Botsu 7'R TnAT(.rs,
BETTER
KNO\ANas the boxelder bug, emerges
from the recesses of hornes and drvellings in early spring.
\t\rhile feared neither for its bite nor for it's sting, most people consider the tiny insect a pest. The critter comes out by
the thousands, r'esting in the sun and staining upholsten'
and draperies with its oranse-colored wastes. Few find it
endearing, u.ith the exception perhaps of entornoloeists. It
doesn't pttrr and won't fetch the morning paper. What's
more, you'll be sorry if ,vou step on it. \A4ren crushed, the
dirninutive creatur-eernits a putrid odor worthy of an anirnal
lnany tiures its sizc. I
For as long as :uryolte could l'ernellt-
ber, Boiseatriuittrttttswas an unwelcomc 1'etfanriliar-grrestin
the offices and r,r'aiting area of a large Midwestern, rnulticounty cornmunity mental hcalth ccnter.
WHAT'S
THE
Professional exterrninators dicl their best
!$EG!|ET
OF
to keep the buss at bay, but ino,itably
1$UGCE!$S?
THEIR
rlrilny eluded the eflblts to elirninatc lhern. Tissues rvere
strategically placed throtrghout the ccntcr t() assist staff
and clients in dispatching the escapees. In tirne, the
by
Sc orr MrrrnR,
Manr HusBr.E,
and
Bannv DUNCAN
\\' \\' \\ . P S \' (. I t () T H E R A P \' l.. F T \\' () R X r. n . O U <; 2
/
:tIr'aDgcll)ctrt llcc:tnrc r()trti11e.or"rt of
tioners rverc strtregling to sta)' afloat
rrt'r'cssit\-.
cvcryol)c t<llcratcrl the nnnufirrancialll'. N{an1 in the prof'essional
al arrrrr>\'arrce-rvithone rrotirltle cxcep- conrnunitl'sought to ernrrlate his suctiott.
cess.In the hopes of learnir-rghis secres
l)lrrr'rr,:t lt)-\'('lrr'\('tcl2rn <ll'tlrt' cclttcr, rir earning his acknonlcclgernerrt, ther'
Icd tlrt' r't'sisl:urct'
to u,ha1slrc consirlcrcrl cotnpeted hard to cnter his inner circle.
" i r r s t ' t t i t i t l t ' . "I r r u r v o r l r l t l l l l t c ( l a g a i l t s t
\ \ ' l r i s p e r e d c ( ) r t rt ' r s a l i o r r s a t I ) : l r t i ( ' s
tltc lrtrgs,slt<'rvls theil orrly allr'.Tir suvt' and local profi:ssional rneetings rnad('
sht' collectc<lalld distril> clcar that othcrs regarded (lordon
tlrt' tirrr' lrt'ast.s,
(
)
l
(
l
ut('(l
r r r a s o rjrl r l s ,i r r r l t k r l i r r u( ) l h ( ' f st ( ) rvith t-rrn ancl cnrnitr'. "Profits talk.
( a t ( l l t l ) ( ' l i t t l t ' < ' r ' i t t c l ss ( ) t l ) a t s h c r ' o t r k l
J)aticnts rvalk," rvas ()ne c()lnnrenl that
sali'lr n'lt'lrsc llrt'rrr orrt<loots.
caplrrrcd the gencrzrl fccling aborrt
Ft'n rr't'tt' srrr-pris<'rllx' [)utr,rr'sr'<'girlrl h i r r r . B t r t t h c c r i t i c s c o u l c l n ' t h a v e b < ' t : r r
lirr thc l>ttgs. Most 1tt'o1rlt:rvho krrt'rv r))()r'cwr'()r){r.The pcople (}orclon sarv
l t t ' t l ' r > r r l r ll r a v t ' t l u r l l r c l t ' r ' i z c r l r t ' r a . sl r i r r h i s p l a c t i c t ' r ' r g a r d c r l h i r n a s r : a r i r r g
h o l r l o u t l i r r r r rt h c S r r r r r r r r t ' r - o[ ,lo v c . H t : r ' all(l (lcnplv c<>rnrrrittccl
t() thcir rr,ell:rrc.
\ \ \ ' r r r i c l o l > r r s ,l l o o r - l t ' n g t h , t i e - ( l i c d Frrrllrt'r'nror-e. hc achievt-d outcornes
s k i r t s . a r r r I l ] i r k t ' r r s t o c k s a n ( l i r l s - c ( ) r n - tltitt u't't'c (irr srrpclior t() th()se ()f the
lrirrt'rl rvith thc ri(('l)t of'
I)1lt(ll()uli arrrl sarrrlirlrvood
tltat lirtgctcrl alit'r' hcr' pirssirq('-s()li(lilicrl cvcrr'orrt.'s
i r r r l r l c s s i o r rt l r i t l s l r t ' r r ' a s l t
lirgitivt' ol llaiulrt-Ashlrrrr1,.
R r r r r r r > r ' l r l r ir tl t l r a t s h t " r l
lrt't'tr t'ont <'iverlzrt!,sitlt'rr.
[ ) r ' s p i t t ' l l r t ' s < 't ' t r ' t ' r r tirr i t i t ^ s .l ) a r r ' r rt a s l r t r r < l s < l o w r r
t l l ( ' n r ( ) s t c l l i ' < ' t i v t 't l r t ' r ' a l t i s t
'l'lris
:rt llr<' ugt'rro.
lirrrlirrg
r r ' l r s t ' s t a l r l i s l r t ' r lt l r r ' o r r g l r a
tiglrllv contrrrllcrl, r't:sr:arch-tr>przrcticc clinicians rvh<l carperl :rltorrt hirtr. In
slrrrlr t'orrrlrrctt'rl:rl lrt'r ag(:l)c\'...\s ;tart
lict. tlrc sAlIlc rl)cllsurestlral conlilrnr:rl
o l t l r i s s l u ( l \ ' ( ) l s u ( ( ( ' s s r ' : r t c si r r i r t : t t r a l I)iuvrr's sttpcrior rcstrlts pl:rccd ()ord<>n
take airrr. thcr hit the bull's-eye.
Nevt'r'thclt's'. sirrcc Ricks's first descriptiorr, littlt' hrr: lrt't'n clone to further the
invcstigutiorr of srrJ)er- and pseur l o s l r l i r r k . . I r r s l t ' : r r l .p r r > f e s s i o n a tl i m e .
er)er'!11.
:rrrrl rt'sorrlrt's halc been directccl t'xclrrsirt'l\ t()\\'ur-(lidorti$'ing effecL i t t ! l t n r t f t tr, . I l r i r r s t o i d e n t i $ ' s p e c i f i c
intcr-r'e'rrtiorr'llr:rt corrlrl be reliably disp t ' l t s t ' r l l i ) r ' \ l ) ( ' (r l i r l t l o l > l e m s h a s a
s t f ( ) l ) g ( ( ) l l l n r () n \ ( l l \ t ' a l t 1 t e a l .N < t o t r e
n r l r l r l u r g r r , ' r r i t l rt l r t ' s r r c ( ' ( ' sosf t h c i d e a
o l p r o I r l t ' r r r - ' J tr tr l i t i t r t t ' r ' r ' c n t i o n isn t h c
I i c l r l o l r r r t ' r l i ri r r t ' . I i r t t l r c e v i d e n c e i s
i r r c o r r I l o r rt t i l r l t. I I 7 r ' , P l o r i d c tsh e t h e r a p r i s l r n r r r tl r r r r ,r rt i r r r l r o l t : I n td e t c r m i l]lult ()l \u( ( ('\\ tlr;rrr ir,/ialtrcatrnent
a l l l t l o l r t l t i . p t , ' r t rl t ' rl .
Theert-denee
is
Whoprovidesthe therap)-is a much more
rhanwhottreatrnent
( l r r r s i < l tr . r . l u ( l \ r ' r ' l t o r t - e dl t 1 ' B r t r c c
\\'urrtl>r,lrl .rrr,l ft lr Brrxvtt irr t.ht:
( ) c t t r l r t ' r . ' )trrt - r f , , t t r u r t o
l f ( , o n . s u l t i t ragn d
<l i r r i c u l s ( ' l l i l l e s . I ) a r v r r u n r l h c r c o l - in the top l2ir pclccnt ol' ps1'chothcra- O l i r t i rt t l 1 ' r . ,1, , , , / , , q I t i n c l u d e d 5 8 1
k r i t q r r c s : r t l r r r i r r i s t c r t ' ra
l s t a r r < l a l c l i z < : r lp i s t ss t u r l i e < li r r t h c U r r i t c r l S t a t c s .
l i c c ' t t s r ' <pl r , ' r r r l t ' r . - 1 r s r <l t o l o e i s t s , p s r tn('1rsru('ol lllogless to cutt:h r:liertt :rl
In l1)7-1. rcscarcher- Dirvicl F. Ricks
ee
l rac h i a l l i s t . . . r r r r l r r r : r s t t ' r - ' s - l t ' rt' h
t'\ t'l t st'ssioil.
c o i r r e r l t h c t e r l l ) s t t l n r . s h r i n k , st ( ) 1 > i s t s - r r ' l r o\ \ ( r ( l r t l r t i r r gi r r l i v e r s es i r m \ \ ' l l : r l r n l r ( [ ( 'l r t ' r ' p t ' r ' l i r l r r r a r r c ca l l t h e
<lcsclibe a cl:rss o['excc-lttionirl thera- p l t ' o f t t ) () t ( l l r : t n t i . ( ) ( X c) l i t ' n t s . T h c
n ) ( ) l ( ' ( ( ) n ) l ) ( ' l l i r r e\ \ ' : r st l l r l s h c w a s t h e
pists-pt'actitiorrcrs rvho st-ood hcacl l h c t ' : r 1 l i r t r .t l t t t l i t r r t t ' l t ' . u n d t h e p r e loll
l
o
r
s
(
.
\
(
i
l
t
(
'
t
l
l
\
<
.
l
t
t
s
I
t
t
t
t
r
r
i
r
t
g
.
a
t t r l s l t o t t l d c r si r l t o v c t h e r c s t . H i s s t u ( h ' : i ( ' l ) t i n gt o r r r p l . i i r r l rr r ( ' l e l l ( r l i f l e r e n t i n
llcr
N{olt'ovcr, lut tols rr'irlclv ltclicvccl to
r:xlrttrirred thc loDg-tcrrtr ()utcol]tes ()l
i l t t t t r r t ' r r r r i r r g l rrrrlu ' rl l r r r t r t h o s e i n c l i n i a l l i ' r ' t l l t ' l r t r r r ( ' n [( ) u t c ( ) n ) ( ' - t l r c c l i c n l ' s "highlv clisturbcd" arlolcsccrrLs.\\Iherr
c a l s t ' t t i t t g r r l r t i o r t r r i r l e ., \ s r v a st h e c a s c
irg(', g('ll(l('r, tliae'ttosis, lcvcl oI Irutc- tlte lc-scalch palticipalrts rvere laterr' r r ' i t h l ) u r r ' r r , t n r l ( , o l c l o r r , t h e c l i e n t s '
t i ( ) r r : r il i l r 1 r : r i I n l ( ' i l(1) .r p t i ( ) r 'l r c i t l i l l ( . i l 1 cxirttrincd lrs nclults, hc Iinrnrl thirt a
agt', gt'rrrlt'r. urr<l rliagttosis had no
I r i s t o l r - < l i < l n ' t : r l l i r c th e r r c s u l t s .( ) t h e r
sr'lc'cterotrl;, trcatcrl lll one p2uticular
irrt;ltcl on tht tr'(':llllrel)l .succes.5
rate.
llrctors thut \vcren't corlelaterl tt> herr' providcr, lured notirbh bctter. In thc
i r r t r l r r t ' i t l r rt , l i r l t l r c t ' x p e l i c r r c c ,t r a i r r ()rrt('()nlestr'<'r'cher age, gcndcr, tfail)- sanle stud)'. bo)'s treatcd bv thc "pseu- i n s , a n r l t h t ' o l t ' t i c u l o r i e r r t a t i o n o f ' t h e
i r r g . J r r - o l i ' s s i r > ndails c i P l i n c , l i c c n s r r r - e , c l o s h r i n k " d c r n ( ) r r s t r a t c d a l a l r r r i n g l v thclity;ists. Horr't'rt'r'.clients of the best
()l \'('ars ol experiencc. Even her thcopoor nrljustment as adults.
irr the sarnplc inrproved at a
thertiryrists
lctr(ul r>ricntatit>rrpx>r'ccl incolscThat ther:rpists diller in their abilin
rat(' ut lt'ust .-r0 l)clcel)t higher and
qucntial.
to all'cct change is hardlv a revelation. droyrpcrl ()rrt ut lr l llte at le ast 50 1>e
rcent
flrntrast l)arvn tvith flordon, rvhc> All ol- trs have participated in hrrshed lorver than lhose lssigncd to the rvorst
corrl<ln't ltlrre llct.rr rnorr: dilt'cr-ent. conversati()ns :rbout colleagues rvhose c l i r r i ti a t t si n t l r c r : r r u p l t ' .
Ri gicllv (:()r)s('rvativc ancl l>rintrnin g lvi th
perfbrnrance rve feel falls short of the
Artother irr)p()r'tantlinding ernerged:
t'orrlldr:ncc ltolrlt'r-irrson nrrogalr ce, he
rnark. \\Ie also recognize that sonre itr casesin rvhich 1>svchotropicrneclicarnallasccl to lrrrilrl a thri\illg prir,ate
practitioners are a cut :rltove the rest. ti<>trrvas corrrl>ineclrvith psvchotherapl',
the drugs clidn't pcrfcrrrn consistently.
l ) l : r (l i ( ( ' i t t t r r r a n ' l r r r ' l t t ' r ei l r o s l p | a c L i - \\Iith rare exceptiolls. whenever thev
2B
rrrr.f
t() I ttt R \t,\
\Lt
I \ ' ( ) R K F tR r
I'oi,r,ltber/I)ttrttbn
2(l)7
'I'hc
l ' l r t ' i l t ' l l i ' c t i r t ' r r t ' s sr l c p c r r r l t ' r l ( ) n t h e
(lrrirlit\ ol thc tlrt'r'apist-d|rrqs trsed in
pr-ojcct rr'orrlrl lravc lt'rtrairrt'<l
s l r e l v e r li r r < l t ' f - r r r i t t 'l ltva r l o n t ' o l ' r r s r t o t
s l r r r t t l > l e (d) l l t ( )l l ) ( ' n ' o t k o l S u t ' r l i s hp s r .
t h o l o g i s t K . A n r k ' r ' s l ' . r ' i t s s o r r .N t ' : r r I r
t \ \ ( ) \ ' c a l s l t l r r l J i i r s s t ' rsl i r r c t ' l t " r l g i r t ' r r
rlelt'r'rrrint'rvh\'.
\\'t' bcean our invcstigirtiou llt look-I'he
t'orrrlrirr:rtionrvith talk thclal>r' rvt'rt' l0
insti
i r r g a t t l r t ' r e s < ' a r < ' lhi l ( ' r a t r l r e .
tirrrt'surorc clli'ctivc rvith tlrc lrt'st tht'r.
ttrtt' has t'irlnt'cl its reptrtation irr part llr
a p i s t s l h a r r r v i t h t l r r ' \ v ( ) r ' s lA. n ) ( ) l q t h ( ' lt'r'icrr'irrglt'st'irlt'h arrd llrrl>lishin{rsurrrrrarlt' Iiltrrallv
lattt'r' grorrp, tlrc <.lr.rrgs
nrarit's arr<l<'ritical nrurlvst'sorr its n'cl>
l l ( ) ( l i l l ( ' l 1 r l ( t ' . S o . i t r t l l ( ' ( l l ( ' D ) i s t r ' \(' ) r sitt' (wrr'w'.tirlkirrgc:rrrt'.conr).
\\i' \\'erc
n r c r t t ; t l I t c a l t l t t l c r r t r r ) c n t , t h ( ' a J ) l ) l i r ' ( l rr'cll urr'alt' at tllc ()uL.i('tthat littlc hurl
( ) r i ( ' n t i l t i ( ) n s , l < ' r : l t t t i r l t t t ' s ,: t r t r l c \ ' ( ' n l>ct'rrrlorrt' sinct' Ricks's orieinal papcr'
l n ( ' ( l i ( a t i ( ) r ) sl u ( ' r ( ' l a t i \ ' ( ' l y i r r r . r ' t .1 ' h c
of srrJrcr.
to rlt'cpt'rr tht' rrrrrl<'r'starrrlirre
c a l : r l y s ti s t l r c t ' l i r r i <i i r r r .
anrl lrst'rrrloslrlinks. Ncvcrtlreless, lr
rrrassivt'zlrnorurt ol' r'csearch harl llccrr
t ' o r t t l r r c t c r lo t t r v l t a l r n a k ( ' s t h ( ' l n l ) i s l s
The
Making
of a
arr<lthclapv t'fIt'ctivt' irr gcncral. \\'h<'rr
Supershrink
I I o r r r l r > t h c s r r p c r s h r i r r k s - p r a c t i l i o r r - \ r ' ( 'l l l l ( ' i l l l ) l ( ' ( ll o r l c l t ' r ' r r r i r ) l(l'l c c h a r a ( .
t'r'srrsrlissinrilul as l):ru'n ar)(l (;()l'(l()lrI c r i s t i r 'o
s l t l r t ' r r r o s lr ' l l i ' tt i r t ' l ) r : r (l i l i ( ) r ) rlo rthul tlrt'r' rlo? .\rc llrt"t' llit(l(' ()r r ' r ' s t r s i r r g ( ) u r ' r ) i l l i ( ) r ) a l r l a t a b a s t ' ,
l X r | r r ?I s i l a i l ) i l t t c r ( ) l ' t t ' r n D t ' r ' a r n c l r( l) r ' Irr'potlrt'sizinutlrat thclapists likc l)arvrr
..I
t r P . ' I ' h t ' n S ( ( ) t t ,l ( ' t l l | i l i r r gt o t l t < 'L r . S .
a l t t ' r ' p r ' o l i < l i r r gu r r t ' t ' k o l t t l i r t i t t u
in Noru'at, lirttrrrl iur at ti( l(' al)()ut
F l r i c s s o r r 'lsi r r r l i r r g sp r r l r l i s h t ' r li n l ' i nt u r t r
t r r a g a z i r r t ' .\ \ ' t ' : r r v I i o r r r t l t t ' r o l < l u t t < l
li':rrklr' lrolcrl. lrr"rl tirkcrr tht' lrcliorlic : r l l i o r r r t l r t ' p u s s i r r el l i s l r t a t t c r r r l a r r t
l r r o l t ' l i r l l l r t ' g l o s s r 'p i t t r n t ' s a r r r l l : t c
t o i r l s t h u r r l i r l i r r t t ' l l < ' t t r r : rsl t i r r r r r l a l i o r r .
Irr sltorl ottlct, lrou't'ttr, lltc tttagazittt'
t i t l c s t ' i z t ' r Il r i s u t t t ' r r t i o n - i r r l r i g l ) ( ) l ( l
l('tt('r's. "\\'ll'\'l' I'l' Il\KllS 1'() llFl
'l'ht'
s r r l r t i t l t ' r ' i n <l r t ' r l i t .
ORll'\T."
I
lncontrovenlOIe.
lrnpOrtant
determinant
of success
approachis provided.
tllritrrrrg?Havc tlrcl' rliscovt'r'crlir s('cr'ol
t r r r k r r o n ' rt ro o t l r c l l ) l a c t i c i n qc l i r r i c i a r r s
( ) l l u ( ' l l r c i l s r r l ; e l i t > rr' ' t ' s r r l t ss i r n l r l v u
I l r t k t ' . t t t o l t ' I n ( ' 1 r s u r ' ( ' n l ( ' nt :tr ' r ' o l l l t : r r r
I r ' l r l r t r l . \ r t s r v l l i t t g t l r t ' s c r l r r t ' s t i o n si s
c r i t i <u l . l t l r t ' i r r g t h c l t t ' s t i s r n a t t er ' o l
b i r l h . 1 l t ' r ' s o r r lrrlli s J r o s i t i r > rorr, c h i r r r tr ' ,
tltt' pltt'trorttt'uolt wotrl<l hirlrllt lrc
l v ( ) r ' l l )l i l l l l l ( ' r ' s l t r < l r ' B
. rrt shorrlrl tlreir'
tak'trts J)l'()\'('tlansl('r-altl<',tlrc irrrpli<lr
t i < > r r sl i r r t l l r i r r i r r g . r ' t ' r t i l i c a l i o r r , l n < l
st't'ticc rlt'lir t'r'r at e notlritrg sholt ol
strrggtrinu.
l l r r t c r t h c l r r s t i t t r t t 'l i r l t h e S t t r < l t o l
'l'lrt'r':r;rt'rrtit'
O l r a r r g t ' .a n i n t t ' r ' r r a l i o r l r l
e t o t r p o l r e r s t ' i r r c l r < ' ra' sr r r l c l i n i c i l n s
dt'rlit :rtt'rl to sttrrlving tvhal rvorks irr Psr.
< ' h o t l r t ' r - u 1 xF. o r l h t ' p : r s t c i e l r t t ' c u r s ,
l l t t ' r - l r ' o t t 1 >i r. t t ' l r r r l i r r g r > r r l s t ' l v t ' s l.r a s
l r t ' t ' r r t l l r c k i r ) s ^t l ) ( ' ( ) u t c ( ) r n ( ' so l ' t h o u s : r r r r l s o l t l r t ' r ' i r l l i s l st l ( ' a t i l ) q t t ' n s o l
t h o t r v r r t r l so l t l i t ' r r t s i n r r r l ' r i a <cl l i n i c a l
s ( ' t t i n g s l r ' r r r s s t l r r ' L r n i t t ' d . S t a t t - sa r r r l
alrroatl. Likt' I)ar irI Rit ks atrcl othe r'
r-t'st'artltcrs. rr'<'lirtrrrtl rlirlc variatiorrs
in clli'ctiven('ss arn()ll{r placticine cliniciarrs. Irrtrigtrcrl, rr'c dr:ridcd t() tr'\' l()
" R c s c a r c h n o w s l r o w s t l r : r t t l r c l : r tk o l
lrrrrl (lor-rlr>nrrrrrslsirtrpll'rlo or crnborll
"it,"
rnolt' ol
rvt' srrriukcrl ht'arllirst into
natrrral T.\l.ENT IS lRRlll,l'l\l\N-I' to
l u b l i c k w ' r r l l .N c i t l r t : r 'l h c 1 > r ' r ' s oot rl ' t h c
1 9 ( ' : r ls r r c ( ( ' s s . ,"\ l t l r o r r e l r t l r r ' l c l r r l l r l t i tlte l ltpist ttor tr'<:hrrit:rlpr'orvt'sss('J)lutrt- <[ c i t s r ' l f \ v : r s r t l I r ( ' r ' ( ' l i r t r r ' 1 l : t g t ' si r t
I t ' n g t h , t h c r ' o n t t ' r r tk t ' p t I r i r r r o t c r r p i c r l
< ' r lt l r c b c s t l i r r r r 1 h ( ' r c s t .
F l r r s t r ' l r t c ( 1 , l r t r t r r r r r l t ' t c r l c r l , w ( ' f i r l t h c ' r ' r ' r r r a i r r i r rtl '4i q h t l r o r r l s o l ' t l r c
|ctrlr( ('(l ()llr sl('J)s.Mat bc rvc'cl nrisst'rl l l i g h t .
s ( ) l l l ( ' t l l i l l f l - a t I i t i t ' l r ls t t l ( h , a t l t t : l l l ( ' ( ' a
,
llli< ssort. St otl lt'ltnrcrl, rvas rvi<[t'Ir
" or'
Irn<lirrq-tll'.rt uorrlrl stccl rrs irr tht'
t n t ' x p t ' r ' t s .F
t o n s i r l t ' r ' r ' r"l t l r c t ' x 1 x ' r ' o
r i g h t ( l i l ( ' c t i o n . \ \ ' c n ' t r r r r r t ' dt o o r r L< x v n t l r e l r c t t < ' r 'p u l l o l l r v o r l t ' t : r r l t ' s ,I r r " < l
rlatabast' t() t:rk(' a st'tonrl look. r'evicrv- l > t ' t ' ns t r r r l l i r r gt l r c r v o r l < l ' sl r t ' s t: r t l r l t ' t t ' s .
i r r g t h c r r r r r n l l t ' r ' s: r r r d <h c c k i r r g t h c
i r r r t h o l s , t l r < ' s s1 l l a 1 t ' r ' sr,l l t l t t l t t o u t ' t s ,
atraltst's.\\'t' askt'<lr'orrsttllarttsorttsirlt' r r r : r t l r c r r r a l i c i : r r r p
s ,i l r n i s l s , 1 t ' l r c l r t ' r ' s .
t l t c i n s t i l t t l t t' o r t ' r ' i l r( ) u r ' (( ) r n l ) l l l : l t i ( ) n s . p i l o t s , p l r r s i t i r r r r s ,: r n < l < > t l r t ' r ' sI .l t ' t r r s
\ \ i ' i r r \ ' i t t ' r lo t l r t ' r ' st ( ) l ) r ' i r i n \ t r ) r ' 1pi lo s s i - i r l s < >i r b i l o l u r r r i n t ' r ' i t ' k .I r r l r v o l l r l
b l e e x p l a r r a t i o n s .( ) p i n i o r t s v a r i t ' r l I r ' o r r r l ) t ( ) r t ( l' ( ) l t t t ti l l t r t t g r ' ( ' : t l D ( ' \1\ o , - . 1 r ' n c t i r
rnarr\ ol tlrt' lirctols u'c'tl alrt'irrly corr- ( ' l l ( l ( ) w l n ( ' l l t . l - r ' i c s s ( ) r rr l i r l r r ' t n ) i n ( ( '
sirlcr'<'rlatt<l lulccl ()rrt t() "it's all :r ntat- \v()r-(ls:" 1'lrt' st'alch lirl stulrlt' lrt'r'itrrblt'
I t ' r o l c l t a t r t ' t ' ,n o i s t ' i t t t l r t ' s y s l c r t t n, l ( ) r ' ( ' c h a r a t ' t t ' r i s t i c sl h l r t t r > r r l r l1 r n ' r l i c l o l l r l
strrtistir:ulirltil:rtt tharr l'act." Sairl anothr 'r t ' r ' l i r r r r l r rtr' <
I t ' : r s ta t r ' o r r r r tI i r l s t r l r t ' r ' i o 1
('r' t\'a), srtpclsll'inks \\,('r'('n'trt'al, tht'ir' o l < ' t t t i n t ' t t it r r < l i v i r l t r r rIl ist t s l r r > t ' t <
s l,t t ' s s .
eillelgel)c(' itt ant' (l:rta aDahsis \\irs t n u s i c , r n c < l i t ' i r r t t' ,' t t . l I r u sl l c et t s t r r ' p t ' i s t ' r t l i t c l y l i l r r r k r t l r . I r r t l r e c u d , r r o t h i n g i n g l t r u r s r r t r c s s l i r l. . . S y s t t ' r r l r t i tl a l l r > rvc coulrl poiut to cxplainccl rvlrv sorner rat()l-\'r('so:ut h . . . prrl irlcs ,io cvi(l('ll( (
clirriciarrs achicvcd r'orrsi-s[enth,
supeliol resrrlts.Sct.irre no solrrtion, we gavc
rrp atrcl lrtrlc<l ()ru'attelrti()n clservlrcre.
l i r r g i l i c r l r r e s .os l i r r n a t t ' t a l c n t . "
Shotrlcl Flricsson'sl>old arrrl swt't'pirrg
cluirtts prr>r'c rlillicrrlt to l>clit'rt'. t:rkt'
\\'\f\f l,\\ (rII() I III R \l,\ \L
I
I U(]RK]
R t t X r . ,2 ( )
the example of Michael Jordan, widelv
regarded as the greatest basketball plar.
er of all time. \\Tren asked, most would
cite natural advantages in height,
reach, and leap as key' to his success.
Nonvitl.rstanding. ferv knorv that "His
Airness" was cut frorn his high school
\,arsity basketball tearn! So nruch for the
idea of being born great. It sirnplv
dr>esn't work that rvay.
The ke1' to sttpe rior perf<rrrnance ? r\
absrrrd as it sotrnds, the best of the best
sirnply work harder at irnprovine their
perfonnance tharr others do. .Jordan.
fbr example, clidn't givc rrp rvhcn
thrown off the tcarn. Inste:rcl. his failurc
drove hirn to the c()rrrts,rvlrcrc he practiced hour aftcr hour. As hc Dut it.
as the average musician.
As tirne-consuming as this level of
it is-it isn't
practicing sounds-and
enough. Accordins to Ericsson, to
reach the top level, attentiveness to
feedback is cnrci:rl. Sttrdies of ph1'sicians rvith an uncarlny knack fbr diagnosing baffline rnedical problems, for
example, prove that the)'act differently
lionr their less capable, but equally'
well-trained, colleaqtrcs. In zrddition t<'r
visiting with, examining, taking carefirl
ll()tes ab()ut, anrl reflecting on their
asscssr))cntof a particular patient, the)'
take onc adclitional criticirl step. 7714'
"prolicicnt"
follou ttlt. Unlikc their
pcerrs, they don't settlc. Call it prof'cssional compulsivencss or prirlc, thesc
l(noraring Wlrat Yorr
Don't ](nour
Infirrnrecl Ix this ne\v perspective, the
tearn nrt>r'cdinto high gear. Strddenly',
l'e'd come across dursevcral strr<lic-s
ing oul rcricrr' of tlre literirtul'e took
()11 ll(-\\' rnearrine, illtrnrinated b1'
E r i c s s o n ' sl i n r l i n g t h a t d i r e c t { c e d b a c k
r n l r r l cl r l r i g r t i l I r ' r ' t ' rcr ri t t <r e a t i t t g p e t r
ple rvh<>t'xt t'llcrl. Tlrc first focused ott
p r i v a t t ' [ ) r ' l r ( t i t i ( ) n ( ' rs' soir k i n g i t r a n r a n asccl lx'lrariolul lrt'alth cztre tretrvork.
\,'etcrarr lcst'urclrt'r's Dcirdrc Hiirtt and
(]colgr' l Iulgllrr t' rrscd pccr- and
p r o v i r l t ' r 'r - : r l i n g \ .: t . n c l l a s a s l a n c l a r d i z c r l o t t t t o r t t ( ' l l l ( ' i r \ r . l r ' ( ' st <. l i t s s e s st h c
s u c c c s sl l t t ' s o l t h t ' r ' u p i s t si n t h c i r s a t n ple. ()n ct' u9:rirr . 1rt, ,r irlcr-srvcrt- Iixtud
"W.henever
I . . . figureel
I oughtto
I'd closemy eyesand seethat list in the locker roorn
my ltaftle
on it, and that usuallv got me going
"\{rhcrtevcr I rvas rvorking out arrd got
tircd and ligtrrcd I ought to stop, I'd
<:lr>scrn1' e1'csancl scc that list in thc
l o r ' k t ' r r o o r r r r l i t l t o t t t r t t t r r a r r r co r r i ( .
:rtrd that ttsrrallyg()t llle eoing again."
Snc.lt deliberale prartire, as E,ricsson
g()es to great lengths to p()int ()ut, isl'l'l
the sarrrcas the rlrunber ot hours spcrrt
()lr the job, btrt rathcr thc alllount ()f
physicians nced to knorv rvhcthcr thcl'
lvcrc right, evcn lh()ugh fincling out is
neitlrcr rcquiretl nor reirnbursirblc.
" ' I l r i s t ' x ( r ' a s t c P . " ! . r i <s s o r r s u 1 s ,{ i t ' c s
thc srrperdi:rgn()stician, "a sigrrilicant
aclvzurlageovcr his pt:crs. It k'ts hiln bctter utrrlcrstartrl lrorv al)d whcn hc's
irnpr'oviug."
\Vithin clal's ol touching rlown, Scott
tirnc spccificallv dcvotcd to reachirrg had shirrcd Ericsson's findings lvith
just bqond ortr's kttel oJpnr
firr' <rl>jerctivcs
Mark arrrl Birrr'1,.,\r iltcllc'cttral fi'cnz1'
.ficiottl. Hc chicles anyonc rvho ltclieves firlkxved. Articlcs rvcre pullccl, seconclt h a t c x p e r i e r r c c c r c a t e s c x p c r t i s c , s a r - ary' t'cf'crcrtces trackccl dow'n, atrd
'-just
ing,
bccarrse you've been rvalking Ericssrrrr's918-paec Conltfidge Handbook
firr 50 vears doesn't n)can you're get- of lixperlise und l.xpert I'erfonnatte purting better at it." Interestinell', hc arrcl chasccl and rcaci c()\'cr t() cover'. In tltc'
his group have lbund that elite perprocess, ollr eirrlier coDfusion gave wa)'
Iirntrcrs across many diff'crcnt domains
to nnderstanding. \\rith considerirble
cr)gage ir"r the sanle anloutrt of such
chagrin, we realized that rr,hat therrapracticc, on 2N'erage,everl' dar,, incluclpists per se do is irrclevant to greatl)css.
inp; seekends. In a stud1,of 2O-y'ear-old The path to excellence rvould ncver be
musicians, fbr exarnple, Ericsson and
found by lirniting our explorations to
colleasues found that the top r'ioliniss
the wt>rld of psvchotherapt', with irs
spent 2 tirnes as rnucl'r time (10,000 attendant theories, tools, and tecl-rh o r r r s o r r a r e r a g e ) r v o r k i r r gl o m e e t s p e - niques. Instead, we rleeded to redirect
cific performaltce targeLs as the next
o u r a t t e n t i o r t t o s u p c r i o r p e I f o r r r r a n te .
best players and l0 times as much tinre
regardless of calling or carecr.
j
O vs:'c:H()TIIER-\pl NETwoRK!:.R r Norerrler/Decrmhr2
r 007
t ( ) \ ' : u ' \ 's i q r r i l i t , r r r t l r i r r t h c i l e l l c c l i v e t r c s s .\ \ ' h a t r v l r . r l r . l r r l l r i n g . t h o r r g h , i s
t h a t t h r ' / r ' r r rrl ' l f t ' r t r r t t l r t ' r a P i s t si n t l t e
s : t n r p l c t h o r r g l r t r l r ( \ \ \ ' ( ' r ' (o' r t p a r r v i t h
l h c l r i . / . \ 1t ' l l t ' r t i r t i . \ s t h t ' b r i l l i a t r t
c l c t c c t i v t ' S l r t ' rl , r k I l o l r n < ' s ( ) l l c c
obscrvt'r|. "\tt'rlior litr knrlts nofhitrg
h i g h e r t h : t r ri t s t ' 1 1 .L"i k t ' < l i : r g n o s t i c i i r n s
rvho rIorr't lollotr ul) lttt<l rttclcll'
2 r . s s l l n ) tch l r t t l r t ' i r ' . r r L r hs i s i s t o t ' t ' c c t .
r v i t h o r r lr l i r c t t l t ' t ' r l l r r r c kt.l r c i n c l l i ' c t i v e :
thcrirpists irr tlrt' Iliir(( ;ul(l I{argravc
studl' :rssrrrrrerlthlrt tlrcv rvcr-cpcrfirrlrtine irclcquatelr.
Elicssorr's\rrrlk orr l)lactice ancl f'eedback :rlso explaint'<l strr<lit-sshowing
that rnost of us grorr' ( ()lltinuzrll)'in conIidence (x'er th(' ('()lusc of'ortr careers.
d e s l > i t el i t t l c , , r 'r r o i r r r p r o r e r n c l liln o u r
IInrd to believe,
actuirl rates of'srr<'r'<'ss.
but true. ()n this sr'or-r'.the experience
of psl,choloeist Patrl Clcrnent is telling.
Throtrghorrt his lt'ar.s of practice, he
kept rrnrrsuallvthor'orrqh records of his
rvork rvith clients. clctailine hundreds of
casesfalling into 8(i rliflerent diagnostic
catep;ories. "I had expectecl t<>fl'rd," he
said in a qualltitati\re analysis, published
in \Iay 1994 in the peer-rer,iewed journal Professional Pqch,olog: Research and
Practire, "that I had gotten better and
better over the years . . . but m), data
failed to suggest an)' . . . change in m1'
therapeutic eff'ectiveness across the 26
vears in qllestion."
Contrarv to conventional rvisdom,
the culprit behind such mistaken selfassessment isn't incompetetrce but
rather proftcienry. Within rveeks and
months of first starting out, noticeable
mistakcs itr ever1.
day' professional
acti\.ities become
increasingly rare,
making intention-
stopr
uuidrout
))
agaln.
al rnodifications
scen) irrelet,ant,
increasingly diflicult, and costly in
tt-rrns <>f time and rc'sources. ()nct:
lr)()re, this is human nature, :l pl'occss
th:rt clogs everv prol-ession. Add to this
tht' r'ustorn in our profcssion of conflating strccessrvith a particular mcthod or
techniqrre, and thc door to greatness
fbr nranv therapists is slarnrned shut
earlr' on.
Dtrring the last fcrv clecades, lllore
than 10,000 "how-to" books on pst.
chothelapr' have been published. At
the sarnc tirne. the nutnber of treatment approaches has mushroomed,
soins frorn around 60 in the earll'days
to morc than 400. There are presently
145 officialh' approved, rnanualized,
evidence-based treatrnents for 5l of the
397 possiblc D.SM diagrrosric groups.
Based on these nunrbers alone, one
would be hard pressed not to believe
that real progress has been made by'the
field. More than ever before, rve knol
what rvorks for whorn. Or do we?
Comparing todar"s success rates with
those of 10, 20, or 30 years ago is a wa\'
of finding out. One rvould expect that
the profession is progressirrg iu a nrarrner cornparable to the Olrrnpics. Fans
knorv that during the last centun', the
best perfon-nance for everl' event has
improved-in
some cases,b1'as much as
50 percent. \\rhat's more, excellence at
the top has had a trickledown effect,
irnpror.ing perfbnnance at everl' level.
The fastest time clocked for the
marathon in the 1896 Ollrnpics rvas.jtrst
we can learn from our experiencesand
improveour rate of success,both as a discipline and in our indir.idualpractices.
Incidentallr', ps1'chotherapistsaren't
alone in the struegle to increase
expertise. Durir.rgorlr sun'e)' of the literature on greatness,we carneacrossall
engaeing and provocative article putllished in the December ti, 2004, ,Vaa
fbrkerntagazine.Usillg the treatment of
c)'sticfibrosis (CF) as an exarnple,science rvriter Atul Garvandeshorvedhorv
the sarneprocesses
undcrnrining excel-
lcncc in psvchothcrap_l'play
o u l i n n r e r d i c i n e. S i n c c
I !)Of , rncclic:rl rcscarchcrs
have been tracking the outcomes ol' patients with CF,
a ge nctic disc:rsc striking
1,000 children yearly. The
discase is proeressive: over
tinte, rnucus fills, harderrs,
and eventually dcstroys thc
lungs.
As is the case rvith ps1.
chothe rapy, the eviderrce
indicatcs that standard CF
trcatmcnt
works. With
mcdical intervention, lifc
expectancy is just over 30
Years; rvithout c:rre, tew
plliculs srrrvire irrfarrr'1.
The reirl story', th()ugh, as
Gawande points out, isn't
that patients with CF livc
one rnirrtrtelaster than thc tinrc currcnl.
longcr whcl) trcatcd, but that, as rvith
11'requircd.jr$t Lo paflidpalein the rnost psychothcrap),, trcatrnent succcss ratcs
cornpctitivc marath()ns likc Bostorr and
van, signilicrantll'. At the best treatment
Chic:rg<r. Bv contrast, rto neasu,rable ccnlcrs, sunival ratcs arc 50 pcrccnt
improuement in, the eJfectiuen,essoJ p$higher than thc national avcragc, lllcanchotlrcrafr,tlrus ortunvd in. tlrc hst 30 years.
ing that paticnls liverto bc -16on avcragc.
The tirne has cornc to confi'ont thc
Such difl-ercnces, ho\,vever, haven't
unpleasirnt truth: our tried-and-true
been achieved through standardization
strategies fbr irnproving lvhat rve do have of care and the top-clown ir-nposition of
f:riled. Instead of'advancing as a field,
the "best" practir:es.Indeed, (linr:innirti
wc've staqnated, rnistaking our fer,'erish C h i l d r e n ' s H o s p i t a l ( C C H ) , o n e o l ' t h e
peddling on a stationarl bicycle for
rlati()n's rnosl-rcspccted tf('lrtrncnt ccr)progress in the Tour de Therapl This
ters-which ernplol's tlo ol-the phy'siisn't to sav that therapy is ineffective.
cians responsible lirr pr-epar-ing the
national CF treatrncnt guidclines-prcr
Quite to the contrary the data are clear
and unequivocal: psychotherapy works.
duced only' average t() poor ()utconles.
Studies conducted over the last three
In fact, on one of the rnost critical
decades show effects equal to or greater
lneasures,lung functioning, this instituthan those achier,ed b1' a host of r,vell- tion scored in the bottom 25 percent.
accepted medical procedures, such as
It's a srnall comfort to knorv that otrr
coronary artery blpass surgery', the pharcounterparts in medicine, a field roumacological trealment of arthritis, and
tinell'celebrated for its scientific risor,
MT for AIDS. At issue, horver,er. is how
stumble and fall in the nursuit of excel-
\\Et\t()RKER.()XC j
r
lence just as much as we "soft-headed"
psychotherapists do. But Cawande's
article, which is clrrrentl)' available for
free from the .N'ea lbr*ar rvebsite
archives (www.nenyorker.com), proridr's much more than an opportuniq
to commiserate: it confirms what ollr
own research revealed to be the essential first .step in inrproring olltcon)es:
knorving your baseline perfornrance. It
just stands to reason. Ifyou call a friend
for directions, her first question rvill be,
"\Vhere are yort?" The same is tr-tre of
RandMcNally, Yahool and evcry other
online mapping scrvice. Tb get where
you want to go, \'ou first have to know
rvhere you are-A fact thc clinical starff
at (lCH put to good use.
Turning to specifics, the truth is we
have l'et to discover how supershrinks
like Darvn and Gordon ascertain their
baselir-re. Our experience leads us to
believe that thel' don't know either.
\\hat's clear is that their appraisal, intuitive though it may be, is more accurate
than ttrat of average practitioners. It's
likeh', and our anah'sis thus far confirms, that the rnethods they enrploy
will prove to be highll'variable, def)'ing
any simple attempt at classification.
Despite such differcnces in approach,
t h e s r r p e r s h r i r t k sr v i t l t ( ) u l e x c e P l i o l l
possess a keen "situational alvareltess":
they"re obsen'ant, alert, and attentive.
They constantly conrparc new information rvith what thcl' already know.
At the same, you shouldn't be surprised or disheartened when your
resulls pro\re to be average. As with
height. rveisht, and intelligence, success
rates of therapiss are normally distrih>
uted, resembling the all-too.familiar bell
cun'e. It's a f:rct: in r.rearly all facets of
life, rnost of us are tightly clustered
arourrd the mean. As the research bv
Hi'.rtt ancl Hargrave shows, a much nrore
serious proLrlern is when therapists
don't knorr'horv the\"re performing or,
worse. think thev knorv their effectiveness rr,ithotrt outside confirmatiou.
Unfbrtrrnatclr, ottr orlrr work in tracking the outconres ol thousauds of therapisLslv<lrking in cliversc clinical settines
has cxposed a consislcnt and alarming
ShouldanyeloulDt
remainregardingr
of determiningone'soverallrate of success,let us I
mereactof rAneasUfing
In truth, nrost llracticing ps1'chothcrapists have no hard data on their success rates with clients. Fewer still have
ant' iclca how thcir outc()rlres conrpitre
t o t h o s c o I o t l r < ' r<l i r r i c i a r r(s) r ' t ( ]n a t i ( ) n al norrns. Unlikc thcrapists, though,
the staff at (l(lH rrot onll' deterrnined
their ovcrall ratc of cfl'ectiveness, but
thev cornpared thcir successrates with
other rrraj<>r CIF' trc:rtrncl)t centers
zrcrossthe c()untry. With such ittforrnation in hand, thev pushed beyond their
current standard of reliable perlirrnrance. In time, their outcornes irnprovcd
nrarkedlv.
A Forrnula
for
Srrccess
\\'ithin the last year, here in this countrr and abroad, we've started teaching
this basic formula fbr success to therapists. Each of the formula's components-(l)
determining your baseline
of effectivcness, (2) engaging in deliberate practice, and (3) getting feedr>n and is inforrned by
back-depends
the others, rl'orking in tandem to create
a "cvcle of excellence."
J
2
vstt:HorHERAp\'
Thanklirlll', fbr the rcst of us rnere
mortals, a shortcut to supershrinkdom
exisls. It entails usirrg simple paper ancl
pclrcil sr:alesand sornc basic statisticsto
c()rnl)u(.c pur bzrst--line-a pr()ccss we
discuss in detail in the article that fbllorvs. In the cnd, y()u rna)' not bccotnc
'figcr
thc Frank Sinatra,
\4krods. or
Melissa Etheridge of the therapy w<>rld,
but Iotr'll be able to sing. srvins, unrl
strtrrn alor-rgwith the best.
The prospect of actualll' knorving
one's tnlc rate ()f sllccess can provoke
anxietl' even in thc best of us. For all
that, studies of workine cliniciarts proridc little reasor-rfor concern. To illustrate, the outcomes reported in a
recent stud1, of 6,000 practitioners ar.rd
,18,000 clients were as good as or better
than tlrr>setypicalll' reported in tightly
controlled studies. Findings like these
are especially notable because clinicians, unlike researchers, don't have
the luxury of handpicking the clients
they treat. Most clinicians do good rvork
most of the tin)e, and do so while rvorking with complex, clifficult cases.
\ ' . E T \ \ ' o R K FR
. t N o r t t n b r r / D e e e n b e2r ( ) ( ) 7
yields i
patten): thosc slorvcst to adoPt a valid
and reliablc proceclttre for establishing
thcir bascline perfbrrnance typically
havc thc lx)()rcst ()utcornesof the lot.
Sh<lrrlrlarry rk>ubt renrail rt'gardirrg
thc valtrc and itnportartcc of detcrtnin's
ing orre overall ratc ol'success, lct us
underscore that the rncre act of Int'asuring Yiclds irnproved outconlcs. In fact.
it's thc Ilrst and arl)ol)g tlre tnost J)()tcnt
forrns o[ fi:edback zrvailablt-to cliniciat.rs
scckirrg cxcellencc. Scveral rccetrt stttdies corrvincingly denronstratc that moni t o r i r r g c l i e r r t p r < , e r c s s( ) n a n o n g o i t t e
basis irn pr-oveseffcctivelt css dranratically. Our own stud\', published last 1'ear in
the Joumal of Bfief Therapy, found that
pror.idine therapist-srrith real-tirne feedback irnproved outcornc nearly 65 percent. So no dorvnside exists to deterrnining 1'otrr baseline eflectiveness: otte
either is pr()\'en effective or becolnes
nrore effective in the process.
Thele's more good news on this
score. Share 1'our baseline-good, bad,
clients and the results
or average-l'ith
are even nrore dramatic. Dropouts. the
single greatest threat to therapeutic success, are cut in half. At the same time,
outcomes improve yet again. in particular among those at greatest risk for treatment failure. Cincinnati Children's
Hospital prorides a case in point.
Although surprised and understandably
embarrassed about their overall poor
national ranking, the medical staff
resolved to share the results with the
patients and families. Contrary to rvhat
rnight have been predicted, not a single
familv chose to leave the progranr.
That everyone decided to remain
cornrnitted rather than bolt should reallv corne as no surprise. Across all typcs
fanrily and
of relationships-business,
friendship, rnedicine-success depends
tion to the alliance. \{re have now confirmed this finding in numerous independent samples of practitioners working in diverse settings lvith a wide range
of presenting problems. The best clinicians, those falling in the top 25 percent
of treatment outcomes, consistently
achieve lower scores on standardized
alliance measures at the outset of therap1'-perhaps because they're more persistent or are rnore believable when
assuring clienls that they rvant honest
answers-enabling
thern to address
potential problerns in the workinp; relationship. Mcdian therapists, by contrast,
cornmonly rcceive negative feedback
later in treatment, at a timc when clienls
have already disengaged and are at
the value and importance
unelerscore
thatthe
improvedoutcomes.
less on a conncction during the good
tirnes than on rnaintaining engagement
through the inevitablc harcl tirncs. Thc
fzrct thc CCH staff sh:rred the inlbrrnation about their poor perfbrmance
incre:rsed the connection thcir paticnls
f-elt rvith them and enhanccd thcir
engagement. It's no different in ps1.
chotherapy. Where wc as therapists
have the rnost impact on securing and
sustainins engagement is through the
relationship with our clients, rvhat is
cornnronly referred to as the "alliance ."
\\Jrcn it works well, client and therapist
rc:rch and maintain agreement about
rvherc thcr,'re going and the means by
which ther"ll get there. Equally important is the strength of the ernotional
connection. the bond.
Supershrinks, our own research
shorr's, are exquisitely attuned to the
vicissitudes of client engagement. In
rvhat amounts to a quantum difference
between themselves and average therapiss, they're much likelier to ask for
and receive negative feedback about the
oualiw of the work and their contribu-
heishtened risk fbr dropping out.
How do the srrpershrinks continually
usc f'cedback rcgarding the zrlliance to
maintain cngagcmcnt? A session cotrdtrcted by Dawn, rescuer of thc boxelde r bugs, is representative of thc work
donc b1'thc ficld's most effective practitioners. At the tirne of' thc visit. rve
were working as consultants to her
agcnc)', teaching thc staff to use the
standardized outc()nle and alliance
scales, and observing selected clinical
interviews from behind a one-way rnirror. She'd been meeting with an eldcrly nran for the better part of an hour.
Although this first therapl'session had
lurched along to begin rvith, an easy
give-and-take soon developed benveen
the two. Everyone lvatching agreed
that, overall, the session had gone
rernarkably well.
At this point, Dawn gave the alliance
measure to the client, saying "This is
the scale I told you about at the beginning of our visit. It's sornething new
we're doing here. It's a way for me to
check in, to get your feedback or input
about what rve did here today."
Without comment, the man took the
form, and after quickly completing it,
handed it back to Darvrr.
"Oh worv," she remarked, after rapidly scoring the measure, "you've given
rne, or the session at least, the highest
marks possible."
With that, everyone behind the oneway mirror began to stir in thcir chairs.
Each of us was expecting Dalvn to wrap
up the 5655i611-6vsn, it appeared, the
client, rvho was inching forward on his
chair. Instead, she leaned torvard him.
"I'rn glad you camc toclal'," she said.
"It lvas a goocl idca," he respondcd,
"urn, my, uh, doctor told mc to corne,
in, and. . . I did, and, urn . . . it's been
a nicc visit."
"So, will you bc comins
bat:k?"
Without rnissing a beirt,
'Yort
ktrorv,
lhc rn:ur repliecl,
I'nr soins to be all right. A
pers()n docsn't gct ()ver il
thing likc this overnight. It's
soins lo tzrkente a whilc. But
don't yorr w()rry."
Rchind thc nrirror, we irnd
the stirll' wcrc surprised
'I'he
lugairr.
scssion had gone
wcll. He'd been ensagcd. r\ fbllolv-up
appointmcnt had been rnadc. Now wc
h e a r d a r n b i v a l c t t c ci n h i s v o i c c .
For her part, Dawtr wastr'l abottt to let
hirrr olf t]rc hook, "I'rn hopirrg y<>uutill
corne birck."
'You
know, I rniss hcr tcrribly'," he sirid,
"it's anfr"rllylonely at rright. Rut, I'll bc all
right. As I said, don't rvorry about rrte."
"I appreciate that, appreciate wtrat
yor.r.justsaid, but actualll'rvhat I rvorry
about is that I rnisseds()rnethine. Come
to think about it, if we rvcre to chatrge
places, if I werc in 1'our shoes, I'd ber
'\{hat
rcalll' can sltc knotv
lvondering,
or understand about this, and nrore,
what can she possiblv do?"'
A long silence follorvecl. Eventualll',
the rnan looked up, ancl rvith tears in
his eyes, caught hcr gaze.
Softly, Dawn continued, "I'd like you
to come back. I'm not sure what this
might mean to you right now but yotr
don't have to do this alone."
Nodding
affirmatively,
the rnan
stood, took Dawn's hand, and gave it a
squeeze. "See you, then."
\\' \\' \\'. P S\' (l H O T II E R A PY r- E T W O R K E U O U C
J J
Several sessionsfollorved. During that
period his scores on the standardized
outcorne nreasure irnproved considerabll'. At the tirne, the team was
inrpressecl with Dar.vn. Her sensitir.itl,
and persistence paid ofi keeping the
elderly nlarl ensased, ancl prevelltine
his droppine out. The rcirl import of
her actiotrs. hou,evcr. didn't occtrr to
an1'of us until much latcr.
All therapisfs experience sirnilar ir.rcisive lnonrents in their work rvith
clicnts-tirnes
when they"re acr.rtely
insightful, discerning, cvcn
uise. Such expcricrrces zrrc
actualll' o[' littlc c()nsequencc
in scparating the good frorn
tlre great. h<xvevcr. Irrstcad,
srrpt'rior pcrfirrnrarrcc is
fcrund in the margins-the
srnrll brrt consisterrt difl'err'nct' irr the nurttbcr of tinres
c<>rrcctil,cfcedback is songht,
srrccessfttllv obtaincd, and
then actcd orr.
rvork together; ther, don't just sa)' thev
do. Dawn perhaps said it best, "I alu'avs
ask. Ninen.nine percent of the tirne. it
doesn't go anlrvhere-at
Ieast at the
mornent. Sonrctinres I'll get a call, bnt
rarehi More likclr: I'll call, irnd every sc)
often m1' nosiness uncovers somethirlg,
some, I don't knorl quite horv to sav it.
sonre barrier or break, sornething in
the wav of our rvorking together." Such
persistence in the Iace of infreqrrcnt
payoff is a definin€i characteristic of
those dcstined- for- greatncss.
As absurdas it I
the bestof the l
per.{
Systernatically
Seeking
Feedback
Most thcr;rpists, whcn askecl,
rcpr>rt checkine in routinelv
rvith thcir clients ancl kn<lrving rvhen to do so. Rtrt our
onl resear-t'hlilrncl this to
bc l:rr fiorn the casc. In r:arly'
l!)!)8, rve iniliated :t sturl1' t<r
i r r v c s t i g a t c 't h c i r r r p a c t t > n
tre:ltrncnt ()utc()nlc <ll-scckinq client fccdback. Scvcral lirrruats
wcre inclrrrlcd. ln 0nc, therapists rr,cre
strpposed to scck r:lient inlttrt infbrrnallr', on their oln. In al)()ther, starrclardizcd, client-conrpleted outcorne and
alliance nlcasures were adrninistercd
and the restrlts shared rvith f-ellorv therirpisLs. Trcatrnent-as-usllal sert'ed as a
third, control group.
Initial results of the str,rdvpointed to
arr advanurge for the feedback conditions. Llltirnateh. hower,er, the entire
pr'oject hnd to be scrapped as a rer.iervof
tlre rirleotupes shorr'ed that the therapists
in thc inlonnal group routinely'failed to
ask clienrs for their input-even though,
when later queried. the clinicians maintained ther' /rarl soueht feedback.
For their part, supershrinks c<tnsistentl)' seek client feedback about horv
the client l-eels abotrt thern and their
J I
v s v t . H ( ) r n E R , \ p l ' N E r \ r ( ) R K ER r
ellg:lgc in signilicantll rnore deliberate
prircticc. Thut is. :rs Ericssol.r.the expert
on ('\l)r'l t\ \il\ \. "elfirrtftrl activity
clesignt'rl t() ir)il)r()\'c individr,ral target
pclfirr-rrlrrrt't'." Spccific rI)ethods of
clc'lilrt'r-uttlrlut tir'e lravc bectr developed
iurcl errrplort'rl in thc training of pilots,
s u l g e ( ) l l \ .; u r r l o t h c r s i n h i g h h ' d e m a n d i n u o t : c r r 1 l l r t i , , r r( s) .t r l r t t o s t r e c e n t r v o r k
hns fircrrst'<lorr urluptitre these procerap)'.
clrtlcs firl rr't' irr psrt-h<)the
I r r J ) r ' l r (i '(t : r l t ( ' r l l l s , t h e p r o c e s s
i r r r ' o l r t ' s ( l r rt ' t ' s t ( ' p s : t h i n k , i t c t ,
lrrrl. llrrrrllr'. r'ct'lect. This
r r 1 > 1 r l r ,l:rr t t ' a l r l > c r e n ) c u ) lrt r t'tl lx tlrt' acronrrrt T.A.R.
f,, l)r('l)iu(' Iirr tttorirtg
l r t ' r , , r r rtll r c r e a l r r ro f r e l i a b l e
1 l t ' r ' l i r r r r r a n c tch, e b c s t o f ' t h e
lx'st ('n{agc in li->r-ethotrght.
'l'lris
r r r t ' a n st h c v s c t s p c c i l i c
soals urrrl irlcntifi' the particrrlul \':rrs thcr"ll rrsc to rear--h
tlrt'ir go:rls. It's iurportant
\\''herezrs birds can f'11',thc rest ol trs [ ( ) n ( ) l ( ' t l r a t s r r p e l i o r p c r f o r t n a t r c e
ncccl an airpl:rner.\\'hcn a sirnplc ntc:rs- r l t ' p t ' r r r l so r r a t t e r r r l i r r gt o b o t h t h e e t r d s
ttre of the alliarrce is usccl in conjtrnc- a r t c lt h t ' n r ( ' : u l s ,s i r t r t r l t a n c o t r s l l :
-Iir
ti<>rrwith a standaldized orrtcorrrcsculer.
i l l r r s t r - l r t t ' ,s r r p p ( ) s c i r t h c r a p i s t
available evidcnce shows clients arc lcss wlrrrtt'rl t() inll)r()\'(' thc engagcntcnt
likelv to deterioratc, rnorc likely t() stav l c r c l o l c l i c r r t s r r r u n d a t ec l i n t o t r e a t Iorrger', and tzuiteirs likclv to achicve a
lil('r)t li)r srrl;sl:rncc abuse. She'd first
clinicalll' sienificant chanse. \{hat's
n t ' t - c l t r > r l t ' l i n t ' i r t n r e a s u r : r b l et e r n r s
trtore, tr'lten applied cln art agencrtvirlc
Irorr'slrr"<l krrorv tlrat the: clicnt rr':rs
basis, tracking client prosress and expe
a( ti\ch t'rrsugcclin the treirtrrlent (c.9.,
rience of the therapeutic relatiouship
attcn(luncc. increased dialoguc, eve
has an eff'ect sirnilar- to the onc rrotccl c()lrtact. l)()sture. etc.). Follorving this,
earlier in the Ollrnpics: perfornrance
thc thelapist rvould develop a step-byinrproves across the board; e\/ervol)e stcp plan lirr :rchieving the specific
objcctive.s.Bccatrsetherapies that foctrs
gets better. AJohn F. Kennedy'was lirrrd
of saying, "A rising tide lifts all boat-s."
on client goals rcsult in gleater partici\4trile it's true that the tide raises pati()n, shc rnight, create a list of queseverJ'one, we'r'e obsen'ed that supertions designed tri elicit and confirrrr
shrinks conlinue to beat others or.lt of
rvhat the client wanted out of therapl'.
the dock. Tivo factors account for this.
She rnight also spend tinre ;urticipating
As noted earlier, superior perfonner-s
rvhat the client rnigl.rt enumerate and
j' ot' r m b er / Dr t c til l) ? | 2 0 (.)7
I)lanning a strateg)'for each response.
In the act phase, successful experts
track their performance: thel' monitor
on irn ongoing basis rvhether thc'1 used
cach of thc stcps or strategies outlitrcd
in tl.rc thinking phase ancl the qualit'r'
rrith rvhich each step was executed. The
shcer rrrlrrrne of detail gathered in
irsscssing their perfornlance distinsrrishes the exceptional fronr their
nlore avefage counterparts.
During the reflection phase, top perfornrcrs rcrierv the details of their perfrrrrnancc, iclerrtifling specific irctions
arrrl altcrn:rtc stratcgics for rcirclring
tlr ci l qoirls. \\1r cre rrnsucccssful I carn crs
pairrt uith broad strokes, attril>utins lailul'c t() cxtcrnal and rrncontr<>llaltlt-lac-
The penchant for seeking explanations for treatment failures can have
life-and-death consequences. In the
1960s, the average lifespan of children
lvith clstic fibrosis treated by "proficient" pediatricians was three vears.The
field as a rvhole rt>utilrelv attribtrted the
hieh mortalilv r:rte to the illness irselfa belief that, in rctrospect, can only' be
vierved as a self-fulfilline prophecl'. After
all, n'hl'search for altcrnative meth()ds if
the disease invariablv kills? Although
certainll' less dranrittic, psychologist
Williarn Millcr rnakcs a sirnilirr point
about ps1'chothclapr',noting that rnost
rnodcls don't accr>rrntlirr lrolv pcople
chanse, but ratlter rvhv thcv stal' the
sanre. Irr orrl experierrcc, diagnostic
Confronted by'novel, complex, or challenging situations, the focus of the
merell' prolicient performers narrows
to the point of tunnel r.ision. In chess,
these people ar-e easy to spot. Ther"re
the ones sittirg hunched over the
board, their firrgers glued to a piece,
conternplating the lc.rl rnove. But sttrdies of pilots, air traffic controllers,
clnergellcy roorn staff, irr-rd others itr
denranding situations ar-rcl pursuits
shorv that superior pcrforrners expand
thcir arvareness rvhen cvcDts are stressftrl, irvailins the nrselvcs ol' all the
options thcr-'r'e identifiecl, rchcarsed,
and pcrfcclcd <>vertirne.
Dclibcrate practice, [o bc sure, isn't firr
the harricd or hassled. Ncither is it lirr
sounels"
I bestsimplyworkharelel"
their
at improving
I
lfornrance
thanothers
do.
tors (c.e., "I hacl a bad da1:" "l rvasrr't
rvith it"), thc cxperls knorr,cxirr:tlyrvhat
//rr,rlo, rnorc ofien citing controllablc
Iactors (c.g., "I shotrlrl ]rave <lone x
irrstea<l ol-1," of "l lbrs()t to clo rcancl will
rlo r plus 1 rrext tinte"). hr our rvork wilh
psvchothcrapisls, wc'vc foun(l th?tt averlu!{cl)r:rctiti()llcrs Al'c far likelier t0 spend
tirnc hrpothcsizing about failed strirtegics-believine
perhaps thal rrndt-rst:rn<ling thc rc:rsons rvlrt' an apltroaclr
<lirln't rvork rvill leurd t() l)etter ()ut-
classificatiorrs ofictt s(:r1,ca sirnilar firrrction by attributins thercarrseof'a lailing
or lirilccl thcrapl' to thc clisorclcr.
The
Valrre
Practice,
of
Practice,
Practice
By' cornparison with cxplanations that
blarne the client or excuso thc thcrapist,
deliberate prar:ticc l)estows clcar advantages. In placc ol'static stolies irnd srunrnary' cortcltrsiott.s,pr:rctice crrhances
oJrtiotrs.Take chess, ftrr exanrple. The
rorner-and
less tirne thinking altotrt trnirnaginable spccd with rvhich nlastcr
stratcgies that rnight be more cffecdve.
players intuit thc lloard and rnake their
Rcturning to thc exilrnple zrbove,an
rnoves gives thern the appcarance oI'wizavcr2rsc thcrapist rvr>uld be significantly
ards, especially to dabblers. Research
likelier to attribute failure to engage proves this to be far frorn case. In point
I ht' rnanclated substance abuser t<t o f f a c t . t h e l l r o s s c s rst o t r r r i q r r eo r i r r n a l e
cleniirl,resistance,or lack of rnotivation.
abiliq' or advantage in memory. Far
The expert, in contrast, would say, frorn it. Their conrrnand of the game is
" l r r s t t - : r d o f o r g a n i z i n g t h e s e s s i o r - r sirnplv a function of numbers: they've
'dnrg
arotrrtrl
t r s e , ' I s h o r r l d h a v e played this ganre and a thousand others
enrphasizecl rvhat the client wantedbefore. As a result, thel' have more
getting his clriver's license back. Next
rneans at their disposal.
tinre, I'll explore in detail rvhat the two
The difference be[veen average and
of us need to do right nolv to get him
rvorld-class players becomes especially
back in the driver's seat."
apparent rvhen stress becomes a factor.
slackt-rs.\'t't, the willinsncss to cngage irt
deliber-:rtc practicc is what separatcs thc
wheat lirrrtt thc chafl. The reason is sintplc: cloirre it is unrcwarding in irltnost
cven' w:r)'. As Ericssotr rrotcs, "Unlike
play, delibcr:rtc praclir:e is rtot itrlrcrenlly
rnotjvzrtilrgi and unlike rvork, it cloes trot
leacl to irnrnt:diate social and ln()nctarJ,
rclards. In irddition, cngaging in Iit]
gcr)erates cost.s." N<> thircl parry' (c.g.,
clicrrt. insurarcc cor)lpirny, or govcnlnrcnt lx)d\') will pay f<rr the tinrc spcnt
trackirrg client proercss ancl alliance,
identifiing at-risk cases,developirrg altt'r.
n a l c s t r a t c g i c s .s c e k i r t g p c n t r i s s i o t t t o
r c c o r d t l e a l n l c n l s c s s i o n s . r ' r r s r rirt t t {
HIPPA compliance and confldcntialiry
s)'stematicall)' rer.iewing the lecordings,
evaluatins arrd refir.ring the execution of
the strategies, and soliciting outside consultation, tririrring, or coaching specific
to particular skill ses. And let's face it.
ferr'of rs are nilling pay f<rrit otrt of pocket. But this, and all rve'r'ejust described,
is exactlv rvhat the supershrinks clo. Irr a
word, ther" re self-rnotivated.
Continued on page 56
\\- \\' \\-. P S \' (J I I O 1' I I E R,\ P l N E T \\' O R K E N. O N C;
J
I
J
M.tt LF,R ftompage35
\4hat leads people, both children
and adults, to devote the time, energ)',
and resources necessar), to achieve
greatness is poorh' understood. Even
when the path to improved performance is clear and requires little effort,
most don't follorr' through. As repoltecl
in the December l-1, 2006, Nau Engl,a,nd
Joumal of Medicine, a study of 12 highly
experienced gastroenterologists found
that some doctors were 10 tirnes better
at finding precancerous polyps thar.r
others. An extremely simple solutior.r,
one involr.ing no technical skill or diagmorc tinre
nostic prowess-spending
and beins more thorough cluring the
found to increase the
procedure-was
polyp-clctection rate by up to 50 percent. Sadl)', acco|dirrg to a Decenrbcr'
19, 2006, Nnu York 7)nrasarticlc on the
strrdy.dcspitc tlris drarnatic irnprovt'
nrcnt. many doctors .spcnd rclatively little tirne-conside rably lcss thar.r 30
rninutes-doing thc procedure.
Ericsson arrcl colleagues bclicve that
{irturc stu(lics o[ clite ocrfbrrners rvill
TAMFT 34th
Annual Conference
The original marriage and family
therapv conference in Texas
give us a better idea of how rnotivation
is promoted and slrstained. Until then,
lve know that deliberate practice works
be.st when done multiple times each
day, including weekends, for short periods, interrupted by brief rest breaks.
"Cramming" or "cr-ash courses" don't
rvork and increase the likelihood of
exhaustion and burnout.
To assist busy behavioral-health professionals,the Institute for the Study of
Therapeutic Change is developing a
wetrbased system for facilitating deliberate practice. The system is patterned
after sinrilar progranls in use with
pilots, surgeons, :rtrd other professionals. The advantase here is that the steps
to cxcellence are autonrated. At
w ' w u . r ' r ) \ ' ( ) l l l c ( ) n r c( )sn. (l . c l i n i c i a r r s a r c
alreadl' ablc to tlack their outc()mcs,
cstablish their trirscline, and comparc
thcir performzlnce to national norms.
Thc svstern also pror,ide.s lecdback to
thcrapists whcn r:lients are itt risk f<tt'
dcterionrting or dropping otrt.
\{'e'rc currcntll' testing alqorithrns
that iclcrrtifl' patte nrs in the data associated with supcrior ()utconles. Such fbrmulas. based on thotrs:rtrds of' clier-rts
and ther:r1>ists,
will cnable us to idcntif1'
rvhen un inclividrral's perf<rrtrt:rnccis :rt
variancc rvith thc pattcrn ofcxcellctrce.
Whcn this happens, thc clitrician will bc
notified b'r' e-rniril of lur online dcliberatc-pr:rcticc opportunit)'. Srrch training
will difl'cr frorn traclitional continrritrs
education in two cr.itical ways. First, it'll
be targctcd to thc dt:r'eloprnel)t of skill
scts specific to the ncccls of thc individual clinician. Second, and of grcater
c()nseqllcnce in thc pursuit of cxcellerrce, the irnpact olr olrtc()r))c rvill l>c
irnmcdiately meixurable. It's our hope
that such a systcm will rnake the process
of dcliberate praclice more ircccssiblc,
less onerous, and rtruch morc efficient.
The present era in psychotherapl'has
been referred to by manv leading
thinkers as the "nge of accor-rntability."
Everl'one wants to knorv rvhat thel"re
getting for their mone)'. But it's no
longer a simple matter of cost and the
bottom line. People are looking for
value. ,{s a field, rve have the means at
our disposal to demonstrate the worth
of psychotherapy in eyes of consumers
ar"rd pavers, and rnarkedlv increase its
value. The question is, will rve? I
xm
lledtlrr
Snong
frInus
}{uch27{9,2ffi8
lslmd
Gdrnston
Conltntion
Cerrtff
SanLuilRnort
TO RECISTER:www.ta mft.ors
J
(? n s vc H o r H E R,\pl
N E T \ \ ' o R K E R r N o u p ub e r /D e c en b e r 2 0 0 7
Scott Miller; Ph.D., Marh Hubblc, Ph.D.,
and Banl Duncan, Psy.D., are cofounders
of tlrc Institute for tlv Studr of Therapeutic
Change. Tbgethry thry\rc authored and edited numerous professional articles and books,
including The Heart and Soul of
Change: \\rhat \\irr-ks in Therapy;
Escape from Babe l; Psvchotherapy with
Irnpossible Cases; and The Heroic
Client. Rerent\, Xlillrr and Hubbk rekased
a self-help DooA, Staring on Top and
Keeping the Sand ()trt of Vrur Pants: A
Surfe r's Guide t() the Good Lil'e.
Duncan publislrcd thr v,ll-hclt Doo&\4rhat's
Right with Vrtr: f)cbrrnkirre D1'sfutrction
and Changing \irrrr I-if'e. Contact:
info@talkingcut?.(om. lAters to the Ediur
about this article may be e-mailed to
letters@psychn etzuorh er.or g.
RrrunnNcns AND Rf,souRcES
Barcla1.,Robclt I-.. foscph .f. Vicari,
[)orrghtr',
zrl.
S.
ct
Andrea
-I'irnes
"Oololroscopic \\'ithrlr':rrr'al
and
Adcnorna f)ctcctiorl rlrrring Screcning
Ocrlrrrroscopr:" .\iir' I'.ttgland Journal of
Medicitre 35ir, no. !-l (Dcct-rnber l-1,
2006),2533--{1.
"Quantitative
l'urrl.
Clcrncnt,
Evalrration ol 2(i \i'als ol Prir':rtc
It
Practicc. " I'nliss i rtttu I I'st r h o k471
: Researc
andPrurlite2ir, no.2 (\lar 1994): 17176.
'\\'lrat
It lhkes to Bt:
Colvin, flcolll'cr.
()reat." I'or!uttt,,( )t tolrt'r 19, 2006.
(]aw:rrrclc,.\ttrl."Tlre Bcll (lurve ." 7he
Nar Yorkerl)cccrttlrt'r' (i. ?00-1.
IIiatt, Dcirdlc. and ()corec E.
I'Iarsravc. "Tht' (.h:rructcristics of
-I'hcrapists
in Managcrl
Highly l.ffectivc
Behavioral Prorirlt' r' N(' t\\'()rks." Ik hauiora.l.
'litntontnt,
I ( 1995): l{)-?2.
Heahhrarr
Miller, Scott l).. Barn L. f)uncatr,
Georgc S. (fcb) Ilrorvrr, et al. "Using
Forrnal Clicnt Ft't'rlback to Irnprove
Retenti<irr arrrl ()rrtcont<'." Jountal oJ'
Brief l'ltenln ir (20{)ti): i>22
Right,
Villarosa, Lincla. "Doue
Colonoscopv Takes Tinre, Study Finds."
The Nau lbrk 7-ittu't.Hcalth Section,
December 19. 200(r.
rrVanrpold, Rnrcc Fl., and (ieorge S.
(feb) Bronn. "Estirnatins Variability in
Outcor.nesAttribtrtable to Therapists: A
Naturalistic Studv of Outcomes itr
Managed Care." Jotuttal of Consulting
and Cliniral Pslcholog;,73, no.5
(Octobe
r 2005):91+23.