How difficult could it be? One scale to assess progress, a second to solicit the client’s perception of the therapeutic relationship. Each containing four questions, administration typically takes between 30 to 60 seconds.

Since first being developed 23 years ago, scores of randomized-controlled and naturalistic studies have found the use of simple tools in care significantly improves outcome (1, 2).

And yet, while both simple and effective, research shows integrating the measures into care is far from easy. First came studies documenting that implementing feedback-informed care took time — up to three years for agencies to see results (3). It’s why we developed and have been offering a two-day itensive training on the subject for more than a decade — the only one of its kind. The next one is scheduled for January (click here for more information or to register). We outline the evidence-based steps and help managers, supervisors, team leads and staff develop a plan.

Other studies show while the vast majority of clients have highly favorable reactions to the use of the scales in care, they do have questions. In a recently survey of 13 clients in a private practice setting, Glenn Stone and colleagues (4) reported 70% were surprised at being asked for feedback! More than half found it helpful to see their progress represented graphically from week to week, roughly the same number who felt the scales helped them identify and maintain the right focus in sessions. At the same time, a handful reported feeling confused about the some of the questions; specifically, how to answer an item (e.g., social well being) when it contained multiple descriptors (e.g., school, work and friendship) — each of which could be answered differently.

Such a fantastic question! One we have addressed, among many others, at every three-day, Feedback Informed Treatment Intensive since 2003 (the next one scheduled back-to-back with the Implementation training in January). Seeing the question in this research report made me think I needed to do a “FIT tip” video for those who’ve started using the measures but have yet to attend.

So what is the “best practice” when clients ask how to complete a question which contains multiple descriptors?

Dr. Danilo Moggia is a psychologist and researcher working at the University of Trier in Germany. Over the last several years, he’s been devoted to studying how “machine learning” (ML) can be used to improve the fit and effect of mental health services.

Wikipedia defines ML as, “an area within artificial intelligence which uses data to ‘train’ computers to discover and ‘learn’ rules for solving a task.” According to Dr. Moggia, when it comes to the application of AI to psychotherapy, therapists fall into one of three groups. The first, and fewest in number, are enthusiastic. They love technology, see the possibilities in a self-driving car or future, therapist-less therapy. The second might best be characterized as reluctant. Still viewing AI and ML as more science fiction than science, they fall squarely in the “wait and see” camp. Third, and final, are the philosophically opposed, those who worry about the loss of the human element in psychotherapy.

So, cutting to the chase, can AI/ML help practitioners tailor care to their clients?

That is the question, Dr. Moggio and colleagues address in their chapter, “Do certain people respond better to specific forms of psychotherapy?” published in the 2023 edition of the APA Handbook of Psychotherapy. After reading it, I immediately emailed to see if he’d talk to me, live. The chapter is definately worth a read. We cover most of it and more in the interview below.

As always, interested in your thoughts and reactions!

Until next time,

Scott

Director, International Center for Clinical Excellence

P.S.: The ICCE “Train the Trainer” intensive is fast approaching. All online, this once-every-other-year event focuses on finding and refining your presentation and training skills. Click here for more information or to register.

Type the title of this post into Google and you get 275 million results. Scroll through the pages and you’ll find most are links to the hit song by Ed Sheeran — videos, fan pages, or stories about the 100 million dollar copyright lawsuit filed by the estate of the Ed Townsend, co-writer of Marvin Gaye’s 1970’s R&B classic, “Let’s Get it On.” Apparently, the two songs sound the same. I can’t hear it, but what do I know?

(By the way, this last May, the courts found in Sheeran’s favor)

Long before the music and controversy, the term “thinking out loud” referred to a method used by scientists to understand human behavior. Together with colleagues, psychologist K. Anders Ericsson — the expert on expertise — found that asking people to “think aloud” while they were engaged in a given set of tasks revealed reliable differences between the best, or “top” performers, and others (1).

I used a version of the method when teaching my youngest to drive a few summers ago. He was 18 at the time. Having grown up in a big city with ready access to mass transit, he hadn’t felt the need to get a license at 16. He still wasn’t feeling it when his mother and I forced the issue. He was heading out of state for college. Knowing how to drive, we believed, was an important life skill.

Anyway, “thinking out loud” wasn’t the first way I approached the task. Rather, I gave commands, “slow down,” “turn your blinker on,” “stop following so closely.” And when I wasn’t telling him what to do, I was explaining why he needed to do it — respectively, “the speed limit is …,” “the law says you need to signal 100 feet ahead of a turn,” and “hey, if that car ahead stops abruptly, you’re going to rear end it.” Neither of these strategies proved particularly helpful. Indeed, they only served to heighten tensions.

The proverbial “light in my head” finally turned on when my son responded to yet another of my explanations with, “I know the rule Dad … but how do I do it?”

Important distinction. Not what. Now why. How. As aerospace engineer and science communictor, Destin Sandlin is fond of saying, “knowledge is not understanding.”

The challenge for me — and anyone else that’s been doing a particular activity for a long time — is being able to recall the “how.” At the point I was teaching my son I’d been driving for nearly 5 decades! In truth, most of my behavior beind the wheel was and is done unconsciously. The same is true of getting out of bed, walking downstairs and making coffee in the morning. Little conscious thought is involved. I just do it.

“Automaticity,” as its known among researchers of deliberate practice, is both good and bad. On the plus side, it frees up our limited cognitive resources so we can attend to other, more important matters. The downside, as Anders Ericsson once pointed out, is the loss of conscious control over our actions means, “People … are no longer able to make specific intentional adjustments to them (p. 694, 2).

Take a moment and reread that last sentence.

Bottom line: if you want to improve your performance, you will need to first regain conscious control over your behavior. It’s why, in Better Results: Using Deliberate Practice to Improve Therapeutic Effectiveness, one of the first exercises we recommend is creating a schematic or blueprint for how you do therapy sufficiently detailed so another practitioner could understand and replicate it (see page 29).

Truth be told, however, when the book was released in 2020, feedback about this exercise was swift and negative. Therapists struggled to describe their work. Not what they did or why, but how. Generally, the results were either too vague (e.g., conduct an assessment, listen and be empathic, suggest a “thought log”) or so granular most got lost in the details and gave up.

We modified the exercise considerably, offering additional details and advice in The Field Guide to Better Results: Evidence-based Exercises to Improve Therapeutic Effectiveness released just this year (see pages 18-20). Combined with “thinking out loud,” most are finding the activity much easier to complete.

Returning to teaching my son to drive. In place of explanations and commands, I simply began verbalizing my thoughts, observations, and behaviors in real time as we drove together. To wit:

• The sign indicating a stop ahead is typically 500 feet from the intersection. I’m reducing pressure on the accelerator.
  
• The car in front of me is about 30 feet away. I check the speedometer. My speed 55 mph. I lift my foot from the accelerator now. At 80 feet, I put my foot back on the accelerator. I maintain the same speed.
  
• Distance is closing between me and the car ahead. I look over my left shoulder. I signal. I look over my left shoulder. No car. I maintain my speed. I slowly turn the wheel to the left about 1 inch. Now I check my blinker. Its still on. Next time I should short stroke the signal rod.

The difference was remarkable. Much less tension and, over time, gradual improvement in my son’s driving.

The application to therapy can be just as straightforward. Instead of attempting to create a map from memory, record a couple of sessions. Then, as you listen, talk out loud, stopping the recording to describe your observations, the thoughts you were having at the time, and the behaviors you exhibted as a result.

As described in Better Results and The Field Guide, creating a detailed blueprint will make it easier to target and change the specific aspects of your performance required for improved results. No worries if you’ve not read the books. Links to the two podcasts provide a fairly thorough review!

OK, that’s it for now. Always interested in your comments.

Scott

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

P.S.: We will be applying the principles of deliberate practice at the upcoming “Training of Trainers.” Over three-days, we’ll help you develop and improve your training and presentation skills. Join colleagues from around the world for this once, every-other-year, training event. Click here, or the image below, for more information or to register.