Reducing Dropout and Unplanned Terminations in Mental Health Services

May 12, 2021 By scottdm Leave a Comment

Being a mental health professional is a lot like being a parent.

Please read that last statement carefully before drawing any conclusions!

I did not say mental health services are similar to parenting. Rather, despite their best efforts, therapists, like parents, routinely feel they fall short of their hopes and objectives. To be sure, research shows both enjoy their respective roles (1, 2). That said, they frequently are left with the sense that no matter how much they do, its never good enough. A recent poll found, for example 60% parents feel they fail their children in first years of life. And given the relatively high level of turnover on a typical clinician’s caseload — with a worldwide average of 5 to 6 sessions — what is therapy if not a kind of Goundhog Day repetition of being a new parent?

For therapists, such feelings are compounded by the number of clients who, without notice or warning, stop coming to treatment. Besides the obvious impact on productivity and income, the evidence shows such unplanned endings negatively impact clinicians’ self worth, ranking third among the top 25 most stressful client behaviors (3, p. 15).

Recent, large scale meta-analytic studies indicate one in five, or 20% (4) of clients, dropout of care — a figure that is slightly higher for adolescents and children (5). However, when defined as “clients who discontinue unilaterally without experiencing a reliable or clinically significant improvement in the problem that originally led them to seek treatment,” the rate is much higher (6)!

Feeling “not good enough” yet?

By the way, if you are thinking, “that’s not true of my caseload as hardly any of the people I see, dropout” or “my success rate is much higher than the figure just cited,” recall that parent who always acts as though their child is the cutest, smartest or most talented in class. Besides such behavior being unbecoming, it often displays a lack of awareness of the facts.

So, turning to the evidence, data indicate therapists routinely overestimate their effectiveness, with a staggering 96% ranking their outcomes “above average (7)!” And while the same “rose colored glasses” may cause us to underestimate the number of clients who terminate without notice, a more troubling reality may be the relatively large number who don’t dropout despite experiencing no measurable benefit from our work with them– up to 25%, research suggests.

What to do?

As author Alex Dumas once famously observed, “Nothing succeeds like success.” And when it comes addressing dropout, a recent, independent meta-analysis of 58 studies involving nearly 22,000 clients found Feedback-Informed Treatment (FIT) resulted in a 15% reduction in the number people who end psychotherapy without benefit (8). The same study — and another recent one (9) –documented FIT helps therapists respond more effectively to clients most at risk of staying for extended periods of time without benefit.

Will FIT prevent you from ever feeling “not good enough” again? Probably not. But as most parents with grown children say, “looking back, it was worth it.”

OK, that’s it for now,

Scott

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

P.S.: If you are looking for support with your implementation of Feedback-Informed Treatment in your practice or agency, join colleagues from around the world in our upcoming online trainings.
FIT Implementation Intensive 2021 FIT Summer CAFÉ

Do We Learn from Our Clients? Yes, No, Maybe So …

March 2, 2021 By scottdm Leave a Comment

When it comes to professional development, we therapists are remarkably consistent in opinion about what matters. Regardless of experience level, theoretical preference, professional discipline, or gender identity, large, longitudinal studies show “learning from clients” is considered the most important and influential contributor (1, 2). Said another way, we believe clinical experience leads to better, increasingly effective performance in the consulting room.

As difficult as it may be to accept, the evidence shows we are wrong. Confidence, proficiency, even knowledge about clinical practice, may improve with time and experience, but not our outcomes. Indeed, the largest study ever published on the topic — 6500 clients treated by 170 practitioners whose results were tracked for up to 17 years — found the longer therapists were “in practice,” the less effective they became (3)! Importantly, this result remained unchanged even after researchers controlled for several patient, caseload, and therapist-level characteristics known to have an impact effectiveness.

Only two interpretations are possible, neither of them particularly reassuring. Either we are not learning from our clients, or what we claim to be learning doesn’t improve our ability to help them. Just to be clear, the problem is not a lack of will. Therapists, research shows, devote considerable time, effort, and resources to professional development efforts (4). Rather, it appears the way we’ve approached the subject is suspect.

Consider the following provocative, but evidence-based idea. Most of the time, there simply is nothing to learn from a particular client about how to improve our craft. Why? Because so much of what affects the outcome of individual clients at any given moment in care is random — that is, either outside of our direct control or not part of a recurring pattern of therapist errors. Extratherapeutic factors, as influences are termed, contribute a whopping 87% to outcome of treatment (5, 6). Let that sink in.

The temptation to draw connections between our actions and particular therapeutic results is both strong and understandable. We want to improve. To that end, the first step we take — just as we counsel clients — is to examine our own thoughts and actions in an attempt to extract lessons for the future. That’s fine, unless no causal connection exists between what we think and do, and the outcomes that follow … then, we might as well add “rubbing a rabbit’s foot” to our professional development plans.

So, what can we to do? Once more, the answer is as provocative as it is evidence-based. Recognizing the large role randomness plays in the outcome of clinical work, therapists can achieve better results by improving their ability to respond in-the-moment to the individual and their unique and unpredictable set of circumstances. Indeed, uber-researchers Stiles and Horvath note, research indicates, “Certain therapists are more effective than others … because [they are] appropriately responsive … providing each client with a different, individually tailored treatment” (7, p. 71).

What does improving responsiveness look like in real world clinical practice? In a word, “feedback.” A clever study by Jeb Brown and Chris Cazauvielh found, for example, average therapists who were more engaged with the feedback their clients provided — as measured by the number of times they logged into a computerized data gathering program to view their results — in time became more effective than their less engaged peers (8). How much more effective you ask? Close to 30% — not a bad “return on investment” for asking clients to answer a handful of simple questions and then responding to the information they provide!

If you haven’t already done so, click here to access and begin using two, free, standardized tools for gathering feedback from clients. Next, ioin our free, online community to get the support and inspiration you need to act effectively and creatively on the feedback your clients provide — hundreds and hundreds of dedicated therapists working in diverse settings around the world support each other daily on the forum and are available regardless of time zone.

And here’s a bonus. Collecting feedback, in time, provides the very data therapists need to be able to sort random from non-random in their clinical work, to reliably identify when they need to respond and when a true opportunity for learning exists. Have you heard or read anything about “deliberate practice?” Since first introducing the term to the field in our 2007 article, Supershrinks, it’s become a hot topic among researchers and trainers. If you haven’t yet, chances are you will soon be seeing books and videos offering to teach how to use deliberate practice for mastering any number of treatment methods. The promise, of course, is better outcomes. Critically, however, if training is not targeted directly to patterns of action or inaction that reliably impact the effectiveness of your individual clinical performance in negative ways, such efforts will, like clinical experience in general, make little difference.

If you are already using standardized tools to gather feedback from clients, you might be interested in joining me and my colleague Dr. Daryl Chow for upcoming, web-based workshop. Delivered weekly in bite-sized bits, we’ll not only help you use your data to identify your specific learning edge, but work with you to develop an individualized deliberate practice plan. You go at your own pace as access to the course and all training materials are available to you forever. Interested? Click here to read more or sign up.

OK, that’s it for now. Until next time, wishes of health and safety, to you, your colleagues, and family.

Scott

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

“My Mother Made Me Do It”: An Interview with Don Meichenbaum on the Origins of CBT (Plus: Tips for Surviving COVID-19)

May 26, 2020 By scottdm Leave a Comment

Imagine having the distinction of being voted one of the top 10 most influential psychotherapists of the 20th Century.

Psychologist Don Meichenbaum is that person. In his spare time, together with Arron Beck and Marvin Goldfried, he created the most popular and researched method of psychotherapy in use today: cognitive-behavior therapy (CBT).

I got to know Don years ago as we shared a car ride, traveling to and from a training venue while teaching separate, week-long workshops in New England. We laughed. We talked. We debated. Fiercely.

We’ve been friends and colleagues ever since, recreating our car ride discussions in front of large audiences of therapists at each Evolution of Psychotherapy conference since 2005.

As Don approaches his 80th birthday, we look back on the development of CBT — what he thinks he got right and how his thinking has evolved over time. Most trace the roots of CBT to various theorists in the field — Freud, Wolpe, and others. Don is clear: his mother made him do it. That’s right. According to him, CBT got its start with Mrs. Meichenbaum. I know you’ll be amused, but I also believe you’ll be surprised by why and how she contributed.

That said, my interview with Don isn’t merely a retrospective. Still actively involved in the field, he shares important, evidence-based tips about trauma and resilience, applying the latest findings to the psychological and economic impacts of the coronavirus. You’ll find the interview below.

All done for now,

Scott

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

Living with Dying: More Resources in the Era of COVID-19

April 23, 2020 By scottdm 3 Comments

It’s nearly impossible to escape. Turn on the television, open a newspaper, or scroll through the newsfeed of whatever app you use, and the subject is the same: death from COVID-19. And it’s grip on our attention only tightens as the numbers continue to rise.

Two polls document the impact. Over a four week period, the percentage of people identifying the outbreak as a “highly dangerous threat” doubled. I’ve felt it intensely myself, working hard to sort fact from fiction, fears from reality. As one of my favorite science writers, Atuwal Gawande wrote in his timely book, Being Mortal, “Whenever serious sickness … strikes … , the vital questions are the same: What is your understanding of the situation and its potential outcomes? What are your fears and what are your hopes? What are the trade-offs you are willing to make and not willing to make? And what is the course of action that best serves this understanding?”

As I, and many others have pointed out (1, 2), no matter the strategy pursued, the outbreak is going to lead to a tragic accumulation of bodies over the next several months. That said, for most people the risk of dying from COVID-19 remains small (< or = 1%). What might help lessen the worry?

Here are three resources:

My colleague, Dublin-based psychologist Gary Cunningham created a colorful and engaging booklet for helping people manage COVID-19-related anxiety. I interview him in the first video below. He’s graciously agreed to make the pamphlet available for free for personal and professional use to anyone who is interested. Click here to get your copy.
Late last week, I interviewed a physician deeply involved in the care and treatment of people with COVID-19 in my home town, Chicago. It’s the second video below. In it, this front line healthcare professional talks about working in an environment where death and dying are commonplace, addressing the impact on healthcare professionals, and the stark realities patients and families face during these uncertain times. The glimpse he provides into the world of the ICU is both informative and moving. His tips for anyone who faces difficult decisions regarding their health and well being are essential.
Finally, I recently stumbled on the work of Stephen Jenkinson, a Canadian-based social worker and theologian whose book, Die Wise, won the prestigious Nautilus Prize. Of everything I’ve ever read on the subject, this book deals the most directly with the subject of living with dying. It is not a book of psychological advise set in a a series of steps for coping with death. Neither does it offers ways to make dying easier. Rather, like the interview with the author below, it places death at the center of life. “We’re death phobic in the extreme,” the author observes, “Your dying is your life, and your refusal to know that is not life affirming, it’s life betraying.” I found the book and interview compelling, profound, and disturbing, but most of all helpful for addressing what we as a civilization are facing at the moment.

Until next time,

Scott

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

It’s Time to Abandon the “Mean” in Psychotherapy Practice and Research

April 8, 2019 By scottdm 6 Comments

Recognize this? Yours will likely look at bit different. If you drive an expensive car, it may be motorized, with buttons automatically set to your preferences. All, however, serve the same purpose.

Got it?

It’s the lever for adjusting your car seat.

I’m betting you’re not impressed. Believe it or not though, this little device was once considered an amazing innovation — a piece of equipment so disruptive manufacturers balked at producing it, citing “engineering challenges” and fear of cost overruns.

For decades, seats in cars came in a fixed position. You could not move them forward or back. For that matter, the same was the case with seats in the cockpits of airplanes. The result? Many dead drivers and pilots.

The military actually spent loads of time and money during the 1940’s and 50’s looking for the source of the problem. Why, they wondered, were so many planes crashing? Investigators were baffled.

Every detail was checked and rechecked. Electronic and mechanical systems tested out. Pilot training was reviewed and deemed exceptional. Systematic review of accidents ruled out human error. Finally, the equipment was examined. Nothing, it was determined, could not have been more carefully designed — the size and shape of the seat, distance to the controls, even the shape of the helmet, were based on measurements of 140 dimensions of 4,000 pilots (e.g., thumb length, hand size, waist circumference, crotch height, distance from eye to ear, etc.).

It was not until a young lieutenant, Gilbert S. Daniels, intervened that the problem was solved. Turns out, despite of the careful measurements, no pilot fit the average of the various dimensions used to design the cockpit and flight equipment. Indeed, his study found, even when “the average” was defined as the middle 30 percent of the range of values on any given indice, no actual pilot fell within the range!

The conclusion was as obvious as it was radical. Instead of fitting pilot into planes, planes needed to be designed to fit pilots. Voila! The adjustable seat was born.

Now, before you scoff — wisecracking, perhaps, about “military intelligence” being the worst kind of oxymoron — beware. The very same “averagarianism” that gripped leaders and engineers in the armed services is still in full swing today in the field of mental health.

Perhaps the best example is the randomized controlled trial (RCT) — deemed the “gold standard” for identifying “best practices” by professional bodies, research scientists, and governmental regulatory bodies.

However sophisticated the statistical procedures may appear to the non-mathematically inclined, they are nothing more than mean comparisons.

Briefly, participants are recruited and then randomly assigned to one of two groups (e.g., Treatment A or a Control group; Treatment A or Treatment as Usual; and more rarely, Treatment A versus Treatment B). A measure of some kind is administered to everyone in both groups at the beginning and the end of the study. Should the mean response of one group prove statistically greater than the other, that particular treatment is deemed “empirically supported” and recommended for all.

The flaw in this logic is hopefully obvious: no individual fits the average. More, as any researcher will tell you, the variability between individuals within groups is most often greater than variability between groups being compared.

Bottom line: instead of fitting people into treatments, mental health care should be to made to fit the person. Doing so is referred to, in the psychotherapy outcome literature, as responsiveness — that is, “doing the right thing at the right time with the right person.” And while the subject receives far less attention in professional discourse and practice than diagnostic-specific treatment packages, evidence indicates it accounts for why, “certain therapists are more effective than others…” (p. 71, Stiles & Horvath, 2017).

I’m guessing you’ll agree it’s time for the field to make an “adjustment lever” a core standard of therapeutic practice — I’ll bet it’s what you try to do with the people you care for anyway.

Turns out, a method exists that can aid in our efforts to adjust services to the individual client. It involves routinely and formally soliciting feedback from the people we treat. That said, not all feedback is created equal. With a few notable exceptions, all routine outcome monitoring systems (ROM) in use today suffer from the same problem that dogs the rest of the field. In particular, all generate feedback by comparing the individual client to an index of change based on an average of a large sample (e.g., reliable change index, median response of an entire sample).

By contrast, three computerized outcome monitoring systems use cutting edge technology to provide feedback about progress and the quality of the therapeutic alliance unique to the individual client. Together, they represent a small step in providing an evidence-based alternative to the “mean” approaches traditionally used in psychotherapy practice and research.

Interested in your thoughts,

Scott

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

PS: Want to learn more? Join me and colleagues from around the world for any or all three, intensive workshops being offered this August in Chicago, IL (USA).

The FIT Implementation Intensive: the only workshop in the US to provide an in depth training in the evidence-based steps for successful integration of Feedback Informed Treatment (FIT) into your agency or clinical practice.
The Training of Trainers: a 3-day workshop aimed at enhancing your presentation and training skills.
The Deliberate Practice Intensive: a 2-day training on using deliberate practice to improve your clinical effectiveness.

Click on the title of the workshop for more information or to register.

Feedback is NOT Enough: A Brief Update about the Empirical Evidence

September 25, 2018 By scottdm 1 Comment

The use of routine outcome monitoring (ROM) is on the rise. In the United States and abroad, regulatory bodies are actually mandating the gathering of outcome data as the new “standard of care.”

As agencies rush to implement–often at great cost in terms of time and money–the question remains: just how much does ROM contribute to improved retention and effectiveness?

Over 20 years ago, I began using outcome and alliance scales in my work as a therapist, asking clients at each visit to give me feedback about the qaulity of our relationship and their experience of progress. Eventually, together with colleagues, I developed two, brief measures: the Outcome and Session Rating Scales.

When studies using the scales began to appear in the literature, I was immediately concerned. In my opinion, the results were just “too good to be true.” First, the results were confounded by allegiance effects, having been done exclusively by people with a significant investment in the results. More to the point, however, I was worried that the studies focused on the measures rather than on therapists.

Soon, as I predicted, other studies appeared with far more modest results. And now, a meta-analysis of all studies using the ORS and SRS has been published, confirming that routinely measuring performance, improves outcome but not as much as reported in the original studies (viz., .27 versus .50).

For those involved in and advocating FIT (Feedback-Informed Treatment), this is an IMPORTANT study. It makes clear that when working feedback-informed, improving effectiveness requires more than the use of two measures. Indeed, it’s not really about the measures at all. Rather, it’s about therapists using feedback to identify opportunities for their own professional development.

As my colleague and fellow psychologist, Birgit Valla, is fond of saying, “A stopwatch will not make you a better runner. It’s not about the clock. It’s how you use the information to identify small, specific aspects of your performance that could be improved and then practicing.”

That’s what the team at ICCE and I have been exploring these past 7 years. The latest article summarizing that research was published just this week.

All the best,

Scott

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

P.S.: Registration for the Spring Intensives is open. Click on the links below to reserve your spot!

Finding Meaning in Psychotherapy Amidst the Trivia and Trivial

April 1, 2018 By scottdm 11 Comments

I don’t know if you feel the same way I do. Looking back, I’m pretty sure its been going on for a while, but somehow I didn’t notice.

Professional books and journals fill my bookshelves and are stacked around my desk. I am, and always have been, a voracious–even compulsive–reader. In the last couple of years, the volume of material has only increased–exponentially so, if I include digital items saved to my desktop.

Now, I’ll be the first to admit: it’s hard keeping up. But that’s really not my problem.

The issue is: I feel like I’m drowning in trivia and the trivial.

How about you? When was the last time you read something truly meaningful?

Increasingly, research journals are filled with studies that are either so narrow in focus as to defy any real world application, or simply revisit the same questions over and over. Just how many more studies does the field need, for example, on cognitive-behavioral therapy? A Google Scholar search on the subject, crossed with the term, “randomized controlled trial,” returns over a million hits!

In terms of translating research into practice, here’s a sample of articles sure to appeal to almost every clinician (and I didn’t have to “dig deep” to find these, by the way, as all were in journals neatly stacked on my desk):

I didn’t make these up. All are real articles in real research journals. If you don’t believe me, click on the links to see for yourself.

Neologisms (#1) and cuteness (#2) aside, their titles often belie a mind-numbing banality in both scope and findings. Take the last study. Can you guess what its about? Satisfaction with life moderates the indirect effect of pain intensity on pain interference through pain catastrophizing. And what findings do you think the authors spent 10 double-column, 10-point font pages relating in one of psychology’s most prestigious journals?

“Satisfaction with life appears to buffer the effect of pain.”

Hmm. Not particularly earth-shattering. And, based on these results, what do the authors recommend? Of course: “Further evaluation in longitudinal and interventional studies” (I foresee another study on cognitive-behavioral therapy in the near future).

Purpose, belonging, sense-making, transcendence, and growth are the foundations of meaning. Most of what shows up in my inbox, is taught at professionals workshops, and appears in scholarly publications has, or engenders, none of those qualities. The cost to our field and the people we serve is staggering. Worldwide, rates of depression, anxiety, and suicide continue to rise. At the same time, fewer and fewer people are seeking psychotherapy–34% fewer according to the latest findings. It is important to note that even when extensive efforts are made, and significant financial support is provided, 85% of those who could benefit choose not go. I just can’t believe its because therapists haven’t attended the latest “amygdala retraining” workshop, or do not know how to “psychodynamize” their cognitive-behavioral interventions.

This last week, I had the pleasure of interviewing Dr. Ben Caldwell. His book, Saving Psychotherapy: Bringing the Talking Cure Back from the Brink, speaks directly to the challenges facing the field as well as steps every clinician can take to restore meaning to both research and practice. Take listen, and then be sure to leave a comment.

Until next time,

Scott

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

Symptom Reduction or Well-being: What Outcome should Matter Most in Psychotherapy

March 12, 2018 By scottdm 11 Comments

So, what contributes to a living a long, healthy life?

Clean Air? Being lean versus overweight? The absence of depression or anxiety? Exercising regularly? Getting a flu vaccine? Abstaining from smoking? Minimizing alcohol intake? Personal sense of meaning? Close interpersonal relationships? Social integration?

OK, I’ll come clean: all contribute–but not equally. Far from it. Some are more important than others.

So, what contributes most? Before reading on, try rank ordering the list from least to most influential.

Now watch the brief video (If you are one of those that don’t want to try, or can’t wait to know the answer, just scroll past video).

Answer: the items as written are presented in order from the least to most influential, the last three being far more important to living a long and healthy life. Distinct from the other items on the list, personal sense of meaning, close interpersonal relationships, and social integration form the core of “well-being.”

Given such findings, it is more than a bit curious that the field of mental health and majority of its supporting research are organized around reducing symptoms. Perhaps this is one reason why, as psychiatrist Robert Cloninger persuasively argues, the profession has, “failed to improve the average levels of happiness and well-being in the general population, despite vast expenditures on psychotropic drugs and psychotherapy manuals.” Indeed, by all measures, mental health is on the decline.

Could it be that our field has the formula for improving health and well-being backwards? Instead of focusing on reducing problems or eliminating symptoms maybe we should be working directly on improving people’s personal sense of meaning, close interpersonal relationships, and social integration.

The evidence is compelling. In addition to a longer, healthier life, improved well-being leads to:

Faster recovery from illness;
Positive health behaviours in adults and children;
Quicker return to and more preseentism on the job;
Greater wellbeing and mental health of others;
Can inform treatment decisions and reduce healthcare costs;
May ultimately reduce the healthcare burden.

Twenty years ago, my team and I developed a quick, simple-to-use measure of well-being. Numerous studies have shown the Outcome Rating Scale (ORS) to be valid and reliable as well as strongly predictive of psychological intervention. The tool is listed on SAMHSA’s National Registry of Evidence-based Programs and Practices , is available in 30 languages, and in wide use in countries around the world. Best of all: individual practitioners can download and begin using the tool for free.

Most exciting of all, use of the tool is serving as the impetus for many new innovations in mental health service delivery. I just spent a week with teams from Slagelse municipality in Denmark who are now using the data generated from routine use of the ORS to transform service delivery at every level. My Scandinavian co-teacher, psychologist Susanne Bargmann will be talking about these new and exciting developments at this summer’s FIT Implementation and Training of Trainers workshops. Is it any wonder that Denmark consistently LEADS the world in well-being?

Until next time,

Scott

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

Ho, Ho, Oh No! Science, politics, and the demise of the National Registry of Evidence-based Programs and Practices

February 7, 2018 By scottdm 13 Comments

While you were celebrating the Holidays–shopping and spending time with family–government officials were busy at work. On December 28th, the Substance Abuse and Mental Health Services (SAMHSA) sent a formal termination notice to the National Registry of Evidence-based Programs and Practices (NREPP).

Ho, ho, oh no…!

Briefly, NREPP is “an evidence-based repository and review system designed to provide the public with reliable information on mental health and substance use interventions.” In plain English, it’s a government website listing treatment approaches that have scientific support. SAMHSA is the Federal Agency overseeing behavior health policy.

Back in November, I’d responded to a request from NREPP to update research on the Outcome and Session Rating Scales, two routine outcome measures currently listed on the registry website site. All’s well until January 4th, when I received a short email stating that “no further review activities will occur” because the program was being ended “for the convenience of the government.”

Like much that comes from our Nation’s capitol, the reason given for the actions taken depends entirely on who you ask. Democrats are blaming Trump. Republicans, and the new SAMHSA director, blame the system, calling the registry not only flawed, but potentially dangerous. As is typical nowadays, everyone is outraged!

As someone whose work was vetted by NREPP, I can personally vouch for the thoroughness of the process and the integrity of the reviewers. No favors were sought and none were given. More, while no one knows exactly what will happen in the future, I sincerely believe officials leading the change have the best of intentions. What I am much less certain of is whether science will finally prevail in communicating “what works” in mental health and substance abuse to the public.

Bottom line: psychological approaches for alleviating human suffering are remarkably effective–on par or better than most medical treatments. That said, NONE work like a medicine.

You have a bacterial infection, antibiotics are the solution. A virus? Well, you are just going to have to tough it out. Take an aspirin and get some rest–and no, the brand you choose doesn’t really matter. Ask a friend or relative, and they likely have a favorite. The truth is, however, it doesn’t matter which one you take: Bayer, Econtin, Bufferin, Alka-Selzter, Anacin, a hundred other names, they’re all the same!

Four decades of research shows psychotherapy works much more like aspirin than an antibiotic. Despite claims, its effects are not targeted nor specific to particular diagnoses. Ask a friend, relative, your therapist or workshop presenter, and they all have their favorite: CBT, IPT, DBT, PD, TFT, CRT, EMDR, four-hundred additional names. And yet, meta-analytic studies of head-to-head comparisons find no meaningful difference in outcome between approaches.

What does all this mean for the future of NREPP and SAMHSA? The evidence makes clear that, when it comes to psychotherapy, any “list” of socially sanctioned approaches is not only unscientific, but seriously misleading. Would it be too much to hope that future governmental efforts stop offering a marketplace for manufacturers of different brands of aspirin and focus instead on fostering evidence-based practice (EBP)?

Really, it’s not a bridge too far. It merely means putting policies in place that help practitioners and agencies live up to the values inherent in the definition of EBP accepted by all professional organizations and regulatory bodies; namely, “the integration of the best available research with with clinical expertise in the context of patient characteristics, culture, and preferences” (pp. 273, APA, 2006).

Until next time,

Scott

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

P.S.: Every other year, the ICCE sponsors the “Training of Trainers” intensive. Over three days, we focus on helping you become a world class presenter and trainer. Join me, and colleagues from around the world for this transformational event.

Better Results through Deliberate Practice

January 16, 2018 By scottdm Leave a Comment

The legendary cellist Pablo Casals was once interviewed by comedian George Carlin. When asked why, at age 93, he continued to practice three hours a day, Casals replied, “I’m beginning to show some improvement!”

Hard not to feel inspired and humbled by such dedication, eh? And while humorous, Casals was not joking. Across a wide variety of domains (e.g., sports, computer programming, teaching), deliberate practice leads to better results. Indeed, our recent study of mental health practitioners documented a growth in effectiveness consistent with performance improvements obtained by elite atheletes.

The January issue of the APA monitor includes a detailed article on the subject. Staff writer Tori DeAngelis lays out the process of applying deliberate practice strategies to clinical work in clear, step-by-step terms. Best of all, it’s free–even continuing education credits are available if you need them.

As mentioned in the article, each summer the International Center for Clincal Excellence sponsors a two-day, intensive training on deliberate practice for therapists. Daryl Chow, Ph.D. and I will be teaching together, presenting the latest scientific and practical information from our forthcoming book, Better Results: Using Deliberate Practice to Improve Therapeutic Effectiveness (APA, 2019).

As in prior years, we promise you will be participating in an intimate, cutting-edge, and highly-personalized learning experience. Many practitioners return to year after year. “I’ve attended the Deliberate Practice Intensive for three years in a row,” says therapist Jim Reynolds, “because there is such a warm camraderie. We are all trying to do the best we can with our clients, but we go beyond that. To do that, I need contact with others who are striving to do better.”

Until next time,

Scott

Scott D. Miller, Ph.D.

That’s it. I’m done. It’s time for me to say goodbye.

November 2, 2017 By scottdm 3 Comments

Ending psychotherapy.

Whether formal or informal, planned or unplanned, it’s going to happen every time treatment is initiated.

What do we know about the subject?

Nearly 50% of people who start, discontinue without warning. At the time they end, half have experienced no meaningful improvement in their functioning or well-being. On the other hand, of those who do continue, between 35-40% experience no measurable benefit despite continuous engagement in lengthy episodes of care.

Such findings remind me of the lyrics to the Beatles’ tune, “Hello Goodbye.”

“You say yes, I say no;

You say stop and I say go, go, go, oh no!

Hello, hello?

I don’t know why you say goodbye, I say hello.”

Here’s another key research finding: the most effective therapists have significantly more planned terminations.

In a recent study, Norcross, Zimmerman, Greenberg, and Swift identified eight core, pantheoretical processes associated with successful termination. You can read the article here. Better yet, download and begin using the “termination checklist”–a simple, yet helpful method for ensuring you are putting these evidence-based principles to work with your clients. Best of all, listen to my recent interview with John Norcross, Ph.D., the study’s first author, as we discuss how therapists can master this vitally important part of the therapeutic experience.

Until next time,

Scott

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

Something BIG is Happening: The Demand for Routine Outcome Measurement from Funders

October 16, 2017 By scottdm 2 Comments

Something is happening. Something big.

Downloads of the Outcome and Session Rating Scales have skyrocketed.

The number of emails I receive has been steadily increasing.

The subject? Routine outcome measurement. The questions:

Where can I get copies of your measures?

Paper and pencil versions are available on my website.

What is the cost?

Individual practitioners can access the tools for free. Group licenses are available for agencies and healthcare systems.

Can we incorporate the tools into our electronic healthcare record (E.H.R.)?

Three companies are licensed and authorized to provide an “Application Program Interface” (or API) for integrating the ORS, SRS, data aggregation formulas, and feedback signals directly into your E.H.R. Detailed information and contact forms are available in a special page on my website.

What evidence is available for the validity, reliability, and effectiveness of the measures?

Always a good question! Since the tools were published seventeen years ago, studies have multiplied. Keeping up with the data can be challenging as the tools are being used in different settings and with diverse clinical populations around the world.

Each year, together with my colleague, New Zealand psychologist, Eeuwe Schuckard, we add the latest research to a comprehensive document available for free online, titled “Measures and Feedback.”

Additionally, the tools have been vetted by an independent group of research scientists and are listed on the Substance Abuse and Mental Health Administration’s National Registry of Evidence-based Programs and Practices.

How can I (or my agency) get started?

Although it may sound simple and straightforward, this is the hardest question to answer. There is often a tone of urgency in the emails I receive, “We need to measure outcomes now,” they say.

I nearly always respond with the same advice: the fastest way to succeed is to go slow.

We’ve learned a great deal about implementation over the last 10 years. Getting practitioners to administer outcome measures is easy. I can teach them how in less than three minutes. Making the process more than just another, dreary “administrative task” takes time, patience, and persistence.

I caution against purchasing licenses, software, or onsite training. Instead, I recommend taking time to explore. It’s why the reviewers at SAMHSA gave our application for evidence-based status the highest ratings on “implementation support.”

To succeed, start with:

Accessing a set of the ICCE Feedback Informed Treatment Manuals–the single, most comprehensive resource available on using the ORS and SRS. Read and discuss them together with colleagues.
Connect with practitioners and agencies around the world who have already implemented. It’s easy. Join the International Center for Clinical Excellence–the world’s largest online community dedicated to routine outcome measurement.
Send a few key staff–managers, supervisors, implementation team leaders–to the Feedback-Informed Treatment Intensives. The Advanced and Supervision workshops are held back-to-back each March in Chicago. Participants not only leave with a thorough understanding of the ORS and SRS, but ready to kick off a successful implementation at home. I tell people to sign up early as the courses are limited to 35 participants and always sell out a couple of months in advance.

Feel free to email me with any questions.

Until next time,

Scott

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

More Deliberate Practice Resources…

May 30, 2017 By scottdm 1 Comment

Last week, I blogged about a free, online resource aimed at helping therapists improve their outcomes via deliberate practice. As the web-based system was doubling as a randomized controlled trial (RCT), participants would not only be accessing a cutting-edge, evidence-based protocol but also contributing to the field’s growing knowledge in this area.

To say interest was high, doesn’t even come close. Within 45 minutes of the first social media blast, every available spot was filled–including those on the waiting list! Lead researchers Daryl Chow and Sharon Lu managed to open a few additional spots, and yet demand still far exceeded supply.

I soon started getting emails. Their content was strikingly similar–like the one I received from Kathy Hardie-Williams, an MFT from Forest Grove, Oregon, “I’m interested in deliberate practice! Are there other materials, measures, tools that I can access and start using in my practice?”

The answer is, “YES!” Here they are:

Resource #1. Written for practicing therapists, supervisors, and supervisees, this volume brings together leading researchers and supervisors to teach practical methods for using deliberate practice to improve the effectiveness of psychotherapy.

Written for practicing therapists, supervisors, and supervisees, this volume brings together leading researchers and supervisors to teach practical methods for using deliberate practice to improve the effectiveness of psychotherapy.

Twelve chapters split into four sections covering: (1) the science of expertise and professional development; (2) practical, evidence-based methods for tracking individual performance; (3) step-by-step applications for integrating deliberate practice into clinical practice and supervision; and (4) recommendations for making psychotherapist expertise development routine and expected.

“This book offers a challenge and a roadmap for addressing a fundamental issue in mental health: How can therapists improve and become experts? Our goal,” the editors of this new volume state, ” is to bring the science of expertise to the field of mental health. We do this by proposing a model for using the ‘Cycle of Excellence’ throughout therapists’ careers, from supervised training to independent practice.”

The book is due out June 1st. Order today by clicking here: The Cycle of Excellence: Using Deliberate Practice to Improve Supervision and Training

Resource #2: The MyOutcomes E-Learning Platform

The folks at MyOutcomes have just added a new module on deliberate practice to their already extensive e-learning platform. The information is cutting edge, and the production values simply fantastic. More, MyOutcomes is offering free access to the system for the first 25 people who email to support@myoutcomes.com. Put the words, “Responding to Scott’s Blogpost” in the subject line. Meanwhile, here’s a taste of the course:

Resource #3:

Last but not least, the FIT Professional Development Intensive. There simply is no better way to learn about deliberate practice than to attend the upcoming intensive in Chicago. It’s the only such training available. Together with my colleague, Tony Rousmaniere–author of the new book, Deliberate Practice for Psychotherapists: A Guide to Improving Clinical Effectiveness, we will help you develop an individualized plan for improving your effectiveness based on the latest scientific evidence on expert performance.

We’ve got a few spaces left. Those already registered are coming from spots all around globe, so you’ll be in good company. Click here to register today!

OK, that’s it for now. Wishing you all the best for the Summer,

Scott D. Miller, Ph.D.

The Illness and the Cure: Two Free, Evidence-based Resources for What Ails and Can Heal Serious Psychological Distress

April 18, 2017 By scottdm 14 Comments

Findings from several recent studies are sobering. Depression is now the leading cause of ill-health and disability worldwide–more than cancer, heart disease, respiratory problems, and accidents. Yesterday, researchers reported that serious psychological distress is at an all-time high, significantly affecting not only quality but actual life expectancy. And who has not heard about the opioid crisis–33,000 deaths in the U.S. in 2015 and rising?

The research is clear: psychotherapy helps. Indeed, its effectiveness is on par with coronary artery bypass surgery. Despite such results, availability of mental health services in the U.S. and other Westernized nations has seriously eroded over the last decade. Additionally, modern clinical practice is beset by regulation and paperwork, much of which gets in the way of treatment’s most important healing ingredient: the relationship.

What can practitioners do? Students Taking Notes at Desks by VCU_Brandcenter

Completing paperwork together with clients during the visit–a process termed, “collaborative (or concurrent) documentation”–has been shown to save full-time practitioners between 6 and 8 hours per week, thereby improving capacity up to 20%.

It’s a great idea: completing assessments, treatment plans, and progress notes together with clients during rather than after the session. Unfortunately, it’s chief selling point to date seems to be that it saves time on documentation–as though filling out paperwork is an end in and of itself! Clearly, the real challenges facing mental health services are getting people into and keeping them in care. Here, the research literature is clear, people are more likely to stay engaged in care that is: (1) organized around their goals; and (2) works. Collaborating on and coming to a consensus regarding the goals for treatment, for example, has the largest impact on outcome among all of the relationship factors in psychotherapy, including empathy! Additionally, when documentation FITs the clients’ view of the process and is deemed transparent and respectful, trust–another essential ingredient of the therapeutic relationship–improves.

For the last several years, practitioners and agencies around the world have been using the ICCE “Service Delivery Agreement” and “Progress Note” as part of their documentation of clinical services. Both were specifically designed to be completed collaboratively with clients at the time the service is provided and both are focused on documenting what matters to people in treatment. Most important of all, however, both are part of an evidence-based process documented to improve engagement and effectiveness listed on SAMHSA’s National Registry of Evidence-based Programs and Practices.

For the next short while, I’ll send you the forms for free, along with a detailed instruction booklet for incorporating them into your clinical work. Reduce the “paper curtain” in your practice. Just email me at scottdmiller@talkingcure.com. Better yet, register for our upcoming intensive trainings this summer in Chicago. Click on any of the course icons to the right for detailed information.

Until next time,

Scott

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

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 cho tarot ose 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.

Until next time,

Scott

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

Why aren’t therapists talking about this?

June 20, 2016 By scottdm 8 Comments

Turns out, every year, for the last several years, and right around this time, I’ve done a post on the subject of deterioration in psychotherapy. In June 2014, I was responding to yet another attention-grabbing story published in The Guardian, one of the U.K.’s largest daily newspapers. “Misjudged counselling and therapy can be harmful,” the headline boldly asserted, citing results from “a major new analysis of outcomes.” The article was long on warnings to the public, but short on details about the study. In fact, there wasn’t anything about the size, scope, or design. Emails to the researchers were never answered. As of today, no results have appeared in print.

One year later, I was at it again—this time after seeing the biopic Love & Mercy, a film about the relationship LOVE-MERCY-POSTER-1308x1940 between psychologist Eugene Landy and his famous client, Beach Boy Brian Wilson. In a word, it was disturbing. The psychologist did “24-hour-a-day” therapy, as he termed it, living full time with the singer-songwriter, keeping Wilson isolated from family and friends, and on a steady dose of psychotropic drugs while simultaneously taking ownership of Wilson’s songs, and charging $430,000 in fees annually. Eventually, the State of California intervened, forcing the psychologist to surrender his license to practice. As egregious as the behavior of this practitioner was, the problem of deterioration in psychotherapy goes beyond the field’s “bad apples.”

Do some people in therapy get worse? The answer is, most assuredly, “Yes.” Research dating back several decades puts the figure at about 10% (Lambert, 2010). Said another way, at termination, roughly one out of ten people are functioning more poorly than they were at the beginning of treatment. Despite claims to the contrary (e.g., Lilenfeld, 2007), no psychotherapy approach tested in a clinical trial has ever been shown to reliably lead to or increase the chances of deterioration. NONE. Scary stories about dangerous psychological treatments are limited to a handful of fringe therapies–approaches that have been never vetted scientifically and which all practitioners, but a few, avoid.

So, what is the chief cause of deterioration in treatment? norw-MMAP-md Norwegian psychologist Jørgen A. Flor just completed a study on the subject. We’ve been corresponding for a number of year as he worked on the project. Given the limited information available, I was interested.

What he found may surprise you. Watch the video or click here to read his entire report (in Norwegian). Be sure and leave a comment!

Until next time,

Scott

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

NERD ALERT: Determining IF, WHAT, and HOW Psychotherapy Works

May 5, 2016 By scottdm 12 Comments

OK, this post may not be for everyone. I’m hoping to “go beyond the headlines,” “dig deep,” and cover a subject essential to research on the effectiveness of psychotherapy. So, if you fit point #2 in the definition above, read on.

It’s easy to forget the revolution that took place in the field of psychotherapy a mere 40 years ago. At that time, the efficacy of psychotherapy was in serious question. As I posted last week, psychologist Hans Eysenck (1952, 1961, 1966) had published a review of studies purporting to show that psychotherapy was not only ineffective, but potentially harmful. Proponents of psychotherapy responded with the own reviews (c.f., Bergin, 1971). Back and forth each side went, arguing their respective positions–that is, until Mary Lee Smith and Gene Glass (19
77) published the first meta-analysis of psychotherapy outcome studies.

Their original analysis of 375 studies showed psychotherapy to be remarkably beneficial. As I’ve said here, and frequently on my blog, they found that the average treated client was better off than 80% of people with similar problems were untreated.

Eysenck and other critics (1978, 1984; Rachman and Wilson 1980) immediately complained about the use of meta-analysis, using an argument still popular today; namely, that by including studies of varying (read: poor) quality, Smith and Glass OVERESTIMATED the effectiveness of psychotherapy. Were such studies excluded, they contended, the results would most certainly be different and behavior therapy—Eysenck’s preferred method—would once again prove superior.

For Smith and Glass, such claims were not a matter of polemics, but rather empirical questions serious scientists could test—with meta-analysis, of course.

So, what did they do? Smith and Glass rated the quality of all outcome studies with specific criteria and multiple raters. And what did they find? The better and more tightly controlled studies were, the more effective psychotherapy proved to be. Studies of low, medium, and high internal validity, for example, had effect sizes of .78, .78, and .88, respectively. Other meta-analyses followed, using slightly different samples, with similar results: the tighter the study, the more effective psychotherapy proved to be.

Importantly, the figures reported by Smith and Glass have stood the test of time. Indeed, the most recent meta-analyses provide estimates of the effectiveness of psychotherapy that are nearly identical to those generated in Smith and Glass’s original study. More, use of their pioneering method has exploded, becoming THE standard method for aggregating and understanding results from studies in education, psychology, and medicine.

sheldon kopp

As psychologist Sheldon Kopp (1973) was fond of saying, “All solutions breed new problems.” Over the last two decades the number of meta-analyses of psychotherapy research has exploded. In fact, there are now more meta-analyses than there were studies of psychotherapy at the time of Smith and Glass’s original research. The result is that it’s become exceedingly challenging to understand and integrate information generated by such studies into a larger gestalt about the effectiveness of psychotherapy.

Last week, for example, I posted results from the original Smith and Glass study on Facebook and Twitter—in particular, their finding that better controlled studies resulted in higher effect sizes. Immediately, a colleague responded, citing a new meta-analysis, “Usually, it’s the other way around…” and “More contemporary studies find that better methodology is associated with lower effect sizes.”

It’s a good idea to read this study, closely. If you just read the “headline”–“The Effect of Psychotherapy for Adult Depression are Overestimated–or skip the method’s section and read the author’s conclusions, you might be tempted to conclude that better designed studies produce smaller effects (in this particular study, in the case of depression). In fact, what the study actually says is that better designed studies will find smaller differences when a manualized therapy is compared to a credible alternative! Said another way, differences between a particular psychotherapy approach and an alternative (e.g., counseling, usual care, or placebo), are likely to be greater when the study is of poor quality.

What can we conclude? Just because a study is more recent, does not mean it’s better, or more informative. The important question one must consider is, “What is being compared?” For the most part, Smith and Glass analyzed studies in which psychotherapy was compared to no treatment. The study cited by my colleague, demonstrates what I, and others (e.g., Wampold, Imel, Lambert, Norcross, etc.) have long argued: few if any differences will be found between approaches.

The implications for research and practice are clear. For therapists, find an approach that fits you and benefits your clients. Make sure it works by routinely seeking feedback from those you serve. For researchers, stop wasting time and precious resources on clinical trials. Such studies, as Wampold and Imel so eloquently put it, “seemed not to have added much clinically or scientifically (other than to further reinforce the conclusion that there are no differences between treatments), [and come] at a cost…” (p. 268).

Until next time,

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

Improving the Odds: Implementing FIT in Care for Problem Gamblers and their Families

April 17, 2016 By scottdm 1 Comment

Quick Healthcare Quiz

What problem in the U.S. costs the government approximately $274 per adult annually?

If you guessed gambling, give yourself one point. According to the latest research, nearly 6 million Americans have a serious gaming problem—a number that is on the rise. One-third of the Nation’s adults visit a Casino every year, losing according to the latest figures an estimated 100 billion dollars.

Which problem is more common? Substance abuse or problem gambling?

If you guessed the former, give yourself another point. Problems related to alcohol and drug use are about 3.5 times more common than gambling. At the same time, 281 times more funding is devoted to treating drug and alcohol problems. In March 2014, the National Council on Problem Gambling reported that government-funded treatment was provided to less than one quarter of one percent of those in need.

Does psychotherapy work for problem gambling?

If you answered “yes,” add one to your score. Research not only indicates that psychological treatment approaches are effective, but that changes are maintained at follow up. As with other presenting problems (e.g., anxiety and depression), more therapy is associated with better outcomes than less.

What is the key to successful treatment of problem gambling?

If you answered, “funding and getting people into treatment,” or some variation thereof, take away three points!

So, how many points do you have left? If you are at or near zero, join the club.

Healthcare is obsessed with treatment. A staggering 99% of resources are invested in interventions. Said another way, practitioners and healthcare systems love solutions. The problem is that research shows this investment, “does not result in positive implementation outcomes (changes in practitioner behavior) or intervention outcomes (benefits to consumers).” Simply put, it’s not enough to know “what works.” You have to be able to put “what works” to work.

Enter the BC Responsible and Problem Gambling Program—an agency that provides free support and treatment services aimed at reducing and preventing the harmful impacts of excessive or uncontrolled gaming. Clinicians working for the program not only sought to provide cutting-edge services, they wanted to know if they were effective and what they could do to continuously improve.

Five years ago, the organization adopted feedback-informed treatment (FIT)—routinely and formally seeking feedback from clients regarding the quality and outcome of services offered. A host of studies documents that FIT improves retention in and outcome of psychotherapy. Like all good ideas, however, the challenge of FIT is implementation.

Last week, I interviewed Michael Koo, the clinical coordinator of the BCRPGP. Listen in as he discusses the principles and challenges of their successful implementation. Learn also how the talented and devoted crew achieve outcomes on par with randomized controlled trials in an average of 7 visits while working with a culturally and clinically diverse clientele.

As you’ll hear, implementation is difficult, but doable. More, you don’t have to reinvent the wheel or do it alone. When FIT was reviewed and deemed “evidence-based” by the Substance Abuse and Mental Health Services organization in 2013, it received perfect scores for “implementation, training, support, and quality assurance” resources. Regardless of the population you serve, you can:

Join a free, online, international community of nearly 10,000 like-minded professionals using FIT in diverse settings (www.iccexcellence.com). Every day, members connect and share their knowledge and experience with each other;
Access a series of “how to” manuals and free, gap assessment tool (FRIFM) to aid in planning, guiding progress, and identifying common blind spots in implementation.
Attend the upcoming, 2-day FIT Implementation workshop. Held once a year in August, this event provides an in-depth, evidence-based training based on the latest findings from the field of implementation science.

Come meet managers, supervisors, practitioners, and team leaders from around the world. You will leave the tools necessary to “put ‘what works’ to work.”

FIT IMP 2016
Until next time,

Scott

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

Are you Better? Improving Effectiveness One Therapist at a Time

January 24, 2016 By scottdm 3 Comments

Greetings from snowy Sweden. I’m in the beautiful city of Gothenburg this week, working with therapists and administrators on implementing Feedback-Informed Treatment (FIT).

I’m always impressed by the dedication of those who attend the intensive workshops. More, I feel responsible for providing a training that not only results in mastery of the material, but also leads to better outcomes.

As commonsensical as it may seem to expect that training should foster better results, it’s not. Consider a recent study out of the United Kingdom. There, massive amounts of money have been spent over the last five years training clinicians to use cognitive behavioral therapy (CBT). The expenditure is part of a well-intentioned government program aimed at improving access to effective mental health services.

Anyway, in the study, clinicians participated in a year-long “high-intensity” course that included more than 300 hours of training, supervision, and practice—a tremendous investment of time, money, and resources. Competency in delivering CBT was assessed at regular intervals and shown to improve significantly throughout the training.

The only problem? Training therapists in CBT did not result in better outcomes.

While one might hope such findings would cause the researchers to rethink the training program, they chose instead to question whether “patient outcome should … be used as a metric of competence…” (p. 27). Said another way, doing treatment the right way was more important than whether it actually worked! One is left to wonder whether the researchers would have reached a similar conclusion had the study gone the other way. Most certainly, the headline would then have been, “Empirical Research Establishes Connection between Competence in CBT and Treatment Outcome!”

Attempts to improve the effectiveness of treatment via the creation of a psychological formulary—official lists of specific treatments for specific disorders—have persisted, and even intensified, despite consistent evidence that the methods clinicians use contribute little to outcome. Indeed, neither clinicians’ competence in conducting specific types of therapy nor adherence to evidence-based protocols have been “found to be related to patient outcome and indeed . . . estimates of their effects [are] very close to zero” (p. 207, Webb, DeRubeis, & Barber, 2010).

So, what gives?

There are two reasons why such efforts have failed:

First, they do not focus on helping therapists develop the skills that account for the lion’s share of variability in treatment outcome.

Empathy, for example, has a greater impact than the combined effect sizes of therapist competence, adherence to protocol, specific ingredients within and differences between various treatment approaches. Still, most, like the present study, continue to focus on method.

Second, they ignore the extensive scientific literature on expertise and expert performance.

Here, research has identified a universal set of processes, and step-by-step directions, anyone can follow to improve performance within a particular discipline. To improve, training must be highly individualized, focused on helping performers reach for objectives just beyond their current ability.

“Deliberate Practice,” as it has been termed, requires grit and determination. “Nobody is allowed to stagnate,” said one clinician when asked to describe what it was like to work at a clinic that had implemented the steps, adding, “Nobody is allowed to stay put in their comfort zone.” The therapist works at Stangehjelpa, a community mental health service located an hour north of Oslo, Norway.

The director of the agency is psychologist, Birgit Valla (left), author of visionary book, Further: How Mental Services Can Be Better. Birgit is on a mission to improve outcomes—not by dictating the methods staff are allowed to use but by focusing on their individual development.

It starts with measuring outcomes. All therapists at Stangehjelpa know exactly how effective they are and, more importantly, when they are not helpful. “It’s not about the measures,” Birgit is quick to point out, “It´s about the therapist, and how the service can support that therapist getting better.” She continues, “It´s like if you want improve your time in the 100 meter race, you need a stopwatch. It would be absurd to think, however, that the stopwatch is responsible for running faster. Rather, it’s how one chooses to practice in relation to the results.”

Recently, researcher Siri Vikrem Austdal interviewed staff members at the clinic about their experience applying deliberate practice in their work. Says one, ““It is strenuous. You are expected to deliver all the time. But being part of a team that dare to have new thoughts, and that wants something, is really exciting. I need it, or I would grow tired. It is demanding, but then there is that feeling we experience when we have climbed a mountain top. Then it is all worthwhile. It is incredibly fun to make new discoveries and experience mastery.”

So, what exactly are they doing at Stangehjelp?

You can read the entire report here (Norwegian), or the abbreviated version here (English). Why not join Birgit this summer at the FIT Professional Development training in Chicago, Illinois. Together with Dr. Daryl Chow, we will teach participants how to incorporate deliberate practice into an individualized, evidence-based plan for continuous professional development. Click on the icon below to reserve your spot now.

Until next time,

Scott

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

The Benefits of Doubt: New Research Sheds Light on Becoming a More Effective Therapist

December 9, 2015 By scottdm 6 Comments

These are exciting times for clinicians. The pieces of the puzzle are falling into place. Researchers are finally beginning to understand what it takes to improve the effectiveness of psychotherapy. Shifting away from the failed, decades-long focus on methods and diagnosis, attention has now turned to the individual practitioner.

Such efforts have already shown a host of factors to be largely ineffective in promoting therapist growth and development, including:

Supervision;
Continuing education;
Therapist personal therapy;
Clinical experience; and
Access to feedback

In October, I blogged about the largest, longitudinal study of therapists ever conducted. Despite having access to ongoing, formal feedback from their clients for as long as 17 years, clinicians in the study not only did not improve, their outcomes actually deteriorated, on average, year after year.

Such findings contrast sharply with beliefs of practitioners who, according to other studies, see themselves as improving with time and experience. In fact, findings on all the practices noted above contrast sharply with beliefs commonly-held in the field:

Supervision is at the top of the list of experiences therapists cite as central to their growth and development as practitioners. By contrast, the latest review of the literature concludes, “We do not seem to be any more able to say now (as opposed to 30 years ago) that psychotherapy supervision contributes to patient outcome” (p. 235, Watkins 2011).

Although most clinicians value participating in continuing education activities—and licensure requirements mandate attendance—there is no evidence such events engender learning, competence, or improved outcomes. Neither do they appear to decrease disciplinary actions, ethical infractions, or inspire confidence on the part of therapy consumers.

Therapist personal therapy is ranked as one of the most important sources of professional development despite there being no evidence it contributes to better performance as a clinician and some studies documenting a negative impact on outcome (see Orlinsky & Ronnestad, 2005);

If any of the research I’ve cited surprises you, or gives you pause, there is hope! Really. Read on.

Doubt, it turns out, is a good thing–a quality possessed by the fields’ most effective practitioners. Possessing it is one of the clues to continuous professional development. Indeed, several studies now confirm that “healthy self-criticism,” or professional self-doubt (PSD), is a strong predictor of both alliance and outcome in psychotherapy (2015).

To be sure, I’m not talking about assuming a “not-knowing” stance in therapeutic interactions. Although much has been written about having a “beginner’s mind,” research by Nissen-Lie and others makes clear that nothing can be gained by either our feigned or willful ignorance.

Rather, the issue is about taking the time to reflect on our work. Doing so on a routine basis prevents us from falling prey to the “over-claiming error”—a type of confidence that comes from the feeling we’ve seen something before when, in fact, we h not listening ave not.

The “over-claiming error” is subtle, unconscious, and fantastically easy to succumb to and elicit. In a very clever series of experiments, for example, researchers asked people a series of questions designed either to engender a feeling of knowledge and expertise or ignorance. Being made to feel more knowledgeable, in turn, lead people to act less open-mindedly and feel justified in being dogmatic. Most importantly, it caused them to falsely claim to know more about the subject than they did, including “knowing” things the researchers simply made up!

In essence, feeling like an expert actually makes it difficult to separate what we do and do not know. Interestingly, people with the most knowledge in a particular domain (e.g., psychotherapy) are at the greatest risk. Researchers term the phenomenon, “The ‘Earned Dogmatism’ Effect.”

What to do? The practices of highly effective therapists provide some clues:

Adopt an “error-centric” mindset. Take time to reflect on your work, looking for and then examining moments that do not go well. One simple way to prevent over-claiming is to routinely measure the outcome of your work. Don’t rely on your judgement alone, use a simple measures like the ORS to enhance facts from your fictions.

Think like a scientist. Actively seek disconfirmation rather than confirmation of your beliefs and practices. Therapy can be vague and ambiguous process—two conditions which dramatically increase the risk of over-claiming. Seeking out a community of peers and a coach to review your work can be helpful in this regard. No need to leave your home or office. Join colleagues in a worldwide virtual community at: iccexcellence.com.

Seek formal feedback from clients. Interestingly, research shows that highly effective therapists are surprised more often by what their clients say than average clinicians who, it seems, “have heard it all before.” If you haven’t been surprised in a while, ask your clients to provide feedback about your work via a simple tool like the SRS. You’ll be amazed by what you’ve missed.

Attend the 2016 Professional Development Intensive this summer in Chicago. At this small group, intensive training, you will the latest evidence-based steps for unlocking your potential as a therapist.

Best wishes for the Holidays. As always, please leave a comment.

Scott

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

Swedish National Audit Office concludes: When all you have is CBT, mental health suffers

November 10, 2015 By scottdm 17 Comments

“The One-Sided Focus on CBT is Damaging Swedish Mental Health”

That’s the headline from one of Sweden’s largest daily newspapers for Monday, November 9th. Professor Gunnar Bohman, together with colleagues and psychotherapists, Eva Mari Eneroth Säll and Marie-Louise Ögren, were responding to a report released last week by the Swedish National Audit Office (NAO).

Back in May 2012, I wrote about Sweden’s massive investment in cognitive behavioral therapy (CBT). The idea was simple: address rising rates of disability due to mental illness by training clinicians in CBT. At the time, a mere two billion Swedish crowns had been spent.

Now, several years and nearly 7 billion Crowns later, the NAO audited the program. Briefly, it found:

The widespread adoption of the method had no effect whatsoever on the outcome of people disabled by depression and anxiety;
A significant number of people who were not disabled at the time they were treated with CBT became disabled thereby increasing the amount of time they spent on disability; and
Nearly a quarter of people treated with CBT dropped out.

The Swedish NAO concludes, “Steering towards specific treatment methods has been ineffective in achieving the objective.”

choice

How, you might reasonably ask, could anyone think that restricting choice would improve outcomes? It was 1966, when psychologist Abraham Maslow famously observed, “I suppose it is tempting, if the only tool you have is a hammer, to treat everything as if it were a nail” (p. 15, The Psychology of Science). Still, many countries and professional organizations are charting a similar path today.

The choice is baffling, given the lack of evidence for differential efficacy among psychotherapeutic approaches. Consider a study I blogged about in April 2013. It was conducted in Sweden at 13 different public health outpatient clinics over a three year period. Consistent with 40 years of evidence, the researchers found that psychotherapy was remarkably effective regardless of the type of treatment offered!

So, what is the key to improving outcome?

As Bohman, Säll and Ögren point out in their article in Svenska Dagbladet, “offering choice…on the basis of patients’ problems, preferences and needs.”

The NAO report makes one additional recommendation: systematic measurement and follow-up.

As readers of this blog know, insuring that services both fit the consumer and are effective is what Feedback-Informed Treatment (FIT) is all about. More than 20 randomized clinical trials show that this transtheoretical process improves retention and outcome. Indeed, in 2013, FIT was deemed evidence-based by the Substance Abuse and Mental Health Services Administration.

Learn more by joining the International Center for Clinical Excellence–a free, web-based community of practitioners dedicated to improving the quality and effectiveness of clinical work. Better yet, join colleagues from around the world at our upcoming March intensive trainings in Chicago! Register soon as both the Advanced Intensive and FIT Supervision Courses are already more than half subscribed.

Until next time,

Scott

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

Do Psychotherapists Improve with Time and Experience?

October 27, 2015 By scottdm 14 Comments

The practice known as “routine outcome measurement,” or ROM, is resulting in the publication of some of the biggest and most clinically relevant psychotherapy studies in history. Freed from the limits of the randomized clinical trial, and accompanying obsession with manuals and methods, researchers are finally able to examine what happens in real world clinical practice.

A few weeks ago, I blogged about the largest study of psychotherapy ever published. More than 1,400 therapists participated. The progress of over 26,000 people (aged 16-95) treated over a 12 year period in primary care settings in the UK was tracked on an ongoing basis via ROM. The results? In an average of 8 visits, 60% of those treated by this diverse group of practitioners achieved both reliable and clinically significant change—results on par with tightly controlled RCT’s. The study is a stunning confirmation of the effectiveness of psychotherapy.

This week, another mega-study was accepted for publication in the Journal of Counseling Psychology. Once more,
ROM was involved. In this one, researchers Goldberg, Rousemanier, Miller, Whipple, Nielsen, Hoyt, and Wampold examined a large, naturalistic data set that included outcomes of 6500 clients treated by 170 practitioners whose results had been tracked an average of 5 years.

Their question?

Do therapists become more effective with time and experience?

Their answer? No.

For readers of this blog, such findings will not be particularly newsworthy. As I’ve frequently pointed out, experience has never proven to be a significant predictor of effectiveness.

What might be a bit surprising is that the study found clinicians’ outcomes actually worsened with time and experience. That’s right. On average, the longer a therapist practiced, the less effective they became! Importantly, this finding remained even when controlling for several patient-level, caseload-level, and therapist-level characteristics, as well as when excluding several types of outliers.

Such findings are noteworthy for a number of reasons but chiefly because they contrast sharply with results from other, equally-large studies documenting that therapists see themselves as continuously developing in both knowledge and ability over the course of their careers. To be sure, the drop in performance reported by Goldberg and colleagues wasn’t steep. Rather, the pattern was a slow, inexorable decline from year to year.

Where, one can wonder, does the disconnect come from? How can therapists’ assessments of themselves and their work be so at odds with the facts? Especially considering, in the study by Goldberg and colleagues, participating clinicians had ongoing access to data regarding their effectiveness (or lack thereof) on real-time basis! Even the study I blogged about previously—the largest in history where outcomes of psychotherapy were shown to be quite positive—a staggering 40% of people treated experienced little or no change whatsoever. How can such findings be reconciled with others indicating that clinicians routinely overestimate their effectiveness by 65%?

Turns out, the boundary between “belief in the process” and “denial of reality” is remarkably fuzzy. Hope is a significant contributor to outcome—accounting for as much as 30% of the variance in results. At the same time, it becomes toxic when actual outcomes are distorted in a manner that causes practitioners to miss important opportunities to grow and develop—not to mention help more clients. Recall studies documenting that top performing therapists evince more of what researchers term, “professional self-doubt.” Said another way, they are less likely to see progress where none exists and more likely to values outcomes over therapeutic process.

What’s more, unlike their more average counterparts, highly effective practitioners actually become more effective with time and experience. In the article below, my colleagues and I at the International Center for Clinical Excellence identify several evidence-based steps any practitioner follow to match such results.

Let me know your thoughts.

Until next time,

Scott

Scott D. Miller, Ph.D.
Registration is now open for our March Intensives in Chicago. Join colleagues from around the world for the FIT Advanced and the FIT Supervision workshops.

Do therapists improve (preprint)

The outcome of psychotherapy yesterday, today, and tomorrow (psychotherapy miller, hubble, chow, seidal, 2013)

The Verdict is “In”: Feedback is NOT enough to Improve Outcome

September 21, 2015 By scottdm 17 Comments

Nearly three years have passed since I blogged about claims being made about the impact of routine outcome monitoring (ROM) on the quality and outcome of mental health services. While a small number of studies showed promise, others results indicated that therapists did not learn from nor become more effective over time as a result of being exposed to ongoing feedback. Such findings suggested that the focus on measures and monitoring might be misguided–or at least a “dead end.”

Well, the verdict is in: feedback is not enough to improve outcomes. Indeed, researchers are finding it hard to replicate the medium to large effects sizes enthusiastically reported in early studies, a well-known phenomenon called the “decline effect,” observed across a wide range of scientific disciplines.

In a naturalistic multisite randomized clinical trial (RCT) in Norway, for example, Amble, Gude, Stubdal, Andersen, and Wampold (2014) found the main effect of feedback to be much smaller (d = 0.32), than the meta-analytic estimate reported by Lambert and Shimokawa (2011 [d = 0.69]). A more recent study (Rise, Eriksen, Grimstad, and Steinsbeck, 2015) found that routine use of the ORS and SRS had no impact on either patient activation or mental health symptoms among people treated in an outpatient setting. Importantly, the clinicians in the study were trained by someone with an allegiance to the use of the scales as routine outcome measures.

Fortunately, a large and growing body of literature points in a more productive direction. Consider the recent study by De Jong, van Sluis, Nugter, Heiser, and Spinhoven (2012), which found that a variety of therapist factors moderated the effect ROM had on outcome. Said another way, in order to realize the potential of feedback for improving the quality and outcome of psychotherapy, emphasis must shift away from measurement and monitoring and toward the development of more effective therapists.

What’s the best way to enhance the effectiveness of therapists? Studies on expertise and expert performance document a single, underlying trait shared by top performers across a variety of endeavors: deep domain-specific knowledge. In short, the best know more, see more and, accordingly, are able to do more. The same research identifies a universal set of processes that both account for how domain-specific knowledge is acquired and furnish step-by-step directions anyone can follow to improve their performance within a particular discipline. Miller, Hubble, Chow, & Seidel (2013) identified and provided detailed descriptions of three essential activities giving rise to superior performance. These include: (1) determining a baseline level of effectiveness; (2) obtaining systematic, ongoing feedback; and (3) engaging in deliberate practice.

I discussed these three steps and more, in a recent interview for the IMAGO Relationships Think Tank. Although intended for their members, the organizers graciously agreed to allow me to make the interview available here on my blog. Be sure and leave a comment after you’ve had a chance to listen!

Until next time,

Scott

Scott D. Miller, Ph.D.
www.whatispcoms.com
www.iccexcellence.com

Intake: A Mistake

September 4, 2015 By scottdm 1 Comment

Available evidence leaves little doubt. As I’ve blogged about previously, separating intake from treatment results in:

• Higher dropout rates;
• Poorer outcomes;
• Longer treatment duration; and
• Higher costs

And yet, in many public behavioral health agencies, the practice is commonplace. What else can we expect?

Chronically underfunded, and perpetually overwhelmed by mindless paperwork and regulation, agencies and practitioners are left with few options to meet the ever-rising number of people in need of help. Between 2009 and 2012, for example, the number of people receiving mental health services increased by 10%. During the same period, funding to state agencies decreased $4.35 billion. Not long ago, in my own home town of Chicago, the city shuttered half—50%–of the city’s mental health clinics, forcing the remaining, already burdened, agencies to absorb an additional 5,000 people in need of care.

Simply put, the practice of separating intake from treatment is little more than a form of “crowd management”–and an ineffective one at that.

Adding to the growing body of evidence is a new study investigating the impact of computerized intake on the consumer’s experience of the therapeutic relationship and continuation in care. Not only did researchers find that therapist use of a computer had a negative impact on the quality of the working relationship—one of the best predictors of outcome–but clients were between 62 and 97% less likely to continue in care!

It’s not hard to see how these well-intentioned—some would argue, absolutely necessary—solutions actually end up exacerbating the problem. Money is wasted when the paperwork is completed but people don’t come back; money that would be better spent providing treatment. Those who do not return don’t disappear, they simply access services in other ways (e.g., the E.R., police and social services, etc.)—after all, they need help! The ones who do continue after intake, experience poorer outcomes and stay longer in care, a cost to both the consumer and the system.

What to do?

In addition to pushing back against the mindless regulation and paperwork, there are several steps practitioners and agency managers can take:

Stop separating intake from treatment

The practices does not save time and actually increases costs. Consider having consumers complete as much of the paperwork as possible before the session begins. The first visit is critical. It determines whether people continue or drop pout. Listen first. At the end of the visit, review the paperwork, filling in missing data, and completing any remaining forms.

Begin monitoring outcome

Research to date shows that routinely monitoring progress reduces dropout rates and the length of time spent in treatment while simultaneously improving outcome. Combined, such results work to alleviate the bottleneck at the entry point of services.

Begin monitoring the quality of the therapeutic relationship:

Engagement and outcomes are improved when problems in the relationship are identified and openly discussed. Even when intake is separated from treatment, feedback should be sought. Data to date indicate that the most effective clinicians seek and more often receive negative feedback, a skill that enables them to better meet the needs of those they serve.

Getting started is not difficult. Indeed, there’s an entire community of professionals just a click away who are working with and learning from one another. The International Center for Clinical Excellence is the largest, web based community of mental health professionals in the world. It’s ad free and costs nothing to join.

The Empirical Basis for Feedback Informed Treatment
Basics of Outcome and Alliance Measurement
Integrating Feedback into Practice & Creating a Culture of Feedback
Understanding Outcome and Alliance Data

Register online at: https://www.eventbrite.ie/e/fall-2015-feedback-informed-treatment-webinar-series-tickets-17502143382. CE’s are available.

Finally, join colleagues and friends from around the world for the Advanced and FIT Supervision courses are held in March in Chicago. We work and play hard. You will leave with a thorough grounding in feedback-informed principles and practice. Registration is limited, and the courses tend to sell out several month in advance.

Until then,

Scott

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

Love, Mercy, & Adverse Events in Psychotherapy

July 9, 2015 By scottdm 10 Comments

Just over a year ago, I blogged about an article that appeared in one of the U.K.’s largest daily newspapers, The Guardian. Below a picture of an attractive, yet dejected looking woman (reclined on a couch), the caption read, “Major new study reveals incorrect…care can do more harm than good.”

I was interested.

As I often do in such cases, I wrote directly to the researcher cited in the article asking for a reprint or pre-publication copy of the study. No reply. One month later, I wrote again. Still, no reply. Two months after my original email, I received a brief note thanking me for my interest in the study and offering to share any results once they became available.

“Wait a minute,” I immediately thought, “The results of this ‘major new study’ about the harmful effects of psychotherapy had already been announced in a leading newspaper. How could they not be available?” Then I wondered, “If there are no actual results to share, what exactly was the article in The Guardian based on?”

So-called “adverse events” are a hot topic at the moment. That some people deteriorate while in care is not in question. Research dating back several decades puts the figure at about 10%, on average (Lambert, 2010). When those being treated are adolescents or children, the rates are twice as high (Warren et al., 2009).

Putting this in context, compared to medical procedures with effect sizes similar to psychotherapy (e.g., coronary artery bypass surgery, stages II and III breast cancer, stroke), the rate is remarkably low. Nonetheless, it is a matter of concern–especially given research showing that therapists are not particularly adept at recognizing when those they serve deteriorate in their care (Hannan et al., 2005)

The question, of course, is the cause?

To date, whenever the question of adverse events is raised, two “usual suspects” are trotted out: (1) the method of treatment used; and (2) the therapist. Let’s take a closer look at each.

In an October 2914 article published in World Psychiatry, Linden and Schermuly-Haupt wrote about estimates of side effects associated with specific methods of treatment that had been reported in an earlier study by Swiss researchers. The numbers were shocking. Patient reported “burdens caused by therapy” were 19.7% with CBT, 20.4% for systemically oriented treatments, 64.8% with humanistic approaches, and a staggering 94.1% with psychodynamic psychotherapy.

Based on such results, one could only conclude that anyone seeking anything other than CBT should have their head examined.

There is only one problem. The figures reported were wrong. Completely and utterly wrong. Linden and Schermuly-Haupt made an arithmetic error and, as a result, totally misinterpreted the Swiss findings. Read the study for yourself. When it comes to adverse events in psychotherapy, CBT–the fair-haired child of the evidence-based practice movement–is not better. Indeed, as the study clearly shows, people treated with humanistic and systemic approaches suffered fewer “burdens” than expected, while those in CBT had a slightly higher, although not statistically significant, level. More, the observed percentage of people in care who perceived the quality of the therapeutic relationship–the single most potent predictor of engagement and outcome–as poor was significantly higher than expected in CBT and lower for both humanistic and systemic approaches.

How could the researchers have gotten it so wrong?

As I pointed out in my blog over year ago, despite claims to the contrary (e.g., Lilenfeld, 2007), no psychotherapy approach tested in a clinical trial has ever been shown to reliably lead to or increase the chances of deterioration. NONE. Scary stories about dangerous psychological treatments are limited to a handful of fringe therapies–approaches that have been never vetted scientifically and which all practitioners, but a few, avoid. In short, its not about the method.

(By the way, over a month ago, I wrote to the lead author of the paper that appeared in World Psychiatry via the ResearchGate portal–a site where scholars meet and share their publications–providing a detailed breakdown of the statistical errors in the publication. No response thusfar)

With only one suspect left, attention naturally turns to the therapist–you know, the “bad apple” in the bunch. Here’s what we know. That some practitioners do more harm than others is not exactly news. Have you seen the new biopic Love & Mercy, about the life of Beach Boy Brian Wilson? You should. The acting is superb.

Wilson’s therapist, psychologist Eugene Landy (chillingly recreated by actor Paul Giamatti), is a prime example of an adverse event. See the film and you’ll most certainly wonder how the guy kept his license to practice so long. And yet, as I also pointed out in my blog last year, there are too few such practitioners to account for the total number of clients who worsen. Consider this unsettling fact: beyond the 10% of those who deteriorate in psychotherapy, an additional 30 and 50% experience no benefit whatsoever!

Where does this leave us when it comes to adverse events in psychotherapy?

Whatever the cause, lack of progress and risk of deterioration are issues for all clinicians and clients. The key to addressing these problems is tracking progress from visit to visit so that those not improving, or getting worse, can be identified and offered alternatives. It’s that simple.

Right now, practitioners can access two simple, easy-to-use scales for free at: www.whatispcoms.com. Both have been tested in multiple, randomized, clinical trials and deemed evidence-based by the Federal Substance Abuse and Mental Health Services Administration (SAMHSA).

Learning to use the tools isn’t difficult. It costs nothing to join the International Center for Clinical Excellence and begin interacting with professionals around the world who are using the measures to improve the quality and outcome of behavioral health services. More detailed instruction is available at the upcoming webinar:

Join us in tackling the issue of adverse events in psychotherapy. In the meantime, be sure and leave a comment below.

Best wishes for the summer,

Scott

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

P .S.: On the one year anniversary of my original email to the reseacher cited in the Guardian, I sent another. That’s over a month ago. So far, no reply. By contrast, the reporter who broke the story, Sarah Boseley , wrote back within a half hour! She’s following up her sources. I’ll let you know if she gets a response.

What do clinicians want anyway?

January 26, 2015 By scottdm 3 Comments

What topics are practitioners interested in learning about?

If you read a research journal, attend a continuing education event, or examine the syllabus from any graduate school course, you’re likely to conclude: (1) diagnosis; (2) treatment methods; and perhaps (3) the brain. As I’ve blogged about previously, the brain is currently a hot topic in our field.

Ask clinicians, however, and you hear something entirely different. That’s exactly what Giorgio Taska and colleagues did, publishing their results in a recent article in the journal, Psychotherapy. Here’s what they found.

Regardless of age or theoretical orientation, the top three topics of interest among practicing clinicians were: (1) the therapeutic relationship; (2) therapist factors; and (3) professional development.

(Cartoon used with permission from www.psychotherapy.net)

Let’s consider each one in turn.

Number one: the therapeutic relationship. Honestly, when was the last time you attended a workshop focused solely on improving your ability to connect with, engage, understand, and relate to your clients? The near complete absence of such offering is curious, isn’t it? Especially when you consider that the quality of the therapeutic bond is the single best predictor of treatment outcome, the most evidence-based principle in the literature!

Paradoxically, research shows that therapists who are able to solicit negative feedback about the alliance early in the treatment process have better outcomes in the end. Turns out, soliciting such feedback and using it to strengthen the working relationship is a skill fewclinicians–despite their beliefs to the contrary–possess.

There’s a simple solution: download and begin using the Session Rating Scale, a simple, four-item alliance measure designed to be administered at the end of each session. Multiple, randomized clinical trials now show that formally seeking client feedback not only improves outcome but decreases both drop out and deterioration rates. Whether you’ve tried to use the scale or not, you can learn how to improve your skills in the comfort of your own home by joining our upcoming Spring webinar series. And yes, CE’s are available!

Number two: therapist factors. In other words, you!

skeptic
Some time ago, veteran psychotherapy researcher Sol Garfield–one of the editors of the prestigious Handbook of Psychotherapy and Behavior Change–called the therapist the “neglected variable” in psychotherapy research. Available evidence documents that the clinician doing the therapy contributes 5 to 9 times more to outcome than the method used. What makes some more effective than others? Recent research by Singapore-based psychologist Daryl Chow shows that the best invest 4.5 more hours outside of work engaged in activities specifically aimed at improving their performance than their average counterparts–an process known as deliberate practice.

Which brings us to topic number three: professional development.

Large, multinational studies document the central importance that professional development plays in the identity and satisfaction of clinicians. And yet, as I reviewed here on this blog not long ago, “the near ubiquitous mandate that clinicians attend so many hours per year of approved “CE” events in order to further their knowledge and skill base has no empirical support.” So, what does work? Together with my colleague Daryl Chow, I’ll be presenting the latest evidence-based information at the first ICCE Professional Development Intensive. The two-day event is limited to 20 practitioners. We’ll not only review the evidence, but also lay out concrete steps, and work together with each participant to develop a highly individualized professional development plan. If you’ve been monitoring the outcome and alliance of your clinical work and are interested in pushing your performance to the next level, join us in August!

OK, that’s it for now. Before I go though, let me ask if you can guess the topics of least interest to practitioners identified in the study mentioned earlier?

PLEASE post your comments below!

Dinner with Paul McCartney (and others)

December 11, 2014 By scottdm 7 Comments

McCartney

Growing up, my family had a game we frequently played around the dining room table. “If you could invite anyone to dinner,” it always started,”who would it be?” Invariably, my father chose historical figures: Abraham Lincoln, Mark Twain, Leonardo Da Vinci. My mom was more inclined toward the living: Jackie O., J.D. Salinger, Lucille Ball. My brothers, Marc and Doug, usually went for sports figures. I recall Wilt Chamberlain and Willie Mays being popular choices–although there were many others whose names I’ve now forgotten.

Me? Always the same answer: Paul McCartney.

Of course, the “name game” didn’t end there. Whatever your choice, you also had to state why. Here, my answer didn’t vary either. “He’s one of the Beatles!” I’d say, frustrated whenever my family acted as though my statement needed further clarification.

To this date, I’ve never had a chance to met much less have dinner with Paul McCartney. Seen him in concert a number of times but always from a distance. Last week, however, I did have the opportunity to meet and spend time with a number of my heroes from the field of psychotherapy–and go to dinner together, not once, but twice!

We were together at the first ever Calgary Counseling Center Outcomes conference. Thanks to Center’s director, Dr. Robbie Wagner, a small group of practitioners, policy makers, and agency managers were invited to spend two, intimate days learning from the field’s leading thinkers and researchers. The Beatles of outcome research: Michael J. Lambert, Bruce E. Wampold, Michael Barkham, Wolfgang Lutz, and Gary Burlingame. I presented the latest results on our studies of top performing therapists.

It was every bit a rock concert–exciting, controversial, and cutting edge. Below, I summarize the “greatest hits.” I’ve also included the slides from each presentation for those who like to read the details contained in the “liner notes!”

Let me know what you think…here goes:

The burden born by people with mental health problems is second only to cancer (Depression alone results in a 70% loss of productivity)

Bottom line: People need the skills mental health professional have to offer

Treatment is effective. However, therapists believe they help far more people than they do (85% versus 20%);
Approximately 10% of adults deteriorate in care;
Between 14 and 25% of children are worse off following treatment;
Serious deterioration recognized in only one-third of cases;

Bottom Line: Mental health professionals overestimate their effectiveness and miss deterioration

Multiple, sophisticated, real world studies find no difference in outcome between people treated with different therapeutic approaches;
Factors related to the therapeutic relationship (i.e., empathy, collaboration, affirmation, genuineness) have a far greater impact on outcome (7:1) than treatment approach, adherence to treatment protocol, or rated competence.

Bottom Line: The pathway to improved effectiveness is not adopting new treatment approaches

Rapid and dramatic change (first 5 visits) occurs in as many as 40% of people and is maintained at two year follow up;
90% chance of failure if there is no change between the 2nd and 8th visit;
As many as 25% of people remain in treatment while experiencing no measurable benefit;

Bottom Line: A large number of people need very little treatment to achieve lasting benefit

Separating intake from treatment results in higher drop out, lower and longer treatment response, and higher costs;

Bottom Line: Any barrier to establishing a relationship with a specific provider has a negative impact on outcome

The majority of individual practitioners are effective;
Around 16% of practitioners achieve outcomes significantly below average;
Less effective practitioners rate empathic understanding more highly as a professional/personal attribute than more effective practitioners;
The clients of the least effective clinicians were assigned to average practitioners, an additional 15% of clients would achieve clinical recovery;
Around 16% of practitioners consistently achieve outcomes significantly above average;
More effective practitioners rate resilience and mindfulness more highly as a professional/personal attribute;
Professional self-doubt and an “error-centric attitude” are associated with better outcomes.

Bottom Line: Choose your therapist carefully as they determine the outcome of care

When therapists receive feedback that clients are deteriorating, they: discuss it with clients about 60% of the time; make efforts to assist with other resources about 27% of the time; adjust therapeutic interventions 30% of the time; vary intensity or dose of services 9% of the time; consult with others (supervision, education, etc.) 7% of the time;
Therapist attitude toward soliciting and using feedback vary and influence results;
Therapists who value feedback achieve better outcomes;
Professional self-doubt and an “error-centric attitude” are associated with better outcomes;

Bottom Line: Regular, formal feedback from clients to therapists improves outcomes (as long as the therapist listens and acts on the feedback)

When asked, 92% of clients say they like the use of outcome measures in care.

Bottom Line: An overwhelming majority of clients endorse progress monitoring or providing feedback

The economic value of monitoring patient treatment response (Lambert, 2014)

How to double client outcomes in 18 seconds (Lambert, 2014)

Practice-based Evidence (Michael Barkham, 2014)

How to Improve Quality of Services by Integrating Common Factors into Treatment Protocols

When & How do Patients Change? Wolfgang Lutz Outcome Presentation

Reach: Pushing Your Clinical Effectiveness to the Next Level

Is Documentation Helping or Hindering Mental Health Care? Please Let me know.

November 23, 2014 By scottdm 44 Comments

So, how much time do you spend doing paperwork? Assessments, progress notes, treatment plans, billing, updates, etc.–the lot?

When I asked the director of the agency I was working at last week, it took him no time to respond. “Fifty percent,” he said, then added without the slightest bit of irony, “It’s a clinic-wide goal, keeping it to 50% of work time.”

Truth is, it’s not the first time I’ve heard this figure. Wherever I travel–whether in the U.S. or abroad–practitioners are spending more and more time “feeding the bureaucratic beast.” Each state or federal agency, regulatory body, and payer wants a form of some kind. Unchecked, regulation has lost touch with reality.

Just a few short years ago, the figure commonly cited was 30%. In the last edition of The Heart and Soul of Change, published in 2009, we pointed out that in one state, “The forms needed to obtain a marriage certificate, buy a new home, lease an automobile, apply for a passport, open a bank account, and die of natural causes were assembled … altogether weighed 1.4 ounces. By contrast, the paperwork required for enrolling a single mother in counseling to talk about difficulties her child was experiencing at school came in at 1.25 pounds” (p. 300).

Research shows that a high documentation to clinical service ratio leads to higher rates of:

Burnout and job dissatisfaction among clinical staff;
Fewer scheduled treatment appointments;
No shows, cancellations, and disengagement among consumers.

Some potential solutions have emerged. “Concurrent ,” a.k.a., “collaborative documentation.” It’s a great idea: completing assessments, treatment plans, and progress notes together with clients during rather than after the session. We started doing this to improve transparency and engagement at the Brief Family Therapy Center in Milwaukee, Wisconsin back in the late 1980’s. At the same time, it’s chief benefit to date seems to be that it saves time on documentation–as though filling out paperwork is an end in and of itself!

Ostensibly, the goal of paperwork and oversight procedures is to improve accountability. In these evidence-based times, that leads me to say, “show me the data.” Consider the wide-spread practice–mandate, in most instances–of treatment planning. Simply put, it is less science than science fiction. Perhaps this practice improves outcomes in a galaxy far, far away but on planet Earth, supporting evidence is spare to non-existent. Where is the evidence that any of the other documentation improves accountability, benefits consumers, or results in better outcomes?

Put bluntly, the field needs an alternative. What practice not only insures accountability but simultaneously improves the quality and outcome of behavioral health services? Routinely and formally seeking feedback from consumers about how they are treated and their progress.

Soliciting feedback need not be time consuming nor difficult. Last year, two brief, easy-to-use scales were deemed “evidence-based” by the Substance Abuse and Mental Health Services Administration (SAMHSA). The International Center for Clinical Excellence received perfect scores for the materials, training, and quality assurance procedures it makes available for implementing the measures into routine clinical practice:

Then again, these two forms add to the paperwork already burdening clinicians. The main difference? Unlike everything else, numerous RCT’s document that using these forms increases effectiveness and efficiency while decreasing both cost and risk of deterioration.

Learn more at the official website: www.whatispcoms.com. Better yet, join us in Chicago for our upcoming intensives in Feedback Informed Treatment and Supervision:

In the meantime, would you please let me know your thoughts? To paraphrase Goldilocks, is the amount of documentation you are required to complete, “Too much,” Too little,” or “Just about Right!” Type in your reply below!

What articles have 140,000 of your colleagues read to improve their practice?

November 21, 2014 By scottdm 1 Comment

Each week, I upload articles to the web about how to improve effectiveness. There are a lot to choose from, but here are the top ones read by behavioral health professionals around the world:

Measures and Feedback 2014

This is the latest version of the most widely-read upload on the site. It summarizes all of the available research about using feedback to improve retention in and outcome of care, including studies using the ORS and SRS.

How to Improve your Effectiveness

A short, fun article that highlights the evidence-based steps for improving one’s effectiveness as a behavioral health provider. Feedback, it turns out, is not enough. This article reviews the crucial step that makes all the difference.

Finally, here’s a link to a simple-to-use tool for interpreting scores on the ORS:

ORS Reliable Change Chart

That’s it for now. Best wishes in your work. Stay in touch.

Scott D. Miller, Ph.D.
Director, International Center for Clinical Excellence
info@scottdmiller.com

Registration is open for the Advanced Training in Feedback-Informed Treatment (FIT). Learn how to integrate this SAMHSA certified evidence-based practice into your work or agency. We promise you three comprehensive, yet fun-filled days of learning together with colleagues from around the world.

Public Attitudes Toward Mental Health Services: A Change for the Worse

July 3, 2014 By scottdm 1 Comment

The results are not encouraging. A recent meta-analysis found that public attitudes toward psychotherapy have become progressively more negative over the last 40 years. The impact on practitioners is staggering. Between 1997 and 2007, use of psychotherapy declined by 35%. Not surprisingly, clinicians’ incomes also suffered, dropping 15-20% over the last decade.

So, if not psychotherapy, what do consumers of mental health services really want?

Well, if you trust the study I’ve cited, the answer seems clear: drugs. During the same time period that talking fell out of favor, use of pharmaceuticals increased a whopping 75%! Some blame society’s short attention span and desire for a “quick fix.” Such an argument hardly seems credible, however, given that psychotherapy works to alleviate distress as fast or faster than most psychotropics.

Others, including the authors of the meta-analysis, blame public education campaigns and pharmacological marketing aimed at “convincing the public that mental disorders have a neurobiological etiology that require biological treatments” (p. 103). At first glance, this idea is compelling. After all, every year, the pharmaceutical industry spends $5 billion dollars on direct-to-consumer advertising.

And yet, what is it the drug companies are really selling in those ads? In one of the most well-known TV commercials for a popular antidepressant, less than 7 seconds is spent on the supposed neurobiological cause. Instead, the majority of the time is spent depicting the positive results one can expect from the product. It’s marketing 101: focus on the benefits not the features of whatever you’re selling.

What do consumers want? The answer is: results. Your training, degree, certification, and treatment approach are irrelevant, mere features most consumers could care less about. Your rate of effectiveness is another matter entirely–its the benefit people are looking for from working with you.

So, how effective are you? Do you know? Not a guess or a hunch, but the actual number of people you treat that are measurably improved? If not, its easy to get started. Start by downloading two, simple, free, SAMHSA-approved scales for measuring progress and quality of mental health services. Next, visit www.whatispcoms.com to learn how individual practitioners and agencies can use these tools to monitor and improve outcome and retention in treatment, as well as communicate results effectively to consumers.

To see how outcomes attract consumers, just take a look at the Colorado Center for Clinical Excellence website. This Denver-based group of practitioners is a model for the future of clinical practice.