This blog is all about helping you become a better therapist.
You've probably heard me say outrageous things and wondered "where does this stuff come from?"
That's I hold a set of assumptions which are very different than most therapsits.
So I wanted to share my sources.
Below are a list of sources which have most influenced my thinking.
At the end I provide a break down of basic assumptions fueling everything I write here.
I hope this serves you.
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Books.
Fooled by Randomness -Nassim Taleb:
This book taught me that much of what we think is skill is actually luck. Worse, the human brain is not wired to see the roll of luck in our lives.
The Black Swan -Nassim Taleb:
This book is about how rare events, black swans, are what move human history. And because it's always rare events, it means those events are almost always unpredictable, so anyone claiming to predict the future is lying to you. However, I really enjoyed it because it really helped me to think statistically, which is hard for humans to do. Our minds just aren’t wired that way.
Antifragile -Nassim Taleb:
his book got me through a personal hard time. This book is all about how to live in a random world, and even prosper in it. I love it because it taught me that many of the things that happened to me were not my fault.
Thinking Fast and Slow (Chap 16–22)-Daniel Kahneman:
Nassim Taleb talks a lot about cognitive biases in Fooled by Randomness (thinking traps). I always wondered where he learned about thinking traps. It turns out he got them from Kahneman’s Thinking Fast and Slow which is all about flaws in decision making. In chapters 16–22 Kahneman systematically goes through the thinking traps that trip experts, and shows how most experts intuition is flawed and many experts don't actually outperform lay people. In other words, he shows we have lots of gurus but few experts.
Sources of Power/ Intuition at Work -Gary Klein:
After reading Taleb’s work you realize intuition is often wrong. The question then is “when is our intuition right?” The answer is "only in situations with clear, quick, consistent feedback." This question is what Klein answers beautifully in his work. Sources of Power is an academic text, while Intuition at Work is the same book but for lay people.
Peak -Anders Ericsson and Robert Pool:
My first big takeaway from this book is the importance of deliberate practice in learning anything. If you want to learn anything well, you need to practice. This is because deliberate practice is a highly structured way to get quick clear feedback, mostly by using a coach.
Noise - Daniel Kahneman:
This book is all about how inconsistent we are. Turns out we’re so inconsistent we don’t even agree with ourselves. Given the same information doctors will give one diagnosis in the morning and another in the afternoon. We’re so inconsistent that simple models and checklist often perform better than we do, simply because they are more consistent.
Key Takeaways?
All of theses sources have taught me that "experts" often think they are more effective than they actually are because 1) they fall to the same thinking traps/cognitive biases as the rest of us, 2) many experts work in environments without clear feedback, which means, 3) they can't actually evaluate the quality of their work.
The way to improve then is through the process of deliberate practice, which involves getting feedback on our work.
Articles & Videos.
The Overselling of Therapy- Neil Jacobson:
Neil Jacobson is a lost treasure. He was one of the first to popularize the idea of “clinical change” in psychotherapy. Jacobson goes through the research on therapy outcomes and shows how across models only about 20% of people recover in therapy.
Mental health is biological health: Why tackling “diseases of the mind” is an imperative for biological anthropology in the 21st century -Kristen Syme and Ed Hagen -:
I love this article for numerous reasons. You just have to read it. However, I cite this article a lot because it’s this one that states rate of mental health disorders haven’t changed in 20 years. While every other industry has improved, mental health has been stagnant for at least 20 years. That’s a problem.
Specific vs nonspecific factors in psychotherapy. A controlled study of outcome - H. Strupp and S Hadley [1]:
This is a landmark study showing that paraprofessionals/ lay counselors often produce results just as good as professional counselors. UPDATED 9/14/21
The Evolution of Psychotherapy: An Oxymoron - Scott Miller:
I’ve heard Scott Miller speak several times and this is the best summary of his field of research. He’s one of the most underrated psychologist of our day. He’s done a lot of the heavy lifting of showing that no therapy model outperforms another, most therapist help 50% of their clients, and that therapist are as effective today as we were 40 years ago.
The Science of Feeling Safe-Stephen Porges.
Porges’ Polyvagal theory is the foundation of how I view therapy. In a nutshell humans heal and grow when we feel safe. If we don’t feel safe we divert all resources to defending ourselves. This is the foundation of all human behavior. If a kid isn’t learning in school, they probably don’t feel safe. If your mother in law isn’t respecting your boundaries, she doesn’t feel safe. If you feel anxious and depressed, you don’t feel safe.
Key Takeaways?
Theses sources have taught me that as a field we've stagnated.
If you look at therapy outcomes or levels of mental illness, we've not improved in at least 20 years, if not longer.
For the average clinician this means in their caseload about 50% of clients will experience some change. This 50% includes the 20% who experience recovery in therapy.
Knowing this we can use track our outcomes with formal tracking systems and use deliberate practice to improve our skills, but we have to privilege safety. Safety is more important than our model or years of experience. If people don't feel safe with us they will reject the therapy.
Podcast.
Bold Conjectures — Most surgeries are ineffective.
One of my favorite podcast ever. I learned that the same forces which corrupt psychotherapy are present in other fields. The problems of psychotherapy are not unique to us.
Bold Conjectures — How we do science determines what we discover.
This podcast has had the most impact on my recent thinking. The biggest idea I took from this is we need robust solutions which work in real world environments. So what’s an example of a robust or weak solution? A strong solution for contraception is a vaginal ring. You put it in once and forget about it for a month. A weak solution is a condom. You have to have one on you, you have to make sure it’s not old or has a hole, you have to make sure you partner is okay with using it, etc. Both work, but in the second there’s just too much room for human error. Too often in therapy we train clinicians to provide weak solutions.
The Knowledge Project- Todd Simkin.
A few days ago I finished writing a post about how my thoughts on therapy have been heavily influenced by the field of investing. Then today I stumbled upon this podcast all about how good investors think. This is a perfect example of everything I was trying to say in the upcoming article- investors know how to make good decisions under uncertainty and therapist could learn a lot from them. UPDATED 9/14/21
Afford Anything-The Radical Invention of the Index Fund, with Robin Wigglesworth.
First, I’m a fan of history and investing, so this episode on the history of index funds was riveting. The biggest reason it’s on this list, though, is because of what it teaches us about innovation. Oftentimes we know the solution, at times its simple, but we just can’t bring ourselves to use it. Until we’re forced too. It’s stories like this which leave me wondering “what great psychological insight is laying in plain sight?” UPDATED 1/10/22
Key Takeaways?
All of theses sources have taught me that the problems of therapy are not unique to therapy.
The way other fields improve is often by finding robust solutions, solutions that are hard for humans to mess up.
If we can do that, if we can help clinicians engage in deliberate practice as well as use robust solutions, then we will finally move the field forward.
TL;DR
The field of therapy has stagnated.
Outcomes haven't improved in 40 years,
rates of mental illness haven't decreased in 20 years,
and no model outperforms another model.
most therapists help 50% of clients
of which only 20% experience recovery
This is because we aren't getting clear and quick feedback on the results of our actions.
And because we aren't getting high quality feedback we don't actually have a class of experts.
Most are simply gurus who are subject to the same cognitive biases and thinking traps and overrate their effectiveness just like the rest of us.
The solution is to track our outcomes and engage in deliberate practice.
But these problems aren't unique to psychotherapy. These same problems are present in medical field.
There are probably other solutions to these problems we haven't explored yet.
Jordan (the Counselor)
-You Finished! Congrats! Thanks for reading! 10 points!-
[Notes]
[1] "The results of this investigation were consistent and straightforward.
Patients undergoing psychotherapy with college professors showed, on the average, quantitatively as much improvement as patients treated by experienced professional psychotherapists.
The greatest amount of change occurred during the treatment period (individual sessions on a twice-a-week basis for up to 25 hours over a period of three to four months) and it was maintained to the follow-up assessment about a year after intake…
Although some form of treatment appeared to be superior to no treatment, the study, on the whole, lent no support to the major hypothesis that, given a benign human relationship, the technical skills of professional psychotherapists produce measurably greater therapeutic change" (pp. 1134–1135)
If you liked this post, consider reading this next. I think you'll like it ;) It's about how to be more persuasive.