One person I knew but never had the privlege of meeting before was psychologist Ronald Bassman.  A few years back, he’d written a chapter that was included in my book, The Heroic Client.  His topic at the Summer Institute was similar to what he’d written for the book: harmful treatment.  Research dating back decades documents that approximately 10% of people detriorate while in psychotherapy.  The same body of evidence shows that clinicians are not adept at identifying: (a) people who are likely to drop out of care; or (b) people who are deteriorating while in care.

Anyway, you can read about Ron on his website or pick up his gripping book A Fight to Be.  Briefly, at age 22 Ron was committed to a psychiatric hospital.  Over the next several years, he was diagnosed with paranoid schizophrenia and forcefully subjected to a series of humiliating, painful, degrading and ultimately unhelpful “treatments.”  Eventually, he escaped his own and the systems’ madness and became a passionate advocate for improving mental health services.  His message is simple: “we can and must do better.”  And, he argues persuasively, the process begins with building better partnerships with consumers.

One way to build bridges with consumers is routinely seeking their feedback regarding the status of the therapeutic relationship and progress of any services offered.  Indeed, the definition of “evidence-based practice” formally adopted by the American Psychological Association mandates that the clinician ”monitor…progress…[and] If progress is not proceeding adequately…alters or addresses problematic aspects of the treatment (e.g., problems in the therapeutic relationship or the implementation of the goals of treatment)” (pp. 276-277, APA, 2006).  Research reviewed in detail on this blog documents significant improvement in both retention and outcome when clinicians use the Outcome and Session Rating Scales to solicit feedback from consumers.  Hope really does transcend.  Thank you Ron and thank you clinicians and organizers at the Institute.

And now, just for fun.  Check out these two new videos:

Magic trick: Do as I do

Magic Trick: Random Numbers

Much to her disappointment I switched from accounting to psychology in my softmore year.  That’s when I first met Dr. Michael Lambert.

Michael J. Lambert, Ph.D.

It was 1979 and I was enrolled in a required course taught by him on “tests and measures.”  He made an impression to be sure.  He was young and hip–the only professor I met while earning my Bachelor’s degree who insisted the students call him by his first name.  What’s more, his knowledge and passion made what everyone considered the “deadliest” class in the entire curriculum seem positively exciting.  (The text, Cronbach’s classic Essentials of Psychological Testing, 3rd Edition, still sits on my bookshelf–one of the few from my undergraduate days).  Within a year, I was volunteering as a “research assistant,” reading and then writing up short summaries of research articles.

Even then, Michael was concerned about deterioration in psychotherapy.  “There is ample evidence,” he wrote in his 1979 book, The Effects of Psychotherapy (Volume 1), “that psychotherapy can and does cause harm to a portion of those it is intended to help” (p. 6).  And where the entire field was focused on methods, he was hot on the trail of what later research would firmly establish as the single largest source of variation in outcome: the therapist.  “The therapist’s contribution to effective psychotherapy is evident,” he wrote, “…training and selection on dimensions of…empathy, warmth, and genuineness…is advised, although little research supports the efficacy of current training procedures.”  In a passage that would greatly influence the arc of my own career, he continued, “Client perception…of the relationship correlate more highly with outcome that objective judges’ ratings” (Lambert, 1979, p. 32).

Fast forward 32 years.  Recently, Michael sent me a pre-publication copy of a mega-analysis of his work on using feedback to improve outcome and reduce deterioration in psychotherapy.  Mega-analysis combines original, raw data from multiple studies–in this case 6–to create a large, representative data set of the impact of feedback on outcome.  In his accompanying email, he said, “our new study shows what the individual studies have shown.”  Routine, ongoing feedback from consumers of behavioral health services not only improves overall outcome but reduces risk of deterioration by nearly two thirds!    The article will soon appear in the Journal of Consulting and Clinical Psychology.

Such results were not available when I first began using Lambert’s measure–the OQ 45–in my clinical work.  It was late 1996.  My colleagues and I had just put the finishing touches on Escape from Babel, our first book together on the “common factors.”

That’s when I received a letter from my colleague and mentor, Dr. Lynn Johnson.

Lynn D. Johnson, Ph.D.

In the envelop was a copy of an article Lynn had written for the journal, Psychotherapy entitled, “Improving Quality in Psychotherapy” in which he argued for the routine measurement of outcome in psychotherapy.  He cited three reasons: (1) providing proof of effectiveness to payers; (2) enabling continuous analysis and improvement of service delivery; and (3) giving consumers voice and choice in treatment. (If you’ve never read the article, I highly recommend it–if for no other reason than its historical significance.  I’m convinced that the field would be in far better shape now had Lynn’s suggestions been heeded then).

Anyway, I was hooked.  I soon had a bootleg copy of the OQ and was using it in combination with Lynn’s Session Rating Scale with every person I met.

It wasn’t always easy.  The measure took time and more than a few of my clients had difficulty reading and comprehending the items on the measure.  I was determined however, and so persisted, occasionally extending sessions to 90 minutes so the client and I could read and score the 45-items together.

Almost immediately, routinely measuring and talking about the alliance and outcome had an impact on my work.  My average number of sessions began slowly “creeping up” as the number of single-session therapies, missed appointments, and no shows dropped.  For the first time in my career, I knew when I was and was not effective.  I was also able to determine my overall success rate as a therapist.  These early experiences also figured prominently in development of the Outcome Ratng Scale and revision of the Session Rating Scale.

More on how the two measures–the OQ 45 and original 10-item SRS–changed from lengthly Likert scales to short, 4-item visual analog measures later.  At this point, suffice it to say I’ve been extremely fortunate to have such generous and gifted teachers, mentors, and friends.

Not long ago, my friend and colleague Dr. Rick Kamins was on vacation in Hawaii.  He was walking along the streets of a small village, enjoying the warm weather and tropical breezes, when the sign on a storefront caught his eye.  Healing Arts Alliance, it read.  The proprieter?  None other than, “Scott Miller, Master of Oriental Medicine.” 

“With all the talking you do about the alliance,” Rick emailed me later, ”I wondered, could it be the same guy?!” 

I responded, “Ha, the story of my life.  You go to Hawaii and all I get is this photo!”

Seriously though, I do spend a fair bit of time when I’m out and about talking about the therapeutic alliance.  As reviewed in the revised edition of The Heart and Soul of Change there are over 1100 studies documenting the importance of the alliance in successful psychotherapy.  Simply put, it is the most evidence-based concept in the treatment literature. 

At the same time, whenever I’m presenting, I go to great lengths to point out that I’m not teaching an “alliance-based approach” to treatment.  Indeed–and this can be confusing–I’m not teaching any treatment approach whatsoever.  Why would I?  The research literature is clear: all approaches work equally well.  So, when it comes to method, I recommend that clinicians choose the one that fits their core values and preferences.  Critically, however, the approach must also fit and work for the person in care–and this is where research on the alliance and feedback can inform and improve retention and outcome. 

Lynn D. Johnson, Ph.D.

Back in 1994, my long time mentor Dr. Lynn Johnson encouraged me to begin using a simple scale he’d developed.  It was called…(drum roll here)…”The Session Rating Scale!”  The brief, 10-item measure was specifically designed to obtain feedback on a session by session basis regarding the quality of the therapeutic alliance.  “Regular use of [such] scales,” he argued in his book Psychotherapy in the Age of Accountability, “enables patients to be the judge of the…relationship.  The approach is…egalitarian and respectful, supporting and empowering the client” (Johnson, 1995, p. 44).

Some 17 years later, research has now firmly validated Lynn’s idea: formally seeking feedback improves both retention and outcome in behavioral health.  How does it work?  Unfortunately science, as Malcoln Gladwell astutely observes, “all too often produces progress in advance of understanding.”  That said, recent evidence indicates that routinely monitoring outcome and alliance establishes and serves to maintain a higher level of baseline performance.   In other words, regularly seeking feedback helps clinicians attend to core therapeutic principles and pocesses easily lost in the complex give-and-take of the treatment hour. 

Such findings are echoed in the research literature on expertise which shows that superior performers across a variety of domains (physics, computer programming, medicine, etc.) spend more time than average performers reviewing basic core principles and practice.    

At an intensive training in Antwerp, Belgium

The implications for improving practice are clear: before reaching for the stars, we should attend to the ground we stand on.  It’s so simple, some might think it stupid.  How can a four item scale given at the end of a session improve anything?  And yet, in medicine, construction, and flight training, there is a growing reliance on such “checklists” to insure

With all the workshops and trainings on “advanced techniques,” I wonder will practitioners interested in the basics?