How can we define expertise or mastery in the practice of psychotherapy? It seems to me that this can only be measured by the outcomes we are able to achieve. Here, I am referring not just to quantitative outcome – like a shift on the Beck Depression inventory – but real clinical change that makes a significant difference in the life of the patient. The quality of change is extremely important. David Malan, one of the first dynamic therapists to study outcome and conduct in depth follow up interviews with patients, found that paper and pencil inventories were woefully insufficient in capturing the qualitative changes in the patient’s subjective experience. He has argued that the quality of the patient’s well being and relationships can only be captured by an in depth interview, in which specific examples of reported change are obtained.
In order to track my own process and outcome, I videotape all my sessions and conduct follow up at 1, 5, and 10 years (I now have some 20-30 year follow up data!). We can only see what we see and hear what we hear at any given moment. Having the videotape to review, when we are under no pressure to respond to patients, gives us another chance to observe and understand the patient, as well as detecting errors or blind spots that become apparent on second view. Having others view the tape, whether for supervision and consultation or teaching, adds value to this practice.
Patients are our best supervisors and give us valuable feedback. Again, I find specific verbal feedback more helpful than data from paper and pencil tests. This is done continually throughout treatment. In addition, by conducting follow up, I can assess whether change lasts and growth continues to expand, or there are reversals. Discovering what kind of patients I do well with and those groups with whom I struggle, gives me additional information I can use for my continued development.
I just finished a treatment this week with a patient who emphasized that it wasn’t just what we did together (though several specific processes were seen as extremely helpful), but who I am in my being that had such an impact on him. He said that he trusted me almost immediately – that I seemed solid, unflappable, and open to anything he had to reveal. He experienced me as someone with integrity and character, and felt my dedication was to him and his healing, rather than to any needs of my own. Over the years I have been struck by how common this kind of feedback has become. Patients report that being helped to face the feelings they had been avoiding was essential, but that it is who I am, and the kind of relationship that I offered them (one of collaboration and partnership), that was so important and impactful. This seems to be reflected in the literature on the supershrinks. They have a model of treatment they are passionate about and skillful in applying but are also flexible, approachable, genuine, responsive, and highly ambitious, challenging themselves and their patients to get the best results possible.
In many ways, I am my own control. I have been practicing dynamic psychotherapy for nearly 40 years. I was good but not great at the start, and became frustrated with my own lack of consistent results. I needed more than my original training provided – more than theory and more than offering interpretations. When I met Davanloo and trained in ISTDP, I was given the tools to intervene in a far more systematic and effective manner than ever before. The depth and breadth of change I was able to facilitate went up dramatically – and with a far wider spectrum of patients than I had previously been able to reach. Of course, I have also attended to my own development – am always reading, going to conferences and maintain my self care – but it was finding a highly effective method that I was passionate about that really increased my effectiveness. I was motivated to become an expert and do the best work I could possible do.
As a teacher and supervisor I am aware that I can teach theory and technique but can’t teach character. I can’t teach integrity or tolerance of complexity and uncertainty. I can’t teach emotional attunement or courage in the face of anxiety and pain. However, these are qualities I can model and can help develop in trainees over time. So teaching and development are different. I feel strongly that we have neglected the personal development of the therapist to our peril. It’s not enough to teach skills but to develop people. We are the instrument and the vehicle of transmission of the treatment and, as such, we must be “in tune” to be effective. You can do skill exercises all day long, but if you don’t when to employ those skills in a particular case or how to do so with caring, it will fall flat, if not back fire all together. It’s complex.
Perhaps this is all in the way of saying that expertise is a life long endeavor. There are no short cuts to mastery. We know that the best therapists spend 7 times the amount of time as their average colleague learning, reflecting and developing their abilities between sessions. Is it time alone that makes the difference? I think not. Only those with passion and persistence are willing to devote that kind of time to their own development. So, again, it’s a complex mix of desire, passion, hard work, willingness to put in the time, to get feedback and to continue to grow that yields expertise.
We don’t seem to be very accurate in our own self assessment, so working alone and failing to get supervision is a huge hindrance to the development of expertise. Research has revealed that therapists whose outcomes fall in the lowest quarter rate themselves as being in the top quarter. Without feedback, we can be seriously off the track. Of interest, the top performers see themselves as good and competent but not great. They are humble and always want to do better. So our own inflated sense of ourselves, complacency and self satisfaction can be a huge hindrance. Paradoxically if someone thinks he is a master, they are probably not! Similarly if we idealize a method and cling to it rigidly, rather than applying it flexibly, we will hinder our own development and undermine treatment effectiveness.
By reading widely and often, we can keep ourselves abreast of the latest developments in the field. In addition to reading psychotherapy journals and books each month, I also read about adult development and have been heavily influenced by people like Robert Kegan. In particular, his emphasis on the importance on the necessity of moving beyond the first stage of adult development (socialized mind) to that of self authorship is really a pre-requisite to the masterful application of psychotherapeutic techniques. Again, if we only teach theory and technique and don’t develop ways to help trainees move into the stage of self authorship, they won’t be able to become experts.
The literature on leadership has also germane to the topic of expertise in psychotherapy. Last summer I attended a week long workshop on leadership with Bob Anderson. His contention that the inner game always runs the outer game, is as true for therapists as it is for business leaders. Self reflection and self development are essential to the development of expertise.
In addition to the scholarly reading already mentioned, an immersion in the arts often facilitates the development of us as human beings. While I have no data to confirm this, I notice that most experts in psychotherapy read literature, attend the theater, watch films, and explore their own creativity. Most experts are geeks and polymaths – they are interested in lots of things. My interest in quantum physics, neuroscience and spirituality, as well as the arts, adds to my own complexity and enriches my work with patients. In the end, experts develop superior meta-cognitive skills and tolerate both complexity and uncertainty. Atul Gawande, the remarkable surgeon and writer, speaks to this in his article entilted “Failure and Rescue”. His writing has been a constant source of information and inspiration.
Expertise is a life long quest and requires continual development of both who we are and what we do. In fact, this was the thesis of my most recent book, Maximizing Effectiveness in Dynamic Psychotherapy!
Dr. Coughlin is on the forefront of clinical research into therapeutic change. Intensive Short-Term Dynamic Psychotherapy (ISDTP) is a scientifically validated method of psychotherapy which dramatically accelerates the process of change, so that patients see measurable results within weeks and months, rather than years.