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Supershrinks: What's the secret of their

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Botsu 7'R TnAT(.rs,
BETTER
KNO\ANas the boxelder bug, emerges

from the recesses of hornes and drvellings in early spring.

\t\rhile feared neither for its bite nor for it's sting, most peo-

ple consider the tiny insect a pest. The critter comes out by

the thousands, r'esting in the sun and staining upholsten'

and draperies with its oranse-colored wastes. Few find it

endearing, u.ith the exception perhaps of entornoloeists. It

doesn't pttrr and won't fetch the morning paper. What's

more, you'll be sorry if ,vou step on it. \A4ren crushed, the

dirninutive creatur-eernits a putrid odor worthy of an anirnal

lnany tiures its sizc. I For as long as :uryolte could l'ernellt-

ber, Boiseatriuittrttttswas an unwelcomc 1'etfanriliar-grrestin

the offices and r,r'aiting area of a large Midwestern, rnulti-

county cornmunity mental hcalth ccnter. WHAT'S THE

Professional exterrninators dicl their best !$EG!|ET OF THEIR

to keep the buss at bay, but ino,itably 1$UGCE!$S?

rlrilny eluded the eflblts to elirninatc lhern. Tissues rvere

strategically placed throtrghout the ccntcr t() assist staff

and clients in dispatching the escapees. In tirne, the

by
Sc orr MrrrnR,
Manr HusBr.E,
and
Bannv DUNCAN

\\' \\' \\ . P S \' (. I t () T H E R A P \' l.. F T \\' () R X r. n . O U <; 2

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 :tIr'aDgcll)ctrt llcc:tnrc r()trti11e.or"rt of tioners rverc strtregling to sta)' afloat take airrr. thcr hit the bull's-eye.
rrt'r'cssit\-. cvcryol)c t<llcratcrl the nnnu- firrancialll'. N{an1 in the prof'essional Nevt'r'thclt's'. sirrcc Ricks's first descrip-
al arrrrr>\'arrce-rvithone rrotirltle cxcep- conrnunitl'sought to ernrrlate his suc- tiorr, littlt' hrr: lrt't'n clone to further the
tiott. cess.In the hopes of learnir-rghis secres invcstigutiorr of srrJ)er- and pseu-
l)lrrr'rr,:t lt)-\'('lrr'\('tcl2rn <ll'tlrt' cclttcr, rir earning his acknonlcclgernerrt, ther' r l o s l r l i r r k . . I r r s l t ' : r r l .p r r > f e s s i o n a tl i m e .
Icd tlrt' r't'sisl:urct' to u,ha1slrc consirlcrcrl cotnpeted hard to cnter his inner circle. er)er'!11. :rrrrl rt'sorrlrt's halc been direct-
" i r r s t ' t t i t i t l t ' . "I r r u r v o r l r l t l l l l t c ( l a g a i l t s t \ \ ' l r i s p e r e d c ( ) r t rt ' r s a l i o r r s a t I ) : l r t i ( ' s ccl t'xclrrsirt'l\ t()\\'ur-(lidorti$'ing effec-
tltc lrtrgs,slt<'rvls theil orrly allr'.Tir suvt' and local profi:ssional rneetings rnad(' L i t t ! l t n r t f t tr, . I l r i r r s t o i d e n t i $ ' s p e c i f i c
tlrt' tirrr' lrt'ast.s, sht' collectc<lalld distril> clcar that othcrs regarded (lordon intcr-r'e'rrtiorr'llr:rt corrlrl be reliably dis-
ut('(l ( ) l ( l r r r a s o rjrl r l s ,i r r r l t k r l i r r u( ) l h ( ' f st ( ) rvith t-rrn ancl cnrnitr'. "Profits talk. p t ' l t s t ' r l l i ) r ' \ l ) ( ' (r l i r l t l o l > l e m s h a s a
( a t ( l l t l ) ( ' l i t t l t ' < ' r ' i t t c l ss ( ) t l ) a t s h c r ' o t r k l
J)aticnts rvalk," rvas ()ne c()lnnrenl that s t f ( ) l ) g ( ( ) l l l n r () n \ ( l l \ t ' a l t 1 t e a l .N < t o t r e
sali'lr n'lt'lrsc llrt'rrr orrt<loots. caplrrrcd the gencrzrl fccling aborrt n r l r l r l u r g r r , ' r r i t l rt l r t ' s r r c ( ' ( ' sosf t h c i d e a
Ft'n rr't'tt' srrr-pris<'rllx' [)utr,rr'sr'<'girlrl h i r r r . B t r t t h c c r i t i c s c o u l c l n ' t h a v e b < ' t : r r o l p r o I r l t ' r r r - ' J tr tr l i t i t r t t ' r ' r ' c n t i o n isn t h c
lirr thc l>ttgs. Most 1tt'o1rlt:rvho krrt'rv r))()r'cwr'()r){r.The pcople (}orclon sarv I i c l r l o l r r r t ' r l i ri r r t ' . I i r t t l r c e v i d e n c e i s
l t t ' t l ' r > r r l r ll r a v t ' t l u r l l r c l t ' r ' i z c r l r t ' r a . sl r i r r h i s p l a c t i c t ' r ' r g a r d c r l h i r n a s r : a r i r r g i r r c o r r I l o r rt t i l r l t. I I 7 r ' , P l o r i d c tsh e t h e r -
h o l r l o u t l i r r r r rt h c S r r r r r r r r t ' r - o[ ,lo v c . H t : r ' all(l (lcnplv c<>rnrrrittccl t() thcir rr,ell:rrc. a p r i s l r n r r r tl r r r r ,r rt i r r r l r o l t : I n td e t c r m i -
\ \ \ ' r r r i c l o l > r r s ,l l o o r - l t ' n g t h , t i e - ( l i c d Frrrllrt'r'nror-e. hc achievt-d outcornes l]lult ()l \u( ( ('\\ tlr;rrr ir,/ialtrcatrnent
s k i r t s . a r r r I l ] i r k t ' r r s t o c k s a n ( l i r l s - c ( ) r n - tltitt u't't'c (irr srrpclior t() th()se ()f the a l l l t l o l r t l t i . p t , ' r t rl t ' rl .
lrirrt'rl rvith thc ri(('l)t of'
I)1lt(ll()uli arrrl sarrrlirlrvood
tltat lirtgctcrl alit'r' hcr' pirs-
sirq('-s()li(lilicrl cvcrr'orrt.'s
i r r r l r l c s s i o r rt l r i t l s l r t ' r r ' a s l t
Theert-denee is
lirgitivt' ol llaiulrt-Ashlrrrr1,.
R r r r r r r > r ' l r l r ir tl t l r a t s h t " r l Whoprovidesthe therap)-is a much more
lrt't'tr t'ont <'iverlzrt!,sitlt'rr.
[ ) r ' s p i t t ' l l r t ' s < 't ' t r ' t ' r r tirr i -
t i t ^ s .l ) a r r ' r rt a s l r t r r < l s < l o w r r rhanwhottreatrnent
t l l ( ' n r ( ) s t c l l i ' < ' t i v t 't l r t ' r ' a l t i s t
'l'lris
:rt llr<' ugt'rro. lirrrlirrg
r r ' l r s t ' s t a l r l i s l r t ' r lt l r r ' o r r g l r a
tiglrllv contrrrllcrl, r't:sr:arch-tr>przrcticc clinicians rvh<l carperl :rltorrt hirtr. In ( l r r r s i < l tr . r . l u ( l \ r ' r ' l t o r t - e dl t 1 ' B r t r c c
slrrrlr t'orrrlrrctt'rl:rl lrt'r ag(:l)c\'...\s ;tart lict. tlrc sAlIlc rl)cllsurestlral conlilrnr:rl \\'urrtl>r,lrl .rrr,l ft lr Brrxvtt irr t.ht:
o l t l r i s s l u ( l \ ' ( ) l s u ( ( ( ' s s r ' : r t c si r r i r t : t t r a l I)iuvrr's sttpcrior rcstrlts pl:rccd ()ord<>n ( ) c t t r l r t ' r . ' )trrt - r f , , t t r u r t o
l f ( , o n . s u l t i t ragn d
<l i r r i c u l s ( ' l l i l l e s . I ) a r v r r u n r l h c r c o l - in the top l2ir pclccnt ol' ps1'chothcra- O l i r t i rt t l 1 ' r . ,1, , , , / , , q I t i n c l u d e d 5 8 1
k r i t q r r c s : r t l r r r i r r i s t c r t ' ra l s t a r r < l a l c l i z < : r lp i s t ss t u r l i e < li r r t h c U r r i t c r l S t a t c s . l i c c ' t t s r ' <pl r , ' r r r l t ' r . - 1 r s r <l t o l o e i s t s , p s r -
tn('1rsru('ol lllogless to cutt:h r:liertt :rl In l1)7-1. rcscarcher- Dirvicl F. Ricks c h i a l l i s t . . . r r r r l r r r : r s t t ' r - ' s - l t ' rt' h ee l ra-
t'\ t'l t st'ssioil. c o i r r e r l t h c t e r l l ) s t t l n r . s h r i n k , st ( ) 1 > i s t s - r r ' l r o\ \ ( r ( l r t l r t i r r gi r r l i v e r s es i r m -
\ \ ' l l : r l r n l r ( [ ( 'l r t ' r ' p t ' r ' l i r l r r r a r r c ca l l t h e <lcsclibe a cl:rss o['excc-lttionirl thera- p l t ' o f t t ) () t ( l l r : t n t i . ( ) ( X c) l i t ' n t s . T h c
n ) ( ) l ( ' ( ( ) n ) l ) ( ' l l i r r e\ \ ' : r st l l r l s h c w a s t h e pists-pt'actitiorrcrs rvho st-ood hcacl l h c t ' : r 1 l i r t r .t l t t t l i t r r t t ' l t ' . u n d t h e p r e -
loll llcr l o r i l t ( ' t s ( . \ ( l l \ < . l t t s I t t t t r r i r t g . a t t r l s l t o t t l d c r si r l t o v c t h e r c s t . H i s s t u ( h ' : i ( ' l ) t i n gt o r r r p l . i i r r l rr r ( ' l e l l ( r l i f l e r e n t i n
N{olt'ovcr, lut tols rr'irlclv ltclicvccl to r:xlrttrirred thc loDg-tcrrtr ()utcol]tes ()l i l t t t t r r t ' r r r r i r r g l rrrrlu ' rl l r r r t r t h o s e i n c l i n i -
a l l i ' r ' t l l t ' l r t r r r ( ' n [( ) u t c ( ) n ) ( ' - t l r c c l i c n l ' s "highlv clisturbcd" arlolcsccrrLs.\\Iherr c a l s t ' t t i t t g r r l r t i o r t r r i r l e ., \ s r v a st h e c a s c
irg(', g('ll(l('r, tliae'ttosis, lcvcl oI Irutc- tlte lc-scalch palticipalrts rvere laterr' r r ' i t h l ) u r r ' r r , t n r l ( , o l c l o r r , t h e c l i e n t s '
t i ( ) r r : r il i l r 1 r : r i I n l ( ' i l(1) .r p t i ( ) r 'l r c i t l i l l ( . i l 1 cxirttrincd lrs nclults, hc Iinrnrl thirt a agt', gt'rrrlt'r. urr<l rliagttosis had no
I r i s t o l r - < l i < l n ' t : r l l i r c th e r r c s u l t s .( ) t h e r sr'lc'cterotrl;, trcatcrl lll one p2uticular irrt;ltcl on tht tr'(':llllrel)l .succes.5 rate.
llrctors thut \vcren't corlelaterl tt> herr' providcr, lured notirbh bctter. In thc i r r t r l r r t ' i t l r rt , l i r l t l r c t ' x p e l i c r r c c ,t r a i r r -
()rrt('()nlestr'<'r'cher age, gcndcr, tfail)- sanle stud)'. bo)'s treatcd bv thc "pseu- i n s , a n r l t h t ' o l t ' t i c u l o r i e r r t a t i o n o f ' t h e
i r r g . J r r - o l i ' s s i r > ndails c i P l i n c , l i c c n s r r r - e , c l o s h r i n k " d c r n ( ) r r s t r a t c d a l a l r r r i n g l v thclity;ists. Horr't'rt'r'.clients of the best
()l \'('ars ol experiencc. Even her thco- poor nrljustment as adults. thertiryrists irr the sarnplc inrproved at a
lctr(ul r>ricntatit>rrpx>r'ccl incolsc- That ther:rpists diller in their abilin rat(' ut lt'ust .-r0 l)clcel)t higher and
qucntial. to all'cct change is hardlv a revelation. droyrpcrl ()rrt ut lr l llte at le ast 50 1>e rcent
flrntrast l)arvn tvith flordon, rvhc> All ol- trs have participated in hrrshed lorver than lhose lssigncd to the rvorst
corrl<ln't ltlrre llct.rr rnorr: dilt'cr-ent. conversati()ns :rbout colleagues rvhose c l i r r i ti a t t si n t l r c r : r r u p l t ' .
Ri gicllv (:()r)s('rvativc ancl l>rintrnin g lvi th perfbrnrance rve feel falls short of the Artother irr)p()r'tantlinding ernerged:
t'orrlldr:ncc ltolrlt'r-irrson nrrogalr ce, he rnark. \\Ie also recognize that sonre itr casesin rvhich 1>svchotropicrneclica-
rnallasccl to lrrrilrl a thri\illg prir,ate practitioners are a cut :rltove the rest. ti<>trrvas corrrl>ineclrvith psvchotherapl',
l ) l : r (l i ( ( ' i t t t r r r a n ' l r r r ' l t t ' r ei l r o s l p | a c L i - \\Iith rare exceptiolls. whenever thev the drugs clidn't pcrfcrrrn consistently.

2B rrrr.f t() I ttt R \t,\ \Lt I \ ' ( ) R K F tR r I'oi,r,ltber/I)ttrttbn 2(l)7

 'I'hc
l ' l r t ' i l t ' l l i ' c t i r t ' r r t ' s sr l c p c r r r l t ' r l ( ) n t h e rlelt'r'rrrint'rvh\'. pr-ojcct rr'orrlrl lravc lt'rtrairrt'<l
(lrrirlit\ ol thc tlrt'r'apist-d|rrqs trsed in \\'t' bcean our invcstigirtiou llt look- s l r e l v e r li r r < l t ' f - r r r i t t 'l ltva r l o n t ' o l ' r r s r t o t
-I'he
t'orrrlrirr:rtionrvith talk thclal>r' rvt'rt' l0 i r r g a t t l r t ' r e s < ' a r < ' lhi l ( ' r a t r l r e . insti s l r r r t t l > l e (d) l l t ( )l l ) ( ' n ' o t k o l S u t ' r l i s hp s r .
tirrrt'surorc clli'ctivc rvith tlrc lrt'st tht'r. ttrtt' has t'irlnt'cl its reptrtation irr part llr t h o l o g i s t K . A n r k ' r ' s l ' . r ' i t s s o r r .N t ' : r r I r
a p i s t s l h a r r r v i t h t l r r ' \ v ( ) r ' s lA. n ) ( ) l q t h ( ' lt'r'icrr'irrglt'st'irlt'h arrd llrrl>lishin{rsurr- t \ \ ( ) \ ' c a l s l t l r r l J i i r s s t ' rsl i r r c t ' l t " r l g i r t ' r r
lattt'r' grorrp, tlrc <.lr.rrgs rrrarlt' Iiltrrallv nrarit's arr<l<'ritical nrurlvst'sorr its n'cl> t r P . ' I ' h t ' n S ( ( ) t t ,l ( ' t l l | i l i r r gt o t l t < 'L r . S .
l l ( ) ( l i l l ( ' l 1 r l ( t ' . S o . i t r t l l ( ' ( l l ( ' D ) i s t r ' \(' ) r sitt' (wrr'w'.tirlkirrgc:rrrt'.conr). \\i' \\'erc a l t t ' r ' p r ' o l i < l i r r gu r r t ' t ' k o l t t l i r t i t t u
n r c r t t ; t l I t c a l t l t t l c r r t r r ) c n t , t h ( ' a J ) l ) l i r ' ( l rr'cll urr'alt' at tllc ()uL.i('tthat littlc hurl in Noru'at, lirttrrrl iur at ti( l(' al)()ut
( ) r i ( ' n t i l t i ( ) n s , l < ' r : l t t t i r l t t t ' s ,: t r t r l c \ ' ( ' n l>ct'rrrlorrt' sinct' Ricks's orieinal papcr' F l r i c s s o r r 'lsi r r r l i r r g sp r r l r l i s h t ' r li n l ' i nt u r t r
l n ( ' ( l i ( a t i ( ) r ) sl u ( ' r ( ' l a t i \ ' ( ' l y i r r r . r ' t .1 ' h c to rlt'cpt'rr tht' rrrrrl<'r'starrrlirre of srrJrcr. t r r a g a z i r r t ' .\ \ ' t ' : r r v I i o r r r t l t t ' r o l < l u t t < l
c a l : r l y s ti s t l r c t ' l i r r i <i i r r r . anrl lrst'rrrloslrlinks. Ncvcrtlreless, lr li':rrklr' lrolcrl. lrr"rl tirkcrr tht' lrcliorli-
rrrassivt'zlrnorurt ol' r'csearch harl llccrr c : r l l i o r r r t l r t ' p u s s i r r el l i s l r t a t t c r r r l a r r t
The Making of a t ' o r t t l r r c t c r lo t t r v l t a l r n a k ( ' s t h ( ' l n l ) i s l s l r r o l t ' l i r l l l r t ' g l o s s r 'p i t t r n t ' s a r r r l l : t c
Supershrink arr<lthclapv t'fIt'ctivt' irr gcncral. \\'h<'rr t o i r l s t h u r r l i r l i r r t t ' l l < ' t t r r : rsl t i r r r r r l a l i o r r .
I I o r r r l r > t h c s r r p c r s h r i r r k s - p r a c t i l i o r r - \ r ' ( 'l l l l ( ' i l l l ) l ( ' ( ll o r l c l t ' r ' r r r i r ) l(l'l c c h a r a ( . Irr sltorl ottlct, lrou't'ttr, lltc tttagazittt'
t'r'srrsrlissinrilul as l):ru'n ar)(l (;()l'(l()lr- I c r i s t i r 'o s l t l r t ' r r r o s lr ' l l i ' tt i r t ' l ) r : r (l i l i ( ) r ) - t i t l c s t ' i z t ' r Il r i s u t t t ' r r t i o n - i r r l r i g l ) ( ) l ( l
rlo rthul tlrt'r' rlo? .\rc llrt"t' llit(l(' ()r r ' r ' s t r s i r r g ( ) u r ' r ) i l l i ( ) r ) a l r l a t a b a s t ' , l('tt('r's. "\\'ll'\'l' I'l' Il\KllS 1'() llFl
'l'ht'
l X r | r r ?I s i l a i l ) i l t t c r ( ) l ' t t ' r n D t ' r ' a r n c l r( l) r ' Irr'potlrt'sizinutlrat thclapists likc l)arvrr ORll'\T." s r r l r t i t l t ' r ' i n <l r t ' r l i t .

..I I
lncontrovenlOIe.
lrnpOrtant determinant
of success
approachis provided.

tllritrrrrg?Havc tlrcl' rliscovt'r'crlir s('cr'ol lrrrrl (lor-rlr>nrrrrrslsirtrpll'rlo or crnborll " R c s c a r c h n o w s l r o w s t l r : r t t l r c l : r tk o l

t r r r k r r o n ' rt ro o t l r c l l ) l a c t i c i n qc l i r r i c i a r r s
( ) l l u ( ' l l r c i l s r r l ; e l i t > rr' ' t ' s r r l t ss i r n l r l v u
I l r t k t ' . t t t o l t ' I n ( ' 1 r s u r ' ( ' n l ( ' nt :tr ' r ' o l l l t : r r r
I r ' l r l r t r l . \ r t s r v l l i t t g t l r t ' s c r l r r t ' s t i o n si s
c r i t i <u l . l t l r t ' i r r g t h c l t t ' s t i s r n a t t er ' o l
b i r l h . 1 l t ' r ' s o r r lrrlli s J r o s i t i r > rorr, c h i r r r tr ' ,
tltt' pltt'trorttt'uolt wotrl<l hirlrllt lrc
l v ( ) r ' l l )l i l l l l l ( ' r ' s l t r < l r ' B
. rrt shorrlrl tlreir'
tak'trts J)l'()\'('tlansl('r-altl<',tlrc irrrpli<lr
t i < > r r sl i r r t l l r i r r i r r g . r ' t ' r t i l i c a l i o r r , l n < l
st't'ticc rlt'lir t'r'r at e notlritrg sholt ol
strrggtrinu.
l l r r t c r t h c l r r s t i t t r t t 'l i r l t h e S t t r < l t o l
'l'lrt'r':r;rt'rrtit'
O l r a r r g t ' .a n i n t t ' r ' r r a l i o r l r l
e t o t r p o l r e r s t ' i r r c l r < ' ra' sr r r l c l i n i c i l n s
dt'rlit :rtt'rl to sttrrlving tvhal rvorks irr Psr.
< ' h o t l r t ' r - u 1 xF. o r l h t ' p : r s t c i e l r t t ' c u r s ,
l l t t ' r - l r ' o t t 1 >i r. t t ' l r r r l i r r g r > r r l s t ' l v t ' s l.r a s
l r t ' t ' r r t l l r c k i r ) s ^t l ) ( ' ( ) u t c ( ) r n ( ' so l ' t h o u -
s : r r r r l s o l t l r t ' r ' i r l l i s l st l ( ' a t i l ) q t t ' n s o l
t h o t r v r r t r l so l t l i t ' r r t s i n r r r l ' r i a <cl l i n i c a l
s ( ' t t i n g s l r ' r r r s s t l r r ' L r n i t t ' d . S t a t t - sa r r r l
alrroatl. Likt' I)ar irI Rit ks atrcl othe r'
r-t'st'artltcrs. rr'<'lirtrrrtl rlirlc variatiorrs
in clli'ctiven('ss arn()ll{r placticine clini-
ciarrs. Irrtrigtrcrl, rr'c dr:ridcd t() tr'\' l()
rnolt' ol "it," rvt' srrriukcrl ht'arllirst into natrrral T.\l.ENT IS lRRlll,l'l\l\N-I' to
l u b l i c k w ' r r l l .N c i t l r t : r 'l h c 1 > r ' r ' s oot rl ' t h c 1 9 ( ' : r ls r r c ( ( ' s s . ,"\ l t l r o r r e l r t l r r ' l c l r r l l r l t i -
tlte l ltpist ttor tr'<:hrrit:rlpr'orvt'sss('J)lutrt- <[ c i t s r ' l f \ v : r s r t l I r ( ' r ' ( ' l i r t r r ' 1 l : t g t ' si r t
< ' r lt l r c b c s t l i r r r r 1 h ( ' r c s t . I t ' n g t h , t h c r ' o n t t ' r r tk t ' p t I r i r r r o t c r r p i c r l
F l r r s t r ' l r t c ( 1 , l r t r t r r r r r l t ' t c r l c r l , w ( ' f i r l t h c ' r ' r ' r r r a i r r i r rtl '4i q h t l r o r r l s o l ' t l r c
|ctrlr( ('(l ()llr sl('J)s.Mat bc rvc'cl nrisst'rl l l i g h t .
s ( ) l l l ( ' t l l i l l f l - a t I i t i t ' l r ls t t l ( h , a t l t t : l l l ( ' ( ' a
, llli< ssort. St otl lt'ltnrcrl, rvas rvi<[t'Ir
Irn<lirrq-tll'.rt uorrlrl stccl rrs irr tht' t o n s i r l t ' r ' r ' r"l t l r c t ' x 1 x ' r ' ot n t ' x p t ' r ' t s .F " or'
r i g h t ( l i l ( ' c t i o n . \ \ ' c n ' t r r r r r t ' dt o o r r L< x v n t l r e l r c t t < ' r 'p u l l o l l r v o r l t ' t : r r l t ' s ,I r r " < l
rlatabast' t() t:rk(' a st'tonrl look. r'evicrv- l > t ' t ' ns t r r r l l i r r gt l r c r v o r l < l ' sl r t ' s t: r t l r l t ' t t ' s .
i r r g t h c r r r r r n l l t ' r ' s: r r r d <h c c k i r r g t h c i r r r t h o l s , t l r < ' s s1 l l a 1 t ' r ' sr,l l t l t t l t t o u t ' t s ,
atraltst's.\\'t' askt'<lr'orrsttllarttsorttsirlt' r r r : r t l r c r r r a l i c i : r r r p s ,i l r n i s l s , 1 t ' l r c l r t ' r ' s .
t l t c i n s t i l t t l t t' o r t ' r ' i l r( ) u r ' (( ) r n l ) l l l : l t i ( ) n s . p i l o t s , p l r r s i t i r r r r s ,: r n < l < > t l r t ' r ' sI .l t ' t r r s
\ \ i ' i r r \ ' i t t ' r lo t l r t ' r ' st ( ) l ) r ' i r i n \ t r ) r ' 1pi lo s s i - i r l s < >i r b i l o l u r r r i n t ' r ' i t ' k .I r r l r v o l l r l
b l e e x p l a r r a t i o n s .( ) p i n i o r t s v a r i t ' r l I r ' o r r r l ) t ( ) r t ( l' ( ) l t t t ti l l t r t t g r ' ( ' : t l D ( ' \1\ o , - . 1 r ' n c t i r
rnarr\ ol tlrt' lirctols u'c'tl alrt'irrly corr- ( ' l l ( l ( ) w l n ( ' l l t . l - r ' i c s s ( ) r rr l i r l r r ' t n ) i n ( ( '
sirlcr'<'rlatt<l lulccl ()rrt t() "it's all :r ntat- \v()r-(ls:" 1'lrt' st'alch lirl stulrlt' lrt'r'itrrblt'
I t ' r o l c l t a t r t ' t ' ,n o i s t ' i t t t l r t ' s y s l c r t t n, l ( ) r ' ( ' c h a r a t ' t t ' r i s t i c sl h l r t t r > r r l r l1 r n ' r l i c l o l l r l
strrtistir:ulirltil:rtt tharr l'act." Sairl anoth- I t ' : r s ta t r ' o r r r r tI i r l s t r l r t ' r ' i o 1
r 'r t ' r ' l i r r r r l r rtr' <
('r' t\'a), srtpclsll'inks \\,('r'('n'trt'al, tht'ir' o l < ' t t t i n t ' t t it r r < l i v i r l t r r rIl ist t s l r r > t ' t < s l,t t ' s s .
eillelgel)c(' itt ant' (l:rta aDahsis \\irs t n u s i c , r n c < l i t ' i r r t t' ,' t t . l I r u sl l c et t s t r r ' p t ' i s -
t ' r t l i t c l y l i l r r r k r t l r . I r r t l r e c u d , r r o t h i n g i n g l t r u r s r r t r c s s l i r l. . . S y s t t ' r r l r t i tl a l l r > -
rvc coulrl poiut to cxplainccl rvlrv sorner rat()l-\'r('so:ut h . . . prrl irlcs ,io cvi(l('ll( (
clirriciarrs achicvcd r'orrsi-s[enth, supeli- l i r r g i l i c r l r r e s .os l i r r n a t t ' t a l c n t . "
ol resrrlts.Sct.irre no solrrtion, we gavc Shotrlcl Flricsson'sl>old arrrl swt't'pirrg
rrp atrcl lrtrlc<l ()ru'attelrti()n clservlrcre. cluirtts prr>r'c rlillicrrlt to l>clit'rt'. t:rkt'

\\'\f\f l,\\ (rII() I III R \l,\ \L I U(]RK] R t t X r . ,2 ( )

I
 the example of Michael Jordan, widelv as the average musician.
regarded as the greatest basketball plar. As tirne-consuming as this level of
er of all time. \\Tren asked, most would practicing sounds-and it is-it isn't
cite natural advantages in height, enough. Accordins to Ericsson, to
reach, and leap as key' to his success. reach the top level, attentiveness to
Nonvitl.rstanding. ferv knorv that "His feedback is cnrci:rl. Sttrdies of ph1'si-
Airness" was cut frorn his high school cians rvith an uncarlny knack fbr diag-
\,arsity basketball tearn! So nruch for the nosing baffline rnedical problems, for
idea of being born great. It sirnplv example, prove that the)'act differently
dr>esn't work that rvay. lionr their less capable, but equally'
The ke1' to sttpe rior perf<rrrnance ? r\ well-trained, colleaqtrcs. In zrddition t<'r
absrrrd as it sotrnds, the best of the best visiting with, examining, taking carefirl
sirnply work harder at irnprovine their ll()tes ab()ut, anrl reflecting on their
perfonnance tharr others do. .Jordan. asscssr))cntof a particular patient, the)'
fbr example, clidn't givc rrp rvhcn take onc adclitional criticirl step. 7714'
thrown off the tcarn. Inste:rcl. his failurc "prolicicnt"
follou ttlt. Unlikc their
drove hirn to the c()rrrts,rvlrcrc he prac- pcerrs, they don't settlc. Call it prof'cs-
ticed hour aftcr hour. As hc Dut it. sional compulsivencss or prirlc, thesc
l(noraring Wlrat Yorr
Don't ](nour
Infirrnrecl Ix this ne\v perspective, the
tearn nrt>r'cdinto high gear. Strddenly',
sevcral strr<lic-s l'e'd come across dur-
ing oul rcricrr' of tlre literirtul'e took
()11 ll(-\\' rnearrine, illtrnrinated b1'
E r i c s s o n ' sl i n r l i n g t h a t d i r e c t { c e d b a c k
r n l r r l cl r l r i g r t i l I r ' r ' t ' rcr ri t t <r e a t i t t g p e t r
ple rvh<>t'xt t'llcrl. Tlrc first focused ott
p r i v a t t ' [ ) r ' l r ( t i t i ( ) n ( ' rs' soir k i n g i t r a n r a n -
asccl lx'lrariolul lrt'alth cztre tretrvork.
\,'etcrarr lcst'urclrt'r's Dcirdrc Hiirtt and
(]colgr' l Iulgllrr t' rrscd pccr- and
p r o v i r l t ' r 'r - : r l i n g \ .: t . n c l l a s a s l a n c l a r d -
i z c r l o t t t t o r t t ( ' l l l ( ' i r \ r . l r ' ( ' st <. l i t s s e s st h c
s u c c c s sl l t t ' s o l t h t ' r ' u p i s t si n t h c i r s a t n -
ple. ()n ct' u9:rirr . 1rt, ,r irlcr-srvcrt- Iixtud

"W.henever
I . . . figureel I oughtto
I'd closemy eyesand seethat list in the locker roorn
my ltaftle on it, and that usuallv got me going

"\{rhcrtevcr I rvas rvorking out arrd got physicians nced to knorv rvhcthcr thcl' t ( ) \ ' : u ' \ 's i q r r i l i t , r r r t l r i r r t h c i l e l l c c l i v e -
tircd and ligtrrcd I ought to stop, I'd lvcrc right, evcn lh()ugh fincling out is t r c s s .\ \ ' h a t r v l r . r l r . l r r l l r i n g . t h o r r g h , i s
<:lr>scrn1' e1'csancl scc that list in thc neitlrcr rcquiretl nor reirnbursirblc. t h a t t h r ' / r ' r r rrl ' l f t ' r t r r t t l r t ' r a P i s t si n t l t e
" ' I l r i s t ' x ( r ' a s t c P . " ! . r i <s s o r r s u 1 s ,{ i t ' c s
l o r ' k t ' r r o o r r r r l i t l t o t t t r t t t r r a r r r co r r i ( . s : t n r p l c t h o r r g l r t r l r ( \ \ \ ' ( ' r ' (o' r t p a r r v i t h
:rtrd that ttsrrallyg()t llle eoing again." thc srrperdi:rgn()stician, "a sigrrilicant l h c l r i . / . \ 1t ' l l t ' r t i r t i . \ s t h t ' b r i l l i a t r t
Snc.lt deliberale prartire, as E,ricsson aclvzurlageovcr his pt:crs. It k'ts hiln bct- c l c t c c t i v t ' S l r t ' rl , r k I l o l r n < ' s ( ) l l c c
g()es to great lengths to p()int ()ut, isl'l'l ter utrrlcrstartrl lrorv al)d whcn hc's obscrvt'r|. "\tt'rlior litr knrlts nofhitrg
the sarrrcas the rlrunber ot hours spcrrt irnpr'oviug." h i g h e r t h : t r ri t s t ' 1 1 .L"i k t ' < l i : r g n o s t i c i i r n s
()lr the job, btrt rathcr thc alllount ()f \Vithin clal's ol touching rlown, Scott rvho rIorr't lollotr ul) lttt<l rttclcll'
tirnc spccificallv dcvotcd to reachirrg had shirrcd Ericsson's findings lvith 2 r . s s l l n ) tch l r t t l r t ' i r ' . r r L r hs i s i s t o t ' t ' c c t .
firr' <rl>jerctivcs just bqond ortr's kttel oJpnr Mark arrrl Birrr'1,.,\r iltcllc'cttral fi'cnz1' r v i t h o r r lr l i r c t t l t ' t ' r l l r r r c kt.l r c i n c l l i ' c t i v e :
.ficiottl. Hc chicles anyonc rvho ltclieves firlkxved. Articlcs rvcre pullccl, seconcl- thcrirpists irr tlrt' Iliir(( ;ul(l I{argravc
t h a t c x p e r i e r r c c c r c a t e s c x p c r t i s c , s a r - ary' t'cf'crcrtces trackccl dow'n, atrd studl' :rssrrrrrerlthlrt tlrcv rvcr-cpcrfirrlrt-
'-just
ing, bccarrse you've been rvalking Ericssrrrr's918-paec Conltfidge Handbook ine irclcquatelr.
firr 50 vears doesn't n)can you're get- of lixperlise und l.xpert I'erfonnatte pur- Elicssorr's\rrrlk orr l)lactice ancl f'eed-
ting better at it." Interestinell', hc arrcl chasccl and rcaci c()\'cr t() cover'. In tltc' back :rlso explaint'<l strr<lit-sshowing
his group have lbund that elite per- process, ollr eirrlier coDfusion gave wa)' that rnost of us grorr' ( ()lltinuzrll)'in con-
Iirntrcrs across many diff'crcnt domains to nnderstanding. \\rith considerirble Iidence (x'er th(' ('()lusc of'ortr careers.
cr)gage ir"r the sanle anloutrt of such chagrin, we realized that rr,hat therra- d e s l > i t el i t t l c , , r 'r r o i r r r p r o r e r n c l liln o u r
practicc, on 2N'erage,everl' dar,, inclucl- pists per se do is irrclevant to greatl)css. actuirl rates of'srr<'r'<'ss. IInrd to believe,
inp; seekends. In a stud1,of 2O-y'ear-old The path to excellence rvould ncver be but true. ()n this sr'or-r'.the experience
musicians, fbr exarnple, Ericsson and found by lirniting our explorations to of psl,choloeist Patrl Clcrnent is telling.
colleasues found that the top r'ioliniss the wt>rld of psvchotherapt', with irs Throtrghorrt his lt'ar.s of practice, he
spent 2 tirnes as rnucl'r time (10,000 attendant theories, tools, and tecl-r- kept rrnrrsuallvthor'orrqh records of his
h o r r r s o r r a r e r a g e ) r v o r k i r r gl o m e e t s p e - niques. Instead, we rleeded to redirect rvork rvith clients. clctailine hundreds of
cific performaltce targeLs as the next o u r a t t e n t i o r t t o s u p c r i o r p e I f o r r r r a n te . casesfalling into 8(i rliflerent diagnostic
best players and l0 times as much tinre regardless of calling or carecr. catep;ories. "I had expectecl t<>fl'rd," he

j O vs:'c:H()TIIER-\pl NETwoRK!:.R r Norerrler/Decrmhr2

r 007
 said in a qualltitati\re analysis, published
in \Iay 1994 in the peer-rer,iewed jour-
nal Professional Pqch,olog: Research and
Practire, "that I had gotten better and
better over the years . . . but m), data
failed to suggest an)' . . . change in m1'
therapeutic eff'ectiveness across the 26
vears in qllestion."
Contrarv to conventional rvisdom,
the culprit behind such mistaken self-
assessment isn't incompetetrce but
rather proftcienry. Within rveeks and
months of first starting out, noticeable
mistakcs itr ever1.
day' professional
acti\.ities become
increasingly rare,
making intention-
stopr
Comparing todar"s success rates with
those of 10, 20, or 30 years ago is a wa\'
of finding out. One rvould expect that
the profession is progressirrg iu a nrarr-
ner cornparable to the Olrrnpics. Fans
knorv that during the last centun', the
best perfon-nance for everl' event has
improved-in some cases,b1'as much as
50 percent. \\rhat's more, excellence at
the top has had a trickledown effect,
irnpror.ing perfbnnance at everl' level.
The fastest time clocked for the
marathon in the 1896 Ollrnpics rvas.jtrst
we can learn from our experiencesand
improveour rate of success,both as a dis-
cipline and in our indir.idualpractices.
Incidentallr', ps1'chotherapistsaren't
alone in the struegle to increase
expertise. Durir.rgorlr sun'e)' of the lit-
erature on greatness,we carneacrossall
engaeing and provocative article putl-
lished in the December ti, 2004, ,Vaa
fbrkerntagazine.Usillg the treatment of
c)'sticfibrosis (CF) as an exarnple,sci-
ence rvriter Atul Garvandeshorvedhorv
the sarneprocesses undcrnrining excel-
lcncc in psvchothcrap_l'play
o u l i n n r e r d i c i n e. S i n c c
I !)Of , rncclic:rl rcscarchcrs
have been tracking the out-
comes ol' patients with CF,
a ge nctic disc:rsc striking
1,000 children yearly. The
discase is proeressive: over
tinte, rnucus fills, harderrs,
and eventually dcstroys thc

uuidrout
))
agaln.
al rnodifications
scen) irrelet,ant,
increasingly difli-
cult, and costly in
tt-rrns <>f time and rc'sources. ()nct:
lr)()re, this is human nature, :l pl'occss
th:rt clogs everv prol-ession. Add to this
tht' r'ustorn in our profcssion of conflat-
ing strccessrvith a particular mcthod or
techniqrre, and thc door to greatness
fbr nranv therapists is slarnrned shut
earlr' on.
Dtrring the last fcrv clecades, lllore
than 10,000 "how-to" books on pst.
chothelapr' have been published. At
the sarnc tirne. the nutnber of treat-
ment approaches has mushroomed,
soins frorn around 60 in the earll'days
to morc than 400. There are presently
145 officialh' approved, rnanualized,
evidence-based treatrnents for 5l of the
397 possiblc D.SM diagrrosric groups.
Based on these nunrbers alone, one
would be hard pressed not to believe
that real progress has been made by'the
field. More than ever before, rve knol
what rvorks for whorn. Or do we?
lungs.
As is the case rvith ps1.
chothe rapy, the eviderrce
indicatcs that standard CF
trcatmcnt works. With
mcdical intervention, lifc
expectancy is just over 30
Years; rvithout c:rre, tew
plliculs srrrvire irrfarrr'1.
The reirl story', th()ugh, as
Gawande points out, isn't
that patients with CF livc
one rnirrtrtelaster than thc tinrc currcnl. longcr whcl) trcatcd, but that, as rvith
11'requircd.jr$t Lo paflidpalein the rnost psychothcrap),, trcatrnent succcss ratcs
cornpctitivc marath()ns likc Bostorr and van, signilicrantll'. At the best treatment
Chic:rg<r. Bv contrast, rto neasu,rable ccnlcrs, sunival ratcs arc 50 pcrccnt
improuement in, the eJfectiuen,essoJ p$- higher than thc national avcragc, lllcan-
chotlrcrafr,tlrus ortunvd in. tlrc hst 30 years. ing that paticnls liverto bc -16on avcragc.
The tirne has cornc to confi'ont thc Such difl-ercnces, ho\,vever, haven't
unpleasirnt truth: our tried-and-true been achieved through standardization
strategies fbr irnproving lvhat rve do have of care and the top-clown ir-nposition of
f:riled. Instead of'advancing as a field, the "best" practir:es.Indeed, (linr:innirti
wc've staqnated, rnistaking our fer,'erish C h i l d r e n ' s H o s p i t a l ( C C H ) , o n e o l ' t h e
peddling on a stationarl bicycle for rlati()n's rnosl-rcspccted tf('lrtrncnt ccr)-
progress in the Tour de Therapl This ters-which ernplol's tlo ol-the phy'si-
isn't to sav that therapy is ineffective. cians responsible lirr pr-epar-ing the
Quite to the contrary the data are clear national CF treatrncnt guidclines-prcr
and unequivocal: psychotherapy works. duced only' average t() poor ()utconles.
Studies conducted over the last three In fact, on one of the rnost critical
decades show effects equal to or greater lneasures,lung functioning, this institu-
than those achier,ed b1' a host of r,vell- tion scored in the bottom 25 percent.
accepted medical procedures, such as It's a srnall comfort to knorv that otrr
coronary artery blpass surgery', the phar- counterparts in medicine, a field rou-
macological trealment of arthritis, and tinell'celebrated for its scientific risor,
MT for AIDS. At issue, horver,er. is how stumble and fall in the nursuit of excel-

\\Et\t()RKER.()XC j r
 lence just as much as we "soft-headed"
psychotherapists do. But Cawande's
article, which is clrrrentl)' available for
free from the .N'ea lbr*ar rvebsite
archives (www.nenyorker.com), pro-
ridr's much more than an opportuniq
to commiserate: it confirms what ollr
own research revealed to be the essen-
tial first .step in inrproring olltcon)es:
knorving your baseline perfornrance. It
just stands to reason. Ifyou call a friend
for directions, her first question rvill be,
"\Vhere are yort?" The same is tr-tre of
RandMcNally, Yahool and evcry other
online mapping scrvice. Tb get where
you want to go, \'ou first have to know
rvhere you are-A fact thc clinical starff
at (lCH put to good use.
In truth, nrost llracticing ps1'chothcr-
apists have no hard data on their suc-
cess rates with clients. Fewer still have
ant' iclca how thcir outc()rlres conrpitre
t o t h o s c o I o t l r < ' r<l i r r i c i a r r(s) r ' t ( ]n a t i ( ) n -
al norrns. Unlikc thcrapists, though,
the staff at (l(lH rrot onll' deterrnined
their ovcrall ratc of cfl'ectiveness, but
thev cornpared thcir successrates with
other rrraj<>r CIF' trc:rtrncl)t centers
zrcrossthe c()untry. With such ittforrna-
tion in hand, thev pushed beyond their
current standard of reliable perlirrnr-
ance. In time, their outcornes irnprovcd
nrarkedlv.
A Forrnula for
\\'ithin the last year, here in this coun-
trr and abroad, we've started teaching
this basic formula fbr success to thera-
pists. Each of the formula's compo-
nents-(l) determining your baseline
of effectivcness, (2) engaging in delib-
erate practice, and (3) getting feed-
back-depends r>n and is inforrned by
the others, rl'orking in tandem to create
a "cvcle of excellence."
2 vstt:HorHERAp\'
J
Turning to specifics, the truth is we
have l'et to discover how supershrinks
like Darvn and Gordon ascertain their
baselir-re. Our experience leads us to
believe that thel' don't know either.
\\hat's clear is that their appraisal, intu-
itive though it may be, is more accurate
than ttrat of average practitioners. It's
likeh', and our anah'sis thus far con-
firms, that the rnethods they enrploy
will prove to be highll'variable, def)'ing
any simple attempt at classification.
Despite such differcnces in approach,
t h e s r r p e r s h r i r t k sr v i t l t ( ) u l e x c e P l i o l l
possess a keen "situational alvareltess":
they"re obsen'ant, alert, and attentive.
They constantly conrparc new informa-
tion rvith what thcl' already know.
ShouldanyeloulDt
of determiningone'soverallrate of success,let us I
mereactof rAneasUfing
Thanklirlll', fbr the rcst of us rnere
mortals, a shortcut to supershrinkdom
exisls. It entails usirrg simple paper ancl
pclrcil sr:alesand sornc basic statisticsto
c()rnl)u(.c pur bzrst--line-a pr()ccss we
discuss in detail in the article that fbl-
lorvs. In the cnd, y()u rna)' not bccotnc
'figcr
thc Frank Sinatra, \4krods. or
Melissa Etheridge of the therapy w<>rld,
but Iotr'll be able to sing. srvins, unrl
strtrrn alor-rgwith the best.
The prospect of actualll' knorving
one's tnlc rate ()f sllccess can provoke
anxietl' even in thc best of us. For all
that, studies of workine cliniciarts pro-
ridc little reasor-rfor concern. To illus-
Srrccess trate, the outcomes reported in a
recent stud1, of 6,000 practitioners ar.rd
,18,000 clients were as good as or better
than tlrr>setypicalll' reported in tightly
controlled studies. Findings like these
are especially notable because clini-
cians, unlike researchers, don't have
the luxury of handpicking the clients
they treat. Most clinicians do good rvork
most of the tin)e, and do so while rvork-
ing with complex, clifficult cases.
. t N o r t t n b r r / D e e e n b e2r ( ) ( ) 7
\ ' . E T \ \ ' o R K FR
At the same, you shouldn't be sur-
prised or disheartened when your
resulls pro\re to be average. As with
height. rveisht, and intelligence, success
rates of therapiss are normally distrih>
uted, resembling the all-too.familiar bell
cun'e. It's a f:rct: in r.rearly all facets of
life, rnost of us are tightly clustered
arourrd the mean. As the research bv
Hi'.rtt ancl Hargrave shows, a much nrore
serious proLrlern is when therapists
don't knorr'horv the\"re performing or,
worse. think thev knorv their effective-
ness rr,ithotrt outside confirmatiou.
Unfbrtrrnatclr, ottr orlrr work in track-
ing the outconres ol thousauds of thera-
pisLslv<lrking in cliversc clinical settines
has cxposed a consislcnt and alarming
remainregardingr
yields i
patten): thosc slorvcst to adoPt a valid
and reliablc proceclttre for establishing
thcir bascline perfbrrnance typically
havc thc lx)()rcst ()utcornesof the lot.
Sh<lrrlrlarry rk>ubt renrail rt'gardirrg
thc valtrc and itnportartcc of detcrtnin-
's
ing orre overall ratc ol'success, lct us
underscore that the rncre act of Int'as-
uring Yiclds irnproved outconlcs. In fact.
it's thc Ilrst and arl)ol)g tlre tnost J)()tcnt
forrns o[ fi:edback zrvailablt-to cliniciat.rs
scckirrg cxcellencc. Scveral rccetrt stttd-
ies corrvincingly denronstratc that mon-
i t o r i r r g c l i e r r t p r < , e r c s s( ) n a n o n g o i t t e
basis irn pr-oveseffcctivelt css dranratical-
ly. Our own stud\', published last 1'ear in
the Joumal of Bfief Therapy, found that
pror.idine therapist-srrith real-tirne feed-
back irnproved outcornc nearly 65 per-
cent. So no dorvnside exists to deter-
rnining 1'otrr baseline eflectiveness: otte
either is pr()\'en effective or becolnes
nrore effective in the process.
Thele's more good news on this
score. Share 1'our baseline-good, bad,
or average-l'ith clients and the results
are even nrore dramatic. Dropouts. the
 single greatest threat to therapeutic suc-
cess, are cut in half. At the same time,
outcomes improve yet again. in particu-
lar among those at greatest risk for treat-
ment failure. Cincinnati Children's
Hospital prorides a case in point.
Although surprised and understandably
embarrassed about their overall poor
national ranking, the medical staff
resolved to share the results with the
patients and families. Contrary to rvhat
rnight have been predicted, not a single
familv chose to leave the progranr.
That everyone decided to remain
cornrnitted rather than bolt should real-
lv corne as no surprise. Across all typcs
of relationships-business, fanrily and
friendship, rnedicine-success depends
the value and importance
unelerscore
improvedoutcomes.
less on a conncction during the good
tirnes than on rnaintaining engagement
through the inevitablc harcl tirncs. Thc
fzrct thc CCH staff sh:rred the inlbrrna-
tion about their poor perfbrmance
incre:rsed the connection thcir paticnls
f-elt rvith them and enhanccd thcir
engagement. It's no different in ps1.
chotherapy. Where wc as therapists
have the rnost impact on securing and
sustainins engagement is through the
relationship with our clients, rvhat is
cornnronly referred to as the "alliance ."
\\Jrcn it works well, client and therapist
rc:rch and maintain agreement about
rvherc thcr,'re going and the means by
which ther"ll get there. Equally impor-
tant is the strength of the ernotional
connection. the bond.
Supershrinks, our own research
shorr's, are exquisitely attuned to the
vicissitudes of client engagement. In
rvhat amounts to a quantum difference
between themselves and average thera-
piss, they're much likelier to ask for
and receive negative feedback about the
oualiw of the work and their contribu-
tion to the alliance. \{re have now con-
firmed this finding in numerous inde-
pendent samples of practitioners work-
ing in diverse settings lvith a wide range
of presenting problems. The best clini-
cians, those falling in the top 25 percent
of treatment outcomes, consistently
achieve lower scores on standardized
alliance measures at the outset of thera-
p1'-perhaps because they're more per-
sistent or are rnore believable when
assuring clienls that they rvant honest
answers-enabling thern to address
potential problerns in the workinp; rela-
tionship. Mcdian therapists, by contrast,
cornmonly rcceive negative feedback
later in treatment, at a timc when clienls
have already disengaged and are at
thatthe
heishtened risk fbr dropping out.
How do the srrpershrinks continually
usc f'cedback rcgarding the zrlliance to
maintain cngagcmcnt? A session cotr-
dtrcted by Dawn, rescuer of thc box-
elde r bugs, is representative of thc work
donc b1'thc ficld's most effective prac-
titioners. At the tirne of' thc visit. rve
were working as consultants to her
agcnc)', teaching thc staff to use the
standardized outc()nle and alliance
scales, and observing selected clinical
interviews from behind a one-way rnir-
ror. She'd been meeting with an eldcr-
ly nran for the better part of an hour.
Although this first therapl'session had
lurched along to begin rvith, an easy
give-and-take soon developed benveen
the two. Everyone lvatching agreed
that, overall, the session had gone
rernarkably well.
At this point, Dawn gave the alliance
measure to the client, saying "This is
the scale I told you about at the begin-
ning of our visit. It's sornething new
we're doing here. It's a way for me to
check in, to get your feedback or input
\\' \\' \\'. P S\' (l H O T II E R A PY r- E T W O R K E U O U C
about what rve did here today."
Without comment, the man took the
form, and after quickly completing it,
handed it back to Darvrr.
"Oh worv," she remarked, after rapid-
ly scoring the measure, "you've given
rne, or the session at least, the highest
marks possible."
With that, everyone behind the one-
way mirror began to stir in thcir chairs.
Each of us was expecting Dalvn to wrap
up the 5655i611-6vsn, it appeared, the
client, rvho was inching forward on his
chair. Instead, she leaned torvard him.
"I'rn glad you camc toclal'," she said.
"It lvas a goocl idca," he respondcd,
"urn, my, uh, doctor told mc to corne,
in, and. . . I did, and, urn . . . it's been
a nicc visit."
"So, will you bc comins
bat:k?"
Without rnissing a beirt,
lhc rn:ur repliecl,
'Yort
ktrorv,
I'nr soins to be all right. A
pers()n docsn't gct ()ver il
thing likc this overnight. It's
soins lo tzrkente a whilc. But
don't yorr w()rry."
Rchind thc nrirror, we irnd
the stirll' wcrc surprised
'I'he
lugairr. scssion had gone
wcll. He'd been ensagcd. r\ fbllolv-up
appointmcnt had been rnadc. Now wc
h e a r d a r n b i v a l c t t c ci n h i s v o i c c .
For her part, Dawtr wastr'l abottt to let
hirrr olf t]rc hook, "I'rn hopirrg y<>uutill
corne birck."
'You
know, I rniss hcr tcrribly'," he sirid,
"it's anfr"rllylonely at rright. Rut, I'll bc all
right. As I said, don't rvorry about rrte."
"I appreciate that, appreciate wtrat
yor.r.justsaid, but actualll'rvhat I rvorry
about is that I rnisseds()rnethine. Come
to think about it, if we rvcre to chatrge
places, if I werc in 1'our shoes, I'd ber
'\{hat
lvondering, rcalll' can sltc knotv
or understand about this, and nrore,
what can she possiblv do?"'
A long silence follorvecl. Eventualll',
the rnan looked up, ancl rvith tears in
his eyes, caught hcr gaze.
Softly, Dawn continued, "I'd like you
to come back. I'm not sure what this
might mean to you right now but yotr
don't have to do this alone."
Nodding affirmatively, the rnan
stood, took Dawn's hand, and gave it a
squeeze. "See you, then."
J J
 Several sessionsfollorved. During that
period his scores on the standardized
outcorne nreasure irnproved consider-
abll'. At the tirne, the team was
inrpressecl with Dar.vn. Her sensitir.itl,
and persistence paid ofi keeping the
elderly nlarl ensased, ancl prevelltine
his droppine out. The rcirl import of
her actiotrs. hou,evcr. didn't occtrr to
an1'of us until much latcr.
All therapisfs experience sirnilar ir.rci-
sive lnonrents in their work rvith
clicnts-tirnes when they"re acr.rtely
insightful, discerning, cvcn
uise. Such expcricrrces zrrc
actualll' o[' littlc c()nsequencc
in scparating the good frorn
tlre great. h<xvevcr. Irrstcad,
srrpt'rior pcrfirrnrarrcc is
fcrund in the margins-the
srnrll brrt consisterrt difl'er-
r'nct' irr the nurttbcr of tinres
c<>rrcctil,cfcedback is songht,
srrccessfttllv obtaincd, and
then actcd orr.
Systernatically
Seeking Feedback
Most thcr;rpists, whcn askecl,
rcpr>rt checkine in routinelv
rvith thcir clients ancl kn<lrv-
ing rvhen to do so. Rtrt our
onl resear-t'hlilrncl this to
bc l:rr fiorn the casc. In r:arly'
l!)!)8, rve iniliated :t sturl1' t<r
i r r v c s t i g a t c 't h c i r r r p a c t t > n
tre:ltrncnt ()utc()nlc <ll-scck-
inq client fccdback. Scvcral lirrruats
wcre inclrrrlcd. ln 0nc, therapists rr,cre
strpposed to scck r:lient inlttrt infbrrnal-
lr', on their oln. In al)()ther, starrclard-
izcd, client-conrpleted outcorne and
alliance nlcasures were adrninistercd
and the restrlts shared rvith f-ellorv ther-
irpisLs. Trcatrnent-as-usllal sert'ed as a
third, control group.
Initial results of the str,rdvpointed to
arr advanurge for the feedback condi-
tions. Llltirnateh. hower,er, the entire
pr'oject hnd to be scrapped as a rer.iervof
tlre rirleotupes shorr'ed that the therapists
in thc inlonnal group routinely'failed to
ask clienrs for their input-even though,
when later queried. the clinicians main-
tained ther' /rarl soueht feedback.
For their part, supershrinks c<tnsis-
tentl)' seek client feedback about horv
the client l-eels abotrt thern and their
J I v s v t . H ( ) r n E R , \ p l ' N E r \ r ( ) R K ER r
rvork together; ther, don't just sa)' thev ellg:lgc in signilicantll rnore deliberate
do. Dawn perhaps said it best, "I alu'avs prircticc. Thut is. :rs Ericssol.r.the expert
ask. Ninen.nine percent of the tirne. it on ('\l)r'l t\ \il\ \. "elfirrtftrl activity
doesn't go anlrvhere-at Ieast at the clesignt'rl t() ir)il)r()\'c individr,ral target
mornent. Sonrctinres I'll get a call, bnt pclfirr-rrlrrrt't'." Spccific rI)ethods of
rarehi More likclr: I'll call, irnd every sc) clc'lilrt'r-uttlrlut tir'e lravc bectr developed
often m1' nosiness uncovers somethirlg, iurcl errrplort'rl in thc training of pilots,
some, I don't knorl quite horv to sav it. s u l g e ( ) l l \ .; u r r l o t h c r s i n h i g h h ' d e m a n d -
sonre barrier or break, sornething in i n u o t : c r r 1 l l r t i , , r r( s) .t r l r t t o s t r e c e n t r v o r k
the wav of our rvorking together." Such hns fircrrst'<lorr urluptitre these proce-
persistence in the Iace of infreqrrcnt clrtlcs firl rr't' irr psrt-h<)the rap)'.
payoff is a definini characteristic of I r r J ) r ' l r (i '(t : r l t ( ' r l l l s , t h e p r o c e s s
those dcstined- for- greatncss. i r r r ' o l r t ' s ( l r rt ' t ' s t ( ' p s : t h i n k , i t c t ,
lrrrl. llrrrrllr'. r'ct'lect. This
r r 1 > 1 r l r ,l:rr t t ' a l r l > c r e n ) c u ) -
lrt r t'tl lx tlrt' acronrrrt T.A.R.
f,, l)r('l)iu(' Iirr tttorirtg
l r t ' r , , r r rtll r c r e a l r r ro f r e l i a b l e
As absurdas it I
the bestof the l
per.{
1 l t ' r ' l i r r r r r a n c tch, e b c s t o f ' t h e
lx'st ('n{agc in li->r-ethotrght.
'l'lris
r r r t ' a n st h c v s c t s p c c i l i c
soals urrrl irlcntifi' the partic-
rrlul \':rrs thcr"ll rrsc to rear--h
tlrt'ir go:rls. It's iurportant
\\''herezrs birds can f'11',thc rest ol trs [ ( ) n ( ) l ( ' t l r a t s r r p e l i o r p c r f o r t n a t r c e
ncccl an airpl:rner.\\'hcn a sirnplc ntc:rs- r l t ' p t ' r r r l so r r a t t e r r r l i r r gt o b o t h t h e e t r d s
ttre of the alliarrce is usccl in conjtrnc- a r t c lt h t ' n r ( ' : u l s ,s i r t r t r l t a n c o t r s l l :
-Iir
ti<>rrwith a standaldized orrtcorrrcsculer. i l l r r s t r - l r t t ' ,s r r p p ( ) s c i r t h c r a p i s t
available evidcnce shows clients arc lcss wlrrrtt'rl t() inll)r()\'(' thc engagcntcnt
likelv to deterioratc, rnorc likely t() stav l c r c l o l c l i c r r t s r r r u n d a t ec l i n t o t r e a t -
Iorrger', and tzuiteirs likclv to achicve a lil('r)t li)r srrl;sl:rncc abuse. She'd first
clinicalll' sienificant chanse. \{hat's n t ' t - c l t r > r l t ' l i n t ' i r t n r e a s u r : r b l et e r n r s
trtore, tr'lten applied cln art agencrtvirlc Irorr'slrr"<l krrorv tlrat the: clicnt rr':rs
basis, tracking client prosress and expe a( ti\ch t'rrsugcclin the treirtrrlent (c.9.,
rience of the therapeutic relatiouship attcn(luncc. increased dialoguc, eve
has an eff'ect sirnilar- to the onc rrotccl c()lrtact. l)()sture. etc.). Follorving this,
earlier in the Ollrnpics: perfornrance thc thelapist rvould develop a step-by-
inrproves across the board; e\/ervol)e stcp plan lirr :rchieving the specific
gets better. AJohn F. Kennedy'was lirrrd objcctive.s.Bccatrsetherapies that foctrs
of saying, "A rising tide lifts all boat-s." on client goals rcsult in gleater partici-
\4trile it's true that the tide raises pati()n, shc rnight, create a list of ques-
everJ'one, we'r'e obsen'ed that super- tions designed tri elicit and confirrrr
shrinks conlinue to beat others or.lt of rvhat the client wanted out of therapl'.
the dock. Tivo factors account for this. She rnight also spend tinre ;urticipating
As noted earlier, superior perfonner-s rvhat the client rnigl.rt enumerate and
j' ot' r m b er / Dr t c til l) ? | 2 0 (.)7
 I)lanning a strateg)'for each response.
In the act phase, successful experts
track their performance: thel' monitor
on irn ongoing basis rvhether thc'1 used
cach of thc stcps or strategies outlitrcd
in tl.rc thinking phase ancl the qualit'r'
rrith rvhich each step was executed. The
shcer rrrlrrrne of detail gathered in
irsscssing their perfornlance distin-
srrishes the exceptional fronr their
nlore avefage counterparts.
During the reflection phase, top per-
fornrcrs rcrierv the details of their per-
frrrrnancc, iclerrtifling specific irctions
arrrl altcrn:rtc stratcgics for rcirclring
tlr ci l qoirls. \\1r cre rrnsucccssful I carn crs
pairrt uith broad strokes, attril>utins lail-
ul'c t() cxtcrnal and rrncontr<>llaltlt-lac-
The penchant for seeking explana-
tions for treatment failures can have
life-and-death consequences. In the
1960s, the average lifespan of children
lvith clstic fibrosis treated by "profi-
cient" pediatricians was three vears.The
field as a rvhole rt>utilrelv attribtrted the
hieh mortalilv r:rte to the illness irself-
a belief that, in rctrospect, can only' be
vierved as a self-fulfilline prophecl'. After
all, n'hl'search for altcrnative meth()ds if
the disease invariablv kills? Although
certainll' less dranrittic, psychologist
Williarn Millcr rnakcs a sirnilirr point
about ps1'chothclapr',noting that rnost
rnodcls don't accr>rrntlirr lrolv pcople
chanse, but ratlter rvhv thcv stal' the
sanre. Irr orrl experierrcc, diagnostic
Confronted by'novel, complex, or chal-
lenging situations, the focus of the
merell' prolicient performers narrows
to the point of tunnel r.ision. In chess,
these people ar-e easy to spot. Ther"re
the ones sittirg hunched over the
board, their firrgers glued to a piece,
conternplating the lc.rl rnove. But sttrd-
ies of pilots, air traffic controllers,
clnergellcy roorn staff, irr-rd others itr
denranding situations ar-rcl pursuits
shorv that superior pcrforrners expand
thcir arvareness rvhen cvcDts are stress-
ftrl, irvailins the nrselvcs ol' all the
options thcr-'r'e identifiecl, rchcarsed,
and pcrfcclcd <>vertirne.
Dclibcrate practice, [o bc sure, isn't firr
the harricd or hassled. Ncither is it lirr

sounels"
I bestsimplyworkharelel"
I
at improving
their
lfornrance thanothers
do.

tors (c.e., "I hacl a bad da1:" "l rvasrr't classificatiorrs ofictt s(:r1,ca sirnilar firrrc- slackt-rs.\'t't, the willinsncss to cngage irt
rvith it"), thc cxperls knorr,cxirr:tlyrvhat tion by attributins thercarrseof'a lailing deliber-:rtc practicc is what separatcs thc
//rr,rlo, rnorc ofien citing controllablc or lirilccl thcrapl' to thc clisorclcr. wheat lirrrtt thc chafl. The reason is sint-
Iactors (c.g., "I shotrlrl ]rave <lone x plc: cloirre it is unrcwarding in irltnost
irrstea<l ol-1," of "l lbrs()t to clo rcancl will The Valrre of Practice, cven' w:r)'. As Ericssotr rrotcs, "Unlike
rlo r plus 1 rrext tinte"). hr our rvork wilh Practice, Practice play, delibcr:rtc praclir:e is rtot itrlrcrenlly
psvchothcrapisls, wc'vc foun(l th?tt aver- By' cornparison with cxplanations that rnotjvzrtilrgi and unlike rvork, it cloes trot
lu!{cl)r:rctiti()llcrs Al'c far likelier t0 spend blarne the client or excuso thc thcrapist, leacl to irnrnt:diate social and ln()nctarJ,
tirnc hrpothcsizing about failed strirte- deliberate prar:ticc l)estows clcar advan- rclards. In irddition, cngaging in Iit]
gics-believine perhaps thal rrndt-r- tages. In placc ol'static stolies irnd srun- gcr)erates cost.s." N<> thircl parry' (c.g.,
st:rn<ling thc rc:rsons rvlrt' an apltroaclr rnary' cortcltrsiott.s,pr:rctice crrhances clicrrt. insurarcc cor)lpirny, or govcnl-
<lirln't rvork rvill leurd t() l)etter ()ut- oJrtiotrs.Take chess, ftrr exanrple. The nrcnt lx)d\') will pay f<rr the tinrc spcnt
rorner-and less tirne thinking altotrt trnirnaginable spccd with rvhich nlastcr trackirrg client proercss ancl alliance,
stratcgies that rnight be more cffecdve. players intuit thc lloard and rnake their identifiing at-risk cases,developirrg altt'r.
Rcturning to thc exilrnple zrbove,an rnoves gives thern the appcarance oI'wiz- n a l c s t r a t c g i c s .s c e k i r t g p c n t r i s s i o t t t o
avcr2rsc thcrapist rvr>uld be significantly ards, especially to dabblers. Research r c c o r d t l e a l n l c n l s c s s i o n s . r ' r r s r rirt t t {
likelier to attribute failure to engage proves this to be far frorn case. In point HIPPA compliance and confldcntialiry
I ht' rnanclated substance abuser t<t o f f a c t . t h e l l r o s s c s rst o t r r r i q r r eo r i r r n a l e s)'stematicall)' rer.iewing the lecordings,
cleniirl,resistance,or lack of rnotivation. abiliq' or advantage in memory. Far evaluatins arrd refir.ring the execution of
The expert, in contrast, would say, frorn it. Their conrrnand of the game is the strategies, and soliciting outside con-
" l r r s t t - : r d o f o r g a n i z i n g t h e s e s s i o r - r sirnplv a function of numbers: they've sultation, tririrring, or coaching specific
'dnrg
arotrrtrl t r s e , ' I s h o r r l d h a v e played this ganre and a thousand others to particular skill ses. And let's face it.
enrphasizecl rvhat the client wanted- before. As a result, thel' have more ferr'of rs are nilling pay f<rrit otrt of pock-
getting his clriver's license back. Next rneans at their disposal. et. But this, and all rve'r'ejust described,
tinre, I'll explore in detail rvhat the two The difference be[veen average and is exactlv rvhat the supershrinks clo. Irr a
of us need to do right nolv to get him rvorld-class players becomes especially word, ther" re self-rnotivated.
back in the driver's seat." apparent rvhen stress becomes a factor. Continued on page 56

\\- \\' \\-. P S \' (J I I O 1' I I E R,\ P l N E T \\' O R K E N. O N C;

J J

I
M.tt LF,R ftompage35
\4hat leads people, both children
and adults, to devote the time, energ)',
and resources necessar), to achieve
greatness is poorh' understood. Even
when the path to improved perform-
ance is clear and requires little effort,
most don't follorr' through. As repoltecl
in the December l-1, 2006, Nau Engl,a,nd
Joumal of Medicine, a study of 12 highly
experienced gastroenterologists found
that some doctors were 10 tirnes better
at finding precancerous polyps thar.r
others. An extremely simple solutior.r,
one involr.ing no technical skill or diag-
nostic prowess-spending morc tinre
and beins more thorough cluring the
procedure-was found to increase the
polyp-clctection rate by up to 50 per-
cent. Sadl)', acco|dirrg to a Decenrbcr'
19, 2006, Nnu York 7)nrasarticlc on the
strrdy.dcspitc tlris drarnatic irnprovt'
nrcnt. many doctors .spcnd rclatively lit-
tle tirne-conside rably lcss thar.r 30
rninutes-doing thc procedure.
Ericsson arrcl colleagues bclicve that
{irturc stu(lics o[ clite ocrfbrrners rvill
TAMFT 34th
Annual Conference
The original marriage and family
therapv conference in Texas
xm
lledtlrr
frInus
Snong
}{uch27{9,2ffi8
lslmd
Gdrnston
Conltntion
Cerrtff
SanLuilRnort
TO RECISTER:www.ta mft.ors
(? n s vc H o r H E R,\pl N E T \ \ ' o R K E R r N o u p ub e r /D e c en b e r 2 0 0 7
J
View publication stats
give us a better idea of how rnotivation
is promoted and slrstained. Until then, Scott Miller; Ph.D., Marh Hubblc, Ph.D.,
lve know that deliberate practice works and Banl Duncan, Psy.D., are cofounders
be.st when done multiple times each of tlrc Institute for tlv Studr of Therapeutic
day, including weekends, for short peri- Change. Tbgethry thry\rc authored and edit-
ods, interrupted by brief rest breaks. ed numerous professional articles and books,
"Cramming" or "cr-ash courses" don't including The Heart and Soul of
rvork and increase the likelihood of Change: \\rhat \\irr-ks in Therapy;
exhaustion and burnout. Escape from Babe l; Psvchotherapy with
To assist busy behavioral-health pro- Irnpossible Cases; and The Heroic
fessionals,the Institute for the Study of Client. Rerent\, Xlillrr and Hubbk rekased
Therapeutic Change is developing a a self-help DooA, Staring on Top and
wetrbased system for facilitating delib- Keeping the Sand ()trt of Vrur Pants: A
erate practice. The system is patterned Surfe r's Guide t() the Good Lil'e.
after sinrilar progranls in use with Duncan publislrcd thr v,ll-hclt Doo&\4rhat's
pilots, surgeons, :rtrd other profession- Right with Vrtr: f)cbrrnkirre D1'sfutrction
als. The advantase here is that the steps and Changing \irrrr I-if'e. Contact:
to cxcellence are autonrated. At info@talkingcut?.(om. lAters to the Ediur
w ' w u . r ' r ) \ ' ( ) l l l c ( ) n r c( )sn. (l . c l i n i c i a r r s a r c about this article may be e-mailed to
alreadl' ablc to tlack their outc()mcs, letters@psychn etzuorh er.or g.
cstablish their trirscline, and comparc
thcir performzlnce to national norms. RrrunnNcns AND Rf,souRcES
Thc svstern also pror,ide.s lecdback to Barcla1.,Robclt I-.. foscph .f. Vicari,
thcrapists whcn r:lients are itt risk f<tt' Andrea S. [)orrghtr', ct zrl.
-I'irnes
dcterionrting or dropping otrt. "Oololroscopic \\'ithrlr':rrr'al and
\{'e'rc currcntll' testing alqorithrns Adcnorna f)ctcctiorl rlrrring Screcning
that iclcrrtifl' patte nrs in the data associ- Ocrlrrrroscopr:" .\iir' I'.ttgland Journal of
ated with supcrior ()utconles. Such fbr- Medicitre 35ir, no. !-l (Dcct-rnber l-1,
mulas. based on thotrs:rtrds of' clier-rts 2006),2533--{1.
"Quantitative
and ther:r1>ists, will cnable us to idcntif1' Clcrncnt, l'urrl.
rvhen un inclividrral's perf<rrtrt:rnccis :rt Evalrration ol 2(i \i'als ol Prir':rtc
variancc rvith thc pattcrn ofcxcellctrce. Practicc. " I'nliss i rtttu I I'st r h o k471 It
: Researc
Whcn this happens, thc clitrician will bc andPrurlite2ir, no.2 (\lar 1994): 17176.
'\\'lrat
notified b'r' e-rniril of lur online dcliber- Colvin, flcolll'cr. It lhkes to Bt:
atc-pr:rcticc opportunit)'. Srrch training ()reat." I'or!uttt,,( )t tolrt'r 19, 2006.
will difl'cr frorn traclitional continrritrs (]aw:rrrclc,.\ttrl."Tlre Bcll (lurve ." 7he
education in two cr.itical ways. First, it'll Nar Yorkerl)cccrttlrt'r' (i. ?00-1.
be targctcd to thc dt:r'eloprnel)t of skill IIiatt, Dcirdlc. and ()corec E.
scts specific to the ncccls of thc individ- I'Iarsravc. "Tht' (.h:rructcristics of
-I'hcrapists
ual clinician. Second, and of grcater Highly l.ffectivc in Managcrl
c()nseqllcnce in thc pursuit of cxcel- Behavioral Prorirlt' r' N(' t\\'()rks." Ik hauiora.l.
'litntontnt,
lerrce, the irnpact olr olrtc()r))c rvill l>c Heahhrarr I ( 1995): l{)-?2.
irnmcdiately meixurable. It's our hope Miller, Scott l).. Barn L. f)uncatr,
that such a systcm will rnake the process Georgc S. (fcb) Ilrorvrr, et al. "Using
of dcliberate praclice more ircccssiblc, Forrnal Clicnt Ft't'rlback to Irnprove
less onerous, and rtruch morc efficient. Retenti<irr arrrl ()rrtcont<'." Jountal oJ'
The present era in psychotherapl'has Brief l'ltenln ir (20{)ti): i>22
been referred to by manv leading Villarosa, Lincla. "Doue Right,
thinkers as the "nge of accor-rntability." Colonoscopv Takes Tinre, Study Finds."
The Nau lbrk 7-ittu't.Hcalth Section,
Everl'one wants to knorv rvhat thel"re
getting for their mone)'. But it's no December 19. 200(r.
longer a simple matter of cost and the rrVanrpold, Rnrcc Fl., and (ieorge S.
bottom line. People are looking for (feb) Bronn. "Estirnatins Variability in
value. ,{s a field, rve have the means at Outcor.nesAttribtrtable to Therapists: A
our disposal to demonstrate the worth Naturalistic Studv of Outcomes itr
of psychotherapy in eyes of consumers Managed Care." Jotuttal of Consulting
ar"rd pavers, and rnarkedlv increase its and Cliniral Pslcholog;,73, no.5
value. The question is, will rve? I (Octobe
r 2005):91+23.