Into The Light
MVP
Supershrinks: What's the secret of their success?
by Scott Miller, Mark Hubble, and Barry Duncan
July 2009
Boisea trivittatus, better known as the boxelder bug, emerges from the recesses of homes and dwellings in early spring. While feared neither for its bite nor for its sting, most people consider the tiny insect a pest. The critter comes out by the thousands, resting in the sun and staining upholstery and draperies with its orange-colored wastes. Few find it endearing, with the exception perhaps of entomologists. It doesn't purr and won't fetch the morning paper. What's more, you'll be sorry if you step on it. When crushed, the diminutive creature emits a putrid odor worthy of an animal many times its size.
For as long as anyone could remember, Boisea trivittatus was an unwelcome yet familiar guest in the offices and waiting area of a large Midwestern, multicounty community mental health center. Professional exterminators did their best to keep the bugs at bay, but inevitably many eluded the efforts to eliminate them. Tissues were strategically placed throughout the center to assist staff and clients in dispatching the escapees. In time, the arrangement became routine. Out of necessity, everyone tolerated the annual annoyance—with one notable exception.
Dawn, a 12-year veteran of the center, led the resistance to what she considered "insecticide." In a world turned against the bugs, she was their only ally. To save the tiny beasts, she collected and distributed old mason jars, imploring others to catch the little critters so that she could safely release them outdoors.
Few were surprised by Dawn's regard for the bugs. Most people who knew her would have characterized her as a holdout from the Summer of Love. Her VW microbus, floor-length, tie-died skirts, and Birkenstock sandals—combined with the scent of patchouli and sandalwood that lingered after her passage—solidified everyone's impression that she was a fugitive of Haight-Ashbury. Rumor had it that she'd been conceived at Esalen.
Despite these eccentricities, Dawn was hands-down the most effective therapist at the agency. This finding was established through a tightly controlled, research-to-practice study conducted at her agency. As part of this study of success rates in actual clinical settings, Dawn and her colleagues administered a standardized measure of progress to each client at every session.
What made her performance all the more compelling was that she was the top performer seven years running. Moreover, factors widely believed to affect treatment outcome—the client's age, gender, diagnosis, level of functional impairment, or prior treatment history—didn't affect her results. Other factors that weren't correlated to her outcomes were her age, gender, training, professional discipline, licensure, or years of experience. Even her theoretical orientation proved inconsequential.
Contrast Dawn with Gordon, who couldn't have been more different. Rigidly conservative and brimming with confidence bordering on arrogance, he managed to build a thriving private practice in an area where most practitioners were struggling to stay afloat financially. Many in the professional community sought to emulate his success. In the hopes of learning his secrets or earning his acknowledgement, they competed hard to enter his inner circle.
Whispered conversations at parties and local professional meetings made clear that others regarded Gordon with envy and enmity. "Profits talk, patients walk," was one comment that captured the general feeling about him. But the critics couldn't have been more wrong. The people Gordon saw in his practice regarded him as caring and deeply committed to their welfare. Furthermore, he achieved outcomes that were far superior to those of the clinicians who carped about him. In fact, the same measures that confirmed Dawn's superior results placed Gordon in the top 25 percent of psychotherapists studied in the United States.
In 1974, researcher David F. Ricks coined the term supershrinks to describe a class of exceptional therapists—practitioners who stood head and shoulders above the rest. His study examined the long-term outcomes of "highly disturbed" adolescents. When the research participants were later examined as adults, he found that a select group, treated by one particular provider, fared notably better. In the same study, boys treated by the "pseudoshrink" demonstrated alarmingly poor adjustment as adults.
That therapists differ in their ability to affect change is hardly a revelation. All of us have participated in hushed conversations about colleagues whose performance we feel falls short of the mark. We also recognize that some practitioners are a cut above the rest. With rare exceptions, whenever they take aim, they hit the bull's-eye. Nevertheless, since Ricks's first description, little has been done to further the investigation of super- and pseudoshrinks. Instead, professional time, energy, and resources have been directed exclusively toward identifying effective therapies. Trying to identify specific interventions that could be reliably dispensed for specific problems has a strong commonsense appeal. No one would argue with the success of the idea of problem-specific interventions in the field of medicine. But the evidence is incontrovertible. Who provides the therapy is a much more important determinant of success than what treatment approach is provided.
Consider a study reported by Bruce Wampold and Jeb Brown in the October 2005 Journal of Consulting and Clinical Psychology. It included 581 licensed providers—psychologists, psychiatrists, and master's-level therapists—who were treating a diverse sample of more than 6,000 clients. The therapists, the clientele, and the presenting complaints weren't different in any meaningful way from those in clinical settings nationwide. As was the case with Dawn and Gordon, the clients' age, gender, and diagnosis had no impact on the treatment success rate, and neither did the experience, training, and theoretical orientation of the therapists. However, clients of the best therapists in the sample improved at a rate at least 50 percent higher and dropped out at a rate at least 50 percent lower than those assigned to the worst clinicians in the sample.
Another important finding emerged: in cases in which psychotropic medication was combined with psychotherapy, the drugs didn't perform consistently. Their effectiveness depended on the quality of the therapist—drugs used in combination with talk therapy were 10 times more effective with the best therapists than with the worst. Among the latter group, the drugs made virtually no difference. So, in the chemistry of mental health treatment, the applied orientations, techniques, and even medications are relatively inert. The catalyst is the clinician.
The Making of a Supershrink
How do the supershrinks—practitioners as dissimilar as Dawn and Gordon—do what they do? Are they made or born? Is it a matter of temperament or training? Have they discovered a secret unknown to other practicing clinicians or are their superior results simply a fluke, more measurement error than reality? Answering these questions is critical. If being the best is matter of birth, personal disposition, or chance, the phenomenon would hardly be worth further study. But should their talents prove transferable, the implications for training, certification, and service delivery are nothing short of staggering.
Enter the Institute for the Study of Therapeutic Change, an international group of researchers and clinicians dedicated to studying what works in psychotherapy. For the past eight years, the group, including ourselves, has been tracking the outcomes of thousands of therapists treating tens of thousands of clients in myriad clinical settings across the United States and abroad. Like David Ricks and other researchers, we found wide variations in effectiveness among practicing clinicians. Intrigued, we decided to try to determine why.
We began our investigation by looking at the research literature. The institute has earned its reputation in part by reviewing research and publishing summaries and critical analyses on its website (TalkingCure.com). We were well aware at the outset that little had been done since Ricks's original paper to deepen the understanding of super- and pseudoshrinks. Nevertheless, a massive amount of research had been conducted on what makes therapists and therapy effective in general. When we attempted to determine the characteristics of the most effective practitioners using our national database, hypothesizing that therapists like Dawn and Gordon must simply do or embody more of "it," we smacked headfirst into a brick wall. Neither the person of the therapist nor technical prowess separated the best from the rest.
Frustrated, but undeterred, we retraced our steps. Maybe we'd missed something—a critical study, a nuance, a finding—that would steer us in the right direction. We returned to our own database to take a second look, reviewing the numbers and checking the analyses. We asked consultants outside the institute to verify our computations. We invited others to brainstorm possible explanations. Opinions varied from many of the factors we'd already considered and ruled out to "it's all a matter of chance, noise in the system, more statistical artifact than fact." Said another way, supershrinks weren't real, their emergence in any data analysis was entirely random. In the end, nothing we could point to explained why some clinicians achieved consistently superior results. Seeing no solution, we gave up and turned our attention elsewhere.
The project would have remained shelved indefinitely had one of us not stumbled onto the work of Swedish psychologist K. Anders Ericsson. Nearly two years had passed since we'd given up. Then Scott, returning to the U.S. after providing a week of training in Norway, found an article about Ericsson's findings published in Fortune magazine. Weary from the road and frankly bored, he'd taken the periodical from the passing flight attendant more for the glossy pictures and factoids than for intellectual stimulation. In short order, however, the magazine title seized his attention—in big bold letters, "What it takes to be great." The subtitle cinched it, "Research now shows that the lack of natural talent is irrelevant to great success." Although the lead article itself was a mere four pages in length, the content kept him occupied for the remaining eight hours of the flight.
Ericsson, Scott learned, was widely considered "the expert on experts." For the better part of two decades, he'd been studying the world's best athletes, authors, chess players, dart throwers, mathematicians, pianists, teachers, pilots, physicians, and others. He was also a bit of a maverick. In a world prone to attribute greatness to genetic endowment, Ericsson didn't mince words: "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."
Should Ericsson's bold and sweeping claims prove difficult to believe, take the example of Michael Jordan, widely regarded as the greatest basketball player of all time. When asked, most would cite natural advantages in height, reach, and leap as key to his success. Notwithstanding, few know that "His Airness" was cut from his high school varsity basketball team! So much for the idea of being born great. It simply doesn't work that way.
The key to superior performance? As absurd as it sounds, the best of the best simply work harder at improving their performance than others do. Jordan, for example, didn't give up when thrown off the team. Instead, his failure drove him to the courts, where he practiced hour after hour. As he put it, "Whenever I was working out and got tired and figured I ought to stop, I'd close my eyes and see that list in the locker room without my name on it, and that usually got me going again."
Such deliberate practice, as Ericsson goes to great lengths to point out, isn't the same as the number of hours spent on the job, but rather the amount of time specifically devoted to reaching for objectives just beyond one's level of proficiency.He chides anyone who believes that experience creates expertise, saying, "Just because you've been walking for 50 years doesn't mean you're getting better at it." Interestingly, he and his group have found that elite performers across many different domains engage in the same amount of such practice, on average, every day, including weekends. In a study of 20-year-old musicians, for example, Ericsson and colleagues found that the top violinists spent 2 times as much time (10,000 hours on average) working to meet specific performance targets as the next best players and 10 times as much time as the average musician.
As time-consuming as this level of practicing sounds—and it is—it isn't enough. According to Ericsson, to reach the top level, attentiveness to feedback is crucial. Studies of physicians with an uncanny knack for diagnosing baffling medical problems, for example, prove that they act differently from their less capable, but equally well-trained, colleagues. In addition to visiting with, examining, taking careful notes about, and reflecting on their assessment of a particular patient, they take one additional critical step. They follow up. Unlike their "proficient" peers, they don't settle. Call it professional compulsiveness or pride, these physicians need to know whether they were right, even though finding out is neither required nor reimbursable. "This extra step," Ericsson says, gives the superdiagnostician, "a significant advantage over his peers. It lets him better understand how and when he's improving."
Within days of touching down, Scott had shared Ericsson's findings with Mark and Barry. An intellectual frenzy followed. Articles were pulled, secondary references tracked down, and Ericsson's 918-page Cambridge Handbook of Expertise and Expert Performance purchased and read cover to cover. In the process, our earlier confusion gave way to understanding. With considerable chagrin, we realized that what therapists per se do is irrelevant to greatness. The path to excellence would never be found by limiting our explorations to the world of psychotherapy, with its attendant theories, tools, and techniques. Instead, we needed to redirect our attention to superior performance, regardless of calling or career.
Knowing What You Don't Know
Informed by this new perspective, the team moved into high gear. Suddenly, several studies we'd come across during our review of the literature took on new meaning, illuminated by Ericsson's finding that direct feedback made a big difference in creating people who excelled. The first focused on private practitioners working in a managed behavioral health care network. Veteran researchers Deirdre Hiatt and George Hargrave used peer and provider ratings, as well as a standardized outcome measures, to assess the success rates of therapists in their sample. Once again, providers were found to vary significantly in their effectiveness. What was disturbing, though, is that the least effective therapists in the sample thought they were on par with the most effective! As the brilliant detective Sherlock Holmes once observed, "Mediocrity knows nothing higher than itself." Like diagnosticians who don't follow up and merely assume that their analysis is correct, without direct feedback, the ineffective therapists in the Hiatt and Hargrave study assumed that they were performing adequately.
Ericsson's work on practice and feedback also explained studies showing that most of us grow continually in confidence over the course of our careers, despite little or no improvement in our actual rates of success. Hard to believe, but true. On this score, the experience of psychologist Paul Clement is telling. Throughout his years of practice, he kept unusually thorough records of his work with clients, detailing hundreds of cases falling into 86 different diagnostic categories. "I had expected to find," he said in a quantitative analysis, published in May 1994 in the peer-reviewed journal Professional Psychology: Research and Practice, "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."
Contrary to conventional wisdom, the culprit behind such mistaken self-assessment isn't incompetence but rather proficiency. Within weeks and months of first starting out, noticeable mistakes in everyday professional activities become increasingly rare, making intentional modifications seem irrelevant, increasingly difficult, and costly in terms of time and resources. Once more, this is human nature, a process that dogs every profession. Add to this the custom in our profession of conflating success with a particular method or technique, and the door to greatness for many therapists is slammed shut early on.
During the last few decades, more than 10,000 "how-to" books on psychotherapy have been published. At the same time, the number of treatment approaches has mushroomed, going from around 60 in the early days to more than 400. There are presently 145 officially approved, manualized, evidence-based treatments for 51 of the 397 possible DSM diagnostic groups. Based on these numbers alone, one would be hard pressed not to believe that real progress has been made by the field. More than ever before, we know what works for whom. Or do we?
Comparing today's success rates with those of 10, 20, or 30 years ago is a way of finding out. One would expect that the profession is progressing in a manner comparable to the Olympics. Fans know that during the last century, the best performance for every event has improved—in some cases, by as much as 50 percent. What's more, excellence at the top has had a trickle-down effect, improving performance at every level. The fastest time clocked for the marathon in the 1896 Olympics was just one minute faster than the time currently required just to participate in the most competitive marathons like Boston and Chicago. By contrast, no measurable improvement in the effectiveness of psychotherapy has occurred in the last 30 years.
The time has come to confront the unpleasant truth: our tried-and-true strategies for improving what we do have failed. Instead of advancing as a field, we've stagnated, mistaking our feverish peddling on a stationary bicycle for progress in the Tour de Therapy. This isn't to say that therapy is ineffective. Quite to the contrary, the data are clear and unequivocal: psychotherapy works. Studies conducted over the last three decades show effects equal to or greater than those achieved by a host of well-accepted medical procedures, such as coronary artery bypass surgery, the pharmacological treatment of arthritis, and AZT for AIDS. At issue, however, is how we can learn from our experiences and improve our rate of success, both as a discipline and in our individual practices.
Incidentally, psychotherapists aren't alone in the struggle to increase expertise. During our survey of the literature on greatness, we came across an engaging and provocative article published in the December 6, 2004, New Yorker magazine. Using the treatment of cystic fibrosis (CF) as an example, science writer Atul Gawande showed how the same processes undermining excellence in psychotherapy play out in medicine. Since 1964, medical researchers have been tracking the outcomes of patients with CF, a genetic disease striking 1,000 children yearly. The disease is progressive: over time, mucus fills, hardens, and eventually destroys the lungs.
As is the case with psychotherapy, the evidence indicates that standard CF treatment works. With medical intervention, life expectancy is just over 30 years; without care, few patients survive infancy. The real story, though, as Gawande points out, isn't that patients with CF live longer when treated, but that, as with psychotherapy, treatment success rates vary significantly. At the best treatment centers, survival rates are 50 percent higher than the national average, meaning that patients live to be 46 on average.
Such differences, however, haven't been achieved through standardization of care and the top-down imposition of the "best" practices. Indeed, Cincinnati Children's Hospital (CCH), one of the nation's most respected treatment centers—which employs two of the physicians responsible for preparing the national CF treatment guidelines—produced only average to poor outcomes. In fact, on one of the most critical measures, lung functioning, this institution scored in the bottom 25 percent.
It's a small comfort to know that our counterparts in medicine, a field routinely celebrated for its scientific rigor, stumble and fall in the pursuit of excellence just as much as we "soft-headed" psychotherapists do. But Gawande's article, which is currently available for free from the New Yorker website archives (The New Yorker), provides much more than an opportunity to commiserate: it confirms what our own research revealed to be the essential first step in improving outcomes: knowing your baseline performance. It just stands to reason. If you call a friend for directions, her first question will be, "Where are you?" The same is true of RandMcNally, Yahoo! and every other online mapping service. To get where you want to go, you first have to know where you are—a fact the clinical staff at CCH put to good use.
In truth, most practicing psychotherapists have no hard data on their success rates with clients. Fewer still have any idea how their outcomes compare to those of other clinicians or to national norms. Unlike therapists, though, the staff at CCH not only determined their overall rate of effectiveness, but they compared their success rates with other major CF treatment centers across the country. With such information in hand, they pushed beyond their current standard of reliable performance. In time, their outcomes improved markedly.
A Formula for Success
Within the last year, here in this country and abroad, we've started teaching this basic formula for success to therapists. Each of the formula's components—(1) determining your baseline of effectiveness, (2) engaging in deliberate practice, and (3) getting feedback—depends on and is informed by the others, working in tandem to create a "cycle of excellence."
Turning to specifics, the truth is we have yet to discover how supershrinks like Dawn and Gordon ascertain their baseline. Our experience leads us to believe that they don't know either. What's clear is that their appraisal, intuitive though it may be, is more accurate than that of average practitioners. It's likely, and our analysis thus far confirms, that the methods they employ will prove to be highly variable, defying any simple attempt at classification. Despite such differences in approach, the supershrinks without exception possess a keen "situational awareness": they're observant, alert, and attentive. They constantly compare new information with what they already know.
Thankfully, 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—a process we discuss in detail in the article that follows. In the end, you may not become the Frank Sinatra, Tiger Woods, or Melissa Etheridge of the therapy world, but you'll be able to sing, swing, and strum along with the best.
by Scott Miller, Mark Hubble, and Barry Duncan
July 2009
Boisea trivittatus, better known as the boxelder bug, emerges from the recesses of homes and dwellings in early spring. While feared neither for its bite nor for its sting, most people consider the tiny insect a pest. The critter comes out by the thousands, resting in the sun and staining upholstery and draperies with its orange-colored wastes. Few find it endearing, with the exception perhaps of entomologists. It doesn't purr and won't fetch the morning paper. What's more, you'll be sorry if you step on it. When crushed, the diminutive creature emits a putrid odor worthy of an animal many times its size.
For as long as anyone could remember, Boisea trivittatus was an unwelcome yet familiar guest in the offices and waiting area of a large Midwestern, multicounty community mental health center. Professional exterminators did their best to keep the bugs at bay, but inevitably many eluded the efforts to eliminate them. Tissues were strategically placed throughout the center to assist staff and clients in dispatching the escapees. In time, the arrangement became routine. Out of necessity, everyone tolerated the annual annoyance—with one notable exception.
Dawn, a 12-year veteran of the center, led the resistance to what she considered "insecticide." In a world turned against the bugs, she was their only ally. To save the tiny beasts, she collected and distributed old mason jars, imploring others to catch the little critters so that she could safely release them outdoors.
Few were surprised by Dawn's regard for the bugs. Most people who knew her would have characterized her as a holdout from the Summer of Love. Her VW microbus, floor-length, tie-died skirts, and Birkenstock sandals—combined with the scent of patchouli and sandalwood that lingered after her passage—solidified everyone's impression that she was a fugitive of Haight-Ashbury. Rumor had it that she'd been conceived at Esalen.
Despite these eccentricities, Dawn was hands-down the most effective therapist at the agency. This finding was established through a tightly controlled, research-to-practice study conducted at her agency. As part of this study of success rates in actual clinical settings, Dawn and her colleagues administered a standardized measure of progress to each client at every session.
What made her performance all the more compelling was that she was the top performer seven years running. Moreover, factors widely believed to affect treatment outcome—the client's age, gender, diagnosis, level of functional impairment, or prior treatment history—didn't affect her results. Other factors that weren't correlated to her outcomes were her age, gender, training, professional discipline, licensure, or years of experience. Even her theoretical orientation proved inconsequential.
Contrast Dawn with Gordon, who couldn't have been more different. Rigidly conservative and brimming with confidence bordering on arrogance, he managed to build a thriving private practice in an area where most practitioners were struggling to stay afloat financially. Many in the professional community sought to emulate his success. In the hopes of learning his secrets or earning his acknowledgement, they competed hard to enter his inner circle.
Whispered conversations at parties and local professional meetings made clear that others regarded Gordon with envy and enmity. "Profits talk, patients walk," was one comment that captured the general feeling about him. But the critics couldn't have been more wrong. The people Gordon saw in his practice regarded him as caring and deeply committed to their welfare. Furthermore, he achieved outcomes that were far superior to those of the clinicians who carped about him. In fact, the same measures that confirmed Dawn's superior results placed Gordon in the top 25 percent of psychotherapists studied in the United States.
In 1974, researcher David F. Ricks coined the term supershrinks to describe a class of exceptional therapists—practitioners who stood head and shoulders above the rest. His study examined the long-term outcomes of "highly disturbed" adolescents. When the research participants were later examined as adults, he found that a select group, treated by one particular provider, fared notably better. In the same study, boys treated by the "pseudoshrink" demonstrated alarmingly poor adjustment as adults.
That therapists differ in their ability to affect change is hardly a revelation. All of us have participated in hushed conversations about colleagues whose performance we feel falls short of the mark. We also recognize that some practitioners are a cut above the rest. With rare exceptions, whenever they take aim, they hit the bull's-eye. Nevertheless, since Ricks's first description, little has been done to further the investigation of super- and pseudoshrinks. Instead, professional time, energy, and resources have been directed exclusively toward identifying effective therapies. Trying to identify specific interventions that could be reliably dispensed for specific problems has a strong commonsense appeal. No one would argue with the success of the idea of problem-specific interventions in the field of medicine. But the evidence is incontrovertible. Who provides the therapy is a much more important determinant of success than what treatment approach is provided.
Consider a study reported by Bruce Wampold and Jeb Brown in the October 2005 Journal of Consulting and Clinical Psychology. It included 581 licensed providers—psychologists, psychiatrists, and master's-level therapists—who were treating a diverse sample of more than 6,000 clients. The therapists, the clientele, and the presenting complaints weren't different in any meaningful way from those in clinical settings nationwide. As was the case with Dawn and Gordon, the clients' age, gender, and diagnosis had no impact on the treatment success rate, and neither did the experience, training, and theoretical orientation of the therapists. However, clients of the best therapists in the sample improved at a rate at least 50 percent higher and dropped out at a rate at least 50 percent lower than those assigned to the worst clinicians in the sample.
Another important finding emerged: in cases in which psychotropic medication was combined with psychotherapy, the drugs didn't perform consistently. Their effectiveness depended on the quality of the therapist—drugs used in combination with talk therapy were 10 times more effective with the best therapists than with the worst. Among the latter group, the drugs made virtually no difference. So, in the chemistry of mental health treatment, the applied orientations, techniques, and even medications are relatively inert. The catalyst is the clinician.
The Making of a Supershrink
How do the supershrinks—practitioners as dissimilar as Dawn and Gordon—do what they do? Are they made or born? Is it a matter of temperament or training? Have they discovered a secret unknown to other practicing clinicians or are their superior results simply a fluke, more measurement error than reality? Answering these questions is critical. If being the best is matter of birth, personal disposition, or chance, the phenomenon would hardly be worth further study. But should their talents prove transferable, the implications for training, certification, and service delivery are nothing short of staggering.
Enter the Institute for the Study of Therapeutic Change, an international group of researchers and clinicians dedicated to studying what works in psychotherapy. For the past eight years, the group, including ourselves, has been tracking the outcomes of thousands of therapists treating tens of thousands of clients in myriad clinical settings across the United States and abroad. Like David Ricks and other researchers, we found wide variations in effectiveness among practicing clinicians. Intrigued, we decided to try to determine why.
We began our investigation by looking at the research literature. The institute has earned its reputation in part by reviewing research and publishing summaries and critical analyses on its website (TalkingCure.com). We were well aware at the outset that little had been done since Ricks's original paper to deepen the understanding of super- and pseudoshrinks. Nevertheless, a massive amount of research had been conducted on what makes therapists and therapy effective in general. When we attempted to determine the characteristics of the most effective practitioners using our national database, hypothesizing that therapists like Dawn and Gordon must simply do or embody more of "it," we smacked headfirst into a brick wall. Neither the person of the therapist nor technical prowess separated the best from the rest.
Frustrated, but undeterred, we retraced our steps. Maybe we'd missed something—a critical study, a nuance, a finding—that would steer us in the right direction. We returned to our own database to take a second look, reviewing the numbers and checking the analyses. We asked consultants outside the institute to verify our computations. We invited others to brainstorm possible explanations. Opinions varied from many of the factors we'd already considered and ruled out to "it's all a matter of chance, noise in the system, more statistical artifact than fact." Said another way, supershrinks weren't real, their emergence in any data analysis was entirely random. In the end, nothing we could point to explained why some clinicians achieved consistently superior results. Seeing no solution, we gave up and turned our attention elsewhere.
The project would have remained shelved indefinitely had one of us not stumbled onto the work of Swedish psychologist K. Anders Ericsson. Nearly two years had passed since we'd given up. Then Scott, returning to the U.S. after providing a week of training in Norway, found an article about Ericsson's findings published in Fortune magazine. Weary from the road and frankly bored, he'd taken the periodical from the passing flight attendant more for the glossy pictures and factoids than for intellectual stimulation. In short order, however, the magazine title seized his attention—in big bold letters, "What it takes to be great." The subtitle cinched it, "Research now shows that the lack of natural talent is irrelevant to great success." Although the lead article itself was a mere four pages in length, the content kept him occupied for the remaining eight hours of the flight.
Ericsson, Scott learned, was widely considered "the expert on experts." For the better part of two decades, he'd been studying the world's best athletes, authors, chess players, dart throwers, mathematicians, pianists, teachers, pilots, physicians, and others. He was also a bit of a maverick. In a world prone to attribute greatness to genetic endowment, Ericsson didn't mince words: "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."
Should Ericsson's bold and sweeping claims prove difficult to believe, take the example of Michael Jordan, widely regarded as the greatest basketball player of all time. When asked, most would cite natural advantages in height, reach, and leap as key to his success. Notwithstanding, few know that "His Airness" was cut from his high school varsity basketball team! So much for the idea of being born great. It simply doesn't work that way.
The key to superior performance? As absurd as it sounds, the best of the best simply work harder at improving their performance than others do. Jordan, for example, didn't give up when thrown off the team. Instead, his failure drove him to the courts, where he practiced hour after hour. As he put it, "Whenever I was working out and got tired and figured I ought to stop, I'd close my eyes and see that list in the locker room without my name on it, and that usually got me going again."
Such deliberate practice, as Ericsson goes to great lengths to point out, isn't the same as the number of hours spent on the job, but rather the amount of time specifically devoted to reaching for objectives just beyond one's level of proficiency.He chides anyone who believes that experience creates expertise, saying, "Just because you've been walking for 50 years doesn't mean you're getting better at it." Interestingly, he and his group have found that elite performers across many different domains engage in the same amount of such practice, on average, every day, including weekends. In a study of 20-year-old musicians, for example, Ericsson and colleagues found that the top violinists spent 2 times as much time (10,000 hours on average) working to meet specific performance targets as the next best players and 10 times as much time as the average musician.
As time-consuming as this level of practicing sounds—and it is—it isn't enough. According to Ericsson, to reach the top level, attentiveness to feedback is crucial. Studies of physicians with an uncanny knack for diagnosing baffling medical problems, for example, prove that they act differently from their less capable, but equally well-trained, colleagues. In addition to visiting with, examining, taking careful notes about, and reflecting on their assessment of a particular patient, they take one additional critical step. They follow up. Unlike their "proficient" peers, they don't settle. Call it professional compulsiveness or pride, these physicians need to know whether they were right, even though finding out is neither required nor reimbursable. "This extra step," Ericsson says, gives the superdiagnostician, "a significant advantage over his peers. It lets him better understand how and when he's improving."
Within days of touching down, Scott had shared Ericsson's findings with Mark and Barry. An intellectual frenzy followed. Articles were pulled, secondary references tracked down, and Ericsson's 918-page Cambridge Handbook of Expertise and Expert Performance purchased and read cover to cover. In the process, our earlier confusion gave way to understanding. With considerable chagrin, we realized that what therapists per se do is irrelevant to greatness. The path to excellence would never be found by limiting our explorations to the world of psychotherapy, with its attendant theories, tools, and techniques. Instead, we needed to redirect our attention to superior performance, regardless of calling or career.
Knowing What You Don't Know
Informed by this new perspective, the team moved into high gear. Suddenly, several studies we'd come across during our review of the literature took on new meaning, illuminated by Ericsson's finding that direct feedback made a big difference in creating people who excelled. The first focused on private practitioners working in a managed behavioral health care network. Veteran researchers Deirdre Hiatt and George Hargrave used peer and provider ratings, as well as a standardized outcome measures, to assess the success rates of therapists in their sample. Once again, providers were found to vary significantly in their effectiveness. What was disturbing, though, is that the least effective therapists in the sample thought they were on par with the most effective! As the brilliant detective Sherlock Holmes once observed, "Mediocrity knows nothing higher than itself." Like diagnosticians who don't follow up and merely assume that their analysis is correct, without direct feedback, the ineffective therapists in the Hiatt and Hargrave study assumed that they were performing adequately.
Ericsson's work on practice and feedback also explained studies showing that most of us grow continually in confidence over the course of our careers, despite little or no improvement in our actual rates of success. Hard to believe, but true. On this score, the experience of psychologist Paul Clement is telling. Throughout his years of practice, he kept unusually thorough records of his work with clients, detailing hundreds of cases falling into 86 different diagnostic categories. "I had expected to find," he said in a quantitative analysis, published in May 1994 in the peer-reviewed journal Professional Psychology: Research and Practice, "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."
Contrary to conventional wisdom, the culprit behind such mistaken self-assessment isn't incompetence but rather proficiency. Within weeks and months of first starting out, noticeable mistakes in everyday professional activities become increasingly rare, making intentional modifications seem irrelevant, increasingly difficult, and costly in terms of time and resources. Once more, this is human nature, a process that dogs every profession. Add to this the custom in our profession of conflating success with a particular method or technique, and the door to greatness for many therapists is slammed shut early on.
During the last few decades, more than 10,000 "how-to" books on psychotherapy have been published. At the same time, the number of treatment approaches has mushroomed, going from around 60 in the early days to more than 400. There are presently 145 officially approved, manualized, evidence-based treatments for 51 of the 397 possible DSM diagnostic groups. Based on these numbers alone, one would be hard pressed not to believe that real progress has been made by the field. More than ever before, we know what works for whom. Or do we?
Comparing today's success rates with those of 10, 20, or 30 years ago is a way of finding out. One would expect that the profession is progressing in a manner comparable to the Olympics. Fans know that during the last century, the best performance for every event has improved—in some cases, by as much as 50 percent. What's more, excellence at the top has had a trickle-down effect, improving performance at every level. The fastest time clocked for the marathon in the 1896 Olympics was just one minute faster than the time currently required just to participate in the most competitive marathons like Boston and Chicago. By contrast, no measurable improvement in the effectiveness of psychotherapy has occurred in the last 30 years.
The time has come to confront the unpleasant truth: our tried-and-true strategies for improving what we do have failed. Instead of advancing as a field, we've stagnated, mistaking our feverish peddling on a stationary bicycle for progress in the Tour de Therapy. This isn't to say that therapy is ineffective. Quite to the contrary, the data are clear and unequivocal: psychotherapy works. Studies conducted over the last three decades show effects equal to or greater than those achieved by a host of well-accepted medical procedures, such as coronary artery bypass surgery, the pharmacological treatment of arthritis, and AZT for AIDS. At issue, however, is how we can learn from our experiences and improve our rate of success, both as a discipline and in our individual practices.
Incidentally, psychotherapists aren't alone in the struggle to increase expertise. During our survey of the literature on greatness, we came across an engaging and provocative article published in the December 6, 2004, New Yorker magazine. Using the treatment of cystic fibrosis (CF) as an example, science writer Atul Gawande showed how the same processes undermining excellence in psychotherapy play out in medicine. Since 1964, medical researchers have been tracking the outcomes of patients with CF, a genetic disease striking 1,000 children yearly. The disease is progressive: over time, mucus fills, hardens, and eventually destroys the lungs.
As is the case with psychotherapy, the evidence indicates that standard CF treatment works. With medical intervention, life expectancy is just over 30 years; without care, few patients survive infancy. The real story, though, as Gawande points out, isn't that patients with CF live longer when treated, but that, as with psychotherapy, treatment success rates vary significantly. At the best treatment centers, survival rates are 50 percent higher than the national average, meaning that patients live to be 46 on average.
Such differences, however, haven't been achieved through standardization of care and the top-down imposition of the "best" practices. Indeed, Cincinnati Children's Hospital (CCH), one of the nation's most respected treatment centers—which employs two of the physicians responsible for preparing the national CF treatment guidelines—produced only average to poor outcomes. In fact, on one of the most critical measures, lung functioning, this institution scored in the bottom 25 percent.
It's a small comfort to know that our counterparts in medicine, a field routinely celebrated for its scientific rigor, stumble and fall in the pursuit of excellence just as much as we "soft-headed" psychotherapists do. But Gawande's article, which is currently available for free from the New Yorker website archives (The New Yorker), provides much more than an opportunity to commiserate: it confirms what our own research revealed to be the essential first step in improving outcomes: knowing your baseline performance. It just stands to reason. If you call a friend for directions, her first question will be, "Where are you?" The same is true of RandMcNally, Yahoo! and every other online mapping service. To get where you want to go, you first have to know where you are—a fact the clinical staff at CCH put to good use.
In truth, most practicing psychotherapists have no hard data on their success rates with clients. Fewer still have any idea how their outcomes compare to those of other clinicians or to national norms. Unlike therapists, though, the staff at CCH not only determined their overall rate of effectiveness, but they compared their success rates with other major CF treatment centers across the country. With such information in hand, they pushed beyond their current standard of reliable performance. In time, their outcomes improved markedly.
A Formula for Success
Within the last year, here in this country and abroad, we've started teaching this basic formula for success to therapists. Each of the formula's components—(1) determining your baseline of effectiveness, (2) engaging in deliberate practice, and (3) getting feedback—depends on and is informed by the others, working in tandem to create a "cycle of excellence."
Turning to specifics, the truth is we have yet to discover how supershrinks like Dawn and Gordon ascertain their baseline. Our experience leads us to believe that they don't know either. What's clear is that their appraisal, intuitive though it may be, is more accurate than that of average practitioners. It's likely, and our analysis thus far confirms, that the methods they employ will prove to be highly variable, defying any simple attempt at classification. Despite such differences in approach, the supershrinks without exception possess a keen "situational awareness": they're observant, alert, and attentive. They constantly compare new information with what they already know.
Thankfully, 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—a process we discuss in detail in the article that follows. In the end, you may not become the Frank Sinatra, Tiger Woods, or Melissa Etheridge of the therapy world, but you'll be able to sing, swing, and strum along with the best.
