It makes intuitive sense that individual achievement and excellence flourish in supportive communities. The practice of psychotherapy is no different. For clinicians, rising to the top depends largely on the professional community that directly surrounds them. Unfortunately, however, the current culture of psychotherapy isn’t designed to foster clinical excellence—if anything, it fosters mediocrity and inertia. Agencies frequently experience such economic instability that their driving goal is solvency and survival—thus the intense focus on billable hours and productivity. Regulation, institutionalized habits, management policies, and cost-effectiveness measures all tend to reward predictability and the appearance of competency.
The private practice model is even more antithetical to achieving excellence. Isolated from view, insulated from supervision or peer review, and lacking any true measure of effectiveness, private clinicians can operate for years without improving their outcomes. Evidence from real-world clinical samples documents that the outcomes of treatment delivered in solo practice settings lag behind those of larger, group practices by as much as 25 percent. The reason is simple. As veteran psychotherapy outcome researchers Bruce Wampold and Jeb Brown point out, “Therapists typically . . . have no way of comparing their treatment outcomes with those obtained by other therapists.”
Furthermore, and without casting aspersions, the current system of reimbursement rewards practitioners for continuing to see clients who keep their appointments, regardless of outcome. The problem extends to how agencies measure productivity. For example, it doesn’t take a genius to calculate the impact of a policy that reduces productivity to a simple ratio of the number of clients seen, divided by the therapist’s available hours.
Compounding the problem of isolation is the well-documented tendency of clinicians to overestimate their level of skill and effectiveness. In one study, a representative sample of psychologists, social workers, psychiatrists, and marriage and family therapists from all 50 states were asked to rank their clinical skills and effectiveness compared with other mental health professionals with similar credentials. Respondents, on average, ranked themselves at the 80th percentile—a statistical impossibility. It gets worse: fewer than 4 percent considered themselves average, and not a single person in the study rated their performance below average.
Our inflated self-assessments notwithstanding, in randomized clinical trials, where clinicians are dealing with carefully selected and screened clientele, small caseloads, and access to high-quality training and supervision, reliable change (improvement demonstrated to be greater than chance, maturation, and measurement error) was achieved with only 50 percent of clients, on average.
So, the therapy profession faces some big challenges in the quest for excellence. Generally speaking, the culture of psychotherapy—in agencies or private practice—tends to punish risk and reward mediocrity. Given these facts, how can the field retool and rebuild itself so that we have a better shot at becoming the kind of therapists we genuinely want to be?
Dr. ZIP Code
Because our clinical institutions don’t encourage excellence, how do leaders in the field become the masters they are? Investigating some of the best agencies and most eminent and successful therapists in the world, we found that if they weren’t already in a community of excellence, they went to great lengths themselves to construct, find, or gain access to one. For instance, one well-known practitioner and writer, when asked to trace his path to superior performance, immediately remarked, “It all goes back to ZIP codes.” As a graduate student, feeling perennially shortchanged by classes in school, he was determined to find better teachers, mentors, and learning opportunities. Since this was pre-computers, he volunteered to mail out workshop brochures for a local professional organization. Sticking labels on 15,000 brochures and organizing them by ZIP code was exceedingly tedious, he recalled, consuming hours of time. He wasn’t even paid, but he did get a priceless payoff: free admission to any of the trainings advertised in the brochures.
“Fellow grad students thought I was nuts and told me I was being exploited,” he said, “but over the three years, I met almost every major theorist and practitioner in the field. Typically, I’d review their publications before the event and come prepared with questions. Given my inexperience, a lot of what they said didn’t make sense to me, so I sought them out on breaks. I always asked if I could call or write to them at some later point, if I had further questions. Very few declined, and I followed up with most. Eventually, these people became my support system, giving generously of their time, providing guidance, and opening doors that would otherwise have remained closed to me.”
What kind of opportunities? In due course, “Dr. Zip Code” went to work with one of the foremost groups of clinicians in the country. “I wanted to be there—not read about it in a book or watch it on film. So, I wrote a letter and asked. True story. Six weeks later, I was packing up my meager belongings and moving across the country. Over the next five years, I spent literally thousands of hours watching these, as well as many other top clinicians, perform ‘unplugged,’ as well as having them watch, comment on, and critique my own work.” He continued, “The job paid very little, and much to my mom’s horror, I had to live in a rooming house with some pretty unsavory types. I loved it. Now, whenever someone watches me work and then asks, ‘How did you know to do or say that?’ I think back to that time.
“I’m still working with a team. Twenty-plus years later. Never seen a client or written a paper without others being involved.” When asked how that’s financially viable in today’s world, he tersely responds, “Wrong question,” and then continues, “The right question is, ‘How can I make that happen?’ I’ll tell you what I did. First, I found other ways to make money. Second, I found a group of friends and colleagues who were willing to volunteer time along with me, observing and assessing each others’ work.”