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RH: So there's no one true cure?
MEICHENBAUM: There's no single model that fits all. I really see myself as an honest broker, so anyone who says I have the cure, like Steven Hayes's idea that his Acceptance and Commitment Therapy is "The Third Wave"—ACT may work with many people, but it's not a panacea.
RH: You've done research specifically on what constitutes therapeutic expertise or mastery. You've written that people need about seven years to become an expert at anything. Is that similar to the 10,000 hours to achieve expert status that Malcolm Gladwell writes about in The Outliers?
MEICHENBAUM: That's exactly right, we're using the same data—10,000 hours, or, if you're a chess player, 50,000. I say it takes seven years for a therapist to become an expert, because that's how long it takes to see enough patients really shape up. You learn by deliberative practice, learning from your mistakes.
RH: So what can less experienced therapists do to provide good client care while they're gaining sufficient experience to move to the next level?
MEICHENBAUM: I think it's a journey. Some people start off a bit ahead of others because they already have core skills, like knowing how to listen, how to reflect, those kinds of things. I think that the main thing is not to be sucked up by the hype that's associated with certain therapy models—you need to be a critical consumer. It's also important to find a good mentor and be part of a peer group in which you look closely at each other's work.
I think that a crucial pathway to expertise in psychotherapy is to have the guts to audiotape or videotape your sessions, and watch them with someone else; we all need that kind of feedback. The other thing is that you should develop a habit of soliciting feedback from your patients. At the end of every session, you should ask them, "Is there anything I said or did, or anything I failed to say or do, that you found particularly helpful or unhelpful?" We all need to regularly do those kinds of dipstick assessments and solicit that kind of feedback. If you're an athlete and you miss the shot, you get immediate feedback. If you hit the golf ball in the rough, you get immediate feedback. Psychotherapists don't get that kind of feedback automatically; they have to ask for it.
RH: As one of the founders of CBT, how far do you think it's come?
MEICHENBAUM: Years ago, the behavioral traditionalists attempted to get all cognitive types kicked out of the American Association of Behavioral Therapy. They tried to make sure that no articles with the word "cognition" appeared in journals like JABA [Journal of Applied Behavior Analysis]. A letter was even circulated specifically identifying people who were bastardizing behavior therapy. Today AABT has changed its name to the American Association of Cognitive Behavior Therapists. One has got to be impressed with that kind of growth.
In addition, there's an increasing appreciation of the particular factors that make cognitive-behavior therapy effective, like the therapeutic alliance and the whole business of nurturing hope and attending to feelings. So I think CBT has continued to develop and embrace a broader perspective, recognizing that feelings impact thoughts, as well as thoughts impacting feelings.
Finally, I think that there's a great deal more humility about the limitations of CBT. Recent studies in the area of depression highlight that behavioral activation and helping people get exercise is equally, or more, effective than cognitive therapy. In the area of substance abuse, CBT is no better than other kinds of interventions, like 12-step groups. In fact, in substance-abuse studies using CBT, there's no evidence that the cognitions have changed, or that the mechanisms of change are in any way linked to the specific CBT procedures. So I think anyone who's sensitive to the data has to be given pause by how little we still know about what particular mechanisms lead to change.
RH: It's humbling!
MEICHENBAUM: Sure. I think if you're honest in this profession, that's usually the right stance.
Ryan Howes, Ph.D., is a psychologist, writer, musician, and clinical professor at Fuller Graduate School of Psychology in Pasadena, California. He blogs "In Therapy" for Psychology Today. Contact: rhowes@mind spring.com; www.ryanhowes.net. Tell us what you think about this article by e-mail at email@example.com, or at www.psychotherapynetworker.org. Log in and you'll find the comment section on every page of the online Magazine section.