Monthly Archives: March 2016

Psychotherapy: Job or Passion?

Tony Rousmaniere sent me a Youtube clip of an athlete who said that climbing for him is, “A passion that inspires you so much that you want to go out and get better at it every day.” That’s what therapy is for me.

For some people therapy is a job. For others therapy is a profession. For some it is a good way to make a living while helping people. For me it’s a passion.

I get home from work. My wife is in the orchestra pit that night. So I slide a DVD into the laptop and study one of my sessions from that day. What will I learn this time? “Wow! That session was a lot better than I realized!” “Holy cow! I was cognizing more than I realized. What was that about?” Every time I study a DVD, I learn more about how to help a patient and more about myself. Then I go to the office the next day knowing how I can improve my work. I’m still learning. It never stops.

Researchers in expertise say that the top performers in every field spend a lot of time reviewing their work in detail. Surgeons review videotapes of their surgeries. Chess masters review every game in detail through chess analysis programs to find out where and how they could have improved their game. Musicians record themselves and listen to the playbacks to see where they could improve pitch, ensemble, or phrasing. Why not us therapists?

In other fields, performance has improved over the past fifty years due to this kind of detailed study. Chess scores are much higher now due to improved chess training and analysis. Baseball pitchers throw faster pitches now due to careful videotape and biomechanical analysis. But outcome studies in therapy do not show progressively higher rates of effectiveness. Why?

I think there are several reasons. First, the vast majority of therapists does not videotape their work and study it. As a result, we can’t study in detail great sessions so we could learn specifically what led to an effective therapy. And we can’t study our problem sessions to find out how we could offer better care next time.

Without a videotape, we can’t show our work to an esteemed colleague who could help us see what we can’t see. The experienced surgeon Atul Gawande described how his work improved greatly by inviting a surgeon to observe his surgeries once a month. We could do the same if we videotaped our work.

We also don’t have forms of focused practice and exercise as we see in music or chess. Musicians practice scales, arpeggios, and musical studies every day of their career. Since the therapy field has not yet agreed on the skills necessary for expert practice, we don’t yet have skill building exercises that everyone can do to enhance their skills. With the exception of Ekman’s METT studies for learning to see micro-expressions of affects and my skill building exercises designed for helping therapists deal with defenses and resistances, therapists have no means to develop, practice, and hone their skills.

A colleague of Tony’s told his graduate students that skills aren’t necessary for psychotherapy. He said all they needed to do is understand the co-constructed nature of reality. Would you go to a surgeon, lawyer, or car mechanic who said skills weren’t necessary? This brings up another problem in our field. We have a significant subset of clinicians who do not believe there are skills or techniques that must be learned. One only needs to know theory, not how it is applied. Obviously, if you do not believe skills are necessary, you will not become more skillful, and your outcomes will remain the same.

As a former professional musician married to a professional musician, I am so impressed by the daily attention to skill building that typifies the high achievers in music, chess, ballet, surgery, baseball, and, yes, psychotherapy.

Musicians don’t stop practicing scales and arpeggios when they get out of college. They don’t stop recording their work and listening to playbacks. They don’t stop asking colleagues to listen to them when they try out a new instrument.

Chess masters don’t stop analyzing their games after they become masters. They don’t stop working on the weak points in their games. They don’t stop studying the games of their colleagues.

How many session transcripts are there for us to study and learn from the work of our colleagues? It’s not in thousands like it is for musicians and chess masters. If the music field were like the therapy field, a CD store would have lots of CDs but they would be CDs of musicians talking about concerts they heard, not the concerts themselves. Most of our journals have articles about sessions, but not the transcripts. Even today, there are very few DVD’s available of actual therapy sessions with master therapists working with difficult patients. [Moment of self-promotion: go to www.istdpinstitute.com to order my DVDs of work with fragile and borderline patients.]

The top surgeons don’t stop studying their videotapes once they become surgeons. The constant study and analysis of their work, together with colleagues, is their path for continued growth and development.

These groups share in common a passion. Whether that passion is for the beauty of music, the elegance of a well-played chess game, the healing and faster recovery of a patient, it is a passion for excellence in the service of a goal.

I hope you start videotaping your work, if you haven’t already. And I hope you form groups with colleagues so you can study videotapes together. The more skilled you become, the more quickly your patients can be healed. Then psychotherapy can be a shared passion that inspires you so much that you want to go out and get better at it every day.