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The Missing Link: Why 80% of People who could benefit will never see a Therapist

March 17, 2017 By scottdm 22 Comments


The facts are startling.  Despite being on the scene for close to 150 years, the field of mental health–and psychotherapy in particular–does not, and never has had mass appeal.  Epidemiological studies consistently show, for example, the majority of people who could benefit from seeing a therapist, do not go.  And nowadays, fewer and fewer are turning to psychotherapy—33% less than did 20 years ago—and a staggering 56% either don’t follow through after making contact or drop out after a single visit with a therapist (Guadiano & Miller, 2012; Marshall, Quinn, & Child, 2016; Swift & Greenberg, 2014).

For those on the front line, conventional wisdom holds, the real problems lie outside the profession.  Insurance companies, in the best of circumstances, make access to and payment for psychotherapy an ordeal.  Another common refrain is nowadays people are looking for a quick fix.  Big Pharma has obliged, using their deep pockets to market “progress in a pill.”  No work required beyond opening wide and swallowing.  And finally, beyond instant gratification or corporate greed, many point to social disapproval or stigma as a continuing barrier to people getting the help they need.

For all that, were psychotherapy held in high regard, widely respected as the way to a better life, people would overcome their hesitancy, put up with any inconvenience, and choose it over any alternative.  They don’t.

WHY?  Mountains of research published over the last four decades document the effectiveness of the “talk therapies.”  With truly stunning results, and a minimal side effect profile compared to drugs, why do most never make it into a therapist’s office?

For the last two years, my longtime colleague, Mark Hubble and I, have explored this question.  We reviewed the research, consulted experts, and interviewed scores of potential consumers.

Our conclusion?  The secular constructions, reductionistic explanations, and pedestrian techniques that so characterize modern clinical practice fall flat, failing to offer people the kinds of experiences, depth of meaning, and sense of connection they want in their lives.

In sum, most choose not to go to psychotherapy because they are busy doing something else–consulting psychics, mediums, and other spiritual advisers–forms of healing that are a better fit with their beliefs, that “sing to their souls.”

Actually, reports show more people attend and pay out of pocket for such services than see mental health practitioners!

More, as I noted in my plenary address at the last Evolution of Psychotherapy conference, our own, large-Consumer Reports style survey, found people actually rated psychics and other “spiritual advisers” more helpful than therapists, physicians and friends.  While certain to cause controversy, I strongly suggested the field could learn from and gain by joining the larger community of healers outside of our field.

Below — thanks to the Erickson Foundation — you can see that speech, as well as learn exactly what people felt these alternative healers provided that made a difference.  An even deeper dive is available in our article, “How Psychotherapy Lost its Magic.”  Thanks to the gracious folks at the Psychotherapy Networker for making it available for all to read, regardless of whether they subscribe to the magazine or not.

Filed Under: Behavioral Health, Dodo Verdict, evidence-based practice, excellence, Feedback Informed Treatment - FIT, Therapeutic Relationship

Would you rather . . . be approved or improved?

February 5, 2017 By scottdm 6 Comments

Some time ago, my son had a minor obsession.  Whether at the dinner table, in the car, or out for a walk, he was constantly peppering us with, “would you rather” questions?  You know the ones I mean, where you are forced to choose between two equally bizarre or unpleasant alternatives?

“Would you rather always have to say everything that is on your mind or never be able to speak again?”

“Would you rather have the hiccoughs the rest of your life or always feel like you have to sneeze but not be able to?”

And finally:

“Would you rather smell like poop and not know it or know you smell like poop but others can’t smell it?”

Fast forward to today.

I was re-reading some recent research on the use of deliberate practice (DP) for improving individual clinician effectiveness.  As I’ve blogged about previously , one of the four crucial components of DP is feedback.  Not just any kind of mind you, but negative feedback–in particular, immediate, ongoing information regarding one’s errors and mistakes.

Put bluntly, receiving negative feedback is hard on the ego.  Despite what we may say or believe, a mountain of literature documents we all possess a strong need for social approval as well as a bias toward attributing positive traits to ourselves.

The same research shows that, beyond selective recall and well-known biases associated with self-assessment, we actively work to limit information that conflicts with how we prefer to see ourselves (e.g., capable versus incompetent, perceptive versus obtuse, intuitive versus plodding, effective versus ineffective, etc.).

As a brief example of just how insidious ours efforts can be, consider an email sent out by the customer service department at a Honda dealership in Richmond, Virginia.

“As you may know,” it began, “we have a wide range of services performed here at our location and strive to do the best we can to accomodate each and everyone of our customers.”   A request for feedback followed, “There may be times we can not meet the needs and we would appreciate any feedback . . . for our company.”

So far so good.  The company was on the way to showing its customers that it cared.  It had sent a follow-up email.  It thanked its customers.  Most importantly, it invited them to provide the type of feedback necessary for improving service in the future.

The correspondence then ended, telling the recipient they would soon receive a survey which, “If you enjoyed or were satisfied with your recent visit and provide a 100% score you will receive a FREE oil change.”

Amazing, eh?  Thanks to my long-time colleague and friend, Arnold Woodruff, for noticing the irony in the email and passing it on to me.

For whatever reason, on reading it, one of those “would you rather” questions immediately came to my mind:

“Would you rather be approved or improved?”

No waffling now.  There is no in-between.  I can hear my son saying, “you have to choose!”

Filed Under: deliberate practice, excellence, Feedback, Feedback Informed Treatment - FIT

“I can’t let others know…”: Shame as a Barrier to Professional Development

January 21, 2017 By scottdm 10 Comments

Shame (noun \ˈshām\): Consciousness of shortcoming, guilt, or impropriety.  

Turns out, for many therapists, this powerful and painful emotion is a significant barrier to professional development.

Doing psychotherapy is challenging in the best of circumstances.  As many as 25% of clients drop out before experiencing a measureable improvement in their functioning.  Of those who do continue, between  40 to 50% will end no different than when they started. And finally, 8 to 10% deteriorate while in care.

Faced with the realities of clinical practice, it’s easy for practitioners to feel they are forever falling short of their own and others hopes and expectations.  Some respond with self-serving resignation: “It’s just not possible to help some people.”  Others, research indicates, deceive themselves, either seeing progress where there is none or overestimating their effectiveness.  Most, it is clear, struggle with the deep sense of responsibility they have assumed for relieving mental and emotional suffering.humility-arrow

As just one example, consider psychologist Tony Rousmaniere.  Early on in his career, Tony started using a couple of simple tools to track the quality and outcome of his work.  The data he gathered shook him to the core, “I was helping far fewer people than I’d thought–50% fewer!”  And while his results were no different than the outcome of most, he recalls instantly thinking, “I can’t let anyone know this!”

“If you want to improve,” Tony says, “You have to embrace the facts. It’s not about humiliation, but rather humility.  Simply put, we are not as effective as we think we are.  Even the most effective among us, fail about a third of the time.  But, in those failures lies the key to success.”

In his book, Deliberate Practice for Therapists, Tony describes, in deeply personal and moving terms, his efforts to become a more effective therapist.  He draws on the latest research on expertise and expert performance, providing a blueprint all clinicians can use to improve and fine-tune their performance via deliberate practice.

Below, you’ll find an interview I did with Tony about his work.

Filed Under: deliberate practice, excellence, Feedback Informed Treatment - FIT

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