SCOTT D Miller - For the latest and greatest information on Feedback Informed Treatment

scottdmiller@ talkingcure.com +1.773.454.8511

The Illness and the Cure: Two Free, Evidence-based Resources for What Ails and Can Heal Serious Psychological Distress

By 14 Comments

141030125424-mental-illness-hands-on-head-live-videoFindings from several recent studies are sobering. Depression is now the leading cause of ill-health and disability worldwide–more than cancer, heart disease, respiratory problems, and accidents.  Yesterday, researchers reported that serious psychological distress is at an all-time high, significantly affecting not only quality but actual life expectancy.  And who has not heard about the opioid crisis–33,000 deaths in the U.S. in 2015 and rising?

The research is clear:  psychotherapy helps.  Indeed, its effectiveness is on par with coronary artery bypass surgery.  Despite such results, availability of mental health services in the U.S. and other Westernized nations has seriously eroded over the last decade.   Additionally, modern clinical practice is beset by regulation and paperwork, much of which gets in the way of treatment’s most important healing ingredient: the relationship.

What can practitioners do?Students Taking Notes at Desks by VCU_Brandcenter

Completing paperwork together with clients during the visit–a process termed, “collaborative (or concurrent) documentation”–has been shown to save full-time practitioners between 6 and 8 hours per week, thereby improving capacity up to 20%.

It’s a great idea: completing assessments, treatment plans, and progress notes together with clients during rather than after the session. Unfortunately, it’s chief selling point to date seems to be that it saves time on documentation–as though filling out paperwork is an end in and of itself!  Clearly, the real challenges facing mental health services are getting people into and keeping them in care.   Here, the research literature is clear, people are more likely to stay engaged in care that is: (1) organized around their goals; and (2) works.  Collaborating on and coming to a consensus regarding the goals for treatment, for example, has the largest impact on outcome among all of the relationship factors in psychotherapy, including empathy!  Additionally, when documentation FITs the clients’ view of the process and is deemed transparent and respectful, trust–another essential ingredient of the therapeutic relationship–improves.

For the last several years, practitioners and agencies around the world have been using the ICCE “Service Delivery Agreement” and “Progress Note” as part of their documentation of clinical services.  Both were specifically designed to be completed collaboratively with clients at the time the service is provided and both are focused on documenting what matters to people in treatment.  Most important of all, however, both are part of an evidence-based process documented to improve engagement and effectiveness listed on SAMHSA’s National Registry of Evidence-based Programs and Practices.

For the next short while, I’ll send you the forms for free, along with a detailed instruction booklet for incorporating them into your clinical work.  Reduce the “paper curtain” in your practice.  Just email me at scottdmiller@talkingcure.com.   Better yet, register for our upcoming intensive trainings this summer in Chicago.  Click on any of the course icons to the right for detailed information.

Until next time,

Scott

Scott D. Miller, Ph.D.
Director, International Center for Clinical Excellence
Scott D. Miller - Australian Drug and Alcohol Symposium

The Missing Link: Why 80% of People who could benefit will never see a Therapist

By 22 Comments


1077-20170313-045746-miller_opener_300x300The facts are startling.  Despite being on the scene for close to 150 years, the field of mental health–and psychotherapy in particular–does not, and never has had mass appeal.  Epidemiological studies consistently show, for example, the majority of people who could benefit from seeing a therapist, do not go.  And nowadays, fewer and fewer are turning to psychotherapy—33% less than did 20 years ago—and a staggering 56% either don’t follow through after making contact or drop out after a single visit with a therapist (Guadiano & Miller, 2012; Marshall, Quinn, & Child, 2016; Swift & Greenberg, 2014).

For those on the front line, conventional wisdom holds, the real problems lie outside the profession.  Insurance companies, in the best of circumstances, make access to and payment for psychotherapy an ordeal.  Another common refrain is nowadays people are looking for a quick fix.  Big Pharma has obliged, using their deep pockets to market “progress in a pill.”  No work required beyond opening wide and swallowing.  And finally, beyond instant gratification or corporate greed, many point to social disapproval or stigma as a continuing barrier to people getting the help they need.

For all that, were psychotherapy held in high regard, widely respected as the way to a better life, people would overcome their hesitancy, put up with any inconvenience, and choose it over any alternative.  They don’t.

WHY?  Mountains of research published over the last four decades document the effectiveness of the “talk therapies.”  With truly stunning results, and a minimal side effect profile compared to drugs, why do most never make it into a therapist’s office?

For the last two years, my longtime colleague, Mark Hubble and I, have explored this question.  We reviewed the research, consulted experts, and interviewed scores of potential consumers.

Our conclusion?  The secular constructions, reductionistic explanations, and pedestrian techniques that so characterize modern clinical practice fall flat, failing to offer people the kinds of experiences, depth of meaning, and sense of connection they want in their lives.

In sum, most chotarotose not to go to psychotherapy because they are busy doing something else–consulting psychics, mediums, and other spiritual advisers–forms of healing that are a better fit with their beliefs, that “sing to their souls.”

Actually, reports show more people attend and pay out of pocket for such services than see mental health practitioners!

More, as I noted in my plenary address at the last Evolution of Psychotherapy conference, our own, large-Consumer Reports style survey, found people actually rated psychics and other “spiritual advisers” more helpful than therapists, physicians and friends.  While certain to cause controversy, I strongly suggested the field could learn from and gain by joining the larger community of healers outside of our field.

Below — thanks to the Erickson Foundation — you can see that speech, as well as learn exactly what people felt these alternative healers provided that made a difference.  An even deeper dive is available in our article, “How Psychotherapy Lost its Magic.”  Thanks to the gracious folks at the Psychotherapy Networker for making it available for all to read, regardless of whether they subscribe to the magazine or not.

Until next time,

Scott

Scott D. Miller, Ph.D.
Director, International Center for Clinical Excellence
ICCE - Advanced FIT Intensive 2019Feedback Informed Treatment SupervisionIntensive2019-Scott D Miller

Would you rather . . . be approved or improved?

By 6 Comments

Bad-SmellSome time ago, my son had a minor obsession.  Whether at the dinner table, in the car, or out for a walk, he was constantly peppering us with, “would you rather” questions?  You know the ones I mean, where you are forced to choose between two equally bizarre or unpleasant alternatives?

“Would you rather always have to say everything that is on your mind or never be able to speak again?”

“Would you rather have the hiccoughs the rest of your life or always feel like you have to sneeze but not be able to?”

And finally:

“Would you rather smell like poop and not know it or know you smell like poop but others can’t smell it?”

Fast forward to today.  fast-forward-button_318-37183

I was re-reading some recent research on the use of deliberate practice (DP) for improving individual clinician effectiveness.  As I’ve blogged about previously , one of the four crucial components of DP is feedback.  Not just any kind of mind you, but negative feedback–in particular, immediate, ongoing information regarding one’s errors and mistakes.

Put bluntly, receiving negative feedback is hard on the ego.  Despite what we may say or believe, a mountain of literature documents we all possess a strong need for social approval as well as a bias toward attributing positive traits to ourselves.

The same research shows that, beyond selective recall and well-known biases thinking-womanassociated with self-assessment, we actively work to limit information that conflicts with how we prefer to see ourselves (e.g., capable versus incompetent, perceptive versus obtuse, intuitive versus plodding, effective versus ineffective, etc.).

As a brief example of just how insidious ours efforts can be, consider an email sent out by the customer service department at a Honda dealership in Richmond, Virginia.

“As you may know,” it began, “we have a wide range of services performed here at our location and strive to do the best we can to accomodate each and everyone of our customers.”   A request for feedback followed, “There may be times we can not meet the needs and we would appreciate any feedback . . . for our company.”

So far so good.  The company was on the way to showing its customers that it cared.  It had sent a follow-up email.  It thanked its customers.  Most importantly, it invited them to provide the type of feedback necessary for improving service in the future.

The correspondence then ended, telling the recipient they would soon receive a survey which, “If you enjoyed or were satisfied with your recent visit and provide a 100% score you will receive a FREE oil change.”

Amazing, eh?  Thanks to my long-time colleague and friend, Arnold Woodruff, for noticing the irony in the email and passing it on to me.

For whatever reason, on reading it, one of those “would you rather” questions immediately came to my mind:

“Would you rather be approved or improved?”

No waffling now.  There is no in-between.  I can hear my son saying, “you have to choose!”

Why not join me and colleagues from around the world who are “choosing to improve” for our two-day intensive on deliberate practice.  Together with Dr. Tony Rousmaniere–the author of the new book Deliberate Practice for Psychotherapists—you’ll learn the latest, evidence-based strategies for improving your effectiveness.  Register today, by clicking here, or on the image below.

Until next time,

Scott D. Miller, Ph.D.
International Center for Clinical Effectiveness
proD

“I can’t let others know…”: Shame as a Barrier to Professional Development

By 10 Comments

shame

Shame (noun \ˈshām\): Consciousness of shortcoming, guilt, or impropriety.  

Turns out, for many therapists, this powerful and painful emotion is a significant barrier to professional development.

Doing psychotherapy is challenging in the best of circumstances.  As many as 25% of clients drop out before experiencing a measureable improvement in their functioning.  Of those who do continue, between  40 to 50% will end no different than when they started. And finally, 8 to 10% deteriorate while in care.

Faced with the realities of clinical practice, it’s easy for practitioners to feel they are forever falling short of their own and others hopes and expectations.  Some respond with self-serving resignation: “It’s just not possible to help some people.”  Others, research indicates, deceive themselves, either seeing progress where there is none or overestimating their effectiveness.  Most, it is clear, struggle with the deep sense of responsibility they have assumed for relieving mental and emotional suffering.humility-arrow

As just one example, consider psychologist Tony Rousmaniere.  Early on in his career, Tony started using a couple of simple tools to track the quality and outcome of his work.  The data he gathered shook him to the core, “I was helping far fewer people than I’d thought–50% fewer!”  And while his results were no different than the outcome of most, he recalls instantly thinking, “I can’t let anyone know this!”

DP for Therapists“If you want to improve,” Tony says, “You have to embrace the facts. It’s not about humiliation, but rather humility.  Simply put, we are not as effective as we think we are.  Even the most effective among us, fail about a third of the time.  But, in those failures lies the key to success.”

In his new book, Deliberate Practice for Therapists, Tony describes, in deeply personal and moving terms, his efforts to become a more effective therapist.  He draws on the latest research on expertise and expert performance, providing a blueprint all clinicians can use to improve and fine-tune their performance via deliberate practice.

Earlier this month, I interviewed Tony about his journey and the new book.  His honesty, transparency, and sage advice are inspiring.  You’ll find the video below.

In the meantime, get hands on experience with deliberate practice this summer by signing up for the FIT Professional Development Intensive.  For more information or to register, simply click the icon under my name.  Hope to see you there!

Until then, best wishes,

Scott

Director, The International Center for Clinical Excellence
proD

Three, Free Evidence-Based Resources for Improving Individual Therapist Effectiveness

By 23 Comments

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

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

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

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

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

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

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

What are these factors?

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

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

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

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

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

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

Until then, best wishes for the New Year!

Scott

Scott D. Miller, Ph.D.
Director, International Center for Clinical Excellence
Scott D Miller Symposium bg3

The Asch Effect: The Impact of Conformity, Rebelliousness, and Ignorance in Research on Psychology and Psychotherapy

By 5 Comments

asch-1
Consider the photo above.  If you ever took Psych 101, it should be familiar.   The year is 1951.  The balding man on the right is psychologist, Solomon Asch.   Gathered around the table are a bunch of undergraduates at Swarthmore College participating in a vision test.

Briefly, the procedure began with a cardboard printout displaying three lines of varying length.  A second containing a single line was then produced and participants asked to state out loud which it best matched.  Try it for yourself:
asch-2
Well, if you guessed “C,” you would have been the only one to do so, as all the other participants taking the test on that day chose “B.”  As you may recall, Asch was not really assessing vision.  He was investigating conformity.  All the participants save one were in on the experiment, instructed to choose an obviously incorrect answer in twelve out of eighteen total trials.

The results?not-me

On average, a third of the people in the experiment went along with the majority, with seventy-five percent conforming in at least one trial.

Today, practitioners face similar pressures—to go along with the assertion that some treatment approaches are more effective than others.

Regulatory bodies, including the Substance Abuse and Mental Health Services Administration in the United States, and the National Institute for Health and Care Excellence, are actually restricting services and limiting funding to approaches deemed “evidence based.”  The impact on publicly funded mental health and substance abuse treatment is massive.

So, in the spirit of Solomon Asch, consider the lines below and indicate which treatment is most effective?

asch-3
If your eyes tell you that the outcomes between competing therapeutic approaches appear similar, you are right.  Indeed, one of the most robust findings in the research literature over the last 40 years is the lack of difference in outcome between psychotherapeutic approaches.

The key to changing matters is speaking up!  In the original Asch experiments, for example, the addition of even one dissenting vote reduced conformity by 80%!   And no, you don’t have to be a researcher to have an impact.  On this score, when in a later study, a single dissenting voter wearing thick glasses—strongly suggestive of poor visual acuity—was added to the group, the likelihood of going along with the crowd was cut in half.

That said, knowing and understanding science does help.  In the 1980’s, two researchers found that engineering, mathematics, and chemistry students conformed with the errant majority in only 1 out of 396 trials!

What does the research actually say about the effectiveness of competing treatment approaches?

You can find a review in the most current review of the research in the latest issue of Psychotherapy Research–the premier outlet for studies about psychotherapy.  It’s just out and I’m pleased and honored to have been part of a dedicated and esteemed group scientists that are speaking up.  In it, we review and redo several recent meta-analyses purporting to show that one particular method is more effective than all others.  Can you guess which one?

The stakes are high, the consequences, serious.  Existing guidelines and lists of approved therapies do not correctly represent existing research about “what works” in treatment.  More, as I’ve blogged about before, they limit choice and effectiveness without improving outcome–and in certain cases, result in poorer results.  As official definitions make clear, “evidence-based practice” is NOT about applying particular approaches to specific diagnoses, but rather “integrating the best available research with clinical expertise in the context of patient characteristics, culture, and preferences” (p. 273, APA, 2006).

Read it and speak up!

Until next time,

Scott

Scott D. Miller, Ph.D.
Director, International Center for Clinical Excellence
Scott D. Miller - Australian Drug and Alcohol Symposium

The Replication Crisis in Psychology: What is and is NOT being talked about

By 9 Comments

reproducePsychology has been in the headlines a fair bit of late—and the news is not positive.  I blogged about this last year, when a study appeared documenting that the effectiveness of CBT was declining–50% over the last four decades.

The problem is serious.  Between 2012 and 2014, for example, a team of researchers working together on their free time tried to replicate 100 published psychology experiments and succeeded only a third of the time!  As one might expect, such findings sent shock waves through academia.

Now, this week, The British Psychological Society’s Research Digest piled on, reviewing 10 “famous” findings that researchers have been unable to replicate—despite the popularity and common sense appeal of each.  Among others, these include:

  • Power posing does not make you more powerful;
  • Smiling does not make you happier;
  • Exposing you to words (known as “priming”) related to ageing does not cause you to walk like an old person;
  • Having a mental image of a college professor in mind does not make you perform more intelligently (another priming study);
  • Being primed to think of money will not cause make you act more selfishly; and
  • Despite being reported in nearly every basic psychology text, babies are not born with the power to imitate.

Clearly, replication is a problem.  sand-castleThe bottom line?  Much of psychology’s evidence-base is built on a foundation of sand.

Amidst all the controversy, I couldn’t help thinking of psychotherapy.  In this area, I believe, the problem with the available research is not so much the failure to replicate, but rather an unwillingness to accept what has been replicated repeatedly.  Contrary to hope and popular belief, one—if not the most—replicated finding is the lack of difference in outcome between psychotherapeutic approaches.

It’s not for lack of trying.  Massive amounts of time and resources have been spent comparing treatment methods.  With few exceptions, either no or inconsequential differences are found.

Consider, for example, the U.S. Government spent same$33,000,000 studying different approaches for problem drinking only to find what we already know: all worked equally well.  A decade later, the British officials spent millions of pounds on the same subject with similar results.

Just this week, a study was released comparing the hugely popular method called DBT to usual care in the treatment of “high risk suicidal veterans.”   Need I tell you what they found?

groundhog

As the Ground-Hog-Day-like quest continues, another often replicated finding is ignored.  One of the best predictors of the outcome of psychotherapy is the quality of the therapeutic relationship between the provider and recipient of care.  That was one of the chief findings, for example, in both of the studies on alcohol treatment cited above (1, 2).  Put simply, better relationship = improved engagement and effectiveness.

Sadly, but not surprisingly, research, writing, and educational opportunities focused on the alliance lags model and techniques.  Consider this: slightly more than 55,000 books are in print on the latter subject, compared to a paltry 193 on the former.  It’s mind-boggling, really.  How could one of the most robust and replicated findings in psychotherapy be so widely ignored?

My colleague Daryl Chow is working hard to get beyond the “lip service” frequently paid to the therapeutic relationship.  At the ICCE Professional Development training this last August, he presented findings from an ongoing series of studies aimed at helping clinicians improve their ability to engage, retain, and help people in psychotherapy by targeting training to the individual practitioners strengths and weaknesses.  Not surprisingly, the results show slow and steady improvement in connecting with a broader, more diverse, and challenging group of clinical scenarios!  Those in attendance learned how to build these skills into an individualized, professional development plan.

Trust me when I say, we won’t be ignoring this and other robust findings related to improving effectiveness at the upcoming ICCE intensive trainings in Chicago.  Registration is open for both the Advanced and Supervision Intensives.  Join us and colleagues from around the world.

Until next time,

Scott

Scott D. Miller, Ph.D.
Director, International Center for Clinical Excellence
headerMain8.png

How Deliberate Practice can Improve Your Therapeutic Effectiveness

By Leave a Comment

One year ago, colleagues and I released the largest, longitudinal study of therapist effectiveness ever published. The study examined outcomes of 6500 clients treated by 170 practitioners whose results had been tracked an average of 5 years—some as long as 17 years!

The result? Clinician outcomes, on average, not only did not improve, but actually slowly and inexorably worsened with time and experience—and this, despite the fact that practitioners involved in the study routinely measured and had access to ongoing feedback about their results. As I’ve blogged about previously, despite the many claims, measurement and feedback are not enough to improve therapist outcomes.

So, what does work?

dpFor the last several years, I’ve been advocating deliberate practice (DP)—conscious and purposeful effort aimed at improving specific aspects of an individual’s performance. DP contains four essential ingredients:

In short, those wishing to improve must: (1) identify objectives just beyond their current ability and then (2), together with a coach, develop and execute a plan complete with steps and strategies for reaching those performance objectives; (3) throughout, attention must be paid to small errors and mistakes and immediate, corrective feedback provided; finally, (4) with time and repetition, slow but steady improvement results.

To date, research shows time spent in deliberate practice is associated with top performance across a variety of domains, including music, medicine, sports, mathematics, and chess.

With regard to psychotherapy, Chow, Miller et al. (2015) found the most effective clinicians spend more than twice as much time in activities specifically designed to improve their outcomes than their more average counterparts (see Figure 1). The impact of making small but consistent investments of time to deliberate practice is especially dramatic, compounding like interest in a savings account, when results are plotted over time (see Figure 2).

deliberate-practice-1-and-2

Most important, however, is that the benefit of engaging in deliberate practice extends far beyond mere “statistical significance.” Clients of top performing clinicians, for example, experience 50% more improvement and 50% less deterioration and drop out.

However, as Mark Hubble and I wrote in the “Road to Mastery,” back in 2011, “knowing the facts and putting them into practice are two altogether different matters.” It turns out there’s a reason why most do not devote much time to deliberate practice: it’s hard. Damn hard. Not only is it labor intensive, the rather glacial progress one makes along the way can be pretty discouraging. The key to long term success, it turns out, is community–a complex, interlocking network of people, places, resources, and circumstances working “behind the scenes” to nurture and support ongoing efforts to improve.

And now the data: just this week, a new study was published–involving more than 150 clinicians and 5500 clients–that documents what’s possible when agencies work purposefully to create a climate for therapist improvement–specifically, putting systems in place that support deliberate practice in the workplace.

The results? Instead of worsening over time, therapists improved in effectiveness year after year over a seven year period. No, the change in outcome wasn’t dramatic. Rather, consistent with findings in other performance domains, it was slow and stead,y ultimately leading to a large cumulative effect.

What’s it take to get started?

  1. Join ICCE . It’s the largest, online community of practitioners, managers, researchers, and educators dedicated to improving the quality and outcome of psychological services. It’s free. No cost to join. No advertising. Simply go to: www.iccexcellence.com.
  2. Take the first step to deliberate practice by establishing your baseline level of effectiveness. All you need to do to get started is download two, brief measurement tools.
  3. Sign up for the Advanced and Supervision Intensive Trainings in March! Every spring, professionals from around the world come to Chicago to “dive deep” into feedback informed practice. Don’t wait, the number of seats is limited and the two courses typically sell out a few months in advance.

In the meantime, get inspired by watching the interview below. Iain Caldwell, the director of an award-winning mental health agency in the U.K, discusses how to develop and sustain a practice committed to superior outcomes and documented professional development. Along the way, we discuss recently published research on the results of a massive government investment in mental health services as well as reports that as many as half of practitioners working within the National Health Service are depressed. Provocative and interesting stuff.

“Mind the Gap”: A Strategy for Insuring you get the Feedback you need to Improve your Game (whatever that is)

By 3 Comments

te1Join me in a brief “thought experiment.”  Suppose you were a gifted painter or photographer and had the chance to provide an image of yourself that would endure–and perhaps be the only one people would know you by–for hundreds of years after your death.  How would you proceed?  What criteria would guide your work, be used to deem it a success?

Seriously, take a moment to picture yourself in your mind’s eye…

Now, consider the painting below.

rembrandt-1669

It’s a self-portrait painted by Rembrandt van Rijn.

Why, you might wonder, would a painter widely considered one, if not, “the greatest . . .in European art” leave the world such an unflattering portrait?   His face is puffy and pale, his hair thin and receding, and his cloak and cap plain and undistinguished. And lest one assume this particular image is an exception to otherwise beautiful renditions of himself, think again.  The self-portraits he painted throughout his life share the same, homely quality.

Clearly, the skills Rembrandt possessed ensure he could have made himself look any way he wanted and the world would have been none the wiser.  Why such brutal honesty?  More to the point, given the choice, would you paint yourself as you truly are or as others generally see you?

The answer, according to some to very interesting and recent research, is, “No.”  The gap between how we view ourselves on the one hand and, on the other, look, think, and act in life is often quite wide.  And, it turns out, we fill that space with people who agree with us, who see us as we want to see ourselves.

Actually, according to Paul Green of the University of North Carolina at Chapel Hill, people actively, “move away from those who provide feedback that is more negative than their view of themselves. They do not listen to their advice and prefer to stop interacting with them altogether . . . tend[ing] to strengthen their bonds with people who only see their positive qualities.”

Surrounding ourselves with people who shore up our self-image is both understandable and needed.  Life is hard.  Support is a must.  The problem is that this largely unconscious behavior undermines performance.  In a variety of work contexts, for example, the researchers have documented that, “dropping relationships that provide disconfirming reviews [leads] to decreases in performance in the succeeding year.”

The importance of being able to see ourselves as we are is something Rembrandt appeared to understand quite well.  Indeed, it likely accounted for a significant portion of his artistic mastery.img_20160922_1024365

Bottom line?  Whatever our particular craft, if the goal is to improve, to get better at what we do, it’s essential to “mind the self-assessment gap.”  First, we have to be aware it exists.  Next, we have to actively work to solicit views other than our own.

In the therapy world, our team has pioneered a simple set of tools clinicians can use to solicit feedback about the quality and effectiveness of their work.  Multiple clinical trials document improved results.  Read this recently published free article to learn how to get started.

Of course, not all feedback is useful.  In the upcoming Intensive Trainings in Chicago, we’ll teach you how to sort helpful from unhelpful, guided by the latest and only empirical research published to date documenting what it takes for individual therapists to become more effective.

Join me, an international faculty, and practitioners from around the world for the Advanced FIT and Supervision trainings this coming March!

Until then,

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

 

 

Does practice make perfect?

By 1 Comment

michael ammart“Practice does not make perfect,” my friend, and award-winning magician, Michael Ammar, is fond of saying.  “Rather,” he observes, “practice makes permanent.”

Thus, if we are not getting better as we work, our work will simply insure our current performance stays the same.

Now, before reading any further, watch a bit of the video below.  It features Diana Damrau singing one of the most recognizable arias from Mozart’s, “The Magic Flute.”  Trust me, even if you don’t like opera, this performance will make the hair on your neck stand on end.

All right, now click on the video below (and listen for as long as you can stand it).

No, the latter recording is not a joke.  Neither is it a reject from one of the “GOT TALENT” shows so popular on TV at present.  It’s none other than Florence Jenkins—an American socialite and heiress who was, according to Wikipedia, “a prominent musical cult figure…during the 1920’s, ‘30’s, and 40’s.”

Florence Jenkins

How could that be, you may well wonder?  Her pitch is off, and there are so many mistakes in terms of rhythm, tempo, and phrasing in the first 30 seconds, one quickly loses count.

The problem?  In a word, feedback—more specifically, the lack of critical feedback extending over many years.

For most of her career, Lady Florence, as she liked to be called, performed to “select audiences” in her home or small clubs. Attendance was invitation-only–and Jenkins controlled the list.  Her guests did their best not to let on what they tought of her abilities.  Instead, they smiled approvingly and applauded–loudly as it turns out, in an attempt to cover the laughter that invariably accompanied her singing!

Jenkins performanceEverything changed in 1944 when Jenkins booked Carnegie Hall for a public performance. This time, the applause was not sufficient to cover the laughter.  If anything, it followed, treating the performance as a comedy act, and encouraging the singer to continue the frivolity.

The reviews were scathing.  The next morning, the critic for the New York Sun, wrote, Lady Florence, “…can sing everything…except notes…”

The moral of the story?  Practice is not enough.  To improve, feedback is required.  Honest feedback–and the earlier in the process, the better.  Research indicates the keys to success are: (1) identifying performance objectives that lie just beyond an individuals current level of reliable achievement; (2) immediate feedback; and (3) continuous effort aimed at gradually refining and improving one’s performance.

Here’s the parallel with psychotherapy: the evidence shows therapist self-appraisal is not a reliable measure of either the quality or effectiveness of their work.  Indeed, a number of studies have found that, when asked, the least effective clinicians rate themselves on par with the most effective–a finding that could well be labelled, “Jenkin’s Paradox.”

Evidence-based measures exists which can help therapists avoid the bias inherent in self-assessment as well as aid in the identification of small, achievable performance improvement objectives.  A recent study documented, for example, how therapists can use such tools, in combination with immediate feedback and practice, to gradually yet significantly improve the quality and effectiveness of their therapeutic relationships–arguably, the most important contributor to treatment outcome.  Using the tools to improve outcome and engagement in psychotherapy will be the focus of the upcoming ICCE webinar.  It’s a simply way to get started, or to refine your existing knowledge.  Learn more or register online by clicking here.

Let me leave you with one last video.  It’s an interview I did with Danish psychologist Susanne Bargmann.  Over the last 5 years, she’s applied the principles described here in an attempt to not only improve her effectiveness as a clinician, but also in music.  Recently, her efforts came to the attention of the folks at Freakonomics radio.  As was the case when you listened to Diana Damrau, you’ll come away inspired!

Until next time,

Scott

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

 

 

 

Dodos and Dropouts: Two Chronic Problems in Psychotherapy (and what clinicians can do about them)

By 8 Comments

Last week, my inbox started filling with emails from colleagues about a new study. Working with a real world sample, researchers compared dynamic therapy to cognitive therapy and found…

(drum roll please)

NO DIFFERENCE IN OUTCOME!

Long ago, psychologist Saul Rosenzweig dubbed the equivalence in outcome between competing brands of psychotherapy, “The Dodo Verdict.” rosenzweig and miller
(I’m the one on the right)

What’s surprising is all the attention the study has been getting.  After all, the “Dodo verdict” is one of the most robust findings in the treatment literature.  And yet, it remains a subject of controversy.  For obvious reasons, those who advocate that certain therapies are more effective than others dislike the Dodo intensely.  In fact, as I’ve reported several times on this blog, that group is forever claiming they’ve found the single study that proves it wrong.

Rome Ultimately, however, the Dodo provides strong empirical support for something practitioners have long known: nothing works for everyone. To find the right path, therapists, and the people they serve, need choice.

Personally, I believe a much more important, yet under reported, finding of the study is the number of people who dropped out after a single visit with their therapist.  In this carefully controlled and executed study, 26% of people in both treatment conditions did not return for a second session.  Slightly more than half—50%–attended 5 sessions or less.  This after having endured a selection and recruitment process that retained only 5% of those initially screened for participation!

Dropout Beyond the impact on those seeking service (e.g., inadequate and ineffective care, longer waiting lists, etc.), unilateral client discontinuation and no shows, available evidence shows, “exact a significant financial burden in terms of staff salaries, overhead, and lost revenue, in addition to personnel losses resulting from low morale and high staff turnover.”

What can be done?

Three evidence-based ideas:

  1. Setting aside time at the outset of treatment specifically aimed at making people feel welcome and comfortable has consistently been shown to improve attendance. Known variously as “role preparation/indunction,” it’s similar to how you would treat a guest in your home, either formally or informally explaining the therapeutic process, addressing any concerns/apprehensions/misconceptions, and creating an expectation of success.
  1. Actively seek negative feedback about the therapeutic relationship.  Clients rarely report negative reactions until they’ve already decided to quit (Horvath, 2001).  Measuring and discussing the status of the working relationship has been shown to improve both retention and outcome.
  1. Monitor progress. Not surprisingly, a felt lack of improvement is predictive of service discontinuation.   Clients whose therapists use measures to identify those not making progress or worsening stay longer and improve more than those who do not.

Learn more about how to create a culture of feedback and formally monitor the progress and the therapeutic relationship in this free article from the newly published book, Quality Improvement in Behavioral Health.

Join me for an in-depth training by registering for our upcoming Fall Webinar.   Over the course of four, 1-hour, online sessions, you will learn to use formal client feedback to track and improve client retention and clinical effectiveness.  Click here to register or for more detailed information.  And yes, CE’s are available!

Until next time,

Scott

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

Making the Impossible, Possible: The Fragile Balance

By 1 Comment

Trip-Advisor scores it # 11 out of 45 things to do Sausalito, California.  No, it not’s the iconic Golden Gate Bridge or Point Bonita Lighthouse.  Neither is it one of the fantastic local restaurants or bars.  What’s more, in what can be a fairly pricey area, this attraction won’t cost you a penny.   It’s the gravity-defying rock sculptures of local performance artist, Bill Dan.

bill dan

So impossible his work seems, most initially assume there’s a trick: magnets, hooks, cement, or pre-worked or prefab construction materials.

Dan 1

Watch for a while, get up close, and you’ll see there are no tricks or shortcuts.  Rather, Bill Dan has vision, a deep understanding of the materials he works with, and perseverance.  Three qualities that, it turns out, are essential in any implementation.

Over the last decade, I’ve had the pleasure of working with agencies and healthcare systems around the world as they work to implement Feedback-Informed Treatment (FIT).  Not long ago, FIT–that is, formally using measures of progress and the therapeutic alliance to guide care–was deemed an evidence-based practice by SAMHSA, and listed on the official NREPP website.  Research to date shows that FIT makes the impossible, possible, improving the effectiveness of behavioral health services, while simultaneously decreasing costs, deterioration and dropout rates.

Dan 2

 

Over the last decade, a number of treatment settings and healthcare systems have beaten the odds.  Together with insights gleaned from the field of Implementation Science, they are helping us understand what it takes to be successful.

One such group is Prairie Ridge, an integrated behavioral healthcare agency located in Mason City, Iowa.  Recently, I had the privilege of speaking with the clinical leadership and management team at this cutting-edge agency.

Click on the video below to listen in as they share the steps for successfully implementing FIT that have led to improved outcomes and satisfaction across an array of treatment programs, including residential, outpatient, mental health, and addictions.

Until next time,

Scott D. Miller, Ph.D.
Director, International Center for Clinical Excellence
Scott D Miller Symposium bg3

P.S.: Looking for a way to learn the principles and practice of Feedback Informed Treatment?  No need to leave home.  You can learn and earn CE’s at the ICCE Fall FIT Webinar.  Register today at: https://www.eventbrite.ie/e/fall-2016-feedback-informed-treatment-webinar-series-tickets-26431099129.

ICCE Fall WEbinar

 

Why aren’t therapists talking about this?

By 8 Comments

shhTurns out, every year, for the last several years, and right around this time, I’ve done a post on the subject of deterioration in psychotherapy.  In June 2014, I was responding to yet another attention-grabbing story published in The Guardian, one of the U.K.’s largest daily newspapers. “Misjudged counselling and therapy can be harmful,” the headline boldly asserted, citing results from “a major new analysis of outcomes.” The article was long on warnings to the public, but short on details about the study.  In fact, there wasn’t anything about the size, scope, or design.  Emails to the researchers were never answered.  As of today, no results have appeared in print.

One year later, I was at it again—this time after seeing the biopic Love & Mercy, a film about the relationship LOVE-MERCY-POSTER-1308x1940 between psychologist Eugene Landy and his famous client, Beach Boy Brian Wilson. In a word, it was disturbing.  The psychologist did “24-hour-a-day” therapy, as he termed it, living full time with the singer-songwriter, keeping Wilson isolated from family and friends, and on a steady dose of psychotropic drugs while simultaneously taking ownership of Wilson’s songs, and charging $430,000 in fees annually. Eventually, the State of California intervened, forcing the psychologist to surrender his license to practice.  As egregious as the behavior of this practitioner was, the problem of deterioration in psychotherapy goes beyond the field’s “bad apples.”

bad-appleDo some people in therapy get worse? The answer is, most assuredly, “Yes.” Research dating back several decades puts the figure at about 10% (Lambert, 2010). Said another way, at termination, roughly one out of ten people are functioning more poorly than they were at the beginning of treatment. Despite claims to the contrary (e.g., Lilenfeld, 2007), no psychotherapy approach tested in a clinical trial has ever been shown to reliably lead to or increase the chances of deterioration. NONE. Scary stories about dangerous psychological treatments are limited to a handful of fringe therapies–approaches that have been never vetted scientifically and which all practitioners, but a few, avoid.

So, what is the chief cause of deterioration in treatment?norw-MMAP-md Norwegian psychologist Jørgen A. Flor just completed a study on the subject. We’ve been corresponding for a number  of year as he worked on the project.  Given the limited information available, I was interested.

What he found may surprise you. Watch the video or click here to read his entire report (in Norwegian).  Be sure and leave a comment!

Until next time,

Scott

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

Scott Abbey Road.jpg

NERD ALERT: Determining IF, WHAT, and HOW Psychotherapy Works

By 12 Comments

Nerd

OK, this post may not be for everyone.  I’m hoping to “go beyond the headlines,” “dig deep,” and cover a subject essential to research on the effectiveness of psychotherapy. So, if you fit point #2 in the definition above, read on.

eysenck

It’s easy to forget the revolution that took place in the field of psychotherapy a mere 40 years ago.  At that time, the efficacy of psychotherapy was in serious question. As I posted last week, psychologist Hans Eysenck (1952, 1961, 1966) had published a review of studies purporting to show that psychotherapy was not only ineffective, but potentially harmful.  Proponents of psychotherapy responded with the own reviews (c.f., Bergin, 1971).  Back and forth each side went, arguing their respective positions–that is, until Mary Lee Smith and Gene Glass (19
77) published the first meta-analysis of psychotherapy outcome studies.

Their original analysis of 375 studies showed psychotherapy to be remarkably beneficial.  As I’ve said here, and frequently on my blog, they found that the average treated client was better off than 80% of people with similar problems were untreated.

Eysenck and other critics (1978, 1984; Rachman and Wilson 1980) immediately complained about the use of meta-analysis, using an argusmith and glassment still popular today; namely, that by including studies of varying (read: poor) quality, Smith and Glass OVERESTIMATED the effectiveness of psychotherapy.  Were such studies excluded, they contended, the results would most certainly be different and behavior therapy—Eysenck’s preferred method—would once again prove superior.

polemicFor Smith and Glass, such claims were not a matter of polemics, but rather empirical questions serious scientists could test—with meta-analysis, of course.

So, what did they do?  Smith and Glass rated the quality of all outcome studies with specific criteria and multiple raters.  And what did they find?  The better and more tightly controlled studies were, the more effective psychotherapy proved to be.  Studies of low, medium, and high internal validity, for example, had effect sizes of .78, .78, and .88, respectively.  Other meta-analyses followed, using slightly different samples, with similar results: the tighter the study, the more effective psychotherapy proved to be.

Importantly, the figures reported by Smith and Glass have stood the test of time.  Indeed, the most recent meta-analyses provide estimates of the effectiveness of psychotherapy that are nearly identical to those generated in Smith and Glass’s original study.  More, use of their pioneering method has exploded, becoming THE standard method for aggregating and understanding results from studies in education, psychology, and medicine.

sheldon kopp

As psychologist Sheldon Kopp (1973) was fond of saying, “All solutions breed new problems.”  Over the last two decades the number of meta-analyses of psychotherapy research has exploded.  In fact, there are now more meta-analyses than there were studies of psychotherapy at the time of Smith and Glass’s original research.  The result is that it’s become exceedingly challenging to understand and integrate information generated by such studies into a larger gestalt about the effectiveness of psychotherapy.

Last week, for example, I posted results from the original Smith and Glass study on Facebook and Twitter—in particular, their finding that better controlled studies resulted in higher effect sizes.   Immediately, a colleague responded, citing a new meta-analysis, “Usually, it’s the other way around…” and “More contemporary studies find that better methodology is associated with lower effect sizes.”

CustomerobjectionsIt’s a good idea to read this study, closely.  If you just read the “headline”–“The Effect of Psychotherapy for Adult Depression are Overestimated–or skip the method’s section and read the author’s conclusions, you might be tempted to conclude that better designed studies produce smaller effects (in this particular study, in the case of depression).  In fact, what the study actually says is that better designed studies will find smaller differences when a manualized therapy is compared to a credible alternative!  Said another way, differences between a particular psychotherapy approach and an alternative (e.g., counseling, usual care, or placebo), are likely to be greater when the study is of poor quality.

What can we conclude? Just because a study is more recent, does not mean it’s better, or more informative.  The important question one must consider is, “What is being compared?”  For the most part, Smith and Glass analyzed studies in which psychotherapy was compared to no treatment.  The study cited by my colleague, demonstrates what I, and others (e.g., Wampold, Imel, Lambert, Norcross, etc.) have long argued: few if any differences will be found between approaches.

The implications for research and practice are clear.  For therapists, find an approach that fits you and benefits your clients.  Make sure it works by routinely seeking feedback from those you serve.  For researchers, stop wasting time and precious resources on clinical trials.  Such studies, as Wampold and Imel so eloquently put it, “seemed not to have added much clinically or scientifically (other than to further reinforce the conclusion that there are no differences between treatments), [and come] at a cost…” (p. 268).

Until next time,

Scott D. Miller, Ph.D.
Director, International Center for Clinical Excellence
Scott D Miller Symposium bg3

Improving the Odds: Implementing FIT in Care for Problem Gamblers and their Families

By 1 Comment

spiraling roulette

Quick Healthcare Quiz

What problem in the U.S. costs the government approximately $274 per adult annually?

If you guessed gambling, give yourself one point.  According to the latest research, nearly 6 million Americans have a serious gaming problem—a number that is on the rise.  One-third of the Nation’s adults visit a Casino every year, losing according to the latest figures an estimated 100 billion dollars.

Which problem is more common?  Substance abuse or problem gambling?

If you guessed the former, give yourself another point.  Problems related to alcohol and drug use are about 3.5 times more common than gambling.  At the same time, 281 times more funding is devoted to treating drug and alcohol problems.  In March 2014, the National Council on Problem Gambling reported that government-funded treatment was provided to less than one quarter of one percent of those in need.

Does psychotherapy work for problem gambling?

If you answered “yes,” add one to your score.  Research not only indicates that psychological treatment approaches are effective, but that changes are maintained at follow up.  As with other presenting problems (e.g., anxiety and depression), more therapy is associated with better outcomes than less.

What is the key to successful treatment of problem gambling?

If you answered, “funding and getting people into treatment,” or some variation thereof, take away three points!

So, how many points do you have left?  If you are at or near zero, join the club.

Healthcare is obsessed with treatment.  A staggering 99% of resources are invested in interventions.  Said another way, practitioners and healthcare systems love solutions.  The problem is that research shows this investment, “does not result in positive implementation outcomes (changes in practitioner behavior) or intervention outcomes (benefits to consumers).”  Simply put, it’s not enough to know “what works.”  You have to be able to put “what works” to work.

BCRPGP

Enter the BC Responsible and Problem Gambling Program—an agency that provides free support and treatment services aimed at reducing and preventing the harmful impacts of excessive or uncontrolled gaming.  Clinicians working for the program not only sought to provide cutting-edge services, they wanted to know if they were effective and what they could do to continuously improve.

Five years ago, the organization adopted feedback-informed treatment (FIT)—routinely and formally seeking feedback from clients regarding the quality and outcome of services offered.    A host of studies documents that FIT improves retention in and outcome of psychotherapy.  Like all good ideas, however, the challenge of FIT is implementation.

Last week, I interviewed Michael Koo, the clinical coordinator of the BCRPGP.  Listen in as he discusses the principles and challenges of their successful implementation.  Learn also how the talented and devoted crew achieve outcomes on par with randomized controlled trials in an average of 7 visits while working with a culturally and clinically diverse clientele.

As you’ll hear, implementation is difficult, but doable.  More, you don’t have to reinvent the wheel or do it alone.  When FIT was reviewed and deemed “evidence-based” by the Substance Abuse and Mental Health Services organization in 2013, it received perfect scores for “implementation, training, support, and quality assurance” resources.  Regardless of the population you serve, you can:

  • Join a free, online, international community of nearly 10,000 like-minded professionals using FIT in diverse settings (www.iccexcellence.com).  Every day, members connect and share their knowledge and experience with each other;
  • Access a series of “how to” manuals and free, gap assessment tool (FRIFM) to aid in planning, guiding progress, and identifying common blind spots in implementation.
  • Attend the upcoming, 2-day FIT Implementation workshop.  Held once a year in August, this event provides an in-depth, evidence-based training based on the latest findings from the field of implementation science.

Come meet managers, supervisors, practitioners, and team leaders from around the world. You will leave the tools necessary to “put ‘what works’ to work.”

FIT IMP 2016
Until next time,

Scott

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

 

Do you know Norman Malone? FIT, Grit, and Grace Personified

By 1 Comment

norman maloneAt the tender age of 10, Norman Malone’s father attacked him and his two younger brothers with a hammer while they slept.  Their mother, drugged into unconsciousness by her husband the prior evening, found the children the next morning.  Each had suffered grave head wounds, but were alive.  Later, all would learn the senior Malone had taken his life shortly after the attack, throwing himself in front of a suburban train.

A long recovery followed, months spent in a hospital learning to walk again.  Despite steady and dramatic improvement, Norman never regained the use of his right hand.  With his single functioning hand, he spent the next seven decades following a dream he’d had since he was five: to become a concert pianist.

It has been a solitary journey throughout.  In his youth, kids made fun of his damaged skull.  Teachers and advisors consistently advised him to give up his quest, deeming it “ludicrous.” Thinking he must be “crazy,” they even sent him for a psychological evaluation.   Wittgenstein

Sustained and focused application, or “grit,” research indicates is key for achieving difficult goals.  Norman Malone is grit and grace personified.  He persisted, eventually meeting a willing teacher at the Chicago Musical College.  That teacher knew the story of another famous left-handed pianist, Paul Wittgenstein—brother of the celebrated philosopher, Ludwig—who following the loss of his right hand in World War 1, used his family’s wealth to commission Ravel, Prokofiev, and other famous composers to write music for him.

Last week, I had the opportunity to meet Norman Malone.  Now 78 years of age, he graciously accepted an invitation to play at my home for participants attending the ICCE Intensive Trainings in Chicago.  Forty-five participants from around the world (US, Canada, the Netherlands, Sweden, Denmark, Finland, Australia) crowded into my living room.  You could hear a pin drop as he spoke.

It startedMalone at home with his story.  Then, he played—doing with one hand what many would think impossible with two.  When asked what drove him to continue in the face of so many challenges, he said, in a quiet yet confident voice, “Because there is so much to learn!”

Mr. Malone will be back in August to perform for participants in the FIT Implementation, Training of Trainers, and FIT Professional Development Intensives.  Come and get inspired!

You can get a taste of his performance at the training, and a watch a video of his life story, by clicking on the videos below.

Until next time,

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

Psychotherapy and the Cure for the Common Cold

By 3 Comments

common cold

What do the common cold and psychotherapy have in common?  Read on, the answers may surprise you…

One other similarity.  Medicine has no cure for the common cold.   In a parallel fashion, the mental health profession has no cure—and has never offered a cure—for any of the 297+ diagnoses identified in the Diagnostic and Statistical Manual of Mental Disorders.

Everyone has their own pet remedy, of course.  For colds, your aunt recommends honey in tea with lemon; your uncle, liquids and vitamin C.   In mental health, new methods emerge every week.  One therapist advises confronting negative cognitions; another, emotions!   According to the organizers of the World Tapping Summit, 600,000 clinicians will be attending “10 full days of life-altering presentations” to learn how and where to tap people to better mental health.

cold causesMedicine’s failure to “cure” the common cold is understandable.  The causes are complex.  Over 200 different viruses can cause symptoms.  Even the most common—the rhinovirus—has 160 different strains!  It’s just not possible to predict which ones will show up in any given season or pack all them into a single injection.

Herein lies another similarity.  The cause of what are called “mental health problems” is equally, if not more complex.

For example, Medicine.net—the website that claims to “Bring Doctors’ Knowledge to You”—reports, “The exact cause of most mental illnesses is not known.”   It then goes on to state, however “many of these conditions are caused by a combination of genetic, biological, psychological, and environmental factors.”

Really?

A combination of genetic, biological, psychological, and environmental factors? mental illness causes

What else is left?  Vermicious knids?  Morgoth, Master of Sauron, from The Lord of the Rings?  Or, the evil machinations of escapees from Area 51?  In other words, the cause of mental and emotional ailments is…complicated!

One final similarity.  Colds respond to the very same curative condition that forms the basis of effective psychotherapy: Empathy.

With a large sample, researcher David Rakel and colleagues found that the duration and severity of the common cold varied depending on patients’ experience of physician-provided empathy.

The formula?

More empathy = Shorter, less severe colds + changes in the immune system

Perhaps what’s important about our pet remedies is not so much the remedy, but the care that accompanies it?

The central role empathy plays in effective therapy will come as no surprise to most clinicians.  As the graph below illustrates, it tops the list of curative factors—especially when compared to other aspects of treatment that get a lot of attention, such as technique and adherence to protocol.

ES of Common versus Specific Factors

What is both surprising and distressing is how little growth occurs in therapist empathic abilities over the course of their careers.  Hard to believe, but true.  In a soon to be released study, however, Chow and colleagues show that significant improvement is possible.  By measuring a therapist’s empathic response to a challenging clinical scenario and then providing targeted feedback and an opportunity to practice, significant improvement occurred and even generalized to novel situations.

Improving empathy skills will be part of the focus on the International Center for Clinical Excellence Professional Development Intensive to be held in August in Chicago.  Co-led by Drs. Daryl Chow and Scott Miller, participants will learn the latest evidence-based skills for enhancing their professional development.  Reserve your spot now as registration is limited to 25 participants in order to insure maximum attention to each attendee!

Hope to see you this August in Chicago!

Scott

Scott D. Miller, Ph.D.
Director, International Center for Clinical Excellence
FitProfessionalDevelopmentIntensiveAug8th2016

What is the essential quality of effective Feedback? New research points the way

By 1 Comment

“We should not try to design a better world,” says Owen Barder, senior fellow at the Center for Global Development, “We should make better feedback loops.”

buzzwordFeedback has become a bit of a buzzword in mental health.  Therapists are being asked to use formal measures of progress and the quality of the relationship and use the resulting information to improve effectiveness.

As it turns out, not all feedback is created alike.  The key to success is obtaining information that gives rise to increased consciousness—the type that causes one to pause, reflect, rethink.  In a word, negative feedback.

feedbackNearly a decade ago, we noticed a curious relationship between effectiveness and the therapeutic alliance.  Relationships that started off poorly but improved were nearly 50% more effective than those rated good throughout.

And now, more evidence from a brand-new, real-world study of therapy with adolescents (Owen, Miller, Seidel, & Chow, 2016).  Therapists asked for and received feedback via the Outcome and Session Rating scales at each and every visit.  Once again, relationships that improved over the course of treatment were significantly more effective.

Importantly, obtaining lower scores at the outset of therapy provides clinicians with an opportunity to discuss and address problems early in the working relationship.  But, how best to solicit such information?

The evidence documents that using a formal measure is essential, but not enough.  The most effective clinicians work hard at creating an environment that not invites, but actively utilizes feedback.  Additionally, they are particularly skilled at asking questions that go beyond platitudes and generalities, in the process transforming client experience into specific steps for improving treatment.

DemingAs statistician and engineer Edward Deming once observed, “If you do not know how to ask the right question, you discover nothing.”

Little useful information is generated when clients are asked, “How did you feel about the session today?” “Did you feel like I (listened to/understood) you?” or “What can I do better?”

The best questions are:

  • Specific rather than general;
  • Descriptive rather than evaluative;
  • Concerned with quantities rather than qualities; and are
  • Task rather than person-oriented.

Over the years, we’ve come to understand that learning to ask the “right” question takes both time and practice.  It’s not part of most training programs, and it only comes naturally to a few.  As a result, many therapists who start using formal measures to solicit feedback about progress and the therapeutic relationship, give up, frustrated in their efforts to solicit helpful feedback.

Learning to develop better “feedback loops,” as Barder recommends, is the focus for the upcoming FIT Implementation, Training of Trainers, and Professional Development Intensives scheduled for August in Chicago, Illinois (USA).  Our March courses sold out months in advance so reserve your spot now by clicking the icons to the right.

Until then, get started with these free articles.

Best wishes,

Scott

Scott D. Miller, Ph.D.
Director, International Center for Clinical Excellence
IMG_20160121_122453

Are you Better? Improving Effectiveness One Therapist at a Time

By 3 Comments

IMG_20160121_122453Greetings from snowy Sweden.  I’m in the beautiful city of Gothenburg this week, working with therapists and administrators on implementing Feedback-Informed Treatment (FIT).

I’m always impressed by the dedication of those who attend the intensive workshops.  More, I feel responsible for providing a training that not only results in mastery of the material, but also leads to better outcomes.

As commonsensical as it may seem to expect that training should foster better results, it’s not.  Consider a recent study out of the United Kingdom.  There, massive amounts of money have been spent over the last five years training clinicians to use cognitive behavioral therapy (CBT).  The expenditure is part of a well-intentioned government program aimed at improving access to effective mental health services.

Anyway, in the study, clinicians participated in a year-long “high-intensity” course that included more than 300 hours of training, supervision, and practice—a tremendous investment of time, money, and resources.  Competency in delivering CBT was assessed at regular intervals and shown to improve significantly throughout the training.

2a-we-are-all-the-same-problemThe only problem?  Training therapists in CBT did not result in better outcomes.

While one might hope such findings would cause the researchers to rethink the training program, they chose instead to question whether “patient outcome should … be used as a metric of competence…” (p. 27).  Said another way, doing treatment the right way was more important than whether it actually worked!  One is left to wonder whether the researchers would have reached a similar conclusion had the study gone the other way.  Most certainly, the headline would then have been, “Empirical Research Establishes Connection between Competence in CBT and Treatment Outcome!”

Attempts to improve the effectiveness of treatment via the creation of a psychological formulary—official lists of specific treatments for specific disorders—have persisted, and even intensified, despite consistent evidence that the methods clinicians use contribute little to outcome.  Indeed, neither clinicians’ competence in conducting specific types of therapy nor adherence to evidence-based protocols have been “found to be related to patient outcome and indeed . . . estimates of their effects [are] very close to zero” (p. 207, Webb, DeRubeis, & Barber, 2010).

So, what gives?

There are two reasons why such efforts have failed:

  • First, they do not focus on helping therapists develop the skills that account for the lion’s share of variability in treatment outcome.

Empathy, for example, has a greater impact than the combined effect sizes of therapist competence, adherence to protocol, specific ingredients within and differences between various treatment approaches.  Still, most, like the present study, continue to focus on method.

  • Second, they ignore the extensive scientific literature on expertise and expert performance.

Here, research has identified a universal set of processes, and step-by-step directions, anyone can follow to improve performance within a particular discipline.  To improve, training must be highly individualized, focused on helping performers reach for objectives just beyond their current ability.

“Deliberate Practice,” as it has been termed, requires grit and determination.  “Nobody is allowed to stagnate,” said one clinician when asked to describe what it was like to work at a clinic that had implemented the steps, adding, “Nobody is allowed to stay put in their comfort zone.”  The therapist works at Stangehjelpa, a community mental health service located an hour north of Oslo, Norway.

BirgitvidereThe director of the agency is psychologist, Birgit Valla (left), author of visionary book, Further: How Mental Services Can Be Better.   Birgit is on a mission to improve outcomes—not by dictating the methods staff are allowed to use but by focusing on their individual development.

It starts with measuring outcomes.  All therapists at Stangehjelpa know exactly how effective they are and, more importantly, when they are not helpful.  “It’s not about the measures,” Birgit is quick to point out, “It´s about the therapist, and how the service can support that therapist getting better.”  She continues, “It´s like if you want improve your time in the 100 meter race, you need a stopwatch.  It would be absurd to think, however, that the stopwatch is responsible for running faster.  Rather, it’s how one chooses to practice in relation to the results.”

Recently, researcher Siri Vikrem Austdal interviewed staff members at the clinic about their experience applying deliberate practice in their work.  Says one, ““It is strenuous. You are expected to deliver all the time. But being part of a team that dare to have new thoughts, and that wants something, is really exciting. I need it, or I would grow tired. It is demanding, but then there is that feeling we experience when we have climbed a mountain top. Then it is all worthwhile. It is incredibly fun to make new discoveries and experience mastery.”

So, what exactly are they doing at Stangehjelp?

You can read the entire report here (Norwegian), or the abbreviated version here (English).  Why not join Birgit this summer at the FIT Professional Development training in Chicago, Illinois.  Together with Dr. Daryl Chow, we will teach participants how to incorporate deliberate practice into an individualized, evidence-based plan for continuous professional development.  Click on the icon below to reserve your spot now.

FitProfessionalDevelopmentIntensiveAug8th2016 Until next time,

Scott

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

 

 

I Was Wrong: The Healing Power of Admitting Mistakes in Psychotherapy

By 1 Comment

i was wrong

 

 

 

 

Across modalities, the therapeutic relationship has consistently been found to be a robust predictor of treatment outcome.  Most practicing clinicians understand this finding and work hard at establishing and maintaining a collaborative working alliance.

mistakes
Here’s a less well known, but sobering statistic: clients report tensions or actual breakdowns in the therapeutic relationship in 19% to 42% of sessions.  These figures rise to 41% to 100% of sessions when trained observers are used to identify “ruptures” between clients and therapists.

Given the frequency of such occurrences, therapy really is about constantly re-pair-ing—a continuous process of getting back “in touch” with and connected to the person seated opposite us in the consulting room.  Findings from a number of studies (1, 2, 3, 4) emphasize the value of therapists openly acknowledging and exploring ruptures, all the while maintaining an open and non-defensive stance.  Failing to do so, the data make clear, leads to higher dropout rates and poorer outcomes.

rebuild

Given the frequency of such occurrences, therapy really is about constantly re-pair-ing—a continuous process of
getting back “in touch” with and connected to the person seated opposite us in the consulting room.  Findings from a number of studies (1, 2, 3, 4) emphasize the value of therapists openly acknowledging and exploring ruptures, all the while maintaining an open and non-defensive stance.  Failing to do so, the data make clear, leads to higher dropout rates and poorer outcomes.

Of course, admittimistakes were madeng a mistake presumes knowing one has been made.  It’s easier said than done.  Clinicians’
experience of the quality of the therapeutic relationship frequently differs from those they treat.  And while a significant body of evidence documents the benefits of systematically monitoring the status of the alliance via simple measures like the Session Rating Scale, little is known about what therapists actually do with such information to inform and improve outcome. That is, until psychologist Chris Laraway entered the picture.

Dr. Laraway’s thorough and engaging study not only provides a systematic review of the alchris larawayliance and feedback
literature, but also the first empirical model for how feedback can be used to resolve ruptures in the therapeutic relationship.  What’s the secret?  The entire study is just a click away—or for those interested in the “Cliff note” version here.  Thanks to Chris for allowing me to make it available.

These, and other, new findings are being integrated into the curriculum for this summer’s Professional Development Intensive.   This two-day event focuses on raising your effectiveness to the next level by improving your ability to engage, retain, and help a more diverse clientele.  Given the intensive nature of the training, registration is limited.  All of our March intensives sold out months in advance.  Register now at: http://www.eventbrite.ie/e/fit-professional-development-intensive-2016-tickets-17740785166.

Until next time,

Scott

Scott D. Miller, Ph.D.
Director, International Center for Clinical Excellence
FitProfessionalDevelopmentIntensiveAug8th2016

 

The Benefits of Doubt: New Research Sheds Light on Becoming a More Effective Therapist

By 6 Comments

puzzle

These are exciting times for clinicians.  The pieces of the puzzle are falling into place.  Researchers are finally beginning to understand what it takes to improve the effectiveness of psychotherapy.  Shifting away from the failed, decades-long focus on methods and diagnosis, attention has now turned to the individual practitioner.

Such efforts have already shown a host of factors to be largely ineffective in promoting therapist growth and development, including:

  • Supervision;
  • Continuing education;
  • Therapist personal therapy;
  • Clinical experience; and
  • Access to feedback

In October, I blogged about the largest, longitudinal study of therapists ever conducted.  Despite having access to ongoing, formal feedback from their clients for as long as 17 years, clinicians in the study not only did not improve, their outcomes actually deteriorated, on average, year after year.

Such findings contrast sharply with beliefs of practitioners who, according to other studies, see themselves as improving with time and experience.  In fact, findings on all the practices noted above contrast sharply with beliefs commonly-held in the field:

  • Supervision is at the top of the list of experiences therapists cite as central to their growth and development as practitioners. By contrast, the latest review of the literature concludes, “We do not seem to be any more able to say now (as opposed to 30 years ago) that psychotherapy supervision contributes to patient outcome” (p. 235, Watkins 2011).
  • Therapist personal therapy is ranked as one of the most important sources of professional development despite there being no evidence it contributes to better performance as a clinician and some studies documenting a negative impact on outcome (see Orlinsky & Ronnestad, 2005);

If any of the research I’ve cited surprises you, or gives you pause, there is hope!  Really. Read on.

doubt_dice

Doubt, it turns out, is a good thing–a quality possessed by the fields’ most effective practitioners.  Possessing it is one of the clues to continuous professional development.  Indeed, several studies now confirm that “healthy self-criticism,” or professional self-doubt (PSD), is a strong predictor of both alliance and outcome in psychotherapy (2015).

To be sure, I’m not talking about assuming a “not-knowing” stance in therapeutic interactions.  Although much has been written about having a “beginner’s mind,” research by Nissen-Lie and others makes clear that nothing can be gained by either our feigned or willful ignorance.

Rather, the issue is about taking the time to reflect on our work.  Doing so on a routine basis prevents us from falling prey to the “over-claiming error”—a type of confidence that comes from the feeling we’ve seen something before when, in fact, we hnot listeningave not.

The “over-claiming error” is subtle, unconscious, and fantastically easy to succumb to and elicit.  In a very clever series of experiments, for example, researchers asked people a series of questions designed either to engender a feeling of knowledge and expertise or ignorance.  Being made to feel more knowledgeable, in turn, lead people to act less open-mindedly and feel justified in being dogmatic.  Most importantly, it caused them to falsely claim to know more about the subject than they did, including “knowing” things the researchers simply made up!

In essence, feeling like an expert actually makes it difficult to separate what we do and do not know.  Interestingly, people with the most knowledge in a particular domain (e.g., psychotherapy) are at the greatest risk.  Researchers term the phenomenon, “The ‘Earned Dogmatism’ Effect.”

What to do?  The practices of highly effective therapists provide some clues:

  1. Adopt an “error-centric” mindset. Take time to reflect on your work, looking for and then examining moments that do not go well. One simple way to prevent over-claiming is to routinely measure the outcome of your work.  Don’t rely on your judgement alone, use a simple measures like the ORS to enhance facts from your fictions.
  1. Think like a scientist. Actively seek disconfirmation rather than confirmation of your beliefs and practices.  Therapy can be vague and ambiguous process—two conditions which dramatically increase the risk of over-claiming.  Seeking out a community of peers and a coach to review your work can be helpful in this regard.  No need to leave your home or office.  Join colleagues in a worldwide virtual community at: iccexcellence.com.
  1. Seek formal feedback from clients. Interestingly, research shows that highly effective therapists are surprised more often by what their clients say than average clinicians who, it seems, “have heard it all before.”  If you haven’t been surprised in a while, ask your clients to provide feedback about your work via a simple tool like the SRS.  You’ll be amazed by what you’ve missed.
  1. Attend the 2016 Professional Development Intensive this summer in Chicago. At this small group, intensive training, you will the latest evidence-based steps for unlocking your potential as a therapist.

Best wishes for the Holidays.  As always, please leave a comment.

Scott

Scott D. Miller, Ph.D.
International Center for Clinical Excellence
Scott D. Miller - Australian Drug and Alcohol Symposium

Swedish National Audit Office concludes: When all you have is CBT, mental health suffers

By 15 Comments

hammer-screw

“The One-Sided Focus on CBT is Damaging Swedish Mental Health”

That’s the headline from one of Sweden’s largest daily newspapers for Monday, November 9th.  Professor Gunnar Bohman, together with colleagues and psychotherapists, Eva Mari Eneroth Säll and Marie-Louise Ögren, were responding to a report released last week by the Swedish National Audit Office (NAO).

Back in May 2012, I wrote about Sweden’s massive investment in cognitive behavioral therapy (CBT).  The idea was simple: address rising rates of disability due to mental illness by training clinicians in CBT.  At the time, a mere two billion Swedish crowns had been spent.

Now, several years and nearly 7 billion Crowns later, the NAO audited the program.  Briefly, it found:

  •  The widespread adoption of the method had no effect whatsoever on the outcome of people disabled by depression and anxiety;
  • A significant number of people who were not disabled at the time they were treated with CBT became disabled thereby increasing the amount of time they spent on disability; and 
  • Nearly a quarter of people treated with CBT dropped out.

The Swedish NAO concludes, “Steering towards specific treatment methods has been ineffective in achieving the objective.”

choice

How, you might reasonably ask, could anyone think that restricting choice would improve outcomes?  It was 1966, when psychologist Abraham Maslow famously observed, “I suppose it is tempting, if the only tool you have is a hammer, to treat everything as if it were a nail” (p. 15, The Psychology of Science).  Still, many countries and professional organizations are charting a similar path today.

The choice is baffling, given the lack of evidence for differential efficacy among psychotherapeutic approaches. Consider a study I blogged about in April 2013.  It was conducted in Sweden at 13 different public health outpatient clinics over a three year period.  Consistent with 40 years of evidence, the researchers found that psychotherapy was remarkably effective regardless of the type of treatment offered!

Key-to-success-h-800So, what is the key to improving outcome?

As Bohman, Säll and Ögren point out in their article in Svenska Dagbladet, “offering choice…on the basis of patients’ problems, preferences and needs.”

The NAO report makes one additional recommendation: systematic measurement and follow-up.

As readers of this blog know, insuring that services both fit the consumer and are effective is what Feedback-Informed Treatment (FIT) is all about.  More than 20 randomized clinical trials show that this transtheoretical process improves retention and outcome.  Indeed, in 2013, FIT was deemed evidence-based by the Substance Abuse and Mental Health Services Administration.

Learn more by joining the International Center for Clinical Excellence–a free, web-based community of practitioners dedicated to improving the quality and effectiveness of clinical work.   Better yet, join colleagues from around the world at our upcoming March intensive trainings in Chicago!  Register soon as both the Advanced Intensive and FIT Supervision Courses are already more than half subscribed.

Until next time,

Scott

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

Do Psychotherapists Improve with Time and Experience?

By 14 Comments

researchThe practice known as “routine outcome measurement,” or ROM, is resulting in the publication of some of the biggest and most clinically relevant psychotherapy studies in history.  Freed from the limits of the randomized clinical trial, and accompanying obsession with manuals and methods, researchers are finally able to examine what happens in real world clinical practice.

A few weeks ago, I blogged about the largest study of psychotherapy ever published.  More than 1,400 therapists participated.  The progress of over 26,000 people (aged 16-95) treated over a 12 year period in primary care settings in the UK was tracked on an ongoing basis via ROM.  The results?  In an average of 8 visits, 60% of those treated by this diverse group of practitioners achieved both reliable and clinically significant change—results on par with tightly controlled RCT’s.  The study is a stunning confirmation of the effectiveness of psychotherapy.

This week, another mega-study was accepted for publication in the Journal of Counselexperienceing Psychology.   Once more,
ROM was involved.  In this one, researchers Goldberg, Rousemanier, Miller, Whipple, Nielsen, Hoyt, and Wampold examined a large, naturalistic data set that included outcomes of 6500 clients treated by 170 practitioners whose results had been tracked an average of 5 years.

Their question?

Do therapists become more effective with time and experience?

Their answer?  No.

readerFor readers of this blog, such findings will not be particularly newsworthy.  As I’ve frequently pointed out, experience has never proven to be a significant predictor of effectiveness.

What might be a bit surprising is that the study found clinicians’ outcomes actually worsened with time and experience.  That’s right.  On average, the longer a therapist practiced, the less effective they became!  Importantly, this finding remained even when controlling for several patient-level, caseload-level, and therapist-level characteristics, as well as when excluding several types of outliers.

Such findings are noteworthy for a number of reasons but chiefly because they contrast sharply with results from other, equally-large studies documenting that therapists see themselves as continuously developing in both knowledge and ability over the course of their careers.   To be sure, the drop in performance reported by Goldberg and colleagues wasn’t steep.  Rather, the pattern was a slow, inexorable decline from year to year.

Where, one can wonder, does the disconnect come from?  How can therapists’ assessments of themselves and their work be so at odds with the facts?  Especially considering, in the study by Goldberg and colleagues, participating clinicians had ongoing access to data regarding their effectiveness (or lack thereof) on real-time basis!  Even the study I blogged about previously—the largest in history where outcomes of psychotherapy were shown to be quite positive—a staggering 40% of people treated experienced little or no change whatsoever.  How can such findings be reconciled with others indicating that clinicians routinely overestimate their effectiveness by 65%?

Turns out, thboundariese boundary between “belief in the process” and “denial of reality” is remarkably fuzzy.  Hope is a  significant contributor to outcome—accounting for as much as 30% of the variance in results.  At the same time, it becomes toxic when actual outcomes are distorted in a manner that causes practitioners to miss important opportunities to grow and develop—not to mention help more clients.  Recall studies documenting that top performing therapists evince more of what researchers term, “professional self-doubt.”  Said another way, they are less likely to see progress where none exists and more likely to values outcomes over therapeutic process.

What’s more, unlike their more average counterparts, highly effective practitioners actually become more effective with time and experience.  In the article below, my colleagues and I at the International Center for Clinical Excellence identify several evidence-based steps any practitioner follow to match such results.

Let me know your thoughts.

Until next time,

Scott

Scott D. Miller, Ph.D.
headerMain8.pngRegistration is now open for our March Intensives in Chicago.  Join colleagues from around the world for the FIT Advanced and the FIT Supervision workshops.

 

Helping Therapists Help: MyOutcomes Wins Medipex NHS Innovation Award in UK

By 2 Comments

Documentation and regulation are on the rise.  On average, clinicians spend 30% of their day doing paperwork that contributes little if anything to the health and welfare of their clients.  What’s more, research shows that a high documentation to clinical service ratio leads to higher rates of:

  • Burnout and job dissatisfaction among clinical staff;
  • Fewer scheduled treatment appointments;
  • No shows, cancellations, and disengagement among consumers.

What practice not only insures accountability but simultaneously improves the quality and outcome of behavioral health services?  According to the Substance Abuse and Mental Health Services Administration (SAMHSA), one evidence-based strategy is routinely and formally seeking feedback from consumers about how they are treated and their progress.

Earlier this year, I reviewed several electronic systems that make gathering and utilizing consumer feedback a snap.

Last week, one of these–MyOutcomes–was recognized by the National Health Service in the UK. Diane Tetley from Lincolnshire Partnership Foundation Trust was awarded the Medipex Innovation Award in the mental health and well being category for her work in using the system to track and enhance consumer engagement and progress.

Using cutting-edge technology to help clinicians help is what the award is all about.  Congratulations to Diane, and the dedicated crew at MyOutcomes.  The system provides a simple, elegant, and highly efficient method for implementing feedback-informed treatment in individual and agency treatment settings.

 

Recent study documents the effectiveness of psychotherapy has been overstated: An example of an RFTM and PEBKAC problem

By 10 Comments

RTFM

Not being a computer nerd, I’d never come across these expressions.  My 14-year-old son was the first person I heard use the terms.  He was referring to a problem I was having with my desktop computer.  To be sure, I’m no Luddite.  Still, “computer” will always be a second language for me.

With a restart and few clicks of the mouse, he resolved my issue.  When I asked him to explain what had caused the problem–hoping either to avoid or be able to resolve a similar occurrences in the future–he quipped, “Dad, it’s an RTFM problem, most likely in the PEBKAC.”

“RTFM problem?  In the PEBKAC?”

“Yeah,” he said with a laugh, then walked away.

Consulting Google, I quickly learned what the terms meant: Read the F%$&ing Manual as the Problem Exists Between the Keyboard and the Computer.  Swallowing my pride (and a fair bit of irritation), I had to admit my son was right.  I had not read the manual.  I didn’t want to read the manual.  I WANTED MY PROBLEM SOLVED!  As a result, I’d spent an increasingly frustrating hour, first tinkering, then on the phone with less than helpful customer service representative.

So, what’s this got to with psychotherapy?

Over the weekend, the twittersphere lit up with posts about a story in the New York Times: Effectiveness of Talk Therapy is Overstated.  The article reported on a new study which had found that psychotherapy was “25% less effective…than previously thought.”

The response to the story was swift, questioning, for the most part, motives and methodology:

  • Who published this study and why?
  • What kind of therapy was studied?  
  • Why the emphasis on quantitative studies?
  • Why is the media always so negative about therapy?
  • Is this the whole picture?

The reaction is understandable.  The headline and story are enough to give any practicing therapist pause.  More so because, as I reviewed in my recent presentation at the Evolution of Psychotherapy conference, they are already working in an challenging practice environment.  Rucost_of_living_income_4x3_1-300x225les and regulation are on the increase.  Incomes are on the decline.  They know the value of the work they do.  They can see it in the people they treat.  Instead of recognizing the value of the services offered, the effectiveness of the field, it’s methods, and practitioners are called into question.

The interaction with my son still fresh in my mind, I wondered, “Could this be a RTFM problem located in PEBKAC?”

Said another way, “Had anyone actually read the study?!”  Despite assurances that “the facts are always friendly” from the likes of Carl Rogers, we know therapists don’t read research, for example.  How do we know?  RESEARCH!

In truth, the study is a merely an empirical call for more openness and transparency in publication of psychotherapy research.  Inflated estimates of effectiveness help no one.  Not practitioners.  Not clients.  Not the field.

The very same factors that lead the media to highlight the most attention-grabbing aspects of a news story, influence what gets submitted, reviewed, and published in scholarly journals.  Sad, but true.  To get the full picture–to determine “what really works”–results from all research–whether published or not–must be tracked and reported.  Not surprisingly, when you get beyond the headlines, the story is almost always less dramatic and more nuanced.

Additionally, the research article contains some real gems!  For example:

  • Psychotherapy was found clearly superior to a variety of placebo and no-treatment controls, including treatment-as-usual, pill-placebo, and non-specific control conditions.
  • Consistent with research reported on this blog, no differences in outcome were found between treatment approaches!
  • No differences in outcome were found between psychological treatments and anti-depressant medication.
  • Finally, the effect of psychotherapy plus medications was superior to anti-depressant medication alone.

What’s not to like?

And while we’re on the subject, this week another study was published.  Click on the link and give it a read.  I’m sure there will be no headline in the New York Times, despite the fact that it’s the largest psychotherapy outcome study in history!   What are the results?  RTFM!

Until next time,

Scott

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

PS: Registration is open for the ICCE March Intensives:

Feedback Informed Treatment Advanced Intensive (March 17-19, 2016)
Feedback Informed Treatment Supervision Intensive (March 21-23, 2016)

The Verdict is “In”: Feedback is NOT enough to Improve Outcome

By 17 Comments

verdict-icon

 

 

 
Nearly three years have passed since I blogged about claims being made about the impact of routine outcome monitoring (ROM) on the quality and outcome of mental health services.  While a small number of studies showed promise, others results indicated that therapists did not learn from nor become more effective over time as a result of being exposed to ongoing feedback.  Such findings suggested that the focus on measures and monitoring might be misguided–or at least a “dead end.”

Well, the verdict is in: feedback is not enough to improve outcomes.  Indeed, researchers are finding it hard to replicate the medium to large effects sizes enthusiastically reported in early studies, a well-known phenomenon called the “decline effect,” observed across a wide range of scientific disciplines.

decline1

 

 

 

 

In a naturalistic multisite randomized clinical trial (RCT) in Norway, for example, Amble, Gude, Stubdal, Andersen, and Wampold (2014) found the main effect of feedback to be much smaller (d = 0.32), than the meta-analytic estimate reported by Lambert and Shimokawa (2011 [d = 0.69]).  A more recent study (Rise, Eriksen, Grimstad, and Steinsbeck, 2015) found that routine use of the ORS and SRS had no impact on either patient activation or mental health symptoms among people treated in an outpatient setting.  Importantly, the clinicians in the study were trained by someone with an allegiance to the use of the scales as routine outcome measures.

Fortunately, a large and growing body of literature points in a more productive direction.  Consider the recent study by De Jong, van Sluis, Nugter, Heiser, and Spinhoven (2012), which found that a variety of therapist factors moderated the effect ROM had on outcome. Said another way, in order to realize the potential of feedback for improving the quality and outcome of psychotherapy, emphasis must shift away from measurement and monitoring and toward the development of more effective therapists.

What’s the best way to enhance the effectiveness of therapists?  Studies on expertise and expert performance document a single, underlying trait shared by top performers across a variety of endeavors: deep domain-specific knowledge.  In short, the best know more, see more and, accordingly, are able to do more.  The same research identifies a universal set of processes that both account for how domain-specific knowledge is acquired and furnish step-by-step directions anyone can follow to improve their performance within a particular discipline.  Miller, Hubble, Chow, & Seidel (2013) identified and provided detailed descriptions of three essential activities giving rise to superior performance.  These include: (1) determining a baseline level of effectiveness; (2) obtaining systematic, ongoing feedback; and (3) engaging in deliberate practice.

I discussed these three steps and more, in a recent interview for the IMAGO Relationships Think Tank.  Although intended for their members, the organizers graciously agreed to allow me to make the interview available here on my blog. Be sure and leave a comment after you’ve had a chance to listen!


Until next time,

Scott

Scott D. Miller, Ph.D.
www.whatispcoms.com
www.iccexcellence.com

headerMain8.png

Intake: A Mistake

By 1 Comment

bad idea

 

 

 

 

Available evidence leaves little doubt.  As I’ve blogged about previously, separating intake from treatment results in:

• Higher dropout rates;
• Poorer outcomes;
• Longer treatment duration; and
• Higher costs

And yet, in many public behavioral health agencies, the practice is commonplace. What else can we expect?

Chronically underfunded, and perpetually overwhelmed by mindless paperwork and regulation, agencies and practitioners are left with few options to meet the ever-rising number of people in need of help. Between 2009 and 2012, for example, the number of people receiving mental health services increased by 10%. During the same period, funding to state agencies decreased $4.35 billion. Not long ago, in my own home town of Chicago, the city shuttered half—50%–of the city’s mental health clinics, forcing the remaining, already burdened, agencies to absorb an additional 5,000 people in need of care.

crowd

 

 

 

Simply put, the practice of separating intake from treatment is little more than a form of “crowd management”–and an ineffective one at that.

feedback keyboard

 

 

 

 

Adding to the growing body of evidence is a new study investigating the impact of computerized intake on the consumer’s experience of the therapeutic relationship and continuation in care. Not only did researchers find that therapist use of a computer had a negative impact on the quality of the working relationship—one of the best predictors of outcome–but clients were between 62 and 97% less likely to continue in care!

domino

 

 

 

 

It’s not hard to see how these well-intentioned—some would argue, absolutely necessary—solutions actually end up exacerbating the problem. Money is wasted when the paperwork is completed but people don’t come back; money that would be better spent providing treatment. Those who do not return don’t disappear, they simply access services in other ways (e.g., the E.R., police and social services, etc.)—after all, they need help! The ones who do continue after intake, experience poorer outcomes and stay longer in care, a cost to both the consumer and the system.

What to do?

solution

 

 

 

 

In addition to pushing back against the mindless regulation and paperwork, there are several steps practitioners and agency managers can take:

  • Stop separating intake from treatment

The practices does not save time and actually increases costs. Consider having consumers complete as much of the paperwork as possible before the session begins. The first visit is critical. It determines whether people continue or drop pout. Listen first. At the end of the visit, review the paperwork, filling in missing data, and completing any remaining forms.

  • Begin monitoring outcome

Research to date shows that routinely monitoring progress reduces dropout rates and the length of time spent in treatment while simultaneously improving outcome. Combined, such results work to alleviate the bottleneck at the entry point of services.

  • Begin monitoring the quality of the therapeutic relationship:

Engagement and outcomes are improved when problems in the relationship are identified and openly discussed. Even when intake is separated from treatment, feedback should be sought. Data to date indicate that the most effective clinicians seek and more often receive negative feedback, a skill that enables them to better meet the needs of those they serve.

Getting started is not difficult. Indeed, there’s an entire community of professionals just a click away who are working with and learning from one another. The International Center for Clinical Excellence is the largest, web based community of mental health professionals in the world. It’s ad free and costs nothing to join.

Sign up for the ICCE Fall Webinar. You will learn:

  • The Empirical Basis for Feedback Informed Treatment
  • Basics of Outcome and Alliance Measurement
  • Integrating Feedback into Practice & Creating a Culture of Feedback
  • Understanding Outcome and Alliance Data

Register online at: https://www.eventbrite.ie/e/fall-2015-feedback-informed-treatment-webinar-series-tickets-17502143382. CE’s are available.

Finally, join colleagues and friends from around the world for the Advanced and FIT Supervision courses are held in March in Chicago. We work and play hard. You will leave with a thorough grounding in feedback-informed principles and practice. Registration is limited, and the courses tend to sell out several month in advance.

Until then,

Scott

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

Scott D. Miller - Australian Drug and Alcohol Symposium

 

What’s happening to CBT? And why all the hoopla misses the point

By 8 Comments

diminished

In May 2012, I blogged about results from a Swedish study examining the impact of psychotherapy’s “favorite son”–cognitive behavioral therapy–on the outcome of people disabled by depression and anxiety.  Like many other Western countries, the percentage of people in Sweden disabled by mental health problems was growing dramatically.  Costs were skyrocketing.  Even with treatment, far too many left the workforce permanently.

evidence-man1
Sweden embraced “evidence-based practice”–most popularly construed as the application of specific treatments to specific disorders–as a potential solution.  Socialstyrelsen, the country’s National Board of Health and Welfare, developed and disseminated a set of guidelines (“riktlinger”) specific to mental health practice.  Topping the list?  CBT.

sweden-map
A billion crowns were spent training clinicians in the method; another billion using it to treat people with diagnoses of depression and anxiety.   As I reported at the time, the State’s “return on investment” was zilch.  Said another way, the widespread adoption of method had no effect whatsoever on outcome (see Socionomen, Holmquist Interview).   Not only that but many who were not disabled at the time they were treated with CBT became disabled along the way, bringing the total price tag, when combined with the 25% who dropped out of treatment, to a staggering 3.5 billon!

And now, a new study–this time from Norway, Sweden’s neighbor to the west.
norw-MMAP-md
Norwegian researchers looked at how the effectiveness of CBT has fared over time.  Examining data from 70 randomized clinical trials, study authors Johnsen and Friborg found the approach to be roughly half as effective as it was four decades ago.  Mind you, not 10 or 20 percent.  Not 30 or 40.  Fifty percent less effective!  Cause for concern, to be sure.

Fearful
So, what’s happening to CBT?  Is the “favored son” losing its effectiveness?

Naturally, the results published by the Norwegian researchers generated a great deal of activity in social media.  Critics were gleeful (see the comments at the end of the article).  Proponents, of course, questioned the results.

If the findings are confirmed in subsequent studies, CBT will be in remarkably good company.  Across a variety of disciplines–pharmacology, medicine, zoology, ecology, physics–promising findings often “lose their luster,” with many fading away completely over time (Lehrer, 2010; Yong, 2012).  Alas, even in science, the truth occasionally wears off.  In psychiatry and psychology, this phenomenon, known as the “decline effect,” is particularly vexing.

That said, while the study and commentary have managed to generate a modest amount of heat, they’ve shed precious little light on the question of how to improve the outcome of psychotherapy.  After all, that’s what led Sweden to invest so heavily in CBT in the first place–doing so, it was believed, would improve the effectiveness of care.  So today, I called Rolf Holmqvist.

RolfHolmqvist
Rolf is a professor in the Department of Behavioral Science and Learning at Linköping University.  He’s also the author of the Swedish study I blogged about over three years ago.  I wanted to catch up, find out what, if anything, had happened since he published his results.

“Some changes were made in the guidelines some time ago.  In the case of depression, for example, the guidelines have become a little more open, a little broader.  CBT is always on top, along with IPT, but psychodynamic therapy is now included…although it’s further down on the list.”

Sounded like progress, until Rolf continued, “They are broadening a bit.  Still the fact is that if you look at the research, for example, with mild and moderate depression, almost any method works if it’s done systematically.”

mindset_defined
Said another way, despite the lack of evidence for the differential effectiveness of psychotherapeutic approaches–in this case, CBT for depression–the mindset guiding the creation of lists of “specific treatments for specific disorders” remains.

Rolf’s sentiments are echoed by uber-researchers, Wampold and Imel (2015), who very recently pointed out, “Given the evidence that treatments are about equally effective, that treatments delivered in clinical settings are effective (and as effective as that provided in clinical trials), that the manner in which treatments are provided much more important than which treatment is provided, mandating particular treatments seems illogical. In addition, given the expense involved in “rolling out” evidence-based treatments in private practices, agencies, and in systems of care, it seems unwise to mandate any particular treatment.”

Right now, in Sweden, an authority within the Federal government (Riksrevisorn) is conducting an investigation evaluating the appropriateness of funds spent on training and delivery of CBT.  In an article published yesterday in one of the countries largest newspapers , Rolf Holmqvist argues, “Billions spent–without any proven results.”

Returning to the original question: what can be done to improve the outcome of psychotherapy?

“We need transparent evaluation systems,” Rolf quickly answered, “that provide feedback at each session about the progress of treatment.  This way, therapists can begin to look at individual treatment episodes, and be able to see when, where, and with whom they are and are not successful.”

“Is that on the agenda?” I asked, hopefully.

“Well,” he laughed, “here, we need to have realistic expectations.  The idea of recommending that you should employ a clinician because they are effective and a good person, rather than because they can do a certain method, is hard for regulatory agencies like Socialstyrelsen.  They think of clinicians as learning a method, and then applying that method, and that its the method that makes the process work…”

“Right,” I thought, “mindset.”

“…and that will take time,” Rolf said, “but I am hopeful.”

But, you don’t have to wait.  You can begin tracking the quality and outcome of your work right now.  It’s easy and free.  Click here to access two simple scales–the ORS and SRS.  the first measures progress; the second, the quality of the working relationship.

Next, read our latest article on how the field’s most effective practitioners use the measures to, as Rolf advised, “identify when, where, and with whom” they are and are not successful, and what steps they take to improve their effectiveness.

Finally, join colleagues from around the world for our Fall Webinar on “Feedback-Informed Treatment.”

Fall webinar 2015
We’ll be covering everything you need to know to integrate feedback into your clinical practice.

Until next time,

Scott

Scott D. Miller, Ph.D.
International Center for Clinical Excellence
Scott D. Miller - Australian Drug and Alcohol Symposium

 

 

 

 

 

Love, Mercy, & Adverse Events in Psychotherapy

By 10 Comments

LOVE-MERCY-POSTER-1308x1940
Just over a year ago, I blogged about an article that appeared in one of the U.K.’s largest daily newspapers, The Guardian.  Below a picture of an attractive, yet dejected looking woman (reclined on a couch), the caption read, “Major new study reveals incorrect…care can do more harm than good.”

I was interested.

As I often do in such cases, I wrote directly to the researcher cited in the article asking for a reprint or pre-publication copy of the study.  No reply.  One month later, I wrote again.  Still, no reply. Two months after my original email, I received a brief note thanking me for my interest in the study and offering to share any results once they became available.

“Wait a minute,” I immediately thought, “The results of this ‘major new study’ about the harmful effects of psychotherapy had already been announced in a leading newspaper.  How could they not be available?”  Then I wondered, “If there are no actual results to share, what exactly was the article in The Guardian based on?”

So-called “adverse events” are a hot topic at the moment.  That some people deteriorate while in care is not in question.  Research dating back several decades puts the figure at about 10%, on average (Lambert, 2010). When those being treated are adolescents or children, the rates are twice as high (Warren et al., 2009).

Putting this in context, compared to medical procedures with effect sizes similar to psychotherapy (e.g., coronary artery bypass surgery, stages II and III breast cancer, stroke), the rate is remarkably low.  Nonetheless, it is a matter of concern–especially given research showing that therapists are not particularly adept at recognizing when those they serve deteriorate in their care (Hannan et al., 2005)

The question, of course, is the cause?

To date, whenever the question of adverse events is raised, two “usual suspects” are trotted out: (1) the method of treatment used; and (2) the therapist.  Let’s take a closer look at each.

In an October 2914 article published in World Psychiatry, Linden and Schermuly-Haupt wrote about estimates of side effects associated with specific methods of treatment that had been reported in an earlier study by Swiss researchers.  The numbers were shocking.  Patient reported “burdens caused by therapy” were 19.7% with CBT, 20.4% for systemically oriented treatments, 64.8% with humanistic approaches, and a staggering 94.1% with psychodynamic psychotherapy.

Based on such results, one could only conclude that anyone seeking anything other than CBT should have their head examined.

HeadExamined
There is only one problem.  The figures reported were wrong.  Completely and utterly wrong.  Linden and Schermuly-Haupt made an arithmetic error and, as a result, totally misinterpreted the Swiss findings.  Read the study for yourself.  When it comes to adverse events in psychotherapy, CBT–the fair-haired child of the evidence-based practice movement–is not better.  Indeed, as the study clearly shows, people treated with humanistic and systemic approaches suffered fewer “burdens” than expected, while those in CBT had a slightly higher, although not statistically significant, level. More, the observed percentage of people in care who perceived the quality of the therapeutic relationship–the single most potent predictor of engagement and outcome–as poor was significantly higher than expected in CBT and lower for both humanistic and systemic approaches.

How could the researchers have gotten it so wrong?

As I pointed out in my blog over year ago, despite claims to the contrary (e.g., Lilenfeld, 2007), no psychotherapy approach tested in a clinical trial has ever been shown to reliably lead to or increase the chances of deterioration.  NONE.  Scary stories about dangerous psychological treatments are limited to a handful of fringe therapies–approaches that have been never vetted scientifically and which all practitioners, but a few, avoid.  In short, its not about the method.

(By the way, over a month ago, I wrote to the lead author of the paper that appeared in World Psychiatry via the ResearchGate portal–a site where scholars meet and share their publications–providing a detailed breakdown of the statistical errors in the publication.  No response thusfar)

bad-apple
With only one suspect left, attention naturally turns to the therapist–you know, the “bad apple” in the bunch.  Here’s what we know.  That some practitioners do more harm than others is not exactly news.  Have you seen the new biopic Love & Mercy, about the life of Beach Boy Brian Wilson?  You should.  The acting is superb.

love-mercy05
Wilson’s therapist, psychologist Eugene Landy (chillingly recreated by actor Paul Giamatti), is a prime example of an adverse event.  See the film and you’ll most certainly wonder how the guy kept his license to practice so long.  And yet, as I also pointed out in my blog last year, there are too few such practitioners to account for the total number of clients who worsen.  Consider this unsettling fact: beyond the 10% of those who deteriorate in psychotherapy, an additional 30 and 50% experience no benefit whatsoever!

roi
Where does this leave us when it comes to adverse events in psychotherapy?

Whatever the cause, lack of progress and risk of deterioration are issues for all clinicians and clients.   The key to addressing these problems is tracking progress from visit to visit so that those not improving, or getting worse, can be identified and offered alternatives.  It’s that simple.

Right now, practitioners can access two simple, easy-to-use scales for free at: www.whatispcoms.com.  Both have been tested in multiple, randomized, clinical trials and deemed evidence-based by the Federal Substance Abuse and Mental Health Services Administration (SAMHSA).

Learning to use the tools isn’t difficult.  It costs nothing to join the International Center for Clinical Excellence and begin interacting with professionals around the world who are using the measures to improve the quality and outcome of behavioral health services.  More detailed instruction is available at the upcoming webinar:

Fall webinar 2015
Join us in tackling the issue of adverse events in psychotherapy.  In the meantime, be sure and leave a comment below.

Best wishes for the summer,

Scott

Scott D. Miller, Ph.D.
Director, International Center for Clinical Excellence
headerMain8.png

P .S.: On the one year anniversary of my original email to the reseacher cited in the Guardian, I sent another.  That’s over a month ago.  So far, no reply.  By contrast, the reporter who broke the story, Sarah Boseley , wrote back within a half hour!  She’s following up her sources.  I’ll let you know if she gets a response.

 

Time to Rethink Burnout: Lessons from Supershrinks

By 2 Comments

Burnout

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.
ethical 2Fit IMP