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The Secrets of Supershrinks: Pathways to Clinical Excellence
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In 1974, researcher David F. Ricks coined the term “supershrinks” to describe a class of exceptional therapists—practitioners who stood head and shoulders above the rest.
His study examined the long-term outcomes of “highly disturbed” adolescents in therapy. When the research participants were later examined as adults, he found that a select group treated by one particular provider (one of these supershrinks) fared notably better. In the same study, boys treated by the “pseudoshrink” demonstrated alarmingly poor adjustment as adults.
That therapists differ in their ability to affect change is hardly a revelation. All of us have participated in hushed conversations about colleagues whose performance we feel falls short of the mark. We also recognize that some practitioners are a cut above the rest. With rare exceptions, whenever they take aim, they hit the bull’s-eye.
Nevertheless, since Ricks’ first description, little has been done to further the investigation of supershrinks and pseudoshrinks. Instead, professional time, energy, and resources have been directed exclusively toward identifying effective therapies. Trying to identify specific interventions that could be reliably dispensed for specific problems has a strong commonsense appeal. No one would argue with the success of the idea of problem-specific interventions in the field of medicine. But the evidence is incontrovertible. Who provides the therapy is a much more important determinant of success than what treatment approach is used.
The Diversity of Supershrinks
Dawn, one of these proverbial supershrinks, was a 12-year veteran of a large Midwestern, multicounty community mental health center. Most people who knew her would have characterized her as a holdout from the Summer of Love. Her VW microbus; floor-length, tie-dyed skirts; and Birkenstock sandals solidified everyone’s impression that she was a fugitive of Haight-Ashbury.
Despite these eccentricities, Dawn was hands-down the most effective therapist at the agency. This finding was established through a tightly controlled, research-to-practice study conducted at her agency.
What made her performance all the more compelling was that she was the top performer seven years running. Moreover, factors people widely believed to affect treatment outcome—the client’s age, gender, diagnosis, level of functional impairment, or prior treatment history—didn’t affect her results. Other factors that weren’t correlated to her outcomes were her age, gender, training, professional discipline, licensure, hours of deliberate practice, or years of experience. Even her theoretical orientation proved inconsequential.
Contrast Dawn with Gordon, another one of these supershrinks, who couldn’t have been more different. Rigidly conservative and brimming with confidence bordering on arrogance, he managed to build a thriving private practice in an area where most practitioners were struggling to stay afloat financially.
Many in the professional community sought to emulate his success. In the hopes of learning his secrets or earning his acknowledgment, they competed hard to enter his inner circle.
Whispered conversations at parties and local professional meetings made clear that others regarded Gordon with envy and enmity. “Profits talk, patients walk,” was one comment that captured the general feeling about him.
But the critics couldn’t have been more wrong. According to his client feedback, the people Gordon saw in his practice regarded him as caring and deeply committed to their welfare. Furthermore, he achieved outcomes that were far superior to those of the clinicians who carped about him. In fact, the same measures that confirmed Dawn’s placement among the supershrinks put Gordon in the top 25% of psychotherapists studied in the United States.
The Catalyst for Supershrinks
Consider a study reported by Bruce Wampold and Jeb Brown that determines the main factor in creating supershrinks. The study included 581 licensed providers—psychologists, psychiatrists, and master’s-level therapists—who were treating a diverse sample of more than 6,000 clients. The therapists, the clients, and the presenting complaints weren’t different in any meaningful way from those in clinical settings nationwide.
As was the case with supershrinks Dawn and Gordon, the clients’ age, gender, and diagnosis had no impact on the treatment success rate, and neither did the experience, training, and theoretical orientation of the therapists. However, clients of the best therapists in the sample improved at a rate at least 50 percent higher and dropped out at a rate at least 50 percent lower than those assigned to the worst clinicians in the sample.
Another important finding emerged: In cases in which psychotropic medication was combined with psychotherapy, the drugs didn’t perform consistently. Their therapeutic effectiveness depended on the quality of the therapist—drugs used in combination with talk therapy were 10 times more effective with the best therapists than with the worst. Among the latter group, the drugs made virtually no difference.
So, in the chemistry of mental health treatment, the applied orientations, techniques, and even medications are relatively inert. The catalyst is the clinician.