Wonderful as all this sounds, the time and effort of launching and sustaining a focus on performance is daunting. “It’s not easy to establish a culture of excellence—staff buy-in isn’t automatic,” says Robbie Babins-Wagner, CEO of the Calgary Counseling Centre (CCC), which has a staff of 62 and sees 8,000 new clients a year. Babins-Wagner began the process of establishing a culture of excellence at her agency 11 years ago, and it’s still a work in progress.“At first, many staff members didn’t believe in it and didn’t even want to be held accountable for their work—they were afraid they’d fail or look bad,” she says. “Even when we told them that their salary and advancement wouldn’t be based on these performance measures, a large percentage of staff didn’t turn in their measures, or did them in a superficial way.” In fact, during the early years of the effort, the agency saw a 40-percent staff turnover. She adds that transforming the work habits of an entire agency can’t be done without a certain amount of negativity, resentment, and staff loss. “Sometimes substantial change is possible only with the hiring of new staff. They know what they’re coming into, and accept it, when they agree to take the job.”
“At first, many staff members didn’t believe in it and didn’t even want to be held accountable for their work—they were afraid they’d fail or look bad,” she says. “Even when we told them that their salary and advancement wouldn’t be based on these performance measures, a large percentage of staff didn’t turn in their measures, or did them in a superficial way.” In fact, during the early years of the effort, the agency saw a 40-percent staff turnover. She adds that transforming the work habits of an entire agency can’t be done without a certain amount of negativity, resentment, and staff loss. “Sometimes substantial change is possible only with the hiring of new staff. They know what they’re coming into, and accept it, when they agree to take the job.”
At CCC, leadership has worked to create “mindful infrastructures.” These include opportunities for staff to brainstorm about the agency’s purpose and goals, and evaluate the work each and all are doing. Remember the one-way mirror? A relic of a bygone era for most therapists, at CCC, clinicians regularly schedule time to watch each other work, providing continuing peer consultation and coaching. Clinical supervision is ongoing and organized around clients whose feedback indicates lack of progress or problems in the therapeutic relationship. Twice a month, the entire staff spends two hours together with an external consultant, reviewing the outcomes of the agency, individual clients, and therapists. Clearly, CCC’s staff is doing something right: the dropout rate after the first session is half that of the worldwide norm, while outcomes have been steadily improving, with success rates almost tripling since the project began.
At CCC, clinicians are free to use whatever treatment approach is congenial to them and their clients, and employ a variety of different models, including CBT, structural-strategic, and psychodynamic. “We’re not interested in controlling how therapists work. Like our clients, our team isn’t homogenous. But we are interested in each therapist being good and getting better.” That means regularly seeking feedback regarding the fit and effect of services offered. Babins-Wagner understands the lack of enthusiasm many clinicians feel about using measurement tools. “As a graduate student, I did everything possible to avoid statistics,” she says. But since then, she’s seen the light. “Here, data are front and center. At every turn, the therapeutic process is linked to outcomes, which allows a dialogue to begin—‘Is what we’re doing working? If not, what else can we do?’” For Babins-Wagner, as for other excellence-driven therapists, measurement keeps practitioners moving forward: good, bad, or indifferent, the numbers tell a tale every therapist needs to heed in order to grow.
All committed therapists want to increase their expertise and effectiveness. They earn advanced degrees, spend years honing their craft, and attend meetings and workshops—and not just to add credentials to their names. The majority hope that they’ll become expert practitioners through the acquisition of knowledge and experience. Findings from a large, long-term, multinational study of behavioral health practitioners confirm that therapists desire to—and see themselves—continually improving throughout their careers.
When researchers examine the evidence, however, they find little proof of increasing expertise. As just one example, in a comparative study of licensed doctoral-level providers, pre- doctoral interns, and practicum students that appeared in last spring’s Journal of Counseling & Development, Scott Nyman, Mark Nafziger, and Timothy Smith found “the extensive efforts involved in educating graduate students to become licensed professionals result in no observable differences in client outcome.”
The problem isn’t that professionals are failing to acquire new knowledge or skills: the problem is that what’s learned is unrelated to improved outcomes. Over time, and through training, clinicians compile a grammar for clinical practice, which heightens their self-confidence and increases their sense of mastery. However, as anyone who’s attempted to learn a second language recognizes, even an extensive vocabulary, ability to conjugate verbs, and knowledge of syntax doesn’t necessarily translate into a capacity to communicate effectively with different people in different settings. Without context, even the simplest of exchanges becomes impossible.
And herein lies the crucial difference between the best and the rest: what researchers refer to as “deep, domain-specific knowledge.” Top performers not only know more than their average counterparts, but are vastly better at recognizing when, where, how, and with whom to use what they know.
For instance, master chess players actually see more than amateurs, recognizing up to 100,000 distinct patterns on the board. A select group of nurses working in neonatal intensive care units develop an uncanny ability to spot infections before symptoms are visible, and despite negative diagnostic testing. Tennis champions correctly perceive where the ball will land and move to intercept it before their opponent serves. The most effective therapists sense many more interpersonal patterns and possibilities for relating to clients than average clinicians.
Consider a recent, groundbreaking study on the therapeutic relationship conducted by researchers Timothy Anderson, Benjamin Ogles, Michael Lambert, and David Vermeersch. Clinicians were asked to respond to a series of video simulations. Each presented a difficult clinical situation, complicated by a client’s anger, dependency, passivity, confusion, or need to control the situation. Their findings: therapist gender, theoretical orientation, professional experience, and overall social skills were found to be unrelated to outcome; the best results were obtained by clinicians who exhibited deeper, broader, more accessible, interpersonally nuanced knowledge. No matter the client’s presenting problem or style of relating, the top-performing practitioners were more collaborative and empathic, and far less likely to make remarks or comments that distanced or offended a client.
Acquiring such understanding, perception, and sensitivity is a common goal for clinicians. Researchers have found that “healing involvement”—a clinician’s experience of feeling engaged, affirming, highly emphatic, flexible, and capable of dealing constructively with difficulties encountered in the therapeutic interaction—is the pinnacle of therapists’ aspirations. However, the study by Anderson, Ogles, Lambert, and Vermeersch proves that some end up having such knowledge while others, of equal experience and social ability, don’t. So the question is how to go beyond believing in your own expertise and actually achieving it. The professional literature on expert performance is clear: no shortcuts exist. The best spend more time engaged in deliberate, ongoing, and systematic practice to improve.
Consider Robbie Babbins-Wagner, who focused exclusively on particular kinds of cases until she’d mapped every possible feature of the territory in her mind. “I’d pick a specific clinical population and see case after case of just that, with the idea that you can’t see a potpourri of different problems if you want to gain genuine mastery over any particular problem. I saw 50 or 100 or 200 cases of depression or domestic violence, and by seeing these cases over and over again, I picked up the patterns common to all of them that I might otherwise have missed.” She learned, for example, while treating violent couples, that even after the violence has ended and the couple is doing better, there’ll almost always be a relapse. Because she knows the pattern, she’s ready for this—it’s not a therapy failure, nor the end of treatment, simply a predictable pothole in the road that needs to be negotiated.