By Sarah Godfrey
Being a therapist is often amazing, inspiring, confronting, fun and hard. I think it is fair to say we all try to be the best that we can. Every now and then we sit at a seminar, attend professional development or seek peer consultation on a sticky case and have a moment of professional anxiety, where the person we listen to makes us in awe of their skill . (By the way if you never have experienced professional anxiety you really need to read on!). These supershrinks are our inspiration. Don’t get me wrong. This is a good thing. These supershrinks are our motivators and push us towards excellence. But as we strive to be as good as them, sometimes we wonder how they got their super shrink skills.
Now we have an answer. The research in Supershrinks: What is the secret of their success? by Scott.D.Miller, Mark Hubble and Barry Duncan confirmed what many psychologist have believed but perhaps not really understood. It is not just the degree you obtain or the type of psychology you practice that determines how successful you will be as a therapist. It is your flexibility as a therapist that makes all the difference. Miller and his colleagues found, “ that who provides the therapy is a much more important determinant of success than what treatment approach is provided. The age, gender, and diagnosis of the client has no impact on the treatment success rate, nor does the experience, training, and theoretical orientation of the therapist.”
This isn’t to say anyone who hangs out a shingle and calls themselves a therapist is qualified to provide psychological treatment. On the contrary professional advice and treatment does require extensive training and experience. What Miller and his colleagues highlighted was the relationship between the client and the therapist as the determining factor. Without this rapport and trust the success rate in therapy drops dramatically. And you can’t teach this at university.
Focusing on your therapeutic treatment as the dominate process to help your client may be doing you and your client a disservice. Apparently specific psychological approaches (such as CBT, DBT, psychodynamic to name a few), contribute very little to actual outcomes with clients. Somewhere around 1% to 8% of all change is related to the treatment approach. (I can hear a thousand therapist’s feathers being ruffled at that statement.) Personally I think the treatment approach is still very important. Clients and their mental health issues are unique and require individually tailored therapy. A ‘one hat, fits all’ approach is destined to fail because no two clients present with the same problems and backgrounds.
Psychology, like any other business, is prone to trends, just therapeutic ones. Cognitive Behavioural Therapy, Mindfulness, Acceptance Commitment Therapy and Positive Psychology (a particular confusing and watered down approach to complex psychological problems, after all isn’t psychology by definition as a process to help and heal, positive?), have all had a turn at being flavour of the month. There is, of course great benefit in each type of treatment, but maybe we can become obsessed with the treatment approach and forget that the rapport we build, the trust we develop and the commitment we agree to each other as therapist and client are more important than the latest style of psychological methodology.
And the research seems to support this notion. In a nutshell it seems that the therapist’s psychological approach of how change happens must be a good fit with the client and they must have multiple techniques. If something is not working, they must be able to change what they are doing. This means therapists need to be skilled in more than one psychological treatment style. The last point is extremely significant as in Australia you would be forgiven for thinking that Cognitive Behavioural Therapy is the panacea for all mental health issues known to man. (Anecdotally I have always found and an eclectic, flexible approach to therapy has yielded the best results).
And there’s more. Miller and his colleagues suggested that there was a ‘basic formula for success’ that therapists could strive towards in becoming a supershrink. It involved:
• Determining your baseline of effectiveness– There are some therapist who “possess a keen situational awareness: they are observant, alert and attentive. They compare new information constantly with what they already know.” Miller and his colleagues suggest, “for the rest of us mere mortals, a shortcut to supershrinkdom exists. It entails using simple paper and pencil scales and some basic statistics to compute your baseline.” Try the Session and Outcome Rating Scales ( 2002, Scott D. Miller, Barry L. Duncan, & Lynn Johnson) that can be download and are a start in the practice of determining a therapeutic effectiveness for your practice, based on the client, not the therapists interpretation of the session. Confronting but enlightening!
• Engaging in deliberate practice. According to Miller and his colleagues, outcomes in a study of 6,000 practitioners and 48,000 clients were as good as or better than those typically reported in tightly controlled studies. Therapists, unlike researchers in controlled studies, ‘do not have the luxury of handpicking the clients they treat. Most clinicians do good work most of the time, and do so while working with complex, difficult cases.’ Become highly skilled in multiple tools and evidence based approaches available in order to meet the client’s needs. Don’t be fooled that one type of therapy is better than another. If one treatment doesn’t work, try another.
• Getting feedback – Miller and co acknowledge that ‘the prospect of knowing one’s true rate of success can provoke anxiety even in the best of us.’ This isn’t a reason to avoid seeking opinion from your client. After all shouldn’t therapists be modelling effective assertive techniques, heathy conflict and honest communications? If we can’t hear negatives, how do we expect our clients to? This is where psychologist can miss a beat. We must build a rapport and an internal practice that can allow us to ask our clients if they have felt each session was productive. If they say no, we should cop it on the chin and work harder.
Here are some more facts they discovered.
• What the client brings to therapy is the real source of change. Their strengths, culture, struggles, likes and dislikes and the events in their lives contribute to successful outcomes in treatment.
• The relationship (or rapport), commitment, hope and expectations between the therapist and client directly contributes to the success of therapy.
• Clients like to be asked about their opinions of the therapy.
• Therapist need to work collaboratively with their clients, evaluate and continue to work hard to improve their skills.
• Therapists must provide an explanation of how change happens and believe it!
Interesting isn’t it? This conceptualisation allows the client to believe that they directly contribute to their own wellbeing outcomes instead of relying solely on the therapist to drive the change. Which ties in with my own belief that the seeds to happiness need autonomy and self reliance in order to grow.
So now we know it is the client more than the therapist that can be a predictor of successful therapy and the rapport and commitment to the relationship by and between the client and the therapist determines how effective change will be. Miller, Hubble and Duncan, have found that the best of the best simply work harder at improving their performance than others and acknowledge that attentiveness to feedback is crucial.
That is what makes a Supershrink.
The main message is invest in your client’s participation in the process of change by asking them how you are going and how they feel your treatment plan is travelling. And be driven by constructive criticism, from your client but equally important from your own baselines of treatment and interpersonal effectiveness. Be flexible with your approach and try different treatments to offer the best opportunity for your clients success. Maybe being a supershrink isn’t so unachievable after all?
