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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Interested in your responses!

Until next time,

Scott

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Until next time,

Scott

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

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

[Read more…]

Which of the following are bad for health and longevity?

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

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

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

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

Medical benefits of dental floss unproven

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

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

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

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

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

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

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

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

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

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

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

Scott

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

Being human means being conscious.  Being conscious means knowing, “reality bites.”

Little wonder evidence shows people have sought to alter their consciousness since the Stone Age.  Whether its music, dance, the ingestion of psychoactive plants, or the modern pharmaceuticals, humans evince a strong desire to move beyond their present reality–to transcend it, even if only temporarily.

In the US, legalization of marijuana is in full swing, with sales poised to exceed 10 billion dollars in 2018.  A recent report found that 70% of Americans take at least one prescription drug, with antidepressants and pain-killing opioids among the most widely used.

Meanwhile, overdoses of prescription drugs and heroin continue to be the leading cause of unintentional death, taking more lives than car accidents, breast cancer, and in 2016, more than the entire Vietnam war.

Yes, reality bites.  More than that, its suffers by comparison.  As an example, consider “talk therapy”–the profession specializing in helping people “get in touch” with themselves.  Over the last decade, numbers are down, with 33% fewer people choosing to see a psychotherapist.  Clear, if altering consciousness is the goal, therapy sucks.

More than at any other time in history, drugs are plentiful and easily available.  One contributing factor, a recent article in Fortune magazine points out, is the growing number of practitioners authorized to write scripts–groups such as nurse practitioners and physicians assistant that, in a brief 5-year period, managed to double the percentage of drugs they prescribe, accounting for almost a fifth of all retail sales.  One of the newest groups to join the ranks is psychologists.  Although the subject of continuing, contentious debate (1), the American Psychological Association is fully-invested in efforts to pass legislation supporting prescriptive authority.  So far, five states are on board.

Given human nature, and the direction mental health professions are taking, I wonder whether there is a therapeutic alternative to more drugs?  PLEASE SHARE your thoughts by hitting the comment button below.

As you do so, take a moment to watch my interview with Dr. Chris Rowe, a counselor whose research focused on the quality of instructional materials used to train psychologists to prescribe psychotropic drugs.  He address the following questions: (1) do the programs and products present a balanced view of pharmaceutical products? (2) will psychologists be prepared, as advocates suggest, to “choose to prescribe or not?” and (3) will psychologists be able to withstand the market pressures that have dramatically shaped the practice of psychiatry?

Until next time,

Scott

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

Does diagnosis matter?

What about the treatment approach?

Applying particular therapeutic methods to specific psychiatric diagnoses is the considered by many a “best practice”–the core of what some label, “empirically-supported” (EST) or “evidence-based psychological treatments” (EBPT).

Now, imagine a place where diagnosis and prescriptive protocols are not required or even considered essential to clinical practice.  A place where practitioners are free–even encouraged–to focus on helping people in whatever way works.  More on that in a moment.

In the meantime, consider a study just out in the Journal of the American Medical Association (JAMA).   Back in 2004, the lead author coined the term, “psychological treatments,” arguing that the future of the field depended on creating a formulary of “psychological treatments…matched to specific forms of pathology.”  The impact of this idea on clinical practice is nothing less than staggering.  Around the world, practice guidelines and funding for services are based on and restricted to methods applied to specific psychiatric diagnoses.

Participants in the newly released study either were treated with an approach specifically designed for their particular diagnosis or a generic alternative.   The results?   No difference in outcome at termination or 6-month follow-up!  Said another way, diagnostic-specific protocols did not improve the effectiveness of treatment.  In their place, the authors promote “transdiagnostic treatment protocols”–a term, I know you will be hearing more about in the future.  No need to be confused (or impressed) by the sophisticated sounding name.  Given decades of research showing all psychological approaches work equally well, this new one is, if nothing else, is a perfect example of “boldly charging forward into the past.”

The truly revolutionary implication of this study is not mentioned by the researchers: neither psychiatric diagnosis or diagnostic-specific treatments improve the outcome of psychological care.  That was the promise.  It failed.

Bottom line: it’s time to move on.

That’s exactly what psychologist Birgit Valla has done.  The leader of a large, community mental health center in Stange, Norway, Birgit publically announced neither she or her staff would employ psychiatric diagnoses or standardized treatment protocols.

Was she brave or foolhardy?  For sure, she had the weight of evidence on her side as well as an unwavering commitment to delivering effective services. Still, she was soon accused of failing to follow the “standard of care.”  An investigated was started.  Sanctions and a withdrawal of funding were threatened.

What happened next?  Watch the interview to find out!

That’s it for now.  Until next time,

Scott

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