Eighty three million, six hundred fifty thousand, thirty seven.

Can you guess what this number represents?

No, its not the net worth of the latest tech millionaire.  Neither is it the budget of a soon-to-be released Hollywood blockbuster.

Guess again.

Give up?

It’s the number of adults in the U.S. who reported struggling with mental health or substance use resulting from efforts to mitigate the SARS-COV-2 virus.

By the way, that figure is from the last week in June, three months ago.  Since then, the isolation, job losses, and economic and political uncertainty and social unrest have continued.

According to the Center for Disease Control, “Younger adults, racial/ethnic minorities, essential workers, and unpaid adult caregivers reported having experienced disproportionately worse mental health outcomes, increased substance use, and elevated suicidal ideation,” with a staggering 25% of 18-24 year-olds having seriously contemplated suicide in the weeks prior to completing the survey.

One glimmer of hope amidst these dire statistics is that access to mental health care has expanded during the pandemic.  In March, U.S. government agencies expanded Medicaid telehealth coverage.  In turn, the U.S. Department of Health and Human Services relaxed HIPPA privacy rules, further reducing barriers to accessing treatment remotely.  Many third party payers have followed suit.  As it is, the dramatic increase in those seeking mental health care and shift to virtual service delivery fit squarely with the theme of this year’s World Mental Health Day.  Falling on Saturday, October 10th, it calls for “ensur[ing] that everyone, everywhere has access to mental health care.”

Of course, increased demand and easier access to care are placing a strain on therapists.  As one recent story noted, “Therapists and counselors are facing the same anxiety, uncertainty and financial stress that are troubling those who seek their services.”  The risk of a “parallel pandemic” of burnout is, according to recent studies, rising.  Consider this, prior to the outbreak, available evidence indicated between 21 and 67 percent already were experiencing high levels.

Not long ago, my colleague Mark Hubble and I reviewed the research on the subject noting that most of currently fashionable approaches (e.g., practice mindfulness meditation, eat healthy snacks, go for short walks, exercise regularly, get enough sleep, join a service organization, take up a hobby, attend a continuing education event, learn to say no, see a therapist, and take time out to value oneself) not only don’t work but often make matters worse.

What does work?

I hope you’ll read (or re-read) the article.  It’s free and provides a detailed review.  That said, all things being equal, one key finding is that effectiveness mitigates risk.  Said another way, the better a therapist’s results, the less likely they are to burnout.  The challenge, particularly in these troubled times, is that we care. People matter to us. We want to make a difference.  In this effort, we place ourselves at risk whenever what we’re there to accomplish takes a back seat to the caring, empathy, and compassion we provide, no matter how lovingly extended.

Bottom line: keep outcome front and center in your work.  After all, genuinely and demonstrably helping people improve is the entire point of therapy and, in the end, the best of all ways to show that we really, deeply care.  One way to do that, of course, is to measure your results.  If you haven’t already done so, you can get my two, evidence-based progress and relationship scales for free by clicking here.  If you need some help learning how to integrate the tools into your online work, check out the many blogposts, how-to videos, and webinars my colleagues and I have produced since the start of the outbreak (1, 2, 3, 4)– again, all free.

If you are looking for a way to improve your effectiveness, my colleague and co-author, Daryl Chow, are launching a self-paced, e-learning workshop on deliberate practice, based on our new book, Better Results.  Beginning November 2nd, we’ll start what we call the “DP Drip.”  Every Monday and Friday for nearly three months, you’ll receive links to brief videos and other goodies aimed at helping you design and execute your own deliberate practice plan.  To ensure you get the individualized help you need, its limited to 40 participants.  Interested?  Click here to watch a short, introductory video.

OK, that’s it for now.

Scott

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

Here’s an interesting dilemma.   In December 1799, three physicians were summoned to the Mount Vernon estate to treat the former first president of the United States for a sore throat.  The accepted therapy of the day was administered skillfully and competently multiple times.  Several hours later, the president was dead.  Historians agree George Washington likely did not die of whatever illness he had, but rather from the care he received killed him.  The intervention, of course, was bloodletting — the chief tool of which remains the title of one of medicine’s leading research journals (i.e., The Lancet [Flexner 1974]).

The question is, did Washington’s physicians act ethically?

According to the ethical codes of the four largest mental health provider organizations in the United States, the answer is an unsatisfying and deeply disconcerting, “yes.”   Standard 2.01 of the Ethical Principles of Psychologists (APA 2017), for example, merely requires practitioners “provide services … with populations and in areas … within the boundaries of their competence, based on their education, training, supervised experience, consultation, study, or professional expertise” — conditions easily met by Washington’s physicians.

Before objecting that professionals should not be held accountable for standards of care yet to be developed, vetted by science, and accepted by peers and regulatory bodies, consider another historical example. The year is 1846. Hungarian-born physician Ignaz Semmelweis is in his first month of employment at Vienna General Hospital when he notices a troublingly high death rate among women giving birth in the obstetrics ward.  Indeed, with rates of 25 to 30 percent many expectant mothers prefer to give birth in the street rather than the clinic.

Medical science at the time attributes the problem to “miasma,” an invisible, poisonous gas believed responsible for a variety of illnesses.  Having noticed that midwives have a rate 6 times lower than physicians, Semmelweis concludes his colleagues contact with dead bodies is somehow involved and orders them to wash their hands prior to interacting with expectant mothers.  The mortality rate on the maternity warm immediately plummets landing at the same level as that of midwives.

Nowadays, of course, handwashing is a “best practice,” supported by a century of scientific evidence.  During Semmelweis’s day, such data was not available. His was merely a hunch—one which, by the way, fell outside the boundaries of then current medical standards, his professional experience, education, and training.  What’s more, he continued to promote the practice even after it was deemed unscientific by his peers and the broader professional community.

Returning to the earlier question, did Semmelweis act ethically?  The answer, according to the field’s current ethical codes, would be “no.”

It’s hard to defend a standard that deems a practitioner who competently delivers an unhelpful, even deadly service (e.g., Washington’s physicians) ethically superior to one who is actually helpful but working beyond the limits of their education, training, supervised experience, consultation, study or professional expertise” (e.g., Semmelweis).  And yet, that is precisely what the competence criterion in the current ethical codes of mental health provider organizations does.

What alternatives exist?  Adopting a standard of “working within and continually to extend the field’s and one’s own level of effectiveness” would achieve what the current criterion has failed to deliver: protecting the public welfare while facilitating ongoing improvement in the results of clinical services.  It would also free therapists to use their creativity as well as take advantage of ideas from a variety of healing traditions.

But how?

Together with my colleagues Joshua Madsen and Mark Hubble, we lay out the details in a new chapter published this month in The Oxford Handbook of Psychotherapy Ethics.  I’m hoping you’ll be interested in reading it.

Click here or email at scottdmiller@talkingcure.com if you’d like a copy.

Until next time,

Scott

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

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

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

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

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

So, what does the research indicate?

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

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

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

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

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

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

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