Scott Miller Training:
Supershrinks
Learning from the Field’s Most
Effective Practitioners
Based on training created by:
Scott D. Miller, Ph.D.
(Mild-mannered clinician and researcher)
About Talkingcure.com
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What is a “Supershrink”?
1.Do they exist?
2.Who are they?
3.Can we learn from them?
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What is a supershrink?
• In 1974, researcher David F. Ricks coined the term supershrinks. His study
examined the long-term outcomes of "highly disturbed" adolescents.
• Research participants were later examined as adults: a select group, fared
notably better than boys treated by another therapist, a "pseudoshrink", who
demonstrated alarmingly poor adjustment as adults.
Supershrink:
(n. soo-per-shrĭngk), slang
1. Unusually effective and talented psychotherapist;
2. Widely believed to exist in real life;
(See virtuoso, genius, savant, expert, master)
Ricks, D.F. (1974). Supershrink: Methods of a therapist judged successful on the basis of
adult outcomes of adolescent patients. In D.F. Ricks, M. Roff, & A. Thomas (eds.). Life
History in Research in Psychopathology. Minneapolis, MN: University of Minnesota Press.
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Do they exist?
Data gathered in many studies over 25 years show:
• Significant differences in effect between clinicians (0-75%,
mean 5-8%);
• Differences persist even when studies are carefully
controlled (e.g., manuals, allegiance, skill & alliance level,
competence [TDCRP, Project MATCH, MCSTPD]).
Orlinsky, D. & Howard, K. (1980). Gender and psychotherapy outcome. In A.M. Brodsky & R.T. Hare-Mustin (eds). Women and
Psychotherapy (pp.3-34). New York: Guilford.
Wampold, B., & Brown, J. (2006). Estimating variability in outcomes attributable to therapists: A naturalistic study of outcomes in
managed care. Journal of Consulting and Clinical Psychology, 73 (5), 914-923.
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How is “successful therapy” measured?
• In research, whether or not therapy has been successful
and the degree to which it has been successful is
determined based on self report measures provided by
the clients
• Some studies also use therapist completed measures
• Some studies also use measures such as physical tests
or recidivism rates (e.g. in drug and alcohol)
• The measures are designed to assess:
–The degree of symptom reduction
–The degree of improvement in functioning
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M.C.S.T.P.D.: Multicenter Collaborative Study for the
Treatment of Panic Disorder
Carefully controlled study comparing CBT, medication, and a placebo either alone
or in combination.
People were excluded if:
– Any history of psychosis;
– Currently suffering from significant medical illness, suicidality, or significant
substance abuse;
– Contraindications to either CBT or medication treatment, prior nonresponse to
CBT or drugs.
Therapists averaged 35 years of age and had ~10 years of experience:
– All therapists trained to competency and certified in conducting panic control
treatment (no improvement after trial began);
– The majority identified CBT as primary theoretical orientation.
– Adherence and competency ratings high across clinicians throughout the study;
Barlow, D., Gorman, J., Shear, M., Woods, S. (2000). Cognitive-behavioral therapy, imipramine, or their
combination for panic disorder: A randomized controlled trial JAMA, 283, 2529-36.
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M.C.S.T.P.D.: Multicenter Collaborative Study for the
Treatment of Panic Disorder
Overall, CBT and medication worked about equally
well!
• Combination produced no better outcome than either
treatment alone.
• Therapists differed significantly in magnitude of
change experienced by consumers (0-18%):
• Unrelated to age, gender match, experience with CBT;
• The best and the worst therapists did not differ in
adherence to protocol or in competency of services
delivered.
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So, differences in outcome appear to have nothing to
do with:
• Therapist age, gender, years of
experience, theoretical
orientation, professional
discipline, training, supervision,
personal therapy, specific or
general competence, licensure
or certification
• Client severity (diagnosis), level
of functioning at intake, length of
treatment or prior treatment
history
In other words – the factors that
we traditionally believe account
for the differences in client
outcomes are not supported
by research
Real world consequences:
• Clients of most effective
therapists average 50% or more
improvement and 50% or less
drop out.
Beutler, L., Malik, M., Alimohamed, S. et al. (2005). Therapist variables. In M. Lambert (ed.). Handbook of Psychotherapy and
Behavior Change (5th ed.) (pp. 227-306). New York: Wiley.
Brown, J., Lambert, M., Jones, E., Minami, T. (2005). Identifying highly effective psychotherapists in a managed care
environment. The American Journal of Managed Care, 11, 513-520.
Garfield, S. (1997). The therapist as a neglected variable in psychotherapy research. Clinical Psychology, 4, 40-43
Seligman, M. (1996). The effectiveness of psychotherapy: The Consumer Reports study. American Psychologist. 50(12), 965-974
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What about medication…
• Medication is generally helpful only when given by an effective
practitioner (Wampold Study). The “catalyst” is therefore the clinician.
For poorer therapists,
there was little
difference in client
outcome between
those given meds and
those not given meds.
On the other hand, for
better therapists,
clients who were given
meds had better
outcomes than those
not given meds
Wampold, B., & Brown, J. (2006). Estimating
variability in outcomes attributable to
therapists: A naturalistic study of outcomes in
managed care. Journal of Consulting and
Clinical Psychology, 73 (5), 914-923.
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Similar findings in Medicine…
Study of experienced
gastroenterologists found:
Real world consequences:
• Each physician had performed more
than 3,000 colonoscopies prior to the
study;
• The “best” physicians found 10 times
as many polyps.
Summary of research on treatment of
cystic fibrosis:
• In 1964, Cystic Fibrosis Foundation
begins collecting data on all treatment
centres:
• In spite of undergoing a rigorous
certification process and following the
same detailed guidelines, wide
variations in outcome exist between
centres and providers.
The most effective
gastroenterologists find 10 times as
many polyps as their equally or more
experienced peers.
People with cystic fibrosis who are
treated by the most effective
practitioners add on the average 14
more years of life;
Clients of most effective therapists
average 50% or more improvement
and 50% or less drop out.
• Average life expectancy nationwide is
33 years: At the “best” centres, 47
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Supershrinks
• Who are they?
• What can we learn from them?
• What makes a Supershrink?
• Is it nature or nurture?
• Are they:
a. Made?
b. Born?
c. Both?
d. None of the above?
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Are they born?
• "The search for stable heritable characteristics that could
predict or at least account for superior performance of
eminent individuals [in sports, chess, music, medicine,
etc.] has been surprisingly unsuccessful. . . . Systematic
laboratory research . . . provides no evidence for
giftedness or innate talent.“ (K. Anders Ericsson)
• Professional training, development, certification & identity
is based on the idea of “making” better therapists.
Ericsson, K.A. & Charness, N. (1994). Expert performance. American Psychologist, 49, 725-747
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What is about supershrinks that makes them
super?
To determine this, we have tended to ask:
What do they do:
–Distillation of “patterns,” clinical routines, techniques;
And who they are:
–Personal qualities, knowledge, manner, attributes,
traits.
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What the research has said about what makes
a “great therapist”
• Handbook of Psychotherapy and Behaviour Change says:
–Interest in people as individuals
–Insight into one’s own personality characteristics
–Sensitivity to the complexities of motivation
–Tolerance
–Ability to establish warm and effective relationships with
others
Beutler, L., Malik, M., Alimohamed, S., Harwood, T., et al. (2005). Therapist variables. In M.Lambert (ed.).
Bergin and Garfields Handbook of Psychotherapy and Behavior Change (5th Ed.). (pp. 227-306). New York: Wiley.
Holt, R. & Luborsky, L. (1958). Personality patterns of psychiatrists (Vol. 1). New York: Basic.
Raimy. V. (1950) (ed.). Training in Clinical Psychology. New York: Prentice-Hall.
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Charman (2005) suggests two primary themes:
1. Sense of self-relatedness:
– Mindful
– Not having an agenda
– Concern for others
– Intelligent
– Flexible personality
structure
– Intuitive
– Self-aware
– Thoughtful
– Knows own issues
– Able to take care of self
– Open, patient, creative…
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2. Capacity for interpersonal
involvement and bonding:
– Listening
– Responding
– Empathy
– Acceptance
– Authenticity
– Genuineness
– In tune
Charman, D. (2005). What makes for a “good”
therapist? A review. Psychotherapy in Australia,
11(3), 68-72.
Charman, D. (2004). Effective psychotherapy and
effective therapists. In D.Charman (ed.). Core
Processes in Brief Psychodynamic Psychotherapy:
Advancing Effective Practice. Englewood, N.J.: LEA.
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But what does that actually tell us?
• Not a great deal!
• Most of us have those
qualities and incorporate
them into our work, but
whilst this is important for
good work, it is not a
formula for greatness or
“Supershrinkdom”
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What makes a superior performer?
• Time and hard work
• Are motivated intrinsically – not for external gain but
rather wanting to be good for one’s own sake
• Tend to be risk takers, will be creative
• Always ask what they could do differently to improve
• Don’t blame external events or factors outside of
themselves when things don’t work
• Always think there is more work to do to improve
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What makes a superior performer?
Examples
Tiger Woods – changed his swing to the detriment of his
game for a period of time with the aim of improving and
growing even though he was already incredibly successful
Chris Rock – creates his comedy shows by taking material to
small clubs, gauging audience reactions and then tweaking
those jokes that did not work so well and then trialling the
show with changes at another club etc. until he feels
satisfied enough to launch it as a “Chris Rock Show” at a
large venue.
Scott Miller as a presenter – after every presentation, notes
down the trainees responses to the material and amends
his presentation style and material accordingly
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Athletes vs Therapists
ATHLETES:
THERAPISTS:
•
• Since the 1960’s:
•
Over the last century, the best
performance for all Olympic
events has improved—in some
cases by more than 50%!
The fastest time for running the
marathon in the 1896 Olympics
was just one minute faster than
the entry time currently required
for participation in large
marathon races (e.g., Boston
and Chicago).
– 10,000 “how to” books published
on psychotherapy;
– Number of treatment approaches
grown from 60 to 400+;
– 145 manualised treatments for 51
of the 397 possible diagnostic
groups;
• Yet – there has been no
improvement in outcomes (or the
effect size of therapy) since 1977
despite this extension in repertoire.
Beutler, L., Malik, M., Alimohamed, S., Harwood, T., et al. (2005). Therapist variables. In M. Lambert (ed.).
Bergin and Garfields Handbook of Psychotherapy and Behavior Change (5th Ed.). (pp. 227-306). New York: Wiley.
Wampold, B. (2001). The Great Psychotherapy Debate. Hillsdale, NJ: LEA.
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Hold on! What is the effect size of therapy?• Before we become disheartened, it is important to remember that the effect size of
therapy is .8
• This is extraordinary and well exceeds the effect sizes of many medications used
widely and is equivalent to the effect size of heart by-pass surgery!
• This means the average treated client is better off than 80% of the untreated
sample. This is consistent across a range of large studies and a wide array of
diagnostic criteria
• In general:
Psychotherapy vs no treatment
Effect size is .82
(those treated with psychotherapy were 80% better off than those
who weren’t)
Psychotherapy vs placebo*
(*supportive counselling that
does not apply any
interventions)
Effect size is .47-.49
(those treated with psychotherapy were 47-49% better off than
those who were given a placebo treatment)
Psychotherapy vs a similar
treatment*
(*e.g. psycho-education)
Effect size is .15
(those treated with psychotherapy were 15% better off than those
who were treated with something similar to treatment)
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Sound clip…
Does research consistently shows that treatment works?
True or False
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A contrast example: The effect size of aspirin?
• The effect size
of psychological
treatments is
close to one
standard
deviation above
the mean
Effect size of Aspirin
• The effect size
of aspirin (in
lowering
chances of heart
attack and
stroke) is only
.03 (3%) above
the mean
• Yet aspirin is
widely marketed
and used as a
preventative
medicine for
heart disease
and stroke.
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Ideas, questions, remarks?
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Are some therapies more effective than others?
• Cognitive Therapy
• Family Effectiveness Training
• Behavioural Therapy
• Multisystemic Therapy
• Cognitive Behavioural Therapy
• Solution-focused Therapy
• Motivational Interviewing
• Brief Strategic Family Therapy
• Twelve Steps
• Psychodynamic Therapy
• Dialectical Behavioural Therapy
• Parent Management Training
• Multidimensional Family Therapy
• Integrative Problem-Solving
Therapy
• Structural Family Therapy
• Functional Family Therapy
• Social Skills Training
• Assertive Community Treatment
• Aggression Replacement Therapy
• EMDR
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Research shows
there is NO
DIFFERENCE in
outcome between
different types of
treatment or differing
amounts of
competing
therapeutic
approaches.
• Interpersonal Psychotherapy
• Transtheoretical Therapy
Rosenzweig, S. (1936). Some implicit common factors in diverse methods in
psychotherapy. Journal of Orthopsychiatry, 6, 412-15.
Wampold, B.E. et al. (1997). A meta-analysis of outcome studies comparing bona
fide psychotherapies: Empirically, "All must have prizes." Psychological Bulletin,
122(3), 203-215.
Ahn, H. & Wampold, B.E. (2001). Where oh where are the specific ingredients? A
meta-analysis of component studies in counseling and psychotherapy. Journal of
Counseling Psychology, 48, 251-257.
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Example…
• Study of real-world clients seen in UK National Health
Service settings treated with CBT, PCT, or PDT or
CBT, PCT, PDT plus integrative, art, or supportive
therapy.
–Little or no meaningful difference between
treatment approaches;
–Improvement across treatment accounted for 100
times more variance in outcome than the specific
approach.
Stiles, W., Barkham, M., Twigg, E.. et al. (2006). Effectiveness of cb, pc, and pd therapies as
practiced in UK National Health Service. Psychological Medicine, 36, 555-566.
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So what’s the bottom line?
• The majority of helpers are effective and efficient most of the time.
• The average treated client accounts for only 7% of expenditures.
So, what’s the problem?
The “Bad News”
• Drop out rates average 47%;
• Therapists frequently fail to identify failing cases;
• Often our theories lead us to conclude those clients
need more of the same treatment that’s not worked so far
• 1 out of 10 clients accounts for 60-70% of
expenditures.
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What can we learn from other fields?
• Remember the study on
colonoscopies that identified
that certain practitioners were
more effective than others in
finding more polyps?
• This study also found that the
practitioners who were more
effective at finding polyps
simply spent more time on their
colonoscopies.
• In spite of this research, most
doctors who participated and
experienced a 50%
improvement in their success
rate for detecting polyps (when they spent longer examining the colon) went back
to their old practices!
Why?
Because they stated that the “onus remains on patients to ask for data on how
proficient their doctors are”
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Burden shifting
• As extraordinary as this seems, this practice of placing the
responsibility onto the patient or client exists in our field as well.
• When a treatment doesn’t work, it is often assumed that it is
something about the client (they are resistant, defensive,
uncooperative, too complex etc.) and not something about us
as therapists.
• Collectively, the field acts “as if” all therapists are equally
effective and put “onus of responsibility” on consumers to ferret
out the difference
The result?
• We keep doing what we are doing and do not amend our
practice so that we are giving clients what they need (rather
than what we believe they need)
• These clients drop out or fail to progress (or even worsen)
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Moreover, we are often not tuned in to our own
effectiveness…
• The least effective therapists tend to think that they are as effective as
the most effective therapists. They do not realise that they need to
improve.
Example:
• Psychologist Paul Clement published a quantitative study of 26 years as
a psychologist
• The study covered 683 cases falling into 84 different DSM categories.
• The findings: “I had expected to find that I had
gotten better and better over the years…but my data
failed to suggest any…change in my therapeutic
effectiveness across the 26 years in question.”
Clement, P. (1994). Quantitative evaluation of 26 years
of private practice. Professional Psychology, 25, 173-176.
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What can we do about it?
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How are superior therapists different from
average therapists?
• They tend to see clients for longer overall but also know how
often and how long to see clients for to achieve the most
effective outcomes (titrating the dose)
• Are much more likely to have phone contact with clients
between sessions during the first 3 sessions – a call to check in
with them, check on homework assigned etc.
• Are actually more likely to get lower SRS scores to begin with
because they are able to create a space where clients can give
honest feedback and then the therapeutic process can be
improved.
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How are superior therapists different from
average therapists?
• Are tuned into when the therapy is not working and look for
ways to improve it.
• Even when they get a good rating on the SRS, will still ask
the client how they could make it even better? How could
they “add value”?
• Constantly look for new information to help them improve
their practice with the motivation of wanting to help clients
improve their outcomes (by talking to others, researching).
• Put a lot of energy into building the relationship with the
client. Know that in a good relationship, “mistakes” can be
recovered from.
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How are superior therapists different from
average therapists?
• In essence – they simply
work harder at improving
their performance than
others do.
• How do they do this?
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How do they do this? Why is this beneficial?
1. They seek consumer
engagement and take
responsibility for
engaging their clients
more effectively
“The quality of the patient’s participation in therapy
stands out as the most important determinant of
outcome…[this] can be considered fact
established by 40-plus years of research on
psychotherapy.” (Orlinsky et al)
2. They seek client
feedback
To get a measure of how effective they are with
that particular client in order to amend their
practice should their effectiveness
3. They engage in
“deliberate practice” –
time specifically devoted
to reaching for
objectives just beyond
one’s level of proficiency
“Just because you’ve been walking for 55 years doesn’t
mean you are getting better at it. It’s a myth that you get
better when you just do the things you enjoy.” (Ericsson)
So – effort to stretch oneself, effortful performance is
where real improvement happens.
Orlinsky et al. (1994). Process and outcome in psychotherapy. In A. Bergin, & S. Garfield (eds). The Handbook of
Psychotherapy and Behavior Change (4th ed.). New York: Wiley, p. 361.
Ericsson, K.A. (2006). The influence of expertise and deliberate practice on the development of expert performance. In
K.A. Ericcson, N. Charness, P.J. Feltovich, & R.R. Hoffman (eds.). The Cambridge Handbook of Expertise and Expert
Performance (pp. 683-704). New York: Cambridge University Press.
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How do we know that deliberate practice makes a
difference?
• “When individuals, based on their extensive experience and
reputation, are nominated by their peers as experts, their actual
performance is…found to be unexceptional…”.
• Ericsson studied experts in chess, music, art, science,
medicine, mathematics, history, computer programming.
• The key difference between experts (so defined because they
demonstrate superior performance in their field) and others –
the amount of deliberate practice
Ericsson, K.A. (2006). The influence of expertise and deliberate practice on the development of
expert performance. In K.A. Ericcson, N. Charness, P.J. Feltovich, & R.R. Hoffman (eds.). The
Cambridge Handbook of Expertise and Expert Performance (pp. 683-704). New York: Cambridge
University Press.
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More on deliberate practice…
• There is little or no difference in outcome
between professional therapists, students,
and minimally trained paraprofessionals;
• The effectiveness of the “average” therapist
plateaus very early.
• So –
• Whilst performance grows in the beginning of
one’s experience, for average therapists
(regardless of type of training), effectiveness
(in terms of client outcomes) quickly evens off
Atkins, D.C., & Christensen, A.
(2001). Is professional training worth
the bother? A review of the impact of
psychotherapy training on client
outcome. Australian Psychologist, 36,
122-130
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• Performance becomes “automatic” and
development is arrested as therapists close
themselves off to new ideas and ways of
working.
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More on deliberate practice…
Supershrink (n. soo-per-shrĭngk):
• “Successful people spontaneously do things differently
from those individuals who stagnate...Elite performers
engage in…effortful activity designed to improve individual
target performance.”
Brown, J., Lambert, M., Jones, E., & Minami, T. (2005). Identifying highly effective
psychotherapists in a managed care setting. The American Journal of Managed Care, 11, 513-520.
Collier, C. (November 2006). Finalword: The expert on experts. Fast Company, 116.
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An example of deliberate practice…
Milton H. Erickson, M.D.
• Indirect or “naturalistic” approach to hypnosis:
– Metaphor
– Interspersal & Embedded commands
– Pattern intervention
– Parallel communication
• Practitioner of “deliberate practice”
• For many years and for each of his clients,
Erickson would do a mental status exam and
then create an imagined social history for the
client before comparing it to their real history (and
vice versa).
Erickson, M.H. & Rossi, E. (1980). The
indirect forms of suggestion. In E.L.
vRossi (ed.). The Collected Papers of
Milton H. Erickson (Vol. 1). New York:
Irvington.
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• Similarly, in his practice of hypnosis, he began by
writing out a 15 page induction that he would
then reduce to 10 pages and then to 5 pages
before using it with a client
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How bad do you want to be good?
“Unlike play, deliberate practice is not inherently motivating; and unlike
work, it does not lead to immediate social and monetary rewards…and
[actually] generates costs…”.
Ericsson, K.A., Krampe, R., & Tesch-Romer, C. (1993). The role of deliberate practice in the acquisition of expert
performance. Psychological Review, 100, 363-406.
• Elite performers engage in practice designed to improve their target
performance:
– Every day of the week, including weekends
– For periods of 45 minutes maximum with rest periods in between
– At least 4 hours per day
• Deliberate practice includes:
– Working hard to overcome automaticity
– Planning, strategising, tracking, reviewing and adjusting plans and steps
– Consistently measuring and then comparing performance to a known
baseline or national average or norm.
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Deliberate Practice: The T.A.R. approach
1. Think – ask “what do I
want to improve?”
2. Act – ask “which
strategy will I use to do
it?”
3. Reflect – evaluate the
strategy employed
Ericsson, K.A. (2006). The influence of expertise and deliberate practice on the development of
expert performance. In K.A. Ericcson, N. Charness, P.J. Feltovich, & R.R. Hoffman (eds.). The
Cambridge Handbook of Expertise and Expert Performance (pp. 683-704). New York: Cambridge
University Press.
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Deliberate practice in action – A suggested process
Step One: Identify “at risk”
case
Step Three: Act
a) Conduct the session;
a) Low SRS score or no progress
or deterioration on ORS.
b) Obtain permission to record
the session for personal
use/development.
b) Take a break prior to the end of the
visit to “self-record” noting the steps
in the planned strategy that were
missed.
Step Four: Reflection
Step Two: Think
a) Develop a strategy;
b) Connect the strategy to a
specific target outcome.
a) Review self-record;
b) Identify specific actions and
alternate methods to implement
strategy.
c) Review video: (stop/commit/imagine
course and consequences/start)
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Deliberate Practice:
Example – Engagement
The client's beliefs, values and experiences
Client Engagement is:
• The best process related
predictor of outcome;
• Mediated by the alliance.
• Alliance is agreement between
the therapist and client on 
What the client
wishes to achieve in
therapy and why
Ericsson, K.A. (2006). The influence of expertise and
deliberate practice on the development of expert
performance. In K.A. Ericcson, N. Charness, P.J.
Feltovich, & R.R. Hoffman (eds.). The Cambridge
Handbook of Expertise and Expert Performance (pp.
683-704). New York: Cambridge University Press.
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What the
client thinks
of the
therapist
What the
client thinks
should be
the way their
goals are
achieved
Bachelor, A., & Horvath, A. (1999). The Therapeutic
Relationship. In M. Hubble, B. Duncan, & S. Miller (eds.). The
Heart and Soul of Change. Washington, D.C.: APA Press.
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Deliberate Practice: Example – Engagement
Principle:
Clients who give their
therapist a low SRS score at
first but a high SRS score by
the end of therapy have the
best outcomes
Clients who give their
therapist a high SRS score
at first but a low SRS score
by the end of therapy have
the worst outcomes
• Negative consumer
feedback is associated with
better treatment outcome.
Finding:
The
difference
between
the best
and worst
outcomes
is 1.2
standard
deviations
First/Last Alliance Scores for 9000+ “At Risk” adolescents
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• Consumers who
experience a problem but
are extremely satisfied with
the way it is handled are
twice as likely to be
engaged as those who
never experience a
problem
Fleming, J., & Asplund, J. (2007). Human
Sigma. NY: Gallup Press.
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Deliberate Practice: Example – Engagement
Step One: Identify “at risk” case
Step Three: Act
a) Client scores 400 on the SRS at the
conclusion of the first visit
a) Conduct the session;
Risk is that they may not achieve the best
outcomes because they are unable to give you
constructive feedback to ensure best fit for the
therapy
Step Two: Think
b) Take a break prior to the end of the
visit to “self-record” noting the steps
in the planned strategy that were
missed.
Step Four: Reflection
a) Develop a strategy;
• Minimum 4 different gambits with 2
additional responses each
That is, 4 different ways you might elicit more
meaningful feedback and for each gambit, a
further 2 things you might say if you still don’t
get the desired feedback
a) Review self-record;
b) Identify specific actions and alternate
methods to implement strategy.
c) Review video: (stop/commit/imagine
course and consequences/start)
b) Connect the strategy to a specific target
outcome
That is, the feedback you are looking for that will help you to amend the
therapy for better fit – getting past “I don’t know
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Ideas, questions, remarks?
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If you remember….
Supershrink: (n. soo-per-shrĭngk)
a. seeks, obtains, and maintains more consumer
engagement;
b. exceptionally alert to risk of drop out and treatment
failure;
c. pushes the limits of their current realm of reliable
performance.
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What are the success rates for therapy?
50% will
Improve on
their own
50% will
Drop Out
50% will not
improve on
their own
Beginning of
Therapy
50% will
Stay
50% will not
improve
50% will
improve
But of that 25% of clients who stay
in therapy and don’t improve –
improvement can happen,
especially with feedback
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Failure generally
happens with 25%
of clients who stay
in therapy
21% improve if
they keep on
with therapy
46% will improve
if they give
feedback to their
therapist
56% will improve
if feedback is
shared between
the therapist and
the client (2 way
feedback)
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Consumer Engagement and Feedback in Therapy
Case Example: Wendy
• Wendy is a therapist in the UK who was identified as a “Supershrink”.
• Wendy sees herself only as an average therapist and observations of
her work reveal that her style and interventions might be considered
quite clumsy and inelegant at times however her clients have
consistently better outcomes than the clients of other therapists
• Wendy reports that her primary motivation is for her clients get better
and so she is constantly on the look out for ways help them,
especially if they are stuck.
• Wendy focuses on the alliance and relationship with the client first
and foremost
• Wendy relies heavily on client feedback and responds to it. Wendy
creates a safe environment for clients to give honest feedback by
explaining to clients that it will help her to help them.
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Consumer Engagement and Feedback in Therapy
Case Example: Wendy
An example of Wendy’s response to client
feedback –
• A client tells Wendy that one of her facial
expressions bothered her in the session.
• Wendy worked with the client to identify which
expression she meant.
• She then consulted with others about their
experience of this facial expression and her
husband confirmed that he has always hated this
facial expression.
• Wendy worked on being conscious of her facial
expressions and choosing to alter the automaticity
of this problematic facial expression.
The result?
• A strengthened relationship with the client who became more engaged in the
therapy and did not drop out, but rather continued in therapy and was able to
achieve her desired outcomes
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How can we increase consumer engagement and be
alert to risk of drop out and treatment failure?
Medical Model
• Diagnosis-driven, “illness model”
• Prescriptive Treatments
Evidence-based
Practice
The Contextual Model
Practice-based
Evidence
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• Emphasis on quality and
competence
• Cure of “illness”
• Client-directed (Fit)
• Outcome-informed (Effect)
• Emphasis on benefit over need
• Restore real-life functioning
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Research and clinical experience indicates…
Outcome of treatment varies depending
on:
1. The unique qualities of the client.
2. The unique qualities of a therapist.
3. The unique qualities of the context in
which the service is offered.
4. The specific activities or therapeutic
interventions
In other words, “who” and “where” better
predictors than “what”
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The “people” account
for 5-8% variance in
treatment outcomes
The “place” accounts
for 2-3% variance in
treatment outcomes
The “things we do in
therapy” account for
1-2% variance in
treatment outcomes
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Contrasting the Medical Model and the Contextual
Model
• The medical model has focussed exclusively on the “what”.
• The contextual model considers all of the variants in
treatment outcome.
• For example, by asking:
–Is what we are doing in therapy a good fit for this
client?
–Is it working?
–What does the client want to work on? (even if this is
not what you, the therapist, believes that they need to
work on)
–Is the client engaged with the therapist and with the
therapy process?
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The four factors that contribute to the variance in
client outcomes (most to least important)
1. Early change: if the client changes early on in the
treatment, then they will make most change overall. That
is, early change in treatment one of the best predictors of
success.
2. Alliance: the client alliance with the therapist and their
ability to relate to the treatment approach being used
3. Allegiance: the therapist’s belief in the approach used
(their positive hope for the effectiveness of the treatment
approach)
4. Model: the treatment approach chosen
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In summary…
The goal is not to standardise the delivery of therapy because
variability in therapeutic approaches in a variable client population
is important. You do not have to ditch your therapeutic
orientation.
The goal is to achieve a fit between therapist and client that is
client directed and that the therapeutic approach (process) is
outcome informed.
That is: ask the question, is the approach I am employing with this
client leading to a positive outcome?
If yes – then continue with this therapeutic process
If no – then you need to adapt your therapeutic process
based on information from your client
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How do you know when the approach you are using
is leading to a positive outcome?
“Therapists typically are not
cognisant of the trajectory of
change of patients seen by
therapists in general…that is to
say, they have no way of
comparing their treatment
outcomes with those obtained
by other therapists.”
Wampold, B., & Brown, J. (2006). Estimating variability in outcomes attributable to therapists: A naturalistic
study of outcomes in managed care. Journal of Consulting and Clinical Psychology, 73 (5), 914-923.
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Available evidence also indicates:
• Therapists are not particularly adept
at identifying people “at risk” for drop
out or treatment failure;
• Therapists appear not recognise
deterioration in treatment.
• Effectiveness ratings by independent
observers, supervisors, and peers are
inconsistent and unreliable.
Charman, D. (2005). What makes for a “good” therapist? A
review. Psychotherapy in Australia, 11(3), 68-72.
Hannan, C., Lambert, M., Harmon, C., Nielsen, S., Smart, D., et
al. (2005). A lab test and algorithms for identifying clients at risk for
treatment failure. Journal of Clinical Psychology, 61, 1-9.
Wampold, B., & Brown, J. (2006). Estimating variability in
outcomes attributable to therapists: A naturalistic study of
outcomes in managed care. Journal of Consulting and Clinical
Psychology, 73 (5), 914-923.
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Expected rates of change
• A typical growth chart for head circumference of infants
• Gives parents and MCH Nurses a way of gauging whether their child is
developing “on track” as compared to “normed” growth rates
• Wide variation in growth rates might be expected but when growth levels are
outside of the top and bottom of the range, this might indicate that there is a
problem that should be investigated.
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Outcome informed clinical work…
• Feedback about outcome is essential for clinical decision
making.
• Therapists do not need to know what treatment to use for
a given diagnosis as much as whether the current
relationship is a good fit and providing benefit and, if not,
to adjust early to maximise the chances of success.
• 40 years of data say:
–The client’s rating of the alliance is the best
predictor of engagement and outcome
–The client’s subjective experience of change early
in the process is the best predictor of success for
any particular pairing.
B. Duncan, & S. Miller (eds.). The Heart and Soul of Change.
Washington, D.C.: APA Press
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How do we as therapists gauge whether clients are
progressing within the “normal range”?
A functioning/ outcome tool. Gives therapists
a way of tracking outcomes from week to
week to measure whether there has been
improvement at the rate of change that will
most likely lead to good outcomes overall
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An alliance tool. Gives therapists a way of
checking on the therapeutic relationship
and seeking feedback that will increase
consumer engagement and alert
therapists to the risk of drop-out
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Creating a culture of feedback…
• When introducing feedback forms to your client, it is important to provide a
rationale for doing so that will make sense to your client and invites their
involvement in their own progress through therapy.
• An example of an introduction might be:
“I want to help you reach your goals. I have found it important to monitor
progress from meeting to meeting using two very short forms that ask you how
you think things are going and whether you think things are on track.
To make the most of our time together and to get the best outcome, it is
important to make sure we are on the same page with one another about how
you are doing, how we are doing and where we are going. We will be using
your answers to tell us if we are on track or if we need to change something
about our approach, or include other resources or referrals to help you get what
you want.
I want to know this sooner rather than later because if I am not the person for
you, then it would be better for me to help you find someone who is a better
match for you and so that I am not an obstacle to you getting what you want.
Will that be okay with you?”
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Using feedback – a refresher on the ORS and SRS
• Assesses individual, relational, and social functioning.
• Correlates .7 with the OQ-45.2.
• Reliability in the .8’s.
• Takes less than a minute to take and score.
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The
ORS
• Scored to the
nearest
millimetre.
• Give at the
beginning of
the visit;
• Add the four
scales
together for
the total
score.
• Client places a
hash mark on
the line.
• Each line 10cm
(100 mm) in
length.
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Creating a culture of feedback – The ORS
• It is important to provide a rationale for seeking client feedback
regarding outcome in the first session. You might advise your client:
–I work a little differently;
–Giving me this feedback on how you are going will help me to know
whether we are getting anywhere
–If we are going to be helpful should see signs sooner rather than
later;
–If our work helps, can continue as long as you like;
–If our work is not helpful, we’ll seek consultation (session 3 or 4),
and consider a referral (within no later than 8 to 10 visits).
• Note: if clients are having difficulty with the ORS ratings for categories
that list a range of dimension (e.g. work, school, friendships) ask them
to rate based on the one that brought them into therapy
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An exercise on Creating a Culture of Feedback for
the ORS
• Pair up
• In each pair, one person should take on the role of the counsellor and
the other the role of the client.
• The counsellor is going to practice introducing the ORS and providing a
rationale for the client as to why you are administering it.
• The client is going to raise an objection that the counsellor will need to
respond to.
• Counsellors – look away from the board for a moment while the clients
read what their objection will be.
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An exercise on Creating a Culture of Feedback for
the ORS
• Clients – your objection is:
“But don’t you know how I feel already?”
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An exercise on Creating a Culture of Feedback for
the ORS
• Counsellors – what was it like introducing the ORS and coping with the
objection from the client?
• Clients – what did you find most convincing about your counsellor’s
introduction that might make you feel willing to fill in the ORS in spite of
your objection? What could your counsellor have said that would have
convinced you more?
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Tracking outcomes
• In every session, the therapist should plot the client's ORS scores. The
client should be involved in tracking their own progress (or otherwise)
• Gives the therapist a measure of the degree of change and how well the
therapy is working to improve outcomes (ORS)
• Can be used as a springboard to reflect on the changes:
–Validate the positives and what the client has done to achieve them
–Reflect on what might be going wrong
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Tracking outcomes
• The shape of the “trajectory of change” line can indicate when there is
a problem. For example, a “see sawing” line can mean:
–The client doesn’t understand how to fill in the measure
–Therapy is not working
–The client is an adolescent (the “see saw” profile is commonly seen
for adolescent clients)
• The longer you go without improvement, the more you risk
therapeutic engagement – the client might start to ask “what am I
doing this for?”
• A study of 6,500 clients showed that when therapists were simply
informed whether clients were engaged or not and whether therapy
was effective or not, there was a 65% improvement in outcomes
Miller, S.D., Duncan, B.L., Sorrell, R., Brown, G.S., & Chalk, M.B. (2005). Using outcome to inform
therapy practice. Journal of Brief Therapy, 5(1).
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Tracking outcomes
• Change in therapy tends to look like
most growth curves – most change
happens at the beginning and then
starts to level off. As the rate of change
slows, then you would start spacing the
sessions more – fitting the “dose” to the
“effects”
• The lower the score to begin with, the
steeper the rate of change and the
earlier it tends to happen.
Howard, K. et al. (1986). The dose-effect
response in psychotherapy. American
Psychologist, 41, 159-164.
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• When outcomes do not improve and
there is also a high alliance, then this is
likely to indicate dependency on the
therapy. The risk is getting into a
“hostage crisis” (“no one can help me
like you can”) and may lead to
abandonment issues if you try to refer
on. It is good to try to catch this early.
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Tracking outcomes – who drops out?
• QU: Who is more likely to drop out,
person A or person B?
• ANS: Person A
• Clients who experience a high
magnitude of change within a short
space of time tend to drop out
because they feel better and see no
need to continue. But data
suggests that they would do better
overall if they stay on in therapy to
consolidate the gains.
• Clients like person B who begin
higher and change more slowly are
more likely to stay in treatment.
• Ideally, you should keep seeing
your client as long as change is
measurable but space out the
sessions more as the rate of
change starts to slow.
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An exercise on plotting the client’s progress in
session
• Get into the same pairs but swap roles
• Counsellors – practice introducing the ORS and administering it.
• Clients – fill in the ORS
• Counsellors – Score and plot the client’s ORS scores on the trajectory of
change graph and share with your client your rationale for doing so.
• Clients – tell your counsellor what was helpful about their explanation to you
and charting your results
• Tell your counsellor what they could have said to explain it a little better to
you.
• Counsellors – Share with your client what the experience of scoring and
graphing their results with them was like for you.
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Engagement and Therapeutic Alliance
“Therapists need to be sensitive
to the risk that their own
estimate of the status of the
relationship…can be at odds
with the client’s…thus it seems
prudent to actively solicit from
the clients their perspective…”
Horvath, A (2001). The Alliance. Psychotherapy, 38(4), 365-372
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A study on the effectiveness of the SRS as a tool to
assist with retention of clients…
• Miller, Duncan, Brown et al. (2007) compared retention rates of 6,424
clinically, culturally, and economically diverse clients:
– Alliance questionnaire built in to medical record system.
– Clinicians were reminded at the end of each session to check in formally
about the alliance.
The results?
• Cases in which therapists “opted out” of assessing the alliance at the end of a
session:
– Two times more likely for the client to drop out;
– Three to four times more likely to have a negative or null outcome.
Miller, S.D., Duncan, B.L., Brown, J., Sorrell, R., & Chalk, M.B. (in press). Using outcome to inform and improve
treatment outcomes. Journal of Brief Therapy.
Miller, S.D., Duncan, B.L., Sorrell, R., & Brown, G.S. (February, 2005). The Partners for Change Outcome
Management System. Journal of Clinical Psychology, 61(2), 199-208.
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Creating a culture of feedback – the SRS
• In the first session, provide a rationale for seeking client feedback regarding the
alliance.
– I work a little differently;
– Want to make sure that you are getting what you need;
– Take the “temperature” at the end of each visit;
– Feedback is critical to success.
– Remind the client that you are not going to take the scores personally, but
that you will take them seriously
• Restate the rationale prior to administering the scale and in subsequent sessions
before administering the scale.
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Clients who object to filling in the SRS
• Remind them that the information will be helpful for you in trying to help them in the
best possible way.
• Let them know about what the research says about client feedback and how it can
enhance the therapeutic process.
Some examples:
• “Sometimes I get into assumptions and I’m not a mind reader, so it will help me to
know from you whether what we are doing here is helpful to you”
• “It is not about pleasing me but is actually like professional development for me. A
score of 10/10 doesn’t help me to grow in my work with you. It is an opportunity for
you to help shape me as your therapist”
• “If I get my feelings hurt, I’ll deal with all that but I need you to be honest with me
because if you can’t tell me that something is wrong in our sessions and things get
worse for you or you don’t want to come back, then I’ll feel worse than I would with
hurt feelings”
• “This is your assessment of our sessions and how I am impacting on how you feel
and whether we are getting anywhere. I am always interested in your perspective on
how this is working”
• “Research into what works in therapy tells us that clients can achieve better
outcomes just by giving their therapist feedback on how the sessions are going so
that the therapist can adjust what they are doing to fit better with the client”
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An exercise on Creating a Culture of Feedback for
the SRS
• Pair up in different pairs
• In each pair, one person should take on the role of the counsellor and
the other the role of the client.
• The counsellor is going to practice introducing the SRS and providing
a rationale for the client as to why you are administering it.
• The client is going to raise an objection that the counsellor will need
to respond to.
• Counsellors – look away from the board for a moment while the
clients read what their objection will be.
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An exercise on Creating a Culture of Feedback for
the SRS
• Clients – your objection is:
“I don’t like giving feedback to people
– I’m having a panic attack right now”
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An exercise on Creating a Culture of Feedback for
the SRS
• Counsellors – what was it like introducing the SRS and coping with
the objection from the client?
• Clients – what did you find most convincing about your counsellor’s
introduction that might make you feel willing to fill in the SRS in spite
of your objection? What could your counsellor have said that would
have convinced you more?
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The
SRS
• Give at the
end of each
session;
• Score in cm
to the
nearest mm;
• Each line 10
cm in length;
• Discuss with
client
anytime total
score falls
below 36.
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Using SRS scores in your client work
First session:
Because most people score high:
• SRS scores are especially important at
the first session:
• You can’t interpret high scores as a positive
alliance;
• The modal number of sessions people
attend is one.
• Always discuss SRS scores especially if
they fall below 36;
• Always:
– Thank the person for completing the form;
– Remain open to and encourage feedback
in the future.
• View low scores as a “last chance”
opportunity to address threats to
engagement.
• Expect:
– Little or no concrete information when
exploring scores.
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After the first session
• Beware of “condemnation with faint praise.” Even a one-point
decrease can signal a change in the alliance that can impact the
outcome;
• Be cautious about making changes to the alliance when ORS
scores indicate that the client is improving;
• If ORS scores are unchanged or decreasing, and the SRS falls even
a single point (whether below 36 or not), address the problems in
the alliance before ending the session.
• If ORS scores remain unchanged or continue to decrease in the
third or subsequent visits, inquire about the alliance regardless of
SRS scores.
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Some general guidelines for working with SRS scores
High scores:
• Even with a rating of 400, it is still valuable to ask clients to think about
what could make things even better. Possible questions might include:
–What worked for you in the session?
–What might make things even better for you?
–Did we cover everything you wanted to talk about today?
Low scores:
• A score that falls below 36 can provide you with valuable information.
Always honour and explore the specific feedback and agree to address it.
Ask:
–Can I contact you between sessions to check in with you?
–What would help you to be able to come back for a follow up
session?
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Guidelines for responding to feedback when it is
given
• It can be very difficult for clients to articulate the reasons behind the
scores they give. As therapists, our role is to help them tease out the
potential problems.
• Acknowledge that it might be difficult for your client to explain what
might be wrong. Ask direct questions to help you both get to the heart
of the problem like:
–Do you feel that sometimes I just don’t get what you are saying?
–Does the homework I set you feel irrelevant to you?
Etc…
• Be positive about your client's honesty:
–“This is really helpful for me, tell me more”
–“Is this something that will prevent us from engaging with each
other? Would you come back so I can try again?”
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Remember that….
Principle:
Clients who give their
therapist a low SRS score at
first but a high SRS score by
the end of therapy have the
best outcomes
Clients who give their
therapist a high SRS score
at first but a low SRS score
by the end of therapy have
the worst outcomes
• Negative consumer
feedback is associated with
better treatment outcome.
Finding:
The
difference
between
the best
and worst
outcomes
is 1.2
standard
deviations
First/Last Alliance Scores for 9000+ “At Risk” adolescents
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• Consumers who
experience a problem but
are extremely satisfied with
the way it is handled are
twice as likely to be
engaged as those who
never experience a
problem
Fleming, J., & Asplund, J. (2007). Human
Sigma. NY: Gallup Press.
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How to make the process of using the SRS easier for
yourself….
• It can be a challenge asking the client to share with you about how they
experienced you, the session, your treatment approach and whether the
session met their needs.
• Remind yourself that this tool is task oriented and not person oriented.
• It is not about judging how good you are as a therapist but rather how
well is this particular therapy working with this particular client
• “Negative” feedback has great value as a guide to improving client
outcomes. Whilst “positive feedback” (being told what you do well) is
very beneficial when you begin as a therapist, the longer you are a
therapist the less impact it has on your work with clients (in terms of
improving their outcomes).
• On the other hand, “negative” feedback (learning what hasn’t worked
and may need to change) has value (in terms of improving client
outcomes) for both beginning and experienced therapists.
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The most compelling reason to continue
incorporating feedback into our with clients…
• RMIT CS Data says that 10-15% of our clients significantly
deteriorate during the course of their therapy with us.
• In Lambert (2007) article, he reiterates that “results indicate that
integrating treatment response research into routine mental health
care, reliably improved positive outcomes and reduced negative
outcomes” for clients. Also in Lambert (1998)…
Source: Lambert, M.J.,
Okiishi, J.C., Finch, A.E., &
Johnson, L.D. (1998).
Outcome assessment: From
conceptualization to
implementation. Professional
Psychology, 29(1), 63-90).
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The most compelling reason to continue
incorporating feedback into our with clients…
• Therefore integrating feedback into our practice is important
because:
–It will benefit the client by improving their outcomes
sooner
–It will alert therapist to clients who are at risk for drop-out
and treatment failure.
–It will help quality assurance and provide a response to
the University should there be a question about our
effectiveness.
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Use of OQ45 and ORS/SRS in Client Review
• RMIT CS data suggests that within the first 3-4 sessions, we are seeing
change in the majority of our clients’ outcome scores (ORS) by 50 points or
more.
• If our clients do not achieve this 50 points or more improvement in ORS
within first 3-4 sessions, then they are at risk for treatment failure (~10-15% of
our clients).
• Therefore, with these clients:
– Therapist will readminister the OQ45 for more clinical information about
what is not changing and might need to be addressed
– Address and evaluate the incorporation of client’s feedback over another
3-4 sessions
– If client’s ORS scores continue to show deterioration or stagnation,
readminister the OQ45 and bring Client’s trajectory of change graph to a
case review meeting for discussion with clinical team
- At clinical team meeting discussion may include alternative action e.g.,
internal/external referral, change in interventions, etc.
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RMIT CS ORS Data 2008
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Remember the defintion of a “Supershrink”: (n. sooper-shrĭngk)
1. Seeks, obtains, and
maintains more
consumer engagement
1. “The quality of the patient’s participation
in therapy stands out as the most
important determinant of outcome…[this]
can be considered fact established by
40-plus years of research on
psychotherapy.”
2. Exceptionally alert to risk
of drop out and
treatment failure.
2. “Clients who [are] identified early as nonresponders to treatment ...[have]
improved outcome and increased
attendance…”.
3. Pushes the limits of their
current realm of reliable
performance.
3. “Successful people spontaneously do
things differently from those individuals
who stagnate...Elite performers engage
in…effortful activity designed to improve
individual target performance.”
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Any questions or comments?
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