On Psychotherapy

What makes for great psychotherapists? Practice versus Talent

Earlier today (11/20/16) I had the good fortunate to listen to the Freakonomics Radio Hour on NPR, which featured a discussion between the show’s host, Stephen Dubner, and the psychologist, K. Anders Ericsson, a professor of psychology at Florida State University in Tallahassee, Florida. Ericcson’s work has focused on how one achieves excellence. It is his thesis that “deliberate practice” is the key to developing excellence, in almost any field. Ericcson’s argument that focused practice, in which one works to strengthen and develops specific skills, is the key to achieving excellence. Ericcson stresses that experience, hours of doing something is not equivalent to deliberate or focused practice. In fact, he cites research which supports this thesis simply doing more of something does not make one better. He provided the example that more experienced physicians were no better at detecting problematic heart beats, on routine exam, than less experienced physicians, and that in fact the more experienced physicians might be less adept at this. A more germane example for therapists would be research cited by Scott Miller showing that more experienced clinicians simply become more proficient at doing what they normally do, not more effective in terms of patient outcome (helping clients feel better and accomplish their treatment goals).

What made this show particularly engaging was that Dubner also interviewed Malcom Gladwell, the author of “Outliers”, which examined the question why certain people excel in their given field. Gladwell argued that while the role of practice is critical, and that Ericcson has made a seminal contribution, that Ericsson has overstated his case, and that focused practiced will not lead to excellence, without talent. Gladwell discussed the “10,000 hour rule” which he highlights in his book, reiterating his main point, that while extensive practice is critical to developing excellence, that talent is essential to the development of excellence in a given field.

How does all of this apply to psychotherapy? My first reaction was that the application may be less relevant, given that psychotherapy is an interactive task, unlike composing music or playing a musical instrument. However, this argument is likely faulty in that many other skills or areas expertise cited by Ericcson are obviously interactive, from chess master to star athlete. My second reaction was that focused practice might be more challenging for therapists, in that psychotherapy has always emphasized the “sanctity” i.e., the privacy, of the therapeutic hour, and Ericcson and Dubner both noted that focused practice requires feedback from experts, to help craft and focus one’s skill development. While clearly not an insurmountable obstacle (therapists have audio and videotaped sessions when in training for decades) professional development and training programs typically often do not emphasize this type experience (do not utilized review of sessions as a central component of training). Finally, psychotherapy appears to have developed a culture that may be inimical to the ethos of focused or deliberate practice, which requires a critical and challenging examination of one’s performance. While this type of challenging approach is common in athletics and the arts, training in psychotherapy seems to have moved in the opposite direction, in which a critical and focused assessment of performance is not normative. Thus, a challenge to the field may be to reconsider our models of training, to include more of the critical ethos that is more typically associated with medical residencies.

The sixty four thousand dollar question remains unanswered: are great therapists born or made? Is there a certain amount of talent (empathy, adeptness in reading social cues, and so forth) that one is born with that is essential to becoming an excellent clinician or can one be trained/practice his/her way to greatness. While most people would argue that in the performing arts and athletics that talent is critical, that this suggestion in professional fields is not accepted so readily. Scott Miller and his colleagues have repeatedly argued that practice and feedback are keys to becoming an exceptional therapist, but their work begs the question: is a certain level of talent plus practice necessary, or is practice alone sufficient? While attempting to answer the chicken versus the egg question of talent versus focused practice, it is clear that we can all better develop our skills by seeking to incorporate focused practice into our professional development.

For more on these issues please consider:

1) The Freakonomics podcast “How to become great at almost anything” at http://freakonomics.com/podcast/peak/  (from April 2016)

2) Outliers: The Story of Success by Malcolm Gladwell

3) Psychological Review 1993, Vol. 100. No. 3, 363-406. The Role of Deliberate Practice in the Acquisition of Expert Performance K. Anders Ericsson, Ralf Th. Krampe, and Clemens Tesch-Romer. Available at: http://projects.ict.usc.edu/itw/gel/EricssonDeliberatePracticePR93.PDF

4) Scott Miller’s article, “Achieving Excellence” in the Psychotherapy Networker,  as well as more on this issue by Miller, at his blog: http://blog.myoutcomes.com/scott-miller-achieving-clinical-excellence/, and at http://scottdmiller.com/wp-content/uploads/2012/11/Achieving-Clinical-Excellence-Handouts-2013.pdf