More than a dozen randomized controlled trials and several meta-analyses have provided strong empirical support for routine outcome monitoring (ROM) in clinical practice. Despite current enthusiasm, advances in implementation, and the growing belief among some proponents and policymakers that ROM represents a major revolution in the practice of psychotherapy, other research has suggested that the focus on measurement and monitoring is in danger of missing the point. Any clinical tool or technology is only as good as the therapist who uses it. Failing to attend to the therapist's contribution, the long neglected variable in psychotherapy outcome, ensures that efforts to create, research, and refine new outcome measurement systems will inevitably fall short. Research from the field of expertise and expert performance provides guidance for realizing the full potential of ROM.

Regarding at least its general efficacy, few believe that therapy need be put to the test any longer.The good news of therapy's usefulness has been accompanied by an unprecedented expansion in the number of mental health practitioners. This boom amounts nearly to a 275% increase in professional therapists since the mid-1980s (Miller, Hubble, & Duncan, 1996). Consumers can currently choose among psychiatrists, psychologists, psychoanalysts, Jungian analysts, social workers, licensed professional counselors, family therapists, marriage and family counselors, psychiatric nurses, pastoral counselors, alcoholism and addiction counselors, and others advertising their services under an assortment of job titles and descriptions. Observers both in and out of the helping professions (e.g.,

In 1963, the first issue of the journal Psychotherapy appeared. Responding to findings reported in a previous publication by Eysenck (1952), Strupp wrote of the "staggering research problems" (p. 2) confronting the field and the necessity of conducting "properly planned an executed experimental studies" to resolve questions about the process and outcome of psychotherapy. Today, both the efficacy and effectiveness of psychotherapy has been well established. Despite the consistent findings substantiating the field's worth, a significant question remains the subject of debate: how does psychotherapy work? On this subject, debate continues to divide the profession. In this paper, a "way out" is proposed informed by research on the therapist's contribution to treatment outcome and findings from studies on the acquisition of expertise.

No abstract

Clients of the best therapists improve at a rate at least 50 per cent higher and drop out at a rate at least 50 per cent lower than those of average clinicians. What is the key to superior performance? Are 'supershrinks' made or born? Is it a matter of temperament or training? Have they discovered a secret unknown to other clinicians or are their superior results simply a fluke, more measurement error than reality? We know that who provides the therapy is a much more important determinant of success than what treatment approach is provided. The age, gender, and diagnosis of the client has no impact on the treatment success rate, nor does the experience, training, and theoretical orientation of the therapist. In attempting to answer these questions, MILLER, HUBBLE and DUNCAN, have found that the best of the best simply work harder at improving their performance than others and attentiveness to feedback is crucial. When a measure of the alliance is used with a standardized outcome scale, available evidence shows clients are less likely to deteriorate, more likely to stay longer, and twice as likely to achieve a change of clinical significance.