NP007 The Road to Clinical Excellence

This blog focuses on discussion regarding the course NP007 The Road to Clinical Excellence.

NP007, Excellence, Session 1, Scott Miller


We all strive to improve at what we do each day, but how do we achieve excellence as therapists? How do we ensure that we consistently succeed in helping clients?

The Road to Clinical Excellence includes six presentations, plus a bonus session, which are sure to change the way you think about clinical mastery. You’ll learn about the most recent research on the topic of excellence, and come away with practical ways that you can use to immediately and dramatically enhance your therapeutic effectiveness.

The first session with Scott Miller, the founder of the International Center for Clinical Excellence, will cover why experience, theoretical orientation, and interpersonal skills actually are not highly correlated with outcome. He’ll discuss ways to drastically enhance your performance and how to reinforce your clinical growth by creating “cultures of excellence.”

Please take a few minutes after each session is over to engage in the Comment Board. Feel free to comment about what you’ve learned in the session, to ask any questions you may have of the presenter or your peers, or to share any relevant experiences.

07.07.2011   Posted In: NP007 The Road to Clinical Excellence   By Psychotherapy Networker
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  • 0 avatar Jack Stoltzfus 07.12.2011 13:19
    There is a bit of a contradiction in the finding which I remember from the sixties or early seventies that college student- novices did as well as experienced therapists and the notion that practice, which I would assume means, to some extent, experience, makes a difference. So it must mean that experience doesn't make a difference unless it's certain type of experience driven by believing that it is important to improve and using a disciplined approach to this. Any reactions.
    • Not available avatar Scott D. Miller, Ph.D. 07.12.2011 19:46
      You've got it exactly right. Practice doesn't make perfect, it makes permanent. And modern clinical practice does not lead, in general, to improved performance as it is missing all of the crucial elements of "deliberate practice"--the chief element being, feedback and planned efforts to improve small elements of practice.
  • 0 avatar Merrilee Gibson 07.12.2011 13:30
    Well, I definitely feel challenged to learn more; will start with reading articles and downloading forms from scott miller’s website. It seems I have work to do.
    I’m a little confused, though. I remember reading a fairly recent article (sorry, don’t have specifics just now) that indicated something to the effect that more effective therapy was done by more experienced clinicians in whatever their chosen therapy mode. I need to look up that reference. Still, much food for thought, much to learn. Thanks for getting me started in this area.
    I hope we are all interested in improving our clinical skills and effectiveness. This webinar provided some specific suggestions to begin a process of improvement.
    • Not available avatar Scott D. Miller, Ph.D. 07.18.2011 12:46
      Hi Merrilee:

      Thanks so much for your note. If you do find the article, send it my way. In the meantime, here's a link that should shock and scare: http://www.msnbc.msn.com/id/43784188/ns/health/?gt1=43001.
  • 0 avatar Kevin Roth 07.12.2011 13:40
    I find it hard to admit when I "fall down" during a session. Each year I gain of professional experience makes it harder for me to show/admit/reveal some of my perceived struggles to my colleagues. I often see my struggles as "basic" and something I shouldn't be struggling with. Seems like my ability to tolerate my own judgements, beliefs and feelings about my clinical work and its imperfection will play a big role in improving my work. Does anyone else struggle with this?
    • Not available avatar Scott D. Miller, Ph.D. 07.12.2011 19:49
      I LOVE this comment Kevin. It is so honest and goes to the very heart of the issue. So, let me offer something I found reassuring in the expertise literature: experts in their chosen field often spend MORE time than average performers reviewing the basics! The rest of us (me included) keep looking for the technique (trick, insight, understanding, method) that will make up for our shortcomings. Thanks for your comment. You have a lot of company...
    • 0 avatar Jussi Light 07.15.2011 18:03
      yes yes - shame is the great enemy!
      • Not available avatar Scott D. Miller, Ph.D. 07.18.2011 10:17
        Yes, absolutely. And the cure? As we point out in the article, not the avoidance of mistakes and appearance of perfection but rather the identification of one's "edge"--zone of proximal development--and support from the community to push performance to the next level.
    • 0 avatar Deborah MunGavin 07.19.2011 17:05
      Thank you, Kevin, and Scott, for highlighting what our perfection-seeking culture makes so difficult to engage in -- talking about our struggles, particularly, for me, when they may seem basic. It was like fresh air to see that in writing, Kevin. Me too. I can be quite self critical when alone and quite able to discuss difficulties with a complicated "case", but it would help me and my colleagues (I work in a school system) if I could allow myself the room to still be a "beginner", a learner who will inevitably sometimes make the obvious mistakes. I think that when we do blunder something we think we should have mastered long ago, it's MOST instructive, but those are the times I find it hardest to talk about with people I want to respect me. I'm thinking of the phrase "beginner's mind", from Zen and Yoga practice, a good way to live, a good way to look at practice. The simple, basic "messup" I didn't want to admit has more often than not led (when I'd finally deal with it) to clearing up a critical blind spot, often led to a break through. I think that's because the basic stuff is the big stuff, not the easy stuff. I wish I could integrate that concept into my work as easily as I can type it! But those old messages we got as kids die hard. A good place for me to "lean in". Thanks again for the inspiration. I'm excited to explore some of the resources suggested.
  • Not available avatar Virginia Hostman 07.15.2011 12:52
    I appreciate the focus on a straight forward model to approach excellence. I'm not in practice, but I do want to keep my skills and knowledge current. I fully agree with the need to have a mentor and support community.
    One request, please use black rather than blue for sub comments on "slides", I couldn't read anything other than the dark large print, The blue was too light. Thank you.
  • Not available avatar amy olson 07.15.2011 13:13
    In my practice, I attempt to periodically check in with clients for feedback on how the work is going for them. With many clients who have a great desire to please, I get responses anywhere from "fine" to "it's just great". It's difficult to pull out what is going well, let alone what is not. I looked at your feedback rating scale, and imagine I'd have similar difficulties even with a written instrument. Can you help me with a few more responses (in addition to the one you mentioned about what could make me an 11 if they rated me 10) if I am wanting more authentic feedback from a client. Particularly if we are just doing it verbally, without a written instrument? Thank you so much for the awareness too, that our profession may operate on insecurity. So much of the desire to learn new techniques comes out of therapist insecurity, vs. what is really best for our clients. We truly have become a generation of workshop junkies. I'm just now learning to stop learning so many new things and deepen and refine what I already do.
    • Not available avatar Scott D. Miller, Ph.D. 07.18.2011 12:51
      Hi Amy...GREAT question...and more than can be answered in a reply like this...may I recommend checking out the ICCE (centerforclinicalexcellence.com). Recently, the entire community was discussing this very question and posts went back and forth with suggestions and ideas. I believe the exchange occurred in the "Expertise and Excellence" forum. That said, obtaining negative feedback is a skill that is teachable. We find that the top performers receive more of it than their more average counterparts. Couple of hints? Stop looking for authentic feedback (its too vague) and look for task specific feedback. Say, "A 10 out of 10 is quite unrealistic, life's not perfect and neither am I, so anything that you would like changed about the work we are doing?" or "This doesn't have to be a big issue or concern, something small, specific--a word, gesture, the focus of the session, homework, etc.--that would leave you feeling more understood?"
      • 0 avatar Judith Gregory Bowes 04.19.2012 17:35
        Scott, this is a very helpful way to get more specific feedback avoiding vague generalities. I hadn't thought about going to the client for feedback as early as you suggest but it does make sense. That, along with good supervision and peer groups, seem essential for me to learn from others and improve my skills. I have gone to your website for the performance measures.
        Sorry to be late in responding here. I had been looking for a quiz but gather this is it? Much more interesting this way! Thanks to you and Rich for making this possible.
  • 0 avatar Jussi Light 07.15.2011 18:01
    It makes sense - I am a guitarist, in addition to a therapist, and if I want better outcomes (to sound better, to get gigs, to play with the really good players) I have to constantly practice, rehearse and expand my abilities (stealing other guys riffs!). Why should it be any different for therapists? I recently watched the Charlie Rose brain-series and on the last show he focussed on creativity and the brain, so he brought the artists Richard Serra and Chuck Close - the discussion started to focus on their genius, to which they each replied words to the effect, "its not about whether we're geniuses or inspiried - its that we work at our art constatnly...and we learn from what doesn't work." This seems to be the same idea that Scott and Rich discussed. Excellence in any field is achieved by working at becoming excellent - nothing less. And the particular work is not mysterious - it is not the result of "being a genius" (although I'm sure that helps) or being inspired...no it is by following time-proven methods like measuring outcomes, getting feedback from others who will be honest about both stengths and weaknesses, working with mentors/teachers etc. Its exciting to think that I/we can acieve excellence as therapists. Thank you Scott for all your work and Rich for these amazing webinars you put on - I have caught the last three and all have challenged me greatly to grow and to continue building my community to achieve excellence - thank you so very much,
    Jussi Light
    • Not available avatar Scott D. Miller, Ph.D. 07.18.2011 12:52
      Brilliant Jussi and spot on. Working on it is key. and recall, DOING therapy day after day is not the same as PRACTICING at improving one's therapeutic skills or outcomes.
      • 0 avatar Jussi Light 07.18.2011 16:52
        right - its like when I first learned to play a difficult song and only got it half right...but I never learned how to really play it accurately - all these years later how do I play it still...the wrong way. Its not me playing it over and over that matters, but me stopping, figuring out how to play it accruately, then practicing the accurate way with feedback and so forth. With therapy, I have to watch my own video tapes, show them to others, get feedback and identify what I'm getting stuck on so I can focus on that and then figure out where and when to actually practice that. The EFT community (Sue Johnson's work) here in San Deigo offers this opportunity monthly and sometimes (like this past weekend) we go in deep and spend 8 hours in small groups with trainers, role-playing and focussing on what we need to improve. But what a difference it makes! Thanks for your comments
  • Not available avatar John Gillick 07.16.2011 13:33
    I found the presentation to be both inspiring and useful. It reminded me of how much I enjoyed working on good clinical teams at the VA where we would review problem cases routinely. It takes a real effort to get a resource for similar review in solo private practice. I downloaded the evaluation tool prior to the broadcast and will begin using it shortly. It was very useful to estimate the percentage of clients improved, static and doing worse. I recognized that I have gotten a bit too complacent doing supportive therapy with some long-term patients who made significant gains earlier in treatment.
  • Not available avatar Charles Hershkowitz 07.17.2011 05:47
    I am a psychiatrist in private individual and couple (Imago) private practice in Brussels, Belgium. This talk was quite exciting. May I also recommend Mihaly Csikszentmihalyi's book "Creativity: Flow and the psychology of Discovery and invention" (Harper Perennial paperback, 1997) on empirical study of 200 recognized very high achievers in varied sciences, arts, corporate areas, etc., and how they actually function to get their results. The most useful points of Miller's talk for me where I am now, after using SRS haphazardly over the last few years: have more of a strategy for right after a laudatory SRS is handed in; build routine SRS use into the written therapy "contract" I use with clients; expand my presently minuscule error-centric Community of Practice, despite the largely error-phobic French cultural environment around me here.
    • Not available avatar Scott D. Miller, Ph.D. 07.18.2011 12:53
      Thanks so much for your note Charles. The members of ICCE can serve as part of that community of excellence!
  • Not available avatar Renee Segal 07.17.2011 09:51
    Thank you for this webinar session. I am a therapist in private practice and I just started using the ORS and the SRS two weeks ago so the timing couldn't be better. I am an LAMFT and was shocked to hear that once formal supervision is done the therapists don't get better. Learning from the client gave me some comfort regarding this. At least I will have a built in feedback system. I also liked Scott's comment regarding when I feel stuck to lean in because I can learn from this.
    Like the others above have commented, most of my clients are rating the sessions either a 9 or 10. A new client told me that she wanted me to help her focus on a specific area of her problem. It was the 2nd session and I just let her go on because I wanted to see what the scope of her feelings were about it. I never would have known had I not given her the rating scale. I like how Scott suggested that we need to learn and expand the negative comments. At first, I was worried about giving the clients the form, but now I look forward to it. This talk was inspiring and very helpful. It is easy to blame the client for not getting better because they are resistant and their disorder is tough but we as therapists are really the ones to create the change. Thank you for providing us this information. I will be thinking differently this week.
    Renee-Minnetonka, MN
    • Not available avatar Scott D. Miller, Ph.D. 07.18.2011 12:57

      Your comments made me think of something--a detail--that I don't believe came out in my discussion with Rich. That is, most people who complete the SRS, score very high. Indeed, in our original normative samples, on average 75% of people score 36 or higher. So, here's what's important to conclude: a single point move is more than likely meaningful. Anytime the scores decrease--even a single point--be sure and address this openly and transparently with the client. If they can't identify anything concrete, offer to contact them at the end of the day. I usually start that call by saying, "I have about 5 minutes here, but just wanted to follow up...". The SRS is helpful in securing engagement in the absense of change or improvement and presence of relational difficulties between client and therapist! Hope this helps.
  • 0.1 avatar Ruchama Fund 07.17.2011 14:54
    Thank you for an inspiring and informative webinar. I'm wondering if you have a suggestion for improving a community of fellow therapists that offers suggestions and support, but is perhaps too polite and not critical enough.
    Ruchama Fund, Ph.D.
  • 0 avatar Liz Forbat 07.17.2011 15:08
    I found this a very inspiring seminar.
    It's the first time i have written myself a to-do list after training... can't wait to get going on it. Thanks Scott.
    Liz, Edinburgh, Scotland.
  • Not available avatar Joy Lang 07.17.2011 16:30
    Thank you for a very enlightening seminar. I took several notes and have already logged on to the website to obtain the session rating scales.
    I liked the straight-forward and practical aspects of the seminar. Thanks again for this!
    Joy, Waterloo, Ontario
  • Not available avatar Bill Frederick 07.18.2011 09:16
    Hi Scott the update was great. It was for me a reminder to be involved with ICCE. In addition the notion to stop and think both before the session over and after it over was helpful. Just seeing clients and actively using ORS and SRS, while helpful is not enough to actively improve. It seems there is alway something else to do that can overtake this process of thinking.
    • Not available avatar Scott D. Miller, Ph.D. 07.21.2011 06:46
      Thanks for your note Bill and the plug about ICCE. It is truly a "community of support" in action. 1000's of therapists working together toward a single goal: improving the quality and outcome of behavioral health services on therapist at a time. Indeed, its the largest such organization online. Most important: it's free! No secret premium levels. Just peer to peer support and interaction.
  • Not available avatar ann 07.18.2011 12:56
    Really enjoyed the presentation on many counts. as a compliance officer and practioner. The state regulatory bodies r asking for more and more 'evidence-based" practices and aside fr single subject design that I learned 20 yrs ago in grad school, no one is generating a simple " how to" that does not get everyone anxious yet pushes the envelop.
    look forward to trying out your scale. Thanks,
  • Not available avatar Karoline 07.18.2011 16:45
    This was a great talk & I have been a rapt follower & user of the ORS & SRS for a number of years.

    One question that I have had, that has also plagued my colleagues at the community agency I work (and where we use the ORS/SRS) relates to the issue of "non-responders." This is a term that I borrow from Moshe Talmon in his work in Single Session Therapy. He says that up to 1/3 of clients presenting to community agencies are "non-reposnsive" to any length of therapy with anyone. He has identified some characteristics of this group in his work.

    We use processes such as reflecting team, supervision, peer consultation, case review, transfer, and so on, and still find that a small group show no improvement. These clients also tend to rate SRS above the cutoff, indicating satisfaction with the service.

    In this presentation, the implication is that, given the right conditions ALL clients will improve. I am wondering what Scott & others think about what Talmon calls "professional clients."
    • Not available avatar Scott D. Miller, Ph.D. 07.22.2011 11:53
      Great comments and questions Karoline. On the issue of non-responders, let me digress a bit and then come around to the question. Data have long indicated that the largest (or at least one of the largest) sources of variability in terms of outcome is the therapist. As I said during the teleseminar, therapist outcome vary considerably and 97% of that variability is attributable to THE THERAPIST. By contrast, client variation in the alliance is not associated with differences in outcome between therapists. Now, returning now to the statement, "some clients are non responsive to any length of therapy with anyone," if you consider the statement carefully, it cannot possibly be true. How would such a hypothesis be tested? How could anyone measure whether a person is not responsive with anyone. NO such evidence exists that I'm aware of, nor could it ever. Does this mean that all therapists can help all clients. No. What it does mean is that individual therapists will not help everyone they meet. In such situations, a therapist in search of excellence will look to him or herself, to the zone of proximal development--the edge of their expertise, seek feedback and coaching, plan, then practice. To do otherwise is to shift the burden of failure to the client. We are the professionals. Even if we fail, the approach should not be to identify the characteristics of the clients that prevent success but rather the qualities of therapists who do. At the same time, clinically, since each therapist will not help all clients, therapists can use the measurement tools to identify the specific client they are not helping and at some point move the client on to another therapist or program. Hope this makes some sense. It's a great comment!
  • Not available avatar Sellina Kaylor 07.19.2011 05:18
    Well, this is good news. As someone new to private practice, through supervision I realized I'm experiencing a significant counter-transference reaction that can feel almost paralyzing at moments. I rarely hear anyone at conferences speak about something they struggled with and quite honestly, I was ambivalent about whether I should continue in the field. Well, Hallelujah is all I can say. I'm on the right track by working the problem. Thanks!
  • Not available avatar Carol McDermott 07.19.2011 11:39
    Thankyou for a helpful guide to improvement. I am looking forward to downloading the outcome forms. Using them will be a challenge to how I usually use the last few minutes of a session. Do you discuss the results with the client? When?
    I have a thought about the supertherapist. I have studied many theorists and notice that they seem to be exceptional because they have discovered what about themselves has worked in the therapeutic alliance..to engender trust(feeling safe, accepted and understood. For me, Carl Rogers is a good example of pushing the envelop with great humility.
    • Not available avatar Scott D. Miller, Ph.D. 07.22.2011 11:54
      Hi Carol...one cautionary note...be careful about assuming any theorist--me included--is a supershrink...most of those with the mega-phone in our field NEVER publish data regarding their own effectiveness. If it were me, I'd demand it...
  • Not available avatar Sharon Kocina 07.19.2011 11:40
    I am currenlty part of a peer consultation group. We're all in private practice and discuss challenges we encounter in our sessions. I haven't used it to discuss my errors, just to get ideas if I'm stuck. Scott, thank you for the idea.

    Rich, when I increased the size of the slides, they became blurry. This is not a problem I encountered in your last series.
    • 0 avatar Psychotherapy Networker 07.21.2011 10:27
      Hi Sharon. You're right - we had some technical issues with formatting this set of slides so they may get a bit blurry when enhanced. It shouldn't happen again in the future, and we're sorry about the inconvenience. You can always download them if you want to see them again from Your Purchased Items or, if you were viewing the rebroadcasts and don't have access to them, feel free to email support@psychotherapynetworker.org and we can e-mail them to you directly so you can have a chance to view them again. Sorry for the inconvenience and hope this helps!
  • 0 avatar Stephanie Buehler 07.24.2011 22:41
    What about the perennial question, what is success? If I help a couple break through a roadblock, but it means the disintegration of their union, have I failed? That depends! I have had at least two couples in my practice recently who decided to divorce--and thanked me for my work. I think it is extremely important to understand what it is the client wants. I also consider it success when I identify that I am *not* the right therapist for the client and refer them to someone who has the expertise they need. I think it is a big mistake for therapists to think they can treat every client who comes in the door. Much more compassionate to let the client go to someone who might provide them with better treatment.
  • Not available avatar Susan Miller 07.25.2011 17:44
    I apologize for the late posting of this comment...I listened to Scott's presentation and then had to fly out of the country..Because I found the presentation so pertinent, I wanted to post... So good to hear the reserach findings re: therapeutic effectiveness over time... Good too to know my tendency to rate my therapeutic effectiveness on the lower side of the scale isn't just self-diminishment but more like reality! I've long used David Burns' "Empathy Scale" to receive feedback from clients. Even though it's been time consuming, it's also been valuable. [I also highly respect Diana Fosha's approach ('The transforming power of affect: A model of accelerated Change' which emphasizes the importance of interaction/connecting/feedback in the client-therapist relationship.] I appreciate Scott's willingness to share other 'feedback' options -- i.e., the Session Rating and Outcome Rating Scales. The steps re: how to use client feedback to improve therapeutic effectiveness are gems! Thanks Rich for another beneficial seminar. This community is great!
  • Not available avatar Suzanne Gamache 07.28.2011 06:53
    As someone who on a good day believes I am nothing more than an average therapist with mediocre results(and we won't get into where my head goes on tougher days), I am so relieved to hear that at the very least I don't need psychiatric hospitalisation. For years, I kept thinking that if I just hit on the right method, training, technique, I'll feel better and perform better. Thank you, Scott, for such a clear message about the smart direction to move in next. I feel inspired and hopeful for future improvement!
  • Not available avatar Karen 08.15.2011 14:32
    Is there a clinical excellence group in Miami FL?
  • 0 avatar Antonia DePalma-Brandt, LCSW 09.07.2011 11:08
    I have just listened to this segment of the clinical excellence program and am both moved to do better with self-assessment and deliberate practice yet somewhat perplexed by the data on unrealistic perceptions of effectiveness by practitioners. Are these private practitioners, are they psychologists, clinical social workers in community mental health, psychiatrists, or lumped together ( I may have missed the detail)? As a clinical social worker in nyc, in small private practice and working in a clinic, I can honestly say I do not have an inflated perception of my effectiveness and accept the need to work at improving skills. I want to comment on my perception of how the impact of overwhelming competition for clients in private practice ( i.e. in NYC); as well as the overall devaluing of mental health services that (in my view) has been occurring over the last 15-20 years, i.e. by insurance companies has become a factor in relation to this topic overall and perhaps the inflated professional self-assessment cited. Many of us persuing private practice are currently being "coached" to market ourselves, find our "niche" and provide bullet points on our practice effectiveness on websites as though we're producing a "guaranteed" product. While I recognize my view may be limited by my experience and agree that improving skills and accountability are important to growth as a clinician ( and to practice); I think it is important to look at the issue of professional "validation" at hand in an increasingly competitive economic environment, where let's face it, we're all trying to support ourselves doing work we believe is our calling. Our clinics expect excellence in comprehensive treatment/accountablility without acknowledgement in pay which is again, a macro issue and we are in the position of fighting for fees (which keep going down due to issues with insurance) that can adequately support practice--- and I'm not talking about inflated fees---- I guess my main point is, although I absolutely agree with the presentation, I think the issue of self-perception in practice is not only a matter of deliberate practicebut has a socio-economic component that often seems "taboo" to discuss. I wonder if some studies have been done on this topic and about how it may be related. Then again, I wonder if the bubble of delusion about effectiveness may have more to do with the level of education that causes a kind of "ivory tower"/"entitlement to excellence" effect on a particular practitioner's self-assessment?
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