Is your therapy making your clients worse? The Guardian Strikes Again

June 12, 2014 By scottdm 1 Comment

Last week, an article appeared in The Guardian, one of the U.K.’s largest daily newspapers. “Counselling and Therapy can be Harmful,” the headline boldly asserted, citing results of a study yet to be published. It certainly got my attention.

Do some people in therapy get worse? The answer is, most assuredly, “Yes.” Research dating back several decades puts the figure at about 10% (Lambert, 2010). Said another way, at termination, roughly one out of ten people are functioning more poorly than they were at the beginning of treatment.

The cause? Here’s what we know. 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.

So, if it’s not about the method, then how to account for deterioration? As the article points out, “some therapists had a lot more clients [who] deteriorated than others.” And yet, while that statement is true–lots of prior research shows that some do more harm than others–there are too few such clinicians to account for the total number of clients who worsen. Moreover, beyond that 10%, between 30 and 50% of people in treatment experience no benefit whatsoever!

Here is where the old adage, “an ounce of prevention is worth a pound of cure,” applies. Whatever the cause, lack of progress and risk of deterioration are issues for all clinicians. A growing body of research makes clear, the key to addressing the problem is tracking the progress of clients from visit to visit so that those not improving, or getting worse, can be identified and offered alternatives.

It’s not hard to get started. You can learn a simple, evidence-based method for tracking progress and the quality of the relationship at: www.whatispcoms.com. Best of all, practitioners can access the tools for free!

After that, join fellow practitioners from the US, Canada, Europe, and Australia for one of our intensive trainings coming up this August in Chicago. I promise you’ll leave prepared to address the issue of deterioration directly and successfully.

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’s disturbing Mental Health? Opportunities Lost

November 29, 2011 By scottdm Leave a Comment

In a word, paperwork. Take a look at the book pictured above. That massive tome on the left is the 2011 edition of “Laws and Regulations” governing mental health practice in the state of California. Talk about red tape! Hundreds and hundreds of pages of statutes informing, guiding, restricting, and regulating the “talking cure.” Now, on top of that, layer federal and third party payer policies and paperwork and you end up with…lost opportunities. Many lost opportunities. Indeed, as pointed out in our recent article, The Road to Mastery, as much as 30% of clinicians time is spent completing paperwork required by various funding bodies and regulatory agencies. THIRTY PERCENT. Time and money that could be spent much more productively serving people with mental health needs. Time and money that could be spent on improving treatment facilities and training of behavioral health professionals. In the latest edition of our book, The Heart and Soul of Change, authors Bob Bohanske and Michael Franczak described their struggle to bring sanity to the paperwork required in public mental health service settings in the state of Arizona. “The forms needed to obtain a marriage certificate, buy a new home, lease an automobile, apply for a passport, open a bank account, and die of natural causes were assembled,” they wrote, “…and altogether weighed 1.4 ounces. By contrast, the paperwork required for enrolling a single mother in counseling to talk about difficulties her child was experiencing at school came in at 1.25 pounds” (p. 300). What gives?

The time has come to confront the unpleasant reality and say it outloud: regulation has lost touch with reality. Ostensibly, the goal of paperwork and oversight procedures is to improve accountability. In these evidence-based times, that leads me to say, “show me the data.” Consider the wide-spread practice–mandate, in most instances–of treatment planning. Simply put, it is less science than science fiction. Perhaps this practice improves outcomes in a galaxy far, far away but on planet Earth, supporting evidence is spare to non-existent (see the review in The Heart and Soul of Change, 2nd Edition).

No amount of medication will resolve this craziness. Perhaps a hefty dose of CBT might do some good identifying and correcting the distoreted thinking that has led to this current state of affairs. Whatever happens, the field needs an alternative. What practice not only insures accountability but simultaneously improves the quality and outcome of behavioral health services? Routine outcome measurement and feedback (ROM^Fb). As I’ve blogged about several times, numerous RCT’s document increased effectiveness and efficiency and decreased costs and rates of deterioration. Simply put, as the slide below summarizes, everybody wins. Clinicians. Consumers. Payers.
Everybody wins

Learn about or deepen your knowledge of feedback-informed treatment (FIT) by attending the upcoming “Advanced Intensive” workshop in March 2012; specfically, the 19th-22nd. We will have four magical days together. Space is filling rapidly, so register now. And then, at the end of the last day of the training, fly to Washington, D.C. to finish off the week by attending the Psychotherapy Networker conference. Excellence is front and center at the event and I’ve been asked to do the keynote on the subject on the first day!

Top Resources for Top Performers

September 28, 2009 By scottdm 1 Comment

Since the 1960’s, over 10,000 “how-to” book on psychotherapy have been published. I joke about this fact at my workshops, stating “Any field that needs ten thousand books to describe what it’s doing…surely doesn’t know what its doing!” I continue, pointing out that, “There aren’t 10,000 plus books on ‘human anatomy,’ for example. There are a handful! And the content of each is remarkably similar.” The mere existence of so many, divergent points of view makes it difficult for any practitioner to sort the proverbial “wheat from the chaff.”

Over the last 100 years or so, the field has employed three solutions to deal with the existence of so many competing theories and approaches. First, ignore the differences and continue with “business as usual”– this, in fact, is the approach thats been used for most of the history of the field. Second, force a consolidation or reduction by fiat–this, in my opinion, is what is being attempted with much of the current evidence-based practice (“specific treatments for specific disorders”) movement. And third, and finally, respect the field’s diverse nature and approaches, while attempting to understand the “DNA” common to all–said another way, identify and train clinicians in the factors common to all approaches so that they can tailor their work to their clients.

Let’s face it: option one is no longer viable. Changes in both policy and funding make clear that ignoring the problem will result in further erosion of clinical autonomy. For anyone choosing option two–either enthusistically or by inaction–I will blog later this week about developments in the United States and U.K. on the “evidence-based practice” front that I’m sure will give you pause. Finally, for those interested in movng beyond the rival factions and delivering the best clinical service to clients, I want to recommend two resources. First, Derek Truscott’s, Becoming an Effective Psychotherapist. The title says it all. Whether you are new to the field or an experienced clinician, this book will help you sort through the various and competing psychotherapy approaches and find a style that works for you and the people you work with. The second volume, is Mick Cooper’s Essential Research Findings in Counselling and Psychotherapy. What can I say about this book? It is a gem. Thorough, yet readable. Empirical in nature, but clinically relevant. When I’m out and about teaching around the globe and people ask me what to read in order to understand the empirical literature on psychotherapy, I recommend this book.

OK, enough for now. Stay tuned for further updates this week. In the meantime, I did manage to find a new technique making the rounds on the workshop circuit. Click on the video below.