These are exciting times for clinicians. The pieces of the puzzle are falling into place. Researchers are finally beginning to understand what it takes to improve the effectiveness of psychotherapy. Shifting away from the failed, decades-long focus on methods and diagnosis, attention has now turned to the individual practitioner.
Such efforts have already shown a host of factors to be largely ineffective in promoting therapist growth and development, including:
- Supervision;
- Continuing education;
- Therapist personal therapy;
- Clinical experience; and
- Access to feedback
In October, I blogged about the largest, longitudinal study of therapists ever conducted. Despite having access to ongoing, formal feedback from their clients for as long as 17 years, clinicians in the study not only did not improve, their outcomes actually deteriorated, on average, year after year.
Such findings contrast sharply with beliefs of practitioners who, according to other studies, see themselves as improving with time and experience. In fact, findings on all the practices noted above contrast sharply with beliefs commonly-held in the field:
- Supervision is at the top of the list of experiences therapists cite as central to their growth and development as practitioners. By contrast, the latest review of the literature concludes, “We do not seem to be any more able to say now (as opposed to 30 years ago) that psychotherapy supervision contributes to patient outcome” (p. 235, Watkins 2011).
- Although most clinicians value participating in continuing education activities—and licensure requirements mandate attendance—there is no evidence such events engender learning, competence, or improved outcomes. Neither do they appear to decrease disciplinary actions, ethical infractions, or inspire confidence on the part of therapy consumers.
- Therapist personal therapy is ranked as one of the most important sources of professional development despite there being no evidence it contributes to better performance as a clinician and some studies documenting a negative impact on outcome (see Orlinsky & Ronnestad, 2005);
If any of the research I’ve cited surprises you, or gives you pause, there is hope! Really. Read on.
Doubt, it turns out, is a good thing–a quality possessed by the fields’ most effective practitioners. Possessing it is one of the clues to continuous professional development. Indeed, several studies now confirm that “healthy self-criticism,” or professional self-doubt (PSD), is a strong predictor of both alliance and outcome in psychotherapy (Nissen-Lie et al., 2015).
To be sure, I’m not talking about assuming a “not-knowing” stance in therapeutic interactions. Although much has been written about having a “beginner’s mind,” research by Nissen-Lie and others makes clear that nothing can be gained by either our feigned or willful ignorance.
Rather, the issue is about taking the time to reflect on our work. Doing so on a routine basis prevents us from falling prey to the “over-claiming error”—a type of confidence that comes from the feeling we’ve seen something before when, in fact, we h
ave not.
The “over-claiming error” is subtle, unconscious, and fantastically easy to succumb to and elicit. In a very clever series of experiments, for example, researchers asked people a series of questions designed either to engender a feeling of knowledge and expertise or ignorance. Being made to feel more knowledgeable, in turn, lead people to act less open-mindedly and feel justified in being dogmatic. Most importantly, it caused them to falsely claim to know more about the subject than they did, including “knowing” things the researchers simply made up!
In essence, feeling like an expert actually makes it difficult to separate what we do and do not know. Interestingly, people with the most knowledge in a particular domain (e.g., psychotherapy) are at the greatest risk. Researchers term the phenomenon, “The ‘Earned Dogmatism’ Effect.”
What to do? The practices of highly effective therapists provide some clues:
- Adopt an “error-centric” mindset. Take time to reflect on your work, looking for and then examining moments that do not go well. One simple way to prevent over-claiming is to routinely measure the outcome of your work. Don’t rely on your judgement alone, use a simple measures like the ORS to enhance facts from your fictions.
- Think like a scientist. Actively seek disconfirmation rather than confirmation of your beliefs and practices. Therapy can be vague and ambiguous process—two conditions which dramatically increase the risk of over-claiming. Seeking out a community of peers and a coach to review your work can be helpful in this regard. No need to leave your home or office. Join colleagues in a worldwide virtual community at: iccexcellence.com.
- Seek formal feedback from clients. Interestingly, research shows that highly effective therapists are surprised more often by what their clients say than average clinicians who, it seems, “have heard it all before.” If you haven’t been surprised in a while, ask your clients to provide feedback about your work via a simple tool like the SRS. You’ll be amazed by what you’ve missed.
- Attend the 2016 Professional Development Intensive this summer in Chicago. At this small group, intensive training, you will the latest evidence-based steps for unlocking your potential as a therapist.
Best wishes for the Holidays. As always, please leave a comment.
Scott
Scott D. Miller, Ph.D.
International Center for Clinical Excellence
Dear Scott
I had to laugh once I’d finished crying and had run out of Kleenex, after reading your post concerning the pieces of the puzzle of what makes for an effective therapist. After leading what I’ve been coyly referring to as “a dynamic life” in my resume, a life so wracked with self doubt that my supervisor for my Masters degree (clinical psychology) sent me to see a psychology within the first week, I now find myself unemployed for lack of everything you’ve noted as a benchmarks for success i.e. supervision, CE, personal therapy, clinical experience and client feedback.
I went straight (no pun intended) from recovery from a myriad of challenges (domestic abuse, substance abuse, single parenthood, depression) to going back to school at age 42, finishing high school, my undergrad (English Lit), post grad, (BEd) and Masters, only to find that no one will give me a job, for lack of experience!
In any case, whomever is reading this is most likely not my beloved Dr. Scott, pretty much the only person, online or otherwise, that has made any sense, when it comes to this calling in life. So, thanks for listening and giving me a sliver of hope that someone, somewhere will give me a chance.
cheers
claire
Scott,
Just reading your Top Performance Blog and as always, you’ve provided information that is informative and motivating.
As an aside, I know that Chicago is not that far from Canada, but I would absolutely love to see is a training here in Canada… Just an idea.
Keep up the great research!
Hi Scott – as an ‘expert’ in ‘the flow’ “mindedness is the enemy of expert coping” – i.e. it can take you out of the “flow”. (That phrase is taken from the book ‘Mind,reason, and being-in-the-world: The McDowell-Dreyfus Debate’ – an argument going on between 2 philosophers on expertise – the expert is in the flow). Pat Ogden, John Shotter, and various other psychotherapists talk of the therapeutic conversation taking on a life of its own (sometimes ‘relational mindfulness’) – we are in the flow. If the expert has to turn away from the ‘game’ and analyse or deliberate (engage in “mindedness” in the above quote), the flow is lost. Thought is born of failure. How then does the “expert” stay in the “flow” and remain open-minded and present to deal with nuances indicating we are at risk of going off track. Chuang-tsu tells of the cook whose knife has remained sharp because when he comes to a piece of gristle or bone, he allows it to slow down and find its way through the gaps there too. Dreyfus, in the above book, talks of the expert pilot being guided by the landing beacon that is silent when he is on track; but can remain in the flow by “automatically” correcting his course when it signals, or he “senses a tension that draws him to correct his course”; and only when ‘no alternative perspective directly draws the coper’ to adjust does he have to turn away and deliberate.
Now when I look at the Nissen-Lie paper’s Professional Self-Doubt (PSD) appears to me to be an unduly negative frame to the not-knowing humility and immense sense of responsibility we have as therapists, which encourages us to remain open and sensitive to the ‘landing beacons’. It appears to me that PSD is picking up on the overconfidence generated by the EST or EBP movement in particular therapies.
The paper does indirectly support Foucault’s late career development of an ethic of self-care to be better parrhesiates. I would note that the paper makes a couple of favourable mentions of Tim Leary’s work before he became notorious, but sadly fails to provide the references in the References.
regards
Nick Drury
Scott,
What sense do you make of the findings that indicate client feedback is
ineffective at promoting growth and development, in terms of the ORS and
SRS?
“Research efforts have already shown a host of factors to be largely
ineffective in promoting therapist growth and development, including:
supervision, CE, personal therapy, clinical experience and client feedback.”
Could session feedback provoke PSD?
Patricia Millar, PhD
http://www.CoachThink.com
Self doubt is a constant companion. Finally, I find a good use for it. Thank you for this thoughtful post that reminds me that people come in with their most intimate feelings and thoughts, how ridiculous I am when I lump them all together.
There were so many times when I was a client in therapy, how I would have loved it if a therapist had been curious about how he/she was impacting me, and a little less sure of the method.
Thank you, Scott, for the work you do. The more I am exposed to it, the more I remember to use my self doubt in the interest of my clients. Keep it coming!
In Broken Images-Robert Graves
He is quick, thinking in clear images;
I am slow, thinking in broken images.
He becomes dull, trusting to his clear images;
I become sharp, mistrusting my broken images,
Trusting his images, he assumes their relevance;
Mistrusting my images, I question their relevance.
Assuming their relevance, he assumes the fact,
Questioning their relevance, I question the fact.
When the fact fails him, he questions his senses;
When the fact fails me, I approve my senses.
He continues quick and dull in his clear images;
I continue slow and sharp in my broken images.
He in a new confusion of his understanding;
I in a new understanding of my confusion.