There are shrinks, and then there are SUPER-shrinks (with Daryl Chow)
Spencer Greenberg speaks with Daryl Chow about "super shrinks" and evaluating therapist performance. They discuss what makes some therapists more effective, the role of models vs. therapist factors, and the importance of feedback and deliberate practice.
Deep Dive Analysis
16 Topic Outline
Introduction to Super Shrinks and Therapy Effectiveness
Defining Therapy Models and Their Impact on Outcomes
Researching Highly Effective Therapists and Outcome Measurement
Predictability of Therapist Effectiveness and Alliance Formation
The Role of Experience and Training in Therapist Outcomes
The Difficult Conversations in Therapy (DCT) Project
Key Elements of a Good Therapist: Care, Craft, and Creativity
Therapist Self-Doubt and Openness to Client Feedback
Pill Model vs. Continuous Calibration in Therapy
The Significant Impact of Client Factors on Outcomes
A Framework for Deliberate Practice in Therapy
The Power of Feedback Loops and Prediction in Learning
Navigating Therapist Beliefs and Client Worldviews
How to Choose an Effective Therapist
Addressing Client Reluctance to Give Feedback
Being a Therapeutic Friend to Others
8 Key Concepts
Therapy Models
These refer to the theoretical orientations or schools of thought (e.g., cognitive behavioral, emotion-focused) that therapists follow. Research indicates these models account for a very small proportion (less than 0-1%) of overall therapy outcomes, with the individual therapist being a much larger factor.
Super Shrinks
This term describes therapists who consistently achieve reliably good outcomes with a wide range of clients. Their effectiveness is determined by systematically measuring client progress over time, rather than relying on peer nominations or years of experience.
Facilitative Interpersonal Skills (FIS)
These are inherent abilities of a therapist to engage effectively with people, encompassing qualities like warmth, persuasiveness, and compassion. This skill set is highly predictive of positive client outcomes and appears to be largely present before formal training.
Care, Craft, and Creativity Framework
This framework outlines three essential elements for effective therapy. 'Care' involves humanizing the client and slowing down, 'Craft' is the deliberate practice dedicated to improving at one's growth edge, and 'Creativity' is the flexibility and responsiveness needed to adapt to each unique client.
Pill Model Approach
This approach to therapy involves therapists adhering strictly to evidence-based models and delivering interventions known to work for specific conditions. While necessary for foundational knowledge, it is considered insufficient without continuous adaptation to individual client needs.
Continuous Calibration Approach
In contrast to the pill model, this approach emphasizes trying out interventions, closely observing how the client responds, and constantly recalibrating methods. The goal is to find what truly resonates and sparks progress for the specific individual in therapy.
Client Factors
These are aspects of a client's life outside of therapy, such as their preferences, personal resources, existing relationships, and external life events. These factors are highly influential, accounting for a significant majority (80-87%) of the variance in client outcomes.
Will Say, Won't Say, Can't Say
This framework helps therapists understand different levels of client communication. 'Will say' refers to obvious problems, 'won't say' covers slightly painful or distressing topics, and 'can't say' pertains to deeply shamed or self-referential beliefs that clients struggle to articulate.
7 Questions Answered
A "super shrink" is a therapist who consistently achieves reliably good outcomes with a diverse pool of clients, based on systematically measuring their clients' progress over time, rather than relying on peer nominations.
The individual therapist accounts for a large proportion of outcome differences, particularly their ability to form a strong alliance. Client factors, including their preferences, resources, and life circumstances, account for the vast majority (80-87%) of outcome variance.
No, years of experience does not reliably predict how well a therapist's clients do. Formal training and continuous education also have very little impact on client outcomes, suggesting inherent facilitative interpersonal skills are more crucial.
Therapists should consistently measure client outcomes to identify blind spots, analyze their own aggregated data to establish a baseline, determine specific individualized areas for improvement, and then develop a sustainable, ongoing learning system.
Clients should seek a therapist who makes them feel liked and respected as a person, creates a safe space to discuss unspoken issues, and provides a sense of hope or a clear path forward beyond just an initial intake Q&A.
Clients may find it difficult to vocalize dissatisfaction or critical feedback due to social pressure, a high temperament for agreeableness, or the inherent tension of bringing up difficult topics, especially those covered by shame or self-referential beliefs.
Friends can be therapeutic by giving space for someone to talk without evading or invading, listening attentively to both spoken and unspoken difficulties, and being willing to offer different perspectives if appropriate, always honoring the friend's viewpoint and level of friendship.
17 Actionable Insights
1. Systematically Measure Client Outcomes
Therapists should consistently measure client outcomes to gain real-time feedback, check blind spots, and inform their work, as this is a crucial first step in improving effectiveness.
2. Integrate Data with Intuition
Therapists should integrate client-rated outcome data with their clinical intuition to make better, more responsive decisions, rather than relying solely on one or the other.
3. Prioritize Therapist’s Personal Effectiveness
As a therapist, understand that therapeutic models (e.g., CBT, emotion-focused) contribute minimally (0-1%) to client outcomes; focus instead on developing your personal effectiveness.
4. Dedicate Time to Deliberate Practice
Therapists should dedicate time outside of therapy sessions to deliberately improve their skills and focus on client outcomes, as this predicts higher effectiveness.
5. Cultivate Alliance Building Skills
Therapists should cultivate their ability to facilitate and engage with a wide array of clients, as the therapist’s skill accounts for 97% of the variance in alliance formation, a key factor in outcomes.
6. Honor Client Preferences & Factors
Therapists must prioritize and attend to client preferences (e.g., spiritual viewpoint, ethnic community) and utilize client factors (resources, relationships) as they account for 80-87% of outcome variance.
7. Adopt Continuous Calibration
Therapists should adopt a continuous calibration approach, adapting and recalibrating their methods based on client responses rather than rigidly applying a “pill model” of therapy.
8. Embrace Self-Doubt and Surprise
Highly effective therapists exhibit a degree of self-doubt and are more frequently surprised by client feedback, indicating an openness to change their views and adapt their approach.
9. Predict Client Outcome Scores
Therapists should predict client outcome scores before clients complete questionnaires, aiming to be disconfirmed to identify blind spots and elicit more specific feedback for improvement.
10. Inquire About Outcome Discrepancies
When client-reported outcomes differ from therapist predictions or expectations, therapists should inquire directly about the discrepancy to uncover new information and adapt their approach.
11. Cultivate a Sustainable Learning System
Therapists should create a sustainable, ongoing learning system to guide their practice, ensuring continuous personal and professional growth that also nourishes them.
12. Hold Personal Truths Lightly
Clinicians should hold their own beliefs and theoretical “truths” lightly, remaining open to different viewpoints and adapting their approach based on the client’s unique worldview.
13. Offer Therapeutic Friendship Space
To help a struggling friend, offer non-evasive, non-invasive space for them to talk, listen attentively to their inner life (what they will, won’t, and can’t say), and focus on their biggest pain points and needs.
14. Predict Before Learning
When reading a new book or learning a topic, first make predictions about what you expect to learn or already know; this creates a “schism” that enhances engagement and learning by highlighting discrepancies.
15. Select Outcome-Tracking Therapists
When seeking a therapist, prioritize those who systematically track client outcomes, demonstrate warmth and care, possess relevant skills, and are licensed, rather than focusing solely on credentials or endorsed modalities.
16. Evaluate Initial Therapy Sessions
In initial therapy sessions, assess if the therapist genuinely likes you, creates a safe space for unspoken concerns, is responsive to your needs, and provides a sense of hope or a clear path forward beyond just an intake Q&A.
17. Give Direct Therapist Feedback
Clients should strive to vocalize feedback to their therapist, even if difficult, as this is crucial for the therapist to understand what’s working or not and to adjust the therapy effectively.
6 Key Quotes
Models accounts for like less than zero to 1% of the outcome. And instead, the differences, the lion's share of differences lie between who the service provider, who the therapist was.
Daryl Chow
A huge proportion of the variance of how well the alliance is formed is due to the therapist, the variance is kind of unheard of in social science is about like 97% of the variance is due to who the therapist is.
Daryl Chow
The more effective therapists were slightly more compressed, a little bit more doubtful of themselves compared to the average practitioners.
Daryl Chow
The highly effective therapists rated more times of being surprised relative to the average practitioners. In other words, they were engaging in what some researchers would call hypercorrection.
Daryl Chow
The paradox is the most professional thing to do is to be personal with someone, to not treat it transactionally, but to treat them with level of honor and respect for their situation and them as a person.
Daryl Chow
We don't come together in our communities, in our friendship circles, we don't come together because of our strengths, we come together in times of weakness, because that's where we seem to bind, that's where we seem to forge good relationships.
Daryl Chow
1 Protocols
Deliberate Practice Framework for Therapist Improvement
Daryl Chow- Consistently measure client outcomes to get real-time feedback and integrate this data to identify blind spots and update your mindset.
- Aggregate your own client data (ideally 20-50 cases) to establish a baseline and understand your unique strengths and growth edges as a therapist.
- Identify specific individualized areas ('the what') for improvement based on your baseline data (e.g., explicate warmth, structure sessions).
- Develop a sustainable, ongoing learning system that guides your practice and nourishes your personal and professional growth.