Words&Dirt

Summary:

William R. Miller and Theresa B. Moyers’s Effective Psychotherapists is a concise and instructive introduction to the particular skills and attitudes that make some therapists more effective than others. In Part One, Miller and Moyers argue that “therapist effects” or “relational factors” that shape the foundational working alliance between therapist and client are at least as important as therapeutic modalities and techniques. In Part Two, they describe eight therapeutic skills that effective therapists develop and deploy in their work: accurate empathy, acceptance, positive regard, genuineness, focus, hope, evocation, and the ability to sensitively deliver information and advice. In Part Three, they share ideas about how therapists can gain expertise that improves client outcomes, how effective clinical skills should be taught, and how clinical research can be broadened and improved.

Key Concepts and Notes:

• As someone new to the field of psychotherapy, I truly appreciate how Miller and Moyers highlight the essential qualities that therapists should seek to cultivate regardless of what type(s) of therapy and/or client population(s) they work with. These are the “meta-skills” of the craft.
• Miller and Moyers do a great job of supporting their arguments with empirical data throughout the book. Each of the eight chapters on therapeutic skills contains a research section that reviews meta-analyses, individual studies, and summarizes average effect sizes on client outcomes. Miller and Moyers are also honest about areas of therapy research that are either inherently hard to study or where reliable data is sparse.
• There is a short chapter at the end of Part Two called “The Far Side of Complexity” that might be the single best essay I have read so far in graduate school. It’s a wide-ranging exploration of how one’s personal quest to develop presence, character, virtue, and lovingkindness can underpin a successful therapeutic practice.
• One of the unfortunate but unsurprising findings in this book is that while effective therapists can do a lot of good for their clients, ineffective ones can actually do harm. Also discomfiting is the finding that therapists generally do not improve over time unless they take certain steps to develop what Miller and Moyers call “deliberate practice.” These facts emphasize the importance of continuous learning and performance feedback in this field.

Favorite Quotes:

In clinical trials, therapist effects are often regarded as nuisance noise that compromises therapeutic effect size, rather than as an important component in effective treatment. We believe Rogers and his students were on the right track in their research. Therapist relational factors have too often been overlooked in mainstream clinical research and training. We do not discount the potential importance of specific treatment procedures with particular disorders. At the same time, evidence-based treatments cannot be separated from the therapists who deliver them. (xiii)

In order to help people change their behavior or lifestyle, you need their expertise and partnership. No one knows more about your clients than they do. They have a lifetime of experience to draw on. You do bring professional expertise that may be helpful, but you cannot be an expert on someone else’s life. A helping relationship is not a matter of an expert doing something to or using techniques on clients. It is about working with, alongside, and for clients. It is not like wrestling; it’s more like dancing together. (6-7)

You have enough in common with your clients to be able to grasp some of their meaning and experience, and yet it is wise to have a beginner’s mind and not assume that you understand fully. A fundamental attitude in empathic understanding is curiosity: an openness to and interest in another’s experience. Often curiosity about human experience is what attracts people to helping professions. A wonderful aspect of being human is that you are not limited to your own experience and perspectives. With flexible openness, you know that you do not start with an accurate understanding of another person’s life, and you want to understand. (21)

People, when given the supportive conditions for change, naturally tend to move in a positive, pro-social, self-determining, and healthy direction. At least part of them wants to do so. That part of their ambivalence is your co-therapist. (78)

Some clients may particularly challenge an attitude of sustained optimism. In the course of treating a client, you may be disappointed, yet your hope need not diminish. It is common for people to cycle several (or many) times through the transtheoretical stages of contemplation, preparation, action, and maintenance before reaching stable change or recovery. Binary thinking about outcomes underestimates the vast range of benevolent changes that lie between total “success” or “failure”… “Two steps forward, one step back” seems to be human nature. It is also worth considering that the benefit a client derives from your work together may not be apparent while you are still in the picture. People often describe previous therapists (or mentors, teachers, parents, or friends) who contributed critically to their lives without realizing it. Remember this when holding onto hope for a client. (83)

Freedom to choose is not something that you can grant to your clients. They already have it. Ultimately, it is up to them whether they will listen to or ignore you, believe or disagree with information that you provide, and follow or shun the advice you offer. You cannot make people change. They get to decide; it’s a given in any helping relationship. Knowing, accepting, and honoring clients’ autonomy is an important context for whatever information and advice you provide. (111-2)

Like many truths, this therapeutic presence, this simplicity beyond complexity, is somewhat paradoxical. It is at once both behavioral practice and underlying attitude or spirit, and the two sculpt each other. Faithful practice strengthens the guiding value system that, in turn, is expressed in practice. (123)

One of our intentions is for this volume to serve as a call for greater attention to therapeutic relationship in clinical practice, research, and a training. Clinical science began with therapeutic relationship, but of late has focused almost exclusively on technical procedures and mechanisms. Such technique is inseparable from the human beings who provide treatment, and who, we hope, understand themselves as far more than technicians. A clinical science that recognizes the value of both technical and relational components will go a long way to further improve the quality of healthcare. Renewed focus on therapeutic relationship may also afford greater meaning and joy in the practice of counseling and psychotherapy, further humanizing the services that we provide. (174)

Rating: 8/10