Over the last several months, I’ve been writing a series of short, but true stories from my life and work. I’ve been surprised by and am grateful for the positive response. All of the stories can be found on my substack account, called “Snippets.” Here’s one from early on in my career, a lesson about working in the real world learned from my collegue and co-author, Insoo Berg.

AGAPE

At six and a half feet in height, and 250 pounds, Gerrard was an imposing figure.  The Capuchin brother-cum-social worker had worked with him for months on the streets to gain his trust.  Now, both were at the office.

I was seated in a large room together with several other therapists.  Surrounding us were a series of one-way mirrored windows, each looking into a different consultation room.  Donning one of the 1950’s-style headsets hanging together on makeshift hooks made it possible to listen in on the session of one’s choosing.

Only all the rooms were empty save one.  The largest room in the complex.  There, sat two people.  One was Insoo Kim Berg; the other, of course, Gerrard – except he was not so much sitting as leaning.  Forward.  Side-to-side.  Back with mouth agape, at times snoring loudly.   

“Yoo hoo,” Insoo called out once, then again, “Yoo hoo, Gerrard.” 

“I have an important question to ask you,” she continued the moment his eyes flitted open. 

It was my second official visit to The Brief Family Therapy Center in Milwaukee, Wisconsin.  I’d met Insoo a year or so earlier while attending a workshop she was giving in Denver, Colorado on treating drug and alcohol problems. 

“Why don’t you come visit us?” she asked on one of the long walks we took together in the mornings before the training began.  It just so happened we were both staying at the home of a mutual friend.  “Stay for a week.  Watch cases,” adding, “You can stay at our home.  We have an extra bedroom, with its own bath.”

I jumped at the chance. 

When Gerrard’s head rolled back on his shoulders, Insoo quickly moved her chair forward and began patting his leg.  

“Yoo hoo, Gerrard.”  Pat.  Pat.  Pat.  Raising her voice, “YOO HOO!”

“This guy is so stoned,” one of the clinicians said loud enough for all of us to hear through our headphones, “he can’t even keep his eyes open.”

That’s when I heard my name being called. 

“Scott?”

Looking up, I could see Insoo was staring in the direction of the mirrored glass. 

“Would you and Brother Joel come in here, please?”

Without thinking, I stood and made my way toward the door to the consultation room, Gerrard’s Capuchin escort not far behind

“Help me get him up,” she directed, “one of you on each side.”

We did as instructed, at times the two of us bearing Gerrard’s entire weight as we dragged him around the room, all the while Insoo hounding him with the types of questions for which she was best known. 

When the meeting ended some 50 minutes later, I was physically exhausted.  Making my way back to observation room, I sat slumped in my chair waiting for Insoo to return to discuss the session with the group.

Her response to the first question raised ensured it the last one asked.  “Why,” the same person who’d commented earlier about Gerrard, asked “when this person is so high he can’t even keep his eyes open, did you carry on?  Why not just reschedule when he’s sober and able to remember what happens?”

Insoo didn’t miss a beat.  “This might be the only chance I get,” she instantly replied, “and if he has any memory of me at all, I want it to be that I tried.”

I did meet Gerrard one additional time.  It was about a year later.  As before, I was seated in the observation room waiting for Insoo to enter with her next client.  Twenty-or-so other therapists from different states and countries were there to watch and learn.  This time, instead of visiting, I was working full time at the center. 

In she walked, trailed by a tall, well-dressed, bespectacled man. 

“Shall I sit here?” he asked, his voice strong and diction clear.  Parting his camel hair topcoat, he sat, crossing his legs at the knee.  Our clients falling on the low end of the socioeconomic spectrum or often homeless, I admit thinking to myself, “I wonder what this guy is doing here?”

I blinked hard, twice, when Insoo began, “Gerrard, its so good to see you …”

Over the last several months, I’ve been writing a series of short, but true stories from my life and work. After some gentle encouragement from Carrie Witta of Very Bad Therapy podcast fame, I created a substack account and have been posting the “Snippets” once a week or so. Some are drawn from encounters in the therapy room, others from childhood — all from experiences that made an impact despite their brevity. The latest is how one of my clients in therapy helped me — it turns out, not an infrequent experience, if allowed.

I’ve cut and pasted it below. You can also read it on substack. Subscribe and you’ll be notified each time a new story is published. Can’t beat the price — its free!

From the oversized bag resting on my office floor, she produced a VHS video cassette. “I’m hoping this,” passing it to me, “will explain, better at least, than I’ve been able to.”

Our session over, she stood and turned toward the door. “S e e yo u t o m o r r o w,” I stammered, feeling awkward as ever – which, by the way, was often.

Partly because I was an intern at the time, but also due to my nature, what seemed to come so easily to others, I found difficult. Suffice it to say, I was no natural therapist. Quite the contrary. I was aware of and deliberate about every action I took and didn’t take, including what I said and didn’t say, when I spoke or chose to remain silent, the movement of my limbs, head and torso, whether I looked away or directly at the person, and for how long.

Anyway, I brought up the hour with my practicum supervisor the following morning. “Let’s see what’s on the tape,” he quickly suggested.

We watched a minute or so, then fast forwarded through a few more.

“Does this mean anything to you?” he asked.

Shaking my head from left to right, “No, uh, I, it doesn’t.”

Speeding through the entire 90-minute cassette, it was clear the video was a carefully edited collection of snippets from various television programs and commercials – some I recognized, others that were unfamiliar. Five seconds of American Bandstand, followed by a clip of a Calvin Klein advertisement, another five or ten second scene from American Bandstand and then extended cuts to the TV series, Dance Fever. If there was a theme, or some intended message, it was lost on me as well as my far more experienced supervisor.

“Did you have a chance to watch the tape?” she asked at the outset of our next session.

“I, I, I did …” falling silent, purposefully lowering my eyes.

“And did it help make things any clearer?”

Looking up, “Could you help me understand what was in the video, what it’s about?” I said, being careful to repeat the words I’d role-played the day before with my supervisor.

A long silence followed.

After 30 years of being a psychologist, there’s little that surprises me about people and their lives – sure, the details differ, but the stories generally have a familiar ring. Then, however, it was all new to me.

Caroline was on the inpatient ward of a hospital where I was completing an extended practicum. Married, stay-at-home mom to several kids, she’d become depressed in the last year. When standard outpatient psychotherapy and medication didn’t help, she was admitted for more intensive care.

And when she eventually said, “It’s about feet,” it all came together. The hour-and-a-half long video was nothing but feet. Feet walking. Feet dancing. Feet in shoes. Feet in flip-flops. Bare feet – loads of bare feet.

For most of the time that remained, I listened, leaning forward, eyes fixed on Caroline as she talked about her husband’s interest in feet. Early on in their relationship, she hadn’t minded. However, when what had started off as a curious, and even intriguing part of their sex life, had warped into an obsession, she ended up feeling alone, unfulfilled, and betrayed.

Years after we met and worked together, I received a letter from Caroline. By this time, I’d graduated, moved out of state and across the country. From the postmark and multiple forwarding address labels, I could see it had been in transit for some time.

“I’ve been meaning to write for some time,” the letter began. After providing some details about her life and family – all generally positive – she explained why she’d chosen to write.

“I wanted to thank you for the help you gave me at that very difficult time …”

Temporarily looking up from the page, I wondered how that could be true. My recollection was I’d done little and understood less. With a mixture of anticipation and dread, I read on.

“I also want to give you some feedback, something I should have said long ago.”

Here it comes, I thought, pursing my lips.

“When we were meeting, I knew there were (many?) times you didn’t know what to say or do.”

Despite hoping my frequent, and often lengthy silences had been interpreted otherwise, her observation was spot on. I smiled in recognition.

She continued, “In case you didn’t know, it’s those moments that stuck with me and were the most helpful. Your stillness gave me the space to hear what I was feeling and accept myself. It was life changing.”

Tucking the letter back into the envelope, I couldn’t help thinking she was returning the favor.

In 1997, Wampold and colleagues published a study that revolutionized psychotherapy outcome research. It addressed a question that had long divided the field; specifically, were some therapeutic approaches more effective than others?

Each side in the debate claimed the data supported their position — and, like a Rorschach ink blot, the available evidence could be interpreted in sharply different, but seemingly valid ways.

(Do you see two researchers sitting opposite one another but looking at the same computer screen?)

In the debate between contrasting positions, its easy to miss the study’s main contribution. True, the authors found no difference in outcome between competing treatment approaches. However, the important question, given years of conflicting results, was “why?”

Turns out, many previous studies — particularly those reporting significant differences between methods — included comparisons to approaches not intended to be therapeutic. If one really wanted to know whether a treatment (e.g., CBT, IPT, ACT, EMDR) was more effective, it had to be directly compared to an approach intended to help — what Wampold and colleagues termed, a “bona fide” treatment. Doing otherwise, they argued, conflated artifacts of research design with actual research results.

“Well, of course,” you say? And yet, a more recent debate among researchers makes obvious, the findings from two-and-a-half decades ago apparently aren’t that obvious. Consider, for example, deliberate practice. Despite rising interest in the topic in psychotherapy, and the publication of several studies, it’s true impact on performance is a matter of debate (1, 2, 3, 4, 5).

Following a meta-analysis of the available research, Miller, Chow, Wampold, Hubble, del Re, Maeschalck and Bargmann (2018) argued that an accurate understanding of deliberate practice would only be, “likely when: (1) research included in any analysis is an actual study of DP; and (2) the criteria for what constitutes DP are standardized, made explicit, accepted by researchers, and applied consistently across studies” (p. 7). They proposed “bona fide” deliberate practice included four, research-based criteria: (1) individualized learning objectives; (2) ongoing feedback regarding performance and learning; (3) involvement of a coach; and (4) successive refinement through repetition most often conducted alone.

Last week, the first study of deliberate practice to meet all four criteria was published in Training and Education in Professional Psychology. It deals with improving therapist ability to handle conversations typically considered difficult in treatment. Bottom line: DP was superior to self-reflection and generalized to novel challenges. I will post the study here as soon as an online or print version becomes available. Until then, my colleague, Daryl Chow, and I discuss the results and practical implications in the video below.

Until next time,

Scott

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

P.S.: The November FIT Intensive is now SOLD OUT. Click here for more information or secure your spot for the upcoming FIT Supervision/Consultation Intensive.

“History” has a way of feeling as though it happened long ago.  Selfies are such a ubiquitous part of our culture it’s hard to believe the technology that gave rise to them appeared only 15 years ago.

One more example.  Seatbelts.  On entering the car, my kids and grandkids fasten theirs without thinking.  Amazing given that the first law mandating their use did not appear until 1984!

1984. 

I’m sure that date seemed far off in the future to George Orwell.  Truth is, however, it’s not so long ago.  I was a graduate student at the time doing a practicum on the psychiatric ward of a local hospital – and it was full to capacity with patients diagnosed with what previously had been considered an exceptionally rare disorder, multiple personality. 

That same year, in what at first seemed an unrelated development, news broke about a child pornography and sexual abuse ring operating at a preschool in Southern California.  Interviews of the children by therapists revealed even more sinister details – ritualistic abuse, animal mutilation, sacrificial murder.  It didn’t stop there.  Other daycare centers were soon implicated, beginning nearby and eventually spreading across the country, exposing a heretofore unknown network of satanic cults.

One day, while working on the unit, I noticed something peculiar.  Amidst the changing names, dress, and interactional styles, several of the patients had multiple sets of eyewear.  I’m not talking about Ray-Ban’s versus Maui Jim, but rather prescription glasses.  More, the pair they wore seemed to vary depending on which of their many personalities was dominant at the time.

And that’s when my dissertation project was born.  Over the next year-and-a-half, I ferried patients from the unit to the office of an ophthalmologist who had volunteered to run the tests for the study.  Three alters per person had their eyes refracted, retina and vascular structure examined, and intraocular pressure measured.  The same tests were completed on an equal number of people who had been trained to feign the disorder during the examination.    

During this time, allegations of sexual abuse by organized groups of devil worshipping pedophiles continued to emerge. I’m not sure where I was when a connection was suggested between satanic ritual abuse and the development of multiple personality disorder.    In truth, it wasn’t a big leap.  A decade earlier, the book, Sybil, and later television mini-series starring Sally Fields, made the public aware of the link between sexual abuse and splintering of personality.  

I do remember where I was when I heard that expressions of doubt about the validity of reports regarding widespread satanic abuse could be evidence of complicity.  I was at a national conference.  Even more mind-bending were the rumors about who was behind the global conspiracy and their true intentions.  Can you guess?

By the time I’d finished my dissertation and published a larger, follow-up study, much had changed.  My own research challenged the view of the diagnosis popular at the time; namely, that the chief characteristic of the disorder was the existence of separate and distinct alter personalities.  Turns out, the visual functioning of people with the diagnosis was indeed highly variable, but not reliably so.

On the legal front, despite spending seven years and fifteen million dollars, the prosecution of the teachers or owners of the original daycare facility resulted in no convictions for any crime.  Excavations of an adjacent lot found no evidence of the “secret underground rooms” reportedly used for photographing and abusing children.  Despite extensive investigations by the FBI and National Center on Child Abuse and Neglect, none of the twelve thousand accusations of cult led sexual abuse were substantiated.  It would take decades in some instances, but all who were convicted were eventually released, including a man whose daughters’ recovered memories of sexual abuse and human sacrifice led to his conviction and twenty-year prison sentence.  In time, even Shirley Mason, the real Sybil, recanted, admitting in a letter to her psychiatrist that she’d fabricated the entire story. 

And then, just as quickly as it all had started, public and professional interest came to an end.  Media stories all but disappeared.  Incidence of the diagnosis in hospitals and clinical practice declined precipitously.  Specialized treatment centers closed, and professional associations disbanded.

Progress, it seems, was to be had elsewhere.  The “decade of the brain” was underway, and the field was moving on.   Remember that?  It wasn’t that long ago.

“Your reach should exceed your grasp,” was one of my dad’s favorite sayings.  Smile on his face, he would often add, “be prepared to end up empty handed” – which reminds me of a memory.

I was seated on the right side of the room, in the aisle seat, second row from the front.  As far as venues go, it was nothing special.  The workshop was another story.  I’d been looking forward to attending for several months.  I wasn’t alone.  Every seat was taken – many of the participants familiar to me, although older and much more experienced. 

I’m sure I was the only grad student in attendance.  It wasn’t for lack of interest.  The cost was simply too high.  I’d only managed to secure a spot by agreeing to help out the organizers.      

Day two began with a video featuring the second meeting with a couple.  We’d seen the first session the day before.   And while the details of the discussion between the couple and therapist are lost to time, I remember with absolute clarity how their visit concluded.   The therapist told the couple to shave their heads and bury the clippings in a hole in their back yard prior to the next visit. 

My reaction was instantaneous.  I started laughing.  I couldn’t control myself.  Neither could the other attendees.  The “intervention” – as the homework task was termed – was just so surprising.  At the same time, it fit the situation.  Like the answers to classic Zen koans, a perfect combination of absurdity, recognition and truth.  You know, “What is the sound of one hand clapping?”  (The answer can be found in the parenthesis below) 

Anyway, when someone in the audience shouted, “Did they come back?” the presenter responded in true cliff-hanger fashion, “You will have to come back tomorrow to find out.”

And there we sat, the room strangely quiet for so early in the morning. 

I didn’t know what to expect.  As the video began playing, the audible gasps of those around me suggested my fellow attendees didn’t either.  But there the couple was, center screen, seated in adjoining chairs, both as bald as Winston Churchill.  According to their statements, engaging in the task had been transformative.  The problems that had proven so intractable to their own and prior professionals’ attempts to help had largely resolved.

Had I not seen it with my own eyes, I would not have believed it.  I listened ever more attentively the rest of the day, taking careful notes and mulling over the answers given to participants questions.  At the end, I bought the presenter’s latest book.  “To Scott,” the personal inscription read, “Use it or lose it.”

I still have the book on my shelf in my office. What I don’t have is a picture of my supervisor’s face when I related the story at our next meeting – not about the video of the couple, mind you, but rather what happened when I instructed my one practicum client to shave their head.  With a roll of their eyes, they’d stood and left the session.  My supervisor?  Kind of like the sound of one hand clapping, silence (in this instance, I believe, the stunned variety).

So, has your reach ever exceeded your grasp in this way? Left you empty handed or worse, with an empty seat in your office? What happened for you? Your client? What, if anything changed in your understanding of the work? Finally, what advise would you offer a person just entering the field given the abundance of therapeutic options and choices?

If you’re interested, more such stories are available on my Substack page.

OK, until next time, I wish you the best,

Scott

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

P.S.: Registration is open for the next, Feedback Informed Treatment Supervision/Consultation Intensive. Click here or the icon below for more information or to secure your spot.

(Shame on you.  Go back and finish the story)

You’ve heard of it, right? Lake Wobegon? The fictional town in Minnesota made famous by master story-teller, Garrison Keller. The place where, “all the people are strong, good-looking, and above average?”

Turns out, if the city were “Psychotherapy,” it would not be a fictional place. Since 2012 when the first study appeared in the literature, others have been published documenting the tendency of practitioners to overestimate their effectiveness — on average, by 65% (1, 2). The impact on professional development could not be greater. Again, multiple studies show, for example, therapists do not improve with time or experience despite obtaining regular supervision or attending the latest continuing education workshops (3).

If you are like most therapists, you’re likely feeling skeptical about such findings — and there are some exceptions. More on that in a moment.

In the meantime, consider the results of a study my colleagues and I just published in Practice Innovations. We knew that research to date had relied exclusively on therapists in Western cultures and wanted to explore whether The Lake Wobegon Effect would be observable in other cultures — particularly, those valuing humility and modesty. Turns out, similar to therapists from the US, Canada, Australia and Europe, Chinese psychotherapists (N = 223) rated themselves as above average (the mean percentile rank being statistically indistinguishable).

So, who are the exceptions? In the studies documenting that most therapists become more confident while remaining average or achieving poorer outcomes, some — between 15 and 25% — defy the trend and actually improve with time and experience.

What is it that they do? Returning to Lake Wobegon, they neither express nor rely on feelings of humility. Rather, they engage in activities that engender the self-doubt required for making changes in how they work. One example is measuring their performance. Indeed, the only study ever published to document improved outcomes at the individual practitioner level involved therapists routinely measuring client progress, identifying those at risk of dropout or a negative or null outcome, and obtaining feedback targeted to their specific clinical errors and performance deficits (4).

Whether you are an experienced practitioner or new to the field, have been measuring your results for years or wanting to get started, the upcoming Feedback Informed Treatment Intensive will help you put Lake Wobegon in the rearview mirror. Three days, online, and ongoing support from a worldwide community of helping professionals dedicated to improving the outcome of behavioral health services. Click the icon below for more information or to register. As always, feel free to reach out with any questions.

Until next time,

Scott

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

UPDATE 9/23/24

Access the article here.

All of us have them. Key developmental experiences. Ones that stick in our memory, make a permanent “dent” in our thinking or behavior.

I was sitting behind a one-way mirror watching a therapy session. The young man being interviewed was dying, his immune system failing due to the AIDS virus. It was the early days of the outbreak. Lots of fear, death, helplessness, and indifference.

“He’s in denial about dying,” the resident physician told us before my fellow psychology intern entered the hospital room, “If things need doing, they have to be done soon as he doesn’t have long.”

The conversation that ensued was painful to watch. The young man talked about what he was going to do when he was released from the hospital. My colleague gently but firmly focused on the man’s impending death.

Pointing to a magazine on a bedside table, “I’m planning a trip, going to sail around the world.”

Following a brief pause, “I know this must be hard to accept, but you are dying.”

“I have been looking at sail boats,” he continued, “I learned how to sail when I was coming up.”

Silence. Then, “Perhaps we should talk about what’s happening right now.”

Once again pointing to the magazine, “Can you hand me that? I’ll show you sailboat I’m thinking about getting.”

And on and on it went.

As a grad student, I’d learned about resistance and denial – according to Freud, “the violent and tenacious” rejection of the therapist’s efforts “to restore the patient to health, to relieve him of the symptoms of his illness.” It was the challenge of therapeutic work, the precursor to being able to help.

To me, however, it seemed like torture. “I don’t get this,” I said to the group, “He’s dying.”

“The point,” our supervisor responded, “is to help him address this, and take care of what needs to get done before he dies.”

“And what if he doesn’t?” I thought to silently to myself, “What’s the worst that can happen? Either way, he’s dead.”

The interview dragged on for another 15 minutes or so. I just watched, feeling helpless. After all, at the time, I didn’t have any alternate suggestions for what to do – something that wouldn’t be seen as participating in or perpetuating the man’s … “denial.”

Next morning, I learned the young man had died during the night. It took my breath away. Then, as now, I felt we really missed … the boat.

I’m not sure what was going on in our field last week. From the emails I received, it seemed something big — no, monumental. Here are just a handful of the highlights:

“The single modality that’s transforming how clinicians do therapy … and making them so successful.”

A new approach for “Getting to the heart of complex and deep-rooted clinical issues, fast.”

A “unique and integrative approach for … building thriving relationships that last!”

You will learn to offer “transformative trauma healing results … [and] become the go-to trauma healer.”

Plus, certifications in “complex trauma, PTSD, and dissociation,” “polyvagal therapy,” and — no irony intended — “Narcissistic Abuse Treatment Clinician.”

Now, truth is, I get a lot of email. On any given day, a certain percentage of what lands in my inbox is made up of solicitations. A couple of advertisements for training in this or that therapy would, therefore, have gone unnoticed.

This was different. One day alone I received 41 separate come-ons — all with the same bold promises and time-limited discounts for “special customers” like me.

I still don’t know what led to the deluge. What is certain is that it had nothing to do with advances in the “science of psychotherapy.” Over the last 50 years, treatment methods have proliferated despite a lack of evidence of differential effectiveness between approaches. And even when a randomized controlled trial indicates a particular approach works, none show practitioners become more effective when they are trained in that modality.

Consider a study out of the United Kingdom (1). There, massive amounts of money have been spent training clinicians to use cognitive behavioral therapy (CBT). Clinicians participated in a high intensity course that included more than 300 hours of training, supervision, and practice. Competency in delivering CBT was assessed at regular intervals and shown to improve significantly over the course of the training program. And yet, despite the tremendous investment of time, money, and resources, outcomes did not improve. In short, clinicians were as effective as they’d been before being trained.

Contrast the field’s relentless pursuit of “treatment technology” with the work of psychologist Timothy Anderson. A decade-and-a-half ago, he developed a tool for measuring therapists’ interpersonal skills. Known as The Facilitative Interpersonal Skills Performance Task (FIS), it assesses a range of abilities (e.g., warmth, empathy, verbal fluency,  hope, emotional expression and persuasiveness) by rating therapist responses to video simulations of challenging client-therapist interactions.  It turns out that therapists who perform well on the FIS establish stronger relationships and are more effective (2). More to the point, the evidence shows FIS-related skills are trainable and that such training leads to better results (3, 4, 5).

Next month, I’ll be posting a summary of a study my colleagues and I just published documenting the impact of using deliberate practice to improve interpersonal skills — namely, empathy (You won’t be surprised to learn that clinicians’ assessment of their abilities did not correlate with their actual performance).

In the meantime, take a listen to the interview below with Dutch researchers, Sabine van Thiel and Kim de Jong. Their recently published study identified multiple, different types of therapist FIS response styles — including the elusive, “supershrink.”

Until next time,

Scott

Director, International Center for Clinical Excellence

P.S.: The final fireside chat with me and Daryl Chow is scheduled for the last Tuesday of this month. It’s free, of course, but you must register to secure a spot. Click here.

She’d started young. At age 3, she was named “Miss Beautiful Baby.” Shortly thereafter, she became a regular –“Bubbles Silverman” — on the Uncle Bob’s Randbow House radio show.

Voted “most likely to succeed” by her high school classmates, she sang everywhere and anywhere before landing a position as “house soprano” at the City Opera of New York in 1955. Her later performance of the aria, “Se Pieta” in Handel’s Julius Ceaser led a New Yorker magazine theatre critic to comment, “If I were recommending the wonders of New York to a tourist, I would place Beverly Sills at the top of the list.” High praise given the vast pool of talent in the “city that never sleeps.”

Not suprisingly, when Sills died in 2007, she was hailed as, “one of this country’s great operatic voices” — a remarkable compliment given that no one had heard her sing at that point in nearly three decades! Rather, in 1980, at the height of her fame, she chose to retire.

“There is a kind of desperation,” she later said, “staying at something too long … and I am not a desperate woman. I wanted people to say, ‘It’s too early,’ rather than, ‘When is that woman ever gonna quit? It was the perfect time to go out — on top.”

In today’s media and influencer saturated world, some might deem Sills’ decision foolish. “Why quit? Why not hang around, make as much ‘bank’ as you can, ride the waves of fame and adulation as long as far as they will carry you?” Heaven knows many in the public eye stick around far longer than their expiration date. For her, however, her commitment to performance excellence trumped any resulting celebrity.

Personally, I admire the choice Sill made. As I age, I’ve found myself wondering more often about when to “hang it up.” It can’t be based on demand, real or perceived. Indeed, there is a kind of conceit in leaving the decision up to others.

Seems to me that exiting at the top of one’s game is even more challenging in the field of therapy where age and experience are believed to confer special advantage. The same may be said of commercial airline pilots — at least, I know I feel more confident when the flight crew trends older than the cast of High School Musical. And yet, given the declines in memory, reasoning, verbal fluency and comprehension skills associated with advancing years, pilots have a mandatory retirement age, a standard applicable across 193 member-nations! Surely, some could continue for longer, but doesn’t that beg the question?

As reviewed here, research on therapists makes clear age and experience confer no advantage and are likely associated with poorer performance (1, 2).

So, what are your criteria?

Until next time,

Scott

Director, International Center for Clinical Excellence

Once upon a time, a nickel (the U.S. 5-cent coin) had value.

As a kid, I could get a generous scoop of ice cream at Sav-On, Big Hunk candy bar at Bock’s variety store, or a super-sized glazed doughnut at the Donut Man shop on Route 66.

At that time, a nickel was considered so valuable that when you wanted to imply something was worthless, you would say, “Yeah, that, and a nickel will get you a cup of coffee.” According to a post on Quora, the expression arose in the 1940’s when a cup typically cost five cents.

Along with, “I’m not going to hold my breath,” the expression was one my Dad sometimes used in response to me making any number of promises (e.g., clean my room, walk the dog, practice the piano or be nice to my younger brother).

I’m sure he hoped I’d follow through, much the same way we therapists believe growing clinical experience results in greater expertise and effectiveness. Why, otherwise, would so many of our websites feature “time in the chair” so prominently?

“I have over 15,000 hours of clinical experience,” says one. “I’ve been a psychotherapist for more than 20 years and have authored 5 best-selling books,” says another.

And yet, when such statements are considered in light of the evidence, it seems clear the most appropriate response is, “Yeah, and that plus $6.75 will get you a grande, soy, caramel macchiato at Starbucks.”

(The cost of a cup of coffee has obviously risen a bit since 1940)

Indeed, as I’ve reported in previous posts, research not only shows therapists do not improve with time and experience in the field, but on average become less effective (1, 2, 3, 4). Other studies document that students achieve outcomes on par or better than licensed professionals who supervise them (5, 6). Given such findings, it is more than a bit ironic that experience is associated with higher per hour fees (7) — increased rates which, it turns out, are tied to higher dropout rates!

Enter a new study by Bugatti and colleagues examining therapist dropout rates. Using data generated by more than 2,500 practitioners working with real clients in real world clinical settings, the researchers found therapists’ dropout rates increased the longer they were in practice.

You read that right.

Similar to the findings on effectiveness, therapist experience is not associated with better client retention rates. More, as noted previously, “therapists working with clients paying higher out-of-pocket fees have higher increases in client dropout over time.” Finally, in case you are wondering, caseload size did impact retention rates, but in a direction opposite to what most expect; specifically, therapists treating the most clients had the lowest dropout rates.

Bottom line? It’s time for the field to stop attributing benefits to clinical experience. Beyond the obvious ethical concerns, doing so actually prevents us from improving our effectiveness! A fundamental element of deliberate practice is challenging automaticity, or the lack of conscious control over and inability to make specific intentional adjustments to our behaviors that comes with … experience.

Raising awareness is the first step. To improve, we have to know where our actions and thinking fall short. Measuring and mapping our performance — as described in Better Results: Using Deliberate Practice to Improve Therapeutic Effectiveness and its companion volume, The Field Guide to Better Results — are two methods proven to help. The latest studies show, for example, both improved retention and effectiveness rates (~25%).

My colleauge and co-author, Daryl Chow, Ph.D., and I will be talking about these two methods (and the latest research findings reported here) at the next, online “Tuesdays with Daryl and Scott.” Held the last Tuesday of each month, the next one will be held on May 28th at 8 a.m. Central time.

No cost — not even a nickel — and you supply your own coffee.

Space is limited, however, so please click here to register and secure your spot.

Its the biggest update to Feedback Informed Treatment (FIT) in two decades.

In the beginning, all we had were the measures. Clinicians administered the outcome and session rating scales at each session and then compared client scores to the clinical cutoffs (CCO) and reliable change index (RCI) to determine whether care was “on or off track.”

The evolution continued. As data gathered from clinical practice settings accumulated, it became possible to develop “trajectories of change.”

Users of Myoutcomes.com, Fitoutcomes.com, and OpenFIT will instantly recognize the graph pictured below.

Gone were the comparisons to percentile rankings of the normative sample. Instead, the green line represented the least amount of progress the client could make from session to session and still be on track for a successful outcome. Yellow was interderminate and red definately, “off track.”

Since first becoming available, the algorithms that produce the predictive trjectories have been checked and updated every three years or so. The latest review — involving millions of completed cases of care — confimed their ability to inform mental health services provided in diverse settings around the world.

All good. Except, it wasn’t.

Isn’t.

While offering a clear advantage over comparisons to the cutoff scores, percentile rankings, and pre-established change indices, the algorithm-driven, predictive trajectories were still static. Said another way, they did not change following the first visit. True, the initial score was a better predictor of success than a host of factors traditionally considered reliable indicators (e.g., diagnosis, prior treatment history, type and level therapist training). But surely, more accurate assessments of progress would be made if they took into account what happened from visit to visit. Indeed, wasn’t that the whole point of soliciting feedback? Improving the chances of success by adjusting services on an ongoing basis to better fit the individual client?

Enter the SPI, or “Success Probability Index.”

Briefly, the SPI offers an indication of the likelihood of success at each session based on the current and historical pattern of SRS and ORS scores. Importantly, the particular pattern used to generate the index at any given session (e.g., average, slope, change in scores since the prior visit or over the course of care) varies depending on which most accurantely predicts success at the end of care. As can be seen in the screenshot below, despite similar start scores, the different patterns of progress represented in the two graphs result in different predictions. Specifically, the case on the left is on track, while the one on the right (coded in red), is about 16.5% below the average successful client.

In the near future, I’ll publish a “FIT TIP” or two explaining in greater detail both meaning and use of the SPI. In the meantime, take a look at the video produced by Myoutcomes.com — the first system to make the SPI available to their users.

Until next time,

Scott
Director, International Center for Clinical Excellence

How difficult could it be? One scale to assess progress, a second to solicit the client’s perception of the therapeutic relationship. Each containing four questions, administration typically takes between 30 to 60 seconds.

Since first being developed 23 years ago, scores of randomized-controlled and naturalistic studies have found the use of simple tools in care significantly improves outcome (1, 2).

And yet, while both simple and effective, research shows integrating the measures into care is far from easy. First came studies documenting that implementing feedback-informed care took time — up to three years for agencies to see results (3). It’s why we developed and have been offering a two-day itensive training on the subject for more than a decade — the only one of its kind. The next one is scheduled for January (click here for more information or to register). We outline the evidence-based steps and help managers, supervisors, team leads and staff develop a plan.

Other studies show while the vast majority of clients have highly favorable reactions to the use of the scales in care, they do have questions. In a recently survey of 13 clients in a private practice setting, Glenn Stone and colleagues (4) reported 70% were surprised at being asked for feedback! More than half found it helpful to see their progress represented graphically from week to week, roughly the same number who felt the scales helped them identify and maintain the right focus in sessions. At the same time, a handful reported feeling confused about the some of the questions; specifically, how to answer an item (e.g., social well being) when it contained multiple descriptors (e.g., school, work and friendship) — each of which could be answered differently.

Such a fantastic question! One we have addressed, among many others, at every three-day, Feedback Informed Treatment Intensive since 2003 (the next one scheduled back-to-back with the Implementation training in January). Seeing the question in this research report made me think I needed to do a “FIT tip” video for those who’ve started using the measures but have yet to attend.

So what is the “best practice” when clients ask how to complete a question which contains multiple descriptors?

Dr. Danilo Moggia is a psychologist and researcher working at the University of Trier in Germany. Over the last several years, he’s been devoted to studying how “machine learning” (ML) can be used to improve the fit and effect of mental health services.

Wikipedia defines ML as, “an area within artificial intelligence which uses data to ‘train’ computers to discover and ‘learn’ rules for solving a task.” According to Dr. Moggia, when it comes to the application of AI to psychotherapy, therapists fall into one of three groups. The first, and fewest in number, are enthusiastic. They love technology, see the possibilities in a self-driving car or future, therapist-less therapy. The second might best be characterized as reluctant. Still viewing AI and ML as more science fiction than science, they fall squarely in the “wait and see” camp. Third, and final, are the philosophically opposed, those who worry about the loss of the human element in psychotherapy.

So, cutting to the chase, can AI/ML help practitioners tailor care to their clients?

That is the question, Dr. Moggio and colleagues address in their chapter, “Do certain people respond better to specific forms of psychotherapy?” published in the 2023 edition of the APA Handbook of Psychotherapy. After reading it, I immediately emailed to see if he’d talk to me, live. The chapter is definately worth a read. We cover most of it and more in the interview below.

As always, interested in your thoughts and reactions!

Until next time,

Scott

Director, International Center for Clinical Excellence

P.S.: The ICCE “Train the Trainer” intensive is fast approaching. All online, this once-every-other-year event focuses on finding and refining your presentation and training skills. Click here for more information or to register.

Type the title of this post into Google and you get 275 million results. Scroll through the pages and you’ll find most are links to the hit song by Ed Sheeran — videos, fan pages, or stories about the 100 million dollar copyright lawsuit filed by the estate of the Ed Townsend, co-writer of Marvin Gaye’s 1970’s R&B classic, “Let’s Get it On.” Apparently, the two songs sound the same. I can’t hear it, but what do I know?

(By the way, this last May, the courts found in Sheeran’s favor)

Long before the music and controversy, the term “thinking out loud” referred to a method used by scientists to understand human behavior. Together with colleagues, psychologist K. Anders Ericsson — the expert on expertise — found that asking people to “think aloud” while they were engaged in a given set of tasks revealed reliable differences between the best, or “top” performers, and others (1).

I used a version of the method when teaching my youngest to drive a few summers ago. He was 18 at the time. Having grown up in a big city with ready access to mass transit, he hadn’t felt the need to get a license at 16. He still wasn’t feeling it when his mother and I forced the issue. He was heading out of state for college. Knowing how to drive, we believed, was an important life skill.

Anyway, “thinking out loud” wasn’t the first way I approached the task. Rather, I gave commands, “slow down,” “turn your blinker on,” “stop following so closely.” And when I wasn’t telling him what to do, I was explaining why he needed to do it — respectively, “the speed limit is …,” “the law says you need to signal 100 feet ahead of a turn,” and “hey, if that car ahead stops abruptly, you’re going to rear end it.” Neither of these strategies proved particularly helpful. Indeed, they only served to heighten tensions.

The proverbial “light in my head” finally turned on when my son responded to yet another of my explanations with, “I know the rule Dad … but how do I do it?”

Important distinction. Not what. Now why. How. As aerospace engineer and science communictor, Destin Sandlin is fond of saying, “knowledge is not understanding.”

The challenge for me — and anyone else that’s been doing a particular activity for a long time — is being able to recall the “how.” At the point I was teaching my son I’d been driving for nearly 5 decades! In truth, most of my behavior beind the wheel was and is done unconsciously. The same is true of getting out of bed, walking downstairs and making coffee in the morning. Little conscious thought is involved. I just do it.

“Automaticity,” as its known among researchers of deliberate practice, is both good and bad. On the plus side, it frees up our limited cognitive resources so we can attend to other, more important matters. The downside, as Anders Ericsson once pointed out, is the loss of conscious control over our actions means, “People … are no longer able to make specific intentional adjustments to them (p. 694, 2).

Take a moment and reread that last sentence.

Bottom line: if you want to improve your performance, you will need to first regain conscious control over your behavior. It’s why, in Better Results: Using Deliberate Practice to Improve Therapeutic Effectiveness, one of the first exercises we recommend is creating a schematic or blueprint for how you do therapy sufficiently detailed so another practitioner could understand and replicate it (see page 29).

Truth be told, however, when the book was released in 2020, feedback about this exercise was swift and negative. Therapists struggled to describe their work. Not what they did or why, but how. Generally, the results were either too vague (e.g., conduct an assessment, listen and be empathic, suggest a “thought log”) or so granular most got lost in the details and gave up.

We modified the exercise considerably, offering additional details and advice in The Field Guide to Better Results: Evidence-based Exercises to Improve Therapeutic Effectiveness released just this year (see pages 18-20). Combined with “thinking out loud,” most are finding the activity much easier to complete.

Returning to teaching my son to drive. In place of explanations and commands, I simply began verbalizing my thoughts, observations, and behaviors in real time as we drove together. To wit:

• The sign indicating a stop ahead is typically 500 feet from the intersection. I’m reducing pressure on the accelerator.
  
• The car in front of me is about 30 feet away. I check the speedometer. My speed 55 mph. I lift my foot from the accelerator now. At 80 feet, I put my foot back on the accelerator. I maintain the same speed.
  
• Distance is closing between me and the car ahead. I look over my left shoulder. I signal. I look over my left shoulder. No car. I maintain my speed. I slowly turn the wheel to the left about 1 inch. Now I check my blinker. Its still on. Next time I should short stroke the signal rod.

The difference was remarkable. Much less tension and, over time, gradual improvement in my son’s driving.

The application to therapy can be just as straightforward. Instead of attempting to create a map from memory, record a couple of sessions. Then, as you listen, talk out loud, stopping the recording to describe your observations, the thoughts you were having at the time, and the behaviors you exhibted as a result.

As described in Better Results and The Field Guide, creating a detailed blueprint will make it easier to target and change the specific aspects of your performance required for improved results. No worries if you’ve not read the books. Links to the two podcasts provide a fairly thorough review!

OK, that’s it for now. Always interested in your comments.

Scott

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

P.S.: We will be applying the principles of deliberate practice at the upcoming “Training of Trainers.” Over three-days, we’ll help you develop and improve your training and presentation skills. Join colleagues from around the world for this once, every-other-year, training event. Click here, or the image below, for more information or to register.

I remember her. My very first, real client. Cynthia — not her real name, her real name was Susan, but I’m not supposed to tell you that! (Just kidding, that wasn’t her name either)

Early thirties. Married. Couple of kids. Depressed.

I was still a student, a therapist-in-training — and I desparately wanted to be helpful. This wasn’t a fellow student role playing a client or presenting a minor concern of their own (“I can’t decide whether to take job X or Y”). Cynthia was in pain and looking to me for help.

I didn’t know much at this point in my professional career. I certainly could reflect feelings (“so you’re feeling very [insert feeling word here] and “what I hear you saying is [insert brief summary of client’s concern]”). Beyond that, not so much — at least anything I felt even the least bit confident about pulling off. More, I was acutely aware of myself — the words I used, how long I spoke, the number of hems-and-haws, the movement and position of my arms and legs, and how long I held eye contact.

Nowadays, my experience doing therapy is entirely different. I glide into the room without the faintest hint of self-consciousness. I sit, move, and interact naturally. The session unfolds in what would strike a casual observer as, seamless. Even the pauses — those earlier, worrisome “hem’s-and-haws” — seem purposeful.

The tendency to equate effortlessness with the development of expertise is not all that surprising. After all, it feels better in almost evevery way — smoother, easier, more polished. And yet, research from the field of expert performance suggests it likely means we’ve stopped growing!

Consider empathy — one of, if not the most important therapeutic skill. As my colleagues and I report in a soon-to-be published study (1), neither years of experience or therapist self assessment are correlated with actual empathic ability.

How, you might reasonably ask, could this be? What stands in the way of our future growth and development? As paradoxical as it may sound, the answer is, our current ability –or what researchers call, automaticity. In short, actions which once required a tremendous amount of mental energy, in time, are executed with barely a thought. While this means we can devote our limited cognitive resources to other pursuits, it also results in the loss of conscious control over our behavior.

The possibility of growth begins with the disruption of automaticity — literally regaining consciousness. A warning, however. While talk of “professional humility” and assuming a “not-knowing” stance is trendy, its also hard on the ego. Professional confidence usually suffers. The good news, as our study of empathy documents, is actual measured ability simultaneously improves!

More detailed information about finding your “sweet spot of discomfort” can be found in our two latest books Better Results and The Field Guide to Better Results. According to Professor Kim de Jong, these volumes offer “a wonderful combination of state-of-the-art scientific evidence … and hands on exercises for clinicians to improve their effectiveness.”

Want to connect with others pushing at their performance edge? Join the ICCE discussion forum. It costs nothing and you’ll meet like-minded practitioners from around the world.

By the way, a few years after leaving university, I received a letter from Cynthia. Don’t ask me how she found me! I suppose, “where there is a will, there is a way.”

Anyway, in the letter, she shared what had happened in her life after we stopped meeting. Her depression had lifted. She went back to school and was in a new relationship. Near the end, she expressed gratitude for our meetings, the support she received. “I know I wasn’t an easy client,” she offered, continuing “when I could tell you, too, were struggling, when it seemed like you weren’t sure what to say, those were some of the best moments.” I kept her letter all these years.

OK, that’s it for now.

Scott

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

P.S.: Looking to become an ICCE Certified Trainer? Want to hone your skills as a speaker, trainer, or presenter? The upcoming “Training of Trainers” is held only once every other year. For more information or to secure your spot, click here or the icon below.

Despite happening decades ago, I remember it as though it were yesterday.

My oldest, Kirk, was fiddling with a cassette tape recorder. He was four at the time and wanted to listen to “his music.” You know, the kind all parents regret having given to their kids at some point? “Wheels on the bus,” “B.I.N.G.O.,” “Itsy bitsy spider.”

Unfortunately, neither the tape or machine were cooperating. Seated at the kitchen table watching, I marveled at his patience and persistence — over and over, inserting the cassette one way, then another.

Eventually, he set the tape down, folded his arms and closed his eyes. That’s when I decided to intervene. I stood and went to sit beside him.

“Hey bud,” I said, gently placing a hand on his knee, “What’s going on?”

“I … AM … MAD!” he responded slowly and deliberately.

His tone took me by surprise. Kirk was such an even-tempered kid. Rarely upset. Stoic, even when provoked. And I’ll let you in on a little secret. As his father, it was a trait I was proud of, told people about and privately believed he’d learned from me!

Anyway, last week, Kirk and I were on the phone together. I was telling him about an article I’d just published (1). Somewhere along the way, I expressed my frustration with the field of mental health. In particular, our habit of apeing our much-envied and more successful cousins in medicine. So, like them, we insisted on calling our work, “treatment,” likened our methods to taking a pill containing ingredients specifically remedial to a client’s problem. We even adopted a manual developed by physicians defining both the nature and scope of concerns falling within our purview!

Kirk didn’t miss a beat. Teasingly, he asked, “You mean, you … are … MAD?!”

We laughed for several minutes after that, reliving the events from so long ago. Truth is though, I was mad. As my colleague and mentor, Bruce Wampold and I had written in the article (1), our field was at it again, not only adopting the language and terms of medicine, but also implying that field was responsible for the clinical innovation developed by therapists and documented to improve retention and outcome of mental health services (2).

You know what I’m talking about, right?

Regardless of the name it is known by (e.g., feedback-informed treatment, routine outcome monitoring, patient focused research, progress feedback, or practice based evidence) research on the subject originated with non-medical mental health researchers and has been going on for a quarter century (3)! And yet, in proposing “practice guidelines” for the American Psychological Assocation, Boswell and colleagues (3), opted for a term developed by a physician in 2006, “measurement-based care” (MBC) (4), claiming it was “closely related, though not necessarily identical to, commonly used terms/practices” noted above (p. 3).

Judge for yourself. Here’s how the authors defined MBC: “(a) routinely collecting patient-generated data throughout the course of treatment; (b) sharing timely feedback with the patient about these data (e.g., patient-reported outcome measure scores) and observed or predicted trends over time to engage patients in their treatment; and (c) acting on these data in the context of the provider’s clinical judgment and the patient’s experiences” (p. 3). Now, compare that to the definition of feedback-informed treatment offered in the FIT Treatment and Training Manuals published years earlier. “FIT is a pantheoretical approach for evaluating and improving the quality and effectiveness of behavior health services. It involves routinely and formally soliciting feedback from consumers regarding the therapeutic alliance and outcome of care and using the resulting information to inform and tailor service delivery” (p. 2).

If the two definitions seem similar, its because they are!

(Sorry for my tone)

Beyond once again emulating medicine, the problem with the term, “measurement-based care,” is that it doesn’t capture what the authors claim it represents. Indeed, wouldn’t the average practitioner on first hearing be most inclined to conclude the point of MBC is, well, measurement? That is precisely the confusion I encounter weekly in emails, phone calls and consultations with mental health professionals, agency managers, and payers.

“Please don’t use my scales,” I generally advise. Their response? Always a but …

“We’ve been told by [our payer, funder, the government, some regulatory body] that we have to use an outcome scale?”

“How will I know if the therapists who work at my agency are effective?”

“We need a way to identify clients we aren’t helping so we can terminate services with them and free up scarce clinical resources.”

Returning to my son, Kirk. On closer examination, it turned out a small part in the compartment of the recorder designed to hold the tape had broken off. Nothing we could do at that point would make it work.

“It’s OK, Dad,” I recall him saying, then quickly adding, “we can sing the songs ourselves.”

What could I say? We did.

It’s time, I think, our field does the same.

All the best,

Scott

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

The evidence shows that using standardized measures to solicit feedback from clients regarding progress and their experience of the working relationship improves retention and outcome.

How much? By 25% (1)

And now, major news out of California.

Psychologists — who are required to earn 36 hours of continuing education credits every other year — can now earn credit towards renewal of their license by implementing feedback-informed treatment (FIT) in their daily clinical work (2)!

Here’s the challenge. The same body of research documenting that FIT works, shows clinicians struggle when it comes to putting it into practice. Private practitioners express concerns about the time it takes. Those working in agencies talk about the challenges of finding alternatives when FIT data indicate the present course of treatment is not working. Finally, many who start, stop after a short while, noting that FIT didn’t add much beyond their “clinical knowledge and experience.”

All such concerns are real. Indeed, as reported a few years back on this blog (3), implemention takes time and skill — in agency settings, up to three years of effort, support and training before the benefits of being feedback-informed begin to materialize. When they do, however, clients are 2.5 times more likely to benefit from care.

So, don’t give-up. Instead, upskill!

In September, the International Center for Clinical Excellence is sponsoring the FIT “Training of Trainers.” Held only once every-other-year, the TOT focuses exclusively on the process of training and supporting others in their use of feedback informed treatment. As with all ICCE events, space is limited to 40 participants. Click on the link above or icon below for more information or to register!

Until next time,

Scott

Scott D. Miller, Ph.D.
Director, ICCE

I never met my uncle Marc. He died decades before I was born. I did know him, however. His mother –my maternal grandmother — made sure of that.

One story has stayed with me from the first time I heard it. It was about the day he passed. He was eleven. According to Grandma Stena, Marc developed “blood poisonin'” a few days after puncturing a blister on his heal with a sewing needle. Over the course of several days, a bright red line began moving up his leg. Fever and sweats soon followed.

Ocurring years before the development of antibiotics, sepsis was a death sentence. Having two kids of my own, I can’t imagine the terror my grandmother must have felt. And yet, the way she talked about the experience was strangely comforting.

Marc lapsed in and out of consciousness. When awake, he carried on lengthy conversations. Not only with his mother, but with deceased family members, many of whom he’d never met in life. As was her habit, Grandma Stena dutifully recorded the experience and names in her journal. One was her own mother, Kristin Enarsdottir — particularly curious given that my Icelandic great-grandmother had died two short weeks after giving birth to my grandmother. She was “taken in” by a family Marc knew as his grandparents, the Runolfssons. Neither my grandmother or Marc had known “Grandma K.”

According to the journal, around 11:30 am on July 22nd, 1929, Marc announced he could only stay “a few more minutes.” When she began to cry, he met her tears and sadness with reassurance. Others were waiting, he told her. They had been speaking with him and she was not to worry. He would be all right.

Marc took his final breath around 12 noon.

For my grandparents, 1929 was a year of challenge and tragedy. Three months after their son died, they lost their modest home and life savings in the aftermath of the stock market crash. Needless to say perhaps, both were transformed by these experiences — in ways one might and might not expect. For example, in the many years that followed, my grandparents never again put money in a bank. The baking soda can they used to store cash sits on my desk to this day. In their home, it was always buried deep in the flour bin inside a kitchen cabinet.

The other changes are harder to relate as succinctly. Growing up, the story’s supernatural elements were often what grabbed my attention. Talking with the dead. Crossing the veil. Life after death (insert theme song from the Twilight Zone here). For my grandparents, however, it was something entirely different. While the experience may have confirmed their beliefs about what happens after death, the real impact was on how they thought about and lived their lives after Marc’s passing. Life is short. Always treat others with kindness and compassion. Practice forgiveness. Listen and, whenever possible, be of help. Relationships, not money or material possessions, are what matters. In both word and deed, my maternal grandparents embodied these values in their daily lives.

Turns out, they were not alone. The Division of Perceptual Studies at the University of Virginia has been studying the nature and impact of “near death” experiences for more than four decades. Bottom line: they are often transformative. And, in contrast to psychotherapy and psychotropic medication, the changes NDE’s faciliate occur with greater speed and are more encompassing.

The problem, of course, is that to benefit, you either have to die or, in the case of my grandparents, witness an NDE close-up! “Unacceptable,” observes Dr. J. Kim Penberthy with a laugh. Professor of Research in Psychiatric Medicine in the Department of Psychiatry and Neurobehavioral Sciences at the University of Virgina, Dr. Penberthy has been investigating how we might obtain the same transformative, consciousness-changing benefits of NDE’s using alternate means.

I’m embarassed to admit I’d never heard of the Division of Perceptual Studies — described on the UVA website as, “a highly productive university-based research group devoted to the investigation of phenomena that challenge mainstream scientific paradigms regarding the nature of human consciousness.” Frankly, it never occurred to me that a program focused on reincarnation and the survival of consciousness after death would be granted space and funding in a top notch scholarly setting.

Back in 2017, I’d written an article describing how psychotherapy might benefit from embracing phenomena that exceed the limits of what is deemed physically possible according to current scientific assumptions. A few years later, together with colleagues from Australia, I published a research article documenting that people reported better outcomes when consulting a psychic/medium than a traditional mental health practioner. Unfortunately, two book projects — Better Results and The Field Guide to Better Results — got in the way of further work on the subject.

Until now.

Mindfulness. Yoga. Psychedelics. Drugs. Alcohol. Religion. Travel. Extreme sports. Now, and throughout history, humans have sought to alter their consciousness — sometimes to escape, but more often to find a new or different reality.

That’s where Dr. Penberty enters the picture. I stumbled upon her work while doing research for our next book, Healing in the Age of Science. She graciously agreed to be interviewed. Personally, I think you’ll find the conversation consciousness-altering.

Decades of research shows the client’s experience of the relationship is one of the best predictors of their engagement and progress in care (1).  As such, when outcome and alliance data indicate a course of treatment is “at risk” for a negative or null outcome, or drop out, it makes sense to explore the helper’s understanding of the client’s expectations and experiences regarding their working relationship.  

Enter the “FIT Alliance Stool” — the subject of the latest “FIT Tip.”

As described in the brief video, the purpose of stool is twofold. First, to remind the clinician of the elements central to client engagement — s factor long ago established as the number one process-related predictor of outcome (2). And second, to provide a practical tool for identifying where alignment might be improved so that the work can proceed in a more effective manner. 

Experiences reveals typical misalignments include:

• Organizing services around the what the referral source rather than client wants
• Equating the client’s goal with their diagnosis/presenting problem, or helper’s theory-driven objectives; and finally
• Inferring, guessing, or assuming rather than explicitly negotiating the client’s desires, objective(s), and expectations for care
• Conflating the “what” (client’s goals, meaning or purpose) for seeking care with the “how” (it’s means, methods, or process)
• A therapist acting in ways incongruent with the client’s preferences, beliefs, values, worldview, or identity (e.g., culture, gender, sexual orientation, ability, religion/spirituality, nationality, socioeconomic status). 

If you’ve never used the “FIT Alliance Stool,” give it a try! If you are a regular user, I hope the “tips” offered in the video below enhance your FIT practice.

Until next time,

Scott

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

P.S.: Registration is now open for the ICCE “Training of Trainers” Intensive. This three-day training is only offered once every two years! As always, space is limited. Click here (or the banner below) for more information or to register.

“It is an uncomfortable fact,” observes physician John Birkmeyer in Lancet, “that a patient’s odds of undergoing surgery often depend more on where [they] live than on [their] clinical circumstances.” Indeed, studies have consistently shown that the number of tonsillectomies, prostatectomies, hip replacements, hysterectomies, even days spent in hospital, varies between two to twenty fold depending on where a person lives despite demographic similarities and payment systems in different geographic locations.

Travel around a bit and you’ll find a similar pattern in mental health service delivery. Here in the United States, for example, “trauma-informed” care and “trauma-specific” treatments are popular. Elsewhere, not nearly as much. Variations in the popularity of particular treatment approaches are even visible within the US, from coast-to-coast and county-to-county.

What might account for such differences?

Could it be that people in the US are more likely to have suffered trauma than European, Australian, and Asian citizens? Medical research does show, as most might expect, that some variation in the use of specific procedures/approaches (e.g., hip replacement) is attributable to regional disease incidence differences.

Or, could it be that variations in the use of particular treatment approaches reflect differences in the rate of uptake and funding for training in novel and innovative therapeutic methods? Studies from many different countries indicate, for example, that variation is less likely when clinical decisions are constrained to a narrow range of options.

After 33 years in the field, I’ve seen a number of “therapeutic” trends rise and fall in popularity and application. Traveling from one region and country to another, I’ve personally witnessed the diverse ways clinicians and agencies approach their work. Given the documented lack of differential efficacy between approaches, I think its safe to conclude that the variation in use of particular methods has little to do with being more effective or possessing a superior understanding of the human condition or change process.

So, what is it all about? My Australian colleague, Dr. Rob Brock, and I explored the possibilities in a recent conversation about Schema Therapy — an approach that is quite popular in his home country of Australia, but curiously far less so here in the States. Our dialogue shows, I believe, that understanding the why, may help improve the effectiveness of how we work with our clients.

Until next time,

Scott

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

P.S.: Registration is now open for the next FIT Intensive and Training of Trainers. Click here or on either of the images below for more information or to register:

At first, we simply hand scored the measures.

Next came an Excel® spreadsheet. It not only automated administration and scoring, but plotted progress from session to session on a graph. Purple represented the client’s actual score. The blue, green, and red lines showed the 50th, 75th and 25 percentile, respectively, for clients with the same start score in the entire normative sample.

Its hard to recall just how revolutionary such technology was at the time. No more paper forms, a single program for keeping track of all clients, the ability to calculate one’s overall effectiveness and, most importantly, a way for determining when an individual client was “at risk” for a negative or null outcome from treatment.

Over time, both science and technology have evolved considerably. Now, three powerful, web-based systems are available that enable clinicians, agencies, and healthcare systems to track client progress in real time, administer the scales both in person and remotely, and provide an array of sophisticated clinician, program and agency metrics.

Of course, the systems still make it possible to identify “at risk” clients. They do so, however, in a far more accurate way. No more guesswork or comparison of individual clients to percentile rankings or sample averages. As explained in this week’s “FIT TIP,” the “signal light” colors on the graphs are predictive, telling you when your specific client is on or off track toward to positive result.

“How?” you might ask.

Well, listen for yourself. True of all FIT TIPS, this one is just a few minutes in length.

Until next time,

Scott

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

P.S.: Learn more about using outcome data to guide and improve service delivery at the upcoming FIT Supervision Intensive — the only approach research has shown leads to improved individual practitioner and program effectiveness. No need to travel! This live, three-day event is entirely online. For more information or to register, click here or the icon below.

I’ve never been enthusiastic about categories, whether aligning myself with a particular therapeutic approach or assigning a diagnostic label to a client. Any order achieved seemed to come at the expense of freedom and possibility.

Lately, however, I’ve found myself feeling an affinity for a particular classification scheme. Maybe its my age. In July, I turn 65. On that birthday, I will have worked as a psychologist for longer than I had been alive when I entered the profession! And according to psychoanalyst Erik Erikson — a person whose work I’ve not thought about since my undergraduate days — that puts me at the doorstep of the eighth, and last stage of psychosocial development: integrity versus despair.

I’d forgotten Erikson coined the term, “identity crisis.” It was central to his theory of personal growth. The nature of the dilemma one faced was different at each stage. Successful resolution led to the development of character strengths a person could use to manage life and circumstance; failure, to an unhealthy sense of self and reduced capacity for fulfillment.

From the time I first heard them, Erickson’s “stages” had struck me as similar to a horoscope. You know, statements that feel personalized and specific but in fact are so vague and general they apply to everyone. That said, with fewer years of my professional life ahead of me than behind, that last stage had started speaking to me. More and more, I found myself thinking about where we were as a field, if we had made any progress and could feel proud of our work?

The challenges were stark, and frankly overwhelming. To name a few:

*An unprecedented rise in the number of people suffering from mental and emotional problems;
*No improvement in the outcome of psychotherapy over the last 50 years;
*No evidence that traditional training models or clinical experience (e.g., diagnostic specific treatments, ongoing supervision, licensing, mandated continuing education) contributes to clinician effectiveness despite widespread belief and regulation to the contrary.

Erikson maintained that each person must learn how to hold both extremes of each specific life-stage challenge in tension with one another, not rejecting one end of the tension or the other.  How, I wondered, could anyone not give into despair in light of the facts noted above?

That’s when I reached out to my longtime, colleague, mentor and friend, Dr. Bruce Wampold. Together, we confront the the present and future state of psychotherapy research and practice. Should we feel discouraged or hopeful? Listen for yourself.

Until next time,

Scott

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

P.S.: Registration for the upcoming FIT Supervision intensive is open. It’s one of the courses required for certification as a FIT practitioner and trainer. Join colleagues from around the world to learn the approach shown to improve individual clinician outcomes.

It’s a question that comes up at some point in most trainings on feedback-informed treatment (FIT):

“Can I use FIT with all my clients?”

Having encountered it many times, I now have a pretty good sense of the asker’s concerns. Given our training as mental health professionals, we think in terms of diagnosis, treatment approach and service delivery setting.

Thus, while the overall question is the same, the particulars vary:

“Does FIT work (with people in recovery for drug and alcohol problems, those with bipolar illness or schizophrenia, in crisis settings, group or family therapy, long term, inpatient or residential care)?

Occasionally, someone will report having read a study indicating FIT either did not work or made matters worse when used with certain types of clients (1) or in particular settings (2).

While I have posted detailed responses to specific studies published over the last couple of years (3), the near limitless number of ways questions of efficacy can be parsed ultimately renders such an approach clinically and pragmatically useless. Think of the panoply of potential parameters one would need to test. The latest edition of the Diagnostic and Statistical Manual of Mental Disorders alone contains 297 diagnoses. Meanwhile, more than a decade ago, Scientific American identified 500 different types of psychotherapy. If history is a reliable guide, the number of approaches has most certainly increased by now. Add to that an ever evolving number of settings in which treatment takes place — most recently online — and the timeline for answering even the most basic questions quickly stretches to infinity.

So, returning to the question, “how best to decide whether to use FIT with ‘this or that’ client, treatment approach, or service setting?”

That’s the subject of my latest FIT TIP: Does FIT work with all Clients?

As promised, every 10 days or so, I’ve released a brief video providing practical guidance for optimzing your use of feedback in treatment. To date, these have addressed:

How to solicit clinically useful feedback

How to use client feedback to improve effectiveness

Identifying the best electronic FIT outcome system for you

What to do when your client is not making progress

Should you start FIT with established clients

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

Scott

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

P.S.: Registration for the next FIT Implementation Online intensive is open. If you or your agency are thinking about or beginning to implement FIT, this is the event to attend. In this highly interactive training, you will learn evidence-based steps for ensuring success.

The date was August 26th, 1910. The place, Leyden, Holland — better known as the “City of Discoveries” owing to its long scientific heritage.

The people present were two giants of Viennese society, composer Gustav Mahler and psychoanalyst, Dr. Sigmund Freud.

By the time of their meeting, the method Freud had pioneered for the alleviation of mental and emotional distress was well-established. Its form was influencing clinicians around the world, best represented by the presence of a couch, free association, and years of contact carried out in frequent, but strict 50-minute “sessions.”

Mahler telegraphed Freud from Munich multiple times requesting help. The situation was dire. Mahler was “impotent,” and his wife, 19 years his junior, was deeply unhappy.

Much of what happened next is lost to history. What is known for certain is that Mahler did travel to Leyden and met with Freud, and that the composer’s sexual functioning was restored following this single meeting.

Bottom line? A great deal of good could be accomplished in a brief period of time and outside of traditional psychotherapy settings. Indeed, Freud did not meet with Mahler in an office. No couch was involved nor sacrosanct time limit. Rather, the two talked while, “strolling about the town—the stocky, confident doctor and the thin, intense composer— smoking the cigars both adored” (Sorel, 1982).

I was reminded of the foregoing story while interviewing Dr. Ed Jones for my blog and YouTube channel. Ed is a psychologist and consultant with an uncanny ability to “see around corners.” Over the years, I’ve learned to pay attention whenever he talks about trends in mental healthcare service delivery. And lately, he’s been focused on the “50-minute hour.”

“Multiple developments — including the rapid increase in the use of digital technology during the pandemic, and integration of behavioral and medical care — are challenging mental health professionals to think and act differently,” he says, then continues, “Instead of relatively circumscribed treatments episodes, delivered across multiple sessions lasting 50 minutes, therapists will need to be helpful on an ongoing, but likely intermittent basis over the course of people’s lives in interactions lasting a handful of minutes.”

Importantly, Ed does not see this development as the end of something, but rather an opportunity to expand the field’s ability to meet with, engage, and help more people in need. Let me know what you think in the comment section below.

Until next time,

Scott

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

P.S.: Registration for the next FIT Supervision Intensive is now open. For more information, or to register, click the link or icon below.

The data are clear: working feedback-informed improves both retention and effectiveness (1). Studies further show FIT achieves these effects, in part, by improving responsiveness to the individual client — particularly those at risk for a negative or null outcome or dropout from treatment (2, 3).

Such positive results notwithstanding, what happens when an outcome measure misleads — when the tool used returns results that are incongruent with the client’s experience?

Consider two recent studies (4). In both, researchers found clients largely agreed when an outcome measure — in this instance, the Outcome Questionnaire 45 — indicated they had improved, but disagreed when it suggested they had worsened. The size of the disconnect was ginormous: 91% saw themselves as benefitting significantly! In such instances, concluding treatment wasn’t helping and opting to terminate or refer, would be the antithesis of responsiveness — which leads me to what I like to call, “my most misunderstood “FIT Tip.”

Early in FIT trainings, therapists learn three ways they can adjust services in the absense of client progress: “Change the ‘what.’ Change the ‘where.’ Change the ‘who.'” Evidence-based guidelines are also provided for when such modifications should be introduced:

1. Little or no progress or deterioration by the third visit? Revisit the goals of treatment, paying particular attention to differences between the services being offered and the client’s stated reason for seeking help.
   
2. Little or no progress or deterioration by the fifth to seventh visit? Consider adding/augmenting services, providers, or participants.
   
3. No improvement or deterioration by the tenth to twelfth? Consider changing the provider, location, or type of services.

Of the three, the third is the most misunderstood. On more than one occasion, for example, I’ve heard therapists say, “According to Scott Miller, if a client isn’t improving by the 10th or 12th visit, treatment should be ended.”

Just to be clear, I have never made such a suggestion. Nor do I believe it. The entire point of FIT is to increase the likelihood of my clients getting what they hope for from their interaction with me. As such, the feedback from standardized measurement tools like the Outcome and Session Rating Scales should be considered starting rather than stopping points, opportunities to lean in and explore, not defer or refer.

I had a chance recently to interview the author of one of the aforementioned studies, Dr. Eric Ghelfi. Not only does he describe the studies in intriguing detail, he offers specific guidance for using the results to enhance responsiveness to the individual client, especially when there’s a disconnect between the tool and the client’s report. The “tips” he offers, I’m certain, will make a difference in your use of FIT.

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

Scott

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

Books, blogposts, interviews, and “how to” manuals …

Each covers a topic in a particular way. I honestly love them all.

That said, despite the massive amount of information available to practitioners interested in FIT and deliberate practice, certain questions pop up time and again. At some point along the way, I started keeping a list. Some eventually made their way into a book or paper. Others were incorporated into live trainings. A not insignificant number were only addressed in the context of private consultations with agencies and practitioners.

Until now.

Enter “FIT TIPS” — a series of videos aimed answering a specific question. Published every 10 days or so, they are brief and to the point, each lasting two minutes or less. You’ll find the first below — a tip I have come to call, “my most frequently given, but ignored advice.”

By the way, if you’d like to be notified about future releases, please enter your email in the “subscribe” box in the upper right hand corner of this page. Rest assured, your name and contact information will not be shared or used to send unsolicited advertizing emails. Of course, if you have a question of your own, please send it my way!

Until next time,

Scott

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

P.S.: Registration is now open for the next FIT Intensive. Click here or on the banner below for more information or to secure your spot!

Eight years ago, I was in Calgary, Alberta Canada, listening to psychologist Wolfgang Lutz talk about his research on using feedback in therapy. Others, including myself, had already presented data documenting the benefits of feedback-informed treatment (FIT), including lower dropout rates and improved outcomes. Dr. Lutz agreed, but was focused elsewhere.

Then, as now, studies of FIT have been limited to comparing groups of clinicians. Typically, that means some are assigned to a feedback condition (i.e., using measures of engagement and progress), others to providing “treatment as usual.” So far, so good. Except, such designs, while useful for documenting a general effect, tell us nothing about why an intervention works or the impact of the individuals involved. And there was reason for concern –overall, results of studies on feedback were highly variable — ranging from zero to absolutely mind blowing effects.

One reason? Apparently, like our clients, we helping professionals have a hard time changing our minds and behavior — even when the data indicate what we think and how we are acting is either not helping or making matters worse! Dr. Lutz provided the evidence. In his study, when feedback showed an individual was deteriorating in their care, therapists endorsed:

1. Discussing it directly with the client less 60% of the time
2. Adjusting their therapeutic approach or assisted with resources 30% of the time
3. Working to improve the therapeutic relationship less than 10% of the time
4. Seeking additional sources of help (e.g., supervision, literature review, continuing education) roughly 5%

Many of us, it seems, are not swayed by … evidence!

(I know, I know, not you or me. Others! What’s wrong with them anyway?)

Seriously though, I was reminded of Dr. Lutz’s results when I came across a study described in a recent Facebook post by NYU Professor Jay Van Bavel. The good news, according to this research, is people are capable of updating their beliefs in light of new evidence. More, doing so, frequently serves to improve performance.

The bad news?

The more that changing our mind conflicts with our “identity” — our core self or values — the greater the tendency is to devalue rather than accommodate new evidence, ultimately leaving us where we were before: status quo. So, a client calls to reschedule an appointment citing a conflict with another obligation (e.g., work, childcare). No conflict with our identity as compassionate, understanding mental health care professionals. Easy peasy. However, when their feedback on a rating of the therapeutic relationship (e.g., Session Rating Scale) indicates they find you less understanding and empathic than you believe yourself to be? MUCH MORE CHALLENGING. In the first instance, we reach for our appointment book; the latter . . . the DSM.

Dr. Van Bavel has been investigating the conflict between evidence and identity for a number of years, documenting the life-threatening consequences that can result when the latter dominates the former. In his new book, The Power of US, he not only writes about this problem but offers detailed, evidence-based solutions. Given the findings cited above, I think his work is vital for mental health professionals. Check out the interview below and let me know your thoughts.

Until next time,

Scott

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

P.S.: Registration is now open for the 2023 Online Feedback Informed Treatment Intensive! Click the icon below for more information or to register:

https://www.eventbrite.ie/e/feedback-informed-treatment-fit-intensive-online-tickets-384236159697

I know, I know. You’re thinking, “A post about the next pandemic?!”

Some will insist, “We’re not done with the current one!” Others will, with the wave of a hand counter, “I’m so tired of this conversation, let’s move on. How about sushi for lunch?”

Now, however, is the perfect time to assess what happened and how matters should be handled in the next global emergency.

Scientists are already on the case. A recent study conducted by the University of Manchester and Imperial College London analyzed the relative effects of different non-pharmacological interventions aimed at controlling the spread of COVID-19. The investigation is notable for both its scope and rigor, analyzing data from 130 countries and accounting for date and strictness of implementation! The results are sure to surprise you. For example, consistent with my own, simple analysis of US state-by-state data published in the summer of 2020, researchers found, “no association between mandatory stay-at-home interventions on cross-country Covid-19 mortality after adjusting for other non-pharmaceutical interventions concurrently introduced.” Read for yourself what approaches did make a difference.

One non-pharmacological intervention that was not included in the analysis was the involvement of “human factors” experts — sociologists, anthropologists, psychologist, implementation scientists — in the development and implementation of COVID mitigation efforts. Indeed, those leading the process treated the last two years like a virus problem rather than a human management problem. The results speak for themselves. Beyond the division and death, the US is experiencing a dramatic mental health crisis, especially among our nation’s youth.

Which brings me to the latest edition of The Book Case — the podcast I do together with my friend and colleague Dr. Dan Lewis. In it, we consider two books with varying perspectives on the outbreak of COVID-19. As acknowledged at the outset of this post, I understand you may already have made up your mind. Whatever you’ve decided, I believe these two books will give you pause to reconsider and refine your thinking.

That’s all for now. Until next time,

Scott

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