Therapeutic Nudging: How Very Little Can Mean a Lot

May 13, 2019 By scottdm 1 Comment

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

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

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

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

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

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

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

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

All the best,

Scott

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

How Does Feedback Informed Treatment Work? I’m Not Surprised

May 6, 2019 By scottdm Leave a Comment

Feedback-Informed Treatment (FIT) — using measures to solicit feedback about progress and the quality of the therapeutic relationship — is a transtheoretical, evidence-based approach. The most recent research shows clients whose therapists use FIT on an ongoing basis are 2.5 times more like to experience benefit from treatment.

But how does it work?

Quick. Take a guess.

Under the first shell: FIT works because clinicians use measures to monitor their performance. The second: Feedback helps clinicians select the most effective treatment methods. Third: FIT enhances the therapeutic relationship.

If you guessed the “proverbial pea” was under the third shell, you’re right. Hard to believe given: (1) the emphasis placed on measurement and treatment methods by researchers and advocates of various scales; and (2) concerns expressed by some clinicians that using measures will negatively impact the relationship.

In a “first of its kind” study, psychologist Heidi Brattland found that the strength of the therapeutic relationship improved more over the course of care when clinicians used the Outcome and Session Rating Scales (ORS & SRS) compared to when they did not. Critically, such improvements resulted in better outcomes for clients, ultimately accounting for nearly a quarter of the effect of FIT.

Below, you will find a link to an interview I did with Heidi this week about the study. It’s really worth watching, and it underscores the main point of her findings. Bottom line: FIT is not about measures and methods. True, the tools provide form and structure, but their purpose is to facilitate connection. So, when therapists in the study used the ORS and SRS, their client’s first session alliance scores tended to be lower, indicating the process facilitated the development of a “culture of feedback” early on in care. As the researchers note, “having been invited to reflect on any negative aspects of the alliance with a responsive therapist in the first session … clients had a more considered and realistic view of the early … [that] facilitated the communication about the treatment process from the first session onward” (p. 10).

That said, Brattland and her colleagues did not find clinicians were equally effective in their use of FIT. Indeed, as detailed in the report, therapists, “significantly differed in the influence of … [FIT] on the alliance, in the influence of the alliance on outcomes, and the residual direct effect of [FIT] … posttreatment” (p. 10). On this score, one advantage of using scales to routinely measure our work, is that doing so enables us to identify our personal “growth edge” — what, where, and how we might improve our ability to relate to and help the diverse clients we meet in our daily work.

Using the tools to facilitate professional growth and development is the focus of this summer’s “Deliberate Practice Intensive.” Together with my colleague, Dr. Daryl Chow, we’ll translate the latest research showing that deliberate practice leads to steady improvements in effectiveness into step-by-step instructions for improving your clinical performance. Click here for more information or to register!

Until next time,

Scott

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

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

April 24, 2019 By scottdm 8 Comments

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Until next time,

Scott

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