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

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

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

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

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

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

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

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

Until next time,

Scott

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

Does diagnosis matter?

What about the treatment approach?

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

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

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

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

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

Bottom line: it’s time to move on.

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

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

What happened next?  Watch the interview to find out!

That’s it for now.  Until next time,

Scott

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

It was just a little over a month ago.  I was doing a workshop somewhere in the States.  My topic?  Using formal client feedback to guide and improve the quality and outcome of psychotherapy– our SAMHSA-approved, NREPP listed evidence-based practice.

At the first break, I was approached by one of the attendees.  “I’m really enjoying your presentation,” they started, then paused.  I could hear a “but” coming.

“And this sounds like it will work with a lot of different kinds of clients…but what about the liars and deniers?”

It’s not the first time I’d been asked this question–the gist of which is, “Can one really trust the feedback given by some clients?”

“We talking about your ex here?”  I jokingly asked.

“No,” the person said with a laugh, “You know, like people who aren’t there voluntarily, clients who are mandated, or in the criminal justice system, substance abusers, sex offenders, or all of the above.”

“Funny you should ask,” I replied, “I just finished an interview with one of the leading experts on working with people who sexually abuse.  I hope to get a blog up in the next few weeks.”

And here it is…

David Prescott is a Fellow and past president of the Association for the Treatment of Sexual Abusers, the largest professional organization of its kind in the world.   He’s produced 14 books and numerous articles and chapters in the areas of assessing and treating sexual violence and trauma.   In the interview below, he talks about the use of FIT with people who sexually abuse–a subject we explore in even greater depth and detail in a chapter we penned together in the eight volume series, The Sex Offender.

Listen in and be sure and leave a comment.  It can be fairly challenging material, requiring a shift in mindset and approach–from delivering interventions to developing relationships, gaining compliance to securing engagement, and managing risk to engendering possibilities.

Anyway, I’m interested in your thoughts and experiences.

Meanwhile, registration has just opened for the March 2018 ICCE intensive trainings.  Join colleagues from around the world coming together to learn step-by-step, evidence-based strategies for improving engagement and outcome with people of all stripes, backgrounds, and clinical presentations.

Until next time,

Scott

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

Chances are your are carrying a smartphone–maybe you’re even reading this post on your Android or Iphone!  One thing I’m almost certain of is that the device you own–can’t live without–is not a Nokia.

The nearly complete absence of the brand is strange.  Not long ago, the company dominated the mobile phone market.  At one time, seventy percent of phones in consumers’ hands were made by Nokia.

“And then,” to quote Agathe Christie, “there were none!”

Today, Nokia’s global market share is an anemic 3 %.

What happened?  Here, the answer is no mystery.  It was not a lack of position, talent, innovative ideas, or know-how.  Rather, the company failed at implementation.  Instead of rapidly adapting to changing conditions, it banked on its brand name and past success to carry it through.  Vague considerations trumped concrete goals.  Spreadsheets and speeches replaced communication, consensus-building, and commitment.   The moral of the story?  No matter how successful the brand or popular the product, implementation is hard.

Nowhere is this truer than in healthcare.  Change is not only constant but accelerating. Each week, hundreds of research findings are published.  Just as frequently, new technologies come online. All have the potential to do good, to improve the quality and outcome of treatment.

Research to date, for example, documents that seeking ongoing, formal feedback from those receiving behavioral health services as much as triples the effectiveness of the care offered, while simultaneously cutting the rate of drop out by 50%, and decreasing the risk of deterioration by 33%.  Enough evidence has amassed to warrant the approach–known as, “Feedback Informed Treatment”– being listed on the National Registry of Evidence-Based Programs and Practices.

Any yet, despite the massive amount of time and resources, agencies and practitioners devote to staying “up-to-date,” most implementation efforts struggle, and far too many fail–according to the available evidence, about 70-95% (a figure equivalent to the number of start-up businesses in the United States that belly up annually).

In their chapter in the new book, Feedback Informed Treatment in Clinical Practice, Randy Moss and Vanessa Mousavizadeh, provide step-by-step instructions, based on the latest research and real-world experience, for creating an organizational culture that supports implementation success.  Recently, I had a chance to talk with Randy about the chpater.  Whether you’ve got the book or not, I think you’ll find the knowledge and experience in the video below, helpful:

Online version of the Fidelity Readiness Index and Fidelity Measure

In the meantime, while on the subject of implementation, here’s a cool, electronic version of a tool you can use to track the progress of your efforts.  It helps identify where you and your organization are in the process as well as identify and set goals in order to remain on track (it’s one of the reasons reviewers at SAMHSA gave our application perfect marks for implementation support).  Thanks to my Danish colleague, Rasmus Kern for developing and making it available.  By the way, the program contains both English and Danish versions (we’ll be releasing more languages soon).

Take the FRIFM Assessment

Until next time,

Scott

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

Take a look at the figure to the right.  
It’s data taken from the largest study conducted in the history of psychotherapy research examining the relationship between experience and effectiveness.

Each of the smaller lines represents the outcomes of an individual practitioner followed, in some cases, over a 17-year period.  The single, thicker, dashed-line plots the average across all, 170 practitioners in total–a group that measured the results of their work at every visit, with every client.

The data confirm what a host of correlational studies have hinted at since the mid-1980’s: in general, clinician effectiveness declines with time and experience.

It’s not a steep slope, to be sure.  It is slow and gradual, like a leak in a bicycle tire.  Most problematically, other research shows, it’s also imperceptible.  Indeed, as experience in the field grows, clinician-confidence increases, leading most to see themselves as more effective than their results actually indicate.

Now, consider the second figure.  Once again, outcomes of individual practitioners are plotted.

Here, however, the slope is positive.  In other words, therapists are becoming more and more effective over time.  As before, the change is slow and gradual.  Said another way, there are no shortcuts to improved outcomes.  Slow and steady wins the race.  More, unlike the prior results, therapists are both aware of their growth and, curiously, less confident about the effectiveness of their work.

Importantly, the data from the latter are not drawn from the application of some hypothetical, yet-to-be-hoped-for treatment model or training scenario.  Indeed, they are from the only published study to date documenting the factors that actually influence development of individual therapist effectiveness. When employed purposefully and mindfully, clinicians improve three times larger than they were documented to decline in the prior study.

What are these factors?

As simple as it sounds: (1) measure your results; and (2) focus on your mistakes.

There is no way around this basic fact: any effort aimed at improving effectiveness begins with a valid and reliable estimate of one’s current outcomes. Without that, there is no way of knowing when progress is being made or not.

On the subject of mistakes, several studies now confirm that “healthy self-criticism,” or professional self-doubt (PSD), is a strong predictor of both alliance and outcome in psychotherapy (Nissen-Lie et al., 2015).  Not surprisingly, therapist effectiveness improves in practice environments that provide: (1) ample opportunity and a safe place for discussing cases that are not making progress (or deteriorating); and (2) concrete suggestions for improvement that are tailored to the individual therapist.

Here are three, evidence-based resources you can tap in your efforts to improve your effectiveness in 2017:

• Begin measuring your results using two simple scales that have been tested in diverse settings and with a wide range of treatment populations.  In 2013, they were approved by the Substance Abuse and  Mental Health Services Administration (SAMHSA) and listed on the National Registry of Evidence-based Programs and Practices.  Get them for free by registering for a free license here.
• For a limited time, I’ll send you a free copy of the “How to” manual for using the two measures.  Just email me at: scottdmiller@talkingcure.com.  Online, the manual retails for $24.95.  It’s one of a series of 5, which SAMHSA gave perfect marks to as a support to implementation of routine outcome measurement in clinical practice.
• If you work alone or need a error-friendly practice community to discuss your work, join the International Center for Clinical Excellence.  It’s our free, online community.  There, you can link up with other like-minded clinicians, share your work, discuss your outcomes, watch “how-to” videos, help and be helped by practitioners around the world.

One final suggestion.  Since “simple” does not necessarily mean, “easy,” join me in Chicago for one of our upcoming intensive trainings.  Coming up in March is the “Advanced Intensive in Feedback Informed Treatment,” and the “Feedback Informed Supervision Intensive.”  You’ll meet colleagues from around the world, learn from an international faculty, and leave with all the knowledge and skills you need to use outcomes to improve the quality and outcome of your practice or agency.  The early bird rate is still available and we’ve only got a few spots left in each course.

Register by clicking on the text above or icons on the right side of the page.

Until then, best wishes for the New Year!

Scott

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

One year ago, colleagues and I released the largest, longitudinal study of therapist effectiveness ever published. The study examined outcomes of 6500 clients treated by 170 practitioners whose results had been tracked an average of 5 years—some as long as 17 years!

The result? Clinician outcomes, on average, not only did not improve, but actually slowly and inexorably worsened with time and experience—and this, despite the fact that practitioners involved in the study routinely measured and had access to ongoing feedback about their results. As I’ve blogged about previously, despite the many claims, measurement and feedback are not enough to improve therapist outcomes.

So, what does work?

For the last several years, I’ve been advocating deliberate practice (DP)—conscious and purposeful effort aimed at improving specific aspects of an individual’s performance. DP contains four essential ingredients:

In short, those wishing to improve must: (1) identify objectives just beyond their current ability and then (2), together with a coach, develop and execute a plan complete with steps and strategies for reaching those performance objectives; (3) throughout, attention must be paid to small errors and mistakes and immediate, corrective feedback provided; finally, (4) with time and repetition, slow but steady improvement results.

To date, research shows time spent in deliberate practice is associated with top performance across a variety of domains, including music, medicine, sports, mathematics, and chess.

With regard to psychotherapy, Chow, Miller et al. (2015) found the most effective clinicians spend more than twice as much time in activities specifically designed to improve their outcomes than their more average counterparts (see Figure 1). The impact of making small but consistent investments of time to deliberate practice is especially dramatic, compounding like interest in a savings account, when results are plotted over time (see Figure 2).

Most important, however, is that the benefit of engaging in deliberate practice extends far beyond mere “statistical significance.” Clients of top performing clinicians, for example, experience 50% more improvement and 50% less deterioration and drop out.

However, as Mark Hubble and I wrote in the “Road to Mastery,” back in 2011, “knowing the facts and putting them into practice are two altogether different matters.” It turns out there’s a reason why most do not devote much time to deliberate practice: it’s hard. Damn hard. Not only is it labor intensive, the rather glacial progress one makes along the way can be pretty discouraging. The key to long term success, it turns out, is community–a complex, interlocking network of people, places, resources, and circumstances working “behind the scenes” to nurture and support ongoing efforts to improve.

And now the data: just this week, a new study was published–involving more than 150 clinicians and 5500 clients–that documents what’s possible when agencies work purposefully to create a climate for therapist improvement–specifically, putting systems in place that support deliberate practice in the workplace.

The results? Instead of worsening over time, therapists improved in effectiveness year after year over a seven year period. No, the change in outcome wasn’t dramatic. Rather, consistent with findings in other performance domains, it was slow and stead,y ultimately leading to a large cumulative effect.

What’s it take to get started?

1. Join ICCE . It’s the largest, online community of practitioners, managers, researchers, and educators dedicated to improving the quality and outcome of psychological services. It’s free. No cost to join. No advertising. Simply go to: www.iccexcellence.com.
2. Take the first step to deliberate practice by establishing your baseline level of effectiveness. All you need to do to get started is download two, brief measurement tools.
3. Sign up for the Advanced and Supervision Intensive Trainings in March! Every spring, professionals from around the world come to Chicago to “dive deep” into feedback informed practice. Don’t wait, the number of seats is limited and the two courses typically sell out a few months in advance.

In the meantime, get inspired by watching the interview below. Iain Caldwell, the director of an award-winning mental health agency in the U.K, discusses how to develop and sustain a practice committed to superior outcomes and documented professional development. Along the way, we discuss recently published research on the results of a massive government investment in mental health services as well as reports that as many as half of practitioners working within the National Health Service are depressed. Provocative and interesting stuff.

Last week, my inbox started filling with emails from colleagues about a new study. Working with a real world sample, researchers compared dynamic therapy to cognitive therapy and found…

(drum roll please)

NO DIFFERENCE IN OUTCOME!

Long ago, psychologist Saul Rosenzweig dubbed the equivalence in outcome between competing brands of psychotherapy, “The Dodo Verdict.” 
(I’m the one on the right)

What’s surprising is all the attention the study has been getting.  After all, the “Dodo verdict” is one of the most robust findings in the treatment literature.  And yet, it remains a subject of controversy.  For obvious reasons, those who advocate that certain therapies are more effective than others dislike the Dodo intensely.  In fact, as I’ve reported several times on this blog, that group is forever claiming they’ve found the single study that proves it wrong.

Ultimately, however, the Dodo provides strong empirical support for something practitioners have long known: nothing works for everyone. To find the right path, therapists, and the people they serve, need choice.

Personally, I believe a much more important, yet under reported, finding of the study is the number of people who dropped out after a single visit with their therapist.  In this carefully controlled and executed study, 26% of people in both treatment conditions did not return for a second session.  Slightly more than half—50%–attended 5 sessions or less.  This after having endured a selection and recruitment process that retained only 5% of those initially screened for participation!

Beyond the impact on those seeking service (e.g., inadequate and ineffective care, longer waiting lists, etc.), unilateral client discontinuation and no shows, available evidence shows, “exact a significant financial burden in terms of staff salaries, overhead, and lost revenue, in addition to personnel losses resulting from low morale and high staff turnover.”

What can be done?

Three evidence-based ideas:

1. Setting aside time at the outset of treatment specifically aimed at making people feel welcome and comfortable has consistently been shown to improve attendance. Known variously as “role preparation/indunction,” it’s similar to how you would treat a guest in your home, either formally or informally explaining the therapeutic process, addressing any concerns/apprehensions/misconceptions, and creating an expectation of success.

2. Actively seek negative feedback about the therapeutic relationship.  Clients rarely report negative reactions until they’ve already decided to quit (Horvath, 2001).  Measuring and discussing the status of the working relationship has been shown to improve both retention and outcome.

3. Monitor progress. Not surprisingly, a felt lack of improvement is predictive of service discontinuation.   Clients whose therapists use measures to identify those not making progress or worsening stay longer and improve more than those who do not.

Learn more about how to create a culture of feedback and formally monitor the progress and the therapeutic relationship in this free article from the newly published book, Quality Improvement in Behavioral Health.

Join me for an in-depth training by registering for our upcoming Fall Webinar.   Over the course of four, 1-hour, online sessions, you will learn to use formal client feedback to track and improve client retention and clinical effectiveness.  Click here to register or for more detailed information.  And yes, CE’s are available!

Until next time,

Scott

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

What do the common cold and psychotherapy have in common?  Read on, the answers may surprise you…

• Lost productivity costs are roughly the same for the common cold and most common mental health problems;
• The common cold and most common mental health problems affect an amazingly large group of people each year. In the United States alone, citizens suffer 1 billion colds annually.  During the same time period, as much as 30% of the population have a “diagnosable mental or addictive disorder”;
• Both the common cold and psychotherapy are chronically under-researched and underfunded.

One other similarity.  Medicine has no cure for the common cold.   In a parallel fashion, the mental health profession has no cure—and has never offered a cure—for any of the 297+ diagnoses identified in the Diagnostic and Statistical Manual of Mental Disorders.

Everyone has their own pet remedy, of course.  For colds, your aunt recommends honey in tea with lemon; your uncle, liquids and vitamin C.   In mental health, new methods emerge every week.  One therapist advises confronting negative cognitions; another, emotions!   According to the organizers of the World Tapping Summit, 600,000 clinicians will be attending “10 full days of life-altering presentations” to learn how and where to tap people to better mental health.

Medicine’s failure to “cure” the common cold is understandable.  The causes are complex.  Over 200 different viruses can cause symptoms.  Even the most common—the rhinovirus—has 160 different strains!  It’s just not possible to predict which ones will show up in any given season or pack all them into a single injection.

Herein lies another similarity.  The cause of what are called “mental health problems” is equally, if not more complex.

For example, Medicine.net—the website that claims to “Bring Doctors’ Knowledge to You”—reports, “The exact cause of most mental illnesses is not known.”   It then goes on to state, however “many of these conditions are caused by a combination of genetic, biological, psychological, and environmental factors.”

Really?

A combination of genetic, biological, psychological, and environmental factors? 

What else is left?  Vermicious knids?  Morgoth, Master of Sauron, from The Lord of the Rings?  Or, the evil machinations of escapees from Area 51?  In other words, the cause of mental and emotional ailments is…complicated!

One final similarity.  Colds respond to the very same curative condition that forms the basis of effective psychotherapy: Empathy.

With a large sample, researcher David Rakel and colleagues found that the duration and severity of the common cold varied depending on patients’ experience of physician-provided empathy.

The formula?

More empathy = Shorter, less severe colds + changes in the immune system

Perhaps what’s important about our pet remedies is not so much the remedy, but the care that accompanies it?

The central role empathy plays in effective therapy will come as no surprise to most clinicians.  As the graph below illustrates, it tops the list of curative factors—especially when compared to other aspects of treatment that get a lot of attention, such as technique and adherence to protocol.

What is both surprising and distressing is how little growth occurs in therapist empathic abilities over the course of their careers.  Hard to believe, but true.  In a soon to be released study, however, Chow and colleagues show that significant improvement is possible.  By measuring a therapist’s empathic response to a challenging clinical scenario and then providing targeted feedback and an opportunity to practice, significant improvement occurred and even generalized to novel situations.

Improving empathy skills will be part of the focus on the International Center for Clinical Excellence Professional Development Intensive to be held in August in Chicago.  Co-led by Drs. Daryl Chow and Scott Miller, participants will learn the latest evidence-based skills for enhancing their professional development.  Reserve your spot now as registration is limited to 25 participants in order to insure maximum attention to each attendee!

Hope to see you this August in Chicago!

Scott

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

Across modalities, the therapeutic relationship has consistently been found to be a robust predictor of treatment outcome.  Most practicing clinicians understand this finding and work hard at establishing and maintaining a collaborative working alliance.

Here’s a less well known, but sobering statistic: clients report tensions or actual breakdowns in the therapeutic relationship in 19% to 42% of sessions.  These figures rise to 41% to 100% of sessions when trained observers are used to identify “ruptures” between clients and therapists.

Given the frequency of such occurrences, therapy really is about constantly re-pair-ing—a continuous process of getting back “in touch” with and connected to the person seated opposite us in the consulting room.  Findings from a number of studies (1, 2, 3, 4) emphasize the value of therapists openly acknowledging and exploring ruptures, all the while maintaining an open and non-defensive stance.  Failing to do so, the data make clear, leads to higher dropout rates and poorer outcomes.

Given the frequency of such occurrences, therapy really is about constantly re-pair-ing—a continuous process of
getting back “in touch” with and connected to the person seated opposite us in the consulting room.  Findings from a number of studies (1, 2, 3, 4) emphasize the value of therapists openly acknowledging and exploring ruptures, all the while maintaining an open and non-defensive stance.  Failing to do so, the data make clear, leads to higher dropout rates and poorer outcomes.

Of course, admitting a mistake presumes knowing one has been made.  It’s easier said than done.  Clinicians’
experience of the quality of the therapeutic relationship frequently differs from those they treat.  And while a significant body of evidence documents the benefits of systematically monitoring the status of the alliance via simple measures like the Session Rating Scale, little is known about what therapists actually do with such information to inform and improve outcome. That is, until psychologist Chris Laraway entered the picture.

Dr. Laraway’s thorough and engaging study not only provides a systematic review of the alliance and feedback
literature, but also the first empirical model for how feedback can be used to resolve ruptures in the therapeutic relationship.  What’s the secret?  The entire study is just a click away—or for those interested in the “Cliff note” version here.  Thanks to Chris for allowing me to make it available.

These, and other, new findings are being integrated into the curriculum for this summer’s Professional Development Intensive.   This two-day event focuses on raising your effectiveness to the next level by improving your ability to engage, retain, and help a more diverse clientele.  Given the intensive nature of the training, registration is limited.  All of our March intensives sold out months in advance.  Register now at: http://www.eventbrite.ie/e/fit-professional-development-intensive-2016-tickets-17740785166.

Until next time,

Scott

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