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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Interested in your responses!

Until next time,

Scott

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Until next time,

Scott

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

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

[Read more…]

Which of the following are bad for health and longevity?

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

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

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

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

Medical benefits of dental floss unproven

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

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

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

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

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

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

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

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

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

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

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

Scott

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

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

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

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

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

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

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

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

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

Until next time,

Scott

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

Does diagnosis matter?

What about the treatment approach?

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

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

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

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

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

Bottom line: it’s time to move on.

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

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

What happened next?  Watch the interview to find out!

That’s it for now.  Until next time,

Scott

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

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

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

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

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

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

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

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

And here it is…

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

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

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

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

Until next time,

Scott

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

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

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

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

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

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

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

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

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

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

Online version of the Fidelity Readiness Index and Fidelity Measure

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

Take the FRIFM Assessment

Until next time,

Scott

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

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

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

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

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

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

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

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

What are these factors?

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

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

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

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

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

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

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

Until then, best wishes for the New Year!

Scott

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

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

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

So, what does work?

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

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

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

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

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

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

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

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

What’s it take to get started?

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

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

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

(drum roll please)

NO DIFFERENCE IN OUTCOME!

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

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

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

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

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

What can be done?

Three evidence-based ideas:

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

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

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

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

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

Until next time,

Scott

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