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?

Plug “psychotherapy” into the Amazon search engine and you get 60,000 hits for books, manuals, worksheets, and videos.  Clearly, when it comes to “how to do it,” our field is rich with resources.

However, if you enter the words, “failure in psychotherapy” the number drops to 75, less than 20 of which are actually on topic.

TWENTY.

How to interpret such results when research shows 50% of people who enter treatment fail to benefit in any meaningful way?  The numbers being what they are, it’s hard to come to any other conclusion than we avoid the subject.

Contrast our field’s relative indifference with the approach of the aviation industry.  Where we avoid the subject, they embrace it, using each instance to learn and improve.  The result?  The safety of air travel has improved dramatically, with fatalities dropping from around 40 per million departures in the late 50’s and early 60’s, to near zero in recent years.   By contrast, during the same span of time, retention and outcome rates in psychotherapy have not improved a single percentage point.

Thankfully, recent developments are challenging the status quo, putting failure center stage in a renewed effort to facilitate professional development.  One of these is a new and deeply moving podcast series, “Very Bad Therapy,” run by two graduate students, Ben Fineman and Carrie Wiita.  Each installment features a different client sharing a, “You would not believe what happened with my therapist” story.

Ben and Carrie are skillful and entertaining interviewers, teasing out nuances and helping reveal the rich learnings hidden in the worst moments of our work as therapists.  Consider this, already they’ve published more episodes than there are books on the subject at Amazon!

Check it out.  And while you’re there, listen to Episode #18, their most recent.  Once again, the subject is failure and professional growth.  This time, the person being interviewed is me!

Until next time,

Scott

Director, International Center for Clinical Excellence

P.S.: Registration for the Spring intensives on Feedback Informed Treatment (FIT) is open! Each year, we sell out months in advance.  Click here for more information or to reserve your spot.

Take a good look at the photo to the left.

Do you know this person?

His name is Myron L. Fox, M.D., a graduate of the Albert Einstein School of Medicine.

Still doesn’t ring a bell?

At one point, he was the one of the highest rated presenters on the continuing education circuit for physicians, psychologists, social workers, and educators.  He delivered hour long lectures followed by 30 minutes of Q & A at major universities.  Among other topics, he spoke about the biochemistry of memory.  Those in attendance routinely described his lectures as “outstanding,” “stimulating,” “thought provoking,” and “clear and well organized.”

Only one wrinkle.  Dr. Fox was not a physician.  He wasn’t a doctor of any kind.  Neither was his name Myron Fox.  In fact, he really knew nothing about the subjects on which he spoke.  Rather, the man in the photo was a paid actor coached by a group of experimenters to present a lecture full of “double-talk, neologisms, non sequiturs, and contradictory statements” in one of two ways: straightforward or entertaining.

No surprise, in the first instance, the participants learned less and performed more poorly on a subsequent test than those who attended a similar lecture delivered by a real scientist.   However, when “Dr. Fox” adopted a lively demeanor, used humor, and displayed warmth toward and interest in his audience, any correlation between the content covered and audience ratings of the experience disappeared.   Indeed, so potent was his style, it masked a completely “meaningless, jargon-filled, and confused presentation” (Merritt, 2008).

The study has been replicated many times with similar results.   Even when participants are warned ahead of time to be on guard, the “Dr. Fox Effect” — as it has come to be known — remains in force.  Over the years, the findings have been cited as evidence against using speaker and student ratings to evaluate teachers and lecturers.  By contrast, I’ve always thought the study showed how important engagement was to effective teaching.  After all, in all versions of the study, participants exposed to entertaining versions of lectures scored more highly on subsequent knowledge tests than those hearing material presented in a “straightforward” manner.

It’s why the International Center for Clinical Excellence is offering the “Training of Trainers” course this summer.   Knowing that WHO you present is just as critical as WHAT, this three-day, evidence-based, bootcamp style workshop is specifically designed to help you become a better presenter/trainer, one that builds on your style and persona.   Click here for more information or to register.

All the best,

Scott

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

My family and I had a frightening experience this past Memorial Day.  While driving through Indiana on the way home to Chicago, our mobile phones began to alert.  You know the sound — part cicada, part microphone feedback, but louder.  

“Tornado warning in this area.”

Not a watch, mind you, a warning.  The difference is critical.  A watch means conditions are favorable for a tornado.  A warning means, IT’S HERE!

Looking ahead, we could see the dark, fast moving clouds.  No rotation, but menacing nonetheless.  That’s when our phones screeched the warning again.

“Take shelter now.  Check local media.”

Turning on the radio, we listened to the weather broadcast, distorted by the now abundant flashes of lightening.  We quickly learned we were heading directly into the affected area.

“What do we do?” I muttered to myself.   Cars and trucks were already pulling to the side, taking up positions under overpasses.  A few had become stuck while attempting to turn around in the already flooded ditch separating the two directions.

“Check Google maps to see where we can get off,” I barked.  I knew from prior experience that sheltering under overpasses was a bad idea.   We had to get off or risk having the Tornado hit us head on.  Problem was we were on the tollway where exits are few and far between.

“Two miles to the next exit,” my son soon replied.

That’s when we first saw it.  The clouds rotating overhead, a conical shape beginning to push downward.

Once more, our phones alerted: Take shelter now.  With my adrenaline pumping, and no other way to go but forward, I pushed on the accelerator.

Thankfully, we made it to the exit, racing northward up a country road at 85 miles-an-hour to escape the storm.  Ten or twelve minutes later, we spied a small gas station and pulled into the lot.  It was pouring rain, alternating with hail.  The sense of relief was palpable nonetheless.

Once the danger had passed, we resumed our journey.  The cabin of the car now quiet, I began running the experience over and over in my mind.  Something about it really bugged me, in particular the warnings and advice we’d received via our mobile phones and from the media.  It was clear, to be sure.  At the same time, it was absolutely unhelpful.  Yes, we were grateful for the warning.  And, of course, it was a good idea to seek shelter.  But where and how?  Absent more concrete direction, the result was people either panicked (like us) or made poor, even dangerous choices (e.g., sheltering under overpasses instead of laying in a ditch).

We have a similar problem in the field of mental health.  Google “advice and psychotherapy” and you get roughly 6 million hits many, if not most, of which are negative.  “The best advice a therapist could get,” one prominent site counsels, is “Stop giving advice.”  Another warns, telling people how to solve their problems, is “counterproductive” and potentially unethical.  A variety of reasons are given — largely having to do with the assumed nature of therapy (i.e., helping people help themselves) or client resistance to such help.

But do clients agree with such sentiments?  Until recently, no one had bothered to ask.  Now, a newly published study provides some provocative answers.  Researchers Cooper, Norcross, Raymond-Barker, and Hogan surveyed therapists and clients about their preferences, finding large and robust differences between the two groups.  Therapists, on average, preferred more emotional intensity and less directiveness.  Their clients?  The reverse!   The researcher’s advise to practitioners?  One page one of the peer reviewed article: Stop projecting your own desires onto the people you treat.

“Easier said than done” says lead author, Professor Mick Cooper.  I had the chance to speak with him about the study.  The interview provides direction for putting these importance findings into practice.

Until next time,

Scott

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

It was a curious finding.  One we stumbled on quite by accident.  Highly effective therapists were more likely to contact their clients between visits than their more average peers.  We wondered whether such behavior might account, at least in part, for their superior retention rates and outcomes?

Turns out, our serendipitous finding fit nicely with results from the field of behavioral economics documenting how very simple actions can have a dramatic impact on people’s behavior.   In one well known example, a study showed the way food is displayed in school cafeterias –it’s location and prominence–significantly impacts whether students make healthy or unhealthy eating choices.  Similar results have been recorded in other areas, such as saving for retirement, choosing the best health insurance plan, deciding whether to exercise or make positive lifestyle changes.

In all cases, the “nudge” –as researchers call such interventions — are simple, inexpensive, and require little time and effort to deliver.  A recent report in The Chronicle of Higher Education found, for example, a single email expressing compassion and support to students who had failed their first semester exam led to better classroom performance and less school drop out.  And since our original discovery, psychotherapy researchers have confirmed what highly effective practitioners have known all along.  The study by Flükiger, Del Re, Wampold, Znoj, Caspar, and Jörg found that clients who were sent a brief letter and had one follow up call between visits experienced significant and lasting improvements in the quality of the therapeutic relationship over the course of care.

Clearly, a little can go a long way.  But where to start?

It would be wrong to conclude that we should start phoning (or sending emails) to all of our clients between visits.  The research cited above and findings from our interviews with highly effective therapists show, to be effective, therapeutic nudges must interrupt “business-as-usual.”  The default choice for most practitioners is not to engage in extratherapeutic contact with clients.  We are busy enough and reaching out crosses a boundary.  Additionally, and importantly, any such efforts need to show our interest in the client while simultaneously leaving them free not to comply.  Simply put, nudges can not be shoves.  

Evidence shows using simple measurement scales on an ongoing basis to  assess progress and the quality of the therapeutic relationship can augment our ability to identify and time these types of interventions.  Indeed, as I posted last week, clients whose therapists do so are less likely to dropout and 2.5 times more like to experience benefit from treatment.   Actually, 10’s of thousands of clinicians around the world are using the tools I created nearly 20 years ago to inform their work.  If you aren’t, click here to download them for free.

In the meantime, if you are looking for new and creative ways to nudge your therapeutic effectiveness upwards, join me in Chicago for one or more of our Summer workshops:

• The two-day “FIT Implementation intensive” is the only evidence-based workshop in the U.S. designed to help you implement feedback informed treatment in your agency or healthcare system.
• The three-day “Training of Trainers” will enhance your presentation and training skills.  It’s a blast, the most fun workshop we do.
• Last but not least, the two-day “Deliberate Practice” workshop will, as the name implies, help you use deliberate practice to improve your clinical effectiveness.  We help you identify the targets and develop a plan.

All the best,

Scott

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

Several weeks ago, the American Psychological Association (APA) released its latest in a series of practice guidelines for psychologists – this time for “Psychological Practice with Boys and Men.”  Prior years had seen guidelines focused on ethnicity, older adults, girls and women, LGBT, and “transgender and gender-non-conforming” persons.

Curiously, despite claiming to be based on 40 years of research, and the product of 12 years of intensive study, the latest release attracted little attention.  More, the responses that have appeared in print and other media have largely been negative (1, 2, 3, 4, 5). 

What happened?

At first blush, the development and dissemination practice guidelines for psychologists would seem a failsafe proposition.  What possibly could go wrong with providing evidence-based information for improving clinical work?  And yet, time and again, guidelines released by APA end up not just attracting criticism, but deep concern.   Already, for example, a Title IX complaint has been filed against the new guidelines at Harvard.

Consider others released in late 2017 for the treatment of trauma.  Coming in at just over 700 pages ensured few, if any, actual working professionals would read the complete document and supportive appendices.  Beyond length, the way the information was presented–especially the lack of hypertext for cross referencing of the studies cited–seriously compromised any straightforward effort to review and verify evidentiary claims.  Nevertheless, digging into the details revealed a serious problem:  a discontinuity between the evidence reviewed and the conclusions reached.  For example, despite “strongly recommending” certain approaches over others, none that topped the list had actually been shown by research to be more effective than any other.

Guidelines are far from benign.  They are meant to shape practice, establishing a “standard of care” — one that will be used, as the name implies to guide training and treatment.  As such, the stakes are high, potentially life altering for both practitioners and those they serve.

And so, on reading the latest release from the APA, we wonder about the consequences for men and boys.  Even a superficial reading leaves little to recommend “being male.”  Gone are any references to the historical or current contributions of men — to their families, communities, marginalized peoples, culture, or civilization.  In their place, are a host of sweeping generalizations often wrapped in copious amounts of political, progressive jargon on a wide variety of subjects, many of which are the focus of research and debate by serious scientists (e.g., the connection between media violence and male aggression, socialization as a primary cause of gender and behavior, the existence of a singular versus multiple masculine ideal, etc.).

Cutting to the chase, when viewed in this way, is it any wonder really, that many men – as the document accurately points out – “do not seek help from mental health professionals when they need it?” (p. 1).

And lest there be any doubt, men as a group, are in need help.  

You’ve likely read the statistics, seen examples in your practice, perhaps in the life of your family or friends.   It starts young, with boys accounting for 90% of discipline problems in schools, and continues to the end of life, with women living 5 to 10 years longer on average.  The “in between” years are not any better, with men significantly more likely to be incarcerated, addicted to drugs, drop and fail out of school, and end their lives by suicide.

To be clear, the document is not overarchingly negative.  At the same time, if our goal, as a profession, is to reduce stigma — which previous, and even the present, guidelines do for other groups and “non-traditional” males — then the latest release risks perpetuating stereotypes and prejudices of “traditional” men and the people in their orbit.

Sticking to the science of helping, instead of conforming to popular standards of public discourse, would have lead to a very different document – one containing a more nuanced and appreciative understanding of the boys and men who are reluctant to seek our care.  In the fractious times in which we find ourselves, perhaps it’s time for guidelines on how to live and work together, as individuals and as a species.

As always, interested in your thoughts,

Scott & David

Scott D. Miller, Ph.D. & David Prescott, LICSW
International Center for Clinical Excellence

P.S.: Registration for our Summer Intensives on Implementing Feedback Informed Treatment and Deliberate Practice is now open — two clinical practices research shows improves retention and outcome in behavioral health care.   For more information, click here.

I’m neither a great psychotherapist or surfer.  I love doing both, however.

Turns out, the two share a fundamental similarity critical to successful execution; in a word, responsiveness.

Scott

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

P.S: Registration is open for the FIT Summer Intensive Trainings.  Click on the icons below for more information or to register.

Nearly two decades have passed since I met Saul Rosenzweig at his home in St. Louis, Missouri.  He was well into his nineties and still working every day.  Truth is, I was surprised to learn he was still alive!

In 1936, he’d penned an article –three and a half pages in total– that became one of the most often cited in psychotherapy research.  He was only 29 years of age at the time.

Then, as now, Rosenzweig’s central premise is controversial: all psychotherapy approaches, regardless of their specific components, produce equivalent outcomes.

Although he didn’t coin the phrase, his observation has since been referred to as, “The Dodo Verdict.”  That’s because he began the article quoting a line uttered by the Dodo from Alice’s Adventures in Wonderland, “Everyone has won, and all must have prizes.”

Over the last eight decades, many have claimed to “beat the dodo verdict” — to have developed an approach more effective than others.   You know them by acronym: CBT, EMDR, ACT, CRT, MI, TFT, SFBT, CDOI, and so on.   Initial research is always promising.  Nevertheless, as I’ve detailed in many blogs over the years, later studies invariably find the “new and improved” is no more effective than the “tried and true” — whatever the accepted standard might be at that moment (1, 2, 3, 4).

The field’s focus on methods is understandable.  The assumption is psychotherapy works like medicine.  To be effective, an approach must contain ingredients specifically remedial to the disorder being treated.  No one questions whether antibiotics are better than aspirin for strep throat.  Why?  Because the former contains an ingredient that kills the bacteria responsible for the infection.  In a similar way, CBT  is widely believed to work because its methods target the root cause of depression, dysfunctional thoughts.

So critical are the techniques of the various psychotherapy approaches believed to be, developers create protocols and manuals for insuring they are delivered correctly.  Professional, regulatory, and funding bodies (e.g., American Psychological Association, National Institute for Health and Care Excellence [NICE], National Institute of Mental Health) have embraced and, in some instances, mandated their use.

But what do the data say?

In 2005, my colleagues and I reviewed the available evidence and concluded, “Although training in manualized psychotherapies does enhance therapist learning of and technical competence in a given approach, there is no relationship between such manuals and outcome.”

And now, a new, updated study.  Briefly, researchers Truijens, Zühlke‐van Hulzen, and Vanheule, conducted a systematic review of the literature — six studies directly comparing manualized and nonmanualized psychotherapy, and nine meta-analyses.  Their conclusion?  “Manualized treatment is not empirically supported … [and] should not be promoted as being superior to nonmanualized psychotherapy.”  It’s Dodo come back life.

What can a mental health professional do to improve their effectiveness?

Here again, the data point the way to finally “beating the Dodo.”  It involves a change of focus.  Instead of learning the latest treatment approach, work on becoming a more effective version of you.  The process is known as deliberate practice.  It begins by creating a detailed map of your clinical performance; specifically, measuring your results, and then using the information to identify opportunities for professional growth.Research to date documents gradual growth in effectiveness consistent with performance improvements obtained by elite athletes.

Want to learn more?  Click here for a free article–actually, the chapter on the subject from our latest book, The Cycle of Excellence.   Still interested?  Watch the recent interview I did on the subject with YouTube blogger, Chris Dorsano.

That’s it for now.  Best for the Holidays,

Scott

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

In my travels each year, I meet 1,000’s of clinicians–professionals who truly want to help others, and are willing to try almost anything to do so.

That’s why I always “lean in” whenever one expresses concern about the rising popularity of using formal measures of progress and the therapeutic relationship to inform and improve the quality and effectiveness of behavioral health services.

The clinicians I meet are usually aware of the research behind the call to incorporate client feedback into care: (1) many people who begin in treatment (~50 to 65%), leave without experiencing a measured improvement in their functioning or well being; and (2) randomized controlled trials show that doing so improves outcomes and reduces costs (1, 2).

Still, they wonder, “What do clients think?” “Do they consider filling out the forms helpful, or a burden?”

Those asking the question have a point. After all, the measures must be used every session with every client, despite studies to date showing the effects of asking for feedback are largely confined to those not making progress. Said another way, many asked to complete measures (between 35-50%), will experience no benefit from participating in the process.

When answering this question, I’ve always relied on what I’ve been able to glean from available studies (1, 2) and my personal experience. “Rarely do my client’s object,” I say, adding, “Neither have other clinicians reported that their clients consider it a burden.” And the research to date, although sparse, largely confirms that experience.

Overall, clients report that using measures is both positive and beneficial, enabling them to: (1) play an active in the care they receive; (2) maintain a focus on what matters most to them; and (3) collaborate more effectively with their treatment provider.

That said, problems have been noted. Chief among these are therapists failing to explain the nature and purpose of the scales (e.g., validity, confidentiality of the data, rationale) as well as not using the resulting feedback to guide service delivery (e.g., increase responsiveness to individual client needs, goals, and preferences; promote greater reflection and collaboration between therapist and client; address problems in the therapeutic relationship; and change the nature, frequency, type or provider of services).

Neither of these findings are particularly surprising. If there’s anything more frustrating than being forced to complete seemingly irrelevant paperwork, it is being asked for feedback and then having it ignored. That said, if the results are so damned obvious, “Why do the problems keep happening?”

The answer, in a word, is: integration.

Learning how to administer progress and alliances measures is simple. Instructions for giving, scoring, and plotting the Outcome and Session Rating Scales, literally takes less than 90 seconds. Making the tools an integral part of one’s clinical work–instead of bookends marking the beginning and end of each visit–is an entirely different matter. Back in May, I blogged about a new study showing that such integration takes time, between two to four years. Once done, however, the results are impressive, with clients whose therapists actively use measures two and a half times more likely to experience improvement.

Integrating feedback tools into your clinical style is the subject of the upcoming, three-day “Advanced Intensive” training on Feedback-Informed Treatment in Chicago.

We go far beyond the basics, giving you concrete strategies and skills for engaging clients in the feedback process, and using the resulting information to improve the quality and outcome of the services you offer.

In 2013, the methods you will learn were vetted by the National Registry and deemed evidence-based. As in prior years, the training is on track to sell out early. Click here, or on either of the banners below, to register or learn more.

Until next time,

Scott

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

It’s just two weeks ago.  I was on a call with movers and shakers from a western state.  They were looking to implement Feedback Informed Treatment (FIT)–that is, using measures of progress and the therapeutic relationship to monitor and improve the quality and outcome of mental health services.

I was in the middle of reviewing the empirical evidence in support of FIT when one of the people on the call broke in.  “I’m a little confused,” they said hesitantly, “I thought you were the anti-evidence-based practice guy.”

It’s not the first time I’ve been asked this question.  In truth, it’s easy to understand why some might believe this about me.  For more than two decades, I have been a vocal critic of the idea that certain treatments are more effective for some problems than others.  Why?  Because of the evidence!  Indeed, one of the most robust findings over the last 40 years is that all approaches work equally well.

Many clinicians, and a host of developers of therapeutic approaches, mistakenly equate the use of a given model with evidence-based practice.  Nothing could be further from the truth.  Evidence-based practice is a verb not a noun.

According to American Psychological Association and the Institute of Medicine, there are three components: (1) using the best evidence; in combination with (2) individual clinical expertise; while ensuring the work is consistent with (3) patient values and expectations.  “FIT,” I responded, “not only is consistent with, but operationalizes the definition of evidence-based practice, providing clinicians with reliable and valid tools for identifying when services need to be adjusted in order to improve the chances of achieving a successful outcome.”

Here’s another recent question: “I’ve read somewhere that FIT doesn’t work.”  When I inquired further, the asker indicated they’d been to a conference and heard about a study showing FIT doesn’t improve effectiveness (1).  With the rising popularity of FIT around the world, I understand how someone might be rattled by such a claim.  And yet, from the outset, I’ve always recommended caution.

In 2012, I wrote about findings reported in the first studies of the ORS and SRS, indicating they were simply, “too good to be true.”  Around that same time, I also expressed my belief that therapists were not likely to learn from, nor become more effective as a result of measuring their results on an ongoing basis.   Although later proven prophetic (1, 2), mine wasn’t a particularly brilliant observation.  After all, who would expect using a stopwatch would make you a faster runner?  Or a stethoscope would result in more effective heart surgeries?  Silly, really.

What does the evidence indicate?

• The latest, most comprehensive meta-analysis of studies published in the prestigious, peer-reviewed journal, Psychotherapy Research, found that routine use of the ORS and SRS resulted in a small, yet significant impact on outcomes.

• Improving the outcome of care requires more than measurement.  If FIT is to have any effect on engagement and progress in care, clinicians must be free of programmatic and structural barriers that restrict their ability to respond in real time to the feedback they receive.  As obvious as it may seem, studies in which clinicians measure, but cannot change what they are doing in response show little or no effect (1).

• With one exception, results reported in studies of FIT are confounded by the amount of training therapists receive, and the stage of implementation they (or the agency in which they work) are in, at the time the research is conducted.  In many of the investigations published to date, participating therapists received 1 hour of training or less prior to beginning, and no supervision during, the study (1).  Consistent with findings from the field of implementation science documenting that productive use of new clinical practices takes from three to five years, a new study conducted in Scandinavia found the impact of FIT grew over time, with few results seen in the first and second year of use.  By year four, however, patients were 2.5 times more likely to improve when their therapists used FIT.  In short, it takes time to learn how to do FIT, and for organizations to make the structural changes required for the development and maintenance of a feedback culture.

• Improving individual therapist effectiveness requires deliberate practice.   It turns out,the best therapists devote twice as much time to the process.  More, when employed purposefully and mindfully, the outcomes of average practitioners steadily rise at a rate consistent with performance improvements obtained by elite athletes (Click here if you want to watch an entertaining and informative video on the subject from the recent Achieving Clinical Excellence conference).

Before ending, let me mention one other question that comes up fairly often. “Why don’t you wear shoes when you present?”  The picture to the left was taken at a workshop in Sweden last week and posted on Facebook!  Over the years, I’ve heard many explanations: (1) it’s a Zen thing; (2) because I’m from California; (3) to make the audience feel comfortable; (3) to show off my colorful socks; and so on.

The truth, it turns out, is like the findings about FIT reported above, much more mundane.  Care to guess?

(You can find my answer below)

Until next time,

Scott

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

P.S.: Registration for the FIT Intensives is open.  As has happened in previous years, we are on track to sell out early.  Email me at info@scottdmiller.com with any questions or click on the icons for more information or sign up.

P.P.S: Men’s shoes hurt my feet and back ache.  I get neither when walking about in my stocking feet while standing and presenting all day.

Most clinicians agree, the therapeutic relationship is an important ingredient in effective psychotherapy.

However, ask them the last time they: (1) read a study on the subject; (2) attended a postgraduate training specifically aimed at improving their skills in this area; or simply to (3) identify and define the factors contributing to an effective relationship, and the answers you’ll get are far more variable.

Why is that?  Why doesn’t the therapeutic relationship get more attention in coursework and postgraduate training?

The truth is, while clinicians readily acknowledge the bond they form with clients matters, they deeply believe other factors are more critical to outcome.

How do we know?  Research.

As far back as 1996, data began to emerge.  In their very interesting study, researchers Sandra Eugster and Bruce Wampold found that therapists’ evaluations of their clinical work were inversely related to the quality of the working relationship.  Think about that!  The better the relationship, the worse evaluation therapists gave of their clinical work.  What mattered most?  Technical expertise!

For clients, the picture was quite different.  The relationship was the real deal — in particular, their experience of being related to, “in a manner or degree not solely prescribed by the formal role of [the] therapist … subtle clues of authenticity and genuine human relatedness” (p. 1024-5).

While unsettling, such findings should surprise no one.  From the outset of training, therapists are not valued for their humanness or personhood, but rather their theoretical knowledge and technical proficiency.  In fact, a recent study done in Australia finds between 40 and 47% of graduate programs in psychology make no reference to relationship skills in their course syllabi, program descriptions, or list of training competencies (watch the interview below with one of the lead researchers).  These facts, combined with frequent “admonitions against over-involvement, breach of boundaries, …and other such departures from good technique” (Eugster & Wampold, p. 1025), establishes a “vicious cycle” that continues after graduate school  — one in which practitioners, and the field, are forever attempting to improve effectiveness by learning new diagnoses, therapy-related terminology, and treatment models.

The latest issue of the journal Psychotherapy goes a long way toward disrupting “business as usual.”  Every article is focused on the therapeutic relationship.  Here are some of the highlights.   If you want to be more effective, bypass learning the latest treatment technique and focus instead on:

• Improving your ability to respond emphatically;
• Putting more of yourself into therapeutic interactions;
• Becoming better at working collaboratively to develop and maintain an explicit agreement on the goals of treatment as well as the respective roles and tasks of various participants (e.g., the therapist and client/s); and
• Routinely and formally assessing the quality of the therapeutic relationship, taking time to address any problems/ruptures in real time.

Here’s one additional resource:  my interview with psychologist, Crystal McMullen, the lead researcher of the study mentioned above documenting the dearth of training on the therapeutic relationship.  “It takes decades for the psychology industry to let anything go,” she observes, “but, there is a change in the air…”.   Hear what is at the core of her optimism, as well as detailed suggestions for the future of the field.

Until next time,

Scott

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

Looking for training on the alliance?  That is the focus on our upcoming March intensives:

What works in the treatment of people with eating disorders?  Search around a bit on the internet, or consult official treatment guidelines, and you’ll find cognitive-behavioral therapy (CBT) and interpersonal therapy (IPT) listed as the “best-supported” or “preferred” psychological approaches for bulimia, anorexia, and binge eating.

Such recommendations strongly imply such approaches contain ingredients specifically remedial to eating disorders which, when applied, result in superior outcomes.  Otherwise, why create the list in the first place?

But what does the evidence actually indicate?  While research in mental health rarely results in definitive findings, in the case of eating disorders, the story is different.  When it comes to psychotherapy, all methods work equally well.   At least, that is the conclusion of the most recent, sophisticated meta-analysis on the subject.  However, if history serves as a guide, many will find the latest results hard to swallow.

Back in 2014, an article penned by proponents of the “specific treatments for specific disorders” — aka the “empirically supported” treatments movement — appeared in The Guardian, claiming science had show that some approaches were “better for certain conditions than others,” in particular eating disorders.   Citing the tremendous cost to sufferers and the healthcare system, they urged the field to “redouble … efforts to identify … and ensure that the most effective therapies are available to all who need them.”

As I blogged about at the time, I received a ton of email when that article first appeared.  “Have you seen the Guardian?” they asked.  “What do you make of it?” others inquired.   A few messages were downright snarky, even gloating,  “Scott, research has finally proven certain approaches are more effective than others.  I knew it all along!”

I responded noting that the claims in the article were based on a single study.  One.  And yes, that one study comparing CBT to psychoanalysis found CBT resulted in superior effects in the treatment of bulimia.  Crucially, I pointed out, the authors failed to mention the existence of another, exhaustive investigation available at the time in Clinical Psychology Review—one that used the statistically rigorous method of meta-analysis to review 53 studies of psychological treatments for eating disorders, and found no differences in effect between competing therapeutic approaches.

Four-and-a-half years later, the question of “what works best” in the treatment of eating disorders is being addressed in a brand new study in the top tier journal, Psychotherapy Research.  (As of right now, you can read it for yourself for free by clicking here.  Be prepared, however, as this is not an opinion piece written in a newspaper, but rather an academically rigorous analysis of the evidence).

What did the authors find?  Confirming the results of the prior meta-analysis: (1) any treatment works better than none; (2) real treatments are more effective than sham approaches; (3) and no method works better than any other.

Similar results, have been found across a wide range concerns that bring people into treatment, including trauma, sexual abuse, alcohol abuse and dependence, depression and anxiety.

Given the evidence, the question is not whether such results can be trusted.  They can.  Indeed, they represent the “state-of-the-art” — the best research has to offer.  The real problem, then as now, is that such findings do not address the question therapists most want answered, “What can I do to better help my clients?”

To answer this question, we have to recognize a simple fact: therapists live in a fundamentally different world than researchers.  We do not deal with groups of people sharing a common diagnosis who are randomized into different treatments.  Neither are we are interested in differences in the means response of aggregate group comparisons.  We deal with individuals.  Confronted daily by their suffering, we want to know how to help the person in our office right now.  The problem comes whenever these two worlds are conflated, as advocates of particular treatment approaches are prone to do.  It’s then our pragmatic focus make us exceptionally vulnerable to anyone claiming to have discovered “a better way.”

So, what can therapists do to improve their effectiveness?

Simply put: find out if what you are doing is helping your client.  Do this by seeking feedback on a formal, session-by-session basis about their progress and experience of the therapeutic relationship–a process known as “Feedback-Informed Treatment” or FIT (you can access two, free, brief and simple-to-use scales by clicking here).  A variety of support materials, and 10,000+ clinicians and administrators are available at no cost via the International Center for Clinical Excellence website.  Importantly, evidence shows clients of therapists who have integrated FIT into their work are 2.5 times more likely to experience improvement over the course of care.

That’s it for now.

Until next time,

Scott

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

“Exposure!” a choir of professional voices sings, “its the only proven way.”

“No, no,” others insist, “You can tap yourself to emotional freedom.”

“Poppycock!” another group jumps in, “Horizontal saccadic eye movements are the ticket!”

“Beware the dominant discourse,” a few, particularly literate warn, “focusing on what was done to the person can retraumatize, help them reauthor their experiences instead.”

Meanwhile, a smaller and less vocal group shakes their heads in disbelief, saying, “There are no shortcuts.  Healing comes only from identifying and ‘working through’ painful unconscious feelings.”

Turning to the research to answer the question–what heals trauma?”–offers little clarity.  Advocates of most approaches can offer evidence that their preferred approach works–at least one study, and often more, many more–a fact all should find puzzling.  Simply put, how could all approaches work, given they offer competing and often contradictory explanations and techniques?   And yet, no consistent superiority of one particular approach over others is exactly what the latest dismantling and meta-analytic studies show (1, 2, 3, 4, 5, 6, 7).

When attempting to account for why all approaches work equally well, the most common argument made is that different models work for different people.  Said another way, what may be effective in the aggregate may not work for the individual.   “Choice is key,” advocates of this position assert.

More recently, and perhaps in response to the continuing failure to find any meaningful difference in outcome between treatment methods, it has become popular to talk of a set of “mechanistically transdiagnostic…therapeutic strategies…[targeting] the role of a given mechanism in the development and maintenance of a range of psychopathology.”   Ironically, the call for a “universal treatment protocol,” is the “go to” position of those who once advocated for the creation of officially sanctioned lists of specific treatments for specific disorders.

So, which explanation holds water?  Here again, the empirical evidence offers little clarity.  What is important, however, is that these two, diametrically opposed perspectives share a common assumption: healing results from the appropriate application of the right treatment methods.

But what if that’s not true?  What if therapeutic techniques–whether specific to a given model or shared by all–have no inherent power to heal?  Where would that leave us as a profession?  Does it mean that our methods are the therapeutic equivalent of Dumbo’s magic feather?

“A great deal changes, in terms of our ability to help and heal,” psychologist Stephen Bacon suggests, “if we embrace what the research indicates.  Psychotherapy, as a science, is not like engineering.  It operates in a different reality.”

Recently, I had a chance to interview Stephen about his work, and new, thought-provoking, and imminently practical book, Practicing Psychotherapy in a Constructed Reality: Ritual, Charisma, and Enhanced Client Outcomes.  

As you’ll see, he’s a very interesting person–six years in an ashram, a neighbor and student of Krishnamurti, a degree in religious studies, and more.  For me, the “enhanced client outcomes” referenced in the title immediately got my attention.   Wait until you have 30, uninterrupted minutes available, as the interview is one of my longer, and you will want to watch every minute.

Until next time,

Scott

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