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.

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.

Practice-Based Evidence Goes Mainstream

September 5, 2009 By scottdm 4 Comments

For years, my colleagues and I have been using the phrase “practice-based evidence” to refer to clinicians’ use of real-time feedback to develop, guide, and evaluate behavioral health services. Against a tidal wave of support from professional and regulatory bodies, we argued that the “evidence-based practice”–the notion that certain treatments work best for certain diagnosis–was not supported by the evidence.

Along the way, I published, along with my colleagues, several meta-analytic studies, showing that all therapies worked about equally well (click here to access recent studies children, alcohol abuse and dependence, and post-traumatic stress disorder). The challenge, it seemed to me, was not finding what worked for a particular disorder or diagnosis, but rather what worked for a particular individual–and that required ongoing monitoring and feedback. In 2006, following years of controversy and wrangling, the American Psychological Association, finally revised the official definition to be consistent with “practice-based evidence.” You can read the definition in the May-June issue of the American Psychologist, volume 61, pages 271-285.

Now, a recent report on the Medscape journal of medicine channel provides further evidence that practice-based evidence is going mainstream. I think you’ll find the commentary interesting as it provides compelling evidence that an alternative to the dominent paradigm currently guiding professional discourse is taking hold. Watch it here.