We can’t say we didn’t see this coming. In the first edition of The Heart and Soul of Change: What Works in Therapy, published in 1999, authors Mark Hubble, Barry Duncan, and Scott Miller predicted that psychotherapists would soon be facing a new era of accountability for their work. Clients, payors, and policymakers would all demand hard evidence that psychotherapy was effective. That era is well underway, and so far we have provided a wealth of the kind of information these parties have demanded.
We can demonstrate that therapy works as an overall conclusion, and within the contexts of specific problems and populations. Proving the effectiveness of specific models has been helpful in many ways (showing that model-based treatment is superior to no treatment) and enlightening in others (showing that, for most problems, the model of therapy has little to no impact on outcome). The brain research discussed by Siegel, Cozolino, and others explains why therapy works. Psychotherapy in general is being held accountable, and it is passing the test with flying colors.
The same cannot be said of specific therapists, or of therapy training programs – yet. Individual therapists have historically not had to prove their effectiveness in any meaningful or measurable way, and training programs have historically been evaluated more on their inputs (like following a common curriculum) than their outputs (whether they produce competent and effective graduates). But accountability on these levels is coming, and quickly.
Greater accountability is going to wind up closing some graduate programs in psychotherapy. Whether morally right or not, this is the reality. Online universities have already seen steep enrollment drops in the face of increased scrutiny from the federal government, and increased attention to their attrition and job placement rates. Accreditors in the psychotherapy professions are now demanding that programs publish information on programs’ costs, completion rates, diversity, license exam pass rates, and employment rates after graduation – information that will likely steer prospective students away from underperforming programs. Even APA-accredited programs in psychology will risk accreditation loss and ultimately closure if they can’t place enough of their students in accredited internships – and there aren’t enough internships to go around.
The domino effect of these pressures will be interesting to watch. In many ways, the outcomes could be good for our field: Programs may reduce enrollments (by eliminating academically weaker applicants) and adopt higher standards for graduation (to ensure their license exam success data remains strong). Fewer programs, and smaller enrollments
in existing programs, would ease the concern among some therapists that there are simply too many professionals in the field.*
These changes in therapist training will necessarily lead to heightened accountability for individual therapists, at least while they are within their training programs. Some programs are already experimenting with structured clinical exercises for students to prove that they can perform specific skills – with those students who fail given additional training. Others are utilizing outcome data on individual therapists to tailor their training and ensure competency before allowing a student to graduate. In this way, programs are slowly transitioning to requiring that students demonstrate not just knowledge (through papers and exams) but measurable clinical effectiveness.
That’s a sea change for the preparation of therapists, and one that is long overdue. Psychotherapy is effective, but unlike the process of advancement in other health care fields, psychotherapy’s outcomes have not improved in decades. The retraining or removal of less-effective therapists is the method that today holds the most promise for increasing the overall effectiveness of psychotherapy.
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* I don’t actually give this concern a lot of weight, for reasons I cover in the book, but it is a concern for many therapists worried about practicing in markets they think of as oversaturated.