Reducing Dropout and Unplanned Terminations in Mental Health Services

May 12, 2021 By scottdm Leave a Comment

Being a mental health professional is a lot like being a parent.

Please read that last statement carefully before drawing any conclusions!

I did not say mental health services are similar to parenting. Rather, despite their best efforts, therapists, like parents, routinely feel they fall short of their hopes and objectives. To be sure, research shows both enjoy their respective roles (1, 2). That said, they frequently are left with the sense that no matter how much they do, its never good enough. A recent poll found, for example 60% parents feel they fail their children in first years of life. And given the relatively high level of turnover on a typical clinician’s caseload — with a worldwide average of 5 to 6 sessions — what is therapy if not a kind of Goundhog Day repetition of being a new parent?

For therapists, such feelings are compounded by the number of clients who, without notice or warning, stop coming to treatment. Besides the obvious impact on productivity and income, the evidence shows such unplanned endings negatively impact clinicians’ self worth, ranking third among the top 25 most stressful client behaviors (3, p. 15).

Recent, large scale meta-analytic studies indicate one in five, or 20% (4) of clients, dropout of care — a figure that is slightly higher for adolescents and children (5). However, when defined as “clients who discontinue unilaterally without experiencing a reliable or clinically significant improvement in the problem that originally led them to seek treatment,” the rate is much higher (6)!

Feeling “not good enough” yet?

By the way, if you are thinking, “that’s not true of my caseload as hardly any of the people I see, dropout” or “my success rate is much higher than the figure just cited,” recall that parent who always acts as though their child is the cutest, smartest or most talented in class. Besides such behavior being unbecoming, it often displays a lack of awareness of the facts.

So, turning to the evidence, data indicate therapists routinely overestimate their effectiveness, with a staggering 96% ranking their outcomes “above average (7)!” And while the same “rose colored glasses” may cause us to underestimate the number of clients who terminate without notice, a more troubling reality may be the relatively large number who don’t dropout despite experiencing no measurable benefit from our work with them– up to 25%, research suggests.

What to do?

As author Alex Dumas once famously observed, “Nothing succeeds like success.” And when it comes addressing dropout, a recent, independent meta-analysis of 58 studies involving nearly 22,000 clients found Feedback-Informed Treatment (FIT) resulted in a 15% reduction in the number people who end psychotherapy without benefit (8). The same study — and another recent one (9) –documented FIT helps therapists respond more effectively to clients most at risk of staying for extended periods of time without benefit.

Will FIT prevent you from ever feeling “not good enough” again? Probably not. But as most parents with grown children say, “looking back, it was worth it.”

OK, that’s it for now,

Scott

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

P.S.: If you are looking for support with your implementation of Feedback-Informed Treatment in your practice or agency, join colleagues from around the world in our upcoming online trainings.
FIT Implementation Intensive 2021 FIT Summer CAFÉ

Making Sense of Client Feedback

January 4, 2021 By scottdm Leave a Comment

I have a guilty confession to make. I really like Kitchen Nightmares. Even though the show finished its run six L O N G years ago, I still watch it in re-runs. The concept was simple. Send one of the world’s best known chefs to save a failing restaurant.

Each week a new ~~disaster~~ establishment was featured. A fair number were dives — dirty, disorganized messes with all the charm and quality of a gas station lavatory. It wasn’t hard to figure out why these spots were in trouble. Others, by contrast, were beautiful, high-end eateries whose difficulties were not immediately obvious.

Of course, I have no idea how much of what we viewers saw was real versus contrived. Regardless, the answers owners gave whenever Ramsey asked for their assessment of the restaurant never failed to surprise and amuse. I don’t recall a single episode where the owners readily acknowledged having any problems, other than the lack of customers! In fact, most often they defended themselves, typically rating their fare “above average,” — a 7 or higher on a scale from 1 to 10.

Contrast the attitude of these restaurateurs with pop music icon Billy Joel. When journalist Steve Croft asked him why he thought he’d been so successful, Joel at first balked, eventually answering, “Well, I have a theory, and it may sound a little like false humility, but … I actually just feel that I’m competent.” Whether or not you are a fan of Joel’s sound, you have to admit the statement is remarkable. He is one of the most successful music artists in modern history, inducted into the Rock and Roll Hall of Fame, winning a Grammy Legend Award, earning four number one albums on the Billboard 200, and consistently filling stadiums of adoring fans despite not having released a new album since 1993! And yet, unlike those featured on Kitchen Nightmares, he sees himself as merely competent, adding “when .. you live in an age where there’s a lot of incompetence, it makes you appear extraordinary.”

Is humility associated with success? Well, turns out, it is a quality possessed by highly effective effective therapists. Studies not only confirm “professional self-doubt” is a strong predictor of both alliance and outcome in psychotherapy but actually a prerequisite for acquiring therapeutic expertise (1, 2). To be clear, I’m not talking about debilitating diffidence or, as is popular in some therapeutic circles, knowingly adopting a “not-knowing” stance. As researchers Hook, Watkins, Davis, and Owen describe, its about feedback — specifically, “valuing input from the other (or client) … and [a] willingness to engage in self-scrutiny.”

Low humility, research shows, is associated with compromised openness (3). Sound familiar? It is the most common reaction of owners featured on Kitchen Nightmares. Season 5 contained two back-to-back episodes featuring Galleria 33, an Italian restaurant in Boston, Massachusetts. As is typical, the show starts out with management expressing bewilderment about their failing business. According to them, they’ve tried everything — redecorating, changing the menu, lowering prices. Nothing has worked. To the viewer, the problem is instantly obvious: they don’t take kindly to feedback. When one customer complains their meal is “a little cold,” one of the owners becomes enraged. She first argues with Ramsey, who agrees with the customer’s assessment, and then storms over to the table to confront the diner. Under the guise of “just being curious and trying to understand,” she berates and humiliates them. It’s positively cringeworthy. After numerous similar complaints from other customers — and repeated, uncharacteristically calm, corrective feedback from Ramsey — the owner experiences a moment of uncertainty. Looking directly into the camera she asks, “Am I in denial?” The thought is quickly dismissed. The real problem, she and the co-owner decide, is … (wait for it) …

Ramsey and their customers! Is anyone surprised the restaurant didn’t survive?

Such dramatic examples aside, few therapists would dispute the importance of feedback in psychotherapy. How do I know? I’ve meet thousands over the last two decades as I traveled the world teaching about feedback-informed treatment (FIT). Research on implementation indicates a far bigger challenge is making sense of the feedback one receives (4, 5, 6) Yes, we can (and should) speak with the client — research shows therapists do that about 60% of the time when they receive negative feedback. However, like an unhappy diner in an episode of Kitchen Nightmares, they may not know exactly what to do to fix the problem. That’s where outside support and consultation can be critical. Distressingly, research shows, even when clients are deteriorating, therapists consult with others (e.g., supervisors, colleagues, expert coaches) only 7% of time.

Since late summer, my colleagues and I at the International Center for Clinical Excellence have offered a series of intimate, virtual gatherings of mental health professionals. Known as the FIT Cafe, the small group (10 max) gets together once a week to finesse their FIT-related skills and process client feedback. It’s a combination of support, sharing, tips, strategizing, and individual consultation. As frequent participant, psychologist Claire Wilde observes, “it has provided critical support for using the ORS and SRS to improve my therapeutic effectiveness with tricky cases, while also learning ways to use collected data to target areas for professional growth.”

The next series is fast approaching, a combination of veterans and newbies from the US, Canada, Europe, Scandinavia, and Australia. Learn more or register by clicking here or on the icon to the right.

Not ready for such an “up close and personal” experience? Please join the ICCE online discussion forum. It’s free. You can connect with knowledgeable and considerate colleagues working to implement FIT and deliberate practice in their clinical practice in diverse settings around the world.

OK, that’s it for now. Until next time,

Scott

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

“My Mother Made Me Do It”: An Interview with Don Meichenbaum on the Origins of CBT (Plus: Tips for Surviving COVID-19)

May 26, 2020 By scottdm Leave a Comment

Imagine having the distinction of being voted one of the top 10 most influential psychotherapists of the 20th Century.

Psychologist Don Meichenbaum is that person. In his spare time, together with Arron Beck and Marvin Goldfried, he created the most popular and researched method of psychotherapy in use today: cognitive-behavior therapy (CBT).

I got to know Don years ago as we shared a car ride, traveling to and from a training venue while teaching separate, week-long workshops in New England. We laughed. We talked. We debated. Fiercely.

We’ve been friends and colleagues ever since, recreating our car ride discussions in front of large audiences of therapists at each Evolution of Psychotherapy conference since 2005.

As Don approaches his 80th birthday, we look back on the development of CBT — what he thinks he got right and how his thinking has evolved over time. Most trace the roots of CBT to various theorists in the field — Freud, Wolpe, and others. Don is clear: his mother made him do it. That’s right. According to him, CBT got its start with Mrs. Meichenbaum. I know you’ll be amused, but I also believe you’ll be surprised by why and how she contributed.

That said, my interview with Don isn’t merely a retrospective. Still actively involved in the field, he shares important, evidence-based tips about trauma and resilience, applying the latest findings to the psychological and economic impacts of the coronavirus. You’ll find the interview below.

All done for now,

Scott

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

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

May 6, 2019 By scottdm 2 Comments

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

But how does it work?

Quick. Take a guess.

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

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

In a “first of its kind” study, psychologist Heidi Brattland found that the strength of the therapeutic relationship improved more over the course of care when clinicians used the Outcome and Session Rating Scales (ORS & SRS) compared to when they did not. Critically, such improvements resulted in better outcomes for clients, ultimately accounting for nearly a quarter of the effect of FIT.

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

That said, Brattland and her colleagues did not find clinicians were equally effective in their use of FIT. Indeed, as detailed in the report, therapists, “significantly differed in the influence of … [FIT] on the alliance, in the influence of the alliance on outcomes, and the residual direct effect of [FIT] … posttreatment” (p. 10). On this score, one advantage of using scales to routinely measure our work, is that doing so enables us to identify our personal “growth edge” — what, where, and how we might improve our ability to relate to and help the diverse clients we meet in our daily work.

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

Until next time,

Scott

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

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

April 24, 2019 By scottdm 9 Comments

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Until next time,

Scott

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

Mountains and Molehills, or What the JFK Assasination and the Therapeutic Relationship have in Common?

April 14, 2019 By scottdm 5 Comments

Over the last 10 days or so, I’ve been digesting a recently published article on the therapeutic alliance — reading, highlighting, tracking down references, rereading, and then discussing the reported findings with colleagues and a peer group of fellow researchers. It’s what I do.

The particular study has been on my “to be read” pile for the better part of a year, maybe more. Provocatively titled, “Is the Alliance Really Therapeutic?” it promises to answer the question in light of “recent methodological advances.”

I know this will sound strange — at least at first — but throughout, I kept finding myself thinking of the assasination of the 35th President of the United States, John F. Kennedy. Bear with me as I explain.

I personally remember the shock and grief of this event. Although I was only six years old at the time, I have vivid memories, watching televised segments of the funeral procession down Pennsylvania Avenue under a grey, overcast and rainy sky. “Why?” my family and the Nation asked, and “How?”

You likely know the rest of the story. Within hours, a suspect was arrested. Two days later, he was murdered on live TV by a Dallas nightclub owner. Ever since, events surrounding the assasination have been the subject of heated debate. More than 2,000 books have been published, each offering a different theory of the event — a veritable “Who’s who” of suspects, including but not limited to the Soviet Union, CIA, Mafia, Cuban government, and Vice President of the United States.

Whatever you might believe, it’s hard to fault the majority of Americans — 61% in the most recent polls — who seriously doubt that the slight, unemployed, thrice court-martialed former marine, acted alone. To many, in fact, it’s simply inconceivable. And, that’s the point. As investigative reporter, Gerald Posner, observed in his book Case Closed, “The notion that a misguided sociopath … wreaked such havoc [makes] the crime seem senseless” (p. xviii). By contrast, concluding there was an elaborate plot involving important and powerful people, embues Kennedy’s death with meaning equal to his stature and significance in the mind of the public.

Said another way, maybe, just maybe, in our attempts to reconcile the facts with our feelings, we made a molehill into a mountain … which brings me back to the article about the therapeutic relationship. The empirical evidence is clear: the quality of the alliance between client and clinician is one of the most potent and reliable predictors of successful psychotherapy.

According to the most recent and thorough review of the empirical literature:

Better alliances result in better outcomes when working with individuals, groups, couples and families, children and adolescents, and mandated/involuntary clients;
With regard to specific qualities, better outcomes result the more therapists:
- Like, value, and care for the client (known as the “real” relationship, it contributes more to outcome than relational elements associated with the doing of therapy. Effect Size [E.S.] ~ .80 );
- Communicate their understanding of and compassion for the client (E.S. ~ .58);
- Collaborate with the client regarding the focus (e.g., problem) and goals for treatment (E.S. ~ .49);
- Present as accessible, approachable, and sincere (i.e., congruent and genuine, E.S. ~ .46)
- Demonstrate respect, warmth, and positive regard (E.S. ~ .36);
- Seek and utilize formal feedback regarding the client’s experience of progress and the therapeutic alliance (E.S. ~ .33 – .49);
- Express emotions and generate hope and expectancy of positive results (E.S. = .56 & .36, respectively).

Sounds pretty straightforward and simple to me. In a relatively efficient fashion (worldwide the average number of visits is around 5 visits), we establish relationships with people that result in significant improvements in their well being. With regard to the latter, as reviewed many times on my blog, the average recipient of psychotherapy is better off than 80% of those with similar problems that do not.

That said, is the relationship we offer people so astounding that it forever changes them? Judging by the article’s dense language and near inpenetrable statistical procedures, you’d assume so. Yet ultimately, it fails to show as much, focusing instead on defining characteristics and qualities of clients amenable to a particular theoretical orientation rather than the relationship.

Now, before you object, please note, I did not say relationships — in life or in therapy — were easy. But therein lies the risk. Challenging or difficult (e.g., a lone gunman taking out a beloved and powerful figure) is equated with complicated (i.e., must have been a conspiracy). Add to that the tendency of professionals to embue their interactions with clients with life-changing significance and voila! we are poised, as a field, to make mountains out of molehills. Nowhere is this more easy to see than in the language we use to describe our work. We “treat,” have “countertransference reactions,” “repair ruptures,” and form “therapeutic alliances” rather than connect, experience frustration (or other feelings), and develop relationships.

It’s time to embrace what 50 years of evidence plainly shows: yes, we offer an important service, an opportunity for someone to feel understood, get support while going through a difficult period, solve problems, learn new and different ways for approaching life’s challenges, and every once in a while –maybe one in a hundred — something more. To do that, what’s needed is humility and a relentless focus on the fundamentals. Given the history of our field, that alone will prove hard enough.

Embracing the evidence and focusing on fundamentals is precisely what we’ll be doing, by the way, at the Deliberate Practice Intensive this summer coming August in Chicago. Join colleagues from around the world to learn how to use this simple (not easy) way for improving your effectiveness! For more info, click here or on the banner below.

Until next time,

Scott

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

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

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

The Replication Crisis in Psychology: What is and is NOT being talked about

November 7, 2016 By scottdm 9 Comments

Psychology has been in the headlines a fair bit of late—and the news is not positive. I blogged about this last year, when a study appeared documenting that the effectiveness of CBT was declining–50% over the last four decades.

The problem is serious. Between 2012 and 2014, for example, a team of researchers working together on their free time tried to replicate 100 published psychology experiments and succeeded only a third of the time! As one might expect, such findings sent shock waves through academia.

Now, this week, The British Psychological Society’s Research Digest piled on, reviewing 10 “famous” findings that researchers have been unable to replicate—despite the popularity and common sense appeal of each. Among others, these include:

Power posing does not make you more powerful;
Smiling does not make you happier;
Exposing you to words (known as “priming”) related to ageing does not cause you to walk like an old person;
Having a mental image of a college professor in mind does not make you perform more intelligently (another priming study);
Being primed to think of money will not cause make you act more selfishly; and
Despite being reported in nearly every basic psychology text, babies are not born with the power to imitate.

Clearly, replication is a problem. sand-castle The bottom line? Much of psychology’s evidence-base is built on a foundation of sand.

Amidst all the controversy, I couldn’t help thinking of psychotherapy. In this area, I believe, the problem with the available research is not so much the failure to replicate, but rather an unwillingness to accept what has been replicated repeatedly. Contrary to hope and popular belief, one—if not the most—replicated finding is the lack of difference in outcome between psychotherapeutic approaches.

It’s not for lack of trying. Massive amounts of time and resources have been spent comparing treatment methods. With few exceptions, either no or inconsequential differences are found.

Consider, for example, the U.S. Government spent same $33,000,000 studying different approaches for problem drinking only to find what we already know: all worked equally well. A decade later, the British officials spent millions of pounds on the same subject with similar results.

Just this week, a study was released comparing the hugely popular method called DBT to usual care in the treatment of “high risk suicidal veterans.” Need I tell you what they found?

groundhog

As the Ground-Hog-Day-like quest continues, another often replicated finding is ignored. One of the best predictors of the outcome of psychotherapy is the quality of the therapeutic relationship between the provider and recipient of care. That was one of the chief findings, for example, in both of the studies on alcohol treatment cited above (1, 2). Put simply, better relationship = improved engagement and effectiveness.

Sadly, but not surprisingly, research, writing, and educational opportunities focused on the alliance lags model and techniques. Consider this: slightly more than 55,000 books are in print on the latter subject, compared to a paltry 193 on the former. It’s mind-boggling, really. How could one of the most robust and replicated findings in psychotherapy be so widely ignored?

My colleague Daryl Chow is working hard to get beyond the “lip service” frequently paid to the therapeutic relationship. At the ICCE Professional Development training this last August, he presented findings from an ongoing series of studies aimed at helping clinicians improve their ability to engage, retain, and help people in psychotherapy by targeting training to the individual practitioners strengths and weaknesses. Not surprisingly, the results show slow and steady improvement in connecting with a broader, more diverse, and challenging group of clinical scenarios! Those in attendance learned how to build these skills into an individualized, professional development plan.

Trust me when I say, we won’t be ignoring this and other robust findings related to improving effectiveness at the upcoming ICCE intensive trainings in Chicago. Registration is open for both the Advanced and Supervision Intensives. Join us and colleagues from around the world.

Until next time,

Scott

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