Over the last several months, I’ve been writing a series of short, but true stories from my life and work. I’ve been surprised by and am grateful for the positive response. All of the stories can be found on my substack account, called “Snippets.” Here’s one from early on in my career, a lesson about working in the real world learned from my collegue and co-author, Insoo Berg.

AGAPE

At six and a half feet in height, and 250 pounds, Gerrard was an imposing figure.  The Capuchin brother-cum-social worker had worked with him for months on the streets to gain his trust.  Now, both were at the office.

I was seated in a large room together with several other therapists.  Surrounding us were a series of one-way mirrored windows, each looking into a different consultation room.  Donning one of the 1950’s-style headsets hanging together on makeshift hooks made it possible to listen in on the session of one’s choosing.

Only all the rooms were empty save one.  The largest room in the complex.  There, sat two people.  One was Insoo Kim Berg; the other, of course, Gerrard – except he was not so much sitting as leaning.  Forward.  Side-to-side.  Back with mouth agape, at times snoring loudly.   

“Yoo hoo,” Insoo called out once, then again, “Yoo hoo, Gerrard.” 

“I have an important question to ask you,” she continued the moment his eyes flitted open. 

It was my second official visit to The Brief Family Therapy Center in Milwaukee, Wisconsin.  I’d met Insoo a year or so earlier while attending a workshop she was giving in Denver, Colorado on treating drug and alcohol problems. 

“Why don’t you come visit us?” she asked on one of the long walks we took together in the mornings before the training began.  It just so happened we were both staying at the home of a mutual friend.  “Stay for a week.  Watch cases,” adding, “You can stay at our home.  We have an extra bedroom, with its own bath.”

I jumped at the chance. 

When Gerrard’s head rolled back on his shoulders, Insoo quickly moved her chair forward and began patting his leg.  

“Yoo hoo, Gerrard.”  Pat.  Pat.  Pat.  Raising her voice, “YOO HOO!”

“This guy is so stoned,” one of the clinicians said loud enough for all of us to hear through our headphones, “he can’t even keep his eyes open.”

That’s when I heard my name being called. 

“Scott?”

Looking up, I could see Insoo was staring in the direction of the mirrored glass. 

“Would you and Brother Joel come in here, please?”

Without thinking, I stood and made my way toward the door to the consultation room, Gerrard’s Capuchin escort not far behind

“Help me get him up,” she directed, “one of you on each side.”

We did as instructed, at times the two of us bearing Gerrard’s entire weight as we dragged him around the room, all the while Insoo hounding him with the types of questions for which she was best known. 

When the meeting ended some 50 minutes later, I was physically exhausted.  Making my way back to observation room, I sat slumped in my chair waiting for Insoo to return to discuss the session with the group.

Her response to the first question raised ensured it the last one asked.  “Why,” the same person who’d commented earlier about Gerrard, asked “when this person is so high he can’t even keep his eyes open, did you carry on?  Why not just reschedule when he’s sober and able to remember what happens?”

Insoo didn’t miss a beat.  “This might be the only chance I get,” she instantly replied, “and if he has any memory of me at all, I want it to be that I tried.”

I did meet Gerrard one additional time.  It was about a year later.  As before, I was seated in the observation room waiting for Insoo to enter with her next client.  Twenty-or-so other therapists from different states and countries were there to watch and learn.  This time, instead of visiting, I was working full time at the center. 

In she walked, trailed by a tall, well-dressed, bespectacled man. 

“Shall I sit here?” he asked, his voice strong and diction clear.  Parting his camel hair topcoat, he sat, crossing his legs at the knee.  Our clients falling on the low end of the socioeconomic spectrum or often homeless, I admit thinking to myself, “I wonder what this guy is doing here?”

I blinked hard, twice, when Insoo began, “Gerrard, its so good to see you …”

Over the last several months, I’ve been writing a series of short, but true stories from my life and work. After some gentle encouragement from Carrie Witta of Very Bad Therapy podcast fame, I created a substack account and have been posting the “Snippets” once a week or so. Some are drawn from encounters in the therapy room, others from childhood — all from experiences that made an impact despite their brevity. The latest is how one of my clients in therapy helped me — it turns out, not an infrequent experience, if allowed.

I’ve cut and pasted it below. You can also read it on substack. Subscribe and you’ll be notified each time a new story is published. Can’t beat the price — its free!

From the oversized bag resting on my office floor, she produced a VHS video cassette. “I’m hoping this,” passing it to me, “will explain, better at least, than I’ve been able to.”

Our session over, she stood and turned toward the door. “S e e yo u t o m o r r o w,” I stammered, feeling awkward as ever – which, by the way, was often.

Partly because I was an intern at the time, but also due to my nature, what seemed to come so easily to others, I found difficult. Suffice it to say, I was no natural therapist. Quite the contrary. I was aware of and deliberate about every action I took and didn’t take, including what I said and didn’t say, when I spoke or chose to remain silent, the movement of my limbs, head and torso, whether I looked away or directly at the person, and for how long.

Anyway, I brought up the hour with my practicum supervisor the following morning. “Let’s see what’s on the tape,” he quickly suggested.

We watched a minute or so, then fast forwarded through a few more.

“Does this mean anything to you?” he asked.

Shaking my head from left to right, “No, uh, I, it doesn’t.”

Speeding through the entire 90-minute cassette, it was clear the video was a carefully edited collection of snippets from various television programs and commercials – some I recognized, others that were unfamiliar. Five seconds of American Bandstand, followed by a clip of a Calvin Klein advertisement, another five or ten second scene from American Bandstand and then extended cuts to the TV series, Dance Fever. If there was a theme, or some intended message, it was lost on me as well as my far more experienced supervisor.

“Did you have a chance to watch the tape?” she asked at the outset of our next session.

“I, I, I did …” falling silent, purposefully lowering my eyes.

“And did it help make things any clearer?”

Looking up, “Could you help me understand what was in the video, what it’s about?” I said, being careful to repeat the words I’d role-played the day before with my supervisor.

A long silence followed.

After 30 years of being a psychologist, there’s little that surprises me about people and their lives – sure, the details differ, but the stories generally have a familiar ring. Then, however, it was all new to me.

Caroline was on the inpatient ward of a hospital where I was completing an extended practicum. Married, stay-at-home mom to several kids, she’d become depressed in the last year. When standard outpatient psychotherapy and medication didn’t help, she was admitted for more intensive care.

And when she eventually said, “It’s about feet,” it all came together. The hour-and-a-half long video was nothing but feet. Feet walking. Feet dancing. Feet in shoes. Feet in flip-flops. Bare feet – loads of bare feet.

For most of the time that remained, I listened, leaning forward, eyes fixed on Caroline as she talked about her husband’s interest in feet. Early on in their relationship, she hadn’t minded. However, when what had started off as a curious, and even intriguing part of their sex life, had warped into an obsession, she ended up feeling alone, unfulfilled, and betrayed.

Years after we met and worked together, I received a letter from Caroline. By this time, I’d graduated, moved out of state and across the country. From the postmark and multiple forwarding address labels, I could see it had been in transit for some time.

“I’ve been meaning to write for some time,” the letter began. After providing some details about her life and family – all generally positive – she explained why she’d chosen to write.

“I wanted to thank you for the help you gave me at that very difficult time …”

Temporarily looking up from the page, I wondered how that could be true. My recollection was I’d done little and understood less. With a mixture of anticipation and dread, I read on.

“I also want to give you some feedback, something I should have said long ago.”

Here it comes, I thought, pursing my lips.

“When we were meeting, I knew there were (many?) times you didn’t know what to say or do.”

Despite hoping my frequent, and often lengthy silences had been interpreted otherwise, her observation was spot on. I smiled in recognition.

She continued, “In case you didn’t know, it’s those moments that stuck with me and were the most helpful. Your stillness gave me the space to hear what I was feeling and accept myself. It was life changing.”

Tucking the letter back into the envelope, I couldn’t help thinking she was returning the favor.

In 1997, Wampold and colleagues published a study that revolutionized psychotherapy outcome research. It addressed a question that had long divided the field; specifically, were some therapeutic approaches more effective than others?

Each side in the debate claimed the data supported their position — and, like a Rorschach ink blot, the available evidence could be interpreted in sharply different, but seemingly valid ways.

(Do you see two researchers sitting opposite one another but looking at the same computer screen?)

In the debate between contrasting positions, its easy to miss the study’s main contribution. True, the authors found no difference in outcome between competing treatment approaches. However, the important question, given years of conflicting results, was “why?”

Turns out, many previous studies — particularly those reporting significant differences between methods — included comparisons to approaches not intended to be therapeutic. If one really wanted to know whether a treatment (e.g., CBT, IPT, ACT, EMDR) was more effective, it had to be directly compared to an approach intended to help — what Wampold and colleagues termed, a “bona fide” treatment. Doing otherwise, they argued, conflated artifacts of research design with actual research results.

“Well, of course,” you say? And yet, a more recent debate among researchers makes obvious, the findings from two-and-a-half decades ago apparently aren’t that obvious. Consider, for example, deliberate practice. Despite rising interest in the topic in psychotherapy, and the publication of several studies, it’s true impact on performance is a matter of debate (1, 2, 3, 4, 5).

Following a meta-analysis of the available research, Miller, Chow, Wampold, Hubble, del Re, Maeschalck and Bargmann (2018) argued that an accurate understanding of deliberate practice would only be, “likely when: (1) research included in any analysis is an actual study of DP; and (2) the criteria for what constitutes DP are standardized, made explicit, accepted by researchers, and applied consistently across studies” (p. 7). They proposed “bona fide” deliberate practice included four, research-based criteria: (1) individualized learning objectives; (2) ongoing feedback regarding performance and learning; (3) involvement of a coach; and (4) successive refinement through repetition most often conducted alone.

Last week, the first study of deliberate practice to meet all four criteria was published in Training and Education in Professional Psychology. It deals with improving therapist ability to handle conversations typically considered difficult in treatment. Bottom line: DP was superior to self-reflection and generalized to novel challenges. I will post the study here as soon as an online or print version becomes available. Until then, my colleague, Daryl Chow, and I discuss the results and practical implications in the video below.

Until next time,

Scott

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