The Cycle of Excellence

Using Deliberate Practice to Improve Supervision and Training

Tony Rousmaniere, Rodney K. Goodyear, Scott D. Miller, Bruce E. Wampold, Tony Rousmaniere, Rodney K. Goodyear, Scott D. Miller, Bruce E. Wampold

• Publisher: Wiley-Blackwell
• Year: 2017
• Print ISBN:
  9781119165569
• Edition: 1
• eBook ISBN:
  9781119165576
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

How do the good become great? Practice! From musicians and executives to physicians and drivers, aspiring professionals rely on deliberate practice to attain expertise. Recently, researchers have explored how psychotherapists can use the same processes to enhance the effectiveness of psychotherapy supervision for career-long professional development. Based on this empirical research, this edited volume brings together leading supervisors and researchers to explore a model for supervision based on behavioral rehearsal with continuous corrective feedback. Demonstrating how this model complements and enhances a traditional, theory-based approach, the authors explore practical methods that readers can use to improve the effectiveness of their own psychotherapy training and supervision.

This book is the 2018 Winner of the American Psychological Association Supervision & Training Section's Outstanding Publication of the Year Award.

Part I
The Cycle of Excellence

1
Introduction

Tony Rousmaniere, Rodney K. Goodyear, Scott D. Miller, and Bruce E. Wampold

An ounce of practice is worth more than tons of preaching.

—Mahatma Gandhi

Over the past century, dramatic improvements in performance have been experienced in sports, medicine, science, and the arts. This is true, for example, in every Olympic sport (e.g., Lippi, Banfi, Favaloro, Rittweger, & Maffulli, 2008). College athletes in running, swimming, and diving perform better than gold medal winners from the early Olympic Games (Ericsson, 2006). In medicine, the number of diseases that can be treated effectively has steadily increased, while mortality from medical complications has decreased (Centers for Disease Control, 2012; Friedman & Forst, 2007). In mathematics, calculus that previously required decades to learn is now taught in a year of high school (Ericsson, 2006). In the arts, modern professional musicians routinely achieve or exceed technical skill that previously was attainable only by unique masters like Mozart (Lehmann & Ericsson, 1998).

Unfortunately, the same cannot be said of mental health treatment. Although the number and variety of psychotherapy models have grown rapidly, the actual effectiveness of psychotherapy has not experienced the dramatic improvements seen in the fields described (Miller, Hubble, Chow, & Seidel, 2013). For example, in modern clinical trials, cognitive behavioral therapy appears to be less effective than was demonstrated in the original trials from the 1970s (Johnsen & Friborg, 2015). That we have remained on this performance plateau is clearly not due to a lack of desire for improvement—virtually all mental health clinicians want to be more effective. So what have we been missing? How can we get better at helping our clients? In this book, we outline procedures that lead to increasing the effectiveness of psychotherapy.

The Overall Effectiveness of Psychotherapy

First, let's step back to examine the big picture concerning the effectiveness of psychotherapists. Good news: The consistent finding across decades of research is that, as a field, we successfully help our clients. Studies examining the effectiveness of clinicians working across the field, from community mental health centers, to university counseling centers, to independent practice, show that, on average, mental health clinicians produce significant positive change for their clients (Lambert, 2013; Wampold & Imel, 2015). The average psychologically distressed person who receives psychotherapy will be better off than 80% of the distressed people who do not (Hubble, Duncan, & Miller, 1999; Wampold & Imel, 2015). Dozens of studies show that the effects of psychotherapy and counseling are at least as large as the effects of psychotropic medications and that psychotherapy and counseling are less expensive, have fewer troubling side effects, and last longer (Forand, DeRubeis, & Amsterdam, 2013; Gotzsche, Young, & Crace, 2015).

Opportunity for Improvement

Although the big picture is positive, there is room for improvement. For example, in clinical trials, only 60% of clients achieve clinical “recovery,” and between 5% and 10% actually deteriorate during treatment (Lambert, 2013). The percentage of clients who terminate care prematurely falls between 20% and 60%, depending on how “prematurely” is defined (Swift, Greenberg, Whipple, & Kominiak, 2012), and these rates have remained largely unchanged for the past five decades.

Furthermore, there is considerable between‐clinician variability in effectiveness. Whereas the most effective therapists average 50% better client outcomes and 50% fewer dropouts than therapists in general (Miller et al., 2013), these “super shrinks” (Miller, Hubble, & Duncan, 2007) are counterbalanced by those therapists who produce, on average, no change or may even cause most of their clients to deteriorate (Baldwin & Imel, 2013; Kraus, Castonguay, Boswell, Nordberg, & Hayes, 2011; Wampold & Brown, 2005). So there is clear room for many therapists to demonstrably increase their effectiveness.

How, then, can clinicians become more effective? Some may assume that the best way to get better at something is simply to do it a lot. A significant body of research documents that musicians, chess players, and athletes, in the correct circumstances, improve with time and experience (at least up to the point of competency; Ericsson & Pool, 2016). However, psychotherapy is a field in which practitioners' proficiency does not automatically increase with experience (Tracey, Wampold, Goodyear, & Lichtenberg, 2015; Tracey, Wampold, Lichtenberg, & Goodyear, 2014). Two large studies have shown that “time in the saddle” itself does not automatically improve therapist effectiveness (Goldberg, Rousmaniere et al., 2016; Owen, Wampold, Rousmaniere, Kopta, & Miller, 2016). One of these studies, based on the outcomes of 173 therapists over a period of time up to 18 years, found considerable variance in the outcomes achieved by the therapists over time. Although some of the therapists were able to continually improve, client outcomes on average tended to decrease slightly as the therapists gained more experience (Goldberg, Rousmaniere et al., 2016). Another study examined the change in outcomes of 114 trainees over an average of 45 months. As in the Goldberg, Rousmaniere et al. (2016) study, in the Owen et al. (2016) study, there was considerable variance in the outcomes achieved by trainees over time. Although trainees, on average, demonstrated small‐size growth in outcomes over time, this growth was moderated by client severity, and some trainees demonstrated worse outcomes over time, leading the authors to observe that “trainees appear to have various trajectories in their ability to foster positive client outcomes over time, and at times not a positive trajectory” (p. 21).

Current Strategies for Improving Effectiveness

What accounts for the failure to improve? Answering that question requires first looking at the four most widely used methods for improving therapist effectiveness: supervision, continuing education (CE), the dissemination of evidence‐based treatments, and outcome feedback systems.

Supervision provides trainees with important professional preparation. For example, supervision has been shown to provide basic helping skills, improve trainees' feelings about themselves as therapists and understanding about being a therapist, and enhance trainees' ability to create and maintain stronger therapeutic alliances, the component of therapy most associated with positive outcomes (e.g., Hill et al., 2015; Hilsenroth, Kivlighan, & Slavin‐Mulford, 2015; Wampold & Imel, 2015). However, evidence concerning the impact of supervision—as it has been practiced—on improving client outcomes is mixed at best (Bernard & Goodyear, 2014; Rousmaniere, Swift, Babins‐Wagner, Whipple, & Berzins, 2016). Indeed, prominent supervision scholars (e.g., Beutler & Howard, 2003; Ladany, 2007) have questioned the extent to which supervision improves clinical outcomes. Summarizing the research in this area, Watkins (2011) reported, “[W]e do not seem to be any more able now, as opposed to 30 years ago, to say that supervision leads to better outcomes for clients” (p. 252).

Continuing education (CE) (“further education” in the United Kingdom) is a second method for improving, or at least maintaining, therapist effectiveness. Many jurisdictions require CE to maintain licensure, certification, or registration necessary for practice. CE is commonly delivered via a passive‐learning format, such as lecture or video (perhaps with some discussion). This format may be effective at imparting knowledge about particular topics (laws, ethics, new treatments, etc.), but typically it includes little interactive practice or corrective feedback for participants and thus has questionable impact on actual skill development. Research from CE in medicine has demonstrated that passive‐learning formats have “little or no beneficial effect in changing physician practice” (Bloom, 2005, p. 380). Summarizing concerns about the limits of CE, Neimeyer and Taylor (2010) reported, “A central concern follows from the field's failure to produce reliable evidence that CE translates into discernibly superior psychotherapy or outcomes, which serves as the cornerstone of the warrant underlying CE and its related commitment to the welfare of the consumer” (p. 668).

A third prominent method for improving therapist effectiveness that has gained considerable momentum over the past half century is the dissemination of evidence‐based treatments (EBTs, also called empirically supported treatments or ps...

Table of contents

• Cover
• Title Page
• Copyright
• Dedication
• Table of Contents
• About the Editors
• List of Contributors
• Part I: The Cycle of Excellence
• Part II: Tracking Performance
• Part III: Applications for Integrating Deliberate Practice into Supervision
• Part IV: Recommendations
• Index
• End User License Agreement