Miller and Moyers on Effective Psychotherapists
If you're like me, you've already somewhat obsessively read at least forty-seven articles on the working alliance and an array of related topics to discover what the best therapists do. One of the reasons I started this wee blog was to share such findings as I come across them.
Over the past few years a picture has built up. It is simultaneously reassuring and terrifying that much of psychotherapy turns not on technique nor years of practice (nor still less--thankfully--on the absurd array of trademarked acronyms promising to move the sun and the other stars), but on certain gifts and characteristics that the therapist either seems to have--or not. In this, it puts me in mind once again of Anna Freud's aphorism (recorded in Robert Coles' workable biography of her) that therapists are either technicians or healers.
This brand new book does not put it quite so bluntly, but the authors do repeatedly note that the best healers in psychotherapy seem to have certain qualities in abundance and to exercise them rather freely. This book is eminently useful in putting before the reader the latest data on what makes for a masterful therapist: Effective Psychotherapists: Clinical Skills That Improve Client Outcomes by William R. Miller and Theresa B. Moyers (Guilford Press, 2021), 213pp.
Miller, of course, is the author of the famous work Motivational Interviewing, which generations of clinicians have heard about if not actually read. (I have read it. It was ever so slightly underwhelming.) Here he teams up with Moyers to write several very workable chapters that eschew fulgurating fireworks and convey some basic qualities and characteristics with clarity.
Right from the get-go the authors reveal the crucial finding: already by the end of the first session, much of the outcome of therapy can be predicted. How is that possible? On what is success predicated so swiftly?
The answer will not surprise you if you are familiar with contemporary research into effective psychotherapists, who have compassion, empathy, and the ability to build a partnership with their patients in what is called the working alliance. These qualities are not time-dependent, either: a novice intern can have them and use them as or even more effectively than someone in practice for thirty years. More on all this in a moment.
This book, Effective Psychotherapists, is divided into three unequal sections. The first, the shortest, nonetheless lays out the centrality of effective empathy as key to the working alliance. The second part, the longest, focuses on what the authors call the eight therapeutic skills you can develop and improve so that patient outcomes also improve. The third and final section contains three chapters and broadly focuses on ongoing training and future developments.
Chapter II, in the first section, is they key to the entire book. Here the authors review more than half a century of research into therapist effects to show that "the answer...is startlingly clear" to the question: what distinguishes a great therapist from the rest? In one study, that answer was almost immediately manifest: a "higher expression of therapist empathy" was found to predict "greater reduction in alcohol use" (p.10) and this could already be noted "as early as the first session" (p.11).
They go on to note that therapists vary in their abilities and successes both between each other and with different patients: "even the best therapists are not effective with every client" (p.13). As a result, it is important not to overlook "the fit between client characteristics and therapist skills" (p.14). Nina Coltart first alerted me to this in her writing on the importance of careful intake assessment to see whether there is a good fit, and, if not, to carefully consider whom one might refer a patient to for a better fit.
Chapter III gets into empathy in detail, considered here as "accurate empathy." The authors introduce the qualifier "accurate" to reflect the fact that a good psychotherapist will modify his or her own affect in response to what the patient is manifesting in the moment. They will also draw on their own curiosity to find out more about what the patient is feeling and experiencing.
Accuracy may also enjoin patience upon the patient and therapist alike. That is to say, psychotherapy may be seen as an invitation to slow down to engage in Listening with the Third Ear for the voices of (in Eliot's lovely words)
Accurate empathy's power, the authors flatly note in this chapter, is well documented now. Drawing on the results of "a meta-analysis of 82 independent" studies, it is clear that "of all the therapeutic factors that have been studied, accurate empathy has the most consistent relationship to positive client outcomes" (p.29).
Chapters IV-VI strike a very Rogerian note. Chapter IV, on Acceptance, stresses the need for psychotherapists to manifest "nonjudgmental acceptance" of everyone who comes before them. Later in the book they will note that "there is a direct relationship between your ability to extend acceptance to others...and your self-acceptance" (p.57).
Chapter V discusses Positive Regard, calling it "a major curative factor in any approach to therapy" (p. 43). What does it look like concretely? The authors suggest that a psychotherapist shows positive regard for patients in "a commitment to their well-being and best interests" (p.44). Towards the end of the chapter they caution that this must be finely "titrated" depending on patient and circumstance. This is especially true--as I have noted in previous entries on here--with patients having psychotic or schizophrenic disorders. With them, excessive or even moderate expressions of positive regard can be taken as serious threats, provoking unexpected and unhelpful reactions.
Chapter VI, Genuineness, may be found in such qualities as "spontaneity, humour, and vulnerability," all of which aid in building and strengthening the working alliance.
Also in this chapter--though, alas, without citing him--they authors refer to the need, precisely to maintain your genuineness as a psychotherapist, to deal with negative feelings towards patients, which D.W. Winnicott famously called "Hate in the Counter-Transference." This remains my favourite of DWW's papers, and I have written about it in several places.
Chapter seven, Focus, looks at the importance of setting goals that both psychotherapist and patient agree to as a way of staying on track and strengthening the working alliance. (Chapter XII will note the common finding that ruptures in the working alliance are associated with poorer outcomes for psychotherapy. But these are rarely irreparable, and the very act of openly repairing such breaches can itself strengthen the alliance new.)
In addition, goals remind both parties that this is not just an ordinary sympathetic chat, which one can get without payment over some tea with a close friend. As my first supervisor drilled into me, the very fact that money is involved (however regrettable that may be, and however much that disturbs some of us!) means that you can never be friends with your patients. It also means that you need a treatment plan, but not one carved in stone. It can and should be revisited on a regular basis to see if we are on track, or if we need to make changes, or to consider moving towards termination--or, in a perhaps better formulation I recently came across, discontinuation of services.
Focus also helps with the ever-present and universal problem of ambivalence. The authors review the evidence to indicate how unhelpful it is to push too far and too fast for change when ambivalence has manifested itself. Your job, rather, is to help your patients talk themselves into change. For some, getting past this ambivalence is all that is necessary: the patient is then off to the races and requires little help. Others, however, may require different skills and assistance from you once they start pursuing change seriously.
Still others may need neutrality from you, or you may deliberately choose that for a variety of reasons. This is my own default position, influenced as I am by psychoanalysis and its very high respect for patient freedom, perhaps most sharply captured by Bion's famous counsel to the psychotherapist to begin every session "without memory and desire" so as to avoid unduly pushing the patient in one direction or another. I do not find a literal and strict interpretation of Bion entirely feasible in most cases, but it remains a useful counsel of perfection as it were.
In all cases, a fine balance must be struck: your job is not to carry patients across the finish line of change, nor to ignore their efforts to get there. And these authors also have a high respect for patient autonomy (p.78) which needs to be set alongside shared goals for "when the goals of therapy are agreed upon, progress is much more likely" (p.79).
Chapter VIII, Hope, reflects longstanding research (going back to the famous HARP studies first published in 1961) that if the psychotherapist is hopeful, even if the patient is not or cannot be just then, such hopefulness can have a very positive effect on outcomes. Hope here extends not just to the prospects of patient improvement, but also to your own attitude towards treatment: do you yourself believe that what you are doing, the treatment you are offering, is effective and important? Hopefulness is, they say, "contagious" and in some cases you can "lend...some of yours" to your patients if they cannot find it just yet. I have done this on occasion with severely traumatized patients feeling overwhelmed by their many challenges and not seeing much light on the horizon. (Of course, like all things, your extension of hope must be finely judged so that you are not foolishly prattling on about the hope of a total, immediate, and facile "recovery" to someone who has been, say, a heavy addict for thirty years, or a lifelong victim of sexual abuse.)
Additional techniques here include asking patients to narrate past experiences where they had some success over a particular challenge. Another is to focus on their strengths.
Hope for change can be seriously undermined, the authors note at the conclusion of this chapter, by a waiting list, for the research indicates that patients do exactly that: sit and wait. They do not, in other words, get started on any changes. This can be demoralizing and deflating of their discipline and desire to get started on change. For this reason, then, I here recall the words of an addictions psychologist I knew: you or your staff who answer the phones (e-mails, etc.) from people seeking services should give the warmest possible response with the utmost dispatch--within 24 hours at the most. People have often taken weeks, months, sometimes years to work up the courage to call for help, and you need to meet them at that moment wherever possible. Do not leave them hanging for days or weeks, even if you are very busy and cannot fit them in at that moment.
Chapter IX, Evocation, focuses on a skill the authors see as uncommon and infrequently developed in the training of therapists. They do so based on the conviction that patient characteristics play a huge role in the success of therapy just as those of the clinician do. So the task of the therapist here is to evoke in the patient his or her own skills at self-healing. This is a position that starts from the assumption that the patient is in not just a state of deficit but also a position of having riches to offer they may not be aware of or able to access just yet. To access these riches, they may need your curiosity as a clinician to call them forth.
One way to help patients do this is summed up as O.A.R.S.: Open Questions, Affirmation, Reflection, and Summary. All this is to evoke that "change talk" that Miller first made famous in Motivational Interviewing.
Chapter X, Offering Information and Advice, is one that, admittedly, I read with the greatest resistance, especially when flatly told by these authors that "Advising is a part of your job" (p.110). I make it very clear to my patients that I am not in the advice business. I think offering advice almost always infantilizing and counter-productive, and I loathe doing it. I am never so much a student of Erich Fromm as here in wanting people to live out their own freedom without fear and to find their own way.
That said, these authors point to an example that I have myself done: recommending reading material. I once had a patient who for several months was manifesting great ambivalence, bordering on anxiety, between two very different career paths, each of which I thought she was romanticizing unduly while being very anxious about what she would miss in choosing one over another. So when she asked for something to read about this my mind shot immediately to Adam Phillips' Missing Out: In Praise of the Unlived Life, which I tried to mention as neutrally as possible so that my great enthusiasm for all of Phillips' works would not come out unduly. I made it clear--I think!--that I was simply reflecting how valuable I have found Phillips, and not telling her that she had to read him. But she turned up at the next session with the book under her arm, half of it read and heavily underlined in parts, and we had two or three sessions profitably discussing the book.
Chapter XI, The Far Side of Complexity, is a bit of a jumble as the authors seem clearly at pains to take avoid taking a clear stand on things bolder clinicians like Coltart have just come out and forthrightly spoken of as "faith; faith in ourselves and in this strange process which we daily create with our patients." For Miller and Moyers, they dance around such seemingly "spiritual" or "theological" language by invoking slogans like "simplicity on the far side of complexity" and talking about transcendence and shoveling in a few gratuitous bits of Buddhism that have too little context or elaboration to be useful.
Coltart is again much better here in capturing this simplicity-within-complexity dynamic in describing the therapist as engaged in
sharply focusing, and scanning; complex involvement in feelings, and cool observation of them; close attention to the patient, and close attention to ourselves; distinguishing our own true feelings from subtle projections into us; communicating insight clearly, yet not imposing it; drawing constantly on resources of knowledge, yet being ready to know nothing for long periods; willing the best for our patients and ourselves, yet abandoning memory and desire; a kind of tolerant steadiness which holds us while we make innumerable, minute moral decisions, yet steering clear of being judgmental (Slouching Towards Bethlehem, p.119).
Chapter XII stands at the start of Part III of Effective Psychotherapists, which, with the exception of the previous chapter, has so far been written with wonderful and admirable cogency and clarity, making this an ideal text for undergraduates or graduates alike. (I am very warmly recommending it to my students next semester in my Introduction to Counselling course.)
This chapter, Developing Expertise, records the startling but simultaneously reassuring and "widely replicated finding that therapists' years of experience are unrelated to their actual expertise" (p.127). Left unsaid here is a tempting line of thought I might have developed about the need for more careful screening of students into training programs to see if some of the attributes discussed earlier in this book are in evidence or not.
Also left unsaid here is any discussion about the centrality of the psychotherapist's own psychotherapy. Raising this point seems to generate a lot of controversy and resistance among some, for reasons which are not clear to me. I regard it as de rigueur that a psychotherapist must have done their own in-depth work. I know I could never do this myself without having spent years on the analytic couch, as I have done in three separate periods. Freud was right, in one of the last essays he wrote, "Analysis Terminable and Interminable," in seeing that one's own analytic therapy offers both skills and insights which are "not ceasing when it ends." But the gains may be limited, which is why he rightly goes on, later in that essay, to call for the therapist "periodically--at intervals of five years or so--[to] submit himself to analysis once more, without feeling ashamed of taking this step."
In addition to one's own semi-regular therapy, Miller and Moyers argue there are things a clinician can do to improve in certain areas or to acquire or reinforce certain skills. These they treat under the heading of "deliberate practice" which has two components: some skill you very consciously focus on developing, and some supervision of it or feedback about it you also consciously cultivate and seek out.
The book concludes with Chapters XIII and XIV, which may be of some limited interest to academics teaching courses in psychotherapy and counseling, including courses in skills and techniques.
Overall, the book is a very useful and up-to-date summary of what we know about Effective Psychotherapists and their clinical skills, and it is written in a way that allows its summaries of relevant and recent research to be made easily accessible to general readers, students, and scholars alike.
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