Science is Real (confusing)

September 17, 2018 By scottdm Leave a Comment

The graphic above is a small sample of the many posts I encountered on social media last week. Obviously, science has a great deal of currency in public discourse.

Now, look at the bottom row. On the far left, we are told that drinking wine will help you live a longer life. On the right, the exact opposite claim is made: no level of alcohol consumption is safe.

Can anyone blame us for being confused? What is the truth? Isn’t that what science is supposed to help us sort out? Judging from the slogans printed on T-shirts, posters, and lawn signs, apparently so:

Science matters!
Science will not be silenced!
In science we trust!

Or, in the words of “Science Guy,” Bill Nye, “If you don’t believe in science, you are holding everyone back.”

How can one respond to that, except to say, “Ouch!”

And yet, at the risk of holding everyone back, I actually think much of the current confusion about what is and is not true comes precisely from believing in science. To me, its a bit like saying, “I believe in hammers.” Yes, each word makes sense, but the resulting sentence is absurd.

Science is not something to believe in or not. Like a hammer, it is merely a tool — one that, as the founder of American psychology, William James (1896), noted, is “first of all a certain dispassionate method.”

James then continued, offering a warning particularly suited to our media-saturated times, “To suppose that [science] means a certain set of results that one should pin one’s faith upon and hug forever is sadly to mistake its genius, and degrades the scientific body to the status of a sect.”

Real world science is a messy affair, with partial, inconclusive, and often contradictory results the norm rather than the exception. When done well and thoroughly understood, it can help tip the scales in one direction or another. Rarely, however, does it offer us a mirror of the universe.

Here’s a recent example from my own work. Are superior performers in sports, art, music, programming, and psychotherapy born or made?

About a decade ago, a slew of books and articles appeared boldly asserting, “Greatness isn’t born. It’s grown” (Coyle, 2009). Anyone, they promised, could accomplish anything if they just practiced long enough (Colvin, 2009; Gladwell, 2008; Shenk, 2010; Syed, 2010).

Then, in 2014, a group of researchers published a meta-analysis questioning the strength of the association between practice and performance. In a popular magazine , the banner for an article penned by one of the study’s authors even claimed the whole idea of improving performance via practice, “perpetuates a cruel myth” as it promotes the false belief, “people can help themselves to the same degree if they just try hard enough.”

What are we to believe?

Sorting out the seemingly contradictory results requires a deep dive into the literature: who did the studies, what questions did they ask, and how was the data analyzed? In other words, longer than the 2 – 4 minute “reads” promised in the social media posts pictured above. In fact, from the start to the publication of our new study on the subject, my co-investigators and I spent hundreds of hours spread out over a three year period examining the question. Here’s what we found:

The correlation researchers cited as demonstrating practice is “not as important as has been argued” (.35 [p. 1, Macnamara et al., 2014]) was greater than the association between mortality (e.g., death) and obesity (.13), excessive drinking (.21), and taking prescribed medications correctly (.23).

When the data set was reanalyzed including only those studies judged by independent, blind raters to be bona fide instances of research on the link between practice and performance, the correlation increased to.40.

So, you decide: if you want to improve your effectiveness –as a pole vaulter, chess player, surgeon, or psychotherapist — should you practice? Please share your thoughts below.

WAIT! Three new science posts just came across my social media feed:

What to do?

Start talking to my dog. Check!
Begin my three day fast. Check!
Nah, I’m just going to watch TV.

All the best,

Scott

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

Psychotherapy’s Most Closely Held Secret: Some Practitioners are more Effective than Others

August 29, 2018 By scottdm 8 Comments

Take a good look at the picture below. Do you recognize this person?

Let me give you a hint. In 1974, he published the first empirical study documenting one of psychotherapy’s most closely held secrets: some therapists are more effective than others.

It’s true. You know it. I know it. Everyone knows it. We just don’t talk about it openly.

The man in the photo is psychologist David F. Ricks, author of “Supershrink: Methods of a Therapist Judged Successful on the Basis of Adult Outcomes of Adolescent Patients.” And until the publication of this post, no public images of him were available. Not a single photo on the net. Hard to believe in our digital age (I promise to explain how I managed to get this picture later on in the post).

Confirming the controversial and uncomfortable nature of the subject, Rick’s article, though groundbreaking, is rarely cited. Google Scholar reports a mere 154 citations over the last forty-four years–and most of those are by the same, small group of authors! More to the point, how to explain the finding that kids treated by one therapist fared far better in adulthood than those cared for by another?

Now, as then, the dominant belief is that any differences in outcome are attributable to the client, their pretreatment level of dysfunction, and the environment in which they live. In Rick’s (1974) study, however, extreme care was taken to ensure the adolescents seen by different therapists were matched on all such possible variables (e.g., level of functioning/severity, gender, IQ, economic class, age, ethnic background, time period treated, level of familiar and parental pathology). The results were dramatic, if not shocking. One the basis of their level of adjustment as adults, seventy-five percent of those seen by the top performing clinician had a positive outcome. By contrast, 84% of those treated by the other practitioner were classified as having a “schizophrenic outcome.”

Had the kids been asked at the time, the field would not have had to wait so long to discover the factor responsible for their success. Indeed, all were aware of the important role their therapist played in their lives. Looking back as adults, they affectionately recalled referring to the clinician who had treated them as “the supershrink”–even going so far as to encourage other kids to seek out this particular person for help.

Despite these results, thirty-years would pass before another empirical analysis appeared in the literature (Okiishi, Lambert, Nielsen, & Ogles, 2003). The size and scope of this later study dwarfed Rick’s, examining results from standardized measures administered on an ongoing basis to over 1800 people treated by 91 therapists. The findings? Those seen by the most effective clinicians experienced a rate of improvement 10 time greater than the mean for the entire sample. Meanwhile, those treated by the least effective, could expect to feel the same or worse than when they started, even after attending 3 times as many sessions!

Isn’t it time our field confronts reality and asks, “why are some therapists more effective than others?” Clinicians invest a great deal of time, energy, and money in professional growth. They undergo personal therapy, receive ongoing postgraduate supervision, and attend continuing education (CE) events (Rønnestad & Orlinsky, 2005). Nevertheless, one searches in vain for any evidence that such efforts help therapists accomplish their goal (Miller, Hubble, & Chow, 2017).

After learning a bit more about the life and work of David Ricks, I strongly believe he would counsel us to, “Go for it!” After all, he was a maverick and pioneer. I mean that literally! Born in 1927 in Wilson, Wyoming (population, 32), his log cabin house had no indoor plumbing or electricity. Hot potatoes lovingly prepared by his mother, warmed his bed and hands during the long, cold winter months.

He literally rode a horse to and from the one-room school house he attended–that is, until the family was forced by the Great Depression to move south in search of more economic opportunities. There, the hardships continued: his father died when he was 15, his mother was often ill, and the family remained poor. Throughout it all, David persisted. Although an elementary school teacher once told his parents, “David can’t learn,” he nonetheless was awarded a full scholarship to attend college, eventually earning a Ph.D. in psychology from the University of Chicago. Over the course of his career, he taught, did research, and was a professor at Harvard, Cornell, and eventually, the University of Cincinnati.

Ever since I first read his study, I’d wondered about the person behind the research. Internet searches, as I mentioned above, were futile. I did learn from a brief online obituary that he had died in March 2004–sadly, just a few years before his findings would begin influencing our own work. I sent letters and emails to various people and Universities, all to no avail.

Recently, I managed to find a potential link to one of his, now adult, children. I reached out via Facebook, and the rest is history. We’ve spoken at length on the phone. In response to my request, I was given a series of photos, including the one in this post. Most special, however, was a personal history Dr. Ricks wrote for his grandchildren. Reading it gave me, I believe, insight into the traits that drove him. When writing about what his parents had taught him to value in life and relationships, he said, first, honesty, and second, courage.

Recent research has finally provided some answers to the question Ricks posed so many years ago (Golberg, Babbins-Wagner, Rousmaniere, Berzins, Hoyt, Whipple et al. 2016): Why are some therapists more effective than others? Put succinctly, the amount of time they engage in deliberate practice is a significant predictor of how effective they become. Indeed, top performing clinicians devote twice as much time to this process than their less effective counterparts. What does it involve? Three things: (1) ongoing measurement of one’s results; (2) continuous identification of specific errors and targets for improvement; and (3) development, testing, and successive refinement of new ways of working.

Still the topic remains controversial and the subject of much misunderstanding. “Please don’t mention anything about supershrinks,” an agency manager advised in hushed tones during a recent phone conversation we were having about topics for a potential in-house training. When I asked, “Why?” they explained, “Clinicians already feel ‘put upon.’ They don’t want to hear about needing to compete with the best.” No wonder this research, I instantly thought to myself, is so off putting. I attempted to clarify, “It’s not about competing with others or even becoming a supershrink, it’s about trying to get a grip on what each of us can do to improve our effectiveness.”

My question to you is, “Did I get the job to do the workshop at that agency?!”

Interested in your responses!

Until next time,

Scott

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

P.S.: Registration for the March 2019 Intensives in Chicago is open. I know it may seem like a long way off in the future, but these trainings have sold out months in advance for the last several years. Click now on the images below to join colleagues from around the world for the fun, interactive, and learning-rich experiences.

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

July 12, 2018 By scottdm 7 Comments

Does the name Barry Marshall ring a bell?

Probably not if you are a mental health professional.

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

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

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

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

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

How about these?

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

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

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

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

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

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

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

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