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Is Psychotherapy Getting Better? - Page 4

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Changing Attitudes

In fact, some believe that the innovations most likely to influence the future of the field may come not so much from theoreticians, clinical innovators, or psychotherapy researchers, but from advances that make it easier for therapists to learn and master their craft. “We don’t need some great new therapeutic breakthroughs to make great strides in improving the quality of our outcomes as a profession,” says Susanne Bargmann, a Danish psychotherapist and trainer who helped create the International Center for Clinical Excellence (ICCE), the world’s largest web-based therapist learning community—currently used by 4,000 psychotherapists—dedicated to improving the standards of practice in the field. “We could raise the level of our clinical work enormously if we simply took more time to review our cases, especially when we’re stuck, and got concrete help when we made mistakes or had questions,” she says. “A big part of the barrier to doing that is one of attitude. Right now, too many therapists think that what they already do is perfect, or else that it’s too dangerous to acknowledge your clinical shortcomings. But, actually, the only time you ever learn something new is when you make a mistake.”

There are many resources available on the ICCE website that Bargmann developed with Scott Miller and others, but the centerpiece is the Fit-Outcomes management system, a specially programmed database of more than 100,000 cases with which practitioners can determine whether their current cases are on track. Including both outcome measures and session-by-session feedback scores, the cases loaded onto the site are categorized by their location on the spectrum from clinical failure to success. To determine whether their current cases are headed toward positive or negative outcomes, members compare them with those in the database by entering their own session-by-session feedback measures for the therapeutic alliance and overall client functioning. Beginning with the second session (so that patterns of progress, stagnation, or decline can be determined from the get-go), therapists can see whether a case is likely to have a positive or negative conclusion. When a case is progressing, a green lamp lights up, while no progress is indicated by a yellow lamp. A red lamp is the attention-getting symbol indicating that a case seems headed for an unsuccessful outcome.

Of course, the system is far from foolproof and offers no crystal ball, but it provides the kind of normative data previously unavailable to most clinicians that practitioners can use to chart the course of cases, especially challenging ones, adding a new dimension to their tool kit with potentially dramatic consequences. Beyond the color-coded alerts that offer a sense of accountability and urgency with cases in trouble, a key element of the Fit-Outcomes management system is the opportunity for members to send posts to the community of fellow practitioners to share frustrations, ask questions, and get new ideas any time of the day or night. Wherever you are on the planet, no matter how geographically remote, you can ask for help with challenging clients through ICCE. “Being a solo practitioner can be very isolating,” says Australian psychologist and ICCE member Vanessa Spiller. “Having a supportive, like-minded community in which I can ask questions and present ideas and thoughts, and have people critically review these, has been very helpful. It’s been great to be able to access this ‘oasis of international expertise,’ providing me with peers willing to critically review my work, identify some of my unquestioned assumptions, and make specific suggestions for changes I can implement and objectively evaluate.”

Like the ICCE system, a database called the Systemic Therapy Inventory for Change (STIC) being developed by William Pinsof of the Family Institute at Northwestern University tracks the session-by-session progress of therapy. But instead of relatively simple questionnaires, the STIC features an initial assessment of 30 different personality, behavior, and relationship dimensions and collects information not only on individual clients, but on every participant in couples or family therapy. Because it’s scored and displayed on a computer, with easy-to-read graphic displays, it can be filled out relatively quickly. Clients fill out STIC measures throughout treatment, which are e-mailed directly to therapists. They can consult the measures before a session and get an instant sense of what’s happened between sessions and whether a case is progressing. It’s not that the STIC dictates a particular intervention, but it gives the therapist information that might otherwise be missed, especially about potentially damaging ruptures that have taken place in the alliance with clients.

“The therapist may have pushed too hard or responded in a way that a client didn’t perceive as empathic in a previous session,” says Pinsof. “Typically, the client might not say anything about this, but the STIC gives the therapist a way of finding out that, for example, a client’s trust in the therapist declined in the last session. Knowing this beforehand enables the therapist to point to the STIC scores and say, ‘It looks like something happened between us last time’ and bring that into the therapeutic conversation.” When used as a tool for monitoring and repairing the therapeutic relationship in this way, Pinsof believes that it amplifies the client’s voice and equips the clinician with an additional sixth sense, helping to overcome the blind spots that are inevitable in every human relationship. He insists that STIC deepens the therapy process and empowers both therapists and clients, rather than taking away therapists’ autonomy, like a therapeutic protocol can.

Technology and the Future

While technology often is seen as a depersonalizing force in our lives, some are beginning to argue that the digital revolution may be the primary means by which the standard of care within in the field will rise to a new level. The expanded video capabilities of the Web are already opening up learning and training opportunities that can help therapists further develop their clinical skills. Cognitive Therapy pioneer Donald Meichenbaum is developing a website that’ll offer video demonstrations of what he considers the core skills required for effective practice, along with assessment instruments to determine which of those skills a given practitioner might need to improve. The Networker regularly broadcasts video interviews with accomplished experts in a range of clinical topics like couples therapy, trauma, and mindfulness practice that focus directly on the fundamentals of clinical craft too often ignored in therapists’ training. Its goal is to radically expand the range of observable clinical role models available to practitioners around the world. The ease of video recording today makes it possible for clinicians to conveniently review their own sessions, either with colleagues or supervisors, and zero in on the nuances of session management and intervention that go beyond generalized discussion, providing the kind of immediate feedback that the literature on human performance and mastery tells us is necessary to change behavior and enhance skill.

Some of the new digital systems being developed offer possibilities that might have seemed like science fiction just a few years ago. For example, Pinsof is now working on an adjunct to STIC, called the Integrative Therapy Session Report, which will gather measures of therapists’ techniques session by session. “After a session, we ask therapists to detail what specific interventions and client strategies they used. This additional information is integrated with the ordinary STIC data to show how the progress of a case—or lack of it—can be related to the therapist’s interventions. As more data are collected, this will give us a road map of how a broad range of clients with all kinds of characteristics responded to different kinds of interventions at different stages of the therapy process. So when a therapist is stuck with a particular client or couple or family, she’ll be able to see how a sample of thousands of past clients with matching characteristics responded to various treatment options.” Pinsof likens his feedback system to an X-ray, blood analysis, or MRI in medicine, and considers his feedback and reporting instruments as sources of vital information that, one day, will be part of every therapist’s essential tool kit, ensuring greater accountability and better care.

So it appears that whether therapy progresses to a new level of effectiveness may be determined, not by some game-changing discovery of new methods, but by whether we can change our time-honored distrust of the very concept of “research.” “Most therapists today see research as something that’s intimidating and controlling, and don’t believe they can integrate scientific data into their work without compromising their clinical intuition and judgment,” says Pinsof. But as technology makes it possible to make immediate, practical use of data in managing the ongoing therapeutic relationship, therapists will be increasingly encouraged to become more discerning investigators of their own practices and more attuned collaborators with their clients, especially when things are looking grim or uncertain in the consulting room.

As 21st-century technology increasingly makes itself felt in psychotherapy, it seems that the pathway toward enhanced effectiveness will require the field’s practitioners to bring together knowledge domains often treated as distinct. Regardless of how hi-tech and data-driven some of the tools practitioners use in their pursuit of clinical excellence become, however, the therapist’s demanding, evolving craft will remain one in which both art and science are inextricably intertwined.

Contributing editor Diane Cole is the author of the memoir After Great Pain: A New Life Emerges and writes for The Wall Street Journal and many other publications. Contact:

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