Does diagnosis matter?

What about the treatment approach?

Applying particular therapeutic methods to specific psychiatric diagnoses is the considered by many a “best practice”–the core of what some label, “empirically-supported” (EST) or “evidence-based psychological treatments” (EBPT).

Now, imagine a place where diagnosis and prescriptive protocols are not required or even considered essential to clinical practice.  A place where practitioners are free–even encouraged–to focus on helping people in whatever way works.  More on that in a moment.

In the meantime, consider a study just out in the Journal of the American Medical Association (JAMA).   Back in 2004, the lead author coined the term, “psychological treatments,” arguing that the future of the field depended on creating a formulary of “psychological treatments…matched to specific forms of pathology.”  The impact of this idea on clinical practice is nothing less than staggering.  Around the world, practice guidelines and funding for services are based on and restricted to methods applied to specific psychiatric diagnoses.

Participants in the newly released study either were treated with an approach specifically designed for their particular diagnosis or a generic alternative.   The results?   No difference in outcome at termination or 6-month follow-up!  Said another way, diagnostic-specific protocols did not improve the effectiveness of treatment.  In their place, the authors promote “transdiagnostic treatment protocols”–a term, I know you will be hearing more about in the future.  No need to be confused (or impressed) by the sophisticated sounding name.  Given decades of research showing all psychological approaches work equally well, this new one is, if nothing else, is a perfect example of “boldly charging forward into the past.”

The truly revolutionary implication of this study is not mentioned by the researchers: neither psychiatric diagnosis or diagnostic-specific treatments improve the outcome of psychological care.  That was the promise.  It failed.

Bottom line: it’s time to move on.

That’s exactly what psychologist Birgit Valla has done.  The leader of a large, community mental health center in Stange, Norway, Birgit publically announced neither she or her staff would employ psychiatric diagnoses or standardized treatment protocols.

Was she brave or foolhardy?  For sure, she had the weight of evidence on her side as well as an unwavering commitment to delivering effective services. Still, she was soon accused of failing to follow the “standard of care.”  An investigated was started.  Sanctions and a withdrawal of funding were threatened.

What happened next?  Watch the interview to find out!

That’s it for now.  Until next time,

Scott

Scott . Miller, Ph.D.
Director, International Center for Clinical Excellence

 

 

 

It was just a little over a month ago.  I was doing a workshop somewhere in the States.  My topic?  Using formal client feedback to guide and improve the quality and outcome of psychotherapy–our SAMHSA-approved, NREPP listed evidence-based practice.

At the first break, I was approached by one of the attendees.  “I’m really enjoying your presentation,” they started, then paused.  I could hear a “but” coming.

“And this sounds like it will work with a lot of different kinds of clients…but what about the liars and deniers?”

It’s not the first time I’d been asked this question–the gist of which is, “Can one really trust the feedback given by some clients?”

“We talking about your ex here?”  I jokingly asked.

“No,” the person said with a laugh, “You know, like people who aren’t there voluntarily, clients who are mandated, or in the criminal justice system, substance abusers, sex offenders, or all of the above.”

“Funny you should ask,” I replied, “I just finished an interview with one of the leading experts on working with people who sexually abuse.  I hope to get a blog up in the next few weeks.”

And here it is…

David Prescott is a Fellow and past president of the Association for the Treatment of Sexual Abusers, the largest professional organization of its kind in the world.   He’s produced 14 books and numerous articles and chapters in the areas of assessing and treating sexual violence and trauma.   In the interview below, he talks about the use of FIT with people who sexually abuse–a subject we explore in even greater depth and detail in a chapter we penned together in the eight volume series, The Sex Offender.

Listen in and be sure and leave a comment.  It can be fairly challenging material, requiring a shift in mindset and approach–from delivering interventions to developing relationships, gaining compliance to securing engagement, and managing risk to engendering possibilities.

Anyway, I’m interested in your thoughts and experiences.

Meanwhile, registration has just opened for the March 2018 ICCE intensive trainings.  Join colleagues from around the world coming together to learn step-by-step, evidence-based strategies for improving engagement and outcome with people of all stripes, backgrounds, and clinical presentations.

Until next time,

Scott

Scott D. Miller, Ph.D.
Director, International Center for Clinical Excellence

Chances are your are carrying a smartphone–maybe you’re even reading this post on your Android or Iphone!  One thing I’m almost certain of is that the device you own–can’t live without–is not a Nokia.

The nearly complete absence of the brand is strange.  Not long ago, the company dominated the mobile phone market.  At one time, seventy percent of phones in consumers’ hands were made by Nokia.

“And then,” to quote Agathe Christie, “there were none!”

Today, Nokia’s global market share is an anemic 3 %.

What happened?  Here, the answer is no mystery.  It was not a lack of position, talent, innovative ideas, or know-how.  Rather, the company failed at implementation.  Instead of rapidly adapting to changing conditions, it banked on its brand name and past success to carry it through.  Vague considerations trumped concrete goals.  Spreadsheets and speeches replaced communication, consensus-building, and commitment.   The moral of the story?  No matter how successful the brand or popular the product, implementation is hard.

Nowhere is this truer than in healthcare.  Change is not only constant but accelerating. Each week, hundreds of research findings are published.  Just as frequently, new technologies come online. All have the potential to do good, to improve the quality and outcome of treatment.  

Research to date, for example, documents that seeking ongoing, formal feedback from those receiving behavioral health services as much as triples the effectiveness of the care offered, while simultaneously cutting the rate of drop out by 50%, and decreasing the risk of deterioration by 33%.  Enough evidence has amassed to warrant the approach–known as, “Feedback Informed Treatment”–being listed on the National Registry of Evidence-Based Programs and Practices.

Any yet, despite the massive amount of time and resources, agencies and practitioners devote to staying “up-to-date,” most implementation efforts struggle, and far too many fail–according to the available evidence, about 70-95% (a figure equivalent to the number of start-up businesses in the United States that belly up annually).

In their chapter in the new book, Feedback Informed Treatment in Clinical Practice, Randy Moss and Vanessa Mousavizadeh, provide step-by-step instructions, based on the latest research and real-world experience, for creating an organizational culture that supports implementation success.  Recently, I had a chance to talk with Randy about the chpater.  Whether you’ve got the book or not, I think you’ll find the knowledge and experience in the video below, helpful:

Online version of the Fidelity Readiness Index and Fidelity Measure

In the meantime, while on the subject of implementation, here’s a cool, electronic version of a tool you can use to track the progress of your efforts.  It helps identify where you and your organization are in the process as well as identify and set goals in order to remain on track (it’s one of the reasons reviewers at SAMHSA gave our application perfect marks for implementation support).  Thanks to my Danish colleague, Rasmus Kern for developing and making it available.  By the way, the program contains both English and Danish versions (we’ll be releasing more languages soon).

Take the FRIFM Assessment

Until next time,

Scott

Scott D. Miller, Ph.D.
Director, International Center for Clinical Excellence