“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 6 Comments

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

Questions and Answers about Feedback Informed Treatment and Deliberate Practice: Another COVID-19 Resource

April 16, 2020 By scottdm 5 Comments

Since they were developed and tested back in the late 90’s, the Outcome and Session Rating Scales have been downloaded by practitioners more than 100,000 times! Judging by the number of cases entered into the three authorized software applications, the tools have been used inform service delivery for millions of clients seeking care for different problems in diverse treatment settings. The number of books, manuals, and “how to” videos describing how to use the tools has continued to grow dramatically. And most weeks, I’m traveling somewhere to provide training or consultation on feedback informed treatment (FIT) — that is, until the COVID-19 outbreak.

Wanting to stay in touch, I offered to meet people online to connect and answer any FIT-related questions. When all 100 spots for the first webinar filled within two hours, we scheduled another. It’s also full to capacity. We are planning more such free events in the future.

In the meantime, I’m making the recordings for each available here. While I know its not the same as being together live, I think you’ll be surprised by the depth and breadth of the information covered. Below you will find the first. You can listen to the entire broadcast or use the guide below to jump directly to the questions that matter most to you. In the meantime, be on the lookout for the announcement of the next live broadcast!

How to get started with FIT? (2:23)
How can I encourage my clients to provide open, honest feedback? (10:30; revisited 36:15)
Should I start using the measures with established clients? (13:18, revisited 17:05)
How do I know how effective I am? (14:45)
How to interpret ORS and SRS feedback (18:10)
How to use the scales online/on the phone? (22:00)
How effective is supervision? (26:58)
How to work with mandated clients? (31:30)
Why do some clients not give feedback? (37:00)
What is deliberate practice and how to apply it for improving therapist effectiveness? (46:00)

Until next time,

Scott

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

Supervision: Time for a New Way or to Dump the Practice Altogether?

January 10, 2020 By scottdm 3 Comments

Therapists value supervision. How do we know? Research.

In their massive, long-term international study of therapist development, for example, Orlinsky and Rønnestad (2005) found, “practitioners at all experience levels, theoretical orientations, professions, and nationalities report that supervised client experience is highly important for their current and career development” (p. 188).

Regulatory boards deem supervision essential, in most jurisdictions requiring trainees have 3,000 hours –or nearly two years of full time work — before becoming licensed to practice independently.

Given such beliefs and requirements, one might reasonably conclude the evidence-base for clinical supervision is substantial. And yet, a thorough search of the literature for studies investigating the relationship between the practice and treatment outcome turns up a mere handful of empirically sound investigations. For these, the best that can be said is, the results are decidedly mixed (1, 2, 3, 4, 5). It’s notable that a popular text on “evidence-based” supervision written by two leading researchers cites zero evidence that it leads to better results!

“Ultimately,” argue researchers Wrape and colleagues (2014), “the criteria by which to evaluate supervision’s efficacy … lie(s) in its power to bring about favorable client changes” p. (36). Clearly, the assumption traditional supervision provides clinicians with the knowledge, skills, and capability necessary to provide safe and effective therapy is empirically questionable. Perhaps the time has come to dump supervision altogether or at least consider new ways for helping clinicians deliver more effective services?

As already indicated, plenty of evidence indicates clinicians appreciate supervision. Indeed, a near linear relationship exists between the number of hours received and levels of practitioner self-efficacy, job satisfaction, burnout, treatment knowledge, acquisition and use of particular treatment techniques and skills. And therein lies the paradox: how, you might reasonably wonder, could such positive results not translate into improved outcomes for clients?

The answer? Experience ([i.e., time in the field] of supervisors and therapists), self-rated efficacy, treatment knowledge, and competence in delivering particular treatment approaches are not, and have never been, related to outcome. So, while regular contact with peers and mentors provides with critical emotional support for clinicians, something more and different is required for them to become more helpful to their clients.

Clues to what might replace traditional supervision can be found in a study by Goldberg et al. (2015) — the only study to date of a process resulting in continuous improvement in therapist effectiveness over time. In it, practitioners engaged in five distinct activities: (1) formal and routine measurement of their client’s experience of progress and quality of the therapeutic relationship; (2) identification of performance shortfalls using the data generated by routine outcome monitoring; (3) ongoing clinical/supportive supervision to aimed at improving responsiveness in real time to the differences between individual clients; (4) coaching from an external expert; and (5) engagement in deliberate practice around basic therapeutic skills.

Clicking on the links above can provide you with ideas and resources to get started. Participating in an intensive training is the next step. Why not join us for the March intensives? With the ICCE international faculty, you will get a thorough grounding in steps 1 through 3. Click here for more information or to register. Only a handful of spots remain.

OK, that’s it for now. Until next time,

Scott

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

Learning Charisma

June 11, 2019 By scottdm Leave a Comment

I entered university an accounting major.

My first year, I took all the recommended courses: accounting theory, fundamentals of financial and managerial accounting, and so on.

I’d likely be sitting in an office balancing company ledgers or completing tax documents had I never met Hal Miller. A Harvard-educated professor, Dr. Miller taught multiple sections of the Psychology 111 course students could take as part of the required “general education” curriculum.

Decades have now passed since I first met him. Still, I remember that first class as if it were yesterday. When I arrived, every seat in the large, theater-style classroom was already taken, students overflowing into the hallway outside. In time, I’d learn many were not officially registered for the class. They were there because they wanted to hear him speak.

Within weeks, I’d changed my major to psychology. I’m not sure how interested I was in the subject at the time. Rather, I wanted to be like Hal Miller. He loved what he was doing, was devoted to learning, and, most importantly, made me want to study. He was, in a word, charismatic.

“Charisma,” researchers Antonakis, Fenley, and Liechti report, “is rooted in values and feelings. It’s influence born of the alchemy that Aristotle called, the logos, the ethos, and the pathos.”

LOGOS = WORDS, LOGIC, FACTS

ETHOS = ETHICS, CREDIBILITY, EXPERTISE

PATHOS = EMOTIONS, CONNECTION, LIKE-MINDEDNESS

Hal Miller embodied all three qualities. His ability to engage, communicate, and inform, literally changed my life. I’m sure you can identify people who’ve had a similar impact on you.

But how did he do what he did? Did he learn it? Was it in his genes?

It turns out, the word, charisma, comes from the Greek χάρισμα, meaning “gift of grace” — a view widely held even today. You either “got it or you ain’t.”

Curiously, while one study in psychotherapy found it to be both relationally and therapeutically helpful, most of the serious research on the subject comes from other fields where social influence is critical to success (e.g., leadership, training, management). There, the evidence is clear: charisma is, “a learnable skill or, rather, a set of skills,” the potency of which can be dramatically improved with practice.

What exactly does that entail?

As a person whose spent his entire professional career providing continuing education workshops to therapists, I can tell you the absence of specific training means its mostly trial and error. A few have the good fortune to work closely with a gifted practitioner or presenter. I had the opportunity, or example, to work closely with Insoo Berg — a person who exuded warmth and charisma both in the therapy room and on the lecture circuit. And yet, rarely are students of charismatic individuals are as successful or magnetic as their mentors.

So, what does it take?

As hackneyed as it may sound at first, the key is “being yourself.” While its tempting to copy the content, style, and mannerisms of the Hal Millers and Insoo Bergs in our lives, doing so, everyone quickly recognizes, is mere tribute. Success means putting the principles of charisma — logos, ethos, pathos — into practice in a way that is congruent with who you are, your own style, persona and, critically, message.

Below, you’ll find a TedTalk by Professor John Antonakis, one of the leading researchers on charisma. It’s worth a listen. The first 5 minutes is interesting and provocative, but you must listen longer to learn about the evidence documenting that you can dramatically improve your ability to communicate with impact.

If you still are looking for something more practical and skill-based, and specific to psychotherapy, then join my colleagues and I for the upcoming “Training of Trainers” workshop, held the first week of August in downtown Chicago. Together with an international faculty, and participants from around the world, we’ll work on helping you become the most effective version of you, either in your role as a therapist or trainer/presenter. For more information or to register, click here.

Until next time,

Scott

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

Time for a New Paradigm? Psychotherapy Outcomes Stagnant for 40 years

February 1, 2019 By scottdm 9 Comments

You’ve heard it said before. Flying is the safest form of transportation.

Facts back up the claim. In fact, it’s not even close. In terms of distance traveled, the fatality rate per billion kilometers is .003, improving dramatically over the years. Cars, by contrast, are almost 1,000 times more dangerous. Still, since 1923, the fatality rate in motor vehicle accidents has declined an eye-popping 93%.

How about psychotherapy? Have outcomes improved? Judging by the size of the Diagnostic and Statistical Manual and growth in the number of treatment approaches, one would expect success rates to have climbed significantly, if not exponentially. Not so, as I first presented at the Evolution of Psychotherapy Conference five years ago, and later on this blog, the empirical evidence clearly shows NO improvement.

And now a new study, this time reviewing the evidence regarding treatments for children and adolescents. Using sophisticated statistical analyses, the researchers examined 453 RCT’s spanning 53 years, involving nearly 32,000 kids treated for anxiety, depression, attention deficit/hyperactivity, and conduct problems. With the rising popularity of “evidence-based practice,” those conducting the study wanted to know whether “… our methods of developing and testing youth psychological therapies [are] producing improvement” (p. 2).

Can you guess what they found?

Outcomes have not changed (much less improved) over the last five decades–that’s 351 in dog years!

Can you imagine the outcry had similar results been published about automobiles or planes? You would fully expect hearings to be held, and leaders to be called called to account. The lives of children are on the line.

Nope. Instead, facing the supersized differences between promises made every year about “advances” in psychotherapy, and the results realized and reported in research studies, the authors meekly call for, “new approaches to treatment design and intervention science” (p. 1).

Really? Is that what’s required? Researchers going back to the drawing board of “treatment and intervention?”

No, what’s needed is an entirely different view of what clinicians actually do — and it starts by giving up the idea that psychotherapy is a form of treatment similar to antibiotics or angioplasty. Let’s face it. Psychotherapy is no more a medical treatment than are the facials, salt glows and body wraps one receives at the local spa. Which is not to say, it doesn’t work.

Outside the halls of academia, millions of therapists worldwide are helping people on a daily basis to live happier, more meaningful and functional lives. Dozens of studies of real world practitioners document outcomes that meet or exceed benchmarks established in tightly controlled, model-driven, randomized trials — all without following a particular, “evidence-based” protocol (see 1, 2, 3,4).

So, how best to conceptualize the effective work clinicians do? And, importantly, what could researchers offer that would be of real help to therapists?

That psychotherapy works, says more about humans and our need for connection, meaning, and purpose, than it does about the particulars of any given model or approach. And that our methods focus on thoughts, feelings, behaviors, and brain chemistry, says more about our Western values and beliefs, than about the ingredients necessary for successful healing.

Simply put, the field does not need to, as the authors of the study argue, “intensify the search for mechanisms of change [and] transdiagnostic … treatments” (p. 1). Doing so is merely a recipe for “more of the same.” Rather, to move forward, it should abandon the medical paradigm that has long had a stranglehold on our research and professional discourse, choosing instead to reconnect with the larger, worldwide family of healers, one that has existed since the dawn of history and which, from the outset, has been deeply engaged in the values and beliefs of those they treat, using whatever means necessary, consistent with the culture, to engender change.

What might that look like in practice?

As already documented, practicing clinicians already do a pretty darn good job helping their clients. There’s nothing wrong with our Westernized approaches when they work. At the same time, we don’t succeed with everyone. The problem, studies show, is we’re not particularly good at knowing when we’re not being helpful, when clients are at risk for dropping out or are actually deteriorating while in our care (1, 2). On this score, research has already provided a solution. Dozens of studies document, for example, using simple measures at the beginning and end of each visit not only provides clinicians with an opportunity to intervene more successfully with “at risk” clients, but also helps identify opportunities for their own growth and development (1, 2). If you’re not routinely and formally measuring the quality and outcome of your work, you can get started by accessing two simple tools here.

With outcome as our guide, all that remains is being willing to look outside the profession for possibilities for healing and change unbound by convention and the medical view. That’s happening already, by the way, in the world’s two most populous countries, India and China, with professionals learning the ways of indigenous healers and government officials tapping local shaman to meet citizen’s mental health and well being needs.

So, what about you? What you are doing to extend your healing reach?

And, in case you haven’t seen it, the video below is from the most recent Evolution of Psychotherapy conference, where I talk about new research documenting psychics achieving the same or better results as psychotherapists.

Until next time,

Scott

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

P.S.: Want to learn more about using outcome to inform and improve your effectiveness? Join me and an international group of teachers and researchers in Chicago for our Summer Intensives. For detailed information and to register, click on the banners below.

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!

Science is Real (confusing)

September 17, 2018 By scottdm 9 Comments

The graphic above is a small sample of the many posts I encountered on social media last week. Obviously, science has a great deal of currency in public discourse.

Now, look at the bottom row. On the far left, we are told that drinking wine will help you live a longer life. On the right, the exact opposite claim is made: no level of alcohol consumption is safe.

Can anyone blame us for being confused? What is the truth? Isn’t that what science is supposed to help us sort out? Judging from the slogans printed on T-shirts, posters, and lawn signs, apparently so:

Science matters!
Science will not be silenced!
In science we trust!

Or, in the words of “Science Guy,” Bill Nye, “If you don’t believe in science, you are holding everyone back.”

How can one respond to that, except to say, “Ouch!”

And yet, at the risk of holding everyone back, I actually think much of the current confusion about what is and is not true comes precisely from believing in science. To me, its a bit like saying, “I believe in hammers.” Yes, each word makes sense, but the resulting sentence is absurd.

Science is not something to believe in or not. Like a hammer, it is merely a tool — one that, as the founder of American psychology, William James (1896), noted, is “first of all a certain dispassionate method.”

James then continued, offering a warning particularly suited to our media-saturated times, “To suppose that [science] means a certain set of results that one should pin one’s faith upon and hug forever is sadly to mistake its genius, and degrades the scientific body to the status of a sect.”

Real world science is a messy affair, with partial, inconclusive, and often contradictory results the norm rather than the exception. When done well and thoroughly understood, it can help tip the scales in one direction or another. Rarely, however, does it offer us a mirror of the universe.

Here’s a recent example from my own work. Are superior performers in sports, art, music, programming, and psychotherapy born or made?

About a decade ago, a slew of books and articles appeared boldly asserting, “Greatness isn’t born. It’s grown” (Coyle, 2009). Anyone, they promised, could accomplish anything if they just practiced long enough (Colvin, 2009; Gladwell, 2008; Shenk, 2010; Syed, 2010).

Then, in 2014, a group of researchers published a meta-analysis questioning the strength of the association between practice and performance. In a popular magazine , the banner for an article penned by one of the study’s authors even claimed the whole idea of improving performance via practice, “perpetuates a cruel myth” as it promotes the false belief, “people can help themselves to the same degree if they just try hard enough.”

What are we to believe?

Sorting out the seemingly contradictory results requires a deep dive into the literature: who did the studies, what questions did they ask, and how was the data analyzed? In other words, longer than the 2 – 4 minute “reads” promised in the social media posts pictured above. In fact, from the start to the publication of our new study on the subject, my co-investigators and I spent hundreds of hours spread out over a three year period examining the question. Here’s what we found:

The correlation researchers cited as demonstrating practice is “not as important as has been argued” (.35 [p. 1, Macnamara et al., 2014]) was greater than the association between mortality (e.g., death) and obesity (.13), excessive drinking (.21), and taking prescribed medications correctly (.23).

When the data set was reanalyzed including only those studies judged by independent, blind raters to be bona fide instances of research on the link between practice and performance, the correlation increased to.40.

So, you decide: if you want to improve your effectiveness –as a pole vaulter, chess player, surgeon, or psychotherapist — should you practice? Please share your thoughts below.

WAIT! Three new science posts just came across my social media feed:

What to do?

Start talking to my dog. Check!
Begin my three day fast. Check!
Nah, I’m just going to watch TV.

All the best,

Scott

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

Better Results through Deliberate Practice

January 16, 2018 By scottdm 1 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.

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.

Can you tell me what I’m supposed to do? A free deliberate practice resource

May 17, 2017 By scottdm 5 Comments

You’ve read the studies. Maybe you’ve even attended a training.

Deliberate practice is the key to improving your effectiveness as a psychotherapist. Top performing therapists devote twice as much time to the process. More, when employed purposefully and mindfully, the outcomes of average practitioners steadily rise over time.

But what exactly is a therapist supposed to practice in order to improve? It’s a question that comes up within minutes of introducing the subject at my workshops–one my colleagues, Daryl Chow, Sharon Lu, Geoffrey Tan, and I have been working on answering.

Just over three years ago, we published preliminary results of a study documenting the impact of individualized feedback and rehearsal on mastering difficult conversations in psychotherapy. Therapists not only improved their ability to respond empathically under especially challenging circumstances, but were able to generalize what they learned to new and different situations.

Now, the entire deliberate practice program has gone online. In light of the research, it’s been both expanded and refined. There’s no need to leave the comfort of your home or office and, best of all, it’s free.

Sign up to participate and you will learn what to practice as well as receive feedback specifically tailored to your professional development. You will also be helping the field as the program is part of a research study on deliberate practice.

****UPDATE! UPDATE! UPDATE! UPDATE!****

Response to the above post has been overwhelming! Despite the size of the study, all of the available spots filled within 45 minutes. I’ve been corresponding with the chief researcher, Daryl Chow, Ph.D.. He tells me 15 more spots have just been added. If you want to participate, click here. The password is: DCT. If all of the spots are taken, please add your name to the wait list.

One more opportunity: join me in Chicago for the upcoming two-day intensive on deliberate practice. For more information or to register, click on the icon below my name. As with the online program, we are nearly full, so register today.

Until next time,

Scott

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

Would you rather . . . be approved or improved?

February 5, 2017 By scottdm 6 Comments

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

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

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

And finally:

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

Fast forward to today. fast-forward-button_318-37183

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

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

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

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

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

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

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

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

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

“Would you rather be approved or improved?”

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

Why not join me and colleagues from around the world who are “choosing to improve” for our two-day intensive on deliberate practice. Together with Dr. Tony Rousmaniere–the author of the new book Deliberate Practice for Psychotherapists—you’ll learn the latest, evidence-based strategies for improving your effectiveness. Register today, by clicking here, or on the image below.

Until next time,

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

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

January 21, 2017 By scottdm 12 Comments

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

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

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

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

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

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

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

Earlier this month, I interviewed Tony about his journey and the new book. His honesty, transparency, and sage advice are inspiring. You’ll find the video below.

In the meantime, get hands on experience with deliberate practice this summer by signing up for the FIT Professional Development Intensive. For more information or to register, simply click the icon under my name. Hope to see you there!

Until then, best wishes,

Scott

Director, The International Center for Clinical Excellence

The Replication Crisis in Psychology: What is and is NOT being talked about

November 7, 2016 By scottdm 8 Comments

Psychology has been in the headlines a fair bit of late—and the news is not positive. I blogged about this last year, when a study appeared documenting that the effectiveness of CBT was declining–50% over the last four decades.

The problem is serious. Between 2012 and 2014, for example, a team of researchers working together on their free time tried to replicate 100 published psychology experiments and succeeded only a third of the time! As one might expect, such findings sent shock waves through academia.

Now, this week, The British Psychological Society’s Research Digest piled on, reviewing 10 “famous” findings that researchers have been unable to replicate—despite the popularity and common sense appeal of each. Among others, these include:

Power posing does not make you more powerful;
Smiling does not make you happier;
Exposing you to words (known as “priming”) related to ageing does not cause you to walk like an old person;
Having a mental image of a college professor in mind does not make you perform more intelligently (another priming study);
Being primed to think of money will not cause make you act more selfishly; and
Despite being reported in nearly every basic psychology text, babies are not born with the power to imitate.

Clearly, replication is a problem. sand-castle The bottom line? Much of psychology’s evidence-base is built on a foundation of sand.

Amidst all the controversy, I couldn’t help thinking of psychotherapy. In this area, I believe, the problem with the available research is not so much the failure to replicate, but rather an unwillingness to accept what has been replicated repeatedly. Contrary to hope and popular belief, one—if not the most—replicated finding is the lack of difference in outcome between psychotherapeutic approaches.

It’s not for lack of trying. Massive amounts of time and resources have been spent comparing treatment methods. With few exceptions, either no or inconsequential differences are found.

Consider, for example, the U.S. Government spent same $33,000,000 studying different approaches for problem drinking only to find what we already know: all worked equally well. A decade later, the British officials spent millions of pounds on the same subject with similar results.

Just this week, a study was released comparing the hugely popular method called DBT to usual care in the treatment of “high risk suicidal veterans.” Need I tell you what they found?

groundhog

As the Ground-Hog-Day-like quest continues, another often replicated finding is ignored. One of the best predictors of the outcome of psychotherapy is the quality of the therapeutic relationship between the provider and recipient of care. That was one of the chief findings, for example, in both of the studies on alcohol treatment cited above (1, 2). Put simply, better relationship = improved engagement and effectiveness.

Sadly, but not surprisingly, research, writing, and educational opportunities focused on the alliance lags model and techniques. Consider this: slightly more than 55,000 books are in print on the latter subject, compared to a paltry 193 on the former. It’s mind-boggling, really. How could one of the most robust and replicated findings in psychotherapy be so widely ignored?

My colleague Daryl Chow is working hard to get beyond the “lip service” frequently paid to the therapeutic relationship. At the ICCE Professional Development training this last August, he presented findings from an ongoing series of studies aimed at helping clinicians improve their ability to engage, retain, and help people in psychotherapy by targeting training to the individual practitioners strengths and weaknesses. Not surprisingly, the results show slow and steady improvement in connecting with a broader, more diverse, and challenging group of clinical scenarios! Those in attendance learned how to build these skills into an individualized, professional development plan.

Trust me when I say, we won’t be ignoring this and other robust findings related to improving effectiveness at the upcoming ICCE intensive trainings in Chicago. Registration is open for both the Advanced and Supervision Intensives. Join us and colleagues from around the world.

Until next time,

Scott

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

The Cryptonite of Behavioral Health: Making Mistakes

May 7, 2011 By scottdm Leave a Comment

Most people readily agree that its important to “learn from mistakes.” In truth, however, few actually believe it. Mistakes are like cryptonite, making us feel and, more importantly, look stupid and weak. As a result, despite what we might advise others, we do our best to avoid making and admitting them. Such avoidance comes with a big cost: personal and professional growth stalls and even atrophies. We take on less challenging tasks, avoid taking risks, and give up more easily when confronted with situations that might expose our weaknesses. Far all that, falling a bit on “error-phobic” side of life is hardly an instance of irrationality. As Alina Tugend, author of Better by Mistake points out, “As much as people hate to make mistakes, they love pointing out the ones others have made.” Indeed, for most of us, the glee others take in pointing out our shortcomings only serves to compound our avoidance and deepen our public denial. And that’s what makes Tony Rousmaniere’s recent blogpost so unusual.

Briefly, Tony is a psychologist in private practice in San Francisco and Palo Alto. As he tells the story, he was riding in his car, listening to a recording of my presentation at the 2009 Evolution of Psychotherapy conference. The subject was “Achieving Clinical Excellence.” The message: routinely seeking feedback from clients about our mistakes decreases dropout rates and improves outcomes in psychotherapy. Tony took the message to heart. Unlike many of our peers who say they routinely ask clients for feedback, Tony actually downloaded the outcome and session rating scales and began formally asking his clients for feedback.

The story he relates makes for compelling reading, most of all because the feedback he received was not always easy to hear. And yet, he persisted, not only asking clients, but recording his work and then seeking input from colleagues. In the article, he gives step-by-step instructions for making use of the painful and sometimes confusing and contradictory feedback one receives.

Tony’s willingness to share his experience makes it tempting to say he is one brave soul. In actuality, he’s pragmatic. He placed outcomes over image. As he reports in the article, his dropout rate has plummeted and his outcomes improved. I say, “Bravo!”
________________________

Addendum

If you are thinking of writing to tell me that I misspelled the word, “cyptonite” (the accepted spelling is kryptonite), don’t bother. I know. I did it on purpose. See what I mean?!

Connecting, Learning, and Sharing: The ICCE at One Year

September 8, 2010 By scottdm 2 Comments

September 7, 2010
Chicago, Illinois USA

I can’t believe it. Summer is over. Kids are back in school. And, the International Center for Clinical Excellence (ICCE) is celebrating its one year anniversary! Time passes so quickly.

On August 25th, 2009, I blogged about the creation of a web-based community of clinicians using the latest Web2.0 technology where participants could learn from and share with each other. The ICCE website and community was officially launched the following December at the Evolution of Psychotherapy conference. In a few short months, ICCE had become the largest, international online community of professionals, researchers, and policy makers working to improve the quality and outcome of behavioral health services.

So much more has happened over the last year, including the development and standardization of a training package for clinicians and agencies interested in streamlining the implementation of Feedback-Informed Treatment (FIT), the annual “training of trainers” conference, and much more. Take a look at the video and see for yourself, and if you are not already a member, join us online today at: www.centerforclinicalexcellence.com.

A week or so ago, I received an email from Susanne Helfgott, the sister of concert pianist David Helfgott who, as you know, will be performing at the upcoming “Achieving Clinical Excellence” conference in Kansas City. She sent me a link to an interview with David that appeared on Australian morning TV. David is a perfect example of the theme of the conference: achieving superior performance under challenging circumstances. Check it out:

Error-centric Practice: How Getting it Wrong can Help you Get it Right

July 22, 2010 By scottdm 1 Comment

It’s an idea that makes intuitive sense but is simultanesouly unappealing to most people. I, for one, don’t like it. What’s more, it flies in the face of the “self-esteem” orientation that has dominated much of educational theory and practice over the last several decades. And yet, research summarized in a recent issue of Scientific American Mind is clear: people learn the most when conditions are arranged so that they have to make mistakes. Testing prior to learning, for example, improves recall of information learned after failing the pre-test regarding that same information. As is well known, frequent testing following learning and/or skill acquisition significantly enhances retention of knowledge and abilities. In short, getting it wrong can help you get it right more often in the future.

So, despite the short term risk to my self-esteem, “error-centric learning” is an evidence-based practice that I’m taking to heart. I’m not only applying the approach in the trainings I offer to mental health professionals–beginning all of my workshop with a fun, fact-filled quiz–but in my attempts to master a completely new skill in my personal life: magic and mind reading. And if the number of mistakes I routinely make in these pursuits is a reliable predictor of future success, well…I should be a master mind reading magician in little more than a few days.

Enough for now–back to practicing. Tonight, in my hotel room in Buffalo, New York, I’m working on a couple of new card tricks. Take a look at the videos of two new effects I recorded over the weekend. Also, don’t miss the interview with Cindy Voelker and John Catalino on the implementation of Feedback-Informed Treatment (FIT) at Spectrum Human Services here in Buffalo.

So you want to be a better therapist? Take a hike!

July 16, 2010 By scottdm Leave a Comment

How best to improve your performance as a clinician? Take the continuing education multiple-choice quiz:

a. Attend a two-day training;
b. Have an hour of supervision from a recognized expert in a particular treatment approach;
c. Read a professional book, article, or research study;
d. Take a walk or nap.

If you chose a, b, or c, welcome to the world of average performance! As reviewed on my blog (March 2010), there is exactly zero evidence that attending a continuing education event improves performance. Zero. And supervision? In the most recent review of the research, researchers Beutler et al. (2005) concluded, “Supervision of psychotherapy cases has been the major method of ensuring that therapists develop proficiency and skill…unfortunately, studies are sparse…and apparently, supervisors tend to rate highly the performance of those who agree with them” (p. 246). As far as professional books, articles, and studies are concerned–including those for which a continuing education or “professional development” point may be earned–the picture is equally grim. No evidence. That leaves taking a walk or nap!

K. Anders Ericsson–the leading researcher in the area of expertise and expert performance–points out the type and intensity of practice required to improve performance, “requires concentration that can be maintained only for limited periods of time.” As a result, he says, “expert performers from many domains engage in practice without rest for only around an hour…The limit…holds true for a wide range of elite performers in difference domains…as does their increased tendency to recperative take naps” (p.699, Erickson, 2006). By the way, Ericsson will deliver a keynote address at the upcoming “Achieving Clinical Excellence” conference. Sign up now for this event to reserve your space!

Two recently released studies add to the evidence base on rest and expertise. The first, conducted at the University of California, Berkeley by psychologist Matthew Walker found that a midday nap markedly improved the brain’s learning capacity. The second, published last week in the European Journal of Developmental Psychology, found that simply taking a walk–one where you are free to choose the speed–similarly improved performance on complex cognitive tasks.

So, there you go. I’d say more but I’m feeling sleepy.

The Road to Clinical Excellence is Paved with Practice, Mistakes, & Hard Work

May 19, 2010 By scottdm Leave a Comment

Last week, I received an email from David Claud. I’ve known Dave for the better part of a decade, having met–I believe–at a Ericksonian Conference in Florida where he lives and works. He and the crew at the Center for Family Service in Palm Beach County figure prominently in the history of routine outcome measure and feedback. After hearing me speak, Dave took the measures back to the center and, together with the staff, became one of the first agencies in the country to formally adopt and use the ORS and SRS. Additionally, data gathered at CFS was used in some of the initial validation studies of the measures. Finally, their own research, cited in the second edition of The Heart and Soul of Change document dramatic improvements in outcome as well as decreased lengths of stay, cancellation and no show rates (40, 40, and 25% respectively).

Anyway, in his email, Dave included a link to a recent article by Ann Hulbert in Slate magazine. I’m lucky to have friends like Dave and others who keep me informed and up-to-date. The title of the piece certainly got my attention: “The Dark Side of the New Theories of Success: What the New Success Books Don’t tell you about Superachievement.”

As readers of my blog know, I’ve been pouring through the literature on excellence over this last year in an attempt to understand why some clinicians achieve reliably better outcomes than others. I first wrote about our findings in an article titled, “Supershrinks: Learning from the Field’s Most Effective Practitioners” that appeared in the Psychotherapy Networker. Since then, I’ve continued to work and research, together with senior associates at the International Center for Clinical Excellence, to deepen and refine the “steps to clinical excellence” that any therapist could follow to improve performance.

Alas, I’m not alone in my interest in the literature on expertise. A number of books, starting with Gladwell’s delightfully engaging Outliers, have appeared in the last year or so on the subject, including: The Talent Code, Bounce: The Science of Success, The Genius in All of Us: Why Everything You’ve Been Told About Genetics, Talent, and IQ Is Wrong and my personal favorite Talent Is Overrated: What Really Separates World-Class Performers from Everybody Else. The appearance of so many books is interesting. With few exceptions (i.e., sports psychology), K. Anders Erickson and colleagues labored in viritual academic obscurity for decades formulating hypotheses, conducting research and assembling evidence. And then suddenly: boom! EVERYBODY is talking about their work.

Always wanting to “hear” both sides of the story, I immediately clicked on the link in Dave’s email and read the article. I was dumbfounded. Hulbert’s gripe about the recent spate of books is in fact the central point of each: achieving superior performance in any field is bloody hard work. “They don’t always do realistic justice to the grunt work they champion,” whines Hulbert, tending instead to, “gloss over the sweaty specifics….distracting us from how arduous, tedious, and dependent on adult pushiness it can be…[and] glamorizing its intensity.”

My response: “Oh, contraire mon fraire!”

All of the books and research studies point to the years of dedicated and painstaking work involved in achieving world class levels of performance across a variety of domains (sports, music, medicine, computer programming, and psychology). K. Ander’s Erickson–who will, by the way, be one of the keynote presenters at the upcoming “Achieving Clinical Excellence” conference–is fond of saying, “Unlike play, deliberate practice is not inherently motivating; and unlike work, it does not lead to immediate social and monetary rewards…and actually generates costs…”. Little wonder few of us–myself included–engage in it on any regular basis.

The question that begs an answer is, “why would anyone do it?” Consider the brief video clip below:

Impressive, huh? I can’t imagine the amount of time it must have taken to master such a performance. No camera tricks. Just plain old fashioned trial-and-error, practice, and hard work.

We are finding the same pattern among top performing therapists. In short, they have an “error-centric” approach to practice–constantly looking for what they do that doesn’t work and taking time to plan, identify and try alternatives, and then reflect and refine their process-improvement efforts. Such activity is cognitively taxing and, in most instances, not immediately rewarding (financially or otherwise). But there is more to the story. It turns out that superior performance is not a matter of working harder. Most of us work hard at our jobs. Rather, becoming a better clinician is about working smarter. Here, the literature on expertise provides clear, empirically-supported guidelines.

If you’re feeling inspired, why not pick up one of the books? Also, be sure and join us at the upcoming “Achieving Clinical Excellence” conference where the ideas and steps will be discussed in detail.

Finding Feasible Measures for Practice-Based Evidence

May 4, 2010 By scottdm Leave a Comment

Let’s face it. Clinicians are tired. Tired of paperwork (electronic or othrwise). When I’m out and about training–which is every week by the way–and encouraging therapists to monitor and measure outcomes in their daily work few disagree in principle. The pain is readily apparent however, the minute the paper version of the Outcome Rating Scale flashes on the screen of my PowerPoint presentation.

It’s not uncommon nowadays for clinicians to spend 30-50% of their time completing intake, assessment, treatment planning, insurance, and other regulatory forms. Recently, I was in Buffalo, New York working with a talented team of children’s mental health professionals. It was not uncommon, I learned, to spend most of two outpatient visits doing the required paperwork. When one considers that the modal number of sessions consumers attend is 1 and the average approximately 5 its hard not to conclude that something is seriously amiss.

Much of the “fear and loathing” dissipates when I talk about the time it usually takes to complete the Outcome and Session Ratings Scales. On average, filling out and scoring the measures takes about a minute a piece. Back in January, I blogged about research on the ORS and SRS, including a summary in PDF format of all studies to date. The studies make clear that the scales are valid and reliable. Most important, however, for day-to-day clinical practice, the ORS and SRS are also the most clinically feasible measures available.

Unfortunately, many of the measures currently in use were never designed for routine clinical practice–certainly few therapists were consulted. In order to increase “complaince” with such time consuming outcome tools, many agencies advise clinicians to complete the scales occasionally (e.g., “prime numbers” [5,7, 11 and so on]) or only at the beginning and end of treatment. The very silliness of such ideas will be immediately apparent to anyone who ever actually conducted treatment. Who can predict a consumer’s last session? Can you imagine a similar policy ever flying in medicine? Hey Doc, just measure your patient’s heart rate at the beginning and end of the surgery! Inbetween? Fahgetabotit. Moreover, as I blogged about from behind the Icelandic ash plume, the latest research strongly favors routine measurement and feedback. In real-world clinical settings feasibility is every bit as important as reliability and validity. Agency managers, regulators, and policy makers ignore it at their own (and their data’s) peril.

How did the ORS and SRS end up so brief and without any numbers? When asked at workshops, I usually respond, “That’s an interesting story.” And then continue, “I was in Israel teaching. I’d just finished a two day workshop on ‘What Works.'” (At the time, I was using and recommending the 10-item SRS and 45-item OQ).

“The audience was filing out of the auditorium and I was shutting down my laptop when the sponsor approached the dais. ‘Scott,’ she said, ‘one of the participants has a last question…if you don’t mind.'”

“Of course not,” I immediately replied.

“His name is Haim Omer. Do you know of him?”

Dr. Haim Omer

“Know him?” I responded, “I’m a huge fan!” And then, feeling a bit weak in the knees asked, “Has he been here the w h o l e time?”

Haim was as gracious as ever when he finally made it to the front of the room. “Great workshop, Scott. I’ve not laughed so hard in a long time!” But then he asked me a very pointed question. “Scott,” he said and then paused before continuing, “you complained a bit about the length of the two measures you are using. Why don’t you use a visual analog scale?”

“That’s simple Haim,” I responded, “It’s because I don’t know what a visual analog measure is!”

Haim described such scales in detail, gave me some examples (e.g., smiley and frowny faces), and even provided references. My review on the flight home reminded me of a simple neuropsychological assessment scale I used on internship called “The Line Bisection Task”–literally a straight line (a measure developed by my neuropsych supervisor, Dr. Tom Schenkenberg). And the rest is, as they say, history.

Learning, Mastery, and Achieving One’s Personal Best

April 25, 2010 By scottdm Leave a Comment

Dateline: Sunday, April 25th, 2010 Chicago, IL

There’s a feeling I get whenever I’m learning something new. It’s a combination of wonder and possibility. Even though I’ve been traveling and teaching full time for over 18 years, I still feel that get that feeling of excitement whenever I step on a plane: What will I see? Who will I meet? What will I learn? Move over Indiana Jones, you’ve got nothing on me!

On my desk right now are stacks of books on the subject of expertise and expert performance: The Talent Code: Greatness Isn’t Born. It’s Grown. Here’s How, The Genius in All of Us: Why Everything You’ve Been Told About Genetics, Talent, and IQ Is Wrong, The Cambridge Handbook of Creativity, The Psychology of Abilities, Competencies, and Expertise, Why We Make Mistakes: How We Look Without Seeing, Forget Things in Seconds, and Are All Pretty Sure We Are Way Above Average, and many, many more.

On the floor, arranged in neat little piles, are reams of research articles, newspaper clippings, and pages torn out of magazines. Literally, all on the same subject: how can we clinicians reliably achieve better results?

I’ve never been one to “settle” for very long. It’s the journey not the destination I find appealing. Thus, I began exploring the common factors when it became clear that treatment models contributed little if anything to outcome (click here to read the history of this transition). When I became convinced that the common factors held little promise for improving results in psychotherapy, I followed the lead of two my mentors, professor Michael Lambert (who I worked with as an undergraduate) and psychologist Lynn Johnson (who trained and supervised me), and began measuring outcome and seeking feedback. Now that research has firmly established that using measures of the alliance and outcome to guide service delivery significantly enhances performance (see the comprehensive summary of research to date below), I’ve grown restless again.

In truth, I find discussions about the ORS and SRS a bit, well, boring. That doesn’t mean that I’m not using or teaching others to use the measures. Learning about the tools is an important first step. Getting clinicians to actually use them is also important. And yet, there is a danger if we stop there.

Right now, we have zero evidence that measurement and feedback improves the performance of clinicians over time. More troubling, the evidence we do have strongly suggests that clinicians do not learn from the feedback they receive from outcome and alliance measures. Said another way, while the outcome of each particular episode of care improves, clinicians overall ability does not. And that’s precisely why I’m feeling excited–the journey is beginning…

…and leads directly to Kansas City where, on October 20-22nd, 2010, leading researchers and clinicians will gather to learn the latest, evidence-based information and skills for improving performance in the field of behavioral health. As of today, talented professionals from Australia, Sweden, Norway, Denmark, Germany, England, Israel, and the United States have registered for the international “Achieving Clinical Excellence” conference. Some common questions about the event include:

1. What will I learn?

How to determine your overall effectiveness and what specifically you can do to improve your outcomes.

2. Is the content new?

Entirely. This is no repeat of a basic workshop or prior conferences. You won’t hear the same presentations on the common factors, dodo verdict, or ORS and SRS. You will learn the skills necessary to achieve your personal best.

3. Are continuing education credits available?

Absolutely–up to 18 hours depending on whether you attend the pre-conference “law and ethics” training. By the way, if you register now, you’ll get the pre-conference workshop essentially free! Three days for one low price.

4. Will I have fun?

Guaranteed. In between each plenary address and skill building workshop, we’ve invited superior performers from sports, music, and entertainment to perform and inspire . If you’ve never been to Kansas City, you’ll enjoy the music, food, attractions, and architecture.

Feel free to email me with any questions or click here to register for the conference. Want a peak at some of what will be covered? Watch the video below, which I recorded last week in Sweden while “trapped” behind the cloud of volcanic ash. In it, I talk about the “Therapists Most Likely to Succeed.”

Measures and feedback 2016 from Scott Miller

Deliberate Practice, Expertise, & Excellence

February 3, 2010 By scottdm 2 Comments

Later today, I board United flight 908 on my way to workshops scheduled in Holland and Belgium. My routine in the days leading up to an international trip is always the same. I slowly gather together the items I’ll need while away: computer (check); european electric adapter (check); presentation materials (check); clothes (check). And, oh yeah, two decks of playing cards and close up performance mat.

That’s me (pictured above) practicing a “ribbon spread” in my hotel room following a day of training in Marion, Ohio. It’s a basic skill in magic and I’ve been working hard on this (and other moves using cards) since last summer. Along the way, I’ve felt both hopeful and discouraged. But I’ve kept on nonetheless taking heart from what I’m reading about skill acquisition.

Research on expertise indicates that the best performers (in chess, medicine, music, sports, etc.) practice every day of the week (including weekends) for up to four hours a day. Sounds tiring for sure. And yet, the same body of evidence shows that world class performers are able to sustain such high levels of practice because they view the acquisition of expertise as a long-term process. Indeed, in a study of children, researcher Gary McPherson found that the answer to a simple question determined the musical ability of kids a year later: “how long do you think you’ll play your instrument?” The factors that were shown to be irrelevant to performance level were: initial musical ability, IQ, aural sensitivity, math skills, sense of rhythm, income level, and sensorimotor skills.

The type of practice also matters. When researchers Kitsantas and Zimmerman studied the skill acquisition of experts, they found that 90% of the variation in ability could be accounted for by how the performers described their practice; the types of goals they set, how they planned and executed strategies, self-monitored, and adapted their performance in response to feedback.

So, I take my playing cards and close-up mat with me on all of my trips (both domestic and international). I don’t practice on planes. Gave that up after getting some strange stares from fellow passengers as they watched me repeat, in obsessive fashion, the same small segment of my performance over, and over, and over again. It only made matters worse if they found out I was a psychologist. I’d get that “knowing look,” that seemed to say, “Oh yeah.” Anyway, I also managed to lose a fair number of cards when the deck–because of my inept handling while trying to master some particular move–went flying all over the cabin (You can imagine why I’ve been less successful in keeping last year’s New Year resolution to learn to play the ukelele).

Once I’m comfortably situated in my room, the mat and cards come out and I work, practice a specific handling for up to 30 minutes followed by a 15-20 minute break. Believe it or not, learning–or perhaps better said, attempting to learn–magic has really been helpful in understanding the acquisition of expertise in my chosen field: psychology and psychotherapy. Together with my colleagues, we are translating our experience and the latest research on expertise into steps for improving the performance and outcome of behavioral health services. This is, in fact, the focus of the newest workshop I’m teaching, “Achieving Clinical Excellence.” It’s also the organizing theme of the ICCE Achieving Clinical Excellence conference that will be held in Kansas City, Kansas in October 2010. Click on the photo below for more information.

In the meantime, check out the two videos I’ve uploaded to ICCETV featuring two fun magic effects. And yes, of course, feedback is always appreciated!

New Year’s Resolutions: Progress Report and Future Plans

January 1, 2010 By scottdm Leave a Comment

One year ago today, I blogged about my New Year’s resolution to “take up the study of expertise and expert performance.” The promise marked a significant departure from my work up to that point in time and was not without controversy:

“Was I no longer interested in psychotherapy?”

“Had I given up on the common factors?

“What about the ORS and SRS?” and was I abandoning the field and pursue magic as a profession?”

Seriously.

The answer to all of the questions was, of course, an emphatic “NO!” At the same time, I recognized that I’d reached an empirical precipice–or, stated more accurately, dead end. The common factors, while explaining why therapy works did not and could never tell us how to work. And while seeking and obtaining ongoing feedback (via the ORS and SRS) had proven successful in boosting treatment outcomes, there was no evidence that the practice had a lasting impact on the professionals providing the service.

Understanding how to improve my performance as a clinician has, as is true of many therapists, been a goal and passion from the earliest days of my career. The vast literature on expertise and expert performance appeared to provide the answers I’d long sought. In fields as diverse as music and medicine, researchers had identified specific principles and methods associated with superior performance. On January 2nd, 2009, I vowed to apply what I was learning to, “a subject I know nothing about…put[ting] into practice the insights gleaned from the study of expertise and expert performance.”

The subject? Magic (and the ukulele).

How have I done? Definitely better than average I can say. In a column written by Barbara Brotman in today’s Chicago Tribune, psychologist Janine Gauthier notes that while 45% of people make New Year’s resolutions, only 8% actually keep them! I’m a solid 50%. I am still studying and learning magic–as attendees at the 2009 “Training of Trainers” and my other workshops can testify. The uke is another story, however. To paraphrase 1988 Democratic vice-presidential candidate, Lloyd Bentsen , “I know great ukulele players, and Scott, you are no Jake Shimabukuro.”

I first saw Jake Shimabukuro play the ukulele at a concert in Hawaii. I was in the islands working with behavioral health professionals in the military (Watch the video below and tell me if it doesn’t sound like more than one instrument is playing even though Jake is the only one pictured).

Interestingly, the reasons for my success with one and failure with the other are as simple and straightforward as the principles and practices that researchers say account for superior (and inferior) performance. I promise to lay out these findings, along with my experiences, over the next several weeks. If you are about to make a New Year’s resolution, let me give you step numero uno: make sure your goal/resolution is realistic. I know, I know…how mundane. And yet, while I’ve lectured extensively about the relationship between goal-setting and successful psychotherapy for over 15 years, my reading about expert performance combined with my attempts to master two novel skills, has made me aware of aspects I never knew about or considered before.

Anyway, stay tuned for more. In the meantime, just for fun, take a look at the video below from master magician Bill Malone. The effect he is performing is called, “Sam the Bellhop.” I’ve been practicing this routine since early summer, using what I’ve learned from my study of the literature on expertise to master the effect (Ask me to perform it for you on break if you happen to be in attendance at one of my upcoming workshops).

International "Achieving Clinical Excellence" Conference

September 12, 2009 By scottdm 3 Comments

Mark your calendars! The International Center for Clinical Excellence is pleased to announce the “Achieving Clinical Excellence” (ACE) conference to be held at the Westin Hotel in Kansas City, Missouri on October 20-22nd, 2010.

K. Anders Erickson, Ph.D., the editor of The Cambridge Handbook of Expertise and Expert Performance and recognized “expert on experts,” will keynote the event. Through a combination of plenary presentations and intensive workshops, an internationally renowned faculty of researchers and educators, including Scott D. Miller, Ph.D. and John Norcross, Ph.D., will help participants discover the means to achieve excellence in clinical practice, leadership, ethics, and personal care.

Attendees will also meet and learn directly from internationally ranked performers from a variety of professions, including medicine, science, music, entertainment, and sports. As just one example, the Head Coach of the Olympic, Gold-Medal-winning Women’s volleyball team, Hugh McCutcheon, will present at the conference. In addition to a pre-conference day on ethics and law, internationally renowned concert pianist David Helfgott, whose heart-warming story was featured in the award winning film Shine, will perform on Thursday evening, October 21st. Join us in Kansas City for three days of science, skill building, and inspiration.

Excellence in Behavioral Health in Arizona

August 29, 2009 By scottdm 4 Comments

For those of you are friends with me on Facebook (and if you’re not already, please do as it’s a blast), you know I was teaching at the 41st Annual Southwestern School for Behavioral Health Studies.

First, let me express my appreciation to the Board and Michelle Brown for bringing me to Tucson to present on “Achieving Clinical Excellence.” If you’ve never attended this particular event, mark your calendar for next year.

This year, the conference theme was “Staying relevant in the 21st Century.” By the time I took the microphone to speak, 350 dedicated professionals from all around the country were on their fifth and last day of the conference. What a crowd! Excited, energized, and dedicated to doing their personal best for consumers of behavioral health services.

I’ve already heard from several folks who were in attendance, relating a personal or clinical story illustrating the principles and practices I talked about during my presentations. Thanks very much for sharing these stories with me.

Meanwhile, you can find the slides I used yesterday below. Feel free to download, use, and forward them to interested friends and colleagues.

In parting, I thought I’d relate one of my own experiences of excellence. It happened two years ago when I was presenting at this same conference. That morning, as I reached into my suitcase to get my clothes, I quickly discovered I’d left my slacks at home! Like this year, I’d worn shorts, a T-shirt, and flip flops on the plane, so no help there. Panicked, I called my co-presenter, Dr. David Mee-Lee—after all, he is a psychiatrist. He offered me an extra pair he had. It was a great idea that we both knew would never work since David is about 8” shorter than me. So I called the front desk. Now, the venue for the SWS for Behavioral Health is at the beautiful Loews Ventana Canyon Resort. It’s nestled in the mountains, miles from the city. Plus it was 7 am. My presentation started in an hour. No store was open at this hour, not even the resort gift shop. But that didn’t stop the dedicated staff at Loews. Within minutes, the manager of the resort shop was at the hotel. We found some pants and a shirt to match but the pants were 6 inches too long. “Not to worry,” the store manager said, she’d take care of it. Within minutes someone from the housekeep staff—not a tailor or seamstress, just a kind, dedicated person—was cutting and sewing the hem on the pants. I made it to the conference hall to present with 5 minutes to spare! I’ve never forgotten their kindness and dedication.

Achieving Clinical Excellence Handouts from Scott Miller

Expertise and Excellence: What it Takes to Improve Therapeutic Effectiveness

April 2, 2009 By scottdm 1 Comment

If you’ve been following my website and the Top Performance Blog you know that my professional interests over the last couples of years have been shifting, away from psychotherapy, the common factors, and feedback and toward the study of expertise and excellence.

Studying this literature (click here for an interesting summary), makes clear that the factors responsible for superior performance are the same regardless of the specific endeavor one sets out to master. The chief principle will come as no surprise: You have to work harder than everyone else at whatever you want to be best at.

In other words, you have to practice.

Hard work is not enough, however. Research shows that few attain international status as superior performers without access to high levels of support and detailed instruction from exceptional teachers over sustained periods of time. In the massive “Cambridge Handbook of Expertise and Expert Performance,” Feltovich et al. note, “Research on what enabled some individuals to reach expert performance, rather than mediocre achievement, revealed that expert and elite performers seek out teachers and engage in specifically designed training activities…that provide feedback on performance, as well as opportunities for repetition and gradual refinement” (p. 61).

What makes for a “good” teacher? Well, in essence, that is what the “Top Performance” blog is all about. I’m going on a journey, a quest really. I’ve decided to take up two hoppies–activities I’ve always had a interest in but never had to the time to study seriously–magic and the ukelele.

Practicing is already proving challenging. Indeed, the process reminds me a lot of when I started out in the field of psychology. In a word, its daunting. There are literally thousands of “tricks” and “songs,” (as there are 100’s of treatment models), millions of how-to books, videos, and other instructional media (just as in the therapy world), as well as experts (who, similar to the field of psychotherapy, offer a wide and bewildering array of different and oftentimes contractory opinions).

By starting completely over with subjects I know nothing about, I hope to put into practice the insights gleaned from our study of expertise and expert performance, along the way reporting the challenges, triumphs and failures associated with learning to master new skills. I’ll review performances, instructional media (live, printed, DVD, etc), and the teachers I met. Stay tuned.