CLEARER THINKING

with Spencer Greenberg
the podcast about ideas that matter

Episode 070: Why does psychotherapy work (when it works at all)? (with Scott Miller)

September 9, 2021

How can we make psychotherapy more effective? How much confidence should psychotherapists have in the efficacy of their methods? How does deliberate practice differ from mere repetition? How can we overcome confirmation bias, the Dunning-Kruger effect, and other blind spots in our own fields of expertise? What are the most significant predictors of positive outcome achievement for clients in psychotherapy? When a patient has a physical ailment, doctors gather data, diagnose the ailment, and prescribe a particular treatment; but to what extent is psychotherapy similar to that model? To what extent do psychological models reflect the culture in which they're created? Has psychotherapy improved its efficacy over the course of its existence? When the therapeutic relationship seems less than optimal or even difficult, how long should clients stick with a therapist before switching to a different one? What are some meta-analyzers getting wrong when they compare treatment methods?

Scott D. Miller, Ph.D. is the founder of the International Center for Clinical Excellence, an international consortium of clinicians, researchers, and educators dedicated to promoting excellence in behavioral health services. Dr. Miller conducts workshops and training in the United States and abroad, helping hundreds of agencies and organizations, both public and private, to achieve superior results. He is one of a handful of invited faculty whose work, thinking, and research is featured at the prestigious Evolution of Psychotherapy Conference. Email him at info@scottdmiller.com or learn more at scottdmiller.com.

JOSH: Hello, and welcome to Clearer Thinking with Spencer Greenberg, the podcast about ideas that matter. I'm Josh Castle, the producer of the podcast. And I'm so glad you've joined us today. In this episode, Spencer speaks with Scott Miller about purposeful and deliberate practice, making therapy more effective, and feedback and measurement for therapists.

SPENCER: Hi, Scott, welcome.

SCOTT: Thanks. It's good to be with you, Spencer.

SPENCER: Yeah, I'm really excited to have you on. In particular, I think you're studying something that is really neglected and incredibly important, which is how do we make therapy more effective? So do you want to tell us first a little bit about your journey? How did you get on this track to try to figure out how therapy can be more effective?

SCOTT: Well, I think this has been my path from the outset for many other people, my classmates at the time I was going to graduate school. They seemed much more confident than I did about their ability to help others. I, by contrast, was fraught with anxiety, freaked out about whether or not I would actually connect with people, know what to do with those folks, and then they would benefit from it. So I was never very certain. And that's what guided me from the outset, simply moving from idea to idea, practice to practice in an effort to find how I uniquely as a person, and as a practitioner be more helpful to the people I worked with.

SPENCER: What do you think the confidence of the other practitioners that you interact with was born out of?

SCOTT: I have no idea, I still don't understand it to this day, I was fraught with anxiety, I can remember a conversation I had with a fellow graduate student and at the time, we were learning about dreams. And I talked about a dream with her that I had. And she instantly and quickly summed it all up. Well, that's an anxiety dream. And I was surprised by her ability to come to that conclusion so quickly. And I also felt ashamed that I hadn't been able to figure it out so fast.

SPENCER: Do you think that this is a personality difference, at the end of the day? Do you think that you have a different personality, which doesn't give you that immediate sense that whatever you're doing is working? Or do you think something else is going on?

SCOTT: You think that now looking back some 35 years in the field that a lot of this has to do with a sense of proficiency. Once you feel you've achieved that and you're proficient, then that begins to interrupt your desire to learn and change. And instead, anything that you encounter that's new is simply integrated into your hypothesized or supposed knowledge. And that sense of proficiency is typically accomplished the research literature and expertise tells us rather quickly. And that same literature says that, after that, we don't grow and develop, in fact, we actually decline in our ability while our confidence increases. But that's some 50 years on, and I've just never felt very proficient at anything I did. And I think for me being able to see that there was somebody who could do this better than I could who had better results than I could. So I wanted to emulate those superior performances.

SPENCER: It's interesting to think about the role of confirmation bias in this, that once someone's convinced that what they're doing is effective, it seems that we humans are incredibly adept at sort of making the evidence fit that strong belief and kind of reinterpreting things in that light. And especially, if we don't have sort of hard numbers staring us in the face showing us whether what we're doing is working or not.

SCOTT: Hmm, you know, the only quibble I have with the expression confirmation bias is the bias part. It's so difficult to know whether you're on track or not. And especially so in a field like psychotherapy, or becoming a mental health practitioner, the feedback that you get is minimal, not only while you're in training but from the clients. It's often inconsistent. And I think we are looking for any evidence that we're on track with the people we work with and with improving our knowledge. Bias may come in later, when in fact, we have achieved a sense of proficiency. And then we look for confirmation that faculty are proficient rather than looking for the evidence that says here's where I could grow and like you say, Spencer, I think it's very difficult unless you have hard and fast numbers. Now, I will say that there are some clinicians, and some performance and other endeavors that are good at that naturally, it seemed their growth edge. But I think the literature is also very clear for most of us, we're not.

SPENCER: It's interesting to contrast this with, let's say, a top athlete, where you imagine if you go to a top athlete, like who's competing in the Olympics, maybe won the gold medal last year. My guess is that they could point out to you a whole variety of ways that they're deficient at their sport and that they're working on actively improving. Would you agree with that?

SCOTT: I would say that they are as a group probably better at that than the general population. I think the key is that they're able to identify their shortcomings without shame, they instead see that as an opportunity as the growth-edge is the thing that will push their performance to the next level. But humans, as a species, regardless of the endeavor, tend to be satisfied with proficiency. You see that, for example, in driving, once you've achieved a certain level of proficiency at it, well, then your growth really stops. And if you haven't had an accident or a moving violation in any length of time, then suddenly not only are you proficient but you're confirmed in that profession, you actually think you're getting better. "I haven't had a ticket in 35 years," people say, which is synonymous with "I'm obviously very good at this activity." But if you measure their actual performance, you can see loads of areas for improvement, in the fact that they haven't been in an accident or received a speeding ticket or another moving violation is more an indication of chance, rather than a meter of their ability.

SPENCER: Yeah, it's interesting because imagine a situation where drivers were just every time they went on the road, they got graded by a third party about how well they drove, I imagine that they would actually improve considerably. Yet, as you point out, you know, people can drive for 30 years, it's not clear that they're actually getting better, which sort of tells the light of that idea that oh, to get better, all you have to do is do something a lot. And you want to comment on that?

SCOTT: Well, I think this is the big challenge and beginning to apply the work that we're presently doing on a subject called Deliberate Practice, and separating that from practice, which is mere repetition. Most people repeat an activity until they're proficient at it, and then doing it in their daily life reinforces the way that they do it. A colleague and a friend and a mentor of mine, an award-winning magician by the name of Michael Amar, always says practice doesn't make perfect, he says it makes permanent. It's a Deliberate Practice that can refine your performance. In the big person, the big researcher in this area, the person who actually coined the term was a psychologist, a Swedish psychologist by the name of Anders Ericsson, who unfortunately left the planet last July 2020. He was a visionary in separating out practice mere repetition from deliberate practice, which is consciously and intentionally trying to push your performance just beyond your current abilities. And that's quite different. And in order to do that, you do need to have feedback, feedback is a big component. But even that isn't enough. You also need to have a meter of your baseline performance and an estimate about how good are you in your performance. Once you identify that, you're going to need a coach, likely that will help develop exercises to master that next small improvement. And then over time, you will focus on continuous refinement of that ability and pushing your performance to the next objective.

SPENCER: So let's use an example to make this concrete. Suppose someone wants to become a better typist, right? They want to type faster and more accurately, how would they apply a Deliberate Practice to that?

SCOTT: Well, here's an area where Deliberate Practice has actually been applied. And there are entire chapters written about this. And some of the work that Anders Ericsson has done, you would have to do a baseline assessment of typing ability. How many words? And what is your accuracy? And what is the performance of your fingers on the keys? Are you able to just read the text and type at the same time? Or are you continuously looking back and forth? All of these are part of the baseline assessment. Once that's known, for example, with regard to speed, a coach could help you develop exercises that would help you improve that speed or help you keep your eyes on the page. And those exercises would hopefully improve your speed or improve your eyes on the page, for example, and then you'd be measuring and seeing what you need to do next. Interestingly enough, it turns out if I'm recalling this correctly, that with regard to typing one of the main differences between very talented typists is that they read further ahead on the page than more average type. So this would be another skill that would be able to be practiced. There's obviously some short-term memory involved here, because I'm having to read further ahead, me having to communicate to my fingers, what words I'm going to be typing, etc. With regard to psychotherapy, which is where I spent the last 15 years researching and writing, we really have to get an estimate of just how effective the clinician is, so that we can then identify when and with whom, in under what circumstances, their outcomes and performance begin to falter. It might be in, for example, dealing with a hostile or an angry client. So your empathy levels, which is a core therapeutic skill, would be assessed, we then have to create an activity or an exercise where you can practice being empathic with a client who expresses anger or hostility at you. We then measure your performance afterward and move on to the next deficit in your performance. It's a long process. Now, let me tell you what is happening in our field in contrast to that because our field has focused for the most part for the last 50 years on learning particular models of therapy. So in a manner consistent with that history, what's happening is that Deliberate Practice has become a hot topic. And videos are being created, which say, practice this skill, for example, well, practice this skill is what Anders Ericsson would call Purposeful Practice, it's designed to achieve proficiency not to push your performance to the next level. So if you're already proficient at that activity, it's not going to improve your performance, you can probably guess what it is going to do, Spencer. It's going to make the performer feel more confident, which is the exact opposite thing that needs to happen. In order to improve, there has to be what some in the field called a sense of humility. Here's what I need to learn, here's where my shortcomings are, in order to push them to the next level.

SPENCER: I want to make sure I understand that there's a subtle point you made there -- this idea of the distinction between Deliberate Practice and practicing a specific skill to proficiency Do you want to just contrast those for a moment?

SCOTT: Well, you know, the idea that people need to practice, it's actually as we write about in our book that a result -- it's millennia's old. So there's nothing new there. Everybody knows that anybody who took piano lessons or ballet or tried to learn a different language knows you have to repeat things over and over again. Every toddler trying to get up on their feet, the first time and parent of that toddler knows they have to practice for a while before they get the hang of it. That's all about proficiency. But Deliberate Practice is really about refining that performance and extending it, getting better at it. So that means we have to first find out where your deficits are. Most continuing education workshops for therapists involve a form of practice here, I'm going to teach you this strategy, whether it's confronting dysfunctional thoughts or moving your hands back and forth in front of a client's eyes to initiate the category movements, whatever it happens to be, most of these workshops involve that kind of practice. The question is, is that what you needed to work on as a clinician? Because if it isn't, all that's likely to do is build confidence, rather than the humility needed to push yourself to learn something new.

SPENCER: Now, you mentioned another thing that caught my attention, which is you mentioned the role of a coach, do you want to talk about that? Because there are some people might think, well, why can't you just design your own exercises for improvement?

SCOTT: So you know, nowadays in professional sports, let's take figure skating, which has been the subject of some research in Deliberate Practice. Most female figure skaters, for example, don't just have one coach anymore. They have multiple coaches because the knowledge in those areas is so specialized. So they may have a choreography coach and upper body, lower body strength, and equipment coach, a coach for the clothing or costumes that you're going to wear during your performance. Each one of these people has specialized knowledge which allows them to create the exercises needed to work that particular weaker muscle in your performance. So I would say that person who designs their own deliberate practice activities has a fool for a coach, you want somebody who has more expertise than you on the subject. And in again, if we apply this to the field of psychotherapy where I've spent my life. Typically, therapists have supervisors, but traditionally, supervisors in psychotherapy are there to do two things. First off, ensure that you are proficient at a particular model, and secondly, to make sure that you don't violate ethical rules of interaction with your clients. And very often it's low-hanging fruit, you'll get the supervisor assigned to you that happens to work at the agency, not the one who may have the requisite knowledge to address the deficit that your performance evinces. So, for me, at least, I'm looking for coaches that can help me fulfill the specific gaps in my performance, knowledge, and ability.

SPENCER: So do you still work with patients?

SCOTT: No, I don't see people directly any longer, and I haven't for about four or five years now. I did for many, many years. But most of my time now is spent doing research and coaching.

SPENCER: So you did see patients for a long time. And I wonder to help this come to life if you could give me a couple of examples of ways that you identified weaknesses in your own practice, and then how you worked on those.

SCOTT: So really, all of our work on Deliberate Practice has followed my clinical experience, rather than led by clinical experience. For me now, I think Deliberate Practice has been a function of my coaching activity and the consultations that I do with agencies and individual therapists, and the presentations that I do. So I'll give you an example of a presentation that I did at the 2017 Evolution of Psychotherapy Conference, I was doing something that I had never done before. The topic of the presentation was how psychotherapy lost its magic. It was based on an article that I did for the psychotherapy networker in the same year, which was how do we expand our ability to connect with people that have different cultural backgrounds and views about the healing process. And I was going to do a demonstration in front of a large audience. And I hired a performance coach. And that particular person, I first off, we looked at the effect that I wanted, they came and saw me present multiple times. And then we started to develop a particular presentation, which I practiced and refined with observation and exercises from him over a two-year period. Most people don't believe it when I say, that I spent two years rehearsing and practicing for what amounted to an hour-long presentation. But I did. And part of the reason was that I was really stretching outside of my comfort zone, and doing things that I had never done before in a presentation. But this particular person was also an expert in how you are in front of an audience. And I wanted to make sure that I just wasn't doing the standard spiel that I usually did.

SPENCER: That's pretty impressive. Is that talk about online, I think that'd be really interesting to see.

SCOTT: There is a version online called the Missing Link.

SPENCER: Great, we can add that to the show notes then.

SCOTT: There is also a presentation called the Evolution of Psychotherapy and Oxymoron, which I think was from the 2013 Evolution Conference. But the particular presentation that I spent hours and hours over a two-year period working on is not online, it was a demonstration. And in order to see it, I believe would have to connect with the Ericsson Foundation to purchase access to that particular video.

SPENCER: Got it. So another thing I wanted to ask you about is you mentioned a few times that you kind of has to identify these deficits. And to me that much I don't know if you can see that suggests that there must be core skills that people can be deficient in. And I'm wondering what your thoughts are on what are the core skills of therapy and how would you kind of categorize them or break them down?

SCOTT: Well, I think you ask what is one of the most important questions -- what is it that I should be practicing? In deliberate practice, it's really important not to put the process ahead of the outcome. This is, in my opinion, what the field has done. We have assumed that certain techniques are specifically remedial to the problems being treated. So for example, with CBT, we assume that it is our identification and dealing with people's dysfunctional thoughts that leads to the remediation of depression or anxiety. There's, in my opinion, virtually no evidence of that. So you can practice whatever CBT technique you want. And it's not likely to improve your outcomes, although it's assumed to do that. So you then ask, Well, are there certain core skills and what should we be practicing which is almost what everybody says? If the work of just tell me what the practice got, and I'll do it, and I say, well, it's not so fast. The first thing, as I said was you have to do a baseline assessment. And for therapists, what that means is first measuring your results. I'm not talking about your impressions, I'm talking about using a standardized measure that can assess just how effective you are, you can also begin to look at not only your overall effectiveness but your effectiveness at engaging people in the work that you do. And it just so happens that is one of the more robust predictors of outcome in the field of therapy. In other words, the quality of the therapeutic relationship. The key here is once you get that baseline assessment, what you practice has to have certain qualities. The first one is it has to be predictive of outcome and engagement. So if what you're going to practice isn't predictive of outcome and engagement, then why are you going to do it? In order to find out if it is you probably need to speak with a coach, but also, you'll probably have to do a bit of work on your own, and you're likely going to have to challenge what you typically believe. Because, again, we have been taught as therapists that certain things correlate with the outcome when they don't mainly be used to particular models of therapy. The second quality of what you practice is it has to be influenceable. If you can't influence the factor, well, then why would you practice it? Third, it has to be ongoing and recurrent. Now here is the biggest challenge when you are practicing as a therapist, because clients are the wildcard of the therapy process, you cannot control who walks in the door. And interestingly enough, done my compound, one of the people responsible for inventing CBT, and a good colleague and friend, he jokingly says, during his workshops, when he's trying to teach therapists how to achieve better results, the best way, the easiest way is to simply select your clients more carefully. Do you want to be more effective, prevent who comes in the door from being a difficult client, somebody difficult to engage or help? So most therapists can't do that. They have to take whoever walks in, which makes clients the wild card. And it is also supported by the evidence, which says the following -- 87% of the variance in treatment outcome are client factors.

SPENCER: Let me unpack that for a second. That would mean that if you measure a bunch of attributes about the client, then you try to predict how well is this person going to do in therapy, you're saying 87% of improvement can be predicted using these factors that are just about the client themselves, not related to the therapist there.

SCOTT: You're assuming, though, that those factors are predictable, and that therapists can do something about them. My point here is that much of what therapists have to do in order to be effective is to respond to the unique qualities of the person in the room because it's entirely a chance event who walks in that day. And what those qualities are, we don't get to choose that. So the point here is that you cannot really deliberately practice that, you have to simply respond at the moment, what you need to get to in order to deliberately practice is beyond the randomness associated with whoever walks in the door to ongoing and recurrent patterns in your behavior that affect the outcome in a negative way. So there are several areas that are influenceable that are predictive of an outcome engagement. And here's what they are in order of their contribution to the outcome. And one is the structure, explanation, strategy, or ritual that you use, it contributes overall about 1% of the variance in treatment outcome.

SPENCER: Could you spend a little bit on that factor?

SCOTT: Sure, all therapists have ways of structuring the care process and explaining it to their patients. Some therapists say, "Well, this is a result of your childhood." Others say, "It's a result of your brain chemistry." And now it's popular to say, "The reason you're suffering is because of traumas you've experienced in the past." And then typically, there's a strategy associated with that, and a ritual, it could be that the work that you're doing with certain kinds of clients, right at the edge of your performance, are missing some critical element of the structure. But it's also important to remember that model and structural deficits are really the smallest contributors to the outcome. There are factors that have a larger impact on the outcome.

SPENCER: So when you're talking about the structure of information, you're talking about the way that it's explained to the client or you're talking about, but also it includes the sort of model you're using, whether it's based on trauma.

SCOTT: Models and techniques work because of the structure they provide for the session. Here's how we begin here's the middle phase. Here's the end. They also work because they provide an explanation to people about the situation If they find themselves in one explanation that hopefully engages them in whatever healing rituals the model says we're going to use.

SPENCER: So it sounds like your argument is it doesn't actually matter whether they're claiming that trauma is the source of the person's problems or thoughts, that source for problems is whatever. What matters is other factors about how it's explained whether the patient buys into it, whether there's a ritual involved in these kinds of things. Is that correct?

SCOTT: Yes.

SPENCER: I think a lot of people would be very surprised by that claim, like, they might say, "Well, how could it not matter? What the theory is behind the work? Surely some theories are more true than other theories, right? Not all theories are equally true. Like if someone says, Well, you're possessed by spirits, and someone else says, this is due to the way your father treated you and your child, surely one of those could be more accurate than another." So yeah, what's your response to that kind of critique.

SCOTT: So we're in a different area than deliberate practice, when we go to talk about whether or not models are true representations of what causes healing or not. So if we step outside of deliberate practice for a moment, and talk about whether or not our models contain ingredients that are specifically remedial to the disorder being treated, I challenge your listeners to provide any evidence for that, really what matters, in fact, the number one predictor of treatment outcome is the level of the client's participation in the care process or their engagement in it. So the real issue here is can I engage this particular person with an explanation of strategy and ritual. And it's just common sense to think that if it fits what that person believes, the barriers to them engaging with you're going to be lowered. So in Western culture, it has become quite popular to attribute problems to our childhood. But in other cultures, the fact that you might be possessed by a spirit or a demon would be exactly what you needed to say. And if you tried to blame their parents, they might view that as disrespectful. So I'm simply saying that psychotherapy does not work like medicine. In medicine, you have a bacterial infection, you want an antibiotic. In psychotherapy, what you want is an engaged client and one that gets results. If that's accepted, then we can find out when your way of engaging with clients doesn't seem to engage this client. In that case, you might have to be more responsive and move in their direction. If you find out that this is a problem with many of your clients, then to go back to where we originally started, then it's an ongoing and recurrent error, that you may need to change something about the way you think and you work through deliberate practice in order to improve.

SPENCER: There's something that still confuses me about this way of thinking, which is, imagine you're trying to fix a clock, right? A clock is broken, it matters a lot, the way the clock is broken, right? Like if the clock is out of batteries, this can be very different. The way to fix this can be totally different than when the gears are cracked, or something like this, right? And I think a lot of people think of people this way, as in, if someone's suffering or struggling to deal with their life, there are particular things that are the matter. And if you can help people identify what's the matter, and then maybe make a strategic change, that could lead to them feeling better, like if you can identify what's broken about the clock, and then you can go intervene on that, like, what batteries in the clock, that's gonna make it better. Whereas, if you do the wrong intervention, like if you think the gears are broken, but they're not, and you replace the gears, that's not going to have any effect. So what's wrong with that model when thinking about helping a person?

SCOTT: People aren't like clocks. They're simply not like clocks. People are all about relationships. And I'm dealing with a clock in this case that has certain beliefs and expectations about their life. And so there simply isn't any evidence that our models are specifically remedial to the problems people bring in that they must contain these specialized ingredients. There's very little evidence of that, but they're popularly believed. So let me give you an example. Our models tend to mirror our culture. We continue to search for core essential truths, when in fact, our ways of working with people are all really about managing people who believe certain things. During Freud's era, is it all that surprising that his theories were all about sex? It isn't during the 1940s and 50s. We had an industrial culture, what were the popular models of the day? They were behavioral models during the Cold War period. What were the popular models of the day, strategic and systemic therapies? During the 80s and 90s, the rise of computers, what were the models of the day? And where did they come from? Cognitive models and out of the universities. So this isn't a criticism. It's an observation that psychotherapy is a cultural approach, and in particular, a western cultural approach to helping people. But other cultures have different ideas. And if I want to engage them in a helping process, then I'm going to have to speak in a way that makes sense to them. And that's just one component of what we can deliberately practice, it's one that we easily get obsessed with because our field has certain beliefs about it. But there are other factors that also have leverage on the outcome, and they can be affected negatively in a recurring way. So for example, hope, expectancy, and allegiance, our explanation needs to create a sense of hope in the process and an expectation of results. Actually, the creation of hope and expectation of results contributes four times more to the outcome of our work than the particular model or technique. So at least when I'm working, I'm looking to see if the explanation that we're weaving is the story that we're weaving together, actually creating a sense in the client that things can be different, if not, well so much for the truth. Now, you know the explanation but it doesn't really help people. What's the utility of that? The third thing that contributes to outcome uniquely in our field, and which is often viewed as an error in medical or manufacturing, is therapist's factors in psychotherapy, who does the therapy matters more than what therapy is actually done. So our ability to reflect on our work, our ability to respond, as I was mentioning earlier, our ability to regulate our emotions and thoughts. During the process, all of these things have an impact on the outcome, in fact, who the therapist is matters between four and nine times more to the results than the particular model or technique used. And of course, one of the big ones on the hit parade is the quality of the relationship, understanding, empathy, collaboration, these contribute eight to nine times more to the outcome than, say, the particular model used. Now again, I'm not saying that your model or your structure isn't important. What I am saying is that improving your results is what your aim is, rather than mere proficiency in a model, which can be obtained in about three to six months, then I have to find out number one where my deficits are, and then I have to figure out which factor is accounting for those deficits? Is it a problem in the structure? In the strategy? Is it a problem in my ability to create expectancy? Is it something to do with my lack of responsiveness or regulating my response in the session? Or is it my inability to connect with a certain type of client presenting in a certain way, during a certain time of day, that I get them that I can be empathic towards them that I can collaborate with them? So there's a step-by-step process. Number one, assessing my performance. Number two, identifying my performance edge, where do my results start to break down? Number three, I have to figure out what factors have leverage on the deficit in my performance, then I'm going to have to reach out to a coach to help me design activities for wherever that deficit lies, whether it's in the structure in the creation of hope and expectancy, my self-regulation, or in the provision of a warm empathic relationship. There are 1000s of gymnasts, 1000s, and 1000s, millions, and there are 20 Olympians, but we can learn something from the Olympians without all having to be the best we can learn how to improve our individual performance because the other choice according to Erickson is to feel better than we are. And that's just the state that I have to tell you. Since my graduate school days, that has been unsatisfactory because I have this sneaking suspicion that I wasn't as good as I hoped I would be. And often, as my professors sort of said, I was.

SPENCER: It reminds me of traditional martial arts, where you can have these traditions of doing movements a certain way. And you learn the different hand motions and the punches and the kicks, huh. And you know, you get evaluated on are you doing the hand motion, right? Are you doing the kick, right? But then you don't actually go and fight with them. So if you know, you're making an analogy to produce the outcomes, getting evaluated on how well you do the hand motion, the kick, but never on how well you fight and sort of like, your teacher can say, Oh, you're an expert, but what are you an expert in, right? you're an expert in the thing that they're evaluating you in as opposed to the thing that allegedly, this whole system so as to produce.

SCOTT: And what I love about your analogy here is that this is about what outcome actually matters. If what you want to do is perform katas in from in front of an audience, and have them be wowed by your kicks and punches. Well, that's one outcome. But that is not what I think a therapist wants, they don't want to wow, the person who is analyzing whether or not you've followed the treatment protocol. What I'm interested in is, was the client helped. And in order to know that I have to measure the outcome, which in your analogy would be, were you able to defend yourself in a real-world fight? Otherwise, you know, it harkens to that famous scene from Indiana Jones, where the martial arts expert runs out and does all of this cop does, and Indiana Jones pulls out a gun and shoots it. I mean, who won?

SPENCER: In psychotherapy, it's hard to tell if someone's doing karate or not. But interestingly enough, in martial arts, we've actually gotten increasing clarity over time with the UFC and things like this, where they actually have different martial arts, fighting each other in the ring of different styles. And suddenly, you took this thing that was very hypothetical, and suddenly, you started to see, oh, wait, actually, these sorts of movies seem to work and these ones don't. And you could just see the proof in the pudding. So I see what you're trying to do is sort of trying to bring that to therapy, this idea of like, okay, but let's actually make the measurement. Let's see what's working?

SCOTT: Exactly. And all of those moves in the ultimate fighting ring, are in a context. So you have different people, perhaps approaching this with slightly different styles. So all we know at that moment is that this style seems to be better than the other. But the top performers are likely going to be pushing and looking for their deficits continuously so that they can move beyond what they're currently able to do.

SPENCER: Absolutely, that makes sense.

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SPENCER: I think there's still something that confuses me about your overall approach, which is that I don't quite understand the theory of change, right? So imagine you get your client to buy into the strategy being used by kind of paying attention to their beliefs about how change occurs, and you foster hope in them. And you regulate your own response in therapy, and you build a strong relationship, use empathy, connect with the patient. So you get all these components in place. I'm just wondering, what is your belief about, like how this leads to the person having better outcomes?

SCOTT: Well, I think it can be one of two things, simply put, what does the client say, led to those outcomes? How do they explain it to themselves? So if in fact, their sense is that we cast out an evil spirit, then the better outcomes as assessed by their well-being and functioning? In other words, in their individual relational and social life, they're actually doing better, then what more explanation do you need?

SPENCER: That's all good and fine from a pragmatic point of view, and the patient feels better? That's great. But I'm interested in going deeper and saying, well, but what actually happened, how is this person better than they were before? If we don't believe that the spirits are real? Is that the saber cast out? Like what actually occurred? Yeah. So I'm curious to hear your thoughts. You have not?

SCOTT: I don't have thoughts about that. I think it's presumptuous on the therapist's part to think that they know it or that it matters. For me, what matters is that we got the results we need it. I mean, what more do I need to know? And if we have a reductionistic view of this, if I were to say to you, well, certain parts of the brain change in response to this? Did that explain it? Does that really explain that's the popular idea at present, that we've reduced it to changes in brain functioning? But I think understanding cause and effect when we make those attributions are much more difficult and problematic than we assume. And these are just, in my opinion, a lot more stories. So we've told clients for decades that their problems were due to their childhood. Really, let's just see if we can actually explain most people's problems in that way. And to me, it doesn't really matter. It is entirely pragmatic, which is what Deliberate Practice is about. And I don't need to explain it in any deeper way. If that's the analogy, we're going to use then talking about the factors that seem to make a difference, model and technique, hope expectancy, therapist factors relationship, these are the things that matter.

SPENCER: So incredibly pragmatic view, I still am very curious on what's actually going on the causal mechanisms there, you know, why you should these factors matters insofar as it does. Yeah. So I hope one day that will make progress understanding that.

SCOTT: So that what?

SPENCER: Well, I do believe that things can get better, so maybe it's actually a good time to talk about the effectiveness of therapy and sort of how it's changed over the decades. Do you want to comment on that?

SCOTT: Well, I think psychotherapy has rearranged the deck chairs on the cruise boat, many, many times, but its outcomes have stayed flat for nearly 45 years.

SPENCER: And that's based on randomized control trials have been done over the decades on many different therapeutic modalities.

SCOTT: Yeah, if you look at the overall effect size of psychological treatments, as reflected in the original meta-analysis by Smithing Glass in 1975-1976, and you're looking at meta-analytic studies today, the effect sizes are the same. When I made this statement in 2017, I believe it was 2017 evolution of psychotherapy comes your way. It was really very controversial. December 2020 issue of the American psychologist, I think it was James Prochaska and John Norcross, they made the same exact claim, hey, we're not getting better. In Bruce Wampold recent address at the Society for psychotherapy research. And Bruce is a mentor and colleague and a former professor of mine, just an Uber researcher, probably as a researcher has had the most impact on psychotherapy research of anybody in the last four decades, he made the same observation, we're not moving forward, and it's because of the way we think about psychotherapy. But the point that you're speaking to is the effect sizes really haven't changed. The number of treatment approaches has mushroomed and exploded, the specialties have arisen, but we just don't see much difference in the outcome. And in a pragmatic level practitioner level, we can't see any difference between psychologists who have between two and four years more education and training than social workers or hold on to your chair, social workers, and peer-lived experienced support. People, we can't see much difference now. How about this? Students, we can't see much difference between a five-year post Ph.D. psychologist and the students that they're supposedly supervising. So I just think that our current way of conceptualizing our work within a medical framework has not helped us achieve better outcomes. And research until the practice is in its infancy, we have produced the only study in the history of the field, which shows that if you engage in this outcomes at the individual therapist level improve, you show me a study where that's the case, in learning treatment models, it doesn't exist.

SPENCER: In that study and your research where you show that individual therapists improve? How does that work exactly? Like how do they actually receive feedback? So I imagine you make a baseline measurement performance, and then they get regular, ongoing performance measurements. But what else do you involve there in that process?

SCOTT: So in the one study, which is an article, the lead author on that article was Simon Goldberg appeared in the journal called Psychotherapy. 153 therapists, 5000 clients, and a number of things including, the first one was the ongoing assessment of performance. So there was an outcome measure in place. And there was also an engagement measure in place. So they were measuring the quality of the therapeutic relationship as well. Therapists were made continuously aware of their outcomes, both in the aggregate and with individual clients, so as to improve their ability to respond to individuals they were helping. Remember, that is the wild card in psychotherapy, who walks in the door. And much of the challenge of doing psychotherapy is treating this individual in front of me who has these unique qualities. That's not Deliberate Practice. However, that's responsiveness. It's not ongoing and recurring, it's random. So the second part in the process was that their deficits were identified, and they were mapped on to these four quadrants that I've mentioned, your four factors that have an influence on the outcome, and therapists were encouraged with their supervisor-slash-coach to develop activities, and exercises that would help them work on those particular areas. So they had access to that on an ongoing basis. And when you look at the outcomes, what's intriguing about this is, you see this slow gradual improvement, we're not talking about making headway in leaps and bounds jumping dramatically in terms of effectiveness, but rather the same kind of improvement you see in Olympic performances over time, slow, consistent, and gradual improvements. We're talking about millimeters, not yards, and meters, we're talking about milliseconds and not minutes. We're slowly and gradually improving the therapist's ability to engage more diverse people, and to achieve better outcomes with those clients.

SPENCER: How does responsiveness develop? Do you want to comment on that?

SCOTT: Well, this is an area that we're investigating. The main way that this has been addressed in the research literature, so far, is by assessing the outcome at every session with every client, comparing client progress to establish norms, and then feeding back to the clinician, when it appears that the client and therapist pair fall outside those norms. So I'm warning the therapist, hey, this client is not engaged with you in the way clients who eventually are successful, engage with their therapist attend to them, so we're giving them help in terms of responding to the individual.

SPENCER: Got it. I think about those assessments that you use and how you develop some of those.

SCOTT: Well, our team started with a measure called the Outcome Questionnaire 45. It was developed by Michael Lambert and is widely used around the world. And we also use an alliance or a relationship tool and engagement assessment tool called the Session Rating Scale that was developed by Lynn Johnson, it was 10 items at the time, the particular context in which I worked, many of the clients had literacy challenges. And using a 45 item measure just presented all sorts of complications. So we developed a simpler visual analog tool for clients' marks on four lines in four different areas of their life, well-being, and functioning. Individual, relational, social, and overall, those particular measures are called the Outcome Rating Scale, and the Four Items Session rating scale, which is available on my website for individual practitioners to download and use for free.

SPENCER: Right. And so they're assessing things like, how much better is the patient feel overall? How much better does the patient feel in different domains? Is that right? Like work, social, do you want to elaborate a little bit?

SCOTT: Yeah, those are the domains of well-being that we are assessing. And the client is completing this and the therapist is hopefully responding to when the data indicate that this particular interaction with his client is either not engaging them as much as they should be engaged in order to end up on the positive side of the ledger in terms of outcome, or that the progress doesn't seem to be made at the same rate.

SPENCER: Right. So the question is around therapeutic alliance and whether the patient has kind of bought into the strategy being employed. My understanding is that you found that if those numbers are not good, it's actually very unlikely that the patient is going to succeed ultimately, with that therapist, is that right?

SCOTT: Well, it's matter of risk. I think what's amazing to us is that our expectations have been so wrong from the outset about what would help therapists most, so if you think about improving responsiveness, we found, for example, that a single point decrease on our session rating scale, if they're 40 points possible on the scale, and a single point decrease at any session is associated with poor treatment outcomes. Declining scores for both adults and adolescents and kids are associated with outcomes that are about 1/5 of the size of outcomes when you have relationships that start good and stay good. Now, here's the reverse of that. If therapists are able to create an atmosphere in the room where clients can provide critical feedback about the work to make it better fit them. In other words, if their scores on the alliance tool or the relationship tool are lower in the beginning and improve over time, this is associated with the best outcomes. So to return back to the theme of deliberate practice, if I didn't know anything about the therapist I was consulting on. I would guess, that they probably didn't know what I just said. And that one thing they could work on was creating an atmosphere, a feedback-friendly atmosphere in those initial stages really soliciting information from the client that will help establish a better fit. Because as I say, it turns out that improving scores have far better outcomes about 50% better than relationships that start good and stay good. And about seven times greater than relationships that start good but deteriorate over time, which in the latter case, I was trained to view as the way relationships had to work. In therapy to be effective, I was trained that initially, you go through a honeymoon phase, and then finally you get to the real stuff. Well, if you do that, chances are your outcomes will be poor much, for now, think about that. Spencer, what is this therapist likely to learn? The client comes in initially, they say it's good. The therapist believes that the relationship has to become complicated or deteriorate a bit before the change takes place. It does that the outcomes are poor, which then confirm the therapist and their belief that this is what they needed to do in the first place.

SPENCER: So why would a poor outcome confirm their belief?

SCOTT: Well, obviously, the client was more ill than they originally thought.

SPENCER: It just misses tripping.

SCOTT: Yes, that's the business. We're in attribution, attribution of meaning. And so if I believe that the client has to get worse before they get better, and I see it, it confirms what I believe, even though what we find is that clients who say that there are problems in their relationship early on, and then improve, have far better outcomes. So it means getting rid of this idea that has dominated the field, that the relationship will become more complicated with the time that those ratings will suffer. But that eventually is what needs to happen so that we get to the truth of their particular problem so that we can help them.

SPENCER: A number of times when I've talked to friends who started therapy, I've had them complain to me about something their therapist was doing or tell me that they think that therapy is not working. Hmm. And I always asked in that situation, okay, have you brought this up with a therapist, and I think, as far as I remember, they have never said yes to that, they always just hide that information from the therapist, which I find really fascinating and horrifying because basically means that on the one hand, therapists can't adapt, because the therapist doesn't realize that the person doesn't believe they're getting better and doesn't like what's being done. And second, a therapist also gets a misguided view of how well things are working. And so I always encourage them to okay, this is this person works for you, their job is to help you be better. They need this information. I try to encourage them to share it with a therapist. But I think a lot of people would be shocked that therapists already don't measure outcomes, right? Like, I mean, it just seems like such a no-brainer idea in a way, right? Why would you not measure how well you're doing? Why would you not collect a feedback form? Do you want to comment on that?

SCOTT: Well, a couple of things. Because what I think you've said is really rich. When was the last time a medical doctor measured your outcomes?

SPENCER: They do and it's appalling.

SCOTT: It is appalling. And health care is the one area where outcomes are secondary still, and where the treaters are not responsible for the outcomes and can explain it away didn't work because the patient is too ill, or they're resistant to the treatment. It's deeply problematic, as opposed to say industries where you've seen continuous improvement over time, like the airline industry, that brings in squadrons of people to investigate when there is an error. When something's happened, when there's been a tragic event, that's not what takes place in medicine, and in psychotherapy. Now, again, all these things can sound very glib on the surface. And most clients have complaints about their physician or their therapist at times, and they hold on to them not zeverything needs to be expressed. In other words, for them to have a positive outcome, there also may be a very good reason why the client is not telling their particular therapist, and I'll tell you this, by the time clients volunteer negative information about the work, it's generally too late to fix. By that time, most clients have begun to disconnect and disengage.

SPENCER: I assume you're talking about outside of the kind of regular feedback mechanism like if so not in the context of filling out a weekly survey,

SCOTT: Even that so if, and I know this probably just stands to reason, but I want to say it anyway. If you believe adding this form, at the beginning and the end of yours, these two forms to the beginning of your session will solve this problem, you're sadly mistaken. What you're going to find is that most clients still don't give you feedback because you need to deliberately practice creating a culture that is feedback friendly in the work and most therapists will say to you, oh, you know, I'm always asking for feedback. Well, we have researched about that and the answer is, No, you're not. Therapists tend to ask for feedback when they think of it, and when they think it's relevant. And they lack skills in processing feedback in general, I'm speaking very generally here, some therapists are amazing at this. But most of us, that includes me, need to find out those areas where we, in some way prevent the client from speaking up, especially early on in the work.

SPENCER: I remember you talking to one of your articles about therapists saying that they would regularly ask for feedback, and then actually having people inspect the videos of those therapy sessions, and realizing that, in fact, it wasn't happening, even though therapists believed it was happening. So it's interesting to see that gap. I've been on this little project of my own to try to give people more direct feedback, when they do something I find is upsetting to me or harmful to me, it really is a difficult thing to do, right? Like, to go to someone say, hey, you know, that actually really bothered me when you did that. It is so much easier to just keep it inside and not rock the boat? And a lot of times, you know, you might even think well, what do I really have to gain from doing this show, I imagine that creating a culture in the therapy of my patient can tell me that I'm doing a bad job, it's probably quite difficult to achieve that where the patient really feels comfortable with that. What do you think?

SCOTT: I do think that this is a very specific skill that most therapists were not trained to do, but that some people do it quite naturally. In the book, better results, we spend an entire chapter talking about how to learn and then deliberately practice getting feedback from your clients creating that feedback-friendly culture, because again, as I say, most of us didn't have any training. And we think that if we're just open, warm, caring people the clients will tell us, but that's simply not the case, there are some very specific skills that are often needed to facilitate that. The second thing is, once clients give feedback, you have to act on it. Right now, our culture, if you look around, is obsessed with feedback. You can't even buy groceries anymore without the cashier turning the receipt around and saying use this little QR code here to give us feedback. What percentage of people who do that aren't pissed off? None, even when you promise them you can win $10,000 worth of groceries? But am I gonna take the time to do this? No, because it really isn't been tied to me, how's it gonna improve my quality of life? That's just gonna take more time from my life. So that process is complicated. And we're just beginning to unpack what does it take for therapists to create that environment in the room, what specific skills are needed? Now, my point here, though, is you may not need to practice that. As a therapist, you may find, for example, that you get lower SRS or Alliance scores, Relationship scores from your clients at a level that is associated with better outcomes. Well, then you don't need to practice that maybe your deficit lies and another of the factors we've mentioned here, but generally speaking, I can say this is a problem for many, many therapists.

SPENCER: Hmm, yeah, that makes sense.

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SPENCER: So how long should people give a therapist shot? You know, if someone goes to a few sessions and they don't feel like it's that helpful? Should they stick with it? Or should they switch therapists?

SCOTT: How many dates should you go on before you decide? This person isn't for me?

SPENCER: It's tough to know. But my understanding though, is you have looked at the evidence of this, about whether people are getting results right away or not.

SCOTT: If the relationship is poor, and you don't feel like you can tell your therapist is probably best to shop around a bit. If you're getting outcomes and you don't like the therapist in some way. Well, then you probably need to examine your values, which is more important to you feeling comfortable or actually improving. In general, you should start to see improvement within the first three to five visits, some improvement within the first three to five visits. If you haven't seen any improvement by session 10, the chances that this therapist is going to be able to help you are rapidly diminishing. And let me just say, it doesn't have anything to do with you. It has to do with that particular pairing. So the key here is to open up to the possibilities. Now, here's what happens. I'll tell you about the tenancy in general. And we're not talking about Deliberate Practice, we're stepping outside of that talking about this from the client's perspective. The tendency of our species is to replace outcomes with the relationship in the absence of outcomes. So initially, would go in and say, I need to stop drinking, I want to be happier in my life, I would like to have a better relationship. But the longer you're in treatment, and it doesn't happen, the more willing you are to accept a kind ear. And that's, in my opinion, dangerous.

SPENCER: At the sad consolation prize, well, I still have a drinking problem, but at least I have someone to listen to me.

SCOTT: And clients don't quite put it in those terms. They usually say I'm still working on it, I'm working very hard. The question that I think you ask is really important as well, how long are you going to give it and I asked the same question of therapists who've been seeing a client for 20-30 visits, and we look at the outcome measures, we don't see that the client is saying it's helping them in the least. And the therapist says, Well, if I think if I just go on a little bit longer, that it will be helpful. And when I asked the question, how long, two weeks, three weeks, four weeks, if the therapist can give me any idea about what they're going to do differently than the absence of change going forward? That to me is a recipe for more of the same.

SPENCER: So how do therapists feel about the ideas that you put forward, about tracking how they're doing getting a baseline assessment, getting feedback after each session, using deliberate practice, or what are the typical reactions you get,

SCOTT: there's a difference between what clinicians say and what they do. So I think clinicians are hungry for feedback. And I think they desperately want to help people. And I will tell you, I've stayed in this field as long as I have because most of the helpers I meet are good people trying to be helpful to others. When I teach this at workshops online, and prior to the pandemic, face-to-face, therapists, in general, are very positive. But in terms of translating this into actual clinical practice, we have a long way to go a very long way to go. Part of that is a bit of will. But I think most of it is about our field, helping therapists with implementation, which is a whole another topic of discussion, there's a difference between learning an idea and implementing it in practice. It's the difference between katas and a fight in a bar for the karate example that we were using before, the real world is different. And we're learning that it takes most agencies, for example, that are trying to adopt what we call feedback, informed treatment, again, distinct from Deliberate Practice between three and five years. And that's with a dedicated and focused effort on supporting clinicians as they learn these ideas and try to apply them with their clients. So the challenge is really about implementation, and a challenge to our current training models, which are that, if we just give these smart, highly educated people information, they'll be able to do it or should be able to do it. And the research is telling us simply untrue, that is simply untrue.

SPENCER: So you don't find that you get a lot of pushback on the ideas. It's more than when people actually go to put them into practice, maybe there are difficulties there or you know, it's hard to fit into what they're doing that kind of thing.

SCOTT: Yeah, exactly. You know, I'm born of the same ilk. I've worked primarily as a therapist throughout my life. And I feel in my heart, the desire that I see every day when I'm out training, a desire to help people to utilize client feedback to connect with the people that they're serving. So I don't see tons of pushback every once in a while. I get that. But I don't think the problems that are encountered here are ones of motivation and will. I think it's really about poor implementation. And let me give you an example of this. In the field of medicine, one of the primary causes of line infections in the ICU is poor hand hygiene. Now, how could that possibly be everyone knows they need to wash their hands nowadays, particularly people who work in an ICU. And yet, one of the leading causes of ICU infections is poor hand hygiene. How many years was it since Semmelweis, close to 200? So, this isn't a failure of imagination. And it's not really even a failure of will. It's a failure of implementation, assuming that the way to get people to do things is to tell them to do it and expect that passing along information will engender compliance. And again, I think this entirely new field of research called Implementation Science is simply showing us that idea is full of hope, is long on hope, and very short on reality.

SPENCER: So I get that they might like the idea of Deliberate Practice and getting feedback. But I would imagine that they might find it upsetting what you say about these different theories of therapy and how there doesn't seem to be much to them, or that they don't seem to lead to better outcomes. I mean, I imagine that's a controversial idea.

SCOTT: Yeah, I would suppose it's controversial. And it's always the second point, it's not something that I say, directly or out loud, I usually approach the audience based on their value, as much as I'm talking about try to approach clients in the same way. Most of the therapists I meet are deeply interested in helping others. The fact that we may differ theoretically, between us and among us is sort of inconsequential. So I'm not going to start off and people do not have to start off by me saying, Hey, you're therapy's bullshit, it's a bunch of air. That's not likely to engage people in what they really want, which is to improve their results. That's where I start, do you want to get better? Well, here's an interesting thing. We're not. And then your usual question that was like, the second question you ask is, well, what do I need to do? That's exactly where the conversation flows. And then I can talk about what they need to do. And I think that most clinicians would be willing, since large numbers identify as eclectic in their orientation, to think you know, what I need to be able to utilize ideas, strategies, and techniques from other approaches if it's going to help this particular client.

SPENCER: Eclectic means mixing different modalities, rather than hearing to one theory, is that right?

SCOTT: There are different kinds of eclecticism. But generally speaking, the way you describe it is accurate. Either they blend series or they blend techniques.

SPENCER: If you look on the Psychology Today, search engine, it's kind of hilarious that people will list like 25 different methods that they apply. I imagine that that's not really true in practice, but they certainly list them on their profiles.

SCOTT: It's difficult to imagine that anyone does that in a reliable way since mastery of these theories and approaches requires a great deal of dedication. So I don't really believe it in most people who call themselves eclectic really aren't eclectic, either. If again, if we're looking at descriptive stats here, most people identify as eclectic blend three or four approaches, the research tells us and those three or four approaches are often have a strong family resemblance.

SPENCER: Like DBT and CBT. Together, something like that.

SCOTT: Yes, solution-focused and narrative, but you're not going to see a solution-focused person talking about whether you were breastfed or not or how you were potty trained.

SPENCER: Hmm. So before we wrap up, I wanted to talk about the evidence a little bit. Obviously, there are a lot of different meta-analyses floating around, and some meta-analyses that claim cognitive therapy is more effective than other therapies. And I know that you're kind of critical of that research, don't it just kind of lay of the land a little bit about, like, what kind of research is out there and sort of what you see as wrong with it?

SCOTT: Well, most of the meta-analyses that in fact, right now, anybody with a computer and access to a database can perform a meta-analysis, it's the number of meta-analyses being published. You know, it's just remarkable how many are coming out. So it can be difficult to stay up to date on this. But the real key here is making sure that in a meta-analysis that you are comparing studies in which two approaches are directly compared. When an approach is compared to a waitlist control or treatment, as usual, it tends to inflate the results of the active treatment. And that's what the field had until Bruce Wampold came along. And Bruce said, Wait a minute, you can't say that two studies, each comparing an active approach to placebo or treatment as usual. And one is better than the other that's true because they weren't directly compared in the study. The minute you directly compare them, any advantages disappear.

SPENCER: I want to dig into that just to make sure listeners understand that. Is that because if you take two studies, each of which separately was comparing to a waitlist control, testing different therapies that those groups are just not comparable, maybe one of the groups had more severe depression other less severe, maybe the amount of time they got to spend with the patient was different, etc. And so all these kinds of confounding differences are not being approached.

SCOTT: Yes, all of the confounds are not being controlled for, especially the measures that are used. So if you're measuring, for example, a dynamically oriented treatment, they're using different outcome tools than, say, a CBT approach, which is going to likely be more symptomatically oriented, and therefore reactive. But when the researchers have gotten really very good, since Bruce Wampold, old original 1997 article, which made this argument that you had to compare bonafide treatments, this is the other thing, that we use a treatment that's actually intended to fail. So much of the earlier studies that and even some current ones, especially in the treatment of trauma, are comparing an active trauma treatment, cognitive reprocessing EMDR, exposure-based therapies, to something that was never intended to be therapeutic, like relaxation. The point here is no therapist would ever rely on relaxation as the sole strategy of dealing with somebody who's been severely traumatized. And so you get an inflated effect of the active treatment. Now, back and forth, we're talking hundreds and hundreds of studies that have been done now. And we did an article in psychotherapy research, it's now a couple of years, maybe 2017, called in Pursuit of Truth. You can go online, Google that, In Pursuit of Truth, my name is associated with the article, and just look at how we take the arguments apart. The point here is that we can go back and forth in this Grand Pre-design in which we're comparing different treatment approaches and asking which works the best. But the field has actually moved beyond that. Even those who advanced sort of the cognitive-behavioral agenda for decades and decades, David Barlow, for example, is now talking about a unified treatment protocol. So it turns out that if there are any differences, they're not clinically meaningful. And they're probably artifacts of the method and design of the study. And what we really need to be looking at our core therapeutic ingredients. And I think this is what you were getting at with the questions we were talking about earlier. Well, what really accounts for effectiveness, we've mentioned, is that you have some structure, strategy, ritual, and explanation that the clients buy into and engage with, that you create hope and expectancy, that the therapist is active and involved can reflect and regulate their emotional and cognitive process during the session. And last but not least, the relationship components continue to get short-shrift in professional training. Most therapists have no training [inaudible] is a small segment, but most have no training and empathy beyond what coursework they got in graduate school. When in fact, empathy is one of the most potent contributors to treatment outcomes. So for me, at least, I think this focus is a distraction. And the approach to take is the same approach that we take towards different cultures that one therapist finds EMDR the most meaningful way of working possible. That doesn't bother me at all, I'm not going to argue with him about it. But I want to know is, does it work all the time? And if it doesn't, what are you going to do next? And third, how will you find out that you get in the way of the client in some non-random recurring way?

SPENCER: So what do you see as the future of therapy, imagine that things go really well? And we end up with much better therapy, you know, 50 years from now, what does that look like to you?

SCOTT: I hope that the focus shifts a bit away from this Western notion of psychotherapy and broadens to include healing and core principles of healing that welcome the many different ways that people can improve, and others can help those people improve. I think psychotherapy is unique to Western culture; exporting it, I think, is a bad idea. Instead, we should be psychologically curious about how other cultures and peoples heal.

SPENCER: Scott, this is really interesting. Thanks so much for coming on.

SCOTT: My pleasure, Spencer.

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Host / Director
Spencer Greenberg

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Josh Castle

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Ryan Kessler

Factotum
Uri Bram

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Janaisa Baril

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Lee Rosevere
Josh Woodward
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Quiet Music for Tiny Robots

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