Contrary to popular belief, on average, therapists do not improve with time and experience. It may be that therapists conflate skill level with automaticity. Since therapeutic interactions tend to become more fluid with time and experience, and therapists do not have to think as much about what they’re doing, which results in a comfort and complacency. Results of the largest study of effect of experience on outcome revealed that, on average, outcome declined with experience^[1]. Perhaps one explanation for why outcomes decline over time and with experience is related to the fact that clinicians lose self-doubt as the techniques of therapy become automatic and reflexive. A therapist’s treatment confidence increases over time, which may lead therapists to make assumptions about their clients and to engage in less reflection on progress and client outcome. Automaticity may result in clinicians simply not noticing their limits because they no longer think about them.

The statistics regarding therapy are grim, with 25% of clients terminating therapy without achieving any progress^[2,3]. Moreover, when considering reliable change indexes (greater than chance or maturation) or clinically significant change, these rates are even higher. Even more alarming, 1 in 10 clients account for 60-70% of resource expenditures^[4]. Given these statistics, it is the responsibility of the clinician to provide the best service possible, even if that mean seeking out expertise or accessing external resources.

Experience can prevent therapists from referring to other providers, as many experienced therapists fail to identify deteriorating cases or may feel as though they are the only one skilled enough to help – both of which impact client outcomes. Further, research shows that clinicians are less likely to experience burnout if they feel as though they are developing professionally^[5]. Perhaps this is why therapists tend to delude themselves into thinking that they are better than they are. Consequently, this may create challenges for supervisors trying to engage more seasoned clinicians.

Supervision

Supervision seems to enhance supervisee self-awareness, treatment knowledge, skill acquisition and utilization, and self-efficacy, however some research indicate that supervisors explain less than 1% of the variance in client outcomes^[5]. In both supervision and therapy, the tendency is to minimize or dismiss local knowledge of the supervisee rather than operational zing principles specific to the context. For many supervisors, the goal is for the supervisee to “just see it.” Supervisors often feel responsible for having the answers; thus, fostering and developing supervisee autonomy can be challenging. The goal of supervision is for the supervisee to develop the ability to think through issues and challenges rather than rely on the supervisor for decision making. Thus, it is better for supervisors to ask the right questions that stimulate and expand thinking, rather than providing answers. Supervisors must consider both the micro (what’s happening with these particular clients at this particular moment) and macro (trends in client data over time) to identify patterns of themes which may be opportunities for continued growth and development. Thus, collecting progress and outcome data on a session-by-session basis is critical for monitoring progress and identifying areas to improve.

Feedback Informed Treatment is a pan theoretical, evidence-based practice measuring progress and alliance on session-by-session basis^[4]. According to Miller, therapists must integrate routine outcome monitoring into practice and not alter the core components of the feedback process (e.g., modifying the measure or frequency of administration). Therefore, it is important that everyone adhere to the fundamentals and principles, and not offer excuses or reasons for how they are already applying some FIT principles in part (e.g., “I already ask my clients about progress, I pay attention to my clients so I know if we are on the same page”).

The role of supervisors should be to form solid supervisory relationships and provide support for working through clinical issues with clients rather than identifying solutions and addressing the challenge for the supervise; the goal is growth and development over time. Therapists are often constrained by their available tools, and so if they adopt a different way of thinking about a challenge or develop new tools, their boundaries expand and their skill level improves. Supervisor need to shift focus from a performance to a learning mindset. Thus, the idea is for the supervisor and supervisee to have a failure-centric mindset in which supervises’ fail small and often in order to identify areas in which they fall short - this mindset is the basis of the learning process. Clinicians with more professional self-doubt and humility tend have better outcomes, as it is this doubt and discomfort that allows the clinician to engage in self-reflection on their performance.

It is important to note that this is a dramatic shift and many clinicians may feel uncomfortable or apprehensive about sharing their struggles or failures. No matter how many times the supervisor reminds supervisees about the rationale for self-reflection and the potential positive impact on their work, clinicians will still feel apprehensive about sharing their clinical vulnerabilities; there is an inherent power dynamic which can make it difficult for therapists to be vulnerable. Thus, it is critical that the supervisor model the process and share his or her challenges and difficult cases as well. In general, the supervisor should not show successful cases when teaching and be prepared to bring negative cases to supervision.

The therapeutic alliance proves to be a powerful predictor of client success. The therapeutic alliance is more specific than a relationship. The alliance is defined by agreement on client preferences, goals, meaning, and purpose of therapy, and the means or methods used^[6]. Thus, the alliance has a purposeful, transactional, more focused quality than a relationship, which tends to be conceptualized more broadly. In supervision, it is critical to ask about alliance components. Rapid or dramatic change occurs in as many as 40% of clients^[4]. Further, there is a 90% chance of failure if the client does not make progress between the 2^nd and 8^th session. Disheartening statistics have revealed as many as 25% of people remain in treatment despite not experiencing any measurable benefit^[3]. Supervision provides the scaffolding to improve the structure of therapeutic interactions for both the supervisor, and the supervisee. Though Rousmaniere and colleagues (2014) determined supervision may not impact treatment outcomes, it is evident supervision does foster an atmosphere of healthy self-doubt and self-awareness, which gives therapists the opportunity to self-improve and seek resources that will be more beneficial to the client.

References

1. 1. Goldberg, S.B., Rousmaniere, T., Miller, S.D., et al. Do psychotherapists improve with time and experience? A longitudinal analysis of outcomes in a clinical setting. (2016) J Couns Psychol 63(1): 1-11.

   Pubmed | Crossref | Others

2. 2. Hansen, N., Lambert, M.J., Forman, E.M. et al. The psychotherapy dose-response effect and its implication for treatment delivery services. (2002) Cli Psy Sci Practice 9(3): 329–343.

   Pubmed | Crossref | Others

3. 3. Lambert, M.J., Ogles, B.M. The efficacy and effectiveness of psychotherapy. (2004) Bergin and Garfield’s handbook of psychotherapy and behavior change 5: 139–193.

   Pubmed | Crossref | Others

4. 4. Miller, S.D. Psychometrics of the ORS and SRS. Results from RCTs and Meta-analyses of Routine Outcome Monitoring & Feedback- The Available Evidence. (2011)

   Pubmed | Crossref | Others

5. 5. Rousmaniere, T.G., Swift, J.K., Babins-Wagner, R., et al. Supervisor variance in psychotherapy outcome in routine practice. (2014) Psychother Res 26(2): 1–10.

   Pubmed | Crossref | Others

6. 6. Watkins, C.E. Does Psychotherapy Supervision Contribute to Patient Outcomes? Considering Thirty Years of Research. (2011) Cli Supervisor 30(2): 235-256.

   Pubmed | Crossref | Others