Even if one disagrees with this grim assessment of the field’s contributions and influence, it’s hard to be sanguine about our status. Over the last decade, median incomes for psychologists, both applied and academic, have dropped by thousands of dollars. In the same period, workloads have increased, professional autonomy has been subverted, and funding for public behavioral healthcare has all but disappeared. At the same time, costs have risen for graduate and professional training and for operating a practice. With regard to the latter, if medicine is any example, as much as a third of the average practitioner’s time and income is spent completing the mindless paperwork required for third-party payers and federal and state regulatory bodies.
Meanwhile, the very relevance of psychotherapy is an open question in the minds of many current and prospective consumers. Despite overwhelming evidence that therapy works, and that more than 90 percent of people say they’d prefer to talk about their problems than take psychopharmacological drugs, most people doubt the efficacy of treatment. Perhaps this accounts for the fact that the use of medications has steadily increased, while visits to a psychotherapist have been decreasing. Worse still, 50 percent of those who begin therapy treatment quit prematurely—a number that’s remained steady year after year. It’s clear that we must do better, individually and collectively. As President Obama observed when addressing the nation’s diminishing prospects, “This is our generation’s Sputnik moment.” Face it. Most efforts aimed at improving quality and outcome in behavioral health start with a call for higher professional standards: more schooling, more specialized training, and more stringent credentialing and rules for professional conduct. Regrettably, research shows this preferred, time-honored approach is an abysmal failure.
Nevertheless, it’s now well established that clinicians are capable of improving their performances. At the end of 2007, we published two articles in the Psychotherapy Networker—“Supershinks: Learning from the Field’s Most Effective Practitioners” and “How Being Bad Can Make You Good,” with Barry Duncan—describing our research on top-performing therapists. In them we concluded: “The key to superior performance is . . . the best of the best simply work harder at improving their performance than others do.”
Working harder is not about filling the week with additional hours on the job, as findings from other areas of endeavor affirm. In fact, the number of hours devoted to playing chess is negatively correlated with performance. Similarly, time spent doing therapy has never been a strong predictor of positive outcome. Instead, reaching the top requires hard work of an entirely different order: consistently and consciously pushing to reach objectives just beyond one’s level of proficiency.
Rachel Hsu is a perfect example. When interviewed in front of the audience following her performance, she readily admitted making, “all sorts of mistakes.” The audience laughed incredulously. Rachel continued undeterred, “Hardly anyone notices, of course, but I do—and I remember.” More laughter. These mistakes, she went on to explain, become the focus of her efforts the next time she practices. Confident of the standard she’s trying to reach, she slows down such passages, playing and replaying them until they’re mastered, all the while being subject to the scrutiny and approval of her mother or teacher.
Rachel’s narrative neatly captures the three steps we reviewed in our two articles, which research has shown are necessary to achieve excellence. First, know your baseline. Rachel is able to accurately assess what she does, mindful of what she’s capable of. Second, engage in deliberate practice—a systematic and critical review during which time problematic aspects of a performance are isolated and rehearsed or, failing that, alternatives are considered, implemented, and evaluated. Third, obtain formal, ongoing feedback. Illustrating this last step, we noticed that, following the performance, Rachel and her mother returned to the piano in the empty hall. Rachel’s mother then directed her daughter’s attention to a short section of the composition, providing suggestions on how to improve it.
To date, more than a dozen randomized clinical trials, involving thousands of clients and numerous therapists, have established that excellence isn’t reserved for a select few. Far from it: it’s within the reach of all. These studies show that applying the steps—know your baseline, engage in deliberate practice, and obtain ongoing feedback—increases the effectiveness of individual practitioners threefold, cuts dropout rates by 50 percent, reduces the rate of deterioration by 33 percent, and speeds recovery by 66 percent, while improving client satisfaction and reducing the cost of care.
However, if we learned anything in the years following the publication of the Networker articles, it’s this: knowing the facts and putting them into practice are two altogether different matters. We didn’t expect readers to beat a path to our door or be able to put the ideas into practice without additional help or training, but we were surprised that, even among the most interested and enthusiastic, the number of clinicians who put the steps to use in daily practice remained stubbornly small. We were also surprised that many who did follow the steps seemed to lose steam quickly. Moreover, agencies and group practices that devoted significant resources to implementation efforts struggled and all too often failed. Reflecting on this experience, we couldn’t help but be reminded of words attributed to Confucius, “The way out is through the door. Why is it that no one will use this method?”
The Culture of Excellence
Once again, we found ourselves with a question and no ready answer. Available research was no help, because no hard data exist to explain why some individuals devote the time, energy, and resources necessary to achieve greatness. Clearly, therapists’ motivation, personality, and developmental history weren’t the deciding factors, since, with few exceptions, we were working with dedicated, hardworking professionals. Neither could the lack of follow-through be attributed to the bureaucratic overload of contemporary clinical practice.
Top performers, we eventually realized, didn’t exist in a vacuum, bursting suddenly on the scene following years of private toil. To a casual observer, it can certainly appear that way. In truth, hearing performers like Rachel Hsu matter-of-factly report that she practices four hours a day, every day of the week, including weekends and holidays, amassing more than 4,000 hours, or the equivalent of almost 170 straight days at the piano had distracted us from a larger reality. It was as though looking into the bright light of greatness had blinded us to the surrounding context, rendering invisible a complex and interlocking network of people, places, resources, and circumstances without which excellence remains out of reach for all but a few. We’ve come to call this social scaffolding the “culture of excellence.”
Without the familial, social, economic, and cultural context to nurture and encourage her, Rachel most likely would never have acquired the skill and presence she now exhibits. She has two parents who devote a massive amount of time, energy, and resources to nurture and advance her abilities. Moreover, she happens to live in a location that affords her opportunities to attend world-class concerts, participate in high-level competitions, and take advantage of unsurpassed professional instruction, all of which her family can afford to provide.