Sunday, February 08, 2009

Supershrinks - Part One

When I teach facilitation skills one of the first activities we do in class is called “Describe the best teacher you ever had”. It’s a chance to model a “think-pair-share” process and provides the basis for the learning outcomes.

Groups invariably come up with a list of behaviours and qualities that, most people would agree, describes a Superteacher. Things like open, approachable, available, funny, genuine, they cared, went above and beyond, challenged me respectfully, passionate, always seem to make the list. Knowledgeable is mentioned but not nearly as much as you would think and never ranked above characteristics that make one likeable.

So, it was no surprise when Scott Miller began the session on Supershrinks by asking a similar question - “What makes some people better at some things than others? Of course, we were a room full of counselors, social workers and therapists so we re-worded the question in our heads and came up with lists of some things that made some counselors, social workers and therapists better than others.

Our combined (aggregated) lists looks suspiciously like my facilitation skills list and low and behold, knowledge didn’t really float to the top here either. What did come up was, charisma, passion, likability, belief that you care, unconditional personal regard, client centered, the ability to connect with clients. When knowledge did come up it was in the form of “being able to draw from many hats”, not expertise in one model or process, more of a generalist’s knowledge.

Interesting stuff that I didn’t know:

Medication generally helpful only when given by high ranked therapists.

Freud used a couch because he didn't like looking at his patients for extended periods of time. (his pathology became a treatment approach)

Person Centered Therapy was originally a placebo that was manualized for consistency. A placebo folks! And as a placebo it was as effective as anything else.

The big message here was and is - “It’s not the tool - it’s the hand that wields the tool.”

Scott went on to provide us with some enlightening (although confusing to me) aggregated statistics. Face it, as a field, we have been studying and researching what we do for a long, long time. The bad news, we suck overall.

No real improvement in outcomes since the 1960’s. And that’s across all treatment models, and we have lots of models. What’s more, as we continue to research new models of treatment we are consistently finding that compared to other models, including placebos, there is really no difference in outcomes. Bottom line, there is no little white pill type model of addictions treatment that works really well, most of the time for most people.

Ok, before you decide to become a plumber (cos they have excellent outcomes) there is some good news. Regardless of the models you use, if you are an effective therapist aka Supershrink, your clients can achieve 50% or more improvement and you can have 50% or less dropout.

Naturally this leads to next topic - What exactly do Supershrinks do?

Well, turns out our little brainstorm at the beginning of the session wasn’t too far off the mark.


a. Seek, obtain and maintain consumer engagement - They connect with their clients. Their client like them. Their clients come back.

b. Are exceptionally alert to the risk of drop out and treatment failure. - They notice and make explicit problems in sessions and in the relationship. They own and fix those problems.

c. Push the limits of their current realm of reliable performance. - They actively work to get better at what they do. They ask for feedback and use it as a tool to improve what they do.

Scott quoted David Orlinsky - “The quality of patient’s participation in therapy is most important..”. I found this article online but most of the others required membership or payment (that’s another blog topic).

So, the word of the day became “alliance”, or more accurately, therapeutic alliance. That’s what works. To drive this point home a bit more we watched some video clips.

The first was of a client (Anna) reflecting on her experiences in therapy. She stated that the one thing that made the most difference in her therapy was.. wait for it… her chats with the cleaning women.

She explained (thankfully) that the reason the chats with the cleaning woman were so beneficial was that the cleaning woman treated her like a real person, not like a patient. The cleaning woman shared parts of her life with Anna. In short she didn’t maintain those all important professional boundaries.

Anna went on to describe a turning point with one of her therapists.. again.. wait for it… it was when her therapist ordered some food in and they ate a meal together. How’s that for busting through professional boundaries.

Now don’t get me wrong, I think boundaries are important. The client’s boundaries are sacred and should always come before my professionally enforced and codified professional boundaries (aka policies, rules and other crap stuff) that gets in the way of building and maintaining therapeutic alliance.

That ended the first session. Stay tuned for part two.

Again, you can download the presentation Scott Miller used at this conference here. It’s a very large download, three parts, and well worth it.

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