Deliberate Practice is hot.  Judging from the rising number of research studies, workshops, and social media posts, it hard to believe the term did not appear in the psychotherapy literature until 2007.

The interest is understandable.  Among the various approaches to professional development — supervision, continuing education, personal therapy — the evidence shows deliberate practice is the only one to result in improved effectiveness at the individual therapist level.

Devoting time to rehearsing what one wants to improve is hardly a novel idea.  Any parent knows it to be true and has said as much to their kids.  Truth is, references to enhancing one’s skills and abilities through focused effort date back more than two millennia.   And here is where confusion and misunderstanding begin.

• Clinical practice is not deliberate practice.  If doing therapy with clients on a daily basis were the same as engaging in deliberate practice, therapists would improve in effectiveness over the course of their careers.  Research shows they do not.  Instead, confidence improves.  Let that sink in.  Outcomes remain flat but confidence in our abilities continuously increases.  It’s a phenomenon researchers term “automaticity” — the feeling most of us associate with having “learned” to do something –where actions are carried out without much conscious effort.  One could go so far as to say clinical practice is incompatible with deliberate practice, as the latter, to be effective, must force us to question what we do without thinking.
• Deliberate practice is not a special set of techniques.  The field of psychotherapy has a long history of selling formulaic approaches. Gift-wrapped in books, manuals, workshops, and webinars, the promise is do this — whatever the “this” is — and you will be more effective.  Decades of research has shown these claims to be empty.  By contrast, deliberate practice is not a formula to be followed, but a form.  As such, the particulars will vary from person to person depending on what each needs to learn.  Bottom line: beware pre-packaged content.
• Applying deliberate practice to mastering specific treatment models or techniques.  Consider a recent study out of the United Kingdom (1).  There, like elsewhere, massive amounts of money have been spent training clinicians to use cognitive behavioral therapy (CBT).  The expenditure is part of a well-intentioned government program aimed at improving access to effective mental health services (2).  Anyway, in the study, clinicians participated in a high intensity course that included more than 300 hours of training, supervision, and practice.  Competence in delivering CBT was assessed at regular intervals and shown to improve significantly throughout the training.  That said, despite the time, money, and resources devoted to mastering the approach, clinician effectiveness did not improve.  Why?  Contrary to common belief, competence in delivering specific treatment protocols contributes a negligible amount to the outcome of psychotherapy.  As common sensical as it likely sounds, to have an impact, whatever we practice must target factors have leverage on outcome.

My colleague, Daryl Chow and I, have developed a tool for helping practitioners develop an effective deliberate practice plan.  Known as the “Taxonomy of Deliberate Practice Activities” (TDPA), it helps you identify aspects of your clinical performance likely to have the most impact on improving your effectiveness.   Step-by-step instructions walk you through the process of assessing your work, setting small individualized learning objectives, developing practice activities, and monitoring your progress.   As coaching is central to effective deliberate practice, a version of the tool is available for your supervisor or coach to complete.  Did I mention, its free?  Click here to download the TDPA contained in the same packet as the Outcome and Session Rating Scales.  While your are at it, join our private, online discussion group where hundreds of clinicians around the world meet, support one another, and share experiences and ideas.

OK, that’s it for now.  All the best,

Scott

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

 
P.S.: Improve your ability to deliver effective presentations online or in-person at the upcoming “Training of Trainers” workshop.  This event is held only once, every two years — this time, online!

“We don’t do ‘treatment,’ can we use FIT?”

It’s a question that comes up with increasing frequency as use of the Outcome and Session Rating Scales in the helping professions spreads around the globe and across diverse service settings.

When I answer an unequivocal, “yes,” the asker often responds as though I’d not heard what they said.

Speaking slowly and enunciating, “But Scott, we don’t do “t r e a t m e n t.‘”  Invariably, they then clarify, “We do child protection,” or “We’re not therapists, we are case managers,” or providers in any of a large number of supportive, criminal justice, or other statutory social services.

How “treatment” became synonymous with psychotherapy (and other medical procedures) is a mystery to me.   The word, as Merriam-Webster defines it, is merely the way we conduct ourselves — our specific manner, actions and behaviors — towards others.

With this definition in mind, working “feedback-informed” simply means interacting with people as though their experience of the service is both primary and consequential.  The challenge, I suppose, is how to do this when lives may be at risk (e.g., child protection, probation and parole), or when rules and regulations prescribe (or proscribe) provider and agency actions irrespective of how service users feel or what they prefer.

Over the last decade, many governmental and non-governmental organizations have succeeded in making statutory services feedback-informed — and the results are impressive.  For recipients, more engagement and better outcomes.  For providers, less burnout, job turnover, and fewer sick days.

I had the opportunity to speak with the members and managers of one social service agency — Gladsaxe Kommune in Denmark — this last week.   They described the ups, downs, and challenges they faced — including retraining staff, seeking variances to existing laws from authorities, — while working to transform agency practice and culture.  If you work in this sector, I know you’ll find their experience both inspiring and practical.  You can find the video below.  Another governmental agency has created a step-by-step guide (in English) for implementing feedback informed treatment (FIT) in statutory service settings.  It’s amazingly detailed and comprehensive.  It’s also free.  To access, click here.

Cliff note version of the results of implementing FIT in statutory services?

• 50% fewer kids placed outside the home
• 100% decrease in complaints filed by families against social service agencies and staff
• 100% decrease in staff turnover and sick days

OK, that’s it for now.  Please leave a comment.  If you, or your agency, is considering implementing FIT, please join us for the two-day intensive training in August.  This time around, you can participate without leaving home as the entire workshop will be held online.  For more information, click on the icon below.

All the best,

Scott

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

Amateurs have goals.  Experts have a system.

Bold statements to be sure, both supported by research on deliberate practice — the one activity documented to improve clinicians’ therapeutic effectiveness.

Much is made in the self-improvement and therapy literature about the importance of setting goals.  Unless you’ve been hiding under a rock, I’m sure you’ve heard the S.M.A.R.T. acronym.  You know, specific, measurable, achievable, and so on.  And should you become discouraged along the way, well, all that’s needed is to “keep on believing you can do it.”

Turns out, however, being goal-oriented — even when accompanied by a strong desire to achieve and generous amounts of self-belief  — can quickly become demotivating.  You are literally in a constant state of “pre-success,” requiring endless pep-talks or hope-infusions to keep going as you continuously fall short.

Systems-oriented people, by contrast, succeed every time they employ their system.  They focus less on the what and more on the how.

Anders Ericsson, the psychologist who coined the term and conducted most of the original research, once told me the big, unanswered question about deliberate practice was, “Why would anyone in their right mind engage in it?”  After all, its tiring, emotionally and cognitively depleting, and frustratingly slow.  What’s more, for most of humanity, proficiency — that is, being good enough — is, good enough.

At this point, science is not much closer in providing an answer to why some push beyond mere proficiency.  A fair bit is known about how.  In our new book, Better Results, my co-authors, Mark Hubble, Daryl Chow, and I lay out the elements of a sustainable deliberate practice system.  Known as A.R.P.S., it includes:

• Automated: If you are asking yourself when, you likely never will.
• Reference point:  Count your steps, not your achievements
• Playful: Give in, let go, have fun.
• Support: Go alone and you won’t go far

Following these steps, we’ve found, helps clinicians maintain their momentum as they apply deliberate practice in their professional development efforts.  Get your own free summary of the tips and suggestions here.  If you are looking for support, why not join colleagues in our free, online discussion forum?

All the best,

Scott

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

Criticizing umpires is as much a part of watching baseball as eating hotdogs and wearing team jerseys on game day.  The insults are legion, whole websites are dedicated to cataloging them:

“Open your eyes!”

“Wake up, you are missing a great game!”

“Your glasses fogged up?”

“Have you tried eating more carrots?”

“I’ve seen potatoes with better eyes!”

“Hey Ump, how many fingers am I holding up?

Are you “seeing” a common theme here?

And interestingly, the evidence indicates fans have reason to question the judgement and visual acuity of most umpires.  A truly massive study of nearly 4 million pitches examined the accuracy of their calls over 11 regular seasons.  I didn’t know this, but it turns out, all major league stadiums are equipped with fancy cameras which track every ball thrown from mound to home plate.  Using this data, researchers found “botched calls and high error rates are rampant.”   How many you ask?  A staggering 34,246 incorrect calls in the 2018 season alone!  It gets worse.  When the pressure was on — a player at bat, for example, with two strikes — umpire errors skyrocket, occurring nearly one-third of the time.  Surely, the “umps” improve with time an experience?  Nope.  In terms of accuracy, youth and inexperienced win out every time!

Now, let me ask, are your “ears burning” yet?

Turns out, umpires and psychotherapists share some common traits.  So, for example, despite widespread belief to the contrary, clinicians are not  particularly good at detecting deterioration in clients.  How bad are we?  In one study, therapists correctly identified clients who worsen in their care a mere two-and-a-half percent of the time (1)!  Like umpires, “we call ’em as we see ’em.”  We just don’t see them.  And if you believe we improve with experience, think again.  The largest study in the history of research on the subject — 170 practitioners treating 6500 clients over a 5 year period — reveals that what is true of umpires applies equally to clinicians.  Simply put, on average, our outcomes decline the longer we are in the field.

If you are beginning to feel discouraged, hold on a minute.  While the data clearly show umpires make mistakes, the same evidence documents most of their calls are correct.  Similarly, therapists working in real world settings help the majority of their clients achieve meaningful change — between 64 and 74% in our database of thousands of clinicians and several million completed treatment episodes.

Still, you wouldn’t be too far “off base” were you to conclude, “room for improvement exists.”

Truth is, umpires and therapists are calling “balls and strikes” much the same way they did when Babe Ruth and Alfred Alder were key players.  Solutions do exist.  As you might guess, they are organized around using feedback to augment and improve individual judgement ability.  So far, major league baseball (and its umpires) has resisted.  In psychotherapy, evidence shows clients of therapists who formally and routinely solicit feedback regarding the quality of the therapeutic relationship and progress over time are twice as likely to experience improvement in treatment.

The measures are free for practitioners to use and available in 25+ languages.  If you don’t have them, click here to register.   You’ll likely need some support in understanding how to use them effectively.  Please join the conversation with thousands of colleagues from around the world in the ICCE Discussion Forum.  If you find yourself wanting to learn more, click on the icon below my name for information about our next upcoming intensive — online, by the way!

What more is there to say, except: BATTER UP!

Until next time, wishes for a safe and healthy Holiday season,

Scott

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

Take a look at the graphic to the left.  It shows the use of the Outcome and Session Rating Scales (ORS & SRS) from the beginning of this year to the present by users of one of the three , authorized FIT software programs.

What do you see?

A couple of things stand out for me.  First, a steady rise in administrations of the tools beginning in late January and continuing to the third week of March when use significantly dropped.  You can literally “see” the pandemic coming.  In the weeks and months that followed, use of the measures steadily recovered and is, as of today, up nearly 30% over its record high in the weeks before virus mitigation efforts brought the world to a standstill.

The cause of the rise in online use of the ORS and SRS is no mystery.  The number of therapists seeing clients virtually has, virtually, exploded.  In this “brave new world” of clinical practice, its clear clinicians are looking for concrete, evidence-based ways to augment the two-dimensional sensory input (sight and sound) characteristic of video conferencing.

In a previous blog, I summarized the research on the effectiveness of online behavioral health services.  The data are clear: it works.  More, a brand new meta-analysis, released just this week, adds to the body of evidence documenting that being physically present is not essential for successful outcomes.

The ORS and SRS are particularly well suited for online service delivery.   Indeed, the original validation studies of the two scales were actually conducted in a teletherapy setting.  It was the era before high-speed broadband and Zoom.  Therapists spoke with their clients by landline, administering the measures orally using a standardized script.  Since those early days, scores of studies have documented the impact of routinely soliciting formal client feedback on both outcome and retention in behavioral health services.  In one recent study, clients of therapists using the ORS and SRS were 2.5 times more likely to experience a successful outcome.  Using standardized measures as part of service delivery is now considered a “standard of care” by Joint Commission and SAMHSA.  Next year, the State of California follows suit, allowing psychologists to use the tools to earn required continuing education credits (see top of page 4, under “Practice Outome Monitoring [POM]”).

If you don’t have copies, you can get them for free here.   Looking for detailed instructions and “how to” videos on integrating the ORS and SRS into online services, click here — all free.  The six-volume set of feedback-informed treatment manuals is the most comprehensive source for using the tools to inform and improve mental health service delivery (if you don’t have a set, you can get the entire set for 80% off the full price through Friday December 4th.  At checkout, simply type in the code: FITMANUALS).

OK, that’s it for now.  Thanking you for your continuing friendship and interest, and wishing you, your family, and colleagues safety and health during these challenging times.

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

P.S.: Registration for the two FIT Intensives is open — both online! As always, space is limited to 40 participants to ensure quality and connection.  Click here for more information or to register.

It’s rarely good news when the phone rings in the wee hours of the morning.  This time, it was a colleague calling to let me know that Rich Simon — the founder and editor of the Psychotherapy Networker and long time friend — had died.

To say the news came as a shock would be a gross understatement.  In the early 1990’s, I sent an unsolicited article to the magazine for consideration.  Rich called me saying he liked the piece and wanted, with some minor revisions, to publish it.  After that, we began talking regularly by phone.  Sometimes the calls were brief.  Others went on for several hours spread out over days and weeks.

How best to describe Rich?  He was insatiably and infectiously curious, always hunting for whatever might improve the reach and effectiveness of psychotherapy.  I can hear his warm, distinct voice in my head right now, “Hey buddy,” he always started our conversations, quickly cutting to, “So, what you working on?”  And then, he’d listen, intently, following up with questions and a gentle challenge or two.  Throughout, it was clear Rich cared — about ideas, the field, people, and me.  I always left our conversations feeling as though I mattered, that I was contributing something vital and important to the field.  In the days since his death, I’ve learned I was not unique.  In fact, everyone I’ve spoken with said they had the same experience.  As one put it, “Rich had this uncanny ability to make you feel like you were his favorite.”

Our last conversation took place just a few weeks ago.  He called to thank me and my co-authors, Mark Hubble and Birgit Valla, for the article we’d written for the latest issue of the magazine.  None of us could imagine then what we would be experiencing now when we titled the piece, “Braving the Unknown.”  At this moment, I don’t have the words to describe what life will be like without him, without his dedication to, and genius in, bringing together the best ideas about the helping profession in one place.

If you never had a chance to meet Rich, or simply want to relive a few moments of his charm and wit, watch the memorial video below.  Should you want to add your own reflections or experiences, a special page has been set up on Facebook.

Wishing you peace, health, and safety,

Scott

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

Here is a smattering of the articles I wrote for Rich over the last 30 years:

Braving the Unknown: The Search for New Solutions (September/October 2020)

Meet You in McGinnis Meadows (January/February 2020)

How Psychotherapy Lost its Magic: Healing in the Age of Science (March/April 2017)

Burnout Reconsidered (May/June 2015)

The Road to Mastery (2011)

Supershrinks: Learning from the field’s most effective practitioners (November/December, 2007)

How Being Bad Can Make your Better (2007)

Exposing the Mythmakers: How the soft sell has replaced hard science (2000)

Their Verdict is Key (1999)

No More Bells and Whistles (1995)

The Resistant Substance Abuser: Court Mandated Cases can Pose Special Problems (1992)

Eighty three million, six hundred fifty thousand, thirty seven.

Can you guess what this number represents?

No, its not the net worth of the latest tech millionaire.  Neither is it the budget of a soon-to-be released Hollywood blockbuster.

Guess again.

Give up?

It’s the number of adults in the U.S. who reported struggling with mental health or substance use resulting from efforts to mitigate the SARS-COV-2 virus.

By the way, that figure is from the last week in June, three months ago.  Since then, the isolation, job losses, and economic and political uncertainty and social unrest have continued.

According to the Center for Disease Control, “Younger adults, racial/ethnic minorities, essential workers, and unpaid adult caregivers reported having experienced disproportionately worse mental health outcomes, increased substance use, and elevated suicidal ideation,” with a staggering 25% of 18-24 year-olds having seriously contemplated suicide in the weeks prior to completing the survey.

One glimmer of hope amidst these dire statistics is that access to mental health care has expanded during the pandemic.  In March, U.S. government agencies expanded Medicaid telehealth coverage.  In turn, the U.S. Department of Health and Human Services relaxed HIPPA privacy rules, further reducing barriers to accessing treatment remotely.  Many third party payers have followed suit.  As it is, the dramatic increase in those seeking mental health care and shift to virtual service delivery fit squarely with the theme of this year’s World Mental Health Day.  Falling on Saturday, October 10th, it calls for “ensur[ing] that everyone, everywhere has access to mental health care.”

Of course, increased demand and easier access to care are placing a strain on therapists.  As one recent story noted, “Therapists and counselors are facing the same anxiety, uncertainty and financial stress that are troubling those who seek their services.”  The risk of a “parallel pandemic” of burnout is, according to recent studies, rising.  Consider this, prior to the outbreak, available evidence indicated between 21 and 67 percent already were experiencing high levels.

Not long ago, my colleague Mark Hubble and I reviewed the research on the subject noting that most of currently fashionable approaches (e.g., practice mindfulness meditation, eat healthy snacks, go for short walks, exercise regularly, get enough sleep, join a service organization, take up a hobby, attend a continuing education event, learn to say no, see a therapist, and take time out to value oneself) not only don’t work but often make matters worse.

What does work?

I hope you’ll read (or re-read) the article.  It’s free and provides a detailed review.  That said, all things being equal, one key finding is that effectiveness mitigates risk.  Said another way, the better a therapist’s results, the less likely they are to burnout.  The challenge, particularly in these troubled times, is that we care. People matter to us. We want to make a difference.  In this effort, we place ourselves at risk whenever what we’re there to accomplish takes a back seat to the caring, empathy, and compassion we provide, no matter how lovingly extended.

Bottom line: keep outcome front and center in your work.  After all, genuinely and demonstrably helping people improve is the entire point of therapy and, in the end, the best of all ways to show that we really, deeply care.  One way to do that, of course, is to measure your results.  If you haven’t already done so, you can get my two, evidence-based progress and relationship scales for free by clicking here.  If you need some help learning how to integrate the tools into your online work, check out the many blogposts, how-to videos, and webinars my colleagues and I have produced since the start of the outbreak (1, 2, 3, 4)– again, all free.

If you are looking for a way to improve your effectiveness, my colleague and co-author, Daryl Chow, are launching a self-paced, e-learning workshop on deliberate practice, based on our new book, Better Results.  Beginning November 2nd, we’ll start what we call the “DP Drip.”  Every Monday and Friday for nearly three months, you’ll receive links to brief videos and other goodies aimed at helping you design and execute your own deliberate practice plan.  To ensure you get the individualized help you need, its limited to 40 participants.  Interested?  Click here to watch a short, introductory video.

OK, that’s it for now.

Scott

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

Here’s an interesting dilemma.   In December 1799, three physicians were summoned to the Mount Vernon estate to treat the former first president of the United States for a sore throat.  The accepted therapy of the day was administered skillfully and competently multiple times.  Several hours later, the president was dead.  Historians agree George Washington likely did not die of whatever illness he had, but rather from the care he received killed him.  The intervention, of course, was bloodletting — the chief tool of which remains the title of one of medicine’s leading research journals (i.e., The Lancet [Flexner 1974]).

The question is, did Washington’s physicians act ethically?

According to the ethical codes of the four largest mental health provider organizations in the United States, the answer is an unsatisfying and deeply disconcerting, “yes.”   Standard 2.01 of the Ethical Principles of Psychologists (APA 2017), for example, merely requires practitioners “provide services … with populations and in areas … within the boundaries of their competence, based on their education, training, supervised experience, consultation, study, or professional expertise” — conditions easily met by Washington’s physicians.

Before objecting that professionals should not be held accountable for standards of care yet to be developed, vetted by science, and accepted by peers and regulatory bodies, consider another historical example. The year is 1846. Hungarian-born physician Ignaz Semmelweis is in his first month of employment at Vienna General Hospital when he notices a troublingly high death rate among women giving birth in the obstetrics ward.  Indeed, with rates of 25 to 30 percent many expectant mothers prefer to give birth in the street rather than the clinic.

Medical science at the time attributes the problem to “miasma,” an invisible, poisonous gas believed responsible for a variety of illnesses.  Having noticed that midwives have a rate 6 times lower than physicians, Semmelweis concludes his colleagues contact with dead bodies is somehow involved and orders them to wash their hands prior to interacting with expectant mothers.  The mortality rate on the maternity warm immediately plummets landing at the same level as that of midwives.

Nowadays, of course, handwashing is a “best practice,” supported by a century of scientific evidence.  During Semmelweis’s day, such data was not available. His was merely a hunch—one which, by the way, fell outside the boundaries of then current medical standards, his professional experience, education, and training.  What’s more, he continued to promote the practice even after it was deemed unscientific by his peers and the broader professional community.

Returning to the earlier question, did Semmelweis act ethically?  The answer, according to the field’s current ethical codes, would be “no.”

It’s hard to defend a standard that deems a practitioner who competently delivers an unhelpful, even deadly service (e.g., Washington’s physicians) ethically superior to one who is actually helpful but working beyond the limits of their education, training, supervised experience, consultation, study or professional expertise” (e.g., Semmelweis).  And yet, that is precisely what the competence criterion in the current ethical codes of mental health provider organizations does.

What alternatives exist?  Adopting a standard of “working within and continually to extend the field’s and one’s own level of effectiveness” would achieve what the current criterion has failed to deliver: protecting the public welfare while facilitating ongoing improvement in the results of clinical services.  It would also free therapists to use their creativity as well as take advantage of ideas from a variety of healing traditions.

But how?

Together with my colleagues Joshua Madsen and Mark Hubble, we lay out the details in a new chapter published this month in The Oxford Handbook of Psychotherapy Ethics.  I’m hoping you’ll be interested in reading it.

Click here or email at scottdmiller@talkingcure.com if you’d like a copy.

Until next time,

Scott

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

I remember exactly where I was on April 4th, 1968 — in a pool doing laps.  I was a junior member of my hometown’s swim team.   I’d barely started when the coach blew his whistle calling the practice to an abrupt halt.  As we toweled off, he told us something terrible had happened.  It was first time I recall hearing the name, Martin Luther King, Jr..

If I close my eyes, I can easily call up other, vivid memories of traumatic, culture-changing events.  The death of Robert Kennedy.  The Challenger explosion.  The attack on the World Trade Center.  And now, only slightly more than half way through the present year, many more.  The first days of the outbreak and lockdown.  The running tally of deaths on the nightly news.  The lines of people at our local foodbanks.  The images of George Floyd being killed, and weeks of protests against racism and inequality that have followed.

Then and now, I struggle with a stark choice; specifically, to connect or disconnect with events as they unfold.  After all, so much is happening in the world and I only have so much bandwidth — and as a person with many advantages, I can disconnect with little real consequence to the well-being of myself and my family.

In the end, however,  I feel ethically compelled to connect, listen, or perhaps more accurately state, hear people — not because I see myself as knowing what to do, but rather because I want to understand if and how I can be helpful.

So, what does the research indicate?

When I was in graduate school, human diversity was treated in what might be called, “the chapter approach.”  Here’s what the field knows about men, for instance, with another on women, African-Americans, Latinos, and so on.  This approach can be directly traced to social, historical, and political events beginning in the 1960’s, and a then growing awareness of the lack of attention paid to diversity in the field of mental health– in particular, culture, race, religion, socioeconomic status, sexual orientation, etc.

For several decades, researchers have built on this framework, developing and testing what have come to be known as “culturally adapted” psychological treatments (e.g., CBT for Latina Women or people of Asian heritage).  Despite years of effort, including scores of randomized trails and meta-analyses,  experts conclude, “Current evidence does not offer a solution to the issue of which components of cultural adaptation are effective, for what population, and whether cultural adaptation works better than noncultural adaption” (1).

Part of the problem with this approach is the sheer number of possible adaptations quickly becomes unmanageable. To illustrate, in developing a culturally adapted psychotherapy, where adjustments are made along only 4 of the 13 officially identified dimensions of diversity, a total of 715 different ways exist to adapt service delivery to fit the individual.  Obviously, any approach that results in so many variations is absurd, making it impossible to apply in the real world and risking being nothing more than window dressing — a kind of superficial “gift wrapping” that conceals more than it helps to reveal the identities and objectives of the participants.  More importantly, however, is that the current approach makes a priori decisions about which dimensions are most important to consider when planning and delivering treatment.

What then are therapists who wish to connect more effectively with a broad and diverse clientele to do?  Research makes clear when practitioners are open to exploring clients’ values, background, and culture, good results follow.  Such evidence suggests, in place of competence (i.e., achieving a certain level of pre-determined knowledge about and skills for working with various cultural groups), its better to have an orientation to treatment that enables practitioners to attend to and integrate cultural dynamics as they naturally occur in the therapy process.

One of the lead researchers on multicultural orientation is Professor Jesse Owen at the University of Denver.  Together with a team of investigators, he’s identified three core principles that both encompass and can guide a therapist’s attitudes, in-and-between session actions, and personal reactions regarding the role of culture in therapy.  Interestingly, much of what he and the group have discovered fits with what my colleagues and I have been learning from our study of highly effective psychotherapists.  I won’t give it away here.  You can watch the interview yourself.

OK.  That’s it for now.  Please let me know your thoughts.

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

Bad therapy.

Are you guilty of it?  A quick internet search turned up only 15 books on the subject.  It’s strange, especially when you consider that between 5 and 10% of clients are actually worse off following treatment and an additional 35-40% experience no benefit whatsoever!  (Yep, that’s nearly 50%)

And what about those numerous “micro-failures.”  You know the ones I’m talking about?  Those miniature ruptures, empathic missteps, and outright gaffs committed during the therapy hour.  For example, seated opposite your client, empathic look glued to your face and suddenly you cannot remember your client’s name?  Or worse, you call them by someone else’s.  The point is, there’s a lot of bad therapy.

Why don’t we therapists talk about these experiences more often?  Could it possibly be that we don’t know?  Four years on, I can still remember the surprise I felt when Norwegian researcher, Jorgen Flor, found most therapists had a hard time recalling any clients they hadn’t helped.

One group does know — and recently, they’ve been talking their experiences!  The Very Bad Therapy podcast is one of my favorites.  After listening to sixty-some-odd episodes of clients exposing our shortcomings, I reached out to the podcast’s two fearless interviewers, clinicians Ben Fineman and Carrie Wiita, to learn what had motivated them to start the series in the first place and what, if anything, they’d learned along the way.  Here’s what I promise: they have no shame (and its a good thing for us they don’t)!

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

Scott

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

P.S.: For the first time ever, we’re offering the FIT Implementation Intensive Online.  It’s one of the four courses required for certification as an ICCE FIT Trainer.  As with our “in-person” events, we have an international faculty and strictly limit the number of participants to 40 to ensure the highest quality experience.  Click here for more information or to register.

One warm, summer June day, Marietta Jaeger, her husband Bill, and their five children packed into their borrowed R.V. for a cross-country road trip touring the American west.  “This was going to be the adventure of a lifetime, a grand family vacation, the one we were going to talk about for the rest of our lives,”  Marietta observes some four decades later, “and it certainly has been.”

On the third night of their stay, camped at the headwaters of the Missouri river, the family’s youngest child — 7-year old Susie Jaeger — was kidnapped.  A slit made with surgical precision in the canvas of the tent in which she slept with her brothers and sisters was the only clue to what had happened.

Hours, days, and weeks passed while local, state, and federal authorities searched.  Although increasingly desperate, Marietta maintained her focus and composure, attending to her other children while constantly juggling interactions with law enforcement and the media.  Then, “A day came,” she recalls, “where I began to get angry.”  By this time, the family had been camped out at the river’s edge for over a month. “By the time I got into bed,” she continues, “I was just ravaged with hatred and a desire for revenge.”   Her eyes narrowing in anger, she confesses, “I wanted this guy to swing,” adding, “I could have killed him for what he had done with my bare hands and a smile on my face.”

No one I know would fault Marietta for her feelings.  Some experts might even suggest her reaction was a necessary, even helpful part of recovering from such a traumatic event.  In the end, however, it was not the path she chose to stay on.  Quite the contrary.  Rather, before daylight broke the next day, and years before she would learn what actually happened to her daughter, Marietta made the decision to forgive the person who had taken Susie.

Believe me when I say, her decision was no mere contrivance or symbolic gesture.  Her behavior followed suit — acts of grace, understanding, and empathy most would find exceptionally difficult to emulate — for example, expressing genuine care and concern for the kidnapper when he called to taunt the family one year later on the date and exact hour he’d absconded with Susie.

I won’t tell you here what happened.  You can watch for yourself in the link to the 20/20 episode below.  What I will say is that Marietta Jaeger’s ability to forgive proved to be the key to solving the kidnapping of her daughter.

Research documents the healing effects of forgiveness on individuals and groups (1, 2, 3, 4, 5).  Other data indicate people, particularly those seeking psychotherapy, want to forgive.  But how?  What exactly are the steps?

I had the opportunity to speak with Marietta Jaeger last week.  During the time we spent together, she told me how she did it.  I experienced a wide range of emotions: anger, discouragement, frustration, bafflement, sadness, and peace.  Once you’ve had a chance to listen to the interview and watch the 20/20 episode, let me know your thoughts.

Until next time,

Scott

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

First, the coronavirus outbreak.  Then the lockdown, followed by an ever-rising number of deaths and catastrophic economic fallout — and just when the tide seemed to be turning, George Floyd was murdered in Minneapolis resulting in nationwide protests and unrest.

I don’t recall a time in recent memory when events were evolving as rapidly and in so many different directions as they are now.

With so much happening, you can’t be faulted for having your attention on matters other than work and professional development.  Back in March, my colleague, Cynthia Maeschalck and I began offering a series of free “meetups and discussions” for mental health professionals interested in feedback informed treatment (FIT) and deliberate practice (DP).  The response surprised both of us, with each webinar filling within hours of being announced.

Soon, people began emailing us backchannel.  Three themes were prominent.  The first was requests for additional webinars.  The second was for opportunities for more personalized consultation. Third, and finally, was an interest in tips about how to get back “on track” with FIT and DP for both individuals and agencies.

Well, as the saying goes, “Ask and you will receive.”

In case you haven’t been able to secure a spot during one of the live broadcasts, I’ve just uploaded the fourth “FIT & DP Meetup & Discussion.”  Watch it below.  As before, we cover a lot of ground.  You can listen to the entire recording or use the guide below to jump ahead to the material of interest to you (Yes, CE’s are available if desired by CEunits.com.  Click on the link below the video for more information):

1. How do you sustain your interest in FIT and deliberate practice? (2:29)
2. Is it possible to use one measure across different contexts and client presenting problems? (12:07; continued at 24:09)
3. What is the best way to implement FIT as an individual practitioner? (19:00)
4. How often should the ORS and SRS be administered? (27.18; continued 50:15)
5. How can the ORS be used to determine the dose and intensity of treatment? (28.20; continued 31:15)
6. Using the Group Session Rating Scale (30:12)
7. Understanding and using the clinical cutoff as feedback in psychotherapy (38.30)
8. What does it cost to implement FIT? (41:36)
9. What is most important when you first start using FIT? (52:25)

If you’re looking for opportunities for more individualized consultation regarding your use of FIT or DP, I’ve just announced the “FIT Cafe” — four intimate, online gatherings limited to 10 participants.  It’s B.Y.O.Q., so “Bring Your Own Questions” and I’ll provide the food for thought and practice.  Click here to register.

And how about those needing help getting back on track?  ICCE Certified Trainer, Stacy Bancroft addresses the subject directly in a new interview with psychologist Susanne Bargmann — another in a series of videos aimed at helping practitioners “stay FIT” in the current practice environment.

OK, that’s it for now.  The foregoing should keep you busy and productive for a while!

Scott

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

I love live trainings.  The spontaneity.  The interactions.  The possibilities inherent in learning together.  Each year, for the past 30, I’ve been out — generally 40 weeks out of 52 — providing workshops on feedback-informed treatment and, more recently, deliberate practice.   It’s been a gift to work with clinicians and agencies in different countries around the globe.

Of course, all that came to an abrupt end with the COVID-19 outbreak.  I quickly found myself missing the time spent with colleagues.  Others in the FIT community, I discovered, felt similarly.  So, together with ICE Community Manager, Cynthia Maeschalck, I began organizing a series of free, web-based meetings.  So far, we’ve held three, each one filled to capacity within hours of being announced.

Nearly a month ago, the recording of the first meetup was released; the second three weeks later.  Now, we have the third.  Looking over the questions, the breadth and depth of information covered is simply amazing.  And, thanks to the folks at CEunits, for a small fee, you can earn continuing education credits for watching!  Simply click on the links below (or contained in the video description on youtube).  No pressure!  Just an opportunity should you need CE’s.

In the meantime, here’s a minute-by-minute catalog of the questions asked and answers given.  Feel free to listen from start to finish or hop ahead to the material of interest to you. The access the videos just complete the form below and you’ll be directed to them.

1. Use of FIT in an online forum: How and should measures be completed ahead of time? (2:10)
2. Using the ORS to gauge need and triage delivery of services (5:19)
3. What is the meaning and relevance of the clinical cutoff on the ORS? (6:12)
4. How to tailor care to the client’s “Theory of Change” (10:10)
5. What do the various “performance metrics” reported in the software systems mean? (12:30)
6. Why you shouldn’t use just the paper and pencil measures? (16:32; 29:55)
7. Should you add items to the ORS to capture areas of client functioning not addressed by the measure? (23:44)
8. What is the average rate of improvement of therapists who have used FIT for two years or more? (26:40; 39:25)
9. How to utilize FIT in a group-based program? (31:31)
10. How to maintain sufficient structure and focus while working to incorporate client feedback? (35:32)
11. Given the lack of evidence for traditional supervision, where can a clinician go to get the kind of support/coaching necessary for effective deliberate practice? (37:10; 45:50)
12. How can FIT and deliberate practice help you improve your effectiveness? (41:35)
13. Using feedback in supervision (48:00)
14. When is the best time to learn about and implement deliberate practice? (49:15)
15. When do we challenge client feedback? (52:57)

Until next time,

Scott

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

This blogpost comes with a “trigger warning.”  For most, the last 60 days have been witness to the complete disruption of daily life.  Many people have died — nearly 250,000 worldwide, 70,000 in the United States — from a virus that the majority of us had never heard of just three, short months ago.  Looking forward, humanity seems to be left with only stark and frightening choices between degrees of death and economic devastation.  Given these realities, it is perfectly understandable if you would rather ignore this post announcing my interview of Stephen Jenkinson.

If you don’t know him, Stephen is teacher, storyteller, palliative care worker, and author of the award-winning book, Die Wise.  I happened to read it back in 2016, right after it was released.  Of his work, Stephen observes, “It’s not really a crowd pleaser.”  Neither does his subject matter “submit to being clever, coy, or especially ironic — all the high water marks of casual conversation in urban centers.”  As the title of his book indicates, he talks about death.

Jenkinson’s thesis?  We are death phobic in the extreme, a culture that not only doesn’t believe in, but is actually hostile toward endings.  We hide away our elderly, spend our final days separated from family, isolated in hospitals, talk euphemistically about transitions rather than the realities of no longer existing.  This fact and this fact alone, he argues, has tremendous consequences for how we live and go about our daily lives.

I reached out a little over a week ago, asking if he would agree to an interview about how our culture’s attitude toward death might be shaping the North American response to the COVID-19 outbreak.  From the concentration of deaths in “nursing homes,” breathless reports of “promising treatments” and a vaccine, the championing of healthcare professionals (while many are losing their jobs), and the media’s relentless (and scientifically uninformative) reporting of “hot spots” and “death counts,” it seemed to me we were dancing around the subject.

I’ve done a lot of interviews over the years, but none like this one.  Several times, I had goosebumps.  I was also concerned.  Was Stephen’s direct and unflinching discussion too much?  I actually asked several colleagues to watch and offer feedback before agreeing to post:

• U.S. based Psychologist Randy Moss said, “Jenkinson’s calm, yet passionate exegesis about the pandemic exposes our collective ignorance about death while inviting us to think deeply about how to go forward.”
• Long-time friend and therapist, Michele Weiner-Davis called the interview, “fascinating, poetic, and provocative.”
• Swedish colleague Patrik Ulander remarked, “it was a handful, kept me awake at 4:30 this morning.  His take is so fundamental and not even really about the corona virus, but instead about us denying the only thing we’re really sure about: we’re all going to die.”

So, over to you.  If you do decide to watch, PLEASE leave a comment (here and on youtube).

Until next time,

Scott

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

P.S.:  In case you didn’t see it, here’s an interview I did two weeks ago with a CCU physician on the frontlines of the COVID-19 outbreak.  As you will see, it affirms and extends much of what Stephen Jenkinson advises, while simultaneously putting a face to the challenges we face as a culture in the near future.

Just over a month ago, as countries around the world began locking down in response to the COVID-19 outbreak, ICCE Community Relations Manager, Cynthia Maeschalck and I, put out a post on Facebook offering an opportunity to meet and discuss Feedback-Informed Treatment and Deliberate Practice.   We were taken by surprise when the webinar filled to capacity in two hours!  Within a day, we announced a second, free webinar.  It, too, quickly filled.  Each time, we’ve covered a lot of ground and managed to met with colleagues from the U.S., Canada, Europe, Asia, Australia, and New Zealand.  We meet for the third on Wednesday the 28th of April (sorry, it’s full to capacity).

Two weeks ago, the recording of the first meetup was released.  As promised, here’s the second.

Topics covered are listed below along with times when particular questions are addressed.

1. How to incorporate deliberate practice (DP) into supervision? (3:10)
2. How to use DP to address personal issues of the therapist? (12:37)
3. When and how to teach and learn FIT? (14:10; 43:37)
4. The importance of a FIT culture (21.45)
5. How to deliberately practice supervision? (23:15)
6. How to to discuss a lack of progress on the ORS with clients? (27:00)
7. Should DP be a part of FIT supervision? (33:10)
8. The learning versus the performance zone (36:09)
9. Tips for analyzing video in deliberate practice (37:55)
10. What if clients fake bad on the ORS to stay in therapy? (40:21)
11. What is the meaning of declining SRS scores? (48:00)
12. How to combine FIT with other approaches and treatment protocols? (50:40)
13. How to address mismatched scores on the ORS and SRS? (52:44)

Click here if you missed my interview of the Chicago-based ICU physician on the front lines of the COVID-19 outbreak in Chicago.  It’s both informative and moving, including tips for anyone who faces difficult decisions regarding their health and well being.

Next week, two new interviews on deliberate practice.

Until then,

Scott

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

When I was around 11 years old, a gag quickly circulated through my school.

Cornering an unsuspecting chum, you’d ask, “Hey, have you seen my hammerfor?”

“What’s a hammerfor?” they’d invariably ask, a quizzical look glued to their face.

“Pounding nails!” you’d then scream, followed by paroxysms of laughter.

Funny in a sad, underhanded kind of way.  “But what,” you might wonder, “has this got to do with using the Outcome and Session Rating Scales in psychotherapy?”

Well, since the COVID-19 crisis began, I’ve been getting a fair bit of email about using the tools in an online format.  Makes sense.  In their effort to provide continuity of care while maintaining physical distance, many practitioners are connecting with clients via the net.

The majority of the questions thus far focus on technical details (e.g., administration, scoring, software application, etc.).  Again, this makes sense.  And in my previous two blogs (1, 2), colleagues Stacy Bancroft and Brooke Mathewes and I provided detailed suggestions and video instruction for working feedback-informed in an online environment.

However, while making the transition, it’s important to keep in mind “What’s an ORSSRSfor?”  The answer, like the old joke, is “soliciting feedback from clients that can be used to fine tune and tailor treatment.”  Whether working face-to-face or digitally, research and clinical experience document that failing to establish a “culture of feedback” is the root cause of most problems encountered when using the measures — in the particular, clients reporting, “everything’s great” and then not returning for their next session.

A great resource for learning to successfully administer the scales is the series of FIT Treatment and Training Manuals.  Right now, you can get them for 50% off the regular price.  Chapter Three in Feedback Informed Treatment in Clinical Practice is also really helpful.  No, you don’t have to buy the whole book — although it really is a phenomenal volume.  I’m giving it away.

Just click here to get your free copy.

Finally, Stacy and Brooke have created another “how to” video specifically target to creating a culture of feedback in online work.

OK, that’s it for now.  Until next time, wishing you health and safety,

Scott

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

You’ve been busy!  Stocking up on food.  Telecommuting.  Home schooling your kids.  And figuring out how you are going to pay bills while not drawing a paycheck or being able to meet with clients face to face.

Many clinicians I know are rapidly transitioning to providing services online.  As you might imagine, many of those work feedback-informed, using the ORS and SRS at each visit to guide and inform treatment decisions.   In fact, I’ve noticed something curious since the COVID-19 crisis began: downloads of the measures from my website are up, significantly — 21% more compared to the prior three month period.

All good but, how to employ the measures online?

Thanks to ICCE Certified Trainer, Stacy Bancroft for pulling together these tips:

1. Use the standardized oral scripting to administer the tools.  It’s available in the download file.
2. Share your screen.  Display the ORS and SRS and then use your finger, moving slowly along each item until they tell you to stop.
3. Use one of the three, authorized software systems.  Each, in slightly different ways, make it possible to email, text or send links to the forms and have them completed either manually or electronically.  Below, you will find several brief, how-to videos for the various systems.
4. Finally, connect with the members of the International Center for Clinical Excellence clinical community.  It’s free to join.  Just click the link below my name.

Until next time, in these uncertain times, I wish you health, safety, and peace.

Scott

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

For FIT-OUTCOMES.COM Users:

For MYOUTCOMES.COM Users:

For OpenFIT Users:

In 2007, my colleagues and I published an article entitled, Supershrinks: What’s the Secret of their Success?  In it, we reported on the status of our then decade long effort to understand why some psychotherapists were consistently more effective than others.  Although the phenomenon had first been reported in the mid-1970’s by psychologist David F. Ricks, accounting for the superior effectiveness of these clinicians had eluded scholarly explanation.  Our objective was as simple: figure out what the best were doing so that the rest of us could copy it and improve our results.

After many false starts and empirical dead ends, it turned out the key was “the best of the best simply work harder at improving their performance than others do” (p. 30).  Known in the expert and expertise literature as “deliberate practice,” their efforts to improve were not merely about putting in hours, but rather spending time reaching for performance objectives just beyond their level of proficiency.  Decades of research had documented the impact of deliberate practice across a wide range of human endeavors including sports, music, surgery, teaching, computer programming, and chess.  Surprisingly, despite this extensive evidence base, until the publication of our article, the term, much less the empirically-based process, had never appeared in any study or publication about psychotherapy.

Four years passed before the next publication on the subject appeared.  In The Road to Mastery, we provided an update about our research, focusing this time on the important role environment played in successful deliberate practice.  In a number of practical applications around the world, we’d discovered that, without a supportive community, the majority failed to sustain their efforts.  Turns out, deliberate practice is hard.  In the article, we described the type of, and even places where, clinicians could get the backing they needed to persevere.

In 2015, we published the very first empirical research in a peer reviewed journal on the role of deliberate practice in psychotherapy.  During the six long years the study was being conducted, we had no idea whether our earlier work would be confirmed or discredited.  Needless to say, we were pleased and relieved when the analysis of the data revealed the most effective practitioners devoted 2.5 times more hours to deliberate practice than clinicians with average outcomes.  Further analysis showed factors long thought to influence the therapist effectiveness were shown to contribute nothing, including years of experience, gender, age, professional discipline, caseload, and theoretical orientation.

By this point, many other projects were underway.

• A review of 40 years of outcome research seeking to determine whether the overall effectiveness of psychotherapy was stagnant, improving, or declining;
• A study of the impact of therapist experience on effectiveness;
• A meta-analysis comparing the impact of deliberate practice versus “mere time spent” engaged in a particular activity;
• A study investigating whether average therapists could improve their results by engaging in deliberate practice; and
• A randomized controlled trial investigating the impact of a specific deliberate practice activity on therapist relationship skills.

The results have challenged many long held beliefs.  More importantly, however, they’ve provided the first concrete evidence of a pathway for accomplishing what had long eluded the field — reliably improving the outcomes of individual therapists.

Taking each in order, here’s what we’ve found:

• Despite the proliferation of treatment models, the overall outcome of psychotherapy has not improved in four decades;
• Contrary to tradition and belief, therapist effectiveness actually declines as experience in the field increases;
• The impact of deliberate practice on performance is twice that of “mere time spent”;
• Engaging in deliberate practice slowly, steadily and significantly improves therapist effectiveness; and
• Targeted deliberate practice training significantly improves the acquisition and generalization of fundamental relationship skills.

For those interested in the details, click here.  Complete the form (just your name and email) and I’ll send you the eight studies referenced above!  I’ll also put you on a list to be notified when our new book, Better Results: Using Deliberate Practice to Improve Therapeutic Effectiveness, is released from the American Psychological Association.  It not only summarizes the research, but lays out in step-by-step fashion how to apply the findings in your professional development efforts.

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

Scott

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

“Everyone understands how a toilet works, don’t you?” ask cognitive scientists Sloman and Fernbach.

The answer, according to their research, is likely no.  Turns out, peoples’ confidence in their knowledge far outstrips their ability to explain how any number of simple, every day items work — a coffeemaker, zipper, bicycle and yes, a toilet.   More troubling, as complexity increases, the problem only worsens.  Thus, if you struggle to explain how glue holds two pieces of paper together — and most, despite being certain they can, cannot — good luck accounting for how an activity as complicated as psychotherapy works.

So pronounced is our inability to recognize the depth of our ignorance, the two researchers have given the phenomenon a name: the “Illusion of Explanatory Depth.”  To be sure, in most instances, not being able to adequately and accurately explain isn’t a problem.  Put simply, knowing how to make something work is more important in everyday life than knowing how it actually works:

• Push the handle on the toilet and the water goes down the drain, replaced by fresh water from the tank;
• Depress the lever on the toaster, threads of bare wire heat up, and the bread begins to roast;
• Replace negative cognitions with positive ones and depression lifts.

Simple, right?

Our limited understanding serves us well until we need to build or improve upon any one of the foregoing.  In those instances, lacking true understanding, we could literally believe anything — in the case of the toilet, a little man in the rowboat inside the tank makes it flush — and be just as successful.   While such apparent human frailty might, at first pass, arouse feelings of shame or stupidity, truth is operating on a “need to know” basis makes good sense.  It’s both pragmatic and economical.  In life, you cannot possibly, and don’t really need to know everything.

And yet, therein lies the paradox: we passionately believe we do.  That is, until we are asked to provide a detailed, step-by-step, scientifically sound accounting — only then, does humility and the potential for learning enter the picture.

When research on routine outcome monitoring (ROM) first began to appear, the reported impact on outcomes was astonishing.  Some claimed it was the most important development in the field since the invention of psychotherapy!  They were also quite certain how it worked: like a blood test, outcome and alliance measures enabled clinicians to check progress and make adjustments when needed.  Voila!

Eight years ago, I drew attention to the assertions being made about ROM, warning “caution was warranted. ” It was not a bold statement, rather a reasoned one.   After all, throughout the waning decades of the last millennium and into the present, proponents of cognitive (CT) and cognitive behavioral therapy (CBT) had similarly overreached, claiming not only that their methods were superior in effect to all others, but that the mechanisms responsible were well understood.  Both proved false.  As I’ve written extensively on my blog, CT and CBT are no more effective in head to head comparisons with other approaches.  More, studies dating back to 1996 have not found any of the ingredients, touted by experts as critical, necessary to success (1, 2, 3).

That’s why I was excited when researchers Mikeal, Gillaspy, Scoles, and Murphy (2016) published the first dismantling study of the Outcome and Session Rating Scales, showing that using the measures in combination, or just one or the other, resulted in similar outcomes.  Some were dismayed by these findings.  They wrote to me questioning the value of the tools.  For me, however, it proved what I’d said back in 2012, “focusing on the measures misses the point.”  Figure out why their use improves outcomes and we stop conflating features with causes, and are poised to build on what most matters.

On this score, what do the data say?  When it comes to feedback informed treatment, two key factors count:

1. The therapist administering the measures; and
2. The quality of the therapeutic relationship.

As is true of psychotherapy-in-general, the evidence indicates that who uses the scales is more important that what measures are used (1, 2).  Here’s what we know:

• Therapists with an open attitude towards getting feedback reach faster progress with their patients;
• Clinicians able to create an environment in which clients provide critical (e.g., negative) feedback in the form of lower alliance scores early on in care have better outcomes (1, 2); and
• The more time a therapists spend consulting the data generated by routinely administering outcome and alliance measures, the greater their growth in effectiveness over time.

In terms of how FIT helps, two lines of research are noteworthy:

• In a “first of its kind” study, psychologist Heidi Brattland found that the strength of the therapeutic relationship improved more over the course of care when clinicians used the Outcome and Session Rating Scales (ORS & SRS) compared to when they did not.  Critically, such improvements resulted in better outcomes for clients, ultimately accounting for nearly a quarter of the effect of FIT.
• Brattland also found therapists, “significantly differed in the influence of … [FIT] on the alliance, in the influence of the alliance on outcomes, and the residual direct effect of [FIT] … posttreatment” (p. 10).  Consistent with other studies, such findings indicate routine measurement can be used to identify a clinician’s “growth edge” — what, where, and with whom — they might improve their ability to relate to and help the diverse clients met in daily work.  Indeed, the combination of FIT, use of aggregate data to identify personal learning objectives, and subsequent engagement in deliberate practice has, in the only study in history of psychotherapy to date, been shown to improve effectiveness at the individual practitioner level.

“Inch by inch, centimeter by centimeter,” I wrote back in 2012, “the results of [new] studies will advance our understanding and effectiveness.”  I’m hopeful that the discussion in this and my two prior posts (1, 2) will help those interested in improving their results avoid the vicious cycle of hope and despair that frequently accompanies new ideas in our field, embracing the findings and what they can teach us rather than looking for the next best thing.

Until next time,

Scott

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

P.S: The March Intensives are sold out.  Register now for the summer trainings to ensure your spot:

Is it just me or has public discourse gone mad?

A brief perusal of social media largely finds accusation, name calling, and outrage instead of exploration, dialogue and debate.  Not that any of the latter options were ever simple, straightforward, or successful, but somehow, somewhere, taking a stand has replaced extending a hand.

Thus, slightly more than a year ago, I was compared to an ignorant, cult leader by a person — a researcher and proponent of CBT — who’d joined an open discussion about a post of mine on Facebook.  From there, the tone of the exchange only worsened.  Ironically, after lecturing participants about their “ethical duties” and suggesting we needed to educate ourselves, he labelled the group “hostile” and left, saying he was going to “unfriend and block” me.

As I wrote about in my last blogpost, I recently received an email from someone accusing me of “hiding” research studies that failed to support feedback informed treatment (FIT).  Calling it “scandalous,” and saying I “should be ashamed,” they demanded I remove them from my mailing list.  I did, of course, but without responding to the email.

And, therein lies the problem: no dialogue. 

For me, no dialogue means no possibility of growth or change — on my part or other’s.  To be sure, when you are public person, you have to choose to what and whom you respond.  Otherwise, you could spend every waking moment either feeling bad or defending yourself.  Still, I always feel a loss when this happens.  I like talking, am curious about and energized by different points of view.

That’s why when my Dutch colleague, Kai Hjulsted, posted a query about the same study I’d been accused of hiding, I decided to devote several blogposts to the subject of “negative research results.”  Last time, I pointed out that some studies were confounded by the stage of implementation clinicians were in at the time the research was conducted.  Brattland et al.’s results indicate, consistent with findings from the larger implementation literature, it takes between two and four years to begin seeing results.  Why?  Because becoming feedback-informed is not about administering the ORS and SRS — that can be taught in a manner of minutes — rather, FIT is about changing practice and agency culture.

(By the way, today I heard through the grapevine that a published study of a group using FIT that found no effect has, in its fourth and fifth years of implementation, started to experience fairly dramatic improvements in outcome and retention)

As critical as time and ongoing support are to successful use of FIT, these two variables alone are insufficient for making sense of emerging, apparently unsupportive studies.  Near the end of my original post, I noted needing to look at the the type of design used in most research; namely, the randomized controlled trial or RCT.

In the evaluation of health care outcomes , the RCT is widely considered the “gold standard” — the best way for discovering the truth.   Thus, when researcher Annika Davidsen published her carefully designed and executed study showing that adding FIT to the standard treatment of people with eating disorders made no difference in terms of retention or outcome, it was entirely understandable some concluded the approach did not work with this particular population.  After all, that’s exactly what the last line of the abstract said, “Feedback neither increased attendance nor improved outcomes for outpatients in group psychotherapy for eating disorders.”

But what exactly was “tested” in the study?

Read a bit further, and you learn participating “therapists … did not use feedback as intended, that is, to individualize the treatment by adjusting or altering treatment length or actions according to client feedback” (p. 491).  Indeed, when critical feedback was provided by the clients via the measures, the standardization of services took precedence, resulting in therapists routinely responding, “the type of treatment, it’s length and activities, is a non-negotiable.”  From this, can we really conclude FIT was ineffective?

More, unlike studies in medicine, which test pills containing a single active ingredient against others that are similar in every way except they are missing that key ingredient, RCTs of psychotherapy test whole treatment packages (e.g., CBT, IPT, EMDR, etc.).  Understanding this difference is critical when trying to make sense of psychotherapy research.

When what is widely recognized as the first RCT in medicine was published in 1948, practitioners could be certain streptomycin caused the improvement in pulmonary tuberculosis assessed in the study.  By contrast, an investigation showing one psychotherapeutic approach works better than a no treatment control does nothing to establish which, if any of, the ingredients in the method are responsible for change.  Consider cognitive therapy (CT).  Many, many RCTs show the approach works.  On this score, there is no doubt.  People who receive it are much better off than those placed on a waiting list or in control groups.  That said, how cognitive therapy works is another question entirely.  Proponents argue its efficacy results from targeting the patterns of “distorted thinking” causally responsible for maladapative emotions and behaviors.  Unfortunately, RCTs were never designed and are not equipped to test such assumptions.  Other research methods must be used — and when they have been, the results have been surprising to say the least.

In my next post, I will address those findings, both as they apply to popular treatment models such as CT and CBT but also, and more importantly, to FIT.

Stay tuned.  In the meantime, I’m interested in your thoughts thus far.

Until then,

Scott

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

A ship’s captain who successfully sails through a strait at night learns nothing, and adds nothing, to their knowledge of the world.

(Please hang with me.  I promise this post will not be a long, metaphysical rant).

Returning to the example.  As paradoxical as it may strike one at first blush, a captain whose ship founders on the rocks while sailing through the strait both learns and adds to their knowledge.  As philosopher Ernst von Glasersfeld once opined, “The only aspect of that ‘real’ world that actually enters into the realm of experience is its constraints.”

The principle identified by von Glasersfeld applies not only to life lessons, but also to scientific advancement and, of course, feedback informed treatment (FIT).  Indeed, identifying and learning from “constraints” — that is, when things go wrong — is the very purpose of FIT.

It’s why, for example, when a client refuses to complete the outcome and alliance measures, my first impulse is to “lean in” and explore their reasons, rather than instantly set the scales aside.   It’s also why I’m most intrigued by studies which find that FIT fails to improve outcome (1, 2).  In both instances, my curiosity is piqued.  “Finally,” I think, “a chance to learn something …”.   Doing so, cognitive science has long shown, is not as easy or straightforward as simply adjusting our beliefs in light of new facts.  Quite to the contrary.

We are prone to see what we expect, fit the “different” into our current way of viewing the world or ignore it altogether.  One brief example before turning attention to FIT (aka Routine Outcome Monitoring [ROM]).  For most of the history of the field, the failure to engage in and respond to psychological intervention has been attributed to a host of client variables (e.g., degree or type of dysfunction, poor attachment history, IQ, etc.).  Therapists, for their part, have been held accountable for making the correct diagnosis and administering the right treatment.

And yet, despite continuous growth in the size of the DSM, and number of treatment approaches, no improvement in the outcome of psychotherapy has occurred in the last 50 years — a fact I first talked publicly about in 2014 and which über-researchers James Prochaska and John Norcross finally acknowledged in the most recent issue of the American Psychologist.  While some have argued that the field’s flat outcomes indicate the effectiveness therapy has reached a natural limit, an alternate point of view is that we should consider looking beyond the current ways of thinking about what matters most in successful treatment.

On this score, one possibility has been staring the field in the face for decades: the impact of the individual therapist on outcome.  Research has long shown, for example, that who does the treatment contributes 5 to 9 times more to outcome than the type of therapy, psychiatric diagnosis, or client history.  The same body of evidence documents some practitioners are consistently more effective than others.  When researcher Scott Baldwin and colleagues looked into why, they found 97% of the difference was attributable to therapist variability in the alliance.  Said another way, more effective therapists are able to establish a strong working relationship with a broader and more diverse group of clients.  I hope you’re seeing new possibilities for improving effectiveness.  If you’re a regular reader of my blog, you already know my colleagues and I published the only study to date documenting that a focus on therapist development via routine outcome measurement, feedback, and deliberate practice improves both agency and individual practitioner outcomes.

Turning to FIT, in my first post of the New Year, I talked about the strong sense of “anticipointment” I felt when thinking about the future of our field.  A colleague from the Netherlands, Kai Hjulsted, responded, saying he’d been having the same feeling about FIT!  The source, he said, was a study by a Dutch researcher conducted in a crisis intervention setting which, “contrary to expectations,” found, “Patients with psychiatric problems and severe distress seeking emergency psychiatric help did not benefit from direct feedback.”

I was well aware of this study, having served on the researcher’s dissertation committee.  And over the last decade, multiple studies have been published showing little or no benefit from feedback (e.g., 1, 2, 3).

How to make sense of such findings?  Having spoken with numerous practitioners (and even some researchers), I can tell you the tendency is to fit the results into our current way of viewing the world.  So, seen through a traditional medicopsychiatric lens, the inevitable conclusion is FIT does not work with people with certain, specific diagnosis (e.g., severe distress, in crisis, or those with eating disorders).  Such a conclusion makes no sense, however, if the totality of evidence is considered.  Why?  Because the results are decidedly mixed.  Thus, in one study, FIT makes a difference with people in crisis, in another it does not.  With one group of “severely distressed” clients, feedback appears to make matters worse, with another, chances of improvement increase 2.5 times.

What then can we conclude?

An answer begins to emerge as soon as we’re able to get beyond thinking of FIT as just one more in a long list of treatment methods rather than a fundamental, organizing principle of agency and practice culture.  As is hopefully obvious, learning to administer measurement scales takes little time.

Cultural change, by contrast, is a much longer process.  How long?  Norwegian researcher Heidi Brattland and colleagues found it took three years ongoing training and support to successfully implement FIT.  Had they stopped to evaluate, like all other studies to date, after an average of 4 hours of instruction, no impact on outcomes would have been recorded.

While its now clear that time and support are critical to successful implementation, these two variables alone are not sufficient to make sense of emerging, apparently unsupportive studies of FIT.  Addressing such findings requires we look at the type of design used in most research: the randomized controlled trial.   That I’ll do in my next post, in particular addressing two, top notch, well-executed studies many have assumed show FIT is not effective in psychological care for people with eating disorders and severe distress.

And so, as I asked at the outset, please “hang with me.”

Until next time,

Scott

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