Time for a New Paradigm? Psychotherapy Outcomes Stagnant for 40 years

February 1, 2019 By scottdm 4 Comments

You’ve heard it said before. Flying is the safest form of transportation.

Facts back up the claim. In fact, it’s not even close. In terms of distance traveled, the fatality rate per billion kilometers is .003, improving dramatically over the years. Cars, by contrast, are almost 1,000 times more dangerous. Still, since 1923, the fatality rate in motor vehicle accidents has declined an eye-popping 93%.

How about psychotherapy? Have outcomes improved? Judging by the size of the Diagnostic and Statistical Manual and growth in the number of treatment approaches, one would expect success rates to have climbed significantly, if not exponentially. Not so, as I first presented at the Evolution of Psychotherapy Conference five years ago, and later on this blog, the empirical evidence clearly shows NO improvement.

And now a new study, this time reviewing the evidence regarding treatments for children and adolescents. Using sophisticated statistical analyses, the researchers examined 453 RCT’s spanning 53 years, involving nearly 32,000 kids treated for anxiety, depression, attention deficit/hyperactivity, and conduct problems. With the rising popularity of “evidence-based practice,” those conducting the study wanted to know whether “… our methods of developing and testing youth psychological therapies [are] producing improvement” (p. 2).

Can you guess what they found?

Outcomes have not changed (much less improved) over the last five decades–that’s 351 in dog years!

Can you imagine the outcry had similar results been published about automobiles or planes? You would fully expect hearings to be held, and leaders to be called called to account. The lives of children are on the line.

Nope. Instead, facing the supersized differences between promises made every year about “advances” in psychotherapy, and the results realized and reported in research studies, the authors meekly call for, “new approaches to treatment design and intervention science” (p. 1).

Really? Is that what’s required? Researchers going back to the drawing board of “treatment and intervention?”

No, what’s needed is an entirely different view of what clinicians actually do — and it starts by giving up the idea that psychotherapy is a form of treatment similar to antibiotics or angioplasty. Let’s face it. Psychotherapy is no more a medical treatment than are the facials, salt glows and body wraps one receives at the local spa. Which is not to say, it doesn’t work.

Outside the halls of academia, millions of therapists worldwide are helping people on a daily basis to live happier, more meaningful and functional lives. Dozens of studies of real world practitioners document outcomes that meet or exceed benchmarks established in tightly controlled, model-driven, randomized trials — all without following a particular, “evidence-based” protocol (see 1, 2, 3,4).

So, how best to conceptualize the effective work clinicians do? And, importantly, what could researchers offer that would be of real help to therapists?

That psychotherapy works, says more about humans and our need for connection, meaning, and purpose, than it does about the particulars of any given model or approach. And that our methods focus on thoughts, feelings, behaviors, and brain chemistry, says more about our Western values and beliefs, than about the ingredients necessary for successful healing.

Simply put, the field does not need to, as the authors of the study argue, “intensify the search for mechanisms of change [and] transdiagnostic … treatments” (p. 1). Doing so is merely a recipe for “more of the same.” Rather, to move forward, it should abandon the medical paradigm that has long had a stranglehold on our research and professional discourse, choosing instead to reconnect with the larger, worldwide family of healers, one that has existed since the dawn of history and which, from the outset, has been deeply engaged in the values and beliefs of those they treat, using whatever means necessary, consistent with the culture, to engender change.

What might that look like in practice?

As already documented, practicing clinicians already do a pretty darn good job helping their clients. There’s nothing wrong with our Westernized approaches when they work. At the same time, we don’t succeed with everyone. The problem, studies show, is we’re not particularly good at knowing when we’re not being helpful, when clients are at risk for dropping out or are actually deteriorating while in our care (1, 2). On this score, research has already provided a solution. Dozens of studies document, for example, using simple measures at the beginning and end of each visit not only provides clinicians with an opportunity to intervene more successfully with “at risk” clients, but also helps identify opportunities for their own growth and development (1, 2). If you’re not routinely and formally measuring the quality and outcome of your work, you can get started by accessing two simple tools here.

With outcome as our guide, all that remains is being willing to look outside the profession for possibilities for healing and change unbound by convention and the medical view. That’s happening already, by the way, in the world’s two most populous countries, India and China, with professionals learning the ways of indigenous healers and government officials tapping local shaman to meet citizen’s mental health and well being needs.

So, what about you? What you are doing to extend your healing reach?

And, in case you haven’t seen it, the video below is from the most recent Evolution of Psychotherapy conference, where I talk about new research documenting psychics achieving the same or better results as psychotherapists.

Until next time,

Scott

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

P.S.: Want to learn more about using outcome to inform and improve your effectiveness? Join me and an international group of teachers and researchers in Chicago for our Summer Intensives. For detailed information and to register, click on the banners below.

Feedback is NOT Enough: A Brief Update about the Empirical Evidence

September 25, 2018 By scottdm 1 Comment

The use of routine outcome monitoring (ROM) is on the rise. In the United States and abroad, regulatory bodies are actually mandating the gathering of outcome data as the new “standard of care.”

As agencies rush to implement–often at great cost in terms of time and money–the question remains: just how much does ROM contribute to improved retention and effectiveness?

Over 20 years ago, I began using outcome and alliance scales in my work as a therapist, asking clients at each visit to give me feedback about the qaulity of our relationship and their experience of progress. Eventually, together with colleagues, I developed two, brief measures: the Outcome and Session Rating Scales.

When studies using the scales began to appear in the literature, I was immediately concerned. In my opinion, the results were just “too good to be true.” First, the results were confounded by allegiance effects, having been done exclusively by people with a significant investment in the results. More to the point, however, I was worried that the studies focused on the measures rather than on therapists.

Soon, as I predicted, other studies appeared with far more modest results. And now, a meta-analysis of all studies using the ORS and SRS has been published, confirming that routinely measuring performance, improves outcome but not as much as reported in the original studies (viz., .27 versus .50).

For those involved in and advocating FIT (Feedback-Informed Treatment), this is an IMPORTANT study. It makes clear that when working feedback-informed, improving effectiveness requires more than the use of two measures. Indeed, it’s not really about the measures at all. Rather, it’s about therapists using feedback to identify opportunities for their own professional development.

As my colleague and fellow psychologist, Birgit Valla, is fond of saying, “A stopwatch will not make you a better runner. It’s not about the clock. It’s how you use the information to identify small, specific aspects of your performance that could be improved and then practicing.”

That’s what the team at ICCE and I have been exploring these past 7 years. The latest article summarizing that research was published just this week.

All the best,

Scott

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

P.S.: Registration for the Spring Intensives is open. Click on the links below to reserve your spot!

Science is Real (confusing)

September 17, 2018 By scottdm 9 Comments

The graphic above is a small sample of the many posts I encountered on social media last week. Obviously, science has a great deal of currency in public discourse.

Now, look at the bottom row. On the far left, we are told that drinking wine will help you live a longer life. On the right, the exact opposite claim is made: no level of alcohol consumption is safe.

Can anyone blame us for being confused? What is the truth? Isn’t that what science is supposed to help us sort out? Judging from the slogans printed on T-shirts, posters, and lawn signs, apparently so:

Science matters!
Science will not be silenced!
In science we trust!

Or, in the words of “Science Guy,” Bill Nye, “If you don’t believe in science, you are holding everyone back.”

How can one respond to that, except to say, “Ouch!”

And yet, at the risk of holding everyone back, I actually think much of the current confusion about what is and is not true comes precisely from believing in science. To me, its a bit like saying, “I believe in hammers.” Yes, each word makes sense, but the resulting sentence is absurd.

Science is not something to believe in or not. Like a hammer, it is merely a tool — one that, as the founder of American psychology, William James (1896), noted, is “first of all a certain dispassionate method.”

James then continued, offering a warning particularly suited to our media-saturated times, “To suppose that [science] means a certain set of results that one should pin one’s faith upon and hug forever is sadly to mistake its genius, and degrades the scientific body to the status of a sect.”

Real world science is a messy affair, with partial, inconclusive, and often contradictory results the norm rather than the exception. When done well and thoroughly understood, it can help tip the scales in one direction or another. Rarely, however, does it offer us a mirror of the universe.

Here’s a recent example from my own work. Are superior performers in sports, art, music, programming, and psychotherapy born or made?

About a decade ago, a slew of books and articles appeared boldly asserting, “Greatness isn’t born. It’s grown” (Coyle, 2009). Anyone, they promised, could accomplish anything if they just practiced long enough (Colvin, 2009; Gladwell, 2008; Shenk, 2010; Syed, 2010).

Then, in 2014, a group of researchers published a meta-analysis questioning the strength of the association between practice and performance. In a popular magazine , the banner for an article penned by one of the study’s authors even claimed the whole idea of improving performance via practice, “perpetuates a cruel myth” as it promotes the false belief, “people can help themselves to the same degree if they just try hard enough.”

What are we to believe?

Sorting out the seemingly contradictory results requires a deep dive into the literature: who did the studies, what questions did they ask, and how was the data analyzed? In other words, longer than the 2 – 4 minute “reads” promised in the social media posts pictured above. In fact, from the start to the publication of our new study on the subject, my co-investigators and I spent hundreds of hours spread out over a three year period examining the question. Here’s what we found:

The correlation researchers cited as demonstrating practice is “not as important as has been argued” (.35 [p. 1, Macnamara et al., 2014]) was greater than the association between mortality (e.g., death) and obesity (.13), excessive drinking (.21), and taking prescribed medications correctly (.23).

When the data set was reanalyzed including only those studies judged by independent, blind raters to be bona fide instances of research on the link between practice and performance, the correlation increased to.40.

So, you decide: if you want to improve your effectiveness –as a pole vaulter, chess player, surgeon, or psychotherapist — should you practice? Please share your thoughts below.

WAIT! Three new science posts just came across my social media feed: