What's Wrong with MFT Education
One of the biggest misconceptions I had going into graduate school was that graduate school was going to teach me how to be a great therapist. I don’t consider myself naïve or to have had unrealistic expectations—a graduate program that literally costs tens of thousands of dollars and is a requirement to achieve a professional license in a given discipline should, at a minimum, teach you how to do that discipline to your highest ability.
As it turns out…graduate training to become a therapist is mostly just concerned with making sure you are competent. And how is “competent” measured? It’s measured by the almost entirely arbitrary standards set forth by state licensing boards, which have a mandate to protect the public from incompetent professionals. So, these boards come up with requirements people must meet in order to become qualified for a license.
For MFTs in the state of California, that means you have to:
Graduate from an “approved” MFT graduate program
Log 3,000 hours of clinical experience in a few different categories of types of hours
Pass a Law & Ethics exam and a Clinical Exam
How do they come up with these specific standards? There must be loads of studies demonstrating that this kind of training, preparation, experience, and testing results in an excellent therapist, right?
Nope.
In fact, this field doesn’t even know why excellent therapists are excellent. We don’t know why some therapists are better than others (though we do know that some therapists are WAY better than others). AND, a lot of the common-sense things you’d think would make someone a better therapist (like number of years practicing, having a PhD. vs. a master’s degree, age, etc.) have NOT been demonstrated to be associated with better outcomes for clients.
(Let me repeat that—you do not get better as a therapist just by doing it for a long period of time. JUST BECAUSE YOUR SUPERVISOR OR PROFESSOR HAS BEEN DOING THIS FOR TWENTY YEARS DOESN’T MEAN THEY ARE TWENTY TIMES BETTER THAN SOMEONE WHO JUST STARTED.)
So, how do these boards come up with the standards of what people need to do to become competent therapists, if the research doesn’t tell us what works?
It’s literally a small group of people who get together and decide what sounds right. In order to figure out what should be on the state licensing exam—the most important and final hoop you have to jump through in order to get a license, and which dictates the curriculum for every single MFT graduate program in the state—this board literally sends out a survey to practicing MFTs and asks them what they think should be on the exam!!!!! WHOEVER SENDS BACK THE SURVEY GETS TO DECIDE WHAT’S ON THE EXAM!!!!!
If it sounds like I’m pissed, that’s because I am.
So, some bureaucrats decide what therapists should probably know in order to make them competent. Then they decide, you know what, 3,000 hours is probably enough experience to make sure they’re competent! And, if you jump through all those hoops, you get to be a fully licensed therapist.
That’s literally it. You don’t need proof that you’re actually good at therapy, like getting letters of recommendation from past clients, or even supervisors. In fact, it is not required that ANYONE EVER SEE YOU WORK WITH A SINGLE CLIENT. Because of the private nature of therapy, it is ENTIRELY POSSIBLE for you to become a fully licensed marriage and family therapist in the state of California without anyone ever seeing you work except for your clients. And then no one asks your clients how you did!!!
Let that sink in.
If you’re the kind of person who feels entirely confident that you could be a brilliant therapist and you’re interested in getting licensed with as little effort as possible, this is probably great news. The bar to entry is, in fact, not that high at all.
But, if you (like me) feel confident that you could become a good therapist, but you’ll need some great training first…all of this might scare the shit out of you. And it should. Because graduate training to become a therapist is not great.
In fact, most likely, after your first semester in graduate school, you will be expected to start working with clients.
AFTER. ONE. SEMESTER. OF. GRADUATE. SCHOOL. They put you in a room with clients. Who expect you to HELP THEM.
It’s terrifying. My entire life I’ve been told that if I want to do something, I need to learn how to do it well first. Then you get to therapist graduate school and they’re all, “YOU’LL BE FINE, LEARN BY DOING, HERE WE GOOOOOO!!!!”
EVEN THOUGH THERE IS NO RESEARCH TO SUGGEST THIS IS THE BEST WAY TO TRAIN THERAPISTS.
Deep breath.
So I learned all this during my first year of graduate school. And it launched me on a fevered and panicked quest to figure out what WOULD make me an excellent therapist, because I figured I owed my clients at least that.
One of the ways I decided to do this was to start a podcast called Very Bad Therapy, where my co-host Ben and I interview clients who have had bad therapy experiences. If no one can tell us why good therapy is good, at least clients can tell us why bad therapy is bad. It’s been an incredibly enlightening experience.
Another thing I decided to try was to find the people who are as incensed about this state of affairs as I was. And fortunately, I found them in a group of people who are focused on a cutting-edge approach to therapist training called deliberate practice.
The concept of deliberate practice is, itself, not that new. In fact, if you play an instrument or a sport, you’re probably pretty familiar with it! Deliberate practice describes how you take a skill you want to learn (playing piano) and break it down into manageable chunks to practice (like music scales). If you’re really good at one piece of the skill, then you want to focus your practice efforts on the parts you’re not so good at—so you don’t fuck it up at the concert.
Doctors do this already in their training. I mean, medical students have been dissecting cadavers for hundreds of years, right? And when they learn how to do surgery, they don’t start by watching a video of a brilliant surgeon doing a successful surgery, then head over to a low-cost clinic operating room and suit up. No! They start by practicing sutures. If you’ve ever known any medical students, you have probably seen them be super annoying by practicing sutures at every awkward opportunity (shout out to my brother). These days, they have all kinds of simulated practice environments to learn in, and the United States Medical Licensing Exam (USMLE) has a component where test-takers are evaluated doing a mock exam on a live standardized patient (an actor playing the role of a patient). This is in addition to all the hours they’ve spent on rounds being directly supervised by real doctors.
Therapists, however? No such luck.
If you’re lucky, one of your assignments in your clinical skills class MIGHT be to write out everything you need to tell your client in an intake session. More likely, though, you’ll spend most of your class time listening to lectures about How to Do Therapy, and then you’ll spend some time doing “role plays,” where a classmate role-plays a client and another classmate pretends to be a therapist and tries out an intervention, like assessing for suicidality. Then, depending on your program, you’ll spend the rest of the time writing academic papers or reflective essays (and looking for parking, if you’re at an in-person program).
Lectures and role-plays are better than nothing, but let me tell you from personal experience—this barely prepares you to handle a situation with a real live client you have come to care about who is sitting six feet from you and talking about killing themselves.
Current therapist training is also remarkably one-size-fits-all. In my program, we all had strengths and weaknesses in the therapy room—but we all had DIFFERENT strengths and weaknesses. I’ve been a performer most of my life, so I didn’t need any extra help getting used to the idea of walking into a room with a total stranger and having a conversation with someone who might ask me, “how long have you been a therapist, anyway?” But some of my colleagues were absolutely petrified at the thought. On the other hand, I’m truly terrible at guiding clients through somatic grounding exercises—not my strong suit and I didn’t get very good training about how to do that (or…why to do that…or when…). My colleague who has a hypnotherapy background, however, is a TOTAL MASTER. We used to make her do guided imagery at wine nights, that’s how good she is!! But we all got exactly the same training.
Unfortunately, the way most graduate programs are structured, they just don’t have the resources or bandwidth or processes in place to monitor individual student progress and offer individualized support. There’s a whole lot of crossing-fingers and hoping for the best.
So, obviously, I have really strong feelings about this. This is why I have partnered with the Sentio Institute, an amazing collaborative headed up by Tony Rousmaniere and Alex Vaz, experts and innovators in the science of deliberate practice for psychotherapists. Together, they run the website Deliberate Practice for Therapists, where they have made available (for FREE) a ton of resources to help therapists interested in becoming better with the help of deliberate practice.
Their vision is to get graduate programs to integrate deliberate practice into their curricula and training sites to incorporate it into how they train therapists, and that’s why I have agreed to a sponsored partnership with Sentio. I would have GIVEN ANYTHING to be trained this way from the beginning, so I want to help in any way I can to make this a reality for future students. Not only was flying blind with my first few clients terrifying for me, it can’t have been all that helpful for them. I constantly think about what I would have been able to do if I had actually been able to practice the things I was taught in graduate school in an environment where I got constructive feedback that helped me improve, before I ever set foot in a room with a client.
The folks at Sentio hope that enough students will demand that deliberate practice be incorporated into their training that institutions will have to accommodate those demands. So that’s why I’m sharing with you my experiences not having deliberate practice be a part of my training—so when YOU get to graduate school, you might be able to specifically request that your professors or supervisors help you incorporate deliberate practice into your training.
Phew…that was long. Thank you for coming to my TED Talk! Now, if you’ve gotten all the way to this part of the post, I want you to know about a free event we’re holding 6/19/2021: I will be hosting a free Q&A with Tony from the Sentio Institute (you may remember him from my enthusiastic book review of one of his books), to spend an hour talking about becoming a psychotherapist. We’ll go over the most commonly asked questions as well as talk about what the mental health field looks like post-COVID. We’ll also be able to take some questions at the end!
