Do counsellors become more effective over time?
The counselling profession prizes clinical experience. For counsellors to advance from intern through to clinical member, there is an expectation that they will be accruing hundreds of hours of counselling practice over years. Exposure over time to a broader range of clients and their issues, training, professional development, and clinical supervision, is likely to lead counsellors to acquire expanded learning at multiple levels. But does this accruing of experience, knowledge, and skill translate into improved outcomes over time? Or put another way, will the senior members in the profession be getting better results than they did when they first began their counselling practice?
Goldberg and colleagues (2016) set out to measure therapist performance over time in a longitudinal study. They reviewed the outcome data from 170 therapists from a university counselling service over a period between .44 to 17.93 years (av 4.73). Therapists covered a continuum of career status, from trainee students through to experienced licensed professionals.
The results of the study were somewhat surprising. Therapists, as a group, did not improve with experience, whether the experience be measured in time or cases. In fact, overall there was a very slight decline of outcomes with experience. Breaking it down further, 60% of therapists declined slightly while the remaining 40% improved slightly over time. The bulk of therapists experienced very little improvement or deterioration in their outcomes over time.
How might we interpret these results?
General effectiveness: Firstly, we need to remember that counselling is generally very effective (Smith & Glass, 1977). Finding that counsellor performance generally does not change over time does not suggest clients are not benefitting from treatment. Most clients will benefit from most counsellors.
Staple profession requirements: The results raise questions about the impact on outcomes of professional development and clinical supervision. Both of these areas have little research support on their contribution to improving outcomes. If counsellors are receiving regular supervision and professional development but not improving in outcomes, we need to understand why. Do these activities simply help us maintain our existing levels of effectiveness? Are benefits of clinical supervision not generalizable across our clients? Or are these activities primarily for other benefits, such as increasing therapist practice knowledge, self-awareness, and resilience?
Over-estimates: Over time, counsellors collectively may not improve in their effectiveness but they tend to increase in confidence and professional self-belief. Research has demonstrated that therapists over-estimate their effectiveness and typically suffer from self-assessment bias (Walfish, McAlister, O’Donnell, & Lambert, 2012). However there is some evidence that counsellors who display more professional self-doubt tend to get better outcomes than those who have more professional self-confidence (Nissen-Lie et al., 2017). The interpretation about why this might be the case is that those who lack professional confidence are likely to spend more time devoted to considering their work in comparison to those who engage in less critical professional reflection.
So how can counsellors continue improving their effectiveness? This area of psychotherapy expertise research is still very young. Current suggestions include ensuring appropriate reliable formal outcome feedback is collected. Therapists are typically over-optimistic in their perceptions of client improvement and fail to recognise failing cases (Hannan et al., 2005), hence objective measurement is important. The second is utilising the feedback and translating it into deliberate practice (Goodyear, Wampold, Tracey, & Lichtenberg, 2017), and then checking to see if this deliberate practice converts into improved outcomes.
Counsellors cannot rely on experience, supervision, professional development as pathways to improve their client effectiveness. Current recommendations suggest counsellors need systematic outcome feedback combined with deliberate practice if they seek to continue to improve.
Click here for a YouTube version of this article.
Goldberg, S. B., Rousmaniere, T., Miller, S. D., Whipple, J., Nielsen, S. L., Hoyt, W. T., & Wampold, B. E. (2016). Do psychotherapists improve with time and experience? A longitudinal analysis of outcomes in a clinical setting. Journal of Counseling Psychology, 63(1), 1-11.
Goodyear, R. K., Wampold, B. E., Tracey, T. J. G., & Lichtenberg, J. W. (2017). Psychotherapy expertise should mean superior outcomes and demonstrable improvement over time. The Counseling Psychologist, 45(1), 54-65. doi:10.1177/0011000016652691
Hannan, C., Lambert, M. J., Harmon, C., Nielsen, S. L., Smart, D. W., Shimokawa, K., & Sutton, S. W. (2005). A lab test and algorithms for identifying clients at risk for treatment failure. Journal of Clinical Psychology, 61(2), 155-163.
Nissen-Lie, H. A., Rønnestad, M. H., Høglend, P. A., Havik, O. E., Solbakken, O. A., Stiles, T. C., & Monsen, J. T. (2017). Love yourself as a person, doubt yourself as a therapist? Clinical Psychology & Psychotherapy, 24(1), 48-60. doi:10.1002/cpp.1977
Smith, M. L., & Glass, G. V. (1977). Meta-analysis of psychotherapy outcome studies. American Psychologist, 32(9), 752-760. doi:10.1037/0003-066x.32.9.752
Walfish, S., McAlister, B., O’Donnell, P., & Lambert, M. J. (2012). An investigation of self-assessment bias in mental health providers. Psychological Reports, 110(2), 639-644. doi:10.2466/02.07.17.PR0.110.2.639-644
Hi Nathan, does this mean that a counsellor who’s been doing the same work for the last 10 years, having to analyse their counselling sessions regularly, can become critical of their work? So what is a systemic outcome feedback?
Hi Florence, I think it is more about therapists analysing their work with particular attention paid to how they can improve. It’s about having sufficient professional doubt to realise we aren’t perfect and there are always opportunity to improve. There is always a risk we just assume everything we do is helpful and we can easily slip into uncritical acceptance of our performance.
Systematic outcome feedback is about using formal objective measures to track client outcomes. The measures I use are the Outcome Rating Scale (and Session Rating Scale to check client satisfaction). This measure is easy to administer, free for individual practitioners, and gives information that our own clinical intuition can easily miss. It also gives us a picture of progress over time both for client progress and if we have a software or online package, compare our performance over time across clients.
Hope these comments help.