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Date: 23rd June 2020.

I started writing the first draft of this list of problems to solve in April 2019. There were like 15-17 problems at first… and that was more than a year ago.

A crisis has a way of accelerating the future, and plus the long percolation period of this blog, you can appreciate why I want to cut to the chase.

Here’s a list of 10 problems I believe we need to be solving:

#1. How to enroll practitioners to systematically track their own outcomes.

Indeed, more therapists are seeing the merits of implementing measures as not just as a bunch of assessment tools, but conversational tools to lit the way for our therapeutic endeavor. (read our Beyond Measure article)

We need to come together to support each other to make this a norm rather than an exception.

#2. How to establish a baseline performance for each clinician.

This is the next step that many agencies around the world who have taken the first step are now trying to do.

Want to figure out where to go? First figure out where you are at.

More on this in our latest book, Better Results (amazon affiliate link) with Scott Miller and Mark Hubble.

#3. How to design a highly individualised roadmap to improve each therapist’s performance.

Deliberate practice (DP) is not just a bag of tricks you need to do. It is intensely personalise, based on the therapist’s baseline performance that resides in their growth edge.

As artist Austin Kleon points out, we want to be the noun and not do the verb. DP is not a new name to a new approach; it’s a framework to help scaffold our efforts to get better. That said, this might morph into a set of specific methodology, or even ways to do deliberate practice for specific models and techniques. This is not what I mean by a highly individualised dp plan. We need to improve “therapists” not models of “therapies.” Two reasons:

1. Adherence to particular models have shown to be a significantly low yield on impacting client outcomes (0-1%)[1], and the influence of the therapist—dubbed as therapist effects in the literature—accounts for more (5-9%)[2], and

2. Our clients need our complete personhood to come to the table of their therapeutic endeavor. They don’t need another cog in the wheel to churn our manualised-based work; they can read a workbook for that.

Be wary. No quick fix here. You’d have to play the long-game. But rest-assured. As my ICCE colleagues and I are seeing, the pay-off is worth every ouch of the effort.

Get help in figuring out that “what” to work on that has leverage on improving your outcomes before getting seduced with the “how tos”.

#4. Evidence-based practice meets practice-based evidence.

Instead of entirely relying on clinical research evidence to others, invest in localised “bench-to-bedside” research that relates with the above (see points #1 to #3).

Instead of having research conducted as a disparate academic enterprise, embed clinical research into all forms of psychotherapeutic service deliveries.

This is not just about becoming “scientist-practitioners.” We need the science to inform the art-form in real-time, and not 12 months after the fact. To close the loop, the art also begins to inform the direction of the science.

#5. Help organisations understand the importance of measuring growth, not competence.

An over-emphasis on performing can terribly impede deep learning. Listen to this podcast episode, When Performing Impedes Learning).

We get over-interested in getting “competent” and as a result, we negate deep learning. Instead, we need to design and embed “learning loops” into our work. (For more, see #10 below). Growth is the measure that we need to align ourselves with. And, we need to make sure our measures match our mission. (see #1 above)

#6. Pill Model vs Continuous Calibration Model:

By and large, the social sciences have been misled and seduced to the “pill model” way of thinking i.e., medical conventions.

The Pill Model says

  • there’s right way of delivering treatment from the outset.
  • next, you SCALE the solution, and
  • you stick to the method, increase adherence to protocol, and God forbid, do not adjust the treatment for fidelity sake.

Instead, we should take a continuous calibration approach.

Continuous calibration model says

  • use timely data, so as to ADAPT AND LEARN
  • encouraged to tweak, not simply to adhere.
  • ensure that the “measure match the mission” i.e., measure what is of value, and not value whatever measures we are told to use.
  • Finally, continuous calibration works when we take the feedback and feed-it-forward to our clients in real-time.

(On that note, we should refrain for bleeding money and time investigating effects of a method of therapy comparing with business as usual. Governmental policies can become truly informed by evidenced-based and practice-based research research, instead of skewing towards political agendas.)

#7. Figure out a systemic plan to reconfigure therapy as a less of a lone endeavor and more of a team sport.

Psychotherapy can be such a painfully private affair, we often lack the context to work collaboratively at improving our craft.

The late K. Anders Ericsson articulated this concern more than a decade ago:

Most professionals – such as doctors, nurses, stockbrokers, and accountants – do not receive the constant pressure from performing in front of an audience of paying ticket holders, like actors, musicians, and athletes. The lack of scrutiny and perhaps feedback may be an important difference that explains why many doctors do not spontaneously adopt the best practice methods for treating their patients, and spend a rather modest amount of time engaged in deliberate practice and effortful training to improve and maintain their skills… The greatest obstacle for deliberate practice during work is the lack of immediate objective feedback. (p. 422) [3]

Clearly, as Ericsson states, the lack of scrutiny from the eyes of another and the lack of objective feedback hinders the possibility of benefiting from another mind pushing us to the next level in our clinical performance.

We need to create hotbeds of training grounds for therapists, both in the physical and online world, to rehearse, play and learn the conversational art-form. I believe the idea is not only to develop formulaic responses to challenges, but to develop your voice and first principles that transfers to generalizable. We need to develop what musician/producer Brian Eno calls a “scenius” community, and tear down this “lone genius” mentality.

(for more on this point, see the chapter on “The Practice and the Practical” in the Feedback Informed Treatment edited book). [4]

#8. Reimagine Education in Psychotherapy

Reimagine our higher education system for training therapists (undergrad, grad and post-grad), supervision and training, with the intend of reliably and demonstrably reflect professional development that leads to better outcomes for our clients. The current evidence suggests that formal education, training and clinical supervision has not reliably moved the needle on improving therapists ability.

See a series of blogposts that I did called, Reimagine Education in Psychotherapy (REP).

And join us at the upcoming virtual conference Therapy Reimagined, as I will give a keynote on this topic.

#9. Solve the highly problematic issue of clients dropping out of therapy, as early as after the first visit.

Yep, I wrote an entire book on this. Some of the chapters not available on Amazon preview are in the Frontiers blog too. (click here)

Why is this topic of first sessions important? Close to 20-30% of people discontinue therapy right after the first contact. I believe this has something to do with the way that we are trained to take a thorough clinical intake assessment. We end up focusing on what we are “taking” and less on focusing less on what we are “giving.” Like one time I heard this man say to his father-in-law over a cuppa, “I paid this shrink to ask me a bunch of questions and that’s it. ‘See you next week,’ she said.”

#10. Design healthcare to become learning healthcare systems

See these blogposts on blackbox thinking for psychotherapists

Nearly all therapists I speak with value life-long development. But the truth is, we have poorly designed learning systems in our workplace and in our daily lives. In turn, we are often firefighting with downstream efforts and not being able to make any upstream efforts to move the needle. This is one of the reasons years of experience does not translate to better outcomes.[5]

In the Deep Learner web-based workshop, I teach trainees and highly seasoned practitioners, as well as leaders from around the world how to become Deep Learners by employing 4 principles to “extend their minds” and harnessing practical wisdom.

The 4 Principles in becoming a Deep Learner

Join us now as we commence the next batch of Deep Learner on 6th of July 2020. If you are on the Frontiers email list, check your inbox for very special 25% discount code. Join the list, if you haven’t already!

Introduction to Deep Learner

Not only do we forget what we’ve learned, but we fail to apply the best of our selves when it’s needed. We go on to acquire more new knowledge, strategies an…


[1] Webb, C. A., DeRubeis, R. J., & Barber, J. P. (2010). Therapist adherence/competence and treatment outcome: A meta-analytic review. Journal of Consulting and Clinical Psychology, 78(2), 200-211. doi:

[2] Baldwin, S. A., & Imel, Z. E. (2013). Therapist Effects: Findings and Methods. In M. J. Lambert (Ed.), Bergin and Garfield’s handbook of psychotherapy and behavior change (6th ed., pp. 258-297). New York: Wiley.
Chow, D., Miller, S. D., Seidel, J. A., Kane, R. T., Thornton, J., & Andrews, W. P. (2015). The role of deliberate practice in the development of highly effective psychotherapists. Psychotherapy, 52(3), 337-345. doi:

[3] Ericsson, K. A. (2009). Enhancing the development of professional performance: Implications from the study of deliberate practice. In K. A. Ericsson (Ed.), Development of professional expertise: Toward measurement of expert performance and design of optimal learning environments (pp. 405-431). New York, NY: Cambridge University Press; US.

[4] Chow, D. (2017). The practice and the practical: Pushing your clinical performance to the next level. In D. S. Prescott, C. L. Maeschalck, & S. D. Miller (Eds.), Feedback-informed treatment in clinical practice: Reaching for excellence (pp. 323-355). Washington, DC, USA: American Psychological Association.

[5] 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. J Couns Psychol, 63(1), 1-11. doi:10.1037/cou0000131
Chow, D., Miller, S. D., Seidel, J. A., Kane, R. T., Thornton, J., & Andrews, W. P. (2015). The role of deliberate practice in the development of highly effective psychotherapists. Psychotherapy, 52(3), 337-345. doi:

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