“It’s All About the Process…”

No, it’s about the result.

The process should always serve the result.

We need to trust the process of therapy, but without clarity on the effect of therapy, you are likely to get lost in the weeds—lost in our theoretical explanations and pet solutions—especially when the client isn’t experiencing any real gain.

The What Before The How

The process is instrumental to the value gained from therapy.
Composer and author of The Path of Least Resistance, Robert Fritz puts it this way,

“The question, ‘What do I want?’ is really a question about results. Perhaps a more precise way of asking that question is ‘What result do I want to create?’ …The question, ‘How (emphasis mine) do I get what I want?” is really a question about process, not results.

If you ask the ‘how’ question before the ‘what’ question, all you can ever hope to create are variations of what you already have.” [1]

Our field is obsessed with the “how’s”. We are inundated in the therapy marketplace, rendering us to think in terms of “which treatment for whom,” which limits us to a medical paradigm about how to think about our humanity. Further, evidence is clear that differences in treatment approaches accounts for 0-1% in outcomes, whereas difference between therapists accounts for 5-9%.[2]

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In previous blogs about our professional development, as an antidote to a blind leap into the “how’s”, I argue that it is critical for us to figure out each of our individual what before the how. (Read Mastery Learning for Therapists; Figure Out Where You are Before Knowing Where You Need to Go).

An Underrated Question

It’s interesting how challenging the following question might be.

“What result do you want to create for your clients?”

Without systematic routine of tracking client outcome, or a feedback informed approach in outcomes monitoring, it can be difficult to be attuned to the actual results, and we consequently get lost in the process. For instance, look at most companies mission statements. They revolve more on improving processes and less focused on improving actual results. In therapy-land, just read the blurbs for most workshops. The emphasis is typically more about challenging core beliefs, increasing cognitive delusion, reducing trauma symptoms, increasing self-compassion, to become more mindful… There is less emphasis about actually improving your client wellbeing and your therapist performance.

An aside: Are symptom reductions the aim of mental health service providers, especially in clinical settings? If so, measuring symptoms of depression, anxiety, and stress makes sense. But is there more than that for our so-called treatment goals? (For more on this, read this article: Vanity metrics: Do We Value What We Measure, or Measure What We Value?) What if we revisit the seemingly basic question Fritz poses, “What result do I want to create?” and stay with that for awhile.

To me, therapy can be a healing project that not only reduces symptoms, but expands and creates a flow of life that promotes improvement of wellbeing and relationships.

And, if we stay focused on the results, i.e. client’s improvement of wellbeing, the solution of therapy might sometimes not be the best way to create life for the person. Maybe it’s helping the person join a volunteer program, enlist to be part of a political movement, or maybe connect with a community of like-minded artists.

The Original Supershrink

As a homage to the first researcher who investigated the outcomes between therapists of difference competencies, my doctoral thesis was titled, The Study of Supershrinks. The term, “supershrink, was coined by the youths in the child guidance clinic, whom this highly effective therapist worked in. Ricks (1974) examined the long-term outcomes of ‘highly disturbed’ adolescents, and when the participants were later reviewed as adults, the results dramatically differed between the two therapists who provided the treatment.

For example, 27% of the first therapist’s cases received the diagnosis of schizophrenia as adults, while 84% of the second therapist’s cases received that diagnosis. (Note: Both therapists’ caseloads were equal in level of disturbance and other variables, e.g., gender, IQ level, socio- economic status, age, ethnicity, period seen, and frequency of psychotic disturbances found in the parents). A significant amount of the adults who had seen the first therapist were more socially well-adjusted, compared to those who saw the second therapist, despite the fact that, at commencement of therapy, both therapists’ caseloads were equal in level of disturbance and other variables (gender, IQ level, socio- economic status, age, ethnicity, period seen, and frequency of psychotic disturbances found in the parents).[3]

Three points stood out to me about the difference between the “supershrink” and the “pseudo-shrink.” Even though both therapists were trained in the psychoanalytic tradition,

1. The more effective therapist tended to be more skilled than the “Pseudoshrink” in developing a deeper and more lasting therapeutic relationship;
2. The more effective therapist employed fewer intrapsychic interventions, and
3. The more effective therapist used resources external to the therapy context.

It is striking to me that the more effective therapist is less fixated on the means, methods and solutions, and more on the outcomes.

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In closing, I hope the words of Robert Fritz echoes in our minds,

“Consider what you want (to achieve) independent of considerations of process.“

(p.135)

Envision. Trust the process, but start with the result in mind.

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Footnotes:
Image: Isalas Ballestas, Peru. by Giancarlo Revolledo
[1] Robert Fritz, The Path of Least Resistance, pages 70-73, 135.
[2] See The Great Psychotherapy Debate, 2nd ed. by Bruce Wampold and Zac Imel for a great summary on this consistent finding across studies. In our super shrinks study, we also found that therapists effects accounts for about 5%.
[3] Ricks, D. F. (1974). Supershrink: Methods of a therapist judged successful on the basis of adult outcomes of adolescent patients. In D. F. Ricks & M. Roff (Eds.), Life History Research in Psychopathology (pp. 275-297). Minneapolis: University of Minnesota Press. See Scott Miller’s interesting blog post about his attempts in figuring out who David Ricks was.
Incidentally, Ricks was a pioneer to highlight the need to systematically monitor outcomes in psychotherapy. He said, “If a major clinic were to set up an ‘outcomes board’ to look over the long-term outcomes of therapy conducted by staff psychotherapists, it would be possible to determine, within a few years, whether particular therapists were unusually harmful or helpful” (p. 292).