Illus                  special anniversary issue                                                                          ...
Getting Better?
on genetics and IQ differences.The paper that concerns us here,                                   “Our ability to         ...
sample of 2,900, psychotherapy seemed              of investigators. There are now treat-        aged care. With providers...
of specific treatment approaches, and                   how, evidence-based practice has come          wrong things. Other...
according to Lambert, is spotting prob-                                                               “Available          ...
whose type of research is superior. Suchis the view of John Norcross, profes-                                             ...
done behind closed doors in our solo           on the spectrum from clinical failure         at Northwestern University tr...
Cole from page 31                            lar client or couple or family, she’ll be                                    ...
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Is psychotherapy getting better (cole)

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Is psychotherapy getting better (cole)

  1. 1. Illus special anniversary issue t r at1 98 2 - 2O1 2 ion b y Ri c h a rd Tu This article’s title poses a challenging question, to be sc hman sure—one filled with ambiguity and open to multiple answers. Getting better than what? Getting better, in what way? Getting bet- ter, according to whom? And the real kicker: Can we get better—and how? But if these tough questions are to be asked, there would seem to be no more fitting occasion than this magazine’s 30th anniversary and the opportunity it provides to reflect on an era in the field of psychotherapy during which systematic efforts to quantify and mea- sure the key factors in the psychotherapeutic process received more attention than ever before. n In a sense, the story of A Progress Report how to assess the effectiveness of therapy and how it on the Science— might be improved began in 1952, 30 years before the and Art—of Our first issue of this magazine appeared. In a classic paper Profession that year, outspoken behavior therapist Hans Eysenck, one of the field’s leading provocateurs at that time, took on psychothera- py. A staunch believer in science, he’d later be the subject of bomb threats and publicly punched in the nose by a protestor for his controversial views by Diane Cole Is PSYCHOTHERAPY 24 p s y c h o t he r a p y n E T W OR K E R n   M a r c h / A p r il 2 0 1 2
  2. 2. Getting Better?
  3. 3. on genetics and IQ differences.The paper that concerns us here, “Our ability to simply put, the quest for psychotherapeutic treat-“The Effects of Psychotherapy: An ments that can be prov-Evaluation,” asserted there was no en to work is especiallyproof that psychotherapy worked. Onthe contrary, he claimed that surveys treat all the important in the current era of accountability andshowed that patients suffering from third-party reimbursement.clinical neuroses improved after two Today, more than ever, timeyears, whether or not they were treatedby a psychotherapist. anxiety disorders is money, and measured results help determine the “In the absence of agreement between allotment of both time andfact and belief,” he proclaimed, “there money for patient servicesis urgent need for a decrease in thestrength of belief, and for an increase with CBT is and for the professionals ren- dering those services. In otherin the number of facts available. Until words, the stakes riding onsuch facts as may be discovered in a the answer to the question ofprocess of rigorous analysis support theprevalent belief in therapeutic effective- leaps and psychotherapy’s effectiveness could scarcely be higher.ness of psychological treatment, it seemspremature to insist on the inclusion of The RCT Modeltraining in such treatment in the cur-riculum of the clinical psychologist.” bounds above Until recently, the most “scien- tifically rigorous” answer to theEysenck concluded that the shortcom- question of determining effective-ings of data “highlight the necessity of ness has been to adopt the modelproperly planned and executed experi-mental studies into this important field.” what it was of research applied within the field of medicine—run randomly The first blast had been fired, and controlled clinical trials (RCTs) toit was up to the profession to answer establish evidence-based (also calledthe challenge. Whatever its origins inFreud’s grand speculations and couch- 30 years ago.” empirically supported or research- supported) treatments that work bet-based methodology, psychotherapy’s ter than a placebo. Just as in medicalmodern quest for scientific legitimacy research, the goal has been to matchmay be said to have begun here. a particular treatment regimen to a From the get-go, however, measure- particular disorder. Aaron Beck, thement issues loomed: How do you go founder of Cognitive Therapy, hadabout proving psychotherapy really is begun testing his systematic treatmentmore effective than a placebo or more for depression as far back as 1973. Buthelpful than a friendly, sympathetic carried the headline “Where’s the sci- clinical trials didn’t begin to become thelistener? How do you determine objec- ence? The sorry state of psychotherapy.” driving force they are today until 1993,tive measures with which to identify, The release’s lead paragraph reads like when the APA established a task forcedefine, and quantify the variable, and an indictment: “The prevalence of men- within its Society of Clinical Psychologysometimes intangible-seeming, factors tal health disorders in this country has to identify criteria for—and then reviewand aspects that contribute to a suc- nearly doubled in the past 20 years. Who and provide a running list of—treat-cessful course of treatment? Moreover, is treating all these patients? Clinical ments that could be shown to be effec-as you go about establishing the science psychologists and therapists are charged tive for a variety of diagnosable disor-of psychotherapy, what happens to the with the task, but many are falling short ders found in the DSM–IV.intuitive art of psychotherapy? Until by using methods that are out of date and Before that task force could issuerecently, this divide between objective lack scientific rigor.” It goes on to cite a its first list of “empirically supported”science and intuitive art characterizing study suggesting that, in the absence of treatments, however, a study appearedthe uneasy relationship between psy- such scientific rigor, “six out of every that, while lacking most essentials ofchotherapy’s researchers and practitio- seven sufferers were not getting the best gold-standard RCT research, power-ners has appeared unbridgeable. care available from their clinicians.” fully established the effectiveness of A 2009 press release from the Ouch. Listen closely and you can hear psychotherapy in the public mind. InAssociation for Psychological Science, the echo of Hans Eysenck and déjà vu November 1995, a widely circulatedan organization formed by researchers all over again. So what is the science in survey of clients’ perceptions of theirwho felt the American Psychological psychotherapy? And why is it so impor- treatment done by a team at ConsumerAssociation (APA) had become more tant? Set aside obvious reasons of public Reports (CR) gave psychotherapy’s legit-of a guild than a scientific organization, trust and professional credibility, and, imacy a huge boost. According to a26 p s y c h o t he r a p y n E T W OR K E R n   M a r c h / A p r il 2 0 1 2
  4. 4. sample of 2,900, psychotherapy seemed of investigators. There are now treat- aged care. With providers today reim-to work, whatever Hans Eysenck once ments that have successfully run this bursing patients for fewer sessionsthought. CR pooled 178,000 readers, research gauntlet and been approved than they did 30 years ago, studiesof whom only 7,000 responded. Of for a wide range of DSM disorders. are now looking at treatment coursesthem, fewer than 3,000 had consulted Those who champion the “medi- that are shorter than they used to be.some type of mental health provider. cal model” research approach believe Previously, “brief therapy” might haveNonetheless, probably no single pub- it’s already demonstrated beyond meant 24 to 30 sessions. Clinical trialslication has so influenced the popular question just how potent and reliable today tend to focus on the impact ofperception of the field. But what did it psychotherapy has become in reliev- 4, 8, or 12 sessions. The good news:prove scientifically? ing human distress. Steven Hollon, a success is achieved in fewer sessions Commenting on the report in the professor of psychology at Vanderbilt than in the past. Today, psychotherapyDecember 1995 issue of American University, comments that, 30 years ago, not only has more empirically provenPsychologist, Martin E. P. Seligman, APA “we didn’t even know the names for treatments, but is demonstrably morepresident and psychology professor at some of the disorders” that can now be efficient. We now know that “You don’tthe University of Pennsylvania, provided treated effectively. By comparison, today have to beat around the bush and firsthis own verdict on what CR had to say: there’s “hard empirical evidence” that establish a good working relationship The study is not without flaws, the chief Cognitive-Behavioral Therapy (CBT), before getting to work,” says Hollon.one being the limited meaning of its answer to interpersonal psychotherapy, and behav- “You just get to work.”the question, “Can psychotherapy help?” This ioral activations work for a number of Effectiveness, efficiency, endurance:question has three possible kinds of answers. specific disorders. Indeed, he says, you sounds like a winning trifecta. But notThe first is that psychotherapy does better than can treat pretty much any nonpsychotic everyone agrees that evidence-basedsomething else, such as talking to friends, disorder just as well with psychosocial testing has provided the evidence itsgoing to church, or doing nothing at all. interventions as you can with medica- supporters say it has.Because it lacks comparison groups, the CR tion, and the results will not only bestudy only answers this question indirectly. as good, but provide broader benefits, Rocking the BoatThe second possible answer is that psycho- such as the longer-lasting effects from In 2002, Bruce Wampold rocked thetherapy returns people to normality or more therapies like CBT that help patients boat of clinical testing big-time with theliberally to within, say, two standard devia- learn how to help themselves. publication of The Great Psychotherapytions of the average. The CR study, lacking Dianne Chambless, professor of psy- Debate. In it, this professor of counselingan untroubled group and lacking measures of chology and director of clinical train- psychology at the University of Wisconsinhow people were before they became troubled, ing at the University of Pennsylvania, delivered an in-depth critique of thedoes not answer this question. The third and the researcher who oversaw the ini- medical model of psychotherapy, andanswer is, “Do people have fewer symptoms tial APA Society of Clinical Psychology did so not by the usual route of rejectingand a better life after therapy than they did commission, also sees progress over the very idea of protocol-driven therapybefore?” This is the question that the CR the past decades. “I think we’ve really and appealing to notions that makestudy answers with a clear “yes.” improved upon our ability to treat a therapists feel warm and fuzzy, like the Even more important, Seligman con- number of different disorders, or have need for “authenticity” and “connec-cluded, “Consumer Reports has provided effective treatments” for them, includ- tion,” but by invoking, of all things, sta-empirical validation of the effective- ing anxiety disorders and interventions tistics. Deploying an impressive array ofness of psychotherapy. Prospective and for bipolar disorders, she says. “Our sophisticated metanalyses on hundredsdiagnostically sophisticated surveys, ability to treat all the anxiety disorders of efficacy studies conducted throughcombined with the well-normed and with CBT is leaps and bounds above the decades, Wampold concluded thatdetailed assessment used in efficacy what it was 30 years ago.” there was “little or no evidence that anystudies, would bolster this pioneering What works, according to clinical stud- one treatment for any particular disor-study. They would be expensive, but, in ies? From the start, behavior therapies der is better than another treatmentmy opinion, very much worth doing.” of different kinds (including Cognitive intended to be therapeutic.”In short, still more science was needed. Therapy) have been, and continue to What he did find evidence for is the That was the mid-1990s, a time that be, the most prominently represented importance of the alliance betweenhad recently witnessed the ascendan- types of therapy on the list of effective patient and therapist. That, along withcy of psychopharmacology and man- treatments. Dissenters have suggested the psychotherapist’s empathy for theaged care—features of the therapeu- that this is because they’ve had the client and the patient’s positive expec-tic landscape that have increased in longest history of testing, but advocates tation for treatment comprise the threestrength and dominance to this day. of evidence-based treatments say it’s key factors leading to a successful out-Since then, expanded numbers of because they work. University research- come, he said. In other words, it’streatments have been deemed “well- ers and insurance companies looking not the treatment or the theoreticalestablished” after being tested in at for accountability have been among the model that makes the major differ-least two randomized clinical trials, staunchest of those advocates. ence. Rather, the characteristics of theeach originating with a different team There’s also a connection to man- therapist and the client, independent www . p s y c h o t he r a p y n e t w o r ke r . o r g 27 
  5. 5. of specific treatment approaches, and how, evidence-based practice has come wrong things. Others include Wampoldthe relationship factors mediating their to mean using a specific method for and Brigham Young University psychol-connection have far more impact than a specific diagnosis, when it actually ogy professor Michael Lambert. Whatthe “treatment factors” themselves. means using approaches supported sets Miller apart is his crusader’s zealPerhaps the old-fashioned clinicians by the best evidence in a treatment for shaking up the status quo and hiswho’d long stressed the human, non- informed by client preferences, cul- polemicist’s flair for presenting his argu-technical elements of the therapeutic tural context, and feedback. He adds, ment in the most provocative light. Heencounter—what are often referred “There’s no proof that clinicians who insists that to improve the quality of careto as the “common factors” underlying use particular models applied to spe- in the field it’s not the treatments or pro-effective therapy—were right after all. cific diagnoses achieve better results. tocols that need adjusting, it’s the atti- The Great Psychotherapy Debate was the What’s more, available data indicate tudes and skills of individual practitionersequivalent of a devastating body-blow that real-world clinicians achieve the that need to change. For psychotherapyto those favoring the medical model same degree of treatment success as to get “better,” he believes, therapistsof psychotherapy, with its emphasis those in randomized clinical trials. So themselves need to get better at gettingon finding the right treatment for what’s all the fuss about?” their clients better.any given DSM disorder. By all means, Going beyond a critique of empirical- In making his case, Miller begins withfollow the science, Wampold urged, ly supported treatments, Miller makes what initially seems like an odd analogybut also make sure you know what the the larger point that, far from estab- to—of all things—airline safety. But fas-science is saying: the medical model lishing the scientific bona fides of its ten your seat belts, and let him explain.may not be the best model for under- methods, the psychotherapy communi- Over the past 35 years, he says, the num-standing how psychotherapy works. ty, in fact, hasn’t had the public health ber of American commercial airlineHis research showed that the “medi- impact it promised three decades ago. crashes has decreased significantly, yetcine” of a particular psychotherapeutic He points out that, by most measures, the technology of the planes themselvestreatment itself isn’t the transportable the sheer number of people suffering hasn’t changed dramatically. What’sobject that, say, a dose of penicillin from mental health problems is on the changed is pilot training—to includeis. Then, again, neither can a skilled increase. Anyone who reads the head- a focus on safety and an emphasis onpsychotherapist be mass-produced to lines—high unemployment, poverty, maintaining standards of professionaldeliver the key ingredients of empathy returning veterans—knows those needs excellence in individual performance.and therapeutic alliance that make the aren’t diminishing. Miller also wonders What that has to do with psychother-difference in what Wampold terms the how it’s possible that a profession can apy is this: by contrast to airplane pilots“contextual model” of psychotherapy. amass so many new clinical techniques and other highly skilled professions, If, as Wampold asserted, treatment and approaches, and yet see a rise in in the field of psychotherapy, Millermethods were a far less potent factor the number of people suffering. says, “we’ve applied nothing that’s beenin influencing the effectiveness of psy- Most troubling of all, he says, is that, learned from the literature on excel-chotherapy than had been previously despite all the expansion of therapeu- lence to strengthening our expertisethought, what had all the research tic knowledge and enormous amount and skills.” Moreover, the pathway foron empirically supported approaches of research activity in the field, overall, psychotherapists to achieve excellence,actually proven? Did study after study the average positive impact of psy- he believes, isn’t illuminated particular-showing a certain method’s superiority chotherapy hasn’t changed since the ly by clinical research studies document-to a placebo necessarily mean that the first metanalyses done in the 1970s. ing the efficacy of a specific treatmentfield had gone as far as its proponents Somewhere between 66 and 75 per- or technique. Instead, the way forwardlike Chambless and Hollon believed? cent of patients appear to improve lies, first, in studying the traits shared byDid the widespread conviction that from treatment. Nevertheless, Miller the most effective psychotherapists (inpsychotherapy had come a long way remains a believer in the effectiveness the same way that, say, the medical orsince the days of Hans Eysenck need to of therapy. “When you look at the statis- management or legal professions seekbe reconsidered? tics, the success rate for psychotherapy to identify the traits associated with best is on par with common medical pro- practices in their fields), and then, get-Making Therapists cedures like coronary bypass surgery,” ting others up to speed. This, he says,Better he says. Yet his reading of the research can be accomplished with evidence thatWell, yes and no. Scott Miller, a founder literature leaves him unconvinced that comes not from clinical trials of specificof the International Center for Clinical even a drastic increase in the number protocols, but evidence generated byExcellence, says, “I agree with the trend of therapists offering specific treat- therapists themselves, based on theirtoward evidence-based practice. It’s just ments for specific disorders would have own strengths—and weaknesses.that what’s being advocated by some any real effect on therapy’s success rate. It’s known as feedback.is decidedly not ‘evidence-based prac- Miller is just one of a number of critics Instead of focusing on evidence abouttice’—at least not according to the of traditional therapy outcome research “better” treatments garnered fromAPA’s definition, or that of the Institute who believe that evidence-based investi- clinical trials, he says, psychotherapistsof Medicine.” He explains that, some- gators too often have been studying the should seek out systematic feedback28 p s y c h o t he r a p y n E T W OR K E R n   M a r c h / A p r il 2 0 1 2
  6. 6. according to Lambert, is spotting prob- “Available lems early in the process. “Therapists are overly optimistic about their ability data indicate to help patients, and they ignore, or even have a positive view about, people getting worse, in that they believe, that real-world erroneously, that in order to get bet- ter, you first have to get worse,” he explains. “When they see a patient get- clinicians achieve ting worse, that doesn’t alarm them.” Lambert’s system doesn’t allow thera- the same degree pists not to be alarmed. His Outcome Questionnaire (OQ) is longer than Miller’s (45 questions, of treatment measuring symptoms, relationship problems, and social-role function). Both the OQ and Miller’s measure success as those can be scored electronically, and are designed to send the therapist an alert in randomized when the measurements fall below a certain level. That serves as a wake-up call to tell therapists to pay attention, clinical trials. treatment is off track, and they should reevaluate and modify what they’reabout their own performance andcase outcomes in the form of sim- So what’s all doing. The OQ’s own track record is impressive. In eight studies (six ofple questionnaires that patients can them published) so far, the failure ratefill out prior to each session. Milleris part of a group that’s developed the fuss of therapists using the OQ declined to 6 percent in comparison with a failurethe four-question Outcome Rating rate of 21 percent among therapistsScale (ORS), an easy-to-use instru-ment for tracking treatment prog- about?” not using the feedback measure. The briefer ORS has been tested in threeress, as well as a therapeutic alliance major studies, and a recent metanalysischecklist that helps therapist and client completed by Lambert shows that bothmake sure their goals for therapy are measures improve outcomes.aligned. It’s his contention that those Still, some clinicians remain skepti-answers—about the client’s well-being cal that closely attending to clients’and sense of progress—are a form of ly on their intuitive judgments about feedback is the magic bullet that somepractical research that enables thera- which interventions will work or when of its advocates seem to claim. “One ofpists to gauge how they’re doing, session to alter treatment tactics, despite the the problems with feedback-informedby session, and patient by patient. By well-established fact that intuition by approach is that it too often seems toregularly and systematically putting that itself is notoriously unreliable, even operate as a kind of customer-is-always-mirror up to themselves, psychothera- for veteran clinicians. Everyone needs right model,” says William Doherty ofpists can become aware immediately of outside norms, baselines, and refer- the University of Minnesota. “But whatclinical missteps and errors in judgment ence points by which to double-check if the complaints the client has aboutthat might otherwise go undetected those judgments; feedback instruments how therapy is going is a reflection ofuntil a client dropped out or ended provide them. At the same time, feed- the very problem that brought him intotreatment without deriving the antici- back helps the therapist align with the therapy in the first place?”pated benefits. patient’s goals and then match treat- Clinicians like Miller and Lambert, ments to them. It provides another tool The Context of Practicehis graduate-school mentor and the for “listening” to the patient’s response If the question of the effectiveness ofpioneer of developing feedback mea- style in treatment. So that, for instance, psychotherapy and how to increase itsures, think that regularly assessing if your client doesn’t like feeling like hinges on the debate between the evi-therapeutic progress is fundamental he’s being “told” what to do, such feed- dence-based traditionalists and the feed-to helping clinicians more dependably back can give you the heads-up that you back-informed insurgents, some believesteer their course in therapy. They need to try a less directive approach. the simplest resolution is, essentially,believe that such systems are essential A crucial consideration in improv- to split the difference and put asidebecause therapists too often rely sole- ing overall levels of treatment success, an unproductive disagreement aboutI l l u s t r at i o n b y B r u n o B u d r ov i c www . p s y c h o t he r a p y n e t w o r ke r . o r g 29 
  7. 7. whose type of research is superior. Suchis the view of John Norcross, profes- “When you think see how people actu- ally employ these toolssor of psychology and distinguisheduniversity fellow at the University ofScranton. Why take sides or engage in about how little in their work. There are also the generic skills that cut across models that thepolarizing arguments, he asks, about research says are funda-what’s more important: the treatmentmethod or the therapist–client rela- real incentive there mental to helping build alli- ances with our clients andtionship. “Sensible people don’t have a achieving good outcomes.debate on all this,” he says. What is sensible, he believes, is to is in our field But once you’re out of your initial grad-school training,take the approach that, when it comes how can you develop thoseto treatment choices, different strokeswork for different folks. Every type to improve our skills? Peer consultation too often leads only to the discus-of therapy has its inadequacies and sion of cases at a theoreticalwon’t work 100 percent of the timefor 100 percent of people, he says. skills, it’s level, or at the level of abstract strategy.” There’s also an isola-“There isn’t one method. There are tion factor endemic to the field,multiple methods.” Whatever themethod, what’s most important is to hard to escape the he notes. “People don’t actually get to see each other’s work andgo beyond either/or debates. In fact, learn about the nuances of deal-Norcross has coauthored a new bookwith Michael Lambert, Evidence-Based conclusion that ing with the unpredictable things that happen in therapy. Most ofTherapy Relationships, in which the two us aren’t part of communities ofdeplore the “culture wars in psycho-therapy” that pit polarized camps of the attitude is practice in which the norm is close examination of what we actually doevidence-based treatment champions with our clients.”against those who advocate the over-arching importance of the therapist– it really doesn’t Putting it more pointedly, profes- sor emeritus Jay Efran of Templeclient relationship. Such squabbles University says, “How do you improveonly distract from the shared goal ofall, the authors say, which is “to pro- matter.” as a therapist? You can’t read how to do it in a book. When you think aboutvide the most efficacious psychological how little real incentive there is in ourservices to our patients.” field to improve our skills, it’s hard to Norcross prefers to emphasize the escape the conclusion that, in someimportance of the two types of research way, the attitude is it really doesn’t mat-in helping psychotherapy continue ter. Think about it. If you’re a surgeon,to progress. “It’s the mutual inter- their skills, they insist that it’s important you’re regularly held accountable in aplay between both of these—between to grasp the everyday context in which way therapists aren’t.”practice and research—that’s leading most therapists practice. To understand Viewed in this way, the discussionto more effective and more efficient why overall success rates in our pro- about evidence-based practice versuspsychotherapy,” he notes. As he and fession don’t appear to be improving what the feedback-informed advocatesLambert write in their book: “Decades despite all the new information coming like to call “practice-based evidence”of psychotherapy research consistently into the field about the brain, mindful- seems too narrow and rarefied, ignor-attest that the patient, the therapist, their ness, and the mind-body connection, ing too much of the nitty-gritty realityrelationship, the treatment method, and and all the research results being regu- of how most therapists ply their trade.the context all contribute to treatment larly reported in the journals, they say Until we look more closely at the actualsuccess (and failure). . . . We should be you must grasp the fact that this infor- context of practice, it’s unlikely thatlooking at all of these determinants and mation isn’t being conveyed to thera- psychotherapy will change markedly.their optimal combinations.” pists in ways that help them improve “Where are the incentives for improv- But others believe that reducing the their actual performance with clients. ing our therapeutic outcomes, or evenargument about psychotherapy’s effec- “In our field, there are model-spe- to become more aware of how we’retiveness to a debate between two differ- cific skills—the procedures you need doing?” asks Doherty, echoing Efran’sent research models ignores far more to learn to do EMDR or CBT or EFT,” point. “If you look at it broadly, most ofcrucial considerations. Looking at the says William Doherty. “We go to didactic us don’t practice in a context that offersbroader issues of how clinicians are workshops to keep up with new develop- a stimulating or effective learning envi-trained and the incentives currently ments, but that’s done largely through ronment for improving our skills. Foroffered for therapists to further develop lecture, with minimal opportunity to most of us, therapy is a private art form,30 p s y c h o t he r a p y n E T W OR K E R n   M a r c h / A p r il 2 0 1 2
  8. 8. done behind closed doors in our solo on the spectrum from clinical failure at Northwestern University tracks thepractices or in group practices where to success. To determine whether their session-by-session progress of therapy.there’s little coordination or shared dis- current cases are headed toward positive But instead of relatively simple question-cussion of the challenging cases we’re or negative outcomes, members com- naires, the STIC features an initial assess-facing. I think too many therapists feel pare them with those in the database ment of 30 different personality, behav-that there’s no real system around them. by entering their own session-by-session ior, and relationship dimensions andIf this field is to do a better job of serv- feedback measures for the therapeutic collects information not only on indi-ing the clients who come to us, we need alliance and overall client functioning. vidual clients, but on every participanta much more radical solution than Beginning with the second session (so in couples or family therapy. Becausejust having more clinicians do more that patterns of progress, stagnation, or it’s scored and displayed on a computer,evidence-based therapy.” decline can be determined from the get- with easy-to-read graphic displays, it can go), therapists can see whether a case be filled out relatively quickly. ClientsChanging Attitudes is likely to have a positive or negative fill out STIC measures throughout treat-In fact, some believe that the inno- conclusion. When a case is progress- ment, which are e-mailed directly tovations most likely to influence the ing, a green lamp lights up, while no therapists. They can consult the mea-future of the field may come not so progress is indicated by a yellow lamp. A sures before a session and get an instantmuch from theoreticians, clinical inno- red lamp is the attention-getting symbol sense of what’s happened between ses-vators, or psychotherapy researchers, indicating that a case seems headed for sions and whether a case is progressing.but from advances that make it eas- an unsuccessful outcome. It’s not that the STIC dictates a particu-ier for therapists to learn and mas- Of course, the system is far from lar intervention, but it gives the therapistter their craft. “We don’t need some foolproof and offers no crystal ball, but information that might otherwise begreat new therapeutic breakthroughs it provides the kind of normative data missed, especially about potentially dam-to make great strides in improving previously unavailable to most clini- aging ruptures that have taken place inthe quality of our outcomes as a pro- cians that practitioners can use to chart the alliance with clients.fession,” says Susanne Bargmann, a the course of cases, especially challeng- “The therapist may have pushed tooDanish psychotherapist and trainer ing ones, adding a new dimension to hard or responded in a way that a clientwho helped create the International their tool kit with potentially dramatic didn’t perceive as empathic in a previ-Center for Clinical Excellence (ICCE), consequences. Beyond the color-coded ous session,” says Pinsof. “Typically, thethe world’s largest web-based therapist alerts that offer a sense of accountabil- client might not say anything aboutlearning community—currently used ity and urgency with cases in trouble, this, but the STIC gives the therapist aby 4,000 psychotherapists—dedicated a key element of the Fit-Outcomes way of finding out that, for example, ato improving the standards of practice management system is the opportu- client’s trust in the therapist declinedin the field. “We could raise the level nity for members to send posts to the in the last session. Knowing this before-of our clinical work enormously if we community of fellow practitioners to hand enables the therapist to point tosimply took more time to review our share frustrations, ask questions, and the STIC scores and say, ‘It looks likecases, especially when we’re stuck, and get new ideas any time of the day or something happened between us lastgot concrete help when we made mis- night. Wherever you are on the planet, time’ and bring that into the thera-takes or had questions,” she says. “A big no matter how geographically remote, peutic conversation.” When used as apart of the barrier to doing that is one you can ask for help with challenging tool for monitoring and repairing theof attitude. Right now, too many thera- clients through ICCE. “Being a solo therapeutic relationship in this way,pists think that what they already do is practitioner can be very isolating,” says Pinsof believes that it amplifies theperfect, or else that it’s too dangerous Australian psychologist and ICCE mem- client’s voice and equips the clinicianto acknowledge your clinical shortcom- ber Vanessa Spiller. “Having a support- with an additional sixth sense, helpingings. But, actually, the only time you ive, like-minded community in which I to overcome the blind spots that areever learn something new is when you can ask questions and present ideas and inevitable in every human relation-make a mistake.” thoughts, and have people critically ship. He insists that STIC deepens the There are many resources available review these, has been very helpful. therapy process and empowers bothon the ICCE website that Bargmann It’s been great to be able to access this therapists and clients, rather than tak-developed with Scott Miller and others, ‘oasis of international expertise,’ pro- ing away therapists’ autonomy, like abut the centerpiece is the Fit-Outcomes viding me with peers willing to critically therapeutic protocol can.management system, a specially pro- review my work, identify some of mygrammed database of more than unquestioned assumptions, and make Technology and100,000 cases with which practitioners specific suggestions for changes I can the Futurecan determine whether their current implement and objectively evaluate.” While technology often is seen as a dep-cases are on track. Including both out- Like the ICCE system, a database ersonalizing force in our lives, somecome measures and session-by-session called the Systemic Therapy Inventory are beginning to argue that the digitalfeedback scores, the cases loaded onto for Change (STIC) being developed by revolution may be the primary meansthe site are categorized by their location William Pinsof of the Family Institute Continued on page 50 www . p s y c h o t he r a p y n e t w o r ke r . o r g 31 
  9. 9. Cole from page 31 lar client or couple or family, she’ll be by which the standard of care within able to see how a sample of thousands in the field will rise to a new level. The of past clients with matching character- expanded video capabilities of the Web istics responded to various treatment are already opening up learning and options.” Pinsof likens his feedback training opportunities that can help system to an X-ray, blood analysis, or therapists further develop their clini- MRI in medicine, and considers his cal skills. Cognitive Therapy pioneer feedback and reporting instruments Donald Meichenbaum is developing a as sources of vital information that, website that’ll offer video demonstra- one day, will be part of every thera- tions of what he considers the core pist’s essential tool kit, ensuring greater skills required for effective practice, accountability and better care. along with assessment instruments to So it appears that whether therapy determine which of those skills a given progresses to a new level of effective- practitioner might need to improve. ness may be determined, not by some The Networker regularly broadcasts game-changing discovery of new meth- video interviews with accomplished ods, but by whether we can change experts in a range of clinical topics like our time-honored distrust of the very couples therapy, trauma, and mindful- concept of “research.” “Most therapists ness practice that focus directly on the today see research as something that’s fundamentals of clinical craft too often intimidating and controlling, and don’t ignored in therapists’ training. Its goal believe they can integrate scientific data is to radically expand the range of into their work without compromising observable clinical role models avail- their clinical intuition and judgment,” able to practitioners around the world. says Pinsof. But as technology makes it The ease of video recording today possible to make immediate, practical makes it possible for clinicians to con- use of data in managing the ongoing veniently review their own sessions, therapeutic relationship, therapists will either with colleagues or supervisors, be increasingly encouraged to become and zero in on the nuances of session more discerning investigators of their management and intervention that go own practices and more attuned col- beyond generalized discussion, provid- laborators with their clients, especially ing the kind of immediate feedback when things are looking grim or uncer- that the literature on human perfor- tain in the consulting room. mance and mastery tells us is necessary As 21st-century technology increas- to change behavior and enhance skill. ingly makes itself felt in psychothera- Some of the new digital systems being py, it seems that the pathway toward developed offer possibilities that might enhanced effectiveness will require the have seemed like science fiction just a field’s practitioners to bring together few years ago. For example, Pinsof is knowledge domains often treated as now working on an adjunct to STIC, distinct. Regardless of how hi-tech and called the Integrative Therapy Session data-driven some of the tools practi- Report, which will gather measures of tioners use in their pursuit of clini- therapists’ techniques session by ses- cal excellence become, however, the sion. “After a session, we ask therapists therapist’s demanding, evolving craft to detail what specific interventions will remain one in which both art and and client strategies they used. This science are inextricably intertwined. n additional information is integrated with the ordinary STIC data to show New York City–based Diane Cole is the how the progress of a case—or lack author of the memoir After Great Pain: of it—can be related to the therapist’s A New Life Emerges, and writes for interventions. As more data are col- many national publications. You can reach lected, this will give us a road map of her at djcole86@gmail.com. Tell us what how a broad range of clients with all you think about this article by e-mail at kinds of characteristics responded to letters@psychnetworker.org, or at www. different kinds of interventions at dif- psychotherapynetworker.org. Log in and ferent stages of the therapy process. So you’ll find the comment section on every when a therapist is stuck with a particu- page of the online Magazine.50 p s y c h o t he r a p y n E T W OR K E R n   M a r c h / A p r il 2 0 1 2

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