An Investigation into the Effectiveness Stasis

It isn’t enough to be right, you got to be effective – Neil deGrasse Tyson

The Recognition of a Fundamental Problem

One of the most significant experiences I had in a psychology class while debating the impact of social media in the modern world was to notice that the influence of a few can shape the thoughts of thousands who then become experts in opinions rather than knowledge. People learn by repetition, by accepting what sounds reasonable and fits their worldview. The complexity of intellectual discourse remains largely unpopular.

This observation became troubling when I recognized that within the field of psychotherapy research, the same phenomenon appears to occur and may be freezing progress.

I present here a case for the following thesis:

Advancing therapeutic effectiveness requires simultaneous transformation across multiple system levels: individual therapist development, training program design, professional education standards, and research paradigms.

The Linear Accumulation Model and Its Failures

The traditional conception of psychotherapy improvement presupposes what I term a linear accumulation model—the assumption that formal training, supervised experience, continuing education, personal therapy, and years of practice naturally culminate in enhanced therapeutic effectiveness. This presupposition constitutes an obstacle to progress and is demonstrably false (Goldberg, Rousmaniere, et al., 2016).

The evidence reveals a paradox: a therapist is most likely to be at their peak effectiveness before they even graduate from psychology training (Anderson et al., 2009). When we combine these findings, a disturbing pattern emerges.

Therapists appear to decrease their effectiveness with experience, and some demonstrate inferior performance after completing formal therapeutic training compared to their pre-training capacity when attending to clients without formal psychological education.

The question naturally arises: Why does this occur?

Therapeutic Power

The research indicates that therapeutic effectiveness derives much more from interpersonal skills (Anderson et al., 2009) rather than adherence to scientific models. The evidence points toward responsiveness to present-moment needs rather than specific techniques, components, and adherence to psychotherapy protocols and models (Webb et al., 2010).

A striking finding emerges from the longitudinal analysis of therapeutic effectiveness: the effect size of an average psychotherapy intervention in 1970 was d = 0.8 standard deviation points. Currently, it remains approximately the same effect size. While we have evolved significantly in other attributes—efficiency, durability of effects, expansion to new conditions, and accessibility (Laska et al., 2014)—the core therapeutic power has remained static.

This represents what I call the effectiveness stasis. We continue studying and attempting more of the same approaches in order to evolve, yet our scientific endeavor has not overcome deeply rooted premises and epistemological tensions that have become limiting factors.

The need for a broader transition in the field from outcome-focused research to more nuanced examination of the therapeutic process itself, advocated by influential researchers like Goldfried and Castonguay (1993), becomes increasingly urgent. After nearly three decades, this recommendation persists in the most recent Bergin & Garfield Handbook of Psychotherapy and Behavior Change 7th edition (2021). Science progresses slowly, as changing habits of entire cultures requires generations to shift paradigms.

My Personal Investigation: The Quest for Understanding

As I intended to become what the field terms a “supershrink,” I embarked on an investigation to understand what distinguishes the most effective practitioners. For me, Carl Rogers, Fyodor Dostoievsky, and Carl Gustav Jung represented those who could reach the greatest distances regarding the knowledge of human behavior. However, I could not rely on words alone.

My mind operates with a certain insecurity, feeling vulnerable to being caught off guard intellectually. Therefore, my skills must be grounded in what I consider “undisputable” evidence (acknowledging the tension this creates with my scientific stance). This compelled me to ground myself as thoroughly as possible in high-quality scientific evidence, however uninspiring the process might be.

Rigorous science may lack the inspirational quality of my three intellectual heroes, but it constitutes the accepted language for communicating among peers and learning collectively about reality. I believe science both constrains and liberates us. Knowledge exists beyond its current frontiers, already in use, but not yet understood sufficiently to be operationalized systematically.

This perspective leads me to consider scientists as a form of intellectual heroes. The task of maintaining objectivity presents extraordinary challenges. Yet science advances—imperfect and imprecise, but substantially more perfect and precise than any individual attempting to comprehend the Universe and Nature alone. (The capitalization reflects my religious orientation at core, though I maintain the skeptical mindset as well. I attempt to analyze the literature and interpret it as usefully and objectively as possible.)

The Systems Perspective: Insights from Software Development

After studying philosophy and working in software development, I developed an analytical framework that proved illuminating. Software development taught me to think systemically in ways that my structural engineering background could not provide.

Software creates an environment, much as therapeutic relationships create environments. Both allow for programming of components and debugging—the process of learning flows and data processing when defects occur. When debugging software, we investigate code systematically until we identify the source error that triggered our investigation.

During this process of traveling to the depths of the code, I naturally grasp the architecture of components that are not defective while pursuing the initial problem. I can improve these functioning elements with minimal effort because they already operate correctly, and I can always revert to previous versions. My increased experience reduces the effort required compared to building the original code.

This insight generated a profound realization: therapy operates analogously to debugging human experience. The core process involves not merely identifying the triggering error, but contemplating all elements encountered during the journey to the depths, which becomes a reflection of ourselves. In debugging, we provide a test environment to examine current behavior extensively without real-world consequences.

Reading Wampold’s Contextual Model alongside Plato’s Socratic dialogues and Robert Martin’s Clean Code principles created a convergence of understanding.

The Development of Situational Awareness

True expertise emerges from recursive cycles of breaking automaticity to develop more effective methods of reaching established goals. Situational awareness serves as the key to reliable progress in any domain one seeks to master.

Situational awareness means the ability to perceive, understand, and project the elements of your environment to make informed decisions and take appropriate actions. This requires paying attention as comprehensively as possible, avoiding the suppression of stimuli due to defensive reactions or threats. It necessitates maintaining psychological safety continuously—remaining defenseless, curious, and processing data input at the highest possible cognitive level.

The research concerning “supershrinks” reveals fascinating insights. It required time for clinical psychologists to discover the expertise research of Anders Ericsson (1947-2020) and apply his accumulated knowledge to the field of psychotherapy. The central insight follows:

A systematic method to trigger greater awareness and train specific skills that are components of a larger skill within the learning edge of an individual is what science can provide to facilitate excellency. We need to break automaticity of current levels of performance and automate another model, improved upon the prior, on how to execute a task. And we need a systemic way of doing this. That is deliberate practice in a nutshell.

The supershrinks in our field were individuals capable of executing this process naturally; now they can do so deliberately. The development of expertise in violin performance and psychotherapy share significant commonalities.

While the violinist trains angles and rhythms to improve overall musical quality, the therapist must train micro-components of the global skill of psychotherapy. How frequently do therapists examine not the structure of their theoretical model, but the specific structure of their own execution?

We must question our foundations regarding how we deliver sessions moment by moment: opening initial sessions, closing topics, managing typical challenges, handling transitions and endings, planning, negotiations, alliance ruptures and repairs, managing countertransference.

The approach requires sorting skills for training, integrating them into therapeutic delivery, accumulating data, and training each skill deliberately based on diagnostic data analysis.

The Challenge of Non-Clinical Development

The problem I encountered was that I am not yet a practicing therapist. While not permitted clinical experience, I must develop through alternative methods. I decided to organize psychotherapy research systematically for myself (and potentially others) to structure my thinking about the most important factors while designing how I would deliver therapy with all my individual characteristics.

Following Charlie Munger’s principle:

“Instead of pursuing brilliance, avoid stupidity.”

The obvious starting point: Therapeutic alliance represents the most critical factor to master initially. Through my investigation, I came to understand that active listening provides the optimal entry point for this development.

My current framework for understanding:

1. Therapeutic Alliance constitutes the primary foundational element requiring mastery, approached optimally through active listening
2. Cognitive Restructuring represents the most critical change mechanism proposed by the most influential therapy model globally, demonstrating effectiveness across multiple psychiatric disorders
3. Socratic questioning serves as the technique targeting cognitive restructuring, identified by experts as the core methodology of the CBT model
4. Effectiveness emerges not from adherence to protocols or mastery of specific techniques per se, but from the quality of relationship delivery

To accumulate knowledge systematically, I developed a framework enabling deep investigation of important topics while constructing evolving global models with interconnected components that could be integrated and linked.

My methodological tools consist of recursive inquiry into premises and an organized meta-system for data organization.

The Medical Model Inheritance Problem

Wampold’s foundational critique identified how the medical model’s influence created a fundamental category error in psychotherapy research. The presumption that psychological interventions operate analogously to pharmacological treatments necessitated searching for specific therapeutic ingredients that could be isolated, standardized, and prescribed for particular diagnostic conditions.

This paradigm generated decades of research attempting to establish treatment specificity—the notion that particular therapeutic approaches work through specific mechanisms for designated disorders.

However, the empirical evidence overwhelmingly contradicts this specificity hypothesis. Meta-analyses consistently demonstrate negligible differences between bona fide therapeutic approaches (Wampold et al., 2017). Studies examining therapist adherence to treatment protocols reveal no correlation between protocol fidelity and client outcomes (Webb, DeRubeis, & Barber, 2010). More significantly, expert ratings of therapist competence in delivering specific therapeutic ingredients show minimal relationship to actual treatment effectiveness.

This represents the classic example of searching for lost keys where illumination exists rather than where they actually fell.

The Contextual Model as Paradigmatic Alternative

I believe a contextual reconceptualization provides a meta-theoretical framework that transcends the limitations of both medical model thinking and common factors reductionism. The contextual model operates simultaneously across practical, theoretical, and ontological dimensions, recognizing psychotherapy as fundamentally a relational healing context rather than a technical intervention delivery system.

The model’s three pathways—the real relationship, outcome expectation creation, and healthy action promotion—function as a complex adaptive system where the therapist’s role involves orchestrating multiple therapeutic processes rather than implementing predetermined protocols. This requires what might be termed contextual intelligence—the capacity to navigate the inherent uncertainty and complexity of human change processes while maintaining therapeutic focus and direction.

The Professional Development Paradox

Perhaps the most concerning finding in psychotherapy research concerns the relationship between traditional professional development activities and therapeutic effectiveness. Despite substantial investments in graduate education, continuing education, supervision, and credentialing, none of these variables correlate meaningfully with client outcomes (Wampold & Owen, 2021).

More disturbing, longitudinal studies suggest that therapist effectiveness may actually decline with experience rather than improve (Goldberg, Rousmaniere, et al., 2016).

This professional development paradox indicates a fundamental misunderstanding of how therapeutic expertise develops. Traditional training assumes that knowledge acquisition and supervised experience naturally translate into enhanced therapeutic capability. The evidence suggests these activities may actually reinforce competence illusions—the conviction that one is improving when objective measures indicate stagnation or decline.

Most therapists operate without systematic outcome measurement, relying instead on subjective impressions that consistently overestimate their effectiveness (Walfish, McAlister, O’Donnell, & Lambert, 2012). This creates effectiveness opacity—the inability to distinguish between feeling effective and being effective.

The recursive loop becomes apparent: without valid effectiveness measurement, therapists cannot identify specific areas for improvement; without identified improvement targets, deliberate practice becomes impossible; without deliberate practice, traditional training activities that feel educational but lack empirical connection to outcomes become the default professional development approach.

The Characteristics of Effective Therapists

The systematic investigation of therapist characteristics reveals a striking pattern: variables traditionally associated with professional competence show minimal correlation with therapeutic effectiveness, while specific interpersonal and meta-cognitive capabilities demonstrate robust predictive validity.

Variables that do not predict effectiveness:

• Demographic characteristics (age, gender, ethnicity)
• Theoretical orientation
• Professional discipline
• Years of experience
• Level of training
• Adherence to treatment protocols

Variables that predict effectiveness:

• Facilitative Interpersonal Skills: verbal fluency, emotional expressiveness, persuasiveness, warmth, positive regard, hopefulness, empathy, and alliance-repair capacity (Anderson et al., 2009)
• Superior countertransference management—the ability to recognize and constructively utilize emotional reactions to clients
• Professional self-doubt combined with personal self-confidence

This final point requires emphasis: therapists who maintain appropriate professional self-doubt while expressing personal self-confidence achieve superior outcomes compared to those who express confidence in their therapeutic abilities (Nissen-Lie et al., 2017). This suggests that confident uncertainty—comfort with the inherent unpredictability of therapeutic work combined with commitment to continuous improvement—may constitute a marker of therapeutic wisdom.

A therapist must preserve the scientific mindset for tolerating the impermanence and limited reliability of knowledge systems—what I would characterize as epistemological humility.

The Deliberate Practice Framework

What I conceptualize as precision-guided professional development represents a complete departure from conventional training models. Deliberate practice, as operationalized through the Taxonomy of Deliberate Practice Activities in Psychotherapy (TDPA), provides complexity-preserving simplicity—a systematic approach that honors the inherent complexity of therapeutic work while creating specific, measurable targets for improvement.

The four essential components—individualized learning objectives, expert coaching, systematic feedback, and successive refinement—create a learning architecture that mirrors the contextual model’s emphasis on creating conditions for change rather than implementing predetermined interventions.

Research demonstrates that top-performing therapists devote approximately 2.5 times more hours to deliberate practice activities than their average-performing colleagues (Chow et al., 2015). The crucial insight involves not simply that effective therapists practice more, but that they practice diagnostically—using systematic feedback to identify specific performance deficits and design targeted improvement activities.

This represents meta-cognitive therapeutic development—the capacity to observe, analyze, and systematically improve one’s own therapeutic processes.

The Pain and Necessity of Scientific Thinking

As I write these words, I experience what I believe represents the pain inherent in scientific thinking. One must endure substantial uncertainty and anxiety in this endeavor. In my experience thus far, no piece of information can truly resist inquiry and diligent investigation. There exists a sense of groundlessness in maintaining a scientific mindset while working seriously.

One must eventually cease skeptical inquiry and rely on premises not fully analyzed in order to function and construct understanding, only to later discover the fragility of these foundations and the inherent limits of conclusions.

This difficulty makes scientific thinking a form of intellectual heroism. Maintaining objectivity presents extraordinary challenges, yet science advances—imperfect and imprecise, but substantially more perfect and precise than any individual attempting to understand reality independently.

The Integration of Multiple Effectiveness Factors

The evidence reveals that therapeutic effectiveness emerges from sophisticated integration of multiple factor domains operating across temporal, epistemological, and ontological dimensions. Rather than resolving apparent tensions between relationship factors, hope/expectancy factors, structural factors, and therapist factors, productive complexity emerges from maintaining these domains in dynamic interaction.

Therapists must monitor their personal models continuously, as maintenance of their primary working instrument. As Rogers and Yalom articulated: the person of the therapist constitutes their main instrument of work. The conceptual model the therapist holds and can consciously monitor represents their source of therapeutic power—how we create relational fields of healing.

Toward Therapeutic Wisdom

What emerges from the confluence of Wampold’s contextual model and deliberate practice research is not merely another approach to therapeutic training, but a complete reconceptualization of what constitutes professional development in the healing arts.

Rather than viewing effectiveness as the accumulation of techniques or mastery of theoretical systems, genuine therapeutic competence emerges from integrating relationship skills, expectancy cultivation abilities, and structural intelligence applied through systematic self-monitoring and continuous improvement processes.

This represents therapeutic wisdom—the capacity to navigate uncertainty and complexity while maintaining therapeutic focus, to form deep therapeutic connections while maintaining effective professional boundaries, and to continuously improve while accepting the inherent limitations of both the healing enterprise and our skills and knowledge.

The Recursive Nature of Scientific-Practice Integration

The recursive nature of this transformation means that developing more effective therapists simultaneously advances our understanding of how psychotherapy works, which enables more precise training methods, which produces more effective therapists in an ongoing cycle of scientific-practice integration.

I believe Skinner attempted to propose a union of clinic, laboratory, and philosophy to advance human behavior comprehension, and I now fundamentally agree with this approach. Recursively questioning issues several layers down to core premises while examining the effects of current implementations through scientific orientation both protects and advances the endeavor toward excellence.

The resolution of the effectiveness stasis requires embracing this complexity rather than seeking simplistic solutions. The field must move beyond the illusion that superior training programs, more sophisticated techniques, or improved theoretical models will automatically yield more effective therapists.

Instead, effectiveness will emerge from sophisticated integration of multiple competencies applied through systematic deliberate practice guided by continuous outcome monitoring. Being process-centered does not mean abandoning outcome focus, but rather understanding that we must manipulate the mechanisms and observe the resulting effects.

This represents not merely an improvement in professional development methods, but a paradigmatic evolution toward a truly scientific approach to therapeutic effectiveness that honors both the complexity of human change processes and the precision requirements of evidence-based practice.

The future of therapeutic effectiveness depends not on discovering perfect techniques or theories, but on developing practitioners capable of navigating complexity with skill, scientific rigor, and wisdom.

References

Anderson, T., Ogles, B. M., Patterson, C. L., Lambert, M. J., & Vermeersch, D. A. (2009). Therapist effects: Facilitative interpersonal skills as a predictor of therapist success. Journal of Clinical Psychology, 65(7), 755–768.

Anderson T, McClintock AS, Himawan L, Song X, Patterson CL. (2016) A prospective study of therapist facilitative interpersonal skills as a predictor of treatment outcome. J Consult Clin Psychol; 84(1):57-66.

Baldwin, S. A., & Imel, Z. E. (2013). Therapist effects: Findings and methods. In M. J. Lambert (Ed.), Bergin and Garfield’s handbook of psychotherapy and behavior change (6th ed., pp. 258–297). John Wiley & Sons.

Chow, D. L., Miller, S. D., Seidel, J. A., Kane, R. T., Thornton, J. A., & Andrews, W. P. (2015). The role of deliberate practice in the development of highly effective psychotherapists. Psychotherapy, 52(3), 337–345.

Goldberg, S. B., Rousmaniere, T., Miller, S. D., Whipple, J., Nielsen, S. L., Hoyt, W. T., & Wampold, B. E. (2016). Do psychotherapists improve with time and experience? A longitudinal analysis of outcomes in a clinical setting. Journal of Counseling Psychology, 63(1), 1–11.

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Nissen-Lie, H. A., Rønnestad, M. H., Høglend, P. A., Havik, O. E., Solbakken, O. A., Stiles, T. C., & Monsen, J. T. (2017). Love yourself as a person, doubt yourself as a therapist? Clinical Psychology & Psychotherapy, 24(1), 48–60.

Walfish, S., McAlister, B., O’Donnell, P., & Lambert, M. J. (2012). An investigation of self-assessment bias in mental health providers. Psychological Reports, 110(2), 639–644.

Wampold, B. E., Flückiger, C., Del Re, A. C., Yulish, N. E., Frost, N. D., Pace, B. T., Goldberg, S. B., Miller, S. D., Baardseth, T. P., Laska, K. M., & Hilsenroth, M. J. (2017). In pursuit of truth: A critical examination of meta-analyses of cognitive behavior therapy. Psychotherapy Research, 27(1), 14–32.

Wampold, B. E., & Owen, J. (2021). Therapist effects: History, methods, magnitude, and characteristics of effective therapists. In M. Barkham, W. Lutz, & L. G. Castonguay (Eds.), Bergin and Garfield’s handbook of psychotherapy and behavior change (7th ed., pp. 297–327). Wiley.

Webb, C. A., DeRubeis, R. J., & Barber, J. P. (2010). Therapist adherence/competence and treatment outcome: A meta-analytic review. Journal of Consulting and Clinical Psychology, 78(2), 200–211.