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How Do We Become Better Therapists? Psychotherapy Debate with Bruce Wampold and Peter Fonagy

by Kristen Moran on March 16, 2017 Last updated on September 1, 2020

How do we become better therapists?

That was one of the main questions being asked during the debate between Peter Fonagy and Bruce Wampold at the Nordic Conference for Mental Health.

The two psychotherapists were invited to discuss four themes related to the current state of psychotherapy research and where we may head in the future:

  • Are some psychological treatments more effective than others?
  • How do we become better therapists?
  • How do we build better services?
  • Where do we go from here? The future of psychotherapy research

Let’s take a look at some of the main points discussed during the talk.

Are some psychological treatments are more effective than others?

Moderator Dr. Jon F Bjaastad began by asking Bruce and Peter if they thought some psychological treatments were more effective than others.

Both agreed that while some psychotherapies work, others do not.

“Is there an importance of figuring out our responsibility to our patient - what works and for whom?” Peter Fonagy explained. “The answer to that is an absolute and unequivocal, yes and I would consider any attempt to hinder that process to be both unethical and unacceptable intellectually.”

Dr. Wampold agreed that there are some that are more effective than others. However, he raised an interesting question: How is it that we keep developing new therapies and the outcomes we get with patients really have not improved over time?

“What really makes a difference is the therapist,” Bruce remarked.

“There are some really good cognitive behaviour therapists who do a great job. And I’m not talking about they look good if you observe them, I mean they actually achieve good outcomes with their patients. But there are some very poor cognitive behaviour therapist. Same with dynamic therapists and emotion-focused therapists. The key to success is that some therapists have the skills to help the patients, regardless of the treatment. The continued focus on treatment really puts the spotlight in the wrong place. It’s us, therapist, who make therapy work.”

Bruce went on to boldly state that “every understanding of a disorder that we have is wrong.”

“We will find out in 10 or 15 or 20 years, every explanation you have will be supplanted by a new one, not necessarily a true one. What’s really important is that the patient accepts the explanation, whether it is evidence based or not, and that it leads to the patient to do something to overcome their difficulties and I agree with Peter that it is usually around the social world. People come to treatment very much for their disrupted social world.”

How do we become better therapists?

Moving on to the second question, one that every practitioner would like to know: How do we become better therapists?

“This is an area that really interests me because the fact of the matter is it’s really difficult to become a better therapist,” Bruce said. “We go into a room by ourselves, we have confidential conversations we really can’t talk to many people about what happens. Maybe we have consultation and supervision. In the US, once you are certified or licensed, it’s no longer required to get any consultation or supervision. We don’t get feedback about what we do.”

“We just published a study where we looked at therapist outcomes over 18 years and it’s really distressing to find that on average, therapists get less effective as they gain experience. We can’t tolerate that. We need to improve our skills.”

So, how do you do that? “I used to think you need to know yourself better, you need to have more experience, see different kinds of patients,” Bruce explained. “I have come to the point where we need to practice the skills that we know are employed by more effective therapists.”

What makes a good therapist

Bruce referenced Tim Anderson’s facilitative interpersonal skills (FIS), who found out that effective therapists, defined as the ones who have better outcomes, tended to rate higher than others in certain interpersonal skills.

“Verbal fluency, ability to be warm and accepting even with a difficult or challenging patient, empathy, the ability to form a good collaborative working relationship across a range of patients, the ability to explain what we are doing therapy in a cogent way - those are the skills that make effective therapists,” Bruce explained.

He went on to say that practice outside of therapy was the only way to improve these certain skills.

“Pablo Casals, the famous cellist, was asked, “Why do you practice five hours a day in your 80s?” and he responded, ‘Because I think I am getting better.”

Peter agreed that practice was important and noted that practicing on camera is a great way to identify what is being done well and what needs improvement. He explained that incorporating video into training was something being used in the UK.

“One thing that we introduced in the UK as part of the improved access psychological therapies program that I was overseeing, for children and young people, was a compulsory part of training where people had to be videod and the supervision had to be of a videod interaction between them and the patient,” he said. “As soon as you see yourself practicing and see yourself doing, you notice things that you’re not aware of, you notice things that you do. You really want to watch yourself work and watch yourself with another person.”

How do we build better services?

When it comes to building better services, one of the biggest issue faced in many countries is the lack of accessibility.

“Access to care is the biggest issue. In epidemiological studies in the Unites States, 50% of the people who have a DSM disorder in a given year don’t get any treatment at all. So we need to expand the services. In the US it’s not as big as an issue as who pays for the service,” Bruce said.

Improve services by improving therapists

Despite alarming numbers that show therapists aren’t getting better, Bruce reminded the audience that, for the most part, therapists of a variety of different orientations or methods, get very commendable outcomes.

“So on the whole, we are doing a damn good job at helping patients,” he said. “What we find when we look at that data a little closer, is that there is a bottom 10 or 15% of therapists whose outcomes need to improve. We could improve the quality of service by excluding those 15% or helping them improve. That would be in the population level, result in a significant improvement in the recovery rate of people we see.”

The future of psychotherapy

When asked about the future of psychotherapy, Bruce said that there is a ton of research to be done that will completely change what we now know about psychotherapy.

“10 years from now, 95% of what we know about therapy will be new. We don’t know very much about what makes psychotherapy effective,” Bruce said. “If I had money to fund the research grants for the future, I would quit funding comparisons between two treatments. We spend in the United States, $100 million or more over the course of a few years comparing two treatments to find out that they both work equally well and better than no treatment at all.

“Let’s study therapists. What makes an effective therapist? What do therapists that consistently have better outcomes do? We are starting to answer this question, but there is more work to do there.

Watch the video below to listen to the entire psychotherapy debate.

About the Author

Kristen Moran

Kristen Moran

Kristen Moran

Kristen is the editor and community manager at Theravue. Kristen's desire to ask questions and share information with others led her to pursue journalism. While she has pursued various avenues in her field, it was her love of self-improvement and zest for life that made Theravue the perfect fit.

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