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.

ethical 2

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


Implementing Feedback Informed Treatment


What do the Sydney Opera House, Boston Central Artery Tunnel, and Eurozone Typhoon Defense Project all have in common?   In each case, their developers suffered from, “The Planning Fallacy” (PF). First recognized in 1979 by Nobel Prize winning psychologists Daniel Kahneman and Amos Tversky, the planning fallacy is the all too human tendency to underestimate the amount of time and money projects will require for completion. The impact is far from trivial, especially if you are footing the bill. The Sydney Opera House, for example, took ten years longer and cost nearly 15 times more money than originally planned (102 versus 7 million). The tunnel project in Boston ran over budget to the tune of 12 billion dollars—a figure equivalent to 19,000 dollars for man, woman, and child living in the city!

Research documents that the same shortsightedness plagues implementation of new best practices in mental healthcare. As I blogged about previously, available data indicate that between 70 and 95 percent of such efforts fail. The same body of evidence shows that prior experience with similar projects offers no protection. Indeed, regardless of experience, when planners are asked to provide a “best” and “worst” case estimate, the vast majority fail to meet even their most dire predictions.

planning fallacy

The impact of a failed implementation on staff morale can be devastating—not to mention the waste of precious time and resources, and missed opportunity to provide more effective services to consumers. I’ve seen it first hand, had it whispered to me on breaks at workshops, as I crisscross the globe teaching about Feedback-Informed Treatment (FIT). At a workshop in Ohio, a woman approached me saying, “So, you are the guy that developed the Outcome and Session Rating Scales?” When I answered yes, she leaned in, and in a quiet voice, asked, “Will you be telling us how to use them? ‘Cause we’ve been using them at my agency for about a year, but no one knows what they’re for.” More recently, at a training on the west coast, a participant told me he and his colleagues started using the scales following a two- day workshop at his agency, but eventually stopped. “Initially, there was a lot of excitement,” he said, “We really bought in. All of us were all doing it, or at least trying. Then, it just kind of fizzled.” I nodded in recognition. The planning fallacy strikes again!

Since first being reviewed and listed on SAMHSA’s National Registry of Evidence Based Programs and Practices, interest in the proven approach to improving the outcome and retention of mental health services has exploded.  More than 100,000 practitioners have downloaded the ORS and SRS.   Given the brevity and simplicity of scales, it is easy to assume that implementation will be quick and relatively easy. Ample evidence, as well as experience in diverse settings around the world, strongly suggests otherwise.

It goes without saying that getting started is not the problem.   Fully implementing FIT is another story. It takes time and careful planning—for most, between five and seven years. Along the way, there’s plenty of support to aid in success:

  • Managers, supervisors, and clinicians can join a free, online, international community of nearly 10,000 like-minded professionals using FIT in diverse settings ( Every day, members connect and share their knowledge and experience with each other;
  • A series of “how to” manuals and free, gap assessment tool (FRIFM) are available to aid in planning, guiding progress, and identifying common blind spots in implementation; ,
  • The 2-day FIT Implementation workshop provides an in-depth, evidence-based training based on the latest findings from the field of implementation science. Over the last few years, we’ve learned a great deal about what leads to success. Immunize yourself against the planning fallacy by joining colleagues from around the world for this event.
  • Finally, there’s technology.  Last blogpost, I introduce, a system for administering the ORS and SRS.  The video below introduces, a simple, easy-to-use website with a clean, Apple-like interface that makes gathering and interpreting outcome and alliance data a snap.

That’s it for now.

Until next time, best wishes,

Scott Miller (Evolution 2014)

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




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