Some therapists seem to achieve consistently better outcomes than the average. There’s lots of speculation about why. Here we take an in-depth look inside the practice of one such ‘supershrink’ and the experiences of her clients to try and better understand this phenomenon.
Meet Eri Vlass. Eri is a clinical psychologist who works as a psychotherapist in private practice in a clinic in Sydney, Australia. Her measured outcomes show her to be an exceptionally effective therapist. So much so, that in a paper from 2015, she is described as a ‘supershrink. But how do we know that Eri is so special, and what makes her so?
The paper I refer to is titled Sudden Gains and Sudden Losses in the Clients of a “Supershrink”: 10 Case Studies. It profiles Eri’s outcomes, how she approaches her therapeutic work, and the experiences of ten clients from her caseload. I found it an absolutely fascinating insight into the work of a clearly exceptional therapist, and one which has got me thinking about elements of my own practice. Isn’t this what we need from research?
In this blog I want to focus on three key areas. First, what is meant by the term supershrink and what makes the term fitting in Eli’s case.
Second, what characterises her approach to her therapeutic work that may shed light on her exceptional outcomes. Third, selected perspectives of the ten clients who were the subjects of the case studies.
What, exactly, is a supershrink?
The term supershrink was first coined in 1974 [i] by researcher David F Ricks, who used it to describe the exceptional long-term adult outcomes achieved by some therapists working with highly disturbed adolescent clients.
A model adopted by an earlier study by Finch et al [ii] was used to examine outcome data for Eri’s clients for the year 2009 – 2010. That study profiled data for over 11,000 outpatient clients who completed an Outcome Questionnaire 45 (OQ-45) measure at every session of their therapy. Recovery was modelled on the beginning level of distress at each session, identifying the 10% of clients who were responding most and least positively between each session.
The 10% of most positive and negative responders were showing sudden gains or sudden losses – statistically exceptional increases or decreases in their levels of distress between one session and that next. Within the research to date, such sudden gains have been found to be strong predictors of outcome at both termination and follow-up.
How did Eri’s clients fare?
Of Eri’s clients for 2009 – 2010, 85 completed three or more sessions of therapy. When the Finch et al models were applied to the OQ-45 scores of these clients, 43 (51%) were found to have experienced sudden gains, and 6 (7%) were found to have experienced sudden losses. Compared with the Finch study, Eri had over five times the expected rate of sudden gains in her caseload, and about a third less than the expected level of sudden losses.
The OQ-45 is scored using a 5-point Likert scale with a scoring range between 0 and 4, with higher scores reflecting higher levels of distress. The clinical cut-off for the measure is 63/64. The pre- and post-therapy scores for Eri’s clients are shown in the table below. The 43 who responded most positively all achieved both clinical and reliable improvement (a move from above to below the cut-off and a positive change of 14 or more points in their scores).
The 36 clients in the middle (80%) range of treatment response on average achieved reliable improvement, finishing just above the clinical cut-off. Put another way, 93% of the 85 clients who had three or more sessions reliably improved.
The rate of improvement isn’t the only thing that’s remarkable about Eri’s outcomes. Not only did the majority of clients improve, they did so within a remarkably short number of sessions – an average of just 3.9 sessions for the 43 most positive responders.
The case study clients
A random selection of five of the 43 clients who experienced sudden gains (blue cases), and five of the six clients who experienced sudden losses (red cases) were selected and agreed to be the subject of the case studies. A range of assessment measures were administered with these clients at two-year-plus follow up. These included:
Treatment outcome was quantitively assessed by scores on the OQ-45, and the Consumer Report Satisfaction Survey (CRSS-4), a 5-item, self-report outcome and satisfaction questionnaire.
Qualitative assessment of treatment outcome and experience was obtained via the clients’ personal narratives using the semi-structured Client Change Interview Protocol (CCIP).
The Working Alliance Inventory (WAI), a 36 item self-report measure scored on a 7-point Likert scale measuring the strength of the therapeutic alliance. The WIA encompasses three sub-scales of the alliance; agreement on goals, agreement on the tasks of therapy, and the strength of the therapeutic bond.
The mean pre-, post- and two year follow up OQ-45 scores for the clients in the blue and red cases are shown in the table below. From this it can be seen that the blue group started therapy, on average, with considerably higher levels of distress (111.4) than the red group. Despite this starting point their post-therapy scores show a remarkable improvement. Among the red group there was also pre to post-therapy improvement, though in this case non-significant. Comparing the post-therapy and follow-up scores shows that both groups remained at a similar level of distress to their final session.
Consistent with the OQ-45 scores shown above, the blues self-ratings on the CRSS-4 described their “overall emotional state when you started counseling” as poorer (when compared with reds); “overall emotional state at the end of treatment” as better; and their “overall emotional state at this time” as better. Compared with the reds, they were more likely to think that “treatment helped with the specific problem that led you to therapy;” and were more satisfied with “this therapist’s treatment of your problems.”
Comparison of the two groups’ ratings on the WIA showed that all blues rated the quality of the therapeutic alliance higher than all but one of the red group. The table below shows each groups’ ratings overall and on each of the three sub-scales of the WIA.
Blues had statistically significantly higher scores on the tasks and goals subscales and overall. They also had higher ratings on the bond subscale, though the difference was not significant. From this we could infer that while task and goal ratings are higher, both groups, as the paper suggests, had “similar trust, acceptance and confidence within the therapeutic relationship with Eri”.
Eri’s approach to her therapeutic work
The paper profiles the OQ-45 scores of each of the ten case study clients at each of their sessions. Thus, we can see where the sudden gains or losses occurred in the journey of each client. The table below shows each of the subjects’ scores, by session and by the level of pre-post change. The sessions at which the significant gain or loss occurred are underlined. (Note that the given names of the blue group begin with a B, and the red group an R).
From the table it can be seen that four of the five clients in the blue group had made their sudden gains by the second session. As the paper points out, this is a remarkably short period when compared to other studies that have examined sudden gains, which have found that they occur, on average, at between five and eight sessions.
At this point it’s worth highlighting a number of aspects of Eri’s practice that may help shed light on this remarkable pattern of sudden gains. Underpinning her approach to therapy are two distinct but complementary theoretical approaches; cognitive behavioural therapy (CBT) and compassionate mind training (CMT). CMT aims to alleviate the high levels of shame and self-criticism that can otherwise undermine the effectiveness of therapy.
In reading about Eri’s philosophy and approach to her practice I was immediately struck by the level of psychoeducation that she undertakes with her clients from the outset, as well as how she seems to refine her approach in the light of feedback. Below I’ve highlighted three areas that for me feel particularly noteworthy.
Prior to their first session, Eri assesses each client using the following assessments: an OQ-45 measure; a Sleep for Health Questionnaire and a clinical interview. Clients also complete the OQ-45 at each subsequent session, thus supporting active tracking of their progress.
2. At the first session
At the first therapy session, as well as inviting the client to tell his or her story, Eri educates clients about how traumatic experiences and stressors impact on the role of the hypothalamus and amygdala, and the role that each neuroanatomical structure plays in memory, stress and emotional regulation. She illustrates the feedback loop that starts with the hypothalamus, which interprets stressors and sends information to the anterior pituitary, which leads to the release of stress hormones in the adrenal cortex.
Eri further provides many of her clients with a graphical handout which describes the stress response cycle, the function of the amygdala and hippocampus in storing emotional memories, and the body’s ability to acquire new information, thereby reducing habitually high stress responses.
Eri also educates her clients about good sleep hygiene and provides principles for improving their quality and quantity of sleep. She also highlights the role of proper nutrition, including the effects of coffee, alcohol and other drugs.
3. During therapy
The approach to therapy is individually tailored to the client’s particular needs. Eri will suggest, where appropriate, medical treatments such as chiropractic work. Where sleep problems, or depression or anxiety could be explained by medical factors, she will refer to a relevant medical practitioner.
Early on she begins to identify themes that may be important in each client’s improvement. These are added to a consolidated, mindfulness CD. This includes the client’s history, an explanation for their suffering, and “a believable ritual for alleviating the distress.”
As therapy proceeds, Eri actively seeks evidence that the client is responding positively, both from the client’s narrative and her own observation, as well as the feedback from the sessional OQ-45. This feedback loop enables her to rapidly adjust the focus of the work to better meet the client’s needs.
The A$64,000 question – so what makes the difference?
Client characteristics clearly play a key part in the outcomes of therapy, and Eri’s clients are no exception. When contrasting the blue and red groups’ responses to the Client Change Interview Protocol (CCIP), some of the factors at play in their respective outcomes are evident. For example:
Blues tended to engage better with therapy and to utilise particular interventions
Red clients tended to make more ambivalent statements about their progress in therapy
Blues tended to realise that changes in therapy would only occur if they invested themselves in the treatment, whereas reds were less likely to comment on the need for struggle in therapy and more likely to voice lack of hope in their futures
Red clients tended to make more negative statements about therapy and expressed less hope in the therapeutic endeavour in general
These factors notwithstanding, Eri’s clients overall showed remarkable levels of improvement in a relatively short space of time. In drawing together the threads from Eri’s outcome data, her way of working, and the perspectives of her clients, the authors conclude:
The client descriptions of their therapeutic relationship with Eri portray a therapist with charisma, with the ability to make a strong, immediate connection, with a clear and persuasive plan for change based on both medical and psychological principles, and with an expectation of quick change. In line with this, her techniques are designed to empower clients to find their own solutions, and her pragmatic approach does not require lengthy treatment. Thus, Eri provides her clients a holistic, top-down view of their psychopathology within the first session, so that they have a working rubric to organize their symptoms and seek to find solutions in a timely period.
In my last blog I referred to the work of Jerome and Julia Frank and Bruce Wampold and their championing of the proposition that clients are helped hugely by having a compelling explanation for their suffering and a road map to a better place. From the paper it’s clear that this is something Eri develops from the outset. From the paper it’s also clear that her clients find this new perspective of great value:
Participants also commented on how the adoption of a new perspective that shifted their worldviews ameliorated their pain. Boscaglia and Clarke (2007) referred to this factor as an increase in a “pervasive and enduring sense of meaningfulness, manageability, and comprehensibility.
How often do you hear clients describing their thoughts, feelings or behaviours as ‘irrational’? I’ve heard it so much that I’ve taken (metaphorically) to banning the word from my counselling room. My message to clients is this: “As humans we are not irrational. If we were, we would have died out long ago. To you, your experience seems irrational, but believe me that it will make sense when we discover the context in which this pattern arose. Then, hopefully, it will also make sense that you treat yourself more compassionately.”
Eri has an expectation that clients will improve and improve quickly. She provides a compelling explanation for their suffering and a road map to somewhere better. That this work begins in the very first session may help to explain the pattern of sudden gains that so many of her clients seem to achieve, as well the as the rapid improvements achieved by most.
I’ve no doubt that Eri has a compelling explanation for her own way of working. I also have a sense that it’s hard-wired into her ‘therapeutic DNA’.
Do the above musings provide you with a compelling explanation for Eri’s outcomes? Or, is Eri too good to be true? Are you a supershrink too? If so, what’s your secret?
Please share your thoughts!
[i] 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, & A. Thomas (Eds.), Life
history research in psychopathology. Minneapolis, MN: University of Minnesota Press.
[ii] Finch, A., Lambert, M., & Schaalje, S. (2001). Psychotherapy quality control: The statistical generation of expected recovery curves for integration into an early warning system. Clinical Psychology and Psychotherapy, 8(4), 231-234.
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