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

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

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

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

By this point, many other projects were underway.

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

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

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

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

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

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

Scott

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

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

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

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

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

Simple, right?

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

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

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

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

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

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

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

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

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

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

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

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

Until next time,

Scott

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

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

Is it just me or has public discourse gone mad?

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

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

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

And, therein lies the problem: no dialogue. 

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

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

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

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

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

But what exactly was “tested” in the study?

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

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

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

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

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

Until then,

Scott

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