When he was pitching his idea for a children’s theme park, American-icon Walt Disney was turned down over 300 times by various bankers and financiers. It’s a hard statistic to believe, especially considering over 150 million people make annual visits to Disneylands in Los Angeles, Hong Kong and Tokyo as well as Disney World in Florida. According to Walt Disney, being rejected that many times by financial institutions helped him hone his ideas and in so doing, he revolutionized the theme-park landscape.
For individuals, failure is expected and often necessary to help with improvement. Walt Disney suffered setbacks and yet went on to create one of the most powerful companies in the world. Imagine for a moment, however, there was evidence the entire theme park industry had stagnated? How would people like Disney react? How could they help to improve it? This is hypothetical of course, as anyone who’s visited MGM, Universal or the Disney properties can attest: the theme park genre is constantly being enhanced. But this concept serves to illustrate what’s happening in the field of psychotherapy. There are stand-out individuals who are seeing excellent results, yet the industry as a whole has stalled.
Psychotherapy Has Been Proven to Work
The financers approached by Walt Disney in the middle of the last century thought the concept of a children’s theme park wouldn’t work. Around that same time, there was a large contingency of professionals who believed psychotherapy was quackery. It wasn’t until 1977 that Mary Lee Smith and Gene Glass published a meta-analysis in the American Psychologist (the leading journal of the American Psychological Association) that quantitative evidence was provided that psychotherapy was remarkably effective—and that many different types of therapy provided about equal benefits. This meta-analysis showed that those who received psychotherapy were less distressed than those who did not.
Since then there have been a myriad of studies providing evidence for the effectiveness of psychotherapy. One need only look at the social landscape to understand the field has grown rapidly since the 1970s, with more practitioners and clients than ever. Despite its rise in popularity, however, the benefits of psychotherapy remain surprisingly similar to what they were over 40 years ago. While it’s heartening to hear success is still being achieved, we, as an industry, need to look at the reasons that psychotherapy has not improved.
Psychotherapy as a Field Has Proven To Be Stalled
Psychotherapy success rates have remained similar to those reported in the 1970s. This is best illustrated by using a statistic described by Letitia Pinson and Gregory E. Gray as the “Number Needed to Treat: An Underused Measure of Treatment Effect.”
The two doctors make the case that NNT (Number Needed to Treat), is the most accurate measurement of how one treatment compares with either a placebo or another active treatment.
When applying the NNT formula to psychotherapy, the doctors came up with an NNT of 3, meaning that for every three clients receiving psychotherapy, only one would have a better outcome had they not received any therapy at all. At first glance these figures appear positive but we must consider these percentages are similar to the ones presented four decades ago.
In another report called “The Secrets of Supershrinks: Pathways to Clinical Excellence,” Dr. Scott Miller writes, “no measurable improvement in the effectiveness of psychotherapy has occurred in the last 30 years….Instead of advancing as a field, we’ve stagnated, mistaking our feverish peddling on a stationary bicycle for progress in the Tour de Therapy.” He goes on to explain there are individual therapists who are improving, but overall the benefits of psychotherapy have not improved. In medicine, there have been dramatic improvements in the treatment of gastric ulcers, cancer, cardiac events, among others.
Other evidence highlighting that treatment is not progressing can be found in the following studies. Two deal with the effectiveness of cognitive behavioural therapy over many years and one is the study of the effectiveness of therapists over the course of their careers.
- The effects of cognitive behavioral therapy as an anti-depressive treatment is falling: A meta-analysis
- A meta-analysis of group cognitive–behavioral therapy as an antidepressive treatment: Are we getting better?
- Do psychotherapists improve with time and experience? A longitudinal analysis of outcomes in a clinical setting
So why is it that we’ve seen a proliferation of the number of treatments developed in the last decades, yet we haven’t seen better patient outcomes? There are three main reasons for this and all fall under the purview of post-secondary institutions and other teaching establishments. They include:
- Too much instructional emphasis placed on treatment methods as opposed to individual therapist skills.
- Too much funding to support developing treatments instead of improvements to individual therapist skills.
- Instructors under-emphasize the importance of deliberate practice during both education and career phases.
Mistake #1: Courses Emphasize Treatment Methodology Rather Than Individual Skill Set
There are now more than 500 distinct forms of psychotherapy, a figure that has increased dramatically in the past 40 years, and many have been integrated into the healthcare systems of first-world countries. They include everything from psychoanalysis and cognitive behavioural therapy to hypnosis and music/art therapy. To teach their nuances, learning institutions dedicate curriculums and courses to each.
The problem with this is there are few (if any) differences among treatments, in terms of effectiveness. As North America’s foremost psychotherapy training expert Bruce Wampold says that something more important than the type of treatment being given is the therapist giving the treatment. “There are effective CBT therapists and less effective CBT therapists. Same with psychodynamic, emotion focused, integrative, and so forth—it is the therapist, not the treatment, that is important,” Wampold said. “Dissemination of evidence-based treatments in many countries, including Great Britain, has not improved outcomes—and such efforts are immensely expensive.”
In essence, it’s the reverse of the forest-for-the-trees conundrum: rather than examining all the types of different forests there are in the world, we should be allocating energy towards the well-being of each tree so they go on to contribute to the health of the forests as a whole. Put another way: teach the skills of effective therapists rather than the differences between therapy methods.
Mistake #2: Funding Is Directed Toward Treatment Methods Rather Than Individual Skill Set
Because psychotherapy services have been integrated into various healthcare systems around the world, there is now more money available for research and training than ever before. But governments, teaching institutions and the psychotherapy industry as a whole keep allocating funds towards the kinds of treatment available: which are the most effective; what changes can be made within each discipline to improve it; how can new disciplines be created to best cope with changing societal norms.
As mentioned above, this process is flawed. As Dr. Wampold said during his psychotherapy talk at the Nordic Mental Health Conference, “The continued focus on treatment, really puts the spotlight in the wrong place. It’s us, therapists, who make therapy work and we need to put emphasis there.” In other words, we should be directing funds towards the individuals who are delivering the methodology, specifically:
- studies that examine the qualities of effective therapists
- practices that support routine outcome monitoring and feedback
- training of therapist skills using deliberate practice
In short, rather than spending money on instructing therapists to give a particular evidence-based treatment in order to improve quality of service, we should put money towards hiring more therapists, helping therapists to become more effective, and ensuring the outcomes they achieve meet established benchmarks.
Mistake #3: Instructors Under-Emphasize The Importance of Deliberate Practice
Any sporting coach, orchestra conductor or art teacher will explain the key to excellence is to practice, practice, practice. But the widely regarded psychologist Dr. K. Anders Ericsson published a library’s worth of papers showing that expertise is the result of not just practice, but “deliberate practice.” In his report “The Making of An Expert” he writes, “Not all practice makes perfect. You need a particular kind of practice—deliberate practice—to develop expertise. When most people practice, they focus on the things they already know how to do. Deliberate practice is different. It entails considerable, specific, and sustained efforts to do something you can’t do well—or even at all. Research across domains shows that it is only by working at what you can’t do that you turn into the expert you want to become.”
In 2017, a decade after “The Making of An Expert” came out, Dr. Ericsson wrote in his book Peak – Secrets from the New Science of Expertise, that experts are of the mindset that they can always be improving. They don’t stop once they’ve achieved a certain level of proficiency, rather they keep striving for better performance and they do this by using deliberate practice.
The research on deliberate practice directly relates to the psychotherapy field. Rather than focus on treatment methods, training should focus on the deliberate practice of the skills that characterize effective therapists.
Thankfully there are ways to improve psychotherapy results and progress the field through its current stagnant state. We cover the ways in which that can be achieved in our article Why Therapists Don’t Improve, And How They Could.