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)

What to Pay Attention to in Therapy?

March 15, 2013 By scottdm Leave a Comment

A week or so ago, I received an email from my friend, colleague, and mentor Joe Yeager. He runs a small listserve that sends out interesting and often provocative information. The email contained pictures from a new and, dare I say, ingenious advertising campaign for Colgate brand dental floss. Before I give you any of further details, however, take a look at the images yourself:

All right. So what caught your attention? If you’re like most people–including me–you probably found yourself staring at the food stuck in the teeth of the men in all three images. If so, the ad achieved its purpose. Take a look at the pictures one more time. In the first, the woman has one too many fingers on her left hand. The second image has a “phamtom arm” around the man’s shoulder. Can you see the issue in the third?

The anomalies in the photos are far from minor! And yet, most of us, captured by the what initially catches our eye, miss them.

Looking beyond the obvious is what Feedback Informed Treatment (FIT) is all about. Truth is, much of the time therapy works. What we do pay attention to gets results–except when it doesn’t! At those times, two things must happen: (1) we have to know when what we usually do isn’t working with a given person; and (2) look beyond the obvious and see a bigger picture. Doing this takes effort and support. What can you do?

1. Download two free, brief, simple to use tools for tracking outcome and engagement in care (the ORS and SRS) and begin using them in your work;

2. Join the International Center for Clinical Excellence, the world’s largest, free, online, non-denominational organization of behavioral health professionals;

3. Read the six cutting-edge treatment and training manuals on feedback-informed treatment–a series which helped earn FIT the highest ratings from the Substance Abuse and Mental Health Services Administration (SAMHSA);

4. Attend a training in Chicago or abroad.

The Importance of "Whoops" in Improving Treatment Outcome

December 2, 2012 By scottdm Leave a Comment

“Ring the bells that still can ring,
Forget your perfect offering
There is a crack in everything,
That’s how the light gets in.”

Leonard Cohen, Anthem

Making mistakes. We all do it, in both our personal and professional lives. “To err is human…,” the old saying goes. And most of us say, if asked, that we agree whole heartedly with the adage–especially when it refers to someone else! When the principle becomes personal, however, its is much more difficult to be so broad-minded.

Think about it for a minute: can you name five things you are wrong about? Three? How about the last mistake you made in your clinical work? What was it? Did you share it with the person you were working with? With your colleagues?

Research shows there are surprising benefits to being wrong, especially when the maker views such errors differently. As author Alina Tugend points out in her fabulous book, Better by Mistake, custom wrongly defines a mistake as ” the failure of a planned sequence of mental or physical activities to achieve its intended outcome.” When you forget a client’s name during a session or push a door instead of pull, that counts as slip or lapse. A mistake, by contrast, is when “the plan itself is inadequate to achieve it’s objectives” (p. 11). Knowing the difference, she continues, “can be very helpful in avoiding mistakes in the future” because it leads exploration away from assigning blame to the exploring systems, processes, and conditions that either cause mistakes or thwart their detection.

Last week, I was working with a talented and energetic group of helping professionals in New Bedford, Massachusetts. The topic was, “Achieving Excellence: Pushing One’s Clinical Performance to the Next Level of Effectiveness.” As part of my presentation, I talked about becoming more, “error-centric” in our work; specifically, using ongoing measurement of the alliance to identify opportunities for improving our connection with consumers of behavioral health services. As an example of the benefits of making mistakes the focus of professional development efforts, I showed a brief video of Rachel Hsu and Roger Chen, two talented musicians who performed at the last Achieving Clinical Excellence (ACE) conference. Rachel plays a piece by Liszt, Roger one by Mozart. Both compositions are extremely challenging to play. You tell me how they did (by the way, Rachel is 8 years old, Roger. 9):

Following her performance, I asked Rachel if she’d made any mistakes during her performance. She laughed, and then said, “Yes, a lot!” When I asked her what she did about that, she replied, “Well, its impossible to learn from my mistakes while I’m playing. So I note them and then later practice those small bits, over and over, slow at first, then speeding up, until I get them right.”

After showing the video in New Bedford, a member of the audience raised his hand, “I get it but that whole idea makes me a bit nervous.” I knew exactly what he was thinking. Highlighting one’s mistakes in public is risky business. Studies documenting that the most effective clinicians experience more self-doubt and are more willing to admit making mistakes is simply not convincing when one’s professional self-esteem or job may be on the line. Neither is research showing that health care professionals who admit making mistakes and apologize to consumers are significantly less likely to be sued. Becoming error centric, requires a change in culture, one that not only invites discloure but connects it with the kind of support and structure that leads to superior results.

Creating a “whoops-friendly” culture will be a focus of the next Achieving Clinical Excellence conference, scheduled for May 16-18th, 2013 in Amsterdam, Holland. Researchers and clinicians from around the world will gather to share their data and experience at this unique event. I promise you don’t want to miss it. Here’s a short clip of highlights from the last one:

My colleague, Susanne Bargmann and I will also be teaching the latest research and evidence based methods for transforming mistakes into improved clinical performance at the upcoming FIT Advanced Intensive training in Chicago, Illinois. I look forward to meeting you at one of these upcoming events. In the meantime, here’s a fun, brief but informative video from the TED talks series on mistakes:

By the way, the house pictured above is real. My family and I visited it while vacationing in Niagara Falls, Canada in October. It’s a tourist attraction actually. Mistakes, it seems, can be profitable.

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.

Error-centric Practice: How Getting it Wrong can Help you Get it Right

July 22, 2010 By scottdm 1 Comment

It’s an idea that makes intuitive sense but is simultanesouly unappealing to most people. I, for one, don’t like it. What’s more, it flies in the face of the “self-esteem” orientation that has dominated much of educational theory and practice over the last several decades. And yet, research summarized in a recent issue of Scientific American Mind is clear: people learn the most when conditions are arranged so that they have to make mistakes. Testing prior to learning, for example, improves recall of information learned after failing the pre-test regarding that same information. As is well known, frequent testing following learning and/or skill acquisition significantly enhances retention of knowledge and abilities. In short, getting it wrong can help you get it right more often in the future.

So, despite the short term risk to my self-esteem, “error-centric learning” is an evidence-based practice that I’m taking to heart. I’m not only applying the approach in the trainings I offer to mental health professionals–beginning all of my workshop with a fun, fact-filled quiz–but in my attempts to master a completely new skill in my personal life: magic and mind reading. And if the number of mistakes I routinely make in these pursuits is a reliable predictor of future success, well…I should be a master mind reading magician in little more than a few days.

Enough for now–back to practicing. Tonight, in my hotel room in Buffalo, New York, I’m working on a couple of new card tricks. Take a look at the videos of two new effects I recorded over the weekend. Also, don’t miss the interview with Cindy Voelker and John Catalino on the implementation of Feedback-Informed Treatment (FIT) at Spectrum Human Services here in Buffalo.

Deliberate Practice, Expertise, & Excellence

February 3, 2010 By scottdm 2 Comments

Later today, I board United flight 908 on my way to workshops scheduled in Holland and Belgium. My routine in the days leading up to an international trip is always the same. I slowly gather together the items I’ll need while away: computer (check); european electric adapter (check); presentation materials (check); clothes (check). And, oh yeah, two decks of playing cards and close up performance mat.

That’s me (pictured above) practicing a “ribbon spread” in my hotel room following a day of training in Marion, Ohio. It’s a basic skill in magic and I’ve been working hard on this (and other moves using cards) since last summer. Along the way, I’ve felt both hopeful and discouraged. But I’ve kept on nonetheless taking heart from what I’m reading about skill acquisition.

Research on expertise indicates that the best performers (in chess, medicine, music, sports, etc.) practice every day of the week (including weekends) for up to four hours a day. Sounds tiring for sure. And yet, the same body of evidence shows that world class performers are able to sustain such high levels of practice because they view the acquisition of expertise as a long-term process. Indeed, in a study of children, researcher Gary McPherson found that the answer to a simple question determined the musical ability of kids a year later: “how long do you think you’ll play your instrument?” The factors that were shown to be irrelevant to performance level were: initial musical ability, IQ, aural sensitivity, math skills, sense of rhythm, income level, and sensorimotor skills.

The type of practice also matters. When researchers Kitsantas and Zimmerman studied the skill acquisition of experts, they found that 90% of the variation in ability could be accounted for by how the performers described their practice; the types of goals they set, how they planned and executed strategies, self-monitored, and adapted their performance in response to feedback.

So, I take my playing cards and close-up mat with me on all of my trips (both domestic and international). I don’t practice on planes. Gave that up after getting some strange stares from fellow passengers as they watched me repeat, in obsessive fashion, the same small segment of my performance over, and over, and over again. It only made matters worse if they found out I was a psychologist. I’d get that “knowing look,” that seemed to say, “Oh yeah.” Anyway, I also managed to lose a fair number of cards when the deck–because of my inept handling while trying to master some particular move–went flying all over the cabin (You can imagine why I’ve been less successful in keeping last year’s New Year resolution to learn to play the ukelele).

Once I’m comfortably situated in my room, the mat and cards come out and I work, practice a specific handling for up to 30 minutes followed by a 15-20 minute break. Believe it or not, learning–or perhaps better said, attempting to learn–magic has really been helpful in understanding the acquisition of expertise in my chosen field: psychology and psychotherapy. Together with my colleagues, we are translating our experience and the latest research on expertise into steps for improving the performance and outcome of behavioral health services. This is, in fact, the focus of the newest workshop I’m teaching, “Achieving Clinical Excellence.” It’s also the organizing theme of the ICCE Achieving Clinical Excellence conference that will be held in Kansas City, Kansas in October 2010. Click on the photo below for more information.

In the meantime, check out the two videos I’ve uploaded to ICCETV featuring two fun magic effects. And yes, of course, feedback is always appreciated!

Why ongoing, formal feedback is critical for improving outcomes in healthcare

January 8, 2010 By scottdm 3 Comments

Not long ago, I had a rather lengthy email exchange with a well-known, high profile psychotherapist in the United States. Feedback was the topic. We both agreed that feedback was central to successful psychotherapy. We differed, however, in terms of method. I argued for the use of simple, standardized measures of progress and alliance (e.g., ORS and SRS). In support of my opinion, I pointed to several randomized clinical trials documenting the impact of routine outcome monitoring on retention and progress. I also cited studies showing traditionally low correlations between consumers and clinician’s rating of outcome and alliance and clinicians frighteningly frequent inability to predict deterioration and drop out in treatment. He responded that such measures were an “unnecessary intrusion,” indicating that he’d always sought feedback from his clients albeit on an “informal basis.” television-reception

When I mentioned our own research which had found that clinicians believed they asked consumers for feedback more often than they actually did, he finally seemed to agree with me. “Of course,” he said immediately–but then he added, “I don’t need to ask in order to get feedback.” In response to my query about how he managed to get feedback without asking, he responded (without a hint of irony), “I have unconditional empathic reception.” Needless to say, the conversation ended there.

It’s a simple idea, feedback. Yet, as I jet around the globe teaching about feedback-informed clinical practice, I’m struck by how hard it seems for many in healthcare to adopt. Whatever the reason for the resistance–fear, hubris, or inertia–the failure to seek out valid and reliable feedback is a conceit that the field can no longer afford. Simply stated, no one has “unconditional empathic reception.” As the video below makes clear, we all need help seeing what is right before our eyes.

New Year’s Resolutions: Progress Report and Future Plans

January 1, 2010 By scottdm Leave a Comment

One year ago today, I blogged about my New Year’s resolution to “take up the study of expertise and expert performance.” The promise marked a significant departure from my work up to that point in time and was not without controversy:

“Was I no longer interested in psychotherapy?”

“Had I given up on the common factors?

“What about the ORS and SRS?” and was I abandoning the field and pursue magic as a profession?”

Seriously.

The answer to all of the questions was, of course, an emphatic “NO!” At the same time, I recognized that I’d reached an empirical precipice–or, stated more accurately, dead end. The common factors, while explaining why therapy works did not and could never tell us how to work. And while seeking and obtaining ongoing feedback (via the ORS and SRS) had proven successful in boosting treatment outcomes, there was no evidence that the practice had a lasting impact on the professionals providing the service.

Understanding how to improve my performance as a clinician has, as is true of many therapists, been a goal and passion from the earliest days of my career. The vast literature on expertise and expert performance appeared to provide the answers I’d long sought. In fields as diverse as music and medicine, researchers had identified specific principles and methods associated with superior performance. On January 2nd, 2009, I vowed to apply what I was learning to, “a subject I know nothing about…put[ting] into practice the insights gleaned from the study of expertise and expert performance.”

The subject? Magic (and the ukulele).

How have I done? Definitely better than average I can say. In a column written by Barbara Brotman in today’s Chicago Tribune, psychologist Janine Gauthier notes that while 45% of people make New Year’s resolutions, only 8% actually keep them! I’m a solid 50%. I am still studying and learning magic–as attendees at the 2009 “Training of Trainers” and my other workshops can testify. The uke is another story, however. To paraphrase 1988 Democratic vice-presidential candidate, Lloyd Bentsen , “I know great ukulele players, and Scott, you are no Jake Shimabukuro.”

I first saw Jake Shimabukuro play the ukulele at a concert in Hawaii. I was in the islands working with behavioral health professionals in the military (Watch the video below and tell me if it doesn’t sound like more than one instrument is playing even though Jake is the only one pictured).

Interestingly, the reasons for my success with one and failure with the other are as simple and straightforward as the principles and practices that researchers say account for superior (and inferior) performance. I promise to lay out these findings, along with my experiences, over the next several weeks. If you are about to make a New Year’s resolution, let me give you step numero uno: make sure your goal/resolution is realistic. I know, I know…how mundane. And yet, while I’ve lectured extensively about the relationship between goal-setting and successful psychotherapy for over 15 years, my reading about expert performance combined with my attempts to master two novel skills, has made me aware of aspects I never knew about or considered before.

Anyway, stay tuned for more. In the meantime, just for fun, take a look at the video below from master magician Bill Malone. The effect he is performing is called, “Sam the Bellhop.” I’ve been practicing this routine since early summer, using what I’ve learned from my study of the literature on expertise to master the effect (Ask me to perform it for you on break if you happen to be in attendance at one of my upcoming workshops).