So, you’re out for a walk.  It’s a beautiful day but you’re caught up in your thoughts, feeling a bit discouraged and concerned.

For whatever reason, some of the people you are working with aren’t improving.  You’re no novice clinician.  You know impasses are a common feature of therapeutic work.  Still, this time your knowledge and experience aren’t helping.  You’re stuck.

That’s when you spot someone on the path ahead, leaning comfortably against a tree.  As you are about to pass by, the stranger smiles kindly, then steps forward.

“Good morning,” he says, calling you by name.

Although you can’t quite place him, you reply in a friendly manner, barely slowing your pace.

“I can see that you’ve got a lot on your mind,” he continues, now walking alongside.  It’s his next question that stops you in your tracks.

“Thinking about your clients again, aren’t you?” Slowly shaking his head from left to right, “It’s hard when you’re not as helpful as you mean to be.”

Before you can say, “Jack and the Beanstalk,” the man reaches into his pants pocket.  Removing his hand, he slowly extends it toward you eventually opening it, palm up.

“Quickly,” he demands, “How many beans do you see?”

Still stunned by the whole experience, you reply, “Five.”

“Right you are!” he exclaims excitedly, “And because you are so sharp, you can easily see these are no normal beans.  They’re magical.  Plant them in your office and by morning they’ll grow right up to the sky, providing a pathway for even your most difficult and challenging clients.”

“Really?” you respond, now feeling more than a bit incredulous.

The man doesn’t miss a beat.  “Of course,” he instantly reassures, “These beans are evidence-based.”  Pointing to a briefcase near the tree, “In there, I have many studies showing beans grow when planted, as well as plethora of PET scan images documenting how climbing the stalks causes real changes in the prefrontal and motor cortex of the brain.”

You move back a step, rub your chin, and eye the man suspiciously.

“Come on,” he says, “You want to help, don’t you?  What you’re doing now isn’t working.  You know that.  What have you got to lose?”

That is the question.  So, what’s the answer?

If you’ve been a therapist for more than a few years, you’ve likely discovered our field is full of beans, bean sellers, and bean counters.  As just one example, for three decades CBT has been touted as the ‘treatment of choice” — a revolutionary advance, actually — for a wide array in mental health problems.

Rarely does a day pass that I don’t receive a brochure (or email to the left) for a workshop on the approach.   Search the term on Amazon and you’ll find more than 4000 books and related products.  At the same time, regulatory bodies around the world have created practice guidelines heavily skewed toward CBT.

And yet, there is no evidence that any of this leads to better outcomes.  The facts are: (1) CBT is no more effective than any other therapeutic approach (1, 2); (2) training in CBT does not improve therapist effectiveness (1); and finally, (3) guidelines favoring the adoption of CBT over other approaches have not resulted in better outcomes, and may inadvertently have led to a decline (1, 2, 3, 4, 5).

Claims about the novelty and effectiveness of other popular approaches fare similarly, including EMDR and Acceptance and Commitment Therapy (ACT).  Here again, books, workshops, and claims abound.  Ultimately, however, these two methods work about as well, but no better, than any other approach.  Plus, there’s no evidence that training in either improves therapist effectiveness (1, 2, 3).

Returning to the question, it turns out a critical opportunity is lost in the trade for a handful of “magical” beans: individual professional development.  As all practitioners know, and have likely counseled their own clients, it is precisely at those moments when we are feeling most stuck that the greatest possibility for growth exists.  It’s also when we’re most vulnerable to promises of a shortcut —  the proverbial “goose that lays a golden egg.”

Until very recently, there’s been no alternative.  In Chapter 2 of the new book, The Cycle of Excellence, friend and colleague Daryl Chow and I describe how practitioners can use deliberate practice to both identify and move beyond their individual growth edge.   It is not an easy route.  At the same time, however, it is the only approach to professional development that has been shown to lead to measureable improvements in effectiveness on par with rates seen in Olympic atheletes in training (1).

If you’re interested, visit here to receive a copy of the chapter.

Until next time,

Scott

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

P.S.: Daryl and I will be together in Chicago in August for a two-day workshop on deliberate practice.  A few spots remain for this intimate, intensive training.  We’ll presenting the latest research — including findings from the “Difficult Conversations in Therapy” randomized controlled trial — and help each participant develop and refine an individualized deliberate practice plan.  Just click on the image below to register.

The subject line of a recent email immediately caught my attention: what is the future of psychotherapy?   

I couldn’t help myself.  I clicked and began reading.

“The future is incredibly bright,” the two, well-known writers and clinicians asserted.  Don’t worry about “rising rates of trauma, anxiety, bullying, depression, or the precipitous decline in people seeking help from therapists,” they counseled as, “There are things emerging that will take us beyond any paradigm that we grew up in!”

Bold and hopeful claims to be sure.  The truth is our field is founded on hope.  Fundamental to the work is the belief that people can change, that the past is not the future, genes and environment are not destiny.  A happier, healthier, more successful life awaits.  We can help.

And yet, the fact remains the effectiveness of psychotherapy has not improved in 40+ years.  More, despite widespread belief to the contrary, individual clinicians do not get better with time, training, or experience in the field.  If anything, the evidence shows the opposite: effectiveness declines!

So, what stands in the way of getting better results?  Could it be, as the email in my inbox suggested, the field suffers from a paucity of appropriate methods for helping people?   It’s a tempting idea.  And yet, on reflection, its hard to believe.  The field (and practitioners) have, at their disposal, literally hundreds of “evidence-based” treatment approaches.

What about a lack of will?  Perhaps practitioners are just too lazy or complacent to improve?  I’ve heard this claim more than once from various sources.  Here again, however, its hard to believe.  Research documents therapists, as a group, overwhelmingly want to get better.  Indeed, continuous improvement is central to their identity, an antidote to compassion fatigue and burnout.

So what is it?  With so many good ideas and intentions, why haven’t outcomes of the field improved?

In a word, the answer is: Implementation.

Although new ideas are plentiful, and literally thousands of research articles are published each month, the support necessary for effective execution of clinical innovations in daily practice is sorely lacking.   Despite their best intentions, many practitioners end up paralyzed by what Dr. Sarah Boon has called, “21st century science overload.”   Others, faced with demands from regulators and payers, do whatever is necessary to comply with new “minimum” standards.   All too often, the result is merely an increased administrative burden with little or no actual payoff in terms of results.

Feedback-Informed Treatment (FIT) is one of those “new ideas.”  A large and growing number of randomized controlled trials document significantly improved quality, retention, and effectiveness of behavioral health services when standardized measures are used to solicit feedback from consumers of behavioral health services.

Each week, hundreds of therapists sign up for a free license to use the Outcome and Session Rating Scales in their work.   I answer scores of emails from agency managers about using the tools to meet new standards from SAMHSA and the Joint Commission for “measurement-based care.”

If improving outcomes via FIT were a simple matter of combining evidence with a desire to improve, success would be guaranteed.   Unfortunately, experience proves otherwise.  The majority of clinicians who download the ORS and SRS never use them; the small number who do, stop within a short period of time.  The same fate affects a suprisingly high number of agencies who invest their meager resources in acquiring licenses or software, and sending staff to 2-day training events.

Last week, I interviewed psychologist Heidi Brattland about her new study on implementing FIT in a hospital-based psychiatric clinic.  As in previous investigations, soliciting feedback via the ORS and SRS resulted in significantly better results–indeed, therapies informed by ongoing feedback where two and a half times more likely to prove beneficial.   Interestingly, however, the results weren’t immediate.  In fact, in the first year, FIT made no difference whatsoever.  Instead, confirming what research from the field of implementation science  has long indicated, success took time–the best results being obtained after four years.

Click on the video below to learn what was essential to sustaining the agency’s effort along the way (You can read the complete research report here).  At  the upcoming ICCE Implementation intensive, we’ll help you translate these findings into a step-by-step, evidence-based plan.  It’s the only such training available–a primary reason that SAMHSA gave the ICCE perfect scores for implementation and support resources.

Until next time,

Scott

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

Which of the following are bad for health and longevity?

A. Smoking;
B. Consuming too much alcohol;
C. Being overweight;
D. Not flossing regularly.

If you answered “yes” to any or all of the items, you are WRONG–that is, at least, if you are determined to rely on evidence derived from randomized controlled trials (RCT’s) alone in making healthcare decisions.

For some time now, RCT’s have been considered the “gold standard” for assessing evidence.  That said, for reasons which are likely obvious to you, no scientist would ever conduct studies in which real people are randomly assigned to either smoke, drink excessively, overeat, floss. or not.

And yet, the Associated Press (AP) recently dismissed flossing because of the paucity of such trials.  Their eye-catching headline?

Medical benefits of dental floss unproven

The story is worth reading.  It has all the qualities of a John Grisham novel: (1) a corrupt government; (2) self-serving business executives; (3) professional organizations with serious conflicts of interest; and best of all (4) secret documents retrieved by valiant news reporters via the Freedom of Information Act.  Seriously!

So, should you stop flossing?  Of course not.  Neither should you take up smoking, begin drinking excessively, or consumer many more calories per day than you burn.  But, surely you knew that.  For many living in the era of evidence-based medicine, however, no RCTs = no evidence.  In fact, this is exactly the thinking behind many of the guidelines steering the practice of psychotherapy today.

Local, state, national, and international regulatory bodies place RCT’s at the top of the hierarchy of scientific methods, generating lists of “approved” methods.  Increasingly, reimbursement and funding decisions are linked to practicing in accordance with these recommendations.   The implicit message is clear.  Where an RCT exists, no thinking on your part is required.  Just do what you are told and all will be well. 

Nothing could be further from the truth.  No evidence exists showing that the widespread adoption of “psychological treatments of known efficacy“– that is, those tested in RCTs, deemed empirically-supported, and listed on regulatory websites — has resulted in any real-world improvement in outcome.  In fact, the overall effectiveness of psychotherapy has remained unchanged for more than 40 years.

Turns out, what does matter in terms of outcome is the very element of treatment that’s largely been pushed aside, even maligned, in current research environment:  YOU! 

In RCT’s, by contrast, the provider of treatment is literally considered a “nuisance variable”  — an aspect of the process that must be controlled with protocols and blinding because they are “of no particular interest” to investigators.

Importantly, however, studies dating back decades show that who provides psychotherapy matters significantly more than what particular method or approach they use — 5 to 9 times more!  It may be difficult to believe, but its true: even when following detailed treatment protocols, differences in outcome between therapists persist.

For consumers, the implication is clear: choose your provider carefully as they significantly influence the results of the care you receive.  For therapists, it means that improving one’s effectiveness is not a matter of using the right treatment approach, but rather working on you; specifically, identifying your unique constellation of strengths and weaknesses, and building on the former while targeting the latter for remediation.  In a series of ingenious studies, for example, clinicians realized significant gains in their ability to successfully manage challenging moments in psychotherapy when provided with feedback specific to their particular deficits and abilities.   Importantly, participants ability to respond warmly, emphatically, and collaboratively not only improved, but also generalized to novel scenarios they had not encountered previously or been given time to rehearse.

My colleague Daryl Chow, Ph.D., and I will be providing step-by-step guidance as well as tools for mapping one’s clinical performance at the upcoming Deliberate Practice Intensive in Chicago.  Here’s the description of what will be covered.  I do hope you’ll join us.  I promise two, personally meaningful days together with practitioners from around the world.

That said, there’s no reason to wait until then to get started.  A year ago, I offered free access to several resources.  If you didn’t see that post, no worries, simply click here as all are still available.  To these, I’d like to add The Taxonomy of Deliberate Practice.  Daryl and I have been using this tool to help clinicians see what they do that does and doesn’t work, as well as to develop an individual professional development plan.  Just email me at: info@scottdmiller.com and I’ll send you a copy.

In the meantime, take a listen to this interview with Daryl from today.  I know its going to sound like a “come on,” but trust me when I say listen all the way to the end as there’s a real gem in the last minute about improving your results as a therapist.

Scott

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