How Do We Become Better Therapists? Psychotherapy Debate with Bruce Wampold and Peter Fonagy

“How do we become better therapists?” That was one of the main questions being asked during the debate between Peter Fonagy and Dr. Bruce Wampold at the Nordic Conference for Mental Health, which is held every year in Stavanger, Norway. The two psychotherapists were invited to discuss four themes related to the current state of psychotherapy research and where we may head in the future. Some of the topics discussed included:

• Are some psychological treatments more effective than others?
• How do we become better therapists?
• How do we build better psychotherapy services?
• What is the future of psychotherapy research?

The debate was moderated by Dr. Jon F Bjaastad who is a doctor of psychology. Below is an edited transcription of the 40-minute discussion.

Are Some Psychological Treatments More Effective Than Others?

Both men agreed that while some psychotherapies work, others do not. “Is there an importance of figuring out our responsibility to our patient – what works and for whom?” Peter Fonagy explained. “The answer to that is an absolute and unequivocal yes and I would consider any attempt to hinder that process to be both unethical and unacceptable intellectually.”

Dr. Bruce Wampold agreed that there are some that are more effective than others. However, he raised an interesting question: How is it that we keep developing new therapies and the outcomes we get with patients really have not improved over time? “What really makes a difference is the therapist,” he remarked. “There are some really good cognitive behaviour therapists who do a great job. And I’m not talking about they look good if you observe them, I mean they actually achieve good outcomes with their patients. But there are some very poor cognitive behaviour therapists. Same with dynamic therapists and emotion-focused therapists. The key to success is that some therapists have the skills to help the patients, regardless of the treatment. The continued focus on treatment really puts the spotlight in the wrong place. It’s us, therapist, who make therapy work.”

Bruce went on to boldly state that “every understanding of a disorder that we have is wrong...We will find out in 10 or 15 or 20 years, every explanation you have will be supplanted by a new one, not necessarily a true one. What’s really important is that the patient accepts the explanation, whether it is evidence based or not, and that it leads to the patient to do something to overcome their difficulties and I agree with Peter that it is usually around the social world. People come to treatment very much for their disrupted social world.”

How Do We Become Better Therapists?

“This is an area that really interests me because the fact of the matter is it’s really difficult to become a better therapist,” Bruce said. “We go into a room by ourselves, we have confidential conversations, we really can’t talk to many people about what happens. Maybe we have consultation and supervision. In the US, once you are certified or licensed, it’s no longer required to get any consultation or supervision. We don’t get feedback about what we do.”

“We just published a study where we looked at therapist outcomes over 18 years and it’s really distressing to find that on average, therapists get less effective as they gain experience,” Bruce continued. “We can’t tolerate that. We need to improve our skills….I used to think you need to know yourself better, you need to have more experience, see different kinds of patients,” Bruce explained. “I have come to the point where we need to practice the skills that we know are employed by more effective therapists.”

Peter countered by saying, “Until we put into place supervision that’s based on actual clinical material...it’s probably not very useful. You want to watch yourself work and watch yourself work with another person.”

What Makes A Good Therapist?

Bruce referenced Tim Anderson’s facilitative interpersonal skills (FIS), who found out that effective therapists, defined as the ones who have better outcomes, tended to rate higher than others in certain interpersonal skills.“Verbal fluency, ability to be warm and accepting even with a difficult or challenging patient, empathy, the ability to form a good collaborative working relationship across a range of patients, the ability to explain what we are doing therapy in a cogent way - those are the skills that make effective therapists,” he explained. He went on to say that practice outside of therapy was the only way to improve these certain skills. “Pablo Casals, the famous cellist, was asked, “Why do you practice five hours a day in your 80s? Because I think I am getting better.”

Peter agreed that practice was important and noted that practicing on camera is a great way to identify what is being done well and what needs improvement. He explained that incorporating video into training was something being used in England. “One thing that we introduced in the UK as part of the improved access psychological therapies program that I was overseeing, for children and young people, was a compulsory part of training where people had to be videod and the supervision had to be of a videod interaction between them and the patient,” he said. “As soon as you see yourself practicing and see yourself doing, you notice things that you’re not aware of, you notice things that you do. You really want to watch yourself work and watch yourself with another person.”

How Do We Build Better Psychotherapy Services?

When it comes to building better services, both Peter and Bruce agreed one of the biggest issues faced in many countries is the lack of accessibility. “Access to care is the biggest issue,” Bruce said, “In epidemiological studies in the United States, 50% of the people who have a DSM disorder in a given year don’t get any treatment at all. So we need to expand the services? In the US it’s not as big as an issue as who pays for the service.” Despite alarming numbers that show therapists aren’t getting better, Bruce reminded the audience that, for the most part, therapists of a variety of different orientations or methods, get very commendable outcomes. “So on the whole, we are doing a damn good job at helping patients,” he said. “What we find when we look at that data a little closer, is that there is a bottom 10 or 15% of therapists whose outcomes need to improve. We could improve the quality of service by excluding those 15% or helping them improve. That would be in the population level, resulting in a significant improvement in the recovery rate of people we see.”

What Is The Future of Psychotherapy Services?

When asked about the future of psychotherapy, Bruce said that there is a ton of research to be done that will completely change what we now know about psychotherapy. “Ten years from now, 95% of what we know about therapy will be new. We don’t know very much about what makes psychotherapy effective,” Bruce said. “If I had money to fund the research grants for the future, I would quit funding comparisons between two treatments. We spend in the United States, $100 million or more over the course of a few years comparing two treatments to find out that they both work equally well and better than no treatment at all...Let’s study therapists. What makes an effective therapist? What do therapists that consistently have better outcomes do? We are starting to answer this question, but there is more work to do there.”

Peter countered with the statement, “Even before that we need treatments that address separately the general aspects of psychopathology and the more symptom-specific aspects of psychopathology. That is research we can do now.”