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Is Psychotherapy Getting Better?

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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  “The plan,” he said, “to work hard and play by the rules to get ahead is now outdated.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.

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

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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!

Is Psychotherapy Dead?

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“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?

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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.

Why is this man laughing?

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May 4th, 2011
Copenhagen, Denmark

Just finished my first day of a two week trip covering spots in Denmark and Holland.  Yesterday, I traveled to Copenhagen from Hilo, Hawaii where I was presenting for the Hawaiian Association of Marriage and Family Therapy.  Dr. Gay Barflied (pictured on the far left above) spent years lobbying to bring me to the “Big Island” for the conference, where I spoke about the latest research on expertise and excellence in the field of behavioral health.  I met so many dedicated and talented clinicians in Hilo, including marriage and family therapist, Makela Bruno-Kidani (pictured in the middle photo above) who started the day off with a traditional Hawaiian chant and then presented me with two beautiful lei to wear during the event.

On a break, Gay mentioned an article that appeared in the May/June 1995 issue of AHP Perspective.  In it, she said, Maureen O’Hara, president of the Association for Humanistic Psychology, quoted one of the first articles me and my colleagues wrote on the common factors, “No More Bells and Whistles” (I’ll upload a copy to the “publications and handouts” section of the website as soon as I’m back in the States).  Carl Rogers, she said, would have been laughing (happily, that is) had he read the findings we cited documented the lack of differential efficacy of competing treatment approaches.  We had, in essence, proved him right!

“It turns out,” OHara wrote, “that Miller, Hubble, and Duncan come to similar conclusions.  Carl Rogers was right.  After all our forays into the dizzing arcana of paradoxical interventions, inner children, narrative therapy, EMDR, behaviorism, psychopharmacology, bioenergetics, TA, Jungian analysis, psychodrama, Gestalt, and so on down the entire list of hundred brand named therapies, what actually creates change is the…creation of a relationship between client and therapist…”.

I’d never seen the article before.  It brought back very positive memories about the journey that has led most recently to the study of excellence.  Indeed, as we point out in the lead article in the upcoming May/June 2011 issue of the Psychotherapy Networker, relationships are not only the “sine qua non” of healing for clients but are responsible for the professional growth for therapists.

The "F" Word in Behavioral Health

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Since the 1960’s, over 10,000 how-to books on psychotherapy/counseling have been published—everything from nude marathon group therapy to the most recent “energy-based treatments.”  Clinicians have at their disposal literally hundreds of methods to apply to an ever growing list of diagnoses as codified in the Diagnostic and Statistical Manual of Mental Disorders (soon available in its 5th and expanded edition).

Conspicuously absent from the psychological cornucopia of diagnoses and treatments is the “F” word: FAILURE. A quick search of Amazon.com led to 32,670 results for the term, “psychotherapy,” 1,393 hits for “psychotherapy and depression,” and a mere 85 citations for “psychotherapy and failure.” Of the latter 85, less than 20 dealt with the topic of failure directly. There are some notable exceptions. The work of psychologist Jeffrey Kottler, for example. The dearth of information and frank discussion points to a glaring fact: behavioral health has a problem with failure.
The research literature is clear on the subject: we fail. Dropout rates have remained embarrassingly high over the last two and a half decades—hovering around 47%. At the same time, 10% of those who stay in services deteriorate while in care. Also troubling, despite the expansion of treatment modalities and diagnoses, the outcome of treatment (while generally good) has not improved appreciably over the last 30 or so years.  Finally, as reviewed recently on this blog, available evidence indicates that clinicians, despite what many believe, do not improve with experience.
In short, behavioral health is failing when it comes to failure. As a group, we do rarely address the topic. Even when we directly addressed, we find it hard to learn from our mistakes.
Our study of top performing clinicians and agencies documents that the best have an entirely different attitude toward failure than the rest. They work at failing. Everyday, quickly, and in small ways. In the lead article of upcoming Psychotherapy Networker, “The Path to Mastery” we review our findings and provide step-by-step, evidence-based directions for using failure to improve the quality and outcome of behavioral health. As we say in the article, “more than a dozen clinical trials, involving thousands of clients and numerous therapists, have established that excellence isn’t reserved for a select few. Far from it: it’s within the reach of all.” Getting there, however, requires that we embrace failure like never before.
At this year’s “Training of Trainers” (TOT) conference, building “mindful infrastructures” capable of identifying and using failure at the individual practitioner, supervisor, and agency level will be front and center. Please note: this is not an “advanced workshop” on client-directed, feedback-informed clinical work (CDOI/FIT). No lectures or powerpoint presentations. Participants get hands on experience learning to provide training, consultation, and supervision to therapists, agencies, and healthcare systems.
But, don’t take our word for it.  Listen to what attendees from the 2010 TOT said. Be sure and register soon as space is limited.

The Turn to Outcomes: A Revolution in Behavioral Health Practice

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Get ready.  The revolution is coming (if not already here).  Whether you are a direct service provider (psychologist, counselor, marriage and family therapist), agency, broker, or funder, you will be required to measure and likely report the outcomes of your clinical work.


Jay Lebow, Ph.D.

Just this month, Dr. Jay Lebow, a professor of psychology at the Family Institute at Northwestern University, published an article in the Psychotherapy Networker–the most widely circulated publication for practitioners in the world–where he claimed the field had reached a “tipping point.”  “Once a matter of interest only among a small circle of academics,” Dr. Lebow writes in his piece entitled, The Big Squeeze, “treatment outcome has now become a part of the national debate about healthcare reform.”


David Barlow, Ph.D.

The same sentiments were expressed in a feature article entitled, “Negative Effects from Psychological Treatments,” written by Dr. David Barlow in the January issue of the American Psychologist.  “Therapists,” he argues both eloquently and persuasively, “do not have to wait for the next clinical trial….[rather] clinicians [can act] as local clinical scientists…[using] outcome measures to track progress…rapidly becom[ing] aware of lack of progress or even deterioration” (p. 19).  What can I say, except that any practitioner with more than a few years to work before retirement, should read these articles and then forward them to every practitioner they know.

During the Holidays, and just before the turn of the New Year, I blogged about the trend toward outcome measurement.  As readers will recall, I talked about my experience on a panel at the Evolution of Psychotherapy conference where Dr. Barlow–who, in response to my brief remarks about the benefits of feedback– suprised me by stating unequivocally that all therapists would soon be required to measure and monitor the outcome of their clinical work. And even though my work has focused almost exclusively on measuring and using outcomes to improve both retention in and the results of behavioral health for the last 15 years, I said his pronouncement frightened me–which, by the way, reminds me of a joke.

A sheep farmer is out in the pasture tending his flock–I promise this is clean, so read on–when from over a small hill comes a man in a custom-tailored, three-piece business suit.  In one hand, the businessman holds a calculator; in the other, an expensive, leather brief case.  “I have a proposition for you,” the well-clad man says as he approaches the farmer, and then continues, “if I can tell you how many sheep are in your flock, to the exact number, may I have one of your sheep?”  Though initially startled by the stranger’s abrupt appearance and offer, the farmer quickly gathers his wits.  Knowing there is no way the man could know the actual number of sheep (since many in his flock were out of site in other pastures and several were born just that morning and still in the barn), the farmer quickly responded, “I’ll take that bet!”

Without a moment’s hesitation, the man calls out the correct number, “one thousand, three hundred and forty six,” then quickly adds, “…with the last three born this morning and still resting in the barn!”  Dumbfounded, the farmer merely motions toward his flock.  In response, the visitor stows his calculator, slings one of the animals up and across his shoulders and then, after retrieving his briefcase, begins making his way back up the hill.  Just as he nears the top of the embankment, the farmer finds his voice and calls out, “Sir, I have a counter proposal for you.”

“And what might that be?” the man replies, turning to face the farmer, who then asked, “If I can tell you, sir, what you do for a living, can I have my animal back?”

Always in the mood for a wager, the stranger replies, “I’ll take that bet!”  And then without a moment’s hesitation, the sheep farmer says, “You’re an accountant, a bureaucrat, a ‘bean-counter.'”  Now, it’s the businessman’s turn to be surprised.  “That’s right!” he says, and then asks, “How did you know?”

“Well,” the farmer answers, “because that’s my dog you have around your neck.”

The moral of the story?  Bureaucrats can count but they can’t tell the difference between what is and is not important.  In my blogpost on December 24th, I expressed concern about the explosion of “official interest” in measuring outcomes.  As the two articles mentioned above make clear, the revolution has started.  There’s no turning back now.  The only question that remains is whether behavioral health providers will be present to steer measurement toward what matters?  Here, our track record is less than impressive (remember the 80-90’s and the whole managed care revolution).  We had ample warning (and did, well, nothing.  If you don’t believe me, click here and read this article from 1986 by Dr. Nick Cummings).

As my colleague and friend Peter Albert is fond of saying, “If you’re not at the table, you’re likely to be on the menu.”  So, what can the average clinician do?  First of all, if you haven’t already done so, began tracking your outcomes.  Right here, on my website, you can download, free, simple-to use, valid and reliable measures.  Second, advocate for measures that are feasible, client-friendly, and have a empirical track record of improving retention and outcome.  Third, and lastly, join the International Center for Clinical Excellence.  Here, clinicians from all over the globe are connecting, learning, and sharing their experiences about how to use ongoing measures of progress and alliance.  Most importantly, all are determined to lead the revolution.

Where is Scott Miller going? The Continuing Evolution

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I’ve just returned from a week in Denmark providing training for two important groups.  On Wednesday and Thursday, I worked with close to 100 mental health professionals presenting the latest information on “What Works” in Therapy at the Kulturkuset in downtown Copenhagen.  On Friday, I worked with a small group of select clinicians working on implementing feedback-informed treatment (FIT) in agencies around Denmark.  The day was organized by Toftemosegaard and held at the beautiful and comfortable Imperial Hotel.

In any event, while I was away, I received a letter from my colleague and friend, M. Duncan Stanton.  For many years, “Duke,” as he’s known, has been sending me press clippings and articles both helping me stay “up to date” and, on occasion, giving me a good laugh.  Enclosed in the envelope was the picture posted above, along with a post-it note asking me, “Are you going into a new business?!”

As readers of my blog know, while I’m not going into the hair-styling and spa business, there’s a grain of truth in Duke’s question.  My work is indeed evolving.  For most of the last decade, my writing, research, and training focused on factors common to all therapeutic approaches. The logic guiding these efforts was simple and straightforward. The proven effectiveness of psychotherapy, combined with the failure to find differences between competing approaches, meant that elements shared by all approaches accounted for the success of therapy (e.g., the therapeutic alliance, placebo/hope/expectancy, structure and techniques, extratherapeutic factors).  As first spelled out in Escape from Babel: Toward a Unifying Language for Psychotherapy Practice, the idea was that effectiveness could be enhanced by practitioners purposefully working to enhance the contribution of these pantheoretical ingredients.  Ultimately though, I realized the ideas my colleagues and I were proposing came dangerously close to a new model of therapy.  More importantly, there was (and is) no evidence that teaching clinicians a “common factors” perspective led to improved outcomes–which, by the way, had been my goal from the outset.

The measurable improvements in outcome and retention–following my introduction of the Outcome and Session Rating Scales to the work being done by me and my colleagues at the Institute for the Study of Therapeutic Change–provided the first clues to the coming evolution.  Something happened when formal feedback from consumers was provided to clinicians on an ongoing basis–something beyond either the common or specific factors–a process I believed held the potential for clarifying how therapists could improve their clinical knowledge and skills.  As I began exploring, I discovered an entire literature of which I’d previously been unaware; that is, the extensive research on experts and expert performance.  I wrote about our preliminary thoughts and findings together with my colleagues Mark Hubble and Barry Duncan in an article entitled, “Supershrinks” that appeared in the Psychotherapy Networker.

Since then, I’ve been fortunate to be joined by an internationally renowned group of researchers, educators, and clinicians, in the formation of the International Center for Clinical Excellence (ICCE).  Briefly, the ICCE is a web-based community where participants can connect, learn from, and share with each other.  It has been specifically designed using the latest web 2.0 technology to help behavioral health practitioners reach their personal best.  If you haven’t already done so, please visit the website at www.iccexcellence.com to register to become a member (its free and you’ll be notified the minute the entire site is live)!

As I’ve said before, I am very excited by this opportunity to interact with behavioral health professionals all over the world in this way.  Stay tuned, after months of hard work and testing by the dedicated trainers, associates, and “top performers” of ICCE, the site is nearly ready to launch.