Why does psychotherapy work (when it works at all)? (with Scott Miller)
Spencer Greenberg speaks with Scott Miller, a researcher and coach, about making therapy more effective. Miller emphasizes the critical role of deliberate practice, objective outcome measurement, and continuous client feedback for therapists to improve their performance and achieve better results.
Deep Dive Analysis
17 Topic Outline
Scott Miller's Journey and Anxiety About Therapy Effectiveness
Confidence, Proficiency, and Confirmation Bias in Therapy
Distinguishing Deliberate Practice from Mere Repetition
Applying Deliberate Practice: Typing and Psychotherapy
The Essential Role of a Coach in Deliberate Practice
Scott Miller's Personal Experience with Performance Coaching
Identifying Core Skills and Deficits in Psychotherapy
Factors Influencing Psychotherapy Outcomes Beyond Models
Psychotherapy Models as Cultural Approaches, Not Universal Truths
Stagnation of Psychotherapy Outcomes Over Decades
Research Showing Therapist Improvement Through Deliberate Practice
Developing Responsiveness and Using Client Outcome Assessments
The Critical Importance of Client Feedback in Therapy
Client Perspective: When to Consider Switching Therapists
Therapist Reactions to Feedback and Deliberate Practice Implementation
Critique of Meta-Analyses Comparing Therapy Modalities
The Future of Therapy: Broadening Beyond Western Notions
6 Key Concepts
Proficiency vs. Expertise
Proficiency is a level of competence that people often achieve quickly, after which their growth typically stops or even declines, while their confidence increases. Expertise, in contrast, involves continuous refinement and pushing performance beyond current abilities, often requiring a sense of humility about one's shortcomings.
Confirmation Bias in Therapy
This refers to the tendency for therapists, especially once they feel proficient, to seek evidence that confirms their existing beliefs about their effectiveness rather than looking for areas to grow. This is particularly prevalent in fields like psychotherapy where objective feedback is often minimal or inconsistent.
Deliberate Practice
A method of improvement that involves consciously and intentionally pushing one's performance just beyond current abilities. It requires a baseline assessment, continuous feedback, a coach to design specific exercises, and ongoing refinement, distinguishing it from mere repetition.
Purposeful Practice
A type of practice designed to achieve proficiency in a skill. Unlike deliberate practice, it doesn't necessarily aim to push performance beyond an already proficient level, and can sometimes lead to increased confidence without actual improvement in performance.
Therapist Factors
These are attributes of the therapist, such as their ability to reflect on their work, respond to clients, and regulate their own emotions and thoughts during sessions. These factors significantly impact client outcomes, contributing between four and nine times more to results than the specific therapy model or technique used.
Feedback-Informed Treatment
An approach where client progress and the quality of the therapeutic relationship are continuously assessed using standardized measures. This ongoing feedback is then used to inform and adjust the treatment process, helping therapists respond more effectively to individual client needs.
8 Questions Answered
Mere repetition leads to proficiency, while deliberate practice involves consciously and intentionally pushing one's performance just beyond current abilities, requiring feedback and targeted exercises for continuous refinement.
The most significant factors, in order of impact, are the client's participation/engagement, hope and expectation of results, therapist factors (e.g., self-regulation, responsiveness), and the quality of the therapeutic relationship (understanding, empathy, collaboration).
No, there is virtually no evidence that specific models or techniques are specifically remedial to the problems being treated. What matters more is whether the explanation, strategy, and ritual provided by any model engage the client and create hope.
Despite a proliferation of treatment approaches and specialties, the overall effect sizes of psychological treatments have remained flat for nearly 45 years, indicating no significant improvement in efficacy.
The quality of the therapeutic relationship, encompassing understanding, empathy, and collaboration, contributes eight to nine times more to positive outcomes than the particular therapy model used.
Clients should generally start to see some improvement within the first three to five visits. If no improvement is observed by session 10, the chances of that particular therapist being able to help are rapidly diminishing, and it may be best to seek a different therapist.
Most therapists are not specifically trained in creating a feedback-friendly culture. Clients often hide negative information to avoid rocking the boat, and by the time they volunteer it, it's often too late to fix the issue, as they may have already disengaged.
Many meta-analyses inflate results by comparing active treatments to weak controls (like waitlist or treatments not intended to be therapeutic) rather than directly comparing two bona fide treatments. When direct comparisons are made, any advantages often disappear or are not clinically meaningful.
18 Actionable Insights
1. Engage in Deliberate Practice
Consciously and intentionally push your performance just beyond your current abilities, rather than merely repeating activities, to truly refine your skills and achieve continuous improvement in any field.
2. Implement Structured Deliberate Practice
Establish a routine for improvement by first measuring your baseline performance, then working with a coach to develop exercises for small, targeted improvements, and continuously refining your abilities towards the next objective.
3. Prioritize Measurable Outcomes
Focus on assessing actual results using standardized measures, rather than relying on impressions or adherence to specific processes, to determine effectiveness in any endeavor, especially therapy.
4. Cultivate Humility for Growth
Actively identify your shortcomings and areas for improvement without shame, viewing them as opportunities to push your performance to the next level, rather than being satisfied with mere proficiency.
5. Seek Expert Coaching
For deliberate practice, work with a coach who possesses more expertise and specialized knowledge than you to help identify specific weaknesses and design targeted exercises, as self-coaching can be ineffective.
6. Therapists: Measure Effectiveness & Engagement
Use standardized measures to assess your overall effectiveness and your ability to engage clients, as this baseline data is crucial for identifying performance deficits and areas for improvement.
7. Therapists: Practice Influenceable Deficits
Focus deliberate practice on aspects of your behavior that are predictive of outcome, influenceable, and represent ongoing, recurrent patterns in your performance, rather than random client factors, to maximize impact.
8. Prioritize Therapeutic Relationship
Actively build a strong therapeutic relationship characterized by understanding, empathy, and collaboration, as these factors contribute significantly more to positive outcomes than specific models or techniques.
9. Foster Client Hope and Expectancy
Craft explanations and strategies that create a strong sense of hope and expectation of positive results in clients, as this is a powerful predictor of treatment success and contributes four times more than the specific model used.
10. Improve Therapist Self-Regulation & Responsiveness
Focus on enhancing your ability to reflect on your work, respond effectively in the moment, and regulate your own emotions and thoughts during sessions, as these personal factors greatly impact outcomes.
11. Create a Feedback-Friendly Culture
Deliberately develop specific skills to encourage clients to provide critical feedback about the therapy, especially early on, as this openness and subsequent improvement in relationship scores are strongly associated with better outcomes.
12. Act on Client Feedback Promptly
Be prepared to genuinely act on feedback received from clients to demonstrate its value and encourage continued open communication, as simply collecting feedback without action is ineffective.
13. Clients: Expect Early Improvement
As a client, expect to see some improvement within the first three to five therapy sessions; if no improvement is evident by session 10, consider seeking a different therapist as the chances of success rapidly diminish.
14. Clients: Share Concerns with Therapist
If you have complaints or feel therapy isn’t working, communicate this directly to your therapist, as they need this information to adapt and improve the process for you.
15. Avoid ‘Sad Consolation Prize’
Do not settle for a comfortable relationship or a ‘kind ear’ in therapy if your primary problems are not being addressed or if you are not seeing actual progress towards your initial goals.
16. Therapists: Don’t Continue Without Progress
If a client is not improving after many sessions and outcome measures show no help, avoid continuing treatment indefinitely without a clear plan for different actions or a defined endpoint.
17. Recognize Implementation Challenges
Understand that putting new ideas into practice requires significant, sustained effort, dedicated support, and often takes years for individuals and agencies, rather than assuming information alone leads to change.
18. Broaden Healing Perspectives
Shift the focus from strictly Western psychotherapy models to a broader understanding of healing, exploring and appreciating how diverse cultures and peoples facilitate improvement and well-being.
6 Key Quotes
Practice doesn't make perfect. He says it makes permanent. It's deliberate practice that can refine your performance.
Michael Amar (quoted by Scott Miller)
The best way, the easiest way, is to simply select your clients more carefully.
Don Meichenbaum (quoted by Scott Miller)
People aren't like clocks. They're simply not like clocks. People are all about relationships.
Scott Miller
Psychotherapy has rearranged the deck chairs on the cruise boat many, many times, but its outcomes have stayed flat for nearly 45 years.
Scott Miller
The tendency of our species is to replace outcomes with relationship in the absence of outcomes.
Scott Miller
If you believe adding this form at the beginning and the end of your, these two forms at the beginning and end of your session will solve this problem. You're sadly mistaken.
Scott Miller
3 Protocols
General Deliberate Practice Process
Scott Miller (describing Anders Eriksson's work)- Obtain a meter of baseline performance (an estimate of current ability).
- Identify your growth edge (the next small improvement needed).
- Work with a coach to develop specific exercises to master that next small improvement.
- Focus on continuous refinement of the ability and pushing performance to the next objective over time.
Deliberate Practice for Therapists
Scott Miller- Assess your performance by measuring your results using standardized measures to determine overall effectiveness and client engagement.
- Identify your performance edge by pinpointing when, with whom, and under what circumstances your outcomes and performance begin to falter.
- Figure out which factors (structure/strategy, hope/expectancy, self-regulation, or relationship quality) are accounting for the deficits in your performance.
- Reach out to a coach to help design specific activities and exercises to address the identified deficit.
Feedback-Informed Treatment Implementation
Scott Miller- Implement ongoing assessment of performance using an outcome measure and an engagement measure (e.g., Outcome Rating Scale, Session Rating Scale).
- Make therapists continuously aware of their outcomes, both in aggregate and with individual clients, to improve their ability to respond to those they are not helping.
- Identify therapist deficits and map them onto the four key outcome factors (structure, hope/expectancy, therapist factors, relationship).
- Encourage therapists, with their supervisor/coach, to develop activities and exercises to work on those particular deficit areas.