Making Sense of Client Feedback

January 4, 2021 By scottdm Leave a Comment

I have a guilty confession to make. I really like Kitchen Nightmares. Even though the show finished its run six L O N G years ago, I still watch it in re-runs. The concept was simple. Send one of the world’s best known chefs to save a failing restaurant.

Each week a new ~~disaster~~ establishment was featured. A fair number were dives — dirty, disorganized messes with all the charm and quality of a gas station lavatory. It wasn’t hard to figure out why these spots were in trouble. Others, by contrast, were beautiful, high-end eateries whose difficulties were not immediately obvious.

Of course, I have no idea how much of what we viewers saw was real versus contrived. Regardless, the answers owners gave whenever Ramsey asked for their assessment of the restaurant never failed to surprise and amuse. I don’t recall a single episode where the owners readily acknowledged having any problems, other than the lack of customers! In fact, most often they defended themselves, typically rating their fare “above average,” — a 7 or higher on a scale from 1 to 10.

Contrast the attitude of these restaurateurs with pop music icon Billy Joel. When journalist Steve Croft asked him why he thought he’d been so successful, Joel at first balked, eventually answering, “Well, I have a theory, and it may sound a little like false humility, but … I actually just feel that I’m competent.” Whether or not you are a fan of Joel’s sound, you have to admit the statement is remarkable. He is one of the most successful music artists in modern history, inducted into the Rock and Roll Hall of Fame, winning a Grammy Legend Award, earning four number one albums on the Billboard 200, and consistently filling stadiums of adoring fans despite not having released a new album since 1993! And yet, unlike those featured on Kitchen Nightmares, he sees himself as merely competent, adding “when .. you live in an age where there’s a lot of incompetence, it makes you appear extraordinary.”

Is humility associated with success? Well, turns out, it is a quality possessed by highly effective effective therapists. Studies not only confirm “professional self-doubt” is a strong predictor of both alliance and outcome in psychotherapy but actually a prerequisite for acquiring therapeutic expertise (1, 2). To be clear, I’m not talking about debilitating diffidence or, as is popular in some therapeutic circles, knowingly adopting a “not-knowing” stance. As researchers Hook, Watkins, Davis, and Owen describe, its about feedback — specifically, “valuing input from the other (or client) … and [a] willingness to engage in self-scrutiny.”

Low humility, research shows, is associated with compromised openness (3). Sound familiar? It is the most common reaction of owners featured on Kitchen Nightmares. Season 5 contained two back-to-back episodes featuring Galleria 33, an Italian restaurant in Boston, Massachusetts. As is typical, the show starts out with management expressing bewilderment about their failing business. According to them, they’ve tried everything — redecorating, changing the menu, lowering prices. Nothing has worked. To the viewer, the problem is instantly obvious: they don’t take kindly to feedback. When one customer complains their meal is “a little cold,” one of the owners becomes enraged. She first argues with Ramsey, who agrees with the customer’s assessment, and then storms over to the table to confront the diner. Under the guise of “just being curious and trying to understand,” she berates and humiliates them. It’s positively cringeworthy. After numerous similar complaints from other customers — and repeated, uncharacteristically calm, corrective feedback from Ramsey — the owner experiences a moment of uncertainty. Looking directly into the camera she asks, “Am I in denial?” The thought is quickly dismissed. The real problem, she and the co-owner decide, is … (wait for it) …

Ramsey and their customers! Is anyone surprised the restaurant didn’t survive?

Such dramatic examples aside, few therapists would dispute the importance of feedback in psychotherapy. How do I know? I’ve meet thousands over the last two decades as I traveled the world teaching about feedback-informed treatment (FIT). Research on implementation indicates a far bigger challenge is making sense of the feedback one receives (4, 5, 6) Yes, we can (and should) speak with the client — research shows therapists do that about 60% of the time when they receive negative feedback. However, like an unhappy diner in an episode of Kitchen Nightmares, they may not know exactly what to do to fix the problem. That’s where outside support and consultation can be critical. Distressingly, research shows, even when clients are deteriorating, therapists consult with others (e.g., supervisors, colleagues, expert coaches) only 7% of time.

Since late summer, my colleagues and I at the International Center for Clinical Excellence have offered a series of intimate, virtual gatherings of mental health professionals. Known as the FIT Cafe, the small group (10 max) gets together once a week to finesse their FIT-related skills and process client feedback. It’s a combination of support, sharing, tips, strategizing, and individual consultation. As frequent participant, psychologist Claire Wilde observes, “it has provided critical support for using the ORS and SRS to improve my therapeutic effectiveness with tricky cases, while also learning ways to use collected data to target areas for professional growth.”

The next series is fast approaching, a combination of veterans and newbies from the US, Canada, Europe, Scandinavia, and Australia. Learn more or register by clicking here or on the icon to the right.

Not ready for such an “up close and personal” experience? Please join the ICCE online discussion forum. It’s free. You can connect with knowledgeable and considerate colleagues working to implement FIT and deliberate practice in their clinical practice in diverse settings around the world.

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

Scott

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

The Expert on Expertise: An Interview with K. Anders Ericsson

June 23, 2020 By scottdm 13 Comments

I can remember exactly where I was when I first “met” Swedish psychologist, K. Anders Ericsson. Several hours into a long, overseas flight, I discovered someone had left a magazine in the seat pocket. I never would have even given the periodical a second thought had I not seen all the movies onboard — many twice. Its target audience wasn’t really aimed at mental health professionals: Fortune.

Bored, I mindlessly thumbed through the pages. Then, between articles about investing and pictures of luxury watches, was an article that addressed a puzzle my colleagues and I had been struggling to solve for some time: why were some therapists more consistently effective than others?

In 1974, psychologist David F. Ricks published the first study documenting the superior outcomes of a select group of practitioners he termed, “supershrinks.” Strangely, thirty-years would pass before another empirical analysis appeared in the literature.

The size and scope of the study by researchers Okiishi, Lambert, Nielsen, and Ogles (2003), dwarfed Rick’s, examining results from standardized measures administered on an ongoing basis to over 1800 people treated by 91 therapists. The findings not only confirmed the existence of “supershrinks,” but showed exactly just how big the difference was between them and average clinicians. Clients of the most effective experienced a rate of improvement 10 times greater than the average. Meanwhile, those treated by the least effective, ended up feeling the same or worse than when they’d started — even after attending 3 times as many sessions! How did the best work their magic? The researchers were at a loss to explain, ending their article calling it a “mystery” (p. 372).

By this point, several years into the worldwide implementation of the outcome and session rating scales, we’d noticed (and, as indicated, were baffled by) the very same phenomenon. Why were some more effective? We pursued several lines of inquiry. Was it their technique? Didn’t seem to be. What about their training? Was it better or different in some way? Frighteningly, no. Experience level? Didn’t matter. Was it the clients they treated? No, in fact, their outcomes were superior regardless of who walked through their door. Could it be that some were simply born to greatness? On this question, the article in Fortune, was clear, “The evidence … does not support the [notion that] excelling is a consequence of possessing innate gifts.”

So what was it?

Enter K. Anders Ericsson. His life had been spent studying great performers in many fields, including medicine, mathematics, music, computer programming, chess, and sports. The best, he and his team had discovered, spent more time engaged in an activity they termed, “deliberate practice” (DP). Far from mindless repetition, it involved: (1) establishing a reliable and valid assessment of performance; (2) the identification of objectives just beyond an individual’s current level of ability; (3) development and engagement in exercises specifically designed to reach new performance milestones; (4) ongoing corrective feedback; and (5) successive refinement over time via repetition.

I can remember how excited I felt on finishing the article. The ideas made so much intuitive sense. Trapped in a middle seat, my row-mates on either side fast asleep, I resolved to contact Dr. Ericsson as soon as I got home.

Anders replied almost immediately, giving rise to a decade and a half of correspondence, mentoring, co-presenting, and friendship. And now he is gone. To say I am shocked is an understatement. I’d just spoken with him a few days prior to his death. He was in great spirits, forever helpful and supportive, full of insights and critical feedback. I will miss him — his warmth, encouragement, humility, and continuing curiosity. If you never met him, you can get a good sense of who he was from the interview I did with him two weeks ago. Let me know your thoughts in the comments below.

Until next time, I wish you health, peace, and progress.

Scott

Mountains and Molehills, or What the JFK Assasination and the Therapeutic Relationship have in Common?

April 14, 2019 By scottdm 5 Comments

Over the last 10 days or so, I’ve been digesting a recently published article on the therapeutic alliance — reading, highlighting, tracking down references, rereading, and then discussing the reported findings with colleagues and a peer group of fellow researchers. It’s what I do.

The particular study has been on my “to be read” pile for the better part of a year, maybe more. Provocatively titled, “Is the Alliance Really Therapeutic?” it promises to answer the question in light of “recent methodological advances.”

I know this will sound strange — at least at first — but throughout, I kept finding myself thinking of the assasination of the 35th President of the United States, John F. Kennedy. Bear with me as I explain.

I personally remember the shock and grief of this event. Although I was only six years old at the time, I have vivid memories, watching televised segments of the funeral procession down Pennsylvania Avenue under a grey, overcast and rainy sky. “Why?” my family and the Nation asked, and “How?”

You likely know the rest of the story. Within hours, a suspect was arrested. Two days later, he was murdered on live TV by a Dallas nightclub owner. Ever since, events surrounding the assasination have been the subject of heated debate. More than 2,000 books have been published, each offering a different theory of the event — a veritable “Who’s who” of suspects, including but not limited to the Soviet Union, CIA, Mafia, Cuban government, and Vice President of the United States.

Whatever you might believe, it’s hard to fault the majority of Americans — 61% in the most recent polls — who seriously doubt that the slight, unemployed, thrice court-martialed former marine, acted alone. To many, in fact, it’s simply inconceivable. And, that’s the point. As investigative reporter, Gerald Posner, observed in his book Case Closed, “The notion that a misguided sociopath … wreaked such havoc [makes] the crime seem senseless” (p. xviii). By contrast, concluding there was an elaborate plot involving important and powerful people, embues Kennedy’s death with meaning equal to his stature and significance in the mind of the public.

Said another way, maybe, just maybe, in our attempts to reconcile the facts with our feelings, we made a molehill into a mountain … which brings me back to the article about the therapeutic relationship. The empirical evidence is clear: the quality of the alliance between client and clinician is one of the most potent and reliable predictors of successful psychotherapy.

According to the most recent and thorough review of the empirical literature:

Better alliances result in better outcomes when working with individuals, groups, couples and families, children and adolescents, and mandated/involuntary clients;
With regard to specific qualities, better outcomes result the more therapists:
- Like, value, and care for the client (known as the “real” relationship, it contributes more to outcome than relational elements associated with the doing of therapy. Effect Size [E.S.] ~ .80 );
- Communicate their understanding of and compassion for the client (E.S. ~ .58);
- Collaborate with the client regarding the focus (e.g., problem) and goals for treatment (E.S. ~ .49);
- Present as accessible, approachable, and sincere (i.e., congruent and genuine, E.S. ~ .46)
- Demonstrate respect, warmth, and positive regard (E.S. ~ .36);
- Seek and utilize formal feedback regarding the client’s experience of progress and the therapeutic alliance (E.S. ~ .33 – .49);
- Express emotions and generate hope and expectancy of positive results (E.S. = .56 & .36, respectively).

Sounds pretty straightforward and simple to me. In a relatively efficient fashion (worldwide the average number of visits is around 5 visits), we establish relationships with people that result in significant improvements in their well being. With regard to the latter, as reviewed many times on my blog, the average recipient of psychotherapy is better off than 80% of those with similar problems that do not.

That said, is the relationship we offer people so astounding that it forever changes them? Judging by the article’s dense language and near inpenetrable statistical procedures, you’d assume so. Yet ultimately, it fails to show as much, focusing instead on defining characteristics and qualities of clients amenable to a particular theoretical orientation rather than the relationship.

Now, before you object, please note, I did not say relationships — in life or in therapy — were easy. But therein lies the risk. Challenging or difficult (e.g., a lone gunman taking out a beloved and powerful figure) is equated with complicated (i.e., must have been a conspiracy). Add to that the tendency of professionals to embue their interactions with clients with life-changing significance and voila! we are poised, as a field, to make mountains out of molehills. Nowhere is this more easy to see than in the language we use to describe our work. We “treat,” have “countertransference reactions,” “repair ruptures,” and form “therapeutic alliances” rather than connect, experience frustration (or other feelings), and develop relationships.

It’s time to embrace what 50 years of evidence plainly shows: yes, we offer an important service, an opportunity for someone to feel understood, get support while going through a difficult period, solve problems, learn new and different ways for approaching life’s challenges, and every once in a while –maybe one in a hundred — something more. To do that, what’s needed is humility and a relentless focus on the fundamentals. Given the history of our field, that alone will prove hard enough.

Embracing the evidence and focusing on fundamentals is precisely what we’ll be doing, by the way, at the Deliberate Practice Intensive this summer coming August in Chicago. Join colleagues from around the world to learn how to use this simple (not easy) way for improving your effectiveness! For more info, click here or on the banner below.

Until next time,

Scott

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

Routine Outcome Monitoring and Deliberate Practice: Fad or Phenomenon?

March 26, 2019 By scottdm 1 Comment

Would you believe me if I told you there was a way you could more than double the chances of helping your clients? Probably not, eh? As I’ve documented previously, claims abound regaring new methods for improving the outcome of psychotherapy. It’s easy to grow cynical.

And yet, findings from a recent study document when clinicians add this particular practice to their clinical work, clients are actually 2.5 times more likely to improve. The impact is so significant, a review of research emerging from a task force of the American Psychological Association concluded, “it is among the most effective ways available to services to improve outcomes.”

That said, there’s a catch.

The simple nature of this “highly rated,” transtheoretical method belies a steep learning curve. In truth, experience shows you can learn to do it — the mechanics — in a few minutes.

But therein lies the problem. The empirical evidence makes clear successful implementation often takes several years. This latter fact explains, in part, why surveys of American, Canadian, and Australian practitioners reveal that, while being aware of the method, they rarely integrate it into their work.

What exactly is the “it” being referred to?

Known by the acronym FIT, feedback-informed treatment (FIT) involves using standardized measures to formally and routinely solicit feedback from clients regarding progress and the quality of the therapeutic relationship, and then using the resulting information to inform and improve care.

The ORS and SRS are examples of two simple feedback scales used in more than a dozen randomized controlled trials as well as vetted and deemed “evidence-based” by the Substance Abuse and Mental Health Services Administration. Together, the forms take less than 3 minutes to administer, score and interpret (less if one of the web-based scoring systems is used).

So why, you might wonder, would it take so long to put such tools into practice?

As paradoxical as it may sound, because FIT is really not about using measures — any more say than making a home is about erecting four walls and a roof. While the structure is the most visible aspect — a symbol or representation — we all know it’s what’s inside that counts; namely, the people and their relationships.

On this score, it should come as no surprise that a newly released study has found a significant portion of the impact of FIT is brought about by the alliance or relationship between client and therapist. It’s the first study in history to look at how the process actually works and I’m proud to have been involved.

Of course, all practitioners know relationships skills are not only central to effective psychotherapy, but require lifelong learning. With time, and the right kind of support, using measurement tools facilitates both responsiveness to individual clients and continuous professional development.

Here’s the rub. Whenever I respond to inquiries about the tools — in particular, suggesting it takes time for the effects to manifest, and that the biggest benefit lies beyond the measurement of alliance and outcome — interest in FIT almost always disappears. “We already know how to do therapy,” a manager replied just over a week ago, “We only want the measures, and we like yours because they are the simplest and fastest to administer.”

Every so often, however, the reply is different. “What do we have to do to make this work to improve the effectiveness of our clinical work and clinicians?” asked Thomas Haastrup, the Coordinator of Family Services for Odense Municipality in Denmark. When I advised, planning and patience, with an emphasis on helping individual practitioners learn to use feedback to foster professional development versus simply measuring their results, he followed through. “We adopted the long view,” Thomas recounts, “and it’s paid off.” Now in their 5th year, outcomes are improving at both the program and provider level across services aimed at helping adults, children, and families.

In addition to the Manual 6 in the ICCE Treatment and Training manuals, the ICCE Summer Intensives offer several opportunities for helping you or your agency to succeed in implementing FIT. First, the 2-day FIT Implementation Training — the only workshop offering in-depth, evidence-based training in the steps for integrating FIT into clinical practice at the individual, agency, and system-of-care level. Second, the Deliberate Practice Intensive — here you not only learn the steps, but begin to set up a professional develop plan designed to enhance your effectiveness.

To help out, I’d like to offer a couple of discounts:

Purchase Manual 6 at 70% off the regular price. Click here to order. Enter the word IMPLEMENTATION at checkout to receive the discount (If you want to purchase the entire set, I’m making them available at 50% off the usual price. Enter IMPLEMENTATION2 at checkout).
Register for any or all of the summer intensives by May 1st and receive an additional discount off the early bird price. Simple enter the code FITPROMOAPRIL at checkout. Please note, registration MUST occur before May 1st. Generally, we sell out 6 to 8 weeks in advance.

Feel free to email me with any questions. In the meantime, as always, I’m interested in your thoughts about FIT and DP.

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.

Just how good are our theories about the causes and alleviation of mental and emotional suffering?

July 12, 2018 By scottdm 7 Comments

Does the name Barry Marshall ring a bell?

Probably not if you are a mental health professional.

For decades, the Australian physician was persona non grata in the field of medicine — or perhaps stated more accurately, persona sciocca, a fool.

Beginning in the early 1980’s, Marshall, together with colleague Robin Warren, advanced the hypothesis that the bacteria heliobacter pylori was at root of most stomach ulcers. That idea proved exceptionally controversial flying, as it did, in the face of years of accepted practice and wisdom. Ulcers caused by something as simple and obvious as a bacterial infection? Bunk, the medical community responded, in the process lampooning the two researchers. After all, everyone knew stress was the culprit. The also knew the cure: certainly not antibiotics. Rather, antacids, sedatives, therapy and, in the more chronic and serious cases, gastrectomy–a surgical procedure involving the removal of the lower third of the stomach.

The textbook used in my Introduction to Psychology course in my first year at University boldly declared, “Emotional stress is now known to relate to … such illnesses as … peptic ulcers” (p. 343, Psychology Today: An Introduction 4th Edition [Braun and Linder, 1979]). The chapter on the subject was full of stories of people whose busy, emotionally demanding lives were clearly the cause of their stomach problems. I dutifully overlined all the relevant sections with my orange highlighter. Later, in my clinical career, whenever I saw a person with an ulcer, I told them it was caused by stress and, not surprisingly, taught them “stress-management” strategies.

The only problem is the field, my textbook, and I were wrong, seriously wrong. Stress was not responsible for stomach ulcers. And no, antacids, sedatives, and psychotherapy, were not the best treatments. The problem could be cured much more efficiently and effectively with a standard course of antibiotics, many of which had been available since the 1960’s! In other words, the cure had been within reach all along. Which begs the question, how could the field have missed it? Not only that, even after conclusively demonstrating the link between ulcers and the h.pylori bacterium, the medical community continued to reject Marshall and Warren’s papers and evidence for another 10 years (Klein, 2013)!

So what was it? Money, ignorance, hubris–even the normal process by which new scientific findings are disseminated–have all been offered as explanations. The truth is, however, the field of medicine, and mental health in particular, has a weakness–to paraphrase Mark Twain–for “knowing with certainty things that just ain’t so.”

How about these?

Structural abnormalities in the ovaries cause neurosis in women;
Psychopathology results from unconscious dynamics originating in childhood;
Optimism, anger control, and the expression of emotion reduces the risk of developing cancer;
Negative thinking, “cognitive distortions,” and/or a chemical imbalance cause depression;
Some psychotherapeutic approaches are more effective than others.

The list is extensive and dates all the way back to the field’s founding nearly 150 years ago. All, at one point or another, deeply believed and passionately advocated. All false.

Looking back, its easy to see that we therapists are suckers for a good story–especially those that appear to offer scientific confirmation of strongly held cultural beliefs and values.

Nowadays, for example, it simply sounds better to say that our work targets, “abnormal activation patterns in dlPFC and amygdala that underlie the cognitive control and emotion regulation impairments observed in Major Depressive Disorder” than, “Hey, I listened attentively and offered some advice which seemed to help.” And while there’s a mountain of evidence confirming the effectiveness of the latter, and virtually none supporting the former, proponents tell us it’s the former that “holds the promise” (Alvarez & Icoviello, 2015).

What to do? Our present “neuroenchantment” notwithstanding, is there anything we practitioners and the field can learn from more than 150 years of theorizing?

Given our history, it’s easy to become cynical, either coming to doubt the very existence of Truth or assuming that it’s relative to a particular individual, time, or culture. The other choice, it seems to me, is humility–not the feigned ignorance believed by some to be a demonstration of respect for individual differences–but rather what results when we closely and carefully examine our actual work.

Take empathy, for example. Not only do most practitioners consider the ability to understand and share the feelings of another an “essential” clinical skill, it is one of the most frequently studied aspects of therapeutic work (Norcross, 2011). And, research shows therapists, when asked, generally give themselves high marks in this area (c.f., Orlinksky & Howard, 2005). My colleagues, Daryl Chow, Sharon Lu, Geoffrey Tan, and I encountered the same degree of confidence when working with therapists in our recent, Difficult Conversations in Therapy study. Briefly, therapists were asked to respond empathically to a series of vignettes depicting challenging moments in psychotherapy (e.g., a client expressing anger at them). Each time, their responses were rated on standardized scale and individualized feedback for improving was provided.

Now, here is the absolutely cool part. The longer therapists participated in the research, the less confident but more demonstrably empathic they became! The process is known as “The Illusion of Explanatory Depth.” Simply put, most of us feel we understand the world and our work with far greater detail, coherence, and depth than we really do. Only when we are forced ourselves to grapple with the details, does this illusion give way to reality, and the possibility of personal and professional growth become possible.

If this makes your head spin, get a cup of coffee and watch the video below in which Dr. Daryl Chow explains these intriguing results.

Until next time,

Scott

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

P.S. Marshall and Warren were awarded the Nobel Prize for their research in 2005. Better late than never.

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.

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

November 2, 2017 By scottdm 3 Comments

Ending psychotherapy.

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

What do we know about the subject?

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

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

“You say yes, I say no;

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

Hello, hello?

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

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

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

Until next time,

Scott

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

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

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

April 18, 2017 By scottdm 14 Comments

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

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

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

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

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

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

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

Until next time,

Scott

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

The Missing Link: Why 80% of People who could benefit will never see a Therapist

March 17, 2017 By scottdm 22 Comments

The facts are startling. Despite being on the scene for close to 150 years, the field of mental health–and psychotherapy in particular–does not, and never has had mass appeal. Epidemiological studies consistently show, for example, the majority of people who could benefit from seeing a therapist, do not go. And nowadays, fewer and fewer are turning to psychotherapy—33% less than did 20 years ago—and a staggering 56% either don’t follow through after making contact or drop out after a single visit with a therapist (Guadiano & Miller, 2012; Marshall, Quinn, & Child, 2016; Swift & Greenberg, 2014).

For those on the front line, conventional wisdom holds, the real problems lie outside the profession. Insurance companies, in the best of circumstances, make access to and payment for psychotherapy an ordeal. Another common refrain is nowadays people are looking for a quick fix. Big Pharma has obliged, using their deep pockets to market “progress in a pill.” No work required beyond opening wide and swallowing. And finally, beyond instant gratification or corporate greed, many point to social disapproval or stigma as a continuing barrier to people getting the help they need.

For all that, were psychotherapy held in high regard, widely respected as the way to a better life, people would overcome their hesitancy, put up with any inconvenience, and choose it over any alternative. They don’t.

WHY? Mountains of research published over the last four decades document the effectiveness of the “talk therapies.” With truly stunning results, and a minimal side effect profile compared to drugs, why do most never make it into a therapist’s office?

For the last two years, my longtime colleague, Mark Hubble and I, have explored this question. We reviewed the research, consulted experts, and interviewed scores of potential consumers.

Our conclusion? The secular constructions, reductionistic explanations, and pedestrian techniques that so characterize modern clinical practice fall flat, failing to offer people the kinds of experiences, depth of meaning, and sense of connection they want in their lives.

In sum, most cho tarot ose not to go to psychotherapy because they are busy doing something else–consulting psychics, mediums, and other spiritual advisers–forms of healing that are a better fit with their beliefs, that “sing to their souls.”

Actually, reports show more people attend and pay out of pocket for such services than see mental health practitioners!

More, as I noted in my plenary address at the last Evolution of Psychotherapy conference, our own, large-Consumer Reports style survey, found people actually rated psychics and other “spiritual advisers” more helpful than therapists, physicians and friends. While certain to cause controversy, I strongly suggested the field could learn from and gain by joining the larger community of healers outside of our field.

Below — thanks to the Erickson Foundation — you can see that speech, as well as learn exactly what people felt these alternative healers provided that made a difference. An even deeper dive is available in our article, “How Psychotherapy Lost its Magic.” Thanks to the gracious folks at the Psychotherapy Networker for making it available for all to read, regardless of whether they subscribe to the magazine or not.

Until next time,

Scott

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

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

“Mind the Gap”: A Strategy for Insuring you get the Feedback you need to Improve your Game (whatever that is)

September 23, 2016 By scottdm 3 Comments

Join me in a brief “thought experiment.” Suppose you were a gifted painter or photographer and had the chance to provide an image of yourself that would endure–and perhaps be the only one people would know you by–for hundreds of years after your death. How would you proceed? What criteria would guide your work, be used to deem it a success?

Seriously, take a moment to picture yourself in your mind’s eye…

Now, consider the painting below.

It’s a self-portrait painted by Rembrandt van Rijn.

Why, you might wonder, would a painter widely considered one, if not, “the greatest . . .in European art” leave the world such an unflattering portrait? His face is puffy and pale, his hair thin and receding, and his cloak and cap plain and undistinguished. And lest one assume this particular image is an exception to otherwise beautiful renditions of himself, think again. The self-portraits he painted throughout his life share the same, homely quality.

Clearly, the skills Rembrandt possessed ensure he could have made himself look any way he wanted and the world would have been none the wiser. Why such brutal honesty? More to the point, given the choice, would you paint yourself as you truly are or as others generally see you?

The answer, according to some to very interesting and recent research, is, “No.” The gap between how we view ourselves on the one hand and, on the other, look, think, and act in life is often quite wide. And, it turns out, we fill that space with people who agree with us, who see us as we want to see ourselves.

Actually, according to Paul Green of the University of North Carolina at Chapel Hill, people actively, “move away from those who provide feedback that is more negative than their view of themselves. They do not listen to their advice and prefer to stop interacting with them altogether . . . tend[ing] to strengthen their bonds with people who only see their positive qualities.”

Surrounding ourselves with people who shore up our self-image is both understandable and needed. Life is hard. Support is a must. The problem is that this largely unconscious behavior undermines performance. In a variety of work contexts, for example, the researchers have documented that, “dropping relationships that provide disconfirming reviews [leads] to decreases in performance in the succeeding year.”

The importance of being able to see ourselves as we are is something Rembrandt appeared to understand quite well. Indeed, it likely accounted for a significant portion of his artistic mastery. img_20160922_1024365

Bottom line? Whatever our particular craft, if the goal is to improve, to get better at what we do, it’s essential to “mind the self-assessment gap.” First, we have to be aware it exists. Next, we have to actively work to solicit views other than our own.

In the therapy world, our team has pioneered a simple set of tools clinicians can use to solicit feedback about the quality and effectiveness of their work. Multiple clinical trials document improved results. Read this recently published free article to learn how to get started.

Of course, not all feedback is useful. In the upcoming Intensive Trainings in Chicago, we’ll teach you how to sort helpful from unhelpful, guided by the latest and only empirical research published to date documenting what it takes for individual therapists to become more effective.

Join me, an international faculty, and practitioners from around the world for the Advanced FIT and Supervision trainings this coming March!

Until then,

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

A Lotta Help from One’s Friends: The Role of Community in the Pursuit of Excellence

August 3, 2012 By scottdm Leave a Comment

Dateline: Chicago, IL USA

Hard not to be impressed with the USA Women’s Gymnastic team. What skill, percision, expertise, and excellence.

By now, I’m sure you’ve seen the interviews. In all instances, each and every one has focused on the team. Despite some in the media attempting to make stars out of the individual members, the atheletes have continually highlighted, “The Team.” When asked to account for their success or the source of their ambition, the reason cited has been: THE TEAM.

Sixteen year old McKayla Maroney said, “I think we’re as close as we can be. We’ve all been working and training together for a long time…I’ve known (fellow team member) Kyla since I was 6 years old. We are all best of friends. They did so great today and I just love this team so much.”

As highlighted in our recent article, “The Road to Mastery,” excellence does not occur in a vacuum. Surrounding every great performer is a community (teachers, coaches, mentors, and peers). In the busy world that is modern clinical practice, where can practitioners finda trsutworthy and supportive community of peers? A group of colleagues that will challenge them to keep growing as professionals and people?

In a word, the ICCE. In December 2009, the International Center for Clinical Excellence was launched and since them become the largest, global, web-based community of clinicians, researchers, administrators, and policy makers dedicated to excellence in behavioral health. The ICCE has it’s own gold-medal winning team! Practitioners working together in locations around the globe.

Practitioners like Jason Seidel, Psy.D., who represented ICCE at last week’s meeting of the American Psychological Association. Jason presented on Feedback Informed Treatment (FIT) and then participated in a panel discussion on Practice Based Evidence together with Paul Clement, Michael Lambert, Bill Stiles, Carol Goodheart, and David Barlow. Jason rocked the packed house with his tight summary of the empirical support for FIT and argument in favor of practice-based evidence!

Then there’s Daryl Chow, a psychologist from Singapore, who is currently finishing up a quantitative study of “Supershrinks.” His research is the first to employ a sophisticated statistical analysis of therapists practices related to superior outcomes. Suffice it to say, his results are mind blowing. Daryl’s work won him a scholarship to this year’s “Training of Trainers” course. If you’re not signed up for that event, you can meet him today by joining the ICCE and looking him up!

There are many, many other dedicated and supportive members. Join and share your expertise with the community today!

Revolution in Swedish Mental Health Care: Brief Update

May 14, 2012 By scottdm 1 Comment

In April 2010, I blogged about Jan Larsson, a Swedish clinician who works with people on the margins of the mental health system. Jan was dedicated to seeking feedback, using the ORS and SRS to tailor services to the individuals he met. It wasn’t easy. Unilke most, he did not meet his clients in an office or agency setting. Rather, he met them where they were: in the park, on the streets, and in their one room aparments. Critically, wherever they met, Jan had them complete the two measures–“just to be sure,” he said. No computer. No I-phone app. No sophisticated web-based adminsitration system. With a pair of scissors, he simply trimmed copies of the measures to fit in his pocket-sized appointment book! I’ve been following his creative application of the scales ever since.

Not surprisingly, Jan was on top of the story I blogged about yesterday regarding changes in the guidelines governing Swedish mental health care practice. He emailed me as I was writing my post, including the link to the Swedish Radio program about the changes. Today, he emailed again, sending along links to stories appearing in two Swedish newspapers: Dagens Nyheter and Goteborg Posten.

Thanks Jan!

And to everyone else, please continue to send any new links, videos, and comments.

A Handy "Little Helper" for the Outcome Rating Scale: A Freebie from the ACE Conference Committee

April 24, 2012 By scottdm Leave a Comment

This last week the planning committee for the upcoming Achieving Clinical Excellence (ACE) conference meet once again in Horsholm, Denmark. In the picture from left to right: Liz Plutt, Bill Andrews, myself, Rick Plutt (Conference Chair), and Bogdan Ion. Taking the photo was Susanne Bargmann.

The agenda for the three day event is now set: (1) one day pre-conference on feedback informed treatment (FIT); (2) two days of plenaries and presentations by an international group of clinicians, researchers, and educators.

On day one, the conference kicks off with a keynote address by the world’s “expert on expertise,” Dr. K. Anders Ericsson. Throughout the day, other speakers will translate Dr. Ericsson’s research into practical steps for enhancing the performance of mental health professionals, agencies, and systems of care.

Day two kicks off with a keynote address by Dr. Robbie Wagner addressing the question, “what barriers stand in the way of improving our effectiveness?” Once again, the rest of the day will be spent identifying solutions for the problems standing in the way of expertise and expert performance.

We still have several openings for presentations at the conference. If you have experiences or data related to: (1) measuring outcomes; (2) implementing feedback informed treatment; (3) the qualities of super effective clinicians or treatment approaches, then PLEASE click go to the ICCE website and submit a description for consideration.

It’ll be a fun, inspiring, and rewarding three days in Amsterdam. Don’t miss it! Register today and get the early bird special, saving you 100’s of dollars!

In the meantime, click on the link below to download a handy little tool for scoring the Outcome and Session Rating Scales. It’s a combination bookmark and 10 centimeter ruler.

Ace Ruler (PDF Format)

The Outcome and Session Rating Scales: Support Tools

March 30, 2012 By scottdm 6 Comments

Japan, Sweden, Norway, Denmark, Germany, France, Israel, Poland, Chile, Guam, Finland, Hungary, Mexico, Australia, China, the United States…and many, many more. What do all these countries have in common? In each, clinicians and agencies are using the ORS and SRS scales to inform and improve behavioral health services. Some are using web-based systems for administration, scoring, interpretation and data aggregation (e.g., myoutcomes.com and fit-outcomes), many are accessing paper and pencil versions of the measures for free and then administering and scoring by hand.

Even if one is not using a web-based system to compare individual client progress to cutting edge norms, practitioners can still determine simply and easily whether reliable change is being made by using the “Reliable Change Chart” below. Recall, a change on the ORS is considered reliable when the difference in scores exceeds the contribution attributable to chance, maturation, and measurement error. Feel free to print out the graph and use it in your practice.

To learn how to get the most out of the measures, be sure and download the six FIT Treatment and Training Manuals. The six manuals cover every aspect of feedback-informed practice including: empirical foundations, basic and advanced applications (including FIT in groups, couples, and with special populations), supervision, data analysis, and agency implementation. Each manual is written in clear, step-by-step, non-technical language, and is specifically designed to help practitioners and agencies integrate FIT into routine clinical practice. Indeed, the manuals were submitted as part of ICCE’s application for consideration of FIT as an “evidence-based practice” to the National Registry of Evidence-Based Programs and Practices

ORS Reliable Change Chart

The Achieving Clinical Excellence Conference CALL FOR PAPERS

March 13, 2012 By scottdm Leave a Comment

In October 2010, the first annual “Achieving Clinical Excellence” was held in Kansas City, Missouri. A capacity crowd joined leading experts on the subject of top performance for three days worth of training and inspiration. K. Anders Ericsson reviewed his groundbreaking research, popularized by Malcolm Gladwell and others. ICCE Director, Scott D. Miller translated the research into speciific steps for improving clinical performance. Finally, classical piansts David Helfgott, Rachel Hsu, and Roger Chen, demonstrated what can be accomplished when such evidence-based strategies are applied to the process of learning specific skills.

The ICCE is proud to announce the 2nd “ACE” conference to be held May 16th-18th, 2013 in Amsterdam, Holland. Join us for three educational, inspiring, and fun-filled days. Register today and receive a significant “Early Bird” discount. The ACE conference committee is also issuing an international “Call for Papers.” If you, your agency, or practice are committed to excellence, using outcomes to inform practice, or have published research on the subject, please visit the conference website to submit a proposal.

Here’s what attendees said about the last event:

Implementation Science, FIT, and the Training of Trainers

March 8, 2012 By scottdm Leave a Comment

The International Center for Clinical Excellence (ICCE) is pleased to announce the 6th annual Training of Trainers event to be held in Chicago, Illinois August 6th-10th, 2012. As always, the ICCE TOT prepares participants provide training, consultation, and supervision to therapists, agencies, and healthcare systems in Feedback-Informed Treatment (FIT). Attendees leave the intensive, hands-on training with detailed knowledge and skills for:

Training clinicians in the Core Competencies of Feedback Informed Treatment (FIT/CDOI);
Using FIT in supervision;
Methods and practices for implementing FIT in agencies, group practices, and healthcare settings;.
Conducting top training sessions, learning and mastery exercises, and transformational presentations.

Multiple randomized clinical trials document that implementing FIT leads to improved outcomes and retention rates while simultanesouly decreasing the cost of services.

This year’s “state of the art” faculty include: ICCE Director, Scott D. Miller, Ph.D., ICCE Training Director, Julie Tilsen, Ph.D., and special guest lecturer and ICCE Coordinator of Professional Development, Cynthia Maeschalck, M.A.

Join colleagues from around the world who are working to improve the quality and outcome of behavioral healthcare via the use of ongoing feedback. Space is limited. Click here to register online today. Last year, one participants said the training was, “truly masterful. Seeing the connection between everything that has been orchestrated leaves me amazed at the thought, preparation, and talent that has cone into this training.” Here’s what others had to say:

The New Average: Meeting the Need to Exceed

February 10, 2012 By scottdm Leave a Comment

No matter where you look,good is no longer “good enough.” In a recent article in the New York Times, author and trend watcher, Thomas L. Friedman, declared, “Average is Over.” It’s an argument similar to the one made over a decade ago by Robert Reich, former Secretary of Labor under Bill Clinton, in his phenomenally prescient book The Future of Success. I read it at the time with a mixture of apprehension and anticipation. Globalization and advances in information technology were then and are now challenging the status quo. At one time, being average enabled one to live an average life, live in an average neighborhood and, most importantly, earn an average living. Not so anymore.

Average is now plentiful, easily accessible, and cheap. What technology can’t do in either an average or better way, a younger, less-trained but equally effective provider can do for less. A variety of computer programs and web-based systems provide both psychological advice and treatment. (By the way, studies to date document outcomes equal to face-to-face services for at least the most common mental health related issues). At the same time, as reviewed here previously on this blog, the evidence again and again shows no difference in outcome between professionally trained clinicians and students or paraprofessionals. Uh-oh.

What is the solution? Friedman says, “everyone needs to find their extra–their unique value contribution that makes them stand out in whatever is their field.” Yeah, exactly. As my father used to say, “Do your best and then a little better. What can behavioral health professionals do to stand out? Well, if you are trained, licensed or certified, practicing evidence-based, know the latest methods and research findings, and understand how the brain works, then you are, in a word, average. Going forward, standing out will require evidence that you are effective; measures documenting not only who you help but identifying those you do not. Professional development will be less about learning a new method than documenting what you do to “do your best and then a little better.”

Helping clincians stand out is what the ICCE is all about. Everyday, thousands meet online to learn, share, and support each other in both measuring and improving the impact of their clinical work. Each year, the ICCE offers two intensive training opportunities: The Advanced Intensive and the Training of Trainers. Both events are designed to help professionals achieve their personal best. The Training of Trainers is specifically designed for participants, such as supervisors, managers, and agency directors, who wish to train others or transform public or private agencies for achieving success. The Advanced Intensive scheduled for March is sold out. By popular demand, we are offering an unprecedented second opportunity to attend the Advanced Intensive this summer. Don’t wait to register. Despite only announcing this event last week, half of the seats are already booked. Either event will insure that you have the tools and skills necessary to meet the need to exceed. Email us with any questions at: training@centerforclinicalexcellence.com.

(By the way, if you are interested, you catch watch a clip of Friedman delivering his message to the Hudson Society here).

Excellence "Front and Center" at the Psychotherapy Networker Conference

January 30, 2012 By scottdm Leave a Comment

This year, the Psychotherapy Networker is celebrating it’s 35th anniversary. I’m not going to let on how long I’ve been a reader and subscriber, but I can say that I eagerly anticipate each issue. Rich Simon and his incredibly dedicated and talented crew always seem to have their fingers on the pulse of the profession.

It is no accident that our most recent work on achieving excellence in behavioral health appeared in the pages of the Networker–in 2007, our study of top performing clinicians, “Supershrinks,” and then last year, “The Road to Mastery” which layed out the most recent findings as well as identified the resources necessary for the development of therapeutic expertise.

I was deeply honored when Rich Simon asked me to give one of the plenary addresses at this year’s Networker Symposium, March 22-25th, 2012. The theme of this year’s event is, “Creating a New Wisdom: The Art and Science of Optimal Well Being” and I’ll be delivering Friday’s luncheon address on applying the science of expertise to the world of clinical practice.

Click here to register online and join me for 3 fantastic days at this historic meeting.

The Role of Mentors in the Development of Expertise: Bruce Wampold wins the Beckman Award Honoring Inspirational Professors

January 12, 2012 By scottdm Leave a Comment

Saturday, January 7th, 2012, 7:00 pm EST
The Carter Presidential Libary
Atlanta, Georgia

In 2008, the Elizabeth Hurlock Beckman Trust Award was created to honor inspirational professors, academic faculty members who have inspired their students to “create an organization, concept, procedure, or movement which has demonsrably conferred a benefit on the community.”

This last week, I had the honor of joining my former professor and long time mentor, Bruce Wampold, Ph.D., at the Carter Presidential Library in Atlanta, Georgia as he received the 2011 Beckman Award. I met Bruce in 1984, my first year in graduate school. As you might guess, he was the statistics instructor. Turns out, it was his first academic post! I learned so much in that class as well as the “Applied Regression/Correlation Analysis” course he taught the following year. Who knew we’d be working, writing papers, and pulishing together 27 years later!

On this blog, and in mutliple articles, I’ve written about the important role that mentors play in the development of expertise. On this score, the impact Bruce has had and continues to have on my career is immeasurable. I can’t think of a more deserving person. Former A.P.A. president Carol Goodheart, Ph.D. delivered the award, captured in the video below:

Looking Back, Looking Forward

January 6, 2012 By scottdm Leave a Comment

Bidding goodbye to last year and welcoming the new always puts me in a reflective frame of mind. How did my life, work, and relationships go? What are my hopes for the future?

Just two short years ago, together with colleagues from around the world, the International Center for Clinical Excellence (ICCE) was launched. Today, the ICCE is the largest, global, web-based community of providers, educators, researchers, and policy makers dedicated to improving the quality and outcome of behavioral health services. Clinicians can choose to participate in any of the 100-plus forums, create their own discussion group, immerse themselves in a library of documents and how-to videos, and consult directly with peers. Membership costs nothing and the site is free of the advertising. With just a few clicks, practitioners are able to plug into a group of like-minded clinicians whose sole reason for being on the site is to raise everyone’s performance level. I have many people to thank for the success of ICCE: senior associates and trainers, our community manager Susanne Bargmann, director of training Julie Tilsen, and our tech wizard Enda Madden.

As membership in ICCE has grown from a few hundred to well over 3000, many in the community have worked together to translate research on excellence into standards for improving clinical practice. Routine outcome monitoring (ROM) has grown in popularity around the world. As a result, new measures and trainings have proliferated. In order to insure quality and consistency, a task force was convened within ICCE in 2010 to develop a list of “Core Competencies”—a document establishing the empirical and practice foundations for outcome-informed clinical work. In 2011, the ICCE Core Competencies were used to develop and standardize the curricula for the “Advanced Intensive” and “Training-of-Trainers” workshops as well as the exam all attendees must pass to achieve certification as an ICCE Trainer. As if these accomplishments were not enough, a small cadre of ICCE associates banded together to compose the Feedback Informed Treatment and Training Manuals—six practical, “how-to”volumes covering everything from empirical foundations to implementation. None of this would have been possible without the tireless contributions of Bob Bertolino, Jason Seidel, Cynthia Maeschalck, Rob Axsen, Susanne Bargmann, Bill Robinson, Robbie Wagner, and Julie Tilsen.

Looking back, I feel tremendous gratitude–both for the members, associates, and trainers of ICCE as well as the many people who have supported my professional journey. This year, two of those mentors passed away: Dick Fisch and James Hillman. During my graduate school years, I read James Hillman’s book, Suicide and the Soul. Many years later, I had the opportunity to present alongside him at the “Evolution of Psychotherapy” conference. Dick, together with his colleagues from MRI, had a great influence on my work, especially during the early years when I was in Milwaukee with Insoo Berg and Steve de Shazer in Milwaukee doing research and writing about brief therapy. Thinking about Dick reminded me of two other teachers and mentors from that period in my life; namely, John Weakland and Jay Haley.

Looking forward, I am filled with hope and high expectations. The “Advanced Intensive” training scheduled for March 19-22^nd is booked to capacity—not a single spot left. Registrations for this summer’s “Training of Trainers” course are coming in at a record pace (don’t wait if you are thinking about joining me, Cynthia and Rob). Currently, I am awaiting word from the National Registry of Evidence Based Programs and Practices (NREPP) formally recognizing “Feedback Informed Treatment” (FIT) as an evidence-based approach. The application process has been both rigorous and time-consuming. It’s worth it though. Approval by this department within the federal government would instantly raise awareness about as well as increased access to funding for implementing FIT. Keep your fingers crossed!

There’s so much more:

Professor Jan Blomqvist, a researcher at the Center for Alcohol and Drug Research at Stockholm University (SoRAD) launched what will be the largest, independent evaluation of feedback informed treatment to date, involving 80+ clinicians and 100’s of clients located throughout Sweden. I provided the initial training to clinicians in October of last year. ICCE Certified Trainers Gunnar Lindfeldt and Magnus Johansson are providing ongoing logistic and supervisory support.
The most sophisticated and empirically robust interpretive algorithms for the Outcome Rating Scale (based on a sample of 427,744 administrations of the ORS, in 95,478 unique episodes of care, provided by 2,354 different clinicians) have been developed and are now available for integration into software and web based applications. Unlike the prior formulas–which plotted the average progress of all consumers successful and not–the new equations provide benchmarks for comparing individual consumer progress to both successful and unsuccessful treatment episodes.
The keynote speakers and venue for the Second Achieving Clinical Excellence Conference have been secured. We’ll be meeting at one of the nicest hotels in Amsterdam, Holland, May 16-18=9^th, 2013. Thanks go to the planning committee: Bill Andrews, Susanne Bargmann, Liz Plutt, Rick Plutt, Tony Jordan, and Bogdan Ion. Please visit the conference website and submit a proposal for a workshop or presentation.
Finally, I’ve been asked to deliver the lunchtime keynote at the upcoming Psychotherapy Networker Conference scheduled on March 23, 2012. The topic? Achieving excellence as a behavioral health practitioner. Last year, my colleague Mark Hubble and I published the lead article in the May-June issue of the magazine, describing the latest research on top performing clinicians. I’m deeply honored by the opportunity to speak at this prestigious event.

More coming in the weeks ahead. Until then, look forward to connecting on ICCE.

Optum Health and the ICCE: Partnering to Achieve Excellence in Behavioral Health

November 26, 2011 By scottdm Leave a Comment

Monday, November 28th, 2011
Chicago, IL & Goldern Valley, MN

The members, associaties, and directors of the International Center for Clinical Excellence are proud to announce a partnership with Optum Health’s Campaign for Excellence. Optum Health works with employers, payers, and providers serving nearly 60,000,000 people. Their “Campaign for Excellence (CFE)” was specifically designed to enhance the quality and outcome of behavioral health services by recognizing top performing clinicians. To date, over 4,000 providers spread across the United States are participating in the CFE, which involves ongoing measurement and benchmarking of client outcome and satisfaction. CFE clinicians are not only provided with feedback regarding the outcome of the individuals they meet and work with but able to compare their overall effectiveness to other providers in the Optum Health network. Performance research makes clear that such comparisons are a necessary first step in the development of expertise. The second? As Miller and Hubble point out in The Road to Mastery, c-o-m-m-u-n-i-t-y. Top performers do not exist in a vacuum. Across a number of domains–chess, mathematics, medicine, or psychotherapy–the “best of the best” benefit from a complex and interlocking network of people, places, resources, and circumstances without which excellence remains out of reach.

And now, we are pleased to welcome these CFE providers to the ICCE community. In December 2009, the International Center for Clinical Excellence was launched and since then, it has grown into the largest, global, web-based network of clinicians, researchers, administrators, and policymakers dedicated to excellence in behavioral health. Clinicians can choose to participate in any of the 100-plus forums, create their own discussion groups, immerse themselves in a library of documents and how-to-videos, and most importantly meet with and consult with peers. Indeed, with the addition of clinicians from Optum Health, total ICCE membership will exceed 5000!

ICCE members will most certainly benefit from the knowledge and experience of the CFE clinicians. And if experience of members to date is any indication, CFE providers will find the community helpful in nurturning their continued professional growth. Indeed, what has been so striking about ICCE is that it transcends its online limitations–which often reinforce anonymity and invisibility–to provide members with the same complex norms of personal connection, openness, and honesty, mutual trust and support, challenge and accountability, that any “land-based” community of excellence offers.

Optum Health is providing CFE clinicians with a unique URL for joining the ICCE. Don’t despair if you are not a provider for Optum Health or participant in the CFE. You too can join the ICCE by going to: http://centerforclinicalexcellence.com/register. Look forward to meeting you online!

Achieving Clinical Excellence Conference 2013: CALL FOR PAPERS

September 20, 2011 By scottdm Leave a Comment

Horsholm, Denmark

Spent the weekend with the planning committe for the 2013 Achieving Clinical Excellence Conference. Committee members came in from all over the world–the USA, Romania, Holland, the UK, and Denmark–to finalize speakers, the conference venue, and mock up the logo for the conference brochure and advertizing. Like last time, we are not only bringing in the top researchers to present the latest scientific findings, but also superior performers from a variety of vocations to inspire all of us to achieve our personal best.

Despite all the effort, a significant part of the program remains incomplete. That part involves YOU! The conference committee is issuing a formal “call for papers”on expertise and expert performance in the field of behavioral health. In keeping with the theme of the conference–“Putting the Pieces Together: The Fragile Balance”–the committe is looking for presentations on:

Innovative strategies for improving the quality and outcome of behavioral health;
Research and experiences of using routine monitoring of progress and the alliance to improve retention and outcome of treatment services;
Principles, practices, and experiences regarding maintaining balance between professional and personal life in the achievement of clinical excellence;
Implementation of strategies for improving performance in agencies and systems of care
How professional development can improve performance of behavioral health professionals;
Management and leadership practices associated with superior performance in behavioral health;

Any and all papers may be submitted directly to: info@scottdmiller.com. The conference website is also available for earlybird registration.

There are so many other developments that I hope to blog in detail about in the coming days. In the meantime, here’s a short summary of what’s in store:

The Mystery of Mastery: Excellence Takes Center Stage in the Psychotherapy Networker

May 16, 2011 By scottdm Leave a Comment

The Psychotherapy Networker has long been the most popular periodical among practicing clinicians. Rumor has it that the magazine has 80,000+ subscribers and sells over 120,000 copies of each issue. If you want to know what therapists are thinking and talking about, the Networker magazine is the place to look. And in the May/June issue, the topic of excellence is front and center.

The reason is obvious: the field of psychotherapy is in trouble. Think about it for a moment. What real accomplishments can psychotherapy boast of in recent years? What was the last truly revolutionary discovery in the field of psychotherapy? What “treatment” (analogous to penicillin in medicine) has ever successfully eradicated a mental or emotional disorder? In fact, while we’ve been at our posts, provisioning and parading an army of techniques and methods, rates of depression and anxiety have soared. Even if one disagrees with this grim assessment of the field’s contributions and influence, it’s hard to be sanguine about our status. Over the last decade, median incomes for psychologists, both applied and academic, have dropped by thousands of dollars. In the same period, workloads have increased, professional autonomy has been subverted, and funding for public behavioral healthcare has all but disappeared. Meanwhile, the very relevance of psychotherapy is an open question in the minds of many current and prospective consumers. Despite overwhelming evidence that therapy works, and that more than 90 percent of people say they’d prefer to talk about their problems than take psychopharmacological drugs, most people doubt the efficacy of treatment. Perhaps this accounts for the fact that the use of medications has steadily increased, while visits to a psychotherapist have been decreasing.

What can be done?

In 2007, we wrote an article that appeared in the pages of the Networker on the subject of “top performing” clinicians–those that consistently achieve superior results with their clients. Over the last four years, we’ve continued to research and write on the subject and in the latest issue of the Networker we review the latest findings. ICCE Associate, Dr. Bob Bertolino, also has an article in the issue detailed the steps required to reac excellence in agencies and healthcare systems.

Scott Miller Mark Hubble Bob Bertolino

Never has a moment in the history of the field existed when the need for a “culture of excellence” has been more pressing or when the qualities of that culture are more unambiguous. Seeing as we spend so much of our lives at work anyway—often more in total than with our families, friends, and in leisure—the question is, “why not?” If not for ourselves, then for our clients, the very people the research shows benefit the most from top performance and on whom our livelihoods depend. Don’t wait. Click on the links above to read both articles.

The "Fragile Balance": Putting the Pieces together at the 2013 Achieving Clinical Excellence Conference in Amsterdam, Holland

May 9, 2011 By scottdm Leave a Comment

Dateline: May 8th, 2011

Copenhagen, Denmark

It is with great pleasure and high expectations that I announce the second “Achieving Excellence Conference” to be held in Amsterdam, Holland on May 16th-18th, 2013.

The title of the 2013 ACE conference is, “Putting the Pieces Together: The ‘Fragile Balance,'” emphasizing the steps, practices, and supports required for excellence in the field of behavioral health.

This last weekend, the organizing committe met in Horsholm, Denmark to begin planning the event. The 2013 conference chair is Dutch psychologist Rick Plutt (pictured on the left in the photo to the right). Committee members flew in from all over Europe and include ICCE associates (from left to right in the photo on the left) Liz Plutt (Holland), Rick Plutt (Holland), Anthony Jordan (Sweden), Bogdan Ion (Romania), Bill Andrews (UK), and Susanne Bargmann (Denmark).

Information about the event is already available on the official ACE 2013 Conference website. Registration will soon be available.

The committee has also issued a “Call for Papers” from clinicians, researchers, and policy makers interested in presenting at the event. Guidelines for submitting a proposal to present at the conference can be obtained by sending an email to: info@centerforclinicalexcellence.com.

Details regarding the event, including keynote presenters will be released shortly so stay tuned. In the meantime, make sure you watch the video highlights from the 2010 conference in Kansas City, Missouri:

More videos from the conference are available on the International Center for Clinical Excellence video channel.

Don’t wait until 2013 to begin improving the quality and outcome of your clinical work. The one and only, official “Training of Trainers” is open for registration. This hands on event is conducted by me and other ICCE Senior Associates. Space is limited to 35 participants. You can register by clicking the icon below.

Here’s what last year’s participants said about the “Training of Trainers”:

The "F" Word in Behavioral Health

April 20, 2011 By scottdm Leave a Comment

Since the 1960’s, over 10,000 how-to books on psychotherapy/counseling have been published—everything from nude marathon group therapy to the most recent “energy-based treatments.” Clinicians have at their disposal literally hundreds of methods to apply to an ever growing list of diagnoses as codified in the Diagnostic and Statistical Manual of Mental Disorders (soon available in its 5^th and expanded edition).

Conspicuously absent from the psychological cornucopia of diagnoses and treatments is the “F” word: FAILURE. A quick search of Amazon.com led to 32,670 results for the term, “psychotherapy,” 1,393 hits for “psychotherapy and depression,” and a mere 85 citations for “psychotherapy and failure.” Of the latter 85, less than 20 dealt with the topic of failure directly. There are some notable exceptions. The work of psychologist Jeffrey Kottler, for example. The dearth of information and frank discussion points to a glaring fact: behavioral health has a problem with failure.

The research literature is clear on the subject: we fail. Dropout rates have remained embarrassingly high over the last two and a half decades—hovering around 47%. At the same time, 10% of those who stay in services deteriorate while in care. Also troubling, despite the expansion of treatment modalities and diagnoses, the outcome of treatment (while generally good) has not improved appreciably over the last 30 or so years. Finally, as reviewed recently on this blog, available evidence indicates that clinicians, despite what many believe, do not improve with experience.

In short, behavioral health is failing when it comes to failure. As a group, we do rarely address the topic. Even when we directly addressed, we find it hard to learn from our mistakes.

Our study of top performing clinicians and agencies documents that the best have an entirely different attitude toward failure than the rest. They work at failing. Everyday, quickly, and in small ways. In the lead article of upcoming Psychotherapy Networker, “The Path to Mastery” we review our findings and provide step-by-step, evidence-based directions for using failure to improve the quality and outcome of behavioral health. As we say in the article, “more than a dozen clinical trials, involving thousands of clients and numerous therapists, have established that excellence isn’t reserved for a select few. Far from it: it’s within the reach of all.” Getting there, however, requires that we embrace failure like never before.

At this year’s “Training of Trainers” (TOT) conference, building “mindful infrastructures” capable of identifying and using failure at the individual practitioner, supervisor, and agency level will be front and center. Please note: this is not an “advanced workshop” on client-directed, feedback-informed clinical work (CDOI/FIT). No lectures or powerpoint presentations. Participants get hands on experience learning to provide training, consultation, and supervision to therapists, agencies, and healthcare systems.

But, don’t take our word for it. Listen to what attendees from the 2010 TOT said. Be sure and register soon as space is limited.