As a mental health professional, how do you approach a New Year?  Are you filled with hope for our field?  Suffering a twinge (or more) of despair?  Maybe you’re in reflective mood, longing for the ‘good ole days’?  Or is the difference between December 31st and January 1st just like any other twenty four hour period?

Recently, I came across a word that captured my experience.  I’d never seen it before.  Anticipointment.  Online sources define it as, “The state of mind resulting from anticipating and then being disappointed when expectations are not met.”  Truth is, I recognize now I’ve often experienced this, but mistaken it for nostalgia. I t’s not.

So what about you?  On one hand, we do have good reason to be hopeful.  After all, decades of evidence provide overwhelming proof of the effectiveness of psychotherapy.  On the other hand, the same research shows our outcomes have not improved in more than 40 years.

Returning to the positive side, researchers have now identified two specific practices — routine outcome monitoring and deliberate practice — that enable clinicians to accomplish something never before recorded in history the history of the field; namely, steadily improve their effectiveness from year to year.

On the negative side, the field –researchers, clinicians, payers, and policy makers alike — continues to be strongly attracted to treatment models, I’d say fatally so.  Crossing the term, “cognitive behavioral therapy” (CBT) with “randomized controlled trial” (RCT) on Google Scholar results in 1,930,000 hits!  In case you glossed over the figure, that’s one million, nine hundred thirty thousand — and that’s just one method out of hundreds.  By contrast, a similar search of “tetanus vaccine,” produces slightly more than 18,000 results.  I ask, does our field really need to spend precious resources on another study of CBT?  It’s discouraging.  More broadly, given the clear and overwhelming evidence of equivalence between treatment methods for any DSM diagnosis that’s been tested — and yes, that includes so-called trauma-specific approaches — do we need any more RCT’s pitting one protocol against another?  Wouldn’t time be better spent studying how practitioners can improve their ability to attune and respond to their clients?  After all, these two transtheoretical skills, researchers Stiles and Horvath, point out, are why “certain therapists are more effective than others” (p. 71)

For me, I approach each New Year with a strong sense of anticipointment.  I want to be hopeful, believe there are good empirical reasons to do so.  At the same time, I fear little will change.  Turns out, some of our field’s beliefs and practices refuse to die.

What can we do to escape these “walking dead?”

A quick Google search of “Surviving the Zombie Apocalypse” turns up in three clear themes.  First, make sure you are not a zombie.  “The main epidemiological risk of zombies,” says Wikipedia, “is that their population just keeps increasing [as] generations of humans merely ‘surviving’ … feed” them.  In the case of psychotherapy, I’ve come to believe practitioners often know certain popular ideas and practices are dead, but go along with them anyway.  We must say, “no” or risk infecting the next generation.

The second suggestion makes the first possible: don’t go it alone.  In short, you have a better chance of surviving in a group that shares your objectives.  If your professional goals as a therapist include improving your results, the International Center for Clinical Excellence might be your people.  It’s free.

Third, and finally, focus on the basics.  In the case of real zombies, that means securing water, shelter, and food over other, possibly more stimulating interests.  Similarly, for therapists, chasing the “new and promising” must give way to personal work; in particular, deepening core skills associated with effective clinical practice.  If becoming a more effective version of you is of interest, check out an article on the subject published this week.  My colleague Brooke Mathewes and I provide concrete guidance for finding your performance edge and then developing, executing, and evaluating a highly individualized plan for improvement.

“I heard Scott Miller say it,” the man sitting next to me said.

“Really?” I responded, somewhat incredulous.  After all, I didn’t recall ever saying such a thing.  More to the point, it’s just not something I would say.  Its wrong.  Then again, it was clear he didn’t know that I was Scott Miller.  Not wanting to disrupt the presenter before me at the conference, I’d quietly snuck into the room, dressed in my “civies,” shortly after the meeting had started.

“Yep,” he replied, his voice full of certainty, “as I understand it, he says it all the time.”  Making “air” quote marks with his fingers, “If the client is not changing within three visits, you should terminate the treatment.”

You should have seen the look on his face when later our eyes met as I took to the stage to do my presentation.

On many occasions over the years, I’ve heard people quote me saying things I’ve never said.  Here’s a common one:

“Scott Miller says all you need for successful treatment is a good therapeutic relationship.”

Just so you know, I’ve never said this.  Ever. And yet, once, after I corrected a nationally known practitioner in front of a large audience, he nonetheless repeated it in his newsletter.  Here’s what I have said and continue to say:

• All treatment models work equally well.  All.
• Of all the factors affecting outcome, the specific approach used has the smallest impact.  By comparison, the relationship between client and therapist contributes eight to nine times more. 

Another:

“Scott Miller says therapists help 80% of their clients.”

Once again, I’ve never said this.  In this instance, the misquote is more understandable.  Here’s what I do say at almost every workshop:

• Decades of research and hundreds of study document psychotherapy works.
• The effectiveness of psychotherapy has remained fairly stable over the years.
• In most studies, the average treated client is better off than 80% of the untreated comparison sample.

I’m certain it’s the last of these statements that causes problems.  Presented, as it, is in “researchspeak,” it’s easy to misunderstand.  Read it again and you’ll see it does not mean we help 80% of our clients.  Rather, its about the advantage therapy offers relative to receiving no treatment at all.  By contrast, the percentage we help — as I’ve blogged about on numerous occasions — is actually around 50%.

Now, in the interest of fairness, let me mention something I often say but have never heard misquoted.  At nearly of all my workshops, I joke, “The ORS and SRS may not be the best scales ever developed … but they are free!”  The latter part of that statement is absolutely true.  Clinicians wishing to solicit feedback from clients about their progress and the quality of the therapeutic relationship simply need to register for a free paper and pencil license.  That said, recent research out of the University of Nottingham is giving me pause about the other half.

Just last week, I interviewed Professor Sam Malins who, together with a team of others, has been studying the use of the scales in real world clinical settings for a number of years.  In addition to replicating a number of important findings (e.g., the longer you use the ORS and SRS, the more impact they have on retention and effectiveness; spending time gathering information for diagnosis and treatment planning results in poorer outcomes, the scales can be used to identify skill development opportunities), he also found the Outcome Rating Scale predicted …  oh, just watch the video yourself.  That way, I won’t be misquoted!