Dinner with Paul McCartney (and others)

McCartneyat WrigleyMcCartney

Growing up, my family had a game we frequently played around the dining room table.  “If you could invite anyone to dinner,” it always started,”who would it be?”  Invariably, my father chose historical figures: Abraham Lincoln, Mark Twain, Leonardo Da Vinci.  My mom was more inclined toward the living: Jackie O., J.D. Salinger, Lucille Ball.  My brothers, Marc and Doug, usually went for sports figures.  I recall Wilt Chamberlain and Willie Mays being popular choices–although there were many others whose names I’ve now forgotten.

Me?  Always the same answer: Paul McCartney.

Of course, the “name game” didn’t end there.  Whatever your choice, you also had to state why.  Here, my answer didn’t vary either.  “He’s one of the Beatles!” I’d say, frustrated whenever my family acted as though my statement needed further clarification.

To this date, I’ve never had a chance to met much less have dinner with Paul McCartney.  Seen him in concert a number of times but always from a distance.  Last week, however, I did have the opportunity to meet and spend time with a number of my heroes from the field of psychotherapy–and go to dinner together, not once, but twice!

calgaryCCC logo

We were together at the first ever Calgary Counseling Center Outcomes conference.  Thanks to Center’s director, Dr. Robbie Wagner, a small group of practitioners, policy makers, and agency managers were invited to spend two, intimate days learning from the field’s leading thinkers and researchers.  The Beatles of outcome research: Michael J. Lambert, Bruce E. Wampold, Michael Barkham, Wolfgang Lutz, and Gary Burlingame.  I presented the latest results on our studies of top performing therapists.


It was every bit a rock concert–exciting, controversial, and cutting edge.   Below, I summarize the “greatest hits.”  I’ve also included the slides from each presentation for those who like to read the details contained in the “liner notes!”

Let me know what you think…here goes:

  • The burden born by people with mental health problems is second only to cancer (Depression alone results in a 70% loss of productivity)

Bottom line: People need the skills mental health professional have to offer

  • Treatment is effective. However, therapists believe they help far more people than they do (85% versus 20%);
  • Approximately 10% of adults deteriorate in care;
  • Between 14 and 25% of children are worse off following treatment;
  • Serious deterioration recognized in only one-third of cases;

Bottom Line: Mental health professionals overestimate their effectiveness and miss deterioration

  • Multiple, sophisticated, real world studies find no difference in outcome between people treated with different therapeutic approaches;
  • Factors related to the therapeutic relationship (i.e., empathy, collaboration, affirmation, genuineness) have a far greater impact on outcome (7:1) than treatment approach, adherence to treatment protocol, or rated competence.

Bottom Line: The pathway to improved effectiveness is not adopting new treatment approaches

  • Rapid and dramatic change (first 5 visits) occurs in as many as 40% of people and is maintained at two year follow up;
  • 90% chance of failure if there is no change between the 2nd and 8th visit;
  • As many as 25% of people remain in treatment while experiencing no measurable benefit;

Bottom Line: A large number of people need very little treatment to achieve lasting benefit

  • Separating intake from treatment results in higher drop out, lower and longer treatment response, and higher costs;

Bottom Line: Any barrier to establishing a relationship with a specific provider has a negative impact on outcome

  • The majority of individual practitioners are effective;
  • Around 16% of practitioners achieve outcomes significantly below average;
  • Less effective practitioners rate empathic understanding more highly as a professional/personal attribute than more effective practitioners;
  • The clients of the least effective clinicians were assigned to average practitioners, an additional 15% of clients would achieve clinical recovery;
  • Around 16% of practitioners consistently achieve outcomes significantly above average;
  • More effective practitioners rate resilience and mindfulness more highly as a professional/personal attribute;
  • Professional self-doubt and an “error-centric attitude” are associated with better outcomes.

Bottom Line: Choose your therapist carefully as they determine the outcome of care

  • When therapists receive feedback that clients are deteriorating, they: discuss it with clients about 60% of the time; make efforts to assist with other resources about 27% of the time; adjust therapeutic interventions 30% of the time; vary intensity or dose of services 9% of the time; consult with others (supervision, education, etc.) 7% of the time;
  • Therapist attitude toward soliciting and using feedback vary and influence results;
  • Therapists who value feedback achieve better outcomes;
  • Professional self-doubt and an “error-centric attitude” are associated with better outcomes;

Bottom Line: Regular, formal feedback from clients to therapists improves outcomes (as long as the therapist listens and acts on the feedback)

  • When asked, 92% of clients say they like the use of outcome measures in care.

Bottom Line: An overwhelming majority of clients endorse progress monitoring or providing feedback

Is Documentation Helping or Hindering Mental Health Care? Please Let me know.

Drowning in paperwork

So, how much time do you spend doing paperwork?  Assessments, progress notes, treatment plans, billing, updates, etc.–the lot?

When I asked the director of the agency I was working at last week, it took him no time to respond. “Fifty percent,” he said, then added without the slightest bit of irony, “It’s a clinic-wide goal, keeping it to 50% of work time.”

Truth is, it’s not the first time I’ve heard this figure.  Wherever I travel–whether in the U.S. or abroad–practitioners are spending more and more time “feeding the bureaucratic beast.”  Each state or federal agency, regulatory body, and payer wants a form of some kind.  Unchecked, regulation has lost touch with reality.

Just a few short years ago, the figure commonly cited was 30%.  In the last edition of The Heart and Soul of Change, published in 2009, we pointed out that in one state, “The forms needed to obtain a marriage certificate, buy a new home, lease an automobile, apply for a passport, open a bank account, and die of natural causes were assembled … altogether weighed 1.4 ounces.  By contrast, the paperwork required for enrolling a single mother in counseling to talk about difficulties her child was experiencing at school came in at 1.25 pounds” (p. 300).

Research shows that a high documentation to clinical service ratio leads to higher rates of:

  • Burnout and job dissatisfaction among clinical staff;
  • Fewer scheduled treatment appointments;
  • No shows, cancellations, and disengagement among consumers.

Some potential solutions have emerged.  “Concurrent ,” a.k.a., “collaborative documentation.”  It’s a great idea: completing assessments, treatment plans, and progress notes together with clients during rather than after the session.  We started doing this to improve transparency and engagement at the Brief Family Therapy Center in Milwaukee, Wisconsin back in the late 1980′s.  At the same time, it’s chief benefit to date seems to be that it saves time on documentation–as though filling out paperwork is an end in and of itself!

Ostensibly, the goal of paperwork and oversight procedures is to improve accountability.  In these evidence-based times, that leads me to say, “show me the data.”  Consider the wide-spread practice–mandate, in most instances–of treatment planning. Simply put, it is less science than science fiction.  Perhaps this practice improves outcomes in a galaxy far, far away but on planet Earth, supporting evidence is spare to non-existent.  Where is the evidence that any of the other documentation improves accountability, benefits consumers, or results in better outcomes?

Put bluntly, the field needs an alternative.  What practice not only insures accountability but simultaneously improves the quality and outcome of behavioral health services?  Routinely and formally seeking feedback from consumers about how they are treated and their progress.

Soliciting feedback need not be time consuming nor difficult.  Last year, two brief, easy-to-use scales were deemed “evidence-based” by  the Substance Abuse and Mental Health Services Administration (SAMHSA).  The International Center for Clinical Excellence received perfect scores for the materials, training, and quality assurance procedures it makes available for implementing the measures into routine clinical practice:



Then again, these two forms add to the paperwork already burdening clinicians.  The main difference?  Unlike everything else, numerous RCT’s document that using these forms increases effectiveness and efficiency while decreasing both cost and risk of deterioration.

Learn more at the official website: www.whatispcoms.com.  Better yet, join us in Chicago for our upcoming intensives in Feedback Informed Treatment and Supervision:

Advanced FIT Training (2015)FIT Supervision Training (2015)

In the meantime, would you please let me know your thoughts?  To paraphrase Goldilocks, is the amount of documentation you are required to complete, “Too much,” Too little,” or “Just about Right!”  Type in your reply below!

What articles have 140,000 of your colleagues read to improve their practice?


Each week, I upload articles to the web about how to improve effectiveness. There are a lot to choose from, but here are the top ones read by behavioral health professionals around the world:

This is the latest version of the most widely-read upload on the site. It summarizes all of the available research about using feedback to improve retention in and outcome of care, including studies using the ORS and SRS.

A short, fun article that highlights the evidence-based steps for improving one’s effectiveness as a behavioral health provider. Feedback, it turns out, is not enough. This article reviews the crucial step that makes all the difference.

Finally, here’s a link to a simple-to-use tool for interpreting scores on the ORS:

That’s it for now. Best wishes in your work. Stay in touch.

Scott Miller (Evolution 2014)
Scott D. Miller, Ph.D.
Director, International Center for Clinical Excellence

Advanced FIT Training (2015)
Registration is open for the Advanced Training in Feedback-Informed Treatment (FIT). Learn how to integrate this SAMHSA certified evidence-based practice into your work or agency. We promise you three comprehensive, yet fun-filled days of learning together with colleagues from around the world.


Something New

something new ICCE

Actually, it’s more accurate to say, “Everything is new!”  The International Center for Clinical Excellence is coming up on its fifth birthday!   Since its launch in 2010, the ICCE has become the largest, online community of behavioral health practitioners and researchers in the world.  To celebrate, we are launching an entirely new web platform.   All the features you’ve come to expect remain—the discussions with colleagues, the document library, the commercial free atmosphere.   At the same time, everything has been streamlined, made faster, easier, and more intuitive.  Log in today!   Join a forum.  Start a conversation.  Share a presentation or paper with others. As you can see my own website has been completely redone.  The “Top Performance” blog is now front and center.  Plug in your email address and you’ll get regular updates regarding how to improve your effectiveness.   As always, my articles, books, video and audio materials are available with the click of a button.  You can also find an up-to-date schedule of workshops and intensive trainings in feedback informed treatment (FIT).

PCOMS Speaking of FIT, have you visited the www.whatispcoms.com website?  It’s the official website for ICCE’s Partners for Change Outcome Management System.  Here you can learn everything you need to know to get started using the feedback process documented to improve effectiveness and approved by SAMHSA as an evidence-based practice.  What’s new?  Thanks to ICCE members around the world, the site is available in five different languages, including: English, Dutch, Swedish, Norwegian, and Danish.   Until next time!

Using Feedback Informed Treatment to Improve Medication Adherence and Reduce Healthcare Costs


Medication adherence is a BIG problem.  According to recent research, nearly one-third of the prescriptions written are never filled.  Other data document that more than 60% of people who actually go the pharmacy and get the drug, do not take it as prescribed.

What’s the problem, you may ask?  Inefficiency aside, the health risks are staggering.  Consider, for example, that the prescriptions least likely to be filled are those aimed at treating headache (51 percent), heart disease (51.3 percent), and depression (36.8)percent).

medication adherence

When cost is factored into the equation, the impact of the problem on an already overburdened healthcare system becomes even more obvious.  Research indicates that not taking the medicines costs an estimated $290 billion dollars per year–or nearly $1000 for every man, woman, and child living in the United States.  It’s not hard to imagine more useful ways such money could be spent.

What can be done?

Pringle_Photo 2013

Enter Dr. Jan Pringle, director of the Program Evaluation Research Unit, and Professor of Pharmacy and Therapeutics at the University of Pittsburgh. As I blogged about back in 2009, Jan and I met at a workshop I did on feedback-informed treatment (FIT) in Pittsburgh.  Shortly thereafter, she went to work training pharmacists working in a community pharmacy to use the Session Rating Scale ([SRS] a four-item measure of the therapeutic alliance) in their encounters with customers.

It wasn’t long before Jan had results.  Her first study found that administering and discussing the SRS at the time medications were dispensed resulted in significantly improved adherence (you can read the complete study below).

She didn’t stop there, however.


Just a few weeks ago, Jan forwarded the results from a much larger study, one involving 600 pharmacists and nearly 60,000 patients (via a special arrangement with the publisher, the entire study is available by clicking the link on her publications page of the University website).

Suffice it to say that using the measures, in combination with a brief interview between pharmacist and patient, significantly improved adherence across five medication classes aimed at treating chronic health conditions (e.g., calcium channel blockers, oral diabetes medications, beta-blockers, statins, and renin angiotemsin system antagonists).  In addition to the obvious health benefits, the study also documented significant cost reductions.  She estimates that using the brief, easy-to-use tools would result in an annual savings of $1.4 million for any insurer/payer covering at least 10,000 lives!

Prior to Jan’s research, the evidence-base for the ORS and SRS was focused exclusively on behavioral health services.  These two studies point to exciting possibilities for using feedback to improve the effectiveness and efficiency of healthcare in general.

The tools used in the pharmacy research have been reviewed and deemed evidence-based by the Substance Abuse and Mental Health Services Administration.

PCOMSLogoKnown as PCOMS, detailed information about the measures and feedback process can be found at www.whatispcoms.com.  It’s easy to get started and the measures are free for individual healthcare practitioners!