supershrinks free report

8/13/2019 Supershrinks Free Report

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The Secrets ofSupershrinks:Pathways toClinical Excellence

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The Secrets of Supershrinks: Pathways to Clinical ExcellenceFor more free reports, visit http://www.psychotherapynetworker.org/free-reports P S Y C H O T H E R A P Y N E T W O R K E R

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Indispensable Resources for Your PracticePsychotherapy Networker is a nonpro t educational organization dedicated to offering practical guidance, creative inspira -

tion, and community support to therapists around the world. Whether you want to stay informed about new ideas and currentdebates in the eld, connect with colleagues who share your professional interests, or just keep the spirit of discovery alive andwell in your work, Psychotherapy Networker provides indispensable guidance and resources for your practice.

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B oisea trivittatus, better known as the boxelder bug,

emerges from the recesses of homes and dwellings inearly spring. While feared neither for its bite nor sting,

most people consider the tiny insect a pest. The critter comesout by the thousands, resting in the sun and staining uphol -stery and draperies with its orange-colored wastes. Few ndit endearing, with the exception perhaps of entomologists.It doesnt purr and wont fetch the morning paper. Whatsmore, youll be sorry if you step on it. When crushed, thediminutive creature emits a putrid odor worthy of an animalmany times its size.

For as long as anyone could remember, Boisea trivittatus was an unwelcome yet familiar guest in the of ces and wait -ing area of a large Midwestern, multicounty communitymental health center. Professional exterminators did theirbest to keep the bugs at bay, but inevitably many eluded theefforts to eliminate them. Tissues were strategically placedthroughout the center to assist staff and clients in dispatchingthe escapees. In time, the arrangement became routine. Outof necessity, everyone tolerated the annual annoyancewithone notable exception.

Dawn, a 12-year veteran of the center, led the resistanceto what she considered insecticide. In a world turnedagainst the bugs, she was their only ally. To save the tinybeasts, she collected and distributed old mason jars, implor -ing others to catch the little critters so that she could safelyrelease them outdoors.

Few were surprised by Dawns regard for the bugs. Mostpeople who knew her would have characterized her as aholdout from the Summer of Love. Her VW microbus, oor-length, tie-died skirts, and Birkenstock sandalscombinedwith the scent of patchouli and sandalwood that lingeredafter her passagesolidi ed everyones impression that shewas a fugitive of Haight-Ashbury. Rumor had it that shed

been conceived at Esalen.Despite these eccentricities, Dawn was hands-down themost effective therapist at the agency. This nding wasestablished through a tightly controlled, research-to-practicestudy conducted at her agency. As part of this study of suc -cess rates in actual clinical settings, Dawn and her colleaguesadministered a standardized measure of progress to eachclient at every session. What made her performance all themore compelling was that Dawn was the top performer seven

years running. Moreover, factors widely believed to affecttreatment outcomethe clients age, gender, diagnosis, levelof functional impairment, or prior treatment historydidntaffect her results. Other factors that werent correlated to heroutcomes either were her age, gender, training, professionaldiscipline, licensure, or years of experience. Even her theo -retical orientation proved inconsequential.

Contrast Dawn with Gordon, who couldnt have beenmore different. Rigidly conservative and brimming with con -dence bordering on arrogance, Gordon managed to build athriving private practice in an area where most practitionerswere struggling to stay a oat nancially. Many in the profes -sional community sought to emulate his success. In the hopesof learning his secrets or earning his acknowledgement, theycompeted hard to become part of his inner circle.

Whispered conversations at parties and local professionalmeetings made clear that others regarded Gordon with envyand enmity. Pro ts talk, patients walk, was one commentthat captured the general feeling about him. But the criticscouldnt have been more wrong. The people Gordon saw inhis practice regarded him as caring and deeply committed totheir welfare. Furthermore, he achieved outcomes that werefar superior to those of the clinicians who carped about him.In fact, the same measures that con rmed Dawns superiorresults placed Gordon in the top 25 percent of psychothera -pists studied in the United States.

In 1974, researcher David F. Ricks coined the term super-shrinks to describe a class of exceptional therapistspractitio -ners who stood head and shoulders above the rest. His studyexamined the long-term outcomes of highly disturbedadolescents. When the research participants were later exam -ined as adults, he found that a select group, treated by oneparticular 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 ishardly a revelation. All of us have participated in hushed con -

versations about colleagues whose performance we feel fallsshort of the mark. We also recognize that some practitionersare a cut above the rest. With rare exceptions, whenever theytake aim, they hit the bulls-eye. Nevertheless, since Ricksrst description, little has been done to further the investiga -tion of super- and pseudoshrinks. Instead, professional time,

The Secrets of Supershrinks:Pathways to Clinical ExcellenceBY SCOTT MILLER, MARK HUBBLE, AND BARRY DUNCAN


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energy, and resources have been directed exclusively towardidentifying effective therapies. Trying to identify speci c inter -

ventions that could be reliably dispensed for speci c problemshas a strong common-sense appeal. No one would argue withthe success of the idea of problem-speci c interventions inthe eld of medicine. But the evidence is incontrovertible.Who provides the therapy treatment is a much more impor -tant determinant of success than what treatment approach is

provided.Consider a study reported by Bruce Wampold and Jeb

Brown in the October 2005 J ournal of Consulting and Clinical Psychology. It included 581 licensed providerspsychologists,psychiatrists, and masters-level therapistswho were treat -ing a diverse sample of more than 6,000 clients. The thera -pists, the clientele, and the presenting complaints werentdifferent in any meaningful way from those in clinical set -tings nationwide. As was the case with Dawn and Gordon,the clients age, gender, and diagnosis had no impact on thetreatment success rate and neither did the experience, train -ing, and theoretical orientation of the therapists. However,clients of the best therapists in the sample improved at a rateat least 50 percent higher and dropped out at a rate at least50 percent lower than those assigned to the worst cliniciansin the sample.

Another important nding emerged: in those cases inwhich psychotropic medication was combined with psycho -therapy, the drugs didnt perform consistently. The effective -ness depended on the quality of the therapistdrugs used incombination with talk therapy were 10 times more effectivewith the best therapists than with the worst therapists. Amongthe latter group, the drugs virtually made no difference. So,in the chemistry of mental health treatment, orientations,techniques, and even medications are relatively inert. Thecatalyst is the clinician.

The Making of a SupershrinkSo how do the supershrinkspractitioners as dissimilar asDawn and Gordondo what they do? Are they made orborn? Is it a matter of temperament or training? Have theydiscovered a secret unknown to other practicing clinicians orare their superior results simply a uke, more measurementerror than reality? Answering these questions is critical. Ifbeing the best is matter of birth, personal disposition, orchance, the phenomenon would hardly be worth furtherstudy. But should their talents prove transferable, the implica -tions for training, certi cation, and service delivery are noth -

ing short of staggering.Enter the Institute for the Study of Therapeutic Change,an international group of researchers and clinicians dedicat -ed to studying what works in psychotherapy. For the past eight

years, the group, including ourselves, has been tracking theoutcomes of thousands of therapists treating tens of thou -sands of clients in myriad clinical settings across the UnitedStates 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 byreviewing research and publishing summaries and criticalanalyses on its website (www.talkingcure.com). We were wellaware at the outset that little had been done since Ricksoriginal paper to deepen the understanding of super- andpseudoshrinks. Nevertheless, a massive amount of research

had been conducted on what makes therapists and therapyeffective in general. When we attempted to determine thecharacteristics of the most effective practitioners using ournational database, hypothesizing that therapists like Dawnand Gordon must simply do or embody more of it, wesmacked head rst into a brick wall. Neither the person ofthe therapist nor technical prowess separated the best fromthe rest.

Frustrated, but undeterred, we retraced our steps. Maybewed missed somethinga critical study, a nuance, a nd -ingthat would steer us in the right direction. We returnedto our own database to take a second look, reviewing thenumbers and checking the analyses. We asked consultantsoutside the institute to verify our computations. We invitedothers to brainstorm possible explanations. Opinions variedfrom many of the factors wed already considered and ruledout to its all a matter of chance, noise in the system, morestatistical artifact than fact. Said another way, supershrinkswerent real, their emergence in any data analysis was entirelyrandom. In the end, nothing we could point to explained whysome clinicians achieved consistently superior results. Seeingno solution, we gave up and turned our attention elsewhere.

The project would have remained shelved inde nitely hadone of us not stumbled on the work of Swedish psychologistK. Anders Ericsson. Nearly two years had passed since we hadgiven up. Then Scott, returning to the U.S. after providing aweek of training in Norway, stumbled on an article aboutEricssons ndings published in Fortune magazine. Wearyfrom the road and frankly bored, hed taken the periodicalfrom the passing ight attendant more for the glossy picturesand factoids than for intellectual stimulation. In short order,however, the magazine title seized his attentionin big boldletters, WHAT IT TAKES TO BE GREAT. The subtitledcinched it, Research now shows that the lack of naturalTALENT IS IRRELEVANT to great success. Although thelead article itself was a mere four pages in length, the contentkept him occupied for the remaining eight hours of the ight.

Ericsson, Scott learned, was widely considered the

expert on experts. For the better part of two decades, hedbeen studying the worlds best athletes, authors, chess play -ers, dart throwers, mathematicians, pianists, teachers, pilots,physicians, and others. He was also a bit of a maverick. Ina world prone to attribute greatness to genetic endowment,Ericsson didnt mince words, The search for stable heritablecharacteristics that could predict or at least account for supe -rior performance of eminent individuals [in sports, chess,music, medicine, etc.] has been surprisingly unsuccessful. . .


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. Systematic laboratory research . . . provides no evidence forgiftedness or innate talent.

Should Ericssons bold and sweeping claims prove dif -cult to believe, take the example of Michael Jordan, widelyregarded as the greatest basketball player of all time. Whenasked, most would cite natural advantages in height, reach,and leap as key to his success. Notwithstanding, few knowthat His Airness was cut from his high school varsity bas -

ketball team! So much for the idea of being born great. Itsimply doesnt work that way.

The key to superior performance? As absurd as it sounds,the best of the best simply work harder at improving theirperformance than others do. Jordan, for example, didnt giveup when thrown off the team. Instead, his failure drove himto the courts, where he practiced hour after hour. As he putit, Whenever I was working out and got tired and gured Iought to stop, Id close my eyes and see that list in the lockerroom without my name on it, and that usually got me goingagain.

Such deliberate practice, as Ericsson goes to great lengths topoint out, isnt the same as the number of hours spent onthe job, but rather the amount of time speci cally devotedto reaching for objectives just beyond ones level of pro ciency. Hechides anyone who believes that experience creates expertise,saying, Just because youve been walking for 50 years doesntmean youre getting better at it. Interestingly, he and hisgroup have found that elite performers across many differentdomains engage in the same amount of such practice, onaverage, every day, including weekends. In a study of 20-year-old musicians, for example, Ericsson and colleagues foundthat the top violinists spent 2 times as much time (10,000hours on average) working to meet speci c performance tar -gets as the next best players and 10 times as much time as theaverage musician.

As time consuming as this level of practicing soundsandit isit isnt enough. According to Ericsson, to reach the toplevel, attentiveness to feedback is crucial. Studies of physicianswith an uncanny knack for diagnosing baf ing medical prob -lems, for example, prove that they act differently than theirless capable, but equally well-trained, colleagues. In additionto visiting with, examining, taking careful notes about, andre ecting on their assessment of a particular patient, theytake one additional critical step. They follow up. Unlike theirpro cient peers, they dont settle. Call it professional com -pulsiveness or pride, these physicians need to know whetherthey were right, even though nding out is neither required

nor reimbursable. This extra step, Ericsson says, gives thesuperdiagnostician, a signi cant advantage over his peers. Itlets him better understand how and when hes improving.

Within days of touching down, Scott had shared Ericssonsndings with Mark and Barry. An intellectual frenzy followed.Articles were pulled, secondary references tracked down, andEricssons 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 con -

siderable chagrin, we realized that what therapists per se dois irrelevant to greatness. The path to excellence would neverbe found by limiting our explorations to the world of psy -chotherapy, with its attendant theories, tools, and techniques.Instead, we needed to redirect our attention to superior per -formance, regardless of calling or career.

Knowing What You Dont KnowInformed by this new perspective, the team moved into highgear. Suddenly, several studies wed come across during ourreview of the literature took on new meaning, illuminatedby Ericssons nding that direct feedback made a big dif -ference in creating people who excelled. The rst focusedon private practitioners working in a managed behavioralhealth care network. Veteran researchers Deirdre Hiatt andGeorge Hargrave used peer and provider ratings, as well as astandardized outcome measures, to assess the success rates oftherapists in their sample. Once again, providers were foundto vary signi cantly in their effectiveness. What was disturb -ing, though, is that the least effective therapists in the samplethought they were on par with the most effective! As the bril -liant detective Sherlock Holmes once observed, Mediocrityknows nothing higher than itself. Like diagnosticians whodont follow up and merely assume that their analysis is cor -rect, without direct feedback, the ineffective therapists in theHiatt and Hargrave study assumed that they were performingadequately.

Ericssons work on practice and feedback also explainedstudies showing that most of us grow continually in con -dence over the course of our careers, despite little or noimprovement in our actual rates of success. Hard to believe,but true. On this score, the experience of psychologist PaulClement is telling. Throughout his years of practice, he keptunusually thorough records of his work with clients, detail -ing hundreds of cases falling into 86 different diagnosticcategories. I had expected to nd, he said in a quantitativeanalysis, published in May 1994 in the peer-reviewed journal

Professional Psychology: Research and Practice, that I had gottenbetter and better over the years . . . but my data failed to sug -gest any . . . change in my therapeutic effectiveness across the26 years in question.

Contrary to conventional wisdom, the culprit behindsuch mistaken self-assessment isnt incompetence but rather

pro ciency. Within weeks and months of rst starting out,noticeable mistakes in everyday professional activities becomeincreasingly rare, making intentional modi cations seem

irrelevant, increasingly dif cult, and costly in terms of timeand resources. Once more, this is human nature, a processthat dogs every profession. Add to this, the custom in ourprofession of con ating success with a particular method ortechnique and the door to greatness for many therapists isslammed shut early on.

During the last few decades, for example, more than10,000 how-to books on psychotherapy have been pub -lished. At the same time, the number of treatment approaches


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stir in their chairs. Each of us was expecting Dawn to wrapup the sessioneven, it appeared, the client, who wasinching forward on his chair. Instead, she leaned towardhim.

Im glad you came today, she said.It was a good idea, he responded, um, my, uh, doc -

tor told me to come, in, and . . . I did, and, um . . . itsbeen a nice visit.

So, will you be coming back?Without missing a beat, the man replied, You know,

Im going to be alright. A person doesnt get over a thinglike this overnight. Its going to take me a while. But dont

you worry.Behind the mirror, we and the staff were surprised

again. The session had gone well. Hed been engaged. Afollow-up appointment had been made. Now we heardambivalence in his voice.

For her part, Dawn wasnt about to let him off thehook, Im hoping you will come back.

You know, I miss her terribly, he said, its awfullylonely at night. But, Ill be alright. As I said, dont worryabout me.

I appreciate that, appreciate what you just said, butactually what I worry about is that I missed something.Come to think about it, if we were to change places, if Iwere in your shoes, Id be wondering, What really can sheknow or understand about this, and more, what can shepossibly do?

A long silence followed. Eventually, the man looked up,and with tears in his eyes, caught her gaze.

Softly, Dawn continued, Id like you to come back. Imnot sure what this might mean to you right now, but youdont have to do this alone.

Nodding af rmatively, the man stood, took Dawnshand, and gave it a squeeze. See you, then.

Several sessions followed. During that period his scoreson the standardized outcome measure improved consider -ably. At the time, the team was impressed with Dawn. Hersensitivity and persistence paid off, keeping the elderlyman engaged, and preventing his dropping out. The realimport of her actions, however, didnt occur to any of usuntil much later.

All therapists experience similar incisive momentsin their work with clients times when theyre acutelyinsightful, discerning, even wise. Such experiences areactually of little consequence in separating the good from

the great, however. Instead, superior performance is foundin the marginsthe small but consistent difference in thenumber of times corrective feedback is sought, successfullyobtained, and then acted on.

Systematically Seeking FeedbackMost therapists, when asked, report checking in routinelywith their clients and knowing when to do so. But our ownresearch found this to be far from the case. In early 1998,

we initiated a study to investigate the impact on treatmentoutcome of seeking client feedback. Several formats wereincluded. In one, therapists were supposed to seek clientinput informally, on their own. In another, standardized,client-completed outcome and alliance measures wereadministered and the results shared with fellow therapists.Treatment-as-usual served as a third, control group.

Initial results pointed to an advantage for the feedback

conditions. Ultimately, however, the entire project had tobe scraped as a review of the videotapes showed that thetherapists in the informal group routinely failed to ask cli -ents for their inputeven though, when later queried, theclinicians maintained they had sought feedback.

For their part, supershrinks consistently seek client feed -back about how the client feels about them and their worktogether; they dont just say they do. Dawn perhaps saidit best, I always ask. Ninety-nine percent of the time, itdoesnt go anywhereat least at the moment. SometimesIll get a call, but rarely. More likely, Ill call, and every sooften my nosiness uncovers something, some, I dont knowquite how to say it, some barrier or break, something inthe way of our working together. Such persistence in theface of infrequent payoff is a de ning characteristic ofthose destined for greatness.

Whereas birds can y, the rest of us need an airplane.When a simple measure of the alliance is used in con -

junction with a standardized outcome scale, availableevidence shows clients are less likely to deteriorate, morelikely to stay longer, and twice as likely to achieve a clini -cally signi cant change. Whats more, when applied on anagency-wide basis, tracking client progress and experienceof the therapeutic relationship has an effect similar to theone noted earlier in the Olympics: performance improvesacross the board; everyone gets better. As John F. Kennedywas fond of saying, A rising tide lifts all boats.

While its true that the tide raises everyone, weveobserved that supershrinks continue to beat others out ofthe dock. Two factors account for this. As noted earlier,superior performers engage in signi cantly more deliber -ate practice. That is, as Ericsson, the expert on expertssays, effortful activity designed to improve individualtarget performance. Speci c methods of deliberate prac -tice have been developed and employed in the training ofpilots, surgeons, and others in highly demanding occupa -tions. Our most recent work has focused on adapting theseprocedures for use in psychotherapy.

In practical terms, the process involves three steps:think, act, and, nally, re ect. This approach can beremembered by the acronym, T.A.R. To prepare for mov -ing beyond the realm of reliable performance, the bestof the best engage in forethought. This means they setspeci c goals and identify the particular ways theyll useto reach their goals. Its important to note that superiorperformance depends on attending to both the ends andthe means, simultaneously.


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To illustrate, suppose a therapist wanted to improve theengagement level of clients mandated into treatment forsubstance abuse. Shed rst need to de ne in measurableterms how shed know that the client was actively engagedin the treatment (e.g., attendance, increased dialogue, eyecontact, posture, etc.). Following this, the therapist woulddevelop a step-by-step plan for achieving the speci cobjectives. Because therapies that focus on client goals

result in greater participation, she might, for example, cre -ate a list of questions designed to elicit and con rm whatthe client wanted out of therapy. She might also spendtime anticipating what the client might enumerate andplanning a strategy for each response.

In the act phase, successful experts track their perfor -mance: they monitor on an ongoing basis whether theyused each of the steps or strategies outlined in the thinkingphase and the quality with which each step was executed.The sheer volume of detail gathered in assessing theirperformance distinguishes the exceptional from their moreaverage counterparts.

During the re ection phase, top performers review thedetails of their performance, identifying speci c actionsand alternate strategies for reaching their goals. Whereunsuccessful learners paint with broad strokes, attributingfailure to external and uncontrollable factors (e.g., I hada bad day, I wasnt with it), the experts know exactlywhat they do, more often citing controllable factors (e.g., Ishould have done x instead of y, of I forgot to do x andwill do x plus y next time). In our work with psychothera -pists, for example, weve found that average practitionersare far more likely to spend time hypothesizing aboutfailed strategiesbelieving perhaps that understandingthe reasons why an approach didnt work will lead to bet -ter outcomesand less time thinking about strategies thatmight be more effective.

Returning to the example above, an average therapistwould be signi cantly more likely to attribute failure toengage the mandated substance abuser to denial, resis -tance, or lack of motivation. The expert, in contrast,would say, Instead of organizing the session around druguse, I should have emphasized what the client wanted getting his drivers license back. Next time, I will explore indetail what the two of us need to do right now to get himback in the drivers seat.

The penchant for seeking explanations for treatmentfailures can have life-and-death consequences. In the

1960s, the average lifespan of children with cystic brosistreated by pro cient pediatricians was three years. Theeld as a whole routinely attributed the high mortality rateto the illness itselfa belief which, in retrospect, can onlybe viewed as a self-ful lling prophecy. After all, why searchfor alternative methods if the disease invariably kills?Although certainly less dramatic, psychologist WilliamMiller makes a similar point about psychotherapy, notingthat most models dont account for how people change,

but rather why they stay the same. In our experience,diagnostic classi cations often serve a similar function byattributing the cause of a failing or failed therapy to thedisorder.

The Value of Practice, Practice,PracticeBy comparison with explanations that blame the client

or excuse the therapist, deliberate practice bestows clearadvantages. In place of static stories and summary conclu -sions, practice enhances options. Take chess, for example.The unimaginable speed with which master players intuitthe board and make their moves gives them the appear -ance of wizards, especially to dabblers. Research provesthis to be far from case. In point of fact, they possess nounique or innate ability or advantage in memory. Far fromit. Their command of the game is simply a function ofnumbers: theyve played this game and a thousand othersbefore. As a result, they have more means at their disposal.

The difference between average and world-class play -ers becomes especially apparent when stress becomes afactor. Confronted by novel, complex, or challenging situ -ations, the focus of the merely pro cient performers nar -rows to the point of tunnel vision. In chess, these peopleare easy to spot. Theyre the ones sitting hunched overthe board, their ngers glued to a piece, contemplatingthe next move. But studies of pilots, air traf c controllers,emergency room staff, and others in demanding situationsand pursuits show that superior performers expand theirawareness when events are stressful, availing themselves ofall the options theyve identi ed, rehearsed, and perfectedover time.

Deliberate practice, to be sure, isnt for the harried orhassled. Neither is it for slackers. Yet, the willingness toengage in deliberate practice is what separates the wheatfrom the chaff. The reason is simple: doing it is unreward -ing in almost every way. As Ericsson notes, Unlike play,deliberate practice is not inherently motivating; and unlikework, it does not lead to immediate social and monetaryrewards. In addition, engaging in [it] generates costs. Nothird party (e.g., client, insurance company, or governmentbody) will pay for the time spent tracking client progressand alliance, identifying at-risk cases, developing alternatestrategies, seeking permission to record treatment sessions,insuring HIPPA compliance and con dentiality, system -atically reviewing the recordings, evaluating and re ning

the execution of the strategies, and soliciting outsideconsultation, training, or coaching speci c to particularskill sets. And lets face it, few of us are willing pay forit out of pocket. But this, and all weve just described, isexactly what the supershrinks do. In a word, theyre self-motivated.

What leads people, both children and adults, to devotethe time, energy, and resources necessary to achieve great -ness is poorly understood. Even when the path to improved


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performance is clear and requires little effort, most dontfollow through. As reported in the December 14, 2006,

New England Journal of Medicine, a study of 12 highly expe -rienced gastroenterologists found that some doctors were10 times better at nding precancerous polyps than others.An extremely simple solution, one involving no techni -cal skill or diagnostic prowessspending more time andbeing more thorough during the procedurewas found

to increase the polyp-detection rate by up to 50 percent.Sadly, according to a December 19, 2006, New York Times article on the study, despite this dramatic improvement,many doctors spend relatively little timeconsiderablyless than 30 minutesdoing the procedure.

Ericsson and colleagues believe that future studies ofelite performers will give us a better idea of how motiva -tion is promoted and sustained. Until then, we know thatdeliberate practice works best when done multiple timeseach day, including weekends, for short periods, interrupt -ed by brief rest breaks. Cramming or crash coursesdont work and increase the likelihood of exhaustion andburnout.

To assist busy behavioral-health professionals, theInstitute for the Study of Therapeutic Change is develop -ing a web-based system for facilitating deliberate practice.The system is patterned after similar programs in use withpilots, surgeons, and other professionals. The advantagehere is that the steps to excellence are automated. Atwww.myoutcomes.com, clinicians are already able to tracktheir outcomes, establish their baseline, and compare theirperformance to national norms. The system also providesfeedback to therapists when clients are at risk for deterio -rating or dropping out.

Were currently testing algorithms that identify pat -terns in the data associated with superior outcomes. Suchformulas, based on thousands of clients and therapists, willenable us to identify when an individuals performanceis at variance with the pattern of excellence. When thishappens, the clinician will be noti ed by e-mail of anonline deliberate-practice opportunity. Such training willdiffer from traditional continuing education in two criticalways. First, itll be targeted to the development of skill setsspeci c to the needs of the individual clinician. Second,and of greater consequence in the pursuit of excellence,the impact on outcome will be immediately measurable.Its our hope that such a system will make the processof deliberate practice more accessible, less onerous, and

much more ef cient.The present era in psychotherapy has been referred toby many leading thinkers as the age of accountability.Everyone wants to know what theyre getting for theirmoney. But its no longer a simple matter of cost and thebottom line. People are looking for value. As a eld, wehave the means at our disposal to demonstrate the worthof psychotherapy in eyes of consumers and payers, andmarkedly increase its value. The question is, will we?

Scott Miller, PhD, Mark Hubble, PhD, and Barry Duncan, PsyD, are cofounders of the Institute forthe Study of Therapeutic Change (ISTC). Together,theyve authored and edited numerous professionalarticles and books, including The Heart and Soul ofChange: What Works in Therapy ; Escape from Babel ;

P sychotherapy with Impossible Cases ; and TheHeroic Client . Recently, Miller and Hubble released a

self-help book, Staying on Top and Keeping the SandOut of Your Pants: A Surfers Guide to the Good Life .

Duncan published the self-help book Whats Right with You: Debunking Dysfunction and Changing YourLife . Contact: [email protected].

References and ResourcesBarclay, Robert L., Joseph J. Vicari, Andrea S. Doughty, et al.

Colonoscopic Withrawal Times and Adenoma Detection dur -

ing Screening Colonoscopy. New England Journal of Medicine 355,no. 24 (December 14, 2006), 2533-41.

Clement, Paul. Quantitative Evaluation of 26 Years of PrivatePractice. Professional Psychology: Research and Practice 25, no. 2(May 1994): 173-76.

Colvin, Geoffrey. What It Takes to Be Great. Fortune, October19, 2006.

Gawande, Atul. The Bell Curve. The New Yorker , December 6,2004.

Hiatt, Deirdre, and George E. Hargrave. The Characteristics ofHighly Effective Therapists in Managed Behavioral ProviderNetworks. Behavioral Healthcare Tomorrow 4 (1995): 19-22.

Miller, Scott D., Barry L. Duncan, George S. (Jeb) Brown, et al.Using Formal Client Feedback to Improve Retention andOutcome. Journal of Brief Therapy 5 (2006): 5-22

Villarosa, Linda. Done Right, Colonoscopy Takes Time, StudyFinds. The New York Times, Health Section, December 19, 2006.

Wampold, Bruce E., and George S. (Jeb) Brown. EstimatingVariability in Outcomes Attributable to Therapists: A NaturalisticStudy of Outcomes in Managed Care. Journal of Consulting andClinical Psychology, 73, no.5 (October 2005), 914-23.

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