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Can you help me understand this?

November 25, 2019 By scottdm 1 Comment

dear johnA 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.”stethoscope

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
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Filed Under: Feedback Informed Treatment - FIT

Some Common Questions (and Answers) about Feedback Informed Treatment

November 6, 2019 By scottdm 7 Comments

TeacherMr. 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 assumebeen 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.

fingers crossedTo 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?which way

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
ICCE Advanced FIT Intensive 2020 Scott D MillerICCE Fit Supervision Intensive 2020 Scott D Miller

 

 

 

 

Filed Under: Feedback Informed Treatment - FIT

Is THAT true? Judging Evidence by How Often its Repeated

October 22, 2019 By scottdm 11 Comments

earI’m sure you’ve heard it repeated many times:

The term, “evidence-based practice” refers to specific treatment approaches which have been tested in research and found to be effective;

CBT is the most effective form of psychotherapy for anxiety and depression;

Neuroscience has added valuable insights to the practice of psychotherapy in addition to establishing the neurological basis for many mental illnesses;

Training in trauma-informed treatments (EMDR, Exposure, CRT) improves effectiveness;

Adding mindfulness-based interventions to psychotherapy improves the outcome of psychotherapy;

Clinical supervision and personal therapy enhance clinicians’ ability to engage and help.

Only one problem: none of the foregoing statements are true.  Taking each in turn:

  • As I related in detail in a blogpost some six years ago, evidence-based practice has nothing to do with specific treatment approaches.  The phrase is better thought of as a verb, not a noun.  According to the American Psychological Association and Institute of Medicine, there are three components: (1) the best evidence; in combination with (2) individual clinical expertise; and consistent with (3) patient values and expectations.  Any presenter who says otherwise is selling something.
  • CBT is certainly the most tested treatment approach — the one employed most often in randomized controlled trials (aka, RCT’s).  That said, studies which compare the approach with other methods find all therapeutic methods work equally well across a wide range of diagnoses and presenting complaints.
  • When it comes to neuroscience, a picture is apparently worth more than 1,000’s of studies.  On the lecture circuit, mental illness is routinely linked to the volume, structure, and function of the hippocampus and amygdala.  And yet, a recent review compared such claims to 19th-century phrenology.  More to the point, no studies show that so-called, “neurologically-informed” treatment approaches improve outcome over and above traditional psychotherapy (Thanks to editor Paul Fidalgo for making this normally paywalled article available).
  • When I surveyed clinicians recently about the most popular subjects at continuing education workshops, trauma came in first place.  Despite widespread belief to the contrary, there is no evidence that learning a “trauma-informed” improves a clinician’s effectiveness.  More, consistent with the second bullet point about CBT, such approaches have not shown to produce better results than any other therapeutic method.
  • Next to trauma, the hottest topic on the lecture circuit is mindfulness.  What do the data say?  The latest meta-analysis found such interventions offer no advantage over other approaches.
  • The evidence clearly shows clinicians value supervision.  In large, longitudinal studies, it is consistently listed in the top three, most influential experiences for learning psychotherapy.   And yet, research fails to provide any evidence that supervision contributes to improved outcomes.

Are you surprised?  If so, you are not alone.

The evidence notwithstanding, the important question is why these beliefs persist?Coke

According to the research, a part of the answer is, repetition.  Hear something often enough and eventually you adjust your “truth bar” — what you accept as “accepted” or established, settled fact.  Of course, advertisers, propagandists and politicians have known this for generations — paying big bucks to have their message repeated over and over.

For a long while, researchers believed the “illusory truth effect,” as it has been termed, was limited to ambiguous statements; that is, items not easily checked or open to more than one interpretation.  A recent study, however, shows repetition increases acceptance/belief of false statements even when they are unambiguous and simple- to-verify.  Frightening to say the least.

EBPA perfect example is the first item on the list above: evidence-based practice refers to specific treatment approaches which have been tested in research and found to be effective.  Type the term into Google, and one of the FIRST hits you’ll get makes clear the statement is false.  It, and other links, defines the term as “a way of approaching decision making about clinical issues.”

Said another way, evidence-based practice is a mindset — a way of approaching our work that has nothing to do with adopting particular treatment protocols.

Still, belief persists.

What can a reasonable person do to avoid falling prey to such falsehoods?fire hydrant

It’s difficult, to be sure.  More, as busy as we are, and as much information as we are subjected to on a daily basis, the usual suggestions (e.g., read carefully, verify all facts independently, seek out counter evidence) will leave all but those with massive amounts of free time on their hands feeling overwhelmed.

And therein lies the clue — at least in part — for dealing with the “illusory truth effect.”  Bottom line: if  you try to assess each bit of information you encounter on a one-by-one basis, your chances of successfully sorting fact from fiction are low.  Indeed, it will be like trying to quench your thirst by drinking from a fire hydrant.

To increase your chances of success, you must step back from the flood, asking instead, “what must I unquestioningly believe (or take for granted) in order to accept a particular assertion as true?”  Then, once identified, ask yourself whether those assumptions are true?

Try it.  Go back to the statements at the beginning of this post with this larger question in mind.

lie detector(Hint: they all share a common philosophical and theoretical basis that, once identified, makes verification of the specific statements much easier)

If you guessed the “medical model” (or something close), you are on the right track.  All assume that helping relieve mental and emotional suffering is the same as fixing a broken arm or treating a bacterial infection — that is, to be successful a treatment containing the ingredients specifically remedial to the problem must be applied.

While mountains of research published over the last five decades document the effectiveness of the “talk therapies,” the same evidence conclusively shows “psychotherapy” does not work in the same way as medical treatments.  Unlike medicine, no specific technique in any particular therapeutic approach has ever proven essential for success.  None.  Any claim based on a similar assumptive base should, therefore, be considered suspect.

Voila!

I’ve been applying the same strategy in the work my team and I have done on using measures and feedback — first, to show that therapists needed to do more than ask for feedback if they wanted to improve their effectiveness; and second, to challenge traditional notions about why, when, and with whom, the process does and doesn’t work.   In these, and other instances, the result has been greater understanding and better outcomes.

So there you have it.  Until next time,

Scott

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

P.S: Registration for the Spring Feedback Informed Treatment intensives is now open.  In prior years, these two events have sold out several months in advance.  For more information or to register, click here or on the images below.

ICCE Advanced FIT Intensive 2020 Scott D Miller

ICCE Fit Supervision Intensive 2020 Scott D Miller

Filed Under: Brain-based Research, evidence-based practice, Feedback Informed Treatment - FIT, PTSD

The Skill that Heals, or Kills…

October 2, 2019 By scottdm 2 Comments

lovers-deathImagine 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?MetaAnalysispyramid

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?

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Filed Under: Feedback Informed Treatment - FIT

Very Bad Therapy (And how it can make you a more effective therapist)

September 18, 2019 By scottdm 4 Comments

wont sayPlug “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.

whateverContrast 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.

very bad therapyThankfully, 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.
ICCE Advanced FIT Intensive 2020 Scott D MillerICCE Fit Supervision Intensive 2020 Scott D Miller

Filed Under: Feedback Informed Treatment - FIT

The Baader-Meinhof Effect in Trauma and Psychotherapy

August 28, 2019 By scottdm 35 Comments

noticingHave you heard of the “Baader-Meinhof” effect?  If not, I’m positive you’ll soon be seeing evidence of it everywhere.

That’s what “it” is, by the way — that curious experience of seeing something you’ve just noticed, been told of, or thought about, cropping up all around you.  So …

You buy a car and suddenly it’s everywhere.  That outfit you thought was so unique?  Boom!  Everyone is sporting it.  How about the conversation you just had with your friend?  You know, the one that was so stimulating and interesting?  Now the subject is on everyone’s lips.

Depending on your level of self-esteem or degree of narcissism, Baader-Meinhof either leaves you feeling on the “cutting edge” of cultural trends or constantly lagging behind others.  For me, it’s generally the latter.  And recently, its a feeling that has been dogging me a fair bit.

The subject?  Trauma.

Whether simple or complex, ongoing or one-off, experienced as a child or adult, trauma is the topic de jour — a cause célèbre linked to anCertified Trauma Professional ever-growing list of problems, including depression, anxiety, dissociation, insomnia, headaches, stomachaches, asthma, stroke, diabetes, and most recently, ADHD.

Then, of course, there are the offers for training.  Is it just me or is trauma the subject of every other email solicitation, podcast announcement, and printed flyer?

The truth is our field has been here many times before.  Over the last 25 years, depression, multiple personality disorder, rapid cycling bipolar disorder II, attention deficit disorder, and borderline personality disorder have all burst on the scene, enjoyed a period of intense professional interest, and then receded into the background.

Available evidence makes clear this pattern — aha, whoa, and hmm what’s next? — is far from benign.  While identifying who is suffering and why is an important and noble endeavor, outcomes of mental healthcare have not improved over the last 40 years.  What’s more, no evidence exists that training in treatment modalities specific to any particular diagnosis — the popularly-termed, “evidence-based” practices — improves effectiveness.  Problematically, studies do show undergoing such training increases practitioner perception of enhanced competence (Neimeyer, Taylor, & Cox, 2012) .

which wayOn more than one occasion, I’ve witnessed advocates of particular treatment methods claim it’s unethical for a therapist to work with people who’ve experienced a trauma if they haven’t been trained in a specific “trauma-focused” approach.  It’s a curious statement — one which, given the evidence, can only be meant to bully and shame practitioners into going along with the crowd.  Data on the subject are clear and date back over a decade (1, 2, 3).  In case of any doubt, a brand new review of the research, published in the journal Psychotherapy, concludes, “There are no clinically meaningful differences between … treatment methods for trauma … [including those] designed intentionally to omit components [believed essential to] effective treatments (viz., exposure, cognitive restructuring, and focus on trauma)” (p. 393).

If you find the results reported in the preceding paragraph confusing or unbelievable, recalling the “Baader-Meinhof” effect can be help.  It reminds us that despite its current popularity in professional discourse, trauma and its treatment is nothing new.  Truth is, therapists have always been helping those who’ve suffered its effects.  More, while the field’s outcomes have not improved over time, studies of real world practitioners show they generally achieve results on par with those obtained in studies of so-called evidence-based treatments 1, 2, 3).

Of course, none of the foregoing means nothing can be done to improve our effectiveness.  As my Swedish grandmother Stena used to say, “The room for improvement is the biggest one in our house!”  20190817_101819

To get started, or fine tune your professional development efforts, listen in to an interview I did recently with Elizabeth Irias from Clearly Clinical (an approved provider of CEU’s for APA, NBCC, NAADAC, CCAPP, and CAMFT).  Available here: What Every Therapist Needs To Know: Lessons From The Research, Ep. 61.  

In it, I lay out several, concrete, evidence-based steps, practitioners can take to improve their therapeutic effectiveness.  It’s FREE, plus you can earn a FREE hour of CE credit.  Additionally, if follow them on Instagram and leave a comment on this post, you’ll be automatically entered into a contest for one year of free, unlimited continuing education — the winner to be announced on October 31st, 2019.

Until next time,

Scott

Scott D. Miller, Ph.D.
Director, International Center for Clinical Excellence
ICCE Fit Supervision Intensive 2020 Scott D MillerICCE Advanced FIT Intensive 2020 Scott D Miller

 

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Filed Under: evidence-based practice, Feedback Informed Treatment - FIT, Practice Based Evidence

Responsiveness is “Job One” in Becoming a More Effective Therapist

June 28, 2019 By scottdm 4 Comments

face in cloudsLook at the picture to the left.  What do you see?

In no time at all, most report a large face with deep set eyes and slight frown.  

Actually, once seen, it’s difficult, if not impossible to unsee.  Try it.  Look away momentarily then back again.

Once set in motion, the process tends to take on a life of its own, with many other items coming into focus. 

Do you see the ghostly hand?  Skeletonized spine and rib cage?  Other eyes and faces?  A clown hat?

From an evolutionary perspective, the tendency to find patterns — be it in clouds, polished marble surfaces, burn marks on toast, or tea leaves in a cup — is easy to understand.  For our earliest ancestors, seeing eyes in the underbrush, whether real or illusory, had obvious survival value.   Whether or not the perceptions or predictions were accurate mattered less than the consequences of being wrong.   

In short, we are hardwired to look for and find patterns.  And, as researchers Foster and Kokko (2008) point out, “natural selection … favour[s] strategies that make many incorrect causal associations in order to establish those that are essential for survival …” (p. 36).   

As proof of the tendency to draw incorrect causal associations,flying couch one need only look at the field’s most popular beliefs and practices, many of which, the evidence shows, have little or no relationship to outcome.  These include:

  • Training in or use of evidence-based treatment approaches;
  • Participation in clinical supervision;
  • Attending continuing education workshops;
  • Professional degree, licensure, or amount of clinical experience;

Alas, all of the above, and more, are mere “faces in the clouds” — compelling to be sure, but more accurately seen as indicators of our desire to improve than reliable pathways to better results.  They are not.

So, what, if anything, can we do to improve our effectiveness?

According to researchers Stiles and Horvath (2017), “Certain therapists are more effective than others … because [they are] appropriately responsive … providing each client with a different, individually tailored treatment” (p. 71).   

Sounds good, right?  The recommendation that one should “fit the therapy to the person” is as old as the profession.   The challenge, of course, is knowing when to respond as well as whether any of the myriad “in-the-moment” adjustments we make in a given therapy hour actually help. 

That is until now.

EngagementConsider a new study involving 100’s real world therapists and more than 10,000 of their clients (Brown and Cazauvielh, 2019).  Intriguingly, the researchers found, therapists who were more “engaged” in formally seeking and utilizing feedback from their clients regarding progress and quality of care — as measured by the frequency with which they logged in to a computerized outcome management system to check their results — were significantly more effective. 

How much, you ask? 

Look at the graph above.  With an effect size difference of .4 σ, the feedback-informed practitioners (green curve) were on average more effective than 70% of their less engaged, less responsive peers (the red).

Such findings confirm and extend results from another study I blogged about back in May documenting that feedback-informed treatment, or FIT, led to significant improvements in the quality and strength of the therapeutic alliance.fitbit

Why some choose to actively utilize feedback to inform and improve the quality and outcome of care, while others dutifully administer measurement scales but ignore the results is currently unknown — that is, scientifically.  Could it really be that mysterious, however?  Many of us have exercise equipment stuffed into closets bought in the moment but never used.  In time, I suspect research will eventually point to the same factors responsible for implementation failures in other areas of life, both personal and professional (e.g., habit, lack of support, contextual barriers, etc.).

Until then, one thing we know helps is community.  Having like-minded to interact with and share experiences makes a difference when it comes to staying on track.  The International Center for Clinical Excellence is a free, social network with thousands of members around the world.  Every day, practitioners, managers, and supervisors meet to address questions and provide support to one another in their efforts to implement feedback-informed treatment.  Click on the link to connect today.

Still wanting more?  Listen to my interview with Gay Barfield, Ph.D., a colleague of Carl Rogers, with whom she co-directed the Carl Rogers Institute for Peace –an organization that applied person-centered principles to real and potential international crisis situations, and for which Dr. Rogers was nominated for the Nobel Peace Prize in 1987.  I know her words and being will inspire you to seek and use client feedback on a more regular basis…

OK, done for now,

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

P.S.: Registration for the Spring 2020 Advanced and Supervision Intensives is open!  Both events sold out months in advance this year.  Click on the icons below for more information or to register.
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Filed Under: evidence-based practice, Feedback Informed Treatment - FIT, Practice Based Evidence

Learning Charisma

June 11, 2019 By scottdm Leave a Comment

accountingI entered university an accounting major.

My first year, I took all the recommended courses: accounting theory, fundamentals of financial and managerial accounting, and so on.

I’d likely be sitting in an office balancing company ledgers or completing tax documents had I never met Hal Miller.  A Harvard-educated professor, Dr. Miller taught multiple sections of the Psychology 111 course students could take as part of the required “general education” curriculum.

Decades have now passed since I first met him.  Still, I remember that first class as if it were yesterday.  When I arrived, every seat in the large, theater-style classroom was already taken, students overflowing into the hallway outside.  In time, I’d learn many were not officially registered for the class.  They were there because they wanted to hear him speak.Hal Miller

Within weeks, I’d changed my major to psychology.  I’m not sure how interested I was in the subject at the time.  Rather, I wanted to be like Hal Miller.  He loved what he was doing, was devoted to learning, and, most importantly, made me want to study.  He was, in a word, charismatic.

“Charisma,” researchers Antonakis, Fenley, and Liechti report, “is rooted in values and feelings.  It’s influence born of the alchemy that Aristotle called, the logos, the ethos, and the pathos.”  

LOGOS = WORDS, LOGIC, FACTS

ETHOS = ETHICS, CREDIBILITY, EXPERTISE

PATHOS =  EMOTIONS, CONNECTION, LIKE-MINDEDNESS

Hal Miller embodied all three qualities.  His ability to engage, communicate, and inform, literally changed my life.  I’m sure you can identify people who’ve had a similar impact on you.

charismaBut how did he do what he did?   Did he learn it?  Was it in his genes?

It turns out, the word, charisma, comes from the Greek χάρισμα, meaning “gift of grace” — a view widely held even today.  You either “got it or you ain’t.”

Curiously, while one study in psychotherapy found it to be both relationally and therapeutically helpful, most of the serious research on the subject comes from other fields where social influence is critical to success (e.g., leadership, training, management).  There, the evidence is clear: charisma is, “a learnable skill or, rather, a set of skills,” the potency of which can be dramatically improved with practice.

What exactly does that entail?

As a person whose spent his entire professional career providing continuing education workshops to therapists, I can tell you the absence of specific training means its mostly trial and error.  A few have the good fortune to work closely with a gifted practitioner or presenter.  I had the opportunity, or example, to work closely with Insoo Berg — a person who exuded warmth and charisma both in the therapy room and on the lecture circuit.  And yet, rarely are students of charismatic individuals are as successful or magnetic as their mentors.

So, what does it take?you

As hackneyed as it may sound at first, the key is “being yourself.”  While its tempting to copy the content, style, and mannerisms of the Hal Millers and Insoo Bergs in our lives, doing so, everyone quickly recognizes, is mere tribute.  Success means putting the principles of charisma — logos, ethos, pathos — into practice in a way that is congruent with who you are, your own style, persona and, critically, message.

Below, you’ll find a TedTalk by Professor John Antonakis, one of the leading researchers on charisma.  It’s worth a listen.  The first 5 minutes is interesting and provocative, but you must listen longer to learn about the evidence documenting that you can dramatically improve your ability to communicate with impact.

If you still are looking for something more practical and skill-based, and specific to psychotherapy, then join my colleagues and I for the upcoming “Training of Trainers” workshop, held the first week of August in downtown Chicago.  Together with an international faculty, and participants from around the world, we’ll work on helping you become the most effective version of you, either in your role as a therapist or trainer/presenter.   For more information or to register, click here.

Until next time,

Scott

Scott D. Miller, Ph.D.
Director, International Center for Clinical Excellence
FIT Training of Trainers Aug 2019 - ICCE

 

 

 

 

 

 

 

Filed Under: Conferences and Training, deliberate practice, Feedback Informed Treatment - FIT

Do you know Dr. Myron Fox?

June 4, 2019 By scottdm 5 Comments

Myron FoxTake 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, Engagingthe “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
FIT Training of Trainers Aug 2019 - ICCEiccexcellence.com

Filed Under: Feedback Informed Treatment - FIT

To Give or Not to Give Advice: Is that in Question?

May 30, 2019 By scottdm 8 Comments

My family and I had a frightening experience this past Memorial Day.  While driving through Indiana on the way home to Chicago, Screenshot_20190528-122146_Messagesour 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.

20190528_122122That’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.  mirrorNow, 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

Filed Under: Feedback Informed Treatment - FIT

Therapeutic Nudging: How Very Little Can Mean a Lot

May 13, 2019 By scottdm 2 Comments

nudgeIt 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?littlegoesalong

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

 

Filed Under: Feedback Informed Treatment - FIT

How Does Feedback Informed Treatment Work? I’m Not Surprised

May 6, 2019 By scottdm Leave a Comment

ShellGameFeedback-Informed Treatment (FIT) — using measures to solicit feedback about progress and the quality of the therapeutic relationship — is a transtheoretical, evidence-based approach.  The most recent research shows clients whose therapists use FIT on an ongoing basis are 2.5 times more like to experience benefit from treatment.

But how does it work?

Quick.  Take a guess.

Under the first shell: FIT works because clinicians use measures to monitor their performance.  The second: Feedback helps clinicians select the most effective treatment methods.  Third: FIT enhances the therapeutic relationship.

If you guessed the “proverbial pea” was under the third shell, you’re right.  Hard to believe given: (1) the emphasis placed on measurement and treatment methods by researchers and advocates of various scales; and (2) concerns expressed by some clinicians that using measures will negatively impact the relationship.

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.

Below, you will find a link to an interview I did with Heidi this week about the study. The Therapeutic Relationship It’s really worth watching, and it underscores the main point of her findings.  Bottom line: FIT is not about measures and methods.  True, the tools provide form and structure, but their purpose is to facilitate connection.  So, when therapists in the study used the ORS and SRS, their client’s first session alliance scores tended to be lower, indicating the process facilitated the development of a “culture of feedback” early on in care.  As the researchers note, “having been invited to reflect on any negative aspects of the alliance with a responsive therapist in the first session … clients had a more considered and realistic view of the early … [that] facilitated the communication about the treatment process from the first session onward” (p. 10).

That said, Brattland and her colleagues did not find clinicians were equally effective in their use of FIT.  Indeed, as detailed in the report, 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).  On this score, one advantage of using scales to routinely measure our work, is that doing so enables us to identify our personal “growth edge” — what, where, and how we might improve our ability to relate to and help the diverse clients we meet in our daily work.

Using the tools to facilitate professional growth and development is the focus of this summer’s “Deliberate Practice Intensive.”  Together with my colleague, Dr. Daryl Chow, we’ll translate the latest research showing that deliberate practice leads to steady improvements in effectiveness into step-by-step instructions for improving your clinical performance.  Click here for more information or to register!

Until next time,

Scott

Scott D. Miller, Ph.D.
Director, International Center for Clinical Excellence
FIT Implementation Intensive Aug 2019 - ICCEFIT Training of Trainers Aug 2019 - ICCE

 

 

 

 

 

 

Filed Under: Feedback Informed Treatment - FIT, PCOMS, Therapeutic Relationship

What does losing your keys have in common with the treatment of trauma?

April 24, 2019 By scottdm 9 Comments

keysLast week, I was preparing to leave the house and could not locate my keys.  Trust me when I say, it’s embarrassing to admit this is not an infrequent occurrence.

Logic and reason are always my first problem solving choices.  That’s why I paused after looking in the kitchen drawer where I am supposed to keep them, along with my wallet and glasses, and found it empty.  When did I last have them?  Not finding them there, the “search” began.

Upstairs to the bedroom to check my pants pockets.  No.  Downstairs to the front closet to look in my coat.  No.  Back upstairs to the hamper in the laundry room.  No.  Once more, down the stairs to the kitchen hutch.  I sometimes leave them there.  This time, however, no.  I then headed back up the stairs to the master bathroom — my pace now a bit frantic — and rummaged through my clothing.  No.  They’ve gotta be on my office desk.  Down two flights of stairs to the basement.  Not there either.

In a fit of pique, I stormed over to the landing, and yelled at the top of my voice, “DID SOMEONE TAKE MY KEYS?” the accusation barely concealed.  Although my head knew this was nuts, my heart was certain it was true. They’ve hidden them!

“No,” my family members kindly reply, then ask, “Have you lost them again?”

“Arrgh,” I mutter under my breath.  And that’s when I do something that, in hindsight, make no sense.  I wonder if you do the same?  Streetlight EffectNamely, I start the entire search over from the beginning — pants, coat, hamper, closet, hutch, office — often completing the exact same cycle several times.  Pants, coat, hamper, closet, hutch, office.   Pants, coat, hamper, closet, hutch, office.  Pants, coat, hamper, closet, hutch, office.

I can’t explain the compulsion, other than, by this point, I’ve generally lost my mind.  More, I can’t think of anything else do.  My problem: I have somewhere to go!  The solution: Keep looking (and it goes without saying, of course, in the same places).

(I did eventually locate my keys.  More on that in a moment)

Yesterday, I was reminded of my experience while reading a newly released study on the treatment of trauma.   Bear with me as I explain. Over a decade ago, I blogged about the U.S. Veteran’s Administration spending $25,000,000 aimed at “discover[ing] the best treatments for PTSD” despite a virtual mountain of evidence showing no difference in outcome between various therapy approaches.

Since that original post, the evidence documenting equivalence between competing methods has only increased (1, 2).  The data are absolutely clear.  Meta-analyses of studies in which two or more approaches intended to be therapeutic are directly compared, consistently find no difference in outcome between methods – importantly, whether the treatments are designated “trauma-focused” or not.   More, other highly specialized studies – known as dismantling research – fail to provide any evidence for the belief that specialized treatments contain ingredients specifically remedial to the diagnosis!  And yes, that includes the ingredient most believe essential to therapeutic success in the treatment of PTSD; namely, exposure (1, 2).

The new study confirms and extends such findings.  Briefly, using data drawn from 39 V.A. treatment centers, researchers examined the relationship between outcome and the degree of adoption of two so-called “evidence-based,” trauma-informed psychotherapy approaches — prolonged exposure and cognitive processing therapy.  If method mattered, of course, then a greater degree of adoption would be associated with better results.  It was not.  As the authors of the study conclude, “programs that used prolonged exposure and cognitive processing therapy with most or all patients did not see greater reductions in PTSD or depression symptoms or alcohol use, compared with programs that did not use these evidence-based psychotherapies.”

Winston Churchill Quote About History Repeating Itself History Doesn't Repeat Itself But It Rhymes | Quote"history Does - QUOTES BY PEOPLE

So what happens now?  If history, and my own behavior whenever I lose my keys, is any indication, we’ll start the process of looking all over again.  Instead of accepting the key is not where we’ve been looking, the field will continue it’s search.  After all, we have somewhere to go — and right back to the search for the next method, model, or treatment approach, we go.

It’s worse than that, actually, as looking over and again in the same place, keeps us from looking elsewhere.  That’s how I generally find my keys.  As simple and perhaps dumb as it sounds, I find them someplace I had not looked.

And where is the field not looking?  As Norcross and Wampold point out in an article published this week, “relationships and responsiveness” are the key ingredients in successful psychological care for people who are suffering as a result of traumatic experiences, going on to say that the emphasis on model or method is actually harmful, as it “squanders a vital opportunity to identify what actually heals.”

Improving our ability to connect with and respond effectively to the diverse people we meet in therapy is the focus on Deliberate Practice Intensive, held this August in Chicago, Illinois.  Unlike training in protocol-driven treatments, studies to date show learning the skills taught at the workshop result in steady improvements in clinicians’ facilitative interpersonal skills and outcomes commensurate with the rate of improvement seen in elite athletes.  For more information or to register, click here.

Until next time,

Scott

Scott D. Miller, Ph.D.
International Center for Clinical Excellence
FIT Deliberate Practice Aug 2019 - ICCEFIT Training of Trainers Aug 2019 - ICCEFIT Implementation Intensive Aug 2019 - ICCE

Filed Under: evidence-based practice, Feedback, Feedback Informed Treatment - FIT, Therapeutic Relationship

It’s Time to Abandon the “Mean” in Psychotherapy Practice and Research

April 8, 2019 By scottdm 7 Comments

car seatRecognize this?  Yours will likely look at bit different.  If you drive an expensive car, it may be motorized, with buttons automatically set to your preferences.  All, however, serve the same purpose.

Got it?

It’s the lever for adjusting your car seat.

I’m betting you’re not impressed.   Believe it or not though, this little device was once considered an amazing innovation — a piece of equipment so disruptive manufacturers balked at producing it, citing “engineering challenges” and fear of cost overruns.

For decades, seats in cars came in a fixed position.  You could not move them forward or back.  For that Plane-Crash-04022016-2matter, the same was the case with seats in the cockpits of airplanes.  The result?  Many dead drivers and pilots.

The military actually spent loads of time and money during the 1940’s and 50’s looking for the source of the problem.  Why, they wondered, were so many planes crashing?  Investigators were baffled.

Every detail was checked and rechecked.  Electronic and mechanical systems tested out.  Pilot training was reviewed and deemed exceptional.  Systematic review of accidents ruled out human error.   Finally, the equipment was examined.  Nothing, it was determined, could not have been more carefully designed — the size and shape of the seat, distance to the controls, even the shape of the helmet, were based on measurements of 140 dimensions of 4,000 pilots (e.g., thumb length, hand size, waist circumference, crotch height, distance from eye to ear, etc.).

It was not until a young lieutenant, Gilbert S. Daniels, intervened that the problem was solved.  Turns out, despite of the careful measurements, no pilot fit the average of the various dimensions used to design the cockpit and flight equipment.  Indeed, his study found, even when “the average” was defined as the middle 30 percent of the range of values on any given indice, no actual pilot fell within the range!

The conclusion was as obvious as it was radical.  Instead of fitting pilot into planes, planes needed to be designed to fit pilots.  Voila!   The adjustable seat was born.

round-head-square-holeNow, before you scoff — wisecracking, perhaps, about “military intelligence” being the worst kind of oxymoron — beware.  The very same “averagarianism” that gripped leaders and engineers in the armed services is still in full swing today in the field of mental health.

Perhaps the best example is the randomized controlled trial (RCT) — deemed the “gold standard” for identifying “best practices” by professional bodies, research scientists, and governmental regulatory bodies.  t-test

However sophisticated the statistical procedures may appear to the non-mathematically inclined, they are nothing more than mean comparisons.

Briefly, participants are recruited and then randomly assigned to one of two groups (e.g., Treatment A or a Control group; Treatment A or Treatment as Usual; and more rarely, Treatment A versus Treatment B).  A measure of some kind is administered to everyone in both groups at the beginning and the end of the study.   Should the mean response of one group prove statistically greater than the other, that particular treatment is deemed “empirically supported” and recommended for all.

The flaw in this logic is hopefully obvious: no individual fits the average.  More, as any researcher will tell you, the variability between individuals within groups is most often greater than variability between groups being compared.

in boxBottom line:  instead of fitting people into treatments, mental health care should be to made to fit the person.  Doing so is referred to, in the psychotherapy outcome literature, as responsiveness  — that is, “doing the right thing at the right time with the right person.”  And while the subject receives far less attention in professional discourse and practice than diagnostic-specific treatment packages, evidence indicates it accounts for why, “certain therapists are more effective than others…” (p. 71, Stiles & Horvath, 2017). 

I’m guessing you’ll agree it’s time for the field to make an “adjustment lever” a core standard of therapeutic practice — I’ll bet it’s what you try to do with the people you care for anyway.on box

Turns out, a method exists that can aid in our efforts to adjust services to the individual client.  It involves routinely and formally soliciting feedback from the people we treat.  That said, not all feedback is created equal.  With a few notable exceptions, all routine outcome monitoring systems (ROM) in use today suffer from the same problem that dogs the rest of the field.  In particular, all generate feedback by comparing the individual client to an index of change based on an average of a large sample (e.g., reliable change index, median response of an entire sample).

By contrast, three computerized outcome monitoring systems use cutting edge technology to provide feedback about progress and the quality of the therapeutic alliance unique to the individual client.  Together, they represent a small step in providing an evidence-based alternative to the “mean” approaches traditionally used in psychotherapy practice and research.

Interested in your thoughts,

Scott

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

PS: Want to learn more?  Join me and colleagues from around the world for any or all three, intensive workshops being offered this August in Chicago, IL (USA).

  1. The FIT Implementation Intensive: the only workshop in the US to provide an in depth training in the evidence-based steps for successful integration of Feedback Informed Treatment (FIT) into your agency or clinical practice.
  2. The Training of Trainers: a 3-day workshop aimed at enhancing your presentation and training skills.
  3. The Deliberate Practice Intensive: a 2-day training on using deliberate practice to improve your clinical effectiveness.

Click on the title of the workshop for more information or to register.

 

 

Filed Under: Behavioral Health, evidence-based practice, Feedback, Feedback Informed Treatment - FIT, FIT, FIT Software Tools

Routine Outcome Monitoring and Deliberate Practice: Fad or Phenomenon?

March 26, 2019 By scottdm 1 Comment

new-improved-newspaper-headline-better-product-update-upgrad-headlines-announcements-upgrade-60079897Would you believe me if I told you there was a way you could more than double the chances of helping your clients?  Probably not, eh?  As I’ve documented previously, claims abound regaring new methods for improving the outcome of psychotherapy.  It’s easy to grow cynical.

And yet, findings from a recent study document when clinicians add this particular practice to their clinical work, clients are actually 2.5 times more likely to improve.  The impact is so significant, a review of research emerging from a task force of the American Psychological Association concluded, “it is among the most effective ways available to services to improve outcomes.”feedback effects

That said, there’s a catch.

The simple nature of this “highly rated,” transtheoretical method belies a steep learning curve.  In truth, experience shows you can learn  to do it — the mechanics — in a few minutes.

But therein lies the problem.  The empirical evidence makes clear successful implementation often takes several years.  This latter fact explains, in part, why surveys of American, Canadian, and Australian practitioners reveal that, while being aware of the method, they rarely integrate it into their work.

What exactly is the “it” being referred to?

Known by the acronym FIT,  feedback-informed treatment (FIT) involves using standardized measures to formally and routinely solicit feedback from clients regarding progress and the quality of the therapeutic relationship, and then using the resulting information to inform and improve care.

The ORS and SRS are examples of two simple feedback scales used in more than a dozen randomized controlled trials as well as vetted and deemed “evidence-based” by the Substance Abuse and Mental Health Services Administration.  Together, the forms take less than 3 minutes to administer, score and interpret (less if one of the web-based scoring systems is used).

So why, you might wonder, would it take so long to put such tools into practice?

As paradoxical as it may sound, because FIT is really not about using measures — any more say than making a home is about erecting four walls and a roof.  While the structure is the most visible aspect — a symbol or representation — we all know it’s what’s inside that counts; namely, the people and their relationships.

On this score, it should come as no surprise that a newly released study has found a significant portion of the impact of FIT is brought about by the alliance or relationship between client and therapist.   It’s the first study in history to look at how the process actually works and I’m proud to have been involved.

Of course, all practitioners know relationships skills are not only central to effective psychotherapy, but require lifelong learning.   With time, and the right kind of support, using measurement tools facilitates both responsiveness to individual clients and continuous professional development.

Here’s the rub.  Whenever I respond to inquiries about the tools — in particular, suggesting it takes time for the effects to manifest, and that the biggest benefit lies beyond the measurement of alliance and outcome — interest in FIT almost always disappears.  “We already know how to do therapy,” a manager  replied just over a week ago, “We only want the measures, and we like yours because they are the simplest and fastest to administer.”fit training

Every so often, however, the reply is different.  “What do we have to do to make this work to improve the effectiveness of our clinical work and clinicians?” asked Thomas Haastrup, the Coordinator of Family Services for Odense Municipality in Denmark.  When I advised, planning and patience, with an emphasis on helping individual practitioners learn to use feedback to foster professional development versus simply measuring their results, he followed through.  “We adopted the long view,” Thomas recounts, “and it’s paid off.”  Now in their 5th year, outcomes are improving at both the program and provider level across services aimed at helping adults, children, and families.

In addition to the Manual 6 in the ICCE Treatment and Training manuals, the ICCE Summer Intensives offer several opportunities for helping you or your agency to succeed in implementing FIT.  First, the 2-day FIT Implementation Training — the only workshop offering in-depth, evidence-based training in the steps for integrating FIT into clinical practice at the individual, agency, and system-of-care level.  Second, the Deliberate Practice Intensive — here you not only learn the steps, but begin to set up a professional develop plan designed to enhance your effectiveness.

To help out, I’d like to offer a couple of discounts:

  1. Purchase Manual 6 at 70% off the regular price.  Click here to order.  Enter the word IMPLEMENTATION at checkout to receive the discount  (If you want to purchase the entire set, I’m making them available at 50% off the usual price.  Enter IMPLEMENTATION2 at checkout).
  2. Register for any or all of the summer intensives by May 1st and receive an additional discount off the early bird price.  Simple enter the code FITPROMOAPRIL at checkout.  Please note, registration MUST occur before May 1st.  Generally, we sell out 6 to 8 weeks in advance.

Feel free to email me with any questions.  In the meantime, as always, I’m interested in your thoughts about FIT and DP.

Until next time,

Scott

Scott D. Miller, Ph.D.
Director, International Center for Clinical Excellence
FIT Implementation Intensive Aug 2019 - ICCEFIT Training of Trainers Aug 2019 - ICCEFIT Deliberate Practice Aug 2019 - ICCE

Filed Under: evidence-based practice, excellence, Feedback, Feedback Informed Treatment - FIT, FIT

Good Intentions or The Proverbial “Road to Hell?”: Trying to Understand the APA guidelines for Men and Boys

March 8, 2019 By scottdm 9 Comments

Clinical Practice GuidelinesSeveral 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). question

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.

bad manAnd 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.  Concern-sign

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.

caringSticking 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.

Filed Under: Feedback Informed Treatment - FIT

Surfing and Psychotherapy (or, How Two of My “Love Affairs” in Life are Alike)

February 26, 2019 By scottdm 2 Comments

blogpost

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.

/rəˈspänsivnəs/
NOUN
The quality of reacting quickly and positively.

In surfing, you take advantage of the waves coming your way.  In psychotherapy, you utilize and react to what the client presents.  In both activities, trying to force matters spoils, if not altogether thwarts, the experience.

Recent research actually shows “certain therapists are more effective than others … because [they are] appropriately responsive … providing each client with a different, individually tailored treatment” (1).

How best to improve this key skill?

Having just returned from a week surfing in Hawaii, I can definitely say “patience and persistence” are key.  I spent a lot of time sitting on my board scanning the surrounding water for incoming waves.  If not that, I was paddling like mad to get in front of a swell I hoped would turn into a good ride.

Sometimes I was ahead of the curve, other times behind.  Even when my timing was right, some waves quickly “fell apart” leaving me slowly sinking into the surrounding water.  Often enough though, it all came together, and what a high.   Soon, and without thinking, I was laying astride my board paddling back out for more.

I’m sure you’ve had similar experiences in psychotherapy.  At times, you are too early; at others, too late.  With some, you are helpful; others, not so much.  For most of the history of the field, patience and endurance, combined with training, supervision, and trial and error, are the ways by which we’ve learned to respond to and tailor the work to the individual.  That is, until recently.engagement

Consider the bar graph displayed on the right.  It shows the results of a brand new study just released by my colleague Jeb Brown tracking the impact Feedback Informed Treatment (FIT)  — the process of using formal measures to track progress and the quality of the therapeutic relationship — has on the outcome of psychotherapy.  Importantly, the data used were drawn from a super-large, real world sample of working clinicians.

Here’s what Jeb found.  Therapists who were more “engaged” in seeking and processing performance feedback were significantly more effective than their peers (an average effect size difference of .2 σ).  In short, FIT improved clinical responsiveness, increasing the odds of practitioners “doing the right thing at the right time.”

If you’re not already using the two FIT scales, you can download and start them using them for free by clicking here.  Several cutting edge software programs are also available that will administer and score the tools, as well as provide you with evidence-based feedback delivered at the point of service delivery.  “Epic!” is likely what a Surfer would say if they to had access to similar tools for enhancing their responsiveness to local surf conditions.

Which reminds me …

StayingA few years back, Mark Hubble and I, together with our surfer bro, Seth Houdeshell, wrote a book about surfing.  Actually, its an inspirational, “how to” volume about living the good life based on the principles of surfing.   Jack Canfield, author of the Chicken Soup of the Soul books, described it “Like a warm sunny day at the beach,” promising  it “would brighten your spirits and put a smile on your face.”

It’s a fun read that won’t strain your brain.  Young or old, surfer or wannabe, I know you’d enjoy it.  Click here if you’re interested.  You can have it at my cost ($4.95 plus shipping) until my supply runs out.

Until next time,

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.

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Filed Under: Feedback Informed Treatment - FIT

Time for a New Paradigm? Psychotherapy Outcomes Stagnant for 40 years

February 1, 2019 By scottdm 9 Comments

airplane in treeYou’ve heard it said before.  Flying is the safest form of transportation.

Facts back up the claim.  In fact, it’s not even close.  In terms of distance traveled, the fatality rate per billion kilometers is .003, improving dramatically over the years.  Cars, by contrast, are almost 1,000 times more dangerous.  Still, since 1923, the fatality rate in motor vehicle accidents has declined an eye-popping 93%.

How about psychotherapy?  Have outcomes improved?  Judging by the size of the Diagnostic and Statistical Manual and growth in the number of treatment approaches, one would expect success rates to have climbed significantly, if not exponentially.  Not so, as I first presented at the Evolution of Psychotherapy Conference five years ago, and later on this blog, the empirical evidence clearly shows NO improvement.

And now a new study, this time reviewing the evidence regarding treatments for children and adolescents.  Using sophisticated statistical analyses, the researchers examined 453 RCT’s spanning 53 years, involving nearly 32,000 kids treated for anxiety, depression, attention deficit/hyperactivity, and conduct problems.  With the rising popularity of “evidence-based practice,” those conducting the study wanted to know whether “… our methods of developing and testing youth psychological therapies [are] producing improvement” (p. 2).

Can you guess what they found?Books in tree

Outcomes have not changed (much less improved) over the last five decades–that’s 351 in dog years!

Can you imagine the outcry had similar results been published about automobiles or planes?  You would fully expect hearings to be held, and leaders to be called called to account.  The lives of children are on the line.

Nope.  Instead, facing the supersized differences between promises made every year about “advances” in psychotherapy, and the results realized and reported in research studies, the authors meekly call for, “new approaches to treatment design and intervention science” (p. 1).

Really?  Is that what’s required?  Researchers going back to the drawing board of “treatment and intervention?”

No, what’s needed is an entirely different view of what clinicians actually do  — and it starts by giving up the idea that psychotherapy is a form of treatment similar to antibiotics or angioplasty.  Let’s face it.  Psychotherapy is no more a medical treatment than are the facials, salt glows and body wraps one receives at the local spa.  Which is not to say, it doesn’t work.

Eva-Strauss-Ivory-Tower

Outside the halls of academia, millions of therapists worldwide are helping people on a daily basis to live happier, more meaningful and functional lives.  Dozens of studies of real world practitioners document outcomes that meet or exceed benchmarks established in tightly controlled, model-driven, randomized trials — all without following a particular, “evidence-based” protocol (see 1, 2, 3,4).

So, how best to conceptualize the effective work clinicians do?  And, importantly, what could researchers offer that would be of real help to therapists?

That psychotherapy works, says more about humans and our need for connection, meaning, and purpose, than it does about the particulars of any given model or approach.  And that our methods focus on thoughts, feelings, behaviors, and brain chemistry, says more about our Western values and beliefs, than about the ingredients necessary for successful healing.

Simply put, the field does not need to, as the authors of the study argue, “intensify the search for mechanisms of change [and] transdiagnostic … treatments” (p. 1).  Doing so is merely a recipe for “more of the same.”  Rather, to move forward, it should abandon the medical paradigm that has long had a stranglehold on our research and professional discourse, choosing instead to reconnect with the larger, worldwide family of healers, one that has existed since the dawn of history and which, from the outset, has been deeply engaged in the values and beliefs of those they treat, using whatever means necessary, consistent with the culture, to engender change.

What might that look like in practice?

As already documented, practicing clinicians already do a pretty darn good job helping their clients.  There’s nothing wrong with our Westernized approaches when they work.  At the same time, we don’t succeed with everyone.  The problem, studies show, is we’re not particularly good at knowing when we’re not being helpful, when clients are at risk for dropping out or are actually deteriorating while in our care (1, 2).  On this score, research has already provided a solution.  Dozens of studies document, for example, using simple measures at the beginning and end of each visit not only provides clinicians with an opportunity to intervene more successfully with “at risk” clients, but also helps identify opportunities for their own growth and development (1, 2).  If you’re not routinely and formally measuring the quality and outcome of your work, you can get started by accessing two simple tools here.

With outcome as our guide, all that remains is being willing to look outside the profession for possibilities for healing and change unbound by convention and the medical view.  That’s happening already, by the way, in the world’s two most populous countries, India and China, with professionals learning the ways of indigenous healers and government officials tapping local shaman to meet citizen’s mental health and well being needs.

So, what about you?  What you are doing to extend your healing reach?

And, in case you haven’t seen it, the video below is from the most recent Evolution of Psychotherapy conference, where I talk about new research documenting psychics achieving the same or better results as psychotherapists.

Until next time,

Scott

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

P.S.: Want to learn more about using outcome to inform and improve your effectiveness?  Join me and an international group of teachers and researchers in Chicago for our Summer Intensives.  For detailed information and to register, click on the banners below.
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Filed Under: deliberate practice, excellence, Feedback, Feedback Informed Treatment - FIT

Beating the Dodo Verdict: Can Psychotherapy Ever Achieve Better Results?

December 18, 2018 By scottdm 3 Comments

rosenzweig and millerNearly 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).

Betty crockerThe 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
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Filed Under: Feedback Informed Treatment - FIT

“Clients Won’t Like It” and Other Concerns about Feedback Informed Treatment

December 7, 2018 By scottdm Leave a Comment

help givenIn 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).

fingers in earsNeither 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

Advanced FIT Intensive Mar 2019 - ICCEFIT Supervision Intensive Mar 2019 - ICCE

Filed Under: Feedback Informed Treatment - FIT

Aren’t You the Anti-Evidence-Based Practice Guy? My Socks. And Other Crazy Questions.

November 20, 2018 By scottdm 14 Comments

Scott the Anti EBT GuyIt’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.”condolence cards

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).

socksBefore 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.
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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.

Filed Under: Feedback Informed Treatment - FIT

What Works in Psychotherapy? Valuing “What Works” rather than Working with What We Value

November 2, 2018 By scottdm 18 Comments

The Therapeutic RelationshipMost 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!

reapFor 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:

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“What works” with eating disorders (and how long will it take the field to swallow these results)?

October 20, 2018 By scottdm 8 Comments

Eating DisordersWhat 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.”

The-use-and-abuse-of-evidenceAs 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.

ill-fitting-suitGiven 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
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What heals trauma?

October 3, 2018 By scottdm 33 Comments

nothing-is-written-in-stone-527756_1920“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).this or that

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.

hold waterSo, 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?

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

Filed Under: Feedback Informed Treatment - FIT

Feedback is NOT Enough: A Brief Update about the Empirical Evidence

September 25, 2018 By scottdm 1 Comment

my way highwayThe use of routine outcome monitoring (ROM) is on the rise.  In the United States and abroad, regulatory bodies are actually mandating the gathering of outcome data as the new “standard of care.”

As agencies rush to implement–often at great cost in terms of time and money–the question remains: just how much does ROM contribute to improved retention and effectiveness?

Over 20 years ago, I began using outcome and alliance scales in my work as a therapist, asking clients at each visit to give me feedback about the qaulity of our relationship and their experience of progress.  Eventually, together with colleagues, I developed two, brief measures: the Outcome and Session Rating Scales.

Concern-signWhen studies using the scales began to appear in the literature, I was immediately concerned.  In my opinion, the results were just “too good to be true.”  First, the results were confounded by allegiance effects, having been done exclusively by people with a significant investment in the results.  More to the point, however, I was worried that the studies focused on the measures rather than on therapists.

Soon, as I predicted, other studies appeared with far more modest results.   And now, a meta-analysis of all studies using the ORS and SRS has been published, confirming that routinely measuring performance, improves outcome but not as much as reported in the original studies (viz., .27 versus .50).

resultsFor those involved in and advocating FIT (Feedback-Informed Treatment), this is an IMPORTANT study.  It makes clear that when working feedback-informed, improving effectiveness requires more than the use of two measures.  Indeed, it’s not really about the measures at all.  Rather, it’s about therapists using feedback to identify opportunities for their own professional development.

As my colleague and fellow psychologist, Birgit Valla, is fond of saying, “A stopwatch will not make you a better runner.  It’s not about the clock.  It’s how you use the information to identify small, specific aspects of your performance that could be improved and then practicing.”

That’s what the team at ICCE and I have been exploring these past 7 years.  The latest article summarizing that research was published just this week.

All the best,

Scott

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

P.S.: Registration for the Spring Intensives is open.  Click on the links below to reserve your spot!
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Filed Under: Behavioral Health, deliberate practice, Feedback Informed Treatment - FIT

Science is Real (confusing)

September 17, 2018 By scottdm 9 Comments

Science confirms

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

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

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

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

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

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

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

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

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

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

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

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

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

What are we to believe?

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

  • The correlation researchers cited as demonstrating practice is “not as important as has been argued” (.35 [p. 1, Macnamara et al., 2014]) was greater than the association between mortality (e.g., death) and obesity (.13), excessive drinking (.21), and taking prescribed medications correctly (.23).
  • When the data set was reanalyzed including only those studies judged by independent, blind raters to be bona fide instances of research on the link between practice and performance, the correlation increased to.40.

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

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

science posts

What to do?

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

All the best,

Scott

Scott D. Miller, Ph.D.
Director, International Center for Clinical Excellence
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Filed Under: deliberate practice, Feedback Informed Treatment - FIT

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

August 29, 2018 By scottdm 12 Comments

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

David F. Ricks, Ph.D.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. practically perfect 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).

prairie_pioneers_10After 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.Core values against compass

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

July 12, 2018 By scottdm 7 Comments

wrong way

Does the name Barry Marshall ring a bell?

Probably not if you are a mental health professional.

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

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

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

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

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

How about these?

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

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

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

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

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

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

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

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

If this makes your head spin, get a cup of coffee and watch the video below in which Dr. Daryl Chow explains these intriguing results.

Until next time,

Scott

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

P.S. Marshall and Warren were awarded the Nobel Prize for their research in 2005.  Better late than never.

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I have some magic beans for sale…you want them?

May 24, 2018 By scottdm 7 Comments

Thru the woodsSo, 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.

hill_o_beans.0

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?”

what-have-you-got-to-lose-85818896

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.

networker adRarely 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).

goose

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.

FIT Deliberate Practice Intensive 2018

 

 

 

 

Filed Under: Feedback Informed Treatment - FIT

Implementation: The KEY to Improving the Effectiveness of Psychotherapy

May 7, 2018 By scottdm 7 Comments

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Filed Under: Feedback Informed Treatment - FIT

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