The term "supershrink" was used to refer to counselors and other mental health professionals who are very good at what they do and who achieve significantly better customer results than average. It is perhaps not surprising that such a funny and playful term comes from an adolescent.
In the early 1970s, David Ricks carried out an analysis of the long-term results of "severely disturbed" adolescents who were treated in a large city counseling center. In this center, some young people had described a provider as a "supershrink". In the subsequent data analysis, Ricks found that adolescents treated by this provider achieved significantly better long-term results than those who saw another provider. It turns out that the teenagers were right; The provider was a super shrink.
The idea that some consultants are exceptional and have very high success rates among customers is not new. In fact, this phenomenon has been verified empirically. Research over the past few decades has shown that some consultants consistently achieve higher customer improvement rates than other consultants. With this in mind, it is important to consider what we can learn from so-called supershrinks as consultants and how we can embody the properties and actions of highly effective consultants in order to improve our own effectiveness.
Consultant Effects and Results Research
The term "therapist effects" or "counselor effects" refers to variations in counseling outcomes attributable to the counselor, as opposed to other factors such as techniques or theories that contribute to counseling outcomes. Results from advisor effects appear in a variety of study environments such as naturalistic clinics and in randomized clinical trials (RCTs). Adviser effects in RCTs are particularly fascinating as these studies are strictly controlled. In RCTs, consultants typically adhere closely to a treatment manual (i.e., follow certain steps to follow a certain theory), and there is also control over the client's severity. RCTs are the gold standard for comparing the effectiveness of specific treatment approaches for specific diseases.
Although there is important insight into the effectiveness of different treatment approaches or theories from RCTs, another insight that has received less attention over the years is that advisor effects are the better predictor of advice results. In other words, who the advisor is is making a greater difference in terms of client improvement than what theory the advisor claims to use. It is impossible to completely separate the characteristics and actions of the consultants from the theories they use, but careful research and meta-analysis by renowned researchers such as Bruce Wampold have shown that the consultant effects in determining client outcomes are up to eight times stronger.
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As Wampold and others have emphasized, these results on the relative strength of advisory effects compared to the theoretical approach are no justification for throwing out advisory theories. Framework, structure, a road map for navigation in the clinical area and conceptualization are just a few of the advantages that result from the basis of our work in consulting theories. However, for decades, the results researchers have primarily focused on comparing different theoretical approaches, while paying relatively little attention to a stronger factor – the characteristics, pan-theoretical practices / actions and attributes of the advisor.
Five characteristics and actions of highly effective advisors
Although there have been consultant effects in results research for several decades, empirical attempts to recognize pan-theoretical characteristics and actions of highly effective consultants are rather new. The development of a list of such characteristics is limited as new research results often emerge. Indeed, it is noteworthy that the five features highlighted in this article are just a few of the key features and actions of highly effective consultants.
The list contained here consists of properties that consultants can actively maintain in their current practice. In other words, there are some growth strategies for each of these five properties. There are other characteristics of highly effective consultants in research literature for which it is currently not clear how these characteristics can be increased or improved (e.g. attachment history, supportive interpersonal skills). Therefore, this list focuses on features and measures that can be improved to improve the effectiveness of the advisor. Accompanying the descriptions of these characteristics, you will find some tips on how you can develop them in your own consulting practice.
1) Presence and
2) Countertransference management
The "way of being" of the advisor serves as a vehicle through which therapeutic actions and interventions take place. Presence and countertransference management are two related concepts from consultant effect research that relate to the "nature of being" and the "type of relationship" of the consultant. Both concepts have theoretical roots.
For example, presence in the existential-humanistic tradition refers to the fact that counselors are “in the moment”, are connected to the experiences of the clients and their own and fully engage in the I-You relationship with a client . Presence can also be defined by identifying it as the opposite of absence (e.g. distraction, boredom, disconnectedness, seclusion).
The countertransference naturally has theoretical roots in psychoanalysis. Sigmund Freud saw this as a point in time when a client's transmission triggered a consultant's unresolved childhood conflicts. In a broader sense, a totalist view of countertransference is that it encompasses all of the adviser's reactions to the client. Although countertransference reactions are common, the impact of countertransference on advisory outcomes mainly depends on how the countertransference is managed. Meta-analytical studies by Jeffrey Hayes and colleagues have shown that successful countertransference management predicts better advisory outcomes. Similarly, the presence of Shari Geller and Leslie Greenberg has been described as a “prerequisite for empathy,” and the empathy of the counselors is a strong predictor of client improvement.
Several factors can lead counselors to increased presence and better countertransference management, including self-awareness (e.g. self-confidence in relationships, cognitive and emotional awareness), fear management, intentionality, and mindfulness. Given all of these factors, consultants may be overwhelmed by methods to strengthen their presence and countertransference management. Fortunately, research results support some overlapping practices to improve both of these properties.
> Meditation / Mindfulness Practice: It has been shown that persistent and consistent meditation practice increases effective countertransference management, promotes regulation and non-reactivity of emotions, increases awareness and increases the presence. There are many different types of meditation and mindfulness practice. Advisors are advised to examine these practices, choose a practice that suits their own preferences, and maintain a consistent mindfulness practice.
> Self-awareness and fear management: Counselors should work on their own mental health and practice self-observation and self-reflection. This can be done under supervision, based on your own experience as a customer, and through targeted planning aimed at increasing self-confidence.
Similarly, fear management is an important part of countertransference management and presence. While it is not uncommon for counselors to experience anxiety within sessions, unmanaged anxiety can have an adverse impact on the counselor's presence, ability to manage countertransference reactions, and therapeutic alliance. A first step is to develop sensitivity to notice anxiety when it occurs. Second, advisors are likely to already have anxiety handling skills (e.g., behavioral, cognitive, mindful) that they apply to clients. Consultants can apply these skills to themselves.
> Centering Before Meeting: A study by Rose Dunn and colleagues found that counselors found themselves more present if they did a short mindfulness centering exercise within five years Minutes of a counseling session. In addition, clients found the sessions more effective when the advisor used the mindfulness exercise prior to the session. The basics of the centering exercise are in line with the principles of acceptance and attachment therapy.
In this case, counselors would simply sit comfortably with a straight spine, take and take gentle and full breaths, notice physical sensations, notice emerging thoughts, acknowledge the existence of these thoughts, and allow them to be present. Imagine creating more space for your thoughts with each breath and then letting go of the thoughts to draw attention to the surroundings. In this mindfulness approach, the counselors aimed to accept the thoughts and experiences as observers rather than clinging to them or pushing them away. For more detailed information on mindfulness and acceptance centering, I recommend the work of John Forsyth and Georg Eifert.
> Self-care: This term is often discussed in our area, and self-care activities can vary considerably among individual advisors. For presence, countertransference management and many other reasons, it is important that consultants take consistent self-care measures. Self-care behavior that appears relatively universal and affects attention (i.e. presence) and the regulation of emotions is sleep. Practicing healthy sleep hygiene (maintaining the room temperature at 62-68 degrees, adhering to a consistent sleep schedule, maintaining a dark environment, nightly technological boundaries, etc.) can provide conditions that are conducive to increased presence and better countertransference management.
3) Professional self-doubt
The essence of this quality of highly effective consultants is recorded in the title of an article by Helene Nissen-Lie and colleagues: "Do you love yourself as a person, do you doubt yourself as a therapist?" At first glance, the idea of professional self-doubt seems obvious unproductive place to be as a consultant. However, if we only consider a basic definition of "doubt" (i.e., are unsure), the benefits for customers will become clearer.
Consultants who are assured of helping a client are likely to close the door to self-criticism and careful consideration of how they can improve their work. In fact, several studies by researchers like Corinne Hannan and others have shown that consultants repeatedly overestimate the effectiveness of their work with clients. Regarding self-doubt, two studies with experienced counselors from Nissen-Lie and colleagues showed that counselors with higher professional self-doubt had stronger alliances with clients and a higher degree of client improvement than counselors with lower professional self-doubt.
It is important that a third study by Patrizia Odyniec and colleagues showed that increased professional self-doubt among trainees / students led to poorer customer results than lower professional self-doubt. An explanation for these results is the difference in the development stage of the consultants. Experienced advisors are likely to have a higher level of confidence in their basic skills than advisors. Professional self-doubt about their effectiveness can therefore be an advantage, since they strive for improvements due to their own uncertainty about the results of the customers. In contrast, a high level of professional self-doubt among trainees can be debilitating due to their earlier stage of counselor development and less confidence in their basic counseling skills.
All in all, there seem to be clear advantages for clients if experienced consultants cultivate professional self-doubt. Here are some strategies for doing so.
> Prevent the "superconsciousness effect". This social-psychological concept is particularly relevant here, since numerous studies have shown that consultants often overestimate whether and how much their clients improve. Only being aware of this tendency to increase the success rate of your clients can help consultants to become increasingly humble and self-reflective about their effectiveness. Deliberately questioning our own prejudices is an important step in maximizing customer improvement rates.
> Monitor your effectiveness. Consultants should use some form of outcome measurement (e.g. outcome assessment scale, clinical outcomes in routine assessment – outcome measurement, outcome questionnaire 45) to assess how well their clients are improving or not. It has been repeatedly noted that routine monitoring of results improves clients 'results, and specific customer reports on their level of improvement can help to keep consultants' excessive trust at bay. In addition, outcome monitoring can promote positive attitudes of professional self-doubt, as awareness of clients who do not improve or worsen
can result in advisers acting deliberately to improve.
> Love yourself as a person. An important limitation in the studies by Nissen-Lie and colleagues is that the advisor's self-doubt can improve the results of the clients in connection with a so-called "self-associative introject". In general, this refers to a higher level of self-affirmation, self-love and self-acceptance. If a self-associative introject or self-affirmation is an area of struggle for consultants, this can affect their work with clients and their ability to accept professional self-doubt. Steps to build and strengthen a self-associative introject or self-affirmation could include self-help, support groups, or personal advice.
4) Deliberate Practice
Conscious practice, a concept that comes from the specialist literature of researchers like Anders Ericsson, refers to intentional and individualized exercises and measures to strengthen certain areas of performance. Early deliberate practice research examined its effects in non-advisory areas such as chess, music and sports, to name a few.
In a consultation, a promising study by Daryl Chow and colleagues from more than 1,600 clients who worked with 17 consultants revealed that the top quartile of advisors (ie those whose clients showed the greatest improvement) spent almost three times as much deliberate practice as a consultant in the lower quartiles of customer improvement. Consistent with some previous research, Chow and colleagues found that the following factors were not significantly related to client outcomes: consultant's age, professional discipline, gender, years of experience, highest level of qualification, and theoretical orientation. Below are some key components of deliberate practice, combined with recommendations for integrating them into your consulting practice.
> Establish your baseline. In order to improve yourself as a consultant and determine whether you will become more effective over time, you need to know how effective you are with your clients. Routine results monitoring is one way to set a baseline. Using a measure of results and then tracking your customers' improvement rates over time is a first step in conscious practice.
> Recording sessions with difficult or stuck cases. Although we are not intrinsically motivating, in cases where our weaknesses are most obvious we will learn a lot about opportunities for improvement. Video recording is simple these days and an indispensable tool that is not just for interns. Video recordings can help counselors identify gaps in consciousness and skills that simple self-reflection alone is unlikely to reveal. It is unlikely that interrupting and changing unhelpful patterns that may have emerged out of our consciousness if we only rely on our self-assumed clinical wisdom by thinking mentally about a session is not helpful.
> Work with a consultant or advisory group. Leaving our own perspective and the potential for selfish prejudice is a critical part of conscious practice. By working with a competent advisor or a competent advisory group, we can gain different perspectives on our weaknesses as a consultant and thus develop specific goals and growth plans, while continuously receiving support and feedback.
> Develop clear, targeted goals. Our goals must be very clear and specific. Setting a goal to improve as a consultant is not very effective. Instead, a first step would be to identify specific areas for potential growth as advisors. This can be done in cooperation with your consultant / advisory group. With conscious practice, the actual growth takes place outside of the actual customer meetings. Outside of the session, you have time, support, and opportunity to think and practice while deliberately trying to develop new therapeutic skills or “beings” in challenging cases.
The specifics of intentional practice are very detailed. Consultants are therefore encouraged to read the work of scientists such as Daryl Chow and Scott D. Miller on the subject for a more comprehensive overview.
5) Multicultural orientation
Multicultural orientation is a fairly new construct, which differs from multicultural competencies. As described by Jesse Owen and colleagues, multicultural skills are seen as a “way of doing”, whereas multicultural orientation is a “way of being”. Multicultural orientation is a way of communicating the client's attitudes and values
to the client. In particular, the multicultural orientation consists of three overlapping pillars. Each of the pillars is described below and accompanied by recommendations to strengthen your counseling practice.
> Cultural humility: This refers to an interpersonal attitude that is “differently oriented” and open to the understanding of the client's cultural experience and background. In addition to this interpersonal dimension of cultural humility, there is also an intrapersonal dimension in which counselors are open and willing to think about their own limitations and blind spots to understand someone else's cultural experience. Four studies with more than 3,000 clients have found a significant positive correlation between customer ratings of their consultant's cultural humility and the results of the advice. An important consideration here is that the “perception of the client” of the level of cultural humility of his advisor is related to the client's results.
There are some strategies and measures advisers can take to make clients feel more culturally humble. First, given the intrapersonal realm of cultural humility, counselors are encouraged to reflect and analyze their own realms of potential prejudice and cultural blind spots. Pamela Hays' "ADDRESSING" model can be a useful framework for determining domains in which an advisor has privileged status, as these privileged domains are likely to be blind spot sources.
Secondly, advisors are encouraged to speak openly about culture in the admission session with clients. This strategy also overlaps with the “cultural opportunities” pillar (strategies are described in this section).
Third, consultants should frequently check in with customers to make sure they understand the customer's cultural perspective. This “cultural check-in” should be part of a broader culture of feedback that is created by the advisor in the session. In particular, advisors must acknowledge to clients that they strive to understand clients' perspectives and cultural experiences, but despite their best efforts, they can sometimes be misunderstood. Openly and repeatedly asking customers to give open feedback (especially negative feedback) is one way to express humility and attempt to repair if an advisor misunderstands or unknowingly commits microaggression.
> Cultural Opportunities: This column refers to opportunities in meetings for the consultant to address the subject of culture with a client. It is important that research on this topic indicates that "missed cultural opportunities" (i.e. the client's perception that the counselor is missing and does not respond to opportunities to discuss / address culture) negatively correlate with the client's results . In other words, as the counselor misses more cultural opportunities, the improvement in clients decreases.
One way to increase the positive impact of cultural humility and opportunities is for consultants to address culture in the recording session. For example: "How does culture affect the problem?" The purpose of such an open question is to better understand the client's perception of culture. If clients are unsure of what “culture” means, alternative phrasing ideas can be found in the “Interview on Cultural Formulation” in the fifth edition of the Handbook for Diagnosis and Statistics on Mental Disorders. The interview offers numerous examples of open questions about customer culture.
Addressing or inquiring about the influence of culture should not be limited to the recording session. Consultants need to be careful with clients to understand how they see
the role of culture in meetings. This can result in consultants making sensitive use of cultural opportunities in meetings in a way that appeals to clients.
> Cultural comfort: The last pillar of the multicultural orientation is the openness, lightness and comfort of the consultants when working with different customers and when dealing with customers on the subject of culture . In a 2017 study, Owen and colleagues found that the consultant's level of cultural comfort predicted customer dropout rates. A higher level of cultural comfort for counselors was associated with lower dropout rates. This is particularly important because a high dropout rate is one of the greatest challenges for our specialist area. A meta-analysis by Joshua Swift and Roger Greenberg in 2012 showed that the average dropout rate in counseling is 20%.
With regard to advisers who increase their cultural comfort, some of the strategies mentioned for cultural humility and cultural possibilities (e.g. deliberate reflection / analysis of prejudices and blind spots, addressing the topic of culture in meetings) be applied . Another strategy that can be helpful in this regard is role play and rehearsal – especially role play with colleagues, where the advisor practices dealing with bogus clients around the subject of culture. Advisers are advised to practice culture in situations that present a wide range of challenges. For example, if an advisor had little or no contact with clients who are transgendered, an RPG in a scenario where the advisor addresses the culture with a sham client who is transgendered would be a way to enhance the advisor's cultural comfort . Inviting and receiving feedback from colleagues in such mock sessions is essential for consultants to expand and improve their clearing skills and increase their cultural comfort.
Conclusion
The number of factors contributing to effective advice is large and unpredictable. As research on this topic continues, we are developing a better understanding of some of these factors. We now have ample research support for advisor effects and the relative strength of these effects compared to theoretical techniques.
The boundaries between advisor characteristics, common factors (e.g. therapeutic alliance, placebo effect) and specific factors (e.g. treatment interventions, techniques) are not clean and discreet. Instead, each of them has a certain overlap and a multi-directional influence on the others. However, recent research shows that counselors' qualities, qualities and pan-theoretical actions play an outstanding role in potentiating the therapeutic alliance and the theoretical techniques to improve client outcomes.
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Sidney Shaw is a key faculty member in the clinical mental health counseling program at Walden University and a certified trainer for the International Center for Clinical Excellence. Contact him at [email protected].
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