E9. Tony Rousmaniere – Improving Psychotherapy Outcomes

1:10 – An outline of the history of psychotherapy outcome research.

Historically, research has focused on improving psychotherapy outcomes by trying to determine the most effective psychotherapy models. After thousands of randomised clinical trials on hundreds of psychotherapy models, outcomes from all/most psychotherapy models are roughly equivalent. This highlights the importance of factors common to all/most psychotherapy models, rather than the elements specific to any particular model, as the active ingredients. Research is now shifting to what about the therapist accounts for outcomes, other than the model of therapy they employ.

6:40 – Reflections on the training of psychotherapists.

The usual training and professional development of psychotherapists is largely unchanged from the time of Freud; a mix of intellectual learning and reviewing/discussing sessions with a supervisor. However, the focus of this training is almost totally on conceptual understanding and the process of therapy, with virtually no explicit focus on therapy outcomes. A closer eye on client outcomes can guide training / practice and lead to better client outcomes.

10:35 – On the use of objective metrics in psychotherapy to confirm progress.

Psychotherapy research consistently shows that there is way more variance in client outcomes explained by client and therapist factors, than due to the model of therapy used. This highlights that what is considered evidence-based practice should not only rely on clinical trials of therapy models, but actual therapist performance. The main pushback Ton’y hears against the use of objective metrics is that it’s a hassle.

15:00 – On the evidence for the use of objective metrics in psychotherapy.

The evidence suggests that the use of objective metrics improves outcomes for clients at risk of deterioration. That is, therapists are more able to course correct before the client’s symptoms worsen. But objective metrics tend not to be as effective in enhancing outcomes where a client is improving, perhaps because these measures tend to be more symptom focused rather capturing more subtle, positive outcomes.

18:50 – On ‘deliberate practice’ in psychotherapy.

Deliberate practice is basically the drilling of specific elements of psychotherapy. This is necessary as the evidence shows that therapists do not reliably get better with experience. Deliberate practice involves; 1) Observing work performance, 2) Getting expert feedback on performance, 3) Setting small incremental skill-based goals, 4) Repetitive behavioural rehearsal, and 5) Assessing performance. Objective metrics can inform such deliberate practice.

31:05 – On the evidence supporting ‘deliberate practice’ in psychotherapy.

Small qualitative studies have been completed. Larger more rigorous studies are just getting under way. Interestingly, Tony is not overly optimistic about such studies. We likely have a long way to go to be able to effectively incorporate ‘deliberate practice’; we need to better understand what and how to practice.

34:55 – Other ways in which might advance psychotherapy outcomes as a field.

Tony highlighted mobile-based therapy, which promises on-demand therapy at a lower cost, albeit only suitable in some cases. Also supervision over video conferencing and virtual-reality based training.

37:30 – Efforts to reduce cases where a client interacts with a therapist only once or twice before leaving therapy.

Jonathan Swift and Jennifer Callahan have done research into this question. We need more research done because it remains difficult to effectively match. Instead, the emphasis has been on the need for therapists to be responsive.

39:40 – On the implications of outcome measurement for the business and economics of psychotherapy.

Tony hasn’t seen this yet and would strongly recommend against it. This is likely to compromise outcome data as it is easy enough to game.

45:05 – Advice to therapists just starting out.

Expect failures. Don’t be discouraged by these. Remember that you are only as good as you practice and aim to gradually improve over your career.