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For therapists: a note on achieving Clinical Excellence in psychotherapy

Achieving Clinical Excellence: How patient feedback can dramatically improve therapy effectiveness

As therapists, many of us claim to want to “better ourselves,” “never stop learning or improving,” and to continue to grow as therapists, for our personal sakes and for the sake of our patients. When it comes down to it, if you ask most therapists to rate themselves on effectiveness, we rate ourselves 80% better than we actually are. When it comes down to it, we are content with the ways in which we practice, because we have been doing it for years, automaticity has set in, and frankly, we just don’t like other people telling us what to do. We did get our slaved-over degrees for a reason, after all!

In December of 2009 I attended the Evolution of Psychotherapy conference, and was struck by Scott D. Miller’s presentation on achieving clinical excellence. As much as I would love to take credit for the ideas and numbers in this article, I would simply like to reiterate what I learned from Scott’s valuable presentation on the research he has conducted in his own practice (

Some surprising numbers:

Most likely, you are reading this article because achieving Clinical Excellence piques your interest. Psychotherapy outcome research tells us that the quality of the relationship between a patient and therapist is the component that has the largest impact on whether a therapy will be effective or not. Many of us agree. Thus, we are warm, empathic, try to nurture a strong alliance and invite open communication between ourselves and our patients. Whereas the patient’s diagnosis only accounts for 1% of outcome variation, it is the therapist along with the patient’s perception of the relationship that determines the therapy’s effectiveness. We hate to think it is this simple, and often hate to take on this amount of responsibility. However, in the spirit of achieving excellence and science/research, let us narrow in on what it means to achieve open communication between patient and therapist.

Open communication requires the therapist not only asking for regular feedback, but accepting and working with it regularly. To accept feedback, we need to be humble, open, and egoless. We should insist that our patients be honest with us, and that a “10 out of 10” rating does not help us improve as clinicians. Intuitively, we fear this might create conflict, defensiveness on our part, and an inevitable appointment cancellation the next week. Scott Miller has found the opposite. He suggests that regular tracking of the patient’s progress, in addition to regular feedback to the therapist, yields a 65% better outcome of therapy. In other words, receiving and incorporating weekly feedback correlates with 65% more symptom reduction combined with overall life improvement for the patient.

How might we “track” a patient’s progress? Scott suggests having the patient fill out a rating scale at the beginning or end of each session. They may do this by paper or online, and the areas to monitor/rate could be the following: 1) Patient’s Individual Functioning, 2) Interpersonal Functioning, 3) Social Functioning, and 4) Overall Functioning. In order to do this, a baseline must be measured as early as the first or second session. The idea is that receiving this weekly feedback opens up a discussion between patient and therapist, regarding the patient’s perception of their own functioning in relation to the therapist’s contribution to each session. This enhances the patient’s perception of therapeutic alignment, feeling heard, important, and in control of the outcome of their treatment. In my psychodynamic mind, this simply addresses the relationship dynamics “in the room,” which in itself can be therapeutic. *In a study with couples in therapy, there was a 50% less rate of divorce in treatment in which the therapist received the patients’ feedback, and this is merely one of the examples given by Miller.

Characteristics of “Superior” Therapists, in short:

Superior therapists engage in “deliberate practice,” or the kind of practice that is cognitively and emotionally demanding, and downright tough to do with a high caseload or lack of adequate breaks in between seeing patients. Superior therapists are egoless, in the sense that they regularly consult with colleagues for advice, regularly ask for feedback, are eager to grow and change their ways of practicing, and are aware of the automaticity that tends to set in with a particular patient after about 50 sessions, or when we start to get non-contingent feedback.

Recommendations to Patients:

Ask your therapist to address your feedback, if not every session, then every few sessions. If you’re feeling up to it, keep track of your own progress or functioning in the areas of your life you are concerned with improving. Keep a journal, and share it with your therapist if you feel unable to convey your thoughts during your sessions. Establish open communication with your therapist early on, and the chances are you will feel empowered and that you are helping to make the most of your therapeutic experience.

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