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How time flies. I have been researching, practicing and supervising psychotherapy for over 35 years. When I began graduate school Hans Eysenck’s claims that psychotherapy was not effective, and likely harmful, was widely disseminated and believed. To say the least, it was not an optimistic time to be in training to become a psychologist. Read more
Interview with Chief Scientist Bruce Wampoldby Dr. Bruce Wampold on July 5, 2017 Last updated on September 1, 2020
Interviewer: Hello Bruce. Thank you for the opportunity to have this interview. You have certainly had a long and distinguished career. Many of your publications are widely cited and your development of a Contextual Model of Psychotherapy has changed the way many people think of psychotherapy. Perhaps not as well known is that you have been involved in the training of therapists over the course of your career as well.
But first, let’s go back to how you got interested in psychotherapy because if I understand this correctly you did not begin your studies in psychology—you were a mathematics major.
Bruce: That’s correct—I never took a psychology course as an undergraduate. When I graduated from the University of Washington with a degree in mathematics, I really didn’t know what I wanted to do for a career. It was a tumultuous time politically with the Vietnam War and Watergate. I decided I would teach mathematics for a year to two and then I would decide on a career course. But serendipity, as Paul Meehl noted, plays an important role and I ended up being a mathematics teacher and wrestling coach at Punahou School in Honolulu for five years (and yes, Barack Obama was a student there but I didn’t have him in class). It was during my time teaching and coaching at Punahou that I became more interested in the students than it the mathematics I taught every day—it was fascinating to see some students, despite economic, racial, cultural, and family barriers, thrive, while others, despite privilege, lacked motivation. As a consequence, I enrolled in a master’s degree in counseling and guidance at the University of Hawai’i and got excited about the power of therapy to influence the life course and provide people opportunities that various mental health problems foreclosed. I then did my Ph.D. at the University of California, Santa Barbara. I have been captivated since then to know how psychotherapy works—how does talking to a therapist for an hour a week typically results in life altering changes.
I: Well, that is an interesting story. I don’t mean to comment on your age, but you certainly have been in the field through some important periods. What has changed and what hasn’t changed in your 40 years being involved in psychotherapy?
B: On the optimistic side, we know much more about how psychotherapy works than we did when I began my graduate studies. I remember that in my first semester Mary Lee Smith and Gene Glass published their meta-analysis of psychotherapy studies and showed, with methodological rigor, that psychotherapy worked! To that point there had been questions about whether psychotherapy even worked—it is an interesting story, but I was relieved to know what I had chosen to learn actually worked!
And since I was a graduate student, we know much more about how therapy works. We can discuss some of this research if you want.
During this period, psychotherapy has been integrated into the health care system in the United States and in many other countries. This is tremendously important because many more people, from all walks of life, have access to psychotherapy. Of course, being in the healthcare system brings with it management of care by the payors—limited number of sessions, mandates on the types of therapy provided, and unfortunately greater reliance on medical treatments for mental health problems (i.e., the use of medications).
As well during my career we have seen a proliferation in the number of treatments that have been developed (there are now over 500 distinct types of psychotherapy). In one way, this is encouraging—more choices for clients and therapists. However, the amount of money spent on developing, testing, and promoting new treatments belies the fact that there are no consistent differences among therapies. New therapies are not more effective the previous ones. Simply, it does not look like we are progressing—There is not convincing evidence that the quality of psychotherapy—and by that I mean the benefits experienced by clients—is improving.
For the most part, the way we train therapists has not changed. The primary means to learn psychotherapy is treating clients and receiving supervision. This is the way I learned psychotherapy 40 years ago and it is remains the predominant way today.
I: Well that is indeed discouraging. What are your thoughts about how to improve the quality of psychotherapy?
B: This is an important question—how can psychotherapy services be improved?
There are essentially three ways that have been offered to improve the outcomes of psychotherapy.
The first method is to disseminate treatments that research has shown to be effective. Some treatments have been studied extensively in clinical trials and shown to be effective. These treatments have had various names over the years: empirically validated treatments, empirically supported treatments, evidence-based treatments, or psychological treatments with research support. In many agencies, systems of care, and even countries, therapists are mandated to deliver such treatments—the logic is clear for such a strategy. Like medicine, if clinicians give the best treatment, then client outcomes will be better. However, for a number of reasons, this does not work in psychotherapy. The most important reason is that there few if any differences among treatments, in terms of effectiveness. More important than the treatment is the therapist giving the treatment. There are effective CBT therapists and less effective CBT therapists. Same with psychodynamic, emotion focused, integrative, and so forth—it is the therapist, not the treatment, that is important. Dissemination of evidence-based treatments in many countries, including Great Britain, has not improved outcomes—and such efforts are immensely expensive.
A second means of improving outcomes of psychotherapy is a procedure that goes by various names: Routine outcome monitoring, feedback, outcome informed practice, and so forth. The idea is to measure the mental health status of the client regularly (e.g., every session) and use this information to guide therapy. It is important for therapists to know how clients are progressing and there is evidence that therapists are not very skilled at identifying cases that are deteriorating or not making expected progress. So, providing information on patient progress is important and there is evidence that doing so improve outcomes, primarily by preventing failing cases.
So, it appears that feedback can improve services. But there is an important issue here. It appears that therapists who use feedback systems, even if the system improves outcomes for individual clients, do not improve. That is, such systems do not help therapists become more effective generally (indeed, there is some evidence that therapist effectiveness declines over time!).
This leads us to the third way to improve psychotherapy outcomes. To become an expert in any field, including sports, music performance, and chess, requires deliberate practice. This has given rise to the popular notion that it takes 10,000 hours to become an expert. There is evidence that therapists can continually improve, which is a characteristic of experts, if they deliberately practice those skills that characterize effective therapists. Research has shown that effective therapists are able to form a strong working alliance with a range of clients, are warm and empathic, are verbally fluent, can read the affective state of their clients, can modulate their own affect to best help their client, are persuasive, provide their clients a cogent rationale for treatment, and make efforts to improve.
I: I understand the notion of deliberate practice and see how it works in athletics, for instance. Basketball players practice dribbling with both hands or practice jump shots from various positions, against various defenses. But how would this work for psychotherapy?
B: The first step is to identify the skills to be practiced. As I mentioned, the characteristics and actions of effective therapists have been identified. Some therapists may be better with some skills than others. Deliberate practice involves repetitious practice of the skill, with feedback. It is not possible to practice the skills when delivering therapy, just as it is not time practice one’s jump shot in a game. The therapist who wants to improve must practice a particular skill over and over again, improving each time. But the issue is how to do this.
Ideally, the therapist would respond, say with empathy, with a variety of challenging clients, with the opportunity to repeat the response until he or she has improved and the response is exemplary. One way to do this efficiently and effectively is to have videos of various clients and have the therapist to respond to a client statement, using one of the skills. Then the therapist can evaluate their own response and then revise the response—an iterative process that results in gradual improvement. The process should also involve having another person—supervisor, instructor, or peer—evaluate the response and provide feedback.
I: This is really an interesting idea—but wouldn’t this be best done using some type of electronic platform for viewing the client statements and then recording the therapist responses?
B: Exactly, I have been working with Theravue.com, as Chief Scientist, to develop an electronic platform for practicing these skills. In Theravue.com the therapist will learn about the various skills that effective therapists use and then have the opportunity to practice and improve. The therapist views a client statement and then records his or her response, using one or more of the skills. The therapist can then evaluate his or her response and record another response to the same client statement, improving each time. When the response has improved and the therapist wishes to receive feedback from a supervisor, instructor, or peer, he or she can submit the response. For each skill, there is a variety of client statements to use for practice.