Tuesday, April 3, 2018

Four Articles for Newcomers

By David S. Prescott, LICSW

Recent discussions in a number of venues have involved which studies and other published papers are essential for people treating clients who have abused. Each offering has been useful, from the basics in risk, need, and responsivity to effective self-care and an understanding of how early adversity influences the lives and treatment of those who abuse. Each of these areas is vital.

Following on previous writings with Gwenda Willis (for example, our only partially tongue-in-cheek call for a “who works doctrine”), it has long seemed to me that our field has overlooked some basics, and that the evidence for these basics has been around for decades. Research continues to find that there is a greater difference between therapists practicing within various methods and models than there is between the methods and models themselves (Wampold & Imel, 2015).

In 2005, Bill Marshall summarized research both in and outside the field of treating sexual violence to ask what qualities make up an exceptional therapist. The four qualities at the center of his analysis, being warm, empathic, rewarding, and directive (guiding and moving the treatment process forward), seem incredibly simple at first. In fact, these four qualities have even produced the acronym WERD, which many practitioners try to live by. Critics have noted that this paper relies on studies outside the field of treating abuse, and yet a recent blog post has highlighted the work of Brandy Blasko and Faye Taxman, who have found that even probation officers who adhere to similar principles have clients who are less likely to return to prison.

Of course, many (likely most) professionals do not view themselves as in need of assistance becoming more “WERD”. Discussions within social media often focus more on scoring items on actuarial measures and what the rules for registration are in various jurisdictions are typically more common than questions about developing these qualities. As research has shown, however, professionals both within and outside our field can overestimate their abilities in a phenomenon known as self-assessment bias.

In one of the most striking studies of self-assessment bias, Steven Walfish and his colleagues found that the average therapist rates themselves at the 80th percentile compared to their peers. 25% rated themselves at the 90th percentile and no one rated themselves below average. Although there are many possible implications of this study, it is entirely possible that one reason that fewer people seek to develop themselves in the above key areas of competency (warmth, empathy, being rewarding and directive) is that they already believe they are as good as or better than their peers in these areas.

The results of these studies beg further questions: If the working alliance and core competencies of effective therapists are so easy to over-estimate and so difficult to excel at meaningfully, are they really the basic skills that many people believe them to be? After years of listening to people who are learning to put collaborative approaches into practice, I’ve concluded that these skills are only “basic” when you are practicing one of them at a time. It’s when one tries to be warm, empathic, rewarding, and directive while staying aligned with what works for each client that these skills become much more advanced and difficult to master. What is the best way forward with this knowledge?

Enter Daryl Chow and his colleagues and their 2015 paper on deliberate practice. Their abstract puts it succinctly: therapist characteristics (e.g., years of experience, gender, age, profession, highest qualification, caseload, degree of theoretical integration) did not significantly predict client-reported outcomes. Consistent with the literature on expertise and expert performance, the amount of time spent targeted at improving therapeutic skills was a significant predictor of client outcomes. Further, highly effective therapists indicated requiring more effort in reviewing therapy recordings alone than did the rest of the cohort.

So what is the take-home message from these four studies?

·         Professionals are often not as effective as they want to believe, but they can become better.
·         This is not to say that average therapy is not good therapy; indeed, people entering treatment typically do considerably better than those who don’t.
·         The most effective therapists attend to the core competencies of therapy and work to improve themselves in these and related areas.
·         Contrary to the practices and beliefs of many professionals, attention to the fundamentals of the working alliance apply to virtually all professionals involved in treating and supervising people who have abused.

If you’re an old master, this all means you can still get better. If you’re a newcomer, it means that many of the skills out there for learning will help you in many areas of your life. I hope you stick around!

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