The Eleanor Enigma: On the Trail of “Natural Born Clinicians”

Appropos of nothing in particular other than a fun conjunction of titles, let’s designate “Natural Born Therapist,” by Crowd the Airwaves, as the unofficial theme song of this post.

I can remember the moment I noticed Psychology Sophomore Eleanor, 15 years ago, just like it was yesterday. In my 300-student lecture she raised her hand to ask a question, and I’m not exaggerating when I say that she was so smart, so tuned in, and so socially skilled that from then on, academically speaking, it was her and 299 other students. When I found out Eleanor wanted to work with children I quickly connected her with my university’s autism training clinic, and that is where our conversation begins.

After Eleanor got the standard week of clinic orientation, I dropped by to see how she was doing. It was her second solo session with a pretty difficult child, and as I stared through the observation window I was stunned. Eleanor was already better, in many respects, than many of her supervisors — doctoral-level therapists with a year or more of clinic experience. She seemed to instinctively get the concept of reinforcement and to notice what the child’s reinforcers were. She knew to vary them. Contingency? Piece of cake. Successive approximations? Dropping back a step when the child stalls out? Prompting and stimulus fading? All easy peasy. The child, who had quite the history of aggression and noncompliance, sat in rapt attention. He was putty in Eleanor’s hands.

Fast forward a decade to Mattias. If Eleanor was a force of nature, then Mattias was a… sinkhole of inertia. He came to class only occasionally, and turned in assignments at about the same rate. He was so painfully shy that across two full semesters he didn’t speak up once in my class. He showed little in the way of intellectual spark or academic ambition, and he seemed to embody the old adage that “Cs make degrees.” I cannot even remember, across 30 weeks of classes, noticing a change in his slack facial expression. Imagine my surprise, therefore, to learn that Mattias, like Eleanor before him, was a star undergraduate clinician at the autism clinic. I went to watch him work and in the therapy room he was no longer inert… He was alive. He and that child were locked in a symbiotic spiral, each intricately attuned to the other’s behavior, and both having an absolute blast. I could scarcely believe this was the same Mattias.

Had I never visited the clinic, I would have told you that Eleanor and Mattias had absolutely nothing in common. I would never have pegged those two as professional comrades in arms. But I saw them both with my own eyes behind that clinic observation window, joyfully knocking it out of the park with something that is very difficult to do well.

I ask you: How it possible that someone without formal clinical training can arrive at the clinic so ready to work, so apparently… fully formed?

Let me be super clear that I’m not saying that there are people who don’t need any training to become therapists. Eleanor went on to graduate school and would now be considered a master therapist who can do things of which her Sophomore self would never have dreamed. But she was also way ahead of the game from the day she first walked into the clinic. In terms of clinical-developmental trajectories, people like Eleanor and Mattias seem to start out at a higher level than other people and seem to learn faster from experience.

Am I imagining this? Misconstruing what I’ve seen? In preparing this post, I reached out to a number of colleagues who work in clinical settings, and they all agreed that there seems to be a certain something that helps certain people thrive with behavioral stuff. Eleanor and Mattias had it. But what is “it”?

If we knew, some cool things might be possible. We could, for instance, be more selective about who we admit to ABA graduate programs. For the good of future clients, all things being equal shouldn’t we prefer trainees who have “it”? And if we could operationalize “it,” might we be able to teach “it” to people who don’t come pre-equipped?

Unfortunately, “it” remains inscrutable. I can’t even prove “it” exists, because I’m not aware of research identifying personal characteristics that predispose someone to become good with behavioral analyses and behavioral procedures. We have research on behavioral skills training with therapists, but nothing of which I’m aware on predictors of “individual differences” in skill acquisition.

I can tell you that, across decades of teaching behavior principles at the undergraduate and graduate level, I’ve seen the reliable expression of a sort of pre-clinical version of “it.” Here, from Flo DiGennaro-Reed of University of Kansas, is a personal account of what I see all the time:

When I first learned about three- and four-term contingencies, I was thrilled I had a name/label for something I already understood. My worldview was already aligned with a behavior analytic philosophy. I have no idea where or how I developed this thinking. A lot of behavior analysts have this first experience when they enter the field.

Among my behavior principles students, about 1/3 are like Flo: They instantly grasp the concepts of positive/negative reinforcement/punishment. Another third struggle mightily. Even after weeks of practice they are so lost that they wouldn’t know a consequence if it clubbed them over the head. Now, maybe I’m just a lousy teacher, but it seems clear to me that something in a behavioral history separates these students. What “it” might be I cannot say.

Pat Friman of Boys Town agrees about the importance of preexisting repertoires.

Regarding masters of anything, including therapy, my belief is that at bottom it involves a congruence of what a person is (ontological status) with what they know and do. As an example, a teacher who’s being includes being a teacher always becomes ‘that teacher.’  And we all had ‘that teacher.’ In fact, those of us that were lucky may have had several ‘that teachers.’  And what distinguishes that teacher is that they always made a difference. The circumstances where the difference was made were incidental.  That teacher just uses what is at hand.  In other words, that teacher makes a difference regardless of circumstances. An example from my world is Don Baer.  Put him anywhere in the world under any set of circumstances and he would teach and it would make a difference. I suspect rather strongly that the point I have made here has some bearing on gifted therapists.

Returning to Eleanor and Mattias, one fascinating thing about them was that, during the precocious early phase of their clinical training, they had no vocabulary for what they were doing so well. In fact, I had the experience with both of them of asking why, on the fly during a session, they had chosen to make a certain protocol tweak, only to find that neither even remembered doing that. For them, much of therapy seemed intuitive.

People who have “it” may not be able to describe “it,” but the confidence that people like Eleanor and Mattias exude, their absolute comfort in a clinical setting, suggests that at some level they know “it” is there. University of Oregon’s Kimberly Marshall agrees:

When I think of the staff who have “it,” I think particularly of their initial success. In that first 15 minutes you can often already see “it.” By the end of their first day, I find I am usually trying to rearrange their schedule so I can have more students benefit from working with them! The immediacy of this is what got me thinking about a specific variable that I think is a part of “it.” These people lack the hesitation and nervousness that we often see when a therapist is initially asked to work with a new client.

In Marshall’s view, that initial comfort in the clinical setting catalyzes client behaviors in ways that makes the therapist’s job easier.

When other therapists first come into the clinical environment, they show signs of nervousness…their arms are crossed and their shoulders are raised. They hesitate when they speak to the client. All of this signals to the client that there is something to be nervous about — and for good reason because with an unskilled therapist there might be something to be nervous about. This could evoke a whole host of behaviors that are incompatible with interacting with the therapist. People with “it” are different. They come in with relaxed shoulders. They speak easily when that’s appropriate and stay quiet comfortably when that’s appropriate. They don’t evoke those incompatible behaviors, so clients attend to the therapist and engage in interactions with them. 

Marshall’s comments start to focus in on the critical question: What exactly do natural-born clinicians do that makes them so effective? Flo DiGennaro-Reed again:

Here are some anecdotal observations of relevant behaviors/qualities I’ve seen over the years in people who have “it’:

  • They get down to learner’s level (on knees, on the floor).
  • They exhibit an open body position.
  • They don’t invade the learner’s space. They quickly read if learner is eager to interact or if a slower introduction/welcome is needed, and then adjusts behavior accordingly.
  • They use an authentic sounding tone of voice.
  • They quickly identify preferred stimuli and topics of conversation.
  • Contingencies make sense to them.
  • They use an approximation of the graduated guidance approach to interactions. They quickly assess whether the learner needs more support, in which case they provide it (but not too much). They also quickly assess when the learner needs less support, in which case they back off. I’m not talking only about physical prompting as in traditional graduated guidance, but rather an approach to all activities and types of support. In plain English we would say that the person exercises “good clinical judgment.”
  • Most generally, they’re good observers. They don’t need to fill every second with words or actions. They listen and watch. Then, their behavior adjusts based on what they take in.

That goes further toward an operational definition than I could manage. But even if we can pin down precisely what “it” is, that leaves the behavioral history responsible for “it” unclear. Which is too bad because, as I mentioned above, if we knew how the Eleanors and Mattiases of the world got “it,” maybe we could teach “it” to everyone.

I’m going to return to this topic fairly soon, with a peek at work from outside of behavior analysis that might offer insights into what makes a “natural born therapist.” In the meantime, if you have thoughts about “it” or know of research illuminating “it,” please let me hear from you at