Public Attitudes Toward Mental Health Services: A Change for the Worse

July 3, 2014 By scottdm 1 Comment

The results are not encouraging. A recent meta-analysis found that public attitudes toward psychotherapy have become progressively more negative over the last 40 years. The impact on practitioners is staggering. Between 1997 and 2007, use of psychotherapy declined by 35%. Not surprisingly, clinicians’ incomes also suffered, dropping 15-20% over the last decade.

So, if not psychotherapy, what do consumers of mental health services really want?

Well, if you trust the study I’ve cited, the answer seems clear: drugs. During the same time period that talking fell out of favor, use of pharmaceuticals increased a whopping 75%! Some blame society’s short attention span and desire for a “quick fix.” Such an argument hardly seems credible, however, given that psychotherapy works to alleviate distress as fast or faster than most psychotropics.

Others, including the authors of the meta-analysis, blame public education campaigns and pharmacological marketing aimed at “convincing the public that mental disorders have a neurobiological etiology that require biological treatments” (p. 103). At first glance, this idea is compelling. After all, every year, the pharmaceutical industry spends $5 billion dollars on direct-to-consumer advertising.

And yet, what is it the drug companies are really selling in those ads? In one of the most well-known TV commercials for a popular antidepressant, less than 7 seconds is spent on the supposed neurobiological cause. Instead, the majority of the time is spent depicting the positive results one can expect from the product. It’s marketing 101: focus on the benefits not the features of whatever you’re selling.

What do consumers want? The answer is: results. Your training, degree, certification, and treatment approach are irrelevant, mere features most consumers could care less about. Your rate of effectiveness is another matter entirely–its the benefit people are looking for from working with you.

So, how effective are you? Do you know? Not a guess or a hunch, but the actual number of people you treat that are measurably improved? If not, its easy to get started. Start by downloading two, simple, free, SAMHSA-approved scales for measuring progress and quality of mental health services. Next, visit www.whatispcoms.com to learn how individual practitioners and agencies can use these tools to monitor and improve outcome and retention in treatment, as well as communicate results effectively to consumers.

To see how outcomes attract consumers, just take a look at the Colorado Center for Clinical Excellence website. This Denver-based group of practitioners is a model for the future of clinical practice.

Dumb and Dumber: Research and the Media

April 2, 2014 By scottdm 1 Comment

“Just when I thought you couldn’t get any dumber, you go and do something like this… and totally redeem yourself!”
– Harry in Dumb & Dumber

On January 25th, my inbox began filling with emails from friends and fellow researchers around the globe. “Have you seen the article in the Guardian?” they asked. “What do you make of it?” others inquired, “Have you read the study the authors are talking about? Is it true?!” A few of the messages were snarkier, even gloating, “Scott, research has finally proven the Dodo verdict is wrong!”

The article the emails referred to was titled, Are all psychological therapies equally effective? Don’t ask the dodo. The subtitle boldly announced, “The claim that all forms of psychotherapy are winners has been dealt a blow.”

Honestly, my first thought on reading the headline was, “Why is an obscure topic like the ‘Dodo verdict’ the subject of an article in a major newspaper?” Who in their right mind–outside of researchers and small cadre of psychotherapists–would care? What possible interest would a lengthy dissertation on the subject–including references to psychologist Saul Rozenzweig (who first coined the expression in the 1930’s) and researcher allegiance effects–hold for the average Joe or Jane reader of The Guardian. At a minimum, it struck me as odd.

And odd it stayed, until I glanced down to see who had written the piece. The authors were psychologist Daniel Freeman–a strong proponent of the empirically-supported treatments–and his journalist brother, Jason.

Briefly, advocates of EST’s hold that certain therapies are better than others in the treatment of specific disorders. Lists of such treatments are created–for example, the NICE Guidelines–dictating which of the therapies are deemed “best.” Far from innocuous, such lists are, in turn, used to direct public policy, including both the types of treatment offered and the reimbursement given.

Interestingly, in the article, Freeman and Freeman base their conclusion that “the dodo was wrong” on a single study. Sure enough, that one study comparing CBT to psychoanalysis, found that CBT resulted in superior effects in the treatment of bulimia. No other studies were mentioned to bolster this bold claim–an assertion that would effectively overturn nearly 50 years of robust research findings documenting no difference in outcome among competing treatment approaches.

In contrast to what is popularly believed extraordinary findings from single studies are fairly common in science. As a result, scientists have learned to require replication, by multiple investigators, working in different settings.

The media, they’re another story. They love such studies. The controversy generates interest, capturing readers attention. Remember cold fusion? In 1989, researchers Stanley Pons and Martin Fleischmann–then two of the world’s leading electrochemists–claimed that they had produced a nuclear reaction at room temperature–a finding that would, if true, not only overturn decades and decades of prior research and theory but, more importantly, revolutionize energy production.

The media went nuts. TV and print couldn’t get enough of it. The hope for a cheap, clean, and abundant source of energy was simply too much to ignore. The only problem was that, in the time that followed, no one could replicate Pons and Fleischmann’s results. No one. While the media ran off in search of other, more tantalizing findings to report, cold fusion quietly disappeared, becoming a footnote in history.

Back to The Guardian. Curiously, Freeman and Freeman did not mention the publication of another, truly massive study published in Clinical Psychology Review—a study available in print at the time their article appeared. In it, the researchers used the statistically rigorous method of meta-analysis to review results from 53 studies of psychological treatments for eating disorders. Fifty-three! Their finding? Confirming mountains of prior evidence: no difference in effect between competing therapeutic approaches. NONE!

Obviously, however, such results are not likely to attract much attention.

Sadly, the same day that the article appeared in The Guardian, John R. Huizenga passed away. Huizenga is perhaps best known as one of the physicists who helped build the atomic bomb. Importantly, however, he was also among the first to debunk the claims about cold fusion made by Pons and Fleischman. His real-world experience, and decades of research, made clear that the reports were a case of dumb (cold fusion) being followed by dumber (media reports about cold fusion).

“How ironic this stalwart of science died on this day,” I thought, “and how inspiring his example is of ‘good science.'”

I spent the rest of the day replying to my emails, including the link to study in Clinical Psychology Review (Smart). “Don’t believe the hype,” I advised, “stick to the data” (and smarter)!

The "F" Word in Behavioral Health

April 20, 2011 By scottdm Leave a Comment

Since the 1960’s, over 10,000 how-to books on psychotherapy/counseling have been published—everything from nude marathon group therapy to the most recent “energy-based treatments.” Clinicians have at their disposal literally hundreds of methods to apply to an ever growing list of diagnoses as codified in the Diagnostic and Statistical Manual of Mental Disorders (soon available in its 5^th and expanded edition).

Conspicuously absent from the psychological cornucopia of diagnoses and treatments is the “F” word: FAILURE. A quick search of Amazon.com led to 32,670 results for the term, “psychotherapy,” 1,393 hits for “psychotherapy and depression,” and a mere 85 citations for “psychotherapy and failure.” Of the latter 85, less than 20 dealt with the topic of failure directly. There are some notable exceptions. The work of psychologist Jeffrey Kottler, for example. The dearth of information and frank discussion points to a glaring fact: behavioral health has a problem with failure.

The research literature is clear on the subject: we fail. Dropout rates have remained embarrassingly high over the last two and a half decades—hovering around 47%. At the same time, 10% of those who stay in services deteriorate while in care. Also troubling, despite the expansion of treatment modalities and diagnoses, the outcome of treatment (while generally good) has not improved appreciably over the last 30 or so years. Finally, as reviewed recently on this blog, available evidence indicates that clinicians, despite what many believe, do not improve with experience.

In short, behavioral health is failing when it comes to failure. As a group, we do rarely address the topic. Even when we directly addressed, we find it hard to learn from our mistakes.

Our study of top performing clinicians and agencies documents that the best have an entirely different attitude toward failure than the rest. They work at failing. Everyday, quickly, and in small ways. In the lead article of upcoming Psychotherapy Networker, “The Path to Mastery” we review our findings and provide step-by-step, evidence-based directions for using failure to improve the quality and outcome of behavioral health. As we say in the article, “more than a dozen clinical trials, involving thousands of clients and numerous therapists, have established that excellence isn’t reserved for a select few. Far from it: it’s within the reach of all.” Getting there, however, requires that we embrace failure like never before.

At this year’s “Training of Trainers” (TOT) conference, building “mindful infrastructures” capable of identifying and using failure at the individual practitioner, supervisor, and agency level will be front and center. Please note: this is not an “advanced workshop” on client-directed, feedback-informed clinical work (CDOI/FIT). No lectures or powerpoint presentations. Participants get hands on experience learning to provide training, consultation, and supervision to therapists, agencies, and healthcare systems.

But, don’t take our word for it. Listen to what attendees from the 2010 TOT said. Be sure and register soon as space is limited.