As tremendously effective as psychotherapy is, and as much as we try to help out students and new professionals, there are some things about working in this field that we don’t eagerly share. It’s not that we don’t want you to know, necessarily, it’s just… these things don’t look so good.
Here are three secrets we keep about the world of therapy. Each one is true, even if we don’t talk about them much.
1. Licensure standards have no scientific basis
Most states require two years of full-time, supervised experience before one is eligible to sit for their final licensing exam. (This is often codified as 3,000 or 3,200 hours of total experience.) What we don’t say is that this standard is nearly 100 years old, was pretty arbitrary even then, and doesn’t stand up to scientific scrutiny. A wealth of more current research suggests that your professional skills do improve within the first year of experience — but that they probably plateau after 150 or fewer hours of clinical work. Mind you, that plateau is in a good, effective place for most therapists.
2. The wrong people fail their licensing exams
We should start by saying that almost everyone passes their licensing exams. Just stay in the process, and you are likely to be one of the more-than-95% who eventually pass even if it takes multiple attempts. (The exact percentage varies a bit by profession and by exam cycle, but above 95% is not unusual.) As for those few who don’t make it, there’s actually no evidence — take that in for a second, no evidence, anywhere — that they are less safe as practitioners compared to those who do pass. Many of those who keep failing the exams either have severe test anxiety, or speak English as a second language.
3. Some therapists are better than others
Scott Miller and others have rightly criticized the mental health field for not improving our overall outcomes in generations, despite continual efforts to develop more and better treatment models. But we could get better as a field today if we simply had the courage to identify, and then either retrain or remove, the therapists who are getting the worst outcomes with their clients. Some therapists are indeed better than others even when working with similar clients, and those therapists who are not as good are identifiable — we just do surprisingly little to identify them. The way for us to get more effective as a field probably isn’t through using new models. It’s by improving the people who use those models, through measurement, accountability, and training that really works.
I talk at great length about each of these problems and several more in my book Saving Psychotherapy. I offer data to support each of the arguments made here, and make the case for why these issues matter. More importantly, the book is focused on solutions — what you as a therapist can do on your own to help fix these issues. The book isn’t a critique, it’s an action plan.
You can learn more about the book here (it’s available now in paperback, and arrives on Kindle March 1), listen to me talk it over on the Talking Therapy podcast here, or check out the Twitter chat I had with AAMFT Executive Director Tracy Todd here. There’s a lot to be done, but each of us also has a lot of capability.