Psychotherapy Research

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The implications of the Dodo bird verdict for

training in psychotherapy: prioritizing process
observation

Henny A. Westra

To cite this article: Henny A. Westra (2023) The implications of the Dodo bird verdict for
training in psychotherapy: prioritizing process observation, Psychotherapy Research, 33:4,
527-529, DOI: 10.1080/10503307.2022.2141588

To link to this article: https://doi.org/10.1080/10503307.2022.2141588

Published online: 16 Dec 2022.

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Psychotherapy Research, 2023
Vol. 33, No. 4, 527–529, https://doi.org/10.1080/10503307.2022.2141588
ARTICLE COMMENTARY
The implications of the Dodo bird verdict for training in psychotherapy:
prioritizing process observation
HENNY A. WESTRA
Department of Psychology, York University, Toronto, Canada
(Received 24 October 2022; accepted 25 October 2022)
Wampold et al.’s 1997 meta-analysis found that the
true differences between bona fide psychotherapies
is zero, supporting the Dodo bird conjecture that
“All have won and must have prizes”. Two and half
decades later, the field continues to be slow to
absorb this and similar uncomfortable discoveries.
For example, entirely commensurate with Wam-
pold’s conclusion is the meta-analytic finding that
adherence to a given model of psychotherapy is unre-
lated to therapy outcomes (Webb et al., 2010).
Despite the clear implication that theoretical
models should not be the main lens through which
psychotherapy is viewed if we are aiming to
improve outcomes, therapists continue to identify
themselves primarily by their theoretical orientation.
And a major corollary of Wampold’s conclusions is
that despite the evidence for non superiority of a
given model, our focus in training continues to be
model-driven. This article seeks to elaborate the
training implications of Wampold et al.’s conclusion,
with a rationale and appeal to incorporate process-
centered training.
Consider these similarly uncomfortable findings
regarding the state of training. We assume, rather
than verify the efficacy of our training programs.
Yet, there is no evidence that continuing education
workshops for example, produce sustained skill
development—quite the opposite. Large effects on
self-report are found but any modest improvement
in performance erodes over time without further
coaching (Madson et al., 2019). Perhaps most con-
cerning, psychotherapists do not appear to improve
Correspondence concerning this article should be addressed to Henny A. Westra, Department of Psychology, York University, 127 Behav-
ioural Sciences Bldg., Toronto, ON, Canada M3J 1P3. Email: hwestra@yorku.ca
© 2022 Society for Psychotherapy Research
with experience and in fact, the evidence suggests
that skills may decline slightly over time (Goldberg
et al., 2016). Not surprisingly then, while the
number of model-based treatments has proliferated,
the rate of client improvement has not followed suit
(Miller et al., 2013). Could stagnant training
methods may be related to stagnant patient
outcomes?
We need innovations in training that better align
our training foci and methods with factors empiri-
cally supported as influencing client outcomes.
Process researchers have long observed that trained
process coders (typically for research purposes)
make better therapists due to their enhanced attune-
ment (e.g., Binder & Strupp, 1997). While such
training is not yet available in training programs, it
arguably should be based on emerging developments
in the science of expertise (Ericsson & Pool, 2016)
and the urgent need to bring outcome information
forward in real time so that it can be used to make
responsive adjustments to the process of therapy. In
fact, such information could be considered “routine
outcome monitoring in real time” (Westra & Di Bar-
tolomeo, 2022).
To elaborate, Tracey et al. (2014) provocatively
argued that acquiring expertise in psychotherapy
may not even be possible. This is because the
ability to predict outcomes is crucial to shaping effec-
tive performance. Yet there is a lack of feedback
available to therapists regarding the outcomes of
their interventions and such information, if it
comes at all, comes too late to make a difference in
528 H. A. Westra
the moment. Therapists are essentially like blind
archers attempting to shoot at a target. The develop-
ment of Routine Outcome Monitoring (ROM)
measures capable of forecasting likely outcomes is a
major advance in correcting this blindness and
improving predictive capacity. However, in order to
be effective for skill development, feedback needs
to occur more immediately so that the relationship
between the therapist action and the client response
(or nonresponse) can be quickly ascertained and
adjustments made in real time. Interestingly, while
ROM has been helpful in improving failing cases, it
has not been effective in enhancing clinical skills
more generally (Miller et al., 2013).
Learning to preferentially attend to, extract and
continuously integrate empirically supported
process data may prove to be the elusive immediate
feedback that has been lacking in psychotherapy
training but that is crucial to developing expertise.
Observable process data that has been validated
through process science as differentiating good
from poor patient outcomes, could be considered
“little outcomes”; which in turn are related to
session outcomes and ultimately treatment outcome
(Greenberg, 1986). Moreover, thin-slicing research
supports that it is possible to make judgements
about important outcomes from even tiny slices of
expressive behavior (Ambady & Rosenthal, 1992).
If one considers real time process information as
micro-outcomes, properly trained clinicians, just
like expert-trained process coders, may no longer
have to be blind. For example, a therapist trained
to identify and monitor resistance and signals of alli-
ance ruptures, can be continuously tracking these
important phenomena and responsively adjusting to
safeguard the alliance. Or a therapist who is sensitive
to markers of low and high levels of experiencing
(Pascual-Leone & Yeryomenko, 2017) and client
ambivalence (Westra & Norouzian, 2018) can not
only optimize the timing of their interventions but
also continuously watch the client for feedback on
the success of their ongoing efforts.
Being steeped in process research gives one a
unique perspective on the promise of process obser-
vation to advance clinical training. Our lab recently
took our first foray into studying practicing commu-
nity therapists. As we coded the session videotapes,
we became aware that we possessed a unique skill
set that was absent in therapist’s test interviews.
Therapists seemed to be guided solely by some
model of how to bring about change but failed to sim-
ultaneously appreciate the ebb and flow of the rela-
tional context of the work. They seemed absorbed
in their own moves (their model) but not aware
that they were in a dance and must continually
track and coordinate the process with their partner.
It seemed that we had incidentally trained ourselves
to detect and use these process signals. Our training
was different and very unique; it was more akin to
deliberate practice focused on discrimination train-
ing for detecting empirically supported processes.
In short, information capable of diagnosing the
health of the process and critically, of forecasting
eventual outcomes is arguably hiding in plain sight if
one can acquire the requisite observational capacity
to harvest it. And transforming an unpredictable
environment into a predictable one makes expertise
possible to acquire (Kahneman, 2011). Importantly,
extracting such vital information relies on observa-
tional skill, rather than patient report, end of session
measures, or longer-term outcome; thus, such real
time data extraction is immediately accessible and
can complement existing outcome monitoring
(Westra & Di Bartolomeo, 2022). Moreover, process
markers are often opaque; requiring systematic obser-
vational training for successful detection. Without
proper discrimination and perceptual acuity training,
this gilded information remains obscured. Thus,
heeding Wampold et al.’s call to refocus our efforts
must include innovations in training; innovations
that harness outcome information. We need more
process research to further uncover the immediately
observable factors capable of differentiating poor
and good outcomes, but existing process science
gives us a good start. And since process-centered
training is transtheoretical, it can exist alongside
models of therapy—learning to see while doing
(Binder & Strupp, 1997). Training in psychotherapy
has primarily prioritized intervention (models) and
now it may be time to emphasize observation.
Disclosure Statement
No potential conflict of interest was reported by the
author(s).
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