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

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Announcement: Evolving in a new direction

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As those of you who have followed my work and blog know, my perspective is evolving.  The direction I’m heading builds on all of the work done to date including the common factors, measurement of outcome and alliance, and feedback.  Crucially, however, it goes one step further; bridging the common and specific factors divide that has long dominated and splintered the field, and identifying the concrete steps that diverse providers can take to improve their effectiveness and the services they offer consumers.

For the past 10 years much of my work has been available through the Institute for the Study of Therapeutic Change (ISTC) and featured on its website.  In line with the evolution in my perspective my work is now increasingly centered on a new organization, the International Center for Clinical Excellence (ICCE), an international consortium of researchers, educators, and clinicians dedicated to understanding and promoting excellence in behavior healthcare.  My colleague Barry Duncan, co-founder of the ISTC, is also developing his work in new directions and we have therefore decided that the time is now right to dissolve our long-term partnership in the ISTC.  I recognise that for many of you, who have followed my work over the years, that this may come as a surprising development and I am hoping that this post and others to follow will provide guidance, reassurance and most importantly continuity.

Central to the mission of the International Center for Clinical Excellence (ICCE) is the creation of a web-based community of clinicians using the latest Web 2.0 technology where participants can learn from and share with each other.  Based on the principles of Clinical Community Social Software (CCSS) it is specifically designed to support clinical excellence through creating virtual clinical networks, groups and clinical communities where clinicians can be supported in the key behavior changes required for developing clinical excellence.  Participants can, using a variety of social networking and collaborative tools, share clinical insights through discussion forums and video posts as well as improve client outcomes through learning the skills of clinical excellence.

We have finished our first round of beta-testing for the site and you can go to the website at: www.centerforclinicalexcellence.com to register to become a member (its free and you’ll be notified the minute the entire site is live)!

For those of you new to the tremendous opportunities for web-based collaborative social software, let me reassure you that the site will permit access and use at whatever level you desire (everything from the familiar email, to online posts and discussions in real time).  It will provide lots of help to learn how to explore the information and resources on offer as well as the support of colleagues in the community.  I am very excited by this opportunity to interact with behavioral health professionals all over the world in this way. Over the next few days, I’ll be posting more information about the ICCE and our first International Conference on Excellence in Behavioral Health on my blog at www.scottdmiller.com.   I encourage you to follow the updates on my blog and post any questions or comments.

Expertise and Excellence: What it Takes to Improve Therapeutic Effectiveness

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downloadIf you’ve been following my website and the Top Performance Blog you know that my professional interests over the last couples of years have been shifting, away from psychotherapy, the common factors, and feedback and toward the study of expertise and excellence.

Studying this literature (click here for an interesting summary), makes clear that the factors responsible for superior performance are the same regardless of the specific endeavor one sets out to master. The chief principle will come as no surprise: You have to work harder than everyone else at whatever you want to be best at.

In other words, you have to practice.

Hard work is not enough, however.  Research shows that few attain international status as superior performers without access to high levels of support and detailed instruction from exceptional teachers over sustained periods of time. In the massive “Cambridge Handbook of Expertise and Expert Performance,” Feltovich et al. note, “Research on what enabled some individuals to reach expert performance, rather than mediocre achievement, revealed that expert and elite performers seek out teachers and engage in specifically designed training activities…that provide feedback on performance, as well as opportunities for repetition and gradual refinement” (p. 61).

What makes for a “good” teacher? Well, in essence, that is what the “Top Performance” blog is all about. I’m going on a journey, a quest really.  I’ve decided to take up two hoppies–activities I’ve always had a interest in but never had to the time to study seriously–magic and the ukelele.

Practicing is already proving challenging.  Indeed, the process reminds me a lot of when I started out in the field of psychology.  In a word, its daunting.  There are literally thousands of “tricks” and “songs,” (as there are 100’s of treatment models), millions of how-to books, videos, and other instructional media (just as in the therapy world), as well as experts (who, similar to the field of psychotherapy, offer a wide and bewildering array of different and oftentimes contractory opinions).

By starting completely over with subjects I know nothing about, I hope to put into practice the insights gleaned from our study of expertise and expert performance, along the way reporting the challenges, triumphs and failures associated with learning to master new skills.  I’ll review performances, instructional media (live, printed, DVD, etc), and the teachers I met.  Stay tuned.

Superior Performance as a Psychotherapist: First Steps

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So what is the first step to improving your performance?  Simply put, knowing your baseline.  Whatever the endeavor, you have to keep score.  All great performers do.  As a result, the performance in most fields has been improving steadily over the last 100 years.

Consider, for instance, the Olympics. Over the last century, the best performance for every event has improved–in some cases by 50%!  The Gold Medal winning time for the marathon in the 1896 Olympics was just one minute faster than the entry time currently required just to participate in the Chicago and Boston marathons.

By contrast, the effectiveness of psychological therapies has not improved a single percentage point over the last 30 years.  How, you may wonder, could that be?  During the same time period: (1) more than 10,000 how-to books on psychotherapy have been published; (2) the number of treatment approaches has mushroomed from 60 to 400; and (3) there are presently 145 officially approved, evidenced-based, manualized treatments for 51 of the 397 possible DSM IV diagnostic groups.  Certainly, given such “growth,” we therapists must be more effective with more people than ever before.  Unfortunately, however, instead of advancing, we’ve stagnated, mistaking our feverish peddling for real progress in the Tour de Therapy.

Truth is, no one has been keeping score, least of all we individual practitioners. True, volumes of research now prove beyond any doubt that psychotherapy works.  Relying on such evidence to substantiate the effectiveness of one’s own work, however, is a bit like Tiger Woods telling you the par for a particular hole rather than how many strokes it took him to sink the ball.  The result on outcome, research indicates, is that effectiveness rates plateau very early in most therapists careers while confidence level continue to grow.

In one study, for example, when clinicians were asked to rate their job performance from A+ to F, fully two-thirds considered themselves A or better. No one, not a single person in the lot, rated him or herself as below average. As researchers Sapyta, Riemer, and Bickman (2005) conclude, “most clinicians believe that they produce patient outcomes that are well above average” (p. 146). In another study, Deirdre Hiatt and George Hargrave used peer and provider ratings, as well as a standardized outcome measure, to assess the success rates of therapists in a sample of mental health professionals. As one would expect, providers were found to vary significantly in their effectiveness. What was disturbing is that the least effective therapists in the sample rated themselves on par with the most effective!

The reason for stagnant success rates in psychotherapy should be clear to all: why try to improve when you already think your the best or, barring that, at least above average?

Here again, expanding our search for excellence beyond the narrow field of psychotherapy to the subject of expertise and expert performance in general can provide some helpful insights. In virtually every profession, from carpentry to policework, medicine to mathematics, average performers overestimate their abilities, confidently assigning themselves to the top tier. Therapists are simply doing what everyone else does. Alas, they are average among the average.

Our own work and research proves that clinicians can break away from the crowd of average achievers by using a couple of simple, valid, and reliable tools for assessing outcome. As hard as it may be to believe, the empirical evidence indicates that performance increases between 65-300% (click here to read the studies). Next time, I’ll review these simple tools as well as a few basic methods for determining exactly how effective you are. Subscribe now so you’ll be the first to know.

One more note, after posting last time, I heard from several readers who had difficulty subscribing. After doing some research, we learned that you must use IE 7 or Firefox 3.0.7 or later for the subscribe function to work properly.  Look forward to hearing from you!

In the meantime, the transcript below is of a recent interview I did for Shrinkrap radio.  It’s focused on our current work: