In Laska, Gurman, & Wampold (2014) and Laska & Wampold (2014) I discussed how to improve the quality of mental health care from a common factor (CF) perspective. Unfortunately, one fundamental misunderstanding of CF theory is that “anything goes” and therapists can do whatever they want. Let me be crystal clear, from a CF perspective, therapists cannot just do whatever they want! In this companion piece I outline 10 evidence–based strategies from a CF perspective for improving outcomes in routine care.

1. Monitor Outcomes

How can we improve psychotherapy outcomes if we don’t even know what they are? It is very difficult to introduce quality improvement strategies when it is unclear how clients are actually doing. A large body of evidence now indicates that routinely monitoring outcomes and providing therapists with feedback on their clients progress improves care (Castonguay, Barkham, Lutz, & McAleavey, 2013; Lambert, 2013). At this point in time, all providers, regardless of theoretical approach or clinical setting, should be monitoring outcomes as part of routine

2. Provide a Theoretically Explicit Rationale for Change

People want an explanation for their distress. One common factor in any effective psychotherapy is that therapists provide to patients an explicit rationale for change that is embedded in a psychological theory. In other words, it is imperative that therapists clearly describe to clients why they are distressed and how therapy will help them change. When therapists provide a clear theory-derived rationale, they express credibility and confidence in the treatment they are going to provide and create positive expectations for change, thereby raising the likelihood that patients will participate in the treatment, factors which are associated with outcome (Frank & Frank, 1993; Wampold & Imel, 2015).

3. Highlight Role Induction into the Therapy Process

“Patients are already burdened with the primary anxiety that brings them to therapy and it makes little sense to plunge them into a process that may create secondary anxiety—anxiety from exposure to an ambiguous social situation without guidelines for proper behavior or participation” (Yalom, 2002, p. 85). Clients should understand their role in the change process and what actions they are responsible for in session. Role induction is a critical part of any effective therapy and an aspect of care that is often neglected. Short motivational enhancement treatments that explicitly address the client’s role in treatment have a growing evidence base and are increasingly being used in outpatient clinics to reduce dropout rates and improve psychotherapy outcomes (Murphy, Thompson, Murray, Rainey, & Uddo, 2009).

4. Be Flexible in Treatment Planning

Strict adherence to a theoretical model results in poor outcomes, whereas adherence flexibility is associated with positive outcomes (Henry, Strupp, Butler, Schacht, & Binder, 1993; Owen & Hilsenroth, 2014). It is critical that therapists are adaptable within the theoretical perspective they adopt (and sometimes change the treatment entirely, if need be). It is important that therapists systematically revisit and address the treatment plan, and if it is not consistent with the client’s goals, shift accordingly. Even strong proponents of implementing ESTs as the primary mechanism for improving outcome highlight the necessity of being flexible (Hofmann & Barlow, 2014).

5. Address Difficult Emotional Material

Therapists who are engaging, confident, active, and persuasive have better psychotherapy outcomes (Ackerman & Hilsenroth, 2003; Andersen, Ogles, Pattersen, Lambert, & Vermeersch, 2009; Beutler, et al., 2004). Part of this entails persuading and engaging the client in order to discuss challenging emotional material (Diener, Hilsenroth, & Weinberger, 2007). Part of our job is to help the client process emotions they likely wish to avoid. Although we are unaware of any research that explicitly addresses this issue, we can be clear that underperforming therapists lack either the active engagement or persuasive skill of how to challenge clients appropriately and work with difficult emotional material.

6. Examine Potential Sources of Confirmatory Bias

Most therapists overestimate their effectiveness. For example, approximately 90% of therapists rank themselves in the top 25% of outcomes (Walfish, McAlister, O’Donnell, & Lambert, 2012). In another study, therapists were asked to predict how many clients would get worse in therapy, and only correctly predicted one case out of a total 41 (Hannen, et al., 2005). Furthermore, evidence from social psychology suggests that in most fields it is the worst performers that rank themselves the highest (Kruger & Dunning, 1999). Given that research indicates therapist self-doubt is a predictor of outcome (Nissen-Lie, Monson, Ulleberg, Ronnestad, 2012), we encourage therapists to adopt a reflective attitude towards their clinical effectiveness as a means of protecting against confirmatory bias. As stated by Paul Meehl (1957), “In any case, psychologists should be sophisticated about the errors of observing, recording, retaining, and recalling to which the human brain is subject. We, of all people, ought to be highly suspicious of ourselves” (p. 27).

7. Limit Self-Disclosure That Is Non-Therapeutic

Providers from different theoretical perspectives think about self-disclosure along a spectrum. Yet, one characteristic of underperforming therapists is an overuse of non-therapeutic self-disclosure. Too much self-disclosure that is off topic, countertransference related, or involves the overuse of interpretation in session can have deleterious effects on psychotherapy outcome. Therapists would do well to ask themselves one simple question: “Am I talking too much?” and relatedly, “Is the talk directed toward helping the patient?"

8. Assess the Impact of the System on Outcome

A variable that has been almost completely ignored in psychotherapy research is the clinical care system. An exception to this is a study that found that organizational instability is a significant predictor of patient dropout (Werbart, Andersson, & Sandell, 2014). Different systems communicate different expectations for change to clients, either explicitly or implicitly. It may be that some systems create cultures of dependency on psychotherapy, are not patient focused and supportive, or are frustratingly complex and provide burdens and barriers for patients. We encourage all those involved in the delivery of mental health care to critically evaluate the impact of the system in which they work on outcome.

9. Graduate Programs Must Take Greater Responsibility for Students Who Are Not Achieving Appropriate Outcomes and May Not Be Suitable as Therapists

This can be a touchy subject. Yet, just like any other profession, students will vary in performance and some may not have the potential to be effective therapists. It is very difficult to accurately assess who will be inappropriate for clinical work during the graduate school application process. Therefore, once it is clear a student is not capable of providing appropriate clinical care, we should take it upon ourselves to ensure (with empathy and care) that they seek alternative career paths. Educators should ask themselves, “Would I want my partner/family member seeing this student?”

10. Re-Assign Underperforming Therapists to Different Tasks

In a recent Monte Carlo simulation (Imel, Sheng, Baldwin, & Atkins, in press), results indicate that in a hypothetical clinic, simply removing the 5% of therapists with the poorest psychotherapy outcomes and replacing them with a random sample of therapists resulted in an additional 4,200 patients benefiting from treatment over a 10 year period. In terms of clinicians who consistently underperform, systems of care have few options. Once underperforming therapists are identified, they should encourage therapists to seek what is necessary to improve, including additional training and supervision. After a period of time if they continue to underperform, systems of care have a duty to re-assign patients to effective therapists.