Sunday, April 28, 2013

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


  1. Excellent article, Kate! I have a niece who has had very poor results with therapists and is in dire need of a good one for her anxiety disorders. I am going to discuss this with her.

    Marie Copeland

  2. Unfortunately, that is likely the case for many people who eventually give up hope and believe that "therapy" just doesn't work for them. I hope this helps your niece and many other people make better informed decisions about how anxiety can be very effectively treated.

  3. Is comparing a therapists treatment methods and a doctor's anitbiotics prescriptions an appropriate analogy? It seems one is based on theory and practices still be researched, while the other is based on chemistry and data collected with objective outcomes. Maybe I am ignorant to the subject, but I thought a therapist's treatment methods are catered to what the therapist is able to do best. From that standpoint, the patient decides if what the therapist does best is going to help them prior to, or early on in therapy. Again, I may not be educated enough on the topic, but I'd love to learn.

    P.S. I miss you!

    Jon Farm

  4. Hey Jon, I appreciate the comment. The question of whether the therapist-physician analogy is appropriate is really based on your perception of mental illness as a disease or not. Outside of the analogy, the study I review here very specifically speaks of individuals who sought treatment for diagnosed anxiety disorders, and the study examined what predicted their symptoms of anxiety alleviating over time. The finding is very clear that therapists who were competent in CBT skills had patients whose presenting problem got better over time. The trouble is that many people with anxiety are not as educated about what treatments are most effective for their disorder and end up staying with a therapist regardless of their symptoms improving. This, again using the questionable analogy, would be the equivalent of a physician treating an infection with fish oil pills instead of antibiotics because they are an expert on fish oil remedies. Most people, due to popular media, would be able to make an educated decision about whether that doctor was the right fit for them, but with psychiatric illnesses, people are less informed about what treatments have been tested and have evidence that they are effective. So this article tries to disseminate that message.

  5. But if competence is defined as having more training during grad school and,I assume, that training does not really require adherence to CBT manual (otherwise the young therapists naturally would follow the manual) then “more training” of inexperienced therapists should be equivalent to “more experience” of seasoned therapists. Please help me figure out this catch 22.

    Also, if more experienced therapists had poorer anxiety outcome but their patients improved in other areas – maybe the CBT manual for treating anxiety is the problem?

  6. I think I see where the confusion is here. Training was never measured in this study, only competence in CBT, adherence to the CBT protocol and patient anxiety symptoms. Competence in CBT was assessed by training researchers watching and coding more than a thousand hours of therapy sessions. The interpretation of their findings was where training came up. Specifically, that more experienced therapists were likely further away from their training which likely explained why more experienced therapists were less likely to have patients improve in their anxiety symptoms. So yes, you would hope that more training for inexperienced therapists would equate to years of training, but the results show that this is not true. Being competent in the core principles and skills of CBT has better patient outcomes while being an experienced therapist didn't.

    As for the second comment. It is entirely possible that the CBT manual is in some ways a problem. Some people have criticized manualized treatments as being too narrow for example. However, these manualized treatments are the most effective way of treating anxiety disorders like these people have. So again, the question is whether that is also the priority for the patient. A very interesting follow-up study for this would be to subjectively ask patients what their main goal in therapy. Your point would be very valid if the patients reported that they wanted to improve in an area outside of their anxiety.


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