A Longitudinal Analysis of the Performance of Evidence-Based Therapists

Do professionals become more effective at their jobs with experience? Although we tend to assume more experienced professionals are more effective, research has not consistently found this to be the case in medicine and in psychotherapy (e.g., Burns & Wholey, 1991; Flood, Scott, Ewy, & Forrest Jr, 1982; Okiishi, Lambert, Nielsen, & Ogles, 2003; Wampold & Brown, 2005). Most research to date examining this question, however, has used a cross-sectional design (e.g., Budge et al., 2013; Okiishi et al., 2003; Okiishi et al., 2006; Wampold & Brown, 2005), focusing on differences in the performance of groups of therapists with different levels of experience. To date, there have been only two longitudinal studies that investigated directly whether therapists improved with time and experience. Both of them collected data from therapists who had an average of less than five years of data in the dataset, and therapists included both individuals in training and licensed professionals (Goldberg, Babins-Wagner, et al., 2016; Goldberg, Rousmaniere, et al., 2016). Despite this, the study that had a clearer system of informative feedback suggested that therapists can improve with experience, whereas the other study did not. This dissertation will focus on evaluating whether evidence-based therapists in a private practice setting do, in fact, improve their performance on various patient outcomes with experience/time, as well as whether other elements of their practice (specifically, decision-support tools that represent ‘best practices’ in providing evidence-based care) improve over time. These questions will be evaluated across two studies.
Study 1 is a single-therapist case study, in which we analyze trajectories of change for one therapist who has collected session-by-session data in her private practice across 39 years. Study 1 is idiographic in nature. We are particularly interested in whether a therapist who has collected data since her first year as a licensed clinician and has dedicated her career to evidence-based practice has experienced improvement in outcomes over time. Measurements of improvement in patient outcomes include changes in degree of improvement on standardized outcome measures, efficiency (speed) of achieving desired outcomes, and changes in the reported quality of her terminations. Measurements of improvement in elements of her practice include changes in the consistency of using decision-support tools—including plotting patient therapy outcomes, writing treatment goals, creating case conceptualizations—and facilitating collaborative terminations. We are also looking at whether the therapist’s caseload and the number and intensity of her personal and professional life events during a given year predicted her patients’ outcomes during that year. Finally, we will examine whether her ability to use decision-support tools effectively and to prevent life events from negatively impacting her patient outcomes improves with experience. Results of Study 1 will be used to inform Study 2.
Study 2 will consist of data from up to 16 therapists in private practice and 674 of their patients who, at some point between 1995-2007, worked at the San Francisco Bay Area Center for Cognitive Therapy. Study 2 will build off of Study 1 by examining whether patterns of change tied to patient outcomes seen in Study 1 generalize to other therapists at the center or whether specific groups of therapists show different patterns of change.
Given the small sample, we cannot make conclusions on whether results of Studies 1 and 2 will generalize to broader groups of therapists and psychotherapy settings. Results of this dissertation, however, highlight the value of an idiographic approach to: (a) examine whether a therapist becomes more effective at reducing patient symptoms and achieving collaborative terminations with time and experience (providing a model that can be used for other therapists and in settings where clinics want to understand trajectories of change for their providers), (b) examine improvement over time in therapeutic practices; specifically, use of decision-support tools, (c) evaluate other factors that may influence patient outcomes, including therapist life events and characteristics of the therapist caseload, and e) consider how therapists’ effective use of certain factors or ability to cope with events, such as decision-support tools and life events, respectively, might improve with time. Together, these results will enhance understanding of what factors may affect therapist effectiveness in real-world settings across the course of therapists’ careers.