Who makes the best psychotherapists? (an open letter)

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Psychotherapy works. All the evidence, and there is lots of it, is that people who undertake psychotherapy do better than those who don’t.  Indeed, when effect sizes (how much bang you get for your buck) are considered psychotherapy is at least three times more effective than psychopharmacology.  If specific types of more complex therapy are considered then the effect size is six times greater than psych meds.

The implication of this is really clear. In any mental health system the focus needs to be on providing consumers access to as much psychotherapy as the system can afford to provide. Thus, the requirement is to employ a workforce that is capable of delivering good quality psychotherapy. This then begs the question of whom does psychotherapy best? Is there a group of ‘SuperShrinks’? Because if there is then those are the guys to employ!

The answer to this question, to the professions that do psychotherapy, is damning. Although there are many claims from psychiatry, the various subsets in psychology, such as Clinical or Counselling Psychologists, and people with generic counselling qualifications, that they do ‘it’ best, the evidence totally denies this. The truth is that  training, professional discipline, psychotherapeutic orientation, age, gender, years of experience, patient diagnoses, clients’ level of functioning or prior treatment history, all things that one might logically think would matter, absolutely don’t. Note that. The above do not matter.

Even the American Psychological Association, not in most people’s view a radical organization, acknowledged the above. In their statement on the effectiveness of psychotherapy in 2012, they reported that not only did factors related to the individual clinician not matter, but that the different brands of psychotherapy didn’t matter either.  What? CBT isn’t best? No, it really isn’t. And, damningly none of us, despite many assertions to the contrary, can claim that ‘we’ do it best.

What is known about what constitutes effective psychotherapy is that the characteristics, and certain practices, of psychotherapists are critical in determining good outcome. Importantly, within any professional subset, such as counselling or clinical psychologists, the variance between excellent, good, poor and bad therapists is greater within, than between, the disciplines. In effect, it really doesn’t matter whether you are a Clinical or Counselling psychologist, your capacity to be a good or bad therapist is not determined by your discipline, but by how you go about the business of psychotherapy.  For example, the capacity to offer clients a place of warmth, interest, support, undivided attention, empathy, understanding and non-judgmentalness, that is clarificatory, helpful, purposive, collaborative, sensitive and also connected, is vital. One well considered perspective is that ‘It is the relationship that heals’. Thus, persons working with mental health consumers need to have an adroit and well developed capacity to form and maintain caring, therapeutic relationships. But it is also clear that the best therapists do something more.  And that extra something has absolutely nothing to do with your discipline or your training.

In a delightful, provocative, but elegantly researched and well-argued piece, Scott Miller, and his colleagues from the Institute of Therapeutic Change, have discovered that the ‘Supershrinks’ are people who not only pay acute attention to the quality of the therapeutic alliance they have with their clients, but they are also constantly building on their practice and maintaining their therapeutic alliances. In effect, they constantly monitor with their clients how they are going.

So as a clinical psychologist in private practice, and also a recovered academic, I am becoming increasing exasperated by the gall of my Clinical colleagues, who keep on asserting that Clinical Psychologists are best. Not only that but many of my colleagues seem to think that doing a Master’s degree in Clinical Psychology bestows them with some special authority and clinical magic that cannot be achieved by so called inferior, substandard pathways of experience, or by doing degrees in other things such as counselling psychology.  So to my Clinical Colleagues may I say your claims to be ‘the best,’ to do ‘it’ best, are totally without foundation. The purported, self-appointed, emperors of psychotherapy, have no clothes.

Even the Chair of the ‘trade union’ group for Clinical Psychologists replied to my email requesting evidence that Clinical Psychologists were best by noting that she knew of no studies that directly compared the effectiveness of Counselling Masters students with their clinically trained counterparts.  She also acknowledged, as Miller and his colleagues have shown,  that  there was no compelling evidence that demonstrated the superiority of those with postgraduate (masters) training as compared with those with more modest levels of competence (e.g., a bachelor’s degree).

Every discipline that does psychotherapy has it stars and its dullards. But, taken overall, each discipline, irrespective of type of training, does well. We all deserve prizes. And, I’m going with the evidence that being a ‘SuperShrink’ has more to do with how you practice than the discipline you practice. I am after all a Clinical Psychologist, so the evidence really does matter. So can my evidence based, clinical psychology colleagues, please stop claiming that they are “better than all the rest?”  Please.

Bill Saunders, BA (Hons) M.Phil., PhD.
Head of Psychotherapy, Abbotsford Private Hospital
Consultant Clinical Psychologist, Abbotsford Psychology
West Leederville WA 6007

Miller S, Hubble M, & Duncan B.  The Secrets of Supershrinks: Pathways to Clinical Excellence, Psychotherapy Networker [Online]. Retrieved from http://daily.psychotherapynetworker.org/free-reports/

NOTE: The points made in the open letter shown above are solely those of the author and do not necessarily represent the view of any other body. All replies to this open letter are to be directed to the email address shown above. Please ensure that any comments left below are respectful, friendly, and constructive.

Also a quick reminder to all Counselling Psychologists while I have your attention, if you wish to support the Association of Counselling Psychologists but are not currently one of our members, you can join us at https://counsellingpsychologists.org/join