Is Time Speeding Up?

Is it me or is time speeding up?  We’re already 40 days into the New Year. Seems like only yesterday, I was planning for the Holidays: meals, get-togethers and, of course, gifts.

Gifts.  Since the turn of the century, researchers tell us our tastes have changed.  Forget toys, aftershave, lingerie, or perfume.  Men and women, young and old, we all want the latest gadget.

What might account for this change?  Surveys tell us it’s about “staying in touch.”  We are busier than ever.  The latest technology extends our reach, keeping us connected to opportunities, resources and, most importantly, people.

For behavioral health professionals, the challenge of “staying in touch” extends to the clinical realm.  Rising caseloads, briefer treatments episodes, and increasingly complex problems combine to test the limits of even the most dedicated professional.

What can help?  Over twenty randomized clinical trials document that Feedback-Informed Treatment (FIT) keeps therapists connected with the people they serve, doubling effectiveness while simultaneously decreasing the risk of deterioration and drop out.  The process involves routinely soliciting feedback from consumers about their experience of and progress in treatment.

Luckily, technology makes FIT efficient and effective.  Multiple systems exist for automating the collection, sorting, and interpretation of feedback.  I’ll be reviewing the growing number of choices available in my next few blogposts, starting today with one web-based and one electronic health record system.

pragmatic tracker

Pragmatic Tracker is an inexpensive, intuitive, web-based system.  Users can select from a variety of feedback tools–including my own Outcome and Session Ratings Scales.   One really innovative feature is the ability to connect with and seek feedback via automated emails.  In the interview below, developer Bill Andrews, describes the service and it’s many features in detail.

(The complete interview can be found at:

Athena Penelope 2

Late last year, Athena integrated the ORS, SRS, and Performance Metrics algorithms into their popular electronic health record, Penelope. The system is cutting edge and comes with Athena’s world-wide, standard-setting customer service.  The video below gives a detailed overview:

To learn more, follow the links on the document below:

OK, that’s it for now.  I’ll return shortly with detailed information about other technological solutions for staying in touch with your clients.

Until then, best wishes,


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

Scott D. Miller - Australian Drug and Alcohol Symposium

What do clinicians want anyway?

what do you want
What topics are practitioners interested in learning about?

If you read a research journal, attend a continuing education event, or examine the syllabus from any graduate school course, you’re likely to conclude: (1) diagnosis; (2) treatment methods; and perhaps (3) the brain.  As I’ve blogged about previously, the brain is currently a hot topic in our field.

Ask clinicians, however, and you hear something entirely different.  That’s exactly what Giorgio Taska and colleagues did, publishing their results in a recent article in the journal, Psychotherapy.  Here’s what they found.

Regardless of age or theoretical orientation, the top three topics of interest among practicing clinicians were: (1) the therapeutic relationship; (2) therapist factors; and (3) professional development.

(Cartoon used with permission from

Let’s consider each one in turn.

Number one: the therapeutic relationship.  Honestly, when was the last time you attended a workshop focused solely on improving your ability to connect with, engage, understand, and relate to your clients?  The near complete absence of such offering is curious, isn’t it?  Especially when you consider that the quality of the therapeutic bond is the single best predictor of treatment outcome, the most evidence-based principle in the literature!

Paradoxically, research shows that therapists who are able to solicit negative feedback about the alliance early in the treatment process have better outcomes in the end.  Turns out, soliciting such feedback and using it to strengthen the working relationship is a skill fewclinicians–despite their beliefs to the contrary–possess.

There’s a simple solution: download and begin using the Session Rating Scale, a simple, four-item alliance measure designed to be administered at the end of each session.   Multiple, randomized clinical trials now show that formally seeking client feedback not only improves outcome but decreases both drop out and deterioration rates. Whether you’ve tried to use the scale or not, you can learn how to improve your skills in the comfort of your own home by joining our upcoming Spring webinar series.  And yes, CE’s are available!

Number two: therapist factors.  In other words, you!

Some time ago
, veteran psychotherapy researcher Sol Garfield–one of the editors of the prestigious Handbook of Psychotherapy and Behavior Change–called the therapist the “neglected variable” in psychotherapy research.  Available evidence documents that the clinician doing the therapy contributes 5 to 9 times more to outcome than the method used.  What makes some more effective than others?  Recent research by Singapore-based psychologist Daryl Chow shows that the best invest 4.5 more hours outside of work engaged in activities specifically aimed at improving their performance than their average counterparts–an process known as deliberate practice.

Which brings us to topic number three: professional development.

Large, multinational studies document the central importance that professional development plays in the identity and satisfaction of clinicians.  And yet, as I reviewed here on this blog not long ago, “the near ubiquitous mandate that clinicians attend so many hours per year of approved “CE” events in order to further their knowledge and skill base has no empirical support.”  So, what does work?  Together with my colleague Daryl Chow, I’ll be presenting the latest evidence-based information at the first ICCE Professional Development Intensive.  The two-day event is limited to 20 practitioners.  We’ll not only review the evidence, but also lay out concrete steps, and work together with each participant to develop a highly individualized professional development plan.  If you’ve been monitoring the outcome and alliance of your clinical work and are interested in pushing your performance to the next level, join us in August!

OK, that’s it for now.  Before I go though, let me ask if you can guess the topics of least interest to practitioners identified in the study mentioned earlier?

PLEASE post your comments below!

Scott D. Miller - Australian Drug and Alcohol Symposium

Therapist Wanted: Dead or Alive


Do you get those letters about the top healthcare providers in your area?

At the beginning of the new year, our city’s local magazine publishes a list of the top healthcare providers.  It’s a big deal.  Organized by location and specialty, the issue contains full-page photos, glossy spreads, and breezy write-ups.  Impressive stuff with a wide and hungry readership anxious to sort the best from the rest.

So, how do the publishers separate the proverbial “wheat from the chaff?”  The answer, depending on whether you are a provider or potential patient, may alternately surprise or frighten you.

Not long ago, Abigail Zuger received one of those letters.  In it, she learned that a relative of hers had been named “one of the worlds top physicians in his area of expertise.”   Ordinarily, she would have been proud.  There was only one problem.  Her now esteemed relative was dead–and not just recently.  He’d been dead 16 years!

Abigal Zuger is a physician and professor of medicine at Columbia University.  The story about her experience appeared in the New York Times.  In it, she notes the temptation to become cynical, to dismiss the Top Doc lists, “as just so much advertisement and avarice.”  She concludes, however, that a “more nuanced and charitable view is…[that] these services may simply be trying, valiantly if not clumsily, to remedy the single biggest mystery in all of health care…what makes a top doctor…[and] how to find one.”

Three methods dominate among list makers: (1) culling names and addresses from phone directories; (2) polling healthcare providers; and (3) collating patient online ratings.  Said another way, consulting available lists lets you know if your healthcare provider once had a phone, was liked by their colleagues, or managed not to piss off too many of the people they treated!

Remarkably absent from the criteria used to identify top providers is any valid and reliable measure of their effectiveness!

Determining one’s effectiveness as a mental health professional is not as difficult or time consuming as it was not long ago.  Whether you work with individuals, groups, or families, in inpatient, residential, or an outpatient setting, a simple set of tools is available for monitoring both the outcome and the quality of the services you provide.  The tools take minutes to administer and score and are free.

If you are worried about statistics, don’t be.  A variety of electronic solutions exist which not only will administer and score the measures but provide normative comparisons for assessing individual client progress and sophisticated analyses of provider, program, and agency effectiveness levels.   I’ll be reviewing each system in an upcoming series of blogposts, so stay tuned.

To see what’s possible, check out the Colorado Center for Clinical Excellence.  There, clinicians not only measure their effectiveness, but set benchmarks for superior performance and report clinician outcomes transparently on the agency website.

It’s easy to get started.  First, download the free tools.  Second, join colleagues from around the world in a four-part online webinar and learn how to use the tools to inform and improve your practice.  We’ll be covering everything you need to know to integrate outcomes into your clinical work.  In the process, as Dr. Zuger pointed out, we’ll be solving “single biggest mystery in all of health care.”

Look forward to connecting with you online!

Scott Miller (Evolution 2014)

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




Dinner with Paul McCartney (and others)

McCartneyat WrigleyMcCartney

Growing up, my family had a game we frequently played around the dining room table.  “If you could invite anyone to dinner,” it always started,”who would it be?”  Invariably, my father chose historical figures: Abraham Lincoln, Mark Twain, Leonardo Da Vinci.  My mom was more inclined toward the living: Jackie O., J.D. Salinger, Lucille Ball.  My brothers, Marc and Doug, usually went for sports figures.  I recall Wilt Chamberlain and Willie Mays being popular choices–although there were many others whose names I’ve now forgotten.

Me?  Always the same answer: Paul McCartney.

Of course, the “name game” didn’t end there.  Whatever your choice, you also had to state why.  Here, my answer didn’t vary either.  “He’s one of the Beatles!” I’d say, frustrated whenever my family acted as though my statement needed further clarification.

To this date, I’ve never had a chance to met much less have dinner with Paul McCartney.  Seen him in concert a number of times but always from a distance.  Last week, however, I did have the opportunity to meet and spend time with a number of my heroes from the field of psychotherapy–and go to dinner together, not once, but twice!

calgaryCCC logo

We were together at the first ever Calgary Counseling Center Outcomes conference.  Thanks to Center’s director, Dr. Robbie Wagner, a small group of practitioners, policy makers, and agency managers were invited to spend two, intimate days learning from the field’s leading thinkers and researchers.  The Beatles of outcome research: Michael J. Lambert, Bruce E. Wampold, Michael Barkham, Wolfgang Lutz, and Gary Burlingame.  I presented the latest results on our studies of top performing therapists.


It was every bit a rock concert–exciting, controversial, and cutting edge.   Below, I summarize the “greatest hits.”  I’ve also included the slides from each presentation for those who like to read the details contained in the “liner notes!”

Let me know what you think…here goes:

  • The burden born by people with mental health problems is second only to cancer (Depression alone results in a 70% loss of productivity)

Bottom line: People need the skills mental health professional have to offer

  • Treatment is effective. However, therapists believe they help far more people than they do (85% versus 20%);
  • Approximately 10% of adults deteriorate in care;
  • Between 14 and 25% of children are worse off following treatment;
  • Serious deterioration recognized in only one-third of cases;

Bottom Line: Mental health professionals overestimate their effectiveness and miss deterioration

  • Multiple, sophisticated, real world studies find no difference in outcome between people treated with different therapeutic approaches;
  • Factors related to the therapeutic relationship (i.e., empathy, collaboration, affirmation, genuineness) have a far greater impact on outcome (7:1) than treatment approach, adherence to treatment protocol, or rated competence.

Bottom Line: The pathway to improved effectiveness is not adopting new treatment approaches

  • Rapid and dramatic change (first 5 visits) occurs in as many as 40% of people and is maintained at two year follow up;
  • 90% chance of failure if there is no change between the 2nd and 8th visit;
  • As many as 25% of people remain in treatment while experiencing no measurable benefit;

Bottom Line: A large number of people need very little treatment to achieve lasting benefit

  • Separating intake from treatment results in higher drop out, lower and longer treatment response, and higher costs;

Bottom Line: Any barrier to establishing a relationship with a specific provider has a negative impact on outcome

  • The majority of individual practitioners are effective;
  • Around 16% of practitioners achieve outcomes significantly below average;
  • Less effective practitioners rate empathic understanding more highly as a professional/personal attribute than more effective practitioners;
  • The clients of the least effective clinicians were assigned to average practitioners, an additional 15% of clients would achieve clinical recovery;
  • Around 16% of practitioners consistently achieve outcomes significantly above average;
  • More effective practitioners rate resilience and mindfulness more highly as a professional/personal attribute;
  • Professional self-doubt and an “error-centric attitude” are associated with better outcomes.

Bottom Line: Choose your therapist carefully as they determine the outcome of care

  • When therapists receive feedback that clients are deteriorating, they: discuss it with clients about 60% of the time; make efforts to assist with other resources about 27% of the time; adjust therapeutic interventions 30% of the time; vary intensity or dose of services 9% of the time; consult with others (supervision, education, etc.) 7% of the time;
  • Therapist attitude toward soliciting and using feedback vary and influence results;
  • Therapists who value feedback achieve better outcomes;
  • Professional self-doubt and an “error-centric attitude” are associated with better outcomes;

Bottom Line: Regular, formal feedback from clients to therapists improves outcomes (as long as the therapist listens and acts on the feedback)

  • When asked, 92% of clients say they like the use of outcome measures in care.

Bottom Line: An overwhelming majority of clients endorse progress monitoring or providing feedback

Is Documentation Helping or Hindering Mental Health Care? Please Let me know.

Drowning in paperwork

So, how much time do you spend doing paperwork?  Assessments, progress notes, treatment plans, billing, updates, etc.–the lot?

When I asked the director of the agency I was working at last week, it took him no time to respond. “Fifty percent,” he said, then added without the slightest bit of irony, “It’s a clinic-wide goal, keeping it to 50% of work time.”

Truth is, it’s not the first time I’ve heard this figure.  Wherever I travel–whether in the U.S. or abroad–practitioners are spending more and more time “feeding the bureaucratic beast.”  Each state or federal agency, regulatory body, and payer wants a form of some kind.  Unchecked, regulation has lost touch with reality.

Just a few short years ago, the figure commonly cited was 30%.  In the last edition of The Heart and Soul of Change, published in 2009, we pointed out that in one state, “The forms needed to obtain a marriage certificate, buy a new home, lease an automobile, apply for a passport, open a bank account, and die of natural causes were assembled … altogether weighed 1.4 ounces.  By contrast, the paperwork required for enrolling a single mother in counseling to talk about difficulties her child was experiencing at school came in at 1.25 pounds” (p. 300).

Research shows that a high documentation to clinical service ratio leads to higher rates of:

  • Burnout and job dissatisfaction among clinical staff;
  • Fewer scheduled treatment appointments;
  • No shows, cancellations, and disengagement among consumers.

Some potential solutions have emerged.  “Concurrent ,” a.k.a., “collaborative documentation.”  It’s a great idea: completing assessments, treatment plans, and progress notes together with clients during rather than after the session.  We started doing this to improve transparency and engagement at the Brief Family Therapy Center in Milwaukee, Wisconsin back in the late 1980′s.  At the same time, it’s chief benefit to date seems to be that it saves time on documentation–as though filling out paperwork is an end in and of itself!

Ostensibly, the goal of paperwork and oversight procedures is to improve accountability.  In these evidence-based times, that leads me to say, “show me the data.”  Consider the wide-spread practice–mandate, in most instances–of treatment planning. Simply put, it is less science than science fiction.  Perhaps this practice improves outcomes in a galaxy far, far away but on planet Earth, supporting evidence is spare to non-existent.  Where is the evidence that any of the other documentation improves accountability, benefits consumers, or results in better outcomes?

Put bluntly, the field needs an alternative.  What practice not only insures accountability but simultaneously improves the quality and outcome of behavioral health services?  Routinely and formally seeking feedback from consumers about how they are treated and their progress.

Soliciting feedback need not be time consuming nor difficult.  Last year, two brief, easy-to-use scales were deemed “evidence-based” by  the Substance Abuse and Mental Health Services Administration (SAMHSA).  The International Center for Clinical Excellence received perfect scores for the materials, training, and quality assurance procedures it makes available for implementing the measures into routine clinical practice:



Then again, these two forms add to the paperwork already burdening clinicians.  The main difference?  Unlike everything else, numerous RCT’s document that using these forms increases effectiveness and efficiency while decreasing both cost and risk of deterioration.

Learn more at the official website:  Better yet, join us in Chicago for our upcoming intensives in Feedback Informed Treatment and Supervision:

Advanced FIT Training (2015)FIT Supervision Training (2015)

In the meantime, would you please let me know your thoughts?  To paraphrase Goldilocks, is the amount of documentation you are required to complete, “Too much,” Too little,” or “Just about Right!”  Type in your reply below!