Episode 186: Using Deliberate Practice to Improve Psychotherapy Results with Dr. Scott Miller

Megan Walsh, Scott Miller, PhD, David Puder, MD

Dr. Miller’s first appearance on the Psychiatry and Psychotherapy Podcast was in episode 077, “Getting Better Results from your Patients as a Psychotherapist,” during which we discussed his book, Better Results. We explored the methodology behind improving outcomes in therapy through targeted development of what Dr. Miller has dubbed the Common Factors, which include therapy structure, hope and expectancy, working alliance, client factors, and therapist factors. In this episode, Dr. Miller returns to expand upon our prior conversation with a focus on how therapists can use deliberate practice to improve their efficacy. We discuss Dr. Miller’s new book, The Field Guide to Better Results, a companion to Better Results, which was recently published in May, 2023.  

“Supershrinks”

Historically, a veil of mystery enveloped psychotherapy—sessions were never observed by outsiders, even for training purposes. Therapist’s training was based on theory, rather than by observing and learning from therapy sessions. The Gloria Films of 1965 are a rare resource of that time that unveiled the therapist’s office, offering an inside view for learners of therapy techniques.

Early in his career, Dr. Miller was drawn to the Brief Family Therapy Center in Milwaukee, Wisconsin, a brief psychotherapy practice that promoted openness among colleagues, such that they could observe and learn from each other. When it was uncovered that this open and collaborative approach did not improve patient outcomes compared to the standard practice, however, Dr. Miller decided to take a look at the common factors of different approaches to therapy. From there, he began to measure results with the goal of uncovering from session-to-session and client-to-client if what therapists were doing was making a difference for patients. Through years of research he found that, in general, therapists are often helpful, but sometimes not as much. Interestingly, however, there seemed to be certain therapists who consistently achieved the best outcomes no matter who the client or what the presenting problem. 

These top performers are colloquially dubbed “supershrinks.” The term supershrink was introduced in 1974 by D. F. Ricks to describe a therapist with exceptional outcomes in working with “highly disturbed” adolescents (Ricks 1974). Patients treated by this supershrink had significantly better outcomes into adulthood compared to those treated by the average therapist. Since that time, however, most research has been conducted on the efficacy of therapy modalities rather than on the factors of the therapists themselves (Okiishi et al., 2003).

Okiishi et al. (2003) examined 1841 clients seen by 91 therapists over 2.5 years to investigate the variability in patient outcomes among therapists. The authors found that certain therapists had clients improve at a rate 10 times greater than the average therapist in the sample, and that those therapists with clients showing the slowest rate of improvement also had more clients reporting an increase in symptoms. Wampold and Brown (2005) reported a similar variability among therapists in patient outcomes. In their study of client encounters of 581 licensed providers (psychologists, psychiatrists, master’s level providers), they found that clients of the top performing quartile of therapists had a higher probability of reliable change following therapy. Interestingly, this individual predilection also extended to medication prescription—efficacy seemed to depend upon who prescribed the drug. The authors reported that experience, training, or theoretical orientation of the therapist had no bearing on efficacy of treatment. Thus, the question of what the individual factors were that contributed to an effective therapist persisted. 

Dr. Miller has spent much of his career investigating this question. With the Institute for Therapeutic Change, he studied thousands of therapists with a multitude of backgrounds and clinical contexts. The authors found that the top performers (i.e., the therapists with the most favorable outcomes on a consistent basis) spent more time in deliberate practice than their average counterparts. As they note, “As absurd as it sounds, the best of the best simply work harder at improving their performance than others” (Miller et al., 2008). 

What Is Deliberate Practice?

The concept of deliberate practice stems from the work of psychologist Dr. K. Anders Ericcson, considered “the expert on experts.” His study of the best performers in sports, art, music, math, medicine, etc. found that reaching the highest level relied upon deliberate practice and attention to direct feedback. He described deliberate practice as reaching for objectives “just beyond one’s level of proficiency.” Compared to purposeful practice, it involves significant discomfort as one pushes to their perceived limit and extends beyond it. Importantly, deliberate practice requires a careful attention to direct feedback from a coach in addressing deficits.

Dr. Miller discusses an example of deliberate practice in therapy from his Difficult Conversations in Therapy Project. Therapists were exposed to a difficult encounter and asked to rate their degree of empathy using a standardized scale as a baseline. Then, coaches gave the participants highly focused feedback on how to improve their emphatic response, tied to their specific deficit exhibited. Over time, these participants’ empathic response improved and, interestingly, generalized to other scenarios than the original encounter. Compared to control participants who self-reflected after the initial encounter and tried to improve their empathic response on their own, the therapists who engaged in deliberate practice showed greater improvement (Chow et al., n.d.).

How To Use Deliberate Practice To Improve Your Results In Therapy

So, how can therapists implement deliberate practice to improve their outcomes? In Better Results and in conjunction with The Field Guide to Better Results, Dr. Miller and co-author Dr. Daryl Chow walk through the Taxonomy of Deliberate Practice Activities (TDPA) – https://drjeffchang.webs.com/Taxonomy%20-%20Therapist%27s%20version%20(v4).pdf. The process can be broken down as follows: 

1. Collect client outcome data. Ideally, Dr. Miller recommends a minimum of 60 sessions to examine using outcome measures such as the ORS or OQ-45. Additionally, engagement in the session from both the client and therapist perspectives should be assessed using the outline of common factors in the TDPA.

2. Look for the pattern of deficits in outcomes. 

3. Identify the common factor that has leverage on the deficit and develop a specific activity to improve that skill.

4. Engage in deliberate practice of this specific activity.

A key point in this structure of deliberate practice is the importance of having a coach to help identify the deficit and create a path for improvement. This outside perspective can offer targeted feedback. In thinking about who these coaches “should” be, their central quality is that they are skilled in helping the individual to excel. They don’t necessarily need to possess the highest level of expertise in the particular skill being coached, but they should be highly effective in helping others to develop that skill.

It is important to keep in mind the slowness of this process. Goldberg et al. (2016) reported a case study of deliberate practice in the Calgary Counseling Center, examining outcomes in 5128 patients seen by 153 psychotherapists. While there was improvement in patient outcomes with regular targeted feedback and deliberate practice, the rate at which this improvement occurred was slow (d = 0.035 per year).

Dr. Miller walks through an example with therapist Michael Harloff (listen to his conversation here https://www.youtube.com/watch?v=qAVDrkJFrxE). After gathering data on outcome and alliance over a number of sessions, Dr. Miller worked with him to investigate patterns in his less effective sessions. They began to notice slightly lower effect sizes with male clients and, after thorough review, they were able to pinpoint that, in particular, it was male clients who were angry. They found that these clients were wanting direct counsel or advice and were subsequently angry when their therapist provided empathy instead. Thus, it was a structure/technique issue reducing his efficacy in these cases. To improve this deficit, Michael engaged in deliberate practice on being more direct with clients—knowing when to give direct counsel and the kind of direct counsel to give. After working on this for some time, his outcomes improved in those cases of male clients who were seeking direct advice.

The Role Of Confidence And Experience

One caveat we discussed was the role of confidence and experience in therapist’s efficacy and engagement in deliberate practice. Dr. Miller discussed his findings currently under review for publication that showed that when therapists received direct feedback on their expressed empathy during difficult client conversations, their self-confidence declined even though their performance improved. This feedback-driven decline in confidence may point to the self-assessment bias which has been reported among mental health providers (Walfish et al., 2012), with therapists tending to overestimate their skill and efficacy.

While one may expect therapists' experience to improve their outcomes, a number of studies have reported otherwise. Goldberg et al. (2016) found there was a slight decline in psychotherapists’ outcomes as experience (in time and/or number of cases) increases. Furthermore, Öst et al. (2011) reported that clinically inexperienced student therapists receiving supervision had treatment effects equal to those of experienced licensed psychotherapists. These findings prompt consideration of whether humility may allow these early trainees to maintain an openness and a genuine curiosity to learn and experiment. They underscore the importance of wonder, awe, and curiosity throughout a career in psychotherapy. 

In Conclusion 

There’s a reason why Malcolm Gladwell’s book, Outliers, has been a bestseller since its release—we are captivated by the notion of potential for greatness. For therapists, striving to be a top performer is striving to provide the best version of themselves in the care of their patients. What underscores the potential to achieve this greatness is a commitment to pay attention to the quality of practice we devote to improving our skills. On a platform of openness and humility, growing from direct feedback, and engaging in deliberate practice, we can move towards the ranks of supershrinks. 

References:

Ricks, D. F. (1974). Supershrink: Methods of a therapist judged successful on the basis of adult outcomes of adolescent patients. In D. F. Ricks, A. Thomas, & M. Roff (Eds.), Life history research in psychopathology: III. University of Minnesota Press. 

Okiishi, J., Lambert, M. J., Nielsen, S. L., & Ogles, B. M. (2003). Waiting for supershrink: An empirical analysis of therapist effects. Clinical Psychology & Psychotherapy: An International Journal of Theory & Practice, 10(6), 361-373.

Wampold, B. E., & Brown, G. S. (2005). 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. https://doi.org/10.1037/0022-006X.73.5.914

Miller, S.D., Duncan, B.L., & Hubble, M.A. (2008). Supershrinks: What is the secret of their success? Psychotherapy in Australia, 14, 14.

Chow, D., Lu, S., Tan, G., Kwek, T., & Miller, S. D.(n.d.). A Randomized Clinical Trial of the difficult conversations in therapy (DCT): Can therapists learn from an environment of self-reflection, feedback and successive refinement? (Manuscript in preparation).

Chow, D., & Miller, S. D. (2015). Taxonomy of deliberate practice activities worksheets. International Center for Clinical Excellence (ICCE).

Goldberg, S. B., Babins-Wagner, R., Rousmaniere, T., Berzins, S., Hoyt, W. T., Whipple, J. L., Miller, S. D., & Wampold, B. E. (2016). Creating a climate for therapist improvement: A case study of an agency focused on outcomes and deliberate practice. Psychotherapy (Chicago, Ill.), 53(3), 367–375. https://doi.org/10.1037/pst0000060

Walfish, S., McAlister, B., O'Donnell, P., & Lambert, M. J. (2012). An investigation of self-assessment bias in mental health providers. Psychological reports, 110(2), 639–644. https://doi.org/10.2466/02.07.17.PR0.110.2.639-644

Goldberg, S. B., Rousmaniere, T., Miller, S. D., Whipple, J., Nielsen, S. L., Hoyt, W. T., & Wampold, B. E. (2016). Do psychotherapists improve with time and experience? A longitudinal analysis of outcomes in a clinical setting. Journal of counseling psychology, 63(1), 1–11. https://doi.org/10.1037/cou0000131

Öst, L. G., Karlstedt, A., & Widén, S. (2012). The effects of cognitive behavior therapy delivered by students in a psychologist training program: an effectiveness study. Behavior therapy, 43(1), 160–173. https://doi.org/10.1016/j.beth.2011.05.001

Learn more from Dr. Miller:

Better Results released in May, 2020. 

Scott Miller’s website: scottdmiller.com