Once upon a time, a nickel (the U.S. 5-cent coin) had value.

As a kid, I could get a generous scoop of ice cream at Sav-On, Big Hunk candy bar at Bock’s variety store, or a super-sized glazed doughnut at the Donut Man shop on Route 66.

At that time, a nickel was considered so valuable that when you wanted to imply something was worthless, you would say, “Yeah, that, and a nickel will get you a cup of coffee.” According to a post on Quora, the expression arose in the 1940’s when a cup typically cost five cents.

Along with, “I’m not going to hold my breath,” the expression was one my Dad sometimes used in response to me making any number of promises (e.g., clean my room, walk the dog, practice the piano or be nice to my younger brother).

I’m sure he hoped I’d follow through, much the same way we therapists believe growing clinical experience results in greater expertise and effectiveness. Why, otherwise, would so many of our websites feature “time in the chair” so prominently?

“I have over 15,000 hours of clinical experience,” says one. “I’ve been a psychotherapist for more than 20 years and have authored 5 best-selling books,” says another.

And yet, when such statements are considered in light of the evidence, it seems clear the most appropriate response is, “Yeah, and that plus $6.75 will get you a grande, soy, caramel macchiato at Starbucks.”

(The cost of a cup of coffee has obviously risen a bit since 1940)

Indeed, as I’ve reported in previous posts, research not only shows therapists do not improve with time and experience in the field, but on average become less effective (1, 2, 3, 4). Other studies document that students achieve outcomes on par or better than licensed professionals who supervise them (5, 6). Given such findings, it is more than a bit ironic that experience is associated with higher per hour fees (7) — increased rates which, it turns out, are tied to higher dropout rates!

Enter a new study by Bugatti and colleagues examining therapist dropout rates. Using data generated by more than 2,500 practitioners working with real clients in real world clinical settings, the researchers found therapists’ dropout rates increased the longer they were in practice.

You read that right.

Similar to the findings on effectiveness, therapist experience is not associated with better client retention rates. More, as noted previously, “therapists working with clients paying higher out-of-pocket fees have higher increases in client dropout over time.” Finally, in case you are wondering, caseload size did impact retention rates, but in a direction opposite to what most expect; specifically, therapists treating the most clients had the lowest dropout rates.

Bottom line? It’s time for the field to stop attributing benefits to clinical experience. Beyond the obvious ethical concerns, doing so actually prevents us from improving our effectiveness! A fundamental element of deliberate practice is challenging automaticity, or the lack of conscious control over and inability to make specific intentional adjustments to our behaviors that comes with … experience.

Raising awareness is the first step. To improve, we have to know where our actions and thinking fall short. Measuring and mapping our performance — as described in Better Results: Using Deliberate Practice to Improve Therapeutic Effectiveness and its companion volume, The Field Guide to Better Results — are two methods proven to help. The latest studies show, for example, both improved retention and effectiveness rates (~25%).

My colleauge and co-author, Daryl Chow, Ph.D., and I will be talking about these two methods (and the latest research findings reported here) at the next, online “Tuesdays with Daryl and Scott.” Held the last Tuesday of each month, the next one will be held on May 28th at 8 a.m. Central time.

No cost — not even a nickel — and you supply your own coffee.

Space is limited, however, so please click here to register and secure your spot.

I never met my uncle Marc. He died decades before I was born. I did know him, however. His mother –my maternal grandmother — made sure of that.

One story has stayed with me from the first time I heard it. It was about the day he passed. He was eleven. According to Grandma Stena, Marc developed “blood poisonin'” a few days after puncturing a blister on his heal with a sewing needle. Over the course of several days, a bright red line began moving up his leg. Fever and sweats soon followed.

Ocurring years before the development of antibiotics, sepsis was a death sentence. Having two kids of my own, I can’t imagine the terror my grandmother must have felt. And yet, the way she talked about the experience was strangely comforting.

Marc lapsed in and out of consciousness. When awake, he carried on lengthy conversations. Not only with his mother, but with deceased family members, many of whom he’d never met in life. As was her habit, Grandma Stena dutifully recorded the experience and names in her journal. One was her own mother, Kristin Enarsdottir — particularly curious given that my Icelandic great-grandmother had died two short weeks after giving birth to my grandmother. She was “taken in” by a family Marc knew as his grandparents, the Runolfssons. Neither my grandmother or Marc had known “Grandma K.”

According to the journal, around 11:30 am on July 22nd, 1929, Marc announced he could only stay “a few more minutes.” When she began to cry, he met her tears and sadness with reassurance. Others were waiting, he told her. They had been speaking with him and she was not to worry. He would be all right.

Marc took his final breath around 12 noon.

For my grandparents, 1929 was a year of challenge and tragedy. Three months after their son died, they lost their modest home and life savings in the aftermath of the stock market crash. Needless to say perhaps, both were transformed by these experiences — in ways one might and might not expect. For example, in the many years that followed, my grandparents never again put money in a bank. The baking soda can they used to store cash sits on my desk to this day. In their home, it was always buried deep in the flour bin inside a kitchen cabinet.

The other changes are harder to relate as succinctly. Growing up, the story’s supernatural elements were often what grabbed my attention. Talking with the dead. Crossing the veil. Life after death (insert theme song from the Twilight Zone here). For my grandparents, however, it was something entirely different. While the experience may have confirmed their beliefs about what happens after death, the real impact was on how they thought about and lived their lives after Marc’s passing. Life is short. Always treat others with kindness and compassion. Practice forgiveness. Listen and, whenever possible, be of help. Relationships, not money or material possessions, are what matters. In both word and deed, my maternal grandparents embodied these values in their daily lives.

Turns out, they were not alone. The Division of Perceptual Studies at the University of Virginia has been studying the nature and impact of “near death” experiences for more than four decades. Bottom line: they are often transformative. And, in contrast to psychotherapy and psychotropic medication, the changes NDE’s faciliate occur with greater speed and are more encompassing.

The problem, of course, is that to benefit, you either have to die or, in the case of my grandparents, witness an NDE close-up! “Unacceptable,” observes Dr. J. Kim Penberthy with a laugh. Professor of Research in Psychiatric Medicine in the Department of Psychiatry and Neurobehavioral Sciences at the University of Virgina, Dr. Penberthy has been investigating how we might obtain the same transformative, consciousness-changing benefits of NDE’s using alternate means.

I’m embarassed to admit I’d never heard of the Division of Perceptual Studies — described on the UVA website as, “a highly productive university-based research group devoted to the investigation of phenomena that challenge mainstream scientific paradigms regarding the nature of human consciousness.” Frankly, it never occurred to me that a program focused on reincarnation and the survival of consciousness after death would be granted space and funding in a top notch scholarly setting.

Back in 2017, I’d written an article describing how psychotherapy might benefit from embracing phenomena that exceed the limits of what is deemed physically possible according to current scientific assumptions. A few years later, together with colleagues from Australia, I published a research article documenting that people reported better outcomes when consulting a psychic/medium than a traditional mental health practioner. Unfortunately, two book projects — Better Results and The Field Guide to Better Results — got in the way of further work on the subject.

Until now.

Mindfulness. Yoga. Psychedelics. Drugs. Alcohol. Religion. Travel. Extreme sports. Now, and throughout history, humans have sought to alter their consciousness — sometimes to escape, but more often to find a new or different reality.

That’s where Dr. Penberty enters the picture. I stumbled upon her work while doing research for our next book, Healing in the Age of Science. She graciously agreed to be interviewed. Personally, I think you’ll find the conversation consciousness-altering.

Over the last several months, I’ve been writing a series of short, but true stories from my life and work. After some gentle encouragement from Carrie Witta of Very Bad Therapy podcast fame, I created a substack account and have been posting the “Snippets” once a week or so. Some are drawn from encounters in the therapy room, others from childhood — all from experiences that made an impact despite their brevity. The latest is how one of my clients in therapy helped me — it turns out, not an infrequent experience, if allowed.

I’ve cut and pasted it below. You can also read it on substack. Subscribe and you’ll be notified each time a new story is published. Can’t beat the price — its free!

From the oversized bag resting on my office floor, she produced a VHS video cassette. “I’m hoping this,” passing it to me, “will explain, better at least, than I’ve been able to.”

Our session over, she stood and turned toward the door. “S e e yo u t o m o r r o w,” I stammered, feeling awkward as ever – which, by the way, was often.

Partly because I was an intern at the time, but also due to my nature, what seemed to come so easily to others, I found difficult. Suffice it to say, I was no natural therapist. Quite the contrary. I was aware of and deliberate about every action I took and didn’t take, including what I said and didn’t say, when I spoke or chose to remain silent, the movement of my limbs, head and torso, whether I looked away or directly at the person, and for how long.

Anyway, I brought up the hour with my practicum supervisor the following morning. “Let’s see what’s on the tape,” he quickly suggested.

We watched a minute or so, then fast forwarded through a few more.

“Does this mean anything to you?” he asked.

Shaking my head from left to right, “No, uh, I, it doesn’t.”

Speeding through the entire 90-minute cassette, it was clear the video was a carefully edited collection of snippets from various television programs and commercials – some I recognized, others that were unfamiliar. Five seconds of American Bandstand, followed by a clip of a Calvin Klein advertisement, another five or ten second scene from American Bandstand and then extended cuts to the TV series, Dance Fever. If there was a theme, or some intended message, it was lost on me as well as my far more experienced supervisor.

“Did you have a chance to watch the tape?” she asked at the outset of our next session.

“I, I, I did …” falling silent, purposefully lowering my eyes.

“And did it help make things any clearer?”

Looking up, “Could you help me understand what was in the video, what it’s about?” I said, being careful to repeat the words I’d role-played the day before with my supervisor.

A long silence followed.

After 30 years of being a psychologist, there’s little that surprises me about people and their lives – sure, the details differ, but the stories generally have a familiar ring. Then, however, it was all new to me.

Caroline was on the inpatient ward of a hospital where I was completing an extended practicum. Married, stay-at-home mom to several kids, she’d become depressed in the last year. When standard outpatient psychotherapy and medication didn’t help, she was admitted for more intensive care.

And when she eventually said, “It’s about feet,” it all came together. The hour-and-a-half long video was nothing but feet. Feet walking. Feet dancing. Feet in shoes. Feet in flip-flops. Bare feet – loads of bare feet.

For most of the time that remained, I listened, leaning forward, eyes fixed on Caroline as she talked about her husband’s interest in feet. Early on in their relationship, she hadn’t minded. However, when what had started off as a curious, and even intriguing part of their sex life, had warped into an obsession, she ended up feeling alone, unfulfilled, and betrayed.

Years after we met and worked together, I received a letter from Caroline. By this time, I’d graduated, moved out of state and across the country. From the postmark and multiple forwarding address labels, I could see it had been in transit for some time.

“I’ve been meaning to write for some time,” the letter began. After providing some details about her life and family – all generally positive – she explained why she’d chosen to write.

“I wanted to thank you for the help you gave me at that very difficult time …”

Temporarily looking up from the page, I wondered how that could be true. My recollection was I’d done little and understood less. With a mixture of anticipation and dread, I read on.

“I also want to give you some feedback, something I should have said long ago.”

Here it comes, I thought, pursing my lips.

“When we were meeting, I knew there were (many?) times you didn’t know what to say or do.”

Despite hoping my frequent, and often lengthy silences had been interpreted otherwise, her observation was spot on. I smiled in recognition.

She continued, “In case you didn’t know, it’s those moments that stuck with me and were the most helpful. Your stillness gave me the space to hear what I was feeling and accept myself. It was life changing.”

Tucking the letter back into the envelope, I couldn’t help thinking she was returning the favor.

“Your reach should exceed your grasp,” was one of my dad’s favorite sayings.  Smile on his face, he would often add, “be prepared to end up empty handed” – which reminds me of a memory.

I was seated on the right side of the room, in the aisle seat, second row from the front.  As far as venues go, it was nothing special.  The workshop was another story.  I’d been looking forward to attending for several months.  I wasn’t alone.  Every seat was taken – many of the participants familiar to me, although older and much more experienced. 

I’m sure I was the only grad student in attendance.  It wasn’t for lack of interest.  The cost was simply too high.  I’d only managed to secure a spot by agreeing to help out the organizers.      

Day two began with a video featuring the second meeting with a couple.  We’d seen the first session the day before.   And while the details of the discussion between the couple and therapist are lost to time, I remember with absolute clarity how their visit concluded.   The therapist told the couple to shave their heads and bury the clippings in a hole in their back yard prior to the next visit. 

My reaction was instantaneous.  I started laughing.  I couldn’t control myself.  Neither could the other attendees.  The “intervention” – as the homework task was termed – was just so surprising.  At the same time, it fit the situation.  Like the answers to classic Zen koans, a perfect combination of absurdity, recognition and truth.  You know, “What is the sound of one hand clapping?”  (The answer can be found in the parenthesis below) 

Anyway, when someone in the audience shouted, “Did they come back?” the presenter responded in true cliff-hanger fashion, “You will have to come back tomorrow to find out.”

And there we sat, the room strangely quiet for so early in the morning. 

I didn’t know what to expect.  As the video began playing, the audible gasps of those around me suggested my fellow attendees didn’t either.  But there the couple was, center screen, seated in adjoining chairs, both as bald as Winston Churchill.  According to their statements, engaging in the task had been transformative.  The problems that had proven so intractable to their own and prior professionals’ attempts to help had largely resolved.

Had I not seen it with my own eyes, I would not have believed it.  I listened ever more attentively the rest of the day, taking careful notes and mulling over the answers given to participants questions.  At the end, I bought the presenter’s latest book.  “To Scott,” the personal inscription read, “Use it or lose it.”

I still have the book on my shelf in my office. What I don’t have is a picture of my supervisor’s face when I related the story at our next meeting – not about the video of the couple, mind you, but rather what happened when I instructed my one practicum client to shave their head.  With a roll of their eyes, they’d stood and left the session.  My supervisor?  Kind of like the sound of one hand clapping, silence (in this instance, I believe, the stunned variety).

So, has your reach ever exceeded your grasp in this way? Left you empty handed or worse, with an empty seat in your office? What happened for you? Your client? What, if anything changed in your understanding of the work? Finally, what advise would you offer a person just entering the field given the abundance of therapeutic options and choices?

If you’re interested, more such stories are available on my Substack page.

OK, until next time, I wish you the best,

Scott

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

P.S.: Registration is open for the next, Feedback Informed Treatment Supervision/Consultation Intensive. Click here or the icon below for more information or to secure your spot.

(Shame on you.  Go back and finish the story)

You’ve heard of it, right? Lake Wobegon? The fictional town in Minnesota made famous by master story-teller, Garrison Keller. The place where, “all the people are strong, good-looking, and above average?”

Turns out, if the city were “Psychotherapy,” it would not be a fictional place. Since 2012 when the first study appeared in the literature, others have been published documenting the tendency of practitioners to overestimate their effectiveness — on average, by 65% (1, 2). The impact on professional development could not be greater. Again, multiple studies show, for example, therapists do not improve with time or experience despite obtaining regular supervision or attending the latest continuing education workshops (3).

If you are like most therapists, you’re likely feeling skeptical about such findings — and there are some exceptions. More on that in a moment.

In the meantime, consider the results of a study my colleagues and I just published in Practice Innovations. We knew that research to date had relied exclusively on therapists in Western cultures and wanted to explore whether The Lake Wobegon Effect would be observable in other cultures — particularly, those valuing humility and modesty. Turns out, similar to therapists from the US, Canada, Australia and Europe, Chinese psychotherapists (N = 223) rated themselves as above average (the mean percentile rank being statistically indistinguishable).

So, who are the exceptions? In the studies documenting that most therapists become more confident while remaining average or achieving poorer outcomes, some — between 15 and 25% — defy the trend and actually improve with time and experience.

What is it that they do? Returning to Lake Wobegon, they neither express nor rely on feelings of humility. Rather, they engage in activities that engender the self-doubt required for making changes in how they work. One example is measuring their performance. Indeed, the only study ever published to document improved outcomes at the individual practitioner level involved therapists routinely measuring client progress, identifying those at risk of dropout or a negative or null outcome, and obtaining feedback targeted to their specific clinical errors and performance deficits (4).

Whether you are an experienced practitioner or new to the field, have been measuring your results for years or wanting to get started, the upcoming Feedback Informed Treatment Intensive will help you put Lake Wobegon in the rearview mirror. Three days, online, and ongoing support from a worldwide community of helping professionals dedicated to improving the outcome of behavioral health services. Click the icon below for more information or to register. As always, feel free to reach out with any questions.

Until next time,

Scott

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

UPDATE 9/23/24

Access the article here.

All of us have them. Key developmental experiences. Ones that stick in our memory, make a permanent “dent” in our thinking or behavior.

I was sitting behind a one-way mirror watching a therapy session. The young man being interviewed was dying, his immune system failing due to the AIDS virus. It was the early days of the outbreak. Lots of fear, death, helplessness, and indifference.

“He’s in denial about dying,” the resident physician told us before my fellow psychology intern entered the hospital room, “If things need doing, they have to be done soon as he doesn’t have long.”

The conversation that ensued was painful to watch. The young man talked about what he was going to do when he was released from the hospital. My colleague gently but firmly focused on the man’s impending death.

Pointing to a magazine on a bedside table, “I’m planning a trip, going to sail around the world.”

Following a brief pause, “I know this must be hard to accept, but you are dying.”

“I have been looking at sail boats,” he continued, “I learned how to sail when I was coming up.”

Silence. Then, “Perhaps we should talk about what’s happening right now.”

Once again pointing to the magazine, “Can you hand me that? I’ll show you sailboat I’m thinking about getting.”

And on and on it went.

As a grad student, I’d learned about resistance and denial – according to Freud, “the violent and tenacious” rejection of the therapist’s efforts “to restore the patient to health, to relieve him of the symptoms of his illness.” It was the challenge of therapeutic work, the precursor to being able to help.

To me, however, it seemed like torture. “I don’t get this,” I said to the group, “He’s dying.”

“The point,” our supervisor responded, “is to help him address this, and take care of what needs to get done before he dies.”

“And what if he doesn’t?” I thought to silently to myself, “What’s the worst that can happen? Either way, he’s dead.”

The interview dragged on for another 15 minutes or so. I just watched, feeling helpless. After all, at the time, I didn’t have any alternate suggestions for what to do – something that wouldn’t be seen as participating in or perpetuating the man’s … “denial.”

Next morning, I learned the young man had died during the night. It took my breath away. Then, as now, I felt we really missed … the boat.

She’d started young. At age 3, she was named “Miss Beautiful Baby.” Shortly thereafter, she became a regular –“Bubbles Silverman” — on the Uncle Bob’s Randbow House radio show.

Voted “most likely to succeed” by her high school classmates, she sang everywhere and anywhere before landing a position as “house soprano” at the City Opera of New York in 1955. Her later performance of the aria, “Se Pieta” in Handel’s Julius Ceaser led a New Yorker magazine theatre critic to comment, “If I were recommending the wonders of New York to a tourist, I would place Beverly Sills at the top of the list.” High praise given the vast pool of talent in the “city that never sleeps.”

Not suprisingly, when Sills died in 2007, she was hailed as, “one of this country’s great operatic voices” — a remarkable compliment given that no one had heard her sing at that point in nearly three decades! Rather, in 1980, at the height of her fame, she chose to retire.

“There is a kind of desperation,” she later said, “staying at something too long … and I am not a desperate woman. I wanted people to say, ‘It’s too early,’ rather than, ‘When is that woman ever gonna quit? It was the perfect time to go out — on top.”

In today’s media and influencer saturated world, some might deem Sills’ decision foolish. “Why quit? Why not hang around, make as much ‘bank’ as you can, ride the waves of fame and adulation as long as far as they will carry you?” Heaven knows many in the public eye stick around far longer than their expiration date. For her, however, her commitment to performance excellence trumped any resulting celebrity.

Personally, I admire the choice Sill made. As I age, I’ve found myself wondering more often about when to “hang it up.” It can’t be based on demand, real or perceived. Indeed, there is a kind of conceit in leaving the decision up to others.

Seems to me that exiting at the top of one’s game is even more challenging in the field of therapy where age and experience are believed to confer special advantage. The same may be said of commercial airline pilots — at least, I know I feel more confident when the flight crew trends older than the cast of High School Musical. And yet, given the declines in memory, reasoning, verbal fluency and comprehension skills associated with advancing years, pilots have a mandatory retirement age, a standard applicable across 193 member-nations! Surely, some could continue for longer, but doesn’t that beg the question?

As reviewed here, research on therapists makes clear age and experience confer no advantage and are likely associated with poorer performance (1, 2).

So, what are your criteria?

Until next time,

Scott

Director, International Center for Clinical Excellence

I remember her. My very first, real client. Cynthia — not her real name, her real name was Susan, but I’m not supposed to tell you that! (Just kidding, that wasn’t her name either)

Early thirties. Married. Couple of kids. Depressed.

I was still a student, a therapist-in-training — and I desparately wanted to be helpful. This wasn’t a fellow student role playing a client or presenting a minor concern of their own (“I can’t decide whether to take job X or Y”). Cynthia was in pain and looking to me for help.

I didn’t know much at this point in my professional career. I certainly could reflect feelings (“so you’re feeling very [insert feeling word here] and “what I hear you saying is [insert brief summary of client’s concern]”). Beyond that, not so much — at least anything I felt even the least bit confident about pulling off. More, I was acutely aware of myself — the words I used, how long I spoke, the number of hems-and-haws, the movement and position of my arms and legs, and how long I held eye contact.

Nowadays, my experience doing therapy is entirely different. I glide into the room without the faintest hint of self-consciousness. I sit, move, and interact naturally. The session unfolds in what would strike a casual observer as, seamless. Even the pauses — those earlier, worrisome “hem’s-and-haws” — seem purposeful.

The tendency to equate effortlessness with the development of expertise is not all that surprising. After all, it feels better in almost evevery way — smoother, easier, more polished. And yet, research from the field of expert performance suggests it likely means we’ve stopped growing!

Consider empathy — one of, if not the most important therapeutic skill. As my colleagues and I report in a soon-to-be published study (1), neither years of experience or therapist self assessment are correlated with actual empathic ability.

How, you might reasonably ask, could this be? What stands in the way of our future growth and development? As paradoxical as it may sound, the answer is, our current ability –or what researchers call, automaticity. In short, actions which once required a tremendous amount of mental energy, in time, are executed with barely a thought. While this means we can devote our limited cognitive resources to other pursuits, it also results in the loss of conscious control over our behavior.

The possibility of growth begins with the disruption of automaticity — literally regaining consciousness. A warning, however. While talk of “professional humility” and assuming a “not-knowing” stance is trendy, its also hard on the ego. Professional confidence usually suffers. The good news, as our study of empathy documents, is actual measured ability simultaneously improves!

More detailed information about finding your “sweet spot of discomfort” can be found in our two latest books Better Results and The Field Guide to Better Results. According to Professor Kim de Jong, these volumes offer “a wonderful combination of state-of-the-art scientific evidence … and hands on exercises for clinicians to improve their effectiveness.”

Want to connect with others pushing at their performance edge? Join the ICCE discussion forum. It costs nothing and you’ll meet like-minded practitioners from around the world.

By the way, a few years after leaving university, I received a letter from Cynthia. Don’t ask me how she found me! I suppose, “where there is a will, there is a way.”

Anyway, in the letter, she shared what had happened in her life after we stopped meeting. Her depression had lifted. She went back to school and was in a new relationship. Near the end, she expressed gratitude for our meetings, the support she received. “I know I wasn’t an easy client,” she offered, continuing “when I could tell you, too, were struggling, when it seemed like you weren’t sure what to say, those were some of the best moments.” I kept her letter all these years.

OK, that’s it for now.

Scott

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

P.S.: Looking to become an ICCE Certified Trainer? Want to hone your skills as a speaker, trainer, or presenter? The upcoming “Training of Trainers” is held only once every other year. For more information or to secure your spot, click here or the icon below.

Despite happening decades ago, I remember it as though it were yesterday.

My oldest, Kirk, was fiddling with a cassette tape recorder. He was four at the time and wanted to listen to “his music.” You know, the kind all parents regret having given to their kids at some point? “Wheels on the bus,” “B.I.N.G.O.,” “Itsy bitsy spider.”

Unfortunately, neither the tape or machine were cooperating. Seated at the kitchen table watching, I marveled at his patience and persistence — over and over, inserting the cassette one way, then another.

Eventually, he set the tape down, folded his arms and closed his eyes. That’s when I decided to intervene. I stood and went to sit beside him.

“Hey bud,” I said, gently placing a hand on his knee, “What’s going on?”

“I … AM … MAD!” he responded slowly and deliberately.

His tone took me by surprise. Kirk was such an even-tempered kid. Rarely upset. Stoic, even when provoked. And I’ll let you in on a little secret. As his father, it was a trait I was proud of, told people about and privately believed he’d learned from me!

Anyway, last week, Kirk and I were on the phone together. I was telling him about an article I’d just published (1). Somewhere along the way, I expressed my frustration with the field of mental health. In particular, our habit of apeing our much-envied and more successful cousins in medicine. So, like them, we insisted on calling our work, “treatment,” likened our methods to taking a pill containing ingredients specifically remedial to a client’s problem. We even adopted a manual developed by physicians defining both the nature and scope of concerns falling within our purview!

Kirk didn’t miss a beat. Teasingly, he asked, “You mean, you … are … MAD?!”

We laughed for several minutes after that, reliving the events from so long ago. Truth is though, I was mad. As my colleague and mentor, Bruce Wampold and I had written in the article (1), our field was at it again, not only adopting the language and terms of medicine, but also implying that field was responsible for the clinical innovation developed by therapists and documented to improve retention and outcome of mental health services (2).

You know what I’m talking about, right?

Regardless of the name it is known by (e.g., feedback-informed treatment, routine outcome monitoring, patient focused research, progress feedback, or practice based evidence) research on the subject originated with non-medical mental health researchers and has been going on for a quarter century (3)! And yet, in proposing “practice guidelines” for the American Psychological Assocation, Boswell and colleagues (3), opted for a term developed by a physician in 2006, “measurement-based care” (MBC) (4), claiming it was “closely related, though not necessarily identical to, commonly used terms/practices” noted above (p. 3).

Judge for yourself. Here’s how the authors defined MBC: “(a) routinely collecting patient-generated data throughout the course of treatment; (b) sharing timely feedback with the patient about these data (e.g., patient-reported outcome measure scores) and observed or predicted trends over time to engage patients in their treatment; and (c) acting on these data in the context of the provider’s clinical judgment and the patient’s experiences” (p. 3). Now, compare that to the definition of feedback-informed treatment offered in the FIT Treatment and Training Manuals published years earlier. “FIT is a pantheoretical approach for evaluating and improving the quality and effectiveness of behavior health services. It involves routinely and formally soliciting feedback from consumers regarding the therapeutic alliance and outcome of care and using the resulting information to inform and tailor service delivery” (p. 2).

If the two definitions seem similar, its because they are!

(Sorry for my tone)

Beyond once again emulating medicine, the problem with the term, “measurement-based care,” is that it doesn’t capture what the authors claim it represents. Indeed, wouldn’t the average practitioner on first hearing be most inclined to conclude the point of MBC is, well, measurement? That is precisely the confusion I encounter weekly in emails, phone calls and consultations with mental health professionals, agency managers, and payers.

“Please don’t use my scales,” I generally advise. Their response? Always a but …

“We’ve been told by [our payer, funder, the government, some regulatory body] that we have to use an outcome scale?”

“How will I know if the therapists who work at my agency are effective?”

“We need a way to identify clients we aren’t helping so we can terminate services with them and free up scarce clinical resources.”

Returning to my son, Kirk. On closer examination, it turned out a small part in the compartment of the recorder designed to hold the tape had broken off. Nothing we could do at that point would make it work.

“It’s OK, Dad,” I recall him saying, then quickly adding, “we can sing the songs ourselves.”

What could I say? We did.

It’s time, I think, our field does the same.

All the best,

Scott

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

The evidence shows that using standardized measures to solicit feedback from clients regarding progress and their experience of the working relationship improves retention and outcome.

How much? By 25% (1)

And now, major news out of California.

Psychologists — who are required to earn 36 hours of continuing education credits every other year — can now earn credit towards renewal of their license by implementing feedback-informed treatment (FIT) in their daily clinical work (2)!

Here’s the challenge. The same body of research documenting that FIT works, shows clinicians struggle when it comes to putting it into practice. Private practitioners express concerns about the time it takes. Those working in agencies talk about the challenges of finding alternatives when FIT data indicate the present course of treatment is not working. Finally, many who start, stop after a short while, noting that FIT didn’t add much beyond their “clinical knowledge and experience.”

All such concerns are real. Indeed, as reported a few years back on this blog (3), implemention takes time and skill — in agency settings, up to three years of effort, support and training before the benefits of being feedback-informed begin to materialize. When they do, however, clients are 2.5 times more likely to benefit from care.

So, don’t give-up. Instead, upskill!

In September, the International Center for Clinical Excellence is sponsoring the FIT “Training of Trainers.” Held only once every-other-year, the TOT focuses exclusively on the process of training and supporting others in their use of feedback informed treatment. As with all ICCE events, space is limited to 40 participants. Click on the link above or icon below for more information or to register!

Until next time,

Scott

Scott D. Miller, Ph.D.
Director, ICCE

Decades of research shows the client’s experience of the relationship is one of the best predictors of their engagement and progress in care (1).  As such, when outcome and alliance data indicate a course of treatment is “at risk” for a negative or null outcome, or drop out, it makes sense to explore the helper’s understanding of the client’s expectations and experiences regarding their working relationship.  

Enter the “FIT Alliance Stool” — the subject of the latest “FIT Tip.”

As described in the brief video, the purpose of stool is twofold. First, to remind the clinician of the elements central to client engagement — s factor long ago established as the number one process-related predictor of outcome (2). And second, to provide a practical tool for identifying where alignment might be improved so that the work can proceed in a more effective manner. 

Experiences reveals typical misalignments include:

• Organizing services around the what the referral source rather than client wants
• Equating the client’s goal with their diagnosis/presenting problem, or helper’s theory-driven objectives; and finally
• Inferring, guessing, or assuming rather than explicitly negotiating the client’s desires, objective(s), and expectations for care
• Conflating the “what” (client’s goals, meaning or purpose) for seeking care with the “how” (it’s means, methods, or process)
• A therapist acting in ways incongruent with the client’s preferences, beliefs, values, worldview, or identity (e.g., culture, gender, sexual orientation, ability, religion/spirituality, nationality, socioeconomic status). 

If you’ve never used the “FIT Alliance Stool,” give it a try! If you are a regular user, I hope the “tips” offered in the video below enhance your FIT practice.

Until next time,

Scott

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

P.S.: Registration is now open for the ICCE “Training of Trainers” Intensive. This three-day training is only offered once every two years! As always, space is limited. Click here (or the banner below) for more information or to register.

I’ve never been enthusiastic about categories, whether aligning myself with a particular therapeutic approach or assigning a diagnostic label to a client. Any order achieved seemed to come at the expense of freedom and possibility.

Lately, however, I’ve found myself feeling an affinity for a particular classification scheme. Maybe its my age. In July, I turn 65. On that birthday, I will have worked as a psychologist for longer than I had been alive when I entered the profession! And according to psychoanalyst Erik Erikson — a person whose work I’ve not thought about since my undergraduate days — that puts me at the doorstep of the eighth, and last stage of psychosocial development: integrity versus despair.

I’d forgotten Erikson coined the term, “identity crisis.” It was central to his theory of personal growth. The nature of the dilemma one faced was different at each stage. Successful resolution led to the development of character strengths a person could use to manage life and circumstance; failure, to an unhealthy sense of self and reduced capacity for fulfillment.

From the time I first heard them, Erickson’s “stages” had struck me as similar to a horoscope. You know, statements that feel personalized and specific but in fact are so vague and general they apply to everyone. That said, with fewer years of my professional life ahead of me than behind, that last stage had started speaking to me. More and more, I found myself thinking about where we were as a field, if we had made any progress and could feel proud of our work?

The challenges were stark, and frankly overwhelming. To name a few:

*An unprecedented rise in the number of people suffering from mental and emotional problems;
*No improvement in the outcome of psychotherapy over the last 50 years;
*No evidence that traditional training models or clinical experience (e.g., diagnostic specific treatments, ongoing supervision, licensing, mandated continuing education) contributes to clinician effectiveness despite widespread belief and regulation to the contrary.

Erikson maintained that each person must learn how to hold both extremes of each specific life-stage challenge in tension with one another, not rejecting one end of the tension or the other.  How, I wondered, could anyone not give into despair in light of the facts noted above?

That’s when I reached out to my longtime, colleague, mentor and friend, Dr. Bruce Wampold. Together, we confront the the present and future state of psychotherapy research and practice. Should we feel discouraged or hopeful? Listen for yourself.

Until next time,

Scott

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

P.S.: Registration for the upcoming FIT Supervision intensive is open. It’s one of the courses required for certification as a FIT practitioner and trainer. Join colleagues from around the world to learn the approach shown to improve individual clinician outcomes.

The data are clear: working feedback-informed improves both retention and effectiveness (1). Studies further show FIT achieves these effects, in part, by improving responsiveness to the individual client — particularly those at risk for a negative or null outcome or dropout from treatment (2, 3).

Such positive results notwithstanding, what happens when an outcome measure misleads — when the tool used returns results that are incongruent with the client’s experience?

Consider two recent studies (4). In both, researchers found clients largely agreed when an outcome measure — in this instance, the Outcome Questionnaire 45 — indicated they had improved, but disagreed when it suggested they had worsened. The size of the disconnect was ginormous: 91% saw themselves as benefitting significantly! In such instances, concluding treatment wasn’t helping and opting to terminate or refer, would be the antithesis of responsiveness — which leads me to what I like to call, “my most misunderstood “FIT Tip.”

Early in FIT trainings, therapists learn three ways they can adjust services in the absense of client progress: “Change the ‘what.’ Change the ‘where.’ Change the ‘who.'” Evidence-based guidelines are also provided for when such modifications should be introduced:

1. Little or no progress or deterioration by the third visit? Revisit the goals of treatment, paying particular attention to differences between the services being offered and the client’s stated reason for seeking help.
   
2. Little or no progress or deterioration by the fifth to seventh visit? Consider adding/augmenting services, providers, or participants.
   
3. No improvement or deterioration by the tenth to twelfth? Consider changing the provider, location, or type of services.

Of the three, the third is the most misunderstood. On more than one occasion, for example, I’ve heard therapists say, “According to Scott Miller, if a client isn’t improving by the 10th or 12th visit, treatment should be ended.”

Just to be clear, I have never made such a suggestion. Nor do I believe it. The entire point of FIT is to increase the likelihood of my clients getting what they hope for from their interaction with me. As such, the feedback from standardized measurement tools like the Outcome and Session Rating Scales should be considered starting rather than stopping points, opportunities to lean in and explore, not defer or refer.

I had a chance recently to interview the author of one of the aforementioned studies, Dr. Eric Ghelfi. Not only does he describe the studies in intriguing detail, he offers specific guidance for using the results to enhance responsiveness to the individual client, especially when there’s a disconnect between the tool and the client’s report. The “tips” he offers, I’m certain, will make a difference in your use of FIT.

OK, that’s it for now! Until next time,

Scott

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

Deliberate practice is hot.  More workshops and trainings are being offered on the topic than ever before.  In the last year, a veritable slew of books has also appeared, with many being tied to a specific therapeutic modality.  Given that the topic was introduced to the field a mere 15 years ago (see Miller, Hubble & Duncan, 2007), the growth in interest and instruction is astonishing.

The purpose of deliberate practice is simple and straightforward: improving outcomes.  And ample evidence documents its impact in fields as diverse as medicine, music, sports, chess and surgery.  Excitement about the potential for using deliberate practice to improve therapeutic effectiveness can be traced to the first study on the topic published in 2015.  Briefly, Chow and colleagues (2015), found the best therapists engaged in significantly more deliberate practice than their more average counterparts and staggering 14 times more than the least effective!   A subsequent study conducted in a real-world clinical setting by Goldberg et al. (2016) linked deliberate practice to steady improvements in outcome at the individual practitioner level – a first in the history of the field.

In his last book, Peak: Secrets from the New Science in Expertise, Anders Ericsson – the Swedish psychologist who coined the term and did most of the original research on the topic – identified three different types of practice (see chapter 1).   These include:

1. Naïve
2. Purposeful
3. Deliberate

The distinction, he maintained, was crucial as only one type was reliably associated with improving individual performance.  The “Naïve” type is what people most commonly associate with practice.  Repetition is seen as the key component, whether its playing a sport or learning to drive a car.  Unfortunately, Ericsson notes, “Research has shown that … once a person reaches [an] level of “acceptable” performance, [more such] “practice” doesn’t lead to improvement.”

Presently, most of the psychotherapy workshops and books with “deliberate practice” in their titles would, according to Ericsson, qualify as examples of “purposeful” practice.  Distinguishing it from the former type, its planned, goal directed, includes feedback and a way to monitor progress.  The objective is proficiency and competence, achieving a predetermined standard for a particular skill or knowledge level.

Of the three, Ericsson points out, only deliberate practice “is informed and guided by the performers’ accomplishments.”  As described in detail his publications and Better Results, it must be individualized, including: (1) an assessment of the performer’s baseline ability or skill level against which progress can be determined; (2) corrective feedback targeted to the individual’s execution of skills being learned; (3) development of a plan for successive refinement over time, and (4) guidance provided by an expert coach or teacher.

What does that look like in the real world?

“Hard work,” says Tor Travis, a clinical social worker living and working in New Mexico.  It’s true.  By comparison, naïve – equating clinical work/experience with practice – and  purposeful  – repeating a model-specific technique until it can be executed with ease – is far easier.   But Tor was not interested in either of these approaches.  In his words, “I wanted to help more people.  To be a better, more effective therapist.”  Thus began his three-year journey.

I’m grateful for the time he spent with me describing what’s happened along the way.  In the brief video below, he recounts the steps (and helpful missteps) with precision and detail – experiences I’m certain will prove helpful to many.

OK, that’s it for now.  Until next time,

Scott

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

P.S.: In the video, Tor mentions an asynchronous, online deliberate practice course taught by me and Daryl Chow.  This is a “go at your own pace” experience.  Each week for several months we send you links to short, instructive videos.  Learning is supported by access to an online community where discussions with the instructors and other clinicians takes place.  Click here or the image below for information about the course or to register.  The next cohort launches on June 6th.

 

 

 

 

 

“Why don’t more therapists do FIT?” a grad student asked me during a recent consultation.  Seated nearby in the room were department managers, supervisors, and many experienced practitioners.

“Well,” I said, queuing up my usual, diplomatic answer, “Feedback informed treatment is a relatively new idea, and the number of therapists doing it is growing.”

Unpersuaded, the student persisted, “Yeah, but with research showing such positive results, seems like ethically everyone should be doing FIT.  What’s all the hesitance about?”

What’s that old expression?  Out of the mouths of babes . . .

Truth is, a large, just released study showed FIT — specifically, the routine monitoring of outcome and relationship with the Outcome and Session Rating Scales — improved effectiveness by 25% over and above usual treatment services (1).

TWENTY-FIVE PERCENT!

In a second, pilot study conducted in a forensic psychiatric setting, use of the ORS and SRS dramatically reduced dropout rates (2).

What other clinical practice/technique can claim similar impacts on outcome and retention in mental health services?

Needless to say, perhaps, the student’s comments were more pointed.  Use of FIT at the agency was decidedly uneven.  Despite being a “clinical standard” for more than two years, many on staff — practitioners and supervisors alike — were not using the tools, or had started and then, just as quickly, stopped.

Here’s where the recent study might offer some help.  The impact of FIT notwithstanding, researchers Bram Bovendeerd and colleagues found its use in routine practice was easily derailed.   In their own words, they observe “implementation is challenging … and requires a careful plan of action.”

Even then, fate can intervene.

In their next paper, they describe how, even when organizational culture is receptive to FIT, contextual variables can get in the way.   At one clinic, for example, it was the unexpected illness of a key staff member leaving everyone else to take up the slack.  Curiously, when asked to explain the decline in use of the measures that followed, the therapists did not cite the increase in workload.  Rather, in what appears to be a classic example of attempting to reduce cognitive dissonance — we know using the measures work, but we’re not doing it anyway — they developed and expressed doubts about the validity of the measures!  Anyway, loads more interesting insights in the interview (below) I did with the lead researcher not long ago.

We’ll be addressing these and other implementation challenges at the next FIT Implementation coming up in August.  Registration is open.  Generally, the training sells out a month or more in advance.  Click here for more information or to register.

Until next time, please share your thoughts in a comment.

Scott

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

 

 

 

 

 

Deliberate Practice is hot.  Judging from the rising number of research studies, workshops, and social media posts, it hard to believe the term did not appear in the psychotherapy literature until 2007.

The interest is understandable.  Among the various approaches to professional development — supervision, continuing education, personal therapy — the evidence shows deliberate practice is the only one to result in improved effectiveness at the individual therapist level.

Devoting time to rehearsing what one wants to improve is hardly a novel idea.  Any parent knows it to be true and has said as much to their kids.  Truth is, references to enhancing one’s skills and abilities through focused effort date back more than two millennia.   And here is where confusion and misunderstanding begin.

• Clinical practice is not deliberate practice.  If doing therapy with clients on a daily basis were the same as engaging in deliberate practice, therapists would improve in effectiveness over the course of their careers.  Research shows they do not.  Instead, confidence improves.  Let that sink in.  Outcomes remain flat but confidence in our abilities continuously increases.  It’s a phenomenon researchers term “automaticity” — the feeling most of us associate with having “learned” to do something –where actions are carried out without much conscious effort.  One could go so far as to say clinical practice is incompatible with deliberate practice, as the latter, to be effective, must force us to question what we do without thinking.
• Deliberate practice is not a special set of techniques.  The field of psychotherapy has a long history of selling formulaic approaches. Gift-wrapped in books, manuals, workshops, and webinars, the promise is do this — whatever the “this” is — and you will be more effective.  Decades of research has shown these claims to be empty.  By contrast, deliberate practice is not a formula to be followed, but a form.  As such, the particulars will vary from person to person depending on what each needs to learn.  Bottom line: beware pre-packaged content.
• Applying deliberate practice to mastering specific treatment models or techniques.  Consider a recent study out of the United Kingdom (1).  There, like elsewhere, massive amounts of money have been spent training clinicians to use cognitive behavioral therapy (CBT).  The expenditure is part of a well-intentioned government program aimed at improving access to effective mental health services (2).  Anyway, in the study, clinicians participated in a high intensity course that included more than 300 hours of training, supervision, and practice.  Competence in delivering CBT was assessed at regular intervals and shown to improve significantly throughout the training.  That said, despite the time, money, and resources devoted to mastering the approach, clinician effectiveness did not improve.  Why?  Contrary to common belief, competence in delivering specific treatment protocols contributes a negligible amount to the outcome of psychotherapy.  As common sensical as it likely sounds, to have an impact, whatever we practice must target factors have leverage on outcome.

My colleague, Daryl Chow and I, have developed a tool for helping practitioners develop an effective deliberate practice plan.  Known as the “Taxonomy of Deliberate Practice Activities” (TDPA), it helps you identify aspects of your clinical performance likely to have the most impact on improving your effectiveness.   Step-by-step instructions walk you through the process of assessing your work, setting small individualized learning objectives, developing practice activities, and monitoring your progress.   As coaching is central to effective deliberate practice, a version of the tool is available for your supervisor or coach to complete.  Did I mention, its free?  Click here to download the TDPA contained in the same packet as the Outcome and Session Rating Scales.  While your are at it, join our private, online discussion group where hundreds of clinicians around the world meet, support one another, and share experiences and ideas.

OK, that’s it for now.  All the best,

Scott

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

 

 

 

 
P.S.: Improve your ability to deliver effective presentations online or in-person at the upcoming “Training of Trainers” workshop.  This event is held only once, every two years — this time, online!

“We don’t do ‘treatment,’ can we use FIT?”

It’s a question that comes up with increasing frequency as use of the Outcome and Session Rating Scales in the helping professions spreads around the globe and across diverse service settings.

When I answer an unequivocal, “yes,” the asker often responds as though I’d not heard what they said.

Speaking slowly and enunciating, “But Scott, we don’t do “t r e a t m e n t.‘”  Invariably, they then clarify, “We do child protection,” or “We’re not therapists, we are case managers,” or providers in any of a large number of supportive, criminal justice, or other statutory social services.

How “treatment” became synonymous with psychotherapy (and other medical procedures) is a mystery to me.   The word, as Merriam-Webster defines it, is merely the way we conduct ourselves — our specific manner, actions and behaviors — towards others.

With this definition in mind, working “feedback-informed” simply means interacting with people as though their experience of the service is both primary and consequential.  The challenge, I suppose, is how to do this when lives may be at risk (e.g., child protection, probation and parole), or when rules and regulations prescribe (or proscribe) provider and agency actions irrespective of how service users feel or what they prefer.

Over the last decade, many governmental and non-governmental organizations have succeeded in making statutory services feedback-informed — and the results are impressive.  For recipients, more engagement and better outcomes.  For providers, less burnout, job turnover, and fewer sick days.

I had the opportunity to speak with the members and managers of one social service agency — Gladsaxe Kommune in Denmark — this last week.   They described the ups, downs, and challenges they faced — including retraining staff, seeking variances to existing laws from authorities, — while working to transform agency practice and culture.  If you work in this sector, I know you’ll find their experience both inspiring and practical.  You can find the video below.  Another governmental agency has created a step-by-step guide (in English) for implementing feedback informed treatment (FIT) in statutory service settings.  It’s amazingly detailed and comprehensive.  It’s also free.  To access, click here.

Cliff note version of the results of implementing FIT in statutory services?

• 50% fewer kids placed outside the home
• 100% decrease in complaints filed by families against social service agencies and staff
• 100% decrease in staff turnover and sick days

OK, that’s it for now.  Please leave a comment.  If you, or your agency, is considering implementing FIT, please join us for the two-day intensive training in August.  This time around, you can participate without leaving home as the entire workshop will be held online.  For more information, click on the icon below.

All the best,

Scott

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

 

 

 

 

 

Criticizing umpires is as much a part of watching baseball as eating hotdogs and wearing team jerseys on game day.  The insults are legion, whole websites are dedicated to cataloging them:

“Open your eyes!”

“Wake up, you are missing a great game!”

“Your glasses fogged up?”

“Have you tried eating more carrots?”

“I’ve seen potatoes with better eyes!”

“Hey Ump, how many fingers am I holding up?

Are you “seeing” a common theme here?

And interestingly, the evidence indicates fans have reason to question the judgement and visual acuity of most umpires.  A truly massive study of nearly 4 million pitches examined the accuracy of their calls over 11 regular seasons.  I didn’t know this, but it turns out, all major league stadiums are equipped with fancy cameras which track every ball thrown from mound to home plate.  Using this data, researchers found “botched calls and high error rates are rampant.”   How many you ask?  A staggering 34,246 incorrect calls in the 2018 season alone!  It gets worse.  When the pressure was on — a player at bat, for example, with two strikes — umpire errors skyrocket, occurring nearly one-third of the time.  Surely, the “umps” improve with time an experience?  Nope.  In terms of accuracy, youth and inexperienced win out every time!

Now, let me ask, are your “ears burning” yet?

Turns out, umpires and psychotherapists share some common traits.  So, for example, despite widespread belief to the contrary, clinicians are not  particularly good at detecting deterioration in clients.  How bad are we?  In one study, therapists correctly identified clients who worsen in their care a mere two-and-a-half percent of the time (1)!  Like umpires, “we call ’em as we see ’em.”  We just don’t see them.  And if you believe we improve with experience, think again.  The largest study in the history of research on the subject — 170 practitioners treating 6500 clients over a 5 year period — reveals that what is true of umpires applies equally to clinicians.  Simply put, on average, our outcomes decline the longer we are in the field.

If you are beginning to feel discouraged, hold on a minute.  While the data clearly show umpires make mistakes, the same evidence documents most of their calls are correct.  Similarly, therapists working in real world settings help the majority of their clients achieve meaningful change — between 64 and 74% in our database of thousands of clinicians and several million completed treatment episodes.

Still, you wouldn’t be too far “off base” were you to conclude, “room for improvement exists.”

Truth is, umpires and therapists are calling “balls and strikes” much the same way they did when Babe Ruth and Alfred Alder were key players.  Solutions do exist.  As you might guess, they are organized around using feedback to augment and improve individual judgement ability.  So far, major league baseball (and its umpires) has resisted.  In psychotherapy, evidence shows clients of therapists who formally and routinely solicit feedback regarding the quality of the therapeutic relationship and progress over time are twice as likely to experience improvement in treatment.

The measures are free for practitioners to use and available in 25+ languages.  If you don’t have them, click here to register.   You’ll likely need some support in understanding how to use them effectively.  Please join the conversation with thousands of colleagues from around the world in the ICCE Discussion Forum.  If you find yourself wanting to learn more, click on the icon below my name for information about our next upcoming intensive — online, by the way!

What more is there to say, except: BATTER UP!

Until next time, wishes for a safe and healthy Holiday season,

Scott

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

Take a look at the graphic to the left.  It shows the use of the Outcome and Session Rating Scales (ORS & SRS) from the beginning of this year to the present by users of one of the three , authorized FIT software programs.

What do you see?

A couple of things stand out for me.  First, a steady rise in administrations of the tools beginning in late January and continuing to the third week of March when use significantly dropped.  You can literally “see” the pandemic coming.  In the weeks and months that followed, use of the measures steadily recovered and is, as of today, up nearly 30% over its record high in the weeks before virus mitigation efforts brought the world to a standstill.

The cause of the rise in online use of the ORS and SRS is no mystery.  The number of therapists seeing clients virtually has, virtually, exploded.  In this “brave new world” of clinical practice, its clear clinicians are looking for concrete, evidence-based ways to augment the two-dimensional sensory input (sight and sound) characteristic of video conferencing.

In a previous blog, I summarized the research on the effectiveness of online behavioral health services.  The data are clear: it works.  More, a brand new meta-analysis, released just this week, adds to the body of evidence documenting that being physically present is not essential for successful outcomes.

The ORS and SRS are particularly well suited for online service delivery.   Indeed, the original validation studies of the two scales were actually conducted in a teletherapy setting.  It was the era before high-speed broadband and Zoom.  Therapists spoke with their clients by landline, administering the measures orally using a standardized script.  Since those early days, scores of studies have documented the impact of routinely soliciting formal client feedback on both outcome and retention in behavioral health services.  In one recent study, clients of therapists using the ORS and SRS were 2.5 times more likely to experience a successful outcome.  Using standardized measures as part of service delivery is now considered a “standard of care” by Joint Commission and SAMHSA.  Next year, the State of California follows suit, allowing psychologists to use the tools to earn required continuing education credits (see top of page 4, under “Practice Outome Monitoring [POM]”).

If you don’t have copies, you can get them for free here.   Looking for detailed instructions and “how to” videos on integrating the ORS and SRS into online services, click here — all free.  The six-volume set of feedback-informed treatment manuals is the most comprehensive source for using the tools to inform and improve mental health service delivery (if you don’t have a set, you can get the entire set for 80% off the full price through Friday December 4th.  At checkout, simply type in the code: FITMANUALS).

OK, that’s it for now.  Thanking you for your continuing friendship and interest, and wishing you, your family, and colleagues safety and health during these challenging times.

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

 

 

 

 

P.S.: Registration for the two FIT Intensives is open — both online! As always, space is limited to 40 participants to ensure quality and connection.  Click here for more information or to register.

It’s rarely good news when the phone rings in the wee hours of the morning.  This time, it was a colleague calling to let me know that Rich Simon — the founder and editor of the Psychotherapy Networker and long time friend — had died.

To say the news came as a shock would be a gross understatement.  In the early 1990’s, I sent an unsolicited article to the magazine for consideration.  Rich called me saying he liked the piece and wanted, with some minor revisions, to publish it.  After that, we began talking regularly by phone.  Sometimes the calls were brief.  Others went on for several hours spread out over days and weeks.

How best to describe Rich?  He was insatiably and infectiously curious, always hunting for whatever might improve the reach and effectiveness of psychotherapy.  I can hear his warm, distinct voice in my head right now, “Hey buddy,” he always started our conversations, quickly cutting to, “So, what you working on?”  And then, he’d listen, intently, following up with questions and a gentle challenge or two.  Throughout, it was clear Rich cared — about ideas, the field, people, and me.  I always left our conversations feeling as though I mattered, that I was contributing something vital and important to the field.  In the days since his death, I’ve learned I was not unique.  In fact, everyone I’ve spoken with said they had the same experience.  As one put it, “Rich had this uncanny ability to make you feel like you were his favorite.”

Our last conversation took place just a few weeks ago.  He called to thank me and my co-authors, Mark Hubble and Birgit Valla, for the article we’d written for the latest issue of the magazine.  None of us could imagine then what we would be experiencing now when we titled the piece, “Braving the Unknown.”  At this moment, I don’t have the words to describe what life will be like without him, without his dedication to, and genius in, bringing together the best ideas about the helping profession in one place.

If you never had a chance to meet Rich, or simply want to relive a few moments of his charm and wit, watch the memorial video below.  Should you want to add your own reflections or experiences, a special page has been set up on Facebook.

Wishing you peace, health, and safety,

Scott

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

Here is a smattering of the articles I wrote for Rich over the last 30 years:

Braving the Unknown: The Search for New Solutions (September/October 2020)

Meet You in McGinnis Meadows (January/February 2020)

How Psychotherapy Lost its Magic: Healing in the Age of Science (March/April 2017)

Burnout Reconsidered (May/June 2015)

The Road to Mastery (2011)

Supershrinks: Learning from the field’s most effective practitioners (November/December, 2007)

How Being Bad Can Make your Better (2007)

Exposing the Mythmakers: How the soft sell has replaced hard science (2000)

Their Verdict is Key (1999)

No More Bells and Whistles (1995)

The Resistant Substance Abuser: Court Mandated Cases can Pose Special Problems (1992)