[Read more…]

Chances are your are carrying a smartphone–maybe you’re even reading this post on your Android or Iphone!  One thing I’m almost certain of is that the device you own–can’t live without–is not a Nokia.

The nearly complete absence of the brand is strange.  Not long ago, the company dominated the mobile phone market.  At one time, seventy percent of phones in consumers’ hands were made by Nokia.

“And then,” to quote Agathe Christie, “there were none!”

Today, Nokia’s global market share is an anemic 3 %.

What happened?  Here, the answer is no mystery.  It was not a lack of position, talent, innovative ideas, or know-how.  Rather, the company failed at implementation.  Instead of rapidly adapting to changing conditions, it banked on its brand name and past success to carry it through.  Vague considerations trumped concrete goals.  Spreadsheets and speeches replaced communication, consensus-building, and commitment.   The moral of the story?  No matter how successful the brand or popular the product, implementation is hard.

Nowhere is this truer than in healthcare.  Change is not only constant but accelerating. Each week, hundreds of research findings are published.  Just as frequently, new technologies come online. All have the potential to do good, to improve the quality and outcome of treatment.

Research to date, for example, documents that seeking ongoing, formal feedback from those receiving behavioral health services as much as triples the effectiveness of the care offered, while simultaneously cutting the rate of drop out by 50%, and decreasing the risk of deterioration by 33%.  Enough evidence has amassed to warrant the approach–known as, “Feedback Informed Treatment”– being listed on the National Registry of Evidence-Based Programs and Practices.

Any yet, despite the massive amount of time and resources, agencies and practitioners devote to staying “up-to-date,” most implementation efforts struggle, and far too many fail–according to the available evidence, about 70-95% (a figure equivalent to the number of start-up businesses in the United States that belly up annually).

In their chapter in the new book, Feedback Informed Treatment in Clinical Practice, Randy Moss and Vanessa Mousavizadeh, provide step-by-step instructions, based on the latest research and real-world experience, for creating an organizational culture that supports implementation success.  Recently, I had a chance to talk with Randy about the chpater.  Whether you’ve got the book or not, I think you’ll find the knowledge and experience in the video below, helpful:

Online version of the Fidelity Readiness Index and Fidelity Measure

In the meantime, while on the subject of implementation, here’s a cool, electronic version of a tool you can use to track the progress of your efforts.  It helps identify where you and your organization are in the process as well as identify and set goals in order to remain on track (it’s one of the reasons reviewers at SAMHSA gave our application perfect marks for implementation support).  Thanks to my Danish colleague, Rasmus Kern for developing and making it available.  By the way, the program contains both English and Danish versions (we’ll be releasing more languages soon).

Take the FRIFM Assessment

Until next time,

Scott

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

“Everyone understands how a toilet works, don’t you?” ask cognitive scientists Sloman and Fernbach.

The answer, according to their research, is likely no.  Turns out, peoples’ confidence in their knowledge far outstrips their ability to explain how any number of simple, every day items work — a coffeemaker, zipper, bicycle and yes, a toilet.   More troubling, as complexity increases, the problem only worsens.  Thus, if you struggle to explain how glue holds two pieces of paper together — and most, despite being certain they can, cannot — good luck accounting for how an activity as complicated as psychotherapy works.

So pronounced is our inability to recognize the depth of our ignorance, the two researchers have given the phenomenon a name: the “Illusion of Explanatory Depth.”  To be sure, in most instances, not being able to adequately and accurately explain isn’t a problem.  Put simply, knowing how to make something work is more important in everyday life than knowing how it actually works:

• Push the handle on the toilet and the water goes down the drain, replaced by fresh water from the tank;
• Depress the lever on the toaster, threads of bare wire heat up, and the bread begins to roast;
• Replace negative cognitions with positive ones and depression lifts.

Simple, right?

Our limited understanding serves us well until we need to build or improve upon any one of the foregoing.  In those instances, lacking true understanding, we could literally believe anything — in the case of the toilet, a little man in the rowboat inside the tank makes it flush — and be just as successful.   While such apparent human frailty might, at first pass, arouse feelings of shame or stupidity, truth is operating on a “need to know” basis makes good sense.  It’s both pragmatic and economical.  In life, you cannot possibly, and don’t really need to know everything.

And yet, therein lies the paradox: we passionately believe we do.  That is, until we are asked to provide a detailed, step-by-step, scientifically sound accounting — only then, does humility and the potential for learning enter the picture.

When research on routine outcome monitoring (ROM) first began to appear, the reported impact on outcomes was astonishing.  Some claimed it was the most important development in the field since the invention of psychotherapy!  They were also quite certain how it worked: like a blood test, outcome and alliance measures enabled clinicians to check progress and make adjustments when needed.  Voila!

Eight years ago, I drew attention to the assertions being made about ROM, warning “caution was warranted. ” It was not a bold statement, rather a reasoned one.   After all, throughout the waning decades of the last millennium and into the present, proponents of cognitive (CT) and cognitive behavioral therapy (CBT) had similarly overreached, claiming not only that their methods were superior in effect to all others, but that the mechanisms responsible were well understood.  Both proved false.  As I’ve written extensively on my blog, CT and CBT are no more effective in head to head comparisons with other approaches.  More, studies dating back to 1996 have not found any of the ingredients, touted by experts as critical, necessary to success (1, 2, 3).

That’s why I was excited when researchers Mikeal, Gillaspy, Scoles, and Murphy (2016) published the first dismantling study of the Outcome and Session Rating Scales, showing that using the measures in combination, or just one or the other, resulted in similar outcomes.  Some were dismayed by these findings.  They wrote to me questioning the value of the tools.  For me, however, it proved what I’d said back in 2012, “focusing on the measures misses the point.”  Figure out why their use improves outcomes and we stop conflating features with causes, and are poised to build on what most matters.

On this score, what do the data say?  When it comes to feedback informed treatment, two key factors count:

1. The therapist administering the measures; and
2. The quality of the therapeutic relationship.

As is true of psychotherapy-in-general, the evidence indicates that who uses the scales is more important that what measures are used (1, 2).  Here’s what we know:

• Therapists with an open attitude towards getting feedback reach faster progress with their patients;
• Clinicians able to create an environment in which clients provide critical (e.g., negative) feedback in the form of lower alliance scores early on in care have better outcomes (1, 2); and
• The more time a therapists spend consulting the data generated by routinely administering outcome and alliance measures, the greater their growth in effectiveness over time.

In terms of how FIT helps, two lines of research are noteworthy:

• In a “first of its kind” study, psychologist Heidi Brattland found that the strength of the therapeutic relationship improved more over the course of care when clinicians used the Outcome and Session Rating Scales (ORS & SRS) compared to when they did not.  Critically, such improvements resulted in better outcomes for clients, ultimately accounting for nearly a quarter of the effect of FIT.
• Brattland also found therapists, “significantly differed in the influence of … [FIT] on the alliance, in the influence of the alliance on outcomes, and the residual direct effect of [FIT] … posttreatment” (p. 10).  Consistent with other studies, such findings indicate routine measurement can be used to identify a clinician’s “growth edge” — what, where, and with whom — they might improve their ability to relate to and help the diverse clients met in daily work.  Indeed, the combination of FIT, use of aggregate data to identify personal learning objectives, and subsequent engagement in deliberate practice has, in the only study in history of psychotherapy to date, been shown to improve effectiveness at the individual practitioner level.

“Inch by inch, centimeter by centimeter,” I wrote back in 2012, “the results of [new] studies will advance our understanding and effectiveness.”  I’m hopeful that the discussion in this and my two prior posts (1, 2) will help those interested in improving their results avoid the vicious cycle of hope and despair that frequently accompanies new ideas in our field, embracing the findings and what they can teach us rather than looking for the next best thing.

Until next time,

Scott

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

P.S: The March Intensives are sold out.  Register now for the summer trainings to ensure your spot:

Is it just me or has public discourse gone mad?

A brief perusal of social media largely finds accusation, name calling, and outrage instead of exploration, dialogue and debate.  Not that any of the latter options were ever simple, straightforward, or successful, but somehow, somewhere, taking a stand has replaced extending a hand.

Thus, slightly more than a year ago, I was compared to an ignorant, cult leader by a person — a researcher and proponent of CBT — who’d joined an open discussion about a post of mine on Facebook.  From there, the tone of the exchange only worsened.  Ironically, after lecturing participants about their “ethical duties” and suggesting we needed to educate ourselves, he labelled the group “hostile” and left, saying he was going to “unfriend and block” me.

As I wrote about in my last blogpost, I recently received an email from someone accusing me of “hiding” research studies that failed to support feedback informed treatment (FIT).  Calling it “scandalous,” and saying I “should be ashamed,” they demanded I remove them from my mailing list.  I did, of course, but without responding to the email.

And, therein lies the problem: no dialogue. 

For me, no dialogue means no possibility of growth or change — on my part or other’s.  To be sure, when you are public person, you have to choose to what and whom you respond.  Otherwise, you could spend every waking moment either feeling bad or defending yourself.  Still, I always feel a loss when this happens.  I like talking, am curious about and energized by different points of view.

That’s why when my Dutch colleague, Kai Hjulsted, posted a query about the same study I’d been accused of hiding, I decided to devote several blogposts to the subject of “negative research results.”  Last time, I pointed out that some studies were confounded by the stage of implementation clinicians were in at the time the research was conducted.  Brattland et al.’s results indicate, consistent with findings from the larger implementation literature, it takes between two and four years to begin seeing results.  Why?  Because becoming feedback-informed is not about administering the ORS and SRS — that can be taught in a manner of minutes — rather, FIT is about changing practice and agency culture.

(By the way, today I heard through the grapevine that a published study of a group using FIT that found no effect has, in its fourth and fifth years of implementation, started to experience fairly dramatic improvements in outcome and retention)

As critical as time and ongoing support are to successful use of FIT, these two variables alone are insufficient for making sense of emerging, apparently unsupportive studies.  Near the end of my original post, I noted needing to look at the the type of design used in most research; namely, the randomized controlled trial or RCT.

In the evaluation of health care outcomes , the RCT is widely considered the “gold standard” — the best way for discovering the truth.   Thus, when researcher Annika Davidsen published her carefully designed and executed study showing that adding FIT to the standard treatment of people with eating disorders made no difference in terms of retention or outcome, it was entirely understandable some concluded the approach did not work with this particular population.  After all, that’s exactly what the last line of the abstract said, “Feedback neither increased attendance nor improved outcomes for outpatients in group psychotherapy for eating disorders.”

But what exactly was “tested” in the study?

Read a bit further, and you learn participating “therapists … did not use feedback as intended, that is, to individualize the treatment by adjusting or altering treatment length or actions according to client feedback” (p. 491).  Indeed, when critical feedback was provided by the clients via the measures, the standardization of services took precedence, resulting in therapists routinely responding, “the type of treatment, it’s length and activities, is a non-negotiable.”  From this, can we really conclude FIT was ineffective?

More, unlike studies in medicine, which test pills containing a single active ingredient against others that are similar in every way except they are missing that key ingredient, RCTs of psychotherapy test whole treatment packages (e.g., CBT, IPT, EMDR, etc.).  Understanding this difference is critical when trying to make sense of psychotherapy research.

When what is widely recognized as the first RCT in medicine was published in 1948, practitioners could be certain streptomycin caused the improvement in pulmonary tuberculosis assessed in the study.  By contrast, an investigation showing one psychotherapeutic approach works better than a no treatment control does nothing to establish which, if any of, the ingredients in the method are responsible for change.  Consider cognitive therapy (CT).  Many, many RCTs show the approach works.  On this score, there is no doubt.  People who receive it are much better off than those placed on a waiting list or in control groups.  That said, how cognitive therapy works is another question entirely.  Proponents argue its efficacy results from targeting the patterns of “distorted thinking” causally responsible for maladapative emotions and behaviors.  Unfortunately, RCTs were never designed and are not equipped to test such assumptions.  Other research methods must be used — and when they have been, the results have been surprising to say the least.

In my next post, I will address those findings, both as they apply to popular treatment models such as CT and CBT but also, and more importantly, to FIT.

Stay tuned.  In the meantime, I’m interested in your thoughts thus far.

Until then,

Scott

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

A ship’s captain who successfully sails through a strait at night learns nothing, and adds nothing, to their knowledge of the world.

(Please hang with me.  I promise this post will not be a long, metaphysical rant).

Returning to the example.  As paradoxical as it may strike one at first blush, a captain whose ship founders on the rocks while sailing through the strait both learns and adds to their knowledge.  As philosopher Ernst von Glasersfeld once opined, “The only aspect of that ‘real’ world that actually enters into the realm of experience is its constraints.”

The principle identified by von Glasersfeld applies not only to life lessons, but also to scientific advancement and, of course, feedback informed treatment (FIT).  Indeed, identifying and learning from “constraints” — that is, when things go wrong — is the very purpose of FIT.

It’s why, for example, when a client refuses to complete the outcome and alliance measures, my first impulse is to “lean in” and explore their reasons, rather than instantly set the scales aside.   It’s also why I’m most intrigued by studies which find that FIT fails to improve outcome (1, 2).  In both instances, my curiosity is piqued.  “Finally,” I think, “a chance to learn something …”.   Doing so, cognitive science has long shown, is not as easy or straightforward as simply adjusting our beliefs in light of new facts.  Quite to the contrary.

We are prone to see what we expect, fit the “different” into our current way of viewing the world or ignore it altogether.  One brief example before turning attention to FIT (aka Routine Outcome Monitoring [ROM]).  For most of the history of the field, the failure to engage in and respond to psychological intervention has been attributed to a host of client variables (e.g., degree or type of dysfunction, poor attachment history, IQ, etc.).  Therapists, for their part, have been held accountable for making the correct diagnosis and administering the right treatment.

And yet, despite continuous growth in the size of the DSM, and number of treatment approaches, no improvement in the outcome of psychotherapy has occurred in the last 50 years — a fact I first talked publicly about in 2014 and which über-researchers James Prochaska and John Norcross finally acknowledged in the most recent issue of the American Psychologist.  While some have argued that the field’s flat outcomes indicate the effectiveness therapy has reached a natural limit, an alternate point of view is that we should consider looking beyond the current ways of thinking about what matters most in successful treatment.

On this score, one possibility has been staring the field in the face for decades: the impact of the individual therapist on outcome.  Research has long shown, for example, that who does the treatment contributes 5 to 9 times more to outcome than the type of therapy, psychiatric diagnosis, or client history.  The same body of evidence documents some practitioners are consistently more effective than others.  When researcher Scott Baldwin and colleagues looked into why, they found 97% of the difference was attributable to therapist variability in the alliance.  Said another way, more effective therapists are able to establish a strong working relationship with a broader and more diverse group of clients.  I hope you’re seeing new possibilities for improving effectiveness.  If you’re a regular reader of my blog, you already know my colleagues and I published the only study to date documenting that a focus on therapist development via routine outcome measurement, feedback, and deliberate practice improves both agency and individual practitioner outcomes.

Turning to FIT, in my first post of the New Year, I talked about the strong sense of “anticipointment” I felt when thinking about the future of our field.  A colleague from the Netherlands, Kai Hjulsted, responded, saying he’d been having the same feeling about FIT!  The source, he said, was a study by a Dutch researcher conducted in a crisis intervention setting which, “contrary to expectations,” found, “Patients with psychiatric problems and severe distress seeking emergency psychiatric help did not benefit from direct feedback.”

I was well aware of this study, having served on the researcher’s dissertation committee.  And over the last decade, multiple studies have been published showing little or no benefit from feedback (e.g., 1, 2, 3).

How to make sense of such findings?  Having spoken with numerous practitioners (and even some researchers), I can tell you the tendency is to fit the results into our current way of viewing the world.  So, seen through a traditional medicopsychiatric lens, the inevitable conclusion is FIT does not work with people with certain, specific diagnosis (e.g., severe distress, in crisis, or those with eating disorders).  Such a conclusion makes no sense, however, if the totality of evidence is considered.  Why?  Because the results are decidedly mixed.  Thus, in one study, FIT makes a difference with people in crisis, in another it does not.  With one group of “severely distressed” clients, feedback appears to make matters worse, with another, chances of improvement increase 2.5 times.

What then can we conclude?

An answer begins to emerge as soon as we’re able to get beyond thinking of FIT as just one more in a long list of treatment methods rather than a fundamental, organizing principle of agency and practice culture.  As is hopefully obvious, learning to administer measurement scales takes little time.

Cultural change, by contrast, is a much longer process.  How long?  Norwegian researcher Heidi Brattland and colleagues found it took three years ongoing training and support to successfully implement FIT.  Had they stopped to evaluate, like all other studies to date, after an average of 4 hours of instruction, no impact on outcomes would have been recorded.

While its now clear that time and support are critical to successful implementation, these two variables alone are not sufficient to make sense of emerging, apparently unsupportive studies of FIT.  Addressing such findings requires we look at the type of design used in most research: the randomized controlled trial.   That I’ll do in my next post, in particular addressing two, top notch, well-executed studies many have assumed show FIT is not effective in psychological care for people with eating disorders and severe distress.

And so, as I asked at the outset, please “hang with me.”

Until next time,

Scott

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

“I heard Scott Miller say it,” the man sitting next to me said.

“Really?” I responded, somewhat incredulous.  After all, I didn’t recall ever saying such a thing.  More to the point, it’s just not something I would say.  Its wrong.  Then again, it was clear he didn’t know that I was Scott Miller.  Not wanting to disrupt the presenter before me at the conference, I’d quietly snuck into the room, dressed in my “civies,” shortly after the meeting had started.

“Yep,” he replied, his voice full of certainty, “as I understand it, he says it all the time.”  Making “air” quote marks with his fingers, “If the client is not changing within three visits, you should terminate the treatment.”

You should have seen the look on his face when later our eyes met as I took to the stage to do my presentation.

On many occasions over the years, I’ve heard people quote me saying things I’ve never said.  Here’s a common one:

“Scott Miller says all you need for successful treatment is a good therapeutic relationship.”

Just so you know, I’ve never said this.  Ever. And yet, once, after I corrected a nationally known practitioner in front of a large audience, he nonetheless repeated it in his newsletter.  Here’s what I have said and continue to say:

• All treatment models work equally well.  All.
• Of all the factors affecting outcome, the specific approach used has the smallest impact.  By comparison, the relationship between client and therapist contributes eight to nine times more. 

Another:

“Scott Miller says therapists help 80% of their clients.”

Once again, I’ve never said this.  In this instance, the misquote is more understandable.  Here’s what I do say at almost every workshop:

• Decades of research and hundreds of study document psychotherapy works.
• The effectiveness of psychotherapy has remained fairly stable over the years.
• In most studies, the average treated client is better off than 80% of the untreated comparison sample.

I’m certain it’s the last of these statements that causes problems.  Presented, as it, is in “researchspeak,” it’s easy to misunderstand.  Read it again and you’ll see it does not mean we help 80% of our clients.  Rather, its about the advantage therapy offers relative to receiving no treatment at all.  By contrast, the percentage we help — as I’ve blogged about on numerous occasions — is actually around 50%.

Now, in the interest of fairness, let me mention something I often say but have never heard misquoted.  At nearly of all my workshops, I joke, “The ORS and SRS may not be the best scales ever developed … but they are free!”  The latter part of that statement is absolutely true.  Clinicians wishing to solicit feedback from clients about their progress and the quality of the therapeutic relationship simply need to register for a free paper and pencil license.  That said, recent research out of the University of Nottingham is giving me pause about the other half.

Just last week, I interviewed Professor Sam Malins who, together with a team of others, has been studying the use of the scales in real world clinical settings for a number of years.  In addition to replicating a number of important findings (e.g., the longer you use the ORS and SRS, the more impact they have on retention and effectiveness; spending time gathering information for diagnosis and treatment planning results in poorer outcomes, the scales can be used to identify skill development opportunities), he also found the Outcome Rating Scale predicted …  oh, just watch the video yourself.  That way, I won’t be misquoted!

Until next time,

Scott

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

Remember these?

Did you ever own or try one?

Remember Beanie Babies?  According to one news story, interest was such, “People neglected other areas of their lives to spend all day trading, and some even invested their children’s college funds in toys that they believed would bring an astronomical return on investment.”

And how about advertising executive Gary Dahl’s product?  You remember him, right?  In the 1970’s, he became an overnight millionaire selling rocks marketed as pets.  Rocks!  Waterbeds, Crocs, cause-branded plastic wristbands, oxygen bars, Pogs, Silly Bandz, and the Macarena — the list is as endless as our attention span is short.

If you’ve been in practice for a while, you know the field of mental health is not immune to fad and fashion.  Like past diet crazes, the drugs, diagnoses, and treatment methods that capture professional interest and then quickly disappear can be hard to remember.  Thus, in the 1980’s it was Xanax, multiple personality disorder, and satanic cult abuse.  The 1990’s brought us the “decade of the brain,” borderline personality disorder, and a flood of Prozac and cognitive-behavior therapy knockoffs.  More recently, mindfulness, energy meridians, and trauma have become the objets de grand intérêt.

One more trend is Feedback-Informed Treatment (FIT).  Known also as Routine Outcome Monitoring, Patient Focused Research, and Measurement-based care, it involves using scales to solicit feedback from clients regarding their experience in treatment and using the resulting information in real time to improve quality and outcome.  The weight of the scientific evidence is such that professional and regulatory bodies in the U.S. and abroad have already deemed ROM a “standard” of care in the delivery of psychological services and clinical supervision (American Psychological Association Presidential Task Force on Evidence-based Practice, 2006; Association of State and Provincial Psychology Boards, 2019; Joint Commission, 2018; Tasca et al., 2019).

But is it just another fad?

Data from two recent surveys suggest FIT is moving beyond the “innovation” to the “mass adoption” phase among mental health providers and treatment agencies.  The study conducted by Myoutcomes® targeted members of Facebook-related psychotherapy interest groups and other sources, finding fairly dramatic growth in: (1) awareness of the empirical support for using measures to assess progress and the quality of the therapeutic relationship; and (2) experience with standardized measurement tools in psychotherapy.

Whether such results indicate FIT will stick around long enough to be the “game changer” remains to be seen.  What is known for sure is that, while important, awareness of, experience with, and research support for the process are insufficient to sustain the interest.  Research shows, for instance, successful implementation of FIT takes significant time, planning, and support, without which between 70 and 95% of efforts fail.  Why?  Because working feedback-informed is about changing culture, not using measurement scales in treatment.  Success requires that all members of management — from administration to clinical supervisors — understand and are actively involved in implementation.  Indeed, when practitioners rather than a team led by a manager are held accountable, the likelihood of FIT being a game changer plummets (80% versus 14 %).

Bottom line?  PLEASE don’t download the ORS and SRS and begin experimenting — testing it out to see “if it works.”  As I blogged about last week, the likelihood of failure is simply too high.   Instead, bring your team to our upcoming Spring intensives in Chicago.  You’ll not only “rub shoulders” with colleagues from around the world and our international faculty, but also leave with a thorough grounding in FIT, as well as skills for transforming the culture in which you work.

Until next time,

Scott

Director, International Center for Clinical Excellence

A couple of weeks ago I received an email from the leader of a group asking me to send them copies of the ORS and SRS. “We are to start using these straight away,” the person wrote.

I replied, of course, providing a link to my website where the scales could be downloaded along with a brief note, highlighting the Feedback Informed Treatment (FIT) Manuals and the upcoming March Intensives in Chicago.  “Both are great resources,” I said, “for learning how to use the measures to improve the quality and outcome of behavioral health services.”

I received a quick and polite response, thanking me for the links but going on to say, “I’ve seen the scales. They are really very simple and self-explanatory so I don’t think we really need much in the way of training or support materials.”

I’d like to say I was surprised. After all, what medical professional would say something similar?  Say, about a stethoscope?  To wit, “No thanks, seems pretty simple, stick these thingies in my ears, and the other end on the patient’s chest and listen…”.

But I was not — surprised, that is. Why?  Of the several hundred downloads of the measures from my website per week, and the more than 200,000 over the last decade, very few practitioners have sought or received any training.  Indeed, most have never even read the FIT manuals!

The impact on those who are initially enthusiastic about seeking formal feedback from their clients is as predictable as it is sad: they quickly give up.  How do I know, you ask?  Every week, as I’m out and about, training and consulting, I run into practitioners who say:

“Yeah, I heard of FIT, I even tried the scales…but they didn’t work…”

“I tried the ORS and SRS scales for a while, but I didn’t get any clinically useful information from them…”

“My clients weren’t honest … so I stopped using them”

And so I ask, what does it take to help people get the information and training they need to succeed?  The question is far from trivial or self-serving.  The measures are free to download and the latest research shows using them more than doubles the chances of helping clients experience meaningful change.  The only caveat is that, despite their simplicity, learning to employ the tools effectively takes time and support.  How do I know that?  Research, of course!

If you have thoughts about what I can do to address this problem, please let me know. In the meantime, in an effort to help, here are several offers:

1. For the time being, get the FIT Treatment and Training Manuals for 50% off;

2. Register for the combined FIT Advanced and Supervision Intensive now using the code FIT-Promo at checkout and get an additional discount off the early bird rate;

3. Sign up for the cutting-edge FIT e-learning program — where you can learn at your own pace from the comfort of your home — and receive the new, deliberate practice module, for free (if interested, email me for details about this offer).

Yes, please feel free to share these links and codes with your colleagues.  And, once more, if you have additional suggestions, I’m interested in hearing them.  Please post a comment below.

That’s it for now.

All the best for the Holidays,

Scott

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

It was a curious finding.  One we stumbled on quite by accident.  Highly effective therapists were more likely to contact their clients between visits than their more average peers.  We wondered whether such behavior might account, at least in part, for their superior retention rates and outcomes?

Turns out, our serendipitous finding fit nicely with results from the field of behavioral economics documenting how very simple actions can have a dramatic impact on people’s behavior.   In one well known example, a study showed the way food is displayed in school cafeterias –it’s location and prominence–significantly impacts whether students make healthy or unhealthy eating choices.  Similar results have been recorded in other areas, such as saving for retirement, choosing the best health insurance plan, deciding whether to exercise or make positive lifestyle changes.

In all cases, the “nudge” –as researchers call such interventions — are simple, inexpensive, and require little time and effort to deliver.  A recent report in The Chronicle of Higher Education found, for example, a single email expressing compassion and support to students who had failed their first semester exam led to better classroom performance and less school drop out.  And since our original discovery, psychotherapy researchers have confirmed what highly effective practitioners have known all along.  The study by Flükiger, Del Re, Wampold, Znoj, Caspar, and Jörg found that clients who were sent a brief letter and had one follow up call between visits experienced significant and lasting improvements in the quality of the therapeutic relationship over the course of care.

Clearly, a little can go a long way.  But where to start?

It would be wrong to conclude that we should start phoning (or sending emails) to all of our clients between visits.  The research cited above and findings from our interviews with highly effective therapists show, to be effective, therapeutic nudges must interrupt “business-as-usual.”  The default choice for most practitioners is not to engage in extratherapeutic contact with clients.  We are busy enough and reaching out crosses a boundary.  Additionally, and importantly, any such efforts need to show our interest in the client while simultaneously leaving them free not to comply.  Simply put, nudges can not be shoves.  

Evidence shows using simple measurement scales on an ongoing basis to  assess progress and the quality of the therapeutic relationship can augment our ability to identify and time these types of interventions.  Indeed, as I posted last week, clients whose therapists do so are less likely to dropout and 2.5 times more like to experience benefit from treatment.   Actually, 10’s of thousands of clinicians around the world are using the tools I created nearly 20 years ago to inform their work.  If you aren’t, click here to download them for free.

In the meantime, if you are looking for new and creative ways to nudge your therapeutic effectiveness upwards, join me in Chicago for one or more of our Summer workshops:

• The two-day “FIT Implementation intensive” is the only evidence-based workshop in the U.S. designed to help you implement feedback informed treatment in your agency or healthcare system.
• The three-day “Training of Trainers” will enhance your presentation and training skills.  It’s a blast, the most fun workshop we do.
• Last but not least, the two-day “Deliberate Practice” workshop will, as the name implies, help you use deliberate practice to improve your clinical effectiveness.  We help you identify the targets and develop a plan.

All the best,

Scott

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

Several weeks ago, the American Psychological Association (APA) released its latest in a series of practice guidelines for psychologists – this time for “Psychological Practice with Boys and Men.”  Prior years had seen guidelines focused on ethnicity, older adults, girls and women, LGBT, and “transgender and gender-non-conforming” persons.

Curiously, despite claiming to be based on 40 years of research, and the product of 12 years of intensive study, the latest release attracted little attention.  More, the responses that have appeared in print and other media have largely been negative (1, 2, 3, 4, 5). 

What happened?

At first blush, the development and dissemination practice guidelines for psychologists would seem a failsafe proposition.  What possibly could go wrong with providing evidence-based information for improving clinical work?  And yet, time and again, guidelines released by APA end up not just attracting criticism, but deep concern.   Already, for example, a Title IX complaint has been filed against the new guidelines at Harvard.

Consider others released in late 2017 for the treatment of trauma.  Coming in at just over 700 pages ensured few, if any, actual working professionals would read the complete document and supportive appendices.  Beyond length, the way the information was presented–especially the lack of hypertext for cross referencing of the studies cited–seriously compromised any straightforward effort to review and verify evidentiary claims.  Nevertheless, digging into the details revealed a serious problem:  a discontinuity between the evidence reviewed and the conclusions reached.  For example, despite “strongly recommending” certain approaches over others, none that topped the list had actually been shown by research to be more effective than any other.

Guidelines are far from benign.  They are meant to shape practice, establishing a “standard of care” — one that will be used, as the name implies to guide training and treatment.  As such, the stakes are high, potentially life altering for both practitioners and those they serve.

And so, on reading the latest release from the APA, we wonder about the consequences for men and boys.  Even a superficial reading leaves little to recommend “being male.”  Gone are any references to the historical or current contributions of men — to their families, communities, marginalized peoples, culture, or civilization.  In their place, are a host of sweeping generalizations often wrapped in copious amounts of political, progressive jargon on a wide variety of subjects, many of which are the focus of research and debate by serious scientists (e.g., the connection between media violence and male aggression, socialization as a primary cause of gender and behavior, the existence of a singular versus multiple masculine ideal, etc.).

Cutting to the chase, when viewed in this way, is it any wonder really, that many men – as the document accurately points out – “do not seek help from mental health professionals when they need it?” (p. 1).

And lest there be any doubt, men as a group, are in need help.  

You’ve likely read the statistics, seen examples in your practice, perhaps in the life of your family or friends.   It starts young, with boys accounting for 90% of discipline problems in schools, and continues to the end of life, with women living 5 to 10 years longer on average.  The “in between” years are not any better, with men significantly more likely to be incarcerated, addicted to drugs, drop and fail out of school, and end their lives by suicide.

To be clear, the document is not overarchingly negative.  At the same time, if our goal, as a profession, is to reduce stigma — which previous, and even the present, guidelines do for other groups and “non-traditional” males — then the latest release risks perpetuating stereotypes and prejudices of “traditional” men and the people in their orbit.

Sticking to the science of helping, instead of conforming to popular standards of public discourse, would have lead to a very different document – one containing a more nuanced and appreciative understanding of the boys and men who are reluctant to seek our care.  In the fractious times in which we find ourselves, perhaps it’s time for guidelines on how to live and work together, as individuals and as a species.

As always, interested in your thoughts,

Scott & David

Scott D. Miller, Ph.D. & David Prescott, LICSW
International Center for Clinical Excellence

P.S.: Registration for our Summer Intensives on Implementing Feedback Informed Treatment and Deliberate Practice is now open — two clinical practices research shows improves retention and outcome in behavioral health care.   For more information, click here.

I’m neither a great psychotherapist or surfer.  I love doing both, however.

Turns out, the two share a fundamental similarity critical to successful execution; in a word, responsiveness.

Scott

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

P.S: Registration is open for the FIT Summer Intensive Trainings.  Click on the icons below for more information or to register.

In my travels each year, I meet 1,000’s of clinicians–professionals who truly want to help others, and are willing to try almost anything to do so.

That’s why I always “lean in” whenever one expresses concern about the rising popularity of using formal measures of progress and the therapeutic relationship to inform and improve the quality and effectiveness of behavioral health services.

The clinicians I meet are usually aware of the research behind the call to incorporate client feedback into care: (1) many people who begin in treatment (~50 to 65%), leave without experiencing a measured improvement in their functioning or well being; and (2) randomized controlled trials show that doing so improves outcomes and reduces costs (1, 2).

Still, they wonder, “What do clients think?” “Do they consider filling out the forms helpful, or a burden?”

Those asking the question have a point. After all, the measures must be used every session with every client, despite studies to date showing the effects of asking for feedback are largely confined to those not making progress. Said another way, many asked to complete measures (between 35-50%), will experience no benefit from participating in the process.

When answering this question, I’ve always relied on what I’ve been able to glean from available studies (1, 2) and my personal experience. “Rarely do my client’s object,” I say, adding, “Neither have other clinicians reported that their clients consider it a burden.” And the research to date, although sparse, largely confirms that experience.

Overall, clients report that using measures is both positive and beneficial, enabling them to: (1) play an active in the care they receive; (2) maintain a focus on what matters most to them; and (3) collaborate more effectively with their treatment provider.

That said, problems have been noted. Chief among these are therapists failing to explain the nature and purpose of the scales (e.g., validity, confidentiality of the data, rationale) as well as not using the resulting feedback to guide service delivery (e.g., increase responsiveness to individual client needs, goals, and preferences; promote greater reflection and collaboration between therapist and client; address problems in the therapeutic relationship; and change the nature, frequency, type or provider of services).

Neither of these findings are particularly surprising. If there’s anything more frustrating than being forced to complete seemingly irrelevant paperwork, it is being asked for feedback and then having it ignored. That said, if the results are so damned obvious, “Why do the problems keep happening?”

The answer, in a word, is: integration.

Learning how to administer progress and alliances measures is simple. Instructions for giving, scoring, and plotting the Outcome and Session Rating Scales, literally takes less than 90 seconds. Making the tools an integral part of one’s clinical work–instead of bookends marking the beginning and end of each visit–is an entirely different matter. Back in May, I blogged about a new study showing that such integration takes time, between two to four years. Once done, however, the results are impressive, with clients whose therapists actively use measures two and a half times more likely to experience improvement.

Integrating feedback tools into your clinical style is the subject of the upcoming, three-day “Advanced Intensive” training on Feedback-Informed Treatment in Chicago.

We go far beyond the basics, giving you concrete strategies and skills for engaging clients in the feedback process, and using the resulting information to improve the quality and outcome of the services you offer.

In 2013, the methods you will learn were vetted by the National Registry and deemed evidence-based. As in prior years, the training is on track to sell out early. Click here, or on either of the banners below, to register or learn more.

Until next time,

Scott

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

It’s just two weeks ago.  I was on a call with movers and shakers from a western state.  They were looking to implement Feedback Informed Treatment (FIT)–that is, using measures of progress and the therapeutic relationship to monitor and improve the quality and outcome of mental health services.

I was in the middle of reviewing the empirical evidence in support of FIT when one of the people on the call broke in.  “I’m a little confused,” they said hesitantly, “I thought you were the anti-evidence-based practice guy.”

It’s not the first time I’ve been asked this question.  In truth, it’s easy to understand why some might believe this about me.  For more than two decades, I have been a vocal critic of the idea that certain treatments are more effective for some problems than others.  Why?  Because of the evidence!  Indeed, one of the most robust findings over the last 40 years is that all approaches work equally well.

Many clinicians, and a host of developers of therapeutic approaches, mistakenly equate the use of a given model with evidence-based practice.  Nothing could be further from the truth.  Evidence-based practice is a verb not a noun.

According to American Psychological Association and the Institute of Medicine, there are three components: (1) using the best evidence; in combination with (2) individual clinical expertise; while ensuring the work is consistent with (3) patient values and expectations.  “FIT,” I responded, “not only is consistent with, but operationalizes the definition of evidence-based practice, providing clinicians with reliable and valid tools for identifying when services need to be adjusted in order to improve the chances of achieving a successful outcome.”

Here’s another recent question: “I’ve read somewhere that FIT doesn’t work.”  When I inquired further, the asker indicated they’d been to a conference and heard about a study showing FIT doesn’t improve effectiveness (1).  With the rising popularity of FIT around the world, I understand how someone might be rattled by such a claim.  And yet, from the outset, I’ve always recommended caution.

In 2012, I wrote about findings reported in the first studies of the ORS and SRS, indicating they were simply, “too good to be true.”  Around that same time, I also expressed my belief that therapists were not likely to learn from, nor become more effective as a result of measuring their results on an ongoing basis.   Although later proven prophetic (1, 2), mine wasn’t a particularly brilliant observation.  After all, who would expect using a stopwatch would make you a faster runner?  Or a stethoscope would result in more effective heart surgeries?  Silly, really.

What does the evidence indicate?

• The latest, most comprehensive meta-analysis of studies published in the prestigious, peer-reviewed journal, Psychotherapy Research, found that routine use of the ORS and SRS resulted in a small, yet significant impact on outcomes.

• Improving the outcome of care requires more than measurement.  If FIT is to have any effect on engagement and progress in care, clinicians must be free of programmatic and structural barriers that restrict their ability to respond in real time to the feedback they receive.  As obvious as it may seem, studies in which clinicians measure, but cannot change what they are doing in response show little or no effect (1).

• With one exception, results reported in studies of FIT are confounded by the amount of training therapists receive, and the stage of implementation they (or the agency in which they work) are in, at the time the research is conducted.  In many of the investigations published to date, participating therapists received 1 hour of training or less prior to beginning, and no supervision during, the study (1).  Consistent with findings from the field of implementation science documenting that productive use of new clinical practices takes from three to five years, a new study conducted in Scandinavia found the impact of FIT grew over time, with few results seen in the first and second year of use.  By year four, however, patients were 2.5 times more likely to improve when their therapists used FIT.  In short, it takes time to learn how to do FIT, and for organizations to make the structural changes required for the development and maintenance of a feedback culture.

• Improving individual therapist effectiveness requires deliberate practice.   It turns out,the best therapists devote twice as much time to the process.  More, when employed purposefully and mindfully, the outcomes of average practitioners steadily rise at a rate consistent with performance improvements obtained by elite athletes (Click here if you want to watch an entertaining and informative video on the subject from the recent Achieving Clinical Excellence conference).

Before ending, let me mention one other question that comes up fairly often. “Why don’t you wear shoes when you present?”  The picture to the left was taken at a workshop in Sweden last week and posted on Facebook!  Over the years, I’ve heard many explanations: (1) it’s a Zen thing; (2) because I’m from California; (3) to make the audience feel comfortable; (3) to show off my colorful socks; and so on.

The truth, it turns out, is like the findings about FIT reported above, much more mundane.  Care to guess?

(You can find my answer below)

Until next time,

Scott

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

P.S.: Registration for the FIT Intensives is open.  As has happened in previous years, we are on track to sell out early.  Email me at info@scottdmiller.com with any questions or click on the icons for more information or sign up.

P.P.S: Men’s shoes hurt my feet and back ache.  I get neither when walking about in my stocking feet while standing and presenting all day.

What works in the treatment of people with eating disorders?  Search around a bit on the internet, or consult official treatment guidelines, and you’ll find cognitive-behavioral therapy (CBT) and interpersonal therapy (IPT) listed as the “best-supported” or “preferred” psychological approaches for bulimia, anorexia, and binge eating.

Such recommendations strongly imply such approaches contain ingredients specifically remedial to eating disorders which, when applied, result in superior outcomes.  Otherwise, why create the list in the first place?

But what does the evidence actually indicate?  While research in mental health rarely results in definitive findings, in the case of eating disorders, the story is different.  When it comes to psychotherapy, all methods work equally well.   At least, that is the conclusion of the most recent, sophisticated meta-analysis on the subject.  However, if history serves as a guide, many will find the latest results hard to swallow.

Back in 2014, an article penned by proponents of the “specific treatments for specific disorders” — aka the “empirically supported” treatments movement — appeared in The Guardian, claiming science had show that some approaches were “better for certain conditions than others,” in particular eating disorders.   Citing the tremendous cost to sufferers and the healthcare system, they urged the field to “redouble … efforts to identify … and ensure that the most effective therapies are available to all who need them.”

As I blogged about at the time, I received a ton of email when that article first appeared.  “Have you seen the Guardian?” they asked.  “What do you make of it?” others inquired.   A few messages were downright snarky, even gloating,  “Scott, research has finally proven certain approaches are more effective than others.  I knew it all along!”

I responded noting that the claims in the article were based on a single study.  One.  And yes, that one study comparing CBT to psychoanalysis found CBT resulted in superior effects in the treatment of bulimia.  Crucially, I pointed out, the authors failed to mention the existence of another, exhaustive investigation available at the time in Clinical Psychology Review—one that used the statistically rigorous method of meta-analysis to review 53 studies of psychological treatments for eating disorders, and found no differences in effect between competing therapeutic approaches.

Four-and-a-half years later, the question of “what works best” in the treatment of eating disorders is being addressed in a brand new study in the top tier journal, Psychotherapy Research.  (As of right now, you can read it for yourself for free by clicking here.  Be prepared, however, as this is not an opinion piece written in a newspaper, but rather an academically rigorous analysis of the evidence).

What did the authors find?  Confirming the results of the prior meta-analysis: (1) any treatment works better than none; (2) real treatments are more effective than sham approaches; (3) and no method works better than any other.

Similar results, have been found across a wide range concerns that bring people into treatment, including trauma, sexual abuse, alcohol abuse and dependence, depression and anxiety.

Given the evidence, the question is not whether such results can be trusted.  They can.  Indeed, they represent the “state-of-the-art” — the best research has to offer.  The real problem, then as now, is that such findings do not address the question therapists most want answered, “What can I do to better help my clients?”

To answer this question, we have to recognize a simple fact: therapists live in a fundamentally different world than researchers.  We do not deal with groups of people sharing a common diagnosis who are randomized into different treatments.  Neither are we are interested in differences in the means response of aggregate group comparisons.  We deal with individuals.  Confronted daily by their suffering, we want to know how to help the person in our office right now.  The problem comes whenever these two worlds are conflated, as advocates of particular treatment approaches are prone to do.  It’s then our pragmatic focus make us exceptionally vulnerable to anyone claiming to have discovered “a better way.”

So, what can therapists do to improve their effectiveness?

Simply put: find out if what you are doing is helping your client.  Do this by seeking feedback on a formal, session-by-session basis about their progress and experience of the therapeutic relationship–a process known as “Feedback-Informed Treatment” or FIT (you can access two, free, brief and simple-to-use scales by clicking here).  A variety of support materials, and 10,000+ clinicians and administrators are available at no cost via the International Center for Clinical Excellence website.  Importantly, evidence shows clients of therapists who have integrated FIT into their work are 2.5 times more likely to experience improvement over the course of care.

That’s it for now.

Until next time,

Scott

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

Take a look at the figure to the right.  
It’s data taken from the largest study conducted in the history of psychotherapy research examining the relationship between experience and effectiveness.

Each of the smaller lines represents the outcomes of an individual practitioner followed, in some cases, over a 17-year period.  The single, thicker, dashed-line plots the average across all, 170 practitioners in total–a group that measured the results of their work at every visit, with every client.

The data confirm what a host of correlational studies have hinted at since the mid-1980’s: in general, clinician effectiveness declines with time and experience.

It’s not a steep slope, to be sure.  It is slow and gradual, like a leak in a bicycle tire.  Most problematically, other research shows, it’s also imperceptible.  Indeed, as experience in the field grows, clinician-confidence increases, leading most to see themselves as more effective than their results actually indicate.

Now, consider the second figure.  Once again, outcomes of individual practitioners are plotted.

Here, however, the slope is positive.  In other words, therapists are becoming more and more effective over time.  As before, the change is slow and gradual.  Said another way, there are no shortcuts to improved outcomes.  Slow and steady wins the race.  More, unlike the prior results, therapists are both aware of their growth and, curiously, less confident about the effectiveness of their work.

Importantly, the data from the latter are not drawn from the application of some hypothetical, yet-to-be-hoped-for treatment model or training scenario.  Indeed, they are from the only published study to date documenting the factors that actually influence development of individual therapist effectiveness. When employed purposefully and mindfully, clinicians improve three times larger than they were documented to decline in the prior study.

What are these factors?

As simple as it sounds: (1) measure your results; and (2) focus on your mistakes.

There is no way around this basic fact: any effort aimed at improving effectiveness begins with a valid and reliable estimate of one’s current outcomes. Without that, there is no way of knowing when progress is being made or not.

On the subject of mistakes, several studies now confirm that “healthy self-criticism,” or professional self-doubt (PSD), is a strong predictor of both alliance and outcome in psychotherapy (Nissen-Lie et al., 2015).  Not surprisingly, therapist effectiveness improves in practice environments that provide: (1) ample opportunity and a safe place for discussing cases that are not making progress (or deteriorating); and (2) concrete suggestions for improvement that are tailored to the individual therapist.

Here are three, evidence-based resources you can tap in your efforts to improve your effectiveness in 2017:

• Begin measuring your results using two simple scales that have been tested in diverse settings and with a wide range of treatment populations.  In 2013, they were approved by the Substance Abuse and  Mental Health Services Administration (SAMHSA) and listed on the National Registry of Evidence-based Programs and Practices.  Get them for free by registering for a free license here.
• For a limited time, I’ll send you a free copy of the “How to” manual for using the two measures.  Just email me at: scottdmiller@talkingcure.com.  Online, the manual retails for $24.95.  It’s one of a series of 5, which SAMHSA gave perfect marks to as a support to implementation of routine outcome measurement in clinical practice.
• If you work alone or need a error-friendly practice community to discuss your work, join the International Center for Clinical Excellence.  It’s our free, online community.  There, you can link up with other like-minded clinicians, share your work, discuss your outcomes, watch “how-to” videos, help and be helped by practitioners around the world.

One final suggestion.  Since “simple” does not necessarily mean, “easy,” join me in Chicago for one of our upcoming intensive trainings.  Coming up in March is the “Advanced Intensive in Feedback Informed Treatment,” and the “Feedback Informed Supervision Intensive.”  You’ll meet colleagues from around the world, learn from an international faculty, and leave with all the knowledge and skills you need to use outcomes to improve the quality and outcome of your practice or agency.  The early bird rate is still available and we’ve only got a few spots left in each course.

Register by clicking on the text above or icons on the right side of the page.

Until then, best wishes for the New Year!

Scott

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