“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

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

The Asch Effect: The Impact of Conformity, Rebelliousness, and Ignorance in Research on Psychology and Psychotherapy

December 3, 2016 By scottdm 5 Comments

asch-1
Consider the photo above. If you ever took Psych 101, it should be familiar. The year is 1951. The balding man on the right is psychologist, Solomon Asch. Gathered around the table are a bunch of undergraduates at Swarthmore College participating in a vision test.

Briefly, the procedure began with a cardboard printout displaying three lines of varying length. A second containing a single line was then produced and participants asked to state out loud which it best matched. Try it for yourself:

Well, if you guessed “C,” you would have been the only one to do so, as all the other participants taking the test on that day chose “B.” As you may recall, Asch was not really assessing vision. He was investigating conformity. All the participants save one were in on the experiment, instructed to choose an obviously incorrect answer in twelve out of eighteen total trials.

The results? not-me

On average, a third of the people in the experiment went along with the majority, with seventy-five percent conforming in at least one trial.

Today, practitioners face similar pressures—to go along with the assertion that some treatment approaches are more effective than others.

Regulatory bodies, including the Substance Abuse and Mental Health Services Administration in the United States, and the National Institute for Health and Care Excellence, are actually restricting services and limiting funding to approaches deemed “evidence based.” The impact on publicly funded mental health and substance abuse treatment is massive.

So, in the spirit of Solomon Asch, consider the lines below and indicate which treatment is most effective?

If your eyes tell you that the outcomes between competing therapeutic approaches appear similar, you are right. Indeed, one of the most robust findings in the research literature over the last 40 years is the lack of difference in outcome between psychotherapeutic approaches.

The key to changing matters is speaking up! In the original Asch experiments, for example, the addition of even one dissenting vote reduced conformity by 80%! And no, you don’t have to be a researcher to have an impact. On this score, when in a later study, a single dissenting voter wearing thick glasses—strongly suggestive of poor visual acuity—was added to the group, the likelihood of going along with the crowd was cut in half.

That said, knowing and understanding science does help. In the 1980’s, two researchers found that engineering, mathematics, and chemistry students conformed with the errant majority in only 1 out of 396 trials!

What does the research actually say about the effectiveness of competing treatment approaches?

You can find a review in the most current review of the research in the latest issue of Psychotherapy Research–the premier outlet for studies about psychotherapy. It’s just out and I’m pleased and honored to have been part of a dedicated and esteemed group scientists that are speaking up. In it, we review and redo several recent meta-analyses purporting to show that one particular method is more effective than all others. Can you guess which one?

The stakes are high, the consequences, serious. Existing guidelines and lists of approved therapies do not correctly represent existing research about “what works” in treatment. More, as I’ve blogged about before, they limit choice and effectiveness without improving outcome–and in certain cases, result in poorer results. As official definitions make clear, “evidence-based practice” is NOT about applying particular approaches to specific diagnoses, but rather “integrating the best available research with clinical expertise in the context of patient characteristics, culture, and preferences” (p. 273, APA, 2006).

Read it and speak up!

Until next time,

Scott

Scott D. Miller, Ph.D.
Director, 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

Evidence-based practice or practice-based evidence? Article in the Los Angeles Times addresses the debate in behavioral health

January 18, 2010 By scottdm Leave a Comment

January 11th, 2010

“Debate over Cognitive & Traditional Mental Health Therapy” by Eric Jaffe

The fight debate between different factons, interest groups, scholars within the field of mental health hit the pages of the Los Angeles Times this last week. At issue? Supposedly, whether the field will become “scientific” in practice or remain mired in traditions of the past. On the one side are the enthusiastic supporters of cognitive-behavioral therapy (CBT) who claim that existing research provides overwhelming support for the use of CBT for the treatment of specific mental disorders. On the other side are traditional, humanistic, “feel-your-way-as-you-go” practitioners who emphasize quality over the quantitative.

My response? Spuds or potatoes. Said another way, I can’t see any difference between the two warring factions. Yes, research indicates the CBT works. That exact same body of literature shows overwhelmingly, however, that any and all therapeutic approaches intended to be therapeutic are effective. And yes, certainly, quality is important. The question is, however, “what counts as quality?” and more importantly, “who gets to decide?”

In the Los Angeles Times article, I offer a third way; what has loosely been termed, “practice-based evidence.” The bottom line? Practitioners must seek and obtain valid, reliable, and ongoing feedback from consumers regarding the quality and effectiveness of the services they offer. After all, what person following unsuccessful treatment would say, “well, at least I got CBT!” or, “I’m sure glad I got the quality treatment.”

DODO BIRD HYPOTHESIS PROVEN FALSE! Study of PTSD finally proves Wampold, Miller, and other "common factor" proponents wrong

January 8, 2010 By scottdm 3 Comments

Researchers Anke Ehlers, Jonathon Bisson, David Clark, Mark Creamer, Steven Pilling, David Richards, Paula Schnurr, Stuart Turner, and William Yule have finally done it! They slayed the “dodo.” Not the real bird of course–that beast has been extinct since the mid to late 17th century but rather the “dodo bird” conjecture first articulated by Saul Rozenzweig, Ph.D. in 1936. The idea that all treatment approaches work about equally well has dogged the field–and driven proponents of “specific treatments for specific disorders” positively mad. In a soon to be published article in Clinical Psychology Review, the authors claim that bias, overgeneralization, lack of transparency, and poor judgement account for the finding that “all therapeutic approaches work equally well for people with a diagnosis of PTSD” reported in a meta-analysis by Benish, Imel, & Wampold (2008).

I guess this means that a public admission by me, Wampold, and other common factors researchers is in order…or maybe not! Right now, we are writing a response to the article. All I can say at this point is, “unbelievable!” As soon as it becomes available, you’ll find it right here on this blog. I’ll be drawing inspiration from Saul Rosenzweig who passed away in 2004. It was such an honor to meet him. Still working at 96 years of age.

Common versus Specific Factors and the Future of Psychotherapy: A Response to Siev and Chambless

October 31, 2009 By scottdm 4 Comments

Early last summer, I received an email from my long time friend and colleague Don Meichenbaum alerting me to an article published in the April 2009 edition of the Behavior Therapist–the official “newsletter” of the Association for Behavioral and Cognitive Therapies–critical of the work that I and others have done on the common factors.

Briefly, the article, written by two proponents of the “specific treatments for specific disorders” approach to “evidence-based practice” in psychology, argued that the common factors position–the idea that the efficacy of psychotherapy is largely due to shared rather than unique or model-specific factors–was growing in popularity despite being based on “fallacious reasoning” and a misinterpretation of the research.

Although the article claimed to provide an update on research bearing directly on the validity of the “dodo verdict”–the idea that all treatment approaches work equally well–it simply repeated old criticisms and ignored contradictory, and at times, vast evidence. Said another way, rather than seizing the opportunity they were given to educate clinicians and address the complex issues involved in questions surrounding evidence-based practice, Siev and Chambless instead wrote to “shore up the faithful.” “Do not doubt,” authors Siev and Chambless were counseling their adherents, “science is on our side.”

That differences and tensions exist in the interpretation of the evidence is clear and important. At the same time, more should be expected from those who lead the field. You read the articles and decide. The issues at stake are critical to the future of psychotherapy. As I will blog about next week, there are forces at work in the United States and abroad that are currently working to limit the types of approaches clinicians can employ when working with clients. While well-intentioned, available evidence indicates they are horribly misguided. Once again, the question clinicians and consumers face is not “which treatment is best for that problem,” but rather “which approach “fits with, engages, and helps” the particular consumer at this moment in time?”

Behavior Therapist (April 2009) from Scott Miller

Dissemination of EST’s (November 2009) from Scott Miller

History doesn’t repeat itself,

September 20, 2009 By scottdm 2 Comments

Image via Wikipedia

“History doesn’t repeat itself,” the celebrated American author, Mark Twain once observed, “but it does rhyme.” No better example of Twain’s wry comment than recurring claims about specifc therapeutic approaches. As any clinician knows, every year witnesses the introduction of new treatment models. Invariably, the developers and proponents claim superior effectivess of the approach over existing treatments. In the last decade or so, such claims, and the publication of randomized clinical trials, has enabled some to assume the designation of an “evidence-based practice” or “empirically supported treatment.” Training, continuing education, funding, and policy changes follow.

Without exception, in a few short years, other research appears showing the once widely heralded “advance” to be no more effective than what existed at the time. Few notice, however, as professional attention is once again captured by a “newer” and “more improved” treatment model. Studies conducted by my colleagues and I (downloadable from the “scholarly publications” are of my website), document this pattern with treatments for kids, alcohol abuse and dependence, and PTSD over the last 30 plus years.

As folks who’ve attended my recent workshops know, I’ve been using DBT as an example of approaches that have garnered significant professional attention (and funding) despite a relatively small number of studies (and participants) and no evidence of differential effectiveness. In any event, the American Journal of Psychiatry will soon publish, “A Randomized Trial of Dialectical Behavior Therapy versus General Psychiatric Management for Borderline Personality Disorder.”

As described by the authors, this study is “the largest clinical trial comparing dialectical behavior therapy and an active high-standard, coherent, and principled approach derived from APA guidelines and delivered by clinicians with expertise in treating borderline personality disorder.”

And what did these researchers find?

“Dialectical behavior therapy was not superior to general psychiatric management with both intent-to-treat and per-protocol analyses; the two were equally effective across a range of outcomes.” Interested readers can request a copy of the paper from the lead investigator, Shelley McMain at: Shelley_McMain@camh.net.

Below, readers can also find a set of slides summarizing and critiquing the current research on DBT. In reviewing the slides, ask yourself, “how could an approach based on such a limited and narrow sample of clients and no evidence of differential effectives achieved worldwide prominence?”

Of course, the results summarized here do not mean that there is nothing of value in the ideas and skills associated with DBT. Rather, it suggests that the field, including clinicians, researchers, and policy makers, needs to adopt a different approach when attempting to improve the process and outcome of behavioral health practices. Rather than continuously searching for the “specific treatment” for a “specific diagnosis,” research showing the general equivalence of competing therapeutic approaches indicates that emphasis needs to be placed on: (1) studying factors shared by all approaches that account for success; and (2) developing methods for helping clinicians identify what works for individual clients. This is, in fact, the mission of the International Center for Clinical Excellence: identifying the empirical evidence most likely to lead to superior outcomes in behavioral health.

Dbt Handouts 2009 from Scott Miller

The Evolution of Psychotherapy: Twenty-Five Years On

September 1, 2009 By scottdm Leave a Comment

In 1985, I was starting my second year as a doctoral student at the University of Utah. Like thousands of other graduate students, I’d watched the “Gloria” films. Carl Roger, Albert Ellis, Fritz Perls were all impressive if not confusing given their radically different styles. I also knew that I would soon have the opportunity to meet each one live and in person. Thanks to Jeffrey K. Zeig, Ph.D. and the dedicated staff at the Milton H. Erickson Foundation, nearly every well known therapist, guru, and psychotherapy cult-leader would gather for the first mega-conference ever held, the field’s Woodstock: The Evolution of Psychotherapy.

Having zero resources at my disposal, I wrote to Jeff asking if I could volunteer for the event in exchange for the price of admission. Soon after completing the multiple-page application, I received notice that I had been chosen to work at event. I was ecstatic. When December finally came around, I loaded up my old car with food and a sleeping bag and, together with a long time friend Paul Finch, drove from Salt Lake City to Phoenix. What can I say? It was alternately inspiring and confusing. I learned so very much and also felt challenged to make sense of the disparate theories and approaches.

At that time, I had no idea that some twenty years later, I’d receive a call from Jeff Zeig asking me to participate as one of the “State of the Art” faculty for the 2005 Evolution Conference. Actually, I can remember where I was when my cell phone rang: driving on highway 12 on southwest Michigan toward Indian Lake, where my family has a small cottage. In any event, I’m looking forward to attending and presenting at the 2009 conference. I encourage all of the readers of my blog to attend. Registration information can be found at the conference website: www.evolutionofpsychotherapy.com. The highlight of the event for me is a debate/discussion I’ll be having with my friend and colleague, Don Meichenbaum, Ph.D. on the subject of “evidence-based practice.”

One more thing. To get a feel for the event, I included a clip of a panel discussion from the first Evolution conference featuring Carl Rogers. Not trying to be hyperbolic, but listening to Rogers speak changed my life. I won’t bore you with the details but the night following his presentation, I had a dream…(more later)…