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How Outcome-Focused Psychotherapy Leads to Clinical Excellence: Interview with Scott Miller PhD


Mr Clinton Power Clinical Counsellor & Gestalt Therapist Founder of Australia Counselling www.AustraliaCounselling.Com.Au

Mr Scott Miller Psychologist, Author Founder of the International Center for Clinical Excellence

www.AustraliaCounselling.Com.Au [START OF VIDEO]

Clinton Power:Hello, this is Clinton Power from AustraliaCounselling.Com.Au, and it's my great pleasure to be here today with Scott Miller, who is the founder of the International Centre for Clinical Excellence, which is an international consortium of clinicians, researchers and educators who are dedicated to promoting excellence in behaviour health science. And

Dr. Miller conducts workshops and training in the United States and abroad, I believe hes been to Australia many times before, and hes helped hundreds of agencies and organizations, both public and private, to achieve superior results. Hes also a handful of invited faculty whose work, thinking, and research is featured at the prestigious Evolution of Psychotherapy Conference, which is where I first encountered certainly Scotts very engaging and entertaining presentation style. Hes also the author of numerous books including The Heart and Soul of Change and The Heroic Client. So welcome, Scott, its such a pleasure to be speaking with you today. Scott Miller: Thanks, Clinton. It's good to be here. Clinton: So weve title this interview Client-directed, Outcome-Informed, How Outcome-Focused Psychotherapy Leads to Clinical Excellence, and many of these trying therapists may not actually be aware of some of the work youre doing in this area, but maybe lets begin by telling me what does the research say at the moment about how effective psychotherapy really is? Scott: I think we can take great solace in the 40 years of research, this has been done on psychotherapy outcome. There was a question in fact I just an article come out in the latest edition of the Journal Psychotherapy which is Division 29 Journal from APA. It summarizes the history of that outcome research, it was an inaugural issue 50 years ago in which Hans Strupp
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and Hans Eysenck debated one another. Of course, Eysenck was making the claim that psychotherapy really didnt have much evidence behind it and what evidence did exist suggest s that the clients were actually worse off after going. Strupp responded that we really didnt have the research necessary to draw such a conclusion and we needed to understand what the variables were in a host of other factors. In our article in, 50 years later, 2013 first issue of this year, we are proud to say that the data collected after that challenging issue was released says that what psychotherapists do works and that works quite well. Thats not only laboratory research but research done from therapists working with diverse clientele in settings that are also diverse. The average-treated person is better off than 80 percent of the untreated sample. Or we can also express it as the amount of deviation from a mean of the untreated sample and whereabout 0.8 to 1.2 standard deviations above that mean. We have outcomes that are four times the effect size of fluoride and the preventation of dental carries that are 27 times the effectiveness of aspirin in the prevention of heart disease and stroke in an otherwise healthy population. We have an effect size that is on par with coronary artery bypass surgery. So what clinicians do in their many and varied ways with clients presenting in many different ways works really quite well. Clinton: Okay, thats comforting, so psychotherapy is effective. Scott: Its absolutely effective, theres no question, and anybody who says otherwise simply doesnt know the research. You know, were often compared to the field of medicine and claims are made that medicine is much more scientific and much more effective when in fact Id rather see a therapist than a physician any whole day of the week. Now, thats an unfair

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comparison but our side effect profile is much less troublesome, very few people die from psychotherapy, and the majority of clients who go are better as a result. Clinton: Well, lets talk about what actually clinical excellence is because I know when I saw you present, I think it was 2010 at the Evolution of Psychology conference, and I was really quite confronted with the question you asked is getting us to consider how effective we think we are, how many of our clients actually do improve. So what do you consider as clinical excellence? Scott: Well, I think that what youre referring to is a piece in a presentation I called Achieving Clinical Excellence where we first start talking about just how effective psychotherapy is and then we look at some very difficult other findings. So, for example, that the overall effectiveness of counselling and psychotherapy really havent improved much over the last 40 years, that our dropout rates are staggering and troubling on average about anywhere between 25 and 50 percent of clients dropout of treatment before achieving a reliable improvement in their functioning, that a very small number about one out of ten clients accounts for 60 to 70 percent of the expenditures in behavioural health services. And also that therapists dont seem to see treatment failure coming or dropout. In other words, theyre often surprised by a therapist, they think they can see when clients are deteriorating the data, say, otherwise therapists may think they can predict when clients are going to drop out of service the data say otherwise. So given those findings the question is how come we havent gone, come further over the last 40 years. We have established that were effective but were not getting much better and narrow these troubling findings, and then the last piece sort of the coup de grace is that
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youre mentioning that I say by McAlfish which is that therapists tend to overestimate their effectiveness anywhere from 50 to 65 percent. And Im sorry, the author on that is Walfish and McAllister, I put the two things together, isnt that interesting? Walfish and McAllister just came out in August of 2012. And so, the problem here is that because we overestimate and we think we are more effective than we actually really are and the other factors we talked about, for example, that we dont see treatment failure coming despite what we believe. This prevents us from pushing our performance to the next level, and clinical excellence really means pushing your performance beyond the realm of your reliable performance, pushing what you do, your skills, your abilities to the next level and that requires conserted, diligent daily effort in order to make that happen. Clinton: This could mean that its a staggering overestimation when you told me about 10 or 15 percentage is rising up to 65 percent? Scott: Well, to be fair and there may be some who are aware of this that are listening in, this isnt a problem that just plagues therapists, this plagues everybody that shouldnt make us feel better. So, for example, the same stat, the average driver believes that theyre better than 80 percent of the people on the road, but thats the same stat for therapists. The average college professor ranks himself at the 94th percentile. The amount of hubris is staggering across a variety of professions, and it seems as if our natural environments contribute to that . Its not comfortable to be pushed to the next level; if you think about, for example, in Conomons terms it says there are two systems of processing information: System 1 and System 2.

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System 2 is a very deliberate time-consuming and tiring system. For that reason, it stays out of our conscious decision-making as much as possible and relies on System 1, which is general heuristics and experience. And so we often rely on System 1 thinking, its kind of a lazy thinking, and as a result we dont see our failures, this leads this compounds the effect that makes us think were more effective than we actually are. In order to enter into System 1 thinking, something has to stop us, shake us, give us pause, and make us aware that we have to rethink what we often take for granted. And again, it would be easy to say this is specific to therapists but its not. Its a phenomenon of human nature, its the way were wired. Clinton: But at moment, I believe, they arrive at 400 treatment models that exist for therapy in the world- does it make a difference if youre a Gestalt therapist or a CBT therapist or some other treatment modality? Scott: Well, in general, it makes no difference whatsoever. So if you look at studies where methods of treatment are directly compared there is absolutely no difference. Theres a bit of a hangover from the 80s when the comparisons that were done seem to show that CBT was a favoured method but that data on re-analysis and on correcting for statistical errors that were made shows that all of these approaches have the potential of being effective. But I think what were saying here when it comes to clinical excellence is no model does therapy. Therapists use models to do therapy and a much better predictor of the outcome of your treatment of your patient or a client is the therapist that you see, not the model that they use. So I always say to people when they say who should I go see, I say talk to people, your friends who have found the therapist particularly effective, make sure you can see the evidence of that in their personal lives, and then second of all ask the therapist do they measure, do they know,
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are they effective or not. Or are there lots of promises that theyre using the latest evidencebased methods. The truth is if you have a therapist thats not very effective, even though theyre using an evidence-based method that is not going to transform that therapist into an effective practitioner. Clinton: And so how can we track our outcomes, how can we start to begin to work at, are we clinically excellent or below par? Scott: Well, I hate to sound so simple-minded but the first thing thats required is will. You have to want to. As I said, beginning an outcome measurement process, which is the first step towards pushing your performance to the next level, requires that its going to require activities, going to push you from your System 1 thinking to System 2 thinking. So you have to make a decision that in fact you really want to know just how effective you are. Not how effective you think you are, not how a select group of patients says you are, but actually crunching the numbers and finding out just how effective am I. We call this, again, Step 1 knowing your baseline performance level. And we are not very good at estimating this, it really does require using some kind of outcome tool. If you are going to say get better at golf or whatever your hobby may be, when I ask at workshops what would you do, people often say take lessons, get better clubs, maybe I would practice more, and I say no, no, and no. What you need to do first is know what your handicap is, what your usual score is, how can you know if youre getting any better unless you know how good you are at the present time. Because the beautiful thing I think about this research and expertise and excellence is that for each of us, what the next step in our performance improvement will be different. So first step, you have to find out how effective am I, and one simple thing you can do is simply go to my website at
How Outcome-Focused Psychotherapy leads to Clinical Excellence: Interview with Scott Miller PhD Page 7 of 18 2013 Australia Counselling & Consulting Pty Ltd and download two simple tools: the Outcome Rating Scale and the Session Rating Scale. Of those two, the outcome rating scale is the measure that you can use to begin to assess just how effective you are from client to client. Clinton: I have to say that your presentation in California in 2010 was so inspiring to me that I went straight home and downloaded those tools, and it was really a fascinating journey to begin with looking at the hard data of what was having in my practice. But I have to say it really was all set the beginning of just looking at whats working and what is not working with my clients and opening up those conversations, which I think is so important. Scott: It is, you know. As I said before, we tried to do a good job and a lot of this is outside of our conscious control. Using the measures does take will and I think some courage in the beginning, and then a lot of folks say exactly what you said, you really do start to notice moments which is the critical piece. Its not about re-fashioning your entire therapy taking on a whole new perspective, learning a new model completely about how do you work with that particular client group, its about fine tuning, you r current way of working and filling in the cracks making sure that youre reaching one more client during one mor e moment of the work that you happen to be doing. Scott: And something you mentioned just early is, for which I think is an important point to highlight, is that and I notice this myself is that certainly I could start to identify the clients that were at risk of dropping out. And if nothing else, I would certainly able to have

conversations with those clients, and sometimes they would still drop out but at least I could bring the conversation in a little earlier. Can you just say a little bit more about how clinicians can do that?
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Scott: Well, I think what youre saying is so important and its staggering, having been a consumer of psychotherapy before, its important for the therapist to figure out whether or not Im pleased with the work. Not that I dont have to do difficult things sometimes when Im meeting with the therapist, but that Im actually happy and connected and engaged with the particular therapist. And so when you think about that upwards of half of clients who start psychotherapy drop out without achieving a reliable change and you just multiply that in terms of dollars. You can see the staggering financial loss, but I think in addition to that something thats talked less about and that we dont have tons of research about is the stag gering emotional and personal costs to the client that they go and the therapist doesnt seem to see that theyre not satisfied or happy or not feeling like theyre making progress. And so they simply disappear, go back into the mix to start things over again. Virtually, all therapists that I talk to will say things like you know, I meet a lot of clients who say Im their fourth or fifth clinician. Not because they have not been helped to some degree but rather because they just lost focus in the therapy or they werent getting exactly what they needed or wanted from a particular therapist, and the therapist didnt seem to know. So what can you do, one thing for example, is to use the SRS which is the Session Rating Scale. Its an alliance measure, youre asking the client to comment on the nature of the interaction from session to session. And heres something we know. We have very solid data which shows that when therapists get negative feedback during the early parts of a treatment relationship that those clients have better outcomes as compared to clients who consistently rate their therapist high. Now, saying that lets connect it with our earlier discussion , Clinton, because when most therapists first download the measures and use the SRS, again thats the Session Rating Scale,
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and thats to have the clients assessment of the working relationship between the two of us. But most therapists get very high scores, and sometimes theyll say in consultations or in workshops to me that what that measure I tried really doesnt work because the client gives you positive results are not being truthful. And I say theyre not being truthful with you , and we assume that the clients simply should tell us, but in fact what we notice is negative feedback varies by therapists. What does this mean? It means that the reason a person gives you a negative feedback or not is because of you. That means this is one area that therapists can begin deliberately practicing. Thats the part, thats the edge of their current realm of reliable performance, the zone of proximal development where they can push their performance to the next level. Youre not going to get negative feedback when you first begin, youre going to have to plan ahead before you go in the room, develop some questions and then refine those questions overtime and the ones you framed at first dont seem to elicit that kind of negative feedback. As again, we know that if you can elicit those critical pieces of feedback in the beginning youre much likelier to have better outcomes. How much better? Fifty percent better. Fifty percent better outcome if you can get your client to tell you the small things that you could do to enhance the engagement of the client and the work with you. Clinton: I think what I hear you saying is its actually critically important we find ways and we can make it easy for us to give us negative feedback. Is that a kind of the essence you want to say? Scott: That is the essence, and generally most questions, and I like to use analogies to restaurants because you can tell the difference between a server who is very good at eliciting your experience versus those who really dont care. So if you get a generic question like hows
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the food, most of the time you get a generic answer. But a good server will say, When the food arrived, was it the right temperature? Its a very different question, learning to ask those qualitatively different questions of a client and soliciting small pieces of critical feedback is really important. Now, let me just say, to be sure, Im not talking about the client making a gross criticism about your interpersonal style. Im talking about small things that you could have done different, the way the chairs are arranged, a word that is used or not used, a question thats asked or not asked, these are small things that the clients say that when theyre disclosed enhance their engagement in the process especially if the therapist responds with understanding and a change on their part. Clinton: Its really quite an art, I think that youre suggesting we need to cultivate it as part of the clinical therapeutic conversation. Scott: Yes, and when you watched really skilled therapists of which there are again many, we see this in them. So part of what we have done with our database now, weve been tracking the outcomes of thousands of therapsists around the world for close to a decade, and weve been interviewing them and what we find is that theres a certain group that reliably achieves better outcomes. Weve tried to reverse engineer what theyre doing, thats where this finding emerged that these top-performing therapists were much more likely to receive negative feedback that is lower SRS scores in the outset of treatment. Interestingly enough, this dovetails I hope Im not jumping ahead too much here, this dovetails very nicely with other research which shows that the most effective therapists are

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much more likely to talk about their errors with their supervisor and think about their errors after the session and make plans for the next session before they made that claim. Now, what you hear, I hope, is these top-performing therapists push themself into again what Kahneman calls System 2-oriented thinking, its deliberate, its time-consuming, its cognitively taxing. Whereas average therapists, we tend to think its good enough or most more of the time we are likely to explain away negative feedback by attributing it what we call burden shifting back to the client. In other words, we explain the clients critique of the look we have on our face by attributing it to the clients life with significant others outside of the therapy. Clinton: Its fascinating. How are you finding the clients are experiencing the therapists that are using the CDOI approach? Do you have feedback on this? Scott: Well, let me just say something about CDOI, this is not a term that I use and I havent for sometime. CDOI was a term given by a publisher. When we first started writing about using feedback in the work, theres nothing wrong with the term, but the publisher of the book Heroic Client was so upset that I refused to name the work we were doing, that they said, I cant wait, what is the essence of it? I said were client-direct, we let in the client give us feedback, and were using outcomes, lets call the client-directed outcome-informed, I thought. Its okay. But whats happened overtime is its turned into a sort of a model of therapy. And I just want everybody listening to know Scott Miller is not interested in creating a model of therapy or actually even telling therapists how to work. Even though we have 400 different models of treatment actually, others say that there are many, many more and there are new models in ways of working that come out everyday. It can be easy to be critical of all
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that diversification, and Im going to say that frankly I think that models of therapy need to grow and evolve and expand because culture changes and therapy is a culturally bound enterprise. But Im not interested in telling therapists which one of those models within our culture they should use with the particular client presenting in a particular way. Im no t interested, you have myriad choices at your fingertips, pick one that you believe in, makes sense to you and makes sense to your client. What I am interested in making sure that whatever therapist do with this client it fits. And so weve been calling our work fit. Feedback in the form of treatment, whether its dynamically oriented, CBT, Gestalts interpersonal, so it doesnt make any difference. The question is does your work fit your client and does it work? Feedback informed treatment. Its more of a metamodel, some might say its a CQI, Continuous Quality Improvement, or even Ive heard it referred to as a Six Sigma System from the business world. Its the way of reviewing our work rather than telling you how to do it. Now, there are some who are interested in the measures, you are very interested in telling therapists, heres how you work, find the clients theory of change. Its just not my stuff, its fine if you want to do that but lets call it what it is, its a model of therapy. Its how you think the therapy would be done better. What is fit about, its about saying when your client complains you will know. When your client is not getting better, you will know, that gives you as a clinician an opportunity to secure the engagement with the client or decide together that maybe this particular partnership wont be the most effective resolution of their problems.

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Clinton: Thank you for clarifying that. I love the term FIT, I mean what I love about what youre saying, Im going to say, really gives me permission to kind of screw up. You know, I can make mistakes but we can talk about it. Scott: Well, let me even finesse that, Clinton, and just to be picky, it gives us the permission to admit the mistakes were already making. And its absolutely right. Much of what we do is an experiment, its a practice so to speak. And this just brings the reality into the room. Now, again, I dont think were saying anything that most talented skilled therapists know. They know that they dont have all the answers through having to work their magic by trying to fit and change and all other things for the client. Hopefully, the measures provide an addition to their intuition, their knowledge and experience. Clinton: So perhaps the therapist would like to introduce the FIT approach, that kind of paradigm, what should they be prepared for or maybe how should I start to introduce this to new clients. Do you have any advice on that? Scott: To new clients. Well, I would say that, that in your question is the key, dont start with your existing clients, start this with your new clients. And I would be upfront, youre trying something new. And then you tell your clients the following, I call this creating a culture of feedback. What you say is that I work in a slightly different way, if youve ever been in therapy before. Im truly interested in making sure that you get what you come for. And so each week, Im going to ask you to complete the couple of very simple tools . One says, howd the week go, the other says how are we doing? Your feedback is critical to our success. Youre not going to hurt my feelings, I really would like to know, its the same thing if you were seeing your
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physician. And the drug they gave you or the surgery that had been done hadnt resolved the problem. The physician would hopefully want to know so that they could continue the service and alter it in some way to make it fit for you. Does this make sense to you? I say to the client. Most of the time they say yes, and then I hand them the ORS. At the end of the visit, theyre giving the SRS with a very similar kind of explanation. I say Im very inte rested in getting your feedback, and again you cant really hurt my feeling and Im no t interested in perfect scores. Im not perfect. Life is not perfect. And sometimes I use an analogy to a suit, you buy a suit and get one off the rack or you can have a tailored suit. What were doing here is tailoring the suit to fit you uniquely and so any small things. If its something big, I want to hear but any small adjustments that might make this work more comfortable and effective for you, thats what I want to know about. And then I hand the measure. I can say as well that doing these measures, this kind of work really requires some kind of support. The process has been portrayed as very simple, and I think its actually misleading. Its much bigger than these two scales as youve discovered, Clinton, as youve applied it. So you need a supportive community. There are lots of clinicians in Australia using the tools, we have several certified trainers from the ICCE that are using the tools in Sydney, in Perth, in Melbourne. And there is the whole ICCE community which is a free web-based community literally thousands of clinicians all over the world, you can post questions, join discussion groups and forums, its ad-free, there are no secret hidden levels, theres nothing you have to buy ever, and we dont bombard you with email solitications either. Its just a place to go to get the support that you need. Clinton: Where can we get
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Scott: And I think those are the two things sorry? Clinton: Yes, so where do we go online to access those resources? Scott: Thats a So Center for Clinical Excellence and you do have to register, youre going to create an avatar, think of it a little bit like Facebook for therapists but I think the information youll fill is more pertinent... Clinton: Wonderful. improving your clinical work. Clinton: Yes, I can certainly say that its an amazing thriving community and you have hours and hours of videos on there- fascinating interviews with therapists that are using the FIT approach, so its certainly worth checking out. Scott: Yes, nowadays, part of our view is that expertise exists in the local community. Im not a therapist in Australia, and I am fully aware that Australia is a country with a different culture, different people, despite our similarities and you can rub shoulders with people from your culture and country that are using the ideas in your context than have unique information that I wouldnt have. Plus you can push the envelop a little because theres folks from all over the world that are there. Clinton: Wonderful. And tell us again, Scott, your website where people can download the tools. Scott: Its at, thats D as in David, and youre going to go down, I think its the fourth or fifth bullet point and it says Performance Metrics. Once you click on that page, youll see the line that says Click here to register for free license. When you register we ask for your name and your email address or country of origin and where you
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heard about us. And I understand people get nervous about submitting email, I certainly do its not my shtick to try to sell peoples stuff, and so youre not going to get email solicitations from me. You may get an occasional update message about the measures or changes to the measures, thats why you register. Clinton: Whats probably worth mentioning is while that there are online tools at a clients I mean, much of us have iPads these days so we can pass the iPad or even it will be electronically kind of registered. Are you involved in that software? Scott: Well, what I do is Ive licensed the two main web -based systems and theres also an IPhone app called the Therapeutic Outcome Management System thats available in the app store that will administer and score the tools so that you can look at them right there on your IPhone. is a web-based system, it sort of has an Apple-like flavour to it, works very well on an iPad, its touch-sensitive just like the iPad. Then there is also which has a more Microsoft kind of feel, very efficient, lots of information that the site gives you. It will administer, score, aggragate your data for you, help you determine your effect size, warn you when the clients are not progressing as usual, and again all of these, if you get a warning, it doesnt mean theres something necessarily wrong, its more about generating hypothesis. What could I do different, what questions should I ask my client. It kicks us from System 1 to System 2 having me think a little bit more before I meet that particular client. So either of those FIT-Outcomes or, both are really good resources. Clinton: Fantastic! Do you have any plans to come to Australia in the near future? Scott: Im going to be in Australia in June actually.
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Clinton: Wonderful! Scott: Thanks for asking. Let me just look here at my calendar. Ill arrive on the 9th of June and Im in Sydney for, I think four or five days, Im flying to Melbourne to connect with the couple of friends, the editors of psychotherapy in Australia who Ive come to know over the last 15 actually almost 20 years, Im getting old, over the week and then I go out to Perth the second week. Clinton: And are any of those events publicly open to the therapists, are you doing any public events? Scott: Absolutely. I know for sure that the events in Perth are open to the public and I believe that the one at University of South Wales is also open to the public, thats 17 th through the 19th of June. And you can go to my website and look at my workshop calendar and click on the email address and mail straight away for information. If you dont get satisfaction you send me an email via my website and tell me. Clinton: Okay, fantastic! Well put those links from the Replay pages as well. Scott: Thank you, that would be great. Clinton: Thank you so much for giving up your time, I know its late in your part of the road, and I really appreciate your sharing of knowledge and wisdom, I hope were inspiring many of the therapists to kind of get onboard with the FIT approach and start having those really important conversations with clients. Scott: Well, I have to tell you Im inspired everyday by the therapists that I meet. You know, I meet incredibly dedicated, talented people, and if I can have any sort of add to any of that I will feel satisfied and happy.
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Clinton: Thank you so much, Scott. Bye for now! Scott: My pleasure. Clinton:Bye! [END OF VIDEO]

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