She’d started young. At age 3, she was named “Miss Beautiful Baby.” Shortly thereafter, she became a regular –“Bubbles Silverman” — on the Uncle Bob’s Randbow House radio show.

Voted “most likely to succeed” by her high school classmates, she sang everywhere and anywhere before landing a position as “house soprano” at the City Opera of New York in 1955. Her later performance of the aria, “Se Pieta” in Handel’s Julius Ceaser led a New Yorker magazine theatre critic to comment, “If I were recommending the wonders of New York to a tourist, I would place Beverly Sills at the top of the list.” High praise given the vast pool of talent in the “city that never sleeps.”

Not suprisingly, when Sills died in 2007, she was hailed as, “one of this country’s great operatic voices” — a remarkable compliment given that no one had heard her sing at that point in nearly three decades! Rather, in 1980, at the height of her fame, she chose to retire.

“There is a kind of desperation,” she later said, “staying at something too long … and I am not a desperate woman. I wanted people to say, ‘It’s too early,’ rather than, ‘When is that woman ever gonna quit? It was the perfect time to go out — on top.”

In today’s media and influencer saturated world, some might deem Sills’ decision foolish. “Why quit? Why not hang around, make as much ‘bank’ as you can, ride the waves of fame and adulation as long as far as they will carry you?” Heaven knows many in the public eye stick around far longer than their expiration date. For her, however, her commitment to performance excellence trumped any resulting celebrity.

Personally, I admire the choice Sill made. As I age, I’ve found myself wondering more often about when to “hang it up.” It can’t be based on demand, real or perceived. Indeed, there is a kind of conceit in leaving the decision up to others.

Seems to me that exiting at the top of one’s game is even more challenging in the field of therapy where age and experience are believed to confer special advantage. The same may be said of commercial airline pilots — at least, I know I feel more confident when the flight crew trends older than the cast of High School Musical. And yet, given the declines in memory, reasoning, verbal fluency and comprehension skills associated with advancing years, pilots have a mandatory retirement age, a standard applicable across 193 member-nations! Surely, some could continue for longer, but doesn’t that beg the question?

As reviewed here, research on therapists makes clear age and experience confer no advantage and are likely associated with poorer performance (1, 2).

So, what are your criteria?

Until next time,

Scott

Director, International Center for Clinical Excellence

Once upon a time, a nickel (the U.S. 5-cent coin) had value.

As a kid, I could get a generous scoop of ice cream at Sav-On, Big Hunk candy bar at Bock’s variety store, or a super-sized glazed doughnut at the Donut Man shop on Route 66.

At that time, a nickel was considered so valuable that when you wanted to imply something was worthless, you would say, “Yeah, that, and a nickel will get you a cup of coffee.” According to a post on Quora, the expression arose in the 1940’s when a cup typically cost five cents.

Along with, “I’m not going to hold my breath,” the expression was one my Dad sometimes used in response to me making any number of promises (e.g., clean my room, walk the dog, practice the piano or be nice to my younger brother).

I’m sure he hoped I’d follow through, much the same way we therapists believe growing clinical experience results in greater expertise and effectiveness. Why, otherwise, would so many of our websites feature “time in the chair” so prominently?

“I have over 15,000 hours of clinical experience,” says one. “I’ve been a psychotherapist for more than 20 years and have authored 5 best-selling books,” says another.

And yet, when such statements are considered in light of the evidence, it seems clear the most appropriate response is, “Yeah, and that plus $6.75 will get you a grande, soy, caramel macchiato at Starbucks.”

(The cost of a cup of coffee has obviously risen a bit since 1940)

Indeed, as I’ve reported in previous posts, research not only shows therapists do not improve with time and experience in the field, but on average become less effective (1, 2, 3, 4). Other studies document that students achieve outcomes on par or better than licensed professionals who supervise them (5, 6). Given such findings, it is more than a bit ironic that experience is associated with higher per hour fees (7) — increased rates which, it turns out, are tied to higher dropout rates!

Enter a new study by Bugatti and colleagues examining therapist dropout rates. Using data generated by more than 2,500 practitioners working with real clients in real world clinical settings, the researchers found therapists’ dropout rates increased the longer they were in practice.

You read that right.

Similar to the findings on effectiveness, therapist experience is not associated with better client retention rates. More, as noted previously, “therapists working with clients paying higher out-of-pocket fees have higher increases in client dropout over time.” Finally, in case you are wondering, caseload size did impact retention rates, but in a direction opposite to what most expect; specifically, therapists treating the most clients had the lowest dropout rates.

Bottom line? It’s time for the field to stop attributing benefits to clinical experience. Beyond the obvious ethical concerns, doing so actually prevents us from improving our effectiveness! A fundamental element of deliberate practice is challenging automaticity, or the lack of conscious control over and inability to make specific intentional adjustments to our behaviors that comes with … experience.

Raising awareness is the first step. To improve, we have to know where our actions and thinking fall short. Measuring and mapping our performance — as described in Better Results: Using Deliberate Practice to Improve Therapeutic Effectiveness and its companion volume, The Field Guide to Better Results — are two methods proven to help. The latest studies show, for example, both improved retention and effectiveness rates (~25%).

My colleauge and co-author, Daryl Chow, Ph.D., and I will be talking about these two methods (and the latest research findings reported here) at the next, online “Tuesdays with Daryl and Scott.” Held the last Tuesday of each month, the next one will be held on May 28th at 8 a.m. Central time.

No cost — not even a nickel — and you supply your own coffee.

Space is limited, however, so please click here to register and secure your spot.

Its the biggest update to Feedback Informed Treatment (FIT) in two decades.

In the beginning, all we had were the measures. Clinicians administered the outcome and session rating scales at each session and then compared client scores to the clinical cutoffs (CCO) and reliable change index (RCI) to determine whether care was “on or off track.”

The evolution continued. As data gathered from clinical practice settings accumulated, it became possible to develop “trajectories of change.”

Users of Myoutcomes.com, Fitoutcomes.com, and OpenFIT will instantly recognize the graph pictured below.

Gone were the comparisons to percentile rankings of the normative sample. Instead, the green line represented the least amount of progress the client could make from session to session and still be on track for a successful outcome. Yellow was interderminate and red definately, “off track.”

Since first becoming available, the algorithms that produce the predictive trjectories have been checked and updated every three years or so. The latest review — involving millions of completed cases of care — confimed their ability to inform mental health services provided in diverse settings around the world.

All good. Except, it wasn’t.

Isn’t.

While offering a clear advantage over comparisons to the cutoff scores, percentile rankings, and pre-established change indices, the algorithm-driven, predictive trajectories were still static. Said another way, they did not change following the first visit. True, the initial score was a better predictor of success than a host of factors traditionally considered reliable indicators (e.g., diagnosis, prior treatment history, type and level therapist training). But surely, more accurate assessments of progress would be made if they took into account what happened from visit to visit. Indeed, wasn’t that the whole point of soliciting feedback? Improving the chances of success by adjusting services on an ongoing basis to better fit the individual client?

Enter the SPI, or “Success Probability Index.”

Briefly, the SPI offers an indication of the likelihood of success at each session based on the current and historical pattern of SRS and ORS scores. Importantly, the particular pattern used to generate the index at any given session (e.g., average, slope, change in scores since the prior visit or over the course of care) varies depending on which most accurantely predicts success at the end of care. As can be seen in the screenshot below, despite similar start scores, the different patterns of progress represented in the two graphs result in different predictions. Specifically, the case on the left is on track, while the one on the right (coded in red), is about 16.5% below the average successful client.

In the near future, I’ll publish a “FIT TIP” or two explaining in greater detail both meaning and use of the SPI. In the meantime, take a look at the video produced by Myoutcomes.com — the first system to make the SPI available to their users.

Until next time,

Scott
Director, International Center for Clinical Excellence