“Scott Miller Ph.D. is co-director for the Institute for the Study of Clinical Change out of Chicago, Illinois. He is the author and co-author of twenty articles and seven book on treatment and research in Psychotherapy including his landmark book The Heroic Client: Principles of Client-Directed, Outcome-Informed Clinical Work (Jossey-Bass, 2000; Revised, 2004). Miller is a frequent invited presenter at the Milton H. Erickson Foundation conferences and known for his work with the homeless and other traditionally under served populations.
Scott was interviewed by Jim Walt, MA, LMFT, director of the Santa Cruz Center for Counseling and Consultation, and past president of the “California Association of Marriage and Family Therapists.”
Jim Walt: I‘ve had the pleasure of knowing you for about six years now– first as an author, researcher, and workshop presenter, and now as a friend. I’ve watched your work evolve considerably in that time. In fact, I can remember a time when I was concerned for you. You wrote about that time in an article entitled, Losing Faith (Miller, 2004).
Scott Miller: I’ve always gone from crisis to crisis in terms of my development as a therapist. And actually, the first major crisis in my career was at the outset! Others seemed much more certain of their ability and skills that I did. I’d watch my supervisors or fellow students work and was surprised, and secretly envious, of the confidence with which they stated their diagnostic opinions and offered their technical expertise. I, on the other hand, was plagued by doubt. Even later, as a fully bona fide treatment professional, seated opposite a particular client, I often felt like I had missed the one crucial day in graduate school—that one day when they taught you the secret handshake, the secret ingredient in the “Big Mac” of therapy.
JM: That sounds very familiar, personally and professionally. The students I teach at John F. Kennedy University want to know, “what do we do?” What did you do to fill the gap?
SM: Two things. First, I entered psychoanalysis.
JW: Did that help?
SM: Let’s just say, it didn’t help me figure out how to do therapy. My thought was that perhaps something was wrong with me. I just didn’t get “it.” So I went to get help.
JW: What else did you do?
SM: Well, I read every book I could get my hands on and went to every workshop I could afford, hoping that I’d learn how to do “it.” In the beginning, the work of Erickson and his students were a great help. Unlike graduate school, they weren’t afraid to show me what they did, to teach specific strategies. Ernest Rossi’s work and books were particularly reassuring. Other important mentors included Lynn Johnson, Jeffrey Zeig, and Corey Hammond.
JW: Did that help?
JW: But you moved on…
SM: Yes, eventually, I made my way to the Brief Family Therapy Center (BFTC) in Milwaukee. Erickson’s work had been important. I learned many things I could do. But, something was missing. I still needed someone to help me figure out where, when, and with whom the things I knew how to do should, in fact, be done—the underlying rules. For some time, I’d been interested in the work of Steve de Shazer. I’d read that he had been plagued by the same question I had, “How did therapists know what to say and do?” At that time, around the mid-1980’s, the team at BFTC was working with the idea of “skeleton keys”—a generic set of therapeutic strategies that could be used depending on certain qualities of the presenting complaints. For the first time in my career, I felt like I knew what I was doing—there were some maps. Steve was an incredibly clear thinker and his partner, Insoo Berg, a gifted teacher. I learned a lot. With time, I got to where I could do solution-focused interviewing in my sleep.
JW: I have a sense here that another crisis was coming!
SM: I’ve always had an affinity for empirical research. In the early 1990’s, several follow up studies were published that challenged much of what we were saying about our work. First, the data indicated that solution-focused brief therapy (SFBT) was, in spite of our claims, no briefer than any other treatment approach on the market. Second, and more troubling, the research indicated that our model of therapy wasn’t any more effective than other models. As you might imagine, these two findings opened up an old wound for me. I thought I knew what I was doing. I was certainly more confident about it. But it turned out that my confidence was misplaced. Yes, the therapy worked. SFBT worked. But if it worked about as well as everything else, then the effectiveness could not have much to do with the specific technical operations—the ingredients in the recipe, so to speak—of SFBT.
JW: So if it wasn’t the specific ingredients, then perhaps factors common to all approaches might account for the overall effectiveness of the talking therapies?
SM: Exactly. Many scholars had offered this explanation before. Jerome Frank is the name usually associated with this perspective, although the first person to suggest and actually write about it was Saul Rosenzweig—a psychologist in the same graduating class as B.F. Skinner. By the way, I should add that I was exposed to the common factors point of view in graduate school but rejected it out of hand. It didn’t tell me what to do. In fact, it strongly suggested that the treatment model mattered very little. “How could this be?”, I wondered at the time, “and anyway, if it’s true, what the hell am I doing in graduate school?” Anyway, with a few years under my belt, the common factors argument suddenly began making sense to me. Depending on how one counted, there were between 400-1000 different models or therapeutic approaches. Study after study found no difference in outcome between the various and competing approaches. With so many models and so few differences, it just didn’t make sense to assume that every approach contained some unique ingredient(s) responsible for success.
JW: Perhaps this also accounts for why most experienced therapists identify with an “eclectic” orientation?
SM: Absolutely. Ideological adherence quickly gives way to technical and theoretical pragmatism. With time and experience, most clinicians, the research indicates, gravitate toward eclecticism—picking and blending a broad range of strategies and techniques in an attempt to find something that will work for the client seated in front of them at that hour. Common factors, it seemed to me at the time, was the perfect marriage of theory and practice. In practice, clinicians could use any of the 400-1000 different approaches as long as, in theory, the particular strategy, technique, or model fit with the client and empowered one or more of the common factors.
JW: Can you give an example of what you mean?
SM: Sure. The therapeutic relationship is widely considered a core common factor, accounting for 30 to 50% of the variance in treatment effects regardless of theoretical orientation. Said another way, it doesn’t matter so much if the therapy is Ericksonian, Strategic, or Cognitive in flavor as long as the clinician’s approach results in a good working alliance. Since client ratings of the alliance have a higher correlation with outcome than therapists’ratings, the preferred strategy will be one that the therapist believes in (thereby enhancing another common factor, “allegiance effects”) but also, and more importantly, something that fits for the client. In Escape from Babel (Norton, 1997), Impossible Cases (Norton, 1997), and The Heart and Soul of Change (APA, 1999), Barry Duncan, Mark Hubble, and I not only summarized the research on the common factors, but offered a framework for operationalizing them in day to day clinical work regardless of the therapist’s preferred orientation.
JW: So what was the epiphany that caused you to “Lose Faith?” It seems to me that what you’re leading up to here is that the common factors still focus too much on therapeutic process: the “how.”
SM: Exactly. Turns out, the common factors are a dead end precisely because they focus on process. First of all, the minute we started talking about the common factors, clinicians would rightly ask, “How do you do it?”
The result was that we were just developing another way of doing therapy—a transtheoretical model, kinder and gentler to be sure, but a model nonetheless. “And what had the research shown about models?” No difference in outcome. Moreover, at most, they account for one percent of the variance in treatment outcome. More troubling, how could there be a common factors informed approach at all since every therapeutic approach out there was already based on and worked because of the common factors.
JM: So, the common factors cannot offer much guidance on how to do therapy. If anything, they muddy the picture.
SM: Hopefully, they challenge us to remain flexible since all therapeutic models have the potential to be helpful. But knowing about the common factors will not, in my opinion, improve outcomes or help you figure out what will work for that client seated in your office at a given hour. In fact, in many ways, the message of the common factors is, “the method really doesn’t matter.”
JW: And that was the question you started with when you entered the field, “What should I do? What would be best?” Hence, another crisis of faith.
SM: Yeah and here’s the paradox: Research on psychotherapy indicates that allegiance, that is, a therapist’s belief in the way he or she works, contributes significantly to treatment outcome—four times more than the model or approach that is actually used. At the same time, the common factors literature makes clear that, in general, the method one uses is of little consequence. For me personally, I found it impossible to maintain faith long enough in something I knew made no difference in order to make it work! Voila, I lost faith.
JW: Wait a minute, can you say that again?!
SM: Let me say it another way. The research is clear: therapy works. The average treated client is better off than 80% of the untreated sample in most studies. Hold onto your seat: psychotherapy has an effect size 27 times greater than the one associated with aspirin for the prevention of heart attacks and stroke. Not surprisingly, research further shows that clinicians attribute the effectiveness of therapy to skill and expertise. Unfortunately, there is little evidence to support clinicians in that belief. If there were, then experienced therapists, licensed clinicians, would on average have better outcomes than, say, students. Typically, they do not. Hopefully you’re anticipating what I’m about to say.
JW: Therapists must believe in what they do, in their skill or expertise, or the chances of success dim considerably. At the same time, it’s hard to believe if or when you know that the particular model of therapy one embraces matters very little in terms of outcome.
JW: So, what happened?
SM: Well, as I describe in the article Losing Faith this was really a difficult transition for me. I seriously considered leaving the field. But then I came to the conclusion that I had simply been putting faith in the wrong place.
JW: In therapy?
SM: Consider two pivotal findings from the research. First, the client’s experience of change early in treatment is a really good predictor of whether or not a particular pairing of client and therapist is likely to be successful. And second, the client’s experience of the alliance—that is the relationship with the therapist—is also highly predictive of whether or not a particular pairing will work.
JW: I remember reading in Walter and Peller’s book, Becoming Solution Focused in Brief Therapy (Brunner-Mazel, 1992), “the meaning is in the response.” What you seem to be suggesting is that the client’s response to the particular therapist in the particular situation – the meaning they make of that – is the definer of whether or not it will be successful.
SM: Compared to the therapist’s assessment of the alliance and progress? You bet. After all, clients’ ratings of the alliance have a higher correlation with outcome than therapists’ ratings. That same research indicates that the client’s experience of change early in the treatment process accounts for at least 15 times more of the variance in outcome than the treatment approach used. Simply put, the client’s experience of process and outcome beats the life out of everything we therapists have been saying leads to good treatment outcomes.
JW: Where does this take us then?
SM: Well, in a manner of speaking, our field has been acting like therapy is (or should be) the psychological equivalent of a pill. The “right” therapy applied competently to the appropriate problem stands the best chance of resulting in symptom amelioration or cure.
JW: And you are suggesting that is a dead end?
SM: More like an abyss (laughing). There are 1000 different treatment approaches, over 100 manualized, evidence-based therapies, and the number is growing. But, as I said earlier, the search for a psychological formulary has been an abysmal failure. There simply are no contextless psychological interventions—that is, therapeutic strategies that apply across clients, diagnosis, and cultures. Said another way, process is not a reliable determinant of outcome.
JW: So our faith has been, as you say, “misplaced.”
SM: As I said, it is important to believe in what you do—in fact it’s critical. I’m not against learning and using treatment models.
JW: But the final arbiter is the client, can they relate and do they think it is working, whatever “it” may be, psychoanalysis or crystals.
SM: Outcome has to drive process. The important question is not, “what works?” but rather, “Is what we are doing together working for you?”
JW: Ultimately then, because allegiance is critical, clinicians have to find a way of working that fits for them—their beliefs, values, personality, etc.—and then, when working with someone in particular, ask, “Can you relate?”
SM: Yes and “is it working?”
JW: Now, I’ve watched you present these ideas in workshops and even taught them myself to students, and it’s not uncommon to hear people say in response, “I check in with my clients all the time.” Are they just out to lunch?
SM: Well, yes and no. Yes, I believe, and my experience confirms, that most therapists work hard at listening to their clients. In fact, I think that explains the drift toward eclecticism I noted earlier. Therapists are trying to tailor treatment to each client. At the same time, we know that therapists check in far less often than they think. More importantly, however, the research shows that the kind of feedback therapists look for and use when determining whether to continue or alter course does not result in better outcomes overall.
JW: Otherwise, eclectic therapists would as a group have better outcomes, since they are supposedly tailoring the way they work to the individual client in response to feedback.
SM: And there is no evidence of this. What we do know is that access to real-time feedback regarding the client’s experience of progress and the therapeutic alliance dramatically improves outcome- by as much as 65% in fact-while simultaneously cutting deterioration and drop out rates by as much as a third! Importantly, such improvements in outcome were achieved without any attempt to dictate the kind of treatment being offered or without training in new diagnoses or therapeutic techniques. Indeed, current research indicates that the effect size of formal feedback on outcome is double that reported for the “best” so-called evidence-based practices.
JW: The implications for training, certification, even reimbursement for services are mind-boggling.
SM: And truly, just beginning to be explored. Training and certification should be based on reliable feedback about a therapist’s ability to connect with and actually help people.
JW: Right now, it’s based on achieving “competence” in core areas associated with the particular therapeutic guild providing training.
SM: Right. It seems to me that instead of empirically supported therapies, the field—and those who use and pay for our services—would benefit from empirically-supported therapists.
JW: Is this happening anywhere?
SM: Yes, and let me share just a few of the developments we’ve noticed in treatment settings and healthcare systems that have switched from an evidence-based practice to what I like to call a practice-based evidence perspective—in essence, using outcome to inform treatment process. First, time-consuming, process-oriented policies, procedures, and paperwork have been reduced significantly. In exchange for seeking and using formal client feedback, a number of settings we consulted with have completely eliminated onerous pre-authorization requirements, treatment planning paperwork, and utilization review procedures that have become the bane of professionals, agencies, and healthcare systems everywhere. As a result, more time is being spent in direct clinical service—the reason that most of us got into this field. At the same time, consumer access to, and utilization of, services has actually increased—and wait until you hear this—with the blessing of the payer.
JW: In a way, everyone wins. On one hand, therapists get to work in a way that fits for them and their clients. On the other, those paying for the service have evidence of a return on their investment.
SM: And clients, they have the first real-time protection against poor outcome and deterioration.
JW: A therapist who hears this for the first time will probably ask, “How do you measure and monitor outcomes?”
SM: Perfect, that’s the dialogue our field should be having in my opinion. Many measures and systems for monitoring outcome are available. Barry Duncan, Jacqueline Sparks and I review these in the latest edition of our book The Heroic Client (Miller et al 2004). Therapists can also access a great deal of practical, step-by-step instructions on our website (www.talkingcure.com) as well as download free, working copies of our own well-validated alliance and outcome questionnaires.
JW: So is there another crisis of faith in your future?
SM: (laughing). I’m sure there is. And while this may sound cliché, so far, each has been both necessary and helpful. I can tell you that incorporating formal, ongoing, and reliable feedback regarding the client’s experience into my work, finally helped me answer the question that dogged me from the outset of my career: “What do I do?”
Duncan, L. and Miller, S. The Heroic Client.
(2004) San Francisco: Jossey-Bass
Miller, S.D. (2004) Losing Faith: Arguing for a New Way to Think about Therapy.
Scott Miller, PhD will present at the December 2018 Brief Therapy Conference.
View the Schedule here.