Symptom Reduction or Well-being: What Outcome should Matter Most in Psychotherapy

March 12, 2018 By scottdm 11 Comments

So, what contributes to a living a long, healthy life?

Clean Air? Being lean versus overweight? The absence of depression or anxiety? Exercising regularly? Getting a flu vaccine? Abstaining from smoking? Minimizing alcohol intake? Personal sense of meaning? Close interpersonal relationships? Social integration?

OK, I’ll come clean: all contribute–but not equally. Far from it. Some are more important than others.

So, what contributes most? Before reading on, try rank ordering the list from least to most influential.

Now watch the brief video (If you are one of those that don’t want to try, or can’t wait to know the answer, just scroll past video).

Answer: the items as written are presented in order from the least to most influential, the last three being far more important to living a long and healthy life. Distinct from the other items on the list, personal sense of meaning, close interpersonal relationships, and social integration form the core of “well-being.”

Given such findings, it is more than a bit curious that the field of mental health and majority of its supporting research are organized around reducing symptoms. Perhaps this is one reason why, as psychiatrist Robert Cloninger persuasively argues, the profession has, “failed to improve the average levels of happiness and well-being in the general population, despite vast expenditures on psychotropic drugs and psychotherapy manuals.” Indeed, by all measures, mental health is on the decline.

Could it be that our field has the formula for improving health and well-being backwards? Instead of focusing on reducing problems or eliminating symptoms maybe we should be working directly on improving people’s personal sense of meaning, close interpersonal relationships, and social integration.

The evidence is compelling. In addition to a longer, healthier life, improved well-being leads to:

Faster recovery from illness;
Positive health behaviours in adults and children;
Quicker return to and more preseentism on the job;
Greater wellbeing and mental health of others;
Can inform treatment decisions and reduce healthcare costs;
May ultimately reduce the healthcare burden.

Twenty years ago, my team and I developed a quick, simple-to-use measure of well-being. Numerous studies have shown the Outcome Rating Scale (ORS) to be valid and reliable as well as strongly predictive of psychological intervention. The tool is listed on SAMHSA’s National Registry of Evidence-based Programs and Practices , is available in 30 languages, and in wide use in countries around the world. Best of all: individual practitioners can download and begin using the tool for free.

Most exciting of all, use of the tool is serving as the impetus for many new innovations in mental health service delivery. I just spent a week with teams from Slagelse municipality in Denmark who are now using the data generated from routine use of the ORS to transform service delivery at every level. My Scandinavian co-teacher, psychologist Susanne Bargmann will be talking about these new and exciting developments at this summer’s FIT Implementation and Training of Trainers workshops. Is it any wonder that Denmark consistently LEADS the world in well-being?

Until next time,

Scott

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

Ho, Ho, Oh No! Science, politics, and the demise of the National Registry of Evidence-based Programs and Practices

February 7, 2018 By scottdm 13 Comments

While you were celebrating the Holidays–shopping and spending time with family–government officials were busy at work. On December 28th, the Substance Abuse and Mental Health Services (SAMHSA) sent a formal termination notice to the National Registry of Evidence-based Programs and Practices (NREPP).

Ho, ho, oh no…!

Briefly, NREPP is “an evidence-based repository and review system designed to provide the public with reliable information on mental health and substance use interventions.” In plain English, it’s a government website listing treatment approaches that have scientific support. SAMHSA is the Federal Agency overseeing behavior health policy.

Back in November, I’d responded to a request from NREPP to update research on the Outcome and Session Rating Scales, two routine outcome measures currently listed on the registry website site. All’s well until January 4th, when I received a short email stating that “no further review activities will occur” because the program was being ended “for the convenience of the government.”

Like much that comes from our Nation’s capitol, the reason given for the actions taken depends entirely on who you ask. Democrats are blaming Trump. Republicans, and the new SAMHSA director, blame the system, calling the registry not only flawed, but potentially dangerous. As is typical nowadays, everyone is outraged!

As someone whose work was vetted by NREPP, I can personally vouch for the thoroughness of the process and the integrity of the reviewers. No favors were sought and none were given. More, while no one knows exactly what will happen in the future, I sincerely believe officials leading the change have the best of intentions. What I am much less certain of is whether science will finally prevail in communicating “what works” in mental health and substance abuse to the public.

Bottom line: psychological approaches for alleviating human suffering are remarkably effective–on par or better than most medical treatments. That said, NONE work like a medicine.

You have a bacterial infection, antibiotics are the solution. A virus? Well, you are just going to have to tough it out. Take an aspirin and get some rest–and no, the brand you choose doesn’t really matter. Ask a friend or relative, and they likely have a favorite. The truth is, however, it doesn’t matter which one you take: Bayer, Econtin, Bufferin, Alka-Selzter, Anacin, a hundred other names, they’re all the same!

Four decades of research shows psychotherapy works much more like aspirin than an antibiotic. Despite claims, its effects are not targeted nor specific to particular diagnoses. Ask a friend, relative, your therapist or workshop presenter, and they all have their favorite: CBT, IPT, DBT, PD, TFT, CRT, EMDR, four-hundred additional names. And yet, meta-analytic studies of head-to-head comparisons find no meaningful difference in outcome between approaches.

What does all this mean for the future of NREPP and SAMHSA? The evidence makes clear that, when it comes to psychotherapy, any “list” of socially sanctioned approaches is not only unscientific, but seriously misleading. Would it be too much to hope that future governmental efforts stop offering a marketplace for manufacturers of different brands of aspirin and focus instead on fostering evidence-based practice (EBP)?

Really, it’s not a bridge too far. It merely means putting policies in place that help practitioners and agencies live up to the values inherent in the definition of EBP accepted by all professional organizations and regulatory bodies; namely, “the integration of the best available research with with clinical expertise in the context of patient characteristics, culture, and preferences” (pp. 273, APA, 2006).

Until next time,

Scott

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

P.S.: Every other year, the ICCE sponsors the “Training of Trainers” intensive. Over three days, we focus on helping you become a world class presenter and trainer. Join me, and colleagues from around the world for this transformational event.

Joint Commission and SAMHSA Set New Standard of Care for Measurement Based Care

January 29, 2018 By scottdm 1 Comment

The Joint Commission has recently revised their standards of care. To maintain accreditation, organizations are now required to assess outcomes with a standardized measurement tool.

The Substance Abuse and Mental Health Services Administration is moving in the same direction.

Two scales I developed met the new standard. Both are listed on the Joint Commission and SAMSHA websites. The Outcome and Session Rating Scales (ORS, SRS) are brief, well-validated tools in use in clinical settings around the world.

The new standard has the potential to significantly improve the effectiveness and efficiency of care. Studies also show, however, that implementation is a complex process with many challenges. Indeed, despite significant investment of time and resources, many organizations fail.

Click here for a free handout to assess the readiness of your agency. It’s one of the many resources provided at the ICCE Feedback-Informed Treatment Implementation workshop—the only evidence-based implementation training on measurement-based care to receive perfect marks for implementation materials, training and support resources, and quality assurance procedures by the National Registry of Evidence-based Programs and Practices (NREPP).

As always, feel free to email me with any questions.

All the best,

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

Better Results through Deliberate Practice

January 16, 2018 By scottdm 1 Comment

The legendary cellist Pablo Casals was once interviewed by comedian George Carlin. When asked why, at age 93, he continued to practice three hours a day, Casals replied, “I’m beginning to show some improvement!”

Hard not to feel inspired and humbled by such dedication, eh? And while humorous, Casals was not joking. Across a wide variety of domains (e.g., sports, computer programming, teaching), deliberate practice leads to better results. Indeed, our recent study of mental health practitioners documented a growth in effectiveness consistent with performance improvements obtained by elite atheletes.

The January issue of the APA monitor includes a detailed article on the subject. Staff writer Tori DeAngelis lays out the process of applying deliberate practice strategies to clinical work in clear, step-by-step terms. Best of all, it’s free–even continuing education credits are available if you need them.

As mentioned in the article, each summer the International Center for Clincal Excellence sponsors a two-day, intensive training on deliberate practice for therapists. Daryl Chow, Ph.D. and I will be teaching together, presenting the latest scientific and practical information from our forthcoming book, Better Results: Using Deliberate Practice to Improve Therapeutic Effectiveness (APA, 2019).

As in prior years, we promise you will be participating in an intimate, cutting-edge, and highly-personalized learning experience. Many practitioners return to year after year. “I’ve attended the Deliberate Practice Intensive for three years in a row,” says therapist Jim Reynolds, “because there is such a warm camraderie. We are all trying to do the best we can with our clients, but we go beyond that. To do that, I need contact with others who are striving to do better.”

Until next time,

Scott

Scott D. Miller, Ph.D.

We Need MORE Drugs, Right?

January 3, 2018 By scottdm 1 Comment

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

That’s it. I’m done. It’s time for me to say goodbye.

November 2, 2017 By scottdm 3 Comments

Ending psychotherapy.

Whether formal or informal, planned or unplanned, it’s going to happen every time treatment is initiated.

What do we know about the subject?

Nearly 50% of people who start, discontinue without warning. At the time they end, half have experienced no meaningful improvement in their functioning or well-being. On the other hand, of those who do continue, between 35-40% experience no measurable benefit despite continuous engagement in lengthy episodes of care.

Such findings remind me of the lyrics to the Beatles’ tune, “Hello Goodbye.”

“You say yes, I say no;

You say stop and I say go, go, go, oh no!

Hello, hello?

I don’t know why you say goodbye, I say hello.”

Here’s another key research finding: the most effective therapists have significantly more planned terminations.

In a recent study, Norcross, Zimmerman, Greenberg, and Swift identified eight core, pantheoretical processes associated with successful termination. You can read the article here. Better yet, download and begin using the “termination checklist”–a simple, yet helpful method for ensuring you are putting these evidence-based principles to work with your clients. Best of all, listen to my recent interview with John Norcross, Ph.D., the study’s first author, as we discuss how therapists can master this vitally important part of the therapeutic experience.

Until next time,

Scott

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

Something BIG is Happening: The Demand for Routine Outcome Measurement from Funders

October 16, 2017 By scottdm 2 Comments

Something is happening. Something big.

Downloads of the Outcome and Session Rating Scales have skyrocketed.

The number of emails I receive has been steadily increasing.

The subject? Routine outcome measurement. The questions:

Where can I get copies of your measures?

Paper and pencil versions are available on my website.

What is the cost?

Individual practitioners can access the tools for free. Group licenses are available for agencies and healthcare systems.

Can we incorporate the tools into our electronic healthcare record (E.H.R.)?

Three companies are licensed and authorized to provide an “Application Program Interface” (or API) for integrating the ORS, SRS, data aggregation formulas, and feedback signals directly into your E.H.R. Detailed information and contact forms are available in a special page on my website.

What evidence is available for the validity, reliability, and effectiveness of the measures?

Always a good question! Since the tools were published seventeen years ago, studies have multiplied. Keeping up with the data can be challenging as the tools are being used in different settings and with diverse clinical populations around the world.

Each year, together with my colleague, New Zealand psychologist, Eeuwe Schuckard, we add the latest research to a comprehensive document available for free online, titled “Measures and Feedback.”

Additionally, the tools have been vetted by an independent group of research scientists and are listed on the Substance Abuse and Mental Health Administration’s National Registry of Evidence-based Programs and Practices.

How can I (or my agency) get started?

Although it may sound simple and straightforward, this is the hardest question to answer. There is often a tone of urgency in the emails I receive, “We need to measure outcomes now,” they say.

I nearly always respond with the same advice: the fastest way to succeed is to go slow.

We’ve learned a great deal about implementation over the last 10 years. Getting practitioners to administer outcome measures is easy. I can teach them how in less than three minutes. Making the process more than just another, dreary “administrative task” takes time, patience, and persistence.

I caution against purchasing licenses, software, or onsite training. Instead, I recommend taking time to explore. It’s why the reviewers at SAMHSA gave our application for evidence-based status the highest ratings on “implementation support.”

To succeed, start with:

Accessing a set of the ICCE Feedback Informed Treatment Manuals–the single, most comprehensive resource available on using the ORS and SRS. Read and discuss them together with colleagues.
Connect with practitioners and agencies around the world who have already implemented. It’s easy. Join the International Center for Clinical Excellence–the world’s largest online community dedicated to routine outcome measurement.
Send a few key staff–managers, supervisors, implementation team leaders–to the Feedback-Informed Treatment Intensives. The Advanced and Supervision workshops are held back-to-back each March in Chicago. Participants not only leave with a thorough understanding of the ORS and SRS, but ready to kick off a successful implementation at home. I tell people to sign up early as the courses are limited to 35 participants and always sell out a couple of months in advance.

Feel free to email me with any questions.

Until next time,

Scott

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

Brave or Foolhardy? Dramatic Implications of a New Psychotherapy Outcome Study

September 4, 2017 By scottdm 15 Comments

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

“What about the Liars and Deniers?” Working Effectively with Mandated and Incarcerated Clients and People who Sexually Abuse

August 24, 2017 By scottdm 7 Comments

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

From Evidence-based Practice to Cultural Change: Steps to Successful Implementation

July 11, 2017 By scottdm Leave a Comment

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. PCOMS - Partners for change outcome management system Scott D Miller - SAMHSA - NREPP

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

More Deliberate Practice Resources…

May 30, 2017 By scottdm 1 Comment

Last week, I blogged about a free, online resource aimed at helping therapists improve their outcomes via deliberate practice. As the web-based system was doubling as a randomized controlled trial (RCT), participants would not only be accessing a cutting-edge, evidence-based protocol but also contributing to the field’s growing knowledge in this area.

To say interest was high, doesn’t even come close. Within 45 minutes of the first social media blast, every available spot was filled–including those on the waiting list! Lead researchers Daryl Chow and Sharon Lu managed to open a few additional spots, and yet demand still far exceeded supply.

I soon started getting emails. Their content was strikingly similar–like the one I received from Kathy Hardie-Williams, an MFT from Forest Grove, Oregon, “I’m interested in deliberate practice! Are there other materials, measures, tools that I can access and start using in my practice?”

The answer is, “YES!” Here they are:

Resource #1. Written for practicing therapists, supervisors, and supervisees, this volume brings together leading researchers and supervisors to teach practical methods for using deliberate practice to improve the effectiveness of psychotherapy.

Written for practicing therapists, supervisors, and supervisees, this volume brings together leading researchers and supervisors to teach practical methods for using deliberate practice to improve the effectiveness of psychotherapy.

Twelve chapters split into four sections covering: (1) the science of expertise and professional development; (2) practical, evidence-based methods for tracking individual performance; (3) step-by-step applications for integrating deliberate practice into clinical practice and supervision; and (4) recommendations for making psychotherapist expertise development routine and expected.

“This book offers a challenge and a roadmap for addressing a fundamental issue in mental health: How can therapists improve and become experts? Our goal,” the editors of this new volume state, ” is to bring the science of expertise to the field of mental health. We do this by proposing a model for using the ‘Cycle of Excellence’ throughout therapists’ careers, from supervised training to independent practice.”

The book is due out June 1st. Order today by clicking here: The Cycle of Excellence: Using Deliberate Practice to Improve Supervision and Training

Resource #2: The MyOutcomes E-Learning Platform

The folks at MyOutcomes have just added a new module on deliberate practice to their already extensive e-learning platform. The information is cutting edge, and the production values simply fantastic. More, MyOutcomes is offering free access to the system for the first 25 people who email to support@myoutcomes.com. Put the words, “Responding to Scott’s Blogpost” in the subject line. Meanwhile, here’s a taste of the course:

Resource #3:

Last but not least, the FIT Professional Development Intensive. There simply is no better way to learn about deliberate practice than to attend the upcoming intensive in Chicago. It’s the only such training available. Together with my colleague, Tony Rousmaniere–author of the new book, Deliberate Practice for Psychotherapists: A Guide to Improving Clinical Effectiveness, we will help you develop an individualized plan for improving your effectiveness based on the latest scientific evidence on expert performance.

We’ve got a few spaces left. Those already registered are coming from spots all around globe, so you’ll be in good company. Click here to register today!

OK, that’s it for now. Wishing you all the best for the Summer,

Scott D. Miller, Ph.D.

Can you tell me what I’m supposed to do? A free deliberate practice resource

May 17, 2017 By scottdm 5 Comments

You’ve read the studies. Maybe you’ve even attended a training.

Deliberate practice is the key to improving your effectiveness as a psychotherapist. Top performing therapists devote twice as much time to the process. More, when employed purposefully and mindfully, the outcomes of average practitioners steadily rise over time.

But what exactly is a therapist supposed to practice in order to improve? It’s a question that comes up within minutes of introducing the subject at my workshops–one my colleagues, Daryl Chow, Sharon Lu, Geoffrey Tan, and I have been working on answering.

Just over three years ago, we published preliminary results of a study documenting the impact of individualized feedback and rehearsal on mastering difficult conversations in psychotherapy. Therapists not only improved their ability to respond empathically under especially challenging circumstances, but were able to generalize what they learned to new and different situations.

Now, the entire deliberate practice program has gone online. In light of the research, it’s been both expanded and refined. There’s no need to leave the comfort of your home or office and, best of all, it’s free.

Sign up to participate and you will learn what to practice as well as receive feedback specifically tailored to your professional development. You will also be helping the field as the program is part of a research study on deliberate practice.

****UPDATE! UPDATE! UPDATE! UPDATE!****

Response to the above post has been overwhelming! Despite the size of the study, all of the available spots filled within 45 minutes. I’ve been corresponding with the chief researcher, Daryl Chow, Ph.D.. He tells me 15 more spots have just been added. If you want to participate, click here. The password is: DCT. If all of the spots are taken, please add your name to the wait list.

One more opportunity: join me in Chicago for the upcoming two-day intensive on deliberate practice. For more information or to register, click on the icon below my name. As with the online program, we are nearly full, so register today.

Until next time,

Scott

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

The Illness and the Cure: Two Free, Evidence-based Resources for What Ails and Can Heal Serious Psychological Distress

April 18, 2017 By scottdm 14 Comments

Findings from several recent studies are sobering. Depression is now the leading cause of ill-health and disability worldwide–more than cancer, heart disease, respiratory problems, and accidents. Yesterday, researchers reported that serious psychological distress is at an all-time high, significantly affecting not only quality but actual life expectancy. And who has not heard about the opioid crisis–33,000 deaths in the U.S. in 2015 and rising?

The research is clear: psychotherapy helps. Indeed, its effectiveness is on par with coronary artery bypass surgery. Despite such results, availability of mental health services in the U.S. and other Westernized nations has seriously eroded over the last decade. Additionally, modern clinical practice is beset by regulation and paperwork, much of which gets in the way of treatment’s most important healing ingredient: the relationship.

What can practitioners do? Students Taking Notes at Desks by VCU_Brandcenter

Completing paperwork together with clients during the visit–a process termed, “collaborative (or concurrent) documentation”–has been shown to save full-time practitioners between 6 and 8 hours per week, thereby improving capacity up to 20%.

It’s a great idea: completing assessments, treatment plans, and progress notes together with clients during rather than after the session. Unfortunately, it’s chief selling point to date seems to be that it saves time on documentation–as though filling out paperwork is an end in and of itself! Clearly, the real challenges facing mental health services are getting people into and keeping them in care. Here, the research literature is clear, people are more likely to stay engaged in care that is: (1) organized around their goals; and (2) works. Collaborating on and coming to a consensus regarding the goals for treatment, for example, has the largest impact on outcome among all of the relationship factors in psychotherapy, including empathy! Additionally, when documentation FITs the clients’ view of the process and is deemed transparent and respectful, trust–another essential ingredient of the therapeutic relationship–improves.

For the last several years, practitioners and agencies around the world have been using the ICCE “Service Delivery Agreement” and “Progress Note” as part of their documentation of clinical services. Both were specifically designed to be completed collaboratively with clients at the time the service is provided and both are focused on documenting what matters to people in treatment. Most important of all, however, both are part of an evidence-based process documented to improve engagement and effectiveness listed on SAMHSA’s National Registry of Evidence-based Programs and Practices.

For the next short while, I’ll send you the forms for free, along with a detailed instruction booklet for incorporating them into your clinical work. Reduce the “paper curtain” in your practice. Just email me at scottdmiller@talkingcure.com. Better yet, register for our upcoming intensive trainings this summer in Chicago. Click on any of the course icons to the right for detailed information.

Until next time,

Scott

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

The Missing Link: Why 80% of People who could benefit will never see a Therapist

March 17, 2017 By scottdm 22 Comments

The facts are startling. Despite being on the scene for close to 150 years, the field of mental health–and psychotherapy in particular–does not, and never has had mass appeal. Epidemiological studies consistently show, for example, the majority of people who could benefit from seeing a therapist, do not go. And nowadays, fewer and fewer are turning to psychotherapy—33% less than did 20 years ago—and a staggering 56% either don’t follow through after making contact or drop out after a single visit with a therapist (Guadiano & Miller, 2012; Marshall, Quinn, & Child, 2016; Swift & Greenberg, 2014).

For those on the front line, conventional wisdom holds, the real problems lie outside the profession. Insurance companies, in the best of circumstances, make access to and payment for psychotherapy an ordeal. Another common refrain is nowadays people are looking for a quick fix. Big Pharma has obliged, using their deep pockets to market “progress in a pill.” No work required beyond opening wide and swallowing. And finally, beyond instant gratification or corporate greed, many point to social disapproval or stigma as a continuing barrier to people getting the help they need.

For all that, were psychotherapy held in high regard, widely respected as the way to a better life, people would overcome their hesitancy, put up with any inconvenience, and choose it over any alternative. They don’t.

WHY? Mountains of research published over the last four decades document the effectiveness of the “talk therapies.” With truly stunning results, and a minimal side effect profile compared to drugs, why do most never make it into a therapist’s office?

For the last two years, my longtime colleague, Mark Hubble and I, have explored this question. We reviewed the research, consulted experts, and interviewed scores of potential consumers.

Our conclusion? The secular constructions, reductionistic explanations, and pedestrian techniques that so characterize modern clinical practice fall flat, failing to offer people the kinds of experiences, depth of meaning, and sense of connection they want in their lives.

In sum, most cho tarot ose not to go to psychotherapy because they are busy doing something else–consulting psychics, mediums, and other spiritual advisers–forms of healing that are a better fit with their beliefs, that “sing to their souls.”

Actually, reports show more people attend and pay out of pocket for such services than see mental health practitioners!

More, as I noted in my plenary address at the last Evolution of Psychotherapy conference, our own, large-Consumer Reports style survey, found people actually rated psychics and other “spiritual advisers” more helpful than therapists, physicians and friends. While certain to cause controversy, I strongly suggested the field could learn from and gain by joining the larger community of healers outside of our field.

Below — thanks to the Erickson Foundation — you can see that speech, as well as learn exactly what people felt these alternative healers provided that made a difference. An even deeper dive is available in our article, “How Psychotherapy Lost its Magic.” Thanks to the gracious folks at the Psychotherapy Networker for making it available for all to read, regardless of whether they subscribe to the magazine or not.

Until next time,

Scott

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

Would you rather . . . be approved or improved?

February 5, 2017 By scottdm 6 Comments

Some time ago, my son had a minor obsession. Whether at the dinner table, in the car, or out for a walk, he was constantly peppering us with, “would you rather” questions? You know the ones I mean, where you are forced to choose between two equally bizarre or unpleasant alternatives?

“Would you rather always have to say everything that is on your mind or never be able to speak again?”

“Would you rather have the hiccoughs the rest of your life or always feel like you have to sneeze but not be able to?”

And finally:

“Would you rather smell like poop and not know it or know you smell like poop but others can’t smell it?”

Fast forward to today. fast-forward-button_318-37183

I was re-reading some recent research on the use of deliberate practice (DP) for improving individual clinician effectiveness. As I’ve blogged about previously , one of the four crucial components of DP is feedback. Not just any kind of mind you, but negative feedback–in particular, immediate, ongoing information regarding one’s errors and mistakes.

Put bluntly, receiving negative feedback is hard on the ego. Despite what we may say or believe, a mountain of literature documents we all possess a strong need for social approval as well as a bias toward attributing positive traits to ourselves.

The same research shows that, beyond selective recall and well-known biases thinking-woman associated with self-assessment, we actively work to limit information that conflicts with how we prefer to see ourselves (e.g., capable versus incompetent, perceptive versus obtuse, intuitive versus plodding, effective versus ineffective, etc.).

As a brief example of just how insidious ours efforts can be, consider an email sent out by the customer service department at a Honda dealership in Richmond, Virginia.

“As you may know,” it began, “we have a wide range of services performed here at our location and strive to do the best we can to accomodate each and everyone of our customers.” A request for feedback followed, “There may be times we can not meet the needs and we would appreciate any feedback . . . for our company.”

So far so good. The company was on the way to showing its customers that it cared. It had sent a follow-up email. It thanked its customers. Most importantly, it invited them to provide the type of feedback necessary for improving service in the future.

The correspondence then ended, telling the recipient they would soon receive a survey which, “If you enjoyed or were satisfied with your recent visit and provide a 100% score you will receive a FREE oil change.”

Amazing, eh? Thanks to my long-time colleague and friend, Arnold Woodruff, for noticing the irony in the email and passing it on to me.

For whatever reason, on reading it, one of those “would you rather” questions immediately came to my mind:

“Would you rather be approved or improved?”

No waffling now. There is no in-between. I can hear my son saying, “you have to choose!”

Why not join me and colleagues from around the world who are “choosing to improve” for our two-day intensive on deliberate practice. Together with Dr. Tony Rousmaniere–the author of the new book Deliberate Practice for Psychotherapists—you’ll learn the latest, evidence-based strategies for improving your effectiveness. Register today, by clicking here, or on the image below.

Until next time,

Scott D. Miller, Ph.D.
International Center for Clinical Effectiveness

“I can’t let others know…”: Shame as a Barrier to Professional Development

January 21, 2017 By scottdm 12 Comments

Shame (noun \ˈshām\): Consciousness of shortcoming, guilt, or impropriety.

Turns out, for many therapists, this powerful and painful emotion is a significant barrier to professional development.

Doing psychotherapy is challenging in the best of circumstances. As many as 25% of clients drop out before experiencing a measureable improvement in their functioning. Of those who do continue, between 40 to 50% will end no different than when they started. And finally, 8 to 10% deteriorate while in care.

Faced with the realities of clinical practice, it’s easy for practitioners to feel they are forever falling short of their own and others hopes and expectations. Some respond with self-serving resignation: “It’s just not possible to help some people.” Others, research indicates, deceive themselves, either seeing progress where there is none or overestimating their effectiveness. Most, it is clear, struggle with the deep sense of responsibility they have assumed for relieving mental and emotional suffering.

As just one example, consider psychologist Tony Rousmaniere. Early on in his career, Tony started using a couple of simple tools to track the quality and outcome of his work. The data he gathered shook him to the core, “I was helping far fewer people than I’d thought–50% fewer!” And while his results were no different than the outcome of most, he recalls instantly thinking, “I can’t let anyone know this!”

“If you want to improve,” Tony says, “You have to embrace the facts. It’s not about humiliation, but rather humility. Simply put, we are not as effective as we think we are. Even the most effective among us, fail about a third of the time. But, in those failures lies the key to success.”

In his new book, Deliberate Practice for Therapists, Tony describes, in deeply personal and moving terms, his efforts to become a more effective therapist. He draws on the latest research on expertise and expert performance, providing a blueprint all clinicians can use to improve and fine-tune their performance via deliberate practice.

Earlier this month, I interviewed Tony about his journey and the new book. His honesty, transparency, and sage advice are inspiring. You’ll find the video below.

In the meantime, get hands on experience with deliberate practice this summer by signing up for the FIT Professional Development Intensive. For more information or to register, simply click the icon under my name. Hope to see you there!

Until then, best wishes,

Scott

Director, The International Center for Clinical Excellence

Three, Free Evidence-Based Resources for Improving Individual Therapist Effectiveness

January 1, 2017 By scottdm 27 Comments

Take a look at the figure to the right. therapist-decline
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.

slope 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. therapist-improve

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. incline

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.

Until then, best wishes for the New Year!

Scott

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

The Asch Effect: The Impact of Conformity, Rebelliousness, and Ignorance in Research on Psychology and Psychotherapy

December 3, 2016 By scottdm 5 Comments

asch-1
Consider the photo above. If you ever took Psych 101, it should be familiar. The year is 1951. The balding man on the right is psychologist, Solomon Asch. Gathered around the table are a bunch of undergraduates at Swarthmore College participating in a vision test.

Briefly, the procedure began with a cardboard printout displaying three lines of varying length. A second containing a single line was then produced and participants asked to state out loud which it best matched. Try it for yourself:

Well, if you guessed “C,” you would have been the only one to do so, as all the other participants taking the test on that day chose “B.” As you may recall, Asch was not really assessing vision. He was investigating conformity. All the participants save one were in on the experiment, instructed to choose an obviously incorrect answer in twelve out of eighteen total trials.

The results? not-me

On average, a third of the people in the experiment went along with the majority, with seventy-five percent conforming in at least one trial.

Today, practitioners face similar pressures—to go along with the assertion that some treatment approaches are more effective than others.

Regulatory bodies, including the Substance Abuse and Mental Health Services Administration in the United States, and the National Institute for Health and Care Excellence, are actually restricting services and limiting funding to approaches deemed “evidence based.” The impact on publicly funded mental health and substance abuse treatment is massive.

So, in the spirit of Solomon Asch, consider the lines below and indicate which treatment is most effective?

If your eyes tell you that the outcomes between competing therapeutic approaches appear similar, you are right. Indeed, one of the most robust findings in the research literature over the last 40 years is the lack of difference in outcome between psychotherapeutic approaches.

The key to changing matters is speaking up! In the original Asch experiments, for example, the addition of even one dissenting vote reduced conformity by 80%! And no, you don’t have to be a researcher to have an impact. On this score, when in a later study, a single dissenting voter wearing thick glasses—strongly suggestive of poor visual acuity—was added to the group, the likelihood of going along with the crowd was cut in half.

That said, knowing and understanding science does help. In the 1980’s, two researchers found that engineering, mathematics, and chemistry students conformed with the errant majority in only 1 out of 396 trials!

What does the research actually say about the effectiveness of competing treatment approaches?

You can find a review in the most current review of the research in the latest issue of Psychotherapy Research–the premier outlet for studies about psychotherapy. It’s just out and I’m pleased and honored to have been part of a dedicated and esteemed group scientists that are speaking up. In it, we review and redo several recent meta-analyses purporting to show that one particular method is more effective than all others. Can you guess which one?

The stakes are high, the consequences, serious. Existing guidelines and lists of approved therapies do not correctly represent existing research about “what works” in treatment. More, as I’ve blogged about before, they limit choice and effectiveness without improving outcome–and in certain cases, result in poorer results. As official definitions make clear, “evidence-based practice” is NOT about applying particular approaches to specific diagnoses, but rather “integrating the best available research with clinical expertise in the context of patient characteristics, culture, and preferences” (p. 273, APA, 2006).

Read it and speak up!

Until next time,

Scott

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

How Deliberate Practice can Improve Your Therapeutic Effectiveness

October 14, 2016 By scottdm Leave a Comment

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?

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.
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.
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.

“Mind the Gap”: A Strategy for Insuring you get the Feedback you need to Improve your Game (whatever that is)

September 23, 2016 By scottdm 3 Comments

Join me in a brief “thought experiment.” Suppose you were a gifted painter or photographer and had the chance to provide an image of yourself that would endure–and perhaps be the only one people would know you by–for hundreds of years after your death. How would you proceed? What criteria would guide your work, be used to deem it a success?

Seriously, take a moment to picture yourself in your mind’s eye…

Now, consider the painting below.

It’s a self-portrait painted by Rembrandt van Rijn.

Why, you might wonder, would a painter widely considered one, if not, “the greatest . . .in European art” leave the world such an unflattering portrait? His face is puffy and pale, his hair thin and receding, and his cloak and cap plain and undistinguished. And lest one assume this particular image is an exception to otherwise beautiful renditions of himself, think again. The self-portraits he painted throughout his life share the same, homely quality.

Clearly, the skills Rembrandt possessed ensure he could have made himself look any way he wanted and the world would have been none the wiser. Why such brutal honesty? More to the point, given the choice, would you paint yourself as you truly are or as others generally see you?

The answer, according to some to very interesting and recent research, is, “No.” The gap between how we view ourselves on the one hand and, on the other, look, think, and act in life is often quite wide. And, it turns out, we fill that space with people who agree with us, who see us as we want to see ourselves.

Actually, according to Paul Green of the University of North Carolina at Chapel Hill, people actively, “move away from those who provide feedback that is more negative than their view of themselves. They do not listen to their advice and prefer to stop interacting with them altogether . . . tend[ing] to strengthen their bonds with people who only see their positive qualities.”

Surrounding ourselves with people who shore up our self-image is both understandable and needed. Life is hard. Support is a must. The problem is that this largely unconscious behavior undermines performance. In a variety of work contexts, for example, the researchers have documented that, “dropping relationships that provide disconfirming reviews [leads] to decreases in performance in the succeeding year.”

The importance of being able to see ourselves as we are is something Rembrandt appeared to understand quite well. Indeed, it likely accounted for a significant portion of his artistic mastery. img_20160922_1024365

Bottom line? Whatever our particular craft, if the goal is to improve, to get better at what we do, it’s essential to “mind the self-assessment gap.” First, we have to be aware it exists. Next, we have to actively work to solicit views other than our own.

In the therapy world, our team has pioneered a simple set of tools clinicians can use to solicit feedback about the quality and effectiveness of their work. Multiple clinical trials document improved results. Read this recently published free article to learn how to get started.

Of course, not all feedback is useful. In the upcoming Intensive Trainings in Chicago, we’ll teach you how to sort helpful from unhelpful, guided by the latest and only empirical research published to date documenting what it takes for individual therapists to become more effective.

Join me, an international faculty, and practitioners from around the world for the Advanced FIT and Supervision trainings this coming March!

Until then,

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

Does practice make perfect?

August 30, 2016 By scottdm 2 Comments

“Practice does not make perfect,” my friend, and award-winning magician, Michael Ammar, is fond of saying. “Rather,” he observes, “practice makes permanent.”

Thus, if we are not getting better as we work, our work will simply insure our current performance stays the same.

Now, before reading any further, watch a bit of the video below. It features Diana Damrau singing one of the most recognizable arias from Mozart’s, “The Magic Flute.” Trust me, even if you don’t like opera, this performance will make the hair on your neck stand on end.

All right, now click on the video below (and listen for as long as you can stand it).

No, the latter recording is not a joke. Neither is it a reject from one of the “GOT TALENT” shows so popular on TV at present. It’s none other than Florence Jenkins—an American socialite and heiress who was, according to Wikipedia, “a prominent musical cult figure…during the 1920’s, ‘30’s, and 40’s.”

How could that be, you may well wonder? Her pitch is off, and there are so many mistakes in terms of rhythm, tempo, and phrasing in the first 30 seconds, one quickly loses count.

The problem? In a word, feedback—more specifically, the lack of critical feedback extending over many years.

For most of her career, Lady Florence, as she liked to be called, performed to “select audiences” in her home or small clubs. Attendance was invitation-only–and Jenkins controlled the list. Her guests did their best not to let on what they tought of her abilities. Instead, they smiled approvingly and applauded–loudly as it turns out, in an attempt to cover the laughter that invariably accompanied her singing!

Everything changed in 1944 when Jenkins booked Carnegie Hall for a public performance. This time, the applause was not sufficient to cover the laughter. If anything, it followed, treating the performance as a comedy act, and encouraging the singer to continue the frivolity.

The reviews were scathing. The next morning, the critic for the New York Sun, wrote, Lady Florence, “…can sing everything…except notes…”

The moral of the story? Practice is not enough. To improve, feedback is required. Honest feedback–and the earlier in the process, the better. Research indicates the keys to success are: (1) identifying performance objectives that lie just beyond an individuals current level of reliable achievement; (2) immediate feedback; and (3) continuous effort aimed at gradually refining and improving one’s performance.

Here’s the parallel with psychotherapy: the evidence shows therapist self-appraisal is not a reliable measure of either the quality or effectiveness of their work. Indeed, a number of studies have found that, when asked, the least effective clinicians rate themselves on par with the most effective–a finding that could well be labelled, “Jenkin’s Paradox.”

Evidence-based measures exists which can help therapists avoid the bias inherent in self-assessment as well as aid in the identification of small, achievable performance improvement objectives. A recent study documented, for example, how therapists can use such tools, in combination with immediate feedback and practice, to gradually yet significantly improve the quality and effectiveness of their therapeutic relationships–arguably, the most important contributor to treatment outcome. Using the tools to improve outcome and engagement in psychotherapy will be the focus of the upcoming ICCE webinar. It’s a simply way to get started, or to refine your existing knowledge. Learn more or register online by clicking here.

Let me leave you with one last video. It’s an interview I did with Danish psychologist Susanne Bargmann. Over the last 5 years, she’s applied the principles described here in an attempt to not only improve her effectiveness as a clinician, but also in music. Recently, her efforts came to the attention of the folks at Freakonomics radio. As was the case when you listened to Diana Damrau, you’ll come away inspired!

Until next time,

Scott

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

Dodos and Dropouts: Two Chronic Problems in Psychotherapy (and what clinicians can do about them)

August 16, 2016 By scottdm 8 Comments

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.” rosenzweig and miller
(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:

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.

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.

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

Making the Impossible, Possible: The Fragile Balance

July 25, 2016 By scottdm 1 Comment

Trip-Advisor scores it # 11 out of 45 things to do Sausalito, California. No, it not’s the iconic Golden Gate Bridge or Point Bonita Lighthouse. Neither is it one of the fantastic local restaurants or bars. What’s more, in what can be a fairly pricey area, this attraction won’t cost you a penny. It’s the gravity-defying rock sculptures of local performance artist, Bill Dan.

So impossible his work seems, most initially assume there’s a trick: magnets, hooks, cement, or pre-worked or prefab construction materials.

Watch for a while, get up close, and you’ll see there are no tricks or shortcuts. Rather, Bill Dan has vision, a deep understanding of the materials he works with, and perseverance. Three qualities that, it turns out, are essential in any implementation.

Over the last decade, I’ve had the pleasure of working with agencies and healthcare systems around the world as they work to implement Feedback-Informed Treatment (FIT). Not long ago, FIT–that is, formally using measures of progress and the therapeutic alliance to guide care–was deemed an evidence-based practice by SAMHSA, and listed on the official NREPP website. Research to date shows that FIT makes the impossible, possible, improving the effectiveness of behavioral health services, while simultaneously decreasing costs, deterioration and dropout rates.

Dan 2

Over the last decade, a number of treatment settings and healthcare systems have beaten the odds. Together with insights gleaned from the field of Implementation Science, they are helping us understand what it takes to be successful.

One such group is Prairie Ridge, an integrated behavioral healthcare agency located in Mason City, Iowa. Recently, I had the privilege of speaking with the clinical leadership and management team at this cutting-edge agency.

Click on the video below to listen in as they share the steps for successfully implementing FIT that have led to improved outcomes and satisfaction across an array of treatment programs, including residential, outpatient, mental health, and addictions.

Until next time,

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

P.S.: Looking for a way to learn the principles and practice of Feedback Informed Treatment? No need to leave home. You can learn and earn CE’s at the ICCE Fall FIT Webinar. Register today at: https://www.eventbrite.ie/e/fall-2016-feedback-informed-treatment-webinar-series-tickets-26431099129.

Improving the Odds: Implementing FIT in Care for Problem Gamblers and their Families

April 17, 2016 By scottdm 1 Comment

Quick Healthcare Quiz

What problem in the U.S. costs the government approximately $274 per adult annually?

If you guessed gambling, give yourself one point. According to the latest research, nearly 6 million Americans have a serious gaming problem—a number that is on the rise. One-third of the Nation’s adults visit a Casino every year, losing according to the latest figures an estimated 100 billion dollars.

Which problem is more common? Substance abuse or problem gambling?

If you guessed the former, give yourself another point. Problems related to alcohol and drug use are about 3.5 times more common than gambling. At the same time, 281 times more funding is devoted to treating drug and alcohol problems. In March 2014, the National Council on Problem Gambling reported that government-funded treatment was provided to less than one quarter of one percent of those in need.

Does psychotherapy work for problem gambling?

If you answered “yes,” add one to your score. Research not only indicates that psychological treatment approaches are effective, but that changes are maintained at follow up. As with other presenting problems (e.g., anxiety and depression), more therapy is associated with better outcomes than less.

What is the key to successful treatment of problem gambling?

If you answered, “funding and getting people into treatment,” or some variation thereof, take away three points!

So, how many points do you have left? If you are at or near zero, join the club.

Healthcare is obsessed with treatment. A staggering 99% of resources are invested in interventions. Said another way, practitioners and healthcare systems love solutions. The problem is that research shows this investment, “does not result in positive implementation outcomes (changes in practitioner behavior) or intervention outcomes (benefits to consumers).” Simply put, it’s not enough to know “what works.” You have to be able to put “what works” to work.

Enter the BC Responsible and Problem Gambling Program—an agency that provides free support and treatment services aimed at reducing and preventing the harmful impacts of excessive or uncontrolled gaming. Clinicians working for the program not only sought to provide cutting-edge services, they wanted to know if they were effective and what they could do to continuously improve.

Five years ago, the organization adopted feedback-informed treatment (FIT)—routinely and formally seeking feedback from clients regarding the quality and outcome of services offered. A host of studies documents that FIT improves retention in and outcome of psychotherapy. Like all good ideas, however, the challenge of FIT is implementation.

Last week, I interviewed Michael Koo, the clinical coordinator of the BCRPGP. Listen in as he discusses the principles and challenges of their successful implementation. Learn also how the talented and devoted crew achieve outcomes on par with randomized controlled trials in an average of 7 visits while working with a culturally and clinically diverse clientele.

As you’ll hear, implementation is difficult, but doable. More, you don’t have to reinvent the wheel or do it alone. When FIT was reviewed and deemed “evidence-based” by the Substance Abuse and Mental Health Services organization in 2013, it received perfect scores for “implementation, training, support, and quality assurance” resources. Regardless of the population you serve, you can:

Join a free, online, international community of nearly 10,000 like-minded professionals using FIT in diverse settings (www.iccexcellence.com). Every day, members connect and share their knowledge and experience with each other;
Access a series of “how to” manuals and free, gap assessment tool (FRIFM) to aid in planning, guiding progress, and identifying common blind spots in implementation.
Attend the upcoming, 2-day FIT Implementation workshop. Held once a year in August, this event provides an in-depth, evidence-based training based on the latest findings from the field of implementation science.

Come meet managers, supervisors, practitioners, and team leaders from around the world. You will leave the tools necessary to “put ‘what works’ to work.”

FIT IMP 2016
Until next time,

Scott

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

Do you know Norman Malone? FIT, Grit, and Grace Personified

March 27, 2016 By scottdm 1 Comment

At the tender age of 10, Norman Malone’s father attacked him and his two younger brothers with a hammer while they slept. Their mother, drugged into unconsciousness by her husband the prior evening, found the children the next morning. Each had suffered grave head wounds, but were alive. Later, all would learn the senior Malone had taken his life shortly after the attack, throwing himself in front of a suburban train.

A long recovery followed, months spent in a hospital learning to walk again. Despite steady and dramatic improvement, Norman never regained the use of his right hand. With his single functioning hand, he spent the next seven decades following a dream he’d had since he was five: to become a concern pianist.

It has been a solitary journey throughout. In his youth, kids made fun of his damaged skull. Teachers and advisors consistently advised him to give up his quest, deeming it “ludicrous.” Thinking he must be “crazy,” they even sent him for a psychological evaluation. Wittgenstein

Sustained and focused application, or “grit,” research indicates is key for achieving difficult goals. Norman Malone is grit and grace personified. He persisted, eventually meeting a willing teacher at the Chicago Musical College. That teacher knew the story of another famous left-handed pianist, Paul Wittgenstein—brother of the celebrated philosopher, Ludwig—who following the loss of his right hand in World War 1, used his family’s wealth to commission Ravel, Prokofiev, and other famous composers to write music for him.

Last week, I had the opportunity to meet Norman Malone. Now 78 years of age, he graciously accepted an invitation to play at my home for participants attending the ICCE Intensive Trainings in Chicago. Forty-five participants from around the world (US, Canada, the Netherlands, Sweden, Denmark, Finland, Australia) crowded into my living room. You could hear a pin drop as he spoke.

It started Malone at home with his story. Then, he played—doing with one hand what many would think impossible with two. When asked what drove him to continue in the face of so many challenges, he said, in a quiet yet confident voice, “Because there is so much to learn!”

Mr. Malone will be back in August to perform for participants in the FIT Implementation, Training of Trainers, and FIT Professional Development Intensives. Come and get inspired!

You can get a taste of his performance at the training, and a watch a video of his life story, by clicking on the videos below.

Until next time,

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

Psychotherapy and the Cure for the Common Cold

February 26, 2016 By scottdm 3 Comments

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

What is the essential quality of effective Feedback? New research points the way

February 8, 2016 By scottdm 1 Comment

“We should not try to design a better world,” says Owen Barder, senior fellow at the Center for Global Development, “We should make better feedback loops.”

Feedback has become a bit of a buzzword in mental health. Therapists are being asked to use formal measures of progress and the quality of the relationship and use the resulting information to improve effectiveness.

As it turns out, not all feedback is created alike. The key to success is obtaining information that gives rise to increased consciousness—the type that causes one to pause, reflect, rethink. In a word, negative feedback.

Nearly a decade ago, we noticed a curious relationship between effectiveness and the therapeutic alliance. Relationships that started off poorly but improved were nearly 50% more effective than those rated good throughout.

And now, more evidence from a brand-new, real-world study of therapy with adolescents (Owen, Miller, Seidel, & Chow, 2016). Therapists asked for and received feedback via the Outcome and Session Rating scales at each and every visit. Once again, relationships that improved over the course of treatment were significantly more effective.

Importantly, obtaining lower scores at the outset of therapy provides clinicians with an opportunity to discuss and address problems early in the working relationship. But, how best to solicit such information?

The evidence documents that using a formal measure is essential, but not enough. The most effective clinicians work hard at creating an environment that not invites, but actively utilizes feedback. Additionally, they are particularly skilled at asking questions that go beyond platitudes and generalities, in the process transforming client experience into specific steps for improving treatment.

As statistician and engineer Edward Deming once observed, “If you do not know how to ask the right question, you discover nothing.”

Little useful information is generated when clients are asked, “How did you feel about the session today?” “Did you feel like I (listened to/understood) you?” or “What can I do better?”

The best questions are:

Specific rather than general;
Descriptive rather than evaluative;
Concerned with quantities rather than qualities; and are
Task rather than person-oriented.

Over the years, we’ve come to understand that learning to ask the “right” question takes both time and practice. It’s not part of most training programs, and it only comes naturally to a few. As a result, many therapists who start using formal measures to solicit feedback about progress and the therapeutic relationship, give up, frustrated in their efforts to solicit helpful feedback.

Learning to develop better “feedback loops,” as Barder recommends, is the focus for the upcoming FIT Implementation, Training of Trainers, and Professional Development Intensives scheduled for August in Chicago, Illinois (USA). Our March courses sold out months in advance so reserve your spot now by clicking the icons to the right.

Until then, get started with these free articles.

Best wishes,

Scott

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

Are you Better? Improving Effectiveness One Therapist at a Time

January 24, 2016 By scottdm 3 Comments

Greetings from snowy Sweden. I’m in the beautiful city of Gothenburg this week, working with therapists and administrators on implementing Feedback-Informed Treatment (FIT).

I’m always impressed by the dedication of those who attend the intensive workshops. More, I feel responsible for providing a training that not only results in mastery of the material, but also leads to better outcomes.

As commonsensical as it may seem to expect that training should foster better results, it’s not. Consider a recent study out of the United Kingdom. There, massive amounts of money have been spent over the last five years training clinicians to use cognitive behavioral therapy (CBT). The expenditure is part of a well-intentioned government program aimed at improving access to effective mental health services.

Anyway, in the study, clinicians participated in a year-long “high-intensity” course that included more than 300 hours of training, supervision, and practice—a tremendous investment of time, money, and resources. Competency in delivering CBT was assessed at regular intervals and shown to improve significantly throughout the training.

The only problem? Training therapists in CBT did not result in better outcomes.

While one might hope such findings would cause the researchers to rethink the training program, they chose instead to question whether “patient outcome should … be used as a metric of competence…” (p. 27). Said another way, doing treatment the right way was more important than whether it actually worked! One is left to wonder whether the researchers would have reached a similar conclusion had the study gone the other way. Most certainly, the headline would then have been, “Empirical Research Establishes Connection between Competence in CBT and Treatment Outcome!”

Attempts to improve the effectiveness of treatment via the creation of a psychological formulary—official lists of specific treatments for specific disorders—have persisted, and even intensified, despite consistent evidence that the methods clinicians use contribute little to outcome. Indeed, neither clinicians’ competence in conducting specific types of therapy nor adherence to evidence-based protocols have been “found to be related to patient outcome and indeed . . . estimates of their effects [are] very close to zero” (p. 207, Webb, DeRubeis, & Barber, 2010).

So, what gives?

There are two reasons why such efforts have failed:

First, they do not focus on helping therapists develop the skills that account for the lion’s share of variability in treatment outcome.

Empathy, for example, has a greater impact than the combined effect sizes of therapist competence, adherence to protocol, specific ingredients within and differences between various treatment approaches. Still, most, like the present study, continue to focus on method.

Second, they ignore the extensive scientific literature on expertise and expert performance.

Here, research has identified a universal set of processes, and step-by-step directions, anyone can follow to improve performance within a particular discipline. To improve, training must be highly individualized, focused on helping performers reach for objectives just beyond their current ability.

“Deliberate Practice,” as it has been termed, requires grit and determination. “Nobody is allowed to stagnate,” said one clinician when asked to describe what it was like to work at a clinic that had implemented the steps, adding, “Nobody is allowed to stay put in their comfort zone.” The therapist works at Stangehjelpa, a community mental health service located an hour north of Oslo, Norway.

The director of the agency is psychologist, Birgit Valla (left), author of visionary book, Further: How Mental Services Can Be Better. Birgit is on a mission to improve outcomes—not by dictating the methods staff are allowed to use but by focusing on their individual development.

It starts with measuring outcomes. All therapists at Stangehjelpa know exactly how effective they are and, more importantly, when they are not helpful. “It’s not about the measures,” Birgit is quick to point out, “It´s about the therapist, and how the service can support that therapist getting better.” She continues, “It´s like if you want improve your time in the 100 meter race, you need a stopwatch. It would be absurd to think, however, that the stopwatch is responsible for running faster. Rather, it’s how one chooses to practice in relation to the results.”

Recently, researcher Siri Vikrem Austdal interviewed staff members at the clinic about their experience applying deliberate practice in their work. Says one, ““It is strenuous. You are expected to deliver all the time. But being part of a team that dare to have new thoughts, and that wants something, is really exciting. I need it, or I would grow tired. It is demanding, but then there is that feeling we experience when we have climbed a mountain top. Then it is all worthwhile. It is incredibly fun to make new discoveries and experience mastery.”

So, what exactly are they doing at Stangehjelp?

You can read the entire report here (Norwegian), or the abbreviated version here (English). Why not join Birgit this summer at the FIT Professional Development training in Chicago, Illinois. Together with Dr. Daryl Chow, we will teach participants how to incorporate deliberate practice into an individualized, evidence-based plan for continuous professional development. Click on the icon below to reserve your spot now.

Until next time,

Scott

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

I Was Wrong: The Healing Power of Admitting Mistakes in Psychotherapy

January 14, 2016 By scottdm 1 Comment

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.

mistakes
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.

rebuild

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, admitti mistakes were made ng 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 al chris laraway liance 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

The Benefits of Doubt: New Research Sheds Light on Becoming a More Effective Therapist

December 9, 2015 By scottdm 6 Comments

These are exciting times for clinicians. The pieces of the puzzle are falling into place. Researchers are finally beginning to understand what it takes to improve the effectiveness of psychotherapy. Shifting away from the failed, decades-long focus on methods and diagnosis, attention has now turned to the individual practitioner.

Such efforts have already shown a host of factors to be largely ineffective in promoting therapist growth and development, including:

Supervision;
Continuing education;
Therapist personal therapy;
Clinical experience; and
Access to feedback

In October, I blogged about the largest, longitudinal study of therapists ever conducted. Despite having access to ongoing, formal feedback from their clients for as long as 17 years, clinicians in the study not only did not improve, their outcomes actually deteriorated, on average, year after year.

Such findings contrast sharply with beliefs of practitioners who, according to other studies, see themselves as improving with time and experience. In fact, findings on all the practices noted above contrast sharply with beliefs commonly-held in the field:

Supervision is at the top of the list of experiences therapists cite as central to their growth and development as practitioners. By contrast, the latest review of the literature concludes, “We do not seem to be any more able to say now (as opposed to 30 years ago) that psychotherapy supervision contributes to patient outcome” (p. 235, Watkins 2011).

Although most clinicians value participating in continuing education activities—and licensure requirements mandate attendance—there is no evidence such events engender learning, competence, or improved outcomes. Neither do they appear to decrease disciplinary actions, ethical infractions, or inspire confidence on the part of therapy consumers.

Therapist personal therapy is ranked as one of the most important sources of professional development despite there being no evidence it contributes to better performance as a clinician and some studies documenting a negative impact on outcome (see Orlinsky & Ronnestad, 2005);

If any of the research I’ve cited surprises you, or gives you pause, there is hope! Really. Read on.

Doubt, it turns out, is a good thing–a quality possessed by the fields’ most effective practitioners. Possessing it is one of the clues to continuous professional development. Indeed, several studies now confirm that “healthy self-criticism,” or professional self-doubt (PSD), is a strong predictor of both alliance and outcome in psychotherapy (2015).

To be sure, I’m not talking about assuming a “not-knowing” stance in therapeutic interactions. Although much has been written about having a “beginner’s mind,” research by Nissen-Lie and others makes clear that nothing can be gained by either our feigned or willful ignorance.

Rather, the issue is about taking the time to reflect on our work. Doing so on a routine basis prevents us from falling prey to the “over-claiming error”—a type of confidence that comes from the feeling we’ve seen something before when, in fact, we h not listening ave not.

The “over-claiming error” is subtle, unconscious, and fantastically easy to succumb to and elicit. In a very clever series of experiments, for example, researchers asked people a series of questions designed either to engender a feeling of knowledge and expertise or ignorance. Being made to feel more knowledgeable, in turn, lead people to act less open-mindedly and feel justified in being dogmatic. Most importantly, it caused them to falsely claim to know more about the subject than they did, including “knowing” things the researchers simply made up!

In essence, feeling like an expert actually makes it difficult to separate what we do and do not know. Interestingly, people with the most knowledge in a particular domain (e.g., psychotherapy) are at the greatest risk. Researchers term the phenomenon, “The ‘Earned Dogmatism’ Effect.”

What to do? The practices of highly effective therapists provide some clues:

Adopt an “error-centric” mindset. Take time to reflect on your work, looking for and then examining moments that do not go well. One simple way to prevent over-claiming is to routinely measure the outcome of your work. Don’t rely on your judgement alone, use a simple measures like the ORS to enhance facts from your fictions.

Think like a scientist. Actively seek disconfirmation rather than confirmation of your beliefs and practices. Therapy can be vague and ambiguous process—two conditions which dramatically increase the risk of over-claiming. Seeking out a community of peers and a coach to review your work can be helpful in this regard. No need to leave your home or office. Join colleagues in a worldwide virtual community at: iccexcellence.com.

Seek formal feedback from clients. Interestingly, research shows that highly effective therapists are surprised more often by what their clients say than average clinicians who, it seems, “have heard it all before.” If you haven’t been surprised in a while, ask your clients to provide feedback about your work via a simple tool like the SRS. You’ll be amazed by what you’ve missed.

Attend the 2016 Professional Development Intensive this summer in Chicago. At this small group, intensive training, you will the latest evidence-based steps for unlocking your potential as a therapist.

Best wishes for the Holidays. As always, please leave a comment.

Scott

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