Excellence in therapy: An Interview with Scott D. Miller, Ph.D.
32 Therapy Today/www.therapytoday.net/May 2013The interviewColin: Can you tell us how you cameto be involved in psychotherapy?Scott: I think it’s due to a series offortunate accidents and run-ins withremarkable people. I started universityat 18 as an accounting major. I grew upin a family of meagre means and the ideawas that, even if I couldn’t make muchmoney, I could be around other people’smoney. I changed to experimentalpsychology and had a professor calledHal Miller, a protégé of BF Skinner. Iloved Hal – he was inspiring and verystimulating. I wanted to be like him! Idiscussed my future with him, thinkingof becoming an assistant professor,and he suggested broader avenues suchas clinical work. Michael Lambert wasin the department; I met him, changedto a clinical focus, and the rest is history.Colin: What are your views onassessment and diagnosis?Scott: I’ve always found the diagnosticcode baffling – not very useful orinformative. I’ve found myself moreinterested in the differences betweenmy clients than in the similarities. That’swhere the work takes place, tailoring itto the unique characteristics of clients.The truth is that clients tend to get thekind of therapy their therapist knowshow to give. Perhaps this will changesomeday. Until then we can take somesatisfaction in knowing that the averagetreated client is better off than 80 percent of the untreated sample.Colin: You’ve said that ‘mosttherapists do good work’ but alsothat ‘most therapists have an inflatedassessment of their own competence’.Can you explain this?Scott: It’s confusing on the face ofit but if you compare the services ofpsychotherapy with, say, medicine,ScottDMiller,founderandDirectoroftheInternationalCenterforClinicalExcellence,talkstoColinFelthamaboutwhatmakesagoodtherapistgreattherapy’s outcomes are either as goodor better. Plus, we have a far betterside-effect profile. I’m surprised a) atthe amount of money that’s spent onmedicine, b) how much positive pressit gets, and c) how little positive presspsychotherapy gets. Psychologicalservices are often on the choppingblock compared with medicine. Thatsaid, what we do is good but it can bebetter. Like other professional groups,we vastly over-estimate how effectivewe are, by 65 per cent on average.Additionally, our outcomes haveremained fairly level for some time now.Colin: Daniel Kahneman, in ThinkingFast and Slow, says that clinicians workwell in the moment, working intuitively,but are not so good at seeing theirlimitations in the longer view.Scott: Absolutely. I love that book. I tellpeople, ‘Don’t read my book, go and readKahneman’s.’ In reading that we’ll seewhere we need to go and why we haven’tgot much beyond where we were 30 or40 years ago in terms of outcomes. I thinkexperienced practitioners find that yougradually move from working in a waywhere you ponder every step to a muchmore intuitive way, but if you want toimprove your work further you needto move into Kahneman’s System 2(deliberative, evaluative), which isvery time-consuming. Client feedbackmeasures give you an idea of whereyou should shift into a more deliberativeprocess. As for therapist reluctance to usecertain measures, we are like medical staffinundated with accountability procedures;it’s amazing that so many can be requiredwithout having any effect whatsoever.Colin: I understand you now use theterm feedback-informed treatment(or therapy) – FIT?ExcellenceintherapyScott: Yes, this is to distinguishwhat we’re now doing from the CDOI(client-directed outcome informed)label. I was never comfortable withthat, honestly. Why? I’m not interestedin telling therapists how to work.There’s a ton of gurus and modeldevelopers from whom to learn. WhatI can do is help clinicians identify whenwhat they’re doing isn’t engaging theclient or leading to progress. FIT is a‘six sigma’ (continuous effort to improvesuccess) approach to clinical practice.Colin: As well as running many FITworkshops, you also apply it to clinicalsupervision (feedback-informedsupervision, FIS)?Scott: We’re holding an FIS workshopthis summer in Chicago, actually.You can check that out on my website:www.scottdmiller.com. We show howthe feedback data can be looked atin supervision to improve the therapyprocess. Not to disparage the othertype of supervision, but much of itis either administrative (did you doyour paperwork?) or a kind of therapyfor the therapist. Another type is model-based (seeing that you’re doing thistherapy the right way), which is whatI want to avoid. FIS is about using thefeedback measures to identify whereyou as a therapist need to stretchbeyond your current way of working.Colin: Does that fit with the ethos ofthe International Centre for ClinicalExcellence, where therapists fromall over can discuss how they’reworking with clients?Scott: Yes. I don’t believe expertiseresides in people like me. Expertiseresides in the local community, butpractitioners seem to have fewer andfewer opportunities to rub shoulders
34 Therapy Today/www.therapytoday.net/May 2013The interviewwith people who understand clients’nuanced characteristics and contexts.Expertise requires close, near-knowledge, deep, domain-specificability, and I can’t do that from herewith someone in, say, Sheffield. I can helpthem identify when they’re not engagingwith clients and then put them togetherwith a community that has somethinguseful, interesting or different to say.Excellence never emerges in a vacuum.Colin: You travel the world giving talksand workshops. When Americans uselanguage like supershrinks, superiorresults and mastery, the British tendto recoil. Is that your experience?Scott: We are not known for being anunderstated people! But we’ve knownfor decades that certain therapistsachieve better outcomes. It’s not aboutall becoming supershrinks but aboutlearning the underlying processesthat lead to superior results.Colin: So it’s about helping peopleto be the best they can be. But onthe other hand, about training andselection, there is the question ofsuitability. I’m thinking of James DGuy’s work on therapist personalitiesand the fact that therapists comefrom those who are self-selecting.Scott: I couldn’t agree more. ButAnders Ericsson’s research on expertperformance and deliberate practiceindicates the selection process isn’tas important as the training process.There are identifiable processes amongmusicians that suggest, regardless ofwhere you start, you can achieve world-class performance levels. The expertiseprocess also applies to therapists. Forsome time we didn’t have any way ofunderstanding superior performance,even from data from thousands oftherapists. We looked at within-sessionphenomena to try to understand this.But it’s before and after sessions whereyou see what makes the best great –they simply spend more time inreflection, planning, preparing,reading and reviewing.Colin: You’ve written about the ‘heroicclient’ with innate resources. Is thatsomething you genuinely believe –that all clients, given the right therapist,can change, or are some hard to helpor so-called non-compliant?Scott: Bringing up my former workreminds me of looking at my prompictures. I had a good time, at the time,but can’t help but be embarrassed byhow I looked! The same is true of myprior writing. It was good at the time.We used to talk about client strengthsand resources because of our work onthe common factors, which indicateda significant portion of the variabilityin outcome was attributable toclient characteristics. However, andimportantly, it borders on presentingthe common factors as a model oftherapy when you say ‘focus on theclient’s strengths’. We know from30 years of research that there’s nodifference between approaches –solution-focused or problem-focused.What’s critical is having a choice oralternative as a therapist. When I’mworking with a therapist whose outcomeindicates the client isn’t engaged, it’sprobably an alliance problem. The keyis for therapists to listen for how clientstalk about their lives. If your therapyisn’t working, you can listen for the clients’views, goals, strengths and resources.Colin: You’ve written in Escapefrom Babel and elsewhere about theproblems of therapy models and theirlanguages and you recently reportedon the Swedish experience of CBTnot living up to its research-groundedhopes. What was going wrong there?Scott: I think the CBT folks in the mentalhealth community got their act togetherlong before others. They saw that clinicaltrials were likely to have currency, theygot them done, and as a result were ableto claim they were in some way better.The Swedish Government took thisevidence seriously and funded CBT,as in the UK. But the Swedes founda CBT monopoly made no difference.The Western world is embedded ina medical perspective that thinksthat effective care is finding the righttreatment for the specific disorder. Thisis not what evidence-based practice isabout, however. The correct and accepteddefinition is, ‘using the best evidencedelivered in the context of clients’needs, preferences and characteristics,informed by ongoing feedback’. Let’sinsist that our leaders and regulatorsstick to the accepted definition.Colin: Take a polar opposite to CBT,like primal therapy from the 1970s,sometimes now written off as adangerous or ‘crazy therapy’. Isalmost any therapy model and trainingOK if the therapist uses feedback?Scott: Our field has done some wildand experimental stuff, but far lessthan other fields, like medicine, wherethousands of people die annually frommedication errors alone. In the US wewhipped kids’ tonsils out and prescribedantibiotics for ear infections – both atgreat risk and cost and with little effect.So, let’s get some perspective. How manypeople were really damaged by primaltherapy? There isn’t a single therapyin an RCT that has reliably producednegative effects. I think therapists andour field are a remarkably sane lot.Colin: There’s a lot of concern withmedication and the de-medicalisationof distress. Are there any signs thatpsychotherapy is winning this battle?Scott: I’m hugely optimistic but Idon’t see it in terms of battle. I thinkwe’re a conservative species and thingssimply evolve very slowly. Our modelsare representations, bound by currentculture and understanding. The ideaswe embrace today will have to bejettisoned in the future. This won’toccur quickly, but it will occur.Colin: And sometimes things haveto get bad enough to change. Perhapssometimes crisis pushes evolution?Scott: I’ve just been reading aboutthe history of phrenology, which wasonce influential in both our countriesin determining people’s lives. Althoughhugely powerful, it was completelybogus. And how about pre-frontallobotomy? It had virtually no evidenceof success – complete rumour –before it was stopped, and there arestill speculations about psychosurgery.But human beings are hopeful and ittakes time for ideas to be adoptedand, when necessary, rejected. Thekey is transparency. I’m hopeful, inpart because social media serves tolevel the playing field a bit, givingvoice to a wider group of people.Colin: You come across as a high-energy, optimistic person. Is thatin your nature, or do you have topush yourself?Scott: Ha! I love what I do, especiallythe exploration. If I suddenly found outwhat the secret was, the whole field wouldlose its allure to me. More important, Ithink, is that I’m driven. This may soundold-fashioned but I’m interested in thetruth, the narrative that brings the partstogether, helps me make sense of theworld and know what to do in my work.Colin: What’s next on your agenda?Scott: I’m convinced expertise isnothing to do with the measureswe’ve developed. Some people I’veworked with are obsessed by them.This misses the point, and risks turningmeasurement into another treatmentmodel. Indeed, claims are being madethat their use is ‘the most effectiveintervention created in the history ofpsychotherapy’. Bullshit. The measuresare a prop, a tool. What really mattersis the therapist, their desire to growand willingness to push beyond theircurrent realm of reliable performance.