laughter and tears at a mindfulness conference

We laughed a lot during the morning talk at The Arts of Mindfulness & Counseling Series in La Jolla, because Scott Miller was an animated, highly engaging, and hilariously funny entertainer. He talked about research on outcomes in psychotherapy, and the work of K. Anders Ericcson and others on expertise (recall Malcolm Gladwell’s 10,000-hour rule, based largely on Ericcson’s work). Studies show that we psychotherapists all think we are above average, as do people in other professions (especially college professors). We consistently overlook treatment failures. We are so focused on doing well, and striving to avoid mistakes, that we do. Or so we think. In actuality, there is tremendous variability in effectiveness across clinicians. The good ones, as it turns out, are error-centric. Miller and colleagues provide ways to measure outcomes of clinicians, and have also interviewed the ones that are very good. These “supershrinks,” as Ricks (1974) first labeled them, carefully elicit client perceptions of problems in the therapeutic relationship and its effectiveness. These therapists are very focused on their errors and correcting them. One therapist, after receiving a 2 mm lower rating on a visual analog scale regarding the therapeutic alliance, had extracted information from the client about what was wrong, and then practiced repeatedly in front of a mirror to learn how not to use a certain facial expression. She believed, by the way, that she was not that good of a therapist, and thus had to work very hard at improving. She would annoy her colleagues because she frequently called them to get help in figuring out what she (not her client) was doing wrong, when things weren’t going well. This focus on deliberate practice of the tough parts of an activity turns out to be the key in other fields as well. It is true for super athletes and super musicians. Miller played some video of child pianists Roger Shen and Rachel Hsu. In the video Rachel plays the violin, her other instrument, at a breakfast prior to her formal performance, to get more practice and to watch her audience. Miller said she later brought some of the audience to tears as she played Franz Liszt’s incredibly difficult Un Sospiro, in which the pianist’s hands must repeatedly cross. When asked about her amazing talent, she replied that it is not talent, but hard work…four hours a day including weekends, vacations, Christmas and her birthday.

Miller stressed that we have to have some way of measuring how we are doing (know our baseline); we need to get formal and routine ongoing feedback and compare it to norms; and we need to engage in deliberate practice. We have to overcome automaticity, and work hard to develop the highly contextualized and deep domain-specific knowledge that allows us to see things that others can’t: Like the NICU nurses who can see infection before the bloodwork comes back, or the baseball players that adjust their fielding positions before the ball is in the air.

The tears came in the afternoon, as Kelly Wilson talked about how things will go horribly, terribly wrong, such as in the deaths of his brothers, the plight of the people of the Mississippi Delta, and in all of our lives. He was especially able to engage the audience when he asked us to imagine what we liked least about ourselves, and how long that that thing had been an issue. As we sat with eyes closed, we were asked to visualize and empathize with our young selves, and to communicate something helpful to them. In doing this activity, Wilson had collected lots of responses over the years, on index cards (from both lay and professional audiences). For some folks it had been bothering them as long as they could remember, and most people said it had been an issue since at least adolescence. Many had kept it to themselves all those years. He wasn’t sure what to do with all the cards, but his daughter had an idea. She made a video of them with her iPhone: A card or a few of them together were each shown for several seconds, set to music. As he showed the video, card after handwritten card said, “I am not enough,” or something very similar. What, he asked, if we all have a dark secret that we carry around, and it turns out it is the same secret?

Our brains evolved to do evaluation and comparison between bears and blueberry bushes, and it was safer to miss lunch than to be lunch. As we developed language we turned this evaluation and comparison device toward ourselves. But as therapists and humans we often must abandon our problem-solving mode of thinking, and simply behold the person in front of us, listening intently, trying to know and understand.

During a break, I talked with Kelly about my preoccupation, experiential acceptance self-efficacy, and he thought that I am on the wrong track (and being error-centric, I found this pretty riveting). He cited recent data that suggest that changes in self-efficacy (and cognitive content in general) are more an effect of than a cause of improvement in client functioning. Fascinating stuff.

Advertisement