Research shows that training in specific techniques and theories contributes little to

effective psychotherapy outcomes. What are well-intentioned clinicians who want to

improve their skills to do? Read The Field Guide to Better Results. This book offers
readers a practical roadmap to making their sessions more successful and enjoyable
while helping them grow as therapists (and as people). I highly recommend this book.
— PA U L J . L E S L I E , E d D , A U T H O R O F T H E A RT O F C R E AT I N G A M A G I C A L S E S S I O N :
K E Y E L E M E N T S F O R T R A N S F O R M AT I V E P S Y C H O T H E R A P Y

One of the biggest questions facing practicing clinicians today is how to improve and
personalize psychological interventions based on the available research literature. This
outstanding book will teach readers how to tackle this important task and how to
develop their clinical skills further. It provides the necessary research basics as well as
deliberate practice training examples to improve treatment options and make use of
available monitoring tools. Comprehensive and fun to read, this volume helps to
move the practice of psychological therapy forward.
— W O L F G A N G L U T Z , P h D , D E PA RT M E N T O F P S Y C H O L O G Y,
UNIVERSITY OF TRIER, TRIER, GERMANY

This field guide offers a user-friendly path on how to engage in deliberate practice in
order to achieve better treatment outcomes. The authors provide detailed exercises on
how to become more effective psychotherapists. Kudos!
—DONALD MEICHENBAUM, PhD, RESEARCH DIRECTOR OF THE MELISSA INSTITUTE FOR VIOLENCE
P R E V E N T I O N A N D T R E AT M E N T, C O R A L G A B L E S , F L , U N I T E D S TAT E S
An eminently original, engaging, and practical book that draws together the latest
research findings to help therapists of all orientations improve their work. “Deliberate
practice” is a major new innovation in the training and development of psychothera-
pists, and this field guide—written by leading figures in the psychotherapy
world—provides unique, step-by-step guidance to applying its method and insights.
—MI C K C O O PER, D Phil, P ROFESSOR OF COUNSELLING P SYCHOLOG Y,
U NI V ERSITY OF ROEHAMP TON, LOND ON, ENG LAND

This book offers a wonderful combination of state-of-the-art scientific evidence on

what makes therapists effective, in understandable language, and hands-on exercises
for clinicians to improve their effectiveness. It is truly unique in that sense!
—KI M de JO N G, PhD , S E NI O R A S SISTANT P ROF ESSOR OF CLINICAL P SYCHOLOG Y,
LEID EN UNIVERSITY, THE NETHERLAND S
The Field Guide to

BETTER
RESULTS
A companion workbook for Better Results

The Field Guide to

BETTER
RESULTS
Evidence-Based
E xercises to Improve
Therapeutic Ef fectiveness

Edited by
S C O T T D. M I L L E R , D A R Y L C H O W,
S A M M A L I N S, a n d M A R K A . H U B B L E
F o r e w o r d b y B R U C E E . WA M P O L D
Copyright © 2023 by the American Psychological Association. All rights reserved. Except
as permitted under the United States Copyright Act of 1976, no part of this publication
may be reproduced or distributed in any form or by any means, including, but not limited
to, the process of scanning and digitization, or stored in a database or retrieval system,
without the prior written permission of the publisher.

The opinions and statements published are the responsibility of the authors, and such
opinions and statements do not necessarily represent the policies of the American
Psychological Association.

Published by
American Psychological Association
750 First Street, NE
Washington, DC 20002
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Library of Congress Cataloging-in-Publication Data

Names: Miller, Scott D., editor. | Chow, Daryl, editor. | Malins, Sam, editor. |
Hubble, Mark A., 1951- editor.
Title: The field guide to better results : evidence-based exercises to
improve therapeutic effectiveness / edited by Scott D. Miller, Daryl Chow,
Sam Malins, and Mark A. Hubble.
Description: First edition. | Washington, DC : American Psychological
Association, [2023] | Includes bibliographical references and index.
Identifiers: LCCN 2022054609 (print) | LCCN 2022054610 (ebook) |
ISBN 9781433837593 (paperback) | ISBN 9781433837609 (ebook)
Subjects: LCSH: Evidence-based psychotherapy. | Psychiatry--Decision making. |
BISAC: PSYCHOLOGY / Education & Training | PSYCHOLOGY /
Psychotherapy / Counseling
Classification: LCC RC455.2.E94 F54 2023 (print) | LCC RC455.2.E94 (ebook) |
DDC 616.89--dc23/eng/20221223
LC record available at https://lccn.loc.gov/2022054609
LC ebook record available at https://lccn.loc.gov/2022054610

https://doi.org/10.1037/0000358-000

Printed in the United States of America

10 9 8 7 6 5 4 3 2 1
CONTENTS

Expanded Contents vii

Contributors xi
Foreword xiii
Bruce E. Wampold
A Personal Preface and Dedication xv
Scott D. Miller

Introduction: How to Use The Field Guide to Better Results 3

Scott D. Miller and Mark A. Hubble

1. Identifying Your “What” to Practice 7

Scott D. Miller and Mark A. Hubble

2. Identifying and Refining Your Individualized Learning

Objective 25
Daryl Chow, Scott D. Miller, and Mark A. Hubble

3. Client Factors 47
Joshua K. Swift, Jesse Owen, and Scott D. Miller

4. Therapist Factors 79
Helene A. Nissen-Lie, Erkki Heinonen, and Jaime Delgadillo

5. Relationship Factors 107

John C. Norcross and Christie P. Karpiak

6. Hope and Expectancy Factors 131

Michael J. Constantino, Heather J. Muir, Averi N. Gaines, and
Kimberly Ouimette

v
vi Contents

7. Structural Factors 155

Nicholas Oleen-Junk and Noah Yulish

8. Habits: The Key to a Sustainable System of Deliberate

Practice 181
Sam Malins, Scott D. Miller, Mark A. Hubble, and Daryl Chow

9. The Last Chapter (but Not the Last Word) on Deliberate

Practice 201
Sam Malins, Daryl Chow, Scott D. Miller, and Mark A. Hubble

Appendix A: Taxonomy of Deliberate Practice Activities in Psychotherapy—

Therapist Version (Version 6) 207
Appendix B: Taxonomy of Deliberate Practice Activities in Psychotherapy
Exercise Guide 225
Index 239
About the Editors 253
EXPANDED CONTENTS

Contributors xi
Foreword xiii
Bruce E. Wampold

A Personal Preface and Dedication xv

Scott D. Miller

Introduction: How to Use The Field Guide to Better Results 3

Scott D. Miller and Mark A. Hubble

Better Results identified the principles and practices associated with using delib-
erate practice to improve therapeutic effectiveness. As soon as it appeared,
readers responded by asking for more—specifically, greater input on how to
identify the types of activities most likely to improve results. The Field Guide
picks up where the previous volume left off by thoroughly reviewing the
research on each of the factors responsible for effective therapy as described in
the Taxonomy of Deliberate Practice Activities in Psychotherapy (TDPA).
Empirically supported principles and exercises are then identified that can
be used to develop and fine-tune each therapist’s plan for deliberate practice.

1. Identifying Your “What” to Practice 7

Scott D. Miller and Mark A. Hubble

Successful deliberate practice depends on creating a plan specifically remedial

to an individual’s performance deficits. This chapter helps practitioners identify
the learning objectives likely to have the greatest leverage in improving their
outcomes.

vii
viii Expanded Contents

2. Identifying and Refining Your Individualized Learning Objective 25

Daryl Chow, Scott D. Miller, and Mark A. Hubble

This chapter addresses the second most common question practitioners ask:
“After I know what to work on, how am I supposed to practice to improve?”
It involves mapping performance data onto the factor having the most leverage
on outcome, narrowing down potential targets for improvement to a single
objective, and breaking the process down into a series of small steps known as a
“learning project.” Whether you are a “data geek” or “dataphobe,” this chapter
sets the stage for successful deliberate practice.

3. Client Factors 47
Joshua K. Swift, Jesse Owen, and Scott D. Miller

Client factors are thought to explain the largest proportion of variance in psycho-
therapy outcomes. In this chapter, the relevant research linked to change in
psychotherapy is reviewed. From this, four evidence-based principles are derived.
Seven exercises designed to help therapists develop and refine their abilities
for personalizing psychotherapy to the individual client are presented.

4. Therapist Factors 79
Helene A. Nissen-Lie, Erkki Heinonen, and Jaime Delgadillo

It is well established the individual therapist makes a difference for client

outcomes. Researchers have gathered information on which aspects of the
therapist’s personal and professional functioning matter and those that are
less relevant. In this chapter, the empirical research in the realm of therapist
effects and evidence-based therapist factors is reviewed. Based on the findings,
three evidence-based principles and a variety of deliberate practice exercises
for enhancing therapist factors in psychotherapy are presented.

5. Relationship Factors 107

John C. Norcross and Christie P. Karpiak

The empirical research on relationship factors in psychotherapy is summarized,

beginning with a synopsis of relationship factors that do not make a difference
in client success. Factors that do make a positive difference are considered next,
including the therapeutic alliance (including collaboration and goal consensus),
empathy, positive regard and affirmation, therapist congruence and genuineness,
the real relationship, emotional expression, and repair of alliance ruptures. From
that robust research base, several evidence-based principles are derived, and
deliberate practice exercises are recommended.

6. Hope and Expectancy Factors 131

Michael J. Constantino, Heather J. Muir, Averi N. Gaines, and Kimberly Ouimette

Client outcome expectation (OE) is the foretelling belief about the likely effec-
tiveness of one’s therapy. OE can range on a dimension from less to more
 Expanded Contents ix

hopeful that improvement will occur, and it can shift over time. Thus, OE can
be assessed before and repeatedly across therapy to inform treatment planning
and therapist responsiveness. This chapter reviews empirical support for the
clinical relevance of OE, identifies OE-relevant principles for clinical inter-
vention, offers deliberate practice exercises to help clinicians leverage OE
principles, and highlights practice-oriented resources related to OE.

7. Structural Factors 155

Nicholas Oleen-Junk and Noah Yulish

The chapter begins with a brief review of structural factors widely believed to
make a difference in the outcome of psychotherapy for which there is little
or no evidence: choice of a particular model, fidelity, adherence, competence,
universal application of psychological formularies, and unwavering deference
to client or therapist preferences. Factors that do make a difference are then
considered (e.g., pretreatment preparation or role preparation, problem focus,
presence of structure and organization, provision of rationale or credibility,
planning for termination), resulting in a transtheoretical metastructure of
effective therapeutic structures.

8. Habits: The Key to a Sustainable System of Deliberate Practice 181

Sam Malins, Scott D. Miller, Mark A. Hubble, and Daryl Chow

Deliberate practice (DP) is challenging. Most people stop once they have achieved
proficiency at a given task. Continuous improvement over the course of one’s
career requires a sustainable DP plan. Current evidence suggests willpower,
motivation, and good intentions are unlikely to be sufficient. To be successful,
DP must become a habit. Evidence regarding habit formation is reviewed and
distilled into key principles and associated exercises for maintaining engage-
ment in DP over time.

9. The Last Chapter (but Not the Last Word) on Deliberate Practice 201
Sam Malins, Daryl Chow, Scott D. Miller, and Mark A. Hubble

Evidence shows deliberate practice (DP) is more effective than traditional

approaches for teaching and training therapists (Barrett-Naylor et al., 2020;
Newman et al., 2022; Westra et al., 2021). Still, much remains unknown and
subject to revision. This chapter summarizes what is known and offers four
concrete suggestions so future work and research remain true to DP’s potential
for transforming the professional development of psychotherapists.

Appendix A: Taxonomy of Deliberate Practice Activities in Psychotherapy—

Therapist Version (Version 6) 207
Appendix B: Taxonomy of Deliberate Practice Activities in Psychotherapy
Exercise Guide 225
Index 239
About the Editors 253
CONTRIBUTORS

Daryl Chow, PhD, Henry Street Centre, Fremantle, Western Australia

Michael J. Constantino, PhD, Department of Psychological and Brain
Sciences, University of Massachusetts Amherst, Amherst, MA, United States
Jaime Delgadillo, PhD, Clinical and Applied Psychology Unit, The
University of Sheffield, Sheffield, United Kingdom
Averi N. Gaines, MS, Department of Psychological and Brain Sciences,
University of Massachusetts Amherst, Amherst, MA, United States
Erkki Heinonen, PhD, Department of Psychology, University of Oslo,
Oslo, Norway
Mark A. Hubble, PhD, International Center for Clinical Excellence,
Danbury, CT, United States
Christie P. Karpiak, PhD, Department of Psychology, University of
Scranton, Scranton, PA, United States
Sam Malins, DClinPsy, PhD, Institute of Mental Health, University of
Nottingham Innovation Park, Nottingham, United Kingdom
Scott D. Miller, PhD, International Center for Clinical Excellence,
Chicago, IL, United States
Heather J. Muir, MS, Department of Psychological and Brain Sciences,
University of Massachusetts Amherst, Amherst, MA, United States
Helene A. Nissen-Lie, PhD, Department of Psychology, University of Oslo,
Oslo, Norway
John C. Norcross, PhD, Department of Psychology, University of Scranton,
Scranton, PA, United States
Nicholas Oleen-Junk, PhD, Psychology Resources, League City, TX,
United States

xi
xii Contributors

Kimberly Ouimette, BS, Department of Psychological and Brain Sciences,

University of Massachusetts Amherst, Amherst, MA, United States
Jesse Owen, PhD, Department of Counseling Psychology, University of
Denver; Sondermind: OrgVitals: Celesthealth: Lifelong, Denver, CO,
United States
Joshua K. Swift, PhD, Department of Psychology, Idaho State University,
Pocatello, ID, United States
Bruce E. Wampold, PhD, Department of Counseling Psychology, University
of Wisconsin–Madison, Madison, WI, United States
Noah Yulish, PhD, The Willow Center for Integrative Health, Chicago, IL,
United States
FOREWORD

So much in our lives rapidly changes. Over 40 years ago, when I started my career
studying psychotherapy and training therapists, if I wanted to reach someone,
I either mailed a letter or called on a phone tethered to a wall. If I needed to find
an article, I physically went to the library and looked through “the stacks.”
To do a statistical analysis for a study, I punched data onto IBM cards, submitted
the deck to the computer center on campus, and returned the next morning to
receive the results (that is if I didn’t mistake a colon for a semicolon). No personal
computers, ethernet, internet, wireless networks, streaming music, and so on . . .
and so on.
It is an understatement. Much has changed in these 40-plus years—that is,
except how we train therapists and how therapists work to get better over
their careers. Sure, we have new therapy models—growing in number every
year. However, then, as now, we teach trainees basic therapy skills and some
treatment models, then we have them see clients in a practicum. Under the
best of circumstances, their work is observed, and supervision is provided.
Unfortunately, the process typically focuses on the client and the client’s
diagnosis; if feedback is provided, it is usually quite general and not focused
on particular therapy skills. After that? More clients and more supervision.
Then, graduation. More of the same follows, with newly minted therapists
documenting hours (not their skills) and passing an examination. After licens-
ing, more lectures, reading, and new models. In some countries, continued
supervision is required but, again, rarely focused on providing feedback on
specific skills. Is it any wonder therapists do not improve over the course of
their careers? Indeed, in terms of outcome, practicing therapists are, on average,

xiii
xiv Foreword

equivalent to trainees (yes, we confidently supervise them, believing our years

of experience make us experts!).
Attention readers: We need something different. Something based on the
science of expertise. Something that will actually lead to better results. Anders
Ericsson, who recently passed away, spent his career as a professor of psychology
studying expertise. His essential conclusion was that to improve in any domain,
individuals must deliberately practice the skills needed for successful perfor-
mance. Fortunately for the field, Scott Miller and Daryl Chow became aware
of Anders’s work and enlisted him to collaborate in applying deliberate practice
to our profession. This is revolutionary—finally, a scientific-based means to
improve psychotherapy outcomes by having therapists advance their skill level.
The Field Guide to Better Results: Evidence-Based Exercises to Improve Therapeutic
Effectiveness, edited by Scott D. Miller, Daryl Chow, Sam Malins, and Mark A.
Hubble, is an extension of Better Results: Using Deliberate Practice to Improve
Therapeutic Effectiveness (Miller et al., 2020), which provided readers with the
first detailed application of deliberate practice to psychotherapy. In any
domain, before one can practice deliberately, the skills needed for successful
performance must be identified. Thankfully, this work has been done. The
factors that characterize effective therapists are now known. In each chapter of
The Field Guide to Better Results, the authors (all experts on a particular factor)
review decades of research, extracting accessible, essential evidence-based
principles, and then offer concrete exercises for skill development.
Improving performance in any domain is difficult, and using deliberate
practice to enhance outcomes involves focused effort. As anyone who has dieted
knows, we only stick to a program if it works and the work toward the goal is
realistic and engaging. Fortunately, The Field Guide to Better Results is not only
pragmatic but also engaging.
The quality of mental health care depends on effective therapists. We
have a duty to our clients and society to provide the most effective services
we can. The best way to do this is to deliberately practice the factors responsible
for therapeutic change—the goal being for every practitioner to improve
continuously.

—Bruce E. Wampold, PhD

Professor Emeritus, University of Wisconsin–Madison
and Skillsetter.com

REFERENCE
Miller, S. D., Hubble, M. A., & Chow, D. (2020). Better results: Using deliberate practice to
improve therapeutic effectiveness. American Psychological Association. https://doi.org/
10.1037/0000191-000
A PERSONAL PREFACE AND
DEDICATION

Slightly more than 20 years ago, my colleagues and I were struggling with a
puzzle. At that time, two tools we had created for monitoring the process and
outcome of mental health care were in wide use around the world. The data
being generated were providing an intriguing glimpse into real-world clinical
practice. Therapists, that evidence clearly showed, were effective—returning
outcomes on par with those obtained in tightly controlled randomized clinical
trials. Such news was both inspiring and reassuring, especially because it con-
trasted so sharply with the field’s insatiable desire for the “new and improved.”
Here was a clear and definitive answer. We did good work. Period.
Equally interesting, but inexplicable at the time, were results showing some
clinicians were more helpful than others—and the difference in effect was far
from small. Compared with their more average counterparts, top performers
had a much bigger impact on the well-being and functioning of their clients,
leading more of them to recovery and doing so in a shorter period. They also
appeared to have a knack for helping the most difficult and challenging clients,
who, when seen by other therapists, failed to benefit despite many visits.
To be sure, we were not the first group of researchers to find therapists varied
in effectiveness. Indeed, published accounts dated back decades. None, how-
ever, offered much in the way of explanation for the differences. One excep-
tion was a 1974 study of two clinicians, one highly effective “supershrink,” the
other, based on their comparatively poor results, deemed a “pseudoshrink”
(Ricks, 1974). Appearing, as it did, in the pages of an obscure and little-read
professional book, this groundbreaking investigation received little subsequent
attention. Sadly, the author’s promised replication with a larger sample never
happened.

xv
xvi Preface

With little or no effort, most of us can name specific people across a wide
range of human endeavors—art, music, medicine, sports, chess—who have
or continue to perform at a measurably superior level. The care each of us would
put into deciding which mental health professional to recommend for a friend
or loved one strongly suggests we believe similar differences exist between
providers.
Our idea was simple: Identify the traits, behaviors, training, and practice
patterns of highly effective therapists so that the rest of us could emulate their
work. Alas, extensive interviews, even watching recordings, provided little
insight into what they were doing. As a group, they hewed to no particular
theoretical orientation or demographic (e.g., age, gender, years of experience,
amount of training, professional degree), and often their work was not especially
inspiring to watch. Frankly, much of it was boring, including a mixture of
advice-giving, long stretches of inactivity, and trite observations and inter­
pretations. Regarding the process, it could be overly regimented if not con-
trolling, while at others, freewheeling and disorganized.
After much effort, we were forced to face facts. If the best clinicians shared
some characteristic or work pattern, we could not see it. For my own part,
I was beginning to believe the differences between therapists were simply
random. After all, our data set, while large, did not extend very far back in
time. Perhaps, as most standard investment disclaimers go, “past performance
was no guarantee of future performance.” Indeed, maybe it was best to think
of a therapist’s outcomes like a stock, rising and falling depending on a host of
factors not always related to actual ability or accomplishment. The implication,
if true, meant nothing could be learned from studying highly effective thera-
pists. They were a mirage—something everyone believed in, even saw, but in
reality, did not exist.
The project was shelved following an email exchange with an internationally
known colleague and fellow researcher. “The whole idea of ‘supershrinks,’”
this person asserted, “is burdensome to the hardworking, underpaid, under-
funded, and frankly overwhelmed professionals already at significant risk
for burning out. Being ‘good enough’ has to be good enough.” And there, our
research would have remained had it not been for a chance event.
As shared in our article titled “Supershrinks: What’s the Secret of Their
Success?” (Miller et al., 2007), I was on a flight home following a training
in Europe. Weary from the road and stuck in a middle seat, I gladly took a
periodical offered by a passing flight attendant. The magazine, Fortune, was new
to me. After a quick glance, my attention was immediately drawn to an article
titled “What It Takes to be Great” (Colvin, 2006). It showcased the research
of Swedish psychologist K. Anders Ericsson, widely regarded as the “expert on
expertise.” He knew why some excelled and others never moved beyond
mere proficiency. He had spent his entire career investigating what he termed
“deliberate practice” (DP).
I had never heard of him. Once home, however, I made sure to learn as
much as I could. Then, I called him. I had been doing that for years—going
 Preface xvii

directly to the source—whenever I had a question or wanted to know more.

As an undergraduate, I even had an extended correspondence with B. F.
Skinner, first reaching out to him for help with a class assignment.
“Maybe you can educate me a bit about your field,” Ericsson said after
exchanging the usual pleasantries. Hard to believe, but no mental health
professional had ever contacted him. He was surprised to learn how little con-
sensus existed among experts and researchers about what mattered most for
success in psychotherapy. With so much disagreement, he observed, “Basically,
it’s likely individual practitioners will find it difficult to improve.” I had to keep
myself from laughing out loud. As an outsider to our field, he had no idea how
on point he was—later studies would show the outcome of psychotherapy had
not improved over the decades, and individual practitioner outcomes actually
decline with experience (Germer et al., 2022; Goldberg et al., 2016)!
At the end of our initial contact, he suggested a slew of articles we could read
to get up to speed on the subject. More, he expressed a willingness to serve as
an advisor should we want to research the application of DP in our profession.
In the years that followed, Anders became a trusted friend and consultant,
offering encouragement, advice, and critical input on our work and writing.
With his inspiration and guidance, we published research in peer-reviewed
journals and articles in popular periodicals, documenting the role DP played
in the development of highly effective therapists.
Through the application of his ideas, we learned, in contrast to what
I initially believed, therapists were consistent in their performance—be it good,
middling, or bad—and that continuously working to improve one’s outcomes
did not give rise to burnout but actually prevented it. Later, hoping to add rigor
to what remained poor and even contradictory definitions in the empirical
literature, we developed a set of criteria by which bona fide instances of DP,
therapy-related or not, could be determined—a list successfully used to rebut
a study that claimed to show it was far less impactful than Ericsson and his
colleagues claimed. Our meta-analysis found
a relatively large correlation between DP and improved performance compared
to other associations considered critical (e.g., the correlations of smoking, obesity,
and excessive drinking with mortality). More . . . the magnitude of the relation-
ship is even greater when studies are limited in the analysis to bona fide instances
of DP. (Miller et al., 2018, p. 7)

In May 2020, Better Results: Using Deliberate Practice to Improve Therapeutic

Effectiveness (Miller et al., 2020) was published. It was the culmination of nearly
2 decades of work, thinking, and research. Always encouraging, Ericsson wrote
in the foreword, “Its publication heralds . . . a major change in the conception
and implementation of training . . . and change in the methods used to ensure
continued refinement of . . . therapists’ performance through their entire
careers” (Miller et al., 2020, p. xiv). For my part, it felt as though we were just
getting started. We had the “picture on the box” to guide us and the border
and some of the more obvious clusters assembled, but the puzzle was far from
complete.
xviii Preface

One month after the publication of our book, I interviewed Dr. Ericsson
for my blog (Miller, 2020). By this time, my colleagues and I were already
developing plans for what would eventually become The Field Guide to Better
Results. Dr. Ericsson was as stimulating and encouraging as ever. It turns out,
after a lifetime of presentations, publications, and interviews, this would
be his last. Days following our conversation, Anders died. It was a deep and
unexpected personal and professional loss. I miss his accessibility, openness,
deep curiosity, and singular focus and hope he would be proud of this volume.
Ending this dedication, I recall his parting words when we last spoke about
deliberate practice: “When I talk to people who are very successful . . . they
have this daily routine, so they don’t really have to ask themselves, ‘Do I really
feel like doing this today?’ No! They just start doing it.”

—Scott D. Miller

REFERENCES
Colvin, G. (2006, October 30). What it takes to be great. Fortune, 154(9), 88–96.
Germer, S., Weyrich, V., Bräscher, A.-K., & Witthöft, M. (2022). Does practice really make
perfect? A longitudinal analysis of the relationship between therapist experience and
therapy outcome. Journal of Counseling Psychology, 69(5), 745–754. https://doi.org/
10.1037/cou0000608
Goldberg, S. B., Rousmaniere, T., Miller, S. D., Whipple, J., Nielsen, S. L., Hoyt, W. T., &
Wampold, B. E. (2016). Do psychotherapists improve with time and experience?
A longitudinal analysis of outcomes in a clinical setting. Journal of Counseling Psychology,
63(1), 1–11. https://doi.org/10.1037/cou0000131
Miller, S. D. (2020, June 22). The expert on expertise: An interview with K. Anders Ericsson
[Video]. YouTube. https://www.youtube.com/watch?v=8WARK0aNX88&t=7s
Miller, S. D., Chow, D., Wampold, B., Hubble, M. A., Del Re, A. C., Maeschalck, C., &
Bargmann, S. (2018). To be or not to be (an expert)? Revisiting the role of deliberate
practice in improving performance. High Ability Studies, 31(1), 5–15. https://doi.org/
10.1080/13598139.2018.1519410
Miller, S. D., Hubble, M. A., & Chow, D. (2020). Better results: Using deliberate practice to
improve therapeutic effectiveness. American Psychological Association. https://doi.org/
10.1037/0000191-000
Miller, S. D., Hubble, M. A., & Duncan, B. L. (2007, November/December). Supershrinks:
Learning from the field’s most effective practitioners. The Psychotherapy Networker,
31(6), 26–35, 56.
Ricks, D. F. (1974). Supershrink: Methods of a therapist judged successful on the basis of
adult outcomes of adolescent patients. In D. F. Ricks & M. Roff (Eds.), Life history
research in psychopathology (pp. 275–297). University of Minnesota Press.
The Field Guide to

BETTER
RESULTS
Introduction
How to Use The Field Guide to Better Results
Scott D. Miller and Mark A. Hubble

You can’t use an old map to explore a new world.

—ALBERT EINSTEIN

W elcome to The Field Guide to Better Results (FG). Books in this genre number
in the thousands. A quick search on the internet reveals field guides can
be purchased on almost any topic—from ants to zebras, moths to mushrooms,
ocean floors to mountain tops, dinosaurs to UFOs and the extraterrestrials who
pilot them. Using a combination of short summaries, illustrations, charts, and
advice, their specific purpose is to help the user quickly and efficiently identify,
locate, and distinguish key characteristics defining the subject of interest—
in this instance, the first field guide ever published on using deliberate practice
(DP) to improve therapist effectiveness.
The FG is the follow-up to Better Results (BR; Miller et al., 2020). It is best
seen as a companion volume, the need for which became evident long before
the first work was completed. Although applied across a variety of performance
domains (e.g., chess, music, medicine, athletics), DP is a relatively new topic
in psychotherapy (Miller & Hubble, 2011; Miller et al., 2007). Conflicting
viewpoints regarding its nature and use are already on the rise (Rousmaniere,
2016, 2019). And, in truth, despite the detailed principles and practices described
in BR, much of the framework provided required further investigation and
exposition based on emerging science. In addition, the practitioners we encoun-
tered who were trying to apply DP to their professional development wanted

https://doi.org/10.1037/0000358-001
The Field Guide to Better Results: Evidence-Based Exercises to Improve Therapeutic Effectiveness,
S. D. Miller, D. Chow, S. Malins, and M. A. Hubble (Editors)
Copyright © 2023 by the American Psychological Association. All rights reserved.
3
4 Miller and Hubble

more—in particular, explicit guidance in a readily accessible format about what

to practice deliberately and how.
While reviewing the galley proofs of BR, mindful of the work left to be
done, we began reaching out to researchers known for their expertise on the
factors responsible for the effectiveness of psychotherapy (e.g., client, therapist,
relationship, hope and expectancy, structure). Each was invited to (a) review
the latest empirical literature on a specific factor, (b) distill evidence-based
principles for empowering it, and last, (c) create exercises practitioners could
immediately perform to strengthen the operation of the principles in their
clinical work. Without exception, all agreed to contribute.
In Chapter 3, Joshua K. Swift, Jesse Owen, and Scott D. Miller focus on
the contribution to outcome made by the client. Research shows who they
are; what qualities, traits, and experiences they bring to therapy; and what
influences in their life outside of treatment have the largest effect on results.
In Chapter 4, Helen A. Nissen-Lie, Erkki Heinonen, and Jaime Delgadillo direct
their attention to what pioneering researcher Sol Garfield (1997) once called
“the neglected variable” in psychotherapy: the therapist. Turns out, who does
the therapy is of critical importance, far more so than any method or approach.
John C. Norcross and Christie P. Karpiak, in Chapter 5, delineate the charac-
teristics of productive helping relationships, adding the nuance and detail
necessary to enable practitioners to customize their connection to each client.
Helping clinicians understand the role of hope and expectancy and how beliefs
in the effectiveness of a given course of mental health care can be supported and
strengthened is the subject of Chapter 6 by Michael J. Constantino, Heather J.
Muir, Averi N. Gaines, and Kimberly Ouimette. Finally, in Chapter 7, Nicholas
Oleen-Junk and Noah Yulish address the last of the factors responsible for the
effectiveness: structure. Structure includes the therapeutic rationale, associated
techniques and rituals, the timing of interventions, and the treatment context
or setting. Regardless of a clinician’s preferred way of working, this chapter
shows how to organize and execute care for maximum benefit.
Beyond the identification of evidence-based principles and specific exercises,
some clinicians reported wanting more help than was provided in BR for
getting started and sustaining their DP efforts. Expressed, too, was an interest
in how to narrow down potential professional development targets to the single
learning objective, which, when reached, would yield the greatest return
on investment. In the first chapter, Scott D. Miller and Mark A. Hubble offer
insight and advice for practitioners who, despite being interested in DP, have yet
to move past the “this-is-a-good-idea” phase. Later in the book, in Chapter 8,
Sam Malins, Scott D. Miller, Mark A. Hubble, and Daryl Chow address what to
do when one’s implementation is marked by fits and starts. Finally, in the second
chapter, Daryl Chow, Scott D. Miller, and Mark A. Hubble offer solutions for
those feeling overwhelmed in their attempt to select the best learning objective
from among the many possibilities. As first introduced in BR, the Taxonomy of
Deliberate Practice Activities in Psychotherapy (Chow & Miller, 2022) plays a key
 Introduction 5

role in helping practitioners develop an individualized, step-by-step professional

development plan (a revised and updated version can be found in Appendix A).
Unlike BR, the FG is not designed to be read from cover to cover. Instead,
it’s best thought of as a reference work, a resource to consult whenever a
specific question, decision point, or challenge arises in one’s application of DP.
Like any field guide, the section that has the most relevance depends on where
the person is and what they need to know or be able to do now.
If you are ready to get going with the FG, consult the map in Figure 1.
It will help identify “where you are” in your implementation of DP and point
you to the next step. For convenience and to help you stay on track, key decision
points selected from the map are included at the beginning and end of each
chapter.

FIGURE 1. The Field Guide Map

6 Miller and Hubble

REFERENCES
Chow, D., & Miller, S. D. (2022). Taxonomy of Deliberate Practice Activities in Psychotherapy—
Therapist Version (Version 6). International Center for Clinical Excellence.
Garfield, S. L. (1997). The therapist as a neglected variable in psychotherapy research.
Clinical Psychology: Science and Practice, 4(1), 40–43. https://doi.org/10.1111/j.1468-
2850.1997.tb00097.x
Miller, S. D., & Hubble, M. (2011). The road to mastery. Psychotherapy Networker, 35(3).
Miller, S. D., Hubble, M., & Chow, D. (2020). Better results: Using deliberate practice to
improve therapeutic effectiveness. American Psychological Association. https://doi.org/
10.1037/0000191-000
Miller, S. D., Hubble, M. A., & Duncan, B. L. (2007). Supershrinks: What’s the secret of
their success? Psychotherapy Networker, 31(6).
Rousmaniere, T. (2016). Deliberate practice for psychotherapists: A guide to improving clinical
effectiveness. Routledge. https://doi.org/10.4324/9781315472256
Rousmaniere, T. G. (2019). Mastering the inner skills of psychotherapy: A deliberate practice
handbook. Gold Lantern Books.
1
Identifying Your “What” to
Practice
Scott D. Miller and Mark A. Hubble

The illiterate of the 21st century will not be those who cannot read and write, but those
who cannot learn, unlearn, and relearn.
—ALVIN TOFFLER

DECISION POINT

Begin here if you have read the book Better Results and

• have not started gathering outcome data or are experiencing difficulty getting
started or maintaining the motivation to measure your performance or

• are measuring your performance but have not collected sufficient data
to establish a reliable, evidence-based profile of your therapeutic
effectiveness.

N o question. Practitioners are a motivated bunch. They want to improve.

They value learning. They are committed to professional development.
In the largest, most comprehensive survey conducted to date, 86% of clinicians
reported being “highly motivated” to transcend their current level of perfor-
mance (Orlinsky & Rønnestad, 2005).

https://doi.org/10.1037/0000358-002
The Field Guide to Better Results: Evidence-Based Exercises to Improve Therapeutic Effectiveness,
S. D. Miller, D. Chow, S. Malins, and M. A. Hubble (Editors)
Copyright © 2023 by the American Psychological Association. All rights reserved.
7
8 Miller and Hubble

It starts early. Admission to graduate programs is highly competitive, with

ratios of 300 applicants to 8 positions being commonplace (Info Learners, 2022).
Once in, the work continues, even intensifies: classes, practica, exams, theses,
and dissertations. “Curriculum creep” has come to define graduate education,
with the number of required hours increasing 25% over the last 30 years
(Caldwell, 2015). Thousands of hours of supervision follow—a practice most
clinicians deem critical to their professional development and of help through-
out their careers. Close behind is personal therapy. Most go (Bike et al., 2009;
Norcross, 2005). And not just for a single course but returning time and again.
By the way, those who do not report the lowest experience of “felt progress”
and highest career “regress and stasis” (Orlinsky & Rønnestad, 2005, p. 121).
There is more. Graduate education does not end with graduate school.
Though required for licensure, practitioners enthusiastically pursue continuing
education. They do so to maintain and update their knowledge and skills
(Neimeyer et al., 2009; Neimeyer & Taylor, 2011). In the United States,
psychologists—the authors conservatively estimate1—spend $38 million per
year on such activities. This amount excludes the costs of travel, lodging, food,
supplementary learning materials (e.g., books, videos), and for some, lost
revenue.
Given clinicians’ dedication to lifelong learning, it should come as no surprise
the arrival of deliberate practice (DP) on the professional scene has attracted
considerable interest. Before 2007, the term had never been heard, much less
used in the context of psychotherapy research or training. That year, Miller,
Hubble, and Duncan introduced the field to the work of Swedish psychologist
K. Anders Ericsson. In numerous studies conducted over 3 decades, he and
other researchers had documented how DP, regardless of domain (e.g., sports,
music, medicine, chess, teaching), was responsible for superior performance.
On review of this work, Miller et al. (2007) proposed DP provided an answer
to a question that had long eluded the field—one that pioneering outcome
researcher Michael Lambert only a few years earlier had characterized as
“a mystery.” To wit, why are some therapists consistently and significantly more
effective than others?
When subsequent research confirmed the most effective therapists devote
a larger amount of time to DP than others (Chow et al., 2015), practitioners—
always hungry for guidance and direction—responded, “Just tell us how to do
it and what to practice, and we’ll do it.” As commendable as this openness
and willingness to learn is, unfortunately, if given what they ask for, no doubt,
the gains desired will never be realized.
That last sentence bears rereading.
Turns out, the promise of DP is in danger of being undermined. Historically,
the mental health professions have never suffered from a shortage of experts
ready and willing to tell practitioners what to do to be effective (Hubble et al.,
1999). The premise has, and continues to be, practice this method or that

1
The estimate was derived by multiplying the number of licensed psychologists in the
United States by the hours of continuing education required to maintain their licensure
and the average cost of each continuing education hour as of 2021.
 Identifying Your “What” to Practice 9

technique until proficiency is reached, and professional growth is assured.

Not surprisingly, in the 15 short years since DP was first introduced to psycho-
therapy, a series of books have appeared applying the term to mastering
specific treatment models (e.g., cognitive behavior therapy, emotion-focused
therapy), even promising certification as a therapist or coach in the process.
Though few in number at present, studies within the field have followed suit,
frequently mistaking repetition and rehearsal for deliberate practice (Chow
et al., 2022). They are not the same. The fallacy of this approach, as detailed
in Chapter 2 of Better Results (BR; Miller, Hubble, & Chow, 2020), is research
evidence convincingly demonstrates training in specific theories and their
associated techniques contribute little, if anything, to outcome.
So, what should practitioners do instead?
Before embarking on a course of professional development, each must answer
the question “What do I need to target to improve my particular results?”
Although it may sound bold, failing to provide a detailed, evidence-based,
and therapist-specific answer to this question all but guarantees (a) clinician
effectiveness will remain flat, as has been seen in the field for the past 40 years
or (b) decline, as studies of individual therapist outcomes show happens,
regardless of the amount of time, money, and energy invested in learning
something new (Germer et al., 2022; Goldberg et al., 2016; Prochaska et al.,
2020; Wampold & Imel, 2015). For all that, the demands of daily clinical work
often make the promise of “do this and you’ll help more people” difficult
to resist.

PRINCIPLES FOR IDENTIFYING YOUR WHAT

In what follows, four evidence-based principles are identified and described,

each aimed at helping practitioners prepare for effective DP. The principles are,
in turn, operationalized in a set of exercises found at the end of the chapter.

Principle 1: Avoid the Athenian Trap

Clearly, K. Anders Ericsson and colleagues were not thinking of how to pitch
their ideas to the masses when, in their original 1993 article on expertise
published in the American Psychologist, they wrote, “In contrast to play, . . .
deliberate practice . . . is not inherently enjoyable, [and] generates no
immediate . . . rewards” (p. 368). Both experience and subsequent research
confirm the accuracy of their observations (Miller, Madsen, & Hubble, 2020).
Plainly put, DP is hard work. Once a modicum of proficiency has been
achieved in a particular performance domain, interest in pushing oneself
typically wanes (Ericsson & Pool, 2016). Moreover, as confidence increases—
generally far outstripping actual, measured ability—most turn their attention
to something more stimulating. It is not solely a question of motivation or
willpower. The brain, hardwired for novelty, naturally selects and rewards the
“new and different” (Bunzeck & Düzel, 2006).
10 Miller and Hubble

The allure of the unfamiliar is as old as recorded history. Consider: In the

Biblical book of Acts, the citizens of Athens are described as “spend[ing] their
time doing nothing but talking about and listening to the latest ideas” (17:21).
So pervasive was this behavior, even the celebrated Greek historian and
general, Thucydides (460–400 BCE), described the Athenian people as routinely
“deceived with the novelty of speech” (Barnes, 1981).
When it comes to professional development, it is as though therapists live
in a modern-day version of Athens. Talk of fresh, exciting discoveries, cutting-
edge research, and improved theories and methods is constant and inescapable,
all breathlessly reported. The underlying promise? The “state-of-the-art” is
one workshop or certification away.
To have any chance of being successful in using DP to improve therapeutic
effectiveness, therapists will need to immunize themselves against the “Athenian
trap.” Isolation, boredom, frustration, uncertainty, comparing oneself with
others (and failing in the comparison), and enduring extended periods of little
or no apparent progress are part of the process. They are also potent triggers.
In all likelihood, others exist, varying from one person to the next.
At the end of this chapter, you will find an exercise designed to improve your
chances of both mobilizing and maintaining the motivation required for DP.

Principle 2: Finding Your What

The idea that improvement depends on practice is hardly new. References

to enhancing a person’s skills or abilities through focused concentration and
effort date back more than 2 millennia (Amirault & Branson, 2006; Ericsson,
2006b). Though DP includes the word practice, it is altogether different. The
highly individualized nature of the process separates it from what practice is
most commonly considered to be. Truly, the goal of DP is neither proficiency
nor mastery. Rather, it is all about continuously reaching for objectives that
lie just beyond one’s current ability. Accomplishing this task relies on a data-
derived identification of “what” specifically each individual needs to target
to improve their performance. As emphasized in BR, one must begin with
identifying the “what” before the “how” (see Miller et al., 2020, pp. 43–47).
Over the last 2 decades, several outcome measurement systems have been
developed, tested, and utilized in real-world clinical settings (Miller, Hubble,
& Chow, 2020). Most include detailed metrics which enable the clinician-user
to develop an evidence-based profile of their work—what, where, and with
whom they excel and, more important, where they fall short or could make
improvements. Detailed information was provided about one of the most
widely used—The Partners for Change Outcome Management System—in BR
(Miller, Hubble, & Chow, 2020, pp. 51–57).
While the technological capacity to identify one’s “growth edge” is now
widely available, some therapists struggle to begin using measures or, once
started, employ them consistently in their work. To be frank, ongoing, real-
time assessment of clinical performance using standardized scales is new
 Identifying Your “What” to Practice 11

to the profession—so much so most have never heard of it, much less received
any formal training in the process (Hatfield & Ogles, 2007; Madsen et al., 2021).
As is true with almost every endeavor, a learning curve exists. In the case of
the two instruments described in BR, their simplicity belies the difficulty
research shows clinicians encounter when implementing them in their daily
work (Brattland et al., 2018). Another consideration—beyond lack of knowl-
edge, training, or experience—is the attitude of the clinician. Not surprisingly,
the evidence documents some are more open to the performance feedback
measurement provides (de Jong et al., 2012).
If the foregoing were not enough, therapists need to be prepared; the
feedback received can be highly disruptive. No, it is highly disruptive. No,
it must be highly disruptive to qualify as DP. In a series of intriguing studies,
Chow and colleagues (Chow et al., 2022; Miller et al., 2015) found engaging
in DP delivered a blow to therapist confidence. The good news is the reduction
in self-assurance enabled therapists first to consider and then make changes in
their behavior, thereby resulting in measured improvements in performance.
Such findings are entirely consistent with evidence from other investigations
demonstrating therapists higher on professional self-doubt and humility estab-
lish stronger therapeutic relationships and achieve better outcomes (Nissen-Lie
et al., 2010; Nissen-Lie & Rønnestad, 2016; Tao et al., 2015; see also Chapter 4,
this volume).
As a case in point, take the example of Brooke Mathewes, an accomplished
and well-regarded psychotherapist working in the United States. For all her
success in the profession, the passion of her life is horses. As a child, she
dreamed of being a cowgirl, decorating her bedroom with toy horses, horse
paintings, and books about horses. The curtains were even hung with wrought-
iron horseshoes.
Talk with Brooke and, in short order, the conversation inevitably turns
to the time she spends at McGinnis Meadows Ranch. There, she’s had the
privilege of being mentored by Shayne, one of the world’s most celebrated
“horse whisperers”—a person with an uncanny, almost magical ability to engage
and heal animals with a history of mistreatment, if not outright abuse.
From the outset, Brooke was a highly motivated student. Her goal? Replicate
her mentor’s success. Toward that end, she spent hours watching him work,
observing his every move: his voice, how he walked, the movement of his
hands, even the angle of his feet in the stirrups. Contributing to her mounting
frustration, he would often say, “Watch closely now. If you blink, you’ll miss it.”
Brooke recalls, “I must have been blinking a lot.”
Continuing, “Early on, my confidence was badly shaken. I’d ridden for
years, spent uncountable hours with horses, but couldn’t match, or see what
Shayne was doing. Even when he gave me explicit directions, I still couldn’t
make it work. That’s when my thoughts would turn harsh. ‘I’m never going to
get this. Cowgirl-shmowgirl. I’m just not good enough.’” Many times, Brooke was
tempted to give up. Pack up her tack, saddle, and boots and go back to riding
at the stable near her home.
12 Miller and Hubble

Pausing, she then shares, “In time, and with Shayne’s ongoing encourage-
ment and coaching, I became better at finding my ‘sweet spot of discomfort,’
actively seeking out experiences that pushed me beyond what I could do
at the moment, but not so far as to risk being crushed whenever I fell short
of the mark.” How Brooke achieved this balance, ultimately improving her
ability to attune to horses and transferring her understanding to clinical work,
is described in depth in the Psychotherapy Networker article “Meet You in
McGinnis Meadows” (Mathewes & Miller, 2020). Suffice it to say, the first step
is befriending doubt, seeing it as a bridge to learning and not as a referendum
on one’s performance.

Principle 3: Connecting Your What to the “Right Stuff”

Physicians at Vienna General Hospital had a major problem. In the mid-1840s,

women giving birth at this premier facility were dying—at a rate of 25% to
30%. The cause was well-known, accepted medical science dating back to
the “father of medicine” himself, Hippocrates (460–370 BCE). Miasma was
the culprit. Bad air. Fog, pollution, defilement, and emanations from rotting
organic matter. In the words of Roman architect Marcus Vitruvius Pollio
(70–15 BCE), it was “mist from marshes . . . blow[ing] toward the town at
sunrise . . . waft[ing] into the bodies of inhabitants” (Karamanou et al.,
2012, p. 52).
The solution? Eliminate waste. Clean the streets. Urge people to close their
doors and windows. Two millennia later, the same explanation held sway.
“All smell is disease,” asserted the English social reformer, Sir Edwin Chadwick
(1800–1890), giving rise to an entire movement aimed at improving public
health. And in truth, such strategies were followed by reductions in the spread
of certain diseases (e.g., cholera). On the obstetrics ward, however, miasma
was not deterred. It remained a killer—a tricky, even cunning one at that.
Enter Ignaz Semmelweis. For him, something about prevailing medical
wisdom did not add up. Literally. Midwives working at the same hospital,
he observed, had a death rate 6 times lower than the medical staff. Following
the death of a colleague who fell ill after puncturing a finger while performing
an autopsy, Semmelweis had an epiphany. Contact with corpses was somehow
associated with morbidity and mortality. He suggested all contact with patients
be preceded and followed by handwashing (Miller, Madsen, & Hubble, 2020).
In no time, the mortality rate in the maternity ward plummeted, dropping to
the same level as that of midwives. Similar results were obtained when he
implemented the same practice in another hospital in Pest, Hungary.
One might expect such a discovery, in addition to bringing about the aban-
donment of miasma theory, would have earned Semmelweis many honors
and awards. It did neither. In fact, his views were rejected by his colleagues
and the field alike. Handwashing simply could not compete with bad air,
in theory or practice. In 1865, after penning what many consider one of the
most important volumes on infectious diseases in history, friends lured him
 Identifying Your “What” to Practice 13

into visiting a mental asylum. Convinced his unrelenting and strident advocacy
of handwashing was a sign of mental instability, they forcibly detained him.
In a cruel twist of fate, the injuries he sustained in the process became infected,
and he died of septicemia 2 weeks later.
Nowadays, of course, the benefits of sanitation are universally accepted.
Handwashing, in particular, is considered a “best practice.” Indeed, decades
of research show it to be the single most effective way to prevent the spread
of infections. Science has also discovered why good hygiene works. It kills
germs. Such information was not available to Semmelweis or his contempo-
raries. His was a hunch—one that defied 2,000 years of medical understanding.
As sad as it is, what happened is not at all surprising. Unable to connect the
declining death rate on the obstetrics ward with the factor responsible for the
success of handwashing, his ideas were rejected, and with the benefits of
general sanitation efforts elsewhere, belief in miasma continued.
The parallel between the story just shared and contemporary psychotherapy
could not be more obvious. Standard interventions such as confronting
dysfunctional thoughts, initiating saccadic eye movements, raising emotional
awareness, facilitating understanding of internal conflicts, and enhancing
communication skills are the miasma “abatement” strategies of our day. Indeed,
despite 50 years of theorizing and research, scant evidence exists documenting
a causal connection between the use of any specific method or technique and
treatment outcomes (Wampold & Imel, 2015). Accordingly, making such
procedures the primary focus of one’s deliberate practice is about as likely to
lead to an improvement in therapeutic effectiveness as closing the windows
of one’s home will stop the spread of disease.
Achieving better results requires connecting an individual’s performance
objectives to factors that actually have leverage on outcomes. A general review
of these empirically established elements can be found in Chapter 11 of BR
(Miller, Hubble, & Chow, 2020, pp. 115–122). Detailed reviews of the sup-
porting research for each, along with evidence-based principles and exercises,
are provided in subsequent chapters of the Field Guide—specifically, 3, 4, 5,
6, and 7. In the meantime, recall, in order of influence, the factors include
(a) client and extratherapeutic factors, (b) alliance and relationship, (c) therapist
effects, (d) hope and expectancy, and (e) structure. More, they form the basis
of the Taxonomy of Deliberate Practice Activities in Psychotherapy (TDPA;
Chow & Miller, 2022; see Appendix A of this volume)—a tool designed to
(a) help align your “what” with the factors likely to exert the greatest impact on
performance, (b) design effective DP exercises, and (c) monitor progress of your
professional development efforts (Miller, Hubble, & Chow, 2020, pp. 179–192).
Unfortunately, experience has shown, if one’s theoretical premises and pre-
suppositions are not carefully examined and, if need be, ruthlessly challenged,
no amount of time and effort will make a difference.
Refer to the end of this chapter for two exercises that will help you examine
your core beliefs, bring how you work into bold relief, and consequently, derive
the most benefit from completing the TDPA.
14 Miller and Hubble

Principle 4: Keep Your Eyes on the Next Step (Not the Prize)

The distance between Camp 4 and the summit of K2—the world’s second-
highest peak—is a mere 2,100 feet. Given an average human stride of 30 inches,
that amounts to 840 steps. Based on the numbers alone, it would seem a
relatively easy task. And yet, only 377 people have ever succeeded, fewer
than have been to outer space! By comparison, climbing Everest is a cakewalk.
Despite being taller, 10 times as many have reached the top. Even then, nearly
one in five dies trying, a rate that increases 60% when K2 is the objective.
Understanding why people commit massive amounts of time, effort, and
resources to such pursuits, even risking their lives, has been the subject of
many articles and research studies. Is it the competitive spirit? Natural human
curiosity? A desire for fame or notoriety? The pride of achieving a goal few
would even consider attempting? Or is it simply as famed British moun-
taineer George Mallory (who perished on his third attempt at Everest) replied,
“Because it’s there.”
The very same question faces those who would engage in DP: Why do it?
DP consumes a significant amount of time. Progress often comes in small
increments and at a rate that is positively glacial. On top, the typical incentives
(e.g., money, status, advancement, validation) are rarely, if ever, commensurate
with the investment. That is why, right up to his death, K. Anders Ericsson
remained puzzled about what motivated those who choose to engage in DP—
calling it the “million-dollar question.”
Turns out, as is the case with mountain climbers, the reasons therapists
give for continuously pushing the limits of their performance vary. Some feel
ethically compelled, duty bound to offer the best to their clients. For others,
it is the satisfaction, even joy, that comes with ongoing learning and professional
growth.
Setting questions of motivation aside, perhaps the more, if not most
important consideration is how to make oneself ready for the sustained effort
DP demands. As a rule, determination, no matter how great, will, in time,
succumb to poor preparation. The good news is that preparation works in
tandem with determination when one maintains a singular focus on the next
step needed to accomplish a just noticeable difference over what one was able
to do before. While the empirical evidence in this area is thin, experience
indicates those who are successful relish the achievement of each advance as
much as or more than reaching the final, desired outcome (Colvin, 2008).
Instead of keeping your eye on the prize, prize each step.
Returning to K2, by the final stage of their ascent, climbers have generally
been in transit for months. Even getting to the base of the mountain is an
ordeal, requiring 7 or 8 days of difficult trekking over rocky terrain on narrow
paths. Then, there are the first three camps, each one at a higher altitude than
the last. The terrain is treacherous, the air increasingly thin, generally forcing
climbers to stay for days along the way to rest and acclimatize. Many are
forced to backtrack multiple times just to “catch their breath”—a process that
can take 3 to 4 weeks! Without exception, those who make it to Camp 4 find
 Identifying Your “What” to Practice 15

themselves short of supplies, physically and mentally exhausted, and starved

for oxygen. They are also facing the most dangerous part of the climb, the spot
responsible for the majority of deaths on K2. It is known as “the bottleneck,”
and it’s not technically difficult, but the house-sized columns of glacial ice
bordering the near vertical crevasse (known as seracs and couloir, respectively)
have a tendency to give way unexpectedly. Given the context, each step short
of the summit is a remarkable accomplishment.
While not putting their lives on the line, therapists do face a bottleneck
of sorts. Actually, two. First, unlike the feeling of accomplishment climbers
experience on reaching the summit of K2, few, if any, incentives exist for
therapists choosing to engage in DP. Beyond the absence of direct financial
rewards for superior results—after all, being average pays the same rate—
current standards of care do not require clinicians to work at improving their
effectiveness. In the Ethical Principles of Psychologists and Code of Conduct, for
example, the word “effective” does not appear a single time. Rather, practi-
tioners need only “provide services . . . with populations and in areas . . . within
the boundaries of their competence, based on their education, training, super-
vised experience, consultation, study, or professional expertise” (Standard 2.01,
Boundaries of Competence, American Psychological Association, 2017, p. 5).
Perversely, that means, as Miller, Madsen, and Hubble (2020) pointed out, “a
practitioner who competently delivers an unhelpful, even deadly service . . . [is
ethically] superior to one who is actually helpful but working beyond” (p. 952)
what they are currently capable of doing—the very heart of DP.
The second and far greater challenge for therapists hoping to improve via
DP is their current level of effectiveness (see BR, pp. 49–58). Evidence from
practicing clinicians shows most are remarkably effective, returning outcomes on
par with those reported in tightly controlled randomized trials—investigations
in which it should be noted study clinicians have many advantages over their
real-world counterparts (e.g., access to the best, ongoing training and super-
vision, lower and less complex caseloads; Minami et al., 2008; Reese et al.,
2014; Saxon & Barkham, 2012; Stiles et al., 2008). Said another way, were
K2 the objective, the average practitioner would typically be starting their DP
journey at Camp 4! The remaining steps before their “summit,” while not
technically difficult, are bound to be the steepest and most slow going. What
is more, unlike any prior professional development experiences, the path
forward is subject to life circumstances and conditions (e.g., family, job, health,
finances, the ease of an established way of working vs. trying something new)
that can, without warning, upend the best intentions.
Think of it this way: If you are reading this book, chances are you have
finished graduate school and are working in an applied setting. It may be
difficult to recall, but at one time, that was your objective—to be a full-fledged,
working therapist. Of course, doing so was preceded by preschool and kinder-
garten, the elementary grades, junior and senior high school, and then college.
Along the way, you took hundreds of tests and completed an untold number
of long-forgotten reading and homework assignments.
16 Miller and Hubble

With effort and focus, you can likely remember the sense of pride you felt on
passing the final exam for a challenging undergraduate course, despite having
many more to complete before graduating. How about the sense of relief you
experienced when you finished collecting data for your thesis or dissertation?
More than likely, you did so even though crunching the numbers, writing up
the results, and defending your project before your faculty committee remained.
And what about passing the licensing exam? We are sure you will agree doing
so was a significant achievement, although finding a job, building a practice,
and establishing yourself in the profession was yet to be realized.
The point? Though your final objective may still be before you, it need not
detract from the satisfaction you experience with each step. Indeed, reaching
your summit will require as much. Otherwise, we run the risk of remaining
in the demotivating state of continuous presuccess failure (Adams, 2013).

SUMMARY

Effective DP begins with identifying “what” you specifically need to target

to improve your effectiveness. Because the pattern of performance strengths
and weaknesses is different for each clinician, no prepackaged, one-size-applied-
to-all set of skills or exercises will work. Therapists hoping to achieve better
results do well to avoid anyone promising otherwise (Principle 1: Avoid the
Athenian Trap). Instead, the process begins with each establishing an evidence-
based profile of their work, using a valid and reliable set of measurement tools
to identify what they do well and where they could do better (Principle 2:
Finding Your What). To ensure that what we practice makes a difference,
it must then be connected to factors that actually have leverage on outcome
(Principle 3: Connecting Your What to the Right Stuff). Research shows most
of what is popularly believed to be responsible for the efficacy of psycho-
therapy contributes little or nothing to the outcome (e.g., treatment models
and techniques, professional and postgraduate training, supervision). Now in
its sixth revision, the TDPA is specifically designed to help connect individual
practitioner performance improvement efforts to what really makes a difference.
The next chapter provides tips for maximizing the utility of the tool based on
feedback from users gathered since its publication in BR. Chief among the
suggestions is helping develop the single DP objective necessary to accomplish
a just noticeable difference in what one was able to do before (Principle 4:
Keep Your Eyes on the Next Step).

EXERCISES FOR IDENTIFYING YOUR WHAT

In what follows, the principles identified in the previous section are linked
to specific DP exercises. While several may strike you as compelling or inter-
esting, avoid the temptation to “get to work.” Instead, read through them all,
 Identifying Your “What” to Practice 17

choosing those specifically tied to your current professional development

objectives.

Principle 1: Avoid the Athenian Trap

The isolation, boredom, frustration, uncertainty, and extended periods of little

or no apparent progress can disrupt the DP efforts of even the most dedicated.
Given that the specifics will be different for each individual, it can be helpful to
take the time to identify your triggers—what might tempt you from the focus
required for success. So, whether using paper and pencil or an electronic
device, list yours, being as detailed and specific as possible.
To help you get started, consider the following questions:

• What specifically could tempt you to forgo DP in favor of less demanding, more
enjoyable, but ineffective professional development activities?

• What role, if any, do people, places, emotional states, prior training, clinical beliefs,
experiences, and so forth play in thwarting the focused, ongoing effort and concen-
tration required for DP?

Once you have identified your specific triggers,

• Recall a time in the past when you were tempted to stray but stayed on course.
Include experiences outside the professional realm (e.g., learning a second language
or to play a musical instrument).

• What role, if any, did people, places, emotional states, personal beliefs and experiences,
and so forth play in supporting and sustaining your commitment to success?

• How will you incorporate and use the natural human predisposition for novelty
into your DP plan?

Finish by providing answers to the following questions:

• On a scale from 0 to 10, where 0 denotes none and 10 absolute certainty, rate your
current level of confidence in your ability to manage triggers.

• Identify a circumstance that you might encounter that would lower your current
rating.

• Imagine what it would take to raise your rating by a single point.

Principle 2: Finding Your What

Introducing measurement into one’s clinical performance can be highly

disruptive; the process of administering scales and reviewing the results may
undermine confidence. Fortunately, the evidence indicates disruptions that
result in reductions in self-assurance can enable therapists to accept and make
needed changes in how they work, thereby resulting in stronger therapeutic
relationships and better outcomes.
18 Miller and Hubble

The following exercise is designed to help you embrace your doubt, seeing
it as a bridge to learning and not as a referendum on your performance. Take
the time necessary to reflect on and respond to the following questions:

• Identify several circumstances—whether as a clinician or in your personal life—

when you felt doubt about your knowledge, skills, or ability to succeed.

• Contrast the times when you embraced the doubt necessary for change or surrendered
to it and gave up. Recall in as much detail as possible the context (i.e., where you
were, who you were with, your thoughts, feelings, and actions).

• Imagine what feelings, thoughts, and behaviors will arise for you while “inhabiting”
your sweet spot of discomfort. How will you stay focused on what you are learning
versus giving in to a sense of incompetence and feelings of shame that so often
accompany failed attempts?

Principle 3: Connecting Your What to the Right Stuff

Getting to the Source of Your Success (Part 1)

Effective DP requires connecting an individual’s performance objective to
factors that have leverage on outcomes. As noted earlier and reviewed in detail
in Chapter 2, the TDPA is specifically designed to help align our professional
development efforts with what matters most for improving our results.
There is more. Early on in BR, we recommended creating a schematic or
blueprint for how you do therapy sufficiently detailed enough that another
practitioner could understand and replicate it—literally, “step into your shoes”
and work how you work (Miller, Hubble, & Chow, 2020, p. 29). The purpose
of the exercise was to make it possible for clinicians to pinpoint where in their
work they could intervene once their “what” had been identified. To illustrate,
did the “what” occur throughout the course of therapy or at certain points
(i.e., beginning, middle, or end)? Was it related to one’s theoretical premises
(e.g., a point of view that undermined the formation and maintenance of
the therapeutic relationship)? Was it linked to the overall plan of action (e.g.,
strategies and objectives that failed to elicit the client’s active participation)?
Or finally, was the “what” connected to one’s use of a particular technique or
its execution?
Feedback received following the publication of BR revealed this exercise to
be among the most difficult in the volume to complete. Many readers reported
having difficulty knowing where to begin (e.g., start with their preferred theory,
what they typically do in a first session, describing the temporal sequence
of their work). Others, when prompted to describe their work as a series of
“if–then” propositions (e.g., IF the client presents as highly reactive, THEN
I adopt a more flexible, nondirective stance; IF the client reports depression
at the first visit, THEN I assign a “thought log” as homework), struggled to
structure, categorize, and even recall how they made the moment-to-moment
decisions that inform their actions.
 Identifying Your “What” to Practice 19

On reflection, mindful of the experiences shared by readers, we realized

more structure was needed to make completing the exercise possible. In con-
sultations, we found ourselves suggesting a framework presented by Marvin
Goldfried (1980) in his classic article, “Toward the Delineation of Therapeutic
Change Principles.” There, he recommended conceptualizing one’s therapeutic
work as “involving various levels of abstraction”:
At the highest level . . . we have the theoretical framework to explain how and
why change takes place, as well as an accompanying philosophical stance on the
nature of human functioning. . . . At the lowest level . . ., we have therapeutic
techniques or clinical procedures that are actually employed during the intervention
process. . . . [To these, add] a level of abstraction somewhere between theory and
technique which, for want of a better term, we might call clinical strategies . . .
[or] principles of change . . . clinical heuristics that implicitly guide our efforts
during the course of therapy. (p. 994, italics in original)

Goldfried’s (1980) three levels of abstraction are listed from highest to lowest
in Table 1.1, which can serve as a template for creating a blueprint of your
therapeutic approach. To these, a fourth can be added. Termed “metatheory,”
it is a higher order concept representing the assumptions on which our theories
are based. With regard to psychotherapy, Wampold (2001) identified two.
The first, commonly known as the medical model, posits the efficacy of psycho-
therapy depends on the clinical procedure being specifically remedial to the

TABLE 1.1. Goldfried’s Levels of Abstraction

How is this represented in your work?
Level of abstraction Beginning Middle End
Metatheory

Theoretical framework

Clinical strategies

Techniques

Note. Data from Goldfried (1980).

FIELD GUIDE TIP

Need help with a concrete example

of applying Goldfried’s classification
to a popular therapeutic approach?
Turn to pages 54–56 in Chapter 3.
20 Miller and Hubble

disorder being treated. The second, the contextual model, holds the benefits
of psychotherapy primarily accrue through social processes characteristic of all
human interaction (e.g., relationship, connection, shared beliefs and values,
negotiated agreements, persuasion).
If you have not already done so, take the time now to create your therapy
blueprint using the framework provided. Recreating the table in a spreadsheet
makes the process easy and ensures ample space for details and future modifi-
cations. As you do so, note how the various levels come into play at different
points—beginning, middle, and end—in your performance of psychotherapy.

Getting to the Source of Your Success (Part 2)

With your blueprint in hand, the next step is to identify how your work—
from start to finish and across the levels of abstraction—leverages the five factors
responsible for outcome (i.e., client and extratherapeutic factors, alliance and
relationship, therapist effects, hope and expectancy, and structure). Make a note
if and when you find presuppositions, beliefs, or actions that may impede,
obstruct, or undermine or cannot be directly connected to any of the factors (see
Table 1.2). Completing this exercise now will help you use the TDPA to identify
those DP activities with the greatest potential for improving your effectiveness.
Recall, as discussed in BR, time and experience lead to the development of
automaticity (pp. 27–29). We literally become able to act without thinking.
While enhancing efficiency, the problem, Ericsson (2006a) pointed out, is
we “lose conscious control over the production of [our] actions” (p. 694).
We literally do not remember how we do what we do. As a result, our ability
to make specific intentional adjustments to our work is compromised.
Regaining consciousness is a necessary first step—one, experience shows,
many find challenging. If you are struggling to complete your blueprint or con-
nect your work to the five factors, consider starting with a smaller task, such as

• reviewing a recent treatment plan and clinical notes;

• recording and reviewing a session, taking time to note your decisions and actions; and
• reflecting on a conversation with a colleague in which you discussed a case, noting
the words you used and what you emphasized and omitted from your description.

TABLE 1.2. Connecting Your Work to the Factors With the Right Stuff
How is this represented in your work,
and what factor is being leveraged?
Level of abstraction Beginning Middle End
Metatheory

Theoretical framework

Clinical strategies

Techniques
 Identifying Your “What” to Practice 21

Principle 4: Keep Your Eyes on the Next Step

Appreciating Each Step

The evidence is clear. Nearly 90% of clinicians are “highly motivated” to tran-
scend their current level of performance. The problem is improving effective-
ness comes slowly, with the pace of progress dramatically disproportionate to
the time and effort required. To combat the risk of giving up, learn to prize
each accomplishment along the way. Toward this end, reflect on an earlier
accomplishment (e.g., playing a musical instrument, learning a new language,
finishing college or graduate school):

• Create a timeline of the decisions, choices, and actions leading up to your achievement.
• In as much detail as possible, recall how you felt as you reached each milestone.
• Note how you addressed setbacks or failures you encountered before reaching your
objective.
• What role did others play (or not) in addressing setbacks or failures encountered
while reaching for your objective?
• Describe how you thought about your final objective at each step along the way.

Now, take a moment to reflect on a time when you started out but stopped
before reaching your final objective (e.g., playing a musical instrument, learning
a new language or skill, writing an article or book):

• Create a timeline of the decisions, choices, and actions leading up to when you stopped.
• In as much detail as possible, recall how you felt as you reached each milestone.
• Note how you addressed setbacks or failures you encountered before reaching your
objective.
• Describe how you thought about your final objective at each step along the way.
• List any differences between the time you stopped and when you reached your objective
in how you approached each step.

Word Work
DP is inherently incremental and cumulative. Progress comes in a series of small
steps instead of a sudden, dramatic, or radical change in how you work. As such,
preparation, pacing, patience, and endurance are key. Bearing this in mind, take
a moment to imagine you are planning to participate in a marathon:

• List as many words that come to mind about what you need to prepare to complete
the race.

Now, imagine you will be participating in a sprint (e.g., 50 or 100 meters):

• List as many words that come to mind about what you need to prepare for to
maximize your performance.

1. Note the differences between the words you generated, striking any the
two lists have in common. With your plan to apply DP to your profes-
sional development in mind, develop one strategy for each unique word
you associated with preparing for a marathon.
22 Miller and Hubble

DECISION POINT

What to do next:

• If you have sufficient performance data for analysis but have yet to use the
TDPA to develop a specific, individualized learning objective, turn to Chapter 2.

• If you have used the TDPA to establish a specific, individualized learning
objective but are struggling to stay focused or motivated, turn to Chapter 8.

• If you have completed the TDPA and need help developing a DP exercise for
your specific objective, turn to
– Chapter 3 for client factors
– Chapter 4 for therapist factors
– Chapter 5 for relationship factors
– Chapter 6 for hope and expectancy factors
– Chapter 7 for structure

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2
Identifying and Refining
Your Individualized Learning
Objective
Daryl Chow, Scott D. Miller, and Mark A. Hubble

Truth, like gold, is to be obtained not by its growth, but by washing away from it all that
is not gold.
—LEO TOLSTOY, TOLSTOY’S DIARIES

DECISION POINT

Begin here if you have read the book Better Results and

• are routinely measuring your performance and

• have collected sufficient data to establish a reliable, evidence-based profile

of your therapeutic effectiveness or

• have created a map or blueprint of how you work sufficiently detailed

another clinician could step into your shoes and

• need guidance using the Taxonomy of Deliberate Practice Activities in

Psychotherapy to identify or refine an individualized learning objective with
the greatest chance of improving your effectiveness.

https://doi.org/10.1037/0000358-003
The Field Guide to Better Results: Evidence-Based Exercises to Improve Therapeutic Effectiveness,
S. D. Miller, D. Chow, S. Malins, and M. A. Hubble (Editors)
Copyright © 2023 by the American Psychological Association. All rights reserved.
25
26 Chow, Miller, and Hubble

T o begin, please rate your response to each of the following questions on

a scale from 1 to 5, where 1 is highly disagree and 5 highly agree:

• You are someone who is often attuned to the feelings of others.

• You are someone who approaches life, work, and problems systematically
and sequentially, often having clearly defined steps and procedures in mind
(i.e., “If x, then y”).

Not surprisingly, psychotherapists tend to assign a 4 or 5 to the first state-

ment and lower scores to the second. Clearly, possessing an empathic disposition
helps in fulfilling the desire to be of assistance to people in distress. Being
in the moment, emphasizing understanding and acceptance, placing trust in
feelings, and relying on intuition to guide decision making are often given
priority in the daily conduct of therapy. Carefully constructing a treatment
plan, following an established protocol, and being able to state clearly and
explicitly the rationale for each and every action taken with clients is less
common. On balance, therapists are more empathizers than systemizers.
As it is, being completely immersed in and sharply attuned to the client’s
experience has long been regarded as the sine qua non of expert clinical work.
Indeed, a large multinational investigation by the University of Chicago’s David
Orlinsky and the University of Oslo’s Michael Rønnestad (2005), involving
more than 10,000 therapists, found the majority not only yearn for but also
consider the experience of connecting deeply with clients the quintessence of
what it means to be a therapist. For all that, healing involvement—the term used
by researchers to characterize this belief and desire—has a curious relation-
ship with results. The more it is valued, the less effective one is likely to be.
In reality, the best clinicians rate it significantly less important to their work
and identity than their more average counterparts (Chow, 2014). What holds
their attention and gets them up and going in the morning? Outcome.
Enter the Taxonomy of Deliberate Practice Activities in Psychotherapy
(TDPA; Chow & Miller, 2022; see Appendix A, this volume), the tool specifi-
cally designed to help practitioners develop a step-by-step professional devel-
opment plan most likely to improve their results. Unfortunately, a cursory
review of the document is likely to strike empathizers as, in a word, foreign.
A spreadsheet of tables, ratings, and detailed instructions has replaced what
they do best, know the most about, and hold in the highest esteem: connec-
tion, caring, intuition, and being in the moment. How can the seemingly
detached, calculating, even antiseptic nature of the TDPA be experienced as
anything other than off-putting?
Turns out, the answer—and the way forward—lies in redefining what
healing involvement encompasses. Nowhere is the need to do so more apparent
than in efforts to address the epidemic levels of burnout seen in the helping
professions. The terms vicarious trauma, secondary traumatic stress, and especially
compassion fatigue all point to the very real risks of deriving meaning and purpose
primarily from the emotionally charged interactions during the therapy hour—
especially with nonimproving clients. The pattern is as easy to see as the results
 Identifying and Refining Your Individualized Learning Objective 27

are predictable: In the face of continued suffering, deepening involvement

feels like the right thing to do.
And yet, as Mathieu and colleagues (2015) pointed out, “Burnout doesn’t
begin with caring, or even caring too much, but continuing to care ineffectively
[emphasis added], losing sight of what we’re there to accomplish with our
clients in the first place” (p. 22). Little wonder the panoply of recommendations
offered by burnout experts—including cultivating mindfulness, going on walks,
doing yoga, joining a service organization, turning off technology, capping
client contact hours, and eliminating caffeine and alcohol intake—do not work.
All miss that key protective factor—doing something that actually helps. Recall
feeling effective is so crucial to the well-being of therapists, they routinely over-
estimate their actual results (see Chow et al., 2015; Lin et al., 2022; Walfish
et al., 2012)!
Thus, it is essential for the definition of healing involvement to be extended
beyond the immediate experience with the client to therapists’ deeply felt desire
to be of help. With this perspective in mind, “empathizers” can transform the
TDPA from a mere chore to a deep and powerful act of caring. At this stage,
it is recommended therapists work consciously and intentionally at developing
a relationship, with achieving better results equal to the relationships one works
so hard to establish and maintain with clients.

FIELD GUIDE TIP

Readers who scored a 4 or 5 on the

second statement (i.e., systemizer)
or who, after reading Better Results
(Miller et al., 2020), are now looking
for tips, suggestions, and practical
guidance for maximizing the utility
of the TDPA may feel free to skip
ahead to the exercises at the end
of this chapter.

BARRIERS TO BETTER RESULTS

To be clear, it is not that therapists do not want to improve. They do. The
evidence reviewed in Chapter 12 of Better Results (BR; Miller et al., 2020)
proves it. However, for empathizers and systemizers alike, three obstacles
get in the way of deepening their relationship with better results:

• what therapists already believe works,

• not knowing what will work to improve their effectiveness, and
• what others insist works if only everyone would do it.
28 Chow, Miller, and Hubble

Regarding the last item on the list, nothing beyond the decades of research
reviewed in Chapter 2 of BR and the first chapter of this volume need be
repeated. The desire to help those in psychological pain is easily exploited by
those promising a better way. In the busy, time-and-resource-limited world in
which clinicians work, one of the major hooks is, “The heavy lifting has been
done. All you need to do is follow directions.” If this remains a temptation,
complete the exercises on page 17 of Chapter 1 under Principle 1 (Avoid the
Athenian Trap).
Turning to the first item, the evidence paints a rather bleak picture. Despite
participating in continuing education throughout one’s career, clinician confi-
dence increases but their outcomes do not (Germer et al., 2022; Goldberg
et al., 2016). Effective deliberate practice (DP) is predicated on developing
an evidence-based profile of each therapist’s effectiveness. The goal is to
strengthen what one does well and target particular weaknesses for improve-
ment. In either case, the expertise literature definitively shows intuition is not
a reliable guide (Miller et al., 2018).
Finally, not knowing what to work on is a major obstacle—perhaps the
biggest. It is also the reason for and purpose of this chapter. Consider the data
presented in Figure 2.1. Displayed are the responses of hundreds of participants
from an ongoing series of asynchronous, web-based trainings on DP conducted
by the authors since the publication of BR. Asked at the outset of the course
to identify the single biggest challenge attendees faced in their professional
development, the majority (∼38%) cited not knowing which goals or perfor-
mance objectives to pursue.
The promise of the TDPA (as originally introduced in BR) was that completing
the tool would help each therapist identify the specific DP activity exerting
the greatest leverage on improving their results (McChesney et al., 2012).
Experience showed clinicians needed more. Putting all the pieces together
and arriving at a single professional development objective proved to be a

FIGURE 2.1. Responses From Deliberate Practice Web-Based Workshop

 Identifying and Refining Your Individualized Learning Objective 29

“bridge too far,” at times eluding even the most dedicated. The sheer volume
of information made it easy to get lost in the details, obscuring connections
between the various inputs and, ultimately, the bigger picture.

KEEPING THE BIGGER PICTURE IN MIND

Step back for a moment. The journey is a series of steps for deepening involve-
ment with better results, beginning with creating a detailed blueprint of how
one works (see Figure 2.2). Recall the blueprint is a guide on “how you do,
what you do” in therapy. A useful way to think about this is to imagine
explaining to someone what you do within the therapy hour. As introduced
in BR and thoroughly described in Chapter 1 of this field guide (FG), the
reason for doing so is to enable the clinician to pinpoint where in their work
they can intervene once they have identified what needs to change. The next
step is measurement, routinely assessing engagement and outcome. The purpose
is to generate data sufficient for the therapist to identify any weaknesses or
deficits in their clinical performance. Once known, completing the TDPA is
supposed to, first, help the therapist link their specific shortcomings to the
factor or factors (and associated clinical activities) having the greatest chance
of improving their results and, second, to develop a single, well-defined, and
achievable professional development goal.
All well and good. Except . . .
Integrating data about one’s performance deficits with the TDPA is where
many end up feeling stuck. Consider the example of Liam.1 First, he created
a blueprint for his approach to clinical work. It took a while to fill in the
details over time as he reflected on and conducted therapy. At the same time,

FIGURE 2.2. The Deliberate Practice Journey

Note. TDPA = Taxonomy of Deliberate Practice Activities in Psychotherapy.

1
All case examples used in the FG are composites of real people whose identifying
information has been altered to ensure anonymity.
30 Chow, Miller, and Hubble

he began administering standardized measures to his clients. Once sufficient

data were gathered for a reliable assessment of his work, he learned his
impact—as reflected in his effect size—was average. Wanting to improve
nonetheless, he turned to the TDPA. Instead of leading him to a specific target
for DP, variable scores within each of the five factors (i.e., structure, hope and
expectancy, relationship, client, therapist) left him puzzled about where to
start. Frustrated, he turned to colleagues in his consultation group: “What
am I supposed to do to get better?”
Experience shows Liam’s struggle is far from unusual. Recall most therapists
are average. As such, an initial examination of one’s overall results often fails
to reveal the one truly transformative DP objective. Instead of returning to
the data with different and more detailed questions, many place their trust
in the TDPA, hoping it will provide direction. Occasionally, when completed
together with a coach, potential targets for improvement are identified. How-
ever, more often than not—as in the case of Liam—nothing specific stands out.
In either instance, disconnected from performance data, both risk investing
significant effort for an unknown return.
Recalling the advice offered earlier, the key to success is to treat the pro-
cess of arriving at a performance improvement objective the same way one
approaches working with clients. Get involved. Dive in, care, be curious, make
connections, think critically, test understandings, continuously adapt, and,
when required, seek consultation. No therapist thinks of “getting to know”
the client as an activity independent of treatment. Similarly, learning what one
needs to learn (and learn next) is not a precursor to but an integral part of DP.
Practically speaking, this means returning to earlier steps as often as needed
with different questions in mind:

• Is my blueprint accurate? Does it reliably capture how I work?

• Have I created an atmosphere that supports and facilitates candid feedback

from clients? How do I use client feedback to inform and improve my work?

• How well do I understand my performance-related data? What gives rise to

the numbers in the report? What variations in my performance (e.g., types
of clients, presenting concerns, times of day, days of the week, treatment
delivery format) might be hidden in the aggregate statistics?

• How does the information from my map, ongoing measurement, perfor-

mance data, and the TDPA tie together? What am I learning about myself,
how I work, with whom, and under what circumstances I am most and
least effective?

Liam sought out a coach who encouraged him to set aside the TDPA tempo-
rarily and revisit his performance data. Specifically, as suggested in Chapter 10
of BR, he was encouraged to begin parsing his outcomes, linking them to a
variety of factors known to be associated with variations in therapist effectiveness
(i.e., level of client distress, amount of improvement over time, culture, gender
or sexual orientation, quality of the alliance, and presenting problem).
 Identifying and Refining Your Individualized Learning Objective 31

To this end, Liam created a spreadsheet.

On the vertical axis, he listed his clients and,
horizontally, the various factors. It took him
the better part of a month to pull the specific
data points for each client and place them in
the appropriate column and row. Importantly,
as he did so, he had no preconceived ideas
about what he might find. Once complete,
however, a pattern imme­diately jumped out.
His poorest outcomes occurred with men.
“Was this the answer?” he wondered. “Should
I get some training on ‘men’s’ issues? Super-
vision?” Feeling uncertain, he returned to
the coach.
Together, they first examined the other dimensions in the spreadsheet,
looking for connections and relationships. No other patterns stood out. The
poor results weren’t linked to the alliance, presenting problem, or differences
in background or culture. Simply put, some men fared worse than others.
“So, what is it I’m supposed to practice?” Liam asked, exasperated. The coach
immediately replied, “Being curious. We’re not done getting to know these
men, what happens when you are with them, what it is about them.” It was
then the coach suggested Liam add a column to his spreadsheet. There, he was
instructed to review his progress notes, tracking any recurring words used when
documenting his work.
“I’ve figured it out!” Liam happily reported the following month: “I need
to deliberately practice working with angry men—that’s the word that showed
up again and again in my notes: angry.” Liam’s experience highlights the
need to modify the picture most people have of DP (see Figure 2.3). Rarely
linear and sequential, more often than not, it is a matter of three steps forward
and two back—and Liam had a couple more steps back ahead of him.
Retrieving the TDPA, the coach wondered how best to understand the anger
reported in Liam’s notes. Was a description of the men, their nature, and how
they presented a client factor? Or was it a result of something taking place
in the therapeutic interaction (i.e., relationship factor)? There is one more

FIGURE 2.3. Deliberate Practice: What People Think and What It Really
Looks Like
32 Chow, Miller, and Hubble

possibility: Was it a therapist factor? Did Liam somehow evoke an angry

response from certain men? If so, what was it about him?
With these questions in mind, Liam returned to his notes. In short order,
he discovered the problem was not “angry men.” Rather, those with the poorest
results became angry when they were not getting what they wanted: advice
and direction, two activities conspicuously missing in Liam’s blueprint.
“I’m not comfortable telling people what to do,” he observed at the next
session with his coach, adding, “In fact, I was trained not to do that.” At this
point, and after months of work, a DP objective likely to have leverage on
Liam’s outcomes started to emerge. Along the way, several shifts in perspec-
tive had occurred. What began abstractly as “men’s issues” (TDPA Dimension 4)
turned into “relating to angry men” (Dimension 3, Di, ii) but eventually landed
on the necessity of being aware of and accommodating the expectations of
certain men (Dimension 4b, c). With the correct focus sorted, Liam was finally
able to act, devoting attention to learning when, with whom, and under
what circumstances being more direct and offering specific guidance were
indicated. In time, he modified his therapeutic map to reflect his new
understandings.

PRINCIPLES FOR IDENTIFYING AND REFINING YOUR

INDIVIDUALIZED LEARNING OBJECTIVE

Three principles essential to developing a learning objective with the greatest

chance of improving your effectiveness are suggested. Derived from expe-
riences working with clinicians like Liam since the publication of BR, they
include

• approaching finding your performance improvement objective with the

same interest and dedication you devote to understanding your clients,
• treating the process of arriving at your performance improvement objective
as an ongoing learning project, and
• focusing on the “what,” and the “know-how” will follow.

Up to this point, the aim of the entire chapter has been operationalizing
the first two principles—what identifying your specific performance objective
actually entails and the perspective required to sustain your efforts along the
way. What more can be said? Like getting to know your clients, no shortcuts
exist. Hopefully, it is clear DP is not an event (or even a series of discrete
events). It is an ongoing, iterative process. Arrival is not possible without the
journey—and in the case of working to achieve better results, it is best to think
of the two as one and the same. You are here now. What are you learning?
What is next?
Whereas the first two principles direct attention to the importance of
attitude, Principle 3 is less about one’s point of view than how the task is best
 Identifying and Refining Your Individualized Learning Objective 33

approached. Toward this end, a specific framework for conceptualizing and

organizing your efforts to identify the “what” and “how” to DP has proven
useful. Known by the acronym OPL, it contains three elements: outcome goal,
process goal, and learning project (see Figure 2.4).
Of the three, the learning project has already been introduced and illus-
trated with an example. Its purpose is to fill in gaps in knowledge. Its nature
is dynamic, flexible, and exploratory. That said, effective learning projects
share three qualities. First, the environment is conducive to learning and
relearning, retrieving and reflecting on prior knowledge, and ultimately
transferring what is being learned into clinical practice (Ahrens, 2017; Chow,
2019a; Haskell, 2001). As recommended in BR, one important strategy is
actively working to protect the time one sets aside for DP (e.g., turning off the
phone, social media, and email notifications, including other interruptions).
Second, effective learning projects are open to a wide variety of inputs. That
means looking beyond the world of therapy for inspiration and guidance. For
example, if creating more effective structure in sessions is the objective,
“know-how” might come from a colleague or therapy book but also from
watching a documentary on how filmmakers craft the narrative arch of a story
to create emotional impact. Third, and last, mindful of “Parkinson’s Law”—
the danger that when left open-ended, work will expand to fill the time
allotted—the most productive learning projects are time bound. As simplistic
as it may seem, Liam was given specific tasks to complete within a given
period, allowing him and his coach to monitor progress easily, make needed
“just-in-time” adjustments, and plan the next steps.
It goes without saying that learning projects are goal directed. Goals both
inform and determine the learning project. Returning to Figure 2.4, the first,
or outcome goal, is “what” one aims to achieve in the learning project. Recall
that Liam’s initial objective was to improve his results. When his attention
shifted to the “how,” or process goal, the initial outcome goal evolved—first,
from improving results with men to becoming eventually more comfortable
and skilled in working with men who wanted and expected direction and
advice. Once clear, the items listed in the TDPA provide numerous evidence-
based suggestions for effective action. As portrayed in the graphic, think of the
process goal as a lever. Its purpose is to provide the structure (i.e., lift) to reach
the desired outcome.

FIGURE 2.4. The OPL Framework

34 Chow, Miller, and Hubble

PRINCIPLE-BASED EXERCISES

Before considering the following exercises, ensure you have taken all the
steps outlined in the decision tree presented at the start of this chapter. It is
assumed you (a) are routinely measuring your performance; (b) have collected
sufficient data to establish a reliable, evidence-based profile of your thera-
peutic effectiveness; (c) have created a map or blueprint sufficiently detailed
so that another clinician could replicate your work; and (d) have tried to
complete the TDPA but want additional help to develop the learning objective
with the greatest chance of improving your effectiveness.
Have your outcome data, blueprint, and TDPA in front of you while deter-
mining which ones will work best for you. If, after considering the suggested
exercises, you still find yourself struggling with outcome goals, process goals,
and a learning project, consult the suggestions and detailed case example at
the end of the chapter.

Exercise 1: Connecting With Your Authentic Self

Principle: 1
Applicability: TDPA Items 3Aiv, 3Biv, 5Avi
Purpose
People routinely equate authenticity with acting in a manner consistent with
their actual selves. For all that, research indicates the experience most often
arises when we think and act in ways consistent with our ideal self (Gan &
Chen, 2017). As already stated, for many psychotherapists—especially those
who principally see themselves as empathizers—data, statistics, and perfor-
mance metrics evoke strong feelings of “not me.” This exercise is designed to
honor and reconnect you with the ideals that brought you to the field—being
of service to others.

Task
Part 1. Set aside 20 minutes once or twice a week for 1 month to think about a
person you hold in high esteem because of who they are and what they do. It
could be anyone from any domain of human performance—an athlete, scien-
tist, musician, philanthropist, a person from the present, or perhaps a historical
figure. “Spend time with them” by looking up their accomplishments, listening
to interviews, watching videos online, reading a biography, or imagining a con-
versation with them. Complete this part of the exercise before reading further.

Part 2. After a month, devote the same amount of time over several weeks
to imagining how others would know that data-driven DP is part of your ideal
self. Using paper and pencil or your favorite note-keeping app, maintain a
record of your thoughts and reflections. Be as specific as possible about what
you would be doing; how others would know your work with statistics, metrics,
and data is critical to being the most helpful you can be. Last, make engaging in
this exercise routine.
 Identifying and Refining Your Individualized Learning Objective 35

Exercise 2: Recovering Your “University Days” Mindset

Principle: 2
Applicability: Potentially All Items on the TDPA
Purpose
Going to college is more than earning a degree and getting a job. It’s about
exploration, self-discovery, learning to tolerate boredom, being exposed to
diverse peoples and ideas, making friends, falling in love, and having fun. It is
noteworthy that most who start end up studying a subject entirely different
from what they originally planned—around 80%, actually (The University of
Tulsa, 2020). Such shifts in interest and focus are both difficult to anticipate
and far from an indication of failure, given their dependence on chance and
experience. Of course, graduation is the ultimate objective (i.e., outcome goal).
And yet, relishing the journey—its fits and starts, ups and downs, twists and
turns—makes earning a degree rewarding and transformational. The same
may be said of DP.

Task
Part 1. Set aside 20 minutes once or twice a week for 1 month to think about
a person, class, relationship, book, time of life, or event that unexpectedly but
positively impacted the direction of your career and life. Keep a log of your
reflections, noting the circumstances, any challenges arising from the change
in direction, and what was required of you to step off your then-current path
and make it so (see Exercise 7). Consider how the change both confirmed or
disrupted your sense of self up to that time.

Part 2. When it comes to your DP learning project, suspend the desire for an
immediate result (i.e., being given a degree before the education). Cultivate
a “university mindset.” For the following month, be open to chance change-
producing events, people, and experiences related to your desire to improve your
therapeutic effectiveness. Keep a log using index cards or a note-keeping app.
Return to this exercise whenever you embark on a new learning project.

Exercise 3: Specifying the Outcome Goal

Principle: 2, 3
Applicability: Potentially All Items on the TDPA
Purpose
The purpose of DP is different from attempting to resolve a difficult or “stuck”
case. The latter is typically focused on anomalies or outliers, one-off experi-
ences from which little can be learned or applied to other clients and contexts
(in BR, referred to as random errors). The former is about identifying and
addressing recurring patterns in one’s behavior that consistently undermine
effective performance (i.e., nonrandom errors). Doing so requires gathering
data via routine outcome monitoring sufficient to offer a reliable and valid
profile of one’s strengths and weaknesses. Once done, patterns can be extracted
and effectively targeted for performance improvement.
36 Chow, Miller, and Hubble

Task
Part 1. Solve for patterns. After you have collected outcome and relationship
data on 40 to 60 cases:

1. Using “closed” cases only, partition your outcome data into “successful”
versus “unsuccessful” groups.

2. Study the two groups, looking for differences (gender, age, presenting prob-
lem, strength of the relationship, amount and trajectory of change, consis-
tencies in your thinking and feeling about the clients).

3. Spend no more than 20 minutes at any one sitting, allowing time in between
for the information to “percolate.” Jot down any observations, thoughts,
or “aha’s” that occur to you during the time away.

Part 2. The next step is separating committed from aspirational outcome goals.
To do so,

1. List all potential targets for DP (i.e., outcome goals) based on the analysis
completed in Part 1.

2. Compare your results with the performance benchmarks (BR, pages 74–75).

3. Get as specific as possible. For example,

– Reduce my youth population dropout rates from 47% to below 20%.
– Reduce deterioration rates for men from 12% to 6%.
– Reduce the rates of clients who make an unplanned termination after
the first session from 35% to 20%.
– Improve the rate of reliable change improvement for clients who have
not experienced improvement after being seen for more than six sessions
from 50% to 60%.

4. Commit to one outcome goal, temporarily designating all others aspira-

tional (Doerr, 2018). The one committed outcome goal is the single target
to which you will devote your efforts. (The next exercises will help identify
and refine the process goal and learning project.) A good rule to follow is
picking “low hanging fruit”—something that has high leverage on improving
your overall effectiveness while also being easy to reach.

Exercise 4: Figuring out Your Process Goal

Principle: 2, 3
Applicability: Potentially All Items on the TDPA
Purpose
Once you know your “what,” the TDPA is specifically designed to help you
figure out the “how” (i.e., your process goal). On the basis of feedback from
therapists since the publication of BR and the research reviewed in the FG,
significant revisions have been made to the tool.
 Identifying and Refining Your Individualized Learning Objective 37

Task
With your outcome goal in mind, review the latest version of the TDPA, taking
time to

1. Rate each item. Spending time reviewing case notes from active clients will
ensure accuracy and representativeness.

2. Go through the document and identify the top three activities you believe
will have the greatest impact on your results.

3. Select one to work on now, making sure it is influenceable and predictive of

the outcome goal you’ve listed (see Figure 2.5).

4. Have a coach or expert—someone who knows your work—complete the

Supervisor/Coach version of the TDPA and compare the ratings. Work
together to identify and design a single process goal.

Exercise 5: Antigoals

Principle: 2
Applicability: Potentially All Items on the TDPA
Purpose
Being clear about what is unimportant in our efforts to improve can be a
powerful way to achieve clarity and maintain focus on our process goal.

Task
This exercise is simple yet effective. Review your completed TDPA, making a
list of the items (and factors) that will not be a part of your primary process
goal. Keep the list handy, reviewing it whenever you are tempted to pursue
training or activities (outside of playful experimentations and just having fun)
unrelated or tangential to your current process goal.

FIGURE 2.5. Influencing Outcome With a Process That Is Predictive and

Influenceable
38 Chow, Miller, and Hubble

Exercise 6: Create a Centralized Note-Taking System

Principle: 1, 2, 3
Applicability: Potentially All Items on the TDPA
Purpose
Journaling and note taking, research indicates, has multiple benefits. A study
in the Journal of Experimental Psychology, for example, found it reduced intru-
sive and avoidant thoughts about negative events while improving working
memory (Klein & Boals, 2001). Such improvements, it is believed, free up
precious (and limited) cognitive resources to focus on other mental activities
(e.g., managing stress, maintaining focus, learning). While popular in the
treatment and self-help literature, the benefits for anyone engaging in DP could
not be clearer. Keeping a consistent and “centralized” (i.e., one fixed note-
taking location) record helps in the recollection, organization, and consolidation
of new learnings (Agarwal & Bain, 2019; Chow, 2019a; Miller et al., 2020).
On the flip side, the lack of a centralized note-taking system is often a barrier
to accelerated learning.

Task
Part 1. Determine how you will keep a record of your DP efforts (e.g., hand-
written, using a note-taking app). In this record, document your experiences,
including those that might strike you as irrelevant to your current learning
project. Treat your record as a garden you must seed, nurture, nourish, and
prune on an ongoing basis to bear fruit.
Here are some tips that others have found helpful:

• If you decide to keep handwritten notes:

– Put them in a bound journal.
– Number and date both the notebook and pages because doing so will
help in recall.
– Leave the first few pages blank to facilitate the later creation of a map
of content. Unlike a traditional table of contents, the map of content is
designed to both highlight where specific content can be found (e.g.,
“Learning Project 1 on improving structure in therapy; see pages, 4, 32,
and 33”) and also facilitate making connections between sections within
and between notebooks.
– Use sticky “flag tabs” to highlight themes (e.g., green for key learnings,
yellow for points requiring further consideration, blue for interesting
but less useful ideas and insights).

• If you choose to use an electronic medium:

– It should be easy to use. Bells and whistles are less important than
accessibility and simplicity.
– It should be easy to search, retrieve, and, most important, create links
between notes. Certain apps (e.g., Notion, Roam Research, Obsidian)
 Identifying and Refining Your Individualized Learning Objective 39

allow for linking one note to another as well as using links to reference
and connect themes within the notes (i.e., bidirectional. For instructions
on the use of Obsidian to link your notes, see https://darylchow.com/
frontiers/rightforyou/).
– Use tags, labeling each note to create relationships amid the content
(e.g., #empathy, #dropout, #couplestherapy). Of course, storing the notes
in themed folders can also help to organize content.

• For the purposes of your learning project, consider keeping a record of the
following:
– Each week, recall the people you worked with, recording one mistake and
one success. Limit each entry to 140 characters to ensure consistency and
efficiency (see https://darylchow.com/frontiers/weeklytherapylearnings/
for an example).
– Note thoughts, reflections, and summaries of readings, movies, books,
and podcasts you have encountered, whether or not they seem relevant
to your current learning project.
– Record client feedback. Although you likely record this in your case notes,
keeping a record in a central location will help in making connections
between the various sources of information related to your learning
project.

Part 2. After creating and starting a note-taking system, the next step is
engaging in what experts in the learning sciences call retrieval practice (Agarwal
& Bain, 2019). In practical terms, this means revisiting your notes on a routine
basis, first looking at the heading or tags and trying to recall the specifics, and
then refreshing your memory by reading the entire entry. Turns out that
“testing yourself to learn” as opposed to “teaching to the test” is a powerful
way of deepening your knowledge and understanding. Researchers believe it
disrupts the false sense of fluency that can develop when details and nuance
are forgotten in the learning process (Bjork, 2011). As you do so, resist early
temptations to come to a conclusion, instead allowing the information to
percolate in the hopes of making “higher order units, or ‘chunks,’ for con-
ceiving, understanding, and organizing” (Miller et al., 2020, p. 27).

JANICE AND THE GIANT OUTCOME GOAL

As an example of applying the preceding exercises, consider Janice, a therapist

with about 7 years of clinical experience who worked in both inpatient and
outpatient mental health clinics. Once she had enough cases for a reliable,
evidence-based analysis of her clinical performance, she took up Exercise 3
(i.e., specifying the outcome goal). In an effort to identify the outcome goal
with the most leverage on improving her results, she created a spreadsheet
listing each client’s data (i.e., outcome and relationship scores) and other
details. In a separate column, a distinction was drawn between those she treated
40 Chow, Miller, and Hubble

successfully (reliable improvement) and unsuccessfully (lack of reliable change,

deteriorated, or dropped out after the first session). Next, with the spreadsheet
open on her computer, she started reviewing the progress notes of her closed
cases, “sorting for patterns.”
Four were immediately apparent. First, many of the clients Janice treated
unsuccessfully were originally seen in an inpatient context. Second, client
progress and the quality of the relationship as measured by the Session Rating
Scale (SRS) covaried. Specifically, SRS scores generally improved over time
for those in the successful group while remaining stable (whether beginning
high or low) among the unsuccessful. Third, no difference in initial SRS scores
was found between clients who made progress over the course of care and
dropped out, deteriorated, or did not improve. Janice knew this was a potential
target for DP, given evidence showing lower initial relationship ratings are
associated with better results at the end of treatment (Miller et al., 2020).
Fourth and finally, the modal number of sessions Janice had with clients was 1,
with 32% attending only a single visit.
As a professional whose identity was closely tied to her commitment to
excellence, Janice’s performance data evoked both anxiety and a strong sense
of inadequacy. On the recommendation of her supervisor/coach, she chose
to spend the next month engaging in Exercise 2 (i.e., recovering your “uni-
versity days” mindset). While she was typically focused on achievement and
performance, she worked at being open to growth instead of just competence
(Chow, 2019b). Although the change in mindset did not come easily, spending
time with her performance data was what did the trick. She marveled at how
the routine administration of simple measures could reveal patterns that had,
despite her best intentions, eluded detection.
Eager to begin actively taking steps to address the problems identified, she
returned to Exercise 3, determined to choose a single, committed outcome goal
on which to work. Once again, Janice found herself struggling. Turns out,
consultation with her supervisor/coach revealed the issue. It is a common one:
focusing on the “how” before being clear about and committed to the “what.”
For example, given the various patterns her SRS data revealed, she decided to
work on developing skills related to eliciting more detailed, critical feedback
(TDPA Dimension 1A). She further concluded that adding more organization
and focus to her sessions (TDPA Dimension 1J) would improve results with
clients she initially met in an inpatient setting and treated for longer periods.
Returning to her spreadsheet to revisit the patterns and choose a single,
committed outcome proved to be the solution. After recording the four patterns
in her journal, Janice spent a week thinking about the clients with whom she
had been unsuccessful, reviewing the case notes for each:

• Clients starting in an inpatient context (∼65%) routinely failed to follow

through with scheduled outpatient appointments.

• Clients whose SRS scores did not improve over the course of care were
significantly more likely to end treatment with little or no improvement in
Outcome Rating Scale scores.
 Identifying and Refining Your Individualized Learning Objective 41

• Clients with high initial SRS scores were equally likely to end treatment
unsuccessfully as successfully.

• Nearly a third of Janice’s clients did not return following their first session.

With help from her supervisor/coach, Janice chose what she believed would
be the easiest to address. In this instance, that “low-hanging fruit” was the
high number of unplanned terminations by clients first seen in an inpatient
setting. Stated specifically, her outcome goal was to reduce dropouts for clients
transitioning from inpatient to outpatient from 65% to 40%. The remaining
three performance concerns were labeled “aspirational” and set aside for
possible DP in the future.
Exercise 4 came next—figuring out the process goal that would decrease the
dropout rate of inpatient clients. After watching video recordings of several
representative sessions together with her supervisor/coach, both agreed the
conversations conducted with hospitalized clients were more unfocused
than typical outpatient visits. Consistent with Janice’s lower rating on TDPA
Dimension 3Ai (3/10), this led to the formulation of a process goal and learning
project organized around establishing and checking goal consensus in first
and later sessions. However, when Janice subsequently interviewed several
former clients, a different angle emerged. A number mentioned being surprised
by her questions about and characterization of not continuing with sessions
on an outpatient basis as “dropping out.”
Discussing her findings with her supervisor/coach, the two agreed hope
and expectancy factors were implicated, one element of which (TDPA Dimen-
sion 2A & D regarding role induction, setting and monitoring client expectations,
and adapting the treatment rationale to foster engagement and hope) Janice
had also rated low (3/10) on her initial completion of the tool.
Janice immediately went to work creating a learning project, taking time
to brainstorm, talk with colleagues, and research ideas related to operational-
izing her process goal. Because she found clients frequently struggled to parlay
improvements made while in the hospital to their lives following discharge,
she created what she later termed her “safety-net” system. Introduced early
in care, it emphasized the critical role she would play and resources she
could bring to bear in supporting lasting change for the client. Appointment
reminders and help with arranging transportation to and from sessions were
two among the many aspects of the system specifically designed to reduce
dropouts.
Together with her supervisor/coach, Janice continued to monitor her
performance data as she put her plans into action. Six months later, she was
disappointed when improvement in the percentage of clients failing to follow
through with posthospitalization outpatient sessions stalled at 50%. At one
point, she began actively considering replacing her committed outcome goals
with one of her remaining (three) aspirational goals. “Actually,” she said,
“nearly all of the items on the TDPA are things I could work on and do better
at. How can I not try to improve on more of these?”
42 Chow, Miller, and Hubble

Completing the “antigoal” exercise (5) persuaded Janice to maintain her

current objective but reconsider her process goal. Addressing TDPA Factor 2
(hopes, expectations, and role) had resulted in a decline in dropouts, but she
was looking for more. Returning to recordings of her sessions and consulting
the therapy blueprint she had created at the outset of her foray into DP,
she noted the significant amount of time spent in initial visits conducting a
thorough psychosocial history. It was an activity that had been ingrained in
her clinical routine from her university days—and yet, she realized, the infor-
mation gathered only rarely informed her work, delayed actively intervening
to help clients, and often resulted in lower levels of engagement.
At this time, she ran across the book The First Kiss (Chow, 2018), which
focused on the importance of the initial therapeutic encounters. In place of
“taking” (paperwork, information gathering, long diagnostic workups), it encour-
aged therapists “giving” to clients, taking full advantage of the change research
shows occurs early in treatment (Lutz et al., 2009, 2014). The same body of
evidence reviewed in the book showed traditional “intake” practices resulted
in higher dropout rates, slower progress, and more expensive care. It also iden-
tified an alternative: resource activation (Gassmann & Grawe, 2006). Instead of
asking about the presenting problem, symptoms, and struggles, it involves
actively soliciting information about client capabilities, motivations, and existing
social support network.
At this point, Janice made a conscious choice to change her process goal
from Items A and D on Dimension 2 (relationship factors) of the TDPA to
Dimension 4 (client factors), specifically, Item D, “incorporating your client’s
strengths, abilities, and resources into care.” In support of this new objective,
she sought out research, training materials, and consultation. After several
months, Janice’s hard work began to pay off. Interestingly, her discontinuation
rates among those clients beginning care in an inpatient setting declined (from
50% to 18%), and the modal number of sessions she met with clients tripled
(from 1 to 3). As often happens, such improvements influenced other perfor-
mance metrics, including a rise in Janice’s overall effectiveness (i.e., effect size).

FINAL CONSIDERATIONS

Our empathic disposition primes us to zoom in on one person rather than

many. In so doing, developmental psychologist Paul Bloom (2016) argued,
we become biased by the spotlight effect, missing bigger patterns, the so-called
forest for the trees. The purpose of this chapter has been to marry our empathic
ability with the systematic approach needed for successful DP. Whatever one’s
primary disposition, the process is hard work. Some suggestions born of
experience follow:

• Unless your data indicate deficits in the structural domain of the TDPA,
limiting your process goals and learning project to mastering a specific theo-
retical orientation is a mistake. Instead of aiming at “doing things right,”
 Identifying and Refining Your Individualized Learning Objective 43

focus on finding the “right thing” to improve your results. In other words,
keep your eyes on the outcome goal.

• If the TDPA and OPL framework took you an hour or so to complete, it prob-
ably isn’t going to serve you well. More time—much more time—is required.

• If your process goal feels easy, it’s unlikely to stretch you sufficiently to
improve your performance.

• If you are struggling with your process goal and learning project, your
outcome goal may be too vaguely defined or ambitious.

• If your outcome goal is proving too difficult to achieve, designate it as

“aspirational” and move on.

• If you find yourself losing track of what you were working on, consider
reviewing your journal (i.e., notes) more often and making your learning
project more visible.

• If your learning project and process goal are not leading to improvement
in your outcome goal, consider the following:
– whether your process goal is clearly linked to your outcome goal
– allowing more time to pass before assessing results
– whether adequate effort has been devoted to your process goal and
learning project
– consulting a coach

• Keep in mind that outcome goals do not always equate with improving or
learning therapy skills. A high “no-show” rate, for example, might best be
addressed by adopting an automated email or message reminder system
rather than new engagement techniques or abilities (Martin et al., 2015).

DECISION POINT

What to do next:

• If you have completed the TDPA and OPL framework and need guidance
developing an exercise for your specific objective, turn to
– Chapter 3 for client factors
– Chapter 4 for therapist factors
– Chapter 5 for relationship factors
– Chapter 6 for hope and expectancy factors
– Chapter 7 for structure

• If you have used the TDPA to establish a specific, individualized learning
objective but are struggling to stay focused or motivated, turn to Chapter 8.
44 Chow, Miller, and Hubble

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Bloom, P. (2016). Against empathy: The case for rational compassion. HarperCollins.
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therapy. Correlate Press.
Chow, D. (2019a). Deep learner: A psychotherapist’s field guide to extend your mind and harness
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Chow, D. (2019b, October 22). Measure growth, not competence. Frontiers of Psychothera-
pist Development. https://darylchow.com/frontiers/measure-growth-not-competence
Chow, D., & Miller, S. D. (2022). Taxonomy of Deliberate Practice Activities in Psychotherapy—
Therapist Version (Version 6). International Center for Clinical Excellence.
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(2015). The role of deliberate practice in the development of highly effective psycho-
therapists. Psychotherapy, 52(3), 337–345. https://doi.org/10.1037/pst0000015
Doerr, J. (2018). Measure what matters: OKRs—the simple idea that drives 10x growth.
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Gan, M., & Chen, S. (2017). Being your actual or ideal self? What it means to feel
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Gassmann, D., & Grawe, K. (2006). General change mechanisms: The relation between
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peutic interactions. Clinical Psychology & Psychotherapy, 13(1), 1–11. https://doi.org/
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Germer, S., Weyrich, V., Bräscher, A.-K., Mütze, K., & Witthöft, M. (2022). Does
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3
Client Factors
Joshua K. Swift, Jesse Owen, and Scott D. Miller

Who should get the credit for this success? Foremost, of course, the patient.
—SÁNDOR FERENCZI,
THE CLINICAL DIARY OF SÁNDOR FERENCZI

DECISION POINT

Begin here if you have read the book Better Results and

• are routinely measuring your performance and

• have collected sufficient data to establish a reliable, evidence-based
profile of your therapeutic effectiveness and
• have completed the Taxonomy of Deliberate Practice Activities in
Psychotherapy and
• need help developing deliberate practice exercises which leverage client
factors.

I magine one day, a team of well-known theorists, researchers, and psycho-

therapists get together and, over the course of a year, develop a new treatment
for depression. Excited about this new development, the team obtains grant
funding and designs a rigorous randomized controlled trial to test the efficacy of
the approach. They spare no expense in recruiting and screening participants,
training study therapists, monitoring fidelity, and carrying out the study.

https://doi.org/10.1037/0000358-004
The Field Guide to Better Results: Evidence-Based Exercises to Improve Therapeutic Effectiveness,
S. D. Miller, D. Chow, S. Malins, and M. A. Hubble (Editors)
Copyright © 2023 by the American Psychological Association. All rights reserved.
47
48 Swift, Owen, and Miller

As the results are analyzed, they discover that 100% of the clients show
clinically significant change. Even those who did not complete a full course of
the treatment completely recovered by termination. Surprised by the results,
the team conducts a second similar study, and again, 100% of the participants
experienced clinically significant change. Other researchers begin testing the
new treatment, and the results are always perfect—without exception, every
person who receives it recovers!
Now, imagine we have a world-renowned psychotherapist who was part
of the team who developed and tested the new approach. As expected, this
clinician knows the treatment inside and out, has perfect mastery of it, and
has now trained hundreds of others in its delivery. Then, one day, a client
with depression presents for help. The “miracle” treatment is described, and on
the basis of the existing research, the psychotherapist guarantees its success.
However, the client is not interested. Because of their culture, values, and
beliefs, they are not willing to engage in it. They understand the guarantee
being made but choose to live with the depression rather than violate their
principles and beliefs. So, while a 100% effective treatment delivered by
an expert psychotherapist exists, the chance of it making a difference for this
particular client is zero. The client—their willingness, motivation, culture,
values, and preferences—is what determines the results of the treatment in
this instance.
Although this scenario is presented in the extreme, a version of it plays out
every day around the world. An experienced therapist, for example, may
employ an evidence-based method (e.g., prolonged exposure therapy) while
working with a veteran experiencing posttraumatic stress disorder (PTSD).
However, the treatment does not seem to have an effect, and the client seems
hesitant to engage fully. Through inquiry, the helper discovers that the accepted
standard of care does not fit the client’s explanation of their problems or the
preferences they have for psychotherapy. In the client’s mind, the PTSD
reactions are closely linked to their strongly held spiritual beliefs and the guilt
and moral injury they feel surrounding their combat experiences—something
the research-supported treatment approach does not fully address.
As reviewed in detail in Better Results (BR; S. D. Miller et al., 2020), the
evidence clearly shows psychotherapy is effective. That said, the effects are
dependent on the individual client and how they engage and interact with
the psychotherapist and the specific treatment approach applied (Wampold &
Imel, 2015). Research over 5 decades makes clear that the contributions made
by the client and extratherapeutic factors explain the majority of the variance
in psychotherapy outcomes—greater than most other factors (e.g., the thera-
peutic relationship, the qualities of the therapist, hope and expectancy, and
the technique or structure; Duncan et al., 2010; Hubble et al., 1999; Wampold
& Imel, 2015).
Therefore, any therapist hoping to improve their effectiveness would
increase their ability to work with and tailor their approach to the individual
client. The material that follows provides a brief review of the evidentiary
support for client factors, a distillation of evidence-based principles for
 Client Factors 49

accommodating and personalizing treatment to the client, and exercises ther-

apists can employ in their deliberate practice (DP) to enhance their skills and
competencies in this area.

REVIEW OF THE RESEARCH

In the following section, we review the research on the influence of client

factors in psychotherapy. This includes a review of client factors that are known
to exert little or no influence on treatment outcomes, as well as client factors
that have been found to play an important role in psychotherapy.

Client Factors Exerting Little or No Influence on Outcomes

When asked to present a description of a particular client, it is not uncommon

for clinicians to mention age, gender identity, sexual orientation, race, ethnicity,
socioeconomic status, education level, and of course, diagnosis. These “client
factors,” so to speak, must therefore be considered relevant. As the first offered
up for consideration, it is often assumed they are not only useful in providing a
basic picture of who the client is but also important in informing care. Curiously,
the evidence shows they play little to no role in determining the choice of
treatment or its outcome.
Consider a recent and comprehensive review of the literature examining the
link between client demographic characteristics (e.g., age, gender or gender
identity, race or ethnicity, sexual orientation or identity, religiosity or spirituality,
and socioeconomic status) and treatment outcomes conducted by Constantino
et al. (2021). As can be seen in Table 3.1, evidence is either nonexistent,
insufficient, mixed, or inconsistent.

TABLE 3.1. Summary of Research Findings on the Relationship Between

Specific Client Demographic Factors, Treatment Outcome, and Dropout Rates
Demographic factor Impact on outcome
Age No significant or consistent correlation

Gender or gender identity Inconsistent associations

Insufficient research on nonbinary and transgender clients
Within therapist disparities in outcomes

Race or ethnicity Disparities in access and quality of care

No significant or consistent correlation
Within therapist disparities in outcomes

Sexual orientation Insufficient

Within therapist disparities in outcomes

Religion or spirituality No significant or consistent correlation

Socioeconomic status Limited evidence of poorer outcomes compared to higher

socioeconomic status
Small number of studies suggests caution when
interpreting results
50 Swift, Owen, and Miller

In all, Constantino and colleagues’ (2021) review suggests practitioners

be exceedingly cautious in drawing firm conclusions about the relationship
between any single client demographic factor and psychotherapy outcome or
dropout rate. Given the potential for bias, the state of the evidence calls into
question the common practice of citing such variables in clinical discussions and
notes or attempting to match clients to therapists or treatments based on such
considerations alone (Cabral & Smith, 2011; Constantino et al., 2021). Indeed,
with regard to the latter, the practice is deeply flawed. Matching therapist to
client on the basis of individual demographic variables alone does not improve
engagement or outcome (e.g., clients matched to therapists because they share
the same gender, cultural identity, or sexual orientation; Cabral & Smith, 2011;
Constantino et al., 2021).
Instead, an emerging line of research points to possibly a better way.
This research suggests that the impact of specific demographic factors on
outcome depends on who treats the client. Said another way, the relation-
ship between therapeutic effectiveness and the race or ethnicity, sexual
orientation, religious affiliation, and gender identity of clients is greater for
some therapists than others (Budge & Moradi, 2018; Drinane et al., 2016,
2022; Hayes et al., 2015, 2016; Imel et al., 2011; Larrison et al., 2011;
Owen et al., 2009, 2012, 2017). Imel et al. (2011), for instance, found that
therapists differed significantly in their effectiveness depending on their
clients’ racial or ethnic makeup.
It is important to note research does show that clients—in particular, those
belonging to a minority group—often prefer working with therapists similar
to themselves (Cabral & Smith, 2011; Constantino et al., 2021; Swift et al.,
2015). While this finding may, at first blush, appear to contradict earlier results
documenting no clear relationship between outcome and client demographic
factors, understanding how research on demographic variables is typically
conducted provides clarification. Such studies are generally carried out at a
group versus individual level, with all clients added together and the average
reported. In so doing, individual differences (critical in the actual psycho-
therapy room) disappear. Matching could be, and often is, important to one
client but not to all people with a similar quality, trait, background, or identity.
Thus, the emphasis should be placed on the individual’s preferences and values
rather than on the group to which they belong.
While on the subject of matching, mention should be made of recent efforts
to link treatment approaches to diagnosis. The “empirically supported treatment”
movement, as it is called, seeks to identify specific psychological approaches for
particular populations, groups, or disorders (Chambless & Hollon, 1998). While
the commonsense appeal for therapists and clients is undeniable—especially
in medicalized Western countries—research has not shown implementation
to result in improved outcomes (Wampold & Imel, 2015). Even studies that
have attempted to match clients to treatments along several demographic
and psychological dimensions have failed to make a difference (e.g., Project
MATCH, 1997). Known as the “ecological fallacy,” the flaw, once again, is
 Client Factors 51

making inferences about individuals based on aggregated group data. More-

over, focusing on demographic variables that do not have a direct influence on
treatment outcomes may lead clinicians to overlook the client factors that do
(i.e., client strengths, abilities, values, and beliefs as seen in the client factors
section of the Taxonomy of Deliberate Practice Activities in Psychotherapy
[TDPA; Chow & Miller, 2022; see Appendix A, this volume]).
Bottom line? Therapists maximize the chances of success by recognizing
their clients as individuals rather than making assumptions about them based
on qualities believed shared by the demographic group to which they belong.
After all, demographic variables are simply labels. They do not capture the
multidimensional nature of clients’ various identities. After reviewing 50 years
of Nigrescence, Cross (2021) noted, for example, the term “African American”
collapses complex and diverse peoples in the United States into a single mono-
lithic group (Cross, 2021). Rarely is the intersection of multiple client identities
or the ones clients deem most salient to their life employed in studies of demo-
graphic variables (Drinane et al., 2022; Hook et al., 2013; Owen, 2013).
To that end, consistent with the approach described in this volume and BR
(S. D. Miller et al., 2020), a more helpful approach to addressing client demo-
graphic factors includes therapists (a) formally and systematically monitoring
their work; (b) analyzing the resulting data to determine which, if any, client
demographic factors are reliably associated with less effective results on their
part; and (c) targeting their professional development efforts at addressing any
identified disparities in their ability to engage and help. After all, as is reviewed
in the next section, research shows adapting care to clients’ race or ethnicity,
religion or spirituality has positive effects on treatment outcomes for some
clients (Constantino et al., 2021; Huey et al., 2014; Soto et al., 2018).

Client Factors That Do Make a Difference

While the foregoing makes clear that treatment decisions should not be made
based on a client’s group membership, tailoring treatment to an individual’s
identity, values, and preferences is an important part of evidence-based practice
in psychology (American Psychological Association Presidential Task Force on
Evidence-Based Practice, 2006). As the factors that do make a difference are
reviewed, it is important to keep in mind they are to be considered with
a view toward tailoring and personalization. Take client preferences. Despite
research showing that 75% of people with mental health concerns prefer
psychotherapy over medication (McHugh et al., 2013), it would be wrong to
assign all clients to psychotherapy first on the basis of the predilections of
the majority. As we discussed for the demographic variables earlier, assump-
tions about individual clients should not be made based on group findings and
averages. Instead, each client needs to be asked about their particular prefer-
ences and accommodated accordingly. The following variables emphasize the
importance of tailoring to the individual client.
52 Swift, Owen, and Miller

Role Expectations
Role expectations refer to clients’ beliefs about what is likely to happen in treat-
ment (Arnkoff et al., 2002), including the provider they might work with
(e.g., gender, discipline, cultural background), what the treatment will look
like (e.g., passive vs. active, daily vs. weekly visits), the roles the client and
therapist will play (e.g., active vs. passive, directive vs. nondirective), and even
how long a course of care might last (e.g., brief, intermittent, ongoing). Such
beliefs can be based on past psychotherapy experiences, stereotypes played
out in the media, or messages heard from friends and family. For example,
because of portrayals in the movies, a client may believe they will be asked
to lie on a couch. Alternatively, after talking to a family member about their
experience in treatment, a client may believe their therapist will offer advice,
giving detailed and explicit instructions for how to solve their problem. Client
beliefs about psychotherapy can be accurate or faulty. For example, research
indicates that most expect to attend fewer sessions than the evidence indicates
are necessary to be effective (Bohart & Wade, 2013; Garfield, 1994; Swift &
Callahan, 2008). As therapists vary in training, discipline, style, and approach,
the fit between expectation and experience will also depend on who the client
happens to meet.
Previous reviews of the literature have questioned the connection between
role expectations and treatment outcome (Arnkoff et al., 2002). However,
as was the case with research on demographic factors, the failure may say as
much about the design of the studies as it does about their influence on out-
come. It is possible, for example, that the negative effects of unmet role expec-
tations for some clients are canceled out by the positive effects of met role
expectations for others in the current summaries of the evidence.
What can be said with certainty is positive outcomes often follow when
therapists spend time preparing their clients for what will happen. Known as
“role induction” or “pretherapy education,” this includes providing a rationale
for what is being offered, a step-by-step outline of what will take place, and an
explication of the role and expectations of the client in the process. Consider
the evidence. Using data from 28 independent studies, a meta-analysis by
Monks (1996) found that including some type of role induction at the start or
before the beginning of psychotherapy led to increased treatment attendance
(d = 0.32), decreased dropout (d = 0.23), and improved outcomes (d = 0.34),
all with small to medium effects observed. In a second and more recent meta-
analysis focused on strategies for increasing treatment attendance, data from
14 randomized controlled studies of pretreatment education showed a medium-
size effect (d = 0.50) on attendance and decreasing dropout (Oldham et al.,
2012). Similar results have been reported in studies testing strategies for
addressing clients’ role expectations concerning treatment duration. In the
most often cited, Swift and Callahan (2011) found clients who received pre-
treatment education about adequate doses of psychotherapy attended nearly
twice the number of sessions (d = 0.55) and were 3.5 times more likely to
be classified as completers than clients who did not receive the educational
preparation.
 Client Factors 53

FIELD GUIDE TIP

Early on in BR, you were asked to create a

schematic or blueprint for how you conduct
therapy sufficiently detailed so another
practitioner could understand and replicate
it—literally, “step into your shoes” and work
how you work (Miller et al., 2020, p. 29). The
purpose of the activity was to make it easy to
pinpoint where to intervene as opportunities
for improving your effectiveness are identified
by analyzing your performance data.
If you have not yet completed a blueprint,
turn to pages 18–20 in this volume for updated,
step-by-step directions.
Next, with your completed blueprint in hand,

• ensure it includes a description of how you

prepare clients for what will take place in
treatment once it begins; and

• should “role-induction” or “pretherapy

education” be absent, turn to the Client
Factors section (the fourth domain) of the
TDPA and complete the first two items
(A and B).

Preferences
While expectations represent clients’ beliefs about what might happen during
psychotherapy, preferences can be thought of as their desires for what they
would want to occur were the choice left up to them (Swift et al., 2018). Like
role expectations, clients may have preferences about the therapist with whom
they work (e.g., age, gender, religious background, lived experience), the type of
treatment they want to receive (e.g., client-centered vs. cognitive behavioral,
directive vs. nondirective), and the nature of the care (e.g., homework, therapist
advice giving, exploration). Like role expectations, preferences may be based
on past experiences in therapy. Nevertheless, they can also be influenced by
clients’ likes and dislikes derived from other relationships, as well as knowledge
about themselves. While client preferences frequently line up with elements
of care most likely to lead to treatment success (Tompkins et al., 2017), this is
not always the case. The evidence shows, for example, that comfort rather than
effectiveness may drive the desire for certain therapist attributes, treatments,
or situations (Swift & Callahan, 2010).
Research documents a number of benefits associated with accommodating
client preferences. A major meta-analysis (Swift et al., 2018) using data drawn
54 Swift, Owen, and Miller

from 53 studies found significantly larger gains in posttreatment outcomes

(d = 0.28) for clients whose preferences were accommodated compared with
those whose were not. Retention in treatment was also significantly affected,
with those whose preferences went unmatched dropping out at a 50% higher
rate. Such effects were consistent across client age, gender, ethnicity, and years
of education and, in terms of impact on outcome, even larger for clients with
anxiety or depression concerns. And finally, while perhaps not surprising, the
evidence shows preference accommodation also leads to stronger ratings of
the therapeutic alliance (Windle et al., 2020), a robust predictor of treatment
outcomes (Flückiger et al., 2018; see also Chapter 5, this volume). Swift et al.
(2021) argued persuasively that choice and a spirit of collaboration can be
empowering to clients, encouraging them to invest more in the work to ensure
their choices prove successful.

Motivation and Stages of Change

As all clinicians know, hope and expectation of success in treatment (see
Chapter 6 for an in-depth review) do not always translate into clients being
ready or willing to put in the effort required to make desired changes happen.
A large body of literature shows treatment that fits the client’s motivational
level or “readiness” is associated with more engagement and better outcomes
(Norcross et al., 2011). The findings are robust, with the latest meta-analysis—
including data from 76 different studies (Krebs et al., 2018)—reporting a
medium-size effect (d = 0.41) when therapists successfully tailor treatment to
the client’s “stage of change.”
According to the stages of change model (Prochaska & DiClemente, 1983),
client motivation or readiness for a particular type or intensity of intervention
can be classified into one of six different categories: (a) precontemplation
(little to no awareness a problem exists and hence, no intention or desire to
change), (b) contemplation (aware a problem exists and weighing the costs
and benefits of change), (c) preparation (getting ready to take steps to change),
(d) action (actively taking steps to address a problem), (e) maintenance (actively
working to maintain a change and prevent relapse), and (f) recurrence (dealing
with a setback or relapse). As illustrated in Table 3.2, each stage is associated
with change processes or interventions most likely to facilitate—or at least
not serve as a barrier to—moving to the next (Krebs et al., 2018).
The key is tailoring the nature, type, and pace of the intervention (e.g.,
therapist activity) to fit each client’s current state of readiness. So, for example,
telling a client in precontemplation to “attend 90 AA meetings in 90 days”
would likely arouse feelings of mistrust and misunderstanding and increase the
chances of them dropping out of care, whereas empathizing with their situation
and providing information related to their particular concerns or questions would
enhance the chances of their returning for future sessions. However, for a client
in the action stage, mere listening and empathizing would likely lead to feelings
of frustration with the pace of treatment. It must be emphasized that working at
being “in sync” with where clients are is an ongoing process, critical throughout
treatment as decisions are made about the various interventions.
 Client Factors 55

TABLE 3.2. The Stages of Change, Associated Change Processes, and Congruent
Stage-Specific Therapeutic Interventions
Stage of change Change process Intervention
Precontemplation Establishing rapport Listening
(not seeing a problem Building trust and Empathizing
or need for change) connection Being nonjudgmental
Securing engagement Providing information about
Raising awareness topics and options of
interest to the client
Using harm reduction
strategies

Contemplation (thinking Addressing ambivalence Exploring specific options

about changing) and uncertainty Weighing costs and benefits
Evaluating current behavior of change
and outcomes Modeling and exploring
Assessing and exploring what changing looks like
client self-efficacy Connecting with people who
support making a change

Preparation (planning to Establishing objectives Setting goals

make a change) Organizing efforts Planning
Securing necessary Establishing timelines
resources and supports Identifying helpful supports
and resources
Considering potential
barriers to success
Offering practical help,
support, and positive
reinforcement

Action (taking steps) Providing valuation and Monitoring successes and

feedback failures
Providing refinement Identifying high risk and
Providing support high success situations
Using counterconditioning
Managing reinforcement
Providing coaching and
advice

Maintenance (ensuring Supporting, affirming, Providing stimulus control

stable change) reinforcing Providing coping strategies
Reviewing long-term goals Finding connections with
and objectives community of support

Recurrence Learning from experience Normalizing

Providing feedback
Providing support
Reconnecting with support-
ive community
56 Swift, Owen, and Miller

FIELD GUIDE TIP

“Stages of change,” “change

processes,” and “interventions”
provide a concrete, evidence-based
illustration of Goldfried’s (1980)
“theoretical framework,” “clinical
strategies,” and “techniques”
described in Chapter 1 (p. 19).

Attachment Styles
Clients enter treatment with unique ways of relating to and interacting with
the world and those around them. Research points to a link between what
is commonly referred to in the literature as client “attachment styles” and the
outcome of psychotherapy. In a meta-analysis of 32 studies, for example, Levy
et al. (2018) found a moderate (d = 0.35) relationship. Specifically, higher levels
of attachment security in clients at the outset of care were associated with
more positive outcomes at termination.
However impressive such findings may appear at first blush, results of
studies examining group-level differences, as previously discussed, are not
particularly applicable to conducting therapy with an individual. They might,
were therapists able to limit their work to clients with the same attachment
style! Given therapists are typically unable to choose the starting attachment
style of their clients, adjusting services to fit each, once therapy starts, is wise.
To that end, Table 3.3 presents the four main attachment styles, associated

TABLE 3.3. Attachment Style, Style Characteristics, and Prevalence

Attachment style Characteristics Prevalence
Secure Able to easily and quickly form secure, 50% to 60% of adults
loving relationships with others
Trusting and trustworthy
Loving and lovable

Anxious Insecure about relationships 15% to 25% of adults

Fearful of abandonment
Hungry for validation

Avoidant Insecure and distant in relationships 20% to 30% of adults

Emotionally unavailable
Independent and self-reliant
Has difficulty being close with or trusting
others

Fearful–avoidant Combination of the anxious and Less researched,

avoidant styles but believed rare
Craves and avoids affection and intimacy
 Client Factors 57

characteristics, and prevalence. Importantly, research suggests changes in

attachment can occur in psychotherapy and are associated with positive out-
comes. In their meta-analysis, for example, Levy and colleagues (2018) found
movement toward attachment security during treatment led to better out-
comes (r = .16), while lowering levels of attachment anxiety was linked with
greater improvements in both symptoms (r = .18) and functioning (r = .16).
In addition, lower levels of attachment avoidance were associated with greater
improvements in symptoms (r = .15).

Reactance
Reactance has been identified as an emotional reaction that people have when
they feel that their ability to make a choice is being threatened (Brehm &
Brehm, 1981). This reaction often leads to a stronger preference for the options
that are perceived as being limited or taken away. Research shows higher levels
of reactance are associated with a greater likelihood of rejecting and derogating
health-promoting messages and their sources (e.g., health care professionals;
C. H. Miller et al., 2007). Fortunately, the same body of literature shows reac-
tance levels are influenceable. C. H. Miller et al. (2007), for example, found
concrete (vs. abstract), low-controlling communication, emphasizing the choices
available to the listener, were viewed as more important, received more atten-
tion, and generated more positive assessments of the source.
As all clinicians know, psychotherapy can be difficult for clients. It may
require them to approach thoughts, memories, feelings, and situations they
have previously labored to avoid. Alternately, change may require giving up
habits, coping styles, and even personal relationships, previously comforting
or rewarding. Not surprisingly, this may give rise to reactance in which,
consciously or unconsciously, the client opposes the change process (Brehm
& Brehm, 1981). Like the findings reported in the broader health care literature,
research shows the degree of reactance can be influenced by the therapist’s
approach. Consider a recent meta-analysis by Beutler et al. (2018) synthesizing
data from 13 different studies. It found a large effect (d = 0.79) when treatment
was tailored to the level of client reactance. Specifically, outcomes were signifi-
cantly better when therapists of highly reactive clients assumed a less directive,
more reflective stance. By contrast, clients low in reactance fared better when
therapists were more active and directive in treatment. Clearly, adjusting
services to fit client reactance level is a potent way to improve client engage-
ment and outcome. It is consistent with the “mobilization of will” listed in
the relationship factors dimension of the TDPA and, when framed as a positive
client trait, can also be seen as a way of tapping into clients’ strengths, values,
and abilities specified in the client factor domain.

Culture
Cultural adaptations, therapists’ cultural competence, and therapist multi­
cultural orientation are positively associated with treatment outcome. A recent
meta-analysis by Soto and colleagues (2018) identified 99 studies of culturally
58 Swift, Owen, and Miller

adapted treatments and 15 addressing the link between therapist cultural

competence and outcomes. Culturally adapted interventions were significantly
more effective than nonadapted interventions for racial and ethnic minority
clients (medium size, d = 0.50). Client ratings of their therapist’s cultural
competence were strongly correlated with effective treatment (r = .38). The
same analysis indicated that higher client ratings of therapist multicultural
orientation are associated with stronger alliances, which, in turn, lead to better
results. Therapist ratings of their own cultural competence were, by contrast,
not related to outcome. Like alliance-related findings (Horvath et al., 2011),
it is the client’s perception of their therapist’s cultural awareness, knowledge,
and skills that matters most, not the therapist’s judgment of their own com-
petence, sensitivity, or abilities.
Adapting care to each client’s culture—a practice now known in the literature
as dynamic sizing—is easier said than done (S. Sue, 2006). In truth, it is much
like threading a needle, the challenge being promoting engagement while
avoiding stereotyping. A case in point: Manualized therapies have been created
for treating people with eating disorders. To be culturally sensitive, specific
adaptations to the standardized protocols have been suggested regarding the
types of foods to be discussed and included in treatment interventions (e.g.,
a “Mexican food guide for Latina women” presenting with bulimia; Reyes-
Rodríguez et al., 2014). Other modifications include employing culturally
specific stories and characters to shape or frame therapeutic interventions
(Costantino et al., 1986). The danger, of course, is presuming everyone who
shares a particular ethnicity eats the same foods or finds the same customs
or concepts meaningful. People always look more similar from a distance,
and yet, what is assumed to apply to the many may, in fact, not apply to any
given person.
Beyond losing sight of individual differences, the sheer number of possible
adaptations can quickly become unmanageable. Official definitions of multi-
cultural competence already include being both aware of and accommodating
differences in race, ethnicity, gender, sexual orientation, culture, religion, and
spirituality. Once one adds, as is recommended, age, maturity, socioeconomic
status, class standing, family history, and a host of other process and demo-
graphic variables, even the most conscientious of practitioners cannot help but
be overwhelmed. To illustrate, in a course of psychotherapy, where a clinician
considers only two of the 13 factors just identified, 78 possible adaptations to
the treatment obtain. Add one and that number triples. If only four dimensions
are identified as consequential, clinicians must master 715 different ways to
nuance service delivery. Obviously, any standard of care that requires clinicians
to juggle so many variables is both absurd and out of touch, with research
showing people are incapable of multitasking (Atchley, 2010).
At length, were it possible to compile an exhaustive list of every cultural
variable and therapists were somehow capable of managing all, a serious
problem would remain. Unless the fundamental organizing principles and
practices underlying clinical work are questioned, any accommodation, no
matter how well-intentioned or comprehensive, risks being little more than
 Client Factors 59

window-dressing, a marketing hook, or the proverbial “spoonful of sugar”

that makes the therapist’s “medicine” more palatable. In place of what might
be called the “chapter-in-a-book” approach to culture adaptation (e.g., do “X”
with clients of African descent, do “Y” with Asian clients, and so on), Owen
et al. (2011; Owen, 2013) offered what has been termed the “multicultural
orientation framework,” a way of being with clients rather than a predetermined
approach for doing therapy. The multicultural orientation framework rests on
three pillars: (a) cultural humility, (b) cultural opportunities, and (c) cultural
comfort.
Being a humble therapist means having an accurate perception of one’s
own values—including the cultural assumptions informing or implicit in the
methods employed—while simultaneously being able to maintain another,
relationally oriented perspective that sponsors respect, equity, and connection
(Davis et al., 2018; Fancher, 1995; Hook et al., 2013). In practice, this means
working continuously on self-awareness (e.g., one’s biases, strengths, weak-
nesses), bringing curiosity to every interaction, and being open to the client—
especially feedback regarding the success achieved in understanding their
experience and world. In addition, cultural humility is at the heart of under-
standing another’s values and worldviews while reminding therapists to
monitor their judgments. Studies to date demonstrate clients who view their
therapist as more culturally humble have better therapy outcomes, including
key therapeutic processes, such as the working alliance (e.g., Davis et al., 2018;
Hook et al., 2013, 2016; Owen et al., 2014).
Seeking out and being responsive to cultural opportunities means being
both aware of and willing to explore and integrate the intersection of clients’
cultural heritage throughout the process of therapy (Owen, 2013; Owen et al.,
2016). “Each therapy session provides multiple [such] opportunities,” Hook
et al. (2017) noted, “but for variety of reasons many of these . . . go unrealized”
(p. 32). A simple example is ensuring that questions about culture on intake
paperwork are broadly inclusive, reflecting a wide range of identities (e.g.,
open-ended vs. forced choice responses allowing clients to present who they
are and what matters most to them). For clients, the evidence shows missing
such opportunities results in poorer treatment outcomes (Owen et al., 2016).
Finally, cultural comfort refers to the feelings surrounding culturally relevant
conversations in therapy. Discussing issues related to culture can be difficult
and uncomfortable. Therapists with high levels of cultural comfort are able to
manage their own feelings, engaging the client in a composed, relaxed, and
connected manner. As a result, their clients are more likely to discuss cultural
topics and form stronger therapeutic alliances (Tao et al., 2016). By contrast,
racial and ethnic minority clients who meet with less “culturally comfortable”
therapists are more likely to drop out of treatment (Owen et al., 2016).

Religion and Spirituality

Research clearly supports the integration of clients’ religious and spiritual
beliefs and practices into the process of psychotherapy. On the basis of data
60 Swift, Owen, and Miller

from 102 independent samples, one meta-analysis (Captari et al., 2018) found
clients who received religious and spiritual tailoring showed more positive
psychological and spiritual outcomes than those in control groups (g = 0.75
and g = 0.75, respectively) and nontailored treatment (g = 0.33 and g = 0. 43,
respectively). Not surprisingly, perhaps, the most rigorously designed studies
in the analysis found standard treatments were as effective as tailored therapies
in reducing psychological distress but significantly less effective in improving
spiritual well-being (g = 0.34) and more positive psychological outcomes. The
findings were consistent across client age, gender, presenting problem, and reli-
gious affiliation and even more effective for racial and ethnic minority clients.
Although therapists as a group remain less religious than those they serve,
surveys consistently show most of their clients believe religion and spirituality
are important and appropriate topics for psychotherapy (Miller & Hubble, 2017).
In fact, most welcome questions and want to discuss their beliefs, viewing
them as an integral part of their treatment experience (Dimmick et al., 2021;
Martinez et al., 2007; Rose et al., 2001; Rosmarin et al., 2015). Unfortunately,
Trusty et al. (2022) found that a sizeable number who consider themselves
religious experience at least one microaggression—defined as subtle, denigrating
comments or behaviors—during therapy, the most common being the mini-
mization or avoidance of religious or spiritual issues.
Consistent with research findings on other client factors (e.g., culture or
ethnicity), such experiences are negatively associated with the therapeutic
alliance and outcome. Concrete and specific guidance for avoiding such mis-
steps and integrating client spirituality and religion into psychological care
can be found in a popular and widely read article, “How Psychotherapy
Lost Its Magick,” by Scott Miller and Mark Hubble (2017)—read more than
70,000 times at the time of the publication of the Field Guide. The authors pre-
sented a three-step framework, noting, “In some important ways, practitioners
are already doing some of this work, but other aspects will undoubtedly prove
more challenging, requiring a radical shift in the way psychotherapy is conceived
and performed” (p. 33). From easiest to most challenging, the steps include

FIELD GUIDE TIP

Chapter 8 of BR describes and

illustrates how to mine your
performance data for deliberate
practice opportunities. In light of the
research presented in this section,
consider sorting your clients according
to their cultural, religious, or spiritual
identity, paying particular attention to
differences in alliance scores, dropout
rates, and effect size.
 Client Factors 61

(a) being willing to ask about and explore beliefs (exploration), (b) consciously
and purposefully working to increase the fit between clients’ religious and
spiritual beliefs and the therapist’s preferred way of thinking about and doing
therapy (entering), and (c) using and incorporating religious practices (e.g.,
prayer, drumming, energy meridians) in care (embodying).

Sexual Orientation and Gender Identity

In recent years, some researchers have begun to develop and test lesbian, gay,
bisexual, transgender, and queer (LGBTQ+)–affirmative therapies. As noted
in the section on demographic variables, the number of studies in this area is
insufficient to draw any firm conclusions regarding their potential advantage
(Constantino et al., 2021). That said, two systematic reviews of the literature
reported, like findings on other demographic variables, that the type of treat-
ment is less important in terms of outcome and dropout than whether a
therapist is open; curious; aware of their own preferences and biases; avoids
subtle, denigrating comments or behaviors; and provides a safe, validating,
and affirmative therapeutic environment (Budge & Moradi, 2018; Moradi &
Budge, 2018). Transgender clients, in particular, express a strong desire for
knowledgeable therapists and affirming therapies, having often experienced
harm in psychotherapy resulting from clinicians’ gender incompetence (Duffy
et al., 2016; Elder, 2016). Given that therapists can err by either ignoring or
overemphasizing gender identity or sexual orientation, the key—as with culture,
religion, and spirituality—is being willing to explore connections between
therapy and client sexual orientation or gender identity as guided by the indi-
vidual client (Budge & Moradi, 2018).

Environmental Supports and Personal Strengths

A 2008 meta-analysis of 27 studies and more than 5,500 clients by Roehrle
and Strouse reported a small but significant association (r = .13) between
greater client social support—both perceived and extant—and psychotherapy
outcome. While a handful of subsequent studies have returned more mixed
results (e.g., Leibert et al., 2011), the weight of the evidence supports therapists
routinely assessing the quantity and quality of actual supports, including
the client’s evaluation of their value and importance, and incorporating the
findings in the conduct of therapy. For example, in their study, Leibert et al.
(2011) showed an emphasis on the therapeutic alliance was particularly
beneficial for clients with low social support. However, Project MATCH deter-
mined that the community provided by Alcoholics Anonymous proved more
effective than comparison treatments for problem drinkers whose existing social
network supported their alcohol use versus sobriety (Longabaugh et al., 1998).
Over the years, much has been written about the role of client strengths
in psychotherapy. Indeed, entire models (e.g., solution-focused, positive psy-
chology) have been developed on the basis of the premise that incorporating
clients’ strengths and abilities is a critical and overlooked key to success. While
the number of clinical trials is low, one meta-analysis found no difference
between strengths-based and other methods in either level of functioning
62 Swift, Owen, and Miller

or quality of life in adults diagnosed with severe mental illness (Ibrahim et al.,
2014). Such findings are consistent with studies comparing different modalities,
indicating it is not the treatment approach per se that matters but a question
of how client strengths are approached within each session. Consider the results
of two studies, both of which demonstrated a relationship between outcome
and the timing and proportion of problem versus resource (e.g., strength)
focus and discussion. Gassmann and Grawe (2006) explored the occurrence
of problem and resource activation strategies in recordings of 120 sessions of
psychotherapy drawn from a large sample of adult outpatient clients. Using a
composite measure of outcome consisting of goal attainment, emotional, behav-
ioral, and relational change and posttreatment client and therapist ratings,
the researchers found (a) resource activation accounted for significantly more
outcome variance than problem focus, and (b) a higher ratio of resource to
problem activation differentiated successful from unsuccessful therapies.
Using multilevel modeling, Malins et al. (2021) showed specific types of
therapeutic interactions predicted the experience of client well-being session
by session; specifically, the greater the proportion of first and second sessions
spent describing problems (as opposed to more active discussions of what to
do with problems arising), the poorer the outcome. An analysis of therapeutic
interactions with a smaller subset of clients (n = 12) revealed that time spent
describing problems was much lower and positive discussions much higher
in sessions immediately preceding client reports of rapid, sudden progress
(see the discussion in the next section).
Taken together, the results just reported are consistent with Points D and F
of the client factors dimension on the TDPA, emphasizing the possibilities
inherent in assessing and using clients’ existing strengths and social support
networks.

Extratherapeutic Change-Producing Events

Researchers Howard et al. (1986) were the first to note, in their classic article,
“The Dose-Effect Relationship in Psychotherapy,” a sizeable number of clients
(15%) were already experiencing improvement before the initial meeting
with a therapist. Subsequent research suggests the incidence of pretreatment
change is much higher—with as many as two thirds of clients reporting prog-
ress related to their reason for seeking help if the topic is raised for discussion by
the therapist (Lawson, 1994; Reuterlov et al., 2000; Weiner-Davis et al., 1987).
Other studies of adults and children have shown many experience significant
therapeutic gains early in treatment that are both predictive of final treatment
outcome and maintained at follow-up (Dour et al., 2013; Stiles et al., 2003;
Tang & DeRubeis, 1999). In 2020, a meta-analysis of 50 studies by Shalom
and Aderka found such “sudden gains” were highly predictive of outcome at
termination (g = 0.68) and follow-up (g = 0.61), exceeding the variance attribut-
able to specific treatments, diagnoses, and settings. Consistent with the recom-
mendation in the client factors section of the TDPA, regardless of treatment
approach or orientation, therapists should be open to, curious about, and
welcoming of change wherever and whenever it occurs.
 Client Factors 63

EVIDENCE-BASED PRINCIPLES RELATED TO CLIENT FACTORS

In presenting evidence-based principles related to client factors, one approach

is to develop a comprehensive list of suggestions, each linking to one of the
specific elements reviewed. For example, a list of principles could be offered
for accommodating each client preference noted in the literature (e.g., offer
clients the type of therapy they request, work at matching the client with
a therapist who fits their particular preferences regarding age, gender, lived
experience), followed by suggestions for religious and spiritual integration
(e.g., create a list of specific practices to use with clients from specific religious
backgrounds, develop therapeutic approaches incorporating the concepts and
beliefs of specific religious), culture, and so on. In so doing, however, dozens
of principles could be identified, each resulting in a long list of specific thera-
peutic “dos and don’ts” (for such a list, see Norcross & Wampold, 2018). While
such an approach has the advantage of specificity, a more accurate represen-
tation of the findings in this area suggests a handful of principles applicable
across all client factors reviewed in this chapter. Thus, regardless of who the
client is, the following principles can be used to guide therapists in the develop-
ment of DP exercises aimed at improving their ability to tailor their work to
the individual client.

Principle 1: Treat Each Client as an Individual Rather Than a Member

or Representative of a Particular Group (e.g., Demographic, Preference,
Culture, Beliefs, or Diagnosis)

Some therapists may believe they are tailoring because, for example, they use
a specific “culturally adapted” treatment for all their African American clients.
Although this is a step in the right direction and will lead to outcomes across
all their clients of African descent, it will misfire for many. As noted previ-
ously, group data does apply to individual clients. Some may desire cultural
adaptations, others not. It is important that therapists not make assumptions
about the individual based on how they look or the group with which they
are identified. Similarly, it might be tempting, given the documented efficacy
of religious and spiritual adaptations in psychotherapy, to include religious
and spiritual discussions and techniques for any religious and spiritual client.
Recall, however, existing research indicates some strongly religious individ-
uals do not desire their beliefs to be a part of their psychotherapy (Dimmick
et al., 2021), while many nonreligious individuals do (Rosmarin et al., 2015).

Principle 2: Actively Solicit Information About Each Client’s Identity

(e.g., Gender, Race and Ethnicity, Sexual Orientation, Religion and
Spirituality) and Elements Known to Impact Psychotherapy Positively
(e.g., Expectations, Preferences, Reactance, and Stage of Change)

When getting to know a client, interest should be on not only what their
identities are but also how those intersect with their presenting problems and
64 Swift, Owen, and Miller

at what level they would like those identities discussed and incorporated into
therapy. In so doing, it is important to remember such considerations might
not always overlap for the individual. A highly religious client may link their
psychological distress to religious concerns, for example, but may not want
to include any religious or spiritual interventions or techniques in their
psychotherapy. Rather, they may prefer to reserve any such approaches or
discussions to religious settings and leaders. Alternatively, a different client
may report no spiritual or religious distress but wish to end each session with
a prayer.
With regard to expectations, preferences, and motivation, be mindful of what
is available and possible in the treatment context. If only female clinicians are
available at a particular agency, for example, asking whether the client had
ideas about the type of therapist they would work best with is preferable to
“Would you rather see a male or female?” Should a particular preference be
unavailable, an opportunity can be offered to explore their reaction (e.g.,
feelings, thoughts), including the desire for a referral.
It is increasingly common for clients to express a preference for a particular
brand or type of treatment (e.g., cognitive behavior therapy, eye movement
desensitization and reprocessing therapy). Because such requests are tied to
the client’s reasons for seeking care, they should be encouraged and explored.
Knowing a client believes their problems are biological in nature might lead
to different engagement strategies (e.g., exercise, diet, medication) than if they
viewed their concerns as primarily interpersonal in origin (e.g., relationship
skills, assertiveness training, family therapy). In short, accommodating client
preferences is more like a negotiation aimed at establishing a common under-
standing than ordering a meal from the menu of a restaurant (e.g., “Would you
like your therapy with fries or a salad?”).

Principle 3: Seek to Understand and Be Respectful of the Individual

Client’s Values and Beliefs, Even When They Are Different From the
Ones Held by the Therapist

As reported earlier, when it comes to cultural and religious identity, a large

percentage of clients report experiencing microaggressions from their therapists
(e.g., 50%–75% of clients; Constantine, 2007; Hook et al., 2016; Owen et al.,
2010, 2014; Shelton & Delgado-Romero, 2013; Trusty et al., 2022). To be sure,
it is unlikely the majority of offenders intend to interact with certain clients in
a hostile manner. Indeed, perpetrators typically find it difficult to believe they
possess any biased attitudes whatsoever (D. W. Sue et al., 1992). Therefore,
a good starting point for putting Principle 3 into practice would be to follow
the ancient Greek aphorism “know thyself.”
In terms of expectations, preferences, and motivation, differences in the
values and beliefs between therapists and clients are also bound to occur.
Consider, for example, the pairing of an active, task-oriented therapist with
a depressed client who complains about homework suggestions. In such a
 Client Factors 65

case, attributing a lack of engagement or progress to “client resistance” would

privilege the therapist’s beliefs, values, and experience over the client’s. A more
effective approach, according to the research cited previously, would be to
adjust the nature, type, and pace of intervention (e.g., therapist activity) to the
client’s state of readiness.
Some clients may have expectations regarding therapy that are inaccurate or
uninformed. Therapists who immediately dismiss these types of expectations or
preferences risk rupturing the therapeutic alliance. Balancing openness to the
client’s point of view with the provision of information is key for securing the
engagement needed to derive a joint plan. For example, when asked about
expected treatment duration, a client might reply they expect to recover fully
in two sessions. In response, the therapist could recognize the client’s initial
expectation (e.g., “That is great! It sounds like you are optimistic about treat-
ment and believe that it can help you quickly. Your optimism will be helpful
as we work together”), provide information (e.g., “Although treatment might
work that quickly for you, it typically doesn’t work that fast for most people.
In fact, the research suggests that it takes around 13 to 18 sessions for 50% of
clients to recover. Some do recover sooner than that, but others take longer”),
and develop a joint plan (e.g., “How about we plan on doing the first two
sessions and then, at the end of the second session, we do a check-in to see
where you are at. If things are all better at that point, that is great, and we will
be done. But, if you need more than that, then we can plan for a few more
sessions together until you get to where you want to be”). Understanding and
respecting clients’ values and beliefs is a concrete way to operationalize the
TDPA client factor regarding values and beliefs while simultaneously making
space for the therapist to better incorporate the client’s strengths, abilities, and
resources in treatment.

Principle 4: Check in With Clients on an Ongoing Basis to Ensure the

Work Fits With Their Expectations, Preferences, Values, Needs, and
Identity, Being Flexible and Accommodating When Needed

Clients’ goals, desires, and expectations change and evolve while in therapy.
What they thought they wanted at the outset may not be what they actually
want once they see it in practice! Circumstances in clients’ lives outside of
therapy may also change. Consider someone who initially presents for help
with work-related stress but learns her partner is having an affair and intends
to end their relationship. Frequent “check-ins” allow therapists to identify
and respond to shifts in goals, preferences, and alliance ruptures before clients
choose to drop out (Swift & Greenberg, 2015). Using brief end-of-session
measures such as the Session Rating Scale (described in detail in BR) is a
particularly helpful way to ensure the therapy and therapist evolves with the
client. It also provides a concrete method for identifying and incorporating
client strengths and abilities, social support, and chance events into care,
consistent with the recommendations on the TDPA.
66 Swift, Owen, and Miller

FIELD GUIDE TIP

“Certain therapists are more effective than

others . . . because [they are] appropriately
responsive . . . providing each client with
a different, individually tailored treatment”
(Stiles & Horvath, 2017, p. 71).

EXERCISES FOR CLIENT FACTOR SKILL DEVELOPMENT

While considering the following exercises, recall that “the goal of DP is neither
proficiency nor mastery. Rather, it is all about continuously reaching for
objectives that lie just beyond one’s current ability” (Chapter 1, this volume).
Said another way, no benefit will result from picking an exercise or two from
the following list to engage in during your free time. To make a difference in
your results, the exercise you choose must be specifically remedial to data-
identified deficits in your clinical performance. As stated at the outset of this
chapter, it is assumed you (a) are routinely measuring your performance;
(b) have collected sufficient data to establish a reliable, evidence-based profile
of your therapeutic effectiveness; (c) completed the TDPA; (d) determined a
deficit exists in your performance related to the operation of client factors;
and (e) narrowed your focus to a single element within the client factors
domain on the TDPA and defined that performance improvement objective in
SMART terms (specific, measurable, achievable, relevant, and time bound).
Now, with the completed TDPA in hand, review the following exercises for
the one most closely aligned with your goal. Keep in mind the list is neither
comprehensive nor exhaustive. You may, along with colleagues or peers, have
ideas of your own. Should none of the exercises speak directly to your needs,
Chapter 2 may prove helpful. It describes a process for using the TDPA in
combination with your data to develop a “learning project,” ultimately resulting
in individualized DP exercises.

Exercise 1: Alternative Descriptions

Principle: 1
Applicability: TDPA Items 4C, E, F (also applicable to 3Bi, ii, iii, v,
5Aii, iv, 5Bi)
Purpose
When speaking about our clients to other providers, we often describe them
based on their disorder or basic demographic variables (e.g., age, gender,
ethnicity, sexual orientation). Although such descriptors allow for quick and
 Client Factors 67

easy communication, they may result in erroneous, simplistic, or stereotypical

assumptions. This exercise is designed to help therapists develop their skills in
making individual decisions about clients rather than on group assumptions
(either assumptions based on the empirical literature in the field or assump-
tions based on individual biases).

Task
Identify clients who have dropped out, reported low or declining scores on the
alliance measure you routinely administer at the end of each visit (e.g., Session
Rating Scale), or whose outcomes are either not improving or declining (e.g.,
Outcome Rating Scale). Using paper and pencil, word processing software,
or your favorite note-keeping app, begin writing a brief description of each,
focusing specifically on who they are as individuals rather than how they are
similar to other clients. The “Four S” approach (Chow, 2022) may be helpful in
completing the process, noting their sense of self (e.g., beliefs, personality, what
they identify with), sparks (e.g., what they care about, what makes them come
alive), significant life events (e.g., traumas, fortuitous and formulative happen-
ings), and systems (e.g., positive and negative impactful relationships, critical
environmental supports). Take your time in completing the task. Devoting a
few minutes each day to the exercise is likely to prove more helpful in fostering
the thinking and reflecting necessary to have an impact on subsequent perfor-
mance than trying to complete it in a single sitting.
To the description, now add a case conceptualization. Do so without
mentioning a specific psychiatric diagnosis or disorder, presenting problem,
demographic characteristic, or another descriptor typically associated with
clinically oriented presentations. Continue this process with new and existing
clients when they meet the previously noted criteria.
After a month, or once a sufficient number of such descriptions and case
conceptualizations have accumulated (∼10–20), review and reflect on what
you have written. Look for patterns. Return to the research review or recom-
mended readings section of the chapter for ideas about expanding the ways
you view and interact with clients. When not doing psychotherapy, take time
to develop concrete examples (e.g., by writing out, role-playing) of including
such ideas in your daily work.

Exercise 2: Asking About Preferences

Principle: 2
Applicability: TDPA Items 4A, B, C, E (also applicable to 3Bi, ii, v; 3Ci)
Purpose
Treatment decisions are guided by therapist beliefs, values, and preferences.
The following exercise is designed to help therapists identify and then use
client preferences to inform and enhance clinical decision making.

Tasks
Retrieve the schematic or blueprint you created for how to do therapy as
described on page 29 of BR and updated in Chapter 1 in the Field Guide
68 Swift, Owen, and Miller

(pp. 18–20). If exploring and accommodating client beliefs, values, and pref-
erences at the outset of care are not specifically mentioned, add them to your
map. Include a detailed description of what you talk over explicitly with your
clients and how.
Next, note the beliefs, values, and preferences reviewed in the research
section of this chapter that are not included in your map or usual way of
working. Using paper and pencil, word processing software, or your favorite
note-keeping app, write out how you would initiate a conversation with
clients about those particular values and beliefs. For example, if clients’ prior
treatment experience was not a topic you typically asked about or explored,
you would write out an initial question (i.e., “I would like to hear about your
past experiences, if any, in psychotherapy”), along with several ways to follow
up (i.e., “What went well?” “What didn’t go so well?” “On the basis of these
experiences, what would you want our work together to look like?”). With a
client who has no prior experience in psychotherapy, you could ask, “Before
coming in for our appointment today, did you have any thoughts about what
you would like to happen as we work together?” following up with, “Did you
have any worries about things I might do that you really do not want to be
a part of your treatment?”
Complete the exercise by considering how you will respond to challenges.
For example, write out what you would say in the event a client describes a
preference you cannot meet (e.g., meeting in a more informal setting, using a
treatment approach you are not trained to deliver or you believe to be contra-
indicated or even harmful). Develop and rehearse several concrete ways for
sharing your concerns while simultaneously building and maintaining a
collaborative working relationship. As a final step, role-play the responses you
develop with colleagues, reflecting on and making adjustments in response
to feedback.

Exercise 3: Approaching the Uncomfortable

Principle: 2
Applicability: TDPA Items 4C, E (also applicable to 5Ai, vii, 5Bi)
Purpose
Sometimes therapists struggle with talking about certain topics with their clients.
Whether due to apprehension about clients’ potential reactions, conflicts with
their own personal values or biases, or felt taboos related to certain topics
(e.g., money, politics, cultural differences, lack of progress in treatment),
the following exercise is designed to provide practice in approaching these
uncomfortable areas.

Tasks
As stated in Chapter 1, effective DP relies on “a data-derived identification of
‘what’ specifically each individual needs to target to improve their perfor-
mance” (p. 10). While you have already determined a focus on client factors
could prove beneficial to improving your results, taking time to gather some
 Client Factors 69

additional information can help in maximizing the effectiveness of exercises

related to becoming more skilled in handling uncomfortable conversations.
Borrowing from a suggestion in BR called the “black box exercise,” take a few
moments at the end of each workday to reflect on the clients you met. On a
sticky note or favorite note-keeping app, write down any instances where you
struggled with or avoided certain topics. For the sake of time and efficiency,
limit your description to a single instance no longer than a sentence or two of
“Twitter length.” After a month, review your notes, organizing the collection
into themes. Should one recur more often than others, make it the focus of
your DP. Alternately, among the themes that emerge, pick one you feel most
important or motivated to resolve. Begin with exploring why the topic might
be difficult for you. Write down your beliefs and assumptions as well as any
concerns you have regarding how clients might interpret you asking about
the topic. Next, return to the research review or recommended readings
section of the chapter to challenge your beliefs and assumptions and learn
new ways of inviting discussions. Set aside time outside the office to script
your inquiries and responses, using examples from your daily work. Practice
with a colleague. Depending on your comfort level, the partner can provide easy
responses or responses that play into your fears about how the client might
respond to the question or toward you for asking the question. After 5 minutes
of practice, spend another 5 minutes receiving feedback and discussing with
your partner how each question sounded.

Exercise 4: Embodiment of a Client

Principle: 3
Applicability: TDPA Item 4E (also applicable to 5Ai, ii, iii, iv, vii, 5Bi)
Purpose
In therapy, as in life, value conflicts and differences between people are
inevitable. This exercise is designed to help you recognize, understand, and
develop more effective strategies for honoring your clients’ values and opinions
in session.

Tasks
While writing out your progress notes at the end of the day, recall any client
with whom you experienced an explicit or implicit value conflict (e.g., politics,
religion, motivation, treatment goal). Close your eyes and picture them in
your mind. State your view of the conflict out loud, including your thoughts
and feelings, as well as why you believe the matter is bothering you so much.
Describe in as much detail as possible how the two of you are different from
one another. Next, rate your level of frustration with the individual (0 = no
frustration, 10 = extreme frustration).
Eyes open and paper or note-keeping app in hand, write down how your
client would describe the conflict. List the experiences or life circumstances
that might have led to their beliefs and values. Note how the client might feel
about having a conflict in this area with you (their therapist). Consider whether
70 Swift, Owen, and Miller

and how, despite any differences, specifically your and your client’s goals for
meeting are similar. If you struggle to articulate why they believe what they
do or how your goals are similar, write out two or three specific ways you will
make inquiries at the next visit. Finish by re-rating your level of frustration
with the client.
The entire process should take no more than 10 to 15 minutes. Revisit
the exercise over several days until a decrease in your frustration is observed.
At that point, make a plan for how you are going to approach this conflict in
the future with your clients. How will the topic be broached? How will you
express empathy and convey understanding?

Exercise 5: Allowing for Differences

Principle: 3
Applicability: TDPA Items 4C, E (also applicable to 5Ai, ii, iv, viii, 5Bi)
Purpose
The purpose of this exercise is to help therapists become more open to the
experiences of their clients. It will also aid in expressing empathy and under-
standing when conflicts occur in sessions. To complete it, you will need to
have access to audio or video recordings of your work.

Tasks
As part of your initial assessment and documentation, begin including a formal
request to record. Samples of informed consent documents are widely available
on the internet. Check to ensure whatever document you adopt meets local
and professional regulations regarding recording psychotherapy sessions.
No fancy equipment is required. If you have a mobile phone, you have access
to a high-quality recording device. Make recording your work the default for
all sessions.
At the end of the day, reflect on your meetings with clients, identifying
any times when you experienced a conflict, whether openly or internally.
Examples might be the reaction you had when a client informed you they had
not completed nor could remember the homework assignment, provided
you with negative feedback, expressed anger toward you, or shared what you
consider a derogatory belief (e.g., homophobic, racist, unnecessarily or inaccu-
rately critical of others or you). Save such recordings and delete the others.
Keep a log identifying the type of conflicts reflected in the recordings. Sort for
patterns, identifying the most frequent or bothersome.
Next, isolate the section on each recording during which the conflict comes
up. Listen and relisten, working purposefully to let go of any judgmental
thoughts and feelings. Once done, test your progress by moving on to the next
recording and repeating. As a final step, return to the first recording, consid-
ering how you responded in the moment. Stop the playback, first reflecting on
and then writing out two responses aimed at communicating understanding
and empathy.
 Client Factors 71

Exercise 6: Soliciting Feedback

Principle: 4
Applicability: TDPA Items 4B, C, F (also applicable to 5Aviii)
Purpose
Improve your comfort with and ability to solicit feedback from clients.

Tasks
Any of the client factors reviewed in the research section of this chapter may
be implicated in clients experiencing low levels of engagement or not making
progress in treatment, including (a) treatment preferences or expectations
not being met; (b) a lack of understanding of the treatment being provided;
(c) a mismatch between the therapy and the client’s relational style, identity,
values, or beliefs; (d) paucity of social support outside of psychotherapy; and
(e) a failure to recognize and reinforce changes in the client’s well-being that
may not be directly related to work or objectives in therapy. While some of
these may reflect a recurring pattern of mistakes on the part of the therapist,
many, as pointed out in BR, are random. “Psychotherapy,” Miller et al. (2020)
pointed out, “is cognitively demanding. Any given hour will, therefore, contain
myriad (a) ‘coulda, woulda, shouldas’ as well as (b) an untold number of
in-the-moment adjustments” (pp. 104–105). In such instances, improving
engagement and outcome depends on increasing therapist responsiveness—
doing the right thing at the right moment together with the client. Soliciting
feedback via the routine administration of standardized measures has proven
particularly helpful in this regard.
As a first step, retrieve the blueprint you created for how you do therapy
(described on p. 29 of BR and updated on pp. 18–20 in Chapter 1 of this
volume). If standardized measures are not included, add them to your map.
If you have not developed a script explaining how and why you are using
such scales, do so now. At the end of each day, reflect on how you discussed
the scores, noting any specific instances where you struggled to communicate
clearly or were tempted to forgo discussing the results (e.g., low alliance scores,
lack of progress or deterioration, running out of time). Pick one and imagine
how you could have addressed client feedback in the moment, committing at
least two alternative responses to paper.

Exercise 7: Getting Comfortable With Negative Feedback

Principle: 4
Applicability: TDPA Item 4F (also applicable to 5Ai, ii, iii, iv)
Purpose
For some therapists, receiving critical feedback is difficult. For others, the bigger
concern is how to respond most effectively in the moment. This exercise, to
be completed with a partner, is designed to increase both comfort and respon-
siveness to negative client feedback.
72 Swift, Owen, and Miller

Tasks
Take time to reflect on feedback you worry about receiving from clients.
It might be broad statements about your overall competence or statements
about specific skills or attributes. If you want to make the experience real,
first list values and beliefs you have about yourself, your identity, and your
work as a clinician (e.g., your effectiveness, skill level, openness, ability to
relate to others). Next, ask a trusted colleague to role-play a client who has
negative feedback to share based either on one of your specific worries or
adopting a perception of you in the feedback that runs counter to how you
see yourself. During the process, your job is to listen and reflect, not resolve
the feedback expressed by the client, continuing the role-play until they feel
understood by you. Pay attention to how you feel, repeating the activity at
regular intervals until you notice a significant increase in your level of comfort.
Should you end up feeling stuck or uncertain about what to do, consult the
relevant sections in the research review and additional resources sections of
this chapter.

FURTHER READINGS AND RESOURCES

This chapter reviewed available research, identified evidence-based principles,

and suggested DP exercises for working with client factors in psychotherapy.
Additional research and recommendations can be found in the following:

• Clinical implications and practice suggestions based on the research evi-

dence regarding client factors can be found in Constantino, M. J., Boswell,
J. F., & Coyne, A. E. (2021). Patient, therapist, and relational factors. In
M. Barkham, W. Lutz, & L. G. Castonguay (Eds.), Bergin and Garfield’s
handbook of psychotherapy and behavior change (7th ed., pp. 229–266). Wiley.

• A thorough review of practice recommendations specific to each of the

reviewed client factors along with case examples can be found in Norcross,
J. C., & Wampold, B. E. (Eds.). (2019). Psychotherapy relationships that work:
Volume 2. Evidence-based therapist responsiveness (3rd ed.). Oxford University
Press.

• An excellent guide for tailoring psychotherapy to the individual client is

Cooper, M., & McLeod, J. (2011). Pluralistic counselling and psychotherapy.
SAGE.

• A recently published resource for accommodating client preferences is

Norcross, J. C., & Cooper, M. (2021). Personalizing psychotherapy: Assessing
and accommodating patient preferences. American Psychological Association.

• A discussion of using these principles to encourage psychotherapy engage-

ment along with case examples can be found in Swift, J. K., & Greenberg,
R. P. (2015). Premature termination in psychotherapy: Strategies for engaging clients
and improving outcomes. American Psychological Association.
 Client Factors 73

• Specific evidence-based strategies for using client strengths and resources,

including chance-change producing events and pretreatment change, can
be found in Miller, S., Duncan, B., & Hubble, M. (1995). Escape from Babel:
Toward a unifying language for psychotherapy practice. Norton.

• Detailed instructions for incorporating routine outcome measurement into

clinical work is available in Prescott, D., Maeschalck, C., & Miller, S. (Eds.).
(2017). Feedback-informed treatment in clinical practice: Reaching for excellence.
American Psychological Association.

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4
Therapist Factors
Helene A. Nissen-Lie, Erkki Heinonen, and Jaime Delgadillo

The essence of therapy is embodied in the therapist.

—BRUCE E. WAMPOLD AND ZAC E. IMEL,
THE GREAT PSYCHOTHERAPY DEBATE

DECISION POINT

Begin here if you have read the book Better Results (BR) and

• are routinely measuring your performance and

• have collected sufficient data to establish a reliable, evidence-based profile
of your therapeutic effectiveness and
• have completed the Taxonomy of Deliberate Practice Activities in
Psychotherapy and
• need help developing deliberate practice exercises that leverage the thera-
pist’s contribution to outcome.

T o understand the effectiveness of treatment, mainstream psychotherapy

researchers have traditionally focused on investigating techniques or strat-
egies associated with specific schools of therapy (psychodynamic, cognitive
behavioral, and humanistic), often matched to client factors (e.g., diagnoses)
at the expense of understanding the impact of the provider of the treatment,
namely, the therapist (see Barkham & Lambert, 2021).

https://doi.org/10.1037/0000358-005
The Field Guide to Better Results: Evidence-Based Exercises to Improve Therapeutic Effectiveness,
S. D. Miller, D. Chow, S. Malins, and M. A. Hubble (Editors)
Copyright © 2023 by the American Psychological Association. All rights reserved.
79
80 Nissen-Lie, Heinonen, and Delgadillo

Over the years, many leading theorists have pointed to the crucial role
therapists play in the outcome of care. As early as the 1930s, Saul Rosenzweig
(1936) said,
It may be said that given a therapist who has an effective personality and who
consistently adheres in his treatment to a system of concepts which he has mastered
and which is in one significant way or another adapted to the problems of the
sick personality, then it is of comparatively little consequence what particular
method that therapist uses. (pp. 414–415)

In the late 1950s, another pioneer in the field, Carl Rogers (1957), proposed
that the positive effects of psychotherapy would crucially depend on the ability
of the therapist to meet their clients with empathy, unconditional positive
regard, and genuineness (i.e., congruence). In the 1960s, Jerome Frank pro-
posed a common factors model that emphasized the therapeutic alliance, the
fostering of hope, and the specific influence of the healer’s persuasiveness as
crucial factors that promote change (Frank, 1961; Frank & Frank, 1991).
While theoretical accounts of how clinicians influence the processes and
outcomes of therapy date back to the first half of the last century, it is only in
the last 30 years that researchers have explicitly focused on therapist effects
and their determinants (e.g., Baldwin & Imel, 2013; Barkham et al., 2017;
Crits-Christoph et al., 1991; Wampold & Owen, 2021).
One reason it took so much time to recognize the impact individual thera-
pists have on the effectiveness of treatment was the influence of the medical
model. Specific therapeutic interventions were seen as responsible for ther-
apeutic results. In The Great Psychotherapy Debate, Bruce Wampold (2001)
questioned the empirical support for thinking of psychological approaches
as analogs of medical treatments (see also Wampold & Imel, 2015). “On the
contrary,” he argued, “the scientific evidence overwhelmingly supports a model
of psychotherapy that gives primacy to the healing context” (p. xii). While
acknowledging therapist effects do not negate the importance of specific
interventions, psychotherapy, evidence shows, cannot be likened to drugs
that work independently of the provider (or the recipient, for that matter).
Rather, success depends on the therapist creating and maintaining engagement
in processes that often require significant effort on the part of the client: that
of changing habitual but dysfunctional ways of coping with life events, both
past and present.
The contextual understanding Wampold (2001) proposed included a grow­
­ing number of demonstrably effective factors relevant across different models
of psychotherapy, which are included in the Taxonomy of Deliberate Practice
Activities in Psychotherapy (TDPA; Chow & Miller, 2022; see Appendix A, this
volume)—the tool that informs the organization of this book. These empirically
supported domains include structure, hope, and expectancy; the therapeutic
relationship; client factors; and therapist factors. This chapter focuses on the last
of these factors, first reviewing studies documenting the therapist skills,
char­acteristics, and qualities associated with positive outcomes and then distilling
the research findings into a series of evidence-based principles. Consistent
 Therapist Factors 81

with other chapters, the findings and principles are operationalized in a series
of practical exercises clinicians can apply in their deliberate practice (DP) efforts
(Miller, Hubble, & Chow, 2020). Focusing on the therapist can, it must be
recognized, give rise to uncertainty and anxiety: Do I have what it takes?
Before proceeding, it might be comforting to know the findings point more to
an approach to practice, personal development, and clinical work rather than
a set of well-defined and stable traits.

REVIEW OF THE RESEARCH

Today, it is regarded as well-established

that individual therapists account for a
significant proportion of client outcomes
in psychotherapy. Referred to as therapist
effects (Baldwin & Imel, 2013; Wampold &
Owen, 2021), meta-analytic reviews show,
in both randomized controlled trials and
naturalistic studies, around 5% of the vari-
ance in client outcomes is attributable to
differences between practitioners (Baldwin
& Imel, 2013; Johns et al., 2019; Wampold
& Owen, 2021). Just how important is the
clinician? Given that treatment, in total,
explains about 14% of the difference in
outcome between clients, the contribution
made by the individual therapists can only be thought of as critical (Baldwin &
Imel, 2013)—accounting for about one third of the total variability in effect.
A few key studies can be used to demonstrate the importance of the
therapist. Okiishi et al. (2003), for example, found recovery rates of the most
effective therapists were twice those attained by the least helpful. Meanwhile,
analyses of routine practice data conducted by Saxon and Barkham (2012)
showed that 15% more clients recovered when seen by an “average” rather than
the least effective clinicians in their sample. The authors further showed the
variability in outcomes due to therapists was greater when clients’ pretreatment
clinical symptoms were more severe, indicating “who” provides treatment is
a critical consideration with more severe cases. Similar findings were reported
by Firth et al. (2015), whose research showed the more effective practitioners
(i.e., above average) achieved almost double the amount of change per session
compared with their “below average” counterparts. Here again, the difference
in outcomes between therapists was especially pronounced with the more
functionally impaired.
What can practitioners learn from such findings about achieving better
results? One key quality of the most effective therapists, it appears, is consistency.
Some studies have shown that therapists are consistent across outcome domains
82 Nissen-Lie, Heinonen, and Delgadillo

(Nissen-Lie et al., 2016), while other studies have demonstrated therapists are
not equally effective across client-presenting problems (e.g., Kraus et al., 2011)
or populations (e.g., racial or ethnic minorities; Hayes et al., 2016; Imel et al.,
2011; Owen et al., 2015). Similar inconsistencies were reported in a recent trial
by Constantino, Boswell, Coyne, et al. (2021), which also found that therapist
self-ratings were unrelated to their actual effectiveness with various client
subgroups and that clients did no better when they were seen by therapists
who perceived themselves as skilled in helping people with particular pre-
senting concerns.
After finding that clinicians who achieved similar results across clients were
also more effective, Owen and colleagues (2019) concluded any definition of
psychotherapeutic expertise needed to include consistency over time and within
caseload. Their study is notable for its large and diverse sample size, nearly
38,000 clients and over 800 therapists (see also Delgadillo et al., 2020; Nissen-
Lie et al., 2016; Wampold & Brown, 2005). Taken together with new research
documenting the existence of meaningful differences between therapists
in their client’s magnitude and rate of change early in therapists’ careers, the
evidence highlights the need for and potential utility of DP at the beginning
of professional training (Edmondstone et al., 2022).
In sum, numerous studies applying appropriate statistical methods (e.g.,
multilevel modeling) to large samples have established that therapists do differ
in their clinical effectiveness—to a degree that makes a substantial difference
in the lives of clients and the overall effectiveness of mental health services.
Hence, the most effective therapists are consistently effective over time, across
outcome domains, and across clients with diverse clinical and demographic

FIELD GUIDE TIP

Professional musicians work at

achieving consistency in their
performance using a simple tool:
a matchbox. While practicing, each
time they get the timing or technical
aspects of a particular stanza, chord,
or progression correct, one match is
removed from the box. If an error is
made along the way, all the matches
are returned, and the process starts
over. Practice of the targeted aspect
of the music is ended when the
matchbox is empty.
Consider how you might adapt or
integrate the “matchbox” method in
your deliberate practice.
 Therapist Factors 83

characteristics. By contrast, the majority (around 70%) of practitioners are not

significantly different from average, and their effectiveness across time, problem
types, and client groups is less stable.
The critical question is what findings about differences between therapists
means for training, supervision, and professional development. Like all people,
clinicians have some stable characteristics that are trait-like and shaped over
the life course. Others are state-like, more situational, and modifiable. Unfor-
tunately, at present, little research exists on whether or how such therapist
dispositions might be changed through focused and intensive training or, for
example, engagement in personal therapy—although a small number of studies
show both avenues to be promising (e.g., Anderson et al., 2016; Orlinsky &
Rønnestad, 2005; Ziede & Norcross, 2020).
Potentially relevant attributes may be related to clinicians’ lives outside of
therapy (i.e., attitudes, values, personality, interpersonal skills). Indeed, some
of these qualities measured before training predict clinical outcomes a year
later (see Anderson et al., 2016, and later in this section). Clearly, education
and training also shape relational manner and style; perceptual, conceptual, and
thinking skills; as well as expertise in carrying out particular techniques and
interventions (Knox & Hill, 2021). Curiously, the latter dominates most instruc-
tional textbooks and training courses despite “the person of the therapist”
being unavoidably intertwined with professional performance. This review
continues with both aspects, beginning with therapists’ professional charac-
teristics (i.e., those developed specifically for therapy work) and ending with
a summary of the personal qualities (i.e., those describing the therapist in
their overall life) associated with treatment outcome.

Therapists’ Professional Characteristics

Asked what qualifies someone to work as a psychotherapist, the average

layperson will likely cite professional training, licensure, and experience. As
reviewed in Chapter 1 of this field guide, a career in the field of mental health
requires a significant investment of time and money, college and graduate
school courses, thousands of hours of supervised practice, and passing a
licensing exam, to name but a few. And yet, various studies show professional
training and discipline (e.g., psychologist, nurse, social worker, professional
counselor, medical doctor) do not explain between-therapist differences in
effectiveness. Neither, it appears, do clinical qualifications, licensure, hours of
supervision, or specialization (see research reviews in Chapters 1, 5, and 7).
Also, as cited by practitioners and clients alike, clinical experience is not a
reliable predictor of better results (Beutler et al., 2004). In fact, an empirical
study found that therapist effectiveness may deteriorate over time (Goldberg,
Rousmaniere, et al., 2016; see Table 4.1 for a summary of the professional
qualities that do not make a difference). To this list of professional characteristics
with little, no, or mixed empirical support, Wampold and Owen (2021), in a
recent, comprehensive review of the literature for the Handbook of Psychotherapy
84 Nissen-Lie, Heinonen, and Delgadillo

TABLE 4.1. Professional Characteristics and Treatment Outcome

Professional characteristic Impact on outcome
Discipline No correlation
Theoretical orientation or integration No correlation
Licensure or certification No correlation
Supervision No correlation
Clinical experience No correlation
Adherence to treatment manuals Mixed evidence
Therapist rated specialization or skills No correlation
Rated competence Mixed evidence
Consistency in outcome Predictive
Empathic ability or responsiveness Predictive
Management of countertransference reactions Predictive
Facilitative interpersonal skills Predictive
Engagement in deliberate practice Promising

and Behavior Change, added theoretical orientation and integration, adherence

to treatment manuals, and rated competence (see also Webb et al., 2010), even
if some recent work points to the potential effects of therapeutic competence
in the delivery of therapeutic techniques on outcomes (Power et al., 2022).
Given the foregoing, what professional characteristics can a therapist focus
on and develop to become more effective? One hypothesis is that crude vari-
ables such as clinical experience or qualifications are poor proxy indicators of
therapeutic skillfulness. Another related possibility is that subtle yet discrete
interpersonal and attitudinal attributes may be more important than experi-
ence when it comes to helping clients.
With regard to the latter, consider research on therapists’ perceptions of
their skillfulness (e.g., self-confidence; see Heinonen & Nissen-Lie, 2020). In
contrast to what one might hope, multiple studies confirm a tendency among
 Therapist Factors 85

practitioners to overestimate their effectiveness (Chow et al., 2015; Walfish

et al., 2012). Ziem and Hoyer (2020) documented the consequences resulting
from the disconnect between therapist actual and perceived impact on client
functioning and well-being. Comparing therapists’ assessments of their clients’
progress with clients’ measured improvement, they found more modest or
conservative therapist estimations (relative to their clients’ actual improvement)
predicted larger reductions of clients’ symptoms and greater improvements in
quality of life.
At first, such findings appear to provide support for humility as an important
characteristic of effective therapists. Research findings on this construct are
mixed, however, with some studies reporting that therapists with higher pro-
fessional self-doubt (i.e., lacking confidence in their ability to be helpful, feeling
unsure about the best way to work with a given client) have better alliances
and outcomes (Nissen-Lie et al., 2010, 2013), with others showing no asso­
ciation (Delgadillo et al., 2022; Odyniec et al., 2019). A plausible interpretation
of these seemingly contradictory findings is that therapist doubt and humility are
not, in and of themselves, curative but rather dispositional traits that engender
other behaviors leading to greater client engagement and improvement. For
example, in two separate studies, Lutz et al. (2015) and de Jong et al. (2012)
found positive therapist attitudes toward client feedback regarding the process
and effectiveness of care predicted better outcomes. Clearly, a therapist who
is willing to accept that they may not be optimally knowledgeable or effective
will be motivated to learn and to improve.
Before moving on to therapist personal qualities, mention should be made
of one last professional characteristic associated with engagement and outcome
in psychotherapy: interpersonal skills. One, empathy, Rogers (1980) defined
as the ability “to perceive the internal frame of reference of another with
accuracy and with the emotional components and meanings which pertain
thereto as if one were the person” (p. 140). As noted by Norcross and Karpiak
(Chapter 5, this volume), “empathic responding is one of the strongest and
best supported contributors to psychotherapy outcome” (p. 112). Research
reveals it to be the quintessential transdiagnostic and transtheoretical skill. And
while therapist assessment of their empathic ability is not reliably associated
with actual, measured performance, a series of studies have shown the skill can
be improved via a combination of individualized, principle-based feedback
and DP (Chow et al., 2022; Miller et al., 2013).
A seminal paradigm for investigating interpersonal skills, known as the
Facilitative Interpersonal Skills (FIS) task, was developed by Timothy Anderson
and colleagues (https://www.fisresearch.com/research.html). In fact, the studies
of empathy just mentioned used a modified version of the FIS rating system.
Briefly, the task presents therapists with short video clips of challenging clinical
cases (e.g., a client angrily expressing severe disappointment with treatment or
strong avoidance and passivity) and records their immediate verbal responses.
In turn, independent raters score the responses along several dimensions,
encompassing verbal fluency, emotional expressiveness, persuasiveness, warmth,
86 Nissen-Lie, Heinonen, and Delgadillo

positive regard, hopefulness, empathy, and capacity to repair the working

relationship.
Performance on the FIS has been shown to predict treatment outcomes of
experienced clinicians of varying orientations, therapist trainees, and even
students from nontherapy-related fields who were told merely to “be helpful”
(Anderson et al., 2009, 2016). Consistent with the findings on professional
discipline, training status (i.e., whether one was learning to be a therapist,
biologist, chemist, or historian) does not predict performance on the FIS.
Confidence in the importance of interpersonal skills is bolstered by results
from two additional prospective studies, documenting their ability to predict
therapist effectiveness over a 5-year period, even after controlling for myriad
therapist (e.g., gender, theoretical orientation, amount of supervision) and client
(age, gender, diagnosis, severity, presence of personality disorder) characteristics
(Anderson et al., 2016; Schöttke et al., 2017).
Interestingly, experiencing the types of interpersonal challenges reflected
on the FIS may be fundamental to the development of personal qualities that
matter in effective therapy, such as self-control, emotional containment, and
empathy. A recent meta-analysis of 36 studies, for example, found that negative
behavioral, cognitive, somatic, and affective therapist reactions toward the
client or work are moderately and inversely related to the outcome. Not
surprisingly, perhaps, managing such reactions was associated with better results
(Hayes et al., 2018).
No section on professional characteristics would be complete without
mention of DP. Of course, this entire field guide is devoted to the subject.
Despite growing interest and popularity, use of the term in relation to the
development of psychotherapists is of recent origin. As reported in Chapter 1,
DP was first introduced in a 2007 article by Miller, Hubble, and Duncan to
account for therapists who were consistently and significantly more effective
than others (Okiishi et al., 2003; Ricks, 1974). The earliest empirical investi-
gation of the role of DP in the performance of highly effective therapists was
carried out by Chow et al. (2015). Consistent with the broader literature on
therapist effects, the study involving 69 practitioners and 4,580 clients found
(a) clinicians contributed 5.1% to the variance in treatment outcomes, and
(b) their age, gender, or caseload were not significant predictors of outcome
(see Johns et al., 2019). The main focus of the study, however, was on a subset
of the group (17 therapists, 1,632 clients) who completed a measure specifi-
cally designed to capture the nature, extent, and time spent in DP activities.
Analyses showed that the most effective practitioners devoted 2.8 times more
time than their less effective counterparts and 14 times more than those whose
outcomes placed them at the bottom of the sample’s distribution.
Since the publication of Chow et al. (2015), several prospective studies have
appeared in the literature (Di Bartolomeo et al., 2021; Hill et al., 2020; Shukla
et al., 2021; Westra et al., 2021). Unfortunately, they fail to meet the four
empirically established criteria to qualify as a bona fide instance of DP (i.e.,
an assessment of the performer’s baseline ability or skill level against which
progress can be determined, corrective feedback targeted to the individual’s
 Therapist Factors 87

execution of skills being learned, development of a plan for successive refine-

ment over time, and guidance provided by an expert coach or teacher; Chow
et al., 2015; Ericsson & Lehmann, 1996; Miller et al., 2017, 2018). Accordingly,
such studies are best regarded as examples of what Ericsson, the researcher
who coined the term deliberate practice and conducted the seminal research
on the topic, would characterize as “purposeful practice”—repetition aimed
at achieving proficiency with a particular skill as opposed to an ongoing process
of reaching for performance objectives just beyond an individual’s current ability
(Ericsson, 2016).
There are two exceptions to this. First, a naturalistic study of routine out-
come monitoring, feedback, and DP involving more than 5,000 clients and
150 therapists showed small but statistically significant growth in individual
clinician effectiveness over time (Goldberg, Babins-Wagner, et al. 2016). Accord-
ing to the authors, the improvement was consistent with findings from the
broader DP literature, “highlighting the potentially large cumulative effect of
small changes accrued over time” (p. 372). The second, by Chow and colleagues
(2022), is the only randomized controlled trial including all four DP compo-
nents. Designed with guidance and direction from K. Anders Ericsson, the
researchers found that therapists employing DP strategies tailored to their
specific interpersonal skill deficits not only improved significantly compared
with controls (62% vs. 15% gains, respectively), but they also reported that
they successfully transferred their newly acquired abilities to different clients,
contexts, and clinical themes. By comparison, the control group as a whole—
which was instructed to reflect and try to improve on their interpersonal
performance scores—did not change appreciably over the course of the study.
Importantly, what remains to be documented in future studies is a connection
between DP-related skill improvements and gains in outcome at the individual
therapist level.
In sum, while promising, much remains unknown about the application
of DP to the professional development of psychotherapists. What are the appro-
priate or most amenable targets (e.g., models, techniques, common contributors
to outcome)? How can one best measure the impact (e.g., proximal vs. distal
indicators, skill acquisition vs. improvement in treatment outcome, continuous
improvement, or proficiency; Miller, Madsen, & Hubble, 2020)? Finally, what
role might therapist effects play in the adoption and implementation of DP?
Research has already established, for example, that feedback—an essential
component of process—is moderated by therapist variables (de Jong et al.,
2012). Some of these questions will hopefully be answered as practitioners and
researchers investigate, apply, and refine the findings, principles, and exercises
recommended in this field guide.

Therapists’ Personal Characteristics

Attention is now turned to personal characteristics of therapists—who they are

in their private or nonprofessional life, recognizing that distinguishing between
the two is sometimes difficult. Myriad qualities could be considered, including
values and attitudes, personality, genetic endowment, number of siblings in the
88 Nissen-Lie, Heinonen, and Delgadillo

family of origin, current level of well-being, quality of life, and job satisfaction,
to name but a few. However, this review is limited to the characteristics that
have been the subject of research.
To begin, the impacts of several of what might best be labeled “immutable”
therapist characteristics have been investigated and found not to contribute
to differences in outcome. These characteristics include age, gender, ethnicity,
personality constellation, reflective ability, and self-reported social skills (Knox
& Hill, 2021). Other more transitory qualities can be added to the list. For
example, therapists’ self-reported interpersonal problems do not appear to pre-
dict their clients’ outcomes. Consider the results of a study of over 4,000 clini-
cians by Heinonen and Orlinsky (2013), which found, across the board, that
mental health professionals judged themselves to be less accepting and tolerant
and more critical and demanding in their personal relationships than those
with clients. Alas, correspondence between functioning in the personal and
professional spheres is not a prerequisite for effectiveness. In their lives outside
the consulting room, therapists experience many of the same struggles and
pursue many of the same satisfactions for their emotional needs as clients—
even if they are trained to put aside those needs in their therapeutic work.
Much attention has been directed to the subject of occupational burnout.
Recent evidence indicates that 50% or more of mental health professionals are
experiencing moderate levels of emotional exhaustion, depersonalization, and
reductions in their sense of accomplishment (Morse et al., 2012; Simionato &
Simpson, 2018; Summers et al., 2020). Most—including therapists—would
expect such feelings to impact effectiveness negatively. And yet, the evidence
is mixed. One large-scale study, for example, found that burnout (specifically
disengagement—i.e., increased mental distance from work—but not exhaustion—
i.e., drained, overwhelmed, unable to keep up) and low job satisfaction were
associated with poorer treatment outcomes (Delgadillo et al., 2018). However,
a more recent investigation conducted in a similar setting found no significant
association (Delgadillo et al., 2022).
Given the conflicting results, it is not possible to draw firm conclusions about
burnout and client outcomes. However, the research evidence as a whole lends
itself to the idea that staying engaged in learning and growing and taking on
challenges as a therapist might be beneficial. In a review on the subject, Miller
et al. (2015) reported that highly effective therapists experienced lower rates
of burnout than average and less effective practitioners. Interestingly, the best
therapists also rated healing involvement (Orlinsky & Rønnestad, 2005)—the felt
sense of being deeply connected to clients—and engagement in traditional self-
care practices as less important to their work and identity than a focus on results.
In relation to self-care, survey data indicate that therapists generally feel per-
sonal therapy is highly influential in their work (Orlinsky et al., 2005). As is true
of many of the professional characteristics reviewed here, little empirical evidence
exists for an association between personal therapy and performance. Some have
suggested experiential practices such as mindfulness activities and self-reflection
(Bennett-Levy, 2019) may be helpful for sustaining a career that is emotionally
and personally demanding. Notwithstanding, strong support for such practices in
terms of measurable outcomes for clients or therapists is thus far lacking.
 Therapist Factors 89

In terms of other personal qualities, studies have also examined a handful

of contemporary concepts. As a predictor of outcome, for example, therapist
mindfulness has received mixed results (Hunt et al., 2021; Ivanovic et al.,
2015; Pereira et al., 2017; Ryan et al., 2012). Emotional intelligence (EI) has
been explored in two investigations. In a small pilot study conducted by
Kaplowitz et al. (2011), therapists with higher ratings of EI achieved better
therapist-rated outcome results and lower dropout rates compared with ther-
apists with lower ratings of EI. A later, larger study of therapist trainees explored
EI in relation to various personality characteristics (e.g., neuroticism, extra-
version, openness, agreeableness, and conscientiousness), reporting that the
combination of high levels of trainee EI and neuroticism accounted for 46% of
the variance in client outcomes (Rieck & Callahan, 2013). While the authors
concluded, “EI could be used in determining trainee needs and associated
development activities” (Rieck & Callahan, 2013, p. 48), a search of the litera-
ture revealed no further publications on the subject.
While investigations of therapists’ personal characteristics are few and far
between, several have found their impact on outcome varies depending on
other client or therapist qualities. So, for instance, while research has generally
failed to establish a relationship between outcome and a secure attachment
style of the therapist (Petrowski et al., 2011), studies do show such attachment
predicts better results for clients with more severe problems (Schauenburg
et al., 2010). Similar patterns have been observed in examinations of reflective
functioning, defined as “the capacity to understand ourselves and others in
terms of intentional mental states, such as feelings, desires, wishes, goals and
attitudes” (Luyten & Fonagy, 2015, p. 366). To wit, in terms of outcome, higher
reflective functioning can compensate for a therapist’s attachment-related
vulnerabilities and vice versa (i.e., a secure attachment style for deficits in their
reflective functioning; Cologon et al., 2017).
In summary, despite an abundance of theory on therapists’ personal features,
strengths, resources, difficulties, and vulnerabilities, the scientific evidence to
date has not yielded replicated support for associations between such features
and clinical outcomes (see Table 4.2).

TABLE 4.2. Personal Characteristics and Treatment Outcome

Personal characteristic Impact on outcome
Age No correlation
Gender No correlation
Ethnicity No correlation
Personal therapy Little or no evidence of correlation
Big Five personality characteristics Limited or mixed evidence
Reflective functioning or ability Promising
Self-reported social skills No correlation
Therapist reported interpersonal problems No correlation
Attachment style Mixed
Mindfulness Mixed
Burnout Mixed
Emotional intelligence Limited evidence
90 Nissen-Lie, Heinonen, and Delgadillo

EVIDENCE-BASED PRINCIPLES RELATED TO THERAPIST FACTORS

According to the evidence base summarized in the preceding sections, three

principles for DP are most clearly indicated: (a) When in doubt, focus on
core interpersonal skills; (b) whatever your model or theoretical approach, be
flexible and responsive; and (c) maintain an attitude of humility that supports
a willingness to learn and improve. A framework for representing the inter-
relationships between these three principles and supporting resources is
presented in Figure 4.1.

Principle 1: When in Doubt, Focus on Improving Core

Interpersonal Skills

Interpersonal qualities, such as empathy, warmth, and effective communication

skills, are the therapist-level characteristics with the most predictive value in
terms of positively influencing client outcomes (Heinonen & Nissen-Lie, 2020;
Wampold & Owen, 2021). Available evidence shows such skills are trainable
(e.g., Anderson et al., 2016). Relatedly, the capacity to tolerate and manage
strong negative affect in therapy and stay focused on the emotional state of
the client has proven particularly effective when treating clients with higher
levels of distress (Heinonen & Nissen-Lie, 2020).
Note that skills and abilities in this
area take place at both an external (or
expressed) and internal (awareness) level.
To function optimally, clinicians need a
capacity for bifurcated attention, being
aware of both the client’s and their own
emotional state, containing or regulating any natural but countertherapeutic
reactions and responses (see Hayes & Vinca, 2017). Noticing how the client
responds to the therapist’s interventions—for example, when an empathic
and warm response is experienced as intrusive for a client (regardless of what
was intended) and evokes withdrawal—offers the opportunity to change tack
and initiate repairs. Figure 4.1 displays the relationship between (a) aware-
ness of one’s own inner state and countertransference management skills and
(b) reflective, perspective taking skills, with both providing essential support for
core interpersonal skills (see arrows). It is important to remember that such
capacities, research shows, are not gained once and for all. To move beyond
mere proficiency, constant work is required across the stages that make up a
therapist’s career.

Principle 2: Whatever Your Model or Theoretical Approach, Be Flexible

and Responsive

Accumulated knowledge in the realm of therapist-level effectiveness indicates

that flexibility and responsiveness—adjusting interventions and interactional
 Therapist Factors 91

FIGURE 4.1. A Framework for Evidence-Based Principles Related to

Therapist Factors

1. Interpersonal skills (a) Awareness of

(FIS) one’s own inner
Conveying accurate state and
empathy, sensitivity, countertransference
communication skills, management
verbal fluency, focus
on client, etc.
2. Flexibility/
responsiveness
-ability to regulate
response; flexibly
use a range of
intervention
modes 3. Humility
-willingness to be (b) Reflective
wrong and to functioning,
correct one’s perspective
interventions and taking
mode

style to the individual client and situation—are key (Constantino et al., 2020;
Power et al., 2022; Silberschatz, 2017). Indeed, Stiles and Horvath (2017)
argued convincingly, “Certain therapists are more effective than others . . .
because [they are] appropriately responsive . . . providing each client with a
different, individually tailored treatment” (p. 71).
Over the years, several studies and reviews have indicated that rigid adher-
ence to a model or protocol may hinder the accommodation and tailoring
required for working effectively with a given client (see Castonguay et al., 1996;
Constantino, Boswell, & Coyne, 2021). Moreover, Owen and Hilsenroth (2014)
found that the flexibility therapists demonstrate in the use of techniques
within a given treatment—in this case, psychodynamic psychotherapy—was
positively related to client improvement. Extending such results, Katz et al.
(2019) showed that responding to individual clients by integrating principles
from different methods rather than adhering to a set of prescribed principles
of one model was also beneficial.
Appropriate responsiveness is defined as “behavior that is affected by emerging
context, including others’ behavior” (Stiles, 2009, p. 87) and should be consid-
ered a prerequisite for technical interventions that are useful to the client (see
Hatcher, 2015; Stiles & Horvath, 2017). For the therapist, it may be thought of
as a metacompetency, tying together a number of lower order skills and capabil-
ities, such as executive functioning, reflection, and interpersonal competencies
(Hatcher, 2015). In practical terms, while it might seem difficult to operationalize
the concept, a recent metasynthesis of mainly qualitative studies of therapist
responsiveness by Wu and Levitt (2020) identified several practical ways
92 Nissen-Lie, Heinonen, and Delgadillo

therapists could flexibly accommodate their clients, including timing of inter-

ventions, affective attunement, attending to underlying relational needs (espe-
cially in cases of alliance ruptures or tension), and altering treatment structure
and interventions. Turning to specific examples, therapists could check in
with the client on a regular basis, be on the lookout for client signals indicating
readiness for insight and interpretations, prioritize responding to in-session
emotions, as well as employ more directive interventions. In the exercise section
that follows, several suggestions are given for DP activities designed to pro-
mote flexibility in tailoring one’s clinical work to the individual client.

Principle 3: Maintain an Attitude of Humility Supportive of a

Willingness to Learn and Improve

In their work and professional development efforts, effective therapists do

not avoid conflict or challenging moments. They are open to feedback, seek
support from colleagues, and are aware of the demanding nature of psycho-
therapy. Humility about one’s abilities and effectiveness is not indicative of
nor synonymous with performance anxiety or crippling self-doubt; rather,
it is a resource that enables therapists to stay alert and remain open to adapting
the work to the client. It means truly accepting room always exists for growth
and pushing beyond one’s current skill level, all the while taking care of oneself,
including seeking the support needed both personally and professionally to
stay on that path.
As Figure 4.1 indicates, humility likely represents the condition (hence the
arrows) necessary for the other skills and resources. Without it, the motivation
and willingness to learn and improve dissipates. Once more, humility is not
about thinking, “I do not know what I’m doing” but rather being open to
disconfirming evidence (see Macdonald & Mellor-Clark, 2014; Nissen-Lie
et al., 2017). “Could I be wrong?” is a question that opens the door to the devel-
opment of expertise. On this score, most practitioners report the process of DP
described in the pages of BR and this field guide—which emphasizes routinely
monitoring the outcome of their work and focusing on one’s performance
deficits—helps engender that mindset. In the next section, additional sugges-
tions in the way of exercises are provided.

EXERCISES FOR THERAPIST FACTOR SKILL DEVELOPMENT

It is often said, “practice makes perfect”; however, that is not necessarily true—
practice often simply reinforces habits. Choosing how you practice is, therefore,
critical. No benefit accrues from engaging in exercises unrelated to your
specific pattern of clinical strengths and deficits. To be effective, your DP efforts
must be focused on helping you reach for performance objectives just beyond
your present abilities. For this reason, before reviewing the following exercises,
ensure you have taken all the steps outlined in the decision tree presented
 Therapist Factors 93

FIELD GUIDE TIP

On the bank of a river, there stood a tall and strong oak tree near to some
reeds. The oak tree was proud of its strength and size. He often used to
make fun of the weak and slender reeds.
One day, as a wind started blowing, the oak tree, as usual, said
mockingly, “Oh! Reeds you move to and fro even with the slightest breeze.”
The reeds kept quiet and continued to sway back and forth. “Look at me.
I am so strong and mighty. Nothing can uproot me or bend me” boasted
the oak tree.
The wind got furious and turned into a hurricane. The little reeds
prevented themselves from getting uprooted by bowing their heads and
swaying with the rhythm of the wind. But the oak tree which stood straight
and tried fighting the hurricane wind was soon uprooted and thrown into
the river.

at the start of this chapter. It is assumed you (a) are routinely measuring
your performance; (b) have collected sufficient data to establish a reliable,
evidence-based profile of your therapeutic effectiveness; (c) completed the
TDPA; (d) determined a deficit exists in your performance related to the oper-
ation of therapist factors; (e) narrowed your focus to a single element within
this domain on the TDPA; and (f) defined that performance improvement
objective in SMART terms (specific, measurable, achievable, relevant, and time
bound). Next, review the suggested exercises, looking for the one that aligns
most closely with your goal.
As you will see, a theme runs through the recommended activities. All are
organized around the relationships between the evidence-based principles
identified from our review of the research as represented in Figure 4.1. This
means, for example, applying the various principles (e.g., interpersonal skills,
94 Nissen-Lie, Heinonen, and Delgadillo

flexibility, responsiveness, humility) in role-play and supervision while simul-

taneously noting how we feel and actively managing our reactions. Expanding
and rehearsing a range of different responses will also prove useful—all the
time working at being open and responsive to feedback from the client. Little of
the improvement we hope for as therapists comes quickly. Commit to the
“long game,” setting aside the time to reflect and mentally review your work
(Bennett-Levy, 2019). This requires personal reflection and then purposeful
action in repetitive practice. As a role model, Miller et al. (2018) offered the
example of Pablo Casals, the renowned cellist, who, when questioned as to why
even in his later years he practiced for hours each day, responded, “I think
I am beginning to show some improvement.” Keep in mind that the objective
is not perfection, but rather continuous refinement, always being willing to
learn and adjust in service of delivering better therapy to clients.

Exercise 1: Who Are You?

Principle: 1
Applicability: TDPA Items 5Ai-iv (also applicable to 3Bi, ii, v, vii,
Di-iv, 4B, C, D)
Purpose
As reviewed in detail in BR, time and experience within a particular perfor-
mance domain (e.g., psychotherapy therapy?) lead to the development of
“automaticity.” While this process enables us to act without having to think
through each step we take, the bad news is we lose conscious control over the
behaviors mastered. Miller, Hubble, and Chow (2020) observed, “Purposefully
counteracting . . . automaticity . . . is at the heart of DP” (p. 28). This exercise
is aimed at increasing self-awareness of those automated elements in your
interpersonal style and interactions so they can, if needed, be altered.

Task
Part 1. At the end of each day spent meeting with clients, take a few moments
to reflect on those sessions you experienced as challenging. With paper and
pencil or using your favorite note-keeping software, list the names of the
clients, a few identifying characteristics, your “gut” reaction at the time, and
your interpersonal response. With regard to the latter, consider the domains
on the FIS assessment (e.g., verbal fluency, emotional expressiveness, persua-
siveness, warmth, positive regard, hopefulness, empathy, capacity to repair
the relationship), rating yourself using a simple Likert rating from 1 to 5.
Limit yourself to 20 minutes.

Part 2. After a month, turn your attention to reviewing the information you
have gathered, again spending no more than 20 minutes at a time.

• What were your gut reactions?

• What did you feel “pulled” to do with particular clients or situations?
 Therapist Factors 95

• What, if any, themes and similarities are present (e.g., types of clients,
issues, interactions, your responses) across the various sessions described?
• Which aspects of your interpersonal skills suffered the most?

It is important not to rush the process. So, in the time between the moments
spent reflecting on your data, resist the temptation to arrive at a firm conclusion.
Be mindful, not obsessed with figuring out what to do. Researchers believe
that mulling over ideas at length “in the back our minds” has two potential
benefits. First, it allows us to make deeper, more nuanced connections between
experiences and ideas that, in turn, increase the possibilities for creative action.
Second, it influences current behavior, in effect priming us to look for opportu-
nities to act in ways consistent with what we are hoping but presently unable
to achieve (e.g., more empathic, less reactive; Wiseman, 2004).

Exercise 2: Civilizing Social Media (or at least trying)

Principle: 1, 3
Applicability: TDPA Items 5Ai-v, viii, 5Bi (also applicable to 3Bi, ii,
iv–vi, Di, ii, iv, 4E)
Purpose
Over a relatively brief period, social media have come to occupy a central
place in human interactions. Almost half of the world’s population is online—
3.5 billion people. Two thirds of those use one or more platforms on a regular
basis (Ortiz-Ospina, 2019). People get their news, stay in touch with friends
and family, connect with like-minded people, watch entertaining videos, and
explore their interests. They also argue and fight. In fact, a recent Yale University
study found that the algorithms that drive content and connections across
various sites actually teach users to engage in more hostile and uncivil exchanges
(Hathaway, 2021). The frequent occurrence of difficult interactions on these
platforms—and the opportunity to reflect for a longer time before responding
than would be possible in a real therapeutic interaction—make them the perfect
place to practice the types of interpersonal skills associated with effective
clinical work.

Task
If you haven’t already done so, take some time to familiarize yourself with the
literature on interpersonal skills, particularly emotional expressiveness, persua-
siveness, warmth, verbal fluency, positive regard, hopefulness, empathy, and
capacity to repair the working relationship. Once done, write out your personal
definition of each as well as several recent instances of their use in interactions
with clients.
Next, open your favorite social media app and join a conversation that is
either heated or in which the participants are in total agreement with one
another. Join in the exchange, mindfully and purposefully using facilitative
interpersonal skills to improve engagement openness and civility. Because
96 Nissen-Lie, Heinonen, and Delgadillo

awareness of your inner state and reactions is critical to responding effectively,

take time to reflect before replying to any post or comment made by others.
What, if any, feelings are you experiencing? Why? And how do you manage
them in the service of maintaining and improving the conversation? Finally,
revisit the exchange several times during the week, noting what did and did not
work. Regarding the latter, imagine alternate ways you might have responded.
Look for any opportunities where you might have been more humble or open
to disconfirmation. Continue the exercise indefinitely, slowly ratcheting up
the difficulty by seeking out exchanges that are increasingly challenging to
your personal beliefs or values.

Exercise 3: Teaching to the Therapeutic Test

Principle: 1, 2
Applicability: TDPA Items 5Aiv, vii, viii (also applicable to 3Bi-iii,
v, vi, 3Di, ii)
Purpose
You have likely heard the expression “teaching to the test.” This exercise is a
variation of that widely discouraged and discredited pedagogical approach!
Instead of teaching you to regurgitate the answer you need to improve your
performance on a test, this exercise—like all good teaching—is designed to
deepen your understanding and use of particular skills. Its origin can be traced
to clinicians routinely monitoring their performance with an outcome and
alliance scale. Although administered and discussed at the beginning and end of
each visit, many reported the tools began to subtly influence how they worked
during the session. In short, mindful of what clients were being asked to rate,
therapists began “doing therapy to the test.” Knowing their client would be
asked at the end of the visit to rate the degree to which they felt “heard, under-
stood, and respected,” for example, encouraged them to reflect on and adjust
their responses throughout.

Task
First, open your copy of BR and reread Chapter 14, “Designing a System of
Deliberate Practice.” Second, before each session, quickly review the questions
on whatever alliance tool you routinely administer at the end of each visit
(e.g., Session Rating Scale; Miller, Duncan, & Johnson, 2000). Even if you
have been using the tool for some time and are familiar with its content, don’t
skip this step. Alternately, write or type out your personal definition of each of
the core facilitative interpersonal skills reviewed in this chapter (e.g., emotional
expressiveness, persuasiveness, warmth, verbal fluency, positive regard, hope-
fulness, empathy). Next, pick one to review at the beginning of each session.
Importantly, whichever avenue you choose, do not will yourself or make a
conscious effort to change what you do in session. Continue with a singular
focus on that one interpersonal skill or alliance domain for at least a week.
 Therapist Factors 97

Third, and finally, the signal you have completed the exercise successfully and
can move on to the next can be found at the end of the Exercises section and
before Further Reading (see p. 99).

Exercise 4: Seeing Red

Principle: 2
Applicability: TDPA Items 5Ai, ii, iv (also applicable to 1E, F, J, 2D, 4C)
Purpose
Research shows that therapists are not as responsive and flexible with clients
who are not progressing or deteriorating in their care. In an analysis of what
therapists did in response to such feedback, Lutz (2014) found adjustments in
therapeutic interventions were made in less than 30% of cases. In slightly
more than 5%, alterations to frequency or intensity and consultations with
additional sources of help (e.g., supervision, continuing education, literature
review) were made. Clearly, the tendency to “stay the course” is strong. Devel-
oping a framework for knowing when and exactly what to do can improve
flexibility and responsiveness.

Task
Begin by identifying all completed cases that ended without making progress or
dropped out of care. The process is easy if you are using one of the electronic
outcome management systems discussed in BR (Miller, Hubble, & Chow, 2020).
Simply look for clients who ended services in the red zone. It is still possible
to do this exercise if you are limited to paper and pencil but just a bit more
work. The “Reliable and Clinically Significant Change” chart on page 175 of BR
(Appendix A) can be used to separate your successful from unsuccessful cases.
Recall, on average, between 24% and 36% of any given therapist’s clients
end treatment without experiencing a reliable or clinically significant improve-
ment in their well-being or functioning (see Chapter 8 in BR). Randomly
select 10 such cases, setting aside no more than 30 minutes two or three times
a week for in-depth review and analysis. Next, choose one, and with the graph
of their outcome scores and your case notes in hand, note the first instance
the client was at risk for a negative or null outcome (e.g., entered the red zone,
no progress from the prior visit, low or decreasing alliance scores) and what
you did in response. For example, did you discuss the results with the client?
Adjust your style, approach, interpersonal stance, or dose? Were additional
resources suggested, arranged, or consulted? If not, why? If yes, did the client
report improvement at the following visit? If not, why? Was it the timing
(too much too soon or too little too late)? After exhausting your initial cases,
continue the process until a decision tree encompassing the timing of and
options for enhanced responsiveness to nonprogressing and “at-risk” clients
begins to take shape. Conclude by integrating it into your blueprint (see p. 29
in BR and pp. 18–20 in Chapter 1 of this volume).
98 Nissen-Lie, Heinonen, and Delgadillo

Exercise 5: Regulating Your Inner Thermometer

Principle: 1
Applicability: TDPA Item 5Ai, ii, iv (also applicable to 3Bi, ii, Di-iv 4C)
Purpose
In the practice of Zen, thoughts and emotions
are often compared with wind and clouds.
They are in constant motion, moving in and
out—at times resulting in captivating shapes
and scenes and, during others, signaling a
storm and the need to take shelter. All are
transitory. Enter the terms cloud and Zen into
your favorite search engine, and 20 million
hits are returned. The advice offered is strik-
ingly similar across the links: watch and do
nothing. Thoughts and emotions, the teachers
counsel, are not the thinker or person emoting.
So, let them float by. No judgment. No con-
necting. No interpretation. As paradoxical as it
may sound, treating thoughts and emotions
impersonally—as nothing more than shifting
weather patterns—heightens our ability to
learn about and better manage our internal
world. According to Jon Kabat-Zinn (2019), it
enables us to “[make] use of thought and
emotion without being caught and imprisoned by unwise and unexamined
habit patterns developed over a lifetime” (para. 13).
Doing therapy provokes a wide range of thoughts and emotions. First,
there are the feelings and experiences of clients, their hurt, sorrow, fear, anger,
guilt, and so on. Second are the thoughts, feelings, and experiences of the
therapist—the empathy they feel for those they work with, the joy, frustration,
excitement, boredom, discouragement, occasional disgust, and other, some-
times inexplicable, reactions that arise in response to a particular client or their
story. As noted in the review of therapist professional characteristics, negative
behavioral, cognitive, somatic, and affective reactions toward the client or work
are inversely related to the outcome. In short, the greater their number, the
less effective the therapy. This exercise is designed to foster awareness and
better management of such reactions.

Task
At the end of every few days spent working with clients, reflect on any with
whom you experienced a negative cognitive, somatic, and affective reac-
tion. Using a Post-it® note or your favorite note-keeping app, choose one and
make a note, listing what you thought or felt, any accompanying physical
sensations and their location (e.g., chest, gut, head). As kids are fond of doing
with clouds, next, give your reaction a name—maybe the shape or location
 Therapist Factors 99

where it was felt, a person it reminds you of, or a memory. Whether you call
it sharp, dull, dog, fish, mountain, stomach, or Bob, do so quickly, without
perseverating or looking for hidden meaning. Next, set what you have written
aside and spend 5 to 10 minutes quietly and uninterruptedly doing nothing.
Whatever happens next, however interesting, foreboding, frightening, or
stimulating it may seem, let it pass by like clouds in the sky.
After a month, review your notes, looking for and sorting into patterns.
Pay attention to those that recur and elicit the strongest or most disruptive
reaction. After refreshing your memory of the particulars, repeat the activity
described in the previous paragraph, devoting 5 to 10 minutes to private medi-
tation. You will know progress is being made when you are able to notice
quickly but not become absorbed or distracted when “Bob,” “sharp,” or “moun-
tain” appears.

Exercise 3 Redux: Teaching to the Therapeutic Test

Consistent with the “Playful Experimentations” dimension of the DP frame-

work, you have successfully completed the first round of this exercise if and
when you spontaneously notice instances of the alliance domain or inter­
personal skill you are striving to be mindful of in therapy in activities and
experiences outside the consulting room (e.g., conversations with family, friends,
and colleagues while watching a TV series or movie, in exchanges on social
media). If you have not, continue with the same focus for another week.

FURTHER READINGS AND RESOURCES

This chapter reviewed available research, identified evidence-based princi-

ples, and suggested DP exercises for working with therapist factors in psycho-
therapy. Additional research and recommendations can be found in the
following:

• The Facilitative Interpersonal Skills (FIS) inventory is a well-validated mea-

sure for assessing and improving interpersonal skills. It is available at https://
www.fisresearch.com.

• Heinonen, E., & Nissen-Lie, H. (2020). The professional and personal char-
acteristics of effective psychotherapists: A systematic review. Psychotherapy
Research, 30(4), 417–432. https://doi.org/10.1080/10503307.2019.1620366

• Castonguay, L. G., & Hill, C. E. (2017). How and why are some therapists better
than others? Understanding therapist effects. American Psychological Association.
https://doi.org/10.1037/0000034-000

• Wampold, B. E., & Owen, J. (2021). Therapist effects: History, methods,

magnitude, and characteristics of effective therapists. In L. G. Castonguay,
M. Barkham, & W. Lutz (Eds.), Bergin and Garfield’s handbook of psychotherapy
and behavior change (7th ed., pp. 301–330). Wiley.
100 Nissen-Lie, Heinonen, and Delgadillo

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5
Relationship Factors
John C. Norcross and Christie P. Karpiak

We are born in relationship, we are wounded in relationship, and we can be healed in

relationship.
—HARVILLE HENDRIX, GETTING THE LOVE YOU WANT

DECISION POINT

Begin here if you have read the book Better Results and

• are routinely measuring your performance and

• have collected sufficient data to establish a reliable, evidence-based profile
of your therapeutic effectiveness and
• have completed the Taxonomy of Deliberate Practice Activities in
Psychotherapy and
• need help developing deliberate practice exercises related to relationship
factors.

S econd only to the client’s contribution, the psychotherapy relationship is the

most important predictor of, and contributor to, outcome. The relation-
ship constitutes the heart and soul of psychotherapy, healing in and of itself.
Even when offered as a manualized intervention and delivered via electronic
means, it is invariably rooted in and dependent on that complex connection

https://doi.org/10.1037/0000358-006
The Field Guide to Better Results: Evidence-Based Exercises to Improve Therapeutic Effectiveness,
S. D. Miller, D. Chow, S. Malins, and M. A. Hubble (Editors)
Copyright © 2023 by the American Psychological Association. All rights reserved.
107
108 Norcross and Karpiak

between the client and therapist. As such, it warrants substantial attention as

part of deliberate practice (DP).
There is little clinicians can do to directly alter most preexisting client
factors or events in clients’ lives outside the session. The relationship, however,
is curated and cultivated by the therapist’s attitudes and behaviors from the
first moments of contact. On this score, the evidence shows clinicians differ
in their ability to facilitate effective therapeutic connections (Castonguay &
Hill, 2017; Norcross & Wampold, 2019), and their capacity can be developed
and improved through monitoring, training, and practice. Importantly, the
efficacy of these relationship factors cuts across theoretical orientations (trans-
theoretical) and largely across client problems (transdiagnostic). The factors
considered in this chapter—the alliance, collaboration, goal consensus, empathy,
positive regard/affirmation, congruence/genuineness, emotional expression,
and repairing alliance ruptures—have all been shown, in dozens of individual
studies and in rigorous meta-analyses, to associate, predict, and contribute to
success. Failure to provide these elements also predicts and contributes to poor
results, however measured (e.g., dropout, deterioration).
Why would any responsible mental health professional deliberately practice
behaviors of unknown, dubious, or no association with psychotherapy success?
Yet, many routinely do so. A case in point can be found in the practice of
“confronting” clients. While it may prove a crowd-pleaser for talk-show thera-
pists, it corresponds with poor therapy outcome—even in treatment areas like
addictions, where there remains some belief that it is a good way for therapists
to behave (W. R. Miller, 2018; W. R. Miller & Rollnick, 2012). Ethics and evi-
dence demand those behaviors that demonstrably work be taught, practiced,
and employed in care. And these evidence-based relational factors do just that.
Indeed, given their significant contribution, it is hard to imagine a better focus
for DP than establishing responsive and respectful relationships.
Before proceeding, it is important to define the terms and register a few
conceptual caveats regarding the material that follows. An operational defi-
nition of the therapeutic relationship is the feelings and attitudes that therapist
and client have toward one another and the manner in which these are
expressed (Gelso & Carter, 1985, 1994). While this definition is quite general,
it is concise, consensual, theoretically neutral, and sufficiently precise.
The frequently used term therapeutic alliance represents a part of the relation-
ship, but only a part. In fact, a pernicious error in the psychotherapy literature
equates the totality of the relationship with the therapeutic alliance. In part,
this mistake occurs inadvertently because the alliance is the most frequently
measured and researched relationship factor in the psychotherapy literature
(Horvath et al., 2016). However, it is also intentional, an effort to misrepresent
and diminish the cumulative power of the relationship. Ironically, the alliance’s
association with psychotherapy success is not even the largest of the relation-
ship factors. That distinction, as will be shown, resides with empathy (see
Table 5.2). In reality, the alliance accounts for less treatment outcome than
the many relationship behaviors research shows are demonstrably effective
(Norcross & Lambert, 2019). Thus, confounding the entirety of the therapy
 Relationship Factors 109

FIELD GUIDE TIP

Keep in mind: The relationship is more than

agreement on goals, tasks, and provision of the
Rogerian core conditions. It actually includes a
genuine liking of the client!

relationship with only the alliance weakens the power of the therapeutic rela-
tionship empirically and clinically.
There are several other caveats to consider. First, the relationship factors
reviewed in this chapter are not independent of one another. They are inher-
ently interrelated, and it is likely many or most happen together in effective
therapy and fail together in a poor one (Nienhuis et al., 2018; Watson &
Geller, 2005). Second, the boundaries among the elements described in this
chapter, and those presented in others, are fuzzy rather than distinct and
mutually exclusive. For instance, therapist responsiveness or personalization
(Norcross & Cooper, 2021; Norcross & Wampold, 2019)—a powerful contrib-
utor to effectiveness—is connected to relationship, client, and therapist factors
(see Chapters 3 and 4, this volume). Third, this review is focused on the contri-
bution of relationship factors to the outcome of individual psychotherapy,
although the evidence is equally compelling for its power in couple, family, and
group therapy (Burlingame et al., 2019; Friedlander et al., 2019), as well as
pharmacotherapy (Totura et al., 2018).
As a field guide, this book is designed to be practical in nature, focusing on
strategy rather than theory. Such pragmatism informs this chapter, including
the review of the empirical research, the identification of evidence-based prin-
ciples, and the recommended DP exercises. With regard to the latter, the majority
are specifically designed to assist practitioners in addressing deficits in their
therapeutic relationships, not achieving brilliance. After all, practice does not
make perfect; it is the adjustments and refinements that follow from practice
(Ripken, 2019).

REVIEW OF THE RESEARCH

Empirical research on the therapeutic relationship spans more than half a

century. Originally considered primarily in psychodynamic and humanistic
therapies, decades ago, it became evident relationship factors are potent regard-
less of theoretical model or modality. Scholarly reviews of transtheoretical
110 Norcross and Karpiak

therapeutic factors (i.e., “common factors”), including the relationship, appeared

in edition after edition of the Handbook of Psychotherapy and Behavior Change
(Lambert & Hill, 1994; Orlinsky et al., 1994). Starting in 2002, the vast accu-
mulated evidence specifically in support of relationship factors was presented
in Norcross’s Psychotherapy Relationships That Work. The most recent, published
in two volumes, compiles meta-analyses of more than 15 relationship factors
(Norcross & Lambert, 2019; Norcross & Wampold, 2019). These studies, also
truncated and reported in special journal issues, are the source of the effect
sizes reported in Table 5.2. Simply put, no scientific doubt exists about the
contribution of the relationship to outcome. Neither is there any doubt that
the relationship is more determinative for results than the treatment model
or type (Wampold & Imel, 2015).
Part of the reason for the contemporary emphasis on learning treatment
packages has been the misconception that, while specific treatments can be
taught, the ability to form therapeutic relationships is both ethereal and fixed.
Recent reviews should forever put such notions and claims to rest (e.g., Knox
& Hill, 2021). The relationship might be part of the “art” of psychotherapy,
but most of its effective components are definable, measurable, and learnable.
In other words, relational abilities are not immutable (Anderson et al., 2020).
While some therapists are better than others at facilitating and maintaining
effective connections, others can learn and improve on those skills. Indeed,
there would be little point in including this chapter in the Field Guide (FG) were
that not the case.

Relationship Factors That Do Not Make a Difference

Translational research is both prescriptive and proscriptive; it tells us what

works and what does not. In this section, ineffective, perhaps even hurtful,
therapist relational behaviors are highlighted (see Table 5.1; Norcross &
Lambert, 2019). One means of identifying such qualities is simply to reverse
the effective behaviors identified in the meta-analyses reviewed in the next
section. Thus, what does not work (and is probably harmful) are low empathy
and poor alliances. Paucity of support, collaboration, and consensus (as expe-
rienced by the client) predict treatment dropout and failure. The ineffective
practitioner will also likely be incongruent in word and deed, be inclined to
overlook alliance ruptures, and disregard emotional expression.
Another means of identifying relational elements that exert a negative
influence is to scour research studies in search of those frequently associated
with negative outcomes and premature discontinuation (e.g., Hardy et al.,

TABLE 5.1. Summary of Ineffective or Harmful Therapist Relational Behaviors

Ineffective Harmful
Low empathy Rigidity
Low collaboration Confrontational style
Low consensus Overconfidence
High reliance on therapist assessment of the alliance Blame, criticism, hostility
 Relationship Factors 111

2019; Swift & Greenberg, 2012). Harmful therapist behaviors include rigidity,
overconfidence, and hostility. Confrontational style, criticism, rigidity, cultural
arrogance (see Chapter 3), assumptions, and therapist-centricity (see Chapter 4)
are also implicated (Norcross & Lambert, 2019; Soto et al., 2019). Because
these behaviors and attitudes exert a potent negative impact, it makes sense
from a DP perspective first to identify and mitigate their influence before turning
attention to effective relationship factors.
As an example of rigidity, consider widespread policies mandating the use
of specific treatment protocols and continued emphasis on training therapists
in manualized treatments to the exclusion of relationship factors. Research
shows neither adherence nor compliance with treatment manuals consistently
relates to positive treatment outcomes (Collyer et al., 2020; Webb et al., 2010).
More, strict adherence can cause a practitioner to overlook important client
or relationship events, within and without of the therapy.
Statements of blame, sarcasm, criticism, or other hostility toward the client
also powerfully predict poor outcome, with process studies indicating it does
not require much animus in an otherwise typical session to create problems
(Binder & Strupp, 1997). To be sure, readers of Better Results (BR; S. D. Miller
et al., 2020) and the FG are unlikely to practice with an intentionally uncaring
or critical style. Unfortunately, these relational behaviors can occur without
therapist awareness. Research shows, for example, therapist assumptions about
clients’ experiences in therapy often don’t align with the clients’ actual experi-
ences. While it might be tempting to believe clinicians can or should know—
either by intuition or experience—when things are going well or badly with the
relationship, studies clearly demonstrate it is not the case (Lambert, 2010); the
client’s perspective is more strongly related to outcome. In fact, meta-analytic
research repeatedly advises therapists to privilege their clients’ experience of the
alliance, empathy, and outcome over their own (Norcross & Lambert, 2019).
Like other blind spots in human cognition, the conditions that promote these
ineffective relational behaviors are often present in the environment and thus
easily ignored. Insurance demands, practitioner anxiety, and external pressure
to adhere to specific treatment techniques can create alliance-ruining rigidity.
Frustration, defensiveness, fatigue, or inattentiveness can prompt hostile state-
ments that practitioners might not even notice. The mere status of “health care
expert” may compound the risk of making incorrect assumptions, engaging in
dominant behavior, and being blind to cultural differences. Here, in particular, is
where routinely soliciting feedback from clients, as described in BR, can prove
critical, both in improving therapist responsiveness in the moment to the indi-
vidual client, as well as identifying, via the aggregation of performance data,
patterns of problematic relational behavior to target with DP.

Relationship Factors That Do Make a Difference

The empirical foundation on which this chapter rests is both mature and robust.
Relationship factors all have effect sizes indicative of small to moderate
benefit. Table 5.2 summarizes the results of meta-analyses. As can be seen,
112 Norcross and Karpiak

TABLE 5.2. Summary of Meta-Analytic Results on Relationship Factors in

Individual Psychotherapy
# of studies # of patients Effect size Principle
Relationship factor k N r d or g #
Empathy 82 6,138 .28 .58 3
Positive regard/affirmation 64 3,528 .28 .57 1
Congruence/genuineness 21 1,192 .23 .46 2
Real relationship 17 1,502 .37 .80 2
Emotional expression 42 925 .40 .85 4
Alliance (adult patients) 306 30,000+ .28 .57 3
Alliance (child & adolescent 43 3,447 .20 .40 3
patients)
Collaboration 53 5,286 .29 .61 4
Goal consensus 54 7,278 .24 .49 3
Repairing alliance ruptures 11 1,318 .30 .62 1
Note. Adapted from “What Works in the Psychotherapy Relationship: Results, Conclusions, and Practices,”
by J. C. Norcross and M. J. Lambert, in J. C. Norcross and M. J. Lambert (Eds.), Psychotherapy relationships
that work (3rd ed., Vol. 1, p. 367), 2019 (https://doi.org/10.1093/med-psych/9780190843953.001.0001).
Copyright 2019 by J. C. Norcross and M. J. Lambert. Adapted with permission.

all nine of the factors listed have been designated effective. In short, no question,
they all work (Norcross & Lambert, 2019).
In the material that follows, the evidence-based relationship factors are
organized into two sets based roughly on their historical roots and groupings
on the Taxonomy of Deliberate Practice Activities in Psychotherapy (TDPA;
Chow & Miller, 2022; see Appendix A, this volume). The first set originated
in the humanistic, client-centered literature and corresponds with TDPA
Domain 3 (relationship), Subgroup B (Impact). The second set originated in the
psychodynamic literature and corresponds with TDPA Domain 3 (relationship),
Subgroupings A (effective focus) and D (difficulties).

Empathy
The term empathy is widely used to mean an array of experiences and behaviors
that are not therapeutic empathy, such as a sympathetic response to the distress
of another or recognizing superficial similarities between one’s own experience
and those of others. Such responses are self rather than client centered in
nature (W. R. Miller, 2018). Therapeutic empathy occurs when the clinician
seeks and then relays an accurate understanding of the client’s feelings, per-
spectives, and experiences, as separate as possible from the therapist’s own.
In sum, an empathic stance is an antidote to the assumptions and therapist-
centricity that prove ineffective for the therapy relationship.
Empathic responding is one of the strongest and best-supported contributors
to outcome (Elliott et al., 2019). Starting with the groundbreaking research
of Carl Rogers, decades of evidence now back up its value, with effect sizes
ranging moderate to large (d = .58), from a whopping 82 high-quality studies.
Even better, the skills and basic stance of empathic understanding can be
 Relationship Factors 113

practiced in everyday relationships outside of a real or simulated therapy

situation (see W. R. Miller, 2018), as long as others in these relationships are
willing and able to provide feedback. Such accessibility, paired with the strength
of empathy’s impact, makes it both one of the simplest and most ideal to
translate into DP activities.
The meta-analytic research points to several central features of effective
empathic responding (Elliott et al., 2019):

• Communication of attunement to the client’s emotions and experiences.

A narrow focus on the words the client says, or other concrete aspects of
content, is not effective attunement, and neither is merely repeating back
their words.

• Being flexible and open to new input from the client. Firm expectations or
assumptions about the client should give way to attending and adjusting
to clients’ in-the-moment experience.

• Humility. Empathic listening involves educated guessing, stated as hypoth-

eses with minimal assumptions. Trying to predict client views of their
experiences (anticipatory empathy) is not particularly helpful.

FIELD GUIDE TIP

Chapter 8 of BR describes and

illustrates how to mine your
performance data for DP opportunities.
In light of the research on empathy
presented in this section, consider
sorting your clients based on their
Session Rating Scale (or whatever
relationship measure you are using)
scores (good = 39–40, fair = 37–38, and
poor 36 or lower), paying particular
attention to the relation between
the scores on the individual items,
dropouts, and poor outcomes.

Positive Regard and Affirmation

Therapist positive regard for the client (and expression of that regard, including
through affirmation) is another relationship factor originally investigated by
Carl Rogers. As with empathy, positive regard has been the subject of much
research since the early days of the field, with effect sizes falling in the moderate
range (d = .57), based on 64 studies of quality appropriate for inclusion in a
meta-analysis (Farber et al., 2019).
114 Norcross and Karpiak

Like empathy, the terms positive regard and affirmation are easily
misunderstood—mistaken for simple compliments, shallow praise, or other
concrete tactics (e.g., preceding requests for compliance). In fact, positive regard
is the therapist’s genuine nonpossessive liking and expressed appreciation for
the client as a unique person. Doing so strengthens the client’s sense of agency
and self. It is important to note that to contribute to outcome, this regard must
be made evident to the client through words and nonverbal signals. Therapists
can express on a regular basis, for example, in both verbal and nonverbal ways,
that they value, care about, and believe in the client. Ideally, the therapist will
experience and express such regard over the course of treatment. However,
it does not need to be (and probably could not be) experienced by the therapist
at every moment across treatment with any given client. Rogers made clear that
positive regard should not be viewed as a stable characteristic of the relation-
ship with a client (Farber et al., 2019).

Therapist Congruence/Genuineness and Real Relationship

This closely related pair of relational factors includes the last of the three
classic Rogerian core conditions (empathy, unconditional positive regard, and
congruence/genuineness) and a concept from the psychodynamic literature,
the real relationship. Both have accumulated sufficient evidence to be classified
as effective.
Congruence/genuineness has both intrapersonal and interpersonal features,
meaning it is both a personal characteristic of the therapist as well as a quality
of the therapeutic interaction. When congruent, therapists’ actions and behav-
iors not only fit their words but also who they are as a person—their values
and identity—exuding groundedness, thoughtfulness, and genuineness. In
short, they are real, not phony, distracted, or playing a role. Studies of the factor
show a moderate effect size, making it a reliable contributor to therapeutic
success (d = .46; Kolden et al., 2019).
The real relationship is composed of both genuineness and realism. Gelso
(2014) described it as “the personal relationship between therapist and patient
marked by the extent to which each is genuine with the other and perceives/
experiences the other in ways that befit the other” (p. 119). In contrast to the
alliance, it refers to a subset of therapist–client interactions not directly focused
on the tasks (Gelso et al., 2019). These interactions are taken at face value in
the here and now. A meta-analysis based on 17 studies and 1,502 patients
revealed a large effect between the real relationship and client success (d = .80;
Gelso et al., 2019).

Emotional Expression
Although emotion is obviously core to psychotherapy, organized research on
the subject is quite recent. Regardless, the evidence shows that the facilitation,
experience, and expression of client emotion in session are strongly correlated
with treatment outcome (d = .85; Peluso & Freund, 2019). Contributions to
this research base come from a wider range of theoretical orientations than the
factors reviewed thus far. Because of this variability, the definition of emotional
 Relationship Factors 115

expression is less precise and has failed to achieve consensus in the field. One
essential and simple clarification: What is not being referenced here is the
“expressed emotion” (EE) from family process and relapse prevention research
with serious mental illnesses, where reducing EE is the goal. Consistent with
the TDPA descriptions, the focus here is on therapist relational actions that
facilitate client emotional expression in individual therapy (see TDPA Domain 3,
Items Bi–v).
Of all the relational elements listed in the TDPA impact factor group (3B),
emotional expression is possibly the most theory bound. It is also the one that
can most clearly go astray in the absence of a clear plan. Treatment model and
case formulation help determine which emotions to address, where a particular
emotional expression fits into the therapeutic endeavor, and what to do with
it—how to attend to and make therapeutic use of it versus allowing the session
to deteriorate into an unfocused rant, wallow, panic, or self-attack.

Alliance in Adult Psychotherapy

The term alliance can be difficult to define and is not easily differentiated from
several other relational concepts. Meaning varies depending on the theoret-
ical orientation of the person using the term. In the professional literature,
the words working, helping, or therapeutic often appear in conjunction with the
term (Flückiger et al., 2019). An early tripartite definition by Bordin (1979)
emphasized (a) a warm emotional bond, (b) agreement on respective tasks,
and (c) consensus on treatment goals. A more recent definition includes
mutual collaboration between client and therapist on goals and tasks of psycho-
therapy, along with the therapeutic bond between the dyad (Del Re et al.,
2021). Because of the emphasis placed on mutual agreement and goal-directed
movement, the alliance is difficult to assess without collecting information from,
at minimum, the therapist and client.
At this point, a huge number of studies have been conducted on the relation
of the alliance to client success. Across raters, a meta-analysis of more than
30,000 clients found a moderate but extremely robust association between
the alliance and outcome in adult individual psychotherapy (d = .57; Flückiger
et al., 2019). No doubt. The alliance relates, predicts, and contributes to success.

Alliance in Youth Psychotherapy

The therapeutic alliance also captures essential aspects of the relationship
with children and adolescents. That said, proper measurement from the
youth’s perspective has been less common, and it is not clear whether youth
collaboration on treatment goals is as central to the alliance as it is with adults
(Karver et al., 2019). Nonetheless, it is important for the outcome of individual
therapy that a child or adolescent experiences a warm bond with the therapist
in a relationship focused on improving the young person’s psychological
functioning. The need to establish an alliance with a parent or caregiver when
working with minors further complicates the picture. Such research and
clinical challenges notwithstanding, a fair bit of evidence has accumulated.
Across 43 studies of child and adolescent therapy (3,447 clients and parents),
116 Norcross and Karpiak

there is a moderate effect size between alliance and treatment outcome (d = .40;
Karver et al., 2019). Importantly, the strength of alliance–outcome relation did
not vary with the type of treatment. Further, the effect size, or clinical impact,
of dual alliances—therapist with youth, therapist with parent—was identical.
Bottom line: Both mightily matter.

Goal Consensus and Collaboration

These two factors are present across theoretical orientations and are sometimes
considered part of the therapeutic alliance. Indeed, both are commonly assessed
for research purposes via measures of the alliance, completed separately by
clinician and client. Goal consensus refers to the agreement between the ther-
apist and client about the targets of their work together and how to achieve
them. Clarity of communication about treatment goals, degree of dedication to
the endeavor, and a mutual understanding of how change will come about are
also vital parts of that consensus. A large body of research documents the vital
role this factor plays in outcome (d = .49; Tryon et al., 2019).
Collaboration is the active mutual engagement of the therapist and client
around the work of therapy. Historically measured with subscales of alliance
measures, recent studies of cognitive and behavioral therapies have conflated
collaboration with completion of homework assignments. Simply put, while
work between client and therapist often extends beyond the therapy hour,
compliance is not collaboration. Research shows a substantial effect size for
the latter (d = .61; Tryon et al., 2019).

Repairing Alliance Ruptures

Ruptures are problems or strains in the collaborative relationship between
client and therapist (Safran et al., 2011) related to treatment goals, agreement
on the tasks of therapy, or the emotional aspect of the dyad’s collaborative
bond (Eubanks et al., 2019). Two main types occur in session: (a) withdrawal,
in which the client moves away from the therapist and the work, and (b) con-
frontation in which the client moves against the therapist, by expressing
anger or dissatisfaction. Although the term rupture may connote a dramatic
breakdown, many studies point to subtle tensions and minor misalignments
as markers.
Therapist efforts to repair alliance ruptures can be overt or indirect. Either
way, research shows attending to them improves treatment outcomes. A meta-
analysis of 11 studies involving 1,318 clients revealed that repair of alliance
ruptures in individual therapy is moderately to strongly associated with out-
come (d = .62). That is, addressing ruptures works; ignoring them does not.
Turns out, repairing ruptures is valuable for all therapists but is especially
important for therapists with less experience and training in negotiating the
therapeutic alliance (Eubanks et al., 2019). For example, a highly specialized
statistical process known as moderator analysis reveals that rupture resolutions
and training are particularly important for cognitive behavioral therapists,
many of whom have not received explicit training in processing relationship
dynamics with their clients.
 Relationship Factors 117

EVIDENCE-BASED PRINCIPLES RELATED TO RELATIONSHIP FACTORS

Principle 1: Avoid the Don’ts, and When You (Invariably) Commit

Them, Repair the Relationship

If the Golden Rule—a maxim found in most religions and cultures—constitutes

sound advice for relationships in life, it can be considered an imperative in
psychotherapy. Like the dos and don’ts reviewed in this chapter, the adage
typically comes in one of two forms: positive (“Treat others as you would
like others to treat you”) and negative (“Do not treat others in ways that you
would not like to be treated”). Flexibility, openness, and humility are research-
supported examples of the former, as are being regularly affirming and pro-
viding positive regard. By contrast, who enjoys confrontation, being blamed or
criticized, or met with sarcasm, arrogance, and rigidity? When ruptures occur,
quickly repair them and fix the relationship.

Principle 2: Engage Genuinely in a Real Relationship

That all practitioners experience days where they are merely going through the
motions, playing a role, or “phoning it in” is understandable. After all, con-
ducting psychotherapy is ofttimes emotionally demanding and inter­personally
grueling work. Of all the relationship factors, engaging in a real relationship—
composed of genuineness and realism—is among the most potent. Mindful
self-awareness is key, including being accepting of self, behaving responsively to
the client, and manifesting both intrapersonal and interpersonal congruence.

Principle 3: Attune, Align, and Collaborate for Impact

For both young and old, it is the client’s

experience of the therapist and the treat-
ment that matters most. The essential ques-
tions are the following: Do they feel heard
and understood? Is the therapist empathi-
cally attuned to their inner experience? Do
they feel supported and validated? Is their
relationship with the therapist collabora-
tive in nature and aligned with their goals?
Better results are achieved when the
answers to the foregoing questions are in
the affirmative.

Principle 4: Facilitate Emotional Expression and Processing for

Best Results

It is self-evident that clients have feelings, but for decades, most practitioners
did not know what to do with them except to listen. New psychotherapy
118 Norcross and Karpiak

research and affective neuroscience converge in directing practitioners to help

clients experience, express, and process those emotions. That leads to more
client health and happiness. The best results ensue when therapists process
feelings consistent with a treatment model and case formulation.

EXERCISES FOR RELATIONSHIP FACTOR SKILL DEVELOPMENT

To be effective, the DP exercises you choose must help you reach for perfor-
mance objectives just beyond your current abilities. As such, prior to reviewing
the following exercises, ensure you have taken all of the steps outlined in
the decision tree presented at the start of this chapter. It is assumed you have
(a) routinely measured your performance, (b) collected sufficient data to
establish a reliable profile of your therapeutic effectiveness, (c) completed the
TDPA, (d) determined a deficit exists in your performance related to relationship
factors, (e) narrowed your focus to a single element within the relationship
factors domain on the TDPA, and (f) defined that performance improvement
objective in SMART terms (specific, measurable, achievable, relevant, and
time bound). Next, choose an exercise that aligns most closely with your goal.
Remember, “deliberate practice is a marathon, not a sprint” (S. D. Miller
et al., 2020, p. 58). Pacing and planning are essential for sustaining the effort
necessary for success. Should none of the exercises speak directly to your needs,
Chapter 2 can provide guidance for developing your own.

Exercise 1: Buddy Up for Improvement

Principle: 1
Applicability: TDPA Items 3Aiii, iv, 3Bi–iv, 3Di, iv
Purpose
Personal soul-searching—even reviewing recordings of our own work—may
not reveal our subtle rigidity and negative process (e.g., negativity, hostility,
sarcasm) in session. Supervision, third-party observation, and feedback from
clients offer the possibility of a broader perspective.

Task
Together with your clinical supervisor or colleague, watch recordings of three
sessions with different clients. Optimize your selection by choosing sessions
(a) that have ended with low scores on whatever alliance/relationship scale
you administer (e.g., Session Rating Scale [SRS]), (b) that have been followed
by the client dropping out of treatment, or (c) during which you experienced
negative emotions toward the client.
DP must be cognitively taxing to be effective, so start by dedicating a half
hour to the process described next. Begin by watching a video, stopping at
points where more flexible/responsive, less critical/hostile responses were
possible but missed. With the help of your colleague or supervisor, craft at least
two alternative responses. For each of these, imagine what a client might say
and how you would respond in an open and empathic manner.
 Relationship Factors 119

For this exercise to be useful, commit to reviewing videos in this way at

least once a week for a month or more. Be forewarned: Watching our mis-
takes on video in front of peers can prove ego bruising, but it is the coura-
geous way forward to better treatment results. As your comfort level increases,
ask your supervisor or peer to role-play more challenging reactions to the
alternative responses you craft. Note if and how your good partnership “do’s”
are improving over time.

Exercise 2: Back to the Classic

Principle: 3
Applicability: TDPA Item 3Bi, v (also applicable to 4C, E)
Purpose
The quality of a therapist’s empathic attunement cannot be accurately assessed
via intuition or deep reflection. We simply are not in possession of the client’s
perception without systematically welcoming and obtaining it.

Task
Write the names of your active clients on separate slips of paper. When done,
mix all the names together in a hat (or box). For the first 15 slips drawn, begin
administering the classic Barrett-Lennard Relationship Inventory (from Barrett-
Lennard, 2015, or online at various sites). After calculating the range (i.e.,
highest and lowest) and average of your clients’ scores,

• compare each client’s score from session to session, considering what

contributed to increases or decreases.

• compare your average score with that of the normative sample, reflecting
on how your clients typically experience your empathic attunement. Look
specifically at those clients whose scores fall below the norms.

• identify any cases of declining scores (while being mindful of research

reviewed earlier in this chapter showing empathic attunement is associated
with better outcomes). Use the method described in Exercise 1 (Buddying
Up for Improvement) to foster the development of more helpful alternatives.

• from month to month, repeat the exercise as described. As data accu-

mulate, sort the scores by age, gender identity, diagnosis, or culture,
identifying any groupings where you perform more poorly on the Barrett-
Lennard Relationship Inventory. Empathic responding includes sensitivity
and adjustment to the individual client and the singular moment. That
includes attending and responding therapeutically to those for whom
conventional, Rogerian empathic responses do not prove ideal, as well as
clients with whom—consciously or unconsciously—you offer suboptimal
understanding.

• use the method described in Exercise 1 (Buddying Up for Improvement) to

foster the development of more helpful alternatives.
120 Norcross and Karpiak

Remember, even if unpleasant in the beginning, the data are always friendly
in the long run. If the results are supportive of your perceived empathic quality
with most clients, then, by all means, move on to remediating other relational
skills. If the results are not supportive, devoting additional time to enhancing
your empathic skills can definitely make a difference in your clinical results.

Exercise 3: Only Connect (E. M. Forster, Howards End)

Principle: 3
Applicability: TDPA Item 3Bi, v (also applicable to 4C, D, E; 5Aiv,
viii, 5Bi)
Purpose
According to research reviews, the best skill training in empathy begins with
didactics and ends with experiential elements (Elliott et al., 2019). This exercise
joins these two critical elements using William R. Miller’s (2018) book Listening
Well: The Art of Empathic Understanding. As you will see, this slim volume contains
didactics presented in brief, clear sections and supported by numerous exercises
designed to improve skills for warm, accurate listening to another person. The
exercises can be done in any reasonably close relationship, providing plenty of
opportunities for practice and refinement of skills outside of therapy.

Task
On pages 14–18, W. R. Miller provides a real gem, a list of 12 roadblocks to
empathic listening. These will surprise many people because they include an
array of behaviors that are commonly employed in what are believed to be
“positive” conversations in daily life (e.g., probing, agreeing, reassuring) but
that interfere with true empathic listening. Instead of helping clients develop
a deeper understanding of what they are feeling and what they mean to say,
these behaviors stop them in their tracks.
Begin by printing the list of the 12 roadblocks and keeping them handy.
Then, for a month, whenever an opportunity presents for a conversation with
a colleague or friend, ask if they would help you with a brief experiment. Let
them know nothing special is required on their part. The two of you will talk
briefly, and you will ask for feedback about the experience. Should they agree,
continue the conversation, interjecting as many of the roadblock responses
as possible in the first 5 minutes. Each should be short and sweet, taking
advantage of whatever opportunity naturally arises in the conversation—for
example, judging (“You should really do that. You need to . . .”) and agreeing
(“Yes, yes, you’re right”). Using a scale from 1 to 10, ask the listener to rate
how well they felt heard and understood. For the next 5 minutes, avoid as
many of the roadblocks as you can. It will prove more difficult than you prob-
ably imagine. Once again, ask the person to rate their experience of being heard
and understood. Keep notes about your experience and learnings.
Return to Listening Well and pay particular attention to Chapter 8, Forming
Reflections. Here you will find specific instructions and examples for developing
the positive behaviors that, used in combination with real attention to the
 Relationship Factors 121

speaker (instead of divided attention while thinking of what to say next or

what you want them to do), will foster better empathic understanding. Here’s
a warning and some advice: The exercise W. R. Miller suggests appears so
simple you might think you already do it well. Practice it with one or two of
your close friends, and you will soon discover it is far more challenging.
Begin by soliciting a commitment from a friend or colleague to help you
practice your listening skills. Ten to 15 minutes is all that is required, with
meetings spread out over an extended period of time (e.g., 1 month), thereby
leaving time in between for reflection and consolidation of learning. Begin
each meeting by having the person say, “Something you should know about
me is that I am _______,” ending with an adjective that is open to interpreta-
tion. Follow their statement with a reflection, which will be your best guess
or hypothesis about the feeling, motivation, or value contained in what the
speaker said. Importantly, your response must not be stated as a question and
should end with downward voice intonation. The speaker follows, either
letting you know you are right or wrong or clarifying. Based on their reply,
you offer another reflection, the process continuing through several turns in
conversation. The challenge for the listener is remembering to reflect not only
the original statement but also the new information added at each turn. At the
end of the conversation, ask for detailed feedback from your friend/listener,
noting, in particular, those times when they felt you had truly heard what
they were attempting to communicate. Note that most find achieving consis-
tency in their reflections difficult! Be patient. Keep a log of your learnings.

Exercise 4: What Would Carl Rogers Do?

Principle: 2, 3
Applicability: TDPA Item 3Bi, ii (also applicable to 4D, 5Aii)
Purpose
Rarely do we recommend reading or watching recordings as efficacious
methods of DP. The one exception is the work of Carl Ransom Rogers. His
published writings and video demonstrations (beyond the infamous Gloria or
Three Approaches to Psychotherapy) on the core facilitative conditions of psycho-
therapy should be a part of every health care practitioner’s professional devel-
opment, particularly on the subject of unconditional positive regard.

Task
Part 1. Decide to immerse yourself in Rogers’s work, locating articles, books,
and recordings. Over the course of a month or more, for no more than an
hour at a time, study his writings or watch videos. Absorb the complexity
and variety of how he talks about and expresses unconditional regard. Pay
particular attention to how he exudes it in so many ways. Be patient. It’s
likely to take time. As he observed, “Tis a way of being” (Rogers, 1980), not a
technique.
Using pen and paper or using your favorite note-keeping app, keep a log
of your observations and learnings, paying particular attention to the “sweet
122 Norcross and Karpiak

spots” in what he did and said. When watching a video of him working with a
client, use the stop–start technique—specifically, stopping the recording prior to
Rogers’s turn in conversation, first writing down how you would respond and
then comparing it with what he said. Keep in mind your reflections about the
difference are more important than getting the wording exactly right. You
will know you are making progress when you (a) jettison the common yet
antiquated notion that Rogers simply fed clients compliments, (b) accumulate
new ways of communicating positive regard, and (c) spontaneously find your-
self experiencing more genuine nonpossessive liking of and appreciation for
your clients’ uniqueness.

Part 2. Part 2 of this exercise might be called “Walk in Your Client’s Shoes.”
The expression is being used here literally rather than figuratively. Part of
communicating respect and care for the people we work with is creating a
safe, peaceful, and nourishing physical environment. Begin by reflecting on
your “therapy space”: the communications clients have prior to their first
appointment, where they enter the building, your waiting area, and your con-
sulting room (even if online). Consider the ambience, color, sound, lighting,
safety, ventilation, flooring, and furniture. Are the reading materials in the
waiting room organized, clean, and current? Are the chairs comfortable? Is the
artwork meaningful? What is the overall feeling? End by asking five non­
therapists to visit. While you wait outside, have them sit in your waiting area
and office, noting their immediate impressions. Embrace any discrepancies
as feedback.
Other environmental features to consider? Paperwork, billing, and any
measures you typically ask clients to complete. Evaluate what these procedures
and experiences communicate. Do they adequately convey positive regard—
an appreciation of the uniqueness of each individual client? Once again, walk
five nontherapists through your process. Ask them to reflect on the experience,
noting what feelings it conjures or inspires. Consider creating a learning project,
as described in Chapters 2 and 9, aimed at rectifying what is unsatisfactory in
the environment you seek to project. Make small tweaks and then repeat the
exercise every 6 months to ensure your therapy environment represents the
best of you.

Exercise 5: Set Your Heart Right (Confucius)

Principle: 2
Applicability: TDPA Item 3Biii, iv (also applicable to 5Avi)
Purpose
Congruence is both intrapersonal (therapist quality) and interpersonal (rela-
tional) in nature. Mindfulness, stretching, and relaxation may all help in “setting
your heart right” for meeting with clients. Indeed, a multisite randomized
controlled trial found that therapists who practiced presession mindfulness were
more present in their meetings with clients. However, it did not necessarily
 Relationship Factors 123

result in them becoming more effective (Dunn et al., 2013). While disappoint-
ing, such a finding will not come as a surprise to anyone who understands DP.
As noted in Chapter 1, to be effective, the time you devote to professional devel-
opment must be aimed at helping you reach for objectives just beyond your
current ability. The process begins by using data to identify performance deficits.

Task
At the end of each day spent meeting with clients, take a few moments to
review those sessions where you experienced a lack of congruence either
internally or in the therapeutic interaction. In 100 words or less, write down
the client and time of day and any other factors you consider contributary.
After you have completed the process a minimum 10 times, retrieve your
notes, sorting the collection into themes. Refine the list by continuing the
exercise additional days.
Develop a plan for addressing the dominant themes (e.g., engaging in
presession mindfulness practices, decreasing the number of clients seen or the
times of day you meet clients, committing to leaving enough time between
visits to read through case notes prior to meeting). Review your plans with a
trusted colleague, supervisor, or expert consultant.

Exercise 6: Go to the Tape

Principle: 4
Applicability: TDPA Items 3Bii, iii, vi, 3Dii, iii, iv (also applicable to
1K, 5Ai,ii)
Purpose
Psychotherapy sessions are often affective crucibles in which neither patient
nor practitioner recall proves accurate about the expression and processing of
in-session emotion. Thus, observer ratings may be better sources of informa-
tion than either therapist or client postsession report in determining when the
therapist unintentionally dampens the experience and expression of emotion.

Task
Part 1. If you have not already started doing so, begin recording your work
(with informed consent, of course). Identify those sessions in which the client
expressed a meager amount of emotion. Next, block out 30 minutes of uninter-
rupted time. For the first 20, watch one of the recordings. Beware! Audio and
video are dense mediums. To guard against information overload, limit your
focus to a single objective: finding exchanges during the hour in which
your verbal response (or lack thereof) unintentionally dampened the client’s
experience, expression, or processing of emotions. Think of this exercise as
a fine-grained analysis of response couplets that did not lead to or result in
affective experiencing in places that the research evidence and your treatment
model would deem desirable.
After locating at least four exchanges, spend the last 10 minutes reflecting
on the reasons (both conscious and partly unconscious) for your discouraging
124 Norcross and Karpiak

or minimizing client emotions. Does it feel too painful? Are you uncomfortable
with strong affect? Are you too fatigued to take it on? Are there any patterns to
your behavior? What might a different response look like that feels congruent
to you and your therapeutic approach?

Part 2. Early on in BR, you were asked to create a schematic or blueprint for
how you do therapy sufficiently detailed so another practitioner could under-
stand and replicate it—literally, “step into your shoes” and work how you work
(S. D. Miller et al., 2020, p. 29). The purpose of the exercise was to make
it possible for clinicians to pinpoint where they could intervene once data-
derived performance improvement opportunities were identified. In response
to reader feedback, a more detailed description (and hopefully improved)
version was developed and included in the FG (see pp. 18–20, Chapter 1). If
you have not completed the activity, please do so now.
Next, with your completed “map” in hand, consider where, when, and
how client emotional expression plays a part in your treatment approach. If it
is not mentioned explicitly, add it, taking time to identify how it is related to
your theoretical premises and overall plan of action. Finish this activity by
returning to the exchanges from the recording you reviewed and, for each,
writing out how specifically you would invite client emotional experiencing
and expression consistent with your therapeutic approach. Wait to check for
progress until you have repeated the exercise a couple of times per week for
at least a month. You can do so by reviewing recordings of subsequent sessions
with the same clients.

Exercise 7: Rate and Predict

Principle: 3
Applicability: TDPA Items 3Ai–iv, 3Cii, vi (also applicable to 1D-F,
4A, B, E)
Purpose
The good news is training in alliance building frequently results in improved
therapeutic alliances in session; the bad news is such training takes a fair bit of
practitioner time and effort (e.g., Ackerman & Hilsenroth, 2003; Crits-Christoph
et al., 2006; Muran et al., 2018). As alignment with another literally means
being in a state of agreeing or matching, success requires knowing when a
difference between our clients and us exists. This activity is designed to foster
such awareness.

Task
At the end of each session, while your clients complete the SRS, fill one out
yourself from the client’s perspective. The aim is to be altered or disconfirmed,
not confirmed. Why? As noted in Chapter 1, our brains are hardwired for
novelty. Simply put, we listen better when we confront challenging or surprising
situations. Continue the activity for a month, keeping notes about what you
 Relationship Factors 125

learn. Once again, sort for patterns. Are there certain clients, presenting
problems, times of day, or days of the week when you are more likely to be
misaligned?

Exercise 8: I Am Clueless

Principle: 3
Applicability: TDPA Items 3Ai, ii (also applicable to 1F, H, I, 2B,
4A, B, E)
Purpose
Treatment planning and the popularity of so-called SMART goals can inadver-
tently lead to viewing therapeutic objectives as static in nature. In truth, the
goals, meaning, or purpose of treatment are constantly evolving. At best, goals
should be viewed as temporary signposts—verbs rather than nouns—subject
to change as progress is achieved (or not) over an episode of care. The purpose
of this exercise is twofold: (a) improve therapist awareness of and adjustment
to client goals, and (b) increase therapist awareness and integration of other
stakeholders’ concerns, hopes, and objectives.

Task
Randomly select 10 clients from your caseload with whom you have met at
least twice but no more than five times. In advance of your next scheduled
visit, write what you believe their goals to be. Note if their goals have evolved
since the start of treatment. When you next meet, ask those clients something
along the following lines: “Let’s take a moment and check back in on what
you hope to accomplish here. Pretend I am clueless about your goals for psy-
chotherapy. What would you say they are?” Continue the process for several
weeks or until you have collected data from 30 total clients. Once done, begin
systematically comparing their answers with your own written answers, noting
the level of agreement and degree of divergence. What patterns, if any, emerge?
Consider the level and rate in your work with mandated clients, youth, couples,

FIELD GUIDE TIP

For the cases you review in Exercise 8,

retrieve each client’s completed Session
Rating Scale. Note whether any identified
misalignment regarding the client’s goals
and objectives is reflected in lower scores
on the second item on the measure. If not,
consider how you might prompt the client
to provide more accurate in-session feedback
(see TDPA Items 1iii–vi).
126 Norcross and Karpiak

or families. Is it more or less frequent? Should discrepancies be apparent,

keep a log of who you tend to align with more and less often. Sort for patterns,
eventually devoting time to developing a plan for improving collaboration and
consensus addressing the dominant themes (e.g., engagement in presession
mindfulness practices, decreasing the number of clients seen or the times of
day you meet clients, committing to leaving enough time between visits to
read through case notes prior to meeting). Review your ideas with a trusted
colleague, supervisor, or expert consultant.

Exercise 9: Repairing Ruptures

Principle: 1
Applicability: TDPA Items 3Bii, Di (also applicable to 5Ai, ii, iv)
Purpose
When it comes to alliance ruptures in psychotherapy, repairing is literally about
re-pairing the therapist with the client. No exact prescription for handling
ruptures exists. Equipping therapists with the skills necessary to derive their
own personalized solutions (Eubanks et al., 2019) entails

• recognizing ruptures when they occur (both withdrawal and confrontation

ruptures),
• tolerating the difficult emotions they evoke,
• affirming clients for expressing their discontent (even if indirectly), and
• responding in empathic and flexible ways.

Task
Part 1. If you have identified rupture repair as a target for DP—either because
of specific metrics in your performance data (e.g., high dropout rate, low SRS
scores, or client report) or because of completion of the TDPA—your first step
is to reflect on your history. Of the four skills listed earlier, note which, whether
in your clinical work or personal therapy, proves the most challenging. After
doing so, create a learning project. Read. Watch and/or engage an expert.
Role-play outside the session—again, reenacting clients or therapists you
have met.

Part 2. Start by making a “collection basket.” When you experience a rupture

with a client or hear one reported by a colleague, write it down and add it to
your collection. Once you have 10 or more, pick two confrontation ruptures
(e.g., an adolescent complaining that “you always take my parents’ side”; an
older client responding to your well-intended expression of understanding
with “You still don’t get me at all”) and two withdrawal ruptures (e.g., a child
physically and verbally withdrawing from the session, an adult manifesting
standoffish discontent but not verbalizing it). Next, record family members or
friends briefly reenacting the ruptures. Play the recording and write out a
response, mindful of incorporating the four skills noted earlier. Continue the
exercise until the scenarios have been exhausted.
 Relationship Factors 127

FURTHER READING AND RESOURCES

This chapter reviewed the research evidence, identified evidence-based prin-

ciples, and suggested DP exercises for working with relationship factors in
psychotherapy. Additional research and recommendations can be found
in the following:

• Two well-validated and clinically relevant measures for assessing and improv-
ing relationship skills are (a) Barrett-Lennard, G. T. (2015). The Relationship
Inventory: A complete resource and guide. Wiley-Blackwell, and (b) Facilitative
Interpersonal Skills inventory, available at https://www.fisresearch.com.

• Detailed review of the research and description of the real relationship and
the therapeutic alliance can be found in Gelso, C. J. (2018). The therapeutic
relationship in psychotherapy practice: An integrative perspective. Routledge.

• As noted in the body of the chapter, William R. Miller’s (2018) Listening

Well: The Art of Empathic Understanding is an excellent resource.

• A framework and detailed instructions for helping clients develop goals,

including creating stakeholder awareness, can be found in classic arti-
cles by Karl Tomm: Tomm, K. (1987). Interventive interviewing: Part II.
Reflexive Questioning as a means to enable self-healing. Family Process, 26(2),
167–183. https://doi.org/10.1111/j.1545-5300.1987.00167.x; Tomm, K.
(1988). Interventive Interviewing: Part III: Intending to ask lineal, circular,
strategic or reflexive questions. Family Process, 27(1), 1–15. https://doi.org/
10.1111/j.1545-5300.1988.00001.x

• The Society for the Advancement of Psychotherapy (APA Division of

Psycho­therapy) has created videos and resources for learning and teach-
ing relationship factors. They can be accessed free of cost at https://
societyforpsychotherapy.org/teaching-learning-evidence-based-relationships/

• Practice recommendations and case examples specific to each of the reviewed

relationship factors can be found in Norcross, J. C., & Lambert, M. J. (2019).
(Eds.). Psychotherapy relationships that work: Volume 1. Evidence-based therapist
contributions (3rd ed.). Oxford University Press.

• The research evidence on personalizing or adapting therapy to the indi-

vidual client can be found in Norcross, J. C., & Wampold, B. E. (2019). (Eds.).
Psychotherapy relationships that work: Volume 2. Evidence-based responsiveness
(3rd ed.). Oxford University Press.

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6
Hope and Expectancy Factors
Michael J. Constantino, Heather J. Muir, Averi N. Gaines, and
Kimberly Ouimette

Expectation colored by hope and faith is an effective force with which we have to reckon . . .
in all our attempts at treatment and cure.
—SIGMUND FREUD, THE COMPLETE PSYCHOLOGICAL
WORKS OF SIGMUND FREUD

DECISION POINT

Begin here if you have read the book Better Results and

• are routinely measuring your performance and

• have collected sufficient data to establish a reliable, evidence-based profile
of your therapeutic effectiveness and
• have completed the Taxonomy of Deliberate Practice Activities in
Psychotherapy and
• need help developing deliberate practice exercises that leverage hope and
expectancy factors.

I n the celebration and discussion of methods and techniques, central elements

in successful therapy—hope and expectancy—more often than not receive
scant attention. This is unfortunate because current evidence convincingly
demonstrates these critical components have a significant influence at the

https://doi.org/10.1037/0000358-007
The Field Guide to Better Results: Evidence-Based Exercises to Improve Therapeutic Effectiveness,
S. D. Miller, D. Chow, S. Malins, and M. A. Hubble (Editors)
Copyright © 2023 by the American Psychological Association. All rights reserved.
131
132 Constantino et al.

beginning and throughout the course of treatment, potentiating an eventual

positive result. Furthermore, specific, trainable therapist skills exist that can culti­
vate clients’ hope and expectancy, in any type of therapy, in a way that is helpful
for both engagement (i.e., the therapeutic relationship) and improvement.
This chapter centers on a central hope and expectancy variable, outcome
expectation (OE). In brief, OE is the prognostic belief about the effectiveness
of a given course of treatment (Constantino, Vîslă, et al., 2019). It is most
closely connected to Domain 2, Hope & Expectancy, in the Taxonomy of
Deliberate Practice Activities in Psychotherapy (TDPA; Chow & Miller, 2022;
see Appendix A, this volume). Empirically, OE has easily received the most
attention among therapy-related beliefs. Because its direct influence on treat-
ment outcomes is well established, it makes sense for therapists to understand
and cultivate their OE abilities.
Of course, other types of client expectations exist, such as the roles they
and their therapist will adopt and the length of treatment. Such beliefs are,
however, less directly connected to clients’ hopes about therapy helping them
in the future. Role or duration expectancies are leveraged clinically by shaping
them through role induction and attunement in the therapeutic relation-
ship. Discussion of client pretreatment role induction and preparation, which
closely corresponds to Item A in Domain 2 of the TDPA, is found in Chapter 3
(“Client Factors”) of this volume. Dyadic processes related to attunement are
covered in Chapter 5 (“Relationship Factors”) and represented in Sections A
(effective focus) and B (impact factor) of Domain 3 of the TDPA.
Whether viewed as a primary change ingredient or a necessary precursor
for other change processes to work more effectively, OE is embedded in many
theories of psychotherapeutic change (Constantino & Westra, 2012; Frank,
1961; Greenberg et al., 2006; Kirsch, 1990). When considered in combination
with the supportive research to be reviewed next, hope and expectancy have
rightful prominence in the TDPA as a focus for deliberate practice (DP).

FIELD GUIDE TIP

According to Constantino, Coyne, et al.

(2021), higher OE signifies

a state of existing or budding optimism

that psychotherapy, with its provider
and surrounding context, has a
personally meaningful change goal
and a viable pathway to achieving it
(Snyder, 2002). Conceptually, then,
such a remoralized and change
motivated state should facilitate
psychological improvement through
one’s course of treatment. (p. 712)
 Hope and Expectancy Factors 133

This chapter (a) reviews the major research that supports the clinical rele-
vance of OE in psychotherapy, (b) identifies evidence-based OE principles
for clinical intervention, (c) offers suggestions for DP exercises to leverage
empirically supported OE principles, and (d) highlights further practice and
training-related OE resources. It is important to note the studies included in
this review are drawn from the literature on adult clients, though many of the
principles can be readily adapted to work with children and adolescents.

REVIEW OF RESEARCH

A client’s OE can be assessed before therapy (a complete forecasting without

experience of the therapist or therapy), early in treatment (a prediction with
some experience of the therapist or therapy), or across treatment (a momentary
prediction in the context of an evolving therapeutic relationship and treat-
ment plan). As a dimensional variable, OE can range from extremely hopeless
(e.g., “This therapy won’t help me”) to being very hopeful (“This treatment is
going to eliminate my concerns”). There can also be grades in between, which
are often represented on measures as an amount of expected improvement,
such as on a scale from 0% to 100% (see Credibility/Expectancy Questionnaire
[CEQ]; Devilly & Borkovec, 2000).
From treatment’s outset, OE is a factor therapists should be mindful of
and attempt to cultivate (if there is room for growth in the degree to which a
client expects to improve from therapy) and harness (if a client’s OE is already
quite high). In addition, because client OE is prone to “wax and wane,” it should
be leveraged when high (e.g., persisting with an originally agreed-on treatment
plan or approach) and responded to when low (e.g., responsively departing
from the agreed-on plan; see Constantino, Coyne, & Muir, 2020; Constantino,
Goodwin, et al., 2021; Coyne et al., 2019). With these objectives in mind,
eight empirical findings related to cultivating and responding effectively to
client OE are reviewed.

OE–Outcome Association

The finding that has put OE on the evidence-based map, so to speak, is the
robust significant correlation between clients’ higher pre- or early-treatment OE
and outcome—specifically, greater reductions in symptomatic and/or functional
impairment. A meta-analysis revealed a small but significant positive effect,
with OE explaining approximately 3% of the variance in clients’ posttreatment
outcomes (Constantino, Vîslă, et al., 2019). To understand this figure, compare
it with the contribution made by a high-quality therapeutic alliance, which
explained, in a meta-analysis, about 7.5% of outcome variance (Flückiger
et al., 2019). As the alliance is considered one of the most important outcome
predictors, these data highlight how even seemingly moderate contributors,
such as OE, can be clinically meaningful. Notably, its association with outcome
134 Constantino et al.

in the Constantino, Vîslă, et al. (2019) meta-analysis held across different types
of therapies and presenting problems, making it a principle of change clini-
cians should attend to and cultivate regardless of their therapeutic orientation
and focus of their clinical work (see also Castonguay et al., 2019).

Moderators of the OE–Outcome Association

Three factors in the Constantino, Vîslă, et al. (2019) meta-analysis were shown
to affect the strength of the link between OE and posttreatment outcome (i.e.,
moderation). First, client OE had an even stronger positive association with
posttreatment improvement for younger versus older clients. Second, the asso-
ciation was stronger when OE was measured with a well-established scale
versus one developed specifically for a given study. Third, and finally, client
OE was a stronger predictor of outcome when therapists were using a treat-
ment manual. The “take home” message is OE can be especially important
under certain clinical circumstances.

Alliance Quality as a Mediator of the OE–Outcome Association

As with any variable–outcome correlation, it is important to understand how

such an effect is transmitted (i.e., mediation). To date, one variable has robustly
emerged as a mediator of the OE–outcome association: the quality of the client–
therapist alliance. In a recent meta-analysis by Constantino, Coyne, et al. (2021),
more hopeful OE early in care (Session 1, 2, or 3) predicted better client-rated
alliance during treatment, which, in turn, predicted better posttreatment
outcomes (see Figure 6.1 for a visual depiction of this mediational pathway).
The indirect effect of OE on outcome through alliance quality accounted for
approximately 35% of the total effect of OE on outcome. This result spotlights
how relational engagement can act as a vehicle for converting a client’s early
optimism about treatment into therapeutic benefit. Indeed, Constantino, Coyne,
et al. (2021) connected the relationship to the three central features of Snyder’s
(2002) hope theory:

A quality alliance . . . embodies patient-therapist collaborative agreement on treat-

ment targets (goals) and the tasks necessary to accomplish them (pathways),
as well as an energizing emotional connection (agency; Snyder, 2002). And more
than just seeing these goals and pathways as present and available, and experi-
encing a sense of agency in one’s change process, goal theory would imply that
the treatment-specific positive OE and hope would also be parlayed into devoting
more psychological and behavioral resources into achieving the targets they now
believe to be within their reach, to at least some degree—a type of “doing the
work” of psychotherapy. (p. 712)

In light of the OE–alliance–outcome pathway to change, clinicians can have

a better sense of how client OE can facilitate or hinder a shared relational
process in therapy (alliance) that is known to relate to client improvement.
This pathway can also manifest dyadically, with one participant’s experience
 Hope and Expectancy Factors 135

FIGURE 6.1. Direct OE-Outcome Association and Indirect OE-Outcome

Association Through Alliance Quality

Total effect

Outcome
Symptoms/distress
expectation c path
(–)

Mediation

Alliance
quality
(+ ath

b (–)
pa
p
)

th
a

Outcome
expectation Symptoms/distress
c ′ path
(–)

Note. The top portion of the figure shows a two-variable correlational analysis that
represents the total effect of pre- or early-treatment OE on posttreatment symptoms/
distress (with no mediator in the model). The results of such an analysis were reviewed
in the previous section, OE-Outcome Association. The bottom portion of the figure
shows each path of a mediator analysis testing alliance quality as a mediator of the
OE-symptoms/distress correlation. As noted, the Constantino, Coyne, et al. (2021)
meta-analysis indicated that more hopeful OE was associated with significantly lower
posttreatment symptoms/distress (this total effect is labeled with a minus sign on the
c’ path). Moreover, the beneficial influence of OE on posttreatment symptoms/distress
was partially transmitted through better alliance quality (mediation). That is, more
hopeful pre- or early-treatment OE was associated with significantly better during-
treatment alliance quality (this path is labeled with a plus sign on the a path). In turn,
better alliance quality was associated with significantly lower posttreatment symptoms/
distress (this total effect is labeled with a minus sign on the b path).
136 Constantino et al.

affecting the subsequent experience of the other in the therapeutic relationship.

For example, in a study of cognitive behavior therapy (CBT) for generalized
anxiety disorder, greater client-rated OE after one session (measured repeatedly
from Sessions 1–13) was associated with increases in therapist-rated alliance
quality after the next session (measured repeatedly from Sessions 2–14), which
in turn predicted lower client-rated worry in the subsequent session (measured
repeatedly from Session 3 to Session 15, which was the last session; Constantino,
Aviram, et al., 2020). This result suggested a client’s hopeful OE can have an
infectious quality on their therapist’s subsequent experience of the alliance.
In turn, the clinician’s positive experience of the alliance can have a beneficial
influence on the client’s subsequent experience of worry. Bottom line? Under-
standing the OE-alliance-outcome path might compel therapists to routinely
measure and monitor alliance and OE over time, which can provide multiple
prompts for appropriate responsiveness by capitalizing on these factors when
higher and explicitly addressing them when lower.

Client Characteristics That Correlate With Presenting OE

Knowing that OE is an important variable for treatment outcome has led to

the study of client demographic, contextual, and clinical factors that correlate
with their presenting OE. For demographic factors, female-identifying clients
indicated more hopeful presenting OE than male-identifying clients in a
college counseling center (Hardin & Yanico, 1983). Also, in a group therapy
context, older versus younger clients presented with higher OE (Tsai et al.,
2014). With regard to contextual variables, some evidence indicates clients
with prior therapy experience reported more positive OE for their current
group therapy than clients with no such treatment history (MacNair-Semands,
2002). As might be expected, one study suggested satisfaction with prior treat-
ment is key—more satisfaction related to more hopeful OE for their current
treatment for substance misuse (Tran & Bhar, 2014). In terms of clinical vari-
ables, when clients were generally more hopeful, they also reported more
positive therapy-specific OE (Goldfarb, 2002; Swift et al., 2012). In addi-
tion, possessing more psychological mindedness (defined as the ability to
be introspective in the service of understanding self and others) was shown
to be a positive predictor of more hopeful OE (Beitel et al., 2009; Constantino
et al., 2017). Finally, a meta-analysis showed that when symptoms or impair-
ment were more severe at the start of therapy, OE was lower (Constantino
et al., 2022).

Perceived Treatment Credibility-Outcome Association: Main Effect of

an OE-Related Construct

A construct related to OE worth noting is client-perceived treatment credi-

bility. It is defined as how coherent, suitable, plausible, and effective an inter-
vention (for which at least some information has been provided) seems to a
 Hope and Expectancy Factors 137

given client (Devilly & Borkovec, 2000). Although distinct from OE (because
it is possible that a client could see a treatment as generally credible and yet
still believe they will not benefit from it), treatment credibility is certainly in
the same belief “soup,” so to speak. Empirically, a small but significant positive
association between credibility and improvement was identified in a recent
meta-analysis (Constantino, Coyne, et al., 2019), explaining approximately 1.5%
of the variance in clients’ posttreatment outcomes. Notably, this association
held across different client demographic variables, presenting problems, and
treatment approaches. Like OE, therefore, client-perceived treatment credibility
is another belief-oriented principle of change clinicians should attend to and
cultivate for clinical benefit (see also Castonguay et al., 2019).

Therapist Utterances or Actions That Influence Client OE

Therapist words, utterances, and in-session actions have received a great deal
of attention over the years. It is assumed, almost like magical talismans, choice,
order, and timing can either harm or heal (Miller & Hubble, 2017). To date,
a few lab-based studies have manipulated therapist utterances and actions to
determine their impact on client OE. For example, Kazdin and Krouse (1983)
found participants reported more hopeful OE after hearing an audio recorded
treatment rationale that included (a) a description of the approach as “presti-
gious”; (b) a description of the approach as focused on affect, cognition, and
behavior; (c) some theoretical jargon; and (d) examples of past successes.
In another lab-based study (Horvath, 1990), participants reported more positive
post-rationale OE when the recording was moderately long (vs. brief or some-
what longer). Thus, messages of moderate length could be a sweet spot that
maximizes client comprehension through conciseness while not sacrificing
the necessary details to be credible and persuasive.
Finally, a more recent clinical analog experiment (Ametrano et al., 2017)
with socially anxious undergraduates compared a standard video-delivered
rationale of CBT for social anxiety (control group) with one enhanced with
expectancy persuasion techniques (experimental group), including those found
in the aforementioned Kazdin and Krouse (1983) and Horvath (1990) studies
(e.g., use of jargon and successful case vignettes). Across both conditions, the
participants’ OE became significantly more positive from pre- to postrationale
delivery. However, no benefit was associated with the use of specific expectancy
persuasion strategies. The authors argued that this lack of additive effect may
have been due to the standalone potency of a clear and compelling CBT rationale
for treating social anxiety. That is, in some cases, a standard rationale may be
sufficient to enhance OE.

Therapist-Rated OE–Outcome Association

Although OE has been historically conceptualized and studied as a client factor,

it is clear therapists also have expectations regarding the degree of success a
138 Constantino et al.

given client will have in treatment. While research on therapist OE and client
improvement is sparse, a handful of studies have provided evidence of impact
over and above client OE ratings (e.g., Connor & Callahan, 2015; Swift et al.,
2018). Moreover, one study added nuance to understanding the association
between therapist OE and client outcome (Constantino, Aviram, et al., 2020).
First, as therapist OE became more hopeful over time, clients evidenced better
next-session outcomes. This demonstrates a dynamic effect of change in therapist
OE on client improvement. Second, when therapist OE for a specific client was
higher than their average OE for all clients in their caseload, those particular
clients achieved better results than the therapist’s average client.

Therapist Differences on Client OE

A few studies have examined whether individual therapists themselves

meaningfully affect the variance in client OE. Of these studies, three have
found, across different types of treatments for varied mental health con-
cerns, some therapists foster significantly more hopeful client OE across all
clients in their caseloads (Constantino, Aviram, et al., 2020; Coyne et al.,
2021; Vîslă et al., 2019). One study found therapists also differed in their
ability to cultivate increases in more hopeful client OE over the course of

FIELD GUIDE TIP

Chapter 8 of Better Results (BR)

describes and illustrates how to mine
your performance data for deliberate
practice opportunities.
You can put the findings on OE
to use in your deliberate practice
efforts by tracking your response
to a question that has been shown
to predict treatment outcome
(scoring information can be found
in Constantino, Aviram, et al., 2020).
“By the end of therapy, how
much improvement in your client’s
(problem) do you really feel will
occur?”
Begin with new clients, in time
computing an average and then
looking closely at the relationship
between your OE and client progress
and outcomes.
 Hope and Expectancy Factors 139

treatment (Vîslă et al., 2021). In sum, a small but growing research base sug-
gests therapists can meaningfully contribute to this factor, both at any given
moment and over time during treatment.

EVIDENCE-BASED PRINCIPLES RELATED TO HOPE AND

EXPECTANCY FACTORS

As the research reviewed is mostly correlational, it is difficult to prescribe

definitive ways in which therapists can clinically address clients’ OE. That said,
the weight of the data is such that several evidence-based principles (based on
the best available science) can be identified for helping therapists cultivate
and respond to their client’s OE (see Table 6.1 for a concise summary of the
previously reviewed research threads organized by the eight principles). Note
that the principles described are drawn mainly from prior syntheses of clinical
OE strategies (i.e., Ametrano et al., 2017; Constantino et al., 2012; Constantino,
Coyne, et al., 2019; Constantino, Vîslă, et al., 2019; Coyne et al., 2019) and
from an unpublished “expectancy persuasion” treatment manual (Constantino
et al., 2006).

Principle 1: Mind Clients’ Pre- and Early-Treatment OE

Therapists should regularly assess any new clients’ presenting OE level to estab-
lish a baseline for how much this belief is a risk (when lower or less hopeful)
or facilitative factor (when higher or more hopeful). Such measurement can be
accomplished with a brief, psychometrically established self-report instrument,
such as the aforementioned CEQ (Devilly & Borkovec, 2000) or the Milwaukee
Psychotherapy Expectations Questionnaire (MPEQ; Norberg et al., 2011).
Second, and especially when OE is low, therapists should prioritize promoting
a client’s treatment-related hopefulness at the outset of therapy. Clinicians can
cultivate client OE by providing a clear treatment rationale well-suited to the
client’s personal understanding of their presenting concerns, therapy goals,
and ideas about how people change. Once the rationale is accepted, therapists
can then propose and begin accompanying therapeutic strategies that are
logically aligned with the rationale. To help therapists know how well this is
going, they can administer the CEQ or MPEQ after presenting a treatment
rationale and repeatedly through treatment. If therapists are unable to use
such a measure, they should, at a minimum, assess client OE verbally.
Third, once treatment is underway and it is revealed a client’s current
OE is less hopeful, the clinician should consider using responsive and explicit
OE-fostering strategies. For instance, they can try to deliver personalized,
hope-inspiring statements, such as how the client appears to be a good candi-
date for the treatment before them and/or how the therapist has witnessed
the treatment help clients with similar demographic and clinical characteristics
in the past. Therapists can also reference in accessible language the research
that supports the efficacy of psychotherapy in general and/or the selected treat-
ment in particular.
140 Constantino et al.

TABLE 6.1. Summary of Findings on Outcome Expectations and

Treatment Outcomes
OE finding Level of Principle
support no.
Higher pre- or early-treatment client OE predicts better MA 1
posttreatment client outcomes
OE—outcome association stronger for younger clients MA 2
OE—outcome association stronger when OE assessed using MA 2
well-established measure
OE—outcome association stronger when therapists use a MA 2
treatment manual
Higher pre- or early-treatment client OE predicts better MA 3
therapeutic alliance quality, which predicts better post­
treatment client outcomes
Higher session one client OE predicts better therapist-rated SS 3
therapeutic alliance quality the next session, which predicts
better client outcome the following session
Clients with higher symptom severity report less hopeful OE MA 4
Clients who are more hopeful in general have higher OE MS 4
Psychologically minded clients report more hopeful OE MS 4
Female-identifying clients have higher OE than male-identifying SS 4
clients
Older adult clients report higher OE for group therapy than SS 4
younger adult clients
Clients with prior therapy experience report higher OE for group SS 4
therapy than clients without prior treatment experience
Clients who are more satisfied with prior treatment experiences SS 4
report higher OE for treatment of substance misuse
Higher pre- or early-treatment credibility predicts better MA 5
posttreatment client outcomes
Describing therapeutic approach as prestigious as part of the SS 6
treatment rationale promotes higher client OE
Describing therapeutic approach as broadly focused on affect, SS 6
cognition, and behavior promotes higher client OE
Using some theoretical jargon as part of the treatment rationale SS 6
promotes higher client OE
Providing examples of past successes as part of the treatment SS 6
rationale promotes higher client OE
Providing a treatment rationale of a moderate length promotes SS 6
higher client OE
Presenting a clear and compelling cognitive behavior therapy SS 6
rationale for treating social anxiety promotes more hopeful
client OE
More hopeful therapist OE predicts better client outcomes MS 7
More hopeful therapist OE at one session predicts better client SS 7
outcome at the next session
Therapists’ more accurate estimation of their clients’ OE predicts SS 7
better posttreatment client outcome
Some therapists foster higher client OE across all clients in their MS 8
caseloads than others
Some therapists are better able to cultivate increases over time in SS 8
hopeful client OE across all clients in their caseloads than others
Note. MA = meta-analysis; MS = multiple studies; OE = outcome expectation; SS = single study.
 Hope and Expectancy Factors 141

Conversely, therapists should consider evidence of high client OE at a

given time during therapy as a “green light” to stay the current treatment course
that has thus far proven to be compelling and hope inspiring. If greater hope-
fulness is accompanied by early client improvement (e.g., as demonstrated
with a routine outcome measure), therapists will want to explicitly spotlight
such progress to their clients. In doing so, therapists can frame this change
as tangible evidence that the client is likely to experience additional future
change as well.
Therapists should also assess and stay attentive to the possible waxing and
waning of client OE throughout treatment. Again, this would ideally involve
the repeated use of a brief OE measure throughout treatment. However, if
unable to use such a measure, repeated verbal check-ins could be a proxy
(e.g., “At this moment, how hopeful are you that this treatment approach will
help you improve?”). Then, as therapists obtain such information, they should
be prepared to maintain (when OE remains marked by more hopefulness) or
adapt (when OE becomes less hopeful) the treatment plan accordingly.

FIELD GUIDE TIP

Early on in BR, you were asked to create a

schematic or blueprint for how you do therapy
sufficiently detailed so another practitioner
could understand and replicate it—literally,
“step into your shoes” and work how you work
(Miller et al., 2020, p. 29).
Retrieve your map, noting if, when, and how
you explicitly address OE in your clinical work
(e.g., from providing a clear and compelling
rationale at the outset of treatment to addressing
the ebb and flow of client OE throughout).

Principle 2: Mind the Circumstances Under Which OE Is Most Potent

When working with younger clients, when measuring OE with a well-

established measure, and when delivering a manualized treatment, clinicians
should be particularly attentive to clients’ pre- and early-treatment OE level.
Once aware that one or more of these contexts applies (where the connection
between OE and client outcome is more potent), clinicians can draw on the
same strategies outlined for Principle 1: Either try to cultivate OE when it trends
toward pessimism or harness it when it trends toward hopefulness. It may be
especially important under these three conditions for therapists to closely track
client OE over time to capitalize on it when it waxes (e.g., persisting with a
142 Constantino et al.

manualized therapy that continues to promote client hopefulness) and appro-

priately respond when it wanes (e.g., empathizing with, and perhaps shifting
treatment course for, a younger client who has lost hope that the therapeutic
approach will help).

Principle 3: Appreciate That OE’s Effect on Outcome Is Partly

Transmitted Through the Alliance

Because the therapeutic alliance helps transmit the beneficial influence of

more hopeful client OE on treatment outcomes, clinicians should regularly
and routinely assess both client OE and alliance quality during a course of
treatment. Alliance measurement provides a proxy marker for OE level. If alli-
ance quality has waned, for example, it would be useful to explore with the
client whether this may have, at least partly, resulted from diminished hope
in the effectiveness of the provider or treatment. One version of alliance repair
could be to engage in OE cultivation or restoration strategies (see Principle 1).
Alternatively, or in addition to these OE strategies, the clinician could engage
in explicit alliance rupture-repair strategies reviewed in Chapter 5 (relationship
factors); a repaired alliance could then promote better subsequent treatment
outcomes.

Principle 4: Consider Known Correlates of Client OE

Therapists should familiarize themselves with client characteristics associated

with OE. Beyond assessing initial risk associated with low hope or facilitating
high hope, doing so can help with developing a personalized treatment plan. For
clients who possess one or more risk factors for low presenting OE (e.g., male
identifying, younger), a therapist might consider using first-step strategies for
cultivating more initial hope (e.g., presenting a clear and compelling rationale).
The strongest signal for using such interventions (without direct measurement
of client OE) is when clients present with more severe impairment. Conversely,
when clients present with more facilitative factors (e.g., satisfaction with prior
treatment, greater psychological mindedness), it may prompt clinicians to move
forward more efficiently with the treatment approach they intend to use. It is
more likely that these clients already trust the therapist and are persuaded by
the direction they will take (thereby capitalizing on their expectation that
treatment will help them to a meaningful degree).

Principle 5: Mind Clients’ Pre- or Early-Treatment Perceptions of

Treatment Credibility

As with OE, at the outset of treatment with any client, therapists should attempt
to foster the perceived credibility of treatment. Again, finding an individually
tailored way to describe treatment that promotes a personally compelling
rationale for the chosen pathway to change can go a long way toward the early
 Hope and Expectancy Factors 143

establishment of credibility (e.g., Larsen & Stege, 2010a, 2010b). While pro-
viding a rationale, therapists can also
tend to patients’ verbal and nonverbal indicators that the rationale is under-
standable, persuasive, and interesting. Although therapists may believe that they
are giving a textbook description of, say, behavioral activation for depression,
a perplexed look can tell a thousand words; in this case, that behavioral activation
may be unconvincing to that particular patient at that particular time. Or, at a
minimum, how you are describing it may require more clarity, or a different tact.
(Constantino, Coyne, et al., 2019, p. 516)

Such credibility can then be enhanced by therapists’ using strategies clients

perceive as consistent with their beliefs about change. Clinicians should assess
credibility in addition to OE (at least verbally or with the CEQ that measures both
credibility and expectancy). As with OE, such assessments should continue
throughout therapy because credibility perceptions can shift.

Principle 6: Say and Do Things That Cultivate Client OE

Therapists should regularly attempt to provide a clear and strong rationale

in a way that is moderate in length versus being overly wordy or under­
developed. In addition, wording can help or hinder. Describing an approach
as “prestigious,” “evidence-based,” and having been successful in past cases
can help in fostering hope and expectation. As previously noted, clinicians
should not overrely on such utterances because current evidence is not strong
for their causal impact.

Principle 7: Appreciate Distinctions Between and Relations Among

Therapist and Client OE

Recall, in different ways, therapists’ OE can influence the degree to which a

client benefits from therapy. First, as a therapist’s OE dynamically increases
over time, so too does the client’s level of subsequent improvement. Second,
higher therapist OE for a specific client relative to all their clients leads to
greater-than-average improvement for that specific client (compared with that
therapist’s average client). As Constantino, Boswell, and Coyne (2021) noted,
Therapists might consider both how their OE for a given patient compares to
their OE for other patients in their caseload (between-patient) and how their OE
for a given patient shifts over time (within-patient). Such information can help
therapists respond effectively to relatively low (at, or averaged across, a specific
time) or lowered (changing across time) OE. (p. 249)

Principle 8: Therapist, Know Thyself

Therapists can differ in their ability to foster their average clients’ early OE or
change in OE over time. Regularly measuring client OE can help therapists
determine whether their clients have consistently more or less hopeful OE.
If ratings tend to be middling or lower across the board, therapists should
144 Constantino et al.

consider receiving specific training on and supervision regarding OE persuasion

and expectancy interventions. And consistent with this volume’s main thesis,
they should deliberately practice what they learn.

EXERCISES FOR HOPE AND EXPECTANCY FACTOR SKILL

DEVELOPMENT

In this section, a number of DP exercises are described, each designed to

help therapists improve their OE-related skills—both those applicable at the
outset or in response to variations in client OE across treatment. As in other
chapters, it is assumed that you (a) are routinely monitoring your therapeutic
outcomes, (b) are in possession of data sufficient to establish a reliable, evidence-
based profile of your therapeutic effectiveness, (c) have completed the TDPA,
(d) identified specific skill deficits in your performance related to hope and
expectancy, (e) narrowed your focus to a single element within this domain
on the TDPA, and (f) defined performance improvement in SMART terms
(specific, measurable, achievable, relevant, and time bound) per the final
instructions. Review the following exercises for those that best align with your
improvement goal.

Exercise 1: Assessing OE Therapeutically

Principle: 1
Applicability: TDPA Items 2A, B, and G (also applicable to Items 1E,
F, H, 3Aiii, iv, Bi, 3D, 4A, E)
Purpose
This exercise aims to increase skills in applying OE assessment in a therapeutic
manner.

Task
Part 1. Begin using a brief, formal measure of OE (e.g., the OE scale of the CEQ
or the MPEQ; Devilly & Borkovec, 2000; Norberg et al., 2011). Together with
a colleague, coach, or supervisor, practice using the measure therapeutically.
In role-plays, help the client

• give responses enabling you to gain an accurate understanding of their

OE, and

• clarify the individual features of their OE—why they feel the way they do
(e.g., previous experiences, your presentation, what they have heard about
the treatment you are offering).

Ask the person practicing with you to enact different levels and types of
OE alongside varying amounts of openness and honesty. Doing so will pro-
vide critical opportunities for enhancing your OE assessment skills as well as
identifying individualized OE features to address or build on. As you did with
 Hope and Expectancy Factors 145

measures of outcome and alliance, practice orienting clients to the nature and
purpose of the questionnaire (e.g., creating a culture of feedback). For instance,
“I am going to ask you to complete a survey that measures how hopeful you
are that therapy will be helpful to you. It will let me know whether we are on
the right track and help us discuss our work together. I invite you to be as open
and honest as possible, even though you might feel pulled to answer in a way
that would please me. Does this sound like something we could try?”

Part 2. Brainstorm questions befitting your style and therapeutic orientation

for assessing and exploring client OE through conversation and test them out
with a practice partner. For example, you may practice asking a direct, specific
question: “I know we have discussed your therapy expectations in general,
but more specifically, on a scale of 0 to 10, how much do you think the treat-
ment I’ve proposed will help you with your concerns—with 0 being not helpful
at all and 10 being substantially helpful?” Your partner should respond to your
entreaties, providing you with an opportunity to “think on your feet.” Seek
feedback, reflect, and revise, and then complete the exercise again with relevant
modifications to your approach.

Exercise 2: Let’s Talk About Hope

Principle: 1
Applicability: TDPA Item 2A and G (also applicable to Items 1D–F,
3Aiii, iv, 3Diii, 4A, B)
Purpose
This exercise aims to build skills in opening and guiding a dialogue about client
OE in the context of varying levels of hopefulness, as well as learning to do so
in different, responsive ways while avoiding being overly scripted.

Task
Practice opening a discussion about the results of the expectancy measure or
verbal assessment based on various possible client responses. Specifically, prac-
tice starting an OE discussion with

• a client who reports low hopefulness where remedial action may be

required or
• a client reporting high hopefulness that can be leveraged for optimal benefit.

For example, you could begin practice activities by testing opening statements
and questions, such as, “I noticed your score on this measure was high—does
this fit with how you’re feeling about how this treatment is going?” or “What
seems to be helpful about this treatment right now?” You can also take time
to imagine how you would respond to a client who is less hopeful by saying,
“I noticed you answered this question in such a way that indicates you might be
feeling that our work together may not prove helpful for you in the long run.
Would you be open to discussing this further with me? I’d like to move away
from those things you don’t find useful.”
146 Constantino et al.

Next, imagine various versions of what you would say to a client who answers
positively, negatively, or ambiguously. Try them out with a colleague who
role-plays the client. As the conversation evolves, aim to identify ways in which
the treatment or its rationale could be adjusted to address low hopefulness.
Conversely, use the conversation to practice identifying ways to capitalize on
high hopefulness for client benefit. For maximum benefit, record and review
your role-playing, limiting the exchange to 5 minutes and using your practice
partner’s feedback to guide successive repetitions of the exercise. Slowly increase
the difficulty over time, asking your partner to use client presentations they
find challenging.

Exercise 3: Just Be Curious

Principle: 1
Applicability: TDPA Items 2D–F (also applicable to Items 1G, 3Aiii, Div)
Purpose
This exercise aims to develop skills in leveraging OE when client outcomes
improve. Through practice, you will learn ways of capitalizing on therapeutic
successes to optimize hope and expectancy.

Task
Part 1. At the end of each day, take 5 minutes to reflect on the clients you
met, paying particular attention to how you responded to reports of progress.
Write down the client’s name, presenting problem, what you said or did (using
no more than a Twitter-length sentence), and how much time was spent on
discussing progress relative to other matters discussed in the session. Continue
this activity several times a week, spending no more than 20 minutes at a time.
After a month, retrieve your notes and begin sorting the collection into themes
(e.g., age, gender identification, level of emotional distress, diagnosis). Refine
the list if needed by continuing the exercise for a few additional days.

Part 2. Recalling that DP is designed to address performance deficits, pick the

theme on which you spent the least amount of time discussing progress, first
exploring the reason for the difference and then writing out how you will be
more curious in the future under such circumstances. Specifically, script how
in your own words and style, you could

• elicit a clear description of the improvement from the client’s perspective,

• elicit the client’s reasons for the improvement,
• identify ways that treatment may have helped with this improvement
(with room to discuss ways it may not have helped), and
• discuss how hopeful they feel about therapy now and possible future
improvements.

Part 3. Finally, try out what you develop with a practice partner who presents
either as a client who attributes improvement to the helpfulness of therapy or
one who does not. Along the way, go slow, stopping to reflect whenever you
encounter a challenging moment or are at a loss for words. Develop at least
 Hope and Expectancy Factors 147

two alternative responses, eventually enacting these in the role play. Whatever
you try out, get feedback from your practice partner on their experience as
the client.

Exercise 4: Responding to Pessimism

Principle: 2
Applicability: TDPA Items 2B–D (also applicable to Items 1F, 3Aiii,
5Aii, iv)
Purpose
This exercise aims to use your clinical experiences to develop skillful responses
to situations where hope and expectancy are low.

Task
Part 1. For several weeks, keep track of clients who express pessimism in
the initial visits about therapy resolving their difficulties. After identifying at
least two or three, pick one and devote 20 minutes to recalling your response,
writing out as much of the dialogue as possible. Set what you’ve written aside,
returning to it in your next scheduled DP period. Check your recollection,
making any needed edits. Now, rewrite your comments, working to strike a
balance between inspiring hope while not being overly optimistic or risking
the client feeling you do not understand their situation. For example, you
might begin with something like, “You’ve been struggling for a long time on
your own, but you’ve come to the right place. I’ve been using this treatment
approach for a number of years to help clients with similar concerns, and
because you’re motivated to explore your thought processes more in depth,
it seems like a great fit for you.” Next, imagine the client’s response, both
positive and accepting and negative and skeptical. Write responses for both
possibilities. Once completed, move on to the next client. Remember, DP is a
marathon, not a sprint. The point of the process is not “crossing the finish line”
but rather reflecting on the moment-to-moment actions making up the race.

Part 2. Having rewritten your conversations with clients, role-play live with
a practice partner. Begin by asking them to recall one of their own clients
who presented with low OE. Have them “turn up” or “turn down” specific client
attributes in, for example, a client who is moderately responsive, slightly respon-
sive, or even unresponsive to your approach. Use your partner’s feedback to
refine successive trials of the hopeful initial dialogue.

Exercise 5: Developing and Refining an Effective Treatment Rationale

Principle: 2, 5, 6
Applicability: TDPA Items 2A–C, E–G (also applicable to Items 1A,
F, K, 3Diii, 4A)
Purpose
In this exercise, you will design and develop a treatment rationale that fits with
existing evidence and can be personalized to different client presentations.
148 Constantino et al.

Task
Part 1. Retrieve the schematic or blueprint you created after reading Better
Results (BR; Miller et al., 2020) and refined after completing the exercises in
Chapter 1 of the Field Guide. Locate when and how you describe your treatment
rationale. If absent, write one out in clear, easily understandable language.
Your rationale should include
• a statement regarding the general efficacy of psychotherapy (e.g., “People
who go to therapy for mental health concerns are better off than 80% of
those who do not”);
• the research support for and a brief description of your specific treatment,
including a basic overview of how it works and the nature of the strategies
employed;
• metaphors that help to communicate the effectiveness of treatment (e.g.,
“Psychotherapy is as effective as coronary artery bypass surgery and has
fewer side effects”); and
• your experience with the method employed and past work with people who
have similar presenting concerns, histories, and/or identities.
Add or update your blueprint accordingly.

Part 2. Ask a trusted colleague to pick two or three different clients with whom
they have worked, and role-play the part of a first meeting during which you
deliver your rationale. Request they include clients on a spectrum from skep-
tical and unenthusiastic to enthusiastic and fully convinced about the benefits
of therapy. Because such exchanges are information dense, spend no more than
5 to 7 minutes on the exercise. Record your practice session for later review
and refinement, including any immediate feedback they provide.

Part 3. Perceptions of treatment credibility suffer when clients experience a

lack of fit with the treatment rationale and plan. This portion of the exercise
is focused on reengaging “at-risk” clients. Begin by reviewing your caseload,
identifying any clients at risk for a negative or null outcome (e.g., less than
reliable change or in the red zone on various outcome management software
programs; see pages 67–69 in BR). Write a brief description of each, focusing
specifically on who they are as individuals rather than how they are similar to
other clients. Chow’s (2022) “Four S” approach may be helpful in completing
the process, noting (a) their sense of self (e.g., beliefs, personality, what they
identify with), sparks (e.g., what they care about, what makes them come alive),
significant life events (e.g., traumas, fortuitous and formulative happenings),
and systems (e.g., positive and negative impactful relationships, critical envi-
ronmental supports).
Next, review the treatment plan for each of these clients, noting the degree
of fit with their 4 Ss. Pay particular attention to how they understand the
origin and nature of their mental health concerns because this will influence
what treatment approaches and activities they find credible. Modify the ratio-
nale and plan in accordance with the individual’s 4 Ss and understanding of
 Hope and Expectancy Factors 149

their presenting concerns. Take your time in completing the task. Devoting a
few minutes each day to the exercise is likely to prove more helpful in fostering
the thinking and reflecting necessary to have an impact on subsequent perfor-
mance than trying to complete it in a single sitting.

Exercise 6: Addressing Correlates of Client OE

Principle: 4
Applicability: TDPA Items 2B–G (also applicable to Items 3Aiv, Ci, 4A–C)
Purpose
This exercise aims to help develop skills in identifying and addressing correlates
of clients’ OE.

Task
First, review your current clients, identifying those possessing features cor-
relating with OE. Recall these include

• greater symptom or impairment severity (associated with lower OE),

• male gender identity (associated with lower OE),
• younger age (associated with higher OE),
• negative experience of previous therapy (associated with lower OE),
• greater psychological mindedness (associated with higher OE), and
• greater general hopefulness (associated with higher OE).

Next, with specific clients in mind, write how you addressed (or will address
with similar clients in the future) their therapy OE. For example, with someone
who has had a prior course of treatment, you might begin with a question
about how satisfied they were, adding context and details to your inquiry:
“Being in treatment before can be both good and bad. Research shows, for
example, both can affect how a person expects to be helped. Would you be open
to discussing your prior experience and if and how it might influence how
helpful you expect our work together to be?”
Finally, referencing one or more of the characteristics described earlier,
identify a previous client who dropped out or had a negative or null outcome,
or identify a current client who is not making progress. After describing the
client to your colleague, supervisor, or coach, practice delivering the responses
you wrote out. Because such exchanges are information dense, spend no more
than 5 to 7 minutes on the exercise. Record your practice session for later
review and refinement, including any immediate feedback they provide.

Exercise 7: How Hopeful Are You?

Principle: 7
Applicability: TDPA Items 2E–G (also applicable to Items 3Biv, 4A,
5Aii, iv)
Purpose
This exercise aims to help you reflect on the way your own OE may impact
your clients.
150 Constantino et al.

Task
At the end of the first session with every new client, rate your hope and
expectation for success using the OE scale of the CEQ, the MPEQ, or a simple
scaling question (e.g., 0–10; Devilly & Borkovec, 2000; Norberg et al., 2011).
After a month, or when you have met each client at least three or four times,
divide them into two groups—one for which you had more hopeful OE (e.g.,
a 7 or higher on a scale from 0 to 10) and another less hopeful (e.g., 3 or lower).
Compare the alliance and outcome scores of the two groups. Should a differ-
ence be present, reflect on how your initial low OE may have influenced your
therapeutic relationship and the treatment’s effectiveness. Next, for each client,
identify the session when your low OE began to have a negative impact. Note
whether a pattern exists in terms of timing or client characteristics. Brainstorm
and document alternative responses. Should no difference be found, choose
to either continue gathering data for another month or reflect on the specific
ways you worked with your client to (a) improve your OE or (b) integrate
your positive OE into care.

FURTHER READINGS AND RESOURCES

As should be evident, OE is an evidence-based, pantheoretical, and pandiagnostic

factor in psychotherapy. As such, it is worthy of attention as therapists work to
hone their craft. To augment the research summary, principles, and exercises
outlined in this chapter, this section provides additional readings and resources
that may prove helpful as clinicians engage in their personalized DP.
Ametrano, R. M., Constantino, M. J., & Nalven, T. (2017). The influence of expectancy
persuasion techniques on socially anxious analogue patients’ treatment beliefs and
therapeutic actions. International Journal of Cognitive Therapy, 10(3), 187–205. https://
doi.org/10.1521/ijct.2017.10.3.187
Constantino, M. J., Ametrano, R. M., & Greenberg, R. P. (2012). Clinician interventions
and participant characteristics that foster adaptive patient expectations for psycho-
therapy and psychotherapeutic change. Psychotherapy, 49(4), 557–569. https://doi.org/
10.1037/a0029440
Constantino, M. J., Boswell, J. F., Coyne, A. E., Kraus, D. R., & Castonguay, L. G. (2017).
Who works for whom and why? Integrating therapist effects analysis into psycho-
therapy outcome and process research. In L. G. Castonguay & C. E. Hill (Eds.), Why
are some therapists better than others? Understanding therapist effects (pp. 55–68). American
Psychological Association. https://doi.org/10.1037/0000034-004
Constantino, M. J., Coyne, A. E., Boswell, J. F., Iles, B., & Vîslă, A. (2019). Promoting treat-
ment credibility. In J. C. Norcross & M. J. Lambert (Eds.), Psychotherapy relationships
that work: Volume 1. Evidence-based therapist contributions (3rd ed., pp. 495–521). Oxford
University Press. https://doi.org/10.1093/med-psych/9780190843953.003.0014
Constantino, M. J., Coyne, A. E., & Muir, H. J. (2020). Evidence-based therapist respon-
sivity to disruptive clinical process. Cognitive and Behavioral Practice, 27(4), 405–416.
https://doi.org/10.1016/j.cbpra.2020.01.003
Constantino, M. J., Vîslă, A., Coyne, A. E., & Boswell, J. F. (2019). Cultivating positive
outcome expectation. In J. C. Norcross & M. J. Lambert (Eds.), Psychotherapy relation-
ships that work: Volume 1. Evidence-based therapist contributions (3rd ed., pp. 461–494).
Oxford University Press. https://doi.org/10.1093/med-psych/9780190843953.003.
0013
 Hope and Expectancy Factors 151

Coyne, A. E., Constantino, M. J., & Muir, H. J. (2019). Therapist responsivity to patients’
early treatment beliefs and psychotherapy process. Psychotherapy, 56(1), 11–15. https://
doi.org/10.1037/pst0000200
DeFife, J. A., & Hilsenroth, M. J. (2011). Starting off on the right foot: Common factor
elements in early psychotherapy process. Journal of Psychotherapy Integration, 21(2),
172–191. https://doi.org/10.1037/a0023889
Muir, H. J., Coyne, A. E., Morrison, N. R., Boswell, J. F., & Constantino, M. J. (2019).
Ethical implications of routine outcomes monitoring for patients, psychotherapists,
and mental health care systems. Psychotherapy, 56(4), 459–469. https://doi.org/
10.1037/pst0000246
Swift, J. K., & Derthick, A. O. (2013). Increasing hope by addressing clients’ outcome
expectations. Psychotherapy, 50(3), 284–287. https://doi.org/10.1037/a0031941

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Patients’ expectations for improvement and their relations to baseline, process and
outcome variables in group cognitive-behavioural therapy for depression. Clinical
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Vîslă, A., Constantino, M. J., & Flückiger, C. (2021). Predictors of change in patient treat-
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https://doi.org/10.1080/10503307.2018.1428379
7
Structural Factors
Nicholas Oleen-Junk and Noah Yulish

You learn techniques to understand principles. When you understand the principles, you
will create your own techniques.
—ALAIN GEHIN, IN ACCESSING THE HEALING POWER
OF THE VAGUS NERVE

DECISION POINT

Begin here if you have read the book, Better Results and

• are routinely measuring your performance and

• have collected sufficient data to establish a reliable, evidence-based profile
of your therapeutic effectiveness and
• have completed the Taxonomy of Deliberate Practice Activities in
Psychotherapy and
• need help developing deliberate practice exercises that leverage structural
factors.

I n this chapter, a lesser discussed but increasingly evidenced-based thera-

peutic factor is conceptualized and operationalized: the structure of treatment
(Duncan et al., 2010; Hubble et al., 1999; Proctor & Rosen, 1983). The purpose
is to help clinicians optimize the contribution to outcome made by structural

https://doi.org/10.1037/0000358-008
The Field Guide to Better Results: Evidence-Based Exercises to Improve Therapeutic Effectiveness,
S. D. Miller, D. Chow, S. Malins, and M. A. Hubble (Editors)
Copyright © 2023 by the American Psychological Association. All rights reserved.
155
156 Oleen-Junk and Yulish

elements in their work, including maintaining focus on the constituent compo-

nents and associated actions important to outcome, ensuring effective pacing
in and between sessions, and understanding when the services as constructed
and delivered by the clinician are (and are not) working. The material that
follows is divided into four sections, each specifically designed to be applicable
across theoretical orientations:

• a review of the research on therapeutic structure

• a framework for conceptualizing the contribution of structure to outcome
• a presentation of evidence-based principles
• exercises for practicing the skills that improve therapeutic structure

Before proposing a conceptualization of therapeutic structure and reviewing

the evidence for its effects on client outcomes, it is important to address what
many view as the quintessence of structure in clinical work: the models and tech-
niques used by practitioners (e.g., cognitive behavior, time-limited dynamic
therapy, solution-focused, eye movement desensitization and reprocessing, inter-
personal psychotherapy). While treatment models (and related theories regarding
human change) are frequently the clinical topics most enthusiastically pursued by
trainees and professionals, decades of sophisticated research consistently show
they bear little, if any, relationship to outcome (Wampold et al., 2017; Wampold
& Imel, 2015). Simply put, it is time to abandon the notion that clinicians can
choose the best approach for a particular problem based on its empirical supremacy.
And while it may at first seem contradictory, when properly considered, the orga-
nization of clinical activity provided by models and techniques does make an
important contribution to the effectiveness of psychotherapy.
Consider first how theoretical models and techniques introduce trainees
to therapy. Whether presented in introductory textbooks, video recordings
of master therapists, detailed treatment manuals, or the reflections of expert
therapists who have reimagined their approaches over the years (e.g., Irvin
Yalom, e.g., 2017; Francine Shapiro, e.g., 2002; Neil Jacobson, e.g., Hines, 1997),
models and techniques provide a sense of focus and direction (i.e., what is
relevant to discuss and explore, the goals deemed important, the route ther-
apeutic work will take, and indicators of success and failure). Thus, in this
chapter, the theories, protocols, and techniques associated with specific treat-
ment approaches are not discussed or analyzed. Instead, emphasis is placed on
identifying and elucidating the structures contributing to the effectiveness of
all treatment models. In so doing, the persistent, cynical, and inaccurate inter-
pretations of the dodo verdict (the well-supported finding that all empirically
validated psychotherapies, regardless of their specific components, produce
equivalent outcomes) are avoided (see the exchange between Hofmann &
Barlow, 2014, and Laska & Wampold, 2014)—interpretations that can engender
either an overly strict or laissez-faire approach to training and professional
development. As we show, the seemingly paradoxical nature of treatment
models (i.e., high interest or importance but little direct effect on outcomes)
disappears when the wisdom accumulated in their telling is balanced with
practical benefits of having a structured story to go by.
 Structural Factors 157

From a philosophical perspective, conceptualizing the underlying structure

of effective treatment represents, in part, “the search for the essence of the
psychotherapeutic transaction” (Mendel, 1963, p. 301). This task is far from
straightforward. Unlike professionals operating in what Bacon (2018) called
“fundamental reality,” the psychotherapist and their client work in a constructed
reality. As the data supporting the dodo verdict make clear, any number of
credible explanatory models and accompanying rituals may bring about wanted
change. The structure of talk therapy might be contrasted with the structure
of cardiology, engineering, and firefighting insofar as the former organizes
the constructed world of beliefs, whereas the latter organizes the more funda-
mental reality of body systems, building materials, burn rates, and drafting.
As such, the psychotherapist is tasked with creating and modulating the
structure of treatment from client to client, session to session, and even within
individual sessions. Developing an understanding of the therapeutic structure
clinicians impose on their clinical work (intentionally or subconsciously) is
essential to remaining flexible and responsive to varying client, therapist, and
cultural factors. To give the reader a sense of both the promise and ambiguity
of the subject, available research is first reviewed.

REVIEW OF RESEARCH

In research and writing, therapeutic structure is often treated as binary in

nature (e.g., structured vs. unstructured), relegated to the status of a moder-
ator variable (e.g., Baskin et al., 2003) or equated with the use of a specific
psychotherapy technique or approach (e.g., structuring in client-centered
therapy; Patterson, 1985). With a few notable exceptions (Duncan et al., 2010;
Hubble et al., 1999), less interest and attention has been paid to structure as an
158 Oleen-Junk and Yulish

independent contributor to outcome. An important early study by Grencavage

and Norcross (1990) identified “treatment structures” as one of five effective
ingredients shared by all therapy modalities that also included client character-
istics, change processes, relationship elements, and therapist qualities. According
to the authors, treatment structures refer to (a) techniques or rituals, (b) a focus
on emotional expression and internal experiences, (c) good communica-
tion (verbal and nonverbal), (d) adherence to theory, (e) a healing setting,
and (f) an explanation of therapy and participants’ roles. Using more advanced
statistical procedures, a later study by Tracey (2003) confirmed the impor-
tance of structure, indicating that all effective therapies (a) were theoretically
consistent, (b) created positive expectations, (c) included a healer working in
a healing setting, and (d) employed specific techniques. Acknowledging the
sparse evidence on therapeutic structure, Tracy nonetheless argued the results
reflected a need for psychotherapy to be “structured in a way that operation-
alizes the treatment for the client” (p. 411).
Thus, by the turn of the 21st century, an empirically informed, trans­
theoretical definition of therapeutic structure was beginning to take shape.
By that time, psychotherapy research had already left a faint but still discernable
trail of evidence indicating successful therapies had something “structural”
in common. An early empirical signal that transtheoretical structural factors
account for better results in therapy can be seen in a study investigating out-
comes in time-limited dynamic therapy, a model that emphasizes the develop-
ment of an explicit focus. Investigating the relationship between certain technical
errors and outcomes, Sachs (1983) found clients’ reports of a lack of focus and
structure were among the errors in technique that proved the most powerful
predictors of poor results. Relatedly, Weisz et al. (1995) found structural factors
accounted for better outcomes in psychotherapy conducted with children and
adolescents. Analyzing the superior outcomes achieved in research treatments
relative to those conducted in clinics, the authors argued there was strong
evidence that structure accounted for the difference. Briefly, their defini-
tion of structure included a preplanned set of procedures used in a particular
order, sometimes guided by a manual, monitored for fidelity by direct obser-
vation or video or audio recording, and involving more specific, focused
treatment methods.
In a study reviewing negative outcomes in self-administered therapy,
Scogin et al. (1996) pointed to the important structural factor of preparing
clients for the tasks involved in treatment as an explanation for the signifi-
cantly reduced deterioration rates in the studies he analyzed. Preparation
involved simply informing clients that they would be receiving a book to read
as the primary therapeutic activity (p. 1088). Although the execution of most
therapies involves a more nuanced implementation or facilitation of structure
(more on this later), the principle remains the same: Structure helps opera-
tionalize therapy for the client (Tracey, 2003). A more detailed review of what,
in the literature, is referred to as “client role preparation/induction” can be
found in Chapter 3 (pp. 52–53).
 Structural Factors 159

A study published in 2003 by Baskin et al. provided some of the strongest,

albeit indirect, evidence that the overall structure of therapy (vs. delivery of
theory-specific “active” ingredients) is responsible for the outcome of treatment.
Briefly, in a meta-analysis of 21 studies involving 921 clients, the researchers
found bona fide psychological treatment approaches outperformed placebos
largely when the latter were “structurally inequivalent” to the former (d = 0.465).
Implicating multiple structural factors in the process, the researchers reported
that when the comparison condition did not differ in (a) the number, length,
format (i.e., group or individual), and content of sessions (i.e., whether clients
were allowed to discuss topics relevant to their concerns or were restricted to
general discussions); (b) the training of the therapists; and (c) the individu-
alization of interventions to the clients, “the benefits produced by [placebo
comparison groups] were largely [equivalent to] the active treatments to which
they were compared (i.e., d = 0.149, which although statistically different from
zero is negligible)” (p. 976).
The most recent evidence on the topic shows therapy is most effective
when it is focused on a specified set of problems and reasonable procedures
for resolving them. A meta-analysis by Yulish et al. (2017) found, for example,
the extent to which a given treatment was structured to create positive expec-
tations for clients while using specific targeted techniques (e.g., behavioral
interventions for anxiety) predicted treatment efficacy (g = .28 for targeted
symptoms; g = −.29 nontargeted symptoms). The results of this analysis involving
135 studies with more than 175 comparisons suggest, regardless of theoretical
orientation, addressing clients’ problems with focused interventions is a key
structural ingredient of effective treatment.
A summary of the research on therapeutic structure is provided in
Table 7.1.

The Metastructure of Effective Psychotherapy Structures

When considered together, a natural order emerges among the individual

findings related to effective treatment structures. Therapeutic structures are
organized along three dimensions based on their function, and help the thera-
pist and client (a) establish the boundaries of the work by delimiting what is and
is not helpful, (b) sequence its delivery to ensure predictability in manner and
form, and (c) accurately appraise the effectiveness of the process in an ongoing
and systematic fashion (see Table 7.2).
The three dimensions offer practitioners an evidence-based structure under-
lying the specifics of their chosen theories and methods that can aid in con-
ceptualizing, assessing, modifying, and, as will be seen shortly, working to
improve their clinical work through deliberate practice (DP). As illustrated in
Figure 7.1, each dimension extends along a continuum from tight, formalized,
and rigid (e.g., manualized, protocol-driven, therapist-directed services) to more
informal, loosely organized, and flexible (e.g., few preplanned interventions,
client directed). The y-axis represents the boundary dimension, indicating the
160 Oleen-Junk and Yulish

TABLE 7.1. Evidence for Transtheoretical Structural Factors That Lead to

Better Outcomes
Structural factors Evidence
Focus and structure Clients or participants endorsed lack of
focus and structure as the most
important errors in technique leading
to poorer outcomes (Sachs, 1983).

Techniques or rituals Content analysis of published works

Focus on affect or internal experience identifying aspects common to all
therapies yielded the superordinate
Good communication category of “structure” (Grencavage
Healing setting & Norcross, 1990).
Explanation of therapy or roles

Preparation for therapy Clients receiving an accurate description

of the intervention achieved better
results in self-directed therapy than
those who did not (Scogin et al., 1996).

Preplanned set of procedures Superior outcomes in youth therapy

Procedures used in a particular order research trials versus private or public
clinics is explained, in part, by structural
Use of a manual differences (Weisz et al., 1995).
Monitored for fidelity via direct observation
or video or audio recording
More specific focused treatment methods

Theory consistency Cluster analysis of survey responses of

Positive expectations therapy experts yielded a superordinate
category, “structural factors” (Tracey,
Healing setting or healer role 2003).
Specific techniques

Number and length of sessions Meta-analysis of outcome trials revealed

Training of the therapist that holding these structural factors
constant eliminates observed differences
Interventions tailored to clients in outcome between placebo comparison
Topics addressed are germane groups and bona fide models of
Session format (e.g., group) psychotherapy (Baskin et al., 2003).

Problem focus Meta-analysis of randomized controlled

Reasonable procedures for resolving trials for anxiety demonstrated these
problems structural factors were associated with
better outcomes (Yulish et al., 2017).
Creating expectations for therapy

extent to which a given therapy remains organized around and focused on

specific content and therapeutic aims. Open-ended conversations of a more
diffuse nature would lie on the unstructured end, while those focusing on
discrete themes with prespecified problem-resolving processes would fall
on the structured side of the continuum (i.e., tightly bounded). Sequence is
found on the x-axis, representing the extent to which elements of time, order,
and format are imposed by the therapist. Following a standardized treatment
protocol would, for example, be considered highly structured. By contrast,
working actively to tailor services to the culture, identity, preferences, and
goals of each client (see Chapters 3 and 5) would fall on the opposite end. The
 Structural Factors 161

TABLE 7.2. Grouping Structural Factors Along Three Dimensions of

Therapeutic Structure
Structural factors identified
Dimension and function in the literature
Boundary Focus
These factors function to keep the client Focus on affect or internal experience
and therapist focused on what is helpful More specific and focused treatment
to delimit the bounds of the therapeutic methods
task and provide a sense of what
Specific techniques
changes may be possible and how they
could be reasonably achieved. Topics addressed are relevant
Problem focus
Creating expectations for therapy
Positive expectations
Reasonable procedures for resolving
problems
Theory consistency
Use of a manual
Training of the therapist

Sequence Techniques
These factors’ primary function is to Preplanned set of procedures
establish a predictable format and Procedures used in a particular order
culturally relevant explanation that enables
Number and length of sessions
clients to do things (e.g., talk, introspect,
practice coping skills) that are not a part Session format (e.g., group)
of their typical daily experience. Healing setting

Appraisal Good communication

These structural factors help the therapist Explanation of therapy and roles
and client to appraise the fruitfulness of Preparation for therapy
their endeavor and make alterations as
Interventions tailored to individual client
indicated.
Routine outcome monitoring
Monitored for fidelity via direct observation
or Video or audio recording

third and final axis, z, represents appraisal, which covers the extent to which
structured procedures are implemented to, first, determine whether treatment
is on track and, second, when changes are necessary to improve engagement
and outcome. Using standardized measures to monitor the alliance and out-
come of treatment, as described in both Better Results (BR) and this volume,
would be a good example of the highly structured end of the continuum. The
more traditional practice of relying on clinical judgment and occasional informal
inquiries would definitely qualify as unstructured appraisal.
It is important to note that no amount of structure (i.e., high vs. low) among
the three dimensions is inherently better. Rather, the “optimal” level will vary
depending on the client; their presenting problem; therapist beliefs, knowledge,
and skills; and the context and circumstances surrounding treatment. As a
practical example, consider studies of client motivation reviewed in Chapter 3.
Robust evidence shows adjusting the focus (boundary), dose (sequence), and
intensity (appraisal) of treatment to the client’s motivational level or “stage
162 Oleen-Junk and Yulish

FIGURE 7.1. Three-Dimensional Representation of Therapeutic Structures

Tightly Structured
Bounded
Formal/Routine

Client-directed X Therapist-directed

Z
Y
Ad hoc/Implicit
Open
Unstructured

X: Sequence Dimension
Y: Boundary Dimension
Z: Appraisal Dimension

of change” is associated with more engagement and better outcomes (Krebs

et al., 2018; Norcross et al., 2011). In this way, as therapy progresses, keeping
the three dimensions in mind can help practitioners be more responsive to the
individual client. In addition, when used in combination with one’s outcome
data, specific DP objectives might become apparent:
• Is there a mismatch between the client’s stage of change and the dose
(sequence) and intensity (appraisal) of the work with those who drop out
of treatment?
• Do clients with poorer outcomes or alliance scores have more (or less) struc-
ture along one or more dimensions (boundary, sequence, and appraisal)?
• Are particular clients, presenting problems, or treatment circumstances asso-
ciated with more mismatches?

FIELD GUIDE TIP

“Certain therapists are more effective

than others . . . because [they are]
appropriately responsive . . . providing
each client with a different, individually
tailored treatment” (Stiles & Horvath,
2017, p. 71).
 Structural Factors 163

Ineffective Psychotherapy Structures

Some decisions therapists make regarding the structure of their work, while
popular and intended to improve engagement and effectiveness, are not actu-
ally supported by the evidence. As one example, consider the popularity of
manuals and diagnostic-specific treatment protocols. Here, as suggested at
the outset of this chapter, the data are clear. First, degree of adherence—how
closely a therapist follows directions—is not associated with outcome (Boswell
et al., 2013; Wampold & Imel, 2015; Webb et al., 2010). Second, as reviewed
in detail in BR, attempts to improve effectiveness via the creation of a psycho-
logical formulary—official lists of specific treatments for specific disorders—
have failed to result in any improvement over the last 5 decades (Miller
et al., 2020). In fact, clinician competence in conducting specific types of
therapy for particular diagnoses has not been “found to be related to patient
outcome and indeed . . . estimates of their effects [are] very close to zero”
(Webb et al., 2010, p. 207). As an example, imagine a physician who inter-
rogated every patient in the same way, always used the same set of lab
tests, and prescribed medications solely on the basis of administrative poli-
cies. The intuitive grotesqueness of this hypothetical form of medicine
equally applies to the practice of psychotherapy. Simply put, blindly
applying interventions based on a single criterion (i.e., psychiatric diag-
nosis) regardless of the personal characteristics, identity, and preferences of
the client does not work.
At the same time, the evidence shows a therapy with minimal structure
can also be unhelpful (Yulish et al., 2017). One clear example of this lies in
the tendency of therapists to rely too heavily on their own and clients’ pref-
erences when it comes to ending treatment. Consider a study in which prac-
titioners were interviewed in an attempt to develop guidelines for structuring
the termination process (Kramer, 1986). The results showed many practi-
tioners, citing autonomy, relied on (e.g., trusted) their clients to bring up the
issue on their own. In cases where therapist and client disagreed, therapists
ignored their clients’ position and encouraged them to continue. Planning
for the end of therapy adds the elements of effective structure, reviewed
earlier, to the termination process, promoting both a greater sense of shared
focus (boundary) and time-oriented expectations (appraisal). Such struc-
tures are clearly important because research shows highly effective thera-
pists have more planned terminations than their more average colleagues
(Chow et al., 2015).
Kramer (1986) offered four guidelines for structuring termination: (a) dis-
cussing termination at the outset of therapy (e.g., negotiating a shared vision of
successful completion), (b) being aware of cues that the therapeutic relation-
ship is changing (e.g., clients require less input, clients behave more like
peers, in-session frequency is reduced), (c) providing a structured review of
treatment progress and process, and (d) introducing an open-door policy
following the suspension of regular meetings (i.e., creating a sense that the
work of therapy is ongoing). A later study by Norcross et al. (2017) confirmed
164 Oleen-Junk and Yulish

and extended Kramer’s early suggestions. On the basis of a factor analysis of

nearly 80 termination-related tasks identified by expert practitioners, Norcross
et al. identified a set of five structure-related termination guidelines: (a) orient­
ing the client toward future growth, (b) explicitly preparing for termination,
(c) consolidating gains achieved, (d) expressing pride in the client’s progress,
and (e) having mutuality in the relationship.

Summary and Conclusions

It might be ideal if therapists could refer to a set of proven structural elements

(e.g., techniques, protocols, strategies), invariably leading to better results.
However, evidence to date indicates clinical decision making is better guided
by adopting the higher level of abstraction offered by the three dimensions
of therapeutic structure outlined previously. Because the set of credible and
effective methods is likely infinite—especially given consistent findings of equiv-
alence between rival approaches—this conceptualization of structure facilitates
flexibility while maintaining the organization and direction research shows is
essential for success (Chen et al., 2020; Hipol & Deacon, 2013; Katz et al.,
2019; Levitt et al., 2016; Mohr, 1995; Saidipour, 2021; van Minnen et al., 2010;
Waller, 2009; Waller & Turner, 2016).

EVIDENCE-BASED PRINCIPLES RELATED TO STRUCTURAL FACTORS

With the evidence at hand, five principles for organizing and guiding DP
activities related to improving therapy structure are proposed: (a) craft
smarter starts to therapy; (b) avoid unhelpful structuring activities;
(c) know your work; (d) know that this, too, shall end; and (e) use data
wisely. Each connects specific, evidence-derived guidance to one of the
three transtheoretical dimensions of therapy structure (boundary, sequence,
and appraisal).

Principle 1: Craft Smarter Starts to Therapy (Sequence Dimension)

When it comes to structuring therapeutic work, the counsel offered in the

song “Do Re Mi” from the classic movie The Sound of Music is spot on: “Let’s
start at the very beginning, a very good place to start.” Shaping expectations
about the content, aims, and conduct of the work should begin at the very first
contact with the client (e.g., screening phone call, intake session). Conveying
warmth (e.g., understanding, concern, hope) while establishing the boundaries
of care not only sets the stage for clients returning for subsequent visits but
also honors their decision to enter therapy.
Scripting a cogent and concise way of describing how you conduct therapy
to novice and familiar clients is sound practice. Metaphors are one way to
 Structural Factors 165

facilitate comprehension of such potentially complex information. Think, for

example, of how you would explain flying on a commercial jet to someone
who had never been on a plane. What would be essential to communicate
about the experience from booking to boarding? Which aspects of the flight
are more or less important (e.g., waiting in line, the safety demonstration,
turbulence, drinks and snacks, bathrooms) to ensuring a pleasant and successful
journey? What difficulties and challenges are most important to know about
and anticipate (e.g., cancellations, rebooking, fees)? While a nearly limitless
number of potential avenues for describing and discussing the experience exists,
suffice it to say you cannot cover them all. Research and experience suggest a
number of essential aspects:

• The topics addressed in therapy can be difficult. “To avoid client deception,”
Levitt et al. (2006) advised, “explicitly communicate the etiquette of therapy
as one in which painful experience needs to be discussed, that therapists
wish not to be protected, and the importance of talking about topics that
might be threatening or invite disapproval” (p. 319).

• Work outside of sessions may be required. Because a large portion of

outcome is due to extratherapeutic factors, what occurs outside the con-
sulting room is essential to success (Duncan et al., 2010; Hubble et al.,
1999; Levitt et al., 2006; Swift & Parkin, 2017; see also Chapter 3, this
volume).

• Collaboration is key. David Orlinsky and colleagues (2004) argued that the
client’s participation in therapy is the most important factor influencing
outcome and that over 40 years of psychotherapy establishes this as a fact.
Accordingly, talking with clients on an ongoing basis about what they are
willing to do and why it is important is critical.

• Both client and therapist have essential roles. Clients determine the desti-
nation. Therapists provide guidance and direction. “Allowing the client to
set goals is experienced as empowering,” Levitt et al. (2006) noted; however,
“when mired in unimportant topics, clients want therapists to provide direc-
tion after checking for client’s consent” (p. 319).

Principle 2: Avoid Unhelpful Structuring Activities

(Boundary Dimension)

Certain ways of being (e.g., rigid, distant, critical, uncertain, overly solicitous)
and particular patterns of therapist behavior (e.g., overstructuring, unyielding
interpretations, inappropriate self-disclosure, talking too much or too little)
are associated with alliance ruptures and poorer outcomes (Ackerman &
Hilsenroth, 2001; see also Chapter 5, this volume). One reliable sign therapists
may be engaging in such unhelpful structuring activities is when they attribute
the resulting low levels of participation or a lack of progress to the client. This
166 Oleen-Junk and Yulish

often appears in the form of invoking client motivational levels, citing resis-
tance, adopting increasingly complex and severe diagnostic formulations, or
what Duncan et al. (1997) referred to as theory countertransference—the tendency
to fit clients into the therapist’s preferred theory rather than closely scrutinizing
their own contribution to any impasse.

Principle 3: Know Your Work (Sequence Dimension)

The expertise literature makes clear that the longer one is engaged in a partic-
ular endeavor, the less aware they become of their decision-making processes
and actions (Chi, 2006; Tracey et al., 2014). Automaticity, as the process is
referred to, is both good and bad. On the one hand, it is a sign that a new,
higher level of control over one’s performance has been attained, allowing
us to devote scarce cognitive resources elsewhere. On the other hand, such
proficiency typically comes at the expense of learning and improvement. As a
result, improvement in performance generally begins to stall and even dete-
riorate. Working purposefully to counteract the loss of conscious control over
behavior that occurs naturally with the mastery of specific skills is at the very
heart of DP.
With time and experience, most practitioners develop an implicit sense of
how therapy ought to flow as well as ideas of when it is getting off track.
Unfortunately, research shows that this “gut feel” is off more of the time than
we realize (Waller & Turner, 2016). Developing an explicit framework of
how one works—a step-by-step map detailing how one’s intuitions, beliefs,
and theories connect to the sequence of events in the consulting room with
clients—not only ensures consistency, predictability, and safety but is also
helpful when attempting to identify where specific intentional adjustments in
the flow of the work could be made to improve engagement and effect.

Principle 4: This, Too, Shall End (Sequence Dimension)

This variation on the popular saying serves as a reminder that endings in

therapy are important. Unfortunately, like death, it is not the most popular
subject. Some therapists, feeling the pull to maintain contact, are less structured
in their approach, rarely broaching the topic and keeping the door open for
unlimited visits. Others, following a predetermined treatment plan or working
in certain treatment settings (e.g., close-ended groups, inpatient or residential
programs), may “graduate” clients once delivery of the standardized protocol
has been made or a requisite amount of time has passed.
Available evidence shows the way termination is introduced, discussed, and
structured throughout therapy can have an important impact on outcome.
Not infrequently, transitions are the reason people seek out a therapist. There-
fore, it is important clinicians model appropriate behaviors regarding that part
of the sequence of therapeutic work surrounding the end of contact. Building in
a shared sense of the scarcity of time throughout the work can be the impetus
for clients taking advantage of therapy.
 Structural Factors 167

Principle 5: Use Data Wisely (Appraisal Dimension)

It goes without saying that the first step in appraising one’s performance is
collecting relevant data. Readers of BR and this field guide know routinely moni­
toring the quality of their relationships and effectiveness of their work are key
components of professional development and DP. In terms of structure, this not
only means administering standardized assessments of outcome and alliance but
also having well-defined, step-by-step processes in place for integrating them
into treatment. Research shows different structures have different impacts
on outcome, with those adopting a more therapeutic approach regarding the
monitoring of their work obtaining greater outcome improvements (Goldberg,
Babins-Wagner, et al., 2016; Goldberg, Rousmaniere, et al., 2016). No one would
expect the introduction of a stopwatch to improve the ability or speed of runners
or a stethoscope to improve heart functioning (Miller, 2018). Simply put, it is
how the information provided by such tools is put to use that matters. Therapists
do well when they create structures around what and how data are collected and
used to appraise their performance, adjust therapeutic activities, and communi-
cate with clients in a way that fosters maximum participation in treatment.

EXERCISES FOR STRUCTURAL FACTORS SKILL DEVELOPMENT

To have an impact, DP efforts must be focused on reaching for performance

objectives just beyond an individual’s present abilities. That means before
selecting an exercise from the following list, it is essential that you have taken
the time to (a) routinely measure your performance; (b) collect sufficient data
to establish a reliable, evidence-based profile of your therapeutic effectiveness;
(c) complete the Taxonomy of Deliberate Practice Activities in Psychotherapy
(TDPA; Chow & Miller, 2022; see Appendix A, this volume); (d) determine
a deficit exists related to the operation of structural factors in your work;
(e) narrow your focus to a single element within this domain on the TDPA; and
(f) define that performance improvement objective in SMART terms (specific,
measurable, achievable, relevant, time bound). Once these steps are completed,
simply review the suggested exercises, looking for the one that aligns most closely
with your goal. Should none of the exercises speak directly to your specific
objective, Chapter 2 provides guidance for developing your own. It describes
a process for using the TDPA in combination with your data to develop a
“learning project,” ultimately resulting in individualized DP exercises.

Exercise 1: Using the Metastructure of Therapeutic Structure for

Self-Assessment

Principle: 1–5
Applicability: TDPA Items 1 A to N
Purpose
This exercise uses the metastructure dimensions presented in the chapter to
help you assess strengths and weaknesses in the way you leverage structural
factors for therapeutic benefit.
168 Oleen-Junk and Yulish

Task
Table 7.3 presents questions to help clinicians identify and clarify how they
impose therapeutic structure in their clinical work. Following each question
are examples of client and therapist behaviors that may signal a need to
improve or adjust structure to maximize fit and effect. As can be seen, beside
each set of example behaviors is a list of strategies for improving therapeutic
structure. Use the following steps to help you identify your learning edge and
activities that may enhance your practice:
1. Using your alliance and outcome data, create a list of clients who have not
benefited from therapy with you.
2. With such clients in mind, review the dimensions, questions, and behaviors
listed in Table 7.3.
3. Identify any trends, behaviors, and/or strategies that come up or are missed
more frequently.
4. Use your findings from this exercise to guide the focus of your DP.

Exercise 2: Using Metaphors

Principle: 1
Applicability: TDPA Items 1 A to C
Purpose
This exercise aims to help you develop clear and simple explanations about the
process of therapy and its structures using metaphors.

Task
Part 1. Script a metaphor for how you do therapy, preferably one that high-
lights the interactive and collaborative nature of the process. An example might
be renovating a house with a contractor, another a glacial expedition with a
guide. What is important is that your metaphor captures how you actually
work (e.g., your blueprint), as well as being consistent with your theoretical
approach. Once done, test your metaphor with a coach or practice partner. As
you gain confidence, rachet up the difficulty by asking your coach or practice
partner to present in more challenging ways. Consider adaptations for different
presentations and needs.

Part 2. Build on the metaphor developed in the previous task by developing

structures for communicating the roles and processes of therapy. With your
script in hand, add elements related to roles and expectations. Consider, for
example, how your metaphor captures
• the role of the therapist (e.g., honest, caring, interested);
• the role of the client (e.g., work outside of the session, the value in addressing
painful experiences);
• the need for client feedback regarding interventions, homework, and progress;
and
• the indicators of success, failure, and completion of therapy.
Once completed, test your additions with a practice partner or coach. Use
your outcome data to identify any client groups or presentations who have been
 Structural Factors 169

TABLE 7.3. How to Assess Therapeutic Structure

Boundary dimension
1. How do you establish and maintain focus in a session?
Consider more structure if or when Structural strategies for focus
• clients are uncertain about what to share • Identify barriers to establishing a helpful
in therapy focus.
• progress notes do not reflect a clear • Explain benefits of narrowing focus to
session focus topics that directly impact client
• therapist is bored or confused functioning.

• there is lack of client-identified progress • Provide psychoeducation regarding

potential avoidance or psychological
defenses.
• Examine therapist resistance to
addressing a clearer focal point in therapy.
2. How do you communicate hopes for therapy success while managing unrealistic
expectations?
Structural strategies for therapy
Consider more structure if or when preparation
• client doubts change is possible • Provide a clear and theoretically consistent
• client has unrealistic expectations about explanation for how interventions lead
change (e.g., eliminate all my anxiety) to change.

• client fears becoming overwhelmed • Provide a theoretically consistent

should certain topics be broached explanation for why certain things are
not helpful in therapy.
• Share examples of how others have
responded to interventions and how to
manage feelings of overwhelm.
3. How do you remain theoretically consistent and ensure interventions seem reasonable
to the client?
Consider more structure if or when Structural strategies for logical coherency
• client notes apparent contradictions in • Acknowledge contradictions and work
therapist’s beliefs or explanations for with client (perhaps at a higher or lower
problems level of abstraction) to reconcile
• therapist feels particularly vulnerable to apparent or problematic contradictions.
client’s intellectual challenges • Help client articulate their own theories
• client appears to be feigning effort (i.e., about change or behavior and make
“going through the motions”) efforts to tailor conceptualizations to
their narrative framework.
Sequence dimension
1. How do you start an initial session and subsequent sessions?
Consider more structure if or when Structural strategies for initiating sessions
• client is confused about how to start • Offer client examples of how an intake
• therapist feels apprehension at the and subsequent sessions can unfold.
beginning of sessions with a particular • Collaborate with client to establish a
client routine at the beginning of sessions.
• client reports anxiety before sessions • Improve consistency at the outset of
• there are repeated occurrences of sessions (note that less structure can
important disclosures at the end of also facilitate session starts).
session
(continues)
170 Oleen-Junk and Yulish

TABLE 7.3. How to Assess Therapeutic Structure (Continued)

2. How do you close sessions?
Consider more structure if or when Structural strategies for better closings
• there are repeated occurrences of • Signal to the client that time is running
important disclosures at the end of low before time has expired and get
sessions comfortable interrupting.
• there is anxious talkativeness in the final • Share theory-consistent reasoning for
moments of the session boundaries around session time.
• there are apparent efforts to extend the • Offer suggestions about how to process
session beyond the time limits (therapist thoughts and feelings that emerge at
or client) the end of the session (i.e., strategies for
reflection and consolidation in between
sessions).
3. How do you ensure continuity between sessions?
Consider more structure if or when Structural strategies for continuity
• client does not complete intersession • Summarize the content of sessions and
goals or tasks (e.g., “homework”) draw back to the key therapeutic focus
• therapist and client forget to follow-up of the work.
on themes addressed in previous • Begin sessions with a summary of the
sessions key content from the previous session
• client misses sessions and link to key therapeutic focal targets.
• Support the client to summarize their
understanding of what each session has
meant for them and therapeutic aims
as they see them.
Appraisal dimension
1. How do you elicit detailed and nuanced feedback in sessions?
Consider more structure if or when Structural strategies for continuity
• it is unclear whether clients are • Develop and use strategies to repair
progressing and why ruptures in the alliance.
• routine outcome monitoring identifies • Develop and apply structured methods
that little therapeutic progress is for addressing nonimprovement in
being made therapy.
• routine monitoring identifies a lower- • Create time at the end of each session
than-expected client-rated therapeutic to review and appraise the session from
relationship both client and therapist perspective,
specifically eliciting critical feedback.
2. How do you change your way of working in response to client feedback?
Consider more structure if or when Structural strategies for continuity
• client feedback indicates that therapy is • Build structured ways to respond to
helpful, but they worry about when client feedback (both positive and
sessions finish negative) that builds on progress and
• client identifies that they are unclear on addresses problems.
the aims or goals of therapy • Construct systems that help to
• client feedback highlights that therapy collaboratively identify, refine, and
is not having the desired impact on agree on therapeutic goals.
symptoms or functioning
 Structural Factors 171

more likely to drop out of therapy or experience a lack of progress. Consider

how you could modify your metaphor to engage better and help these specific
client groups.

Part 3. Further refine your metaphor, distilling the content to its core elements
for ultra-brief communication. With your metaphor in hand, pretend you are
in an elevator with a new client. Using the timer on your mobile phone, deliver
your pitch as written. Note the time. Without speaking faster, work to convey
the key elements in 45 seconds or less. In service of clarity, practice providing
your refined message to five different people, including at least one child, one
colleague, and one person demographically different from yourself (e.g., in
gender, culture, sexual orientation, socioeconomic status). Next, using your out-
come data, first identify clients who dropped out after the first or second visit.
Consider how you might have modified your message to keep them engaged,
writing down different possibilities.

Exercise 3: Mapping Your Flow

Principle: 3
Applicability: TDPA Items 1 I–K
Purpose
Selecting, sequencing, and individualizing interventions are key aspects of
therapeutic structure. This exercise is designed to help you refine the way these
elements work in your clinical practice.

Task
Early on in BR, you were asked to create a schematic or blueprint for how you
do therapy sufficiently detailed so another practitioner could understand and
replicate it—literally, “step into your shoes” and work how you work (Miller
et al., 2020, p. 29). The purpose of the activity was to make it easy to pinpoint
where to intervene as opportunities for improving your effectiveness are
identified by analyzing your performance data. If you have not yet completed
a blueprint, turn to pages 18–20 in Chapter 1, this volume, for updated, step-
by-step directions.
Next, using your outcome data, build a list of clients who did not improve
while in therapy with you. With your blueprint in hand, review the work
you did with each client, noting any recurring themes or mismatches among
the three dimensions of therapeutic structure (e.g., boundary, sequence, and
appraisal). Consider what changes or nuances need to be added to your map
to more effectively structure therapy for these clients.

Exercise 4: When Therapists Drift

Principle: 2
Applicability: TDPA Items 1F, H–K
Purpose
This exercise aims to help therapists address some of the key barriers to
effectively applying structure in therapy.
172 Oleen-Junk and Yulish

Task
Using your outcome or alliance data, identify one client for whom therapeutic
benefit was limited. Review your case notes for each session, noting where
your intended interventions or approach did not go as you hoped. Consider
the following questions (derived from Waller & Turner, 2016):

• To what extent did you fully use the therapeutic intervention chosen and
associated structure? Consider specifically whether you drifted from in vivo
(fully experiencing) to in sensu (giving a sense of rather than supporting
full experiencing).

• How did the following factors affect the way you used therapeutic tech-
niques in the work?
– feedback from the client: Was feedback sought on the client’s expe-
rience of the therapeutic activity? If so, was your reaction proportionate
and responsive to feedback?
– the client’s beliefs: To what extent did the client understand the ratio-
nale behind the activity, how it was expected to work, what they might
experience in the process, and the possible outcomes?
– the client’s emotions: Was your response to the client’s emotional
experience proportionate and appropriate? Were you happy that any
adjustments made were the best fit for how the client was feeling and
what they could manage?
– the therapist’s emotions: From reviewing the session, can you gain a
sense of how your own emotions may have affected the way you applied
structured methods and techniques? What helped, and what hindered?
– the therapist’s beliefs: How did your own beliefs affect the way you
approached this therapeutic activity? Are there ideas about the methods
that might have prevented you from using the technique more effectively?

Once you have reviewed the sessions as described, work to identify one key
learning objective. Depending on your answers to the foregoing questions,
it could be about helping the client to understand the process of the activity
before starting or perhaps giving structured choices for how treatment can
be adapted when necessary. Recalling the advice offered in BR that it’s “never
too late to have a good session” (see pages 165–166), imagine what you would
do differently if given the chance for a do-over, being as specific as possible.

Exercise 5: Finishing Strong

Principle: 4
Applicability: TDPA Items 1 A, F–I
Purpose
Depending on one’s theoretical orientation, the structure of therapy endings
will look different. Regardless, as reviewed in this chapter, research shows
 Structural Factors 173

successful completions of treatment incorporate similar elements and pacing.

This exercise explores how the structural elements identified as important to
effective endings operate in your therapeutic practice.

Task
Part 1. Norcross et al. (2017) identified certain structural elements central
to effective endings: (a) explicitly preparing for termination, (b) orienting the
client toward future growth, (c) consolidating gains achieved, (d) expressing
pride in the client’s progress, and (e) having mutuality in the relationship. For
1 month, keep a journal of your reflections on how you address each of these
factors in your clinical practice. Consider the following questions, for example,
regarding how you

• explicitly prepare for termination

– How do you talk about termination in the first session, middle sessions,
and when approaching an actual termination?
– How do you connect goals to endings? (e.g., “How will we know therapy
is complete?” or “How would you want this goal to look 12 sessions or
a year from now?”)
– How do your personal needs account for how you do endings?

• orient the client toward future growth

– How do you prepare the client for approaching future psychological
concerns without you?
– How do you convey to the client that growth and change are continuous,
never-ending processes?
– How do you speak to the client about problems or goals yet to achieve
without sounding critical or dashing confidence and hope?

• consolidate gains achieved

– How do you communicate about the progress clients have made in
treatment?

• express pride in the client’s progress

– In what ways do you share your authentic feelings with clients regarding
their progress?
– Do you notice any patterns with specific clients or presenting concerns
where you struggle to express such pride?

• work toward mutuality in the relationship

– How do you support the client’s independence, sense of self-confidence,
and ability to solve problems in the future?
– How do you foster a sense of equality in the relationship?
174 Oleen-Junk and Yulish

Part 2. Using your outcome data, identify five clients with whom the ending
of treatment could have been improved. These might include the following:

• unplanned endings
• endings where the client reported being unprepared for termination
• episodes of therapy that seemed to continue for longer than necessary

Using paper and pencil or your favorite note-taking software, list each client
by name. Next, note which of the following evidence-based approaches to
structuring the ending of therapy were missing: (a) termination discussed
at the outset of therapy, (b) routinely connecting therapeutic activities during
treatment to the desired goal for services, (c) structured reviews of progress
throughout therapy, (d) explicit mentions from the outset of treatment regard-
ing the potential for growth beyond therapy, (e) sufficient planning for and
discussion of termination before the final visit, and (f) discussion and affirma-
tion of client improvement, including links being made to the impact of progress
on posttherapy functioning.
Sort for themes, noting whether any patterns in your structure of thera-
peutic endings are reliably associated with a higher rate of dropout, unplanned
terminations, poorer outcomes, or therapies that continue despite a lack of mea-
surable progress. Adjust your therapy blueprint to include the missing activities
at the appropriate moments during treatment.

Exercise 6: Making Data Collection Structurally Therapeutic

Principle: 5
Applicability: TDPA items 1 D–F
Purpose
This exercise aims to help therapists develop the therapeutic structure needed to
sustain the use of outcome and alliance measures, even in challenging clinical
situations.

Task
Next, you will find five challenging clinical scenarios related to the appraisal
dimension of therapeutic structure. Taking one example per week, consider the
structure you would bring to address the examples in a therapeutic manner,
particularly considering how they connect to your theoretical orientation and
treatment experience.
It is important not to rush the process. Let the scenarios percolate in the
“back of your mind” throughout the day, keeping notes about the thoughts,
feelings, and reactions that occur to you while simultaneously resisting the
temptation to “solve the puzzle.” The evidence indicates mulling over ideas
allows us to make deeper, more nuanced connections between experiences and
ideas that, in turn, increase the possibilities for creative action. When able, for
each scenario, be specific about what you would focus on (boundary), when you
would focus on it (sequence), and how you would continue to seek feedback
 Structural Factors 175

through the administration and discussion of standard measures along the way
(appraisal).

Scenario 1. You have been incorporating assessments into your clinical work
for a year. You get a new client who tells you in the first session they are
not particularly interested in doing assessments at the beginning and end of
therapy because they are a waste of time. They indicate that if you insist on
using the tools, they will either refuse to fill them out or answer the items
randomly.

Scenario 2. A client you have been working with for several visits completes
the outcome measure in a manner that suggests significant improvement since
their last session. As you inquire about the change in scores, the client breaks
into tears describing the last week as “the worst period in [their] life.”

Scenario 3. On asking a client to complete the outcome measure you routinely

use to assess progress, they cursorily mark all the items the same way (e.g., high
or low).

Scenario 4. Your work with a client has been going fairly well; you have been
conducting a structured, protocol-driven treatment. Regular assessments over
the course of care have shown steady progress. At what is the final visit, the
client expresses frustration about having to end therapy merely “because
the preplanned number of sessions have been conducted.” They insist that,
despite their improved scores, they continue to feel miserable.

Scenario 5. Looking back over your clients over the last month, identify those
with whom you have done your best to adjust to their structural requests (e.g.,
focus, scheduling, assessment of progress) but who continue to make little or
no progress (poor outcome scores, missed sessions, low levels of engagement).
Pick one and consider which structural adjustments are next, including ending
treatment, referring to another provider or setting, or increasing the dose or
intensity of services.

FURTHER READINGS AND RESOURCES

This chapter reviewed the available research, identified evidence-based prin-

ciples, and suggested DP exercises for working with structural factors in psycho-
therapy. Additional research and recommendations can be found in the
following:

• Particularly approachable for its concise storytelling and practical advice,

Irvin Yalom’s (2002) book The Gift of Therapy: An Open Letter to a New Gener-
ation of Therapists and Their Patients (HarperCollins) is chock-full of insights
for therapists striving to improve various structural elements in their work.
176 Oleen-Junk and Yulish

Specifically, Chapters 27, 29–33, 36, 47–51, 59, 62, 65, and 73 focus on
the boundary dimension; Chapters 14–23, 52, 56, 60, and 69 focus on the
sequence dimension; and Chapters 11, 13, 20, 24, 37–40, 53, and 54 focus
on the appraisal dimension.

• Principle 3 (know your work) invites clinicians to be more intentional about

the flow of their work and how it influences client interactions. Even the
most client-centered and present-focused therapists develop implicit pat-
terns (or rituals) that govern sessions and decision making. To understand
more about the importance of ritual in psychotherapy (sequence dimen-
sion, primarily), see the following:
Moore, R. L. (1983). Contemporary psychotherapy as ritual process: An initial
reconnaissance. Zygon, 18(3), 283–294. https://doi.org/10.1111/j.1467-9744.
1983.tb00515.x.
Al-Krenawi, A. (1999). An overview of rituals in Western therapies and intervention:
Argument for their use in cross-cultural therapy. International Journal for the
Advancement of Counseling, 21, 3–17. https://doi.org/10.1023/A:1005311925402

• For an excellent discussion of strategies and considerations related to

Principle 1 (craft smarter starts to therapy), we recommend Daryl Chow’s
(2018) The First Kiss: Undoing the Intake Model and Igniting the First Sessions in
Psychotherapy (Correlate Press).

• As noted in Principle 2 (avoid unhelpful structuring activities), when a

therapist attributes stagnation or regression to the client, it can be a sign
that structuring activities are not tailored to more productive therapeutic
foci. For a discussion on evidence-based decision making regarding session
focus (i.e., client resources vs. client problems), see
Smith, E. C., & Grawe, K. (2005). Which therapeutic mechanisms work when?
A step towards the formulation of empirically validated guidelines for therapists’
session-to-session decisions. Clinical Psychology and Psychotherapy, 12(2), 112–123.
https://doi.org/10.1002/cpp.427

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8
Habits
The Key to a Sustainable System of Deliberate
Practice
Sam Malins, Scott D. Miller, Mark A. Hubble, and Daryl Chow

We are what we repeatedly do. Excellence, then, is not an act, but a habit.
—WILL DURANT, THE STORY OF PHILOSOPHY

DECISION POINT

Begin here if you have read the book Better Results (BR) and

• are routinely measuring your performance and

• have collected sufficient data to establish a reliable, evidence-based profile
of your therapeutic effectiveness and
• have completed the Taxonomy of Deliberate Practice Activities in
Psychotherapy and
• have identified an individualized learning objective with the greatest chance
of improving your effectiveness and
• need help developing consistent deliberate practice routines.

T he previous chapters have summarized key factors worthy of deliberate

practice (DP) and offered concrete exercises to support the development
of related skills. It is hoped the information presented thus far serves to support
a decision to employ DP and provide clear direction on what to do. If this has
happened, there is some important news: Deciding to engage in DP is half the

https://doi.org/10.1037/0000358-009
The Field Guide to Better Results: Evidence-Based Exercises to Improve Therapeutic Effectiveness,
S. D. Miller, D. Chow, S. Malins, and M. A. Hubble (Editors)
Copyright © 2023 by the American Psychological Association. All rights reserved.
181
182 Malins et al.

battle in becoming more effective. Establishing a system to support implemen-

tation and make it a routine is the next step in ensuring DP has a lasting impact
(Carden & Wood, 2018).
As has been said before, DP is a long game. Frequently, gains are not notice-
able in the short term (Ericsson, 2009; Ericsson et al., 1993). For this reason,
reliance on intention, willpower, or motivation is risky and unlikely to be
sufficient to sustain engagement following the burst of activity often associated
with interest in a new endeavor (Ajzen et al., 2009). Incidentally, brain systems
focused on thinking, decision making, and intentions operate differently from
those fueling long-standing behavior patterns, which are much slower to
change and require less conscious decision making (Wood & Rünger, 2016).
Said another way, force of will may be sufficient to scale a mountain today
but not support a daily exercise regimen committed to yesterday. Doing the
latter requires establishing a new habit—defined as “a settled tendency or usual
manner of behavior . . . that has become nearly or completely involuntary”
(Merriam-Webster, n.d.). Thankfully, research provides a clear picture of the
process involved.
This chapter will

• briefly summarize the empirical literature on long-term habit formation,

• identify evidence-based principles for making DP a default part of one’s

daily routine, and

• provide exercises to support the development of and overcome any barriers

to a “DP habit.”

FIELD GUIDE TIP

Set the Field Guide down and reread Chapter 14

in Better Results, “Designing a Sustainable System
of Deliberate Practice.”
Next, using a scale from 1 to 5 (where
5 is high and 1 low), rate how well you have
implemented each of the four elements of a
successful deliberate practice plan. Known as
ARPS, these include (a) automated structure,
(b) reference point, (c) playful experimentations,
and (d) support persons.
Reading further without first working at
improving the implementation of any element
scoring 3 or lower risks DP becoming just one
more interesting but unused idea a therapist
will come across in the course of their profes-
sional lifetime (Michie et al., 2009; Webb &
Sheeran, 2006).
 Habits 183

REVIEW OF THE RESEARCH

A defining characteristic of a habit is that it occurs with little conscious effort

or thought (Mazar & Wood, 2018; Verplanken, 2006; Wood & Neal, 2007).
Central to its development is “automaticity,” wherein environmental cues
trigger the execution of a predictable pattern of behavior outside a person’s
intention or awareness (Bargh, 1994). This definition clarifies habit formation
is more than repetition (although, as will be seen, doing something over and
again plays a role) or merely the development of a sense of familiarity. Speaking
metaphorically, an established habit is like part of the furniture. It exists and
is employed effectively, with neither acknowledgment nor attention.
Wood (2019) identified three reliable pathways to habit formation and
revision. The first is regular repetition. While it is widely believed habits take
21 days to form, the evidence shows otherwise. It takes much longer. In what is
now known as the seminal study on the subject, Lally et al. (2010) asked 96
volunteers to work on developing a new, healthy habit (e.g., eating, drinking, or
activity). Data on the frequency of completion and degree of automaticity indi-
cated an average of 66 days were required (with a range from 18 to 254), with
more complex changes taking longer. Several other findings from the study
are informative. First, missing the occasional opportunity to practice a new
behavior resulted in only a negligible drop in the development of automaticity.
Clearly, hope for success is not dashed when choice or circumstance results
in a “time-out.” Second, context is important (Lally et al., 2011). Practicing in
the same location on the same day at the same time is facilitative. Environ-
ments with unique or memorable features are also helpful, providing cues for
action (e.g., “I do 20 minutes DP every Friday in my office following the team
meeting, and that’s also when I have a caramel latte each week”). Third, and
finally, the wide range in times reported by Lally and colleagues indicates
some habits can form much more quickly. Identifying these and breaking
down more complex ones into their smaller constituent parts makes shorter,
easier-to-schedule practice periods possible, thereby increasing opportunities
for automation to develop more quickly (Kaushal & Rhodes, 2015). While on
the subject of time, Fogg (2020), following years of research at the Behavior
Design Lab at Stanford, concluded consistency is far more important than
amount. Doing a few minutes of a given activity on a regular basis, he reported,
yields more dividends than regularly increasing the time allotted to practice.
The reason is simple. It is easier to commit to and follow through with small
“entry points,” recognizing they can always be extended. By contrast, setting
up longer periods and then failing to fill the time with practice can sponsor
frustration and disappointment.
The second pathway is rewards. Forming new habits requires persistence
despite the pressure of distractions or more desirable pursuits (Andersson &
Bergman, 2011). Along the way, rewards can help maintain focus and con-
centration, with particular types superior to others. Intrinsic rewards (e.g.,
reminders of internal motivations) tend to be more effective than extrinsic
(e.g., money, validation by managers or a supervisor; Lally & Gardner, 2013).
184 Malins et al.

External rewards can enhance habit formation, provided they do not become
the sole purpose of practicing (Deci et al., 1999). For example, a meta-analysis
of 40 years of research conducted by Cerasoli et al. (2014) found extrinsic
rewards negatively alter the link between internal motivation and perfor-
mance outcomes. In particular, when the locus of control shifts to someone
or something outside the self, what one once did because it felt right or good
becomes a chore.
The last pathway is reducing friction. Consider the following: slightly
delaying the time an elevator takes to arrive once the call button is pressed,
increasing the distance one must cross to access unhealthy food, and placing
recycling bins close to workers. All share a common characteristic. They either
increase or decrease the likelihood of a desirable behavior occurring and being
repeated: increasing the use of stairs, decreasing the consumption of “junk”
food, and separating reusables from trash, respectively (Clohessy et al., 2019;
Houten et al., 1981; Ludwig et al., 1998; Rozin et al., 2011; Soler et al., 2010;
Wansink et al., 2016). In the literature, such elements or conditions have come
to be called “friction” (Wood & Neal, 2016). Common to all work environments
and pursuits, they can be modified in the service of promoting habit formation.
Reduce the source to increase behavioral options and repetition; increase them,
and the opposite occurs.
In their study of highly effective therapists, Miller and Hubble (2011) found
those who eventually rise to the top, becoming “supershrinks,” do not “exist
in a vacuum, bursting suddenly on the scene following years of private toil”
(p. 25). Far from it. The best reside in a social context consisting of people—
family, partners, colleagues, supervisors, teachers, coaches—who nurture and
support habits of excellence. It is familiar to anyone committed to DP: What
is required is continuously reaching for performance objectives beyond one’s
current ability, adopting an error-centric mindset (i.e., welcoming mistakes as
learning opportunities), and being open to feedback.
Greaney et al. (2018) reported on the role of social support in changing
risky habits (e.g., smoking, unhealthy eating, sedentary lifestyle). Participants
who identified one supportive person were significantly more successful than
those who tried to go it alone. “Participants identifying multiple support
persons,” the authors found, “had 100% greater reduction” in multiple risky
behaviors (p. 198). Thus, when it comes to developing new habits, social support
is good, and more is better.

EVIDENCE-BASED PRINCIPLES RELATED TO HABIT FORMATION

No doubt, DP has the potential to help you achieve better results. The same
is seen in many domains of human performance. The challenge, once you
begin to implement it, is sustainability. Detailed suggestions were provided in
Chapter 14 of Better Results (BR; pp. 157–170). If you haven’t already done so
and find yourself struggling to be consistent, we recommend returning to that
 Habits 185

section first, paying particular attention to the discussion of ARPS (automated

structure, reference point, playful experimentations, and support persons).
For ease of reference, Table 14.2 from BR summarizing the four elements and
potential action steps is represented here.

System Think . . . Description

Automated structure Algorithmically Schedule it
Protect the DP environment
Create a black box
Reference point Directionally Keep one eye on your outcome data
Keep the other eye on your current learning
objectives (see TDPA)

Playful experimentation Like a child Lateral learning

Call on your ideal identity
The “it’s never too late to have a good
session” technique
Arrange a surprise party
Test to learn, don’t learn for the test

Support Communally Form a scenius community

Seek out separate coaches for performance
and development

The ARPS framework is supported by the research on habit formation

reviewed in this chapter. By definition, habits do not require planning or
forethought. Transforming new behaviors into habits does, however. You
must establish systems (e.g., turning off the phone, email notifications) and
structures (e.g., time, place, focus) that make engagement in DP automatic,
independent of one’s motivational state. Rewards are also important. Here
is where having a reference point is essential. What better reward for DP exists
than comparing your current performance data with your baseline and seeing
progress, the results of your hard work? In addition, maintaining a playful
attitude and spirit of experimentation—especially in the face of the setbacks and
mistakes that are an integral part of DP—supports the risk-taking necessary for
the development of new ways of thinking and behaving (Brown & Vaughan,
2009). Last but not least is social support; its importance cannot be overstated.
Friends, colleagues, coaches, and a community greatly increase the chances
of successful habit formation.
In addition to ARPS, three principles emerge from the review of the empir-
ical literature.

Principle 1: Identity Matters

The role therapist identity can play in developing and sustaining DP habits
was introduced, along with concrete exercises, in BR (Miller et al., 2020,
186 Malins et al.

pp. 123–137, 165). Simply put, our professional identity reflects the values
we hold about the world and our work. When consciously and intentionally
aligned with our DP objectives, the time and effort we devote to improving
our ability to help become intrinsically rewarding, adding meaning and
purpose to our engagement in challenging, long-term projects. Such align-
ment, research further shows, enhances our sense of personal authenticity
(Gan & Chen, 2017).

Principle 2: Anticipation Is the Best Defense

Having a clear DP plan helps in habit formation. That said, many are too
idealistic in scope, failing to consider the barriers likely encountered along
the way (Buehler et al., 2010). When it comes to goal setting, current evi-
dence suggests the combination of two strategies works best: first, visualizing
the desired objective (e.g., reviewing outcome data twice a week, spending
20 minutes twice a week at the end of the workday completing one of the
many exercises recommended in the Field Guide) and, second, connecting it
with the key barriers to achievement and concrete plans for addressing such
obstacles. Making it easy to anticipate and adapt to problems encountered
(i.e., if situation X arises, I will use strategy Y to achieve goal Z) lessens
the chance of disrupting automaticity, characteristic of established habits
(Gollwitzer, 1999).

Principle 3: You Have Done This Before

More than 40% of what we do on a daily basis is habitual—patterns of thinking

and behaving you have already successfully created (Wood, 2019). Whether
deemed “good” or “bad,” “healthy,” or “unhealthy,” the same process is
involved. In short, you have done this before. Habits may be hard work to
establish or change, but doing so is nothing new. Using what you have learned
from these experiences will be helpful in developing the habits necessary to
sustain your engagement in DP.

EXERCISES FOR DEVELOPING THE HABITS SUPPORTING

DELIBERATE PRACTICE

The following exercises are aligned with the principles and aim to help make
DP a permanent and evolving part of your professional development. Each
is to be completed within a specified time—most within 5 minutes. For this
reason, it will be helpful to have a timer present. No need for a fancy stop-
watch because most mobile phones come with one. Each can be completed
alone or together with a colleague or coach. Table 8.1 provides an at-a-glance
summary of the principles and their associated exercises. The first four revisit
the ARPS framework.
TABLE 8.1. Summary of Principles and Exercises
Principle Principle summary Related exercises Exercise summary
1: Automated structure Build DP into your existing 1: Make it so Schedule DP and specify the particular activities for
automated habits. each episode to make them more likely to happen.
2: Make it easy and rewarding Incorporate small, but meaningful rewards into DP,
ideally linked to its overall purpose.
2: Reference point Finding a range of ways to track 3: Where are you now? Build qualitative and quantitative performance benchmarks
progress toward goals helps into DP alongside regular reviews.
when improvement is slow.
3: Playful experimentation Approach DP with playfulness to 4: Playful progress Use comic rewards, light-hearted exercises with friends
maintain creativity and manage 5: All change and family, music or rhyming in DP.
difficulties. Capitalize on current or upcoming changes that disrupt
6: Parallel play
existing habits and may make room for new ones.
Try out DP in areas of your life other than psychotherapy,
particularly active rest hobbies.
4: Support Do not approach DP alone; 7: Choosing a coach Identify one or two potential coaches and contact them
invite and recruit others to 8: Building a support network for an initial conversation.
support DP. Reach out to a peer or network of peers who are either
using DP or you think could benefit from trying it.
5: Identify your identity Build rewards into DP that remind 9: The retirement party Write a speech that includes what you would like to be
you of who you are becoming said about you and your future work at retirement.
as you practice.
6: Forewarned is forearmed When planning goals, make sure 10: The premortem Plan for potential problems with implementing DP by
they account for the most imagining you have already failed and why it happened.
important barriers to progress.

Habits 187
7: You have done this before Use strategies and knowledge 11: This is not your first rodeo Go through your habit history, identifying factors that
you have gained from building helped and hindered you in building habits.
habits previously.
Note. DP = deliberate practice.
188 Malins et al.

Exercise 1: Make It So (5 minutes)

Principle: The A in ARPS

Purpose
Busyness is a common barrier to making DP routine. Scheduling ahead of
time is the “antidote.” Start small—10 to 20 minutes. Eliminate as much
prep work as possible by identifying specific tasks you can begin at the outset
of your scheduled time. Small, meaningful, and clearly defined tasks will help
you to get going and make the time feel like it was well spent, especially at
the start.

Task
Make short periods of DP a part of your schedule for the coming month.
To ensure success,

• make it obvious in your calendar so it cannot be overwritten and is visible

to you and anyone who handles your schedule;
• connect your DP to an established habit in your work routine (e.g., after
lunch or a regular meeting that is unlikely to be canceled);
• reward yourself after completing a DP activity;
• include time to rest in the scheduling—DP is effortful, so shorter, intensive
periods of DP followed by brief rests is more effective; and
• share what you are doing with others, friends, family, and particularly
colleagues who are incorporating DP in their work.

Exercise 2: Make It Easy and Rewarding (5–15 minutes)

Principle: 1
Purpose
It is learning theory 101. What you reward increases. Punishment suppresses
behavior. Identifying small, meaningful rewards will support your motivation
to continue DP, especially at the outset when the most effort is required.

Task
Mindful of the research reviewed earlier documenting the potency of intrinsic
rewards and the reduction of friction in habit formation, devote time to
creating a work environment that makes DP easy, enjoyable, and productive
(people, decor, artwork, furniture, natural light, everyday conveniences, and
tangible rewards).

• Make a list of your reasons for doing DP. In constructing or organizing your
workspace, find ways to remind yourself of your best intentions. It could be
a picture, an objet d’art, a poster with an inspirational quote, or an avatar
on your social media profile. It could even be a reminder on your phone or
computer.
 Habits 189

• Spend a few minutes each week for 1 month noting what gets in the way
of your DP. It could be clutter, excessive noise, hunger, size of caseload, or
anything. The following month, rank order the barriers from most to least
disruptive and start addressing them one at a time, starting at the top.

• Make a list of people with whom you will share your successes and strug-
gles, seeking out cheerleaders rather than naysayers, team players rather
than competitors.

Exercise 3: Where Are You Now? (5–15 minutes)

Principle: 2
Purpose
In a long-term learning project such as DP, having a regular, understandable
assessment of key performance indicators helps identify progress where it
might not be noticed otherwise.

Task
Identify and/or build in key performance reference points of where you
are now:

• Find out or calculate your current outcome performance metrics, ideally

benchmarked against the performance of other psychotherapists, as dis-
cussed in Chapter 1.

• Identify your current individualized learning objective, preferably using

recordings of your sessions to help you discover it, coupled with your
aggregated outcomes.

• Keep a recording of a recent session that highlighted some current skill

deficits you will work on with DP, where you have permission to retain
the recording for a few months. Diarize a time to listen back to this session
segment after a couple of months of DP.

• Use your current “how I do therapy” blueprint (see Chapter 1 for further
explanation) as a qualitative benchmark, redrafting and reviewing it as
your practice evolves with DP.

At least once a month, review these way markers as part of your DP to help
identify points of change.

Exercise 4: Playful Progress (5–15 minutes)

Principle: 3
Purpose
DP can be hard, and the slow progress can be disheartening. Therefore, this
exercise aims to help find ways of bringing playfulness to the process, which
can maintain a sense of fun, creativity, and lightheartedness.
190 Malins et al.

Task

Brainstorm ways to bring playfulness into DP, then try one or two out at
your next DP sessions. Some examples of bringing playfulness to DP are
• setting your individualized learning goals to music, such as a jingle on a
commercial (alternatively, work out a rhyme that describes your learning
objective);
• trying out the therapeutic skills you are developing in DP with friends and
family members during casual conversations and seeking their feedback
in a lighthearted way; and
• making comic rewards for attempts at improvement (e.g., winning a jelly
bean or chocolate, gaining a plastic trophy for a set number of DP hours).

Exercise 5: All Change (5–15 minutes)

Principle: 3
Purpose
This exercise aims to help you identify areas of upcoming or existing change that
may present a way to playfully introduce new habits that could support DP.

Task
Take 2 to 5 minutes to list changes that are going on in your home or work
life at the moment or that have occurred recently. Your list can include any-
thing, but the following are some examples to prompt your thinking to
include changes you may have badged as positive or negative:
• changing jobs (Yes. Drastic. But some jobs are hazardous to your well-being
and are not conducive to your development.)
• moving desks
• working in a new way or system
• having a new supervisor or coach
• getting a new pet, child, or partner
Consider the following:
• How could these changes disrupt the status quo in a way that paves a route
to new DP-related habits? Take 2 to 5 minutes to brainstorm ways that
changes in your life might facilitate the introduction of DP.
• Take 1 to 5 minutes to consider where you might start with leveraging this
change to support DP.

Exercise 6: Parallel Play (5–10 minutes to start)

Principle: 3
Purpose
Many high achievers in demanding roles find active rest, hobbies that, in some
ways, reflect themes of their work but without key drawbacks. A quintessential
 Habits 191

example of this is academics who are rock climbers: Climbing takes thought,
planning, and a strategy and is time consuming—just like research. However,
with rock climbing, you get the exhilaration of success by the end of the
day rather than having to wait months or years for the outcome of research
(Mitchell, 1983). This exercise aims to identify activities that are outside the
realm of psychotherapy DP but might draw on parallel principles.

Task
Are there any activities you do or used to do that can give a similar sense of
achievement or satisfaction as psychotherapy but in a different sphere of life?
For example, playing basketball may, at face value, look completely unrelated
to psychotherapy, but perhaps there are parallels in the way that you aim to
collaborate with players on your team or the way you strategically analyze how
to address particularly challenging defenses in a time-out. However, basketball
also avoids some of the difficulties of psychotherapy—you get to know how
it pans out by the end of the evening rather than working for several weeks,
months, or years to see the fruit of your labor.

• Identify an activity or hobby that is like psychotherapy but not psycho-

therapy, and consider trying DP in this area at the same time as DP in psycho­
therapy. Continuing our basketball example, rather than just shooting around
at random when you are starting to play, work out a short practice that is
likely to help you shoot more effectively, even though it may take small
incremental gains. A similar approach could be taken to swimming, running,
chess, crochet, or any hobby requiring specific trainable skills. Think of a
way of doing DP that isn’t psychotherapy DP and can be playful or fun.

• If you once found an activity that gave similar satisfaction to psychotherapy,

but you no longer do it, now might be a good time to restart this pursuit
to provide a release from the efforts of DP for psychotherapy in a different
area that could provide a similar sense of reward.

Exercise 7: Choosing a Coach (5–10 minutes)

Principle: 4
Purpose
Given the central role of a coach in DP, this exercise aims to help identify
someone with the appropriate characteristics.

Task
Identify one or two potential coaches and contact them one at a time for an
initial conversation. Aim high with this choice (see BR; Miller et al., 2020,
pp. 35–39, 112–113). Aim for someone who you feel

• has authority but is not authoritarian,

• is invested in you finding your best way of doing things rather than repli-
cating their approach,
192 Malins et al.

• is clear about where you want help, and

• has sufficient skill to be able to identify your deficits and offer strategies to
remediate them.

Exercise 8: Building a Support Network (5–10 minutes)

Principle: 4
Purpose
Given the central role of a coach in DP, this exercise aims to help identify
someone with the appropriate characteristics.

Task
Reach out to a peer or network of peers who are embarking on the use of DP
in their practice or people you would like to encourage to do so. You could
collaborate with someone who works in your area or reach out beyond.
The International Center for Clinical Excellence network might be a useful
starting place (see https://www.iccexcellence.com).

Exercise 9: The Retirement Party (30 minutes)

Principle: 5
Purpose
This is an adaptation of an existing exercise (Harris, 2009) that aims to link
personal values with DP and the longer term results of persisting with it.

Task
Imagine you set up a sustainable system of DP from this day forth. It is now
your retirement party, and a close friend who knows you well and cares about
you gets up in front of your family, friends, and colleagues to give a speech
about how you conducted the remainder of your career. What would you want
them to be able to say about you and what was important to you during the
rest of your career?
• Take a couple of minutes to picture the scene and imagine what principles
or values you would like to hear your friend say that you upheld and stood
for through the rest of your career. Write these down (5 minutes).
• Now your friend describes some of the things you did on a regular basis that
showed what you valued. What routine practices would you like them to
be able to cite? Some might be activities you already do, but some may be
activities you aspire to do. List these regular, routine activities (3 minutes).
• Where would DP fit in this speech? What would your friend say about
– what you did,
– how you made DP part of your day-to-day life,
– how you overcame barriers to keep it going throughout your career, and
– how DP impacted your personal and professional life and those you
encountered?
 Habits 193

• Spend 3 minutes on each of these areas, writing down what you would
like your friend to be able to say at your retirement party.
• Look back over what you have written either alone, with a colleague who
has completed the same exercise or with a coach or supervisor. Spend
10 minutes reviewing these questions in reflection on this exercise:
– What are the central threads running throughout the speech that are
components of your identity you would like to nurture and grow?
– How might DP support this?
– What does this exercise tell you about how DP might need to look for it
to play a consistent role in your career?
– What does this speech tell you about where to start with implementing
DP now?

Exercise 9: The 5-Minute Version

Imagine a close friend giving a speech about the rest of your career at your
retirement party. Spend a minute each on (a) thinking about where DP would
fit in this speech, (b) how DP would support the important values you would
like to uphold in the rest of your career, and (c) how DP would look and fit in
your ideal future career. Now spend 2 minutes reflecting on what this tells
you about how you want DP to affect your identity and where it would be
best to start with this system.

Exercise 10: The Premortem (30 minutes)

Principle: 6
Purpose
Prospective hindsight is a process of imagining a future event has already
happened and helps people to be more accurate in predicting how plans
will progress (Mitchell et al., 1989). Gary Klein (2007) applied this approach
to project planning by asking participants to imagine a project has already
failed. This approach helped participants identify weaknesses in the plan and
adjustments required to improve it. The premortem approach is applied to DP
implementation in this exercise.

Task
Imagine you started a system of DP today, and you are looking back a year
from now. It has been a complete disaster and has failed miserably.
• Write a detailed description of why it failed so badly and all the reasons
that caused the failure. Remember to write in the past tense, looking back
a year from now. This helps overcome futuristic optimism and the planning
fallacy and gives clarity on potential barriers that may be difficult to call to
mind when hopeful about a future plan (10 minutes).
• Create an “if–then” guide for each potential problem your DP system may
face. Discuss this with a colleague or a coach or supervisor to help brainstorm
194 Malins et al.

adaptations to your plans that would account for the barriers you are likely
to face (15 minutes).
• In case these were not identified in your premortem, some of the most
likely barriers are described next. Spend 5 minutes checking whether the
plans you have made will address these issues:
– The pull to perform: It is unlikely anyone in your service will be
pushing you to make DP happen, but there may well be a pull to get
more clients seen more quickly, which could cut into DP time. How
would you deal with that?
– A hard day’s night: As described earlier, DP is effortful and tiring, so it
may not be the most appetizing activity to follow a hard day, week, or
therapy session. The mental effort involved in DP could spoil your plans
when internal resources are depleted. How could you overcome that?
– Resource restriction: Professional development activities are limited
in almost all psychotherapy organizations and are usually focused on
attaining competence (or at least familiarity) with new therapeutic
techniques. This is unlikely to leave much room for DP, which aims to
be an ongoing component of professional development for all therapy
techniques. How would you tackle this conundrum?
– Softening the blow (maybe too much): Some supervisors or coaches
might feel DP is a way of being excessively self-critical. They may empha-
size the complexity of a client’s problems, say that your efforts are good
enough, or perhaps infer that you are nit-picking by identifying a small
unhelpful habit in the grand scheme of things. In general, your support
systems may aim to comfort you in a well-meaning manner when you
identify microskills for DP. There may be truth in what they say, but how
will you manage this dynamic to progress with DP?

Exercise 10: The 5-Minute Version

Spend 2 minutes imagining that your attempt to embed DP fails terribly

over the coming months. Spend 1 minute identifying the top three reasons
why this happened. Pick the most important of these three reasons and take
2 minutes to make at least one “if–then” plan for how you would tackle it.

Exercise 11a: This Is Not Your First Rodeo, Part 1—Your Forgotten
Rodeos (15–20 minutes for each part, ideally alone initially, then reflect
with a coach, practice partner, or small group)

Principle: 7
Purpose
This series of exercises aims to draw on your previous experience of building
sustainable habits (or attempts to do so) and how this can inform your plan
for a sustainable DP system.
 Habits 195

Task
Think through times in your personal or professional life when you have felt
excited, enthused, determined, or energized to try something new or different,
and it has not worked out. Perhaps you started but could not stick with it, or
nothing happened at all. With the benefit of hindsight, what got in the way
in each of these areas?

• Existing routine: Specifically, what daily structures or habits prevented

this from becoming part of your normal life?

• Environment: What environmental cues (or the absence of such cues)

might have made it harder for this habit to form?

• People: Which people did you not have on board who might have helped
with this (or potentially obstructed habit formation because they were not
involved)?

• Willpower: How much importance did you place on willpower in making

this habit work?

Exercise 11b: This Is Not Your First Rodeo, Part 2—Your Winning
Rodeos (15–20 minutes)

Principle: 7
Purpose
This part of the exercise aims to make use of helpful strategies established in
previous or existing habits that may be applied to DP.

Task
Think about helpful, healthy, and/or valued activities you do regularly as part
of your current routine at work or in your personal life.

• Specifically identify two to five habits or routines that are important to

you that support aspects of your work or your life more broadly. These
are likely to be habits you take completely for granted and may be so deep
in the water that you could easily overlook them. If it is hard to think of
these, go through a typical day from waking up, and in 30-minute inter-
vals, identify activities that are helpful for you.

• What helped these habits to form? Again, be aware of the urge just to
shrug your shoulders and say, “Well, they just seemed to happen.” If this
is your experience, it is just underlining that massive, long-standing bouts
of willpower are not the key to long-standing habit formation. This is the
beauty of habits: Their ability to continue is barely noticeable in terms of
conscious effort, but this makes it difficult to identify their mechanisms.
One way to do this is to track back to a time when you were not doing the
habit and consider how it started.
196 Malins et al.

• Think through the role played by each of the following areas in forming
each habit.
– Existing routine: What aspects of your existing routine (at the time
the habit was started) helped the new habit to form? In what way did
existing behaviors cue the new habit? What factors were reinforcing,
rewarding, reminding, or recognizing occasions of carrying out the habit?
– Environment: What was going on in your environment that cued the
new habit—even if in small, seemingly trivial ways, such as objects being
close and accessible or far away and inaccessible?
– People: Who was involved in either helping form this habit (maybe
you did it with someone or for someone) or supported you in forming
this habit? What did they do? How did you get them involved?
– Willpower: In the long term, what role did willpower play in estab-
lishing this habit?

Exercise 11c: This Is Not Your First Rodeo, Part 3—Your Next Rodeo
(15–20 minutes)

Principle: 7
Purpose
The final part of this exercise uses what was learned in Parts 1 and 2 to distill
strategies likely to be helpful in DP, alongside possible barriers and how to
manage them.

Task
Reflect on the key themes you noticed while completing Parts 1 and 2 with a
coach, practice partner, or small group who have also completed the exercise.
• Use your reflections from Parts 1 and 2 to complete Table 8.2.
• Identify what has been helpful and unhelpful from your previous experi-
ences of successful and unsuccessful attempts to integrate new habits into
your routine.

TABLE 8.2. Applying Learning From Previous Habits to a Sustainable System of DP

Areas for rewards, reinforcers, Unhelpful with Helpful with Helpful for DP
reminders, and recognition habits before habits before habits now
Integrating into routine

Environmental cues

Involvement of people

Where willpower fits

 Habits 197

• From these elements, what do you think might help you establish a
sustainable system of DP? Pay particular attention to rewards, reinforcers,
reminders, and recognition in the way you could
– integrate DP into your existing routine,
– shape your environment to encourage DP,
– helpfully involve other people in your DP habits, and
– keep willpower in its rightful place.

Exercise 11: The 5-Minute Version

Spend 2 minutes identifying healthy, helpful, and/or valued activities you carry
out on a regular basis. Now spend 2 minutes identifying habits you wanted to
form but failed to do so. Take a minute to reflect on the differences between the
two and how this informs your approach to embedding DP sustainably.

SUMMARY

No matter how motivated you feel about DP right now or how strong you
perceive your willpower to be, the main message of this chapter is that the
structured systems you build around DP hold more sway in keeping you going
in the longer term. Specifically, this chapter outlined current evidence on using
rewards linked to intrinsic motivators, managing the environment to promote
and protect DP, finding appropriate support, and tracking progress. Perhaps most
important, this chapter discussed the likelihood of failure and how responses
to obstacles can be key in the continuation of a challenging but important
activity like DP. Like some sustainable practices in energy use, the activities
recommended in this chapter could seem to slow immediate progress and feel
costly, but in the long run, aim to generate their own energy, requiring less
motivation-related resources over time for sustaining DP.

FURTHER READINGS AND RESOURCES

This chapter reviewed the available research, identified evidence-based prin-

ciples, and suggested a DP practice plan. Additional research and recommen-
dations can be found in the following:

Clear, J. (2018). Atomic habits: An easy and proven way to build good habits and break bad
ones. Random House.
This book offers a simple and practical explanation of how habits are formed and how
the mechanisms for habit formation can be harnessed strategically.

Ericsson, K. A., & Pool, R. (2016). Peak: Secrets from the science of expertise. Houghton
Mifflin Harcourt.
A summary of the evidence on DP and its processes and outcomes, alongside the
experience of using it.
198 Malins et al.

Gardner, B., Abraham, C., Lally, P., & de Bruijn, G. J. (2012). Towards parsimony in
habit measurement: Testing the convergent and predictive validity of an automaticity
subscale of the Self-Report Habit Index. International Journal of Behavioral Nutrition
and Physical Activity, 9(1), 1–12. https://doi.org/10.1186/1479-5868-9-102.
A brief self-report assessment of whether automaticity has been achieved.

Miller, S. D., Hubble, M. A., & Chow, D. (2020). Better results: Using deliberate practice to
improve therapeutic effectiveness. American Psychological Association. https://doi.org/
10.1037/0000191-000
An explanation of how DP can be applied to psychotherapy to improve outcomes.

Pang, A. S. K. (2016). Rest: Why you get more done when you work less. Basic Books.
A deep dive into case studies and more generalizable evidence on the value of rest
for effective and mentally taxing work.

Wood, W. (2019). Good habits, bad habits: The science of making positive changes that stick.
Macmillan.
An explanation of the science behind habit formation from a leading researcher in
the field.

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9
The Last Chapter (but Not
the Last Word) on Deliberate
Practice
Sam Malins, Daryl Chow, Scott D. Miller, and Mark A. Hubble

After climbing a great hill, one only finds that there are many more hills to climb.
—NELSON MANDELA

DECISION POINT

Begin here if you have read the book Better Results and

• are routinely measuring your performance and

• have collected sufficient data to establish a reliable, evidence-based profile
of your therapeutic effectiveness and
• have completed the Taxonomy of Deliberate Practice Activities in Psycho-
therapy and
• no longer need help leveraging the factors responsible for treatment
outcome nor developing a consistent deliberate practice routine.

A bove all else, a field guide is supposed to be practical—an accessible, easy-

to-use repository of information pertinent to a particular area of interest
or subject. It is not a textbook. It is a “ready reference” designed to help the
reader quickly find what they want or need to know when they want or need
to know it.
In the preceding chapters, leading experts have reviewed and summarized
the empirical literature, distilled evidence-based principles, and offered concrete

https://doi.org/10.1037/0000358-010
The Field Guide to Better Results: Evidence-Based Exercises to Improve Therapeutic Effectiveness,
S. D. Miller, D. Chow, S. Malins, and M. A. Hubble (Editors)
Copyright © 2023 by the American Psychological Association. All rights reserved.
201
202 Malins et al.

exercises you can use to improve your results. The focus is idiographic, not
nomothetic—it is focus on you, the individual practitioner, what you can do
to improve at a given point in your career; it is your development, not what
you are being told to do to be effective (Chow et al., 2022).
The Field Guide (FG) picks up where Better Results left off. Chapter 1, “Iden-
tifying Your ‘What’ to Practice,” covered how to determine your specific target
for deliberate practice (DP). Chapter 2, “Identifying and Refining Your Indi-
vidualized Learning Objective,” clarified how to break down your target into a
series of executable steps, turning hoped-for improvements into well-defined
learning goals, along with specific activities designed to promote progress.
Chapters 3 through 7 shifted attention to the factors most responsible for change.
Which to read will depend on your objective. Need help leveraging client
factors? Start with Chapter 3. If your performance data and completed Tax-
onomy of Deliberate Practice Activities in Psychotherapy (TDPA; Chow & Miller,
2022; see Appendix A, this volume) reveal a deficiency in building hope and
an expectation of success, turn to Chapter 6. The same holds for Chapters 4, 5,
and 7—you, the therapist, your relationship with your clients, and the structure
you bring to your work, respectively. Finally, Chapter 8, “Habits: The Key to a
Sustainable System of Deliberate Practice,” provided direction for transforming
your “good intentions” into a sustainable system of DP.
In content and form, the FG leaves room for the novel and unexpected.
On your journey, you may not encounter all that is described in the volume.
Hopefully, it helps you see and understand what you might otherwise miss
and even venture into uncharted territory, making discoveries of your own.
Encouraging their readers to explore the unknown when they have a guide
for what is known has, for example, stretched human understanding of nature
and wildlife (Pearson & Shetterly, 2006).
True, the current evidence shows DP is more effective than traditional
approaches for teaching and training therapists (Barrett-Naylor et al., 2020;
Newman et al., 2022; Westra et al., 2021). Still, much remains unknown and
subject to revision; for example,

• how long DP takes to facilitate improvement,

• whether everyone benefits from DP in the same way,
• if certain types of DP plans yield faster and better results (Ericsson & Pool,
2016),
• how to tailor DP to the individual to maximize benefit,
• the characteristics of effective coaches and learning feedback, and
• the environmental conditions (e.g., social support, schedule, intrinsic and
extrinsic rewards) most supportive of DP (Clements-Hickman & Reese, 2020).

At the most basic level, agreement about what DP is and what it is not
has yet to make its way into the profession. As noted in Chapter 1, some
are equating DP with just another way of mastering particular methods and
techniques, assuming that doing so will yield better results. It is also noteworthy
that no investigation published to date includes a DP condition meeting the four
 The Last Chapter (but Not the Last Word) on Deliberate Practice 203

FIGURE 9.1. The Four Pillars of Deliberate Practice (DP)

empirically established criteria. As reported in a meta-analysis by Miller et al.

(2018), these include (a) an assessment of the performer’s baseline ability or
skill level against which progress can be determined, (b) corrective feedback
targeted to the individual’s execution of skills being learned, (c) development
of a plan for successive refinement over time, and (d) guidance provided by
an expert coach or teacher (see Figure 9.1). Until consensus is reached and
qualifying studies are performed, our knowledge remains principally based on
naturalistic and retrospective studies. Even then, though desirable, the dominant
form of research employed in the field—randomized controlled trials—will
likely need to give way to designs congruent with the highly individualized
nature of DP. For all these reasons, as with all field guides, this one should be
viewed as a “work in progress.”
Looking forward, as interest and research on the subject grow, understanding
of DP will likely (and hopefully) change and evolve. To ensure DP remains
true to Ericsson’s discoveries for transforming professional development versus
being made a servant of conventional thinking and practices, we believe four
points are critical for both clinicians and researchers to keep in mind.

MAKE CLEAR DISTINCTIONS BETWEEN NAIVE, PURPOSEFUL,

STRUCTURED, AND DELIBERATE PRACTICE

In their last book, Peak: Secrets from the New Science in Expertise, Ericsson and
Pool (2016) identified three different types of practice (see Chapter 1): naive,
purposeful, and deliberate. A 2019 paper called attention to a fourth: struc-
tured (Ericsson & Harwell, 2019). Distinguishing between the various forms
was crucial, Ericsson and Pool maintained, because only one was reliably
associated with improving individual performance.
The “naive” type is what is most commonly associated with the word prac-
tice. Repetition is seen as the key component, whether playing a sport or
learning to drive a car. Unfortunately, Ericsson and Pool (2016) noted, “Research
has shown that . . . once a person reaches [an] level of ‘acceptable’ performance,
[more such] ‘practice’ doesn’t lead to improvement” (p. 13). As such, consistent
204 Malins et al.

with the literature reviewed in BR and this volume, clinical experience would,
at best, qualify as an example of “naive practice.”
Most psychotherapy workshops and books with “deliberate practice” in their
titles would, according to Ericsson and Pool (2016), at best, be examples of
either structured or purposeful practice. With regard to the former, the objective
is proficiency and competence, achieving a predetermined standard for the
execution of a particular skill. It is planned and goal directed and includes feed-
back and a way to monitor progress but not individualized learning objectives.
Studying, attending a workshop, or reading a book would be examples of
the latter. Such practice can certainly be planned and goal directed. Without the
input of a coach, however, efforts are subject to a number of threats, including
self-assessment bias, limitations in the learner’s knowledge and ability that
impede development, and the absence of expert feedback designed to optimize
learning.
Of the four, only DP is individualized, requiring the performer to “constantly
try things that are just beyond [their] current abilities” (Ericsson & Pool, 2016,
p. 99). For knowledge to advance, the design of future studies must include
“bona fide” DP conditions, reflecting the four criteria reported earlier (see
Table 9.1).

GET BEYOND “TIME SPENT” FALLACY IN DP

Ever since writer Malcolm Gladwell (2008) coined the term “the 10,000-hour”
rule, many have conflated effective DP with the amount of time devoted to
the activity. In fact, Ericsson never made such a claim. Yes, the first study of DP
in psychotherapy did find the amount of time a therapist devoted to DP was
correlated with effectiveness (Chow et al., 2015). However, as everyone learns
in their first statistics course, correlation is not causation. In this context, this
was confirmed in the meta-analysis by Miller et al. (2018), revealing mere
time spent is not a reliable predictor of effective DP. Naturally, DP takes time.
By now, it is hopefully clear the quality and characteristics of practice are what
matter most (Ericsson, 2008).

TABLE 9.1. Naive, Purposeful, Structured, and Deliberate Practice

Purposeful Structured Deliberate
Naive practice practice practice practice
Guidance from a coach? N N Y Y
Individualized learning N Y N Y
objectives?
Learning feedback (LF) PF only (if routine PF only PF only LF & PF
and performance outcome
feedback (PF)? measurement is
employed)
Successive refinement? N Y Y Y
 The Last Chapter (but Not the Last Word) on Deliberate Practice 205

ADOPT RESEARCH METHODS AND DESIGNS CONGRUENT WITH

THE NATURE AND AIMS OF DELIBERATE PRACTICE

Throughout BR and the FG, the point has repeatedly been made that DP is a
long-term process—once more, “a marathon, not a sprint.” Unfortunately, most
studies published in our field are short in duration. For example, Chow et al.’s
(2022) investigations of DP lasted no more than a few hours. What is more, the
typical research design employed—the randomized controlled trial—is far more
applicable to assessing the type of mastery associated with purposeful practice
than the slow, highly individualized growth that is the hallmark of DP. They
can be done, but naturalistic, retrospective, mixed methods, and developmental
designs have a better chance of capturing the nuance and complexity of DP.

FOCUS ON PRINCIPLES (NOT MODELS AND METHODS)

Models and their associated techniques have a negligible relationship with

outcome. For this reason, linking DP—whether in research or training—to
particular approaches is senseless. Better to focus on “first principles,” defined
as the “fundamental proven axioms in the given arena” ("First Principle,"
2022, para. 3). The factors at the core of all effective therapy represented in the
TDPA and reviewed in detail in Chapters 3 through 7 are exemplary.
The evidence shows that when DP is organized around principles rather
than emulating a reference example (i.e., here is how it’s done, do it this way),
people are better able to transfer what they learn to novel situations (Chow
et al., 2022; Haskell, 2001). Thus, instead of testing for the mastery of a partic-
ular skill, future research and training programs should assess the degree to
which whatever is taught transfers successfully to other clients, contexts, and
conditions. After all, as MacKeough and colleagues (1995) noted, “Transfer of
learning . . . [is] the ultimate aim of teaching” (p. vii).

CONCLUSION

In the end, the ultimate test of BR and the FG—the only outcome that matters—
is outcome. Administering measures, seeking feedback, regularly scrutinizing
our performance, exposing ourselves to critique, pouring over data, and devoting
time and resources to completing the exercises in both volumes will all have
been for naught unless more of the people who seek your help are being helped.
After all, for most of us, that is the reason we chose this profession, our first first
principle.

REFERENCES
Barrett-Naylor, R., Malins, S., Levene, J., Biswas, S., Mays, C., & Main, G. (2020). Brief
training in psychological assessment and interventions skills for cancer care staff:
A mixed methods evaluation of deliberate practice techniques. Psycho-Oncology, 29(11),
1786–1793. https://doi.org/10.1002/pon.5393
206 Malins et al.

Chow, D., & Miller, S. D. (2022). Taxonomy of Deliberate Practice Activities in Psychotherapy—
Therapist Version (Version 6). International Center for Clinical Excellence.
Chow, D. L., Miller, S. D., Seidel, J. A., Kane, R. T., Thornton, J. A., & Andrews, W. P.
(2015). The role of deliberate practice in the development of highly effective psycho-
therapists. Psychotherapy, 52(3), 337–345. https://doi.org/10.1037/pst0000015
Chow, L., Miller, K., & Jones, H. (2022). Improving difficult conversations in therapy:
A randomized trial of a deliberate practice training program [Manuscript submitted for
publication]. International Center for Clinical Excellence, Chicago, IL.
Clements-Hickman, A. L., & Reese, R. J. (2020). Improving therapists’ effectiveness: Can
deliberate practice help? Professional Psychology: Research and Practice, 51(6), 606–612.
Advance online publication. https://doi.org/10.1037/pro0000318
Ericsson, K. A. (2008). Deliberate practice and acquisition of expert performance:
A general overview. Academic Emergency Medicine, 15(11), 988–994. https://doi.org/
10.1111/j.1553-2712.2008.00227.x
Ericsson, K. A., & Harwell, K. W. (2019). Deliberate practice and proposed limits on the
effects of practice on the acquisition of expert performance: Why the original definition
matters and recommendations for future research. Frontiers in Psychology, 10, 2396.
https://doi.org/10.3389/fpsyg.2019.02396
Ericsson, K. A., & Pool, R. (2016). Peak: Secrets from the science of expertise. Houghton
Mifflin Harcourt.
First principle. (2022, April 25). In Wikipedia. https://en.wikipedia.org/wiki/First_
principle
Gladwell, M. (2008). Outliers: The story of success. Little, Brown and Company.
Haskell, R. E. (2001). Transfer of learning: Cognition, instruction, and reasoning. Academic
Press. https://doi.org/10.1016/B978-012330595-4/50003-2
MacKeough, A., Lupart, J., & Marini, A. (Eds.). (1995). Teaching for transfer: Fostering
generalization in learning. Routledge.
Miller, S. D., Chow, D., Wampold, B., Hubble, M. A., Del Re, A. C., Maeschalck, C., &
Bargmann, S. (2018). To be or not to be (an expert)? Revisiting the role of deliberate
practice in improving performance. High Ability Studies, 31(1), 5–15. https://doi.org/
10.1080/13598139.2018.1519410
Newman, D. S., Villarreal, J. N., Gerrard, M. K., McIntire, H., Barrett, C. A., & Kaiser,
L. T. (2022). Deliberate practice of consultation communication skills: A randomized
controlled trial. School Psychology, 37(3), 225–235. Advance online publication. https://
doi.org/10.1037/spq0000494
Pearson, D. L., & Shetterly, J. A. (2006). How do published field guides influence inter-
actions between amateurs and professionals in entomology? American Entomologist,
52(4), 246–252. https://doi.org/10.1093/ae/52.4.246
Westra, H. A., Norouzian, N., Poulin, L., Coyne, A., Constantino, M. J., Hara, K.,
Olson, D., & Antony, M. M. (2021). Testing a deliberate practice workshop for devel-
oping appropriate responsivity to resistance markers. Psychotherapy, 58(2), 175–185.
https://doi.org/10.1037/pst0000311
APPENDIX A

Taxonomy of Deliberate Practice

Activities in Psychotherapy—
Therapist Version (Version 6)
Daryl Chow and Scott D. Miller (© 2015, 2017, 2019, 2022)

Your Name: _________________    Your Coach’s Name: ________________

Date: _______________

Objectives:

1. To develop clear and concrete learning objectives specific to the clinical

population you work with in order to promote professional development.

2. To establish a baseline of learning goals and to evaluate professional growth

routinely (i.e., monthly), in concert with routine outcome monitoring (ROM)
practices.

Overview:
There are five broad domains for deliberate practice in psychotherapy:

1. 2. 3. 4. 5.
Structure Hope & Relationship Client Therapist
Expectancy Factors Factors Factors

Copyright 2022 by Daryl Chow, PhD & Scott D. Miller, PhD. Reprinted with permission.
The “Taxonomy of Deliberate Practice Activities in Psychotherapy” (TDPA) may not
be copied, transmitted, or modified without written permission of the authors.
207
208 Appendix A

Instructions:

1. Know Your Work:

Begin with regular monitoring of your clinical work using standardized mea-
sures of relationship and outcome. Once sufficient data has been collected to
establish a reliable, evidence-based profile of your work, identify parameters
indicating where your performance falls short of established norms.
Recall as vividly as possible your clients in the last typical work week
(extend to the last 2 work weeks if necessary). To aid with your recall, review
audio/video recordings of your sessions.

2. Rate:
Go through the list of activities contained in the TDPA, rating each of them
according to your own appraisal of how you perform in each of the domains.

3. Describe:
Put notes in on the last column to add richness and detail to your ratings.

4. Prioritize:
Review the ENTIRE document, identifying the top 3 activities you believe
will have a significant impact on improving your ability to engage and help
your clients. After you have identified your top 3 activities, select one to
work on.

5. Compare and Contrast:

Enlist a coach, or content-area expert to complete the Coach version of the
TDPA. Compare ratings and the top 3 activities. Work together to identify
and design a single learning objective.

6. Consolidate:
Complete the final page of the TDPA, Consolidation, and

7. Plan:
Develop a routine for reviewing the TDPA periodically (i.e., every month).
Expect learning objectives to change and evolve as you make progress.

*Notes: Please select the TOP 3 ACTIVITIES across the entire list (e.g., not necessarily
within each of the domains). The three do not have to be the lowest scored item. Complete
the consolidation section at the end to help clarify your professional development plan.
TABLE A.1. The Structure Domain of Deliberate Practice Activities

Current Rating Select & Rank the TOP 3

Themes Activities (0–10) Activities to work on* Notes

A.
How do you start a first session?

B.
How do you start subsequent sessions?

C.
How do you close a session?
1. Structure

D.
How do you formally elicit detailed and
nuanced feedback at each session?

E.

Appendix A 209
How do you integrate the use of feedback
measures into your way of working?

(continues)
 210 Appendix A
TABLE A.1. The Structure Domain of Deliberate Practice Activities (Continued)

Current Rating Select & Rank the TOP 3

Themes Activities (0–10) Activities to work on* Notes

F.
How do you change your way of working in
response to client feedback (e.g., the method,
the frequency/dose, the provider)?

G.
How do you prepare for a planned closure of
therapy?

H.
How do you plan and decide on the number
and length of sessions you offer?

I.
How do you share with your client that your
work together is unfolding as it should so they
know progress is being made toward the
resolution of their problem/concern?

J.
How do you maintain the organization and
focus in your work from session to session?
 K.
How do you ensure the accuracy and timing
of your therapeutic interventions?

L.
How do the methods, techniques, and
activities within and outside of formal sessions
flow logically from your theory/model for
helping clients?

M.
What structured procedures do you have for
resolving problems in therapy and how do you
use them?

N.
How do you balance structure and flexibility in
therapeutic boundaries, sequence, and appraisal
on the model of therapeutic structure?

O.
How does the space in which you work
embody a therapeutic climate (color,
furnishings, artwork)?

Appendix A 211
P.
Others (please describe specifically to
structuring the session):

*Note. Please select the TOP 3 ACTIVITIES across the entire list (e.g., not necessarily within each of the domains). The three do not have to be the lowest scored item. Complete the
consolidation section at the end to help clarify your professional development plan.
 212 Appendix A
TABLE A.2. The Hope and Expectancy Domain of Deliberate Practice Activities

Current Rating Select & Rank the TOP 3

Themes Activities (0–10) Activities to work on* Notes

A.
How do you induct clients into therapy?
Inform them about what to expect from one
session to the next? Explain your respective
roles (e.g., client, therapist)?

B.
How does the explanation you offer for your
client’s distress engender hope and
expectation for change?

C.
How do you persuade the client to have a
2. Hope & favorable assessment and acceptance of your
Expectancy clinical rationale and related techniques?

D.
How do you adapt your treatment rationale
to foster client engagement and hope?

E.
How do you communicate a hopeful and
optimistic stance toward your client and
their problem/concerns (including
capitalizing on times when clients express
high hope and expectancy)?
 F.
How do you convey a sense of confidence
and belief in you and your treatment
approach?

G.
How to you measure/assess client hope and
expectancy at the outset of and throughout
care?

H.
Others (please describe specifically to hope
and expectancy):

*Note. Please select the TOP 3 ACTIVITIES across the entire list (e.g., not necessarily within each of the domains). The three do not have to be the lowest scored item. Complete the
consolidation section at the end to help clarify your professional development plan.

Appendix A 213
 214 Appendix A
TABLE A.3. The Relationship Factors Domain of Deliberate Practice Activities

Current Rating Select & Rank the TOP 3

Themes Activities (0–10) Activities to work on* Notes

i.
How do you establish goal consensus in
the first/subsequent sessions?

ii.
How do you help a client who has no
clear goals in therapy?

3. Relationship
A. Effective Focus iii.
How do you mobilize clients’ willingness
to engage in a therapeutic process/
activity?

iv.
How do you encourage your client to
confront, experience, or deal with
difficult topics or problems?
 i.
How do you explicitly convey warmth,
understanding, acceptance, and positive
regard toward your client?

ii.
How do you promote emotional engage-
ment/safety?

iii.
How do you foster a sense of mutuality
with your client (e.g., responsiveness,
3. Relationship feelings, expectations, reciprocity)?

B. The Impact
iv.
Factor
How do you remain true to yourself and
in the interaction with your client?

v.
How do you explicitly communicate
empathic attunement?

vi.

Appendix A 215
How do you deepen your client’s
emotional experiencing?

(continues)
 216 Appendix A
TABLE A.3. The Relationship Factors Domain of Deliberate Practice Activities (Continued)

Current Rating Select & Rank the TOP 3

Themes Activities (0–10) Activities to work on* Notes
i.
How do you assess and work with a
client’s readiness for change?

3. Relationship
C. Motivation ii.
How do you increase homework
compliance?

i.
How do you deal with ruptures in the
alliance?

ii.
3. Relationship How do you deal with an angry client?
D. Difficulties

iii.
How do you deal with a client who is
feeling hopeless?
 iv.
How do you deal with strong and difficult
emotions arising in the session?

v.
How do you manage a client who is at
high risk of suicide?

vi.
How do you manage a client mandated
for treatment?

vii.
Others (please describe specifically to
alliance factors):

*Note. Please select the TOP 3 ACTIVITIES across the entire list (e.g., not necessarily within each of the domains). The three do not have to be the lowest scored item. Complete the
consolidation section at the end to help clarify your professional development plan.

Appendix A 217
 218 Appendix A
TABLE A.4. The Client Factors Domain of Deliberate Practice Activities

Current Rating Select & Rank the TOP 3 Notes

Themes Activities (0–10) Activities to work on*

A.
Prior to initiating treatment, how do you
actively and directly prepare your client
for what will happen while they are in
care?

B.
How do you learn about your client’s
expectations regarding treatment and
their role in the process?

4. Client C.
Factors How to you actively tailor the type,
intensity, and nature of treatment
interventions to fit the client’s level of
interest, engagement, and relational style
throughout (and at each session of)
treatment?

D.
How do you incorporate your client’s
strengths, abilities, and resources
into care?
 E.
How do you incorporate your client’s
values, beliefs (including but not limited
to religious and spiritual), and cultural
systems into care?

F.
How do you actively utilize extrathera-
peutic events (positive and negative) to
influence participation and progress?

G.
How do you incorporate or help the
client build their social support network?

H.
Others (please describe specifically to
client factors):

*Note. Please select the TOP 3 ACTIVITIES across the entire list (e.g., not necessarily within each of the domains). The three do not have to be the lowest scored item. Complete the
consolidation section at the end to help clarify your professional development plan.

Appendix A 219
 220 Appendix A
TABLE A.5. The Therapist Factors Domain of Deliberate Practice Activities

Current Rating Select & Rank the TOP 3

Themes Activities (0–10) Activities to work on* Notes

i.
How do you regulate your anxiety
when encountering a difficult
interaction with a client?

ii.
How do you manage negative feelings
toward your client (e.g., anger,
discouragement, hostility, blame)?

iii.
How do you maintain appropriate
5. Therapist boundaries and roles with your
A. The Use of the Self clients (e.g., not letting personal
emotions or life events bleed into/
affect your clinical work)?

iv.
How do you remain reflective versus
reactive in session with clients?

v.
How do you utilize self-disclosure?
 vi.
How do you integrate your life
experiences, identity, and self into
your personal clinical style?

vii.
How do you operationalize empiri-
cally supported principles of effective
clinical work in a way unique to you
as a person?

viii.
How do you find the right words at
the right time or in the right
situation?

i.
How do you engage in solitary
deliberate practice outside of
sessions in your typical work week?
5. Therapist
B. Outside of Sessions ii.
Others (please describe specifically to
therapist factors):

Appendix A 221
*Note. Please select the TOP 3 ACTIVITIES across the entire list (e.g., not necessarily within each of the domains). The three do not have to be the lowest scored item. Complete the
consolidation section at the end to help clarify your professional development plan.
222 Appendix A

CONSOLIDATION:

Instructions:

1. The Top 3 Activities to work on from the taxonomy are your Stretch Goals.
They are the objectives at the margin of your “zone of proximal develop-
ment.” List them in order of priority. Once listed, choose ONE to focus on in
deliberate practice. Recall, to improve results, your one identified stretch goal
must be associated with treatment outcome. Consult the research evidence
to confirm (see https://darylchow.com/frontiers/what-are-the-perennial-
pillars-for-psychotherapists/ for some examples).

2. Discrepancies are likely to exist between the goals you and your coach iden-
tify and are a good place to begin dialogue. Choosing and refining learning
objectives is an iterative process. Revise until agreement is reached that fits
your interests and your coach or supervisor’s knowledge and skills.

3. State your chosen stretch goal in “SMART” terms (Specific, Measurable,

Achievable, Relevant, Time bound) to assist you in identifying concrete
activities you can engage in to reach your stretch goal.

4. Review your Stretch and SMART Goals on an ongoing basis, also setting
aside a specific date and time to review your progress. Check for impact on
your performance metrics.
Current Date: __________________ Review Date: _________________

TABLE A.6. Consolidation of Stretch and Smart Goals

STRETCH GOAL SMART GOAL

(Your current identified (Specific, Measurable, Achievable, Relevant,
S/N “Top 3 Activities” to work on) Time bound) Review & Reflect

Appendix A 223
APPENDIX B

Taxonomy of Deliberate Practice

Activities in Psychotherapy
Exercise Guide

Exercises in The Field Guide are linked to the five factors having leverage on the
outcome psychotherapy. Once you have collected sufficient data to establish
a reliable, evidence-based profile of your therapeutic effectiveness, completed
the Taxonomy of Deliberate Practice Activities in Psychotherapy, and narrowed
your focus to a single learning objective, this guide may be used to quickly locate
applicable exercises.

225
 226 Appendix B
TABLE B.1. Structure Activities

Themes Activities Chapter Exercise number Page/s

A. 6 5 147
How do you start a first session? 7 1, 2, 5 167, 168, 172

B. 7 1, 2 167, 168
How do you start subsequent sessions?

C. 7 1, 2 167, 168
How do you close a session?
1. Structure

D. 5 8 125
How do you formally elicit detailed and nuanced feedback 6 2 145
at each session?
7 1, 6 167, 174

E. 4 4 97
How do you integrate the use of feedback measures into your 5 7 124
way of working?
6 1, 2 144, 145
7 1, 6 167, 174
 F. 4 4 97
How do you change your way of working in response to client 5 7, 8 124, 125
feedback (e.g., the method, the frequency/dose, the provider)?
6 1, 2, 4, 5 144, 145, 147, 147
7 1, 4, 5, 6 167, 171, 172, 174

G. 6 3 146
How do you prepare for a planned closure of therapy? 7 1, 5 167, 172

H. 5 8 125
How do you plan and decide on the number and length of 6 1 144
sessions you offer?
7 1, 4, 5 167, 171, 172

I. 5 8 125
How do you share with your client that your work together 7 1, 3, 4 167, 171, 171
is unfolding as it should so they know progress is being made
toward the resolution of their problem/concern?

J. 4 4 97
How do you maintain the organization and focus in your work 7 1, 3, 4, 5 167, 171, 171, 172
from session to session?

Appendix B 227
K. 5 6 123
How do you ensure the accuracy and timing of your therapeutic 6 5 147
interventions?
7 1, 3, 4 167, 171, 171

(continues)
TABLE B.1. Structure Activities (Continued)

228 Appendix B
Themes Activities Chapter Exercise number Page/s

L. 7 1 167
How do the methods, techniques, and activities within and outside
of formal sessions flow logically from your theory/model for
helping clients?

M. 7 1 167
What structured procedures do you have for resolving problems
in therapy and how do you use them?

N. 7 1 167
How do you balance structure and flexibility in therapeutic
boundaries, sequence, and appraisal on the model of therapeutic
structure?

O.
How does the space in which you work embody a therapeutic
climate (color, furnishings, artwork)?

P.
Others (please describe specifically to structuring the session):
TABLE B.2. Hope and Expectancy Activities

Themes Activities Chapter Exercise number Page/s

A. 6 1, 2, 5 144, 145, 147

How do you induct clients into therapy? Inform them
about what to expect from one session to the next?
Explain your respective roles (e.g., client, therapist)?

B. 5 8 125
How does the explanation you offer for your client’s 6 1, 4, 5, 6 144, 147, 147, 149
distress engender hope and expectation for change?

C. 6 4, 5, 6 147, 147, 149

How do you persuade the client to have a favorable
2. Hope & assessment and acceptance of your clinical rationale
Expectancy and related techniques?

D. 4 4 97
How do you adapt your treatment rationale to foster 6 3, 4, 6 146, 147, 149
client engagement and hope?

E. 6 3, 5, 6, 7 146, 147, 149, 149

Appendix B 229
How do you communicate a hopeful and optimistic
stance toward your client and their problem/concerns
(including capitalizing on times when clients express
high hope and expectancy)?

(continues)
 230 Appendix B
TABLE B.2. Hope and Expectancy Activities (Continued)

Themes Activities Chapter Exercise number Page/s

F. 6 3, 5, 6, 7 146, 147, 149, 149

How do you convey a sense of confidence and belief
in you and your treatment approach?

G. 6 1, 2, 5, 6, 7 144, 145, 146, 149, 149

How to you measure/assess client hope and expectancy
at the outset of and throughout care?

H.
Others (please describe specifically to hope and
expectancy):
TABLE B.3. Relationship Factors Activities

Themes Activities Chapter Exercise number Page/s

i. 5 7, 8 124, 125
How do you establish goal consensus in the first/subsequent
sessions?

ii. 5 7, 8 124, 125

How do you help a client who has no clear goals in therapy?

3. Relationship
iii. 5 1, 7 118, 124
A. Effective Focus
How do you mobilize clients’ willingness to engage in 6 1, 2, 3, 4 144, 145, 146, 147
a therapeutic process/activity?

iv. 2 1 34
How do you encourage your client to confront, experience, 5 1, 7 118, 124
or deal with difficult topics or problems?
6 1, 2, 6 144, 145

Appendix B 231
(continues)
TABLE B.3. Relationship Factors Activities (Continued)

232 Appendix B
Themes Activities Chapter Exercise number Page/s

i. 3 1, 2 66, 67
How do you explicitly convey warmth, understanding, 4 1, 2, 3, 5 94, 95, 96, 98
acceptance, and positive regard toward your client?
5 1, 2, 4 118, 119, 121
6 1 144

ii. 3 1, 2 66, 67
How do you promote emotional engagement/safety? 4 1, 2, 3, 5 94, 95, 96, 98
5 1, 4, 6, 9 118, 121, 123, 126

iii. 4 3 96
How do you foster a sense of mutuality with your client 5 1, 3, 5, 6 118, 120, 122, 123
(e.g., responsiveness, feelings, expectations, reciprocity)?
3. Relationship
B. The Impact
Factor iv. 2 1 34
How do you remain true to yourself and in the interaction 4 2 95
with your client?
5 1, 5, 6 118, 122, 123
6 6, 7 149, 149

v. 3 1 66
How do you explicitly communicate empathic attunement? 4 2, 3 95, 96
5 2, 3 119, 120

vi. 4 2, 3 95, 96
How do you deepen your client’s emotional experiencing?
 i. 3 2 67
How do you assess and work with a client’s readiness 6 6 149
for change?

3. Relationship
C. Motivation ii. 5 7 124
How do you increase homework compliance?

i. 4 1, 2, 3, 5 94, 95, 96, 98

How do you deal with ruptures in the alliance? 5 1, 9 118, 126

ii. 4 1, 2, 3, 5 94, 95, 96, 98

How do you deal with an angry client?

3. Relationship
D. Difficulties iii. 4 1, 5 94, 98
How do you deal with a client who is feeling hopeless? 6 2, 5 145, 147

iv. 4 1, 2, 5 94, 95, 98

Appendix B 233
How do you deal with strong and difficult emotions arising 5 1 118
in the session?
6 3 146

(continues)
 234 Appendix B
TABLE B.3. Relationship Factors Activities (Continued)

Themes Activities Chapter Exercise number Page/s

v.
How do you manage a client who is at high risk of suicide?

vi.
How do you manage a client mandated for treatment?

vii.
Others (please describe specifically to alliance factors):
TABLE B.4. Client Factors Activities

Themes Activities Chapter Exercise number Page/s

A. 3 2 67
Prior to initiating treatment, how do you actively and directly 5 7, 8 124, 125
prepare your client for what will happen while they are in care? 6 1, 2, 5, 6, 7 144, 145, 147, 149, 149

B. 3 2, 6 67, 71
How do you learn about your client’s expectations regarding 4 1 94
treatment and their role in the process? 5 7, 8 124, 125
6 2, 6 145, 149

C. 3 1, 3, 5, 6 66, 68, 70, 71

4. Client How to you actively tailor the type, intensity, and nature of 4 1, 4, 5 94, 97, 98
Factors treatment interventions to fit the client’s level of interest, 5 2, 3 119, 120
engagement, and relational style throughout (and at each
6 6 149
session of) treatment?

D. 4 1 94
How do you incorporate your client’s strengths, abilities, 5 3, 4 120, 121
and resources into care?

E. 3 1, 2, 3, 4, 5 66, 67, 68, 69, 70

Appendix B 235
How do you incorporate your client’s values, beliefs 4 2 95
(including but not limited to religious and spiritual), and 5 3, 7, 8 120, 124, 125
cultural systems into care?
6 1 144

(continues)
 236 Appendix B
TABLE B.4. Client Factors Activities (Continued)

Themes Activities Chapter Exercise number Page/s

F. 3 1, 6, 7 66, 68, 71
How do you actively utilize extratherapeutic events
(positive and negative) to influence participation and progress?

G.
How do you incorporate or help the client build their social
support network?

H.
Others (please describe specifically to client factors):
TABLE B.5. Therapist Factors Activities

Themes Activities Chapter Exercise number Page/s

i. 3 1 66
How do you regulate your anxiety when encountering 4 1, 2, 4, 5 94, 95, 97, 98
a difficult interaction with a client?
5 6, 9 123, 126

ii. 3 1, 4, 7 66, 69, 71

How do you manage negative feelings toward your client 4 1, 2, 5 94, 95, 98
(e.g., anger, discouragement, hostility, blame)?
5 4, 6, 9 121, 123, 126
6 4, 7 147, 149

iii. 3 7 71
5. Therapist
How do you maintain appropriate boundaries and 4 1, 2
A. The Use of 94, 95
roles with your clients (e.g., not letting personal
the Self emotions or life events bleed into/affect your
clinical work)?

iv. 3 1, 4, 5, 7 66, 69, 70, 71

How do you remain reflective versus reactive 4 1, 2, 3, 5 94, 95, 96, 98
in session with clients?
5 3, 9 120, 126
6 4, 7 147, 149

v. 4 2 95

Appendix B 237
How do you utilize self-disclosure?

(continues)
 238 Appendix B
TABLE B.5. Therapist Factors Activities (Continued)

Themes Activities Chapter Exercise number Page/s

vi. 2 1 35
How do you integrate your life experiences, identity,
and self into your personal clinical style?

vii. 3 3 68
How do you operationalize empirically supported 4 3 96
principles of effective clinical work in a way unique
to you as a person?

viii. 3 5, 6 70, 71
How do you find the right words at the right time 4 2, 3 95, 96
or in the right situation?
5 3 120

i. 3 1, 3, 4, 5 66, 68, 69, 70

How do you engage in solitary deliberate practice 5 3 120
outside of sessions in your typical work week?
5. Therapist
B. Outside of
ii.
Sessions
Others (please describe specifically to therapist
factors):
INDEX

A
Abilities of client, incorporating, 218, 235 Alignment
Abraham, C., 198 with client, 117, 119–122, 124–126
Abstraction, levels of, 19–21, 56 of identity and objectives, 185–186
Acceptance Al-Krenawi, A., 176
conveying, 215, 232 All Change (Exercise 5), 187, 190
of treatment rationale, 212, 229 Alliance, 115–116. See also Therapeutic
Accomplishments, reflecting on, 21 alliance
Accuracy, of interventions, 211, 227 adjusting work to improve, 96–97
Action stage, 54, 55 in adult psychotherapy, 115
Active rest, 190–191 defined, 115
Activities of therapy, flow to, 211, 228 humility and, 85
Addressing Correlates of Client OE and OE–outcome association, 134–136,
(Exercise 6), 149 142
Aderka, I. M., 62 real relationship vs., 114
Adherence as relationship factor, 112
to treatment manuals, 84, 111, 163 ruptures in. See Ruptures in alliance
to treatment model, 91, 160 sustainable use of metrics for, 174–175
Adolescents in youth psychotherapy, 115–116
alliance with, 115–117 Allowing for Differences (Exercise 5), 70
therapeutic structure for, 158 Alternative Descriptions (Exercise 1),
Adult psychotherapy, alliance in, 115 66–67
Affect, focusing on, 160 American Psychological Association (APA),
Affirmation, 112–114 15
“African American,” use of term, 51 American Psychologist, 9
Age Ametrano, R. M., 137, 150
client’s, 49, 134, 136–142 Anderson, Timothy, 85
correlation of OE with, 136 Angry clients, 216, 233
and strength of OE–outcome association, Anticipation, 186
134, 141–142 Antigoals (Exercise 5), 37, 42
therapist’s, 88, 89 Anxiety, regulation of, 220, 237
Alcoholics Anonymous, 61 Anxious attachment style, 56, 57

239
240 Index

APA (American Psychological Association), client emotional expression in, 124

15 creating, 18–20
Appraisal, 159, 161, 167, 170 enhancing responsiveness in, 97
Appreciating Each Step (exercise), 21 integrating data on deficits in, 29–32
Approaching the Uncomfortable (Exercise 3), mapping flow on, 171
68–69 role induction in, 53
ARPS framework, 185, 188 standardized measures in, 71
Asking About Preferences (Exercise 2), 67–68 treatment rationale in, 148
Aspirational outcome goals, 36 Bordin, E. S., 115
Assessing OE Therapeutically (Exercise 1), Boswell, J. F., 82, 143, 151
144–145 Boundaries
Assumptions, about client experience, 111 assessing, 169
Athenian trap, avoiding, 9–10, 17 establishing, 159, 160
Atomic Habits (Clear), 197 maintaining, 220, 237
Attachment style, 56–57, 89 principles related to, 165–166
Attention, bifurcated, 90 Buddy Up for Improvement (Exercise 1),
Authentic self, 34 118–119
Automated structure, 185, 187–189 Budge, S. L., 61
Automaticity, 94–95, 166, 183, 185 Building a Support Network (Exercise 8),
Aviram, A., 136 187, 192
Avoidant attachment style, 56, 57 Burnout, 26–27, 88, 89

B C
Babins-Wagner, R., 87 Callahan, J. L., 52, 89
Back to the Classic (Exercise 2), 119–120 Captari, L. E., 60
Bacon, S., 157 Caregivers, alliance with, 115, 116
Barkham, M., 72, 81, 83–84, 99 Casals, Pablo, 94
Barrett-Lennard Relationship Inventory, Castonguay, L. G., 72, 83–84, 99, 150
119, 127 Centralized note-taking system, 38–39
Barriers to better results, 27–29, 186, 194 CEQ (Credibility/Expectancy
Baseline assessment, 86, 139, 203 Questionnaire), 139, 150
Baskin, T. W., 159, 160 Cerasoli, C. P., 184
Behavior Design Lab, 183 Certification, 83, 84
Belief(s). See also Role expectations Chadwick, Edwin, 12
about change, 143 Change. See also Readiness for change
incorporating, 219, 235 areas of upcoming, 187, 190
influence of, on techniques, 172 client beliefs about, 143
religious and spiritual, 49, 59–61, 63, 64 extratherapeutic events that produce, 62
in treatment approach, 213, 230 levels of abstraction and principles of, 19
understanding and being respectful of, OE in theories of, 132
64–65, 69–70 stages of change model, 54–56
Bergin, A. E., 110 “Chapter-in-a-book” approach to culture
Bergin and Garfield’s Handbook of adaptation, 59
Psychotherapy and Behavior Change, Check-ins with clients
7th ed. (Barkham et al.), 71, 83–84, 99 on fit of therapy, 65–66, 71–72
Better Results (Miller et al.), xiv, xvii, 9, 13, on outcome expectation, 141
16, 33, 48, 96, 161, 184–185, 198, 202 Children
Beutler, L. E., 57 alliance with, 115–117
Bhar, S., 136 therapeutic structure for, 158
Bifurcated attention, 90 Choosing a Coach (Exercise 7), 187, 191–192
Big picture focus, 29–32 Chow, D., xiv, 42, 86, 87, 94, 176
Black box exercise, 69 Chow, L., 11, 205
Blame, 111 Civilizing Social Media (Exercise 2), 95–96
Bloom, Paul, 42 Clear, J., 197
Blueprint for clinical work Clear goals, 214, 231
addressing outcome expectation in, 141 Client engagement
client beliefs, values and preferences in, adapting treatment rationale for, 212, 229
67–68 emotional, 215, 232
 Index 241

mobilizing willingness to engage, 214, 231 Colvin, G., xvi

respecting differences to improve, 65 Comfort, cultural, 59
soliciting feedback to improve, 71 Committed outcome goals, 36
tailoring interventions to level of, 218, Common factors model, 80, 109–110
235 Communication
Client experience of empathic attunement, 113, 215, 232
alignment with therapist and, 117, of hopefulness, 145–146, 169
119–122, 124–126 of optimistic stance, 212, 229
assumptions about, 111 as structural factor, 160
Client factors, 4, 47–73 Compassion fatigue, 26
attachment style, 56–57 Competence, therapist, 84, 163
culture, 57–59 Confidence
demographic characteristics, 49–51 continuing education and, 28
environmental supports and personal effect of deliberate practice on, 11, 17
strengths, 61–62 in treatment approach, 213, 230
evidence-based principles related to, Confrontational style, 108, 111
63–66 Confrontation ruptures, 116, 126
exercises for skill development, 66–72, Congruence, 112, 114
235–236 Connecting With Your Authentic Self
extratherapeutic change-producing (Exercise 1), 34
events, 62 Connection, with client, 120–121
motivation and stage of change, 54–56 Consensus, on goal, 112, 116, 214, 231
and outcome expectation, 136, 149 Consistency, 81–84, 169, 183–185
preferences, 53–54 Constantino, M. J., 49, 50, 82, 132–134,
reactance, 57 136, 143, 150, 151
religious and spiritual beliefs, 59–61 Constructed reality, 157
research on, 49–62 Contemplation stage, 54, 55
resources on, 72–73 “Contemporary Psychotherapy as Ritual
role expectations, 52–53 Process” (Moore), 176
sexual orientation and gender identity, 61 Contextual model, 20, 80–81
Client Factors domain (TDPA), 218–219, Continuing education, 8, 28
235–236 Continuity, between sessions, 170
Clinical experience, 83, 84 Cooper, M., 72
Clinical performance, standardized scales Core interpersonal skills, 90, 94–99
for, 10–11 Countertransference management, 84
Clinical strategies, 19, 56 Couple therapy, 109
Clinical style, integrating self in, 221, 238 Coyne, A. E., 82, 132, 134, 143, 150, 151
Clinical symptom severity Create a Centralized Note-Taking System
impact of therapist attachment style on (Exercise 6), 38–39
outcome and, 89 Credibility. See Perceived treatment
outcome expectation and, 136, 142 credibility
therapist effects and, 81 Credibility/Expectancy Questionnaire
“Clinician Interventions and Participant (CEQ), 139, 150
Characteristics That Foster Adaptive Criticism, giving, 111
Patient Expectations for Cross, W. E., Jr., 51
Psychotherapy and Psychotherapeutic Cultural arrogance, 111
Change” (Constantino et al.), 150 Cultural comfort, 59
Closing sessions, 170, 209, 226 Cultural competence, 58
Coach Cultural humility, 59
choosing a, 187, 191–192 Culturally adapted interventions, 57–59,
in four pillars, 87, 203 63
Cognitive behavioral therapy, 116 Culture, client’s, 57–59, 219, 235
Collaboration Curriculum creep, 8
and alliance, 115
on goals, 125–126
D
for impact, 117, 119–122, 124–126
preference accommodation and, 54 Data collection, 174–175
as relationship factor, 112, 116 De Bruijn, G. J., 198
shaping expectations about, 165 Decision-making process, 166
242 Index

Dedication, 32, 34, 38–39 E

DeFife, J. A., 151
Early treatment, sudden gains in, 62
De Jong, K., 85, 87
Ecological fallacy, 51
Deliberate practice (DP)
EE (expressed emotion), 115, 123–124
defining, 202–203
Effective focus, in TDPA, 214–215, 231–232
engagement in, 84, 86–87
Effectiveness
establishing a system to support, 182
current level of, 15
focusing on principles of, 205
feelings of, 27
four pillars of, 86–87, 203
EI (emotional intelligence), 89
future of, 202, 203
Einstein, Albert, 3
goal of, 10
Electronic note-taking, 38–39
improving therapist factors with, 92–93
Elliott, R., 113
incentives for engaging in, 14, 15
Embodiment of a Client (Exercise 4), 69–70
as iterative process, 31, 32
Emotional engagement, 215, 232
other types of practice vs., 203–204
Emotional experiencing, 215, 232
outside of sessions, 221, 238
Emotional expression
in psychotherapy, xvi–xvii
dampening, 123–124
purpose of, 35 facilitating, 117–118, 123–124
repetition and rehearsal vs., 8–9 as relationship factor, 112, 114–115
research methods/designs congruent Emotional intelligence (EI), 89
with aims of, 205 Emotions
“time spent fallacy” in, 204 difficult, 217, 233
Demographic characteristics, 49–51, 136 focusing on client’s, 90
Derthick, A. O., 151 influence of, on therapeutic techniques,
Detailed feedback, 170, 209, 226 172
Determination, 14 nonjudgmental stance toward, 98–99
Developing and Refining an Effective processing of, 117–118, 123–124
Treatment Rationale (Exercise 5), strong, 217, 233
147–149 Empathic attunement
Diagnosis, treatment based on, 50–51, 163 communicating, 113, 215, 232
Differences, allowing for/respecting, 64–65, for impact, 117, 119–122, 124–126
70 Empathic listening, 120–121
Difficult cases, 35 Empathic responding, 112–113
Difficult emotions, 217, 233 Empathizers, 26–27
Difficulties in relationship, in TDPA, Empathy
216–217, 233–234 and alliance, 108
Difficult interactions, 220, 237 as relationship factor, 112–113
Difficult topics, 165, 214, 231 as therapist factor, 80, 84, 85
Discipline, therapist, 83, 84 Empirically supported principles,
Disengagement, 88 operationalization of, 221, 238
Distress, explanation for, 212, 229 Empirically supported treatment
Dodo verdict, 156 movement, 50–51
“The Dose-Effect Relationship in Environment
Psychotherapy” (Howard), 62 creating safe, peaceful, and nourishing,
Doubt, 11–12, 18, 85 122
DP. See Deliberate practice for habit formation, 183, 195, 196
DP plan, 186 for learning project, 33
Drift, from in vivo use of intervention, social supports in, 61–62
171–172 as structural factor, 160
Dropout rate therapeutic climate in, 211, 228
client demographic characteristics and, Ericsson, K. A., xiv, xvi–xviii, 8, 9, 14, 20,
50 87, 197, 203, 204
cultural comfort and, 59 Escape From Babel (Miller et al.), 73
ineffective/harmful therapist behaviors “Ethical Implications of Routine Outcomes
and, 110–111 Monitoring for Patients,
role induction and, 52 Psychotherapists, and Mental Health
Duncan, B. L., 8, 73, 86, 166 Care Systems” (Muir et al.), 151
Durant, Will, 181 Ethical Principles of Psychologists and Code of
Dynamic sizing, 58 Conduct (APA), 15
 Index 243

Ethnicity, 49, 88, 89 Final objective, 14–16

Eubanks, C. F., 116 Finishing Strong (Exercise 5), 172–173
“Evidence-Based Therapist Responsivity to The First Kiss (Chow), 42, 176
Disruptive Clinical Process” First principles, focusing on, 205
(Constantino et al.), 150 Firth, N., 81
Expectations. See also Hope and expectancy FIS Inventory. See Facilitative Interpersonal
factors; Outcome expectation (OE) Skills Inventory
addressing, pretreatment, 132 Flexibility
check-ins on therapy fit with, 65–66, balancing rigidity of structure and,
71–72 161–162, 211, 238
learning about client’s, 64, 218, 235 and openness to client input, 113
managing unrealistic, 169 of therapeutic structure, 159, 162
respecting differences in, 64–65 as therapist factor, 90–92, 96–97, 99
shaping client’s, 164–165 Flückiger, C., 115
as structural factor, 159, 160 Focus in work
of therapist, 137–138 establishing, in session, 169
Experimentation, 185, 187, 189–191 maintaining, 169, 210, 227
Expertise, 82 as structural factor, 158, 160
Explanation Fogg, B., 183
for client’s distress, 212, 229 Forewarned, being, 187, 193–194
of therapy, 165, 168, 171 Four Pillars of Deliberate Practice, 86–87,
Explicit framework of therapy, 166–171 203
Expressed emotion (EE), 115, 123–124 Four S approach, 67, 148–149
Extratherapeutic events, 62, 219, 236 Frank, Jerome, 80
Extratherapeutic factors, 48 Freud, Sigmund, 131
Extrinsic rewards, 183–184 Friction, habit formation and, 184
Fundamental reality, 157
F
G
Facilitative interpersonal skills, 84–86,
95–96 Gardner, B., 198
Facilitative Interpersonal Skills (FIS) Garfield, S. L., 4, 110
Inventory, 85–86, 99, 127 Gassmann, D., 62
Failure, imagining, 193–194 Gehin, Alain, 155
Family therapy, 109 Gelso, C., 114, 127
Fearful-avoidant attachment style, 56, 57 Gender
Feedback as client factor, 49
change in response to, 170, 210, 227 correlation of OE and, 136
comfort with negative, 71–72 as therapist factor, 88, 89
eliciting detailed and nuanced, 170, 209, Gender identity, 49, 61
226 Genuineness
in four pillars, 86–87, 203 engaging with, 117, 121–123
identifying ineffective behaviors from, as relationship factor, 112, 114
118–119 as therapist factor, 80
influence of, on therapeutic techniques, Getting Comfortable With Negative
172 Feedback (Exercise 7), 71–72
note-taking on, 39 Getting to the Source of Your Success
positive attitude toward, 85 (exercise), 18–20
soliciting, 71 The Gift of Therapy (Yalom), 175–176
therapist variables and, 87 Gladwell, Malcolm, 204
Feedback-Informed Treatment in Clinical Goal consensus, 112, 116, 214, 231
Practice (Prescott et al.), 73 Goal consolidation, 173
Feedback measures, integrating, 209, 226 Goal-directed learning projects, 33
Feelings, toward client, 220, 237. See also Goals, clear, 214, 231
Emotions Goal setting, 186
Ferenczi, Sándor, 47 Goldberg, S. B., 87
Fidelity monitoring, 160 Golden Rule, 117
Figuring Out Your Process Goal (Exercise 4), Goldfried, Marvin, 19, 56
36–37, 41 Good Habits, Bad Habits (Wood), 198
244 Index

Go to the Tape (Exercise 6), 123–124 Hopefulness

Grawe, K., 62, 176 communicating, 145–146, 169
Greaney, M. L., 184 outcome expectation and, 136
The Great Psychotherapy Debate (Wampold), reflection on level of, 149–150
80 Hopelessness, 216, 233
Greenberg, R. P., 72, 150 Hope theory, 134
Grencavage, L. M., 158, 160 Horvath, A. O., 66, 91, 162
Group therapy, 109 Horvath, P., 137
Growth edge, 10–11 Hostility, 111
Growth orientation, 173 How and Why Are Some Therapists Better Than
Others? (Castonguay & Hill), 99, 150
Howard, K. I., 62
H
How Hopeful Are You? (Exercise 7),
Habit, defined, 182 149–150
Habit formation, 181–198 “How Psychotherapy Lost Its Magick”
evidence-based principles related to, (Miller & Hubble), 60–61
184–186 “How,” your. See Process goal
exercises for developing supportive Hoyer, J., 85
habits, 186–197 Hubble, M., xiv, 8, 60–61, 73, 86, 94, 184
research, 183–184 Humility
resources on, 197–198 attitude of, 92, 95–96
Handbook of Psychotherapy and Behavior cultural, 59
Change, 4th ed. (Bergin & Garfield), 110 and empathic responding, 113
Handwritten notes, 38 as therapist factor, 85, 90
Hardin, S. I., 136
Hard work, 9–10
I
Harmful therapist behaviors, 110–111,
117–119, 126 I Am Clueless (Exercise 8), 125–126
Healer role, 160 Ibrahim, N., 61–62
Healing involvement, 26–27, 88 Identity
Healing setting, 160 check-ins on therapy fit with, 65–66,
Heinonen, E., 88, 99 71–72
Hendrix, Harville, 107 client demographics and, 51
Hill, C. E., 99, 150 and habit formation, 185–186
Hilsenroth, M. J., 91, 151 identifying your, 187, 192–193
Hindsight, prospective, 193 integrating, in clinical style, 221, 238
Hippocrates, 12 soliciting information about client’s,
Hobbies, 187, 190–191 63–64, 67–69
Homework compliance, increasing, 216, Imel, Z. E., 50, 79
233 Immutable therapist characteristics, 88
Hook, J. N., 59 Impact factor, in TDPA, 215–216, 232–233
Hope and Expectancy domain (TDPA), Incentives, 14, 15
212–213, 229–230 “Increasing Hope by Addressing Clients’
Hope and expectancy factors, 131–151 Outcome Expectations” (Swift &
client characteristics correlated with OE, Derthick), 151
136 Individual, treating each client as, 63,
evidence-based principles related to, 66–67, 171
139–144 Individualized learning objective, 32–33
exercises for skill development, 144–150, and giant outcome goals, 39–42
229–230 identifying and refining, 32–33, 172
impact of therapist utterances/actions on keeping bigger picture in mind to
OE, 137 identify, 29–32
OE–outcome association, 133–138 principle-based exercises on, 34–39
perceived treatment credibility–outcome using TDPA to arrive at, 28–29
association, 136–137 Induction process, 52, 212, 229
research on, 133–139 Ineffective psychotherapy structures,
resources on, 150–151 163–164
and therapist differences in client OE, Ineffective therapist behaviors, 110–111,
138–139 117–119, 126
 Index 245

Influenceable activities, 37 Learning objective. See Individualized

“The Influence of Expectancy Persuasion learning objective
Techniques on Socially Anxious Learning project
Analogue Patients’ Treatment Beliefs arriving at improvement objective as, 32,
and Therapeutic Actions” (Ametrano 33, 35–39
et al.), 150 creating, 41
Initial session, starting, 169, 209, 226 note-taking on, 39
Inner state, awareness of, 91 in OPL framework, 33
Inner thermometer, 98–99 Leibert, T. W., 61
In sensu use of intervention, 172 Let’s Talk About Hope (Exercise 2),
Intake model, 42 145–146
Interest(s) Levitt, H., 92, 165
in finding performance improvement Levy, K. N., 56, 57
objective, 32, 34, 38–39 LGBTQ+–affirmative therapies, 61
tailoring interventions to client’s, 218, Licensure, 83, 84
235 Life experiences, integrating, 221, 238
Internal experience, focus on, 160 Listening Well (Miller), 120–121, 127
Interpersonal problems, therapist’s, 88, 89 Lutz, W., 72, 83–85, 97, 99
Interpersonal skills
core, 90, 94–99
M
facilitative, 84–86, 95–96
improving, 90, 94–97, 99 MacKeough, A., 205
as therapist factor, 84–86, 90 MacNair-Semands, R., 136
Interventions Maeschalck, C., 73
accuracy of, 211, 227 Maintenance stage, 54, 55
reasonable, 169 Make It Easy and Rewarding (Exercise 2),
tailoring, to client, 160, 218, 235 188–189
timing of, 211, 227 Make It So (Exercise 1), 188
in vivo vs. in sensu use of, 172 Making Data Collection Structurally
“Interventive Interviewing” (Tomm), 127 Therapeutic (Exercise 6), 174–175
Intrinsic rewards, 183–184 Malins, S., 62
In vivo use of intervention, 172 Mallory, George, 14
Mandated treatment, 217, 234
Mandela, Nelson, 201
J
Manualized therapies, 107–108, 111
Journaling, 38 adherence in, 84, 111, 163
Journal of Experimental Psychology, 38 dynamic sizing of, 58
Just Be Curious (Exercise 3), 146–147 OE–outcome association for, 134,
141–142
structural factors for, 160
K
Map of content, 38
K2 (mountain), 14–15 Mapping Your Flow (Exercise 3), 171
Kabat-Zinn, Jon, 98 Matchbox method, 82
Karver, M. S., 115–116 Mathewes, Brooke, 11–12
Katz, M., 91 Mathieu, F., 27
Kazdin, A. E., 137 McGinnis Meadows Ranch, 11
Key performance indicators, 189 McLeod, J., 72
Klein, Gary, 193 Measurement and metrics
Kramer, S. A., 163 of client hope and expectancy, 213, 230
Krouse, R., 137 for feedback, 209, 226
of outcome expectation, 143–145
standardized, 71
L
sustainable use of, 174–175
Lally, P., 183, 198 well-established, 134, 141–142
Lambert, M. J., 8, 127, 150 Mediators of OE–outcome association,
Learning 134–136
from past experience, 186, 187, 194–197 Medical model, 19–20, 80
by testing yourself, 39 “Meet You in McGinnis Meadows”
therapist’s willingness to learn, 92, 95–96 (Mathewes), 12
246 Index

Mendel, W. M., 157 OE. See Outcome expectation

Metaphors, 165, 168, 171 OE–outcome association, 133–138
Metastructure of effective psychotherapy, alliance as factor in, 142
159–163, 167–168 circumstances increasing, 141–142,
Metatheory, 19–20 147–149
Methods, flow from theory to, 211, 228 and client characteristics, 136
Miasma theory, 12–13 described, 133–134
Microaggressions, 60, 64 mediators of, 134–136
Miller, C. H., 57 moderators of, 134
Miller, S. D., xiv, xvi, xvii, 8, 9, 13, 16, 33, and perceived treatment credibility,
48, 60–61, 71, 73, 86, 88, 94, 96, 118, 136–137
161, 184–185, 198, 202–204 therapist-rated, 137–138
Miller, William R., 120–121, 127 and therapist utterances/actions, 137
Milwaukee Psychotherapy Expectations Okiishi, J., 81
Questionnaire (MPEQ), 139, 150 Oldham, M., 52
Mindfulness, 89, 122–123 Only Connect (Exercise 3), 120–121
Mobilization of will, 57 Openness, 92, 113
Moderators of OE–outcome association, Operationalization, of empirically
134 supported principles, 221, 238
Monks, G. M., 52 OPL (outcome goal, process goal, learning
Moore, R. L., 176 project) framework, 33
Moradi, B., 61 Optimistic stance, 212, 229
Morrison, N. R., 151 Organization, 210, 227
Motivation Orlinsky, D. E., 26, 88, 165
adjusting structural factors based on, Outcome expectation (OE). See also
161–162 OE–outcome association
as client factor, 54–56 of client, based on therapist, 138–139
respecting differences in, 64–65 client characteristics correlated with,
soliciting information about, 64 136, 149
in TDPA, 216, 233 cultivating client’s, 143, 147–149
for therapist, 7–8, 14 defined, 132
MPEQ (Milwaukee Psychotherapy known correlates of, 136, 142, 149
Expectations Questionnaire), 139, 150 potency of, 141–142, 147–149
Muir, H. J., 150, 151 pre- and early treatment, 139, 141,
Multicultural competence, 58–59 144–147
Mutuality, 173, 215, 232 therapist utterances/actions and client’s,
137, 143, 149–150
of therapist vs. client, 143, 149–150
N
timing of assessment of, 133
Naive practice, 203–204 Outcome goal(s)
Nalven, T., 150 aspirational vs. committed, 36
Nature of care, preferences on, 53 giant, 39–42
Needs of client, fit with, 65–66, 71–72 improving therapy skills as, 43
Negative affect, 90 in OPL framework, 33
Negative feedback, 71–72 specifying, 35–36, 40–41
Negative feelings toward client, 220, 237 Overconfidence, 111
Next step, keeping your eyes on, 14–16, 21 “An Overview of Rituals in Western
Nissen-Lie, H., 99 Therapies and Intervention”
Nonjudgmental stance, 98–99 (Al-Krenawi), 176
Norcross, J. C., 72, 110, 127, 150, 158, 160, Owen, J., 82–84, 91
163–164, 173
Note-taking system, 38–39
P
Nuanced feedback, 170, 209, 226
Pang, A. S. K., 198
Parallel Play (Exercise 6), 187, 190–191
O
Parents, alliance with, 115, 116
Observer ratings of behavior, 118–119, Parkinson’s Law, 33
123–124 Participation, extratherapeutic events that
Obsidian, 39 increase, 219, 236
 Index 247

Partners for Change Outcome Management Preplanned procedures, 160

System, 10 Prescott, D., 73
Past experience Pretherapy education, 52, 53
learning from, 186, 187, 194–197 Pride, in client’s progress, 173
outcome expectation and, 136 Problem focus, 62, 159, 160
preferences based on, 53 Problem-resolution procedures, 159, 160,
Peak (Ericsson & Pool), 197, 203 211, 238
Perceived treatment credibility Procedures, in levels of abstraction, 19
association of outcome and, 136–137 Process goal, 33, 36–37, 41
pre- and early-treatment levels of, “The Professional and Personal
142–143, 147–149 Characteristics of Effective
Performance data Psychotherapists” (Heinonen &
integrating, into practice, 29–32 Nissen-Lie), 99
using, 167–170, 174–175 Professional characteristics, therapist’s,
Performance improvement objective 83–87
arriving at, as learning project, 32, 33, Professional identity, 185–186
35–39 Progress
interest in and dedication to finding, 32, clients’ ability to gauge own, 210, 227
34, 38–39 clients who fail to make, 97
Personal characteristics, therapist’s, 87–89 expressing pride in client’s, 173
Personality, therapist’s, 88, 89 extratherapeutic events to influence,
Personalizing Psychotherapy (Norcross & 219, 236
Cooper), 72 playful mindset about, 187, 189–190
Personal strengths. See Strengths Project MATCH, 50–51, 61
Personal therapy, 8, 83, 88–89 Prospective hindsight, 193
Perspective taking, 90, 91 Pseudoshrink, xv
Pessimism, responding to, 147 Psychological formulary, 163
Pest, Hungary, 12 Psychological mindedness, 136
Pharmacotherapy, 109 Psychological safety, 215, 232
Philosophical stance, 19 Psychotherapy Relationships That Work: Volume
Playful experimentation, 185, 187, 1, 3rd ed. (Norcross & Lambert), 150
189–191 Psychotherapy Relationships That Work: Volume 2,
Playful Progress (Exercise 4), 187, 189–190 3rd ed. (Norcross & Wampold), 72,
Pluralistic Counselling and Psychotherapy 110, 127
(Cooper & McLeod), 72 Pull to perform, 194
Pool, R., 197, 203, 204 Purposeful practice, 87, 204
Positive psychology, 61
Positive regard, 112–114, 215, 232
R
Precontemplation stage, 54, 55
Predictive activities, 37 Race, treatment outcome and, 49
Preferences Racial and ethnic minority clients, 58, 59
asking about, 51, 67–68 Rate and Predict (Exercise 7), 124–125
check-ins on therapy fit with, 65–66, Reactance, 57, 64
71–72 Readiness for change
as client factor, 53–54 adjusting structural factors based on,
overreliance on, 163 161–162
respecting, 64–65 assessing and working with, 216, 233
soliciting information about, 64 as client factor, 54–56
Premature Termination in Psychotherapy (Swift soliciting information about, 64
& Greenberg), 72 Realism, 114
The Premortem (Exercise 10), 187, Reality, constructed vs. fundamental, 157
193–194 Real relationship
Preparation engaging in, 117, 121–123
to address barriers, 186 genuineness in, 114
for termination of therapy, 173, 210, 227 as relationship factor, 112
for therapist factor skill development, Reasonable interventions, 169
92–93 Recovering Your “University Days” Mindset
for treatment, 52, 158, 160, 218, 235 (Exercise 2), 35, 40
Preparation stage of change, 54, 55 Recurrence stage, 54, 55
248 Index

Reference examples, 205 Ricks, D. F., xv

Reference point, 185, 187, 189 Rieck, T., 89
Reflection, 94–95 Right words, finding, 221, 238
Reflective ability, 88, 90 Rigidity
Reflective functioning, 89–91 balancing structural flexibility and, 211,
Reflective stance, 20, 237 238
Regulating Your Inner Thermometer as relationship factor, 111
(Exercise 5), 98–99 as structural factor, 159, 162
Rehearsal, 8–9 Roehrle, B., 61
Relational style, client’s, 218, 235 Rogers, C. R., 80, 85, 112–114, 121–122
Relationship factors, 4, 107–127 Role expectations
alliance, 115–116 as client factor, 52–53
congruence/genuineness, 114 learning about client’s, 218, 235
emotional expression, 114–115 shaping client’s, 165
empathy, 112–113 Role induction, 52, 53, 132, 158
evidence-based principles related to, Rønnestad, Michael, 26
117–118 Rosenzweig, Saul, 80
exercises for skill development, 118–126, Routines, habits and, 195, 196
231–234 Ruptures in alliance
goal consensus and collaboration, 116 confrontation, 116, 126
ineffective/harmful therapist behaviors, dealing with, 216, 233
110–111 OE cultivation/restoration to repair, 142
interactions and boundaries between, over differences in expectation, 65
109 repairing, 112, 116, 126, 142
positive regard and affirmation, unhelpful structuring activities and,
113–114 165–166
repairing alliance ruptures, 116 withdrawal, 117, 126
research on, 109–116
resources on, 127
S
Relationship Factors domain (TDPA),
214–217, 231–234 Sachs, J. S., 158, 160
Religious beliefs Safety, psychological, 215, 232
as client factor, 59–61 Sarcasm, 111
tailoring therapy to, 63, 64 Satisfaction, with previous therapy, 136
treatment outcome and, 49 Saxon, D., 81
Repairing alliance ruptures Scheduling, 188
by cultivating/restoring OE, 142 Scogin, F., 158, 160
exercise on, 126 Secondary traumatic stress, 26
as relationship factor, 112, 116 Secure attachment style, 56, 57, 89
Repairing Ruptures (Exercise 9), 126 Seeing Red (Exercise 4), 97
Repetition, 8–9, 94, 183, 203 Self
Research designs and methods, 205 sense of, 67, 148
Resource activation, 42, 62, 218, 235 use of, 220–221, 237–238
Resource restriction, 194 Self-administered therapy, 158
Respect, 64–65, 69–70 Self-awareness, 59, 94–95, 117
Responding to Pessimism (Exercise 4), Self-criticism, 194
147 Self-disclosure, 220, 237
Responsiveness Self-ratings by therapist
to cultural opportunities, 59 of alliance, 124–125
displaying, 91–92, 96–97, 99 of cultural competence, 58
and effectiveness, 66 of effectiveness, 82, 84–85
with structural adjustments, 162 of own social skills, 88, 89
as therapist factor, 84, 90–91 of social skills, 88, 89
Rest (Pang), 198 Semmelweis, Ignaz, 12–13
Rest, active, 190–191 Sense of self, in Four S approach, 67, 148
The Retirement Party (Exercise 9), 187, Sequence of treatment delivery, 159, 160
192–193 assessing, 169–170
Retrieval practice, 39 principles related to, 164–166
Rewards, 183–184, 188–189 Session Rating Scale (SRS), 40, 65, 113, 125
 Index 249

Sessions Stop–start technique, 122

closing, 170, 209, 226 Strengths, client, 61–62, 218, 235
continuity between, 170 Stretch Goals, 222, 223
deliberate practice outside of, 221, 238 Strong emotions, 217, 233
empathic responding outside of, 112–113 Strouse, J., 61
establishing and maintaining focus in, Structural factors, 4, 155–176
169 evidence-based principles related to,
format of, as structural factor, 160 164–167
improving interpersonal skills/alliances exercises for skill development, 167–175,
outside of, 99 226–228
number and length of, 160, 210, 227 ineffective psychotherapy structures,
shaping client expectations outside of, 163–164
165 metastructure of effective psychotherapy
starting, 169, 209, 226 structures, 159–163
Set Your Heart Right (Confucius) (Exercise research on, 157–164
5), 122–123 resources on, 175–176
Sexual orientation, 49, 61 Structure domain (TDPA), 209–211,
Shalom, J. G., 62 226–228
Significant life events, 67, 148 Structured practice, 204
Skill improvement, with deliberate practice, Subsequent sessions, starting, 169, 209,
87 226
Skinner, B. F., xvii Success
SMART (Specific, Measurable, Achievable, getting to the source of your, 18–20
Relevant, Time bound) Goals, 66, 125, leveraging client’s therapeutic, 146–147
222, 223 Successive refinement, 87, 203
Smith, E. C., 176 Sudden gains, in early treatment, 62
Snyder, C. R., 134 Suicide risk, 217, 234
Social media, 95–96 Supershrink, xv, 184
Social skills, therapist’s, 88, 90 “Supershrinks: What’s the Secret of Their
Social support Success?” (Miller et al.), xvi
for behavioral transformation, 185 Supervision, xiii–xiv, 8
building your own network for, 187, 192 identifying ineffective behaviors in,
for habit formation, 184 118–119
helping clients rebuild their, 219, 236 therapist effectiveness and, 83, 84
treatment outcome and, 61 Support people. See also Social support
Society for the Advancement of in ARPS framework, 185
Psychotherapy, 127 for DP implementation, 187, 191–192
Socioeconomic status, 49 for previous habit formation, 195, 196
Softening the blow (barrier), 194 Swift, J. K., 52–54, 72, 151
Soliciting Feedback (Exercise 6), 71 Systemizers, 26, 27
Solution-focused psychology, 61 Systems, in Four S approach, 67, 148
Soto, A., 57–58
Sparks, in Four S approach, 67, 148
T
Specialization, 83, 84
Specific, Measurable, Achievable, Relevant, Target for improvement. See “What,” your
Time bound Goals. See SMART Goals Taxonomy of Deliberate Practice Activities
Specificity, of treatment method, 160 in Psychotherapy–Therapist Version
Specifying the Outcome Goal (Exercise 3), (Version 6), 4–5, 207–223
35–36, 40–41 Client Factors domain, 218–219,
Spirituality, 49, 59–61, 63 235–236
Spotlight effect, 42 connecting your “what” to, 13, 16
SRS. See Session Rating Scale consolidation, 222
Stages of change model, 54–56 contextual model, 80–81
“Starting Off on the Right Foot” (DeFife & emotional expression in, 115
Hilsenroth), 151 exercises linked to, 225–238
Starting sessions, 169, 209, 226 figuring out process goal with, 36–37
Start of therapy, crafting, 164–165, getting to the source of your success
167–171 with, 20
Stiles, W. B., 66, 91, 162 and healing involvement, 26, 27
250 Index

Hope and Expectancy domain, 212–213, Therapist behaviors

229–230 impact of, on outcome expectation, 137
identifying anti-goals with, 37 ineffective and harmful, 110–111
identifying individualized learning Therapist-centricity, 111
objective with, 28–29 Therapist effects, 81
instructions, 208 Therapist factors, 4, 79–99
integrating data on performance deficits evidence-based principles related to,
with, 29–32 90–92
objectives, 207 exercises for skill development, 92–99,
outcome expectation and, 132 237–238
overview, 207 personal characteristics, 87–89
Relationship Factors domain, 214–217, professional characteristics, 83–87
231–234 research on, 81–89
Structure domain, 209–211, 226–228 resources on, 99
Therapist Factors domain, 220–221, Therapist Factors domain (TDPA), 220–221,
237–238 237–238
Teaching to the Therapeutic Test (Exercise 3), “Therapist Responsivity to Patients’ Early
96–97, 99 Treatment Beliefs and Psychotherapy
Techniques Process” (Coyne et al.), 151
flow from theory to, 211, 228 Therapy skills, outcome goals and, 43
in level of abstraction, 19, 56 Third-party observation, of behavior,
outcome and, 156–157 118–119, 123–124
as structural factor, 160 This Is Not Your First Rodeo (Exercise 11),
“10,000 hour” rule, 204 187, 194–197
Termination of therapy Thoughts, nonjudgmental stance on,
discussing, 166–170, 172–174 98–99
effective, 172–174 Thucydides, 10
preparing client for, 173, 210, 227 Time-bound learning projects, 33
structured process for, 163–164 Time spent fallacy, 204
“Testing yourself to learn” approach, 39 Timing, of interventions, 211, 227
Theoretical framework, 19, 56 Toffler, Alvin, 7
Theoretical orientation Tolstoy, Leo, 25
consistency in, 169 Tomm, K., 127
effectiveness and, 84 “Toward Parsimony in Habit Measurement”
flow of methods, techniques, and (Gardner et al.), 198
activities from, 211, 228 “Toward the Delineation of Therapeutic
mastering, 42–43 Change Principles” (Goldfried), 19
Theory consistency, 160 Tracey, T. J. G., 158, 160
Theory countertransference, 166 Training
Therapeutic alliance. See also Alliance to improve therapist factors, 83
for clients with low social support and, 61 as structural factor, 160
cultural comfort and, 59 on treatment models/techniques,
defined, 108 156–157
outcome variance due to OE vs., 133 Tran, D., 136
preference accommodation and, 54 Transdiagnostic relationship factors, 108
and religious beliefs/spirituality, 60 Transgender clients, 61
Therapeutic climate, 211, 228 Transtheoretical relationship factors,
Therapeutic relationship, defined, 108, 109 108–110
The Therapeutic Relationship in Psychotherapy Treatment
Practice (Gelso), 127 belief and confidence in, 213, 230
Therapeutic structure, defined, 158. See also matching diagnosis to, 50–51
Structural factors preferences about type of, 53, 64
Therapist(s) preparing client for, 52, 53, 218, 235
client preferences for, 53, 64 Treatment manual, adherence to, 84, 111,
differences in client OE across, 138–139 163
matching demographics of clients and, Treatment model, 91, 156–157, 160
49, 50 Treatment outcome measures
OE of client and OE of, 143, 149–150 adjusting work to improve scores on,
OE–outcome association ratings from, 96–97
137–138 sustainable use of, 174–175
 Index 251

Treatment plan, fit with, 148–149 Webb, C. A., 163

Treatment rationale Weisz, J. R., 158, 160
adapting, to improve client engagement, Well-being, resource activation and, 62
212, 229 “What It Takes to be Great” (Colvin), xvi
client’s assessment/acceptance of, 212, 229 What Would Carl Rogers Do? (Exercise 4),
developing and refining, 147–149 121–122
enhancing OE with, 137, 139 “What,” your
increasing perceived credibility with, 143 connecting, to the right stuff, 12–14,
Treatment structures, defined, 158. See also 18–21
Structural factors finding, 10–12, 17–18
True to yourself, remaining, 215, 232 focusing on, 32, 35–39
Trusty, W. T., 60 importance of identifying, 7–9
Tryon, G. S., 116 principle-based exercises for identifying,
Tsai, M., 136 16–21
principles for identifying, 9–16
When Therapists Drift (Exercise 4),
U
171–172
Uncomfortable topics, approaching, 68–69 Where Are You Now? (Exercise 4), 187,
Unconditional positive regard, 80, 121–122 189
Understanding, conveying, 215, 232 “Which Therapeutic Mechanisms Work
Unhelpful structuring activities, avoiding, When?” (Smith & Grawe), 176
165–172 Who Are You? (Exercise 1), 94–95
“University days” mindset, 35, 40 “Who Works for Whom and Why?”
Unrealistic expectations, managing, 169 (Constantino et al.), 150
Using Metaphors (Exercise 2), 168, 171 Willingness to engage, 214, 231
Using the Metastructure of Therapeutic Willingness to learn, 92, 95–96
Structure for Self-Assessment Willpower, 195, 196
(Exercise 1), 167–170 Withdrawal ruptures, 117, 126
Wood, W., 183, 198
Word Work (exercise), 21
V
Working alliance, cultural humility and, 59.
Values See also Alliance
check-ins on therapy fit with, 65–66, Wu, M. B., 92
71–72
incorporating client’s, 219, 235
Y
linking DP to personal, 192–193
understanding and being respectful of, Yale University, 95
64–65, 69–70 Yalom, Irving, 175–176
Vicarious trauma, 26 Yanico, B. J., 136
Vienna General Hospital, 12 Youth psychotherapy
Vîslă, A., 133–134, 138–139 alliance in, 115–116
Visualization, 186 therapeutic structure for, 158
Vitruvius Pollio, Marcus, 12 Yulish, N. E., 159, 160

W Z
Wampold, B. E., 19, 72, 79, 80, 83–84, 110 Zen Buddhism, 98
Warmth, conveying, 215, 232 Ziem, M., 85
ABOUT THE EDITORS

Scott D. Miller, PhD, is the founder of the International Center for Clinical
Excellence, an international consortium of clinicians, researchers, and educators
dedicated to promoting excellence in behavioral health services. Dr. Miller
conducts workshops and training in the United States and abroad, helping
hundreds of agencies and organizations, public and private, to achieve superior
results. He is one of a handful of “invited faculty” whose work, thinking, and
research are featured at the prestigious “Evolution of Psychotherapy” conference.
He is the author, editor, and coauthor of scores of professional and research arti­
cles and 15 books, including The Heart and Soul of Change: What Works in Therapy
and Better Results: Using Deliberate Practice to Improve Therapeutic Effectiveness.

Daryl Chow, PhD, is a practicing psychologist and trainer. He published the

first empirical study of deliberate practice in psychotherapy. His books include
The Write to Recovery: Personal Stories and Lessons About Recovery From Mental Health
Concerns, The First Kiss: Undoing the Intake Model and Igniting First Sessions in Psycho­
therapy, and Better Results: Using Deliberate Practice to Improve Therapeutic Effective­
ness. His website, Frontiers of Psychotherapist Development (https://darylchow.
com/frontiers/), is aimed at inspiring and sustaining practitioners’ professional
and personal development.

Sam Malins, PhD, is a clinical psychologist working on the integration of

physical and mental health care at Nottinghamshire Healthcare NHS Foun­
dation Trust and the University of Nottingham. He works clinically in cancer
care. His research focuses on ways to enhance psychological care across settings,
often using digital technology. He is currently a National Institute for Health

253
254 About the Editors

and Care Research clinical lecturer in the Integrated Clinical Academic Pro­
gramme and is working on methods to help psychological therapists improve
their effectiveness.

Mark A. Hubble, PhD, graduated from the prestigious postdoctoral fellowship

in clinical psychology at Menninger and is a founding member of the Inter­
national Center for Clinical Excellence. He formerly served as a contributing
editor for the then Family Therapy Networker and as editor for the Journal of
Systemic Therapies. With Scott Miller, he has coauthored or coedited eight books,
numerous book chapters, peer-reviewed articles and research, and various
commentaries. Their bestselling volume (with Barry Duncan), The Heart and Soul
of Change: What Works in Therapy, earned the Menninger Alumni Association
Scientific Writing Award. Dr. Hubble’s scholarship extends to the transtheoretical
curative factors in psychotherapy, data-based outcome management systems,
and excellence in clinical practice.