Getting in the Deliberate Practice HABIT

July 22, 2021 By scottdm Leave a Comment

Type the words, “Old habits …” into Google, and the search engine quickly adds, “die hard” and “are hard to break.” When I did it just now, these were followed by two song titles — one by Hank Williams Jr., the other by Mick Jagger — both dealing with letting go of past relationships. Alas, in love and life, breaking up is hard to do.

Like it or not, and despite our best intentions, we often end up returning to what we know. What are generally referred to as, “habits,” researchers in the field of expert performance label, “automaticity,” literally meaning thoughts and behaviors engaged in reflexively, involuntarily or unconsciously.

The evidence shows more than 40% of what we do on a daily basis is habitual in nature; that is, carried out while we’re thinking about something else (1). While such data might generate concern for most — “that’s a lot of acting without thinking” — the expertise literature indicates its absolutely essential to improving performance. Simply put, automaticity frees up our limited cognitive resources to focus on achieving performance objectives just beyond our current abilities — a process known as deliberate practice.

So, what’s your sense? How long does it typically take for new behaviors to be executed without a high degree cognitive effort?

A. 14 days

B. 21 days

C. 36 days

D. 56 days

E. 66 days

Please jot down your answer before reading further.

Did you do it?

Now, before I provide a research-based answer, would you watch the video below? (It’s fun, I promise)

Having watched the video, would you care to change your answer? With a self-reported 5-minutes of practice per day, it took Destin 8 months to achieve automaticity on his “backwards bicycle.” His experience is far from unique. Turns out, most of us — like many of those in the video who confidently seated themselves on the bike, then failed — seriously underestimate the amount of time and effort required for establishing new, more effective habits.

Somehow, somewhere, sometime, someone asserted the road to automaticity was about 21 days (3). Research actually shows it takes, on average, three times as long and, in many instances, up to 8 months (2)! Does that latter figure sound familiar? Complicating such findings is the fact that many of the “habits” studied by researchers are relatively simple in nature (e.g., drinking a bottle of water with lunch, running 15 minutes after dinner). Imagine a more complex behavior, such as learning to respond empathically to the diverse clients presenting for psychotherapy — and, just so you know, soon to be published research shows such abilities do not improve with experience nor correlate with clinicians’ estimates of their ability — and the challenge involved in improving clinical performance becomes even more apparent.

And did I mention the sense of failure, even incompetence, that frequently accompanies attempts to establish new habits? It’s understandable why so many of our efforts to improve are short lived. Frankly, its far easier to see oneself as getting better than to actually do what’s necessary long enough to improve. The evidence, reviewed previously on this blog, documents as much (4).

In our latest book, Better Results (APA, 2020), we identify a series of evidence-based steps for helping therapists develop a sustainable deliberate practice plan. Known by the acronym A.R.P.S. (5), it includes:

Automated: If you are asking yourself when, you likely never will.
Reference point: Count your steps, not your achievements.
Playful: Give in, let go, have fun.
Support: Go alone and you won’t go far

Following these steps, we’ve found, helps clinicians maintain their momentum as they apply deliberate practice in their professional development efforts. To these, I add a precursor: Change your mindset. Yeah, I know, that results in C.A.R.P.S, meaning “to find fault or complain querulously or unreasonably; be niggling in criticizing minor errors,” but that’s precisely the point. Recalling that deliberate practice is about reaching for performance objectives just beyond our current abilities, think “small and continuous improvement” rather than “achieving proficiency and mastery.”

OK, that’s it for now.

Scott

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

P.S.: Join me and my co-author Dr. Daryl Chow for our Online Deliberate Practice course. Designed for the busy professional, you learn at your own pace. Each week , you receive a bite-sized lesson. We provide ongoing support alongside a community of clinicians working to apply deliberate practice to their professional development. For more information or to register, click the icon below:
DP Asynchronous Course

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.

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

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

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

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

Do Psychotherapists Improve with Time and Experience?

October 27, 2015 By scottdm 18 Comments

The practice known as “routine outcome measurement,” or ROM, is resulting in the publication of some of the biggest and most clinically relevant psychotherapy studies in history. Freed from the limits of the randomized clinical trial, and accompanying obsession with manuals and methods, researchers are finally able to examine what happens in real world clinical practice.

A few weeks ago, I blogged about the largest study of psychotherapy ever published. More than 1,400 therapists participated. The progress of over 26,000 people (aged 16-95) treated over a 12 year period in primary care settings in the UK was tracked on an ongoing basis via ROM. The results? In an average of 8 visits, 60% of those treated by this diverse group of practitioners achieved both reliable and clinically significant change—results on par with tightly controlled RCT’s. The study is a stunning confirmation of the effectiveness of psychotherapy.

This week, another mega-study was accepted for publication in the Journal of Counseling Psychology. Once more,
ROM was involved. In this one, researchers Goldberg, Rousemanier, Miller, Whipple, Nielsen, Hoyt, and Wampold examined a large, naturalistic data set that included outcomes of 6500 clients treated by 170 practitioners whose results had been tracked an average of 5 years.

Their question?

Do therapists become more effective with time and experience?

Their answer? No.

For readers of this blog, such findings will not be particularly newsworthy. As I’ve frequently pointed out, experience has never proven to be a significant predictor of effectiveness.

What might be a bit surprising is that the study found clinicians’ outcomes actually worsened with time and experience. That’s right. On average, the longer a therapist practiced, the less effective they became! Importantly, this finding remained even when controlling for several patient-level, caseload-level, and therapist-level characteristics, as well as when excluding several types of outliers.

Such findings are noteworthy for a number of reasons but chiefly because they contrast sharply with results from other, equally-large studies documenting that therapists see themselves as continuously developing in both knowledge and ability over the course of their careers. To be sure, the drop in performance reported by Goldberg and colleagues wasn’t steep. Rather, the pattern was a slow, inexorable decline from year to year.

Where, one can wonder, does the disconnect come from? How can therapists’ assessments of themselves and their work be so at odds with the facts? Especially considering, in the study by Goldberg and colleagues, participating clinicians had ongoing access to data regarding their effectiveness (or lack thereof) on real-time basis! Even the study I blogged about previously—the largest in history where outcomes of psychotherapy were shown to be quite positive—a staggering 40% of people treated experienced little or no change whatsoever. How can such findings be reconciled with others indicating that clinicians routinely overestimate their effectiveness by 65%?

Turns out, the boundary between “belief in the process” and “denial of reality” is remarkably fuzzy. Hope is a significant contributor to outcome—accounting for as much as 30% of the variance in results. At the same time, it becomes toxic when actual outcomes are distorted in a manner that causes practitioners to miss important opportunities to grow and develop—not to mention help more clients. Recall studies documenting that top performing therapists evince more of what researchers term, “professional self-doubt.” Said another way, they are less likely to see progress where none exists and more likely to values outcomes over therapeutic process.

What’s more, unlike their more average counterparts, highly effective practitioners actually become more effective with time and experience. In the article below, my colleagues and I at the International Center for Clinical Excellence identify several evidence-based steps any practitioner follow to match such results.

Let me know your thoughts.

Until next time,

Scott

Scott D. Miller, Ph.D.
Registration is now open for our March Intensives in Chicago. Join colleagues from around the world for the FIT Advanced and the FIT Supervision workshops.

Do therapists improve (preprint)

The outcome of psychotherapy yesterday, today, and tomorrow (psychotherapy miller, hubble, chow, seidal, 2013)

Love, Mercy, & Adverse Events in Psychotherapy

July 9, 2015 By scottdm 10 Comments

Just over a year ago, I blogged about an article that appeared in one of the U.K.’s largest daily newspapers, The Guardian. Below a picture of an attractive, yet dejected looking woman (reclined on a couch), the caption read, “Major new study reveals incorrect…care can do more harm than good.”

I was interested.

As I often do in such cases, I wrote directly to the researcher cited in the article asking for a reprint or pre-publication copy of the study. No reply. One month later, I wrote again. Still, no reply. Two months after my original email, I received a brief note thanking me for my interest in the study and offering to share any results once they became available.

“Wait a minute,” I immediately thought, “The results of this ‘major new study’ about the harmful effects of psychotherapy had already been announced in a leading newspaper. How could they not be available?” Then I wondered, “If there are no actual results to share, what exactly was the article in The Guardian based on?”

So-called “adverse events” are a hot topic at the moment. That some people deteriorate while in care is not in question. Research dating back several decades puts the figure at about 10%, on average (Lambert, 2010). When those being treated are adolescents or children, the rates are twice as high (Warren et al., 2009).

Putting this in context, compared to medical procedures with effect sizes similar to psychotherapy (e.g., coronary artery bypass surgery, stages II and III breast cancer, stroke), the rate is remarkably low. Nonetheless, it is a matter of concern–especially given research showing that therapists are not particularly adept at recognizing when those they serve deteriorate in their care (Hannan et al., 2005)

The question, of course, is the cause?

To date, whenever the question of adverse events is raised, two “usual suspects” are trotted out: (1) the method of treatment used; and (2) the therapist. Let’s take a closer look at each.

In an October 2914 article published in World Psychiatry, Linden and Schermuly-Haupt wrote about estimates of side effects associated with specific methods of treatment that had been reported in an earlier study by Swiss researchers. The numbers were shocking. Patient reported “burdens caused by therapy” were 19.7% with CBT, 20.4% for systemically oriented treatments, 64.8% with humanistic approaches, and a staggering 94.1% with psychodynamic psychotherapy.

Based on such results, one could only conclude that anyone seeking anything other than CBT should have their head examined.

There is only one problem. The figures reported were wrong. Completely and utterly wrong. Linden and Schermuly-Haupt made an arithmetic error and, as a result, totally misinterpreted the Swiss findings. Read the study for yourself. When it comes to adverse events in psychotherapy, CBT–the fair-haired child of the evidence-based practice movement–is not better. Indeed, as the study clearly shows, people treated with humanistic and systemic approaches suffered fewer “burdens” than expected, while those in CBT had a slightly higher, although not statistically significant, level. More, the observed percentage of people in care who perceived the quality of the therapeutic relationship–the single most potent predictor of engagement and outcome–as poor was significantly higher than expected in CBT and lower for both humanistic and systemic approaches.

How could the researchers have gotten it so wrong?

As I pointed out in my blog over year ago, despite claims to the contrary (e.g., Lilenfeld, 2007), no psychotherapy approach tested in a clinical trial has ever been shown to reliably lead to or increase the chances of deterioration. NONE. Scary stories about dangerous psychological treatments are limited to a handful of fringe therapies–approaches that have been never vetted scientifically and which all practitioners, but a few, avoid. In short, its not about the method.

(By the way, over a month ago, I wrote to the lead author of the paper that appeared in World Psychiatry via the ResearchGate portal–a site where scholars meet and share their publications–providing a detailed breakdown of the statistical errors in the publication. No response thusfar)

With only one suspect left, attention naturally turns to the therapist–you know, the “bad apple” in the bunch. Here’s what we know. That some practitioners do more harm than others is not exactly news. Have you seen the new biopic Love & Mercy, about the life of Beach Boy Brian Wilson? You should. The acting is superb.

Wilson’s therapist, psychologist Eugene Landy (chillingly recreated by actor Paul Giamatti), is a prime example of an adverse event. See the film and you’ll most certainly wonder how the guy kept his license to practice so long. And yet, as I also pointed out in my blog last year, there are too few such practitioners to account for the total number of clients who worsen. Consider this unsettling fact: beyond the 10% of those who deteriorate in psychotherapy, an additional 30 and 50% experience no benefit whatsoever!

Where does this leave us when it comes to adverse events in psychotherapy?

Whatever the cause, lack of progress and risk of deterioration are issues for all clinicians and clients. The key to addressing these problems is tracking progress from visit to visit so that those not improving, or getting worse, can be identified and offered alternatives. It’s that simple.

Right now, practitioners can access two simple, easy-to-use scales for free at: www.whatispcoms.com. Both have been tested in multiple, randomized, clinical trials and deemed evidence-based by the Federal Substance Abuse and Mental Health Services Administration (SAMHSA).

Learning to use the tools isn’t difficult. It costs nothing to join the International Center for Clinical Excellence and begin interacting with professionals around the world who are using the measures to improve the quality and outcome of behavioral health services. More detailed instruction is available at the upcoming webinar:

Join us in tackling the issue of adverse events in psychotherapy. In the meantime, be sure and leave a comment below.

Best wishes for the summer,

Scott

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

P .S.: On the one year anniversary of my original email to the reseacher cited in the Guardian, I sent another. That’s over a month ago. So far, no reply. By contrast, the reporter who broke the story, Sarah Boseley , wrote back within a half hour! She’s following up her sources. I’ll let you know if she gets a response.

Something Fun for Summer: Mindreading, Memory, and Top Performance

May 20, 2015 By scottdm 5 Comments

Over the last several weeks, I’ve posted a series of blogs on some pretty serious subjects: (1) new and counterintuitive findings about the therapeutic relationship; (2) data documenting the lack of difference in outcome between mental health professionals, students, paraprofessionals, and a compassionate friend; and (3) cutting edge research on what therapists can do to address the surprisingly high failure rate of traditional psychiatric and psychological treatments. Thanks to all of those who read the posts and posted comments.

With summer finally arriving, and the long Memorial Day weekend fast approaching, I’ve been in the mood for something a little lighter and fun. Last week, I was in Gothenburg, Sweden teaching a three-day intensive on Feedback-Informed Treatment Supervision. As part of the training, my co-teacher, Susanne Bargmann, and I include the latest findings on top performing therapists. If you’re not familiar with the research, take a moment and read the interview in the latest issue of The Carlat Psychiatry Report (posted by permission).

As pointed out in the article, top performing clinicians spend two to four and a half times more hours per week than their more average counterparts engaged in “deliberate practice”–that is, attempting to improve their performance by consciously engaging in activities that push beyond what they already do well. To illustrate the point, and hopefully inspire the group to take up this challenging activity, Susanne and I move beyond our comfort zones, performing material that is completely outside the realm of therapy but which we have each been deliberately practicing. She sings. I do mindreading or feats of memory. Importantly, we only do what we have yet to perfect. Sometimes we fail–miserably. Whatever the outcome, the feedback is always invaluable.

So, just for fun, take a moment and watch the videos below. The first was filmed last week at the training in Sweden. It’s a piece on memory. The second video features a bit of mindreading. Be sure and leave a comment with your thoughts!

More fun and sun is available at the ICCE Intensive trainings this summer in Chicago. We have a few spots left for the FIT Implementation and FIT Ethics workshops. Participants will be attending from all around the world, including Sweden, Denmark, Norway, Australia, Canada, and the United States. Continuing education credits are available for both events. Hope to see you this summer.

Until next time,

Scott

Scott D. Miller, Ph.D.
International Center for Clinical Excellence
www.whatispcoms.com

Becoming a more effective therapist: Three evidence-based clues from research on the field’s most effective practitioners

April 15, 2015 By scottdm 2 Comments

It’s one of those secrets everyone knows, but few talk openly about: some therapists are more effective than others. Available evidence indicates that clients seen by these practitioners experience 50% more improvement, 50% less drop out, have shorter lengths of stay, and are significantly less likely to deteriorate while in care.

So, how do these top performers achieve the superior results they do? More to the point, is there anything the rest of us can learn from them? The answer is a resounding, “YES!” Over the last decade, researchers have started to unlock the secret to their success.

If you want to improve your effective effectives:

Give yourself, “The Benefit of Doubt”

Turns out, top performing therapists evince more of what researchers term, “professional self-doubt.” They are, said another way, less certain about how they work and the results they achieve than their less effective peers. To be sure, their doubt is not disabling but rather a first step, the harbinger of new learning. As UCLA basketball coach John Wooden once quipped, “It’s what you learn after you know it all that counts.”

One sure fire way to give yourself the benefit of doubt is to measure your results. Research shows, for example, that most of us overestimate how effective we really are—on average, by 65%! Augmenting your clinical judgement with reliable and valid feedback about when you are and are not successful will challenge you to reconsider what you long ago stopped questioning.

Assessing the outcome of your work is no longer difficult nor time-consuming. For example, the Outcome Rating Scale (ORS) takes less than a minute to administer and score and can be downloaded and used for free. More, a number of web based systems exist that not only alert you to clients “at risk” for dropping out, or experiencing a negative or null outcome from treatment, but also compute and compare your effectiveness to national norms. I reviewed two such systems in recent blog posts (1, 2).

Connect for Success

Research shows that 97% of the difference in outcome between therapists can be accounted for by therapist variability in the therapeutic relationship. Said another way, the single largest difference between the best and the rest is the former’s ability to connect with a broader, more complex, and diverse group of clients.

Can you think of any aspect of clinical practice that has yielded such unequivocal results? The bottom line for those wishing to become more effective is, work on your relationship skills.

As far as which element of the relationship you might want to focus on, consider the graph below. In it, you will find the effect size associated with each. To the right of the blue bar are aspects of psychotherapy that receive the majority of professional attention in graduate school and continuing education events, and their relative contribution to outcome.

By the way, for the first time this summer, the ICCE is offering a single day intensive ethics training. If you need ethics CE’s, this is the event you want to attend. The focus? The relationship. Given the findings noted above, isn’t that the right thing to be talking about?!

Mark your calendar: August 12^th, 2015. Chicago, Illinois.

Register early as the number of participants has been capped at 35 in order to insure an intimate, individualized experience.

Slow and Steady Wins the Race

In the proverbial race between Tortoises and Hares, the most effective clinicians fall squarely in the camp of the ectotherms. For them, there are no shortcuts. No fast track to success. No models that, when applied with fidelity, will lead them to treatment nirvana.

Top performing clinicians approach the subject of improving their outcomes the same way investors prepare for retirement: a little bit every day over a long period of time. Compared to average therapists these top performers spend 2.5 to 4.5 more hours per week outside of work in activities specifically designed to improve the effectiveness of their work—an activity known as, “Deliberate Practice.”

You can see how the investment in professional development compounds over time the graph below taken from a study soon to appear in the journal, Psychotherapy.

Of course, the quality of the return depends on the nature of the investment. So, what should you invest in? To get better, you must first identify the edge of your “realm of reliable performance”—that spot where what you normally do well begins to break down. From there, you have to develop a concrete plan, complete with small, measureable process and outcome objectives. This is often best accomplished with the help of a mentor or coach, someone who possesses the skill you need and is capable of teaching it to others. Trial, error, and review follows.

You can learn to apply the latest findings about deliberate practice to your own professional development at a special, two-day intensive this summer. Cutting edge research will be translated into highly individualized, step-by-step instructions for improving your clinical performance and effectiveness. We promise you will leave with an evidence-based plan tailored to your personal, professional development needs.

Mark your calendar: August 10-11^th, 2015.

Given the highly individualized nature of this event, registration is limited to 20 participants. You can reserve your spot today by clicking here.

Looking forward to meeting you this Summer in Chicago!

Scott

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

Therapist Wanted: Dead or Alive

January 15, 2015 By scottdm 1 Comment

Do you get those letters about the top healthcare providers in your area?

At the beginning of the new year, our city’s local magazine publishes a list of the top healthcare providers. It’s a big deal. Organized by location and specialty, the issue contains full-page photos, glossy spreads, and breezy write-ups. Impressive stuff with a wide and hungry readership anxious to sort the best from the rest.

So, how do the publishers separate the proverbial “wheat from the chaff?” The answer, depending on whether you are a provider or potential patient, may alternately surprise or frighten you.

Not long ago, Abigail Zuger received one of those letters. In it, she learned that a relative of hers had been named “one of the worlds top physicians in his area of expertise.” Ordinarily, she would have been proud. There was only one problem. Her now esteemed relative was dead–and not just recently. He’d been dead 16 years!

Abigal Zuger is a physician and professor of medicine at Columbia University. The story about her experience appeared in the New York Times. In it, she notes the temptation to become cynical, to dismiss the Top Doc lists, “as just so much advertisement and avarice.” She concludes, however, that a “more nuanced and charitable view is…[that] these services may simply be trying, valiantly if not clumsily, to remedy the single biggest mystery in all of health care…what makes a top doctor…[and] how to find one.”

Three methods dominate among list makers: (1) culling names and addresses from phone directories; (2) polling healthcare providers; and (3) collating patient online ratings. Said another way, consulting available lists lets you know if your healthcare provider once had a phone, was liked by their colleagues, or managed not to piss off too many of the people they treated!

Remarkably absent from the criteria used to identify top providers is any valid and reliable measure of their effectiveness!

Determining one’s effectiveness as a mental health professional is not as difficult or time consuming as it was not long ago. Whether you work with individuals, groups, or families, in inpatient, residential, or an outpatient setting, a simple set of tools is available for monitoring both the outcome and the quality of the services you provide. The tools take minutes to administer and score and are free.

If you are worried about statistics, don’t be. A variety of electronic solutions exist which not only will administer and score the measures but provide normative comparisons for assessing individual client progress and sophisticated analyses of provider, program, and agency effectiveness levels. I’ll be reviewing each system in an upcoming series of blogposts, so stay tuned.

To see what’s possible, check out the Colorado Center for Clinical Excellence. There, clinicians not only measure their effectiveness, but set benchmarks for superior performance and report clinician outcomes transparently on the agency website.

It’s easy to get started. First, download the free tools. Second, join colleagues from around the world in a four-part online webinar and learn how to use the tools to inform and improve your practice. We’ll be covering everything you need to know to integrate outcomes into your clinical work. In the process, as Dr. Zuger pointed out, we’ll be solving “single biggest mystery in all of health care.”

Look forward to connecting with you online!

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

Dinner with Paul McCartney (and others)

December 11, 2014 By scottdm 7 Comments

McCartney

Growing up, my family had a game we frequently played around the dining room table. “If you could invite anyone to dinner,” it always started,”who would it be?” Invariably, my father chose historical figures: Abraham Lincoln, Mark Twain, Leonardo Da Vinci. My mom was more inclined toward the living: Jackie O., J.D. Salinger, Lucille Ball. My brothers, Marc and Doug, usually went for sports figures. I recall Wilt Chamberlain and Willie Mays being popular choices–although there were many others whose names I’ve now forgotten.

Me? Always the same answer: Paul McCartney.

Of course, the “name game” didn’t end there. Whatever your choice, you also had to state why. Here, my answer didn’t vary either. “He’s one of the Beatles!” I’d say, frustrated whenever my family acted as though my statement needed further clarification.

To this date, I’ve never had a chance to met much less have dinner with Paul McCartney. Seen him in concert a number of times but always from a distance. Last week, however, I did have the opportunity to meet and spend time with a number of my heroes from the field of psychotherapy–and go to dinner together, not once, but twice!

We were together at the first ever Calgary Counseling Center Outcomes conference. Thanks to Center’s director, Dr. Robbie Wagner, a small group of practitioners, policy makers, and agency managers were invited to spend two, intimate days learning from the field’s leading thinkers and researchers. The Beatles of outcome research: Michael J. Lambert, Bruce E. Wampold, Michael Barkham, Wolfgang Lutz, and Gary Burlingame. I presented the latest results on our studies of top performing therapists.

It was every bit a rock concert–exciting, controversial, and cutting edge. Below, I summarize the “greatest hits.” I’ve also included the slides from each presentation for those who like to read the details contained in the “liner notes!”

Let me know what you think…here goes:

The burden born by people with mental health problems is second only to cancer (Depression alone results in a 70% loss of productivity)

Bottom line: People need the skills mental health professional have to offer

Treatment is effective. However, therapists believe they help far more people than they do (85% versus 20%);
Approximately 10% of adults deteriorate in care;
Between 14 and 25% of children are worse off following treatment;
Serious deterioration recognized in only one-third of cases;

Bottom Line: Mental health professionals overestimate their effectiveness and miss deterioration

Multiple, sophisticated, real world studies find no difference in outcome between people treated with different therapeutic approaches;
Factors related to the therapeutic relationship (i.e., empathy, collaboration, affirmation, genuineness) have a far greater impact on outcome (7:1) than treatment approach, adherence to treatment protocol, or rated competence.

Bottom Line: The pathway to improved effectiveness is not adopting new treatment approaches

Rapid and dramatic change (first 5 visits) occurs in as many as 40% of people and is maintained at two year follow up;
90% chance of failure if there is no change between the 2nd and 8th visit;
As many as 25% of people remain in treatment while experiencing no measurable benefit;

Bottom Line: A large number of people need very little treatment to achieve lasting benefit

Separating intake from treatment results in higher drop out, lower and longer treatment response, and higher costs;

Bottom Line: Any barrier to establishing a relationship with a specific provider has a negative impact on outcome

The majority of individual practitioners are effective;
Around 16% of practitioners achieve outcomes significantly below average;
Less effective practitioners rate empathic understanding more highly as a professional/personal attribute than more effective practitioners;
The clients of the least effective clinicians were assigned to average practitioners, an additional 15% of clients would achieve clinical recovery;
Around 16% of practitioners consistently achieve outcomes significantly above average;
More effective practitioners rate resilience and mindfulness more highly as a professional/personal attribute;
Professional self-doubt and an “error-centric attitude” are associated with better outcomes.

Bottom Line: Choose your therapist carefully as they determine the outcome of care

When therapists receive feedback that clients are deteriorating, they: discuss it with clients about 60% of the time; make efforts to assist with other resources about 27% of the time; adjust therapeutic interventions 30% of the time; vary intensity or dose of services 9% of the time; consult with others (supervision, education, etc.) 7% of the time;
Therapist attitude toward soliciting and using feedback vary and influence results;
Therapists who value feedback achieve better outcomes;
Professional self-doubt and an “error-centric attitude” are associated with better outcomes;

Bottom Line: Regular, formal feedback from clients to therapists improves outcomes (as long as the therapist listens and acts on the feedback)

When asked, 92% of clients say they like the use of outcome measures in care.

Bottom Line: An overwhelming majority of clients endorse progress monitoring or providing feedback

The economic value of monitoring patient treatment response (Lambert, 2014)

How to double client outcomes in 18 seconds (Lambert, 2014)

Practice-based Evidence (Michael Barkham, 2014)

How to Improve Quality of Services by Integrating Common Factors into Treatment Protocols

When & How do Patients Change? Wolfgang Lutz Outcome Presentation

Reach: Pushing Your Clinical Effectiveness to the Next Level

What articles have 140,000 of your colleagues read to improve their practice?

November 21, 2014 By scottdm 1 Comment

Each week, I upload articles to the web about how to improve effectiveness. There are a lot to choose from, but here are the top ones read by behavioral health professionals around the world:

Measures and Feedback 2014

This is the latest version of the most widely-read upload on the site. It summarizes all of the available research about using feedback to improve retention in and outcome of care, including studies using the ORS and SRS.

How to Improve your Effectiveness

A short, fun article that highlights the evidence-based steps for improving one’s effectiveness as a behavioral health provider. Feedback, it turns out, is not enough. This article reviews the crucial step that makes all the difference.

Finally, here’s a link to a simple-to-use tool for interpreting scores on the ORS:

ORS Reliable Change Chart

That’s it for now. Best wishes in your work. Stay in touch.

Scott D. Miller, Ph.D.
Director, International Center for Clinical Excellence
info@scottdmiller.com

Registration is open for the Advanced Training in Feedback-Informed Treatment (FIT). Learn how to integrate this SAMHSA certified evidence-based practice into your work or agency. We promise you three comprehensive, yet fun-filled days of learning together with colleagues from around the world.

Are you any good as a therapist? The Legacy of Paul W. Clement

March 26, 2014 By scottdm 4 Comments

Twenty years ago, I came across an article published in the journal, Professional Psychology. It was written by a psychologist in private practice, Paul Clement. The piece caught my eye for a number of reasons. First, although we’d never met, Paul lived and worked in a town near my childhood home: Pasadena, California. Second, the question he opened his article with was provocative, to say the least, “Are you any good?” In other words, how effective are YOU as a psychotherapist? Third, and most important, he had compiled and was reporting a quantitative analysis of his results over the last 26 years as a practicing clinician. It was both riveting and stunning. No one I knew had ever done had published something similar before.

In graduate school, I’d learned to administer a variety of tests (achievement, vocational, personality, projective, IQ, etc.). Not once, however, did I attend a course or sit in a lecture about how to measure my results. I was forced to wonder, “How could that be?” Six years in graduate school and not a word about evaluating one’s outcomes. After all, if we don’t know how effective we are, how are any of us supposed to improve?

What was the reason for the absence of measurement, evaluation, and analysis? It certainly wasn’t because psychotherapy wasn’t effective. A massive amount of research existed documenting the effectiveness of treatment. Paul’s research confirmed these results. Of those he’d worked with, 75% were improved at termination. Moreover, such results were obtained in a relatively brief period of time, the median number of sessions used being 12.

Other results he reported were not so easy to accept. In short, Paul’s analysis showed that his outcomes had not improved over the course of his career. At the conclusion of the piece, he observed, “I had expected to find that I had gotten better and better over the years, but my data failed to suggest any systematic change in my therapeutic effectiveness across the 26 years in question…it was a bad surprise for me.” (p. 175).

For years, I carried the article with me in my briefcase, hoping that one day, I might better understand his findings. Maybe, I thought, Clement was simply an outlier? Surely, we get better with experience. It was hard for me to believe I hadn’t improved since my first, ham-handed sessions with clients. Then again, I didn’t really know. I wasn’t measuring my results in any meaningful way.

The rest is history. Within a few short years, I was routinely monitoring the outcome and alliance at every session I did with clients. Thanks to my undergraduate professor, Michael Lambert, Ph.D., I began using the OQ 45 to assess outcomes. Another mentor, Dr. Lynn Johnson had developed a 10-item scale for evaluating the quality of the therapeutic relationship, know as the Session Rating Scale. Both tools became an integral part of the way I worked. Eventually, a suggestion by Haim Omer, Ph.D., led me to consider creating shorter, less time consuming visual analogue versions of both measures. In time, together with colleagues, the ORS and SRS were developed and tested. Throughout this process, Paul Clement, and his original study remained an important, motivating force.

Just over a year ago, Paul sent me an article evaluating 40 years of his work as a psychotherapist. Once again, I was inspired by his bold, brave, and utterly transparent example. Not only had his outcomes not improved, he reported, they’d actually deteriorated! Leave it to him to point the way! As readers of this blog know, our group is busy at work researching what it takes to forestall such deterioration and improve effectiveness. Last year, we summarized our findings in the 50th Anniversary issue of Psychotherapy. As I write, we are preparing a more detailed report for publication in the same journal.

Yesterday, I was drafting an email, responding to one I’d recently received from him, when I learned Paul had died. I will miss him. In this, I know I’m not alone.

Good News and Bad News about Psychotherapy

March 25, 2014 By scottdm 3 Comments

Have you seen this month’s issue of, “The National Psychologist?” If you do counseling or psychotherapy, you should read it. The headline screams, “Therapy: No Improvement for 40 Years.” And while I did not know the article would be published, I was not surprised by the title nor it’s contents. The author and associate editor, John Thomas, was summarizing the invited address I gave at the recent Evolution of Psychotherapy conference.

Fortunately, it’s not all bad news. True, the outcomes of psychotherapy have not been improving. Neither is there much evidence that clinicians become more effective with age and experience. That said, we can get better. Results from studies of top performing clinicians point the way. I also reviewed this exciting research in my presentation.
Even if you didn’t attend the conference, you can see it here thanks to the generosity of the Milton H. Erickson Foundation. Take a look at the article and video, then drop me a line and let me know what you think. To learn more, you can access a variety of articles for free in the scholarly publications section of the website.

Click here to access the article from the National Psychologist about Scott Miller’s speech at the Evolution of Psychotherapy Conference in Anaheim, California (US)

How Cool is Kuhl? A Man with Vision on a Mission

April 19, 2013 By scottdm Leave a Comment

This week, my colleague and friend, Dr. David Mee-Lee, sent me a link to a blogpost written by Don Kuhl. Actually, I was already a subscriber to Don’s Minful MIDweek blog (you should be too), but my travel this week had prevented me from reading his latest installment. His posts always leave me inspired and give me something to think about. This week was no different. More on that in a moment.

In the meantime, let me tell you about Don. He is the founder and CEO of The Change Companies, a company whose mission is to create tailored materials and programs to support behavioral change for special populatons. And create they do. Hundreds of bright, attractive, highly readable publications and guided workbooks for use by professionals and the people they serve. Their material is exhaustive and comprehensive, including adult behavioral health, criminal justice, education and prevention, clinical assessment, and faith-based programs. A side note, it was Don and his skillful team at The Change Companies that produced the ICCE Feedback Informed Treatment and Training Manuals. If you’ve not seen them, you should. They are the cutting edge of information about FIT.

What is most striking about Don, however, is his passion. I met him at a conference in San Francisco nearly a decade ago. On several occasions, he flew to Chicago from his home base in Carson City, Nevada just to meet, talk, and share ideas. The photo above is from one of the meetings he arranged. Don is devoted to improving the quality and experience of behavioral health services for professionals and clients alike. Simply said, Don Kuhl is cool.

In his blogpost this week, Don wrote about that meeting with Jim Prochaska, David Mee-Lee, me, and Bill Miller. He referred to it as a “highlight” of his recent professional life, a lucky event resulting from his mindful pursuit of relationships with “people who have smiles on their faces and goodness in their hearts.”

My thought? I was and am the lucky one. Thanks Don. Thanks Change Companies. Keep up the good work.

An Easy Way to Improve Our Schools (and Psychotherapy)

November 13, 2012 By scottdm Leave a Comment

If you didn’t see the October Atlantic Monthly, you really missed a great issue. In it, Amanda Ripley wrote a delightful and informative article about a simple and straightforward method for improving the performance of the public schools: have kids grade teachers. What kind of grades you ask? Not those on standardized achievement tests, and certainly not measures of a teacher’s popularity. Although both of those methods are widely advocated and used, neither has proven particularly predictive of student performance. Rather, grades should be based on how well teachers engage students; particularly whether the kids believe the teacher makes them want to work hard, pay attention, understand the course material, and identify and correct their mistakes. Indeed, in thousands of surveys, kids as young as kindergartners “can identify with uncanny accuracy, their most–and least effective teachers.”

The findings stood out for me not only because I am a parent but also because they mirror results from psychotherapy research. First, data gathered over the last three decades documents that client engagement is the number one process-related predictor of treatment outcome. Second, a growing number of studies indicates that clients can identify “with uncanny accuracy” the most and least effective treatment services and providers. Importantly, this same body of evidence shows that client assessments of their sessions and progress can be used to enhance treatment results in general as well as the effectiveness and skill level of individual clinicians.

Viewpoint clearly matters–and in the case of schools and psychotherapy, it is the recipient of the service whose opinion we should be seeking. In her article, Ripley identifies the types of questions that can be used in schools. If you are a therapist, two brief, simple-to-use scales are available for free. Research has shown that regularly using the measures to solicit client feedback improves both retention in and outcome of psychotherapy. The largest, international professional community dedicated to enhancing the quality and outcome of behavioral healthcare is available to support you in your use of the tools. There, you will find a wealth of information, discussion forums, and how-to videos available at no charge 24 hours a day, 7 days a week, 365 days a year.

In March, many members from around the world will be joining colleagues from around the world for four days of intensive training. Why not join us? We work and play hard. Rest assured that by the end of the four days, you’ll be playing an “A” game. Click here to register today. In the meantime, here’s what participants from last year said about the event.

Psychotherapy Training: Is it Worth the Bother?

October 29, 2012 By scottdm 2 Comments

Big bucks. That’s what training in psychotherapy costs. Take graduate school in psychology as an example. According to the US Department of Education’s National Center (NCES), a typical doctoral program takes five years to complete and costs between US$ 240,000-300,000.00.

Who has that kind of money laying around after completing four years of college? The solution? Why, borrow the money, of course! And students do. In 2009, the average amount of debt of those doctoral students in psychology who borrowed was a whopping US$ 88,000–an amount nearly double that of the prior decade. Well, the training must be pretty darn good to warrent such expenditures–especially when one considers that entry level salaries are on the decline and not terribly high to start!

Oh well, so much for high hopes.

Here are the facts, as recounted in a recent, concisely written summary of the evidence by John Malouff:

1. Studies comparing treatments delivered by professionals and paraprofessionals either show that paraprofessionals have better outcomes or that there is no difference between the two groups;

2. There is virtually no evidence that supervision of students by professionals leads to better client outcomes (you should have guessed this after reading the first point);

3. There is no evidence that required coursework in graduate programs leads to better client outcomes.

If you are hoping that post doctoral experience will make up for the shortcomings of professional training, well, keep hoping. In truth, professional experience does not correlate often or significantly with client therapy outcomes.

What can you do? As Malouf points out, “For accrediting agencies to operate in the realm of principles of evidence-based practice, they must produce evidence…and this evidence needs to show that…training…contribute(s) to psychotherapy outcomes…[and] has positive benefits for future clients of the students” (p. 31).

In my workshops, I often advise therapists to forgo additional training until they determine just how effective they are right now. Doing otherwise, risks perceiving progress where, in fact, none exists. What golfer would buy new clubs or pursue expensive lessions without first knowing their current handicap? How will you know if the training you attend is “worth the bother” if you can’t accurately measure the impact of it on your performance?

Determining one’s baseline rate of effectiveness is not as hard as it might seem. Simply download the Outcome Rating Scale and begin using it with your clients. It’s free. You can then aggregate and analyze the data yourself or use one of the existing web-based systems (www.fit-outcomes.com or www.myoutcomes.com) to get data regarding your effectiveness in real time.

After that, join your colleagues at the upcoming Advanced Intensive Training in Feedback Informed Treatment. This is an “evidence-based” training event. You learn:

• How to use outcome management tools (e.g., the ORS) to inform and improve the treatment services you provide;

• Specific skills for determining your overall clinical success rate;

• How to develop an individualized, evidence-based professional development plan for improving your outcome and retention rate.

There’s a special “early bird” rate available for a few more weeks. Last year, the event filled up several months ahead of time, so don’t wait.

On another note, just received the schedule for the 2013 Evolution of Psychotherapy conference. I’m very excited to have been invited once again to the pretigious event and will be bring the latest information and research on acheiving excellence as a behavioral health practitioner. On that note, the German artist and psychologist, Andreas Steiner has created a really cool poster and card game for the event, featuring all of the various presenters. Here’s the poster. Next to it is the “Three of Hearts.” I’m pictured there with two of my colleagues, mentors, and friends, Michael Yapko and Stephen Gilligan:

Is Psychotherapy Getting Better?

October 11, 2012 By scottdm Leave a Comment

This last month, I spent a significant amount of time traveling around Europe and Scandanavia (Germany, Sweden, Denmark, the Netherlands) working with clinicians and mental health agencies implementing Feedback-Informed Treatment. Not infrequently, people ask me, “doesn’t all the travel wear you out?” My pat response is, “No, not at all! The worst part is being away from my family. But, meeting with practitioners and agency managers always buoys my spirits.” I mean it. I miss my family and the airlines (and airport food) are a real drag. Practitioners are, on the other hand, a different story. Despite the numerous challenges (funding, documentation, regulatory demands, etc.), they persist, working to improve their skills and provide effective help to their clients.

As happened a few months ago, I was in the SAS lounge at the Copenhagen airport, waiting for a flight, enjoying a cup of coffee, and catching up on the news, when I ran across another article by Thomas Friedman that caught my eye. “The plan,” he said, “to work hard and play by the rules to get ahead is now outdated. It takes much more than that.”

Wow, I thought, he’s so right–especially when it comes to the field of mental health. I was raised in an era when “working hard at your job” was the formula for success, the pathway to a fruitful and enjoyable career. As I travel the world, however, I see just how little reason there is to believe in this ideal any longer. The rules have changed. The world, observed Friedman, “is now a more open system. Technology and globalization are wiping out lower-skilled jobs faster, while raising the skill level required for new jobs. More than ever now, lifelong learning is the key to getting into and staying in the middle class.”

As I said earlier, the therapists I meet are working very hard–harder than either I or they ever anticipated. They are putting in more hours and, in many cases, making less money than they did a few years earlier. It’s true! Did you know, psychologists incomes are down 17% in the last decade? Simply put, working hard is a recipe for…eventual failure. If we are to survive and thrive, a change of order–not magnitude–is required.

Recently, Diane Cole addressed the challenges facing practitioners in a special issue of the Psychotherapy Networker. It’s worth a read (click here). Importantly, she doesn’t just bemoan the problems currently facing the field, but provides crucial information for helping each and every one of us take charge of our fate.

Thomas Szasz, M.D.: Memories of a Friend and Mentor

September 26, 2012 By scottdm 4 Comments

Very early in the morning of December 9th, 2009, I received a call in my hotel room. My long time colleague and mentor, Jeffrey Zeig was on the other end.

“May I ask you a favor?” he said.

“Of course,” I instantly replied, completely unaware of what was coming.

“Tom Szasz is caught in a snow storm and hasn’t been able to get out of New York, do you think you could fill in for him? He was scheduled as a discussant for a presentation today being given by Otto Kernberg.”

Otto Kernberg? I thought to myself. The Otto Kernberg? The psychoanalyst and professor of psychiatry at Cornell? The author of…

“Oh my,” I replied, without thinking.

“It’s scheduled for around 4 this afternoon in the Anaheim Convention Center Arena.”

The big room?! I instantly thought, my panic rising.

“Oh my,” I once again replied, and then after a brief pause, answered, “Sure.”

“Thanks so very, very much Scott,” Jeff said, “you are a life saver.”

With that, I hung up the phone. Sitting on the bed, I thought about Tom Szasz. We’d met for the first time four years earlier at the same conference, The 2005 Evolution of Psychotherapy. That’s when the photo of the two of us together was taken. He was sitting at a table, eating breakfast alone, in the executive lounge at the conference hotel. All the other places were occupied. Of course, I knew who he was. I’d read all of his books, a number more than once. I’d also been to a number of presentations he’d given over the years. Whether one agreed with his positions or not, you had to be awed by his careful, clear, and deliberate thinking. On more than one occasion I’d seen him ensnare and then dispatch detractors with ease.

When I asked if I could sit at this table, he was instantly friendly. “But of course,” he replied, his Hungarian accent immediately familiar to me. For the next half hour, we talked, although not exclusively, mostly about the current state of the field of mental health. I was struck by how many questions he asked me: where I was from, what I did, and especially about my work on top performing therapists. Thereafter, we met every morning for breakfast. It is a memory I cherish.

Once more, I find myself thinking about Dr. Szasz, who passed away at the age of 92 earlier this month. He authored over 30 books and 1000 articles. As a lifelong libertarian, he argued consistently against what he considered instrusions on the freedom and dignity of individuals treated in the mental health system. His work was often misunderstood and mischaracterized by people in and out of the profession, including the frequent association of his work with the anti-psychiatry movement (a movement he ridiculed, by the way, labelling it “quackery squared”).

For these, and many other reasons, personal and professional, I will miss him. If you are not familiar with his work and thinking, the video below will give you a good introduction. I promise you will be moved.

One final note. The presentation by Otto Kernberg and my response certainly generated some fireworks (you can listen by clicking: Kernberg). Given the short notice, tt had not been possible for to prepare in any meaningful way. I did not have a chance to read the speech prior to hearing it. As I listened, I took careful notes, and then, with Dr. Szasz in mind, did my level best to develop a thougtful, rational response based on my core values. I pointed to recent research–an area I did know something about–which found Kernberg’s approach less effective than alternative approaches. Needless to say, this led to a demand by Dr. Kernberg to respond. The resulting back and forth between the two of us was exhilirating. I hope Dr. Szasz would have been proud.

REACHing the Next Level of Clinical Performance: What it Really Takes

September 1, 2012 By scottdm 2 Comments

Do any of these people look familiar? Well, of course, I’m the guy in the middle pointing. To my left is the rock and roll guitarist Joe Walsh. On my right is world-renowned, card mechanic Richard Turner. Why have I pictured myself sandwiched between these two? Because they are both inspiring examples of what can be accomplished when individuals push beyond the “tried and true,” to reach the next level of performance.

Back in June, I read an article about Joe Walsh in the Chicago Tribune. Buried deep in the piece was a brief biography of the guitarist that exemplifies what it takes to achieve excellence. Walsh, who is 67 years old, began playing back in the late 1960’s. Like many of his generation, he was inspired by the Beatles. One day, he was listening to the band’s song, “And Your Bird can Sing,” which contains a “ridiculously finger stretching George Harrison guitar solo.” According to the article, Walsh worked tirelessly until he mastered the riff. It was only years later, long after he’d become famous, that he met Ringo Starr. Walsh related the story to the drummer who “looked at Walsh like he was nuts.” Harrison, Ringo told him, had played two guitar parts separately and tracked them on top of each other and later tracked them together in the studio.

Good thing no one told Walsh the truth. As a result, he did what no one–even now–thought posssible.

On to Richard Turner. Unless you are into magic or gambling, this may be the first time you’ve ever heard of this person. Author Alex Stone, in his phenomenally fun and informative book, Fooling Houdini, describes him as “a card handler without equal, a man whose prowess with a deck borders on the supernatural.” The supernaturnal? Really? I would have deemd such praise so much more hype, typical of “hollywood” and the media, if I hadn’t meet Turner personally and seen him work. Simply put, there’s nothing he can’t do with a deck of cards.

Watch the brief video below filmed at this year’s “Training of Trainers” event in Chicago. At all training events, we bring in top performers to entertain, inspire, and inform participants about what it takes to achieve excellence.

Not bad eh? Especially when one considers that Turner is blind. And the video above is only the tiniest snippet of his performance. At one point, he dealt out hands of poker and black jack, asking audience members which position they would like to have dealt the winning cards. Sure enough, whatever position was called, luck struck there and only there. “Give me a number between 1 and 52,” he asked. Whatever number was called out, he cut the cards to that exact position in the deck. Did I mention he’s also a 6th degree black belt? Simply put, Turner is a performer that is always pushing the limits. Once he was cited for a driving motor cycle while blind! How does he do it? Practice. Yep, seventeen hours a day! For years, he slept with a deck of cards. Like Walsh, he persisted until he mastered moves that no one considered possible or, more accurately, no one ever even imagined.

So, what can mental health professionals do to REACH the next level of clinical performance? Over the last few years, together with my colleagues, we’ve been writing about the steps thrapists can take to achieving excellence. This year, I was privileged to summarize the current state of the research on the subject in a keynote address at the Psychotherapy Networker conference in Washington, DC. Here, for the first time, is “Part 1” of that address (the second half will follow soon). In it, I lay out what the evidence says it takes to excel.

A Lotta Help from One’s Friends: The Role of Community in the Pursuit of Excellence

August 3, 2012 By scottdm Leave a Comment

Dateline: Chicago, IL USA

Hard not to be impressed with the USA Women’s Gymnastic team. What skill, percision, expertise, and excellence.

By now, I’m sure you’ve seen the interviews. In all instances, each and every one has focused on the team. Despite some in the media attempting to make stars out of the individual members, the atheletes have continually highlighted, “The Team.” When asked to account for their success or the source of their ambition, the reason cited has been: THE TEAM.

Sixteen year old McKayla Maroney said, “I think we’re as close as we can be. We’ve all been working and training together for a long time…I’ve known (fellow team member) Kyla since I was 6 years old. We are all best of friends. They did so great today and I just love this team so much.”

As highlighted in our recent article, “The Road to Mastery,” excellence does not occur in a vacuum. Surrounding every great performer is a community (teachers, coaches, mentors, and peers). In the busy world that is modern clinical practice, where can practitioners finda trsutworthy and supportive community of peers? A group of colleagues that will challenge them to keep growing as professionals and people?

In a word, the ICCE. In December 2009, the International Center for Clinical Excellence was launched and since them become the largest, global, web-based community of clinicians, researchers, administrators, and policy makers dedicated to excellence in behavioral health. The ICCE has it’s own gold-medal winning team! Practitioners working together in locations around the globe.

Practitioners like Jason Seidel, Psy.D., who represented ICCE at last week’s meeting of the American Psychological Association. Jason presented on Feedback Informed Treatment (FIT) and then participated in a panel discussion on Practice Based Evidence together with Paul Clement, Michael Lambert, Bill Stiles, Carol Goodheart, and David Barlow. Jason rocked the packed house with his tight summary of the empirical support for FIT and argument in favor of practice-based evidence!

Then there’s Daryl Chow, a psychologist from Singapore, who is currently finishing up a quantitative study of “Supershrinks.” His research is the first to employ a sophisticated statistical analysis of therapists practices related to superior outcomes. Suffice it to say, his results are mind blowing. Daryl’s work won him a scholarship to this year’s “Training of Trainers” course. If you’re not signed up for that event, you can meet him today by joining the ICCE and looking him up!

There are many, many other dedicated and supportive members. Join and share your expertise with the community today!

Revolution in Swedish Mental Health Care: Brief Update

May 14, 2012 By scottdm 1 Comment

In April 2010, I blogged about Jan Larsson, a Swedish clinician who works with people on the margins of the mental health system. Jan was dedicated to seeking feedback, using the ORS and SRS to tailor services to the individuals he met. It wasn’t easy. Unilke most, he did not meet his clients in an office or agency setting. Rather, he met them where they were: in the park, on the streets, and in their one room aparments. Critically, wherever they met, Jan had them complete the two measures–“just to be sure,” he said. No computer. No I-phone app. No sophisticated web-based adminsitration system. With a pair of scissors, he simply trimmed copies of the measures to fit in his pocket-sized appointment book! I’ve been following his creative application of the scales ever since.

Not surprisingly, Jan was on top of the story I blogged about yesterday regarding changes in the guidelines governing Swedish mental health care practice. He emailed me as I was writing my post, including the link to the Swedish Radio program about the changes. Today, he emailed again, sending along links to stories appearing in two Swedish newspapers: Dagens Nyheter and Goteborg Posten.

Thanks Jan!

And to everyone else, please continue to send any new links, videos, and comments.

A Progress Report on the Science (and Art ) of Psychotherapy: The Psychotherapy Networker 30th Anniversary Edition

March 18, 2012 By scottdm Leave a Comment

The 30th Anniversary Edition of the Psychotherapy Networker has hit newsstands. In it, is an article by Diane Cole taking the measure of psychotherapy. Her question? Has the field gotten any better over the last three decades? The entire issue is a “must read,” starting with editor Rich Simon’s lengthy and thought provoking editorial, “Still Crazy After All These Years.”

Even if you are not a subscriber, much of the current edition is available FOR FREE online at the Networker website. It is an honor that the work that I have been doing on excellence and expert performance, together with many Senior Associates at ICCE (Susanne Bargman, Cynthia Maeschalck, Julie Tilsen, Rob Axsen, Jason Seidel, and Bob Bertolino) is featured prominently in this special issue magazine.

Don’t miss it! And don’t miss the Networker conference scheduled this week in Washington, D.C. I’ll be there on Friday delivering the luncheon keynote address and a workshop on pushing your clinical performance to the next level of effectiveness!

The New Average: Meeting the Need to Exceed

February 10, 2012 By scottdm Leave a Comment

No matter where you look,good is no longer “good enough.” In a recent article in the New York Times, author and trend watcher, Thomas L. Friedman, declared, “Average is Over.” It’s an argument similar to the one made over a decade ago by Robert Reich, former Secretary of Labor under Bill Clinton, in his phenomenally prescient book The Future of Success. I read it at the time with a mixture of apprehension and anticipation. Globalization and advances in information technology were then and are now challenging the status quo. At one time, being average enabled one to live an average life, live in an average neighborhood and, most importantly, earn an average living. Not so anymore.

Average is now plentiful, easily accessible, and cheap. What technology can’t do in either an average or better way, a younger, less-trained but equally effective provider can do for less. A variety of computer programs and web-based systems provide both psychological advice and treatment. (By the way, studies to date document outcomes equal to face-to-face services for at least the most common mental health related issues). At the same time, as reviewed here previously on this blog, the evidence again and again shows no difference in outcome between professionally trained clinicians and students or paraprofessionals. Uh-oh.

What is the solution? Friedman says, “everyone needs to find their extra–their unique value contribution that makes them stand out in whatever is their field.” Yeah, exactly. As my father used to say, “Do your best and then a little better. What can behavioral health professionals do to stand out? Well, if you are trained, licensed or certified, practicing evidence-based, know the latest methods and research findings, and understand how the brain works, then you are, in a word, average. Going forward, standing out will require evidence that you are effective; measures documenting not only who you help but identifying those you do not. Professional development will be less about learning a new method than documenting what you do to “do your best and then a little better.”

Helping clincians stand out is what the ICCE is all about. Everyday, thousands meet online to learn, share, and support each other in both measuring and improving the impact of their clinical work. Each year, the ICCE offers two intensive training opportunities: The Advanced Intensive and the Training of Trainers. Both events are designed to help professionals achieve their personal best. The Training of Trainers is specifically designed for participants, such as supervisors, managers, and agency directors, who wish to train others or transform public or private agencies for achieving success. The Advanced Intensive scheduled for March is sold out. By popular demand, we are offering an unprecedented second opportunity to attend the Advanced Intensive this summer. Don’t wait to register. Despite only announcing this event last week, half of the seats are already booked. Either event will insure that you have the tools and skills necessary to meet the need to exceed. Email us with any questions at: training@centerforclinicalexcellence.com.

(By the way, if you are interested, you catch watch a clip of Friedman delivering his message to the Hudson Society here).

The Role of Mentors in the Development of Expertise: Bruce Wampold wins the Beckman Award Honoring Inspirational Professors

January 12, 2012 By scottdm Leave a Comment

Saturday, January 7th, 2012, 7:00 pm EST
The Carter Presidential Libary
Atlanta, Georgia

In 2008, the Elizabeth Hurlock Beckman Trust Award was created to honor inspirational professors, academic faculty members who have inspired their students to “create an organization, concept, procedure, or movement which has demonsrably conferred a benefit on the community.”

This last week, I had the honor of joining my former professor and long time mentor, Bruce Wampold, Ph.D., at the Carter Presidential Library in Atlanta, Georgia as he received the 2011 Beckman Award. I met Bruce in 1984, my first year in graduate school. As you might guess, he was the statistics instructor. Turns out, it was his first academic post! I learned so much in that class as well as the “Applied Regression/Correlation Analysis” course he taught the following year. Who knew we’d be working, writing papers, and pulishing together 27 years later!

On this blog, and in mutliple articles, I’ve written about the important role that mentors play in the development of expertise. On this score, the impact Bruce has had and continues to have on my career is immeasurable. I can’t think of a more deserving person. Former A.P.A. president Carol Goodheart, Ph.D. delivered the award, captured in the video below:

Psychologist Alan Kazdin Needs Help: Please Give

September 25, 2011 By scottdm Leave a Comment

Look at this picture. This man needs help. He is psychologist, Alan Kazdin, former president of the American Psychological Association, and current Professor of Psychology at Yale University. A little over a week ago, to the surprise and shock of many in the field, he disclosed a problem in his professional life. In an interview that appeared online at TimeHealthland Dr. Kazdin reported being unable to find a therapist or treatment program to which he could refer clients–even in Manhattan, New York, the nation’s largest city!

After traveling the length and breadth of the United States for the last decade, and meeting and working with hundreds of agencies and tens of thousands of therapists, I know there are many clinicians that can help Dr. Kazdin with his problem. Our group has been tracking the outcome of numerous practitioners over the last decade and found average outcomes to be on par with those obtained in tightly controlled randomized clinical trails! That’s good news for Dr. Kazdin.

Now, just to be sure, it should be pointed out that Dr. Kazdin is asking for practitioners who adhere to the Cochrane Review’s and the American Psychological Association’s definition of evidence-based practice (EBP)–or, I should say, I believe that is what he is asking for as the interview is not entirely clear on this point and appears to imply that EBP is about using specific treatment methods (the most popular, of course, being CBT). The actual definition contains three main points, and clearly states that EBP is the integration of:

The best available research;
Clinical expertise; and
The client’s culture, values, and preferences.

Interestingly, the official APA policy on evidence-based practice further defines clinical expertise as the “monitoring of patient progress (and of changes in the patient’s circumstances)…that may suggest the need to adjust the treatment. If progress is not proceeding adequately, the psychologist alters or addresses problematic aspects of the treatment (e.g., problems in the therapeutic relationship or in the implementation of the goals of the treatment) as appropriate.”

I say “interestingly” for two reasons. First, the definition of EBP clearly indicates that clinicians must tailor psychotherapy to the individual client. And yet, the interview with Dr. Kazdin specifically quotes him as saying, “That’s a red herring. The research shows that no one knows how to do that. [And they don’t know how to monitor your progress].” Now, admittedly, the research is new and, as Dr. Kazdin says, “Most people practicing who are 50 years or older”–like himself–may not know about it, but there are over a dozen randomized clinical trials documenting how routinely monitoring progress and the relationship and adjusting accordingly improves outcome. The interview also reports him saying that “there is no real evidence” that the relationship (aka alliance) between the therapist and client matters when, in fact, the APA Interdivisional Task Force on Evidence-Based Therapy Relationships concluded that there is abundant evidence that “the therapy relationship accounts for substantial and consistent contributions to…outcome….at least as much as the particular method.” (Incidently, the complete APA policy statement on EBP can be found in the May-June 2006 issue of the American Psychologist).

Who knows how these two major bloopers managed to slip through the editing process? I sure know I’d be embarrased and immediately issue a clarification if I’d been misquoted making statements so clearly at odds with the facts. Perhaps Dr. Kazdin is still busy looking for someone to whom he can refer clients. If you are a professional who uses your clinical expertise to tailor the application of scientifically sound psychotherapy practices to client preferences, values, and culture, then you can help.

Is Psychotherapy Dead?

August 26, 2011 By scottdm 1 Comment

“AMERICANS PREFER DRUGS” screams the headline posted by the Reuters news service and attributed to Consumer Reports–one of the most respected periodical for the average American reader. “NEARLY 80 PERCENT TAKE A PILL FOR DEPRESSION,” the article continues. Read a little further and do some searching around on the internet and a different story emerges. Americans it turns out don’t necessarily prefer drugs but rather, “78 percent of those seeking treatment for depression or anxiety were prescribed antidepressants.”

With respected news agencies advertizing for the pharaceutical companies, is it any wonder why the practice of “talk therapy” is suffering? AA’s Executive Director for Professional Practice, Dr. Kaherine Nordal, in a recent editorial asked, “Where has all the psychotherapy gone?” The percentage of Americans who receive outpatinet mental health care has remained unchanged over the last several decades. Moreover, as Dr. Mark Hubble and I point out in the lead article in the May-June issue of the Psychotherapy Networker, “median incomes for psychologists, both applied and academic, have dropped between 17 and 33 percent at the same time that workloads have increaed, profssional autonomy has been subverted, and funding for public behavioral healthcare has all but disappeared.”

In a recent, highly publicized exchange on psychotherapy that appeared on Medscape: Psychiatry and Health, panel participants (all psychiatrists) repeated the same, old, tired argument about the field. To wit, “the research base is insufficient.” How such statements can be made with a straight face, much less by mental health professionals, on a public website, defies explanation. The truth is, the evidence-base for psychological treatments is as large and robust as any. What’s more, seeing a talk therapist does not require invasive surgery or a black box warning. Clearly, the issue is not research. It is about awareness.

The members and associates of the International Center for Clinical Excellence (ICCE) are working diligently to raise consciousness among the public and policy makers. Every day, 1000’s of professionals connect to, learn from, and share with colleagues around the world. The mission of the organization? To use community to improve the quality and outcome of behavioral health services. On the ICCE web-based community, clinicians share experiences and real world data regarding the effectiveness of talk therapy. For example, ICCE associate Dan Buccino shared outcomes from a 7 year project aimed at “promoting recovery and accountability.” Using the Outcome and Session Ratings Scales, Dan documented effectiveness levels that far exceeded national benchmarks for clinical practice. Why not email him for a copy of the report? Meanwhile, providers serving US Airforce personnel began using the same measures in early 2010 and have reported very similar findings. Finally, to date, more than a dozen randomized clinical trials, involving thousands of clients and numerous therapists, have established that using feedback to inform services increases effectiveness of individual practitioners three fold, cuts dropout rates by 50 percent, reduces the rate of deterioration by 33 percent, and speeds recovery by 66 percent, while simultaensouly improving client satisfaction and reducing the cost of care.

To paraphrase Mark Twain, the rumored death of psychotherapy has been greatly exaggerated. Now is not the time, however, to merely hope for a better future. Join the discussion taking place on ICCE right now. Membership is free and a strong, supportive community just a few clicks away.

Deliberate Practice: What’s all the fuss about?

August 24, 2011 By scottdm Leave a Comment

Whatever they might be engaged in—dancing, singling, teaching, or doing therapy, top performers make “it” look so easy. Witnessing such a performance inspires awe and wonder, leading many unitiated to whisper about some being lucky, “born with talent.” How else can one explain the superior abilities of those we admire? “Sure, most will readily acknowledge, “the best work hard.” “BUT,” they quickly add, “THAT person has a gift.” Even the dictionary contributes to this continuing belief, defining gift as “innate capacity, talent, or endowment.” What is widely believed however is not always true: flat earth, phrenology, cold fusion, and…innate talent.

Turns out that the factor that separates the best from the rest is the amount of time spent practicing. And not just any kind of practice. Deliberate practice. A planned, conscious effort aimed at making small, continuous, and measurable improvement in one’s level of performance.

“It don’t come easy,” to borrow a line from an old rock and roll tune. If you are not exhausted at the end of the process you are probably not doing it right. As detailed previously on this blog, it requires time, patience, reflection, and—as we recently wrote in the Psychotherapy Networker, support. Interestingly, despite the challenges, the idea is catching on in the therapy world. I spoke with Alex Millham who lives and works in the U.K. not long ago about the subject. Click to read the interview.