Supervision: Time for a New Way or to Dump the Practice Altogether?

January 10, 2020 By scottdm 3 Comments

Therapists value supervision. How do we know? Research.

In their massive, long-term international study of therapist development, for example, Orlinsky and Rønnestad (2005) found, “practitioners at all experience levels, theoretical orientations, professions, and nationalities report that supervised client experience is highly important for their current and career development” (p. 188).

Regulatory boards deem supervision essential, in most jurisdictions requiring trainees have 3,000 hours –or nearly two years of full time work — before becoming licensed to practice independently.

Given such beliefs and requirements, one might reasonably conclude the evidence-base for clinical supervision is substantial. And yet, a thorough search of the literature for studies investigating the relationship between the practice and treatment outcome turns up a mere handful of empirically sound investigations. For these, the best that can be said is, the results are decidedly mixed (1, 2, 3, 4, 5). It’s notable that a popular text on “evidence-based” supervision written by two leading researchers cites zero evidence that it leads to better results!

“Ultimately,” argue researchers Wrape and colleagues (2014), “the criteria by which to evaluate supervision’s efficacy … lie(s) in its power to bring about favorable client changes” p. (36). Clearly, the assumption traditional supervision provides clinicians with the knowledge, skills, and capability necessary to provide safe and effective therapy is empirically questionable. Perhaps the time has come to dump supervision altogether or at least consider new ways for helping clinicians deliver more effective services?

As already indicated, plenty of evidence indicates clinicians appreciate supervision. Indeed, a near linear relationship exists between the number of hours received and levels of practitioner self-efficacy, job satisfaction, burnout, treatment knowledge, acquisition and use of particular treatment techniques and skills. And therein lies the paradox: how, you might reasonably wonder, could such positive results not translate into improved outcomes for clients?

The answer? Experience ([i.e., time in the field] of supervisors and therapists), self-rated efficacy, treatment knowledge, and competence in delivering particular treatment approaches are not, and have never been, related to outcome. So, while regular contact with peers and mentors provides with critical emotional support for clinicians, something more and different is required for them to become more helpful to their clients.

Clues to what might replace traditional supervision can be found in a study by Goldberg et al. (2015) — the only study to date of a process resulting in continuous improvement in therapist effectiveness over time. In it, practitioners engaged in five distinct activities: (1) formal and routine measurement of their client’s experience of progress and quality of the therapeutic relationship; (2) identification of performance shortfalls using the data generated by routine outcome monitoring; (3) ongoing clinical/supportive supervision to aimed at improving responsiveness in real time to the differences between individual clients; (4) coaching from an external expert; and (5) engagement in deliberate practice around basic therapeutic skills.

Clicking on the links above can provide you with ideas and resources to get started. Participating in an intensive training is the next step. Why not join us for the March intensives? With the ICCE international faculty, you will get a thorough grounding in steps 1 through 3. Click here for more information or to register. Only a handful of spots remain.

OK, that’s it for now. Until next time,

Scott

Scott D. Miller, Ph.D.
Director, International Center for Clinical Excellence

Learning Charisma

June 11, 2019 By scottdm Leave a Comment

I entered university an accounting major.

My first year, I took all the recommended courses: accounting theory, fundamentals of financial and managerial accounting, and so on.

I’d likely be sitting in an office balancing company ledgers or completing tax documents had I never met Hal Miller. A Harvard-educated professor, Dr. Miller taught multiple sections of the Psychology 111 course students could take as part of the required “general education” curriculum.

Decades have now passed since I first met him. Still, I remember that first class as if it were yesterday. When I arrived, every seat in the large, theater-style classroom was already taken, students overflowing into the hallway outside. In time, I’d learn many were not officially registered for the class. They were there because they wanted to hear him speak.

Within weeks, I’d changed my major to psychology. I’m not sure how interested I was in the subject at the time. Rather, I wanted to be like Hal Miller. He loved what he was doing, was devoted to learning, and, most importantly, made me want to study. He was, in a word, charismatic.

“Charisma,” researchers Antonakis, Fenley, and Liechti report, “is rooted in values and feelings. It’s influence born of the alchemy that Aristotle called, the logos, the ethos, and the pathos.”

LOGOS = WORDS, LOGIC, FACTS

ETHOS = ETHICS, CREDIBILITY, EXPERTISE

PATHOS = EMOTIONS, CONNECTION, LIKE-MINDEDNESS

Hal Miller embodied all three qualities. His ability to engage, communicate, and inform, literally changed my life. I’m sure you can identify people who’ve had a similar impact on you.

But how did he do what he did? Did he learn it? Was it in his genes?

It turns out, the word, charisma, comes from the Greek χάρισμα, meaning “gift of grace” — a view widely held even today. You either “got it or you ain’t.”

Curiously, while one study in psychotherapy found it to be both relationally and therapeutically helpful, most of the serious research on the subject comes from other fields where social influence is critical to success (e.g., leadership, training, management). There, the evidence is clear: charisma is, “a learnable skill or, rather, a set of skills,” the potency of which can be dramatically improved with practice.

What exactly does that entail?

As a person whose spent his entire professional career providing continuing education workshops to therapists, I can tell you the absence of specific training means its mostly trial and error. A few have the good fortune to work closely with a gifted practitioner or presenter. I had the opportunity, or example, to work closely with Insoo Berg — a person who exuded warmth and charisma both in the therapy room and on the lecture circuit. And yet, rarely are students of charismatic individuals are as successful or magnetic as their mentors.

So, what does it take?

As hackneyed as it may sound at first, the key is “being yourself.” While its tempting to copy the content, style, and mannerisms of the Hal Millers and Insoo Bergs in our lives, doing so, everyone quickly recognizes, is mere tribute. Success means putting the principles of charisma — logos, ethos, pathos — into practice in a way that is congruent with who you are, your own style, persona and, critically, message.

Below, you’ll find a TedTalk by Professor John Antonakis, one of the leading researchers on charisma. It’s worth a listen. The first 5 minutes is interesting and provocative, but you must listen longer to learn about the evidence documenting that you can dramatically improve your ability to communicate with impact.

If you still are looking for something more practical and skill-based, and specific to psychotherapy, then join my colleagues and I for the upcoming “Training of Trainers” workshop, held the first week of August in downtown Chicago. Together with an international faculty, and participants from around the world, we’ll work on helping you become the most effective version of you, either in your role as a therapist or trainer/presenter. For more information or to register, click here.

Until next time,

Scott

Scott D. Miller, Ph.D.
Director, International Center for Clinical Excellence

Time for a New Paradigm? Psychotherapy Outcomes Stagnant for 40 years

February 1, 2019 By scottdm 8 Comments

You’ve heard it said before. Flying is the safest form of transportation.

Facts back up the claim. In fact, it’s not even close. In terms of distance traveled, the fatality rate per billion kilometers is .003, improving dramatically over the years. Cars, by contrast, are almost 1,000 times more dangerous. Still, since 1923, the fatality rate in motor vehicle accidents has declined an eye-popping 93%.

How about psychotherapy? Have outcomes improved? Judging by the size of the Diagnostic and Statistical Manual and growth in the number of treatment approaches, one would expect success rates to have climbed significantly, if not exponentially. Not so, as I first presented at the Evolution of Psychotherapy Conference five years ago, and later on this blog, the empirical evidence clearly shows NO improvement.

And now a new study, this time reviewing the evidence regarding treatments for children and adolescents. Using sophisticated statistical analyses, the researchers examined 453 RCT’s spanning 53 years, involving nearly 32,000 kids treated for anxiety, depression, attention deficit/hyperactivity, and conduct problems. With the rising popularity of “evidence-based practice,” those conducting the study wanted to know whether “… our methods of developing and testing youth psychological therapies [are] producing improvement” (p. 2).

Can you guess what they found?

Outcomes have not changed (much less improved) over the last five decades–that’s 351 in dog years!

Can you imagine the outcry had similar results been published about automobiles or planes? You would fully expect hearings to be held, and leaders to be called called to account. The lives of children are on the line.

Nope. Instead, facing the supersized differences between promises made every year about “advances” in psychotherapy, and the results realized and reported in research studies, the authors meekly call for, “new approaches to treatment design and intervention science” (p. 1).

Really? Is that what’s required? Researchers going back to the drawing board of “treatment and intervention?”

No, what’s needed is an entirely different view of what clinicians actually do — and it starts by giving up the idea that psychotherapy is a form of treatment similar to antibiotics or angioplasty. Let’s face it. Psychotherapy is no more a medical treatment than are the facials, salt glows and body wraps one receives at the local spa. Which is not to say, it doesn’t work.

Outside the halls of academia, millions of therapists worldwide are helping people on a daily basis to live happier, more meaningful and functional lives. Dozens of studies of real world practitioners document outcomes that meet or exceed benchmarks established in tightly controlled, model-driven, randomized trials — all without following a particular, “evidence-based” protocol (see 1, 2, 3,4).

So, how best to conceptualize the effective work clinicians do? And, importantly, what could researchers offer that would be of real help to therapists?

That psychotherapy works, says more about humans and our need for connection, meaning, and purpose, than it does about the particulars of any given model or approach. And that our methods focus on thoughts, feelings, behaviors, and brain chemistry, says more about our Western values and beliefs, than about the ingredients necessary for successful healing.

Simply put, the field does not need to, as the authors of the study argue, “intensify the search for mechanisms of change [and] transdiagnostic … treatments” (p. 1). Doing so is merely a recipe for “more of the same.” Rather, to move forward, it should abandon the medical paradigm that has long had a stranglehold on our research and professional discourse, choosing instead to reconnect with the larger, worldwide family of healers, one that has existed since the dawn of history and which, from the outset, has been deeply engaged in the values and beliefs of those they treat, using whatever means necessary, consistent with the culture, to engender change.

What might that look like in practice?

As already documented, practicing clinicians already do a pretty darn good job helping their clients. There’s nothing wrong with our Westernized approaches when they work. At the same time, we don’t succeed with everyone. The problem, studies show, is we’re not particularly good at knowing when we’re not being helpful, when clients are at risk for dropping out or are actually deteriorating while in our care (1, 2). On this score, research has already provided a solution. Dozens of studies document, for example, using simple measures at the beginning and end of each visit not only provides clinicians with an opportunity to intervene more successfully with “at risk” clients, but also helps identify opportunities for their own growth and development (1, 2). If you’re not routinely and formally measuring the quality and outcome of your work, you can get started by accessing two simple tools here.

With outcome as our guide, all that remains is being willing to look outside the profession for possibilities for healing and change unbound by convention and the medical view. That’s happening already, by the way, in the world’s two most populous countries, India and China, with professionals learning the ways of indigenous healers and government officials tapping local shaman to meet citizen’s mental health and well being needs.

So, what about you? What you are doing to extend your healing reach?

And, in case you haven’t seen it, the video below is from the most recent Evolution of Psychotherapy conference, where I talk about new research documenting psychics achieving the same or better results as psychotherapists.

Until next time,

Scott

Scott D. Miller, Ph.D.
Director, International Center for Clinical Excellence

P.S.: Want to learn more about using outcome to inform and improve your effectiveness? Join me and an international group of teachers and researchers in Chicago for our Summer Intensives. For detailed information and to register, click on the banners below.