Psychotherapy Bulletin

Psychotherapy Bulletin

This question was asked by Clara Hill as a moderator for a structured discussion section on expertise in psychotherapy in the last international meeting of the Society for Psychotherapy Research in Philadelphia in June 2015. The background for the discussion was an article by Tracey, Wampold, Lichtenberg, and Goodyear (2014) in which the authors argued that psychotherapy is not a field with any expertise.

The article has been followed up by Tracey, Wampold, Goodyear and Lichtenberg (2015). Echoing and extending the critique proposed by Robyn Dawes (1996) in the book The House of Cards, the authors argued that there was no relationship between psychotherapists’ experience level (defined as number of years in practice) and client outcome. In other words, psychotherapists did not become more effective over time. As a participant in the discussion, I would like to share some perspectives on the issue.

Tracey and collaborators have raised an important issue that deserves the serious attention of everybody involved in the training and provision of mental health services. Not to be misunderstood, they emphasized that their focus was on [characteristics of] the profession, rather than on the identification of expertise in individuals. They suggested the lack of expertise development within the field of psychotherapy could be attributed to the lack of information available to therapists regarding the outcomes of their interventions, to the difficulty in using the information that does exist, and also to the lack of adequate models about how psychotherapy produces client change.

In their discussion of the concept of expertise, Tracey et al. (2014) suggested three ways to define or understand expertise—by reputation, by performance, and by client outcome—and discussed the limitations of each. The authors discarded the first two as relevant definitions, and stated that, in spite of limitations, client outcome is the preferred criterion in their view.

To answer the question of whether expertise is a useful construct for psychotherapy, it is necessary to define both expertise and psychotherapy. Conceptually, to define expertise only by reputation confuses where to look to locate expertise with outcome and the performance associated with expert behavior. So, although expertise should not be defined by reputation, it can be considered a search tool, albeit an imperfect one, for expertise.

This approach has been successfully applied to the study of master therapists (e.g., Jennings & Skovholt, 1999; Jennings, Skovholt, Goh, & Lian, 2013). Defining expertise solely by outcome has limitations similar to those found in the early phase of psychotherapy research, when only input and output data were analyzed in pre-post research designs, thus providing limited or no knowledge of what takes place during psychotherapy.

I share the view suggested by Tracey and his collaborators that client outcome, in spite of its limitations, is probably the best criterion for expertise. However, contrary to what they suggest, I believe the construct of expertise needs to be supplemented with what therapists do (i.e., performance) to give it substance. As they also recognized, performance criteria are complex, difficult to define and assess, and hard to aggregate into an indicator of expertise. Nevertheless, we need to take on the task of overcoming these challenges in order to arrive at a comprehensive and in-depth understanding of expertise.

To do so, we also need to keep in mind that the arguments proposed in the debates on expertise are embedded not only within theoretical frameworks (i.e., theories of psychotherapy), but also within explicitly or implicitly articulated epistemological frameworks. This becomes evident in the authors’ extensive reference to an earlier published critique of psychotherapy launched by James Shanteau (1992) and followed up by Shanteau and Weiss (2014). I will argue that Shanteau’s conception of expertise cannot be applied to psychotherapy. It is epistemologically inconsistent to do so. Also, to limit the discussion of expertise to Shanteau’s (1992) conception of expertise is to restrict what can be discussed and observed, thereby limiting the lenses through which the phenomenon of expertise can be studied.

Two of the task characteristics Shanteau found to be associated with good performance (e.g., represented by astronomers, chess masters, physicists, and grain inspectors) were: 1) that stimuli are relatively constant, and 2) that repetitive or similar conditions arise over time. Neither of these are relevant descriptions of psychotherapy unless you see psychotherapy within a traditional medical model conception (i.e., where you as a therapist, a subject, provides or administers a treatment to a client, as an object).

However, if you view psychotherapy as a continually changing interpersonal enterprise where meaning making subjects (not subjects/objects) interact and where processes and directions continually vary, these task characteristics can never apply. They belong to an epistemological universe that implies an objectivation of the client and suggests clients with similar diagnoses are equivalent on all parameters that may impact outcome. Therefore, to my understanding, Shanteau’s conception of task characteristics associated with expertise is mostly (or possibly only) relevant for understanding how people relate to inanimate objects, and not relevant to understanding how people (i.e., therapists) relate to other people (i.e., clients) as subjects.

Back to the question of whether expertise is a useful construct in psychotherapy: The answer is yes and no. As suggested above, it depends on how we define expertise, and also how we define psychotherapy. If we define expertise the way Shanteau does, and only in terms of client outcome, it is not a useful construct, as it provides no information that can be applied in the understanding of what contributes to good outcome; neither can it be applied to draw implications for training or practice.

However, expertise is a useful construct if we define it in terms of nuanced and rich descriptions of performances of those psychotherapists who are more likely than others to obtain good results (particularly lasting good results) with their clients across a variety of client problems. That was the aim in a study of highly reputable and experienced psychotherapists (the criterion of reputation), who were also psychotherapy teachers (Rønnestad et al., 2014).

In this “treatment as usual” study of private practitioners, client dropout rate was low and preliminary results suggest that good client outcome was maintained and continued to improve three to four years post-therapy. The significant effect size (Cohen´s d) of change on OQ-45 from initial assessment to assessment three to four years post-therapy was 1.45. Low drop-out rate and extending client outcome to include enduring client outcome (i.e., outcomes that are maintained for some defined follow-up period) could be considered as additional criteria for expertise.

Given the good client-outcome of the above study, the results suggest the following task characteristics as empirically-supported candidates for a concept of expertise in psychotherapy: (1) the ability to engage clients in a collaborative relationship, which finds its expression in a high client-rated working alliance (Oddli & Rønnestad, 2002; Rønnestad et al., 2014); (2) a high degree of variability in client-assessed changes and change processes (Ekroll & Rønnestad, 2016), which suggests that expert therapists have available to them and use a broad range of strategies to assist their clients; (3) psychotherapists’ use of forward-driven strategies, context-sensitive decisions, implicit and intuitive processes, and engagement in therapist/client interactions characterized by flexibility and moment-to-moment adjustments to the non-linearity of psychotherapy processes (Oddli & Halvorsen, 2014; Oddli, Halvorsen, & Rønnestad, 2014; Oddli, McLeod, Reichelt, & Rønnestad, 2014); (4) the ability to work efficiently with “difficult to treat clients,” which requires psychotherapists to maintain a therapeutic attitude and not be drawn into dysfunctional patterns of interaction, but rather invite clients into a reciprocal, resource-focused change project, while consistently expressing sensitivity to the client’s agenda (von der Lippe, Oddli, & Halvorsen, 2014); (5) psychotherapists’ deep engagement in the client’s welfare, willingness and capacity to confront the client’s dysfunctional behavior, maintenance of optimism and a resource-focus while also being playful (Råbu, Halvorsen, & Haavind, 2011); and (6) psychotherapists’ careful attention to, and skillful handling of, the termination process ( Råbu, Binder, & Haavind, 2013; Råbu, Haavind, & Bindner, 2013).

As a conclusion, and with reference to the perspectives and results presented above, the following recommendations are made to advance the knowledge of expertise in psychotherapy: 1) Studies should be designed to enable careful and in-depth quantitative and qualitative analyses of performances of therapists’ who obtain exceptionally good client outcomes; 2) Reputation of psychotherapists is one option to locate these psychotherapists; 3) Designs should include frequent measurements of processes and outcomes (including micro-outcomes), enabling assessments from different observational perspectives (i.e., from clients, psychotherapists, and external observers) and analyses from different theoretical perspectives, as well as frequent registration of life events, both during therapy and in the follow-up period; and 4) The timeframe of studies should be sufficient to enable assessment of long-term outcome. By doing so, we may reach a conception of expertise that is rich, complex, and nuanced, and from which we can draw implications for training and practice.

Cite This Article

Rønnestad, M. H. (2016). Is expertise in psychotherapy a useful construct? Psychotherapy Bulletin, 51(1), 11-13.

References

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Tracey, T. J. G., Wampold, B. E., Goodyear, R. K., & Lichtenberg, J. W. (2015). Improving expertise in psychotherapy. Psychotherapy Bulletin, 50(1), 7-13.

Tracey, T. J. G., Wampold, B. E., Lichtenberg, J. W., & Goodyear, R. K. (2014). Expertise in psychotherapy: An elusive goal. American Psychologist, 69, 218-229. doi: 10.1037/a0035099

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