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Practical steps to clinical excellence

What makes a great therapist? What are the characteristics of therapists who stand head and shoulders above their peers in delivering effective outcomes for individuals involved in therapy? Researchers have focused on the following factors:

  • Innate talent
  • A particular temperament
  • Superior training
  • An empirically-proven clinical model

Scott Miller, Mark Hubble, and Barry Duncan, cofounders of the Institute for the Study of Therapeutic Change, have been studying for more than 20 years those therapist factors that contribute to effective therapy. As part of the Institute, an international group of researchers and clinicians, these clinical psychologists have analyzed the outcomes of thousands of clinicians and tens of thousands of clients.

Upsetting the traditional focus of the four areas described above, their lengthy multi-year meta-analysis resulted in the identification of two key factors as the driving and common qualities shared by outstanding providers:

  1. Deliberate practice
  2. Attentiveness to feedback

For therapists to increase the odds that their time spent providing therapy makes a real difference in their clients’ lives or to be recognized among the most effective therapists, we offer a pathway – a deliberate practice approach, a systematic measurement of progress, and a willingness to respond to feedback.

Discover the value of deliberate practice and the use of systematic client feedback

Deliberate practice: Outstanding therapists – the best-of-the-best – work harder at perfecting their performance than others. While they put in many hours to hone their skill, it’s not about just putting in long hours. These therapists are also highly attuned to feedback and use it to guide their practices.

Attentiveness to feedback: The most successful therapists actively and intentionally seek direct feedback from their clients on how well the therapy is working. In addition to discussing, reviewing and taking careful notes, and reflecting on the findings, these therapists follow up to see whether their client is improving. They formally seek evidence or verification that the process is actually making a helpful difference. They want to know how and when their client is getting better – or not in some cases – so they can adjust their process.

The most successful therapists actively and intentionally seek direct feedback from their clients on how well the therapy is working.

The “formula for success” calls for the application of the following three key principles:

  1. the therapist establishes the starting point or baseline at the first session, capturing client feedback using a standardized instrument;
  2. the therapist engages in the deliberate practice – providing therapy, listening for process feedback, and introducing strategic interventions; and
  3. the therapist systematically collects feedback using the same standardized intake instrument and applies this new information to further inform next steps.

How measuring the process of change leads to therapists of distinction

The mere act of measuring the process improves outcomes. Therapists who use this practice method demonstrate improved outcomes by nearly 63 percent compared to therapists not using this process. Typically, the process of requesting the feedback in and of itself strengthens the connection between therapist and client – even when the feedback is not positive! Being able to say, “this is not working for me”, when applicable, provides the opportunity for a therapist course correction.

To reinforce that the process is not designed to selectively solicit positive feedback, the studies have found that the top 25 percent-performing therapists consistently received lower ratings on the “alliance” measure at the start of treatment, but made necessary adjustments during the course of treatment using the feedback loop. Median-performing therapists typically had stronger initial engagement scores but weaker outcomes later in treatment, often marked by early drop-outs and terminations. This phenomenon points to an erosion of the therapeutic alliance most likely due to the lack of attention to the working relationship.

This process is the hallmark of a great therapist. There are various clinical tools available to support measurement-based care. In addition to provider-selected measurement tools, including the repeated use of standard screening instruments, such as the PHQ-9 for depression, Beacon Health Options supports this evidence-based approach through two clinical measurement tools, OnTrack and Tridiuum. (Click on the hyperlink to access Beacon’s OnTrack, available at no cost).


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