Not getting better in therapy? Some reasons why.

As a therapist-in-training, I am often self-conscious about being younger than my patients expect me to be. I primarily work with children, so I am always worried that my patients’ parents will doubt my ability to help them (given that I am still in training and am unmarried and childless). However, whether being a new therapist results in less improvement for your patients is an empirical question. Luckily, Dr. Lily Brown from UCLA and her colleagues from around the country took the time to investigate this issue.

More specifically, these psychologists, psychiatrists and public health researchers were interested in what therapist characteristics predict improvement for patients with anxiety. Anxiety disorders, while debilitating for individuals who suffer from them, are very effectively treated with Cognitive Behavioral Therapy (CBT). CBT is a form of talk therapy that teaches patients skills for managing anxious thoughts and the behaviors that perpetuate those thoughts. In fact, CBT has been so effective for treating a range of anxiety disorders in a myriad of settings, that it is now the cornerstone of most training programs for new therapists. In the recently published investigation, the researchers assessed adherence to a CBT manual for treating anxiety, overall competence in CBT skills, and years of experience as a therapist for almost 200 therapists all over the country. To do this, they had expert clinicians and research assistants watch videotaped therapy sessions for more than 1,000 patients being treated for anxiety by these therapists to assess how closely they were following a CBT for anxiety manual and how competently they explained and taught the skills of CBT. They then looked at how adherence, competence, and experience related to their patients’ anxiety symptoms 6, 12, and 18 months after beginning treatment.

They found that adhering to the CBT manual was unrelated to patient improvement. This is great news for many practicing therapists who believe that strictly following therapy manuals depersonalizes the therapy experience. However, they did find that therapists with high competence in CBT had patients whose anxiety improved the most. They also found that years of experience as a therapist was negatively related to patient improvement. In other words, the least experienced therapists had the best patient outcomes. But what does that mean? Taken together with the finding that more competence in CBT results in better patient outcomes, novice therapists having better patient outcomes is likely a reflection of these young therapists having more training in CBT during graduate school and having been through that training more recently. There are two factors at play here, both doing a disservice to patients. First, depending on when and where the therapist went to school, they may have never been trained in CBT at all. Second, many therapists’ practice evolves over time, usually moving away from the core components of a therapy’s effectiveness, which is often referred to as therapist drift.

Regardless of how it happens, the important issue is how to make sure that you are getting the most effective therapy available. Unfortunately, most people don’t know how to evaluate the effectiveness of a therapist. Instead, people choose their therapist based on other factors, such as convenience and whether they “connect” with or like a therapist. While these may seem important, the evidence suggests that whether you and your therapist like each other won’t make a difference in whether your anxiety improves over time. Just like whether you like your physician won’t impact how effective his prescribed antibiotics are for your infection. What matters is whether your therapist is trained in the most effective method of treating what you would like to have treated, and how well they have maintained those skills since that training. "But Kate, how am I supposed to find out about your therapist’s training?" "Just ask!" Recently, Harriet Brown of the New York Times wrote an article discussing this very issue and included some very helpful questions to ask when shopping for a therapist (“Looking for evidence that therapy works” Click here to access this article).

It should be noted that this study only looked at patients with anxiety, so their findings on patient improvement may not necessarily apply to patients with other psychiatric disorders, such as depression. However, CBT is still considered the most effective form of talk therapy for most psychiatric disorders and is certainly the intervention with the most empirical support to date. It is also important to keep in mind that anxiety symptoms were the only outcome measure in the study, even though people go to therapy for many reasons. It is very likely that while more experienced therapists had poorer anxiety outcomes over time, their patients improved in other areas, like self-esteem or relationship quality, which cannot be discounted as long as these gains are what the patient wanted. The problem arises when patients are interested in treating their anxiety, which never improves as a consequence of limitations to the therapists’ skills. Every patient should be able to choose what they spend their time and money on in therapy, and we all deserve to be well-informed when making that choice.

Brown, L. A., Craske, M. G., Glenn, D. E., Stein, M. B., Sullivan, G., Sherbourne, C., ... & Rose, R. D. (2013). CBT Competence in Novice Therapists Improves Anxiety Outcomes. Depression and anxiety, 30(2), 97-115