Episode 077: Getting Better Results from your Patients as a Psychotherapist
On this week’s episode of the Psychiatry and Psychotherapy podcast, I interview Scott D. Miller, Ph.D. and Daryl Chow, Ph.D., authors (along with Mark A. Hubble, Ph.D.) of Better Results. Better Results is a book that sums up thirty years of research to demonstrate what clinicians can reliably do to improve therapy results by personal and professional development.
By listening to this episode, you can earn 1 Psychiatry CME Credits.
Other Places to listen: iTunes, Spotify
Article Authors: Joseph Wong BS, BA, David Puder, MD
There are no conflicts of interest for this episode.
How Good Is Your Current therapy?
Every therapist can agree that they are better than when they first started. Through a journey of personal development, supervision, mentoring and copious amounts of experience, therapists come to a point where they believe they have become effective at therapy. In Better results, Dr. Miller mentions that in one survey, therapists believe that 80% of their patients improved after their therapy. Some therapists are confident up to 90% of their patients benefited from their therapy (Walfish, McAllister, O'Donnell, & Lambert, 2012).
The authors make the argument that because the outcomes in the field of psychotherapy have not improved in over 40 years and because in general psychotherapists hit a plateau at a certain point, it will be important to re-evaluate how we continue to progress as therapists and improve our outcomes over time (Wampold & Imel 2015). They argue that many of the things that therapists turn to when they seek to improve their therapy outcomes, such as continued education, supervised training and clinical experience, do not make that much of an improvement. There is a lack of connection between CE and improvement in the therapy outcomes (Neimeyer, Taylor, & Wear, 2009). Also, the influence of supervisors (regardless of experience and qualification) on psychotherapy outcomes is minimal (Rousmaniere, Swift, Babins-Wagner, Whipple and Berzins, 2016).
Finally, instead of more clinical experience leading to greater therapeutic effectiveness, there is a decline in therapeutic effectiveness after a period over time (Golberg et al., 2016).
Rather than therapeutic effectiveness increasing over time, it is actually our confidence that increases with experience, and with it, an understanding that we are helping more people than we actually are (Walfish, McAllister, O'Donnell, & Lambert, 2012).
So if all the commonly held thoughts of improvement have been shown to not be efficacious in actually improving outcomes, what can be done?
In the podcast, Dr. Miller recounts a common conversation he has with trainees seeking to improve their therapy skills. In this case, it’s trauma-focused therapy. From the trainee’s point of view, their first thought was that to improve their outcomes, they had to learn how to do better trauma treatment; however, when asked on how effective they currently were, the trainee was unable to give a clear answer. The point of this conversation is to show that before we are able to work on improving ourselves, we need to know where we’re starting from, a baseline.
If therapists aren’t able to really say where they’re coming from, how can they know where they’re going? As Dr. Chow puts it, before the days of Google maps, if you are telling someone how to reach a destination, first you need to know their starting point. Most therapists just assume their starting point. Most therapists don’t factually know how effective they are at their jobs.
Therapy results are not the same as medical results as in they are not as concrete. Now, however, as Better Results highlights, there are certain concrete methodologies we can implement to improve our outcomes with patients.
How Can You Get better?
Therapists always ask, “What method do I need to learn to get better results?” This question assumes that it’s the method that makes the difference in outcomes, and while the method does contribute to outcome, the authors’ research shows that technique and the treatment model used only accounts for <1% for the variability in psychotherapy outcome.
So, what can therapists work on to improve their psychotherapy outcomes? We cannot directly affect the patient, their life circumstances and all the other factors that they bring to the table; however, there are two things we can address that directly impact therapy outcomes. The first is improving our therapeutic alliance with the patient. The authors’ research shows that therapeutic alliance accounts for about 5-8% of successful psychotherapy outcome variance, which includes factors such as:
being mindful of transference/countertransference that have been discussed in detail in this podcast.
The second is by improving ourselves. Each therapist brings an unique mix of their own personality, life and professional experiences to the table and this specific makeup contributes to the therapeutic alliance between the therapist and the patient (Baldwin, Wampold, & Imel, 2007).
So how does an individual therapist improve, with therapy being so intangible? In Better Results, the authors cover everyone from Mozart to Michael Jordan and discuss what others have discussed in detail, namely, how to improve. The answer comes in the form of a term coined by the psychologist Dr. K. Anders Ericsson—deliberate practice. Deliberate practice is exemplified in the best of the best of a given field, who not only put in more hours than their peers, but they were more purposeful with their time and had the help of top-tier teachers (e.g. Mozart and his father). In Better Results, the authors summarize the four key components of deliberate practice, which consist of:
Setting individualized learning goals
A good coach
Effective feedback
Successive refinement
How To Implement Deliberate Practice Into Psychotherapy
So now that we know that the answer to improving ourselves as therapists in order to improve therapy outcomes is through deliberate practice, how can we apply it to psychotherapy? While it’s easy to apply deliberate practice to something like basketball, where coaches are a natural part of the sport, and where feedback is instantaneous (e.g. making the basket), we have to wait until the next session or even several sessions to find out if our patient has improved from our therapy. So what are the steps that we can begin taking to start this process of deliberate practice?
1. Before you can set specific learning goals for yourself, you have to be able to identify your individual breakdown—the key things that you can work on that will directly impact your outcome.
If you leave this to therapists alone to figure out without any empirical data on themselves, they will report very treatment-model specific modalities, which actually have very little impact when it comes to patient-to-patient improvement and interaction as discussed above. So how do you identify what your individual breakdown or weaknesses are?
We need to establish our baseline of clinical effectiveness via the use of standardized measures. Most therapists have no hard empirical data on their therapeutic effectiveness, which necessitates the use of standardized measures as the first step in understanding one’s baseline (Boswell, Kraus, Miller, & Lambert, 2015). One well-established standardized measure for assessing therapeutic effectiveness that is simple to use and learn is known as Partner’s for Change Outcome Management System (PCOMS [Miller, Duncan, Sorrell, & Brown, 2005]), which is made up of 2 scales:
Outcome Rating Scale (ORS, [Miller, Duncan, Brown, Sparks & Claud, 2003)])
Session Rating Scale (SRS [Miller, Duncan, & Johnson, 2000]) (Duncan 2012; Duncan & Reese, 2015; Miller, Duncan, Sorrell, & Brown, 2005). The Outcome Rating Scale and Session Rating Scale can be found for free at Dr. Miller’s website and are displayed below.
Once your self-surveys show what areas you are lacking in, and also what areas you are excelling in, you can then take that data, plot learning goals specific to your needs and begin constructing an organic style unique to yourself that can get the best results for each patient.
Rather than learning to mimic empathic phrases and saying them at specific points during the session, we can begin to develop ourselves in such a way that leads to a natural empathic experience on our patient’s part. But once again, in order to even know what specific steps you need to take to improve your outcomes, you need your own, individual data to know what to focus on in the first place.
2. Figure out how to get performance and learning feedback from your patients.
However, before you even begin asking your patients for constructive criticism, you should ask yourself if your patients feel comfortable providing you with constructive criticism, and what kind of environment have you set up that supports them or prohibits them from doing so. Therapists that continue to work on their therapeutic alliance with their patients see improved therapy outcomes, and being able to get feedback from your patients is part of that process (Owen, Miller, Seidel & Chow, 2016).
So how do we go about getting feedback from our patients? In Better Results, the authors suggest providing surveys to your patients in the beginning and end of each therapy session to receive real-time feedback from your patients (here are their free surveys). Although this may make some therapists uncomfortable in the sense that their entire session is now under scrutiny by the patient, it is, however, the most effective way to gather data on yourself.
3. Have someone to guide you—a coach.
Change and growth is specific to the person who needs it. What type of patient do you not enjoy working with? What type of patient do you need improvement with? Where are you not seeing results in your practice? A coach can help you identify those pitfalls, look at the data you’ve collected, and help recommend a directed course of action.
What commonly happens with supervision early on in one’s training is that when you ask your supervisor about a case that you’re working on, what you’re really doing is trying to paint a picture of what you think is happening and having someone else try to interpret that picture. At the end of the day, it’s unclear whether or not you came any closer to understanding the inner world of the patient. Therefore, it’s important to get direct feedback from the patient on whether they felt connected to or understood. Then, you must relay that information to your coach, who can then go over what needs to be done in order to improve your therapy.
This emphasis on finding a good coach links to my own research interests on supervision, for which I have found that the most connected supervisors (high empathy, high psychological safety, high educational alliance and accurate feedback) led to a place where less negative emotion was experienced by the trainee and also had an impact on the psychological wellbeing of the resident.
An excellent supervisor will decrease shame and allow you to accurately assess yourself without needing to look good in front of them. For Dr. Chow, an overemphasis on performance can impede deep learning at an intuitive level. We aren’t trying to measure competency, we are trying to measure growth. Our goal, as Dr. Miller says, is to learn good rather than look good (learning outlook vs. performance outlook).
4. Practice successive refinement.
Successive refinement is not just putting the time into doing therapy, but about practicing deliberately with the goal of ever reaching higher and further in this process of self-improvement as just putting in effort and time is only about half as effective as deliberate practice (Miller et al., 2018). Successive refinement really depends on working at the edge of one’s ability as much as possible because it’s much too easy to stay in one’s comfort zone once one has reached a certain level of confidence; however, the danger of staying in one’s comfort zone is the eventual decline in effectiveness (Golberg et al., 2016).
An important thing to note is that this process is different for every therapist. During his heydays, Tiger Woods was constantly redeveloping his swinging technique. This drew people to try to film his new swings, and eventually someone was caught filming from a bush on the golf course. The filmer then sold the video to golf professionals and aspirants alike who were trying to improve their swing. The problem is that no one took into account that Tiger Woods’ swing is a product unique to his body, strengths, limitations, habits, etc. It is a proprietary, one-hit-wonder that only Woods can perfect, because it’s tailor made for him.
Can Therapists Improve From Deliberate Practice?
Yes. They see improvement on individual, patient and even agency levels as they implement what Better Results suggests—feedback surveys before and after sessions with patients, individualized learning goals based on that feedback, coaches that help navigate that process and the mindset to continually work at the edge of one’s ability. When therapists begin implementing these ideas into their practice, they can see an improvement in their outcomes by means of a good therapeutic alliance with patients, decreased drop out rates, increased number of patients with significant improvement, etc.
In terms of improvement, the authors of Better Results argue that the factor that contributed to growth the most was the amount of time spent working at one’s growth edge, the point in between one’s comfort zone and being stressed out. When you focus time and attention on where your individual performance breaks down, and train in that area, you will be able to see significant improvements in your abilities.
Other Points Of Nuance...
Going back to their assertion that in general the outcomes for psychotherapy have not improved, I think that while that might be the case in general, it should be noted that as we have progressed in our understanding of certain conditions, we now understand that there are specific therapy modalities more efficacious than others for the treatment of those conditions. For example:
CBTI for insomnia, is better than the other types of treatment for insomnia (van Straten et al., 2018).
DBT, mentalization, transference focused therapy, and schema-focused therapy are better treatments than we had for borderline personality disorder in the past (although they have similar outcomes as compared to each other) (Bateman & Fonagy, 2010; Doering et al., 2010; Farrell, Shaw & Webber, 2009; Kliem, Kröger & Kosfelder, 2010; Zanarini, 2009).
In my personal experience, I have also found an improvement in outcomes for patients with somatic symptoms that undergo a program of intensive treatments in the program I help run, but not in other partial programs.
Finally, I am currently looking into the value of supervision on the mental wellbeing of the person learning. I have found in my research that a highly-connected supervisor reduces burnout almost 1 point (out of a 7 point Likert scale). Just like how the authors looked at daily connection and progress in treatment, I believe that we should also be looking at connection in the supervision sessions.
In Conclusion
Studies show that most people get into a career, experience an uptick in improvement and engagement at first, then level off and coast for the majority of their working lives. We spend more time at work than we do in our waking hours at home. This entire podcast and article assumes that we want to improve, and why wouldn’t we? Therapists typically go into this field with good hearts to help others through the emotionally taxing process of therapy, and are willing to go through what it takes to become good at what we do.
So rather than assuming that our jobs are done when people tell us that we’re helping them, or that people who don’t improve are just people that we can’t reach, we can continue to strive, to put in that bit of extra time and ensure that we are giving quality care to our patients, and even, to ourselves.
As Dr. Miller put it, deliberate practice is a marathon, not a sprint. The promise of deliberate practice, as opposed to just pulling random therapies off the shelf to learn, is that you will personally grow as a therapist and thus from that, your therapy will improve.
Learn more from Dr. Miller, Dr. Chow:
Better Results is slated to release in May, 2020. There are a ton of resources on their websites I would recommend checking out: scottdmiller.com & darylchow.com.