Good News and Bad News about Psychotherapy

March 25, 2014 By scottdm 1 Comment

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)

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.

The Study of Excellence: A Radically New Approach to Understanding "What Works" in Behavioral Health

December 24, 2009 By scottdm 2 Comments

“What works” in therapy? Believe it or not, that question–as simple as it is–has and continues to spark considerable debate. For decades, the field has been divided. On one side are those who argue that the efficacy of psychological treatments is due to specific factors (e.g., changing negative thinking patterns) inherent in the model of treatment (e.g., cognitive behavioral therapy) remedial to the problem being treated (i.e., depression); on the other, is a smaller but no less committed group of researchers and writers who posit that the general efficacy of behavioral treatments is due to a group of factors common to all approaches (e.g., relationship, hope, expectancy, client factors).

While the overall effectiveness of psychological treatment is now well established–studies show that people who receive care are better off than 80% of those who do not regardless of the approach or the problem treated–one fact can not be avoided: outcomes have not improved appreciably over the last 30 years! Said another way, the common versus specific factor battle, while generating a great deal of heat, has not shed much light on how to improve the outcome of behavioral health services. Despite the incessant talk about and promotion of “evidence-based” practice, there is no evidence that adopting “specific methods for specific disorders” improves outcome. At the same time, as I’ve pointed out in prior blogposts, the common factors, while accounting for why psychological therapies work, do not and can not tell us how to work. After all, if the effectiveness of the various and competing treatment approaches is due to a shared set of common factors, and yet all models work equally well, why learn about the common factors? More to the point, there simply is no evidence that adopting a “common factors” approach leads to better performance.

The problem with the specific and common factor positions is that both–and hang onto your seat here–have the same objective at heart; namely, contextlessness. Each hopes to identify a set of principles and/or practices that are applicable across people, places, and situations. Thus, specific factor proponents argue that particular “evidence-based” (EBP) approaches are applicable for a given problem regardless of the people or places involved (It’s amazing, really, when you consider that various approaches are being marketed to different countries and cultures as “evidence-based” when there is in no evidence that these methods work beyond their very limited and unrepresentative samples). On the other hand, the common factors camp, in place of techniques, proffer an invariant set of, well, generic factors. Little wonder that outcomes have stagnated. Its a bit like trying to learn a language either by memorizing a phrase book–in the case of EBP–or studying the parts of speech–in the case of the common factors.

What to do? For me, clues for resolving the impasse began to appear when, in 1994, I followed the advice of my friend and long time mentor, Lynn Johnson, and began formally and routinely monitoring the outcome and alliance of the clinical work I was doing. Crucially, feedback provided a way to contextualize therapeutic services–to fit the work to the people and places involved–that neither a specific or common factors informed approach could.

Numerous studies (21 RCT’s; including 4 studies using the ORS and SRS) now document the impact of using outcome and alliance feedback to inform service delivery. One study, for example, showed a 65% improvement over baseline performance rates with the addition of routine alliance and outcome feedback. Another, more recent study of couples therapy, found that divorce/separation rates were half (50%) less for the feedback versus no feedback conditions!

Such results have, not surprisingly, led the practice of “routine outcome monitoring” (PROMS) to be deemed “evidence-based.” At the recent, Evolution of Psychotherapy conference I was on a panel with David Barlow, Ph.D.–a long time proponent of the “specific treatments for specific disorders” (EBP)–who, in response to my brief remarks about the benefits of feedback, stated unequivocally that all therapists would soon be required to measure and monitor the outcome of their clinical work. Given that my work has focused almost exclusively on seeking and using feedback for the last 15 years, you would think I’d be happy. And while gratifying on some level, I must admit to being both surprised and frightened by his pronouncement.

My fear? Focusing on measurement and feedback misses the point. Simply put: it’s not seeking feedback that is important. Rather, it’s what feedback potentially engenders in the user that is critical. Consider the following, while the results of trials to date clearly document the benefit of PROMS to those seeking therapy, there is currently no evidence of that the practice has a lasting impact on those providing the service. “The question is,” as researcher Michael Lambert notes, “have therapists learned anything from having gotten feedback? Or, do the gains disappear when feedback disappears? About the same question. We found that there is little improvement from year to year…” (quoted in Miller et al. [2004]).

Research on expertise in a wide range of domains (including chess, medicine, physics, computer programming, and psychotherapy) indicates that in order to have a lasting effect feedback must increase a performer’s “domain specific knowledge.” Feedback must result in the performer knowing more about his or her area and how and when to apply than knowledge to specific situations than others. Master level chess players, for example, have been shown to possess 10 to 100 times more chess knowledge than “club-level” players. Not surprisingly, master players’ vast information about the game is consilidated and organized differently than their less successful peers; namely, in a way that allows them to access, sort, and apply potential moves to the specific situation on the board. In other words, their immense knowledge is context specific.

A mere handful studies document similar findings among superior performing therapists: not only do they know more, they know how, when, and with whom o apply that knowledge. I noted these and highlighted a few others in the research pipeline during my workshop on “Achieving Clinical Excellence” at the Evolution of Psychotherapy conference. I also reviewed what 30 years of research on expertise and expert performance has taught us about how feedback must be used in order to insure that learning actually takes place. Many of those in attendance stopped by the ICCE booth following the presentation to talk with our CEO, Brendan Madden, or one of our Associates and Trainers (see the video below).

Such research, I believe, holds the key to moving beyond the common versus specific factor stalemate that has long held the field in check–providing therapists with the means for developing, organizing, and contextualizing clinical knowledge in a manner that leads to real and lasting improvements in performance.