As some of you probably noticed from my posts on Facebook, I spent the first half of August in the hospital, where I went through two life-saving surgeries. Unfortunately, the second one was caused by a serious medical error committed during the first one.
In this way, I was given an opportunity to personally and painfully experience something I had been aware of for a long time: treatments do not deliver themselves, they are always delivered by specific people in specific circumstances. The value of any intervention and medical procedure depends on who performs it and not on how it scored in randomized controlled trials. Anything can be screwed up, my friends. This is the difference between theory and practice. This applies to somatic medicine as well as psychotherapy.
Unfortunately, in the case of psychotherapy, some seemingly intelligent people ignore this obvious fact and fight against standardization of training, certification and against controlled access to clients. The price is to be paid by clients and their relatives.
This article is my personal account of psychotherapy training and was inspired by the recent events.
How does it really go with the quality and safety of psychotherapy?
All in all, pretty well. But while overall data on the effectiveness of psychotherapy are positive, the fact is that on the average only 60 percent of patients in randomized controlled trials show clinical improvement and about 10 percent deteriorate during the treatment. According to a recent study, 43 percent of psychotherapy clients report unwanted side effects. So, there is plenty of room for the improvement of our results and for caution.
What’s more important, research on psychotherapy shows that in terms of effectiveness, individual differences between therapists are much more significant than the methods they use. Fifteen percent of the most effective therapists systematically achieve twice as good results as the rest of their colleagues. Their extraordinary performance does not depend on the therapeutic approach they use.
On the other hand, clients of the fifteen percent of the worst therapists do not improve at all or their mental health worsens during the treatment, also independently of the applied approach.
So, whereas there might be better or poorer chosen interventions, there are for sure good and bad therapists.
How to maintain clients’ safety?
First of all, by securing a high standard of training and the delivery of treatments. It can’t be done without certification and without an ongoing monitoring of the training progress.
The majority of psychotherapeutic schools seem to understand that. Acceptance and Commitment Therapy is an exception in the field.
The lack of training standardization and certification in ACT is thought to help build Association for Contextual Behavioral Science as a non-hierarchical community.
To be honest, I never really understood the idea. Yes, I can agree that certification may lead to economic exploitation and exclusiveness. Yet there are ways to prevent and counter human greed.
But how about the idea of “non-hierarchical community” itself? Look at these two words – they exclude each other. Hierarchy is an intrinsic property of any community. It’s namely the hierarchy that creates any social structure. I think that from the evolutionary point of view we had to look back to the level of bacteria to find non-hierarchical colonies.
So, as it is obvious to me that any human organization and community has its own (formal or informal) hierarchy, the question remains: “What is the hierarchy based on and whom does it serve?” In my view, any hierarchy of an organization whose aim is to serve clients must be based on the level of clinical competence of its members.
How to become an effective and safe therapist?
The answer is complex, as it requires answering a more fundamental question: What makes some therapists extraordinarily effective? One thing is for sure – not a protocol and not techniques.
You can become an effective therapist neither through participating in workshops or conferences, nor through reading books or attending academic lectures. Research clearly indicates two key components of an effective psychotherapy training:
- Intentional and systematic practicing of specific skills, combined with continuous feedback (called deliberate practice);
- Mentoring – a stable and secure supervisory relationship with a more experienced colleague who offers support, provides precise feedback and motivates you to take up new challenges. In other words, a master-student relationship.
By the way, do you know about any systematic ACT training that contains these two key components? If so, let me know. I’m certainly aware of such training programs, but within other therapeutic schools.
Who might be your teacher?
The simple truth is that a clinician can learn practical skills only from another clinician. More precisely, only from someone who treats the same conditions and the same populations.
You can’t learn psychotherapy from people who live off book writing, workshops or research grants. It would be like learning to paint from an art historian.
What do I value most in my own development as a therapist?
Well, I’m a flesh and blood clinician. My over 30-year-long professional career consists primarily of direct clinical work with clients in mental health care. But there’s a bit more to it.
In 2013-2017, I presented my work at 11 international conferences in 8 different countries. During that time, I participated also in panel debates with some prominent researchers.
After earning my university degree in psychology, I have additionally completed a 5-year post-graduate training program to become a licensed specialist in clinical psychology. Having the psychodynamic background, I was subsequently trained in Cognitive Behavior Therapy, Dialectic Behavior Therapy (DBT), Motivational Interviewing and a couple of other things. I became also one of the few ACBS peer-reviewed ACT trainers, after a long and tough learning process. I have completed tens of different professional courses. And you know what? I do not view all this as my most valuable references.
What I really value in my background are years of experience in working with multidisciplinary teams in public hospitals. Each of my clinical decisions must be professionally justified and is subject to scrutiny. Every conclusion is continuously confronted with the views of people representing various professions and different theoretical approaches. Results of my work are constantly evaluated by those whom I serve and by their relatives. It teaches humility, self-discipline and self-reflection – the three pillars of the therapist’s professional development.
If you aspire to become an excellent therapist, make yourself open and available to an independent scrutiny and feedback. Do not lock yourself within closed societies of mutual admiration. It might be pleasant, but it’s a trap that leads to stagnation.
What psychotherapy is and what it isn’t?
The existential and ideological crisis looming over Western societies drives some people to treat psychotherapy as a substitute for religion. But when psychotherapy becomes a personal religion, a “way of living”, it begins to cast a shadow that all ideologies have always cast. The shadow is fanaticism, which means psychological inflexibility.
Where do you place your therapeutic allegiance?
As a young boy, I was fascinated by the life story of Miyamoto Musashi – a Japanese swordsman who lived in the 17th century.
Musashi won his first duel with a samurai when he was only 13 years old. At the age of 15, he went on the journey through Japan looking for swordsmen from whom he could learn new fighting techniques. During the wandering, he fought numerous duels and finally developed his own fighting style.
In feudal Japan, Musashi belonged to the caste of free people and for many years he did not serve anyone but himself. However, according to his life story, at the age of 32 he entered the service of one of the Shoguns and voluntarily pledged allegiance to his family, fighting on their side.
The story of the life of Musashi reminds me of the path of professional development of a typical therapist. We begin our career as a journey in search for inspiration and wisdom, and during this journey we work on developing our unique therapeutic style and identity. But at some point of that path we must decide who we want to pledge our allegiance to: the theoretical model/approach, our clients or something/someone else.
This choice is very important and impacts the rest of our career, the way we relate to our clients and to our profession. So choose wisely, because as the Bible says: “No one can serve two masters. Either you will hate the one and love the other, or you will be devoted to the one and despise the other. You cannot serve both…” (Matthew 6:24)
My personal message
The situation in which you look at your own life as a possibly closed chapter is a special experience. From this perspective all priorities and goals are viewed differently. And so are all worries, too. This is a perspective from which all personal and professional compromises begin to look ridiculous and pathetic. No, I did not have a near-death experience. To the contrary, I had a near-life experience.
Be bold my friends, be yourselves and never trade your integrity and standards for being groomed by anyone. In your private lives, care about those who care about you. In our professional lives we will always be surrounded both by jerks and by decent people. Sort the ones from others. Our time on this planet is too precious to waste it on jerks: either by giving in to them or by fighting them. And if you feel like the water in the tank is getting silted, consider moving to the ocean. There is plenty of room there.
Life is short and unpredictable. Never postpone it for later. Most people have an irrational belief that “this can’t happen to them”. Everything can happen to anyone and there may be no “later”.
My next article will be on the Multidimensional Model of Change – a client-centered, meta-theoretical conceptual framework for structuring therapy. The model allowed our team to integrate Acceptance and Commitment Therapy with the work of British psychologist Paul Gilbert. I was literally taken to hospital from the desk at which I was working on the article. The work will continue when I’m ready. Stay attuned.
- Bible (preferably whole)
- Castonguay, L. G., & Hill, C. E. (2017). How and why are some therapists better than others?: Understanding therapist effects. American Psychological Association.
- Rousmaniere, T., Goodyear, R. K., Miller, S. D., & Wampold, B. E. (Eds.). (2017). The cycle of excellence: Using deliberate practice to improve supervision and training. John Wiley & Sons.
- Schermuly-Haupt, M. L., Linden, M., & Rush, A. J. (2018). Unwanted Events and Side Effects in Cognitive Behavior Therapy. Cognitive Therapy and Research, 42(3), 219-229.
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