Colin: Can you tell us how you came to be involved in psychotherapy?
Scott: I think it’s due to a series of fortunate accidents and run-ins with remarkable people. I started university at 18 as an accounting major. I grew up in a family of meagre means and the idea was that, even if I couldn’t make much money, I could be around other people’s money. I changed to experimental psychology and had a professor called Hal Miller, a protégé of BF Skinner. I loved Hal – he was inspiring and very stimulating. I wanted to be like him! I discussed my future with him, thinking of becoming an assistant professor, and he suggested broader avenues such as clinical work. Michael Lambert was in the department; I met him, changed to a clinical focus, and the rest is history.
Colin: What are your views on assessment and diagnosis?
Scott: I’ve always found the diagnostic code baffling – not very useful or informative. I’ve found myself more interested in the differences between my clients than in the similarities. That’s where the work takes place, tailoring it to the unique characteristics of clients. The truth is that clients tend to get the kind of therapy their therapist knows how to give. Perhaps this will change someday. Until then we can take some satisfaction in knowing that the average treated client is better off than 80 per cent of the untreated sample.
Colin: You’ve said that ‘most therapists do good work’ but also that ‘most therapists have an inflated assessment of their own competence’. Can you explain this?
Scott: It’s confusing on the face of it but if you compare the services of psychotherapy with, say, medicine, therapy’s outcomes are either as good or better. Plus, we have a far better side-effect profile. I’m surprised a) at the amount of money that’s spent on medicine, b) how much positive press it gets, and c) how little positive press psychotherapy gets. Psychological services are often on the chopping block compared with medicine. That said, what we do is good but it can be better. Like other professional groups, we vastly over-estimate how effective we are, by 65 per cent on average. Additionally, our outcomes have remained fairly level for some time now.
Colin: Daniel Kahneman, in Thinking Fast and Slow, says that clinicians work well in the moment, working intuitively, but are not so good at seeing their limitations in the longer view.
Scott: Absolutely. I love that book. I tell people, ‘Don’t read my book, go and read Kahneman’s.’ In reading that we’ll see where we need to go and why we haven’t got much beyond where we were 30 or 40 years ago in terms of outcomes. I think experienced practitioners find that you gradually move from working in a way where you ponder every step to a much more intuitive way, but if you want to improve your work further you need to move into Kahneman’s System 2 (deliberative, evaluative), which is very time-consuming. Client feedback measures give you an idea of where you should shift into a more deliberative process. As for therapist reluctance to use certain measures, we are like medical staff inundated with accountability procedures; it’s amazing that so many can be required without having any effect whatsoever.
Colin: I understand you now use the term feedback-informed treatment (or therapy) – FIT?
Scott: Yes, this is to distinguish what we’re now doing from the CDOI (client-directed outcome informed) label. I was never comfortable with that, honestly. Why? I’m not interested in telling therapists how to work. There’s a ton of gurus and model developers from whom to learn. What I can do is help clinicians identify when what they’re doing isn’t engaging the client or leading to progress. FIT is a ‘six sigma’ (continuous effort to improve success) approach to clinical practice.
Colin: As well as running many FIT workshops, you also apply it to clinical supervision (feedback-informed supervision, FIS)?
Scott: We’re holding an FIS workshop this summer in Chicago, actually. You can check that out on my website: www.scottdmiller.com. We show how the feedback data can be looked at in supervision to improve the therapy process. Not to disparage the other type of supervision, but much of it is either administrative (did you do your paperwork?) or a kind of therapy for the therapist. Another type is model-based (seeing that you’re doing this therapy the right way), which is what I want to avoid. FIS is about using the feedback measures to identify where you as a therapist need to stretch beyond your current way of working.
Colin: Does that fit with the ethos of the International Centre for Clinical Excellence, where therapists from all over can discuss how they’re working with clients?
Scott: Yes. I don’t believe expertise resides in people like me. Expertise resides in the local community, but practitioners seem to have fewer and fewer opportunities to rub shoulders with people who understand clients’ nuanced characteristics and contexts. Expertise requires close, near-knowledge, deep, domain-specific ability, and I can’t do that from here with someone in, say, Sheffield. I can help them identify when they’re not engaging with clients and then put them together with a community that has something useful, interesting or different to say. Excellence never emerges in a vacuum.
Colin: You travel the world giving talks and workshops. When Americans use language like supershrinks, superior results and mastery, the British tend to recoil. Is that your experience?
Scott: We are not known for being an understated people! But we’ve known for decades that certain therapists achieve better outcomes. It’s not about all becoming supershrinks but about learning the underlying processes that lead to superior results.
Colin: So it’s about helping people to be the best they can be. But on the other hand, about training and selection, there is the question of suitability. I’m thinking of James D Guy’s work on therapist personalities and the fact that therapists come from those who are self-selecting.
Scott: I couldn’t agree more. But Anders Ericsson’s research on expert performance and deliberate practice indicates the selection process isn’t as important as the training process. There are identifiable processes among musicians that suggest, regardless of where you start, you can achieve world-class performance levels. The expertise process also applies to therapists. For some time we didn’t have any way of understanding superior performance, even from data from thousands of therapists. We looked at within-session phenomena to try to understand this. But it’s before and after sessions where you see what makes the best great – they simply spend more time in reflection, planning, preparing, reading and reviewing.
Colin: You’ve written about the ‘heroic client’ with innate resources. Is that something you genuinely believe – that all clients, given the right therapist, can change, or are some hard to help or so-called non-compliant?
Scott: Bringing up my former work reminds me of looking at my prom pictures. I had a good time, at the time, but can’t help but be embarrassed by how I looked! The same is true of my prior writing. It was good at the time. We used to talk about client strengths and resources because of our work on the common factors, which indicated a significant portion of the variability in outcome was attributable to client characteristics. However, and importantly, it borders on presenting the common factors as a model of therapy when you say ‘focus on the client’s strengths’. We know from 30 years of research that there’s no difference between approaches – solution-focused or problem-focused. What’s critical is having a choice or alternative as a therapist. When I’m working with a therapist whose outcome indicates the client isn’t engaged, it’s probably an alliance problem. The key is for therapists to listen for how clients talk about their lives. If your therapy isn’t working, you can listen for the clients’ views, goals, strengths and resources.
Colin: You’ve written in Escape from Babel and elsewhere about the problems of therapy models and their languages and you recently reported on the Swedish experience of CBT not living up to its research-grounded hopes. What was going wrong there?
Scott: I think the CBT folks in the mental health community got their act together long before others. They saw that clinical trials were likely to have currency, they got them done, and as a result were able to claim they were in some way better. The Swedish Government took this evidence seriously and funded CBT, as in the UK. But the Swedes found a CBT monopoly made no difference. The Western world is embedded in a medical perspective that thinks that effective care is finding the right treatment for the specific disorder. This is not what evidence-based practice is about, however. The correct and accepted definition is, ‘using the best evidence delivered in the context of clients’ needs, preferences and characteristics, informed by ongoing feedback’. Let’s insist that our leaders and regulators stick to the accepted definition.
Colin: Take a polar opposite to CBT, like primal therapy from the 1970s, sometimes now written off as a dangerous or ‘crazy therapy’. Is almost any therapy model and training OK if the therapist uses feedback?
Scott: Our field has done some wild and experimental stuff, but far less than other fields, like medicine, where thousands of people die annually from medication errors alone. In the US we whipped kids’ tonsils out and prescribed antibiotics for ear infections – both at great risk and cost and with little effect. So, let’s get some perspective. How many people were really damaged by primal therapy? There isn’t a single therapy in an RCT that has reliably produced negative effects. I think therapists and our field are a remarkably sane lot.
Colin: There’s a lot of concern with medication and the de-medicalisation of distress. Are there any signs that psychotherapy is winning this battle?
Scott: I’m hugely optimistic but I don’t see it in terms of battle. I think we’re a conservative species and things simply evolve very slowly. Our models are representations, bound by current culture and understanding. The ideas we embrace today will have to be jettisoned in the future. This won’t occur quickly, but it will occur.
Colin: And sometimes things have to get bad enough to change. Perhaps sometimes crisis pushes evolution?
Scott: I’ve just been reading about the history of phrenology, which was once influential in both our countries in determining people’s lives. Although hugely powerful, it was completely bogus. And how about pre-frontal lobotomy? It had virtually no evidence of success – complete rumour – before it was stopped, and there are still speculations about psychosurgery. But human beings are hopeful and it takes time for ideas to be adopted and, when necessary, rejected. The key is transparency. I’m hopeful, in part because social media serves to level the playing field a bit, giving voice to a wider group of people.
Colin: You come across as a high-energy, optimistic person. Is that in your nature, or do you have to push yourself?
Scott: Ha! I love what I do, especially the exploration. If I suddenly found out what the secret was, the whole field would lose its allure to me. More important, I think, is that I’m driven. This may sound old-fashioned but I’m interested in the truth, the narrative that brings the parts together, helps me make sense of the world and know what to do in my work.
Colin: What’s next on your agenda?
Scott: I’m convinced expertise is nothing to do with the measures we’ve developed. Some people I’ve worked with are obsessed by them. This misses the point, and risks turning measurement into another treatment model. Indeed, claims are being made that their use is ‘the most effective intervention created in the history of psychotherapy’. Bullshit. The measures are a prop, a tool. What really matters is the therapist, their desire to grow and willingness to push beyond their current realm of reliable performance.