The date was August 26th, 1910. The place, Leyden, Holland — better known as the “City of Discoveries” owing to its long scientific heritage.

The people present were two giants of Viennese society, composer Gustav Mahler and psychoanalyst, Dr. Sigmund Freud.

By the time of their meeting, the method Freud had pioneered for the alleviation of mental and emotional distress was well-established. Its form was influencing clinicians around the world, best represented by the presence of a couch, free association, and years of contact carried out in frequent, but strict 50-minute “sessions.”

Mahler telegraphed Freud from Munich multiple times requesting help. The situation was dire. Mahler was “impotent,” and his wife, 19 years his junior, was deeply unhappy.

Much of what happened next is lost to history. What is known for certain is that Mahler did travel to Leyden and met with Freud, and that the composer’s sexual functioning was restored following this single meeting.

Bottom line? A great deal of good could be accomplished in a brief period of time and outside of traditional psychotherapy settings. Indeed, Freud did not meet with Mahler in an office. No couch was involved nor sacrosanct time limit. Rather, the two talked while, “strolling about the town—the stocky, confident doctor and the thin, intense composer— smoking the cigars both adored” (Sorel, 1982).

I was reminded of the foregoing story while interviewing Dr. Ed Jones for my blog and YouTube channel. Ed is a psychologist and consultant with an uncanny ability to “see around corners.” Over the years, I’ve learned to pay attention whenever he talks about trends in mental healthcare service delivery. And lately, he’s been focused on the “50-minute hour.”

“Multiple developments — including the rapid increase in the use of digital technology during the pandemic, and integration of behavioral and medical care — are challenging mental health professionals to think and act differently,” he says, then continues, “Instead of relatively circumscribed treatments episodes, delivered across multiple sessions lasting 50 minutes, therapists will need to be helpful on an ongoing, but likely intermittent basis over the course of people’s lives in interactions lasting a handful of minutes.”

Importantly, Ed does not see this development as the end of something, but rather an opportunity to expand the field’s ability to meet with, engage, and help more people in need.

The data are clear: working feedback-informed improves both retention and effectiveness (1). Studies further show FIT achieves these effects, in part, by improving responsiveness to the individual client — particularly those at risk for a negative or null outcome or dropout from treatment (2, 3).

Such positive results notwithstanding, what happens when an outcome measure misleads — when the tool used returns results that are incongruent with the client’s experience?

Consider two recent studies (4). In both, researchers found clients largely agreed when an outcome measure — in this instance, the Outcome Questionnaire 45 — indicated they had improved, but disagreed when it suggested they had worsened. The size of the disconnect was ginormous: 91% saw themselves as benefitting significantly! In such instances, concluding treatment wasn’t helping and opting to terminate or refer, would be the antithesis of responsiveness — which leads me to what I like to call, “my most misunderstood “FIT Tip.”

Early in FIT trainings, therapists learn three ways they can adjust services in the absense of client progress: “Change the ‘what.’ Change the ‘where.’ Change the ‘who.'” Evidence-based guidelines are also provided for when such modifications should be introduced:

1. Little or no progress or deterioration by the third visit? Revisit the goals of treatment, paying particular attention to differences between the services being offered and the client’s stated reason for seeking help.
   
2. Little or no progress or deterioration by the fifth to seventh visit? Consider adding/augmenting services, providers, or participants.
   
3. No improvement or deterioration by the tenth to twelfth? Consider changing the provider, location, or type of services.

Of the three, the third is the most misunderstood. On more than one occasion, for example, I’ve heard therapists say, “According to Scott Miller, if a client isn’t improving by the 10th or 12th visit, treatment should be ended.”

Just to be clear, I have never made such a suggestion. Nor do I believe it. The entire point of FIT is to increase the likelihood of my clients getting what they hope for from their interaction with me. As such, the feedback from standardized measurement tools like the Outcome and Session Rating Scales should be considered starting rather than stopping points, opportunities to lean in and explore, not defer or refer.

I had a chance recently to interview the author of one of the aforementioned studies, Dr. Eric Ghelfi. Not only does he describe the studies in intriguing detail, he offers specific guidance for using the results to enhance responsiveness to the individual client, especially when there’s a disconnect between the tool and the client’s report. The “tips” he offers, I’m certain, will make a difference in your use of FIT.

Books, blogposts, interviews, and “how to” manuals …

Each covers a topic in a particular way. I honestly love them all.

That said, despite the massive amount of information available to practitioners interested in FIT and deliberate practice, certain questions pop up time and again. At some point along the way, I started keeping a list. Some eventually made their way into a book or paper. Others were incorporated into live trainings. A not insignificant number were only addressed in the context of private consultations with agencies and practitioners.

Until now.

Enter “FIT TIPS” — a series of videos aimed answering a specific question. They are brief and to the point, each lasting two minutes or less. You’ll find the first below — a tip I have come to call, “my most frequently given, but ignored advice.”