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How to Train Good Therapists

As it’s become increasingly clear that the client–therapist alliance is probably the most important feature of effective therapy and positive outcome, the question arises of how well the field’s professional training does at providing graduates with the skills they need to establish the kind of relationships with their clients that are the hallmark of effective therapy. Critics contend that many graduate programs have a ways to go in that regard for a number of reasons, starting with the admissions process itself.

“The criteria that are used to get into grad school have nothing to do with therapeutic competence,” says L.A. psychologist Nicholas Ladany, director of Loyola Marymount University’s Counseling Program, who trains therapists and supervisors around the world. “Almost every graduate program uses grade point average, GRE test scores, and research experience as entrance criteria, and there’s not one bit of research that shows any relationship between these and therapeutic competence.”

Training programs typically assume that therapeutic skill will be acquired when the students do their internships and get on-the-job training, right? What isn’t widely recognized is that therapists with a limited capacity for developing solid clinical skills can easily slip through their field placements. Theoretically, field supervisors tell a school liaison how a student is doing, but how many supervisors have the awareness or courage to say to the school, “This student will never become a decent therapist”? And if they do, how should the school handle that information? Clinical acumen and skills, says Ladany, simply aren’t evaluated well. Most graduate schools, he says, “overload students with content-based knowledge, dabble in self-awareness, and give little attention to evaluating clinical experience.”

There are exceptions, of course. Some Ph.D. programs focus predominantly upon clinical work and include a strong supervisory evaluation component. But even at this level, there are seldom any reliable mechanisms in place to ensure that students who graduate have actually acquired the skills they need to practice therapy effectively. “Sometimes there are student clinicians who just don’t seem to grow or benefit enough from supervisory feedback,” says a faculty member at a Ph.D. clinical training institute. “In the beginning, you want to give people a chance, and you hope that through continued training and practice, they’ll get better. So the issue of whether they should be practicing never gets directly confronted, and all of a sudden they’ve graduated.” Ladany puts it more succinctly: “Basically, we pass people through if they can get good grades and don’t piss off a supervisor.”

A controversy at Webster University in St. Louis illustrates the problems that emerge when a school strays beyond the objective—albeit clinically irrelevant—criteria used to assess and graduate students. Earlier this year, a student who’d received all A’s and one C, was kicked out of the master’s program in Counseling Psychology on the grounds that several of his taped counseling sessions demonstrated that he “lacked empathy.” He’s now suing the university for $3 million in losses and damages.

Part of the lawsuit’s contention is that the code of ethics of the American Counseling Association stipulates that schools have an obligation to help students improve their deficiencies. Currently, there’s no objective way to determine whether the Webster University student really has enough empathy to become a competent clinician, and if he does lack empathy, what his training program could have done about that. Ladany thinks that part of the problem is that the qualities of empathy and the other clinical skills involved in being a good therapist aren’t defined well enough, making it impossible to evaluate students fairly. Beyond empathy, the skills in question are other hard-to-quantify talents, like interpersonal competence, curiosity about others, and sensitivity to multicultural issues, along with the ability to manage countertransference, tolerate ambiguity, and establish a working alliance. What’s needed in our graduate schools, claims Ladany, is a live-session exam that students have to pass. If they fail, they’d get more training and have to take other live exams that honed in on the skills in which they hadn’t demonstrated proficiency.

There’s another neglected component to students’ training that requires attention, Ladany adds: old-fashioned modeling by faculty. When faculty members exhibit strong qualities of interpersonal connection, empathy, and interest in and care for others, their students are likelier to develop those qualities, too. Unfortunately, says Ladany, too often such sterling models simply aren’t represented in training programs around the country.

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