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

March 8, 2019 By scottdm 2 Comments

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

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

What happened?

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

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

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

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

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

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

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

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

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

As always, interested in your thoughts,

Scott & David

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

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

Surfing and Psychotherapy (or, How Two of My “Love Affairs” in Life are Alike)

February 26, 2019 By scottdm 2 Comments

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

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

/rəˈspänsivnəs/
NOUN
The quality of reacting quickly and positively.

In surfing, you take advantage of the waves coming your way. In psychotherapy, you utilize and react to what the client presents. In both activities, trying to force matters spoils, if not altogether thwarts, the experience.

Recent research actually shows “certain therapists are more effective than others … because [they are] appropriately responsive … providing each client with a different, individually tailored treatment” (1).

How best to improve this key skill?

Having just returned from a week surfing in Hawaii, I can definitely say “patience and persistence” are key. I spent a lot of time sitting on my board scanning the surrounding water for incoming waves. If not that, I was paddling like mad to get in front of a swell I hoped would turn into a good ride.

Sometimes I was ahead of the curve, other times behind. Even when my timing was right, some waves quickly “fell apart” leaving me slowly sinking into the surrounding water. Often enough though, it all came together, and what a high. Soon, and without thinking, I was laying astride my board paddling back out for more.

I’m sure you’ve had similar experiences in psychotherapy. At times, you are too early; at others, too late. With some, you are helpful; others, not so much. For most of the history of the field, patience and endurance, combined with training, supervision, and trial and error, are the ways by which we’ve learned to respond to and tailor the work to the individual. That is, until recently.

Consider the bar graph displayed on the right. It shows the results of a brand new study just released by my colleague Jeb Brown tracking the impact Feedback Informed Treatment (FIT) — the process of using formal measures to track progress and the quality of the therapeutic relationship — has on the outcome of psychotherapy. Importantly, the data used were drawn from a super-large, real world sample of working clinicians.

Here’s what Jeb found. Therapists who were more “engaged” in seeking and processing performance feedback were significantly more effective than their peers (an average effect size difference of .2 σ). In short, FIT improved clinical responsiveness, increasing the odds of practitioners “doing the right thing at the right time.”

If you’re not already using the two FIT scales, you can download and start them using them for free by clicking here. Several cutting edge software programs are also available that will administer and score the tools, as well as provide you with evidence-based feedback delivered at the point of service delivery. “Epic!” is likely what a Surfer would say if they to had access to similar tools for enhancing their responsiveness to local surf conditions.

Which reminds me …

A few years back, Mark Hubble and I, together with our surfer bro, Seth Houdeshell, wrote a book about surfing. Actually, its an inspirational, “how to” volume about living the good life based on the principles of surfing. Jack Canfield, author of the Chicken Soup of the Soul books, described it “Like a warm sunny day at the beach,” promising it “would brighten your spirits and put a smile on your face.”

It’s a fun read that won’t strain your brain. Young or old, surfer or wannabe, I know you’d enjoy it. Click here if you’re interested. You can have it at my cost ($4.95 plus shipping) until my supply runs out.

Until next time,

Scott

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

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

Time for a New Paradigm? Psychotherapy Outcomes Stagnant for 40 years

February 1, 2019 By scottdm 6 Comments

You’ve heard it said before. Flying is the safest form of transportation.

Facts back up the claim. In fact, it’s not even close. In terms of distance traveled, the fatality rate per billion kilometers is .003, improving dramatically over the years. Cars, by contrast, are almost 1,000 times more dangerous. Still, since 1923, the fatality rate in motor vehicle accidents has declined an eye-popping 93%.

How about psychotherapy? Have outcomes improved? Judging by the size of the Diagnostic and Statistical Manual and growth in the number of treatment approaches, one would expect success rates to have climbed significantly, if not exponentially. Not so, as I first presented at the Evolution of Psychotherapy Conference five years ago, and later on this blog, the empirical evidence clearly shows NO improvement.

And now a new study, this time reviewing the evidence regarding treatments for children and adolescents. Using sophisticated statistical analyses, the researchers examined 453 RCT’s spanning 53 years, involving nearly 32,000 kids treated for anxiety, depression, attention deficit/hyperactivity, and conduct problems. With the rising popularity of “evidence-based practice,” those conducting the study wanted to know whether “… our methods of developing and testing youth psychological therapies [are] producing improvement” (p. 2).

Can you guess what they found?

Outcomes have not changed (much less improved) over the last five decades–that’s 351 in dog years!

Can you imagine the outcry had similar results been published about automobiles or planes? You would fully expect hearings to be held, and leaders to be called called to account. The lives of children are on the line.

Nope. Instead, facing the supersized differences between promises made every year about “advances” in psychotherapy, and the results realized and reported in research studies, the authors meekly call for, “new approaches to treatment design and intervention science” (p. 1).

Really? Is that what’s required? Researchers going back to the drawing board of “treatment and intervention?”

No, what’s needed is an entirely different view of what clinicians actually do — and it starts by giving up the idea that psychotherapy is a form of treatment similar to antibiotics or angioplasty. Let’s face it. Psychotherapy is no more a medical treatment than are the facials, salt glows and body wraps one receives at the local spa. Which is not to say, it doesn’t work.

Outside the halls of academia, millions of therapists worldwide are helping people on a daily basis to live happier, more meaningful and functional lives. Dozens of studies of real world practitioners document outcomes that meet or exceed benchmarks established in tightly controlled, model-driven, randomized trials — all without following a particular, “evidence-based” protocol (see 1, 2, 3,4).

So, how best to conceptualize the effective work clinicians do? And, importantly, what could researchers offer that would be of real help to therapists?

That psychotherapy works, says more about humans and our need for connection, meaning, and purpose, than it does about the particulars of any given model or approach. And that our methods focus on thoughts, feelings, behaviors, and brain chemistry, says more about our Western values and beliefs, than about the ingredients necessary for successful healing.

Simply put, the field does not need to, as the authors of the study argue, “intensify the search for mechanisms of change [and] transdiagnostic … treatments” (p. 1). Doing so is merely a recipe for “more of the same.” Rather, to move forward, it should abandon the medical paradigm that has long had a stranglehold on our research and professional discourse, choosing instead to reconnect with the larger, worldwide family of healers, one that has existed since the dawn of history and which, from the outset, has been deeply engaged in the values and beliefs of those they treat, using whatever means necessary, consistent with the culture, to engender change.

What might that look like in practice?

As already documented, practicing clinicians already do a pretty darn good job helping their clients. There’s nothing wrong with our Westernized approaches when they work. At the same time, we don’t succeed with everyone. The problem, studies show, is we’re not particularly good at knowing when we’re not being helpful, when clients are at risk for dropping out or are actually deteriorating while in our care (1, 2). On this score, research has already provided a solution. Dozens of studies document, for example, using simple measures at the beginning and end of each visit not only provides clinicians with an opportunity to intervene more successfully with “at risk” clients, but also helps identify opportunities for their own growth and development (1, 2). If you’re not routinely and formally measuring the quality and outcome of your work, you can get started by accessing two simple tools here.

With outcome as our guide, all that remains is being willing to look outside the profession for possibilities for healing and change unbound by convention and the medical view. That’s happening already, by the way, in the world’s two most populous countries, India and China, with professionals learning the ways of indigenous healers and government officials tapping local shaman to meet citizen’s mental health and well being needs.

So, what about you? What you are doing to extend your healing reach?

And, in case you haven’t seen it, the video below is from the most recent Evolution of Psychotherapy conference, where I talk about new research documenting psychics achieving the same or better results as psychotherapists.

Until next time,

Scott

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

P.S.: Want to learn more about using outcome to inform and improve your effectiveness? Join me and an international group of teachers and researchers in Chicago for our Summer Intensives. For detailed information and to register, click on the banners below.