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:  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


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!

ethical 2


Until next time,


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