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

Can you guess what this number represents?

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

Guess again.

Give up?

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

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

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

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

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

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

What does work?

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

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

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

OK, that’s it for now.

Scott

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

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

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

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

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

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

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

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

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

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

But how?

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

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

Until next time,

Scott

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

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

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

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

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

So, what does the research indicate?

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

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

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

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

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

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

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

Bad therapy.

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

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

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

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

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

Scott

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

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

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

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

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

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

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

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

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

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

Until next time,

Scott

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

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

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

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

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

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

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

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

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

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

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

Scott

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

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

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

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

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

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

Until next time,

Scott

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

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

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

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

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

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

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

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

Until next time,

Scott

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

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

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

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

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

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

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

Next week, two new interviews on deliberate practice.

Until then,

Scott

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

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

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

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

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

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

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

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

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

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

Just click here to get your free copy.

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

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

Scott

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

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

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

All good but, how to employ the measures online?

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

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

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

Scott

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

For FIT-OUTCOMES.COM Users:

For MYOUTCOMES.COM Users:

For OpenFIT Users:

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

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

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

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

By this point, many other projects were underway.

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

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

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

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

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

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

Scott

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

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

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

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

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

Simple, right?

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

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

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

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

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

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

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

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

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

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

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

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

Until next time,

Scott

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

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

Is it just me or has public discourse gone mad?

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

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

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

And, therein lies the problem: no dialogue. 

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

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

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

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

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

But what exactly was “tested” in the study?

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

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

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

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

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

Until then,

Scott

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

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

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

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

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

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

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

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

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

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

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

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

What then can we conclude?

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

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

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

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

Until next time,

Scott

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

As a mental health professional, how are you approaching the New Year?  Are you filled with hope for our field?  Suffering a twinge (or more) of despair?  Maybe you’re in reflective mood, longing for the ‘good ole days’?  Or is the difference between December 31st and January 1st just like any other twenty four hour period?

While catching up on reading over the Holidays, I came across a word that captured my experience.  I’d never seen it before.  Anticipointment.  Online sources define it as, “The state of mind resulting from anticipating and then being disappointed when expectations are not met.”  Truth is, I recognize now I’ve often experienced this, but mistaken it for nostalgia. I t’s not.

So what about you?  On one hand, we do have good reason to be hopeful.  After all, decades of evidence provide overwhelming proof of the effectiveness of psychotherapy.  On the other hand, the same research shows our outcomes have not improved in more than 40 years.  Returning to the positive side, researchers have now identified two specific practices — routine outcome monitoring and deliberate practice — that enable clinicians to accomplish something never before recorded in history the history of the field; namely, steadily improve their effectiveness from year to year.  On the negative side, the field –researchers, clinicians, payers, and policy makers alike — continues to be strongly attracted to treatment models, I’d say fatally so.  Crossing the term, “cognitive behavioral therapy” (CBT) with “randomized controlled trial” (RCT) on Google Scholar results in 1,930,000 hits!  In case you glossed over the figure, that’s one million, nine hundred thirty thousand — and that’s just one method out of hundreds.  By contrast, a similar search of “tetanus vaccine,” produces slightly more than 18,000 results.  I ask, does our field really need to spend precious resources on another study of CBT?  It’s discouraging.  More broadly, given the clear and overwhelming evidence of equivalence between treatment methods for any DSM diagnosis that’s been tested — and yes, that includes so-called trauma-specific approaches — do we need any more RCT’s pitting one protocol against another?  Wouldn’t time be better spent studying how practitioners can improve their ability to attune and respond to their clients?  After all, these two transtheoretical skills, researchers Stiles and Horvath, point out, are why “certain therapists are more effective than others” (p. 71)

For me, I approach the New Year with a strong sense of anticipointment.  I want to be hopeful, believe there are good empirical reasons to do so.  At the same time, I fear little will change.  Turns out, some of our field’s beliefs and practices refuse to die.

What can we do to escape these “walking dead?”

A quick Google search of “Surviving the Zombie Apocalypse” turns up in three clear themes.  First, make sure you are not a zombie.  “The main epidemiological risk of zombies,” says Wikipedia, “is that their population just keeps increasing [as] generations of humans merely ‘surviving’ … feed” them.  In the case of psychotherapy, I’ve come to believe practitioners often know certain popular ideas and practices are dead, but go along with them anyway.  We must say, “no” or risk infecting the next generation.

The second suggestion makes the first possible: don’t go it alone.  In short, you have a better chance of surviving in a group that shares your objectives.  If your professional goals as a therapist include improving your results, the near 10,000 members of the International Center for Clinical Excellence might be your people.  It’s free.

Third, and finally, focus on the basics.  In the case of real zombies, that means securing water, shelter, and food over other, possibly more stimulating interests.  Similarly, for therapists, chasing the “new and promising” must give way to personal work; in particular, deepening core skills associated with effective clinical practice.  If becoming a more effective version of you is of interest, check out an article on the subject published this week.  My colleague Brooke Mathewes and I provide concrete guidance for finding your performance edge and then developing, executing, and evaluating a highly individualized plan for improvement.  Normally behind a “paywall,” the article is currently available for free thanks to the generosity of the journal editors.

As always, I’m interested in your thoughts and reflections.  Please post them below!

Until next time,

Scott

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

“I heard Scott Miller say it,” the man sitting next to me said.

“Really?” I responded, somewhat incredulous.  After all, I didn’t recall ever saying such a thing.  More to the point, it’s just not something I would say.  Its wrong.  Then again, it was clear he didn’t know that I was Scott Miller.  Not wanting to disrupt the presenter before me at the conference, I’d quietly snuck into the room, dressed in my “civies,” shortly after the meeting had started.

“Yep,” he replied, his voice full of certainty, “as I understand it, he says it all the time.”  Making “air” quote marks with his fingers, “If the client is not changing within three visits, you should terminate the treatment.”

You should have seen the look on his face when later our eyes met as I took to the stage to do my presentation.

On many occasions over the years, I’ve heard people quote me saying things I’ve never said.  Here’s a common one:

“Scott Miller says all you need for successful treatment is a good therapeutic relationship.”

Just so you know, I’ve never said this.  Ever. And yet, once, after I corrected a nationally known practitioner in front of a large audience, he nonetheless repeated it in his newsletter.  Here’s what I have said and continue to say:

• All treatment models work equally well.  All.
• Of all the factors affecting outcome, the specific approach used has the smallest impact.  By comparison, the relationship between client and therapist contributes eight to nine times more. 

Another:

“Scott Miller says therapists help 80% of their clients.”

Once again, I’ve never said this.  In this instance, the misquote is more understandable.  Here’s what I do say at almost every workshop:

• Decades of research and hundreds of study document psychotherapy works.
• The effectiveness of psychotherapy has remained fairly stable over the years.
• In most studies, the average treated client is better off than 80% of the untreated comparison sample.

I’m certain it’s the last of these statements that causes problems.  Presented, as it, is in “researchspeak,” it’s easy to misunderstand.  Read it again and you’ll see it does not mean we help 80% of our clients.  Rather, its about the advantage therapy offers relative to receiving no treatment at all.  By contrast, the percentage we help — as I’ve blogged about on numerous occasions — is actually around 50%.

Now, in the interest of fairness, let me mention something I often say but have never heard misquoted.  At nearly of all my workshops, I joke, “The ORS and SRS may not be the best scales ever developed … but they are free!”  The latter part of that statement is absolutely true.  Clinicians wishing to solicit feedback from clients about their progress and the quality of the therapeutic relationship simply need to register for a free paper and pencil license.  That said, recent research out of the University of Nottingham is giving me pause about the other half.

Just last week, I interviewed Professor Sam Malins who, together with a team of others, has been studying the use of the scales in real world clinical settings for a number of years.  In addition to replicating a number of important findings (e.g., the longer you use the ORS and SRS, the more impact they have on retention and effectiveness; spending time gathering information for diagnosis and treatment planning results in poorer outcomes, the scales can be used to identify skill development opportunities), he also found the Outcome Rating Scale predicted …  oh, just watch the video yourself.  That way, I won’t be misquoted!

Until next time,

Scott

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

Remember these?

Did you ever own or try one?

Remember Beanie Babies?  According to one news story, interest was such, “People neglected other areas of their lives to spend all day trading, and some even invested their children’s college funds in toys that they believed would bring an astronomical return on investment.”

And how about advertising executive Gary Dahl’s product?  You remember him, right?  In the 1970’s, he became an overnight millionaire selling rocks marketed as pets.  Rocks!  Waterbeds, Crocs, cause-branded plastic wristbands, oxygen bars, Pogs, Silly Bandz, and the Macarena — the list is as endless as our attention span is short.

If you’ve been in practice for a while, you know the field of mental health is not immune to fad and fashion.  Like past diet crazes, the drugs, diagnoses, and treatment methods that capture professional interest and then quickly disappear can be hard to remember.  Thus, in the 1980’s it was Xanax, multiple personality disorder, and satanic cult abuse.  The 1990’s brought us the “decade of the brain,” borderline personality disorder, and a flood of Prozac and cognitive-behavior therapy knockoffs.  More recently, mindfulness, energy meridians, and trauma have become the objets de grand intérêt.

One more trend is Feedback-Informed Treatment (FIT).  Known also as Routine Outcome Monitoring, Patient Focused Research, and Measurement-based care, it involves using scales to solicit feedback from clients regarding their experience in treatment and using the resulting information in real time to improve quality and outcome.  The weight of the scientific evidence is such that professional and regulatory bodies in the U.S. and abroad have already deemed ROM a “standard” of care in the delivery of psychological services and clinical supervision (American Psychological Association Presidential Task Force on Evidence-based Practice, 2006; Association of State and Provincial Psychology Boards, 2019; Joint Commission, 2018; Tasca et al., 2019).

But is it just another fad?

Data from two recent surveys suggest FIT is moving beyond the “innovation” to the “mass adoption” phase among mental health providers and treatment agencies.  The study conducted by Myoutcomes® targeted members of Facebook-related psychotherapy interest groups and other sources, finding fairly dramatic growth in: (1) awareness of the empirical support for using measures to assess progress and the quality of the therapeutic relationship; and (2) experience with standardized measurement tools in psychotherapy.

Whether such results indicate FIT will stick around long enough to be the “game changer” remains to be seen.  What is known for sure is that, while important, awareness of, experience with, and research support for the process are insufficient to sustain the interest.  Research shows, for instance, successful implementation of FIT takes significant time, planning, and support, without which between 70 and 95% of efforts fail.  Why?  Because working feedback-informed is about changing culture, not using measurement scales in treatment.  Success requires that all members of management — from administration to clinical supervisors — understand and are actively involved in implementation.  Indeed, when practitioners rather than a team led by a manager are held accountable, the likelihood of FIT being a game changer plummets (80% versus 14 %).

Bottom line?  PLEASE don’t download the ORS and SRS and begin experimenting — testing it out to see “if it works.”  As I blogged about last week, the likelihood of failure is simply too high.   Instead, bring your team to our upcoming Spring intensives in Chicago.  You’ll not only “rub shoulders” with colleagues from around the world and our international faculty, but also leave with a thorough grounding in FIT, as well as skills for transforming the culture in which you work.

Until next time,

Scott

Director, International Center for Clinical Excellence

A couple of weeks ago I received an email from the leader of a group asking me to send them copies of the ORS and SRS. “We are to start using these straight away,” the person wrote.

I replied, of course, providing a link to my website where the scales could be downloaded along with a brief note, highlighting the Feedback Informed Treatment (FIT) Manuals and the upcoming March Intensives in Chicago.  “Both are great resources,” I said, “for learning how to use the measures to improve the quality and outcome of behavioral health services.”

I received a quick and polite response, thanking me for the links but going on to say, “I’ve seen the scales. They are really very simple and self-explanatory so I don’t think we really need much in the way of training or support materials.”

I’d like to say I was surprised. After all, what medical professional would say something similar?  Say, about a stethoscope?  To wit, “No thanks, seems pretty simple, stick these thingies in my ears, and the other end on the patient’s chest and listen…”.

But I was not — surprised, that is. Why?  Of the several hundred downloads of the measures from my website per week, and the more than 200,000 over the last decade, very few practitioners have sought or received any training.  Indeed, most have never even read the FIT manuals!

The impact on those who are initially enthusiastic about seeking formal feedback from their clients is as predictable as it is sad: they quickly give up.  How do I know, you ask?  Every week, as I’m out and about, training and consulting, I run into practitioners who say:

“Yeah, I heard of FIT, I even tried the scales…but they didn’t work…”

“I tried the ORS and SRS scales for a while, but I didn’t get any clinically useful information from them…”

“My clients weren’t honest … so I stopped using them”

And so I ask, what does it take to help people get the information and training they need to succeed?  The question is far from trivial or self-serving.  The measures are free to download and the latest research shows using them more than doubles the chances of helping clients experience meaningful change.  The only caveat is that, despite their simplicity, learning to employ the tools effectively takes time and support.  How do I know that?  Research, of course!

If you have thoughts about what I can do to address this problem, please let me know. In the meantime, in an effort to help, here are several offers:

1. For the time being, get the FIT Treatment and Training Manuals for 50% off;

2. Register for the combined FIT Advanced and Supervision Intensive now using the code FIT-Promo at checkout and get an additional discount off the early bird rate;

3. Sign up for the cutting-edge FIT e-learning program — where you can learn at your own pace from the comfort of your home — and receive the new, deliberate practice module, for free (if interested, email me for details about this offer).

Yes, please feel free to share these links and codes with your colleagues.  And, once more, if you have additional suggestions, I’m interested in hearing them.  Please post a comment below.

That’s it for now.

All the best for the Holidays,

Scott

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

Mr. Gomm was my sixth grade teacher.  Tall and angular, with a booming voice and stern demeanor, he remains a forbidding figure from my childhood.

I’ll never forget the day he slammed his open hand on my desk, bellowing “That, Mr. Miller, is an assumption!”  Turning abruptly, he walked to the chalkboard, and began writing, one capital letter at a time: A, S, S, U, M, E.

“And do you know what happens when we assume, Mr. Miller?” he asked.

“Speak up!” I remember him commanding.  But I just sat there, like a deer in the headlights.

I’m sure you know what happened next.  Returning to the board, he quickly drew slash marks between the S and U, and U and M:  ASS/U/ME.

For emphasis, he then tapped each section loudly with his chalk as he spoke, “Let me spell it out for you, Mr. Miller.  To assume is to make an ass out of you and me!”

It’s a moment I recall with absolute clarity.  Only later — much later —  did I come to realize I’d not understood the point he’d been trying to make at the time.  Indeed, at recess, all anyone could talk about was that Mr. Gomm said the word “ass” out loud in class.  Soon, we were applying our new knowledge to anything anyone did on the playground that we didn’t like: butting in line, missing a critical shot in kick ball, or any of the other possible social faux pas among marginally pubescent adolescents.

“You just made an ass out of you and me!” we repeated with glee at the slightest provocation.

Beyond the obvious irony involved, it turns out tr. Gomm was only half right.  Yes, assuming — supposing without proof — is fraught with risk.  That said, presuming — taking something for granted based on probability — is, as the incident so clearly demonstrates, just as problematic.  In his mind, he’d made a sensible presumption: we would get “it.”  After all, he knew us.  We were his students.  We made the same mistake.  Based on our experience of him, we figured he was teaching us another valuable lesson, and then assumed we’d understood what he’d said.

Prior to last week, I’d not thought of Mr. Gomm for ages.  I was was reminded of him after puzzling over a slew of questions about feedback-informed treatment (FIT) posted on our online discussion forums at the International Center for Clinical Excellence.  On the surface, all appeared to be straightforward requests for information, requiring nothing more than a simple and direct response.  The trouble was that any answer one might give ended up confirming assumptions contained in the queries that were fundamentally untrue or inaccurate.

While the particulars varied, a theme shared by many of the posts was whether one could or should trust scores on the Outcome and Session Rating Scales (ORS & SRS) with certain clients — in particular, people who were shy, mandated into treatment, cognitively compromised, or emotionally disturbed.

To be sure, it’s not the first time I’d encountered such concerns.  Indeed, they frequently come up at the beginning of introductory workshops on FIT:

“Court ordered clients won’t be truthful.”

“The feedback from client’s with (borderline personality disorder, bipolar, psychosis) won’t be reliable or valid.”

“People from this (age group, culture) are not (accustomed to or incapable of) providing feedback to professionals.”

When I have several hours to teach, interact, and illustrate, I usually ask people to wait with such observations, promising an answer will emerge in time.  In the truncated, two-dimensional space of most social media interactions, however, I’ve found a similar evolution of understanding much more challenging.  Hence this post.

Of course, in the best of all worlds, people would get more training.  Answers are available. Given the simplicity of the scales — you can learn to administer and score the ORS and SRS in less than a minute — the temptation to dive in, presuming our existing clinical knowledge and experience applies to their use, is simply too great for most to resist.  Consider this: several hundred thousand practitioners have download the measures from my website in just the last couple of years!  Of these, fewer than 2 or 3% have had any training!  In the end, the unquestioned assumptions brought to the process cause most to get stuck and eventually give up.

So, what about the concerns noted above?

All make perfect sense IF the ORS and SRS are thought of as assessments, the helpfulness of which depend on the accuracy of the data collected.  By contrast, were the measures primarily seen as tools to help engage clients, an entirely different set of assumptions becomes possible.  For example, rather than interpreting high ORS scores of a court-ordered client as evidence of dishonesty or denial that must be confronted or overcome, they could be treated as an opportunity to connect with, explore, and understand their experience and world view.

In practical terms that means taking client scores at face value.  Leaving traditional assumptions aside, the clinician would first acknowledge and then respond logically to what is reported on the scale.  “I see from your responses, you are doing quite well,” continuing, “So, why did you decide to come see me today?”  Should the client say, as most readily do, they were sent by the courts (or employer, parents, or partner), the clinician responds by asking them to complete the measure as if they were the person who sent them.  After all, from their perspective, that’s why they are there!  The discussion can then turn to closing the gap between the client’s and referral source’s scores, beginning, for instance, with asking, “What have they missed about you that, once recognized, will lead them to score you higher?”  Along the way, the result of this line of inquiry is greater participation of the client in treatment — the factor long ago established as the number one process-related predictor of outcome (see Orlinsky, Grawe, & Parks, 1994).

And what about the other questions?

As already stated, answers are available — ones that leave most thinking, “Duh, why didn’t I think of that?”  To be blunt, we can’t so long as we are unaware we are thinking something else!  That’s where a more in-depth training in FIT can prove helpful.  Join colleagues from around the world and our international faculty this coming Spring in Chicago for the three-day, Advanced FIT Intensive.  We’ll not only challenge your thinking, we’ll provide a thorough grounding in the principles and skills of using feedback to inform and improve the quality of mental health and substance abuse services with a broad and diverse clinical population — training which, research shows, improves therapist effectiveness.  Registration is limited to 40 participants.  Click either of the icons below for more information.

Until next time,

Scott

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

Imagine a power so great that those who possess it are able to heal the sick, and those without it, cause death. By definition, it would qualify as a superpower — and, in fact, one Marvel comic character has claimed this one for their own.

More than seven dozen studies have investigated the impact of this “power” on the outcome of psychotherapy, finding that it contributes nine times more to success than whatever treatment method is employed (1 [see table, p. 258]).  And now, a population-based study out of the UK has shown that diabetic patients whose physicians wield this special power have a lower risk of cardiovascular events and mortality.

Strangely, while the evidence shows this ability can be greatly enhanced with proper instruction (1), little time is spent in graduate or medical schools helping students acquire or refine it.  The trend continues after formal training.  For example, search the web for continuing education on the subject and the offerings are few and far between.  And finally, if you think clinical experience contributes to the development of the skill, think again.  Despite widespread belief to the contrary, time is not a good teacher, with studies showing no correlation between the strength of the power and the number of years a practitioner has been in the field.

So, what exactly is the “it” we are talking about?

Notice your reaction when I tell you…

EMPATHY

Skeptical?  Surprised?  Bemused?  Knew it all along?

Whatever your response, the documented power of empathy to heal (or harm) makes clear more attention to the skill is warranted in our professional development efforts.  What steps can clinicians take in this regard?  A recent meta-analysis containing every study on the subject to date concludes, since “clients’ reports of therapist empathy best predict eventual treatment outcome, … regularly assessing … the client’s experience of empathy, instead of trying to intuit whether therapist behavior is empathic or not” is key.

Regularly assessing the client’s experience instead of trying to intuit.

Two decades ago, my colleagues and I developed a brief tool to do just that.  Known as the Session Rating Scale, or SRS, it’s been vetted in numerous clinical trials and shown to be a valid and reliable way for clinicians to solicit feedback from clients regarding the quality of the therapeutic relationship (including empathy).

If you don’t already have a copy, you can get yours free by clicking here.  Several web-based systems exist for administering and interpreting the data you gather, all of which offer free trials.  More, a brand new book, and series of “how-to” manuals are available which provide step-by-step directions for using the scale in diverse settings and populations.  Finally, registration for two training workshops is now open where you can get hands on training on using the measure to improve your therapeutic effectiveness.  Each year, these events fill up months advance.  Click here for more information.

That’s it for now!

Until next time,

Scott

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

P.S.: The photo at the outset of this post displays two cards from the Thoth Tarot: (1) The Lovers; and (2) Death.  The first is about the possibilities inherent in uniting through love and acceptance.  The second, about transformation.  Sounds like psychotherapy, eh?