Training in mental health is unreasonably long

2010-07-20 Black windup alarm clock faceJust as a quick thought experiment, go over to this piece at Slate discussing medical training, and every time it references “medicine” change that to “mental health.” (Accordingly, change “physicians” and “doctors” to “therapists.”) You’ll find most of it applies perfectly. To wit:

Over the past century, there have been additions to, but few subtractions from, the training process. Residency and fellowship programs became longer and longer … and longer.


The long process doesn’t just weed out the incompetent and the lazy from the potential pool of physicians—it deters students who can’t pay for so many years of education or who need to make money quickly to support their families. That introduces a significant class bias into the physician population, depriving a large proportion of the population of doctors who understand their background, values, and challenges.


The fundamental problem here is that the argument between traditionalists and reformers [debating the appropriate length of training] is essentially theoretical — we are in an evidence vacuum.

In the time I’ve been in academia, I’ve watched as the requirements for training in mental health have increased dramatically. Family therapist training in California increased from 48 to 60 units based not on science but on workplace competitiveness. (MFTs were fighting clinical social workers for some of the same jobs, and since LCSWs need 60 units of training, MFTs couldn’t really argue that their training at 48 units was equivalent.) I’ve also watched as education in general has gotten much more expensive, and loans harder to come by. And I’ve been enlightened by learning that our 3,000-hour supervised training requirement is based entirely on tradition, and is in virtually no way linked to the science that we now have available (though admittedly, it isn’t much) on how therapist skill develops over time.

Our old apprenticeship model is broken. It’s as true in therapy as it is in medicine. It will be interesting to see how experimentation with medical training goes, as it can blaze the trail for similar efforts in other health care professions like ours. I’m just not sure we should be waiting for doctors to do it first.

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Your comments are welcome. You can post them in the comments below, by email to ben[at]bencaldwell[dot]com, or on my Twitter feed.

How to make a better therapist

It isn’t experience, and it isn’t the kind of training we usually do.

I’m blogging this week from the Evolution of Psychotherapy Conference in Anaheim, where many of the world’s leaders in psychotherapy gather to discuss the state of the field and share new and innovative research findings.

Therapy is tremendously effective. The average treated client ends up better off than 80% of untreated people with similar problems. Psychotherapy for mental health problems is as effective as coronary bypass surgery for heart problems and four times as effective as flouride toothpaste in preventing dental problems. But we’re not getting better, Scott Miller said in yesterday’s opening workshop.

Miller summarizes our field’s efforts to figure this out thusly: We started by looking at our treatment models, hoping to build better techniques to reach better outcomes. This is where many training programs still live: We teach manualized, empirically-supported treatments in hopes that it will make for the most effective therapists. Except it doesn’t; the models formalize and standardize our work, but they don’t make us any more effective, according to outcome studies.

So we then moved to looking at common factors, those things that work across all theoretical models. But teaching common factors doesn’t seem to make us more effective, nor does it relieve the need to know specific models, since it is through those models that the common factors work. (My good friend Sean Davis has the leading text on common factors in couple and family therapy, and in it he makes the same point.)

So the focus then shifted to the study of outcomes rather than methods, and what we found was that some therapists consistently achieve better outcomes than their peers. That has moved the field into a close examination of excellence and expertise.

The findings there are striking, and I can’t do them full justice here — I’ll address the training issues in more detail in a future post. But the short version is this: We don’t spend a ton of time training students to do the things that actually seem to make them better therapists (“better” here meaning more effective). Miller cited a vast literature identifying deliberate practice — not just more hours seeing clients, but significant time focused on reviewing weaknesses in those sessions while not actively in them and then taking action to address those weaknesses — as the key task in making people more effective. What I hear in my therapy-teacher framework: We need to be doing a lot more videotaping.

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Your comments are welcome. You can post them in the comments below, by email to ben[at]bencaldwell[dot]com, or on my Twitter feed.

Announcing the Self-Injury Institute

KISI logo, (c) 2013 Kahn Institute for Self-Injury, used by permission. Any external use requires separate permission.Non-suicidal self-injury is newly in the DSM-5, which is a welcome change reflecting a new scientific understanding of the phenomenon. It just isn’t where you might expect it, as I wrote last week on the new blog for my friend and colleague Angela Kahn’s new institute: The Self-Injury Institute.

I’ve been lamenting over the past few months that as the dynamic first-generation leaders in the family therapy profession have been passing on, there really haven’t been loud, passionate voices ready to take their places. Kahn, however, is just such a voice. She offers a full-throated defense of family-based treatment for most cases of self-injury. The crowded rooms and warm receptions she has received at conferences put on by NAMI, AAMFT-CA, and AAMFT show just how much of a hunger there is for her work and her insight.

Based in Los Angeles, SII was born partly out of necessity. There are few places in the country specializing in self-injury treatment, and few if any of them seem to offer what Kahn does: An understanding and treatment of self-injury based in family dynamics. As word of her family-based treatment has spread, she has found herself with more clients than she can take on — and no one who provides similar local services who she could refer clients to.

The Institute is starting with trainings and treatment. KISI offers family-based, outpatient therapy for self-injury through Kahn and several registered MFT interns. The first official KISI training for mental health professionals will be July 12 in Los Angeles, with Kahn herself as the instructor. Complete information and registration is at

In the interest of full disclosure, I’ve been assisting the Institute in getting started, and hold the title of Fellow there. But it’s a volunteer role, and I would be happily cheering SII on even if I weren’t directly involved. This institute will be great for the family therapy profession, and more importantly, for the many families struggling with self-harm who have spent far too much time with diagnoses that don’t really match their problems, and in treatments that, far too often, don’t work.

Welcome to the world, SII. We need you.

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Your comments are welcomed. You can post them in the comments below, or email me at ben[at]bencaldwell[dot]com.

Blogging the AAMFT Conference

I’m headed to Sacramento on Thursday for this year’s AAMFT Annual Conference, where leaders in the field from around the world gather to share clinical and research insights. It’s a great event every year, and with plenary presentations from Bruce Kuehl, Richard Schwartz, Susan Johnson, and Dorothy Becvar, this year promises to be outstanding.

I’ll be posting as frequently as I can while I’m there; you can also tune into my Twitter feed (@benjamincaldwel) for additional — if very brief — commentary.