How to use your career to have a large impact (with Ben Todd)
Spencer Greenberg speaks with Scott Miller about making therapy more effective. They discuss the importance of deliberate practice, objective measurement, and continuous feedback for therapists, highlighting that client engagement and therapist factors are more crucial than specific techniques.
Deep Dive Analysis
14 Topic Outline
Journey to Improving Therapy Effectiveness
The Pitfalls of Proficiency and Confirmation Bias
Distinction Between Practice and Deliberate Practice
The Role of a Coach in Deliberate Practice
Personal Examples of Deliberate Practice
Core Skills in Therapy and Outcome Factors
Why Therapeutic Models Don't Matter as Much as Believed
Psychotherapy Outcomes Stagnant for Decades
How Deliberate Practice Improves Therapist Outcomes
The Importance of Client Feedback and Responsiveness
When to Switch Therapists: Client Perspective
Therapist Reactions and Implementation Challenges
Critique of Therapy Research and Meta-Analyses
The Future of Healing Beyond Western Psychotherapy
5 Key Concepts
Proficiency Trap
Once individuals achieve a certain level of proficiency in an activity, their desire to learn and change diminishes. This often leads to a decline in actual ability over time, even as confidence increases, because they stop actively seeking improvement.
Deliberate Practice
A conscious and intentional effort to push one's performance just beyond current abilities, requiring continuous feedback, a baseline assessment, and often a coach to develop specific exercises. It differs from mere repetition, which only reinforces existing habits.
Therapeutic Relationship
The quality of the connection, understanding, empathy, and collaboration between a client and therapist. This factor is a robust predictor of positive treatment outcomes, contributing significantly more to results than the specific therapy model or technique used.
Feedback-Informed Treatment
An approach where therapists continuously assess client progress and engagement using standardized measures, then use this feedback to adjust their approach. This helps therapists respond to individual client needs and identify recurring patterns in their own performance that need improvement.
Implementation Science
A field of research that studies how to effectively integrate evidence-based practices into real-world settings. It highlights that simply providing information or training is often insufficient to change behavior, and dedicated support is needed for successful adoption of new methods.
8 Questions Answered
Mere practice involves repeating an activity until proficiency is achieved, which often stops further growth. Deliberate practice, however, is consciously and intentionally pushing performance just beyond current abilities, requiring feedback and targeted exercises for continuous refinement.
A coach provides specialized expertise to help identify specific weaknesses and design tailored exercises to address them, preventing individuals from designing their own activities which might be less effective due to their own biases or lack of advanced knowledge.
The core factors, in order of increasing contribution to outcome, are: the therapy's structure/explanation/strategy/ritual, hope/expectancy created in the client, therapist factors (e.g., self-regulation, responsiveness), and the quality of the therapeutic relationship.
The episode suggests that specific models or techniques contribute minimally to outcome (about 1% of variance), and there's little evidence they contain uniquely remedial ingredients. What matters more is if the explanation, strategy, and ritual engage the client and create hope.
Psychotherapy outcomes have remained largely flat for nearly 45 years, with meta-analytic studies showing similar effect sizes today as in 1975-1976, despite a proliferation of new treatment approaches and specialties.
Therapists can improve by continuously assessing their performance with outcome and engagement measures, identifying specific deficits, and then engaging in deliberate practice with a coach to develop skills in areas like creating hope, self-regulation, or fostering a strong therapeutic relationship.
Clients often hide negative feedback because it's difficult to give, they may not see the benefit, and therapists often lack the specific skills to create a truly feedback-friendly culture. By the time clients volunteer negative information, it's generally too late to fix the problem.
Clients should generally see some improvement within the first three to five visits. If no improvement is seen by session 10, the chances of that particular therapist being able to help are rapidly diminishing, and it's advisable to consider switching.
20 Actionable Insights
1. Implement Deliberate Practice
Engage in deliberate practice by consciously and intentionally pushing your performance just beyond your current abilities, rather than merely repeating activities to achieve proficiency.
2. Measure Outcomes Objectively
For therapists, conduct a baseline assessment of your effectiveness using standardized outcome measures (not just impressions) and continuously monitor results to identify where and with whom your outcomes falter.
3. Seek Expert Coaching
Engage a coach with more expertise than yourself to help design specific exercises that target your identified performance deficits, as self-coaching can be ineffective.
4. Cultivate Humility for Growth
Adopt a mindset of humility by acknowledging your shortcomings and areas for learning, as this is essential for pushing your performance to the next level rather than simply building false confidence.
5. Prioritize Therapeutic Relationship
Focus on building a strong therapeutic relationship characterized by understanding, empathy, and collaboration, as this factor contributes 8-9 times more to positive outcomes than specific models or techniques.
6. Foster Client Hope & Expectancy
Actively create a sense of hope and positive expectation of results in clients, as this factor contributes four times more to treatment outcomes than the particular model or technique used.
7. Develop Therapist Self-Regulation
Work on your ability to reflect on your work, respond effectively, and regulate your emotions and thoughts during sessions, as who the therapist is matters significantly more to results than the specific model.
8. Create Feedback-Friendly Culture
Deliberately practice specific skills to cultivate an atmosphere where clients feel comfortable providing critical feedback early in therapy, as clients often withhold negative information until it’s too late to intervene effectively.
9. Utilize ORS and SRS Tools
Use free tools like the Outcome Rating Scale (ORS) and Session Rating Scale (SRS) to regularly assess client well-being across individual, relational, and social domains, and to measure the quality of the therapeutic relationship.
10. Identify Your Performance Edge
Pinpoint the specific circumstances (e.g., types of clients, presenting issues) where your therapeutic outcomes and performance begin to break down, as these are the areas ripe for deliberate practice.
11. Focus on Influenceable Deficits
When choosing what to practice, ensure the skill is predictive of positive outcomes, is influenceable by your actions, and addresses ongoing, recurrent patterns in your behavior rather than random client variables.
12. Avoid Proficiency Complacency
Be wary of the tendency to stop learning and improving once you’ve achieved a sense of proficiency, as confidence can increase while actual ability declines over time.
13. Evaluate Therapy Duration
As a client, expect to see some improvement within the first 3-5 sessions; if no improvement is evident by session 10, consider switching therapists, as the chances of success with that particular pairing rapidly diminish.
14. Don’t Replace Outcomes with Relationship
As a client, guard against the tendency to accept a comfortable relationship with a therapist as a substitute for actual therapeutic outcomes, especially if your initial goals are not being met.
15. Recognize Implementation Challenges
Understand that successfully adopting new, effective practices requires significant effort in implementation, as merely learning an idea does not guarantee its successful application in practice.
16. Broaden Healing Perspective
Shift your focus beyond Western psychotherapy models to explore and understand how other cultures and peoples heal, fostering a more inclusive and effective approach to helping.
17. Seek Empathy-Specific Training
Actively pursue specific training in empathy, as it is a crucial and potent contributor to treatment outcomes that is often neglected in traditional professional education beyond basic coursework.
18. Critically Evaluate Research
Be critical of meta-analyses that don’t directly compare bona fide treatments or that compare active treatments to inert controls (like relaxation for trauma), as these methods can inflate perceived effectiveness differences.
19. Leverage Self-Doubt for Growth
Use any anxiety or uncertainty about your ability to help others as a guiding force to continuously seek ways to be more effective and improve your practice.
20. Act on Client Feedback
Once clients provide feedback, ensure you act on it to adapt your approach and improve the fit of the therapy to their needs, rather than just collecting the information.
6 Key Quotes
Practice doesn't make perfect. He says it makes permanent. It's deliberate practice that can refine your performance.
Scott Miller (quoting Michael Amar)
People aren't like clocks. They're simply not like clocks. People are all about relationships.
Scott Miller
In psychotherapy, who does the therapy matters more than what therapy has actually done.
Scott Miller
By the time clients volunteer negative information about the work, it's generally too late to fix.
Scott Miller
If the therapist can't give me any idea about what they're going to do different in the absence of change going forward, that to me is a recipe for more of the same.
Scott Miller
This isn't a failure of imagination. And it's not really even a failure of will. It's a failure of implementation.
Scott Miller
1 Protocols
Therapist Performance Improvement Process
Scott Miller- Assess baseline performance by measuring results using standardized outcome and engagement measures.
- Identify performance edge, pinpointing when, with whom, and under what circumstances outcomes and performance falter.
- Determine which of the four factors (structure/strategy, hope/expectancy, therapist factors, relationship) is accounting for the identified deficits.
- Reach out to a coach to help design specific activities and exercises to work on the identified deficit area.
- Continuously refine the ability and push performance to the next objective through ongoing practice and measurement.