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!

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What is the difference between a therapist and a compassionate friend?

What’s the difference between a trained therapist and a compassionate friend?  Look at outcomes and you are likely to be disappointed.  For example, meta-analyses of studies comparing professionals to paraprofessionals (or students) either find that the latter group achieve significantly better results or, at worst, the same!

A clearer difference can be found in area of ethics.  Unlike one’s BFF, a therapist is bound by their commitment to a code of professional practice.  Keeping confidences and doing no harm are two prime examples.  Most clinicians spend a semester or two studying ethics during their training.  Continuing education on the subject is mandated by most state licensing boards in order for therapists renew their license to practice.

Unfortunately, much of current ethics training is focused on staying up-to-date with laws governing the profession or minimizing the risk of malpractice suits.  Even the occasional focus on ethical “dilemmas” misses the point, narrowing the focus to the unusual and acting as though once resolved, we can go back to doing what we do.


As my colleague and friend, Dr. Julie Tilsen, observed, “We have detached ethics from the whole of practice, made it an ‘add-on.’  But, whether we realize or not, everything we do—and don’t do—is a matter of ethics. There is always an ethical standard in place, and that ethic typically reflects taken-for-granted values and understandings.”

Julie, who also serves as the Director of Ethics and Practice for the International Center for Clinical Excellence, concludes, “Any approach to practice is incomplete if it fails to articulate a stance on the ethics of the work—and by this I’m referring to the effects of what we do, in every moment of every encounter, with every person—whether or not a “dilemma” presents itself.”

As readers of this blog know, becoming aware of the effects of our work is what Feedback-Informed Treatment (FIT) is all about.  That’s why Julie and I will be co-teaching the first ICCE small group intensive on Ethics this summer.  In it, we’ll answer the question, “How do we know when clinical practice is responsible and ethical?” holding the assumption that ethical practice requires that our work is engaging and effective—from our clients’ point of view.  The course will venture far beyond the traditional focus on legal issues and policy matters, helping participants learn an ethical stance that is both consistent with and informed by FIT.

The workshop is appropriate for case managers, social workers, professional counselors, alcohol and drug treatment professionals, psychologists, psychiatrists, clinical supervisors and agency managers.  It is open to all practitioners regardless of discipline or theoretical orientation but of special interest to FIT practitioners who are interested in highlighting their response to client feedback as central to ethical practice.

The course is limited to 35 participants so register today.  If you need Ethics CE’s, this is the course to attend!

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Until next time,


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


The Failure Rate of Psychotherapy: What it is and what we can do?

50 percent

You are not going to believe me when I say it. Fifty percent. It’s true. Even in studies where carefully selected therapists who receive copious amounts of training, support, and supervision, and treat clients with a single diagnosis or problem, between 5 and 10% get worse and 35-40% experience no benefit whatsoever! That’s half, or more.

What happens to these people?

Well, as readers of this blog know, if the therapist formally and routinely solicits feedback regarding the quality of the relationship and progress in care, drop out and deterioration rates fall, and outcome improves.

Still, a significant percentage of people do not improve—as many as 25%!  What can we do? The ethical standards for all of the professional mental health organizations require clinicians both monitor and end ineffective treatments as well as suggest helpful alternatives to clients (ACA [C2.d], APA [10.10]).  But what?


Enter Lynn D. Johnson, Ph.D., a psychologist whose work and thinking is always a step ahead.  I’ve known Lynn for 30 years, met him when I was a graduate student.  As I blogged previously about, it was Lynn who in 1996 first suggested routinely measuring outcomes.  He is also responsible for the creation of the original Session Rating Scale–a 10-item version that I later shortened to four.  For several years, Lynn pushed me to do research on top performing therapists, believing they held clues to improving the practice of psychotherapy in general.

Well, my long time colleague and mentor is at it again, once more seeing “over the horizon.”  Based on the latest findings on “human flourishing,” he says that lifestyles provide a pathway to health for the non-responders.  True to form, he’s freely sharing what he knows, offering an online course–at no charge–on “Lifestyle secrets of the happy and healthy.”

Are you interested?

Click on this link: and you can see his first video.  More are coming.  Lynn claims that these ideas and techniques are the next thing in both physical medicine and psychotherapy. Watch the video and let me know what you think.

Until next time, wishing you a healthy and happy life,


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



Becoming a more effective therapist: Three evidence-based clues from research on the field’s most effective practitioners


It’s one of those secrets everyone knows, but few talk openly about: some therapists are more effective than others. Available evidence indicates that clients seen by these practitioners experience 50% more improvement, 50% less drop out, have shorter lengths of stay, and are significantly less likely to deteriorate while in care.

So, how do these top performers achieve the superior results  they do? More to the point, is there anything the rest of us can learn from them?  The answer is a resounding, “YES!” Over the last decade, researchers have started to unlock the secret to their success.

If you want to improve your effective effectives:

  • Give yourself, “The Benefit of Doubt”

Turns out, top performing therapists evince more of what researchers term, “professional self-doubt.” They are, said another way, less certain about how they work and the results they achieve than their less effective peers. To be sure, their doubt is not disabling but rather a first step, the harbinger of new learning.  As UCLA basketball coach John Wooden once quipped, “It’s what you learn after you know it all that counts.”

One sure fire way to give yourself the benefit of doubt is to measure your results. Research shows, for example, that most of us overestimate how effective we really are—on average, by 65%!  Augmenting your clinical judgement with reliable and valid feedback about when you are and are not successful will challenge you to reconsider what you long ago stopped questioning.

Assessing the outcome of your work is no longer difficult nor time-consuming. For example, the Outcome Rating Scale (ORS) takes less than a minute to administer and score and can be downloaded and used for free. More, a number of web based systems exist that not only alert you to clients “at risk” for dropping out, or experiencing a negative or null outcome from treatment, but also compute and compare your effectiveness to national norms. I reviewed two such systems in recent blog posts (1, 2).

  • Connect for Success

Research shows that 97% of the difference in outcome between therapists can be accounted for by therapist variability in the therapeutic relationship. Said another way, the single largest difference between the best and the rest is the former’s ability to connect with a broader, more complex, and diverse group of clients.

Can you think of any aspect of clinical practice that has yielded such unequivocal results?  The bottom line for those wishing to become more effective is, work on your relationship skills.

As far as which element of the relationship you might want to focus on, consider the graph below. In it, you will find the effect size associated with each. To the right of the blue bar are aspects of psychotherapy that receive the majority of professional attention in graduate school and continuing education events, and their relative contribution to outcome.

ES of Common versus Specific Factors

By the way, for the first time this summer, the ICCE is offering a single day intensive ethics training.  If you need ethics CE’s, this is the event you want to attend. The focus? The relationship.  Given the findings noted above, isn’t that the right thing to be talking about?!

Mark your calendar: August 12th, 2015. Chicago, Illinois.

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Register early as the number of participants has been capped at 35 in order to insure an intimate, individualized experience.

  • Slow and Steady Wins the Race

In the proverbial race between Tortoises and Hares, the most effective clinicians fall squarely in the camp of the ectotherms. For them, there are no shortcuts. No fast track to success. No models that, when applied with fidelity, will lead them to treatment nirvana.

Top performing clinicians approach the subject of improving their outcomes the same way investors prepare for retirement: a little bit every day over a long period of time. Compared to average therapists these top performers spend 2.5 to 4.5 more hours per week outside of work in activities specifically designed to improve the effectiveness of their work—an activity known as, “Deliberate Practice.”

You can see how the investment in professional development compounds over time the graph below taken from a study soon to appear in the journal, Psychotherapy.

Experience and DP Graph

Of course, the quality of the return depends on the nature of the investment. So, what should you invest in? To get better, you must first identify the edge of your “realm of reliable performance”—that spot where what you normally do well begins to break down. From there, you have to develop a concrete plan, complete with small, measureable process and outcome objectives. This is often best accomplished with the help of a mentor or coach, someone who possesses the skill you need and is capable of teaching it to others. Trial, error, and review follows.

You can learn to apply the latest findings about deliberate practice to your own professional development at a special, two-day intensive this summer. Cutting edge research will be translated into highly individualized, step-by-step instructions for improving your clinical performance and effectiveness. We promise you will leave with an evidence-based plan tailored to your personal, professional development needs.

Mark your calendar: August 10-11th, 2015.

Professional Development

Given the highly individualized nature of this event, registration is limited to 20 participants. You can reserve your spot today by clicking here.

Looking forward to meeting you this Summer in Chicago!


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