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