Deliberate practice and distributional thinking

How many people normally get better ? 

How many people normally drop out ?

How many people would have gotten better anyway?

In this podcast Aaron presents a framework for thinking about clinical outcomes and helping you to identify where you can improve.

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Transcript

SPEAKER_01 0:00

So you're a therapist who's interested in getting better outcomes, but you're overwhelmed and not really sure where to start. You look at all of those training workshops and they cost a fortune and it's unclear whether they're actually going to lead to better outcomes. In this video, I'm going to teach you a completely different way to think about improving your outcomes, and I'm going to do it in less than three minutes. The key is to think distributionally. And what I meant by that is it's the absolute opposite to everything we have been taught in our psychology training up to date. We think about the individual client in front of us. I want you to change your thinking entirely and think about the entire distribution.

SPEAKER_00 0:41

There are 162 games in a major league baseball season and the players have a saying. Every team's going to win 54 games, every team's going to lose 54. It's what you do with the other 54 games, it counts.

SPEAKER_01 0:49

Our equivalent of that baseball analogy is the hundred clients that you're going to see each and every year. Now, of those hundred clients, it is predictable that for the average therapist, 30 of them are going to drop out, which means there's only 70 left to go. Of those 70, 5 to 10 of them are going to get worse. That brings us down to 60. The difference between the top therapists and the mediocre therapists, all therapists are going to produce good outcomes with 20 to 30 of them. Great therapists are going to produce great outcomes with 50% of them. The difference between the good therapists and the poor therapists is that middle 30%. Now let's look at a really good therapist data to get a sense of what I'm talking about. Right here, we've got the outcome distribution for one of the best therapists that I've worked with. Now, to try and make sense of it, I've ordered it by outcomes. So if you have a look here, you can see from the people who got the worst outcome to the people who got the best outcome. Let me try and make sense of it. Right here, we've got the quadrant of people who deteriorated. Here, we've got the people who made no gains or who dropped out early. Here, we've got the people where she's made positive gains, but they're small. And here is the group who have made large improvements. Every therapist has the same distribution of four. The group of people who deteriorate, the group of people who drop out, the group of people who make small gains, and the group of people who make large gains. What makes this therapist one of the best is the low number of people dropping out, the low number of people deteriorating, and the large number of people who are making large gains. Your challenge, and the way I want you to think about it, is not whether you need to learn schematherapy or EMDR or metacognitive therapy or go off on a silent mindfulness retreat. Your challenge is to look at your distribution and figure out what can you do that will lead to the biggest gains that are going to skew things in the right direction. For most people, it's going to be dropout. Great therapists have dropout rates that sit more like 10%. Average therapists have dropout rates of 30%. If you can improve that one number, your dropout rate, overall your effectiveness is going to improve out of the ballpark. The next thing you can do is to look at the group of clients that you are unsuccessful with. Who do you fail to make rapport? Who do you fail to understand what their needs are? And who do you fail to come up with a meaningful therapeutic connection that moves them from where they want to be towards their goals? I'm going to throw it back to you, but that's your challenge. Think distributionally, find out where on the distribution you can have the most impact, and set all of your goals for this year about shifting that part of the distribution. Good luck.