Effective Psychotherapists: Clinical Skills That Improve Client Outcomes

by William R. Miller, Theresa B. Moyers

What is it that makes some therapists so much more effective than others, even when they are delivering the same evidence-based treatment? This instructive book identifies specific interpersonal skills and attitudes--often overlooked in clinical training--that facilitate better client outcomes across a broad range of treatment methods and contexts. Reviewing 70 years of psychotherapy research, the preeminent authors show that empathy, acceptance, warmth, focus, and other characteristics of effective therapists are both measurable and teachable. Richly illustrated with annotated sample dialogues, the book gives practitioners and students a blueprint for learning, practicing, and self-monitoring these crucial clinical skills.
 

Genres: Psychology, Nonfiction

213 pages, Hardcover

Published February 8, 2021

About the author

William Richard Miller is an American clinical psychologist, an emeritus distinguished professor of psychology and psychiatry at the University of New Mexico in Albuquerque. Miller and Stephen Rollnick are the co-founders of motivational interviewing.

Reviews

[Alan · Rating 5 out of 5]

Wish I could get a copy of this for any student who is nervous and shaking before seeing his/her first client. It wouldn’t get rid of the nerves or the shakes, but it would distract them while laying down top tier wisdom.

[Sheri · Rating 5 out of 5]

I bought this book because Miller is a beast. He developed MI and has done a ton of research on the specific, measurable aspects that improve the therapeutic relationship and how to move folks towards change. I have taken short MI classes a few times, most recently the instructor was really touting this book. Turns out I have read a few chapters in classes in the past, but having a reference volume with some research and reminding me not only of the techniques of MI, but the spirit felt useful.

Overall it is a very easy and short read for clinicians that want to think about how to create better therapeutic relationships.

[Miles · Rating 4 out of 5]

Summary:

William R. Miller and Theresa B. Moyers’s Effective Psychotherapists is a concise and instructive introduction to the particular skills and attitudes that make some therapists more effective than others. In Part One, Miller and Moyers argue that “therapist effects” or “relational factors” that shape the foundational working alliance between therapist and client are at least as important as therapeutic modalities and techniques. In Part Two, they describe eight therapeutic skills that effective therapists develop and deploy in their work: accurate empathy, acceptance, positive regard, genuineness, focus, hope, evocation, and the ability to sensitively deliver information and advice. In Part Three, they share ideas about how therapists can gain expertise that improves client outcomes, how effective clinical skills should be taught, and how clinical research can be broadened and improved.

Key Concepts and Notes:

––As someone new to the field of psychotherapy, I truly appreciate how Miller and Moyers highlight the essential qualities that therapists should seek to cultivate regardless of what type(s) of therapy and/or client population(s) they work with. These are the “meta-skills” of the craft.
––Miller and Moyers do a great job of supporting their arguments with empirical data throughout the book. Each of the eight chapters on therapeutic skills contains a research section that reviews meta-analyses, individual studies, and summarizes average effect sizes on client outcomes. Miller and Moyers are also honest about areas of therapy research that are either inherently hard to study or where reliable data is sparse.
––There is a short chapter at the end of Part Two called “The Far Side of Complexity” that might be the single best essay I have read so far in graduate school. It’s a wide-ranging exploration of how one’s personal quest to develop presence, character, virtue, and lovingkindness can underpin a successful therapeutic practice.
––One of the unfortunate but unsurprising findings in this book is that while effective therapists can do a lot of good for their clients, ineffective ones can actually do harm. Also discomfiting is the finding that therapists generally do not improve over time unless they take certain steps to develop what Miller and Moyers call “deliberate practice.” These facts emphasize the importance of continuous learning and performance feedback in this field.

Favorite Quotes:

In clinical trials, therapist effects are often regarded as nuisance noise that compromises therapeutic effect size, rather than as an important component in effective treatment. We believe Rogers and his students were on the right track in their research. Therapist relational factors have too often been overlooked in mainstream clinical research and training. We do not discount the potential importance of specific treatment procedures with particular disorders. At the same time, evidence-based treatments cannot be separated from the therapists who deliver them. (xiii)

In order to help people change their behavior or lifestyle, you need their expertise and partnership. No one knows more about your clients than they do. They have a lifetime of experience to draw on. You do bring professional expertise that may be helpful, but you cannot be an expert on someone else’s life. A helping relationship is not a matter of an expert doing something to or using techniques on clients. It is about working with, alongside, and for clients. It is not like wrestling; it’s more like dancing together. (6-7)

You have enough in common with your clients to be able to grasp some of their meaning and experience, and yet it is wise to have a beginner’s mind and not assume that you understand fully. A fundamental attitude in empathic understanding is curiosity: an openness to and interest in another’s experience. Often curiosity about human experience is what attracts people to helping professions. A wonderful aspect of being human is that you are not limited to your own experience and perspectives. With flexible openness, you know that you do not start with an accurate understanding of another person’s life, and you want to understand. (21)

People, when given the supportive conditions for change, naturally tend to move in a positive, pro-social, self-determining, and healthy direction. At least part of them wants to do so. That part of their ambivalence is your co-therapist. (78)

Some clients may particularly challenge an attitude of sustained optimism. In the course of treating a client, you may be disappointed, yet your hope need not diminish. It is common for people to cycle several (or many) times through the transtheoretical stages of contemplation, preparation, action, and maintenance before reaching stable change or recovery. Binary thinking about outcomes underestimates the vast range of benevolent changes that lie between total "success" or "failure"…"Two steps forward, one step back" seems to be human nature. It is also worth considering that the benefit a client derives from your work together may not be apparent while you are still in the picture. People often describe previous therapists (or mentors, teachers, parents, or friends) who contributed critically to their lives without realizing it. Remember this when holding onto hope for a client. (83)

Freedom to choose is not something that you can grant to your clients. They already have it. Ultimately, it is up to them whether they will listen to or ignore you, believe or disagree with information that you provide, and follow or shun the advice you offer. You cannot make people change. They get to decide; it’s a given in any helping relationship. Knowing, accepting, and honoring clients’ autonomy is an important context for whatever information and advice you provide. (111-2)

Like many truths, this therapeutic presence, this simplicity beyond complexity, is somewhat paradoxical. It is at once both behavioral practice and underlying attitude or spirit, and the two sculpt each other. Faithful practice strengthens the guiding value system that, in turn, is expressed in practice. (123)

One of our intentions is for this volume to serve as a call for greater attention to therapeutic relationship in clinical practice, research, and a training. Clinical science began with therapeutic relationship, but of late has focused almost exclusively on technical procedures and mechanisms. Such technique is inseparable from the human beings who provide treatment, and who, we hope, understand themselves as far more than technicians. A clinical science that recognizes the value of both technical and relational components will go a long way to further improve the quality of healthcare. Renewed focus on therapeutic relationship may also afford greater meaning and joy in the practice of counseling and psychotherapy, further humanizing the services that we provide. (174)

This review was originally published on my blog, words&dirt.

[Pia · Rating 3 out of 5]

Mixed feelings about this book. It started very strong, and I liked that each trait was given its own chapter. However, I felt that the book could have done with more case studies (especially re: reactive and resistant clients - the bulk of the examples seemed to feature largely receptive clients that already used change talk, and as they seemed theoretical, there was never actually any follow up as to whether this sequence of conversation was actually *effective in the long-term* or if it just looked like it was effectively using a skillset in the moment, with no attention to outcome).

For me, this book seemed to lose its way around the chapter that focused on Evocation. I still think the first half is extremely useful, and the second half has good training suggestions, but there's actually no indication of concrete individual case studies that used examples that impacted outcomes. Large studies/numbers are cited, or theoretical conversations are used. At least Bessel Van Der Kolk described specific clients, approaches, methodologies and outcomes. Here, a lot seems to be left to theory. Do we ever find out if 'theoretical client' actually does start exercising? Or are we just gently coaxed to believe they do, because of the way a book is written? Plenty of clients can use change talk and not change, and I dearly wish there had been more outcome focus that wasn't focused only on broader studies, but looked at real case studies as well.

Overall a handy tool set, but I think it over-promises on 'clinical skills that improve client outcomes.' With a lack of long-term one-on-one individual case studies demonstrated in this book, I feel a teaching opportunity was really missed.

(Also, minor pet peeve, the in-text referencing made some paragraphs almost impossible to read. Some are literally comprised of 30-40 researcher names, and you have to hunt to find the sentence fragments between every giant series of references. This is a bigger problem in the beginning and smooths out later, but oof).

[Cameron · Rating 5 out of 5]

Concise, provides examples, and evidence based.

[Carla · Rating 5 out of 5]

recommandation d’Idir. ramenez moi au québec par pitié

[Ilona · Rating 5 out of 5]

Lektura tej książki początkowo przychodziła mi z pewnym trudem. Styl narracji wydawał się dość toporny, a tempo czytania spowalniała duża liczba odniesień bibliograficznych umieszczonych w nawiasach. Rozumiem ich wagę z perspektywy naukowej rzetelności, jednak w odbiorze czytelniczym bywało to męczące i wybijało mnie z rytmu lektury.

Jednocześnie nie sposób nie docenić zakresu i znaczenia poruszanych treści. Autorzy podejmują kwestie fundamentalne dla pracy pomocowej, szczególnie istotne dla początkujących psychologów i terapeutów. Dużo miejsca poświęcono empatii, akceptacji, pozytywnemu nastawieniu, autentyczności, ukierunkowaniu nadziei, wydobywaniu zasobów klienta, oferowaniu informacji i porad, a także złożoności samej relacji terapeutycznej. Wyraźnie akcentowane są również kompetencje profesjonalne, co sprawia, że książka ma charakter wzmacniający i porządkujący podstawy pracy klinicznej.

Na plus należy zaliczyć fakt, że proponowane techniki i sposoby argumentacji są konsekwentnie podparte badaniami naukowymi, co nadaje całości konkretności i buduje poczucie metodologicznej solidności. Szczególnie wartościowe były dla mnie fragmenty zawierające przykładowe dialogi, pozwalające zobaczyć, jak omawiane koncepcje funkcjonują w praktyce. Zdecydowanie jednak odczuwałam niedosyt i chętnie zobaczyłabym ich znacznie więcej.

Warto też zaznaczyć, że klienci przedstawieni w książce odpowiadają w sposób dość modelowy, wręcz zgodny z tym, czego jako terapeuci moglibyśmy sobie życzyć. Brakuje tu przykładów pracy z klientami bardziej opornymi, ambiwalentnymi czy trudnymi w kontakcie. Z drugiej strony rozumiem, że intencją autorów było przede wszystkim zaprezentowanie konkretnych technik i założeń, a nie realistyczne spektrum reakcji klienta.

Podsumowując, jest to wartościowa i wzmacniająca pozycja, szczególnie na etapie budowania tożsamości zawodowej, choć momentami wymagająca w odbiorze i pozostawiająca przestrzeń na pogłębienie aspektu klinicznego w bardziej złożonych przypadkach.

[Hannah Stokes]

This is a nice and cohesive introduction to common factor skills. I like that Miller and Moyers have divided the chapter into what the skill is and then some research evidence for the skill. In my opinion that's better than reading just a journal article on just the research evidence for common factors. I used this for my Intro to Psychotherapy class to introduce beginning therapists to common factors. While it was a bit simplistic to someone that wants more theory, it is a good intro text.

[Beth Glicker · Rating 5 out of 5]

There are 8 skills, with each getting a chapter. If you are familiar with Motivational Interviewing, then you'll be familiar with skills such as acceptance, focus, evocation, etc... They weave some interesting studies done on therapist efficacy along with narrative stories.

[Elisabeth · Rating 5 out of 5]

A brilliant book looking a therapies, therapists and what makes one efficient as a therapist. Evidenced by a plethora of studies, I learnt so much that I hope will improve me and the outcomes of my patients.

[Philip Allen Alexander · Rating 4 out of 5]

Sections of this book was assigned reading for my previous clinical psych class. Excited to use these clinical skills moving forward! First half of the book was great. Second half seemed out of place and too formal with research.

[Victoria Colaluca · Rating 4 out of 5]

Such an informative book for future mental health clinicians! Highly recommend.

4.5⭐️

[Tiffani · Rating 4 out of 5]

4.5 stars

[Nancy · Rating 5 out of 5]

Should be required in therapist training programs. Very much aligned with MI.