What makes a better therapist?: an investigation of therapist development with beginning, intermediate and advanced therapists using an expert performance approach

The aim of this project as a whole, including the literature review, was to further understand the nature of the “empirically supported psychotherapist”. The literature review presents clear evidence that some therapists are more effective than others, and highlights the current lack of understanding about what accounts for the differences between therapists. Findings that particular therapist variables (e.g., professional experience, degree completed) do not necessarily lead to improved client outcomes are perplexing and point to the need for new paradigms. The expert performance framework is then introduced as a hitherto largely unexplored yet potentially useful paradigm for investigating questions about therapist effectiveness. Drawing on the expert performance framework, a theoretical model to explain the acquisition of therapeutic expertise is developed. Within this model, it is assumed that optimal therapist development is captured by four interrelated domains: Motivation and Sustained Interest; Expert Performance; Effective Practice; and Developmental Influences. It is also assumed that optimal therapist development facilitates becoming (and remaining) a more effective therapist. Building on these conceptual underpinnings, the empirical component of the thesis examines the contexts and processes that support optimal therapist development. A cross sectional research design with retrospective interviews was used and therapists at three points in the career were recruited (beginning, middle, later). An attempt was also made to identify better performing therapists within each cohort using a combination of peer-nomination and literature-based indicators of effective practice and expert performance. The final sample comprised 23 therapists: 6 beginners (< 5 years’ experience), 6 intermediate therapists (7 – 10 years’ experience), and 11 advanced therapists (> 15 years experience). All therapists participated in a 90-minute interview about their practice and development. Interviews were audio-recorded and manually transcribed by the researcher. Thematic analysis comprised four separate inductive analyses, one for each of the domains in the theoretical model, and then a deductive/inductive analysis that integrated the findings across the domains. To facilitate trustworthiness, a codebook was developed and the integrated findings were refined though member checks. A model describing six phases of optimal therapist development was presented. This model considers the influence of early family environment and pre-formal training experience as precursors to (but not determinants of) therapist performance. The first key finding was that the concept of domain-specific learning (i.e., exposure and learning that directly supports clinical practice) may be a more precise measure of therapist performance than crude proxies, such as years of experience or degree completed. The other key finding was that therapist discernment (comprising a cycle of ongoing reflection, deepening self-awareness, and strategic decision-making) appears essential to optimal therapist development. The role of an individual, ongoing supervision relationship to support therapist discernment, and by implication, the delivery of effective practice, was also highlighted. Limitations associated with the small number of therapists interviewed, the broad scope of the study, and the method for selecting therapists mean that the present findings are best viewed tentatively and require validation in future research.Thesis accepted in satisfaction of the requirements for the degree of Master of Psychology (Counselling) / Doctor of Philosophy