We’re big fans of Scott Miller and his Top Performance Blog around here. Miller has allowed his career to be guided by emerging research, a trait that is surprisingly rare in the psychotherapy world. It has led him to some very useful conclusions about how we can become more effective. Deliberate practice and using outcome data are two specific things that we all could do that would almost certainly improve our outcomes.
There are many things about his work to admire. But what I appreciate most is his skill at walking the difficult line between being alarmist — it’s kind of a big deal that therapy outcomes haven’t gotten better in 40 years — and being supportive and uplifting for therapists who are doing their own part individually to improve. So it was an honor to meet him at the 2017 Evolution of Psychotherapy Conference, and to have him interview me earlier this year for his blog.
It isn’t experience, and it isn’t the kind of training we usually do.
I’m blogging this week from the Evolution of Psychotherapy Conference in Anaheim, where many of the world’s leaders in psychotherapy gather to discuss the state of the field and share new and innovative research findings.
Therapy is tremendously effective. The average treated client ends up better off than 80% of untreated people with similar problems. Psychotherapy for mental health problems is as effective as coronary bypass surgery for heart problems and four times as effective as flouride toothpaste in preventing dental problems. But we’re not getting better, Scott Miller said in yesterday’s opening workshop.
Miller summarizes our field’s efforts to figure this out thusly: We started by looking at our treatment models, hoping to build better techniques to reach better outcomes. This is where many training programs still live: We teach manualized, empirically-supported treatments in hopes that it will make for the most effective therapists. Except it doesn’t; the models formalize and standardize our work, but they don’t make us any more effective, according to outcome studies.
So we then moved to looking at common factors, those things that work across all theoretical models. But teaching common factors doesn’t seem to make us more effective, nor does it relieve the need to know specific models, since it is through those models that the common factors work. (My good friend Sean Davis has the leading text on common factors in couple and family therapy, and in it he makes the same point.)
So the focus then shifted to the study of outcomes rather than methods, and what we found was that some therapists consistently achieve better outcomes than their peers. That has moved the field into a close examination of excellence and expertise.
The findings there are striking, and I can’t do them full justice here — I’ll address the training issues in more detail in a future post. But the short version is this: We don’t spend a ton of time training students to do the things that actually seem to make them better therapists (“better” here meaning more effective). Miller cited a vast literature identifying deliberate practice — not just more hours seeing clients, but significant time focused on reviewing weaknesses in those sessions while not actively in them and then taking action to address those weaknesses — as the key task in making people more effective. What I hear in my therapy-teacher framework: We need to be doing a lot more videotaping.
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