What’s happening to CBT? And why all the hoopla misses the point


In May 2012, I blogged about results from a Swedish study examining the impact of psychotherapy’s “favorite son”–cognitive behavioral therapy–on the outcome of people disabled by depression and anxiety.  Like many other Western countries, the percentage of people in Sweden disabled by mental health problems was growing dramatically.  Costs were skyrocketing.  Even with treatment, far too many left the workforce permanently.

Sweden embraced “evidence-based practice”–most popularly construed as the application of specific treatments to specific disorders–as a potential solution.  Socialstyrelsen, the country’s National Board of Health and Welfare, developed and disseminated a set of guidelines (“riktlinger”) specific to mental health practice.  Topping the list?  CBT.

A billion crowns were spent training clinicians in the method; another billion using it to treat people with diagnoses of depression and anxiety.   As I reported at the time, the State’s “return on investment” was zilch.  Said another way, the widespread adoption of method had no effect whatsoever on outcome (see Socionomen, Holmquist Interview).   Not only that but many who were not disabled at the time they were treated with CBT became disabled along the way, bringing the total price tag, when combined with the 25% who dropped out of treatment, to a staggering 3.5 billon!

And now, a new study–this time from Norway, Sweden’s neighbor to the west.
Norwegian researchers looked at how the effectiveness of CBT has fared over time.  Examining data from 70 randomized clinical trials, study authors Johnsen and Friborg found the approach to be roughly half as effective as it was four decades ago.  Mind you, not 10 or 20 percent.  Not 30 or 40.  Fifty percent less effective!  Cause for concern, to be sure.

So, what’s happening to CBT?  Is the “favored son” losing its effectiveness?

Naturally, the results published by the Norwegian researchers generated a great deal of activity in social media.  Critics were gleeful (see the comments at the end of the article).  Proponents, of course, questioned the results.

If the findings are confirmed in subsequent studies, CBT will be in remarkably good company.  Across a variety of disciplines–pharmacology, medicine, zoology, ecology, physics–promising findings often “lose their luster,” with many fading away completely over time (Lehrer, 2010; Yong, 2012).  Alas, even in science, the truth occasionally wears off.  In psychiatry and psychology, this phenomenon, known as the “decline effect,” is particularly vexing.

That said, while the study and commentary have managed to generate a modest amount of heat, they’ve shed precious little light on the question of how to improve the outcome of psychotherapy.  After all, that’s what led Sweden to invest so heavily in CBT in the first place–doing so, it was believed, would improve the effectiveness of care.  So today, I called Rolf Holmqvist.

Rolf is a professor in the Department of Behavioral Science and Learning at Linköping University.  He’s also the author of the Swedish study I blogged about over three years ago.  I wanted to catch up, find out what, if anything, had happened since he published his results.

“Some changes were made in the guidelines some time ago.  In the case of depression, for example, the guidelines have become a little more open, a little broader.  CBT is always on top, along with IPT, but psychodynamic therapy is now included…although it’s further down on the list.”

Sounded like progress, until Rolf continued, “They are broadening a bit.  Still the fact is that if you look at the research, for example, with mild and moderate depression, almost any method works if it’s done systematically.”

Said another way, despite the lack of evidence for the differential effectiveness of psychotherapeutic approaches–in this case, CBT for depression–the mindset guiding the creation of lists of “specific treatments for specific disorders” remains.

Rolf’s sentiments are echoed by uber-researchers, Wampold and Imel (2015), who very recently pointed out, “Given the evidence that treatments are about equally effective, that treatments delivered in clinical settings are effective (and as effective as that provided in clinical trials), that the manner in which treatments are provided much more important than which treatment is provided, mandating particular treatments seems illogical. In addition, given the expense involved in “rolling out” evidence-based treatments in private practices, agencies, and in systems of care, it seems unwise to mandate any particular treatment.”

Right now, in Sweden, an authority within the Federal government (Riksrevisorn) is conducting an investigation evaluating the appropriateness of funds spent on training and delivery of CBT.  In an article published yesterday in one of the countries largest newspapers , Rolf Holmqvist argues, “Billions spent–without any proven results.”

Returning to the original question: what can be done to improve the outcome of psychotherapy?

“We need transparent evaluation systems,” Rolf quickly answered, “that provide feedback at each session about the progress of treatment.  This way, therapists can begin to look at individual treatment episodes, and be able to see when, where, and with whom they are and are not successful.”

“Is that on the agenda?” I asked, hopefully.

“Well,” he laughed, “here, we need to have realistic expectations.  The idea of recommending that you should employ a clinician because they are effective and a good person, rather than because they can do a certain method, is hard for regulatory agencies like Socialstyrelsen.  They think of clinicians as learning a method, and then applying that method, and that its the method that makes the process work…”

“Right,” I thought, “mindset.”

“…and that will take time,” Rolf said, “but I am hopeful.”

But, you don’t have to wait.  You can begin tracking the quality and outcome of your work right now.  It’s easy and free.  Click here to access two simple scales–the ORS and SRS.  the first measures progress; the second, the quality of the working relationship.

Next, read our latest article on how the field’s most effective practitioners use the measures to, as Rolf advised, “identify when, where, and with whom” they are and are not successful, and what steps they take to improve their effectiveness.

Finally, join colleagues from around the world for our Fall Webinar on “Feedback-Informed Treatment.”

Fall webinar 2015
We’ll be covering everything you need to know to integrate feedback into your clinical practice.

Until next time,


Scott D. Miller, Ph.D.
International Center for Clinical Excellence
Scott D. Miller - Australian Drug and Alcohol Symposium






Love, Mercy, & Adverse Events in Psychotherapy

Just over a year ago, I blogged about an article that appeared in one of the U.K.’s largest daily newspapers, The Guardian.  Below a picture of an attractive, yet dejected looking woman (reclined on a couch), the caption read, “Major new study reveals incorrect…care can do more harm than good.”

I was interested.

As I often do in such cases, I wrote directly to the researcher cited in the article asking for a reprint or pre-publication copy of the study.  No reply.  One month later, I wrote again.  Still, no reply. Two months after my original email, I received a brief note thanking me for my interest in the study and offering to share any results once they became available.

“Wait a minute,” I immediately thought, “The results of this ‘major new study’ about the harmful effects of psychotherapy had already been announced in a leading newspaper.  How could they not be available?”  Then I wondered, “If there are no actual results to share, what exactly was the article in The Guardian based on?”

So-called “adverse events” are a hot topic at the moment.  That some people deteriorate while in care is not in question.  Research dating back several decades puts the figure at about 10%, on average (Lambert, 2010). When those being treated are adolescents or children, the rates are twice as high (Warren et al., 2009).

Putting this in context, compared to medical procedures with effect sizes similar to psychotherapy (e.g., coronary artery bypass surgery, stages II and III breast cancer, stroke), the rate is remarkably low.  Nonetheless, it is a matter of concern–especially given research showing that therapists are not particularly adept at recognizing when those they serve deteriorate in their care (Hannan et al., 2005)

The question, of course, is the cause?

To date, whenever the question of adverse events is raised, two “usual suspects” are trotted out: (1) the method of treatment used; and (2) the therapist.  Let’s take a closer look at each.

In an October 2914 article published in World Psychiatry, Linden and Schermuly-Haupt wrote about estimates of side effects associated with specific methods of treatment that had been reported in an earlier study by Swiss researchers.  The numbers were shocking.  Patient reported “burdens caused by therapy” were 19.7% with CBT, 20.4% for systemically oriented treatments, 64.8% with humanistic approaches, and a staggering 94.1% with psychodynamic psychotherapy.

Based on such results, one could only conclude that anyone seeking anything other than CBT should have their head examined.

There is only one problem.  The figures reported were wrong.  Completely and utterly wrong.  Linden and Schermuly-Haupt made an arithmetic error and, as a result, totally misinterpreted the Swiss findings.  Read the study for yourself.  When it comes to adverse events in psychotherapy, CBT–the fair-haired child of the evidence-based practice movement–is not better.  Indeed, as the study clearly shows, people treated with humanistic and systemic approaches suffered fewer “burdens” than expected, while those in CBT had a slightly higher, although not statistically significant, level. More, the observed percentage of people in care who perceived the quality of the therapeutic relationship–the single most potent predictor of engagement and outcome–as poor was significantly higher than expected in CBT and lower for both humanistic and systemic approaches.

How could the researchers have gotten it so wrong?

As I pointed out in my blog over year ago, despite claims to the contrary (e.g., Lilenfeld, 2007), no psychotherapy approach tested in a clinical trial has ever been shown to reliably lead to or increase the chances of deterioration.  NONE.  Scary stories about dangerous psychological treatments are limited to a handful of fringe therapies–approaches that have been never vetted scientifically and which all practitioners, but a few, avoid.  In short, its not about the method.

(By the way, over a month ago, I wrote to the lead author of the paper that appeared in World Psychiatry via the ResearchGate portal–a site where scholars meet and share their publications–providing a detailed breakdown of the statistical errors in the publication.  No response thusfar)

With only one suspect left, attention naturally turns to the therapist–you know, the “bad apple” in the bunch.  Here’s what we know.  That some practitioners do more harm than others is not exactly news.  Have you seen the new biopic Love & Mercy, about the life of Beach Boy Brian Wilson?  You should.  The acting is superb.

Wilson’s therapist, psychologist Eugene Landy (chillingly recreated by actor Paul Giamatti), is a prime example of an adverse event.  See the film and you’ll most certainly wonder how the guy kept his license to practice so long.  And yet, as I also pointed out in my blog last year, there are too few such practitioners to account for the total number of clients who worsen.  Consider this unsettling fact: beyond the 10% of those who deteriorate in psychotherapy, an additional 30 and 50% experience no benefit whatsoever!

Where does this leave us when it comes to adverse events in psychotherapy?

Whatever the cause, lack of progress and risk of deterioration are issues for all clinicians and clients.   The key to addressing these problems is tracking progress from visit to visit so that those not improving, or getting worse, can be identified and offered alternatives.  It’s that simple.

Right now, practitioners can access two simple, easy-to-use scales for free at: www.whatispcoms.com.  Both have been tested in multiple, randomized, clinical trials and deemed evidence-based by the Federal Substance Abuse and Mental Health Services Administration (SAMHSA).

Learning to use the tools isn’t difficult.  It costs nothing to join the International Center for Clinical Excellence and begin interacting with professionals around the world who are using the measures to improve the quality and outcome of behavioral health services.  More detailed instruction is available at the upcoming webinar:

Fall webinar 2015
Join us in tackling the issue of adverse events in psychotherapy.  In the meantime, be sure and leave a comment below.

Best wishes for the summer,


Scott D. Miller, Ph.D.
Director, International Center for Clinical Excellence

P .S.: On the one year anniversary of my original email to the reseacher cited in the Guardian, I sent another.  That’s over a month ago.  So far, no reply.  By contrast, the reporter who broke the story,  Sarah Boseley, wrote back within a half hour!  She’s following up her sources.  I’ll let you know if she gets a response.


Time to Rethink Burnout: Lessons from Supershrinks


The world seems to be in the midst of a pandemic of burnout, spread across all age groups, genders, professions, and cultures. Research specific to mental health providers finds that between 21 and 67 percent may be experiencing high levels.  Other related “conditions” have been identified, including compassion fatigue (CF), vicarious traumatization (VT), and secondary traumatic stress (STS), all aimed at describing the negative impact that working in human services can have on mental and physical health.

An entire industry of authors, coaches, and trainers has sprung up to address the problem, providing books, videos, presentations, retreats, and organizational consultation. There’s only one problem: currently fashionable approaches to burnout don’t work.  In fact, they may make it worse!

What can be done?  In the latest issue of the Psychotherapy Networker, my long time colleague and co-writer, Dr. Mark Hubble, and I review research on the field’s Top Performing therapists.  Once again, they have something to teach us, this time about “healing the heart of the healer.”

Until next time,


Scott D. Miller, Ph.D.
ethical 2Fit IMP


Something Fun for Summer: Mindreading, Memory, and Top Performance

Fit IMPethical 2

Over the last several weeks, I’ve posted a series of blogs on some pretty serious subjects: (1) new and counterintuitive findings about the therapeutic relationship; (2) data documenting the lack of difference in outcome between mental health professionals, students, paraprofessionals, and a compassionate friend; and (3) cutting edge research on what therapists can do to address the surprisingly high failure rate of traditional psychiatric and psychological treatments.  Thanks to all of those who read the posts and posted comments.

With summer finally arriving, and the long Memorial Day weekend fast approaching, I’ve been in the mood for something a little lighter and fun.  Last week, I was in Gothenburg, Sweden teaching a three-day intensive on Feedback-Informed Treatment Supervision.  As part of the training, my co-teacher, Susanne Bargmann, and I include the latest findings on top performing therapists.  If you’re not familiar with the research, take a moment and read the interview in the latest issue of The Carlat Psychiatry Report posted by permission below:

As pointed out in the article, top performing clinicians spend two to four and a half times more hours per week than their more average counterparts engaged in “deliberate practice”–that is, attempting to improve their performance by consciously engaging in activities that push beyond what they already do well.  To illustrate the point, and hopefully inspire the group to take up this challenging activity, Susanne and I move beyond our comfort zones, performing material that is completely outside the realm of therapy but which we have each been deliberately practicing.  She sings.  I do mindreading or feats of memory.  Importantly, we only do what we have yet to perfect.  Sometimes we fail–miserably.  Whatever the outcome, the feedback is always invaluable.

So, just for fun, take a moment and watch the videos below.  The first was filmed last week at the training in Sweden.  It’s a piece on memory.  The second video features a bit of mindreading.   Be sure and leave a comment with your thoughts!

More fun and sun is available at the ICCE Intensive trainings this summer in Chicago.  We have a few spots left for the FIT Implementation and FIT Ethics workshops.  Participants will be attending from all around the world, including Sweden, Denmark, Norway, Australia, Canada, and the United States.  Continuing education credits are available for both events.  Hope to see you this summer.

Until next time,


Scott D. Miller, Ph.D.
International Center for Clinical Excellence

Room for Improvement: Feedback Informed Treatment and the Therapeutic Relationship

My Scandinavian Grandmother Christina was fond of saying, “The room for improvement…is the biggest one in our house.”

Turns out, when it comes to engaging people in physical and mental health services, Grandma was right.  We healthcare professionals can do better—and recent research points the way.

Stanford psychologists Sims and Tsai found that recipients of care both choose, and are more likely to follow the recommendations of, healthcare providers who match how they ideally want to feel.   People who valued feeling excitement, for example, were more likely to choose a professional who promoted excitement and vice versa.

Bottom line?  Making the helping relationship FIT how people want to feel—their goals, values, and preferences—improves engagement and effectiveness.

Tailoring services in the manner suggested by Sims and Tsai is precisely what Feedback-Informed Treatment (FIT) is all about.  Two simple scales—the Outcome and Session Ratings Scales—facilitate this process, enabling helping professionals to assess and adjust treatment in real time to improve the FIT.

Overwhelmed by paperwork?  No worries.  As I have written about in previous blogposts (1, 2), several web-based and electronic solutions exist that make integration a snap.  The pioneer–the very first to come online–is MyOutcomes.


Since coming on the scene, the owners have doggedly sought feedback from users, working steadily to provide a system that maximizes practitioners’ effectiveness.  The latest version is packed full of goodies, including a mobile app and the ability to have clients provide feedback remotely (e.g., home, between visits, etc.).  Watch the video below to get a more comprehensive overview of its many features.

I’m also proud to say that the parent company of MyOutcomes has partnered with the International Center for Clinical Excellence to create the first online training on Feedback-Informed Treatment.   Importantly, the FIT E-learning program is not another webinar.  It is a true online classroom, complete with video instruction and an intuitive software interface that tailors learning and mastery to the individual user.

Together, the ORS and SRS, FIT E-learning, and MyOutcomes make “the room for improvement” a much less daunting, even enjoyable, undertaking.

I can almost see my Granma Stina smiling!

Until next time,


Scott D. Miller, Ph.D.
International Center for Clinical Excellence

P.S.:  We still have a few spots open for our FIT Implementation and FIT Ethics courses coming up in August. Don’t wait.  The number of participants is limited and both courses fill about two months in advance!

ethical 2Fit IMP