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Bruce Wampold on What Actually Makes Us

Good Therapists
by Greg Arnold

Expert clinician and researcher Bruce Wampold talks about his "contextual model" of psychotherapy
which, rooted in the most comprehensive and up-to-date scientific research, incorporates the most
effective elements across all therapy modalities.
The Zero Percent Difference

Greg Bruce, you’ve been in the field of psychotherapy for over 30 years and have made a
Arnold: tremendous contribution to our understanding of psychotherapy from empirical,
historical, and anthropological perspectives through what you call the “contextual model
of psychotherapy.” Your fantastic book, The Great Psychotherapy Debate: The Evidence
for What Makes Psychotherapy Work is in its second edition, and I highly recommend it
to our readers.

I want to start right out with what I see as the most significant thing to share with our
readers. In your research, you’ve found that the difference in effectiveness of various
types of psychotherapy is zero percent. Is that right?

Bruce With some qualifications. I would put the differences between various types of
Wampold: psychotherapy at very close to zero percent. That statistic comes from clinical trials
comparing treatment A to treatment B—often CBT to another form of CBT or to a
dynamic therapy, a humanistic therapy, an interpersonal therapy—and there we don’t
find any differences that are consistent or very large. Sometimes they’re small
differences. The other area of research, “dismantling studies,” takes out the ingredient
that is supposed to be the most important element of the treatment. It turns out that
treatment is just as effective without the particular ingredient.

But here’s the qualification. There are a number of trials that compare a coherent,
cogent, structured treatment to what’s often called “supportive therapy,” where the
patient just sits with an empathic therapist, but there’s no treatment plan, there’s no
explanation to the patient about what they’re going to do in therapy to help them get
better. And we know, all the way back to Jerome Frank, that we need a coherent
explanation for what’s bothering the patient and a believable treatment for
them—something for the patient to do so that they work hard to overcome their
difficulties. Supportive therapies are a lot more effective than doing nothing, but
they’re not as effective for targeted outcomes as those that have a coherent explanation
 and treatment plan.

So if a patient comes in with problems in

interpersonal relationships, depression, anxiety,
we have to come up with a cogent explanation As long as what they’re
and a believable treatment to overcome their doing is believable,
difficulties. As long as what they’re doing is accepted, is given by a
believable, accepted, is given by a therapist therapist who’s skilled
who’s skilled and believes in the treatment as and believes in the
well, the treatment tends to go well.
treatment as well, the
treatment tends to go
well.

GA: Regardless of the treatment?

BW: That’s right. So that’s the long answer to your question about all treatments being equal. Of
course, not all treatments are equal—there are harmful treatments. In my workshops, I show
Bob Newhart doing “stop it” therapy.
... Continue Reading Interview >>

GA: Yes, I’ve seen it. It’s hilarious.

BW: You can Google it on YouTube. He just keeps saying to the patient, “Stop it!” When we say
all therapies are equally effective, we need to be clear that we are not talking about harmful or
sarcastic therapy.

GA: Of course. So let’s take a case example, say someone with severe OCD. Most people think
exposure with response prevention is far and away superior, its treatment rationale is better
than anyone else’s treatment rationale, and that it’s the only therapy that will cure it.

BW: OCD is an interesting one to bring up. Exposure

and response prevention is pretty good, with some
provisos, but it’s never been compared to another Exposure and response
bona fide, legitimate treatment for OCD. I would prevention is pretty good,
like to see a focused dynamic treatment for OCD, with some provisos, but
and I would predict it doing just as well. it’s never been compared
to another bona fide,
The other thing about OCD is if you read the
literature, outcomes are almost exclusively legitimate treatment for
measured in terms of symptom reduction. There’s a OCD.
failure to measure quality of life or interpersonal
functioning. OCD is a terribly disturbing disorder,
and the people who suffer from OCD often have a terrible quality of life—they’re isolated,
they’re alienated from people, they’re not integrated into social networks because their
disorder interferes, or they have other issues as well. So it’s very misleading to just measure
targeted symptoms.
GA: It’s stacking the deck a little bit.

BW: I had a debate with a psychologist here in Wisconsin who has an OCD clinic, and he said the
same thing: We know how to reduce symptoms. But the people are not back to work, they
don’t have romantic or intimate relationships. So now we’re starting to augment the exposure
and response prevention with vocational therapy and counseling for other issues. OCD is an
area where we need to do more research.

Another area where we thought CBT was the most

effective treatment is panic disorder. But now
Barbara Milrod and others have dynamic therapy The claims about CBT
for panic, and it’s just as effective. Social anxiety is being superior to other
another area. If you read the clinical trials carefully, treatments are not
there isn’t convincing evidence that one particular founded.
treatment is more effective. CBT folks have done
some amazingly good research and have helped the
field immeasurably. I don’t want to discount that, but the claims about CBT being superior to
other treatments are not founded.

GA: Those claims are far and wide, deeply rooted. Given that, among the bona fide treatments,
they’re all equally effective, then the medical model is not superior either, correct?

BW: Yes. In Western culture, we’re so indoctrinated by the medical model that we ignore the
social factors that make psychotherapy particularly effective. Humans are evolved as social
animals, and we’re influenced through verbal means. How many of us learn not to stick our
fingers in electric sockets because of classical conditioning? Our parents didn’t put our
fingers into the socket to learn by experience, or put their fingers in there and have us watch
them writhe on the floor in pain. All the parent had to do is say, “that’s dangerous.” We have
evolved in such a way that significant others have tremendous influence on us through social
means. Psychotherapy very effectively does just that.

The medical model can have some unfortunate

consequences. It leads us to think that a “cure” can
come through specific “interventions,” that if a A skilled therapist makes
therapist follows some kind of protocol, they will a big difference no
have good outcomes. That’s a myth. A skilled matter the orientation.
therapist makes a big difference no matter the
orientation.

GA: Which is good news, right? People are going to be happy to hear we make a difference.

BW: Therapists Deteriorate Over Time

Yes, but it comes with responsibility. Let’s ensure that our outcomes are commendable, that
they meet benchmarks, and that they improve. We just did a study where we looked at
therapists over almost 20 years of practice, and the therapists did not improve. In fact, they
deteriorated a bit.
GA: Sobering.

BW: It is. But it’s not surprising when you think about it. What other profession do you go into a
room, do your work in privacy, aren’t really allowed to talk about it because it’s confidential,
and don’t get any feedback about how you’re doing. How can we expect to get better? Would
we go to hear a musician who only performed and never practiced? Do you think world class
tennis players just play Wimbledon and the U.S. Open and Australian Open? No, they
practice hours a day on particular skills. So becoming a better therapist takes a lot of
deliberate practice.

GA: Can you talk a little bit about the therapist factors that make us better or worse that we could
be working on—be it in consultation groups or in feedback informed therapy.

BW: For many years I said the fundamental unanswered question in psychotherapy was, “What
characterizes an effective therapist? What do they do?” And we didn’t know. But we’re
starting to get good scientific evidence about what effective therapists do, so I’ll run through
it.

GA: Please do!

BW: Effective therapists are able to form a working alliance—a collaborative working
relationship—with a range of patients. The motivated patients with solid attachment histories
who easily form an alliance with you—those aren’t the ones that challenge us. The ones that
challenge us have poor attachment styles, do not have social networks, they alienate people in
their lives, they have borderline features, they’re interpersonally aggressive, they tell us we’re
no good. A really effective therapist is able to form a relatively good collaborative working
relationship with those types of patients. The therapist effect is larger for more severely
disturbed patients, which makes sense.

Effective therapists are also verbally fluent, they can describe the disorder as well as their
treatment rationale.

GA: They get the buy-in from the client.

BW: Yes, they’re persuasive as well as verbally fluent, so when they explain things, they do it in
two or three sentences and it’s coherent. I have my students practice explaining what they’re
going to do in therapy. It’s difficult to do and you have to practice until you can do it in three
or four sentence.

An effective therapist can read the emotional state of clients even when they’re trying to hide
it. And we know the patients hide what they’re feeling. It isn’t intentional; it’s part of their
struggle in life. They suppress anger or they’re not allowed to express sadness. A good
therapist can understand and respond to the patient affect. Good therapists also can modulate
their own affect. Can you be expressive and
activated when you have a really depressed patient
who just kind of sits there? Affect is really Can you be expressive
contagious. We know that from basic science. and activated when you
 have a really depressed
On the other hand, if we have an extremely anxious patient who just kind of
patient, can we be relaxed and calm? Modulating
our own affect takes some practice as well. Are we
sits there?
warm, understanding, and caring? You may think
all therapists are warm, understanding, and caring,
but it takes work. I had a student whose patient didn’t bathe, so it reeked when the patient
came in. What would your facial expression be?

GA: It would be hard not to feel some disgust.

BW: Exactly. We had to practice not displaying disgust. Being warm and empathic is easy with
some patients, but really hard with others.

GA: Do people lose faith when they realize that the medical model, that any model really, isn’t the
X factor in therapy? Do they just throw in the towel?

BW: I wouldn’t say that. When therapists say, “My treatment is the best there is for X, Y and Z,” in
a way I’m glad. I want people to believe in their treatment, as that is an element of effective
therapy. But instead of thinking that treatment X is the most effective treatment, we should
believe that treatment X as I deliver it to this particular patient is effective.

This is where the focus on outcomes is so helpful. Is this patient getting better? Are they
reaching their goals? If so, you can have faith not in the treatment itself but in your use of the
treatment with the patient who is getting better. If we’re rigidly attached to a treatment, that’s
problematic. I dislike it when therapists say in the first session, “Here’s how I work. This is
what we’re going to do here.” You haven’t even listened to the patient yet and understood
how the patient wants to work.

You need to modify treatment for some patients, or you might have to abandon it and do
something very different for particular patients. Flexibility is another characteristic of
effective therapists. That doesn’t mean doing something different every week with them,
which is confusing; we need to be consistent, but also flexible.

GA: Dogma gets in the way here, and you’ve shown that more fidelity to a treatment actually gives
less positive outcomes.

BW: The Sweet Spot

There’s a sweet spot. You don’t want to be so flexible that you lack coherence, as that is not
effective either. We need to be kind of in that sweet spot where there’s consistency in what
we’re doing so the patient feels like we’re working towards their goals with a logical
treatment plan.

But there may be a crisis in a patient’s life or a dramatic event or they’re just resistant. One of
the things I teach my trainees is to see the nonverbal signs of resistance—they’re not
following through on activities or when we explain what we’re doing they look away. They
don’t want to say, “No, that doesn’t make sense, you’ve got it wrong.” So we have to be
really attuned to those signs and willing to explore them.
GA: Still, it seems like this contextual model kind of suggests that we don’t really need particular
treatment models. That if we are naturally good at making alliances with all kinds of clients
and verbally skilled, we don’t need to be steeped in a particular treatment model.

BW: Well that’s where coherence and clear articulation of a treatment plan come into play. You
don’t have that without having some kind of approach. When we go to a doctor, we want to
know what’s wrong with us and how we’re going to get better. CBT therapists are great at
this. They incorporate psychoeducation into the treatment structure, so a coherent treatment
plan is central to the work they do with clients.

Where CBT therapists can fall short if they don’t attend to it is the warm, empathic,
understanding treatment expectation part of the contextual model. If you administer CBT
without warmth and understanding, it’s not going
to be nearly as effective. On the other side are the
humanistic therapists who are often great at the If you administer CBT
warm, empathic part of therapy but don’t always without warmth and
have a coherent treatment structure. I think we all understanding, it’s not
have to look at our practice and assess what we are going to be nearly as
really good at, what are the elements that seem to effective.
work well with our clients and then have a good
hard look at the areas where we are falling short.

GA: Yes, for me it’s figuring out the fine line between non-directive and directionless.

BW: That a good way to put it.

GA: It sounds like we should all be multi-modal, integrative, competent in several modalities
because different things are going to work with different clients. None of us should be one-
trick ponies.

To what extent does this call upon us to be more educated and trained in multiple modalities?
Training culture these days seems to be trending towards manualized therapies, those that
have been shown to be effective with particular disorders, etc. How do you think students
should be getting trained these days?

BW: That’s an interesting question. I’m a counseling psychologist, and in counseling psychology
we usually start by teaching the basic interpersonal skills first. In clinical programs, they are
more often these days teaching manualized treatment—CBT for panic disorder or exposure
therapy for OCD. We need to integrate the basic humanistic skills that are necessary for
effective treatments as well as learning treatment protocols.

I have no problem with treatment protocols. I think people should be relatively fluent in
several. And we should recognize our limitations. If we’re psychodynamic and have a client
who is more interested in doing CBT, or we think would be better served by a CBT therapist,
we should refer them out. We often have this belief
that we can help everybody, but it’s really not true.
We often have this belief
Look at how many treatment failures there are for that we can help
widely accepted medical practices. We’re not going
 to help every psychotherapy patient, and maybe everybody, but it’s really
some other therapists could do a better job with not true.
particular patients. Flexibility is called for not just
within a particular therapist, but within the
community of therapists.

GA: One of the elements of effective therapy you cited was being able to create a positive working
alliance with a variety of patients, and difficult patients, so how do you balance that with
knowing when to refer out?

BW: Well, the really effective therapists probably don’t refer out much because they’re pretty good
at accommodating their treatment style to the particular patient. And we have to be careful
about referrals because if it appears to the patient that they’re just being referred out because
they’re difficult, that can be very wounding. I’ve heard of difficult patients saying, “I didn’t
really get better, but this therapist stuck with me, and that was really helpful to me.”

Some disorders are going to take maintenance therapy to keep people out of the hospital and
functioning. So even though they’re not going to approach what we would call “normal”
functioning, it’s still an appropriate use of therapy. The medical model doesn’t really support
this kind of treatment though. It’s looking for a specific outcome in a limited amount of time.

In the United States we’re paid by the health delivery system, which is advantageous for
therapists because they’re getting paid, and advantageous for patients because there was a
time when only the rich could pay out-of-pocket for therapy. Those without resources simply
couldn’t afford psychotherapy and now it is available to many more people, which is a great
thing. But there are some unfortunate consequences of being forced into this medical model.
Limitations on sessions is probably the one that impacts therapists and clients the most.

GA: This isn’t going to change overnight. It’s deeply embedded in our culture. But in order to
change the culture, we need a positive vision for the alternative. What would that look like? I
think the contextual model has the potential to really change the system because not only is it
scientific, it’s more scientific than the medical model.

BW: That’s a fundamental question we have to address.

Many of us are working hard to influence policy,
and the way to do that in my view is to present the We know psychotherapy
evidence. I’ve dedicated my career to providing the is remarkably effective. It
evidence for the humane delivery of mental health helps many people. It’s as
services. We know psychotherapy is effective. It’s effective as medication,
remarkably effective. It helps many people. It’s as and longer lasting. But
effective as medication, and longer lasting. But we
have to influence policy makers. There are places we have to influence
where we’re making progress, and there are places policy makers.
where it’s frustrating as hell.

GA: I bet.

BW:
 But we also have to be making progress as therapists. We have a responsibility to provide
effective services.

GA: It’s disheartening to hear that we aren’t getting better over the course of our own professional
lives.

BW: Coming Out of Isolation

We don’t, but as we learn more through research about what makes therapists effective, we
can begin to incorporate what we learn into our training and professional development. I’m
involved in a start-up company, TheraVue that’s dedicated to online skill building for
psychotherapists. I think technology can play an important role in making not just therapy, but
consultation and training more accessible to people.

GA: That’s hopeful to hear. So many people want to be in consultation groups, but it’s much harder
to make happen than you would think.

BW: This is an isolating profession. We’re sitting one-on-one or sometimes with couples or
families, but essentially we’re doing our work in isolation. We have to have that peer support
to help us both fight the isolation and to get better, but it’s difficult. We work six, eight hours
a day with patients and at the end of the day, we don’t want to drive somewhere for a peer
consultation. We want to get home to our families and friends.

GA: So given that there are these challenges, how do we get more therapists to make consultation a
regular part of the practice?

BW: Psychotherapy is not the road to riches. I think most of us are in this field because we’re
dedicated to helping people, so I think there’s an intrinsic motivation to get better. I don’t
think there’s going to be resistance when people really understand what it takes to be a better
therapist. In fact, there’s going to be eagerness to improve if it’s built-in in a way that makes
it accommodating. I think it’s absurd that we don’t give CE units for actual efforts to improve
other than going to workshops and doing online courses. I’m a licensed psychologist, so I do
them, and some of them are really good, but is this helping me become a more effective
therapist? Tomorrow are my patients going to be getting better therapy than they got before I
went to this workshop? So the training and accreditation processes need to support the
activities that actually help therapists get better.

GA: So we know that workshops and online courses and reading books isn’t enough. We recently
did an interview with Tony Rousmaniere on deliberate practice, although we haven’t
published this yet. It’s a concept he learned from Scott Miller that involves literally
practicing—like tennis players do between games—the skills of therapy outside of the therapy
office. Videotaping ourselves, practicing how we talk, having mentors watch our work, trying
to eliminate things that aren’t helping clients—weird idiosyncrasies we wouldn’t necessarily
pick up without an outside observer. Are these the kinds of practices you are talking about?

BW:
 Good Therapists Are Humble
Yes, exactly. You can’t just reflect and think about your practice, just do process notes or
whatever. It’s important to do those things, and certainly one of the characteristics of effective
therapists is professional humility. Good therapists, the ones that get better outcomes, are the
ones who say, “I’m not sure I’m helping patients. I need to get better.” But Daryl Chow and
Scott Miller did a study that revealed that people who work outside of their practice to get
better actually have better outcomes.

The skills I’ve talked about, you have to do them

over and over again with feedback from somebody.
This is what we’re doing with practicum students Good therapists, the ones
now. Often students will go, “I’m an advanced that get better outcomes,
student now; these are basic skills you’re teaching.” are the ones who say,
No, we all need to practice these things. By the end, “I’m not sure I’m helping
they often say, “this was the best practice class I’ve patients. I need to get
ever had because we actually practiced the skills
we use in therapy.” better.”

GA: So we can improve our skills through practice, get unambiguous feedback from someone we
respect and hopefully challenge our own confirmation bias that we’re the best therapist ever,
by cultivating some humility.

Still, if the motivation to get better was intrinsic, don’t you think more therapists would be
doing these things? Sell us a little more on it if you don’t mind. Like, how much am I going to
improve if I implement these new strategies?

BW: That’s a great question. In my presentations I use the example of baseball. The difference
between a 300 hitter and a 275 hitter is not very much. In fact, if you watch the poor hitter for
two weeks, they may have more hits than the 300 hitter. But if you look over the career, the
300 hitter helps his team immensely more.

An incremental improvement doesn’t have to be

dramatic, but it has a tremendous impact on the
number of patients who benefit from A small improvement by
psychotherapy. I can give you the facts and figures each therapist would
because I love math and statistics, but a small have a tremendous
improvement by each therapist would have a impact and benefit to
tremendous impact and benefit to patients. It’s patients.
quite remarkable.

GA: So that’s our call to action as a profession.

BW: Yes.

GA: We know what we need to do, the gains are there for the taking, and we need to keep pushing
on policy to support those efforts. None of us are going to get rich doing it, but it’s hopeful
that we can really make a difference as we improve and grow.
BW: I think it is hopeful. We have the strategies and the technology for continual improvement as
therapists. Let’s get better. Let’s work at it. Let’s support each other. And let’s measure
outcomes so that we know how we’re doing.

GA: That’s a whole other piece we hadn’t talked about: measuring outcomes.

BW: Yes, it’s very important. What the research seems to show is that at least for cases at risk for
deterioration, feedback may improve outcomes. But it’s pretty clear that just getting
feedback—this patient is improving; this patient is not—doesn’t help the therapist become
more skilled.

But it is important to know if you’re actually helping patients, if you’re gradually improving
over time. Look and see what types of patients you’re having difficulty with.

GA: Routinely.

BW: Yes, and I would add that, in my experience, and I think the research supports this, discussing
the feedback with patients is helpful. What it communicates to the patient is that you are
improving and that their feedback actually matters to you. But it also makes it clear that the
focus is on, “Are you getting better?” I want to know that continually. We should all be
discussing with our patients how therapy is going and how we can change to more readily
support their goals. That’s a tremendously powerful message when we discuss that with
patients. If we’re not meeting the goals, what can we do differently? Some would call that
client-informed, but all therapists are client-informed. To a large degree, we should all be
discussing with our patients how therapy is going and how we can change to more readily
support their goals.

GA: There’s also an indirect benefit in that it communicates care in a new way to the client,
bringing them in on monitoring outcome.

BW: It’s not indirect. It’s direct. In the contextual model, we don’t minimize these things as
indirect. This is deliberate.

GA: The meat and potatoes.

BW: Absolutely. The focus on patient progress is central to what we do.

GA: So we have a call to action for clinicians, one for policy makers, what about for psychotherapy
researchers?

BW: My plea to all researchers would be, if you’re going

to do a clinical trial, please include a quality of life
measure because I want to see that your treatment
 actually has a significant benefit to patients in the My plea to all
quality of their life. That’s why they come to researchers would be, if
treatment. I don’t want to just see targeted
symptoms are reduced and therefore your model is
you’re going to do a
best for a particular disorder. clinical trial, please
include a quality of life
measure because I want
to see that your
treatment actually has a
significant benefit to
patients in the quality of
their life.

GA: Any final words of wisdom you’d like to leave our readers from your years in the industry?

BW: I would say to therapists—to all of us—let’s work to get better, to continually improve over
the course of our careers. It will benefit patients. It will benefit us. Our satisfaction with our
work will improve as well. At this point in my career, I want to do whatever I can to help
therapists do that.

GA: I am so grateful for the work you do, and I want everyone to go out and read your work so that
we can all become better therapists.

BW: Thank you, Greg, it’s been such a pleasure talking to you.

© 2017, Psychotherapy.net, LLC

Bruce E. Wampold, PhD, was trained in mathematics (University of
Washington) before earning his doctorate in counseling psychology (University
of California, Santa Barbara), is the Patricia L. Wolleat Professor of Counseling
Psychology at the University of Wisconsin–Madison as well as the director of
Research Institute at Modum Bad Psychiatric Center in Vikersund, Norway.
Currently his work involves understanding psychotherapy from empirical,
historical, and anthropological perspectives, which has led to the development of
a contextual model of psychotherapy. His work is summarized in The Great
Psychotherapy Debate: The Evidence for What Makes Psychotherapy Work (with Z. Imel, 2nd ed.,
Routledge, 2015). He is a Fellow of the American Psychological Association, a Diplomate in
Counseling Psychology of the American Board of Professional Psychology, the recipient of the 2007
Distinguished Professional Contributions to Applied Research Award from the American
Psychological Association, and an Honorary Doctor in the Social Sciences, Stockholm University.

Greg Arnold, MA, LMHCA, Account Manager, resides in

Bellingham, WA, so he’s basically Canadian. He holds an MA in Counseling
Psychology, is completing his doctoral degree, and puts the wisdom he's gained
from hours of watching Psychotherapy.net videos to use providing couples,
 individuals, and families, with person-centered, humanistic psychotherapy in
Bellingham. As Account Manager at Psychotherapy.net, Greg helps universities
and community mental health organizations integrate the inspiring work of our
expert therapists-on-video into the training and professional development of
students and career professionals alike.

CE credits: 1
Learning objectives:

• Illustrate the fundamental elements of the contextual model of psychotherapy.

• Identify common obstacles to therapist improvement.
• Describe deliberate practice and how it can be applied by psychotherapists.