For much of psychotherapy's history, clinicians have worshiped at the shrine of the field's superstars, the charismatic "masters," who were revered as much for their outsized, often theatrical, personalities, as for the inborn therapeutic wisdom they seemed to exude from every pore. It was these paragons who inspired many of us to enter this often puzzling and frustrating field in the first place. In the secret recesses of our hearts, we might even have dreamed that we, too, would one day join the ranks of what the authors of the lead article in this issue call the "supershrinks." According to the mythology of supershrinkdom, once we spent enough years getting the requisite training and experience under our belts, the mysterious "it" factor that we knew all great therapists must have would surely kick in. Failing that, we'd discover the magic approach or technique that would launch our practice to the super level.
Well, leave it to empirical science to burst another beautiful bubble! As Scott Miller, Mark Hubble, and Barry Duncan report in their article, "Supershrinks," the incontrovertible evidence is in: studies of the top 25 percent of therapists—those whose success rates are at least 50 percent better than the average—show unequivocally that neither training, experience, personality style, theoretical orientation, nor (get this) innate talent—has anything much to do with what makes the greats better than all the rest. So, what is the elusive factor that separates the gold from the gravel? "As absurd as it sounds, the best of the best simply work harder at improving their performance than others," assert the authors, citing the available research. And they seek constant feedback, either instinctively or using performance measures, to determine how they're doing.
But they don't just work harder, they work smarter. They appear to do three things that set them apart. They "think, act, and reflect"—set goals, track their progress, and reflect on their performance—case after case after case.
"How boring, how pedestrian, how mechanical," I hear you saying. "Besides, I already do all that stuff anyway—without a lot of fancy performance measures and forms." Most likely, however, you don't do it. Miller et al. demonstrated empirically (via videotaped sessions) that many therapists who believed they regularly asked for client feedback informally, without using standardized measures, in fact rarely did ask. This simply reinforces another uncomfortable fact that the authors' research has uncovered: most therapists become more confident of their abilities over the years, despite little or no improvement in actual success rate. It isn't only our clients who are in denial.
What's really astonishing, however, is that simply engaging in this habit of due diligence mysteriously produces its own kind of magic. These "mechanical" forms not only evaluate client engagement: they actually seem to increase it. Cynthia Maeschalck and Rob Axsen in their article, "But What About �Those' Clients?" report that filling out the feedback forms makes clients feel more empowered and helps them better understand what they need from therapy. In other words, completing the measures is itself therapeutic.
So, are Miller et al. arguing that the long-hallowed "therapeutic alliance" has been trumped by the old bugbear quantification? Just the opposite. The therapeutic alliance—the ability to engage a client in therapy, to forge and maintain a strong, personal connection with her, convince her that the two of you are on a common path—remains the single most important element of all therapy. The advantage that great therapists have, however, is that they attend to how the alliance is going by constantly seeking feedback. As one supershrink says, "I always ask. Ninety-nine percent of the time, it doesn't go anywhere. . . . [But] every so often my nosiness uncovers something, some barrier or break, something in the way of our working together."
In short, alliance is still critical, but the methodical, even plodding, procedures of checking up on ourselves and our clients help us determine whether an alliance really exists and isn't just a figment of our wishful thinking. These measures—dreams of supershrinkdom aside—act as a hedge against those universal human susceptibilities, as true of psychotherapists as of everybody else, to self-interest and self-deception. In short, they keep us honest.