Commentary published in the Psychotherapy Networker, March-April Issue 2015 dealing with the question of how the field can become more effective

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2. day. The result is that we're warier
and more compartmentalized than
everbefore. Therapy needs to acknowl-
edge how increasingly fragmented
we're becoming and explore how to
help people connect different parts of
themselves,even if we never saya word
about global climate change.
Evolution has designed us to
respond to proximal information-
how things smell, look, sound, and
who and what we can touch. But
all of a sudden with our global
communication system, there's no
such thing as distal information-
all information is proximal. That's
doing odd things to our arousal sys-
tems, our sleep system,our cogni-
tive-appraisal systems.
Along the same lines, National
Public Radio recently ran a fascinat-
ing report on Alex Bentley's meta-
analysis of the emotional content
of printed words over the last cen-
turv. They no$' have computers that
can take all the words that appear
in print and perform massiveanaly-
ses of how the use of language has
changed. What these analysesshow
is that, contrary to what we think in
our psychologizedculture, we aren't
using more emotional words now
than we used in the early part of the
century and the words we actually
use have changed. The roaring'20s
were the high point for words that
expressedhappiness;the World War
II years were the era in which sad-
ness was most frequently expressed.
But the last part of the 20th century
sawa dramatic increase in the use of
words communicating fear. In 2008,
the last year of the study, we used
more fearful words than during any
year in the last century.
In many ways,we're treating people
in therapy offices asif it were 1960.But
it's a really different time, and there
are a lot of issueswe're not approach-
ing becausewe don't know how.
For me, as a therapist, the most
interesting question to ask is still
"What's your emotional experience of
the world?" And if you ask that ques-
tion in the right way,the result can be
a conversation that increasesthe mor-
al imagination of both therapist and
client, which I believe is one of the
most important goalsof therapy.@
Mary Piphea PhD, is a therapist and the
authorof nine books.
identity or message to the public
about what we can offer people.
We might actually learn a thing or
two about public relations from Big
Pharma, Much of its successreflects
the fact that it didn't just sell drugs:
it sold an idea. Starting with the mar-
keting of Prozac in the
'80s,
it pro-
moted the idea that depression was
a biochemical illness. Forget that
there was never any evidence for this
notion. Consumers, and dare I say a
fair number of therapists,bought the
idea that what was troubling people
wasthe result of some chemical prob-
lem in their brains. In sharp contrast,
despite all the empirical evidence of
our effectiveness,we've failed miser-
ably to sell people the truth: psycho-
therapy has been proven to help peo-
ple live healthier, happier lives, all
without frightening side effects,such
as dry mouth, erectile dysfunction,
kidney failure, and death.
Part of the problem has been our
own continuing lack of public clar-
ity over what makes psychotherapy
work. I think our recent fascination
with neurobiology or mindfulness
or this or that technique amount to
running away from what's actually
responsible for the central efficacy
of our work: the therapeutic rela-
tionship. Somehow, PET scans and
new clinical techniques get atten-
tion, while decadesof data show that
neither contributes much, if any-
thing, to the overall effectiveness of
psychotherapy.
On a related note, I find it strange
that whenever one of us is inter-
viewed in a public forum, most of the
time is spent talking about the prob-
lems people have, rather than the
strength of the solution we have to
offer. We need to embrace what our
research tells us: a professional rela-
tionship organized around empa-
thy, genuineness,respect,openness,
congruence, collaboration, and goal
consensushelps people change.And
these are things we're good at.
How can we get even better? The
answer is really quite simple and
straightforward: garner and usemore
client feedback. Evidence shows that
RuoluingOurldentitylrisis
y now research has demonstrat-
ed that people by and large feel
helped by psychotherapy. And
even more than that, it's a real
B Y S C O T T M I L L E R
bargain: the amount of change you
get for the cost of the servicesis out
of proportion to most other kinds of
professional services,be it lawyersor
physiciansor a masseuse.So there's
a lot right with psychotherapy that
we should embrace, even trumpet.
But how can we improve what
we do and th'e results we achieve?
We first need to face up to our
continuing identity confusion as
a profession. Who exactly are we
in the world, and what is it that
we do? The fact is, as a field, we
seem to shift our focus every few
yearsand emphasize different ideas
and theoretical perspectives.In the
'60s,
we were all about behavior
and strategy.Through the
'70s
and
'80s,
we zeroed in on cognitions
and thoughts. Then in the
'90s,
of course, we began the so-called
decade of the brain. Now every-
where you look, we're talking about
bringing more mindfulness into
therapy. But we lack a consistent
r"
P s Y c H o r H E R A P Y N E r w o R K e n . o n of J

3. we're not particularly good at detect-
ing which clients aren't progress-
ing or are actually getting worse.
By monitoring our work and for-
mally seeking and responding to cli-
ent feedback regarding therapeu-
tic progress and the quality of the
relationship, outcomes improve and
dropouts decline.
We need to augment our intuition
with a systematic metric to measure
the progress of therapy. We live in a
highly technical world, where clients
can check every aspectabout us in an
instant. Accurately and reliably mea-
suring our own work, in turn, allows
us to communicate more accurate-
ly who we are and what we have to
offer. This is something that almost
every successful business does; con-
stantly seek feedback from consum-
ers, try to aggregate and understand
it, and make changes accordingly.
Here's another finding from
research about us therapists:we want
to see ourselves as developing pro-
fessionally over the course of our
careers. Of course, we want to get
better at what we do! And yet avail-
able evidence indicates that we don't,
not with time and experience alone.
Although we may like to see ourselves
as becoming wiser and better as we
age, that wisdom doesn't translate
into better outcomes, which is what
our clients want. Continuing educa-
tion workshops won't enhance your
craft. Rather, to get better, you have to
identi!' your specific errors in clinical
practice-not his or hers, but yours-
the times when you failed to engage
the person you were working with.
It comes down to payng attention
to the relationship qualities men-
tioned above. You have to identifu
when you uniquely failed to do that
and then develop a plan for how
you're going to address it next time.
This means not learning some fan-
cy new technique, but going back to
the basicsof therapeutic communica-
tion. Researchshowsthat most errors
that lead to clients' disengagement
and
'dropout
are a result of their
experiencing the therapeutic interac-
tion as not empathic, not consistent
with their values and preferences,
and not addressingwhat they want.
{hat we're learning is that the
better therapists are, the more time
they spend outside of work engaged
in activities specifically designed to
address their errors-what we call
reflective or deliberate practice. If
you want to be average or below aver-
age,it's fine to leaveyourjob at work,
but top performers don't do that:
they read, they consult with peers,
they get consultation, they plan.
There's no magic to it. Theyjust sim-
ply do it more than the rest of us. @
Scott Millet PhD, is the founder of the
InternationalCenterfor ClinicalExcellence.
B Y K E N N E T H H A R D Y
"legitimate." Many of these commu-
nity-based approaches are chang-
ing disconnected lives,even though
they may not match the current cri-
teria of what constitutes "good" evi-
dence-based psychotherapy. Plenty
of people are working in placeslike
the Bronx, North Philadelphia, and
Oakland who are doing really cre-
ative work that wouldn't be pub-
Iished in our professionaljournals.
In two important ways,good com-
munity work stands apart from the
kind of approaches being encour-
aged in the field today. First, there
aren't rigid prescriptions governing
who shows up for treatment, where
the treatment takes place, or how
many providers are engaged in the
process. Therapists doing commu-
nity work might invite participation
from a client's nonblood-related
aunt, homeboys, or someone else
who's not a blood relative but might
have an instrumental role in the
person's life. Second, when you're
dealing with multiproblem fami-
lies, there isn't the same pressure to
focus on the saliencyof a single pre-
senting problem. You find yourself
dealing with whatever the problem
dujour happens to be.
Just last week, I supervised an
inner-city community-based case
in which an adolescent, Thsha, was
the Identified Patient because of
chronic truancy. She had an older
TheAttailon0iuedty
s a profession, we've become
increasingly focused on our
economic survival and seem to
have turned a blind eye toward
the broader socialcondition, voicing
little about matters that aren't cen-
tral to our professional interest. For
example, we've been mute around
the recent race-related issues con-
nected to Ferguson, Missouri, and
Staten Island, New York. I don't
hear therapists becoming part of
the cultural conversation about the
strain in the relationship between
police and communities of color,
even though no professional group
is more qualified to address relation-
ship conflict than we are.
A tendency to ignore the wider
social context is reflected in our
increasing embrace of more manu-
alized approaches to therapy, pred-
icated on the notion that cultural
differences don't matter much, and
you can apply techniques more or
less uniformly across different treat-
ment populations. While I don't
think that's the intentional goal of
manualized treatment, you might
even see the increasing manualiza-
tion as an indirect attack on diversi-
ty, squeezing out people who live on
the margins of mainstream society.
Meanwhile, therapists on the
ground in the barrios, in the hoods,
and in the trenches often receive
no recognition that what they do is
2 4 r s y c H o r H E R A p y N E T W o R K E R . M A R C H / A I R I L2 o r 5