Here’s the Payoff

It all begins with an investment of faith. Organisations, supervisees, and practitioners whom I consult with know that, for the most part, they wouldn’t see immediate results. It’s a calculated gamble.

I recently began to see significant payoffs. By comparing these inspiring teams and individual outcomes from their previous years/half-years, these handful of therapists whom I was coaching with are now reaping the rewards. Their dedication and focus in designing and implementing a tailored plan for deliberate practice.

By first using their baseline data to determine where they are at before “where they need to go,” and then spending the time to identify and work on the stuff that has leverage on moving the needle on their performance, they now see the fruits of their labor:

• An improvement in overall effectiveness,
• Reduction of dropout rates,
• An increase in the percentage of clients achieving reliable improvement and even
• A more efficient rate of change.

It is indeed possible to improve our outcomes, one at a time.

~~~

One therapist found out that her overall initial high alliance rating was actually something to work on (i.e., highly effective therapists tend to be able to elicit lower alliance scores at the initial engagement). Her sustained efforts on eliciting more critical feedback from the get-go had led to an improvement of engagement and consequentially, outcomes.

Another therapist, after picking herself up from a slump when she discovered that a large percentage of clients did not return for therapy after the first visit, she began working at undoing the intake model of clinical assessment and instead, began to zoom in on what her clients are receiving in the initial session. Much to her surprise, this had a domino effect of improving her effectiveness and efficiency of change in not just her retention rates, but also her overall outcomes!

Another therapist, during the early phase of our consults, was so beaten down by the fact that his efforts to improve (money spent at workshops; reading all that he could on various treatment approaches while maintaining a practice… and balancing a family life with young kids), not only did not translate to better results, but actually led to a dip in his aggregated performance.  You can imagine how vexing this must be.

We went back to the drawing board. We began to relook at the taxonomy of deliberate practice (TDPA) worksheets, combined with his outcome data, and began to ask ourselves some hard questions. What does his data say? Anything glaring? Any patterns that we can detect from the data and his session recordings? What is ONE thing he can work on that is influenceable and predictive of better results? We identified one key area that he should keep his eyes on (in his case, it was about establishing a consensual and effective focus on what client’s wanted to work on). More importantly, given the opportunity cost, we had to make the decision for him to subtract other aspects that he was working on that took alot of his time (not that these didn’t matter), but yielded little returns in improving client outcomes at this stage of his development.  

Some months later, we began to see the payoff. Once he had enough cases to make a new comparison, he saw a change of tide in his stats. . But still, he wasn’t satisfied, because he wasn’t achieving “super shrink” [1] results just yet. 

“There is nothing so useless as doing efficiently

that which should not be done at all.”

~ Peter Drucker

Here’s what I suggested for this highly motivated therapist to think about, “Direction over speed.” He needed to take stock that he had made some course-correction, and now his intentions and efforts are aligned. Being in the right direction trumps being efficient. A small degree change in direction at the onset can literally mean either hitting the moon or missing it completely. I stressed that this was a ripe time for him to extrapolate principles he discovered through the process that led to good outcomes

For me, this is hugely rewarding. This renews my faith in what we do. But, we need to start to see the practice of psychotherapy less or an individual sport, and more of a team sport (see this blog post on scenius vs. genius).  We can also begin to challenge our business-as-usual ways of clinical supervision, which has not consistently demonstrated actual improvement in outcomes.[2] I’m guilty of this too. Working with someone in clinical supervision, and continuing to do so, despite the lack of improvement, or conflating therapist’s feeling of benefit from supervision with actual client improvement.

All of this is not possible in the examples above, had we not begin to systematically obtain client feedback using measures on a routine basis, BEFORE investing our efforts in “deliberate practice.” (Again, take the time to figure out where you are before where you need to go. We are all prone to work on stuff that has little to no leverage on improving our outcomes.)

“Any clinical tool or technology is only as good as the therapist who uses it.” [3]. It’s not about the measures nor the numbers. A top athlete wouldn’t say that it’s the stopwatch that helped her run faster [4]. Ultimately, in order to achieve better performance, measurement precedes professional development.

We need to invest in improving individual therapists, and less on improving therapies.

Notes:

[1] Chow, D., Miller, S. D., Seidel, J. A., Kane, R. T., Thornton, J., & Andrews, W. P. (2015). The role of deliberate practice in the development of highly effective psychotherapists. Psychotherapy, 52(3), 337-345. doi:http://dx.doi.org/10.1037/pst0000015

[2] Rousmaniere, T. G., Swift, J. K., Babins-Wagner, R., Whipple, J. L., & Berzins, S. (2016). Supervisor variance in psychotherapy outcome in routine practice. Psychotherapy Research, 26(2), 1-10. doi:10.1080/10503307.2014.963730

[3] see p. 449 of Miller, S. D., Hubble, M. A., Chow, D. L., & Seidel, J. A. (2015). Beyond measures and monitoring: Realizing the potential of feedback-informed treatment. Psychotherapy, 52(4), 449-457. doi:http://dx.doi.org/10.1037/pst0000031

[4] Birgit Villa, personal communication, 9th of August 2015.

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