5/5/16%

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REACHPushing Your Clinical Effectiveness to the Next Level

Sco)%D.%Miller,%Ph.D.%Interna8onal%Center%for%Clinical%Excellence%

Daryl%Chow,%Ph.D.%Interna8onal%Center%for%Clinical%Excellence%

WELCOME!%

5/5/16%

2%

The%Evolu8on%of%Psychotherapy:%Agenda%

Iden8fying%What%&%How%to%Improve%

The%Prac8cal%Applica8on%of%Deliberate%Prac8ce%

5/5/16%

3%

The%Evolu8on%of%Psychotherapy:%

Goal%for%Today%

Iden8fying%What%&%How%to%Improve%

The%Evolu8on%of%Psychotherapists:%Exercise%

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4%

• In%most%studies%of%treatment%conducted%over%the%last%40%years,%the%average%treated%person%is%be)er%off%than%80%%of%the%untreated%sample.%%

• The%outcome%of%behavioral%health%services%equals%and,%in%most%cases,%exceeds%medical%treatments.%%

• On%average,%mental%health%professionals%achieve%outcomes%on%par%with%success%rates%obtained%in%randomized%clinical%trials%(with%and%without%co\morbidity).%

Duncan,'B.,'Miller,'S.,'Wampold,'B.,'&'Hubble,'M.%(eds.)%(2009).%%The$Heart$and$Soul$of$Change:$Delivering$What$Works.%%Washington,%D.C.:%APA%Press.%%

Minami,'T.,'Wampold,'B.,'Serlin,'R.,'Hamilton,'E.,'Brown,'G.,'Kircher,'J.%(2008).%%Benchmarking%for%psychotherapy%efficacy.%Journal$of$Consul:ng$and$Clinical$Psychology,$75$232C243.%

The%Evolu8on%of%Psychotherapy:%Progress%?%

Ericsson,'K.A.,'Charness,'N.,'Feltovich,'P.'&'Hoffman,'R.'(eds.).%%(2006).%%The$Cambridge$Handbook$of$Exper:se$and$Expert$Performance%(pp.%683\704).%%New%York:%Cambridge%University%Press.%Nyman,'S.'et'al.'(2010).%%Client%outcomes%across%counselor%training%level%within%%mul88ered%supervision%model.%%Journa$of$Counseling$and$Development,$88,%204\209.%Malouff,'J.'(2012).''The%need%for%empirically%supported%psychology%training%standards.%%Psychotherapy$in$Australia,$18(3),%28\32.'Miller,'S.D.,'&'Hubble,'M.A.'(2011).%%The%road%to%mastery.%%The$Psychotherapy$Networker,$35(2),%22\31,%60.%

• The%effec8veness%of%the%“average”%helper%plateaus%very%early.%%

• Li)le%or%no%difference%in%outcome%between%professionals,%students%and%para\professionals.%%

The%Evolu8on%of%Psychotherapy:%Progress?%

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5%

•  The'largest'study'to'date'on'the'effect'of'experience'on'outcome;'

•  75'Therapists'followed'over'17'years;'

•  On'average'outcomes'declined'over'Vme.'?%

The%Evolu8on%of%Psychotherapy:%Progress?%

Goldberg,%S.B.,%Rousmaniere,%T.,%Miller,%S.D.,%Whipple,%J.,%Nielsen,%S.L.,%Hoyt,%W.T.,%&%Wampold,%B.E.%(2016).%Do%psychotherapists%improve%with%8me%and%experience?%A%longitudinal%analysis%of%real%world%outcome%data.%%Journal%of%Counseling%Psychology,%63,%1\11.%

The%Evolu8on%of%Exper8se:%

The%Streetlight%Effect%

How%Top%Therapists%Improve?%

5/5/16%

6%

The%Evolu8on%of%Psychotherapists:%How%can%Therapists%Improve?%

BEFORE' AFTER'C%T%

Therapy%

Method% Diagnosis%

Edge'of'Ability'

Too'Difficult'Too'Easy'

Zone'of'“Proximal'Development”:''

• Reliable%performance%inconsistent%• Iden8fica8on%of%errors,%mispercep8ons%• Selng%small%process%and%outcome%objec8ves%• Involves%planning,%rehearsal,%reflec8on%• Encourages%a%“Growth”%mindset%

%

Realm'of'“Reliable”'Performance:%%

• Processes%executed%quickly,%automa8cally%• Involves%recogni8on,%retrieval,%execu8on%

Ambit'of'AdmiraVon:''

• Abili8es%of%others%appear%flawless,%magical,%drama8c%• Effort%and%a)en8on%focused%on%easily%recognized,%but%non\causal%factors%and/or%processes%(supers88on)%• Risk%of%failure%and%injury%high%• Tempta8on%to%adopt%“Fixed”%mindset%

The%Evolu8on%of%Psychotherapists:%

5/5/16%

7%

The%Evolu8on%of%Psychotherapists:%

Make%a%note%

The%Evolu8on%of%Psychotherapists:%Exercise%

5/5/16%

8%

The%Evolu8on%of%Psychotherapists:%

Self-Assessment Bias

Walfish%et%al%%(2012):%%

•  Avg%effec8veness%ra8ngs%of%%•  80th%Percen8le%(SD:%9.06);%%•  25%%rated%above%90th%percen8le;%%•  none%rated%below%50th%percen8le.%

Chow%et%al.%(2014):%%

•  Avg%effec8veness%ra8ngs%of%71st%percen8le%(SD:17.38);%

•  ½%rated%above%average;%•  None%rate%below%50th%percen8le;%•  No%significant%correla8ons%with%outcomes.%•  Therapist%Demo%&%characteris8cs%not%predic8ve%of%

outcomes%

Walfish,'S.,'McAlister,'B.,'O'Donnell,'P.,'&'Lambert,'M.'J.'(2012).%An%inves8ga8on%of%self\assessment%bias%in%mental%health%providers.Psychological$Reports,$110(2),%639\644.%Chow,'D.'(2014).%The$study$of$supershrinks:$Development$and$deliberate$prac:ces$of$highly$effec:ve$psychotherapists.%(PhD),%Cur8n%University,%Australia.%%

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9%

• Drop$out$rates$average$47%;$$

• Mental$health$professionals$frequently$fail$to$iden:fy$failing$cases;$$

• 1$out$of$10$consumers$accounts$for$60C70%$of$expenditures.$

Harmon,%S.J.,%Lambert,%M.J.,%Smart,%D.M.,%Hawkins,%E.,%Nielsen,%S.L.,%Slade,%K.,%Lutz,%W.,%(2007)%Enhancing%outcome%for%poten8al%treatment%failures:%Therapist\client%feedback%and%clinical%support%tools.%Psychotherapy$Research,$17(4),$379C392%

Lambert,%M.J.,%Whipple,%J.,%Hawkins,%E.,%Vermeersch,%D.,%Nielsen,%S.,%&%Smart,%D.%(2004).%%Is%it%8me%for%clinicians%rou8nely%to%track%client%outcome?%A%meta\analysis.%%Clinical$Psychology,$10,%288\301.%

Chasson,%G.%(2005).%%A)ri8on%in%child%treatment.%%Psychotherapy$Bulle:n,$40(1),%4\7.%

Aubrey,%R.,%Self,%R.,%&%Halstead,%J.%(2003).%%Early%non%a)endance%as%a%predictor%of%con8nued%non\a)endance%and%subsequent%a)rib8on%from%psychological%help.%%Clinical$Psychology,$32,$6C10.%

More Assessment Bias

Hannan,%C.,%Lambert,%M.,%Harmon,%C.,%Lielsen,%S.,%Smart,%D.,%&%Shimokawa,%K.%(2005).%%A%lab%test%and%algorithms%for%iden8fying%clients%at%risk%for%treatment%failure.%%Interna:onal$Journal$of$Clinical$Psychology,$61,%155\163%

MEASURE%%

Miller,'S.D.,'&'Hubble,'M.A.'(2011).%%The%road%to%mastery.%%The$Psychotherapy$Networker,$35(2),%22\31,%60.%

The%Evolu8on%of%Psychotherapists:%

5/5/16%

10%

“LAG”%MEASURE%

Free'copies'available'at:%h)p://sco)\d\miller\ph\d.myshopify.com/collec8ons/performance\metrics/products/performance\metrics\licenses\for\the\ors\and\srs%%

• Scored$to$the$nearest$millimeter.$

• Add$the$four$scales$together$for$the$total$score.$

• Give$at$the$beginning$of$the$visit;$

• Client$places$a$hash$mark$on$the$line.$

• Each$line$10$cm$(100$mm)$in$length.%

MEASURE%

Brown,'J.'(2014).%%Measurement%+%feedback%=%improved%outcomes.%h)ps://psychoutcomes.org/DecisionSupportToolkit/ToolkitUsageAndOutcomes.%%Retrieved%August%20,%2014.%%

5/5/16%

11%

Establishing%your%Baseline%Performance%Level%

Performance%Metrics%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%Ac8ve%%%%Inac8ve%

Corrected%Effect%Size:%•  Compares%client%progress%to%%

progress%of%clients%in%the%norma8ve%sample%who%have%the%same%intake%score%(compares%like%to%like)%

•  A%corrected%ES%of%0.0%indicates%change%is%%average;%above%0.0%is%be)er%than%average;%less%than%0.0%is%below%average%

•  The%larger%the%number%of%clients%in%the%data%pool%the%more%confidence%in%the%Corrected%Effect%Size.%

MEASURE%

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12%

Miller,'S.D.,'&'Hubble,'M.A.'(2011).%%The%road%to%mastery.%%The$Psychotherapy$Networker,$35(2),%22\31,%60.%

Expectancy,%Placebo,%and%Allegiance%%Effects%

Client/ExtratherapeuVc'Factors'

Treatment%Effects%

Model/Technique%Effects%

Therapist%Effects%

Alliance%Effects%

The%Therapeu8c%Factors%

(13\20%)%

(5\8%)%

(4\9%)%

(1%)%

(4%)%

Wampold,%B.,%&%Imel,%Z.%(2015).%%The$Great$Psychotherapy$Debate.%%New%York:%Lawrence%Erlbaum.%

• Model'&'Technique'(1%):'Structure,%explana8on,%strategy,%ritual%

• Hope'&'Allegiance'(4%):'Belief%in%the%process%and%expecta8on%%of%results%

• RelaVonship'(8d9%):'Understanding,%empathy,%collabora8on%

The%Evolu8on%of%Psychotherapists:%Iden8fying%“What”%

5/5/16%

13%

Natfufral''SeflecfVon'ˈnaCHərəl/%səˈlekSHən/%

The%Evolu8on%of%Psychotherapists:%

Top%Performing%Clinicians:%%

• Deliver$more$reliably$effec:ve$treatment;$• Achieve$50%$be^er$outcomes;$• Suffer$50%$fewer$dropouts;$• Provide$more$value$per$dollar$spent.%

“The%process%whereby%organisms%be)er%adapted%to%their%environment%tend%to%survive.”%

How?%

Edge'of'Ability'

Too'Difficult'Too'Easy'

Deliberate'PracVce'Zone'of'“Proximal'Development”:'

'

• Reliable%performance%inconsistent%• Iden8fica8on%of%errors,%mispercep8ons%• Selng%small%process%and%outcome%objec8ves%• Involves%planning,%rehearsal,%reflec8on%• Encourages%a%“Growth”%mindset%

%

Realm'of'“Reliable”'Performance:%%

• Processes%executed%quickly,%automa8cally%• Involves%recogni8on,%retrieval,%execu8on%

Ambit'of'AdmiraVon:''

• Abili8es%of%others%appear%flawless,%magical,%drama8c%• Effort%and%a)en8on%focused%on%easily%recognized,%but%non\causal%factors%and/or%processes%(supers88on)%• Risk%of%failure%and%injury%high%• Tempta8on%to%adopt%“Fixed”%mindset%

5/5/16%

14%

The Evolution of Expertise:Exercise

Which professional development activities fall in the%“Panic Zone?”

Learning Zone

Comfort Zone

Panic Zone

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15%

The%Evolu8on%of%Psychotherapists:%Crea8ng%a%Professional%Development%Map%

Performing% Learning%

Priorities vs. Priority

Energy Energy

Adapted from Essentialism, Greg McKeown, 2014.

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16%

Setting Bite Size Goals

Stretch Goal

SMART Goal

The 80/20 Rule

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17%

ROCK (Lag

Measure)

Adapted from 4DX, McChesney, Covey, & Huling, 2002

Predictive

Influenceable

The%Evolu8on%of%Psychotherapists:%

The%Evolu8on%of%Psychotherapists:%Taxonomy%of%Deliberate%Prac8ce%

•  Review$the$taxonomy;$$

•  Rate$each$area;$$

•  Rank$the$top$3$according$to$the$80/20$rule.$

5/5/16%

18%

The Law of Diminishing Returns

NUMBER OF GOALS (in addition to BAU stuff)

2d3' 4d10' 11d20'

GOALS ACHIEVED WITH EXCELLENCE

2-3 1-2 0

Adapted from 4DX, McChesney, Covey, & Huling, 2002

5/5/16%

19%

Think “From X to Y by When”'

Taxonomy of Deliberate Practice Activities

Themes Activities

Structural: “The Sandwich”

How do you start a first session?

How do you start a subsequent session?

How do you conduct an induction into therapy? (Optimising Expectations of Therapy) - what to expect

- role of therapist, role of client - thearapeutic activities

How do you close a session?

How do you elicit feedback?

How do you integrate the use of feedback measures into therapy?

How do you prepare for a planned termination?

Alliance: Effective Focus

How do you establish goal consensus in the first/subeq sessions?

How do you mobilise client’s willingness to work on their goals?

How do you help a client who has not client goals in therapy?

Alliance: The Impact Factor

How do you deepen client’s emotional experiencing? (see Experiencing Scale)

How do you promote emotional engagement/bond/ real-relationship?

How do you provide a rationale for a particular method of working?

Motivation How do you work with a client’s level of motivation?

How do you increase homework compliance?

Alliance: Difficulties How do you deal with alliance rupture?

How do you deal with an angry client?

How do you deal with a client who is feeling hopeless?

…

Therapist: The Use of the Self

How do you regulate your anxiety in a difficult interaction with your clients?

How do you activate reflective functioning in-session with your clients (vs. being reactive and rational)?

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Themes Activities

Alliance: The Impact Factor

How do you deepen client’s emotional experiencing? (see Experiencing Scale)

How do you promote emotional engagement/bond/ real-relationship? How do you provide a rationale for a particular method of working?

Motivation How do you work with a client’s level of motivation? How do you increase homework compliance?

Alliance Difficulties

How do you deal with alliance rupture?

How do you deal with an angry client? How do you deal with a client who is feeling hopeless?

Therapist: The Use of the Self

How do you regulate your anxiety in a difficult interaction with your clients?

How do you activate reflective functioning in-session with your clients (vs. being reactive and rational)?

Taxonomy of Deliberate Practice Activities

The%Evolu8on%of%Psychotherapists:%

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21%

Ericsson,'K.A.,'Charness,'N.,'Feltovich,'P.'&'Hoffman,'R.'(eds.).%%(2006).%%The$Cambridge$Handbook$of$Exper:se$and$Expert$Performance%(pp.%683\704).%%New%York:%Cambridge%University%Press.%Goldberg,'S.'et%al.%(in%press).%Do%psychotherapists%improve%with%8me%and%experience?%A%longitudinal%analysis%of%real%world%outcome%data.%%Psychotherapy$Research.%Malouff,'J.'(2012).''The%need%for%empirically%supported%psychology%training%standards.%%Psychotherapy$in$Australia,$18(3),%28\32.'Miller,'S.D.,'&'Hubble,'M.A.'(2011).%%The%road%to%mastery.%%The$Psychotherapy$Networker,$35(2),%22\31,%60.%

• The%effec8veness%of%the%“average”%helper%plateaus%very%early.%%

• Li)le%or%no%difference%in%outcome%between%professionals,%students%and%para\professionals.%%

The%Evolu8on%of%Psychotherapy:%Progress?%

• Professional%degree,%post%graduate%training,%supervision%not%correlated%with%outcome.%

•  Studied%experts%in%chess,%music,%art,%science,%medicine,%mathema8cs,%history,%computer%programming.%

%Ericsson,'K.A.,'Charness,'N.,'Feltovich,'P.'&'Hoffman,'R.%(eds.).%%The$Cambridge$Handbook$of$Exper:se$and$Expert$Performance%(pp.%683\704).%%New%York:%Cambridge%University%Press.%

The%Evolu8on%of%Psychotherapists:%

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•  Deliberate practice includes:

a.  Working hard at overcoming “automaticity”; b.  Planning, strategizing, tracking, reviewing, and

adjusting plan and steps; c.  Consistently measuring and then comparing

performance to a known baseline or national standard or norm.

•  Elite performers engage in practice designed to improve target performance: a.  Every day of the week, including weekends; b.  For periods of 45 minutes maximum, with periods of

rest in between; c.  The best up to 4 hours per day.

Ericsson, K.A., Krampe, R., & Tesch-Romer, C. (1993). The role of deliberate practice in the acquisition of expert performance. Psychological Review, 100, 363-406.

Deliberate'PracVce'

AS%WELL%AS…%%

PIANO%CHESS%SURGERY%RADIOGRAPHY%TEACHING%PROGRAMMING%SOCCER%TENNIS%SINGING…%

The%Evolu8on%of%Exper8se:%How%Top%Therapists%Improve?%

Charness,'N.,'Krampe.'R.,'&'Mayu,'U.'(1996).%%The%role%of%prac8ce%and%coaching%in%entreprenurial%skill%domains.%%In%K.A.%Ericsson%(ed.).%%The$road$to$excellence:$The$acquisi:on$of$expert$performance$in$the$arts$and$sciences,$sports,$and$games$(pp.%51\80).%%Hillsdale,%NJ:%LEA.%

Chow,'D.,'Miller,'S.'D.,'Seidel,'J.'A.,'Kane,'R.,'&'Thornton,'J.,'Andews,'W.'P.'(2015).%The%role%of%deliberate%prac8ces%in%the%development%of%highly%effec8ve%psychotherapists.%Psychotherapy.%

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23%

The%Evolu8on%of%Exper8se:%How%Top%Therapists%Improve?%

Dezlibzerzate%diˈlibərit/%%

Adjec8ve%%

Done%consciously%and%inten8onally%

Pracz8ce%ˈpraktəs/%%

Noun%%

To%carry%out%a%par8cular%ac8vity%regularly%

Hours%per%week%spent%alone%seriously%engaging%in%ac8vi8es%related%to%improving%therapy%skills%0%

2%

4%

6%

8%

Top% 2nd% 3rd% 4th%

Hours/Week'

Hours%

Chow,'D.,'Miller,'S.'D.,'Seidel,'J.'A.,'Kane,'R.,'&'Thornton,'J.,'Andews,'W.'P..'(2015).%The%role%of%deliberate%prac8ces%in%the%development%of%highly%effec8ve%psychotherapists.%Psychotherapy.%

Deliberate'PracVce'

•  Learning Plan•  Coach•  Immediate Feedback•  Successive Refinement

The%Four%Essen8als%

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24%

The%Evolu8on%of%Psychotherapists:%What%stands%in%the%way?%

The%Evolu8on%of%Psychotherapists:%What%stands%in%the%way?%

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25%

Ingredients for a Potent DP Plan

Automated Structure;

Reference Point;

Playful Experimentations, &

Support Persons.

Inoculate%burnout%%

The%Evolu8on%of%Psychotherapists:%Reference Point•  Learning Goals: What is it you want to work on?•  Multidimensional Evaluation of Learning & Performing:

How you are performing now? Where are you falling short? Who besides you has appraised this?

Support Persons•  How will you find a coach (supervisor/expert) &assess the learning ?Automated Structure•  What are you going to do in between now and the next time to work

on this area?How will you keep track of your learning day to day?

Playful Experimentations•  How will you maintain and increase receptivity/openness to learning/

feedback/surprise?

A%Role\play%

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26%

The%Evolu8on%of%Psychotherapy:%

Goal%for%Today%

Iden8fying%What%&%How%to%Improve%

FIT'Professional'Development'Intensive''

End%of%Day%Evalua8on%&%Feedback%

1.  The%training%and%trainers%are%keeping%me%engaged:%

1-------------2------------3-------------4--------------5

Poor Fair Excellent Good Very Good

2.%Overall,%I%would%rate%the%usefulness%of%today’s%session:%

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Poor Fair Excellent Good Very Good

3.%Comments:%