I can remember exactly where I was when I first “met” Swedish psychologist, K. Anders Ericsson.  Several hours into a long, overseas flight, I discovered someone had left a magazine in the seat pocket.  I never would have even given the periodical a second thought had I not seen all the movies onboard — many twice.  Its target audience wasn’t really aimed at mental health professionals: Fortune.  

Bored, I mindlessly thumbed through the pages. Then, between articles about investing and pictures of luxury watches, was an article that addressed a puzzle my colleagues and I had been struggling to solve for some time: why were some therapists more consistently effective than others?

In 1974, psychologist David F. Ricks published the first study documenting the superior outcomes of a select group of practitioners he termed, “supershrinks.”  Strangely, thirty-years would pass before another empirical analysis appeared in the literature.

The size and scope of the study by researchers Okiishi, Lambert, Nielsen, and Ogles (2003), dwarfed Rick’s, examining results from standardized measures administered on an ongoing basis to over 1800 people treated by 91 therapists.  The findings not only confirmed the existence of “supershrinks,” but showed exactly just how big the difference was between them and average clinicians.  Clients of the most effective experienced a rate of improvement 10 times greater than the average.  Meanwhile, those treated by the least effective, ended up feeling the same or worse than when they’d started — even after attending 3 times as many sessions!   How did the best work their magic?  The researchers were at a loss to explain, ending their article calling it a “mystery” (p. 372).

By this point, several years into the worldwide implementation of the outcome and session rating scales, we’d noticed (and, as indicated, were baffled by) the very same phenomenon.  Why were some more effective?  We pursued several lines of inquiry.  Was it their technique?  Didn’t seem to be.  What about their training?  Was it better or different in some way?  Frighteningly, no.  Experience level?  Didn’t matter.  Was it the clients they treated?  No, in fact, their outcomes were superior regardless of who walked through their door.  Could it be that some were simply born to greatness?  On this question, the article in Fortune, was clear, “The evidence … does not support the [notion that] excelling is a consequence of possessing innate gifts.”

So what was it?

Enter K. Anders Ericsson.  His life had been spent studying great performers in many fields, including medicine, mathematics, music, computer programming, chess, and sports.  The best, he and his team had discovered, spent more time engaged in an activity they termed, “deliberate practice” (DP).  Far from mindless repetition, it involved: (1) establishing a reliable and valid assessment of performance; (2) the identification of objectives just beyond an individual’s current level of ability; (3) development and engagement in exercises specifically designed to reach new performance milestones; (4) ongoing corrective feedback; and (5) successive refinement over time via repetition.

I can remember how excited I felt on finishing the article.  The ideas made so much intuitive sense.  Trapped in a middle seat, my row-mates on either side fast asleep, I resolved to contact Dr. Ericsson as soon as I got home.

Anders replied almost immediately, giving rise to a decade and a half of correspondence, mentoring, co-presenting, and friendship.  And now he is gone.  To say I am shocked is an understatement.  I’d just spoken with him a few days prior to his death.  He was in great spirits, forever helpful and supportive, full of insights and critical feedback.  I will miss him — his warmth, encouragement, humility, and continuing curiosity.  If you never met him, you can get a good sense of who he was from the interview I did with him two weeks ago.  Let me know your thoughts in the comments below.

Until next time, I wish you health, peace, and progress.

Scott

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.

Some time ago, my son had a minor obsession.  Whether at the dinner table, in the car, or out for a walk, he was constantly peppering us with, “would you rather” questions?  You know the ones I mean, where you are forced to choose between two equally bizarre or unpleasant alternatives?

“Would you rather always have to say everything that is on your mind or never be able to speak again?”

“Would you rather have the hiccoughs the rest of your life or always feel like you have to sneeze but not be able to?”

And finally:

“Would you rather smell like poop and not know it or know you smell like poop but others can’t smell it?”

Fast forward to today.  

I was re-reading some recent research on the use of deliberate practice (DP) for improving individual clinician effectiveness.  As I’ve blogged about previously , one of the four crucial components of DP is feedback.  Not just any kind of mind you, but negative feedback–in particular, immediate, ongoing information regarding one’s errors and mistakes.

Put bluntly, receiving negative feedback is hard on the ego.  Despite what we may say or believe, a mountain of literature documents we all possess a strong need for social approval as well as a bias toward attributing positive traits to ourselves.

The same research shows that, beyond selective recall and well-known biases associated with self-assessment, we actively work to limit information that conflicts with how we prefer to see ourselves (e.g., capable versus incompetent, perceptive versus obtuse, intuitive versus plodding, effective versus ineffective, etc.).

As a brief example of just how insidious ours efforts can be, consider an email sent out by the customer service department at a Honda dealership in Richmond, Virginia.

“As you may know,” it began, “we have a wide range of services performed here at our location and strive to do the best we can to accomodate each and everyone of our customers.”   A request for feedback followed, “There may be times we can not meet the needs and we would appreciate any feedback . . . for our company.”

So far so good.  The company was on the way to showing its customers that it cared.  It had sent a follow-up email.  It thanked its customers.  Most importantly, it invited them to provide the type of feedback necessary for improving service in the future.

The correspondence then ended, telling the recipient they would soon receive a survey which, “If you enjoyed or were satisfied with your recent visit and provide a 100% score you will receive a FREE oil change.”

Amazing, eh?  Thanks to my long-time colleague and friend, Arnold Woodruff, for noticing the irony in the email and passing it on to me.

For whatever reason, on reading it, one of those “would you rather” questions immediately came to my mind:

“Would you rather be approved or improved?”

No waffling now.  There is no in-between.  I can hear my son saying, “you have to choose!”

Why not join me and colleagues from around the world who are “choosing to improve” for our two-day intensive on deliberate practice.  Together with Dr. Tony Rousmaniere–the author of the new book Deliberate Practice for Psychotherapists—you’ll learn the latest, evidence-based strategies for improving your effectiveness.  Register today, by clicking here, or on the image below.

Until next time,

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