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Scott D. Miller, Ph.D. - Guest
Dr. Miller is the founder of the International Center for Clinical Excellence, an international consortium of clinicians, researchers, and educators dedicated to promoting excellence in behavioral health services. Scott conducts workshops and training in the United States and abroad, helping hundreds of agencies and organizations, both public and private, to achieve superior results. He is one of a handful of "invited faculty" whose work, thinking, and research is featured at the prestigious "Evolution of Psychotherapy Conference." His humorous and engaging presentation style and command of the research literature consistently inspires practitioners, administrators, and policy makers to make effective changes in service delivery. He is the author of numerous articles and co-author of Better Results: Using Deliberate Practice to Improve Therapeutic Effectiveness, The Heroic Client: A Revolutionary Way to Improve Effectiveness through Client-Directed, Outcome-Informed Therapy, and Feedback Informed Treatment in Clinical Practice: Reaching for Excellence. |
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W. Keith Sutton, Psy.D. - Host
Dr. Sutton has always had an interest in learning from multiple theoretical perspectives, and keeping up to date on innovations and integrations. He is interested in the development of ideas, and using research to show effectiveness in treatment and refine treatments. In 2009 he started the Institute for the Advancement of Psychotherapy, providing a one-way mirror training in family therapy with James Keim, LCSW. Next, he added a trainer and one-way mirror training in Cognitive Behavioral Therapy, and an additional trainer and mirror in Emotionally Focused Couples Therapy. The participants enjoyed analyzing cases, keeping each other up to date on research, and discussing what they were learning. This focus on integrating and evolving their approaches to helping children, adolescents, families, couples, and individuals lead to the Institute for the Advancement of Psychotherapy's training program for therapists, and its group practice of like-minded clinicians who were dedicated to learning, innovating, and advancing the field of psychotherapy. Our podcast, Therapy on the Cutting Edge, is an extension of this wish to learn, integrate, stay up to date, and share this passion for the advancement of the field with other practitioners. |
Dr. Keith Sutton: (00:22)
Welcome to Therapy on the Cutting Edge podcast for therapists who want to be up to date on the latest advancements in the field of psychotherapy. I'm your host, Dr. Keith Sutton, a psychologist in the San Francisco Bay Area and the Director of the Institute for the Advancement of Psychotherapy. In today's episode, I interview Scott Miller PhD. , who's the founder of the International Center for Clinical Excellence, which is an international consortium of clinicians, researchers, and educators dedicated to promoting excellence in behavioral health services. Scott conducts workshops and trainings in the United States and abroad helping hundreds of agencies and organizations, both public and private to achieve superior results. He is one of a handful of invited faculty whose work thinking and research is featured at the prestigious Evolution of Psychotherapy conference, and his humor and engaging presentation style and command of the research literature consistently inspires practitioners, administrators, and policymakers to make effective changes in service delivery.
Dr. Keith Sutton: (01:20)
He is the author of numerous articles and co-author of the books, the Heart and Soul of Change, What Works in Therapy, The Heroic Client, a revolutionary way to improve effectiveness through client directed outcome informed therapy and feedback informed treatment in clinical practice, reaching for excellence. Let's listen to the interview. So hi, Scott. Welcome. Thanks for coming in today. So I'm so glad we had this chance to do this interview. So, I saw you at the Evolution of Psychotherapy conference and I think what was in 2004, and I was really struck by the work that you were doing and the-the common factors research and, and the feedback questionnaires that you use, the outcome rating scale and session rating scale, which I started using at that time with my clients and have been using that ever since. And I've used various forms with a paper form and Tom's app, and now I'm actually using my outcomes.com. So, I think it's just, and it's something that when I teach, I talk about all the time of how that aspect of that feedback is so important. And really how the research show that basically therapists could increase outcome by 65% regardless of theoretical orientation. So, I think it's really important work. First find out a little bit about kind of your evolution of your thinking and how you got to the work you were thinking about.
Dr. Scott Miller: (02:59)
I would say that my journey has been all about me trying to figure out how to do this thing. We all do called therapy, that from the outside, others seem to be much more confident in their thoughts and ideas and how they worked. I than-I was, I've always been from the time I was a graduate student, sort of fraught with anxiety. And in decisiveness, I would go to workshops at the time. The big names were people like Jay Haley and Chloe Madonnas and Burns was another one whose book Feeling Good, you know, what an amazing success and when they spoke and when they showed videos, what they did seem to work. And they were very confident about it, not me-get me in front of a real life person, and suddenly I was indecisive and unsure, and it was all aimed at trying to be helpful to people, but I just didn't often feel helpful.
Dr. Scott Miller: (04:06)
And I think I've taken a path that many therapists take. And I still feel alone in that uncertainty when I go to workshops even today, and I hear the pronouncements being made by, by presenters about how therapy works and the protocol, if you follow it will resolve client's traumatic memories. For example, I sit back after 35 years of experiencing thing. It doesn't seem so clear to me really. My path, I think, has been similar in some respects to many that I started by attending as many workshops as I could. I eventually was invited to work with two very forward thinking, clinicians and Sue Bergen, Steve [inaudible]. I moved from Southern sunny, Southern California to the inner city of Milwaukee to work at that particular agency and clinic for nearly five years. And the hope was that I would become more confident. After all, they were confident.
Dr. Scott Miller: (05:05)
They were promising at the time that one session could make a difference in people's lives. But really a brief contact of five visits was, was sufficient in most cases. And I have to say within short order being there, I developed much more confidence. I could sit in the room, I could speak with people. I had an organized plan. We had some researchers come in from different places to different universities actually. And they came back. I can't remember how long it was a year, maybe two. And they said, we have good news and bad news. And we all said, well, what's the good news. Well, what you're all doing here works. That's great. And we kind of knew it all along. What's the bad news, not any quicker and not any more than anybody else, which was a big shock because we were talking about the nuts and bolts, what you say from moment to moment, the overall theoretical thrust or vision of the work.
Dr. Scott Miller: (06:07)
And we were about as effective as everybody else. This, it turns out is the conclusion of 99% of the research on psychological treatments. Whenever two treatments are directly compared their effectiveness is about the same. And you can, you can persist in your path because after all, if your CBT therapist, if you do EMDR, if you do, uh, interpersonal psychotherapy for depression, or for me at the time solution focused work, all of those paths work. But once again, I was now fraught with uncertainty. I wanted to know how I could get better because all that following my same path would do would mean I was confident, but I didn't help everybody. And I wasn't going to improve. So, we began to cast about looking for ideas about what to do about that. I had a professor as a graduate student, his name was Michael Lambert, Michael Lambert, and together with another mentor of mine, Lynn Johnson had been suggesting that when you measure your results.
Dr. Scott Miller: (07:21)
So, I picked up their two measures. Mike Lambert invented the OCU 45. It was an outcome tool. I could administer it at each session. And here was what was interesting about it, I could then find out was my client getting better or not? And if they weren't getting better, maybe that means I needed to change my mind or my approach. What I wasn't going to do was explain the failure in terms of the technique or the theory that I was following the field has a pension for shifting the blame subtly to the clients. They're too resistant. They're too biologically impaired. They're two relationally impaired. Their childhood is getting in the way of my brilliant work that wasn't satisfying to me. Lynn Johnson's measure was an Alliance measure, a relationship tool. And so I started to use that. And the key for me here was that I could find out before the client dropped out, that I had a rupture of some kind in the relationship. They didn't feel understood by me. Maybe I was pursuing one objective when they wanted to pursue another objective or the way we were working together, didn't fit who they were as a person from a particular culture and background. This would give me the opportunity to adjust in the moment.
Dr. Scott Miller: (08:40)
Once we started measuring and being the evidence that came in at the time, suggested that doing so could improve therapist responsiveness. Now, I know I'm giving a lot of detail here. I hope I'm making sense. When a client walks in the door, they are the wild card of treatment. You can apply your protocol, but really what you have to do, what every therapist knows at some point is they're going to have to make tweaks to fit that person. They're going to have to accommodate the client because they don't all present the same way. So, we could, by using the measures, enhance our responsiveness to the individual, that way they stayed in the care longer. And they seem to experience better outcomes. That was what the initial research said, which was intriguing. But remember, I also wanted to figure out what skills could I learn as a therapist in session.
Dr. Scott Miller: (09:38)
Yes. Right. That would improve that as opposed to just constantly accommodating the client, which was fine. I was willing to do that. We find out after administering these measures to thousands of clients and being administered by thousands of therapists and tracking their outcomes that certain therapist year on year in and year out rose to the top in terms of effectiveness. Now, this is something, this was the super shrink piece. And what's curious about it. I'm doing this in the late eighties, early nineties, but David F Ricks, who was a psychologist in the seventies, he had already talked about and published this in an obscure place where he had noted that one of the primary differences between which clients got better in which did not was who had treated them. David efforts had no idea why that was happening. He could just point to the therapist as a key variable. For me, it was like the lights went on. Exactly. Right? Regardless of whatever theory I happen to learn, or my ability to accommodate the individual, what really was my question was, what do I need to do about me? How can I get better at what I do?
Dr. Scott Miller: (11:00)
So we began to look and try to understand what was different about those top performers. So, 1974 is the first time the field even talks about them 30 years. I think it was 30 years exactly. Pass before Mike Lambert, once again, and a student of his, the last name was [inaudible]. I think it was dissertation research actually, replicated David F Ricks work with a massive sample and they find it again, certain therapists are more effective than others. And that-that difference between the average and the best resulted in something like 10 times as many clients achieving change. Wow. So, you think about that over the course of a therapist, lifetime, if we could figure out what they're doing. And so our team did what many teams do at the time we thought within our therapy box. So what, what I, what we asked for was these top performing therapists.
Dr. Scott Miller: (12:05)
If they'd let us watch them work, and I have to tell you, it was a frustrating process, they did let us watch them work, but we couldn't figure out what the heck they were doing that might account for their superior effectiveness. And it wasn't until I stumbled across this Swedish psychologist, by the name of Anders Ericsson, that the answer to individual professional development started to come together. And Anders Ericsson had been studying top performers in a variety of endeavors, human endeavors, computer programming, science, education, surgery, sports. And he was talking about why some within those domains excelled became the Olympians. Whereas the rest of us were mostly hobbyists or worse.
Dr. Scott Miller: (13:07)
And he identified the difference as engaging in an activity. He termed deliberate practice. And here's what deliberate practice is in the short description. It is reaching for performance objectives just beyond your current ability. Too far, and you fail big time and you may get injured in the process. Think of an athlete, trying to improve by meters rather than millimeters. So too little, and all you were doing was repeating what you already knew. So you had to get to this sweet spot where you identified, what were, what, what was going on, where are you and working with whom when your outcomes begin to fall apart when they're not quite as good? Is it the type of people? Is it the time of day? Is that the strategy you use? What is it that once we discover it, we can help you reach beyond that current ability. And that's where our work has been now for about the last 10, 12 years.
Dr. Scott Miller: (14:25)
We've been publishing research, sort of providing the empirical basis for a deliberate practice as applied to professional development of therapists. Interestingly enough when I read this article actually about Ericsson on a plane coming home from some training workshop, and we were still struggling to make sense of these top performing therapists. So when I got home, I did what I've done since I was an undergraduate. I picked up the phone and I called him and I told him our dilemma and he said, one of the first things he said was, you're the first person in mental health that's ever called. Wow. So, sports figures called investment advisors called Olympic athletes that are called no one from the field of mental health that ever called about or commented on the applicability of his work.
Dr. Keith Sutton: (15:23)
Oh, interesting. I think this aspect and I talked with you some years ago getting some consultation, picking your brain, same kind of thing, picked up the phone. And I remember talking to you about because I run an Institute where we do training and so on and I was saying, and I think you were saying that if you're going to do any trainings or you're going to offer any kind of development for clinicians, teaching them how to have better relationships with their clients is, is probably the most important thing beyond whatever, like the next best theory is or technique or so on. And I think you were saying that you, that you have done some research on whether therapists will go to those trainings. And I won't get the punchline, but I don't know if you remember at all, anything that you had talked about.
Dr. Scott Miller: (16:09)
I do remember. And of course, initially we, after discovering Erickson's work and Ericsson's next question is, well, what is it that your therapist could practice to improve? That's this deliberate practice piece. He says, you have to, you have to get them to practice it their edge. But what is it that has leveraged on outcomes in your field? And I said, on this subject, sadly, despite 50 years of research, there's still a great deal of debate. And he was baffled by this. So, most of what the field offers in terms of continuing education to therapists is either diagnostic in nature. Here's how to determine whether your clients had a trauma. Here's how to distinguish depression from anxiety, whatever it might be. Here's the latest diagnosis that seems to be afflicting the patients coming to psychotherapy. If it's not that, then it's about the techniques for treating those diagnoses.
Dr. Scott Miller: (17:07)
So, if the client's traumatized and you're going to need to give a course of exposure or EMDR, and so what's practice are the components within those methods. The question is how much leverage do those components have on outcome, those specific details. So, in my own tradition, just so I'm not picking on others, the idea that we started teaching therapist was, and I think it's a fairly simple thought. You have to have a picture of the future for the client. What are they aiming at? So we had the miracle question. Then what you did was once you got a picture of what you wanted to go, their preferred future, you would look to see was that already happening. These were called exceptions, or if you're in the narrative frame, unique outcomes, and then you have to somehow ascertain how can you get the person to make that happen more often that that's the basic idea of it now all the way back in the early nineties, when we had the researchers come in, we had been told by the researchers that the clients don't seem to mention any of the techniques you're teaching in these workshops, they don't talk about the scaling.
Dr. Scott Miller: (18:16)
They don't talk about the exception questions. They don't talk about the miracle question. And that was a pretty big question. Suppose a miracle happens. Clients never mentioned it. And I said, oh, that's curious. Unless they said they didn't like it, then they would bring it up. Well, you know, I thought it was very weird that thing, you know, about suppose a miracle. And I told them, I didn't believe in miracles, but they persist anyway.
Dr. Scott Miller: (18:39)
Now, I hear that very differently. So, we assumed that the technical strategies in and of themselves were specifically remedial to the problem we were treating. And therefore we should help you train on asking the miracle question. What I hear this as now is, we sometimes created relationship ruptures. When we insisted that clients stick to our strategies, where the common factors fit in, in terms of all of this whole picture, is that they start to provide some guides about what's most likely to improve outcome. So if you are, if you are measuring your results and you identify that with men who are angry, your outcomes are less than with women who are depressed.
Dr. Scott Miller: (19:34)
The first tendency of therapists might be, I need to go to a workshop on angry men and figure out what techniques do you use when really, if you look at what has leverage on outcome, I would probably start with what you mentioned just a moment ago and that's relationship since it is the most potent contributor to outcome there's something perhaps would be the reasoning within that relationship. When they happen to be men who are angry, that suffers, and we could get some hints at that. By once again, going back to your data and looking at the Alliance scores that you might get on a measure like the SRS, which was Lynn Johnson's measure his assessment of the Alliance. We might be able to figure out that with angry men, they experience you as less caring and empathic. So if I just send you to a general workshop on angry men, they might teach you whatever it is they would teach you. When in fact what it is is a deficit peculiar particular to you because my deficit, maybe it's, again, that I'm less empathic, but for another, it might be that I mess up what the client wanted from care. Maybe what they want is to fix their relationship with their partner. And I was all focused on them getting in touch with their emotions. If I'm making sense. Here's the curious-
Dr. Keith Sutton: (21:00)
Kind of what's most important to the client.
Dr. Scott Miller: (21:03)
Yes. And for me, this is born out again in research about continuing education. I defy your listeners to show me any evidence that attending continuing education workshops improves your outcomes. I defy it. It doesn't exist. It's not there. It's all assumed. From a deliberate practice point of view. The reason it doesn't work is because most of it isn't tied to what you uniquely need to learn. And then I'll add another sort of maybe turning that, twisting the knife here. And that is when therapists leave those continuing education workshops. Here's what they say almost uniformly. They say it was very enjoyable. Presenters get very good at entertaining their audiences and giving them something to think about. But the second thing they leave feeling confident from those workshops and confidence is an anathema to learning. It's antithetical to learning. You can't learn while you're confident. In fact, you have to become a bit doubtful about what you have to have
Dr. Keith Sutton: (22:13)
Like the beginner's mind. There you
Dr. Keith Sutton: (22:14)
Go. There you go.
Dr. Keith Sutton: (22:16)
Yeah. Yeah. One thing that I took away, I got training in motivational interviewing very, very early before I even went to grad school. When I was working at shelter for teenagers and what I took away from that was that resistance is something that's due to the therapist, not something that's within the client. And that's always kind of stood with me about when experiencing resistance or so on. That's kind of the moment to back up and look at what's going on and is, am I understanding my client? And ultimately does my client feel like I'm understanding them because if we don't have that, we can't move forward. And you, like you're saying the therapist might try to push forward with a technique or so on, but they've kind of lost a client.
Dr. Scott Miller: (22:59)
Agreed. I would say that when we're doing deliberate practice coaching, once we've identified an error, a good predictor of challenge is when the therapist is seeking to explain why their treatment didn't work, rather than be curious about what it is in their behavior, that might be changed to facilitate a better engagement and better outcome. So being able to explain why the client, so let me give you one more example. There's some fabulous research it's been replicated now twice, but the original study was by Scott Baldwin. Scott did something really intriguing. I think they original publication date was 2008 or 2009. He had a lot of therapists, don't hold me to this, but I think there were 50 of them. There were 81 therapists in the sample, 331 clients. And he measured the outcomes of these therapists and computed effect sizes.
Dr. Scott Miller: (24:01)
How effective were the therapist? Now? Here's the big secret that we all know, but don't talk about openly. Some therapists are more effective and less effective than others. That was what David efforts found. My sense is instead of avoiding that or worse, assuming that if we're all trained the same, did the same technique. We're all going to get better outcomes or the same outcomes. That's not true either. Again. What we should be curious about is how come some are better. So he rank ordered them from least effective to most effective. And here's what he found and be careful because this can be interpreted the wrong way. Sure. 97% of the difference in outcome between therapists was attributable to therapist variability in the Alliance. Meaning some therapists were simply better at connecting with and engaging their clients than others. Now we all know this. We all know this because we don't just indiscriminately refer people to whomever we say, "see Suzanne, see Bob."
Dr. Scott Miller: (25:03)
And then when certain names come up, "Cindy, oh yeah, don't avoid, avoid that person." We know this, but we don't have reliable data about them. So 97% of the difference in outcome attributable to therapist, being able to connect with their client. This goes back to your point that if you know nothing about your practice, if you haven't measured, but you want to invest some time in professional development efforts, that's probably where I would start. But even that for me is not fine tuned enough, because if you were measuring your outcomes, you would be able to parse your data and begin to look for where you fall short. Maybe it's with certain types of clients or certain types of problems who knows, but you'll be able to see that eventually, once you begin to gather the data, a picture will be revealed of your strengths and your weaknesses.
Dr. Keith Sutton: (26:03)
And I think part of your research also has looked at her, or I've heard you talk about that therapist and to overestimate how good the outcome is going with the therapy and also overestimate how good their alliances. So getting actual data and particularly with your measures it's session by session. But by getting that data, you're actually getting a more accurate kind of perception of a measure of kind of what's going on in the therapy, because you can't necessarily trust your own, your own judgment sometimes around that.
Dr. Scott Miller: (26:34)
And really what using the measures, the whole purpose of using the measures. In addition to identifying deliberate practice activities is to put the therapist in closer contact with the client. So, I think that the correlation between therapist's view of the relationship and client view of the relationship is like 0.3. So, we're not talking about a huge relationship there. So, it makes sense since it's the client's view of the relationship, which predicts whether they continue to work with you, that you'd want to know how they are viewing things. And many therapists say, well, I can just ask that and, or they'll say, common thing I hear is, oh, I asked that already. No you don't. We tend to ask when we think there's an issue and we're not reliably good at determining when we should ask. So the second piece is we need a formal way in a structured way for seeking the feedback.
Dr. Keith Sutton: (27:41)
I actually found this myself. When I was in my practicum, I started using the measure with middle school students. And after a while I was just looking at the, you know, the forum each time, not really commenting or really utilizing it. And one of the kids was like, why aren't we doing this? I'm like, I don't know. And so I stopped, uh, cause it was very beginning and again, like not very confident. And then later on in my next year practicum or my, my pre doc, I started using it again and decided to kind of get more committed. I realized that, although I thought I was asking for feedback each session, the sessions that maybe didn't go so great were the ones that were the hardest to, but that structure of actually passing that form across to the client made me acknowledge and say, you know, how has this today? Yeah, I know this was, was a little rough or maybe I wasn't getting this. I would love some feedback, again, anything for me to do more or less, or it's really helpful to, to make sure that I'm on the right track. But those were the times that it was needed. The most were the time that I realized that I probably would not have asked if I had not had that.
Dr. Scott Miller: (28:42)
And we call this creating a culture of feedback. I love the way you said it. Initially when with the students you were dutifully following through on what you've been taught in school, no Harmon and dad, but then the person you give it to ask the obvious question, "well, why are we doing this," that speaks to the need for this culture around this, I'm doing this because I really want to know, and I don't always get it right. And so please tell me no harm, no foul. When you do, I'll try to work it out in your favor. That's this whole idea. And that by the way, is a skill that takes some practice. And some time it's not easy to get clients initially to give us feedback, I have to learn how to do that, to come back to the other thing you mentioned, which was about therapists, overestimating their effectiveness.
Dr. Scott Miller: (29:28)
Again, this is something that we've known for a long time. Well, over two decades and therapists tend to think clients are that they are more effective than they actually, and they rate themselves more effective than their peers. The point here is not to make fun at how diluted we are, because this is an all too human tendency to overestimate. All drivers think they're better than the idiot. They just haunt that, you know, that's the way it is. The problem is that if you already think you're pretty good, why are you going to put an effort to get better? And the attitude of that person in a CE workshop is how can I finesse what I do as opposed to what is in it, what I do now that needs to be changed fundamentally.
Dr. Keith Sutton: (30:20)
Yeah. And I think that, you know, part of what you had said is when I was asking about what kind of workshops should, should people be providing or so on. And I think you were saying that you did some research on, you know, uh, whether or not therapists would go to workshops on having better relationships with their clients. And you were kind of saying actually therapists would prefer to go to the latest and greatest theory rather than on actually learning how to strengthen their relationship. And so that, although it is really the central part related to outcome.
Dr. Scott Miller: (30:52)
Response is often the response is often that I already know about empathy. I don't want to be bothered with these fundamentals. What the deliberate practice literature suggest is that fundamentals are where it's at Nobel prize, winning physicists. For example, Ericsson once pointed out to me spend more time reading basic physics texts than regular physicists. I think that's interesting. They're rereading the fundamentals. They're reminding themselves of the basics. And for us in our field, the basics are what largely have leverage on outcomes, relationship, the role of the therapist, creation of hope and expectancy, and last but not least, the structure. So, my earlier comments about models and techniques, not withstanding, you could find in fact that a shortcoming in your work has to do with the inability to adjust the rationale and to use techniques that fit your client's background, language, culture will review. So all of those things are on the table. The difference here is that we're looking for the factors that have leveraged on outcomes without assuming that the techniques within any given model have any inherent healing power, which I think 50 years of research shows they don't.
Dr. Keith Sutton: (32:31)
Yeah, well, I know that allegiance to one's model is also an aspect and that again, it's necessarily the model itself, but how it connected and the way I've thought about it, that is that, that they're having something that the person feels competent in. I think also translates through the relationship to the therapist, you know, has a roadmap and feels like they know where they are and where they're going. Oftentimes that's helpful whether that be, you know, doing something that's totally more woo for one therapist or more structured and cognitive for another therapist or so on. But that it's kind of oftentimes the confidence that the person's bringing to their approach while at the same time, the humility of really kind of being able to, to balance that with what the client needs and where the client's at.
Dr. Scott Miller: (33:26)
I think about a more apt metaphor here in medicine. If you have strep throat, you don't want aspirin as a first choice, you'll take aspirin. If the first choice isn't available, which is an antibiotic, you want something that kills the bacteria responsible for strep throat. If you take that analogy and you apply it to medicine or to psychotherapy, it doesn't work because again, none of these ingredients within the models appear to have any inherent healing ability. That doesn't mean you shouldn't do them because as you say, we're able to convey direction and engage people in a hopeful pursuit of a better life with those theories and ideas. I like to think of therapy models as like a GPS. If you go in a GPS, it says at the next corner turn, right. If you don't it doesn't say go back and repeat step one, it adjusts immediately. It says, now go one mile this way and then turn left. It has the objective in mind. Well, the objective is the outcome we're trying to measure with it, which is improved wellbeing or functioning of the client, but all roads, even though the distance may be slightly longer or shorter or more convoluted can get people there. The point is adjusting in the moment.
Dr. Keith Sutton: (34:45)
Definitely. The, the other aspect I think I thought about this, you know, this work is around a two minutes. So, I particularly for, for my models, I integrate CBT EMDR family systems and emotionally focused couples therapy. And so very much influenced by the ideas around attachment. But I oftentimes think about this measure as a way of being attuned to my clients. And particularly that I think about attachment as whether or not the person feels like the other is responsive. Whether to talk about that bad day or a thing that they said that upset them or sex or money or whatever it might be. And also to the extent that they feel loved accepted and respected by using this model, that we are being responsive to our clients, they're saying, "yeah, this didn't really fit for me or something."
Dr. Keith Sutton: (35:33)
And that also not necessarily that we love them, but we have that unconditional positive regard value and respect. And so when the client says, "yeah, I felt like you really didn't get what I was saying about my mom today." I can say, "that's important." Let me write that down because I want to start that off in the next session, or I can say you're right. I don't think I was conveying, you know, how betrayed you felt by her, because then we're being responsive to our clients and we're valuing and respecting what they're having to say rather than again, kind of saying like, oh, well, you know, either not saying anything about it or just saying, "oh, well I was doing this instead of getting defensive or whatever, it might be."
Dr. Scott Miller: (36:08)
Lovely, lovely, extrapolation from what we've been talking about. There is an article written by Bruce Matthews online, available for free called meet me at McGuinness Meadows. And she follows much of what you said in terms of thinking of the measurement process as assessments of attunement. What's interesting about Brooke is that she is well, she's interested in horses, but really what she is a horse whisperer. She's able to take horses that have been traumatized and make them feel safe in being approached by humans and even in even written by humans. And she describes the process of therapy through this, through her work with, with horses and then this other more central construct of attachment it's worth a read, but it fits very closely what you're arguing here.
Dr. Keith Sutton: (37:08)
Yeah, definitely. Yeah. And I think that the, the other aspect that I always kind of run into is I had, so originally my grounding is family systems model and, and helping, you know, kids and parents talk and talk and so on. And so it's a lot of work. It's well worth it, but it's so hard to think like, oh, well, if somebody were just doing, supportive psychotherapy with the kid individually, that would be just as good. How do you reconcile that with or I don't know for therapists, maybe they have a hard time believing that what they're doing is not any more effective than another. I mean, I guess it's just in the research, right? I mean, it's so hard to move away from, from one's beliefs of like, it feels like so much, it makes sense or that it's more effective or better or so on.
Dr. Scott Miller: (38:00)
Well, the truth is that when you look at therapist outcomes, so we were, we were just a moment ago sort of poking them by saying that they overestimate their effectiveness, but we know how effective therapists are on average. Here's the shocking piece therapists on average have outcomes that are on par with outcomes in tightly controlled randomized clinical trials. So, let's just step back and think about that for a minute. Right now, the currency in presentations is to say, have tested our approach in a randomized clinical trial. And the effect size of our treatment is 0.8 standard deviations above the mean of the untreated sample. Well, that's exactly what we find therapists are in terms of their effectiveness, worldwide, working with a diverse body of clients, many of whom are in fact more complicated than the clients that they've tested in randomized trials, because while our field has made some progress in this comorbidity is still the exception in studies published about psychotherapy rather than the rule, even though in clinical practice, morbidity is the rule.
Dr. Scott Miller: (39:11)
You can expect, people are going to come in with all sorts of issues. They don't come in and say, "I'm depressed." They say, "I'm depressed. I have a drug problem. My kid is in trouble. My partner is leaving me. I'm losing my house and I don't have a job." That's what therapists have to deal with. Researchers have to deal with clients who are depressed. All right. So when we compare the outcomes of these average therapist, RCTs, we see that they're equally effective. So, this should give you pause about going to a workshop to learn a new method because outcomes can't be improved that way. They just simply can't, they're too general. They're too vague. And think of it this way, learning some new method and trying to incorporate it in your work might screw up virtuous cycles in your work.
Dr. Scott Miller: (40:02)
In other words, it might not be enhancing of outcomes. It might actually effect them negatively. So what should we be doing in that case? I think the first thing is to know you probably are average level of effectiveness. And so you don't have to change your whole model, your way of working. But what you can do is change how you think of your work. And so I like to view psychotherapy through largely a cultural lens that theories have currency because they fit certain cultural developments. Is it any surprise? For example, the popularity of cognitive therapy, really, we have the most literate population on earth ever that we're dealing with. Secondly, we've all been taught. How do you solve your problems? You have to think differently. Third, cognitive therapy was developed in a university context where people are supposed to be doing lots of thinking. So, game theory and strategic therapy and systems theory all emerged out of the sixties and the cold war.
Dr. Scott Miller: (41:12)
So, you know, it's not like a big mystery to me. What I think you have to do is acknowledge that cultural influences are really significant. And what really matters is does the story I'm selling the client or spinning with them, fit them? Does it engage them? This is why I think that her whole, the fields, current interest in making our therapies culturally adapted is so very important because we don't live in a society with a uniform culture and we live with many diverse microcultures and we're going to have to be adjusting what we do to fit the culture of the person that we work with. So it's not about taking away something from you. You don't have to change the way you think about therapy, but wouldn't, you want to know. And this goes back to your question about attunement. I don't want to know when I'm attuned. That is not interesting to me at all. What's interesting to me is when I'm not and what the, hell's the matter with me? Why am I not attuned with this person? What am I missing here?
Dr. Keith Sutton: (42:22)
And particularly with the measure those session rating scale that you're measuring did the client feel heard, understood, respected. The next one is whether you're working on what they want to be working on, whether the goals or topics of the session were aligned with what they want to be working on. And then whether they felt like the therapist's approach or method is a good fit for them. And then kind of actually rating that each session to be able to kind of stay attuned, because again, it's the method and the goals and so on are again kind of determined by the client and what they feel is fitting or not fitting, or whether you're missing them or so on. So, that's really helpful feedback to kind of figure out. Do I need to adjust here? Do I need to reflect on what my client's experiences and where I might be missing that and such, and really kind of shifting around
Dr. Scott Miller: (43:21)
Can I say one thing on that side? And I don't know how relevant this is, and maybe it seems too vague and decontextualized, but I cannot believe that people pay me for consultation. Given that seven times out of 10, we don't get very much farther than me asking, what is it your client wants? And what I often hear is, well, you know, they have X disorder, Y disorder, Z disorder, I say, but what did they say? They wanted? Well, what I think they need is, and as I say, "no, what I want to know is what did they say was the reason for coming in?" And then typically the eyes go up and this is a starting point, not the end point, but its starting point for getting back on the same side as the person I'm working with in the case that they're not making progress or the alliances at risk.
Dr. Keith Sutton: (44:16)
Yeah. Kind of going back to that. Yeah, I did. I was with the strategic family therapy team at MRI for awhile. And the idea of contracting or the idea of are you working on what's most important to the client? And sometimes what was most important? One session is not necessarily the most important the next session. And actually making sure that you're really connecting with the client around that each and every session
Dr. Scott Miller: (44:41)
Or at least right. At least knowing when you're not. Because it's easy in the flow of conversation with people who are in pain to think we've got this and sometimes clients don't speak in a way that we completely understand their feedback. And again, not that the SRS is the only way or any Alliance scale that you might view is the only way it's clearly not. It's just one extra tool that can help the therapist realign and start to know if the client and you aren't aligned or attuned.
Dr. Keith Sutton: (45:23)
I think another aspect too. And we're calling a lot from our conversation some years ago. I think I was asking you, are you ever going to make this outcome measure more robust and, and include symptoms or so on. And you had pointed out that actually symptoms and functioning or clients report functioning were not necessarily so significantly correlated because in the measure you're asking, how's the person feeling individually kind of their general wellbeing, how they're doing interpersonally and their family, that close relationships, socially at work school friendships, and then overall, so there's not kind of a symptom measure of what your anxiety symptoms or depression or so on. Can you talk a little bit about that?
Dr. Scott Miller: (46:07)
It's a reasonable question. And generally when I start to talk about outcome research, one of the first questions that clinicians bring up and it's, and it's a really good one is what, what qualifies as an outcome. And so historically speaking, our field has followed almost in lockstep with the medical model. And the assumption was that if we identified the symptoms and reduced those, that that was a good outcome. You'll come in, you have white spots on your throat. That's a symptom that's associated with this disorder. I'm going to give this pill and the test will be, do the white spots go away because if they don't could be something else, but in most of the cases are diagnosis accurate. The question is, does that model apply to psychotherapy? And I would say the outcome research doesn't have to support any of it. Most specifically that as I've said, our techniques are specifically remedial to disorder being treated.
Dr. Scott Miller: (46:56)
So we've been measuring symptoms for a very long time, but I want you to think about your clients for a second. When I first started my very one of my very first jobs, which I got by the way, because I did not know that I had to sign up each year to be a TA to the professor. I was TA for a research assistant. His name was Tom Kale, great guy, very interesting researcher. I came back to second year in grad school and I said, Hey Tom, ready to work? And he goes, what are you talking about? I didn't think you wanted the job. Of course I wanted the job. He says, "you have to sign up." Anyway, there were no jobs left except for at Weeber county drug and alcohol. And I needed a job. And so I went to work at Weeber county drug and alcohol.
Dr. Scott Miller: (47:45)
And here's what I found happened. People would come in and they were in terrible shape, terrible shape. And when they would leave and I'm doing talk therapy and recommending, they go to AA and sending them to the psychiatrist for abuse and blah, blah, blah. I was left off with the thought, why the hell didn't you come in years ago? Because by this time, many of them had lots of other issues and problems. I'm not just talking about personal ones. Like their partners left them. They've lost their job, but they're have cirrhosis. It's like, why didn't you come earlier? Well, because people don't go to treatment. When they have symptoms, they tend to go when their symptoms affect their wellbeing or their functioning. So this is why days like national depression awareness day have always struck me as strange. But the explanation is, well, people must not know.
Dr. Scott Miller: (48:42)
Otherwise they'd come well. They know fully well they're symptomatic, but somehow whether they feel like they're eking out some sense of wellbeing or functioning, as soon as functioning is affected, I lose my job. My partner threatens to leave, oh my gosh, you can't get them out of our office. They're there. They're saying I need help. So the two and just turns out that changes in well-being or in functioning tend to predict better when clients decide I'm going to get help. And when they've decided I can do it now on my own, more so than say symptoms. In addition, as I know, most therapists know many of our clients, their symptoms don't change, but their functioning improves. So they do struggle on and off to a greater or lesser degree with depression. I see it every week. People who've had it for years, but as sad as that is, they go to work and they love their partner and they take care of their families, you know? Okay. Maybe that's the way it is.
Dr. Keith Sutton: (49:51)
Yeah. It makes me think of kind of more of the third wave CBT treatments, like an acceptance commitment therapy where learning to change that relationship rather than creating one's whole life around, focusing on getting rid of the anxiety or whatever it might be. Those aspects. And one of my colleagues don't know who's who the quote is around, but basically kind of talked about how a diagnosis, or is only as good as it gives us empathy for our clients. And that kind of gives us some direction of somewhere to go with that. That measure is, is one aspect, it also makes me think of that. There's a clip that I use from when I'm teaching about behavioral interventions for OCD from obsessed from Annie, where the client is going into treatment. Now that he's in his forties because he wants to move his boyfriend in with him to his home. He'd been living with this his whole life and just accommodating to the OCD. But now, because of that functioning aspect, like you're saying about the relationship that was leading to the motivation to want to make change and address the symptoms.
Dr. Scott Miller: (51:02)
That's a lovely example. Yeah. Again, my sense is that therapist at some level know this, but we are bewitched by our language. And then the system enforces that. To me, I think it's really questionable that we actually teach the DSM as though there were real in the same way. Strep throat is real. It's surprising to me. And again, like you say, not that giving people a name for weather struggles, doesn't help many. It does. "Oh, my coach, my kid can't pay attention to school." Yeah. We call that attention deficit disorder. Really? There's a thing like that. Lots of kids have the, oh my gosh, what do I do? Perfect. But then to act as though our techniques are specifically remedial to that, like we are the equivalent, the psychological equivalent of a pill
Dr. Keith Sutton: (52:03)
Well, you can get the blinders on if you get too hyper-focused on the diagnosis itself and not seeing kind of the whole person, especially, well, thank you so much. This is really a great, and we'll put some information on our website kind of looking, linking some of your information. And I know that the measures used to be able to be downloaded even for free. The old website was talkinghere.com.
Dr. Scott Miller: (52:31)
It's on my it's on my current personal website called Scott D miller.com. You can get, you can get them there. And then we talk about how to use the measures in our latest book from APA called better results which is all of this that we spent much of the interview talking about about, well, how do I find what I need to learn? That's what better results is about.
Dr. Keith Sutton: (52:53)
Yeah, definitely. And I think too, it's just so, I mean, oftentimes when I'm supervising others or consulting with others, it's oftentimes about the relationship and really, you know, videotaping sessions and so on, and being able to see that you get to see it much more clearly than sometimes somebody just talking about, "oh, this is what we're, we're stuck on" or so on. And you can see that misattunement in that moment. Well thank you so much. I really appreciate it.
Dr. Scott Miller: (53:18)
My pleasure. Thanks for the opportunity.
Dr. Keith Sutton: (53:21)
Have a good one. Take care. Bye, bye, thank you for joining us. If you're wanting to use this podcast, earn continuing education credits, please go to our website at therapyonthecuttingedge.com. Our podcast is brought to you by the Institute for the Advancement of Psychotherapy, providing in-person and remote therapy in the San Francisco Bay Area. IAP provides screening for licensed clinicians through our in-person and online programs, as well as our treatment for children, adolescents, families, couples, and individual adults. For more information, go to sfiap.com or call 415-617-5932. Also, we really appreciate feedback. And if you have something you're interested in something that's on the cutting edge of the field of therapy, and think clinicians should know about it, send us an email or call us. We're always looking for the advancements in the field of psychotherapy to help in creating lasting changes for our clients.
Welcome to Therapy on the Cutting Edge podcast for therapists who want to be up to date on the latest advancements in the field of psychotherapy. I'm your host, Dr. Keith Sutton, a psychologist in the San Francisco Bay Area and the Director of the Institute for the Advancement of Psychotherapy. In today's episode, I interview Scott Miller PhD. , who's the founder of the International Center for Clinical Excellence, which is an international consortium of clinicians, researchers, and educators dedicated to promoting excellence in behavioral health services. Scott conducts workshops and trainings in the United States and abroad helping hundreds of agencies and organizations, both public and private to achieve superior results. He is one of a handful of invited faculty whose work thinking and research is featured at the prestigious Evolution of Psychotherapy conference, and his humor and engaging presentation style and command of the research literature consistently inspires practitioners, administrators, and policymakers to make effective changes in service delivery.
Dr. Keith Sutton: (01:20)
He is the author of numerous articles and co-author of the books, the Heart and Soul of Change, What Works in Therapy, The Heroic Client, a revolutionary way to improve effectiveness through client directed outcome informed therapy and feedback informed treatment in clinical practice, reaching for excellence. Let's listen to the interview. So hi, Scott. Welcome. Thanks for coming in today. So I'm so glad we had this chance to do this interview. So, I saw you at the Evolution of Psychotherapy conference and I think what was in 2004, and I was really struck by the work that you were doing and the-the common factors research and, and the feedback questionnaires that you use, the outcome rating scale and session rating scale, which I started using at that time with my clients and have been using that ever since. And I've used various forms with a paper form and Tom's app, and now I'm actually using my outcomes.com. So, I think it's just, and it's something that when I teach, I talk about all the time of how that aspect of that feedback is so important. And really how the research show that basically therapists could increase outcome by 65% regardless of theoretical orientation. So, I think it's really important work. First find out a little bit about kind of your evolution of your thinking and how you got to the work you were thinking about.
Dr. Scott Miller: (02:59)
I would say that my journey has been all about me trying to figure out how to do this thing. We all do called therapy, that from the outside, others seem to be much more confident in their thoughts and ideas and how they worked. I than-I was, I've always been from the time I was a graduate student, sort of fraught with anxiety. And in decisiveness, I would go to workshops at the time. The big names were people like Jay Haley and Chloe Madonnas and Burns was another one whose book Feeling Good, you know, what an amazing success and when they spoke and when they showed videos, what they did seem to work. And they were very confident about it, not me-get me in front of a real life person, and suddenly I was indecisive and unsure, and it was all aimed at trying to be helpful to people, but I just didn't often feel helpful.
Dr. Scott Miller: (04:06)
And I think I've taken a path that many therapists take. And I still feel alone in that uncertainty when I go to workshops even today, and I hear the pronouncements being made by, by presenters about how therapy works and the protocol, if you follow it will resolve client's traumatic memories. For example, I sit back after 35 years of experiencing thing. It doesn't seem so clear to me really. My path, I think, has been similar in some respects to many that I started by attending as many workshops as I could. I eventually was invited to work with two very forward thinking, clinicians and Sue Bergen, Steve [inaudible]. I moved from Southern sunny, Southern California to the inner city of Milwaukee to work at that particular agency and clinic for nearly five years. And the hope was that I would become more confident. After all, they were confident.
Dr. Scott Miller: (05:05)
They were promising at the time that one session could make a difference in people's lives. But really a brief contact of five visits was, was sufficient in most cases. And I have to say within short order being there, I developed much more confidence. I could sit in the room, I could speak with people. I had an organized plan. We had some researchers come in from different places to different universities actually. And they came back. I can't remember how long it was a year, maybe two. And they said, we have good news and bad news. And we all said, well, what's the good news. Well, what you're all doing here works. That's great. And we kind of knew it all along. What's the bad news, not any quicker and not any more than anybody else, which was a big shock because we were talking about the nuts and bolts, what you say from moment to moment, the overall theoretical thrust or vision of the work.
Dr. Scott Miller: (06:07)
And we were about as effective as everybody else. This, it turns out is the conclusion of 99% of the research on psychological treatments. Whenever two treatments are directly compared their effectiveness is about the same. And you can, you can persist in your path because after all, if your CBT therapist, if you do EMDR, if you do, uh, interpersonal psychotherapy for depression, or for me at the time solution focused work, all of those paths work. But once again, I was now fraught with uncertainty. I wanted to know how I could get better because all that following my same path would do would mean I was confident, but I didn't help everybody. And I wasn't going to improve. So, we began to cast about looking for ideas about what to do about that. I had a professor as a graduate student, his name was Michael Lambert, Michael Lambert, and together with another mentor of mine, Lynn Johnson had been suggesting that when you measure your results.
Dr. Scott Miller: (07:21)
So, I picked up their two measures. Mike Lambert invented the OCU 45. It was an outcome tool. I could administer it at each session. And here was what was interesting about it, I could then find out was my client getting better or not? And if they weren't getting better, maybe that means I needed to change my mind or my approach. What I wasn't going to do was explain the failure in terms of the technique or the theory that I was following the field has a pension for shifting the blame subtly to the clients. They're too resistant. They're too biologically impaired. They're two relationally impaired. Their childhood is getting in the way of my brilliant work that wasn't satisfying to me. Lynn Johnson's measure was an Alliance measure, a relationship tool. And so I started to use that. And the key for me here was that I could find out before the client dropped out, that I had a rupture of some kind in the relationship. They didn't feel understood by me. Maybe I was pursuing one objective when they wanted to pursue another objective or the way we were working together, didn't fit who they were as a person from a particular culture and background. This would give me the opportunity to adjust in the moment.
Dr. Scott Miller: (08:40)
Once we started measuring and being the evidence that came in at the time, suggested that doing so could improve therapist responsiveness. Now, I know I'm giving a lot of detail here. I hope I'm making sense. When a client walks in the door, they are the wild card of treatment. You can apply your protocol, but really what you have to do, what every therapist knows at some point is they're going to have to make tweaks to fit that person. They're going to have to accommodate the client because they don't all present the same way. So, we could, by using the measures, enhance our responsiveness to the individual, that way they stayed in the care longer. And they seem to experience better outcomes. That was what the initial research said, which was intriguing. But remember, I also wanted to figure out what skills could I learn as a therapist in session.
Dr. Scott Miller: (09:38)
Yes. Right. That would improve that as opposed to just constantly accommodating the client, which was fine. I was willing to do that. We find out after administering these measures to thousands of clients and being administered by thousands of therapists and tracking their outcomes that certain therapist year on year in and year out rose to the top in terms of effectiveness. Now, this is something, this was the super shrink piece. And what's curious about it. I'm doing this in the late eighties, early nineties, but David F Ricks, who was a psychologist in the seventies, he had already talked about and published this in an obscure place where he had noted that one of the primary differences between which clients got better in which did not was who had treated them. David efforts had no idea why that was happening. He could just point to the therapist as a key variable. For me, it was like the lights went on. Exactly. Right? Regardless of whatever theory I happen to learn, or my ability to accommodate the individual, what really was my question was, what do I need to do about me? How can I get better at what I do?
Dr. Scott Miller: (11:00)
So we began to look and try to understand what was different about those top performers. So, 1974 is the first time the field even talks about them 30 years. I think it was 30 years exactly. Pass before Mike Lambert, once again, and a student of his, the last name was [inaudible]. I think it was dissertation research actually, replicated David F Ricks work with a massive sample and they find it again, certain therapists are more effective than others. And that-that difference between the average and the best resulted in something like 10 times as many clients achieving change. Wow. So, you think about that over the course of a therapist, lifetime, if we could figure out what they're doing. And so our team did what many teams do at the time we thought within our therapy box. So what, what I, what we asked for was these top performing therapists.
Dr. Scott Miller: (12:05)
If they'd let us watch them work, and I have to tell you, it was a frustrating process, they did let us watch them work, but we couldn't figure out what the heck they were doing that might account for their superior effectiveness. And it wasn't until I stumbled across this Swedish psychologist, by the name of Anders Ericsson, that the answer to individual professional development started to come together. And Anders Ericsson had been studying top performers in a variety of endeavors, human endeavors, computer programming, science, education, surgery, sports. And he was talking about why some within those domains excelled became the Olympians. Whereas the rest of us were mostly hobbyists or worse.
Dr. Scott Miller: (13:07)
And he identified the difference as engaging in an activity. He termed deliberate practice. And here's what deliberate practice is in the short description. It is reaching for performance objectives just beyond your current ability. Too far, and you fail big time and you may get injured in the process. Think of an athlete, trying to improve by meters rather than millimeters. So too little, and all you were doing was repeating what you already knew. So you had to get to this sweet spot where you identified, what were, what, what was going on, where are you and working with whom when your outcomes begin to fall apart when they're not quite as good? Is it the type of people? Is it the time of day? Is that the strategy you use? What is it that once we discover it, we can help you reach beyond that current ability. And that's where our work has been now for about the last 10, 12 years.
Dr. Scott Miller: (14:25)
We've been publishing research, sort of providing the empirical basis for a deliberate practice as applied to professional development of therapists. Interestingly enough when I read this article actually about Ericsson on a plane coming home from some training workshop, and we were still struggling to make sense of these top performing therapists. So when I got home, I did what I've done since I was an undergraduate. I picked up the phone and I called him and I told him our dilemma and he said, one of the first things he said was, you're the first person in mental health that's ever called. Wow. So, sports figures called investment advisors called Olympic athletes that are called no one from the field of mental health that ever called about or commented on the applicability of his work.
Dr. Keith Sutton: (15:23)
Oh, interesting. I think this aspect and I talked with you some years ago getting some consultation, picking your brain, same kind of thing, picked up the phone. And I remember talking to you about because I run an Institute where we do training and so on and I was saying, and I think you were saying that if you're going to do any trainings or you're going to offer any kind of development for clinicians, teaching them how to have better relationships with their clients is, is probably the most important thing beyond whatever, like the next best theory is or technique or so on. And I think you were saying that you, that you have done some research on whether therapists will go to those trainings. And I won't get the punchline, but I don't know if you remember at all, anything that you had talked about.
Dr. Scott Miller: (16:09)
I do remember. And of course, initially we, after discovering Erickson's work and Ericsson's next question is, well, what is it that your therapist could practice to improve? That's this deliberate practice piece. He says, you have to, you have to get them to practice it their edge. But what is it that has leveraged on outcomes in your field? And I said, on this subject, sadly, despite 50 years of research, there's still a great deal of debate. And he was baffled by this. So, most of what the field offers in terms of continuing education to therapists is either diagnostic in nature. Here's how to determine whether your clients had a trauma. Here's how to distinguish depression from anxiety, whatever it might be. Here's the latest diagnosis that seems to be afflicting the patients coming to psychotherapy. If it's not that, then it's about the techniques for treating those diagnoses.
Dr. Scott Miller: (17:07)
So, if the client's traumatized and you're going to need to give a course of exposure or EMDR, and so what's practice are the components within those methods. The question is how much leverage do those components have on outcome, those specific details. So, in my own tradition, just so I'm not picking on others, the idea that we started teaching therapist was, and I think it's a fairly simple thought. You have to have a picture of the future for the client. What are they aiming at? So we had the miracle question. Then what you did was once you got a picture of what you wanted to go, their preferred future, you would look to see was that already happening. These were called exceptions, or if you're in the narrative frame, unique outcomes, and then you have to somehow ascertain how can you get the person to make that happen more often that that's the basic idea of it now all the way back in the early nineties, when we had the researchers come in, we had been told by the researchers that the clients don't seem to mention any of the techniques you're teaching in these workshops, they don't talk about the scaling.
Dr. Scott Miller: (18:16)
They don't talk about the exception questions. They don't talk about the miracle question. And that was a pretty big question. Suppose a miracle happens. Clients never mentioned it. And I said, oh, that's curious. Unless they said they didn't like it, then they would bring it up. Well, you know, I thought it was very weird that thing, you know, about suppose a miracle. And I told them, I didn't believe in miracles, but they persist anyway.
Dr. Scott Miller: (18:39)
Now, I hear that very differently. So, we assumed that the technical strategies in and of themselves were specifically remedial to the problem we were treating. And therefore we should help you train on asking the miracle question. What I hear this as now is, we sometimes created relationship ruptures. When we insisted that clients stick to our strategies, where the common factors fit in, in terms of all of this whole picture, is that they start to provide some guides about what's most likely to improve outcome. So if you are, if you are measuring your results and you identify that with men who are angry, your outcomes are less than with women who are depressed.
Dr. Scott Miller: (19:34)
The first tendency of therapists might be, I need to go to a workshop on angry men and figure out what techniques do you use when really, if you look at what has leverage on outcome, I would probably start with what you mentioned just a moment ago and that's relationship since it is the most potent contributor to outcome there's something perhaps would be the reasoning within that relationship. When they happen to be men who are angry, that suffers, and we could get some hints at that. By once again, going back to your data and looking at the Alliance scores that you might get on a measure like the SRS, which was Lynn Johnson's measure his assessment of the Alliance. We might be able to figure out that with angry men, they experience you as less caring and empathic. So if I just send you to a general workshop on angry men, they might teach you whatever it is they would teach you. When in fact what it is is a deficit peculiar particular to you because my deficit, maybe it's, again, that I'm less empathic, but for another, it might be that I mess up what the client wanted from care. Maybe what they want is to fix their relationship with their partner. And I was all focused on them getting in touch with their emotions. If I'm making sense. Here's the curious-
Dr. Keith Sutton: (21:00)
Kind of what's most important to the client.
Dr. Scott Miller: (21:03)
Yes. And for me, this is born out again in research about continuing education. I defy your listeners to show me any evidence that attending continuing education workshops improves your outcomes. I defy it. It doesn't exist. It's not there. It's all assumed. From a deliberate practice point of view. The reason it doesn't work is because most of it isn't tied to what you uniquely need to learn. And then I'll add another sort of maybe turning that, twisting the knife here. And that is when therapists leave those continuing education workshops. Here's what they say almost uniformly. They say it was very enjoyable. Presenters get very good at entertaining their audiences and giving them something to think about. But the second thing they leave feeling confident from those workshops and confidence is an anathema to learning. It's antithetical to learning. You can't learn while you're confident. In fact, you have to become a bit doubtful about what you have to have
Dr. Keith Sutton: (22:13)
Like the beginner's mind. There you
Dr. Keith Sutton: (22:14)
Go. There you go.
Dr. Keith Sutton: (22:16)
Yeah. Yeah. One thing that I took away, I got training in motivational interviewing very, very early before I even went to grad school. When I was working at shelter for teenagers and what I took away from that was that resistance is something that's due to the therapist, not something that's within the client. And that's always kind of stood with me about when experiencing resistance or so on. That's kind of the moment to back up and look at what's going on and is, am I understanding my client? And ultimately does my client feel like I'm understanding them because if we don't have that, we can't move forward. And you, like you're saying the therapist might try to push forward with a technique or so on, but they've kind of lost a client.
Dr. Scott Miller: (22:59)
Agreed. I would say that when we're doing deliberate practice coaching, once we've identified an error, a good predictor of challenge is when the therapist is seeking to explain why their treatment didn't work, rather than be curious about what it is in their behavior, that might be changed to facilitate a better engagement and better outcome. So being able to explain why the client, so let me give you one more example. There's some fabulous research it's been replicated now twice, but the original study was by Scott Baldwin. Scott did something really intriguing. I think they original publication date was 2008 or 2009. He had a lot of therapists, don't hold me to this, but I think there were 50 of them. There were 81 therapists in the sample, 331 clients. And he measured the outcomes of these therapists and computed effect sizes.
Dr. Scott Miller: (24:01)
How effective were the therapist? Now? Here's the big secret that we all know, but don't talk about openly. Some therapists are more effective and less effective than others. That was what David efforts found. My sense is instead of avoiding that or worse, assuming that if we're all trained the same, did the same technique. We're all going to get better outcomes or the same outcomes. That's not true either. Again. What we should be curious about is how come some are better. So he rank ordered them from least effective to most effective. And here's what he found and be careful because this can be interpreted the wrong way. Sure. 97% of the difference in outcome between therapists was attributable to therapist variability in the Alliance. Meaning some therapists were simply better at connecting with and engaging their clients than others. Now we all know this. We all know this because we don't just indiscriminately refer people to whomever we say, "see Suzanne, see Bob."
Dr. Scott Miller: (25:03)
And then when certain names come up, "Cindy, oh yeah, don't avoid, avoid that person." We know this, but we don't have reliable data about them. So 97% of the difference in outcome attributable to therapist, being able to connect with their client. This goes back to your point that if you know nothing about your practice, if you haven't measured, but you want to invest some time in professional development efforts, that's probably where I would start. But even that for me is not fine tuned enough, because if you were measuring your outcomes, you would be able to parse your data and begin to look for where you fall short. Maybe it's with certain types of clients or certain types of problems who knows, but you'll be able to see that eventually, once you begin to gather the data, a picture will be revealed of your strengths and your weaknesses.
Dr. Keith Sutton: (26:03)
And I think part of your research also has looked at her, or I've heard you talk about that therapist and to overestimate how good the outcome is going with the therapy and also overestimate how good their alliances. So getting actual data and particularly with your measures it's session by session. But by getting that data, you're actually getting a more accurate kind of perception of a measure of kind of what's going on in the therapy, because you can't necessarily trust your own, your own judgment sometimes around that.
Dr. Scott Miller: (26:34)
And really what using the measures, the whole purpose of using the measures. In addition to identifying deliberate practice activities is to put the therapist in closer contact with the client. So, I think that the correlation between therapist's view of the relationship and client view of the relationship is like 0.3. So, we're not talking about a huge relationship there. So, it makes sense since it's the client's view of the relationship, which predicts whether they continue to work with you, that you'd want to know how they are viewing things. And many therapists say, well, I can just ask that and, or they'll say, common thing I hear is, oh, I asked that already. No you don't. We tend to ask when we think there's an issue and we're not reliably good at determining when we should ask. So the second piece is we need a formal way in a structured way for seeking the feedback.
Dr. Keith Sutton: (27:41)
I actually found this myself. When I was in my practicum, I started using the measure with middle school students. And after a while I was just looking at the, you know, the forum each time, not really commenting or really utilizing it. And one of the kids was like, why aren't we doing this? I'm like, I don't know. And so I stopped, uh, cause it was very beginning and again, like not very confident. And then later on in my next year practicum or my, my pre doc, I started using it again and decided to kind of get more committed. I realized that, although I thought I was asking for feedback each session, the sessions that maybe didn't go so great were the ones that were the hardest to, but that structure of actually passing that form across to the client made me acknowledge and say, you know, how has this today? Yeah, I know this was, was a little rough or maybe I wasn't getting this. I would love some feedback, again, anything for me to do more or less, or it's really helpful to, to make sure that I'm on the right track. But those were the times that it was needed. The most were the time that I realized that I probably would not have asked if I had not had that.
Dr. Scott Miller: (28:42)
And we call this creating a culture of feedback. I love the way you said it. Initially when with the students you were dutifully following through on what you've been taught in school, no Harmon and dad, but then the person you give it to ask the obvious question, "well, why are we doing this," that speaks to the need for this culture around this, I'm doing this because I really want to know, and I don't always get it right. And so please tell me no harm, no foul. When you do, I'll try to work it out in your favor. That's this whole idea. And that by the way, is a skill that takes some practice. And some time it's not easy to get clients initially to give us feedback, I have to learn how to do that, to come back to the other thing you mentioned, which was about therapists, overestimating their effectiveness.
Dr. Scott Miller: (29:28)
Again, this is something that we've known for a long time. Well, over two decades and therapists tend to think clients are that they are more effective than they actually, and they rate themselves more effective than their peers. The point here is not to make fun at how diluted we are, because this is an all too human tendency to overestimate. All drivers think they're better than the idiot. They just haunt that, you know, that's the way it is. The problem is that if you already think you're pretty good, why are you going to put an effort to get better? And the attitude of that person in a CE workshop is how can I finesse what I do as opposed to what is in it, what I do now that needs to be changed fundamentally.
Dr. Keith Sutton: (30:20)
Yeah. And I think that, you know, part of what you had said is when I was asking about what kind of workshops should, should people be providing or so on. And I think you were saying that you did some research on, you know, uh, whether or not therapists would go to workshops on having better relationships with their clients. And you were kind of saying actually therapists would prefer to go to the latest and greatest theory rather than on actually learning how to strengthen their relationship. And so that, although it is really the central part related to outcome.
Dr. Scott Miller: (30:52)
Response is often the response is often that I already know about empathy. I don't want to be bothered with these fundamentals. What the deliberate practice literature suggest is that fundamentals are where it's at Nobel prize, winning physicists. For example, Ericsson once pointed out to me spend more time reading basic physics texts than regular physicists. I think that's interesting. They're rereading the fundamentals. They're reminding themselves of the basics. And for us in our field, the basics are what largely have leverage on outcomes, relationship, the role of the therapist, creation of hope and expectancy, and last but not least, the structure. So, my earlier comments about models and techniques, not withstanding, you could find in fact that a shortcoming in your work has to do with the inability to adjust the rationale and to use techniques that fit your client's background, language, culture will review. So all of those things are on the table. The difference here is that we're looking for the factors that have leveraged on outcomes without assuming that the techniques within any given model have any inherent healing power, which I think 50 years of research shows they don't.
Dr. Keith Sutton: (32:31)
Yeah, well, I know that allegiance to one's model is also an aspect and that again, it's necessarily the model itself, but how it connected and the way I've thought about it, that is that, that they're having something that the person feels competent in. I think also translates through the relationship to the therapist, you know, has a roadmap and feels like they know where they are and where they're going. Oftentimes that's helpful whether that be, you know, doing something that's totally more woo for one therapist or more structured and cognitive for another therapist or so on. But that it's kind of oftentimes the confidence that the person's bringing to their approach while at the same time, the humility of really kind of being able to, to balance that with what the client needs and where the client's at.
Dr. Scott Miller: (33:26)
I think about a more apt metaphor here in medicine. If you have strep throat, you don't want aspirin as a first choice, you'll take aspirin. If the first choice isn't available, which is an antibiotic, you want something that kills the bacteria responsible for strep throat. If you take that analogy and you apply it to medicine or to psychotherapy, it doesn't work because again, none of these ingredients within the models appear to have any inherent healing ability. That doesn't mean you shouldn't do them because as you say, we're able to convey direction and engage people in a hopeful pursuit of a better life with those theories and ideas. I like to think of therapy models as like a GPS. If you go in a GPS, it says at the next corner turn, right. If you don't it doesn't say go back and repeat step one, it adjusts immediately. It says, now go one mile this way and then turn left. It has the objective in mind. Well, the objective is the outcome we're trying to measure with it, which is improved wellbeing or functioning of the client, but all roads, even though the distance may be slightly longer or shorter or more convoluted can get people there. The point is adjusting in the moment.
Dr. Keith Sutton: (34:45)
Definitely. The, the other aspect I think I thought about this, you know, this work is around a two minutes. So, I particularly for, for my models, I integrate CBT EMDR family systems and emotionally focused couples therapy. And so very much influenced by the ideas around attachment. But I oftentimes think about this measure as a way of being attuned to my clients. And particularly that I think about attachment as whether or not the person feels like the other is responsive. Whether to talk about that bad day or a thing that they said that upset them or sex or money or whatever it might be. And also to the extent that they feel loved accepted and respected by using this model, that we are being responsive to our clients, they're saying, "yeah, this didn't really fit for me or something."
Dr. Keith Sutton: (35:33)
And that also not necessarily that we love them, but we have that unconditional positive regard value and respect. And so when the client says, "yeah, I felt like you really didn't get what I was saying about my mom today." I can say, "that's important." Let me write that down because I want to start that off in the next session, or I can say you're right. I don't think I was conveying, you know, how betrayed you felt by her, because then we're being responsive to our clients and we're valuing and respecting what they're having to say rather than again, kind of saying like, oh, well, you know, either not saying anything about it or just saying, "oh, well I was doing this instead of getting defensive or whatever, it might be."
Dr. Scott Miller: (36:08)
Lovely, lovely, extrapolation from what we've been talking about. There is an article written by Bruce Matthews online, available for free called meet me at McGuinness Meadows. And she follows much of what you said in terms of thinking of the measurement process as assessments of attunement. What's interesting about Brooke is that she is well, she's interested in horses, but really what she is a horse whisperer. She's able to take horses that have been traumatized and make them feel safe in being approached by humans and even in even written by humans. And she describes the process of therapy through this, through her work with, with horses and then this other more central construct of attachment it's worth a read, but it fits very closely what you're arguing here.
Dr. Keith Sutton: (37:08)
Yeah, definitely. Yeah. And I think that the, the other aspect that I always kind of run into is I had, so originally my grounding is family systems model and, and helping, you know, kids and parents talk and talk and so on. And so it's a lot of work. It's well worth it, but it's so hard to think like, oh, well, if somebody were just doing, supportive psychotherapy with the kid individually, that would be just as good. How do you reconcile that with or I don't know for therapists, maybe they have a hard time believing that what they're doing is not any more effective than another. I mean, I guess it's just in the research, right? I mean, it's so hard to move away from, from one's beliefs of like, it feels like so much, it makes sense or that it's more effective or better or so on.
Dr. Scott Miller: (38:00)
Well, the truth is that when you look at therapist outcomes, so we were, we were just a moment ago sort of poking them by saying that they overestimate their effectiveness, but we know how effective therapists are on average. Here's the shocking piece therapists on average have outcomes that are on par with outcomes in tightly controlled randomized clinical trials. So, let's just step back and think about that for a minute. Right now, the currency in presentations is to say, have tested our approach in a randomized clinical trial. And the effect size of our treatment is 0.8 standard deviations above the mean of the untreated sample. Well, that's exactly what we find therapists are in terms of their effectiveness, worldwide, working with a diverse body of clients, many of whom are in fact more complicated than the clients that they've tested in randomized trials, because while our field has made some progress in this comorbidity is still the exception in studies published about psychotherapy rather than the rule, even though in clinical practice, morbidity is the rule.
Dr. Scott Miller: (39:11)
You can expect, people are going to come in with all sorts of issues. They don't come in and say, "I'm depressed." They say, "I'm depressed. I have a drug problem. My kid is in trouble. My partner is leaving me. I'm losing my house and I don't have a job." That's what therapists have to deal with. Researchers have to deal with clients who are depressed. All right. So when we compare the outcomes of these average therapist, RCTs, we see that they're equally effective. So, this should give you pause about going to a workshop to learn a new method because outcomes can't be improved that way. They just simply can't, they're too general. They're too vague. And think of it this way, learning some new method and trying to incorporate it in your work might screw up virtuous cycles in your work.
Dr. Scott Miller: (40:02)
In other words, it might not be enhancing of outcomes. It might actually effect them negatively. So what should we be doing in that case? I think the first thing is to know you probably are average level of effectiveness. And so you don't have to change your whole model, your way of working. But what you can do is change how you think of your work. And so I like to view psychotherapy through largely a cultural lens that theories have currency because they fit certain cultural developments. Is it any surprise? For example, the popularity of cognitive therapy, really, we have the most literate population on earth ever that we're dealing with. Secondly, we've all been taught. How do you solve your problems? You have to think differently. Third, cognitive therapy was developed in a university context where people are supposed to be doing lots of thinking. So, game theory and strategic therapy and systems theory all emerged out of the sixties and the cold war.
Dr. Scott Miller: (41:12)
So, you know, it's not like a big mystery to me. What I think you have to do is acknowledge that cultural influences are really significant. And what really matters is does the story I'm selling the client or spinning with them, fit them? Does it engage them? This is why I think that her whole, the fields, current interest in making our therapies culturally adapted is so very important because we don't live in a society with a uniform culture and we live with many diverse microcultures and we're going to have to be adjusting what we do to fit the culture of the person that we work with. So it's not about taking away something from you. You don't have to change the way you think about therapy, but wouldn't, you want to know. And this goes back to your question about attunement. I don't want to know when I'm attuned. That is not interesting to me at all. What's interesting to me is when I'm not and what the, hell's the matter with me? Why am I not attuned with this person? What am I missing here?
Dr. Keith Sutton: (42:22)
And particularly with the measure those session rating scale that you're measuring did the client feel heard, understood, respected. The next one is whether you're working on what they want to be working on, whether the goals or topics of the session were aligned with what they want to be working on. And then whether they felt like the therapist's approach or method is a good fit for them. And then kind of actually rating that each session to be able to kind of stay attuned, because again, it's the method and the goals and so on are again kind of determined by the client and what they feel is fitting or not fitting, or whether you're missing them or so on. So, that's really helpful feedback to kind of figure out. Do I need to adjust here? Do I need to reflect on what my client's experiences and where I might be missing that and such, and really kind of shifting around
Dr. Scott Miller: (43:21)
Can I say one thing on that side? And I don't know how relevant this is, and maybe it seems too vague and decontextualized, but I cannot believe that people pay me for consultation. Given that seven times out of 10, we don't get very much farther than me asking, what is it your client wants? And what I often hear is, well, you know, they have X disorder, Y disorder, Z disorder, I say, but what did they say? They wanted? Well, what I think they need is, and as I say, "no, what I want to know is what did they say was the reason for coming in?" And then typically the eyes go up and this is a starting point, not the end point, but its starting point for getting back on the same side as the person I'm working with in the case that they're not making progress or the alliances at risk.
Dr. Keith Sutton: (44:16)
Yeah. Kind of going back to that. Yeah, I did. I was with the strategic family therapy team at MRI for awhile. And the idea of contracting or the idea of are you working on what's most important to the client? And sometimes what was most important? One session is not necessarily the most important the next session. And actually making sure that you're really connecting with the client around that each and every session
Dr. Scott Miller: (44:41)
Or at least right. At least knowing when you're not. Because it's easy in the flow of conversation with people who are in pain to think we've got this and sometimes clients don't speak in a way that we completely understand their feedback. And again, not that the SRS is the only way or any Alliance scale that you might view is the only way it's clearly not. It's just one extra tool that can help the therapist realign and start to know if the client and you aren't aligned or attuned.
Dr. Keith Sutton: (45:23)
I think another aspect too. And we're calling a lot from our conversation some years ago. I think I was asking you, are you ever going to make this outcome measure more robust and, and include symptoms or so on. And you had pointed out that actually symptoms and functioning or clients report functioning were not necessarily so significantly correlated because in the measure you're asking, how's the person feeling individually kind of their general wellbeing, how they're doing interpersonally and their family, that close relationships, socially at work school friendships, and then overall, so there's not kind of a symptom measure of what your anxiety symptoms or depression or so on. Can you talk a little bit about that?
Dr. Scott Miller: (46:07)
It's a reasonable question. And generally when I start to talk about outcome research, one of the first questions that clinicians bring up and it's, and it's a really good one is what, what qualifies as an outcome. And so historically speaking, our field has followed almost in lockstep with the medical model. And the assumption was that if we identified the symptoms and reduced those, that that was a good outcome. You'll come in, you have white spots on your throat. That's a symptom that's associated with this disorder. I'm going to give this pill and the test will be, do the white spots go away because if they don't could be something else, but in most of the cases are diagnosis accurate. The question is, does that model apply to psychotherapy? And I would say the outcome research doesn't have to support any of it. Most specifically that as I've said, our techniques are specifically remedial to disorder being treated.
Dr. Scott Miller: (46:56)
So we've been measuring symptoms for a very long time, but I want you to think about your clients for a second. When I first started my very one of my very first jobs, which I got by the way, because I did not know that I had to sign up each year to be a TA to the professor. I was TA for a research assistant. His name was Tom Kale, great guy, very interesting researcher. I came back to second year in grad school and I said, Hey Tom, ready to work? And he goes, what are you talking about? I didn't think you wanted the job. Of course I wanted the job. He says, "you have to sign up." Anyway, there were no jobs left except for at Weeber county drug and alcohol. And I needed a job. And so I went to work at Weeber county drug and alcohol.
Dr. Scott Miller: (47:45)
And here's what I found happened. People would come in and they were in terrible shape, terrible shape. And when they would leave and I'm doing talk therapy and recommending, they go to AA and sending them to the psychiatrist for abuse and blah, blah, blah. I was left off with the thought, why the hell didn't you come in years ago? Because by this time, many of them had lots of other issues and problems. I'm not just talking about personal ones. Like their partners left them. They've lost their job, but they're have cirrhosis. It's like, why didn't you come earlier? Well, because people don't go to treatment. When they have symptoms, they tend to go when their symptoms affect their wellbeing or their functioning. So this is why days like national depression awareness day have always struck me as strange. But the explanation is, well, people must not know.
Dr. Scott Miller: (48:42)
Otherwise they'd come well. They know fully well they're symptomatic, but somehow whether they feel like they're eking out some sense of wellbeing or functioning, as soon as functioning is affected, I lose my job. My partner threatens to leave, oh my gosh, you can't get them out of our office. They're there. They're saying I need help. So the two and just turns out that changes in well-being or in functioning tend to predict better when clients decide I'm going to get help. And when they've decided I can do it now on my own, more so than say symptoms. In addition, as I know, most therapists know many of our clients, their symptoms don't change, but their functioning improves. So they do struggle on and off to a greater or lesser degree with depression. I see it every week. People who've had it for years, but as sad as that is, they go to work and they love their partner and they take care of their families, you know? Okay. Maybe that's the way it is.
Dr. Keith Sutton: (49:51)
Yeah. It makes me think of kind of more of the third wave CBT treatments, like an acceptance commitment therapy where learning to change that relationship rather than creating one's whole life around, focusing on getting rid of the anxiety or whatever it might be. Those aspects. And one of my colleagues don't know who's who the quote is around, but basically kind of talked about how a diagnosis, or is only as good as it gives us empathy for our clients. And that kind of gives us some direction of somewhere to go with that. That measure is, is one aspect, it also makes me think of that. There's a clip that I use from when I'm teaching about behavioral interventions for OCD from obsessed from Annie, where the client is going into treatment. Now that he's in his forties because he wants to move his boyfriend in with him to his home. He'd been living with this his whole life and just accommodating to the OCD. But now, because of that functioning aspect, like you're saying about the relationship that was leading to the motivation to want to make change and address the symptoms.
Dr. Scott Miller: (51:02)
That's a lovely example. Yeah. Again, my sense is that therapist at some level know this, but we are bewitched by our language. And then the system enforces that. To me, I think it's really questionable that we actually teach the DSM as though there were real in the same way. Strep throat is real. It's surprising to me. And again, like you say, not that giving people a name for weather struggles, doesn't help many. It does. "Oh, my coach, my kid can't pay attention to school." Yeah. We call that attention deficit disorder. Really? There's a thing like that. Lots of kids have the, oh my gosh, what do I do? Perfect. But then to act as though our techniques are specifically remedial to that, like we are the equivalent, the psychological equivalent of a pill
Dr. Keith Sutton: (52:03)
Well, you can get the blinders on if you get too hyper-focused on the diagnosis itself and not seeing kind of the whole person, especially, well, thank you so much. This is really a great, and we'll put some information on our website kind of looking, linking some of your information. And I know that the measures used to be able to be downloaded even for free. The old website was talkinghere.com.
Dr. Scott Miller: (52:31)
It's on my it's on my current personal website called Scott D miller.com. You can get, you can get them there. And then we talk about how to use the measures in our latest book from APA called better results which is all of this that we spent much of the interview talking about about, well, how do I find what I need to learn? That's what better results is about.
Dr. Keith Sutton: (52:53)
Yeah, definitely. And I think too, it's just so, I mean, oftentimes when I'm supervising others or consulting with others, it's oftentimes about the relationship and really, you know, videotaping sessions and so on, and being able to see that you get to see it much more clearly than sometimes somebody just talking about, "oh, this is what we're, we're stuck on" or so on. And you can see that misattunement in that moment. Well thank you so much. I really appreciate it.
Dr. Scott Miller: (53:18)
My pleasure. Thanks for the opportunity.
Dr. Keith Sutton: (53:21)
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