al. (2015) created four broad categories of expertise: reputation, skill and adherence to a prescribed standard of performance, clinical accuracy, and client outcomes. Hill et al. (2017) agreed with the general categories of expertise defined by Tracey et al. (2015) with the exception of clinical accuracy. Hill et al. (2013) considered diagnostic skills to be an entirely separate domain of expertise that should be considered outside the definition of expertise with therapy.
Hill et al. (2017) delineated their criteria further from Tracey et al. (2015) by creating eight broad categories of expertise. In addition, they ranked the categories in order of relative importance to one another. Within each category, they identified more granular measures to help determine level of expertise in the overall category. The end result was a comprehensive list of measurable skills to contribute to therapist expertise ranked in order of relative importance.
Table 1. Criteria and Related Measures for Assessing Expertise according to Hill et al. (2017)
1. Performance
A. Client-rated working alliance
B. Client-rated real relationship
C. Observer-rated responsiveness
D. Use of observer-rated theoretically appropriate interventions
E. Observer-rated competence
F. Client-rated multicultural competence
G. Observer-rated responsiveness
H. Supervisor-rated competence or responsiveness
2. Cognitive functioning
A. Observer-rated assessment of cognitive processing
B. Observer-rated assessment of case conceptualization ability
3. Client outcomes
A. Engagement in therapy (percentage of clients who return after intake)/dropout rates
B. Clinically significant change on reports by clients, therapists, significant others, or observers using measures of symptomatology, interpersonal functioning, quality of life/well-being, self-awareness/understanding/acceptance, satisfaction with work
C. Behavioral assessments (e.g., fewer missed days of work, fewer doctor visits)
4. Experience
A. Years of experience
B. Number of client hours
C. Variety of clients
D. Amount of training
E. Amount of supervision
F. Amount of reading
5. Personal and relational qualities of the therapist
A. Self-rated self-actualization, well-being, quality of life, lack of symptomatology, reflectivity, mindfulness, flexibility
B. Empathy ability (self-rated, nonverbal assessments, observer ratings)
C. Nonverbal assessments of empathy
6. Credentials
A. Graduation from an accredited training program
B. Board certification
7. Reputation
A. Professional interactions
B. Advancement to positions of honor within organizations based on recognition of clinical expertise
C. Positive feedback and referrals from clients
D. Reports from colleagues/friends
E. Invitations to demonstrate methods in videos, workshops, or books
F. Lack of ethical complaints
8. Therapist self-assessment
A. Evaluation of own skills
Note. 1 is most relevant and 8 is least relevant when assessing level of expertise.
Many researchers have responded to both Hill et al. (2017) and Tracey et al. (2014). Reese (2017) examines the differences between Hill et al. (2017) and Tracey et al. (2014) and finds that the former focuses on the possibilities of where research regarding therapist expertise could go, where the latter focuses on what current research has discovered. Reese (2017) concludes that Hill et al. (2017) “offer the promise of better understanding what makes an excellent psychotherapist”(p. 76). O’Shaughnessy et al. (2017) urge any discussion regarding therapist expertise to focus on cultural humility, but conclude that Hill et al. (2017) ultimately accomplished stimulating debate on therapist expertise, an important goal. Norcross and Karpiak (2017) also responded to both Hill et al. (2017), Tracey et al. (2014, 2015), and to a growing consensus that graduating students’ competencies and the quality of their training is assumed more than verified and that expertise and experience have little, if any, correlation. Norcross and Karpiak (2017) conclude that expertise comes from commitment to practice and focus on the relationship rather than attempts to master a particular method. They write that their opinion is that the person of the therapist will ultimately determine who becomes expert.
The various reactions to Hill et al. (2017) commented on many of the specific ranked categories. An exploration of these provides more insight regarding the complexities of defining therapist expertise.
Performance
Hill et al. (2017) identify the ability to create a therapeutic relationship as the primary skill to consider when evaluating therapist expertise. They treat this skill as more fundamental than technical skills. They claim intellectual and conceptual abilities, emotional maturity, and interpersonal skills are the main constituents of facilitating a therapeutic alliance across a diverse client pool. They separate the less expert from the more expert by comparing those who become therapists because of a genuine desire to help based upon their own life experiences, but struggle to help those with symptoms dissimilar from their own personal experiences because of fewer capacities in the constituent skills.
Reese (2017) agrees that the quality of the therapist relates highly to the quality of the relationships formed, but questions whether the specific skills and attributes can be distilled into researchable components. He also questions if doing so would even deliver actionable results. He illustrates this with an example from the TV show Big Bang Theory, when friendless and socially inept, Sheldon, creates a complex diagram of how to make friends, but then fails miserably at accomplishing the task once it’s treated in a mechanical, process-focused manner. He warns that psychotherapy will not likely easily be reduced to variables and processes that can be trained with consistent results.
When considering technical expertise, Hill et al. (2017) acknowledge that there is no research that compares experts to novices. As a result, they attempt to estimate how technical differences may manifest. They conclude that technical expertise leads to more flexibility from the therapist who can adapt interventions not only to each client, but to varying contexts within treating individual clients. This implies that strict adherence to a treatment manual or protocol is representative of the approach used by less expert practitioners.
In their follow-up to Hill et al. (2017), Goodyear et al. (2017) agree with the rebuke of therapist training, but offer some differing opinions in some areas. They criticize observer competency ratings as a criteria for expertise because judgements may be made based upon theoretical orientation and not outcomes. They have concerns, for example, that a psychodynamic-oriented therapist evaluating a CBT-oriented therapist may deduct “style-points” if making an observable competency evaluation. Their ultimate critique is that having so many criteria makes it too easy to overlook the primary aim of increasing expertise as a therapist, which is to help clients to improve. Because of this, Goodyear et al. (2017) reiterate, that expertise should only be considered a function of client outcomes, even in the face of research that shows that therapist factors contribute a significant, but reasonably small percentage to that goal (Chow et al., 2015; Tracey et al., 2014; Imel et al., 2015).
Reese (2017) is highly critical of using technical definitions of expertise, mainly because of the difficulty in identifying what works and how. He attributes the effectiveness of therapy to exist somewhere in the “gestalt of the process” where so many confounding interactions between therapist and client occur, that specifics can’t be identified. If they can’t be identified, then they can’t be trained toward more expertise, he says.
Cognitive functioning.
Regarding cognitive processing, Hill et al. (2017) warn that being able to recall, organize, and process vast amounts of information regarding client history, theoretical models, and other relevant knowledge does not directly imply expert interventions. They reiterate that talented case formulations, while possibly dazzling to consultation groups, might not translate to effective interventions in the room with a real client. Nevertheless, being able to conceptualize more detailed and nuanced hypothesis indicates higher expertise in the domain of cognitive processing. Norcross and Karpiak (2017) encourage down-grading the ability of a therapist to create complex case conceptualizations when applied to determining expertise. They claim it is more of an academic exercise than a demonstration of therapeutic skill.
Client outcomes.
Hill et al. (2017) claim that expert therapists should have lower drop-out rates and higher client self-report outcomes. They warn against using client self-report outcomes as the primary factor for evaluating expertise as Tracey et al. (2014) urge, because of the many inherent flaws in client self-report. The main flaw they mention is the “hello, good-bye effect” where clients’ self-reports may be lower when starting a treatment so as to better justify entry, but may be higher when terminating to justify exit. Reese (2017) considers the many flaws in client reported outcome measures but feels it’s still the best metric for determining therapist expertise. He compares the complex variables of therapy to baseball. He says that while baseball statistics are imperfect and lead to many debates, it’s still the best means for determining the quality of the player and deciding who you want on your team. O’Shaughnessy et al. (2017) admit that client outcomes are determined more by factors outside the therapist’s control, but claim that in spite of that, the more expert therapist can navigate these variables and therefore should have superior outcomes.
Personal and relational qualities of the therapist.
Personal qualities of the therapist rank near the middle in Hill et al. (2017). These skills encompass the qualities that a therapist must have naturally, or cultivate to aid in the therapeutic process. According to Hill et al. (2017), these include dedication, concern, ability to maintain boundaries and model appropriate behaviors, professional self-awareness, nonverbal intelligence, emotional intelligence, and social skills. They also warn against only measuring these characteristics as traits, since in the state of practicing therapy, they may not necessarily manifest. It is interesting that few responses to Hill et al. (2017) discussed therapist qualities in detail compared to other categories.
Experience, reputation, credentials, and self-assessment.
These rank at the bottom of the list of categories relevant to therapist expertise according to Hill et al. (2017). They are critical of how experience is accounted for, saying that years since graduation is an oversimplification. They encourage tracking experience more accurately by using client hours per year, diversity of clientele, and independent education hours. While Hill et al. (2017) rank credentials low, they feel a degree from an accredited program is still a requirement when considering expertise. They also feel reputation and self-appraisal should be considered, but consider them the least important criteria to use for evaluation expertise. Norcross and Karpiak (2017) feel that the criteria of self-assessment and experience should be completely removed. They illustrate this criticism when they write, “My grandmother drove an auto for 65 years and prided herself on her driving ability, and she was absolutely the worst driver I have ever witnessed.” Norcross and Karpiak (2017) consider the reputation of being a “psychotherapy expert” as having no correlation to client outcomes. They write that being an expert about psychotherapy can be acquired without having any actual experience conducting clinical psychotherapy. Reese (2017) acknowledges that the literature provides no support to conclude that expertise can be assumed a priori from experience, reputation, and credentials. O'Shaughnessy et al. (2017) deride using experience, reputation, and credentials to establish expertise. In their view, reputation is likely more a function of being academic, extraverted, and having time and means to spend networking at conferences and events. O'Shaughnessy et al. (2017) reiterate that there is no support for claiming that experience in the form of number of sessions, or years working as a therapist leads to expertise.
Multicultural expertise.
Expertise as a psychotherapist must also include multicultural competencies. Having established that the therapeutic alliance plays a vital role in client outcomes, a therapist who lacks multicultural competencies will not be able to handle cases that require those competencies in an expert manner. Owen, Imel, Wampold, and Rodolfa (2014) found that 53% of the psychotherapy clients in their research experienced microaggressions in the therapy room. There is no doubt that many of the professionals who are defining expertise are also some of the ones contributing to the presence of microaggressions and multicultural deficiencies in the enactment of therapy. O’Shaughnessy et al. (2017) write critically that since minorities and people of color continue to have drop-out rates that are higher than whites and higher levels of dissatisfaction with therapy, that current measures of expertise are still lacking when considered from a multicultural context. Defining expertise not only involves how it’s defined, but also who defines it, and whether they seriously consider the outcomes of all patients (O’Shaughnessy et al., 2017). In Hill et al. (2017) this competency was not neglected. It’s ranked in the most important category, that of performance. Reese (2017) writes that expertise shouldn’t be considered as a static quality because therapists may be expert with some clients and not others, particularly those from other cultural backgrounds.
Mechanisms to Gain Expertise
Assuming a basic definition of what expertise entails, how does one actually gain it as a psychotherapist? Current research concludes that expertise isn’t gained simply by conducting therapy sessions. Miller, Duncan, and Hubble (2008) claim that three primary processes are involved in gaining expertise: understanding current level of skills, performing regular, deliberate practice, and obtaining feedback. Since therapist self-assessment is tremendously flawed, supervision is the primary mechanism to be explored for understanding current level of skills.
Deliberate Practice. Norcross and Karpiak (2017) write that “deliberate practice may well make the master” (p. 69). However, the difficulty in determining the value or necessity of deliberate practice (DP) is similar to the difficulties encountered in most psychological research. Decisions about what to measure, how variables are operationalized, the difficulty of controlling for external factors, and more, make it challenging to determine the best ways to practice or if deliberate practice outside of sessions is even necessary.
Goldberg et al. (2016) performed a case study of a clinic committed to improving client outcomes with the use of DP, feedback, and consultation. The study included n = 5,128 cases seen by n = 153 psychotherapists over 7 years. They found the efforts of the clinic efficacious, with therapists improving slightly year-over-year.
Chow et al. (2015) studied the role of deliberate practice in developing therapist expertise. They found that unlike theoretical approach, caseload, and degree of approach integration, the amount of time a therapist spent practicing outside sessions significantly related to outcomes. Interestingly, they also found that the significance remained no matter what particular method of DP was used which included reviewing cases, receiving training, reflecting on past sessions, and contemplating future sessions.
Hill at al. (2017) support Chow et al. (2015) when they write that time spent thinking about and reflecting on sessions directly impacts client outcomes. Goodyear et al. (2017) claim that deliberate practice is the most beneficial method for gaining expertise. They agree with Miller et al. (2017) that DP has four components: a formalized system of effort to improve over time, mentor guidance, timely feedback regarding skills performance, repeated refinements made during practice sessions outside of performance time.
Klostermann and Mignone (2017) write that a reformulation of training models is necessary, one that replaces seminars, conferences, and workshops with on-going, realistic practice plans that continuously bring therapists out of their comfort zones into the learning zone. They believe the “entrenchment” of the traditional model is the biggest impediment to the field embracing DP and wish to see internships and practica incorporate it as a fundamental part of the training mindset.
Client Feedback.
Soliciting client feedback has some difficulties associated with it such as the amount of time used to obtain it (Brown, Dreis, & Nace, 1999) and disruption of the therapeutic process (Reese, Slone, & Miserocchi, 2013). Nevertheless, Goodyear et al. (2017) support the use of routine outcome monitoring to solicit actionable client feedback. Lambert, Hansen, & Finch (2001) found that when therapists use client feedback, ten percent more cases obtain clinically significant improvement. They also found that substantially fewer cases deteriorated when client feedback was used during treatment (6% deterioration with feedback, 23% deterioration without). Tracey, Wampold, Lichtenberg, and Goodyear (2014) mention the importance of this since therapists have been shown to not do well at identifying deteriorating cases using their judgement alone. Reese (2017) writes that client feedback is an important activity for many reasons, including accountability, a chance for the therapist to reflect, and as a component of DP. Hill et al. (2017) encourage client feedback, but more in the form of immediacy in-session. They believe therapists need to learn to be genuinely curious about their clients and learn to engage clients deeply about what is happening in the room during treatment. Flückiger et al. (2012) concluded that when clients are able to give therapists feedback on the relationship that the alliance improves. They attribute this improvement to gained expertise via the feedback loop. Norcross and Karpiak (2017) emphasize this point of using client feedback, but not as a means unto itself. Without using the data to improve performance and outcomes, they consider collection of client feedback mindless and without purpose. To that aim, Norcross and Karpiak (2017) write that using multiple sources of client feedback is optimal.
Several popular client feedback mechanisms are discussed by Reese, Slone, and Miserocchi (2013). The Session Rating Scale (SRS) and Outcome Rating Scale (ORS) are intended to be easy to integrate into sessions so that clients may quickly deliver feedback about how they are doing outside of therapy and regarding the therapy session. Using these measures can be useful in preventing client deterioration. In a study by Reese, Norsworthy, and Rowlands (2009), therapists who implemented the Partners for Change Outcome Management System (PCOMS) reduced deterioration rates from 21% to 8%.
Supervision
Hill and Knox (2013) write that during supervision, trainees learn a multitude of improvements in a short period time, but since supervision typically ends at licensure, its long-term effect on therapist expertise is difficult to know. Hill et al. (2017) also acknowledge that ethical considerations prohibit a study that compares graduate training with and without supervision. Nevertheless, those researchers exploring therapist expertise believe ongoing mentoring and supervision is a required component (Hill et al., 2017).
McMahan, E. H. (2014) write that supervision likely provides an essential ingredient for composting the activities of deliberate practice including obtaining and using client feedback. They also point out that in places such as the United Kingdom and Australia, supervision is required for a much longer time period. Klostermann and Mignone (2017) encourage the selection of a supervisor who embraces the process of deliberate practice, one who will understand and support the trainee in that endeavor. Watkins (2012) encourages the use of recorded therapy sessions with a supervisor as an additional component of developing expertise.
Discussion
What happens in the lives of clients and how much they are in engaged in treatment will influence outcomes more than measurable therapist factors (Bohart & Tallman, 2010; Orlinsky, Rønnestad, & Willutzki, 2004) Nevertheless, it appears that an examination of client outcomes in aggregate is still the most broadly accepted way for determining therapist expertise. This is challenging since client outcomes are difficult to obtain and even more elusive to get from a patient’s family and friends to provide outcome measures with the greater weight that broader perspectives bring.
Various models of expertise have been formulated and discussed. Where they differ, they agree that current models of training completely neglect any serious empirical appraisal of developing expertise. When considering Hill et al. (2017) along with criticisms, perhaps the model contains too many criteria to effectively research or practice. Reconceptualizing the model after incorporating professional critiques yields a stream-lined model that can enable researchers and practitioners to focus on fewer areas of concern. This model is shown in Table 2.
Table 2. Reconceptualized Criteria and Related Measures for Assessing Expertise
1. Client outcomes
A. Engagement in therapy (fewer dropouts, more motivated clients)
B. Clinically significant change on reports by clients, therapists, significant others, or observers using measures of symptomatology, interpersonal functioning, quality of life/well-being, self-awareness/understanding/acceptance, satisfaction with work
C. Behavioral assessments (e.g., fewer missed days of work, fewer doctor visits)
2. Personal and relational qualities of the therapist
A. Reflectivity, mindfulness, flexibility
B. Empathy and acceptance
C. Ability to model behaviors and emotions, and maintain boundaries
D. Personal therapy
3. Performance
A. Client-rated working alliance
B. Client-rated real relationship
C. Client-rated multicultural competence
D. Supervisor-rated competence or responsiveness
Note. 1 is most relevant and 3 is least relevant when assessing level of expertise.
Although therapist factors contribute a smaller percentage to patient outcomes than client factors, it ranks highest in this model, not only because that is the primary concern of therapy, but also because this criteria achieved the most consensus among recent researchers exploring the domain of therapist expertise. By considering a graduate degree from an accredited program and lack of ethical complaints, both not qualities of expertise, but rather, qualifications to practice, those categories were eliminated. Since personal qualities are more difficult to operationalize and measure, they appear lower in the set of criteria than client outcomes.
Research Conclusion
Many researchers are attempting to create accurate models of expertise hoping that current therapist training and assessment models can be improved. While a noble endeavor, the complexity of the domain will present many challenges no matter what models are considered for actual scientific research. O'Shaughnessy et al. (2017) are concerned that focusing on expertise may result in a hierarchical way of thinking rather than a curious and open style. They claim there are practically infinite ways of being expert and as a result, creating models and variables to quantify it will be challenging. What is clearer, is that individual therapists do play a role in client outcomes and that merely obtaining experience may not be enough to improve client outcomes over a career. Therapists who wish to improve can likely do so by performing several activities, including deliberate practice, obtaining and using client feedback, and continuing with guidance and supervision beyond what is required for licensure. The initial hurdle for many therapists to overcome will be that of overly-high self-appraisals that may lead to inaccurate beliefs of peer superiority. Inflated self-assessment, while possibly a moderator of burn-out, could lead to inaction regarding the important areas of expertise development and a subsequent deterioration of client outcomes. An important point to consider may be that if deliberate practice outside of the therapy room yields more results than experience, then caseloads of 25 or more patients a week may reduce the possibility that a practitioner will have time for DP and related activities. It may be that keeping a smaller case load helps create the necessary conditions for deliberate practice, and subsequently for expertise to blossom.
Recommendations
In an effort to revamp clinical therapist training in a way that develops measurable skills that are involved in gaining expertise, research can begin to focus on operationalizing measurable skills and determining practical methods for improving them. While this is a complex and inherently difficult task, accepting current models as sufficient goes against the general conclusions drawn from the existing body of research. If psychotherapy wants to continue to compete with medical models of treatment, the ability to more accurately train and improve the expertise of therapists must be treated seriously and rigorously.
Therapists who want to gain expertise are encouraged to create and enact a system of deliberate practice that includes soliciting and using client feedback as well as obtaining the aid of a mentor for guidance. While research is inconclusive regarding the use of personal therapy for improving expertise, Hill et al. (2017) believe that the self-awareness, insight, and ability to work with countertransference gained from it, make the endeavor worthwhile for all therapists.
How to become an expert psychotherapist References
Baldwin, S. A., & Imel, Z. E. (2013). Therapist effects: Findings and methods. In M. J.Lambert (Ed.), Bergin and Garfield’s handbook of psychotherapy and behavior change (5th ed., pp. 258–297). Somerset, NJ: Wiley.
Bohart, A. C., & Tallman, K. (2010). Clients: The neglected common factor in psychotherapy. In B. L. Duncan, S. D. Miller, B. E. Wampold, & M. A. Hubble (Eds.), The heart and soul of change: Delivering what works in therapy (2nd ed., pp. 83-111). Washington, DC: American Psychological Association.
Brown, J. Dreis, S., & Nace, D. (1999). What really makes a difference in psychotherapy outcome? Why does managed care want to know? In M. Hubble, B. Duncan, & S. Miller (Eds.), The heart and soul of change (pp. 389-406). Washington, DC: APA Press.
Brown GS, Lambert MJ, Jones ER, & Minami T. (2005). Identifying highly effective psychotherapists in a managed care environment. American Journal of Managed Care, 11(8), 513–520.
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, (3), 337.
Flückiger, C., Del Re, A., Wampold, B. E., Znoj, H., Caspar, F., & Jorg, U. (2012). Valuing Clients’ Perspective and the Effects on the Therapeutic Alliance: A Randomized Controlled Study of an Adjunctive Instruction. Journal of Counseling Psychology, 59(1), 18–26.
Goldberg, S. B., Babins-Wagner, R., Rousmaniere, T., Berzins, S., Hoyt, W. T., Whipple, J. L., … Wampold, B. E. (2016). Creating a Climate for Therapist Improvement: A Case Study of an Agency Focused on Outcomes and Deliberate Practice. Psychotherapy, (3), 367.
Goldberg, S. B., Miller, S. D., Nielsen, S. L., Rousmaniere, T., Whipple, J., 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.
Goodyear, R. K., Wampold, B. E., Tracey, T. J. G., & Lichtenberg, J. W. (2017). Psychotherapy Expertise Should Mean Superior Outcomes and Demonstrable Improvement Over Time. Counseling Psychologist, 45(1), 54–65.
Hayes, S. C., Strosahl K. D., & Wilson K. G. (2003). Acceptance and Commitment Therapy: An Experiential Approach to Behavior Change. New York, NY: The Guilford Press
Hill, C. E., & Knox, S. (2013). Training and supervision in psychotherapy: Evidence for effective practice. In M. J. Lambert (Ed.), Handbook of psychotherapy and behavior change (6th ed., pp. 775-811). New York, NY: John Wiley.
Hill, C. E., Spiegel, S. B., Hoffman, M. A., Kivlighan, D. M., Jr., & Gelso, C. J. (2017). Therapist expertise in psychotherapy revisited ψ. The Counseling Psychologist, 45(1), 7–53.
Imel, Z. E., Sheng, E., Baldwin, S. A., & Atkins, D. C. (2015). Removing very low-performing therapists: A simulation of performance-based retention in psychotherapy. Psychotherapy, 52(3), 329–336.
Klostermann K, Mignone T (2017) Improving Therapist Effectiveness: The Case for Deliberate Practice. J Addict Med Ther 5(2): 1034.
Krech G. (2001). Naikan: Gratitude, Grace, and the Japanese Art of Self-Reflection. Albany, CA: Stone Bridge Press.
Lambert, M. J., Hansen, N. B., & Finch, A. E. (2001). Patient-Focused Research: Using Patient Outcome Data to Enhance Treatment Effects. JOURNAL OF CONSULTING AND CLINICAL PSYCHOLOGY, (2), 159.
McMahan, E. H. (2014). Supervision, a nonelusive component of deliberate practice toward expertise. American Psychologist, 69(7), 712–713.
Miller, S. D., Hubble, M. A., & Chow, D. L. (2017). Professional development: From oxymoron to reality. In T. Rousmaniere, R. K. Goodyear, S. D. Miller, & B. E. Wampold (Eds.), The cycle of excellence: Using deliberate practice to improve supervision and training. New York, NY: John Wiley.
Miller, S. (2012, May 13). Top Performance Blog [Web log post]. Retrieved from https://www.scottdmiller.com/revolution-in-swedish-mental-health-practice-the-cognitive-behavioral-therapy-monopoly-gives-way/
Norcross, J. C., & Karpiak, C. P. (2017). Our best selves: Defining and actualizing expertise in psychotherapy. The Counseling Psychologist, 45(1), 66–75.
Orlinsky, D. E., Rønnestad, M. H., & Willutzki, U. (2004). Fifty years of psychotherapy process-outcome research: Continuity and change. In M. J. Lambert (Ed.), Bergin and Garfield’s handbook of psychotherapy and behavior change (5th ed., pp. 307-390). New York, NY: John Wiley.
O’Shaughnessy, T., Du, Y., & Davis, C., III. (2017). Reflections on the power to define psychotherapy expertise. The Counseling Psychologist, 45(1), 90–98.
Owen, J., Tao, K. W., Imel, Z. E., Wampold, B. E., & Rodolfa, E. (2014). Addressing racial and ethnic microaggressions in therapy. Professional Psychology: Research and Practice, 45(4), 283–290.
Reese, R. J. (2017). The promise and challenge (and reality) of defining therapist expertise. The Counseling Psychologist, 45(1), 76–89.
Reese, R. J., Slone, N. C., & Miserocchi, K. M. (2013). Using client feedback in psychotherapy from an interpersonal process perspective. Psychotherapy, 50(3), 288–291.
Reese, R. J., Norsworthy, L. A., & Rowlands, S. R. (2009). Does a Continuous Feedback System Improve Psychotherapy Outcome? PSYCHOTHERAPY -RIVER EDGE-, (4), 418.
Spengler, P. M., White, M. J., Aegisdottir, S., Maugherman, A. S., Anderson, L. A., Cook, R. S., … Rush, J. D. (2009). The Meta-Analysis of Clinical Judgment Project: Effects of Experience on Judgment Accuracy. Counseling Psychologist, 37(3), 350–399.
Tracey, T. J. G., Wampold, B. E., Goodyear, R. K., & Lichtenberg, J. W. (2015). Improving expertise in psychotherapy. Psychotherapy Bulletin, 50, 7-13.
Tracey, T. J., Wampold, B. E., Lichtenberg, J. W., & Goodyear, R. K. (2014). Expertise in Psychotherapy: An Elusive Goal? American Psychologist, 69(3), 218–229.
Walfish, S., McAlister, B., O’Donnell, P., & Lambert, M. J. (2012). An investigation of self-assessment bias in mental health providers. Psychological Reports, (2), 639.
Watkins, C. E. (2012). Psychotherapy Supervision in the New Millennium: Competency-Based, Evidence-Based, Particularized, and Energized. JOURNAL OF CONTEMPORARY PSYCHOTHERAPY, (3), 193.
Williams, E. F., Dunning, D., & Kruger, J. (2013). The hobgoblin of consistency: Algorithmic judgment strategies underlie inflated selfassessment of performance. Journal of Personality and Social Psychology, 104, 976–994. doi:10.1037/a0032416