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 8 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