Search Results for: trauma

The Baader-Meinhof Effect in Trauma and Psychotherapy

August 28, 2019 By scottdm 35 Comments

Have you heard of the “Baader-Meinhof” effect? If not, I’m positive you’ll soon be seeing evidence of it everywhere.

That’s what “it” is, by the way — that curious experience of seeing something you’ve just noticed, been told of, or thought about, cropping up all around you. So …

You buy a car and suddenly it’s everywhere. That outfit you thought was so unique? Boom! Everyone is sporting it. How about the conversation you just had with your friend? You know, the one that was so stimulating and interesting? Now the subject is on everyone’s lips.

Depending on your level of self-esteem or degree of narcissism, Baader-Meinhof either leaves you feeling on the “cutting edge” of cultural trends or constantly lagging behind others. For me, it’s generally the latter. And recently, its a feeling that has been dogging me a fair bit.

The subject? Trauma.

Whether simple or complex, ongoing or one-off, experienced as a child or adult, trauma is the topic de jour — a cause célèbre linked to an ever-growing list of problems, including depression, anxiety, dissociation, insomnia, headaches, stomachaches, asthma, stroke, diabetes, and most recently, ADHD.

Then, of course, there are the offers for training. Is it just me or is trauma the subject of every other email solicitation, podcast announcement, and printed flyer?

The truth is our field has been here many times before. Over the last 25 years, depression, multiple personality disorder, rapid cycling bipolar disorder II, attention deficit disorder, and borderline personality disorder have all burst on the scene, enjoyed a period of intense professional interest, and then receded into the background.

Available evidence makes clear this pattern — aha, whoa, and hmm what’s next? — is far from benign. While identifying who is suffering and why is an important and noble endeavor, outcomes of mental healthcare have not improved over the last 40 years. What’s more, no evidence exists that training in treatment modalities specific to any particular diagnosis — the popularly-termed, “evidence-based” practices — improves effectiveness. Problematically, studies do show undergoing such training increases practitioner perception of enhanced competence (Neimeyer, Taylor, & Cox, 2012) .

On more than one occasion, I’ve witnessed advocates of particular treatment methods claim it’s unethical for a therapist to work with people who’ve experienced a trauma if they haven’t been trained in a specific “trauma-focused” approach. It’s a curious statement — one which, given the evidence, can only be meant to bully and shame practitioners into going along with the crowd. Data on the subject are clear and date back over a decade (1, 2, 3). In case of any doubt, a brand new review of the research, published in the journal Psychotherapy, concludes, “There are no clinically meaningful differences between … treatment methods for trauma … [including those] designed intentionally to omit components [believed essential to] effective treatments (viz., exposure, cognitive restructuring, and focus on trauma)” (p. 393).

If you find the results reported in the preceding paragraph confusing or unbelievable, recalling the “Baader-Meinhof” effect can be help. It reminds us that despite its current popularity in professional discourse, trauma and its treatment is nothing new. Truth is, therapists have always been helping those who’ve suffered its effects. More, while the field’s outcomes have not improved over time, studies of real world practitioners show they generally achieve results on par with those obtained in studies of so-called evidence-based treatments 1, 2, 3).

Of course, none of the foregoing means nothing can be done to improve our effectiveness. As my Swedish grandmother Stena used to say, “The room for improvement is the biggest one in our house!”

To get started, or fine tune your professional development efforts, listen in to an interview I did recently with Elizabeth Irias from Clearly Clinical (an approved provider of CEU’s for APA, NBCC, NAADAC, CCAPP, and CAMFT). Available here: What Every Therapist Needs To Know: Lessons From The Research, Ep. 61.

In it, I lay out several, concrete, evidence-based steps, practitioners can take to improve their therapeutic effectiveness. It’s FREE, plus you can earn a FREE hour of CE credit. Additionally, if follow them on Instagram and leave a comment on this post, you’ll be automatically entered into a contest for one year of free, unlimited continuing education — the winner to be announced on October 31st, 2019.

Until next time,

Scott

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

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What does losing your keys have in common with the treatment of trauma?

April 24, 2019 By scottdm 9 Comments

Last week, I was preparing to leave the house and could not locate my keys. Trust me when I say, it’s embarrassing to admit this is not an infrequent occurrence.

Logic and reason are always my first problem solving choices. That’s why I paused after looking in the kitchen drawer where I am supposed to keep them, along with my wallet and glasses, and found it empty. When did I last have them? Not finding them there, the “search” began.

Upstairs to the bedroom to check my pants pockets. No. Downstairs to the front closet to look in my coat. No. Back upstairs to the hamper in the laundry room. No. Once more, down the stairs to the kitchen hutch. I sometimes leave them there. This time, however, no. I then headed back up the stairs to the master bathroom — my pace now a bit frantic — and rummaged through my clothing. No. They’ve gotta be on my office desk. Down two flights of stairs to the basement. Not there either.

In a fit of pique, I stormed over to the landing, and yelled at the top of my voice, “DID SOMEONE TAKE MY KEYS?” the accusation barely concealed. Although my head knew this was nuts, my heart was certain it was true. They’ve hidden them!

“No,” my family members kindly reply, then ask, “Have you lost them again?”

“Arrgh,” I mutter under my breath. And that’s when I do something that, in hindsight, make no sense. I wonder if you do the same? Namely, I start the entire search over from the beginning — pants, coat, hamper, closet, hutch, office — often completing the exact same cycle several times. Pants, coat, hamper, closet, hutch, office. Pants, coat, hamper, closet, hutch, office. Pants, coat, hamper, closet, hutch, office.

I can’t explain the compulsion, other than, by this point, I’ve generally lost my mind. More, I can’t think of anything else do. My problem: I have somewhere to go! The solution: Keep looking (and it goes without saying, of course, in the same places).

(I did eventually locate my keys. More on that in a moment)

Yesterday, I was reminded of my experience while reading a newly released study on the treatment of trauma. Bear with me as I explain. Over a decade ago, I blogged about the U.S. Veteran’s Administration spending $25,000,000 aimed at “discover[ing] the best treatments for PTSD” despite a virtual mountain of evidence showing no difference in outcome between various therapy approaches.

Since that original post, the evidence documenting equivalence between competing methods has only increased (1, 2). The data are absolutely clear. Meta-analyses of studies in which two or more approaches intended to be therapeutic are directly compared, consistently find no difference in outcome between methods – importantly, whether the treatments are designated “trauma-focused” or not. More, other highly specialized studies – known as dismantling research – fail to provide any evidence for the belief that specialized treatments contain ingredients specifically remedial to the diagnosis! And yes, that includes the ingredient most believe essential to therapeutic success in the treatment of PTSD; namely, exposure (1, 2).

The new study confirms and extends such findings. Briefly, using data drawn from 39 V.A. treatment centers, researchers examined the relationship between outcome and the degree of adoption of two so-called “evidence-based,” trauma-informed psychotherapy approaches — prolonged exposure and cognitive processing therapy. If method mattered, of course, then a greater degree of adoption would be associated with better results. It was not. As the authors of the study conclude, “programs that used prolonged exposure and cognitive processing therapy with most or all patients did not see greater reductions in PTSD or depression symptoms or alcohol use, compared with programs that did not use these evidence-based psychotherapies.”

So what happens now? If history, and my own behavior whenever I lose my keys, is any indication, we’ll start the process of looking all over again. Instead of accepting the key is not where we’ve been looking, the field will continue it’s search. After all, we have somewhere to go — and right back to the search for the next method, model, or treatment approach, we go.

It’s worse than that, actually, as looking over and again in the same place, keeps us from looking elsewhere. That’s how I generally find my keys. As simple and perhaps dumb as it sounds, I find them someplace I had not looked.

And where is the field not looking? As Norcross and Wampold point out in an article published this week, “relationships and responsiveness” are the key ingredients in successful psychological care for people who are suffering as a result of traumatic experiences, going on to say that the emphasis on model or method is actually harmful, as it “squanders a vital opportunity to identify what actually heals.”

Improving our ability to connect with and respond effectively to the diverse people we meet in therapy is the focus on Deliberate Practice Intensive, held this August in Chicago, Illinois. Unlike training in protocol-driven treatments, studies to date show learning the skills taught at the workshop result in steady improvements in clinicians’ facilitative interpersonal skills and outcomes commensurate with the rate of improvement seen in elite athletes. For more information or to register, click here.

Until next time,

Scott

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

What heals trauma?

October 3, 2018 By scottdm 33 Comments

“Exposure!” a choir of professional voices sings, “its the only proven way.”

“No, no,” others insist, “You can tap yourself to emotional freedom.”

“Poppycock!” another group jumps in, “Horizontal saccadic eye movements are the ticket!”

“Beware the dominant discourse,” a few, particularly literate warn, “focusing on what was done to the person can retraumatize, help them reauthor their experiences instead.”

Meanwhile, a smaller and less vocal group shakes their heads in disbelief, saying, “There are no shortcuts. Healing comes only from identifying and ‘working through’ painful unconscious feelings.”

Turning to the research to answer the question–what heals trauma?”–offers little clarity. Advocates of most approaches can offer evidence that their preferred approach works–at least one study, and often more, many more–a fact all should find puzzling. Simply put, how could all approaches work, given they offer competing and often contradictory explanations and techniques? And yet, no consistent superiority of one particular approach over others is exactly what the latest dismantling and meta-analytic studies show (1, 2, 3, 4, 5, 6, 7).

When attempting to account for why all approaches work equally well, the most common argument made is that different models work for different people. Said another way, what may be effective in the aggregate may not work for the individual. “Choice is key,” advocates of this position assert.

More recently, and perhaps in response to the continuing failure to find any meaningful difference in outcome between treatment methods, it has become popular to talk of a set of “mechanistically transdiagnostic…therapeutic strategies…[targeting] the role of a given mechanism in the development and maintenance of a range of psychopathology.” Ironically, the call for a “universal treatment protocol,” is the “go to” position of those who once advocated for the creation of officially sanctioned lists of specific treatments for specific disorders.

So, which explanation holds water? Here again, the empirical evidence offers little clarity. What is important, however, is that these two, diametrically opposed perspectives share a common assumption: healing results from the appropriate application of the right treatment methods.

But what if that’s not true? What if therapeutic techniques–whether specific to a given model or shared by all–have no inherent power to heal? Where would that leave us as a profession? Does it mean that our methods are the therapeutic equivalent of Dumbo’s magic feather?

“A great deal changes, in terms of our ability to help and heal,” psychologist Stephen Bacon suggests, “if we embrace what the research indicates. Psychotherapy, as a science, is not like engineering. It operates in a different reality.”

Recently, I had a chance to interview Stephen about his work, and new, thought-provoking, and imminently practical book, Practicing Psychotherapy in a Constructed Reality: Ritual, Charisma, and Enhanced Client Outcomes.

As you’ll see, he’s a very interesting person–six years in an ashram, a neighbor and student of Krishnamurti, a degree in religious studies, and more. For me, the “enhanced client outcomes” referenced in the title immediately got my attention. Wait until you have 30, uninterrupted minutes available, as the interview is one of my longer, and you will want to watch every minute.

Until next time,

Scott

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

What Works in the Treatment of Post Traumatic Stress Disorder? The Definitive Study

September 15, 2010 By scottdm 1 Comment

What works in the treatment of people with post-traumatic stress? The influential Cochrane Collaboration–an “independent network of people” whose self-professed mission is to help “healthcare providers, policy makers, patients, their advocates and carers, make well-informed decisions, concludes that, “non trauma-focused psychological treatments [do] not reduce PTSD symptoms as significantly…as individual trauma focused cognitive-behavioral therapy (TFCBT), eye movement desensitization and reprocessing, stress mamangement and group TFCBT.” The same conclusion was reached by the National Institute for Health and Clinical Excellence (or NICE) in the United Kingdom which has developed and disseminated practice guidelines that unequivocally state that , “all people with PTSD should be offered a course of trauma focused psychological treatment (TFCBT) or eye movement desensitization and reprocessing (EMDR).” And they mean all: adults and kids, young and old. Little room for left for interpretation here. No thinking is required. Like the old Nike ad, you should: “Just do it.”

Wait a minute though…what do the data say? Apparently, the NICE and Cochrane recommendations are not based on, well…the evidence–at least, that is, the latest meta-analytic research! Meta-analysis, you will recall, is a procedure for aggregating results from similar studies in order to test a hypothesis, such as, “are certain approaches for the treatment of post traumatic stress more effective than others?” A year ago, I blogged about the publication of a meta-analysis by Benish, Imel, & Wampold which clearly showed that there was no difference in outcome between treatments for PTSD and that the designation of some therapies as “trauma-focused” was devoid of empirical support, a fiction.

So, how to account for the differences? In a word, allegiance. Although written by scientists, so-called “scholarly” reviews of the literature and “consensus panel” opinions inevitably reflect the values, beliefs, and theoretical predilections of the authors. NICE guidelines, for example, read like a well planned advertising campaign for single psychotherapeutic modality: CBT. Indeed, the organization is quite explicit in it’s objective: “provide support for the local implementation of…appropriate levels of cognitive beheavioral therapy.” Astonishingly, no other approach is accorded the same level of support or endorsement despite robust evidence of the equivalence of outcomes among treatment approaches. Meanwhile, the review of the PTSD literature and treatment recommendations published by the Cochrane Collaboration has not been updated since 2007–a full two years following the publication of the Benish et al. (2008) meta-analysis–and that was penned by a prominent advocate of…CBT…Trauma-focused CBT.

As I blogged about back in January, researchers and prominent CBT proponents, published a critique of the Benish et al. (2008) meta-analysis in the March 2010 issue of Clinical Psychology Review (Vol. 30, No. 2, pages 269-76). Curiously, the authors chose not to replicate the Benish et al. study, but rather claim that bias, arbitrariness, lack of transparency, and poor judgement accounted for the findings. As I promised at the time, I’m making the response we wrote–which appeared in the most recent issue of Clinical Psychology Review—available here.

Of course, the most important finding of the Benish et al. (2008) and our later response (Wampold et al. 2010) is that mental health treatments work for people with post traumatic stress. Such a conclusion is unequivocal. At the same time, as we state in our response to the critique of Benish et al. (2008), “there is little evidence to support the conclusion…that one particular treatment for PTSD is superior to others or that some well defined ingredient is crucial to successful treatments of PTSD.” Saying otherwise, belies the evidence and diverts attention and scarce resources away from efforts likely to improve the quality and outcome of behavioral health services.

View more documents from Scott Miller.

Culture and Psychotherapy: What Does the Research Say?

August 7, 2020 By scottdm 5 Comments

I remember exactly where I was on April 4th, 1968 — in a pool doing laps. I was a junior member of my hometown’s swim team. I’d barely started when the coach blew his whistle calling the practice to an abrupt halt. As we toweled off, he told us something terrible had happened. It was first time I recall hearing the name, Martin Luther King, Jr..

If I close my eyes, I can easily call up other, vivid memories of traumatic, culture-changing events. The death of Robert Kennedy. The Challenger explosion. The attack on the World Trade Center. And now, only slightly more than half way through the present year, many more. The first days of the outbreak and lockdown. The running tally of deaths on the nightly news. The lines of people at our local foodbanks. The images of George Floyd being killed, and weeks of protests against racism and inequality that have followed.

Then and now, I struggle with a stark choice; specifically, to connect or disconnect with events as they unfold. After all, so much is happening in the world and I only have so much bandwidth — and as a person with many advantages, I can disconnect with little real consequence to the well-being of myself and my family.

In the end, however, I feel ethically compelled to connect, listen, or perhaps more accurately state, hear people — not because I see myself as knowing what to do, but rather because I want to understand if and how I can be helpful.

So, what does the research indicate?

When I was in graduate school, human diversity was treated in what might be called, “the chapter approach.” Here’s what the field knows about men, for instance, with another on women, African-Americans, Latinos, and so on. This approach can be directly traced to social, historical, and political events beginning in the 1960’s, and a then growing awareness of the lack of attention paid to diversity in the field of mental health– in particular, culture, race, religion, socioeconomic status, sexual orientation, etc.

For several decades, researchers have built on this framework, developing and testing what have come to be known as “culturally adapted” psychological treatments (e.g., CBT for Latina Women or people of Asian heritage). Despite years of effort, including scores of randomized trails and meta-analyses, experts conclude, “Current evidence does not offer a solution to the issue of which components of cultural adaptation are effective, for what population, and whether cultural adaptation works better than noncultural adaption” (1).

Part of the problem with this approach is the sheer number of possible adaptations quickly becomes unmanageable. To illustrate, in developing a culturally adapted psychotherapy, where adjustments are made along only 4 of the 13 officially identified dimensions of diversity, a total of 715 different ways exist to adapt service delivery to fit the individual. Obviously, any approach that results in so many variations is absurd, making it impossible to apply in the real world and risking being nothing more than window dressing — a kind of superficial “gift wrapping” that conceals more than it helps to reveal the identities and objectives of the participants. More importantly, however, is that the current approach makes a priori decisions about which dimensions are most important to consider when planning and delivering treatment.

What then are therapists who wish to connect more effectively with a broad and diverse clientele to do? Research makes clear when practitioners are open to exploring clients’ values, background, and culture, good results follow. Such evidence suggests, in place of competence (i.e., achieving a certain level of pre-determined knowledge about and skills for working with various cultural groups), its better to have an orientation to treatment that enables practitioners to attend to and integrate cultural dynamics as they naturally occur in the therapy process.

One of the lead researchers on multicultural orientation is Professor Jesse Owen at the University of Denver. Together with a team of investigators, he’s identified three core principles that both encompass and can guide a therapist’s attitudes, in-and-between session actions, and personal reactions regarding the role of culture in therapy. Interestingly, much of what he and the group have discovered fits with what my colleagues and I have been learning from our study of highly effective psychotherapists. I won’t give it away here. You can watch the interview yourself.

OK. That’s it for now. Please let me know your thoughts.

Scott D. Miller, Ph.D.
Director, International Center for Clinical Excellence
FIT Intensive Oct 2020 online

Does Teletherapy Work?

July 22, 2020 By scottdm Leave a Comment

With the outbreak of the coronavirus, much of mental health service delivery shifted online. Regulations regarding payment and confidentiality were scaled back in an effort to deal with the unprecedented circumstances, allowing clinicians and their clients to meet virtually in order to reduce the spread of the illness.

But is teletherapy helpful?

Listening to discussions among therapists on social media, the assessment is decidedly mixed. Almost all are grateful for the opportunity online platforms provide to meet with clients. On the other hand, many question its effectiveness relative to in person services. At a minimum, challenges exist.

So, what does the research indicate?

Drum roll please …

no difference in outcome for adults, adolescents and children being treated for the most common concerns addressed in psychotherapy (e.g., depression, anxiety, trauma, eating problems, substance abuse). What’s more, online services are associated with greater utilization of and less dropout from mental health care.

That said, challenges are evident. For most clinicians and clients, teletherapy is an entirely new enterprise requiring a period of learning and adjustment. Critically, the sensory input clinicians rely upon to make clinical judgments is also restricted — all the more reason to make “Feedback-Informed Treatment (FIT) a routine part of the services you provide. Even if you’re regularly seeking feedback from clients using standardized measures like the Outcome and Session Rating Scales, doing so virtually will be new for most.

It’s why many of my posts since mid-March have provided detailed information using the measures online (read them by clicking: 1, 2, 3, 4, 5, 6, 7, 8, 9). Below you’ll finds links to all the “how-to” videos FIT Certified Trainers created over the last four months. No need to re-invent the wheel –and, no, if you’ve downloaded paper and pencil copies, digitizing the measures is not allowed — but there’s really no need. Three authorized systems are available that administer, score, and most importantly, provide access to real time feedback and a series of evidence-based metrics for assessing your performance and developing deliberate practice objectives.

Until next time,

Scott

Scott D. Miller, Ph.D.

Director, International Center for Clinical Excellence

Forgiveness

July 1, 2020 By scottdm 8 Comments

One warm, summer June day, Marietta Jaeger, her husband Bill, and their five children packed into their borrowed R.V. for a cross-country road trip touring the American west. “This was going to be the adventure of a lifetime, a grand family vacation, the one we were going to talk about for the rest of our lives,” Marietta observes some four decades later, “and it certainly has been.”

On the third night of their stay, camped at the headwaters of the Missouri river, the family’s youngest child — 7-year old Susie Jaeger — was kidnapped. A slit made with surgical precision in the canvas of the tent in which she slept with her brothers and sisters was the only clue to what had happened.

Hours, days, and weeks passed while local, state, and federal authorities searched. Although increasingly desperate, Marietta maintained her focus and composure, attending to her other children while constantly juggling interactions with law enforcement and the media. Then, “A day came,” she recalls, “where I began to get angry.” By this time, the family had been camped out at the river’s edge for over a month. “By the time I got into bed,” she continues, “I was just ravaged with hatred and a desire for revenge.” Her eyes narrowing in anger, she confesses, “I wanted this guy to swing,” adding, “I could have killed him for what he had done with my bare hands and a smile on my face.”

No one I know would fault Marietta for her feelings. Some experts might even suggest her reaction was a necessary, even helpful part of recovering from such a traumatic event. In the end, however, it was not the path she chose to stay on. Quite the contrary. Rather, before daylight broke the next day, and years before she would learn what actually happened to her daughter, Marietta made the decision to forgive the person who had taken Susie.

Believe me when I say, her decision was no mere contrivance or symbolic gesture. Her behavior followed suit — acts of grace, understanding, and empathy most would find exceptionally difficult to emulate — for example, expressing genuine care and concern for the kidnapper when he called to taunt the family one year later on the date and exact hour he’d absconded with Susie.

I won’t tell you here what happened. You can watch for yourself in the link to the 20/20 episode below. What I will say is that Marietta Jaeger’s ability to forgive proved to be the key to solving the kidnapping of her daughter.

Research documents the healing effects of forgiveness on individuals and groups (1, 2, 3, 4, 5). Other data indicate people, particularly those seeking psychotherapy, want to forgive. But how? What exactly are the steps?

I had the opportunity to speak with Marietta Jaeger last week. During the time we spent together, she told me how she did it. I experienced a wide range of emotions: anger, discouragement, frustration, bafflement, sadness, and peace. Once you’ve had a chance to listen to the interview and watch the 20/20 episode, let me know your thoughts.

Until next time,

Scott

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

“My Mother Made Me Do It”: An Interview with Don Meichenbaum on the Origins of CBT (Plus: Tips for Surviving COVID-19)

May 26, 2020 By scottdm 6 Comments

Imagine having the distinction of being voted one of the top 10 most influential psychotherapists of the 20th Century.

Psychologist Don Meichenbaum is that person. In his spare time, together with Arron Beck and Marvin Goldfried, he created the most popular and researched method of psychotherapy in use today: cognitive-behavior therapy (CBT).

I got to know Don years ago as we shared a car ride, traveling to and from a training venue while teaching separate, week-long workshops in New England. We laughed. We talked. We debated. Fiercely.

We’ve been friends and colleagues ever since, recreating our car ride discussions in front of large audiences of therapists at each Evolution of Psychotherapy conference since 2005.

As Don approaches his 80th birthday, we look back on the development of CBT — what he thinks he got right and how his thinking has evolved over time. Most trace the roots of CBT to various theorists in the field — Freud, Wolpe, and others. Don is clear: his mother made him do it. That’s right. According to him, CBT got its start with Mrs. Meichenbaum. I know you’ll be amused, but I also believe you’ll be surprised by why and how she contributed.

That said, my interview with Don isn’t merely a retrospective. Still actively involved in the field, he shares important, evidence-based tips about trauma and resilience, applying the latest findings to the psychological and economic impacts of the coronavirus. You’ll find the interview below.

All done for now,

Scott

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

Do you ever have “Anticipointment?”

January 2, 2020 By scottdm 8 Comments

As a mental health professional, how are you approaching the New Year? Are you filled with hope for our field? Suffering a twinge (or more) of despair? Maybe you’re in reflective mood, longing for the ‘good ole days’? Or is the difference between December 31st and January 1st just like any other twenty four hour period?

While catching up on reading over the Holidays, I came across a word that captured my experience. I’d never seen it before. Anticipointment. Online sources define it as, “The state of mind resulting from anticipating and then being disappointed when expectations are not met.” Truth is, I recognize now I’ve often experienced this, but mistaken it for nostalgia. I t’s not.

So what about you? On one hand, we do have good reason to be hopeful. After all, decades of evidence provide overwhelming proof of the effectiveness of psychotherapy. On the other hand, the same research shows our outcomes have not improved in more than 40 years. Returning to the positive side, researchers have now identified two specific practices — routine outcome monitoring and deliberate practice — that enable clinicians to accomplish something never before recorded in history the history of the field; namely, steadily improve their effectiveness from year to year. On the negative side, the field –researchers, clinicians, payers, and policy makers alike — continues to be strongly attracted to treatment models, I’d say fatally so. Crossing the term, “cognitive behavioral therapy” (CBT) with “randomized controlled trial” (RCT) on Google Scholar results in 1,930,000 hits! In case you glossed over the figure, that’s one million, nine hundred thirty thousand — and that’s just one method out of hundreds. By contrast, a similar search of “tetanus vaccine,” produces slightly more than 18,000 results. I ask, does our field really need to spend precious resources on another study of CBT? It’s discouraging. More broadly, given the clear and overwhelming evidence of equivalence between treatment methods for any DSM diagnosis that’s been tested — and yes, that includes so-called trauma-specific approaches — do we need any more RCT’s pitting one protocol against another? Wouldn’t time be better spent studying how practitioners can improve their ability to attune and respond to their clients? After all, these two transtheoretical skills, researchers Stiles and Horvath, point out, are why “certain therapists are more effective than others” (p. 71)

For me, I approach the New Year with a strong sense of anticipointment. I want to be hopeful, believe there are good empirical reasons to do so. At the same time, I fear little will change. Turns out, some of our field’s beliefs and practices refuse to die.

What can we do to escape these “walking dead?”

A quick Google search of “Surviving the Zombie Apocalypse” turns up in three clear themes. First, make sure you are not a zombie. “The main epidemiological risk of zombies,” says Wikipedia, “is that their population just keeps increasing [as] generations of humans merely ‘surviving’ … feed” them. In the case of psychotherapy, I’ve come to believe practitioners often know certain popular ideas and practices are dead, but go along with them anyway. We must say, “no” or risk infecting the next generation.

The second suggestion makes the first possible: don’t go it alone. In short, you have a better chance of surviving in a group that shares your objectives. If your professional goals as a therapist include improving your results, the near 10,000 members of the International Center for Clinical Excellence might be your people. It’s free.

Third, and finally, focus on the basics. In the case of real zombies, that means securing water, shelter, and food over other, possibly more stimulating interests. Similarly, for therapists, chasing the “new and promising” must give way to personal work; in particular, deepening core skills associated with effective clinical practice. If becoming a more effective version of you is of interest, check out an article on the subject published this week. My colleague Brooke Mathewes and I provide concrete guidance for finding your performance edge and then developing, executing, and evaluating a highly individualized plan for improvement. Normally behind a “paywall,” the article is currently available for free thanks to the generosity of the journal editors.

As always, I’m interested in your thoughts and reflections. Please post them below!

Until next time,

Scott

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

Feedbak Informed Treatment: Game Changer or Another Therapeutic Fad?

December 4, 2019 By scottdm 1 Comment

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

Is THAT true? Judging Evidence by How Often its Repeated

October 22, 2019 By scottdm 11 Comments

I’m sure you’ve heard it repeated many times:

The term, “evidence-based practice” refers to specific treatment approaches which have been tested in research and found to be effective;

CBT is the most effective form of psychotherapy for anxiety and depression;

Neuroscience has added valuable insights to the practice of psychotherapy in addition to establishing the neurological basis for many mental illnesses;

Training in trauma-informed treatments (EMDR, Exposure, CRT) improves effectiveness;

Adding mindfulness-based interventions to psychotherapy improves the outcome of psychotherapy;

Clinical supervision and personal therapy enhance clinicians’ ability to engage and help.

Only one problem: none of the foregoing statements are true. Taking each in turn:

As I related in detail in a blogpost some six years ago, evidence-based practice has nothing to do with specific treatment approaches. The phrase is better thought of as a verb, not a noun. According to the American Psychological Association and Institute of Medicine, there are three components: (1) the best evidence; in combination with (2) individual clinical expertise; and consistent with (3) patient values and expectations. Any presenter who says otherwise is selling something.
CBT is certainly the most tested treatment approach — the one employed most often in randomized controlled trials (aka, RCT’s). That said, studies which compare the approach with other methods find all therapeutic methods work equally well across a wide range of diagnoses and presenting complaints.
When it comes to neuroscience, a picture is apparently worth more than 1,000’s of studies. On the lecture circuit, mental illness is routinely linked to the volume, structure, and function of the hippocampus and amygdala. And yet, a recent review compared such claims to 19th-century phrenology. More to the point, no studies show that so-called, “neurologically-informed” treatment approaches improve outcome over and above traditional psychotherapy (Thanks to editor Paul Fidalgo for making this normally paywalled article available).
When I surveyed clinicians recently about the most popular subjects at continuing education workshops, trauma came in first place. Despite widespread belief to the contrary, there is no evidence that learning a “trauma-informed” improves a clinician’s effectiveness. More, consistent with the second bullet point about CBT, such approaches have not shown to produce better results than any other therapeutic method.
Next to trauma, the hottest topic on the lecture circuit is mindfulness. What do the data say? The latest meta-analysis found such interventions offer no advantage over other approaches.
The evidence clearly shows clinicians value supervision. In large, longitudinal studies, it is consistently listed in the top three, most influential experiences for learning psychotherapy. And yet, research fails to provide any evidence that supervision contributes to improved outcomes.

Are you surprised? If so, you are not alone.

The evidence notwithstanding, the important question is why these beliefs persist?

According to the research, a part of the answer is, repetition. Hear something often enough and eventually you adjust your “truth bar” — what you accept as “accepted” or established, settled fact. Of course, advertisers, propagandists and politicians have known this for generations — paying big bucks to have their message repeated over and over.

For a long while, researchers believed the “illusory truth effect,” as it has been termed, was limited to ambiguous statements; that is, items not easily checked or open to more than one interpretation. A recent study, however, shows repetition increases acceptance/belief of false statements even when they are unambiguous and simple- to-verify. Frightening to say the least.

A perfect example is the first item on the list above: evidence-based practice refers to specific treatment approaches which have been tested in research and found to be effective. Type the term into Google, and one of the FIRST hits you’ll get makes clear the statement is false. It, and other links, defines the term as “a way of approaching decision making about clinical issues.”

Said another way, evidence-based practice is a mindset — a way of approaching our work that has nothing to do with adopting particular treatment protocols.

Still, belief persists.

What can a reasonable person do to avoid falling prey to such falsehoods?

It’s difficult, to be sure. More, as busy as we are, and as much information as we are subjected to on a daily basis, the usual suggestions (e.g., read carefully, verify all facts independently, seek out counter evidence) will leave all but those with massive amounts of free time on their hands feeling overwhelmed.

And therein lies the clue — at least in part — for dealing with the “illusory truth effect.” Bottom line: if you try to assess each bit of information you encounter on a one-by-one basis, your chances of successfully sorting fact from fiction are low. Indeed, it will be like trying to quench your thirst by drinking from a fire hydrant.

To increase your chances of success, you must step back from the flood, asking instead, “what must I unquestioningly believe (or take for granted) in order to accept a particular assertion as true?” Then, once identified, ask yourself whether those assumptions are true?

Try it. Go back to the statements at the beginning of this post with this larger question in mind.

(Hint: they all share a common philosophical and theoretical basis that, once identified, makes verification of the specific statements much easier)

If you guessed the “medical model” (or something close), you are on the right track. All assume that helping relieve mental and emotional suffering is the same as fixing a broken arm or treating a bacterial infection — that is, to be successful a treatment containing the ingredients specifically remedial to the problem must be applied.

While mountains of research published over the last five decades document the effectiveness of the “talk therapies,” the same evidence conclusively shows “psychotherapy” does not work in the same way as medical treatments. Unlike medicine, no specific technique in any particular therapeutic approach has ever proven essential for success. None. Any claim based on a similar assumptive base should, therefore, be considered suspect.

Voila!

I’ve been applying the same strategy in the work my team and I have done on using measures and feedback — first, to show that therapists needed to do more than ask for feedback if they wanted to improve their effectiveness; and second, to challenge traditional notions about why, when, and with whom, the process does and doesn’t work. In these, and other instances, the result has been greater understanding and better outcomes.

So there you have it. Until next time,

Scott

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

P.S: Registration for the Spring Feedback Informed Treatment intensives is now open. In prior years, these two events have sold out several months in advance. For more information or to register, click here or on the images below.

Good Intentions or The Proverbial “Road to Hell?”: Trying to Understand the APA guidelines for Men and Boys

March 8, 2019 By scottdm 9 Comments

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.

Beating the Dodo Verdict: Can Psychotherapy Ever Achieve Better Results?

December 18, 2018 By scottdm 3 Comments

Nearly two decades have passed since I met Saul Rosenzweig at his home in St. Louis, Missouri. He was well into his nineties and still working every day. Truth is, I was surprised to learn he was still alive!

In 1936, he’d penned an article –three and a half pages in total– that became one of the most often cited in psychotherapy research. He was only 29 years of age at the time.

Then, as now, Rosenzweig’s central premise is controversial: all psychotherapy approaches, regardless of their specific components, produce equivalent outcomes.

Although he didn’t coin the phrase, his observation has since been referred to as, “The Dodo Verdict.” That’s because he began the article quoting a line uttered by the Dodo from Alice’s Adventures in Wonderland, “Everyone has won, and all must have prizes.”

Over the last eight decades, many have claimed to “beat the dodo verdict” — to have developed an approach more effective than others. You know them by acronym: CBT, EMDR, ACT, CRT, MI, TFT, SFBT, CDOI, and so on. Initial research is always promising. Nevertheless, as I’ve detailed in many blogs over the years, later studies invariably find the “new and improved” is no more effective than the “tried and true” — whatever the accepted standard might be at that moment (1, 2, 3, 4).

The field’s focus on methods is understandable. The assumption is psychotherapy works like medicine. To be effective, an approach must contain ingredients specifically remedial to the disorder being treated. No one questions whether antibiotics are better than aspirin for strep throat. Why? Because the former contains an ingredient that kills the bacteria responsible for the infection. In a similar way, CBT is widely believed to work because its methods target the root cause of depression, dysfunctional thoughts.

So critical are the techniques of the various psychotherapy approaches believed to be, developers create protocols and manuals for insuring they are delivered correctly. Professional, regulatory, and funding bodies (e.g., American Psychological Association, National Institute for Health and Care Excellence [NICE], National Institute of Mental Health) have embraced and, in some instances, mandated their use.

But what do the data say?

In 2005, my colleagues and I reviewed the available evidence and concluded, “Although training in manualized psychotherapies does enhance therapist learning of and technical competence in a given approach, there is no relationship between such manuals and outcome.”

And now, a new, updated study. Briefly, researchers Truijens, Zühlke‐van Hulzen, and Vanheule, conducted a systematic review of the literature — six studies directly comparing manualized and nonmanualized psychotherapy, and nine meta-analyses. Their conclusion? “Manualized treatment is not empirically supported … [and] should not be promoted as being superior to nonmanualized psychotherapy.” It’s Dodo come back life.

What can a mental health professional do to improve their effectiveness?

Here again, the data point the way to finally “beating the Dodo.” It involves a change of focus. Instead of learning the latest treatment approach, work on becoming a more effective version of you. The process is known as deliberate practice. It begins by creating a detailed map of your clinical performance; specifically, measuring your results, and then using the information to identify opportunities for professional growth.Research to date documents gradual growth in effectiveness consistent with performance improvements obtained by elite athletes.

Want to learn more? Click here for a free article–actually, the chapter on the subject from our latest book, The Cycle of Excellence. Still interested? Watch the recent interview I did on the subject with YouTube blogger, Chris Dorsano.

That’s it for now. Best for the Holidays,

Scott

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

“What works” with eating disorders (and how long will it take the field to swallow these results)?

October 20, 2018 By scottdm 8 Comments

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

Implementation: The KEY to Improving the Effectiveness of Psychotherapy

May 7, 2018 By scottdm 7 Comments

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Clinical Practice Guidelines: Beneficial Development or Bad Therapy?

December 4, 2017 By scottdm 16 Comments

A couple of weeks ago, the American Psychological Association (APA) released clinical practice guidelines for the treatment of people diagnosed with post-traumatic stress disorder (PTSD). “Developed over four years using a rigorous process,” according to an article in the APA Monitor, these are the first of many additional recommendations of specific treatment methods for particular psychiatric diagnoses to be published by the organization.

Almost immediately, controversy broke out. On the Psychology Today blog, Clinical Associate Professor Jonathon Shedler, advised practitioners and patients to ignore the new guidelines, labeling them “bad therapy.” Within a week, Professors Dean McKay and Scott Lilienfeld responded, lauding the guidelines a “significant advance for psychotherapy practice,” while repeatedly accusing Shedler of committing logical fallacies and misrepresenting the evidence.

One thing I know for sure, coming in at just over 700 pages, few if any practitioners will ever read the complete guideline and supportive appendices. Beyond length, the way the information is presented–especially the lack of hypertext for cross referencing of the studies cited–seriously compromises any strainghtforward effort to review and verify evidentiary claims.

If, as the old saying goes, “the devil is in the details,” the level of mind-numbing minutae contained in the offical documents ensures he’ll remain well-hidden, tempting all but the most compulsive to accept the headlines on faith.

Consider the question of whether certain treatment approaches are more effective than others? Page 1 of the Executive Summary identifies differential efficacy as a “key question” to be addressed by the Guideline. Ultimately, four specific approaches are strongly recommended, being deemed more effective than…wait for it… “relaxation.”

My first thought is, “OK, curious comparison.” Nevertheless, I read on.

Only by digging deep into the report, tracing the claim to the specific citations, and then using PsychNET, and another subscription service, to access the actual studies, is it possible to discover that in the vast majority of published trials reviewed, the four “strongly recommended” approaches were actually compared to nothing. That’s right, nothing.

In the few studies that did include relaxation, the structure of that particular “treatment” precluded sufferers from talking directly about their traumatic experiences. At this point, my curiosity gave way to chagrin. Is it any wonder the four other approaches proved more helpful? What real-world practitioner would limit their work with someone suffering from PTSD to recording “a relaxation script” and telling their client to “listen to it for an hour each day?”

(By the way, it took me several hours to distill the information noted above from the official documentation–and I’m someone with a background in research, access to several online databases, a certain facility with search engines, and connections with a community of fellow researchers with whom I can consult)

On the subject of what research shows works best in the treatment of PTSD, meta-analyses of studies in which two or more approaches intended to be therapeutic are directly compared, consistently find no difference in outcome between methods–importantly, whether the treatments are designated “trauma-focused” or not. Meanwhile, another highly specialized type of research–known as dismantling studies–fails to provide any evidence for the belief that specialized treatments contain ingredients specifically remedial to the diagnosis! And yes, that includes the ingredient most believe essential to therapeutic success in the treatment of PTSD: exposure (1, 2).

So, if the data I cite above is accurate–and freely available–how could the committee that created the Guideline come to such dramatically different conclusions? In particular, going to great lengths to recommend particular approaches to the exclusion of others?

Be forewarned, you may find my next statement confusing. The summary of studies contained in the Guideline and supportive appendices is absolutely accurate. It is the interpretation of that body of research, however, that is in question.

More than anything else, the difference between the recommendations contained in the Guideline and the evidence I cite above, is attributable to a deep and longstanding rift in the body politic of the APA. How otherwise is one able to reconcile advocating the use of particular approaches with APA’s official policy on psychotherapy recognizing, “different forms . . . typically produce relatively similar outcomes”?

Seeking to place the profession “on a comparable plane” with medicine, some within the organization–in particular, the leaders and membership of Division 12 (Clinical Psychology) have long sought to create a psychological formulary. In part, their argument goes, “Since medicine creates lists of recommended treatments and procedures, why not psychology?”

Here, the answer is simple and straightforward: because psychotherapy does not work like medicine. As Jerome Frank observed long before the weight of evidence supported his view, effective psychological care is comprised of:

An emotionally-charged, confiding relationship with a helping person (e.g., a therapist);
A healing context or setting (e.g., clinic);
A rational, conceptual scheme, or myth that is congruent with the sufferer’s worldview and provides a plausible explanation for their difficulties (e.g., psychotherapy theories); and
Rituals and/or procedures consistent with the explanation (e.g., techniques).

The four attributes not only fit the evidence but explain why virtually all psychological approaches tested over the last 40 years, work–even those labelled pseudoscience (e.g., EMDR) by Lilienfeld, and other advocates of guidelines comprised of “approved therapies.”

That the profession could benefit from good guidelines goes without saying. Healing the division within APA would be a good place to start. Until then, encouraging practitioners to follow the organization’s own definition of evidence-based practice would suffice. To wit, “Evidence based practice is the integration of the best available research with clinical expertise in the context of patient (sic) characteristics, culture, and preferences.” Note the absence of any mention of specific treatment approaches. Instead, consistent with Frank’s observations, and the preponderance of research findings, emphasis is placed on fitting care to the person.

How to do this? The official statement continues, encouraging the “monitoring of patient (sic) progress . . . that may suggest the need to adjust the treatment.” Over the last decade, multiple systems have been developed for tracking engagement and progress in real time. Our own system, known as Feedback Informed Treatment (FIT), is being applied by thousands of therapists around the world, with literally millions of clients. It is listed on the National Registry of Evidence based Programs and Practices. More, when engagement and progress are tracked together with clients in real time, data to date document improvements in retention and outcome of mental health services regardless of the treatment method being used.

Until next time,

Scott

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

“What about the Liars and Deniers?” Working Effectively with Mandated and Incarcerated Clients and People who Sexually Abuse

August 24, 2017 By scottdm 7 Comments

It was just a little over a month ago. I was doing a workshop somewhere in the States. My topic? Using formal client feedback to guide and improve the quality and outcome of psychotherapy– our SAMHSA-approved, NREPP listed evidence-based practice.

At the first break, I was approached by one of the attendees. “I’m really enjoying your presentation,” they started, then paused. I could hear a “but” coming.

“And this sounds like it will work with a lot of different kinds of clients…but what about the liars and deniers?”

It’s not the first time I’d been asked this question–the gist of which is, “Can one really trust the feedback given by some clients?”

“We talking about your ex here?” I jokingly asked.

“No,” the person said with a laugh, “You know, like people who aren’t there voluntarily, clients who are mandated, or in the criminal justice system, substance abusers, sex offenders, or all of the above.”

“Funny you should ask,” I replied, “I just finished an interview with one of the leading experts on working with people who sexually abuse. I hope to get a blog up in the next few weeks.”

And here it is…

David Prescott is a Fellow and past president of the Association for the Treatment of Sexual Abusers, the largest professional organization of its kind in the world. He’s produced 14 books and numerous articles and chapters in the areas of assessing and treating sexual violence and trauma. In the interview below, he talks about the use of FIT with people who sexually abuse–a subject we explore in even greater depth and detail in a chapter we penned together in the eight volume series, The Sex Offender.

Listen in and be sure and leave a comment. It can be fairly challenging material, requiring a shift in mindset and approach–from delivering interventions to developing relationships, gaining compliance to securing engagement, and managing risk to engendering possibilities.

Anyway, I’m interested in your thoughts and experiences.

Meanwhile, registration has just opened for the March 2018 ICCE intensive trainings. Join colleagues from around the world coming together to learn step-by-step, evidence-based strategies for improving engagement and outcome with people of all stripes, backgrounds, and clinical presentations.

Until next time,

Scott

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

Time to Rethink Burnout: Lessons from Supershrinks

June 3, 2015 By scottdm 2 Comments

The world seems to be in the midst of a pandemic of burnout, spread across all age groups, genders, professions, and cultures. Research specific to mental health providers finds that between 21 and 67 percent may be experiencing high levels. Other related “conditions” have been identified, including compassion fatigue (CF), vicarious traumatization (VT), and secondary traumatic stress (STS), all aimed at describing the negative impact that working in human services can have on mental and physical health.

An entire industry of authors, coaches, and trainers has sprung up to address the problem, providing books, videos, presentations, retreats, and organizational consultation. There’s only one problem: currently fashionable approaches to burnout don’t work. In fact, they may make it worse!

What can be done? In the latest issue of the Psychotherapy Networker, my long time colleague and co-writer, Dr. Mark Hubble, and I review research on the field’s Top Performing therapists. Once again, they have something to teach us, this time about “healing the heart of the healer.” Click here to access a PDF of the article.

Until next time,

Scott

Scott D. Miller, Ph.D.

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Feedback Informed Treatment Manuals

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A PrimerManual 1 reviews key empirical literature detailing “what works” in behavioral health treatment, including:
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Upon completion of the manual, readers will be able to:
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Manual 2 – Feedback-Informed Treatment

The BasicsManual 2 details key knowledge and skills regarding the use of routine outcome measurement in clinical practice, including:
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3. Using feedback to inform and improve careUpon completion of the manual, readers will be able to:
• Describe the specific components of routine outcome measurement
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Manual 3 – Feedback-Informed Supervision

Manual 3 details key knowledge and skills involved in the practical application of FIT in clinical supervision. The chief areas of focus are:
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6. How to develop a collaborative service/provider improvement planUpon completion of the manual, readers will be able to:
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• Use aggregate data to identify and develop a plan of remediation.
Price: $24.95 U.S
*Please note: The manuals are e-books licensed for a single-user. If you or your agency would like to provide access to all staff, please email info@scottdmiller.com for a quote and significant discount off the sale price

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Manual 4 – Documenting Change

A Primer on Measurement, Analysis and ReportingManual 4 explores key areas involved with documenting and monitoring client progress, analyzing data, and reporting on those data. Specific sections of the manual include:
1. Psychometric Properties of the ORS and SRS
2. Case Documentation of Client Progress
3. Methods of Data Analysis for Individual Providers, Programs, and Agencies
4. Data ReportingUpon completion of the manual, readers will be able to:
• Describe the psychometric properties of popular outcome and alliance measures in clear, nontechnical terms
• Use methods for documenting client progress in case notations
• Use methods for analyzing outcome data consistently and reliably in a variety of treatment contexts (e.g., private practice, agency, residential settings).
• Describe processes for using data in various formats for the purposes of reporting to third party payers, funding bodies, regulatory agencies
Price: $24.95 U.S
*Please note: The manuals are e-books licensed for a single-user. If you or your agency would like to provide access to all staff, please email info@scottdmiller.com for a quote and significant discount off the sale price

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Manual 5 – Feedback-Informed Treatment

Advanced ApplicationsManual 5 addresses into the advanced applications of clinical work with diverse populations, treatment modalities, and service settings. In addition, Manual 5 offers steps for achieving clinical excellence through deliberate practice. Specific content areas include:
1. Using routine outcome measurement in group therapy
2. Applying FIT with special populations (i.e., children, families, couples, SPMI, DD, mandated clients, etc.)
3. Applying FIT in specific service settings (i.e., inpatient, outpatient, residential, homebased, etc.)
4. Steps to achieving clinical excellenceUpon completion of the manual, readers will be able to:
• Use of routine outcome measurement in group settings
• Apply FIT with a number of special populations
• Applying FIT in specific service settings
• Apply skills of deliberate practice to continuousl
y improve clinical skills and effectiveness
Price: $24.95 U.S
*Please note: The manuals are e-books licensed for a single-user. If you or your agency would like to provide access to all staff, please email info@scottdmiller.com for a quote and significant discount off the sale price

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Manual 6 – Implementing Feedback

Informed Work in Agencies and Systems of CareManual 6 addresses key knowledge and steps for implementing and developing a structure for sustaining feedback-informed work in agencies and larger systems of care. This manual offers detailed guidelines from planning to training to sustainability in organizations. Specific content areas of the manual include:
1. Using the GAP Assessment to identify target areas for organization change (i.e., identification of clinical, policy, administrative, funding, regulatory, supervisory, consumer challenges)2. How to conduct basic staff training
3. Chief management, leadership, and supervision challenges and obligations
4. Creating and utilizing a transition oversight group to facilitate successful implementation
5. Conducting a pilot project
6. Sustainability strategies (e.g., development of a training program, policy, etc.)Upon completion of the manual, readers will be able to:
• Understand how to perform a GAP Assessment and assess organizational readiness for a transition to outcome-informed work
• Convey strategies for administration, management, leadership, and supervision
• Prepare a plan and implement a staff training program
• Pilot and implement an outcome management system
• Describe strategies for sustaining and improving the outcome management system
Price: $24.95 U.S
*Please note: The manuals are e-books licensed for a single-user. If you or your agency would like to provide access to all staff, please email info@scottdmiller.com for a quote and significant discount off the sale price

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All 6 Feedback

Informed Treatment Manuals:The complete set of all 6 FIT manuals.
Price: $119.95 U.S. (a 20% savings)
*Please note: The manuals are e-books licensed for a single-user. If you or your agency would like to provide access to all staff, please email info@scottdmiller.com for a quote and significant discount off the sale price

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Psychotherapy Books

The Heart & Soul Of Change

What Works in Therapy, Second EditionBarry L. Duncan, Scott D. Miller, Bruce E. Wampold, Mark A. HubbleA review of 40 years of research on what works in therapy by the leading researchers in the field. Winner of Menniger’s 15th Annual Award for Scientific Writing.
“How do you improve on a classic? By incorporating all of the most recent research and making it readable and relevant to the student, the practitioner, and the researcher. This volume is a must-read for all of these groups.”–George Stricker, Ph.D.
List price: $59.95 U.S

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The Heroic Client

Barry L. Duncan, Scott D. Miller & Jacqueline SparksIf you’re looking for step-by-step instructions for using outcome and alliance to guide therapeutic process, the revised edition of Heroic Client is for you!
If you purchased the original version, you’ll appreciate the comprehesive updating!
List price: $35.00 U.S.
Price: $32.00 U.S

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The Outcome And Session Rating Scales: Administration And Scoring Manual CORPORATE (in English and French)

Scott D. Miller & Barry L. DuncanNew release! This e-book summarizes the latest research about the ORS and SRS as well as provides step-by-step instructions for administering, scoring, and interpreting the measures in routine clinical practice.
Full length case examples illustrate use of the scales with a variety of typical as well as challenging clinical situations.
A must have for any user of the outcome and alliance tools pioneered by the Founders of I.S.T.C.
Price: $399.95 U.S.
(your order will be added to a shopping cart in case you want to return to these pages for additional purchases).
This manual is available in English and French. When you purchase the manual, you will download a zipped file that contains both versions. Purchase of the corporate version allows use by up to 50 people

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The Outcome And Session Rating Scales: Administration And Scoring ManualINDIVIDUAL (In English And French)

Scott D. Miller & Barry L. DuncanNew release! This e-book summarizes the latest research about the ORS and SRS as well as provides step-by-step instructions for administering, scoring, and interpreting the measures in routine clinical practice.
Full length case examples illustrate use of the scales with a variety of typical as well as challenging clinical situations. A must have for any user of the outcome and alliance tools pioneered by the Founders of I.S.T.C.
Price: $39.95 U.S.
(your order will be added to a shopping cart in case you want to return to these pages for additional purchases).
This manual is available in English and French. When you purchase the manual, you will download a zipped file that contains both versions

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Escape From Babel

Toward a Unifying Language for Psychotherapy PracticeScott D. Miller, Barry L. Duncan, & Mark A. HubbleMichelle Weiner Davis, author of Divorce Busting,says,
“Th
is book pulls the therapeutic rug out from beneath our feet, challenging us to eschew our dogged allegiance to our preferred treatment models and instead explore the real salient ingredient ingredients inherent in all effective therapy.”
List price: $32.00 U.S.
Price: $29.95 U.S

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Psychotherapy With “Impossible” Cases

Barry L. Duncan, Mark A. Hubble, & Scott D. Miller”This is a truly significant work,” says author and Professor Kenneth J. GergenList
price: $35.00 U.S.
Price: $33.00 U.S

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Handbook Of Solution

Focused Brief TherapyScott D. Miller, Mark A. Hubble, & Barry L. Duncan (editors)Recently deemed one of the “9 essential books every therapist needs.”
Price: $75.00 U.S

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Working With The Problem Drinker

A Solution-FocusedInsoo Berg & Scott D. Miller”This book is significant,” says Dr. Fulton Caldwell of the National Institute on Alcohol Abuse and Alcoholism, “makes an important contribution to the growing body of clinical knowledge on the treatment of alcohol-related problems.”
Price: $27.00 U.S

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Effective Techniques For Dealing With Highly Resistant Clients 2nd EditionClifton W. Mitchell, Ph.D.A

practically written guide that presents tangible, stress-reducing techniques for dealing with your most difficult clients. Theories of resistance are examined and a model presented that empowers mental health professionals to resolve roadblocks in therapy. For the first time, hundreds of ideas from a broad array of theories are presented together in one complete package. When consistently used together, these ideas and techniques allow the therapist to create a therapeutic environment where resistance is successfully managed. A valuable resource that both the working professional and student will turn to when seeking realistic, pragmatic ideas and strategies for overcoming stagnation and creating therapeutic movement. The book is indexed and designed for quick access to ideas and approaches.”
Price: $24.95 U.S

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Self-Help Book

The Miracle Method

A Radically New Approach to Problem DrinkingScott D. Miller & Insoo BergDo you or someone you love have a drinking problem? This book is a dramatically useful alternative to the Disease Model of Addiction and the Twelve Steps of A.A.
Price: $13.95 U.S.

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Staying On Top And Keeping The Sand Out Of Your PantsScott

Mark A. Hubble, & Seth HoudeshellLooking for a fun summer read? This short, anecdote and cartoon filled book certainly fits the bill. By the same publisher as the Chicken Soupseries, it will lift your spirits and put a smile on your face.
Price: $9.95 U.S

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Audio

Outcome Informed Clinical Work

Scott D. Miller, Ph.D.On this professional produced hour-long CD, Scott Miller teaches clinicians how to use outcome measures in routine clinical practice to inform and improve service delivery and outcomes. Research to date shows that following the steps outlined in detail on this program significantly improves outcome and retention in behavioral health services. The CD is formatted to play in a car or home stereo as well as via computer. The disk includes a comprehensive set of slides in PDF format to aid learning..
List price: $14.95
Price: $9.95

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The Therapeutic Alliance

Translating Research into Evidenced-Based Skills for Clinical PracticeScott D. Miller, Ph.D.On this professionally produced hour-long audio on CD, Scott Miller translates the latest research on the therapeutic alliance into practical clinical skills. Learn “what works,” as well as strategies for dealing with and overcoming alliance ruptures. The lecture also includes step-by-step instructions for using the Session Rating Scale as well as a comprehensive set of slides in PDF format.
List price: $14.95
Price: $9.95

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Working With Uncooperative, Resistant, Or Mandated Clients

A Client-Directed ApproachScott D. MillerNowadays, therapists are asked to work with people who have been forced to enter treatment services. In this lively and funny audiotape, learn specific strategies for forming helping relationships with such clients. Professionally-produced 90 minute audio on CD.List
price: $14.95 U.S.
Price: $9.95 U.S.

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Videos

Feedback Informed Treatment

Feedback-Informed Treatment (FIT) is a pantheoretical approach for evaluating and improving the quality and effectiveness of behavioral health services. Research to date documents that FIT dramatically improves both retention and outcome of behavioral health services. FIT involves routinely and formally soliciting feedback from clients regarding the therapeutic alliance and outcome of care and using the resulting information to inform and tailor service delivery. FIT is not only consistent with but operationalizes the American Psychological Association’s (APA) definition of evidence-based practice. To wit, FIT involves “the integration of the best available research…and monitoring of patient progress (and of changes in the patient’s circumstances — e.g. job loss, major illness) that may suggest the need to adjust the treatment…(e.g., problems in the therapeutic relationship or in the implementation of the goals of the treatment)” (American Psychologist, May 2006, p. 273, 276-277).In this video, Drs. Scott D. Miller and Julie Tilsen, describe and demonstrate how clinicians can integrate the principles and practices of FIT into their work regardless of theoretical orientation or professional discipline. Dr.’s Miller and Tilsen provide an overview discussion of FIT and then demonstrate how to use it with three different clients. 1. The client with SPMI (Serious and Persistent Mental Illness) 2. The mandated client and 3. A mother/daughter duo seeking help with relationship issues. In the video, you will learn:The empirical foundation for routine monitoring of the alliance and outcome in treatmentHow to administer valid, reliable, and feasible measures of alliance and outcomeHow to use alliance and outcome measures to inform and improve the quality and outcome of behavioral healthcareSpecial Introductory, invididual version price: $49.95

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What Works In Psychotherapy

Individual EditionScott D. Miller with Randall C. WyattWhat works in psychotherapy? In this interview by Randall C. Wyatt, Miller shares everything he knows about psychotherapy outcomes. For starters, it’s the therapeutic alliance that’s one of the most important elements. And here’s the real ticker—Miller has found that the therapist is the determining factor, not the treatment model. This means that therapists can learn, grow and be more effective with their clients by systematically monitoring therapy outcomes, inviting negative feedback, and asking the simple question that so often seems too difficult for therapists to ask: “How is this working for you?”Miller warns against manualized systems that require therapists to narrowly work in a particular model, citing research that shows that therapists are the most effective when they are allowed to practice what they believe and are confident in. This means you don’t need to change your modality to be more effective, and, in fact, can have a meaningful evidence-based practice by adapting some of Miller’s simple tools to invite client feedback.From watching this video, you’ll learn:What factors determine positive and negative outcomes in psychotherapy.How to be the most effective therapist with all your clients by learning to monitor outcomes.When the most important times to intervene are, and how therapy approaches vary depending on the client’s own stage of change.“Our diversity as a profession… is not a weakness that needs to be cured with evidence-based practice. It’s a strength and it needs to be nurtured with outcome-informed measures.”
–Scott D. Miller, Ph.D.
Invididual Version Price: $49.00
Institutional/Instructors Version Price: $149.00

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Client-Directed, Outcome-Informed Psychotherapy

Scott D. Miller, Ph.D.Studio-produced DVD from the American Psychological Association’s famed “Systems of Psychotherapy” series. Learned the principles of client-directed, outcome informed work by watching a real case unfold during a live, unscripted interview. The case features a young dually-diagnosed mother struggling with relationship and family issues. The process of using the outcome and alliance scales is covered in detail, including the use of the computerized tracking system..
Price: $99.95 U.S

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Healing Trauma Through Conversation

Scott D. Miller, Ph.D.A moving session on DVD of client-directed clinical work with a woman who has just learned that her daughter has a brain tumor. Learning the basics of the approach are facilitated by the use of subtitles which explain the therapeutic process as the session unfolds. The tape includes the first session plus a follow up with the client some six months latter during which she talks about the fate of her daughter as well as highlights the helpful aspects of the previous visit.
List price: $75.00 U.S.
Price: $69.95 U.S

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Heart, Soul, And Research On Psychotherapy

An Interview with Scott D. MillerDavid AndrewsWant to learn what research over the last 40 years indicates are the effective ingredients of therapy? This engaging interview with one of the founders of the Institute for the Study of Therapeutic Change provides an in-depth review of the data. The video is sure to both reassure and challenge.
List price: $75.00
Price: $69.95

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How To Interview For A Change

Scott D. Miller, Ph.D.Classic demonstration of strengths-based interviewing. A female client rediscovers her abilities following the death of her mother and close family member.
List price: $75.00 U.S.
Price: $49.95 U.S.

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Believing is Seeing: How Wishing Makes Things So

January 3, 2013 By scottdm Leave a Comment

Yesterday evening, my family and I were watching a bit of T.V. My son, Michael commented about all the ads for nutrional supplements, juicing machines, weight loss programs and devices. “Oh yeah,” I thought, then explained to him, “It’s the start of a new year.” Following “spending more time with family,” available evidence shows exercise and weight loss top the bill of resolutions. Other research shows that a whopping 80% eventually break these well intentioned commitments. Fully a third won’t even make it to the end of the month! Most attribute the failure to being too busy, others to a lack of motivation. Whatever the cause, it’s clear that, when it comes to change, hope and belief will only take you so far.

What can help? More on that in a moment.

In the meantime, consider a recent study on the role of hope and belief in research on psychotherapy. Beginning in the 1970’s, study after study, and studies of studies, have found a substantial association between the effectiveness of particular treatment models and the beliefs of the researchers who conduct the specific investigations. In the literature, the findings are referred to under the generic label, “research allegiance” or R.A. Basically, psychotherapy outcome researchers tend to find in favor of the approach they champion, believe in, and have an affinity towards. Unlike New Year’s resolutions, it seems, the impact of hope and belief in psychotherapy outcome research is not limited; indeed, it carries investigators all the way to success–albeit a result that is completely “in the eye of the beholder.” That is, if one believes the research. Some don’t.

Hang with me now as I review the controversy about this finding. As robust as the results on researcher allegiance appear, an argument can be made that the phenomenon is a reflection rather than a cause of differences in treatment effectiveness. The argument goes: researcher allegiance is caused by the same factors that lead to differences in outcome between approaches: real differences in outcome betweepproaches. In short, researchers’ beliefs do not cause the effects, as much as the superior effects of the methods cause researchers to believe. Makes sense, right? And the matter has largely nguished there, unresolved for decades.

That is, until recently. Turns out, believing is seeing. Using a sample of studies in which treatments with equivalent efficacy were directly compared within the same study, researchers Munder, Fluckiger, Gerger, Wampold, and Barth (2012) found that a researcher’s allegiance to a particular method systemically biases their results in favor of their chosen approach. The specific methods included in this study were all treatments designated as “Trauma-focused” and deemed “equally effective” by panels of experts such as the U.K.’S National Institute for Clinical Excellence. Since the TFT approaches are equivalent in outcome, researcher allegiance should not have been predictive of outcome. Yet, it was–accounting for an incredible 12% of the variance. When it comes to psychotherapy outcome research, wishing makes it so.

What’s the “take-away” for practitioners? Belief is powerful stuff: it can either help you see possibilities or blind you to important realities. Moreover, you cannot check your beliefs at the door of the consulting room, nor would you want to. Everyday, therapists encourage people to take the first steps toward a happier, more meaningful life by rekindling hope. However, if researchers, bound by adherence to protocol and subject to peer review can be fooled, so can therapists. The potentially significant consequences of unchecked belief become apparent when one considers a recently published study by Walfish et al. (2012) which found that therapists on average overestimate their effectiveness by 65%.

When it comes to keeping New Year’s resolutions, experts recommend avoiding broad promises and grand commitments and instead advise setting small, concrete measureable objectives. Belief, it seems, is most helpful when its aims are clear and effects routinely verified. One simple way to implement this sage counsel in psychotherapy is to routinely solicit feedback from consumers about the process and outcome of the services offered. Doing so, research clearly shows, improves both retention and effectiveness.

You can get two, simple, easy-to use scales for free by registering at: http://scottdmiller.com/srs-ors-license/ A world wide community of behavioral health professionals is available to support your efforts at: www.centerforclinicalexcellence.com.

You can also join us in Chicago for four days of intensive training. We promise to challenge your both beliefs and provide you with the skills and tools necessary for pushing your clinical performance to the next level of effectiveness.

The DSM 5: Mental Health’s "Disappointingly Sorry Manual" (Fifth Edition)

June 11, 2012 By scottdm 2 Comments

Have you seen the results from the field trials for the fifth edition of the Diagnostic and Statistical Manual? The purpose of the research was to test the reliability of the diagnoses contained in the new edition. Reliable (ri-lahy–uh-buhl), meaning “trustworthy, dependable, consistent.”

Before looking at the data, consider the following question: what are the two most common mental health problems in the United States (and, for that matter, most of the Western world)? If you answered depression and anxiety, you are right. The problem is that the degree of agreement between experts trained to used the criteria is unacceptably low.

Briefly, reliability is estimated using what statisticians call the Kappa (k) coefficient, a measure of inter-rater agreement. Kappa is thought to be a more robust measure than simple percent agreement as it takes into account the likelihood of raters agreeing by chance.

The results? The likelihood of two clinicians, applying the same criteria to assess the same person, was poor for both depression and anxiety. Although there is no set standard, experts generally agree that kappa coefficients that fall lower that .40 can be considered poor; .41-.60, fair; .61-.75, good; and .76 and above, excellent. Look at the numbers below and judge for yourself:

Diagnosis	DSM-5	DSM4	ICD-10	DSM-3
Major Depressive Disorder	.32	.59	.53	.80
Generalized Anxiety Disorder	.20	.65	.30	.72

Now, is it me or do you notice a trend? The reliability for the two most commonly diagnosed and treated “mental health disorders” has actually worsened over time! The same was found for a number of the disorders, including schizophrenia (.46, .76, .81), alcohol use disorder (.40, .71, .80), and oppositional defiant disorder (.46, .51., .66). Antisocial and Obsessive Personality Disorders were so variable as to be deemed unreliable.

Creating a manual of “all known mental health problems” is a momumental (and difficult) task to be sure. Plus, not all the news was bad. A number of diagnoses demonstrated good reliability (autism spectrum disorder, posttraumatic stress disorder (PTSD), and attention-deficit/hyperactivity disorder (ADHD) in children (.69, .67, .61, respectively). Still, the overall picture is more than a bit disconcerting–especially when one considers that the question of the manual’s validity has never been addressed. Validity (vuh–lid-i-tee), meaning literally, “having some foundation; based on truth.” Given the lack of any understanding of or agreement on the pathogenesis or etiology of the 350+ diagnoses contained in the manual, the volume ends up being, at best, a list of symptom clusters–not unlike categorizing people according to the four humours (e.g., phlegmatic, choleric, melancholy, sanquine).

Personally, I’ve always been puzzled by the emphasis placed on psychiatric diagnoses, given the lack of evidence of diagnostic specific treatment effects in psychotherapy outcome research. Additionally, a increasing number of randomized clinical trials has provided solid evidence that simply monitoring alliance and progress during care significantly improves both quality and outcome of the services delivered. Here’s the latest summary of feedback-related research.

The International Center for Clinical Excellence: Using Social Networks for "Real Time" Research

June 6, 2012 By scottdm 1 Comment

The International Center for Clinical Excellence was officially lauched at the Evolution of Psychotherapy Conference in December 2009. Since that time, membership has grown steadily. With over 3800 members, the ICCE is the largest, web-based community of behavioral health professionals dedicated to improving the quality and outcome of service delivery. The site features nearly a hundred discussion forums, taking place in a number of languages, on topics specific to treatment and research.

Many agencies and systems of care are using the site to coordinate implementation of feedback-informed treatment. Of course, those attending ICCE training events (e.g., the Advanced Intensive, Training of Trainers, and Achieving Clinical Excellence conference), use the site for both pre and post training support and continuing education.

And now, the site is being used for a new purpose: research. ICCE member and associate Wendy Amey was the first. She used the site successfully for her dissertation, surveying members about how they work with trauma. I am pleased to announce two new research projects that will access the ICCE community.

The first is being conducted by McGill University counseling psychology doctoral candidate Ionita Gabriela. Her study focuses on clinicians’ experiences with using measures to monitor client progress in the services they offer. Implementation is the challenge most clinician and agencies face when incorporating routine outcome monitoring into practice. All participants will be entered into a drawing for a $100 Amazon gift certificate. More importantly, participants will contribute to the expanding knowledge base on feedback informed treatment. Whether or not you are a member of ICCE, you can contribute by taking part in the study. Click here to send an email to Ionita to complete the interview (it only takes about 15 minutes).

The second study is being conducted by me and ICCE Associate Daryl Chow as part of ICCE’s continuing emphasis on clinical excellence. The study builds on groundbreaking research by Ronnestad and Orlinksy on the subject of therapist development. Particpants are asked to complete a brief (8-12 minutes), online survey with questions pertaining to your development as a clinician. All participants will be entered into a drawing, the winner receiving all 6 of the newly released FIT Treatment and Training Manuals (valued at $100). Again, you can participant whether or not you are currently a member of the ICCE. In fact, please ask your colleagues to participate as well! Click here to complete the secure, online survey (no identifying information will be sought).

Feedback-Informed Treatment as Evidence-based Practice: APA, SAMSHA, and NREPP

November 1, 2011 By scottdm 1 Comment

What is evidence-based practice? Visit the UK-based NICE website, or talk to proponents of particular theoretical schools or therapeutic models, and they will tell you that being “evidence-based” means using the approach research has deemed effective for a particular diagnosis (e.g., CBT for depression, EMDR for trauma). Over the last two decades, numerous organizations and interest groups have promoted lists of “approved” treatment approaches–guidelines that clinicians and funding bodies should follow when making practice decisions. Throughout the 1990’s, for example, division 12 within the American Psychological Association (APA) promoted the idea of “empirically supported treatments.”

However, when one considers the official definition of evidence-based practice offered by the Institute of Medicine and the APA, it is hard to fathom how anyone could come to such a conclusion. According to the APA, evidence-based practice is, “the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences.” (see American Psychologist, May 2006). Nothing here about “empirically supported treatments” or the mindless application of specific treatment protocols. Rather, according to the APA and IOM, clinicians must FIT the treatment to the client, their preferences, culture, and circumstances. And how can one do that? Well, conspicuously absent from the definition is, “consult a set of treatment guidelines.” Rather, when evidence-based, clinicians must monitor “patient progress (and of changes in the patient’s circumstances—e.g.,job loss, major illness) that may suggest the need to adjust the treatment. If progress is not proceeding adequately, the psychologist alters or addresses problematic aspects of the treatment (e.g., problems in the therapeutic relationship or in the implementation of the goals of the treatment) as appropriate.”

The principles and practices of feedback-informed treatment (FIT) are not only consistent with but operationalize the American Psychological Association’s (APA) definition of evidence-based practice. To wit, 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. And indeed, over the last 9 months, together with Senior Associates, I completed and submitted an application for FIT to be reviewed by NREPP–SAMSHA’s National Registry of Evidence-based Practices and Approaches! As part of that application and ICCE’s commitment to improving the quality and outcome of behavioral health, we developed a list of “core competencies” for FIT practice, a series of six detailed treatment and implementation manuals, a gap assessment tool that organizations can use to quickly and expertly assess implementation and fidelity problems, and supportive documentation and paperwork. Finally, we developed and rigorously tested training curricula and administered the first standardized exam for certifying FIT practitioners and trainers. We are in the final stages of that review process soon and I’m sure I’ll be making a major announcement right here on this blog shortly. So, stay tuned.

In the meantime, this last Saturday, clinicians located the globe–Canada, New Zealand, Australia, the US,a nd Romania–sat for the first administration of ICCE “Core Competency” Exam. Taking the test is the last step in becoming an ICCE “Certified Trainer.” The other requirements include: (1) attending the “Advanced Intensive” and “Training of Trainers” workshops; and (2) submitting a training video on FIT for review. The exam was administered online using the latest technology.

The members, directors, and senior associates of ICCE want to congratulate (from top left):

Eeuwe Schuckard, Psychologist, Wellington, New Zealand;
Aaron Frost, Psychologist, Brisbane, Australia;
Cindy Hansen, BA-Psych, HHP, Manager Myoutcomes;
David Prescott, Director of Professional Development, Becket Family of Services, Portland, Maine;
Arnold Woodruff, LMFT, Clinical Director, Home for Good, Richmond, Virginia;
Bogdan, Ion, Ph.D., Bucharest University, Bucharest, Romania;
Daniel Buccino, Clinical Supervisor, Community Psychiatry Program. Johns Hopkins;
Dwayne Cameron, Outreach Counselor, Prince Albert, Saskatoon, Canada;
Mark Goheen, the Clinical Practice Lead at Fraser Health, British Columbia.

If you are not yet a member of the ICCE community, please join the largest, fastest growing, and friendly group of behavioral health professionals today at: www.centerforclinicalexcellence.com.

The War on Unhappiness Heats Up

November 24, 2010 By scottdm Leave a Comment

Back in September, I blogged about an article by Gary Greenberg published in the August issue of Harper‘s magazine that took aim at the “helping profession.” He cast a critical eye on the history of the field, it’s colorful characters, constantly shifting theoretical landscape, and claims and counterclaims regarding “best practice.” Several paragraphs were devoted to my own work; specifically, research documenting the relatively inconsequential role that particular treatment approaches play in successful treatment and the importance of using ongoing feedback to inform and improve mental health services.

Just this last week, while I was overseas teaching in Romania (more on that trip soon), I received an email from Dr. Dave of ShrinkRapRadio who felt the piece by Greenberg was unfair to the field in general and a mischaracterization of the work by many of the clinicians cited in the article, including me. “I’ve got a blog on the Psychology Today website and I’m planning to take him to task a bit,” he wrote.

If you have not had a chance to read the Greenberg article, you can find it on my original blogpost. It’s a must read, really. As I said then, whatever your opinion about the present state of practice, “Greenberg’s review of current and historical trends is sobering to say the least–challenging mental health professionals to look in the mirror and question what we really know for certain–and a must read for any practitioner hoping to survive and thrive in the current practice environment.” Then, take a moment and read Dr. Dave’s response. With his permission, I’ve posted it below!

Popping The Happiness Bubble: The Backlash Against Positive Psychology

Readers will recall that in Part 1, I suggested that a backlash against the ebullience of the positive psychology movement was probably inevitable. The most visible sign of that rebellion was last year’s best-selling book by Barbara Ehrenreich, Bright-Sided: How The Relentless Promotion of Positive Thinking Has Undermined America. While I found myself in agreement with much of her appraisal of American culture and our historical fascination with “positive thinking,” I thought her critique of positive psychology fell short by equating positive psychology to “positive thinking.” It also seemed to me that she failed to recognize that a huge body of research conducted by an army of independent researchers is emerging on a very diverse range of topics, which have been subsumed under the general heading of positive psychology. And, finally, much of her argument was based on an ad hominem attack on Martin Seligman.

I found further evidence of this backlash in the lead article in the October 2010 issue of Harper’s by psychotherapist Gary Greenberg, “The War on Unhappiness: Goodbye Freud, Hello Positive Thinking.” Greenberg is the author of Manufacturing Depression, a book that came out earlier this year. In addition, he is a prolific writer who has published articles that bridge science, politics, and ethics in a number of leading magazines. So he’s got great credentials both as a psychologist and a writer. Yet, I found this particular article unsatisfying. At least, that was my reaction upon first reading. As I later read it a second time to write about it here, I got a clearer sense of what he was up to and found myself in substantial agreement with his overall thrust.

The stimulus for Greenberg’s piece appears to have been his attendance at the annual Evolution of Psychotherapy Conference in Anaheim earlier this year. He seems to take a pretty dyspeptic view of the whole event: “Wandering the conference, I am acquainted, or reacquainted, with Cognitive Behavioral Therapy, Ericksonian Hypnosis, Emotionally Focused Therapy, Focusing, Buddhist Psychology, Therapist Sculpting, Facilitating Gene Expression, and Meditative methods.” A forty-year veteran of the California personal-growth/therapy scene, myself, it’s easy to develop a jaundiced eye over time as a panoply of approaches come and go. Yet, I have to say my own view, as a result of over 300 podcast interviews with psychologists across a broad spectrum of orientations, is there is more of a developing consensus and that the differences between many approaches are relatively minor.

By contrast, Greenberg seems to go into despair.

As I say, it took two readings of Greenberg’s article to really get the overall sweep. On first reading, it seems to be a bit of a meander, beginning with some slighting anecdotes about Freud. Then we’re on to the Anaheim conference and some handwringing about the seeming tower of Babel created by the profusion of therapeutic approaches. This segues into a discussion of Rozenzwig’s 1936 “Dodo Bird Effect” which asserts that therapeutic orientation doesn’t matter because all orientations work. As the Dodo pronounces in Alice in Wonderland, “Everyone has won and all must have prizes.” According to Greenberg, the Dodo Bird Effect has been borne out in subsequent studies and the requisite common ingredient for therapeutic success is faith, both the client’s and the therapist’s.

Greenberg goes on to describe several of the presentations, most notably by Otto Kernberg, Scott D. Miller, David Burns, and Martin Seligman. Part of what put me off about this article on my first reading is that I have conducted in-depth interviews with the first three of these gentlemen and I would not have recognized them from Greenberg’s somewhat muddled account.

Otto Kernberg, MD, one of the grand old men of psychoanalysis, is characterized as intoning “the old mumbo jumbo about the Almost Untreatable Narcissistic Patient…” In my opinion, this really slights his lifetime commitment to research, his many contributions to object relations theory, and his role as Director of The Institute for Personality Disorders at the Cornell Medical Center. In my interview with Dr. Kernberg, I was struck by the flexibility of this octogenerian to incorporate the findings of neuroscience, genetics, and even cognitive behavioral therapy in this thinking.

Greenberg seems to use Dr. Scott D. Miller’s research as supporting the Dodo Bird effect. I attended a daylong workshop with Scott Miller a few years ago and it was one of the best presentations I’ve ever seen. I also interviewed him for one of my podcasts. The key takeaway for me from Scott Miller’s work is that the Dodo Bird effect shows up only when therapeutic effectiveness is averaged across therapists. That is, on average, all psychotherapies are moderately effective. However, Miller reports that not all therapists are equally effective and that, if you look at therapists who are consistently rated as effective by their clients vs. therapists who are consistently rated as ineffective, then therapy emerges as a highly worthwhile enterprise.

As Miller said in my interview with him, “If the consumer is able to feed back information to the system about their progress, whether or not progress is being made, those two things together can improve outcomes by as much as 65%.”

As I say, I had difficulty recognizing Miller in Greenberg’s account. Evidently, Greenberg is critical of Miller having developed a standardized set of rating scales for clients to provide feedback to their therapists. Greenberg sees these scales as playing into the hands of managed care and the trend towards “manualized” therapies. However, in my interview with Miller, he is very clearly critical of managed care, at least in terms of their emphasis on particular treatments for particular diagnostic categories. As Miller said in his interview with me, “If there were inter-rater reliability that would be one thing; the major problem with the DSM is that is lacks validity, however. That these groupings of symptoms actually mean anything… and that data is completely lacking… We are clustering symptoms together much the way medicine did in the medieval period: this is the way we treated people and thought about people when we talked about them being phlegmatic for example; or the humors that they had. Essentially they were categorizing illnesses based on clusters of symptoms.”

I also had difficulty recognizing Stanford psychiatry professor, David Burns, from Greenberg’s summary of the session he attended with Burns. In short, Greenberg portrays Burns, who has developed a Therapist’s Toolkit inventory as wishing to replace “open-ended conversation with a five-item test… to take an X-ray of our inner lives.” This runs counter to my experience of Burns who, for example, in my interview with Dr. Burns about his cognitive therapy approach to couples work said, “…cognitive therapy has become probably the most widely practiced and researched form of psychotherapy in the world. But I really don’t consider myself a cognitive therapist or any other school of therapy; I’m in favor of tools, not schools of therapy. I think all the schools of therapy have had important discoveries and important angles, but the problem is they are headed up by gurus who push too hard trying to say cognitive therapy is the answer to everything, or rational emotive therapy is the answer to everything, or psychoanalysis is the answer to everything. And that is reductionism, and kind of foolish thinking to my point of view.” This hardly sounds like someone who thinks he’s invented a paper-and-pencil test that will be the end-all of psychotherapy.

And then Greenberg goes on to skewer positive psychology, which is what drew me to his article in the first place. After all, the title “The War on Unhappiness” seems to promise that. Like Ehrenreich, however, Greenberg’s critique is largely an ad hominem attack on Seligman. For example, referring to his earlier work subjecting dogs to electric shock boxes to study learned helplessness, Greenberg characterizes Seligman as, “More curious about dogs than about the people who tortured them…” He goes on to recount Seligman’s presentation to the CIA on learned helplessness which became the basis for enhanced “interrogation” techniques in Iraq. Now, we are told Seligman is working with the U.S. Army to teach resilience to our troops. In Greenberg’s view, Seligman would have us going his dogs one better by “thriving on the shocks that come our way rather than merely learning to escape them.”

So, it turns out that Greenberg’s attack on positive psychology is rather incidental to his larger concern which turns out to be that clinical psychology has sold its soul to the evidence-based, managed-care lobby in order to feed at the trough of medical reimbursement.

Greenberg’s article is a circular ramble that begins with slighting references to Freud and psychoanalysis and then ends with Freud as the champion of doubt.

It took me two readings to see that Greenberg is essentially using Miller, Burns, and Seligman as foils to attack smug certainty and blind optimism, the enemies of doubt. Of himself, Greenberg concludes, “I’m wondering now why I’ve always put such faith in doubt itself, or, conversely, what it is about certainty that attracts me so much, that I have spent twenty-seven years, thousands of hours, millions of other people’s dollars to repel it.”

Greenberg evidently values the darker side, the questions, the unknown, the mystery. “Even if Freud could not have anticipated the particulars – the therapists-turned-bureaucrats, the gleaming prepackaged stories, the trauma-eating soldiers-he might have deduced that a country dedicated in its infancy to the pursuit of happiness would grow up to make it a compulsion. He might have figured that American ingenuity would soon, maybe within a century, find a way to turn his gloomy appraisal of humanity into a psychology of winners.”

I think I’m in agreement with at least some of Greenberg’s larger argument. My fear, however, is that the general reader will come away with the impression that psychotherapists don’t know what they are doing and that the whole enterprise is a waste of time and money. That would be too bad. Both because I don’t think it’s true and I don’t think Greenberg does either.

I encourage you to find Greenberg’s article and to post your own reactions here in the comments area.

I had planned to stake out my own position on positive psychology in response to the critiques of Ehrenreich and Greenberg. It’s looking like there may need to be a Part 3. Stay tuned!

Clinician Beware: Ignoring Research Can be Hazardous to Your Professional (and Economic) Health

September 25, 2010 By scottdm Leave a Comment

“Studies show…”

“Available data indicate…”

“This method is evidence-based…”

My how things have changed. Twenty years ago when I entered the field, professional training, continuing education events, and books rarely referred to research or evidence. Now, everyone refers to the “data.” The equation is simple: no research = no money. Having “an evidence-base” increasingly determines book sales, attendance at continuing education events, and myriad other funding and reimbursement decisions.

So what do the data actually say? S adly, the answer is often, “it depends on who you ask.” If you read the latest summary and treatment recommendations for post-traumatic stress disorder (PTSD) posted by the Cochrane Collaboration, you are told that TFCBT and EMDR are the most effective, “state of the art” treatments on offer. Other summaries, as I recently blogged about, arrive at very—even opposite—conclusions; namely, all psychotherapies (trauma-focused and otherwise) work equally well in the treatment of PTSD. For the practicing clinician (as well as other consumers of research), the end result is confusion and, dare I say, despair.

Unable to resolve the discrepant findings, the research is either rejected out of hand (“it’s all crap anyway”) or cherry-picked (“your research is crap, mine is good”). In a world where experts disagree–and vehemently–what is the average Joe or Jane therapist to do?

Fortunately, there is another way, beyond agnosticism and instead of fundamentalism. In a word, it is engagement. This last week, I spent 5 days teaching an intensive workshop with ICCE Senior Associate Susanne Bargmann to a group of Danish psychologists on “Statistics and Research Design.” That’s right. Five days, 6 hours a day spent away from work and clients learning how to understand, read, and conduct research.

The goal of the training was simple and straight-forward: help practitioners learn to evaluate the methods and meanings, strengths and weaknesses, and political and paradigmatic influences associated with research and evidentiary claims. At the conclusion of the five days, none of those assembled had difficulty engaging with and understanding the reasons for the seemingly discrepant findings noted above. As a result, they could state with confidence “what works” with PTSD, helping clarify this not only to colleagues, payers, and policy members but also to consumers of behavioral health services.

The “Statistics and Research Design” course will be held again in Denmark in 2011. If the experience of this year’s participants proves anything, it is that, “The only thing therapists have to fear about statistics and research design, is fear itself.” Please contact Vinther and Mosgaard directly for more information.

Finally, as part of the International Center for Clinical Excellence (ICCE) efforts to improve the quality and outcome of behavioral health services worldwide, two additional intensive trainings will be offered in Chicago, Illinois (USA). First, the “Advanced Training in Feedback-Informed Treatment (FIT).” And second, the annual “Training of Trainers.” In the Advanced Training, participants learn:

· The empirical foundations of feedback-informed clinical work (i.e., empirically supported factors underlying successful clinical work, the impact of feedback on performance)

· Clinical skills for enhancing client engagement that cut across different therapeutic orientations and diverse treatment populations

· How to integrate outcome management tools (including one or more of the following: ORS, SRS, CORE, and OQ 45) into clinical practice

· How to use the outcome management tools to inform and improve service delivery

· How to significantly improve your clinical skills and outcomes via feedback and deliberate practice

· How to use data generated from outcome measures to inform management, supervision, and training decisions

· Strategies for successful implementation of CDOI and FIT in your organization or practice

Need more information about the course? Email us or click on the video below to hear more about the course. In the meantime, space is limited so register early at: http://www.eventbrite.ie/o/the-international-centre-for-clinical-excellence-298540255.

Whoa Nellie! A 25 Million Dollar Study of Treatments for PTSD

October 27, 2009 By scottdm 1 Comment

I have in my hand a frayed and yellowed copy of observations once made by a well known trainer of horses. The trainer’s simple message for leading a productive and successful professional life was, “If the horse you’re riding dies, get off.”

You would think the advice straightforward enough for all to understand and benefit. And yet, the trainer pointed out, “many professionals don’t always follow it.” Instead, they choose from an array of alternatives, including:

Buying a strong whip
Switching riders
Moving the dead horse to a new location
Riding the dead horse for longer periods of time
Saying things like, “This is the way we’ve always ridden the horse.”
Appointing a committee to study the horse
Arranging to visit other sites where they ride dead horses more efficiently
Increasing the standards for riding dead horses
Creating a test for measuring our riding ability
Complaining about how the state of the horse the days
Coming up with new styles of riding
Blaming the horse’s parents as the problem is often in the breeding.

When it comes to the treatment of post traumatic stress disorder, it appears the Department of Defense is applying all of the above. Recently, the DoD awarded the largest grant ever awarded to “discover the best treatments for combat-related post-traumatic stress disorder” (APA Monitor). Beneficiaries of the award were naturally ecstatic, stating “The DoD has never put this amount of money to this before.”

Missing from the announcements was any mention of research which clearly shows no difference in outcome between approaches intended to be therapeutic—including, the two approaches chosen for comparison in the DoD study! In June 2008, researchers Benish, Imel, and Wampold, conducted a meta-analysis of all studies in which two or more treatment approaches were directly compared. The authors conclude, “Given the lack of differential efficacy between treatments, it seems scientifically questionable to recommend one particular treatment over others that appear to be of comparable effectiveness. . . .keeping patients in treatment would appear to be more important in achieving desired outcomes than would prescribing a particular type of psychotherapy” (p. 755).

Ah yes, the horse is dead, but proponents of “specific treatments for specific disorders” ride on. You can hear their rallying cry, “we will find a more efficient and effective way to ride this dead horse!” My advice? Simple: let’s get off this dead horse. There are any number of effective treatments for PTSD. The challenge is decidedly not figuring out which one is best for all but rather “what works” for the individual. In these recessionary times, I can think of far better ways to spend 25 million than on another “horse race” between competing therapeutic approaches. Evidence based methods exist for assessing and adjusting both the “fit and effect” of clinical services—the methods described, for instance, in the scholarly publications sections of my website. Such methods have been found to improve both outcome and retention by as much as 65%. What will happen? Though I’m hopeful, I must say that the temptation to stay on the horse you chose at the outset of the race is a strong one.

Practice-Based Evidence Goes Mainstream

September 5, 2009 By scottdm 4 Comments

For years, my colleagues and I have been using the phrase “practice-based evidence” to refer to clinicians’ use of real-time feedback to develop, guide, and evaluate behavioral health services. Against a tidal wave of support from professional and regulatory bodies, we argued that the “evidence-based practice”–the notion that certain treatments work best for certain diagnosis–was not supported by the evidence.

Along the way, I published, along with my colleagues, several meta-analytic studies, showing that all therapies worked about equally well (click here to access recent studies children, alcohol abuse and dependence, and post-traumatic stress disorder). The challenge, it seemed to me, was not finding what worked for a particular disorder or diagnosis, but rather what worked for a particular individual–and that required ongoing monitoring and feedback. In 2006, following years of controversy and wrangling, the American Psychological Association, finally revised the official definition to be consistent with “practice-based evidence.” You can read the definition in the May-June issue of the American Psychologist, volume 61, pages 271-285.

Now, a recent report on the Medscape journal of medicine channel provides further evidence that practice-based evidence is going mainstream. I think you’ll find the commentary interesting as it provides compelling evidence that an alternative to the dominent paradigm currently guiding professional discourse is taking hold. Watch it here.