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FIT Implementation Intensive 2021

March 7, 2021 By Yas h

FIT Implementation Intensive 2021

FIT Implementation Intensive training will held August 2 & 3  ONL INE.

This two day intensive training is designed to provide participants with a comprehensive understanding of how to implement Feedback Informed Treatment (FIT) in agencies, and healthcare systems in the United States and abroad.

Over the 2 days we will draw on the science of implementation, exploring strategies, processes and tools that are known to lead to successful implementation. We will also explore common challenges or barriers to implementing FIT and how to address these. Finally, we will look at processes and strategies to sustain FIT implementation.

The FIT Implementation training will be led by  ICCE Director, Scott D. Miller, Ph.D. and the ICCE professional development team.

The FIT Implementation Intensive training is one of the required courses for those seeking ICCE Certified Trainer status. They must also complete the FIT Intensive, FIT Supervision Intensive and Training of Trainers Intensive, pass a competency exam and provide a video demonstrating their knowledge of FIT and skills as a FIT Trainer. 

Continuing Education Credits (CE’s) can be purchased upon registration. CE’s are provided by CEUnits.com®, the leading nationally accredited provider of continuing education for healthcare professionals in North America. CEUnits is approved to provide CE credits for APA. ASWB, NBCC, and NAADAC, and some state approvals. 

Scott D. Miller, PhD, is a co-founder of the Center for Clinical Excellence, an international consortium of clinicians, researchers, and educators dedicated to promoting excellence in behavior health. Dr. Miller conducts workshops and training in the United States and abroad, helping hundreds of agencies and organizations, both public and private, to achieve superior results. He is one of a handful of “invited faculty” whose work, thinking, and research is featured at the prestigious “Evolution of Psychotherapy Conference.” His humorous and engaging presentation style and command of the research literature consistently inspires practitioners, administrators, and policy makers to make effective changes in service delivery.

 Scott is the author of numerous articles and co-author of Working with the Problem Drinker: A Solution Focused Approach (with Insoo Berg [Norton, 1992]), The “Miracle” Method: A Radically New Approach to Problem Drinking (with Insoo Kim Berg [Norton, 1995]), Finding the Adult Within: A Solution-Focused Self-Help Guide (with Barbara McFarland [Brief Therapy Center Press, 1995]), Handbook of Solution-Focused Brief Therapy: Foundations, Applications, and Research (with Mark Hubble and Barry Duncan [Jossey-Bass, 1996]), Escape from Babel: Toward a Unifying Language for Psychotherapy Practice (with Barry Duncan and Mark Hubble [Norton, 1997]), Psychotherapy with Impossible Cases: Efficient Treatment of Therapy Veterans (with Barry Duncan and Mark Hubble [Norton, 1997]), The Heart and Soul of Change (with Mark Hubble and Barry Duncan [APA Press, 1999] and Bruce Wampold [2nd Edition, 2009]), The Heroic Client: A Revolutionary Way to Improve Effectiveness through Client-Directed, Outcome-Informed Therapy (with Barry Duncan [Jossey-Bass, 2000], and Jacqueline Sparks [Revised, 2004]), The Cycle of Excellence: Using Deliberate Pratice to Improve Supervison and Training (with Tony Rousmaniere, Rodney Goodyear and Bruce Wampold [Wiley, 2017]), Feedback Informed Treatment in Clincial Practice: Reaching for Excellence (with David Prescott and Cynthia Maeschalck [APA Press, 2017]), Better Results: Using Deliberate Practice to Improve Therapeutic Effectiveness (with Mark Hubble and Daryl Chow [APA Press, 2020])

For more information about this event contact events@centerforclinicalexcellence.com or follow us on Twitter and Facebook.

CANCELLATION POLICY

To insure an optimal learning environment, registration for this event is limited in number. The quality of the training depends on all registrants attending and preparing for the event by completing the pre-conference reading assignments. A 50% refund or 100% of tuition will be applied toward the next available training will be made if requested if cancellation occurs 75 days or more prior to the first day of the scheduled event. If cancellation occurs 74-31 days prior to the first day of the event there will be no refund but a 50% of the tuition portion of registration fees will be applied toward the next available training if requested. If cancellation occurs 30 days or less before the event there will be no refunds or deferral of tuition. CE fees will not be refunded.

Implementation: The KEY to Improving the Effectiveness of Psychotherapy

May 7, 2018 By scottdm 7 Comments

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Filed Under: Feedback Informed Treatment - FIT

From Evidence-based Practice to Cultural Change: Steps to Successful Implementation

July 11, 2017 By scottdm Leave a Comment

stopandthinkChances 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. PCOMS - Partners for change outcome management system Scott D Miller - SAMHSA - NREPP

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

Filed Under: Feedback Informed Treatment - FIT

Implementation Science, FIT, and the Training of Trainers

March 8, 2012 By scottdm Leave a Comment

The International Center for Clinical Excellence (ICCE) is pleased to announce the 6th annual Training of Trainers event to be held in Chicago, Illinois August 6th-10th, 2012.  As always, the ICCE TOT prepares participants provide training, consultation, and supervision to therapists, agencies, and healthcare systems in Feedback-Informed Treatment (FIT).  Attendees leave the intensive, hands-on training with detailed knowledge and skills for:

  1. Training clinicians in the Core Competencies of Feedback Informed Treatment (FIT/CDOI);
  2. Using FIT in supervision;
  3. Methods and practices for implementing FIT in agencies, group practices, and healthcare settings;.
  4. Conducting top training sessions, learning and mastery exercises, and transformational presentations.

Multiple randomized clinical trials document that implementing FIT leads to improved outcomes and retention rates while simultanesouly decreasing the cost of services.

This year’s “state of the art” faculty include: ICCE Director, Scott D. Miller, Ph.D., ICCE Training Director, Julie Tilsen, Ph.D., and special guest lecturer and ICCE Coordinator of Professional Development, Cynthia Maeschalck, M.A.

Scott Miller (Evolution 2014)

tilsencynthia-maeschalckJoin colleagues from around the world who are working to improve the quality and outcome of behavioral healthcare via the use of ongoing feedback. Space is limited.  Click here to register online today.  Last year, one participants said the training was, “truly masterful.  Seeing the connection between everything that has been orchestrated leaves me amazed at the thought, preparation, and talent that has cone into this training.”  Here’s what others had to say:

 

Filed Under: Behavioral Health, Conferences and Training, evidence-based practice, excellence, Feedback Informed Treatment - FIT Tagged With: addiction, Carl Rogers, cdoi, magic, psychometrics

Training of Trainers 2021

March 7, 2021 By Yas h

TOT 2021 will be held August 4-6th ONLINE

The ICCE’s Training of Trainers (TOT) will be held  August 4-6, 2021 ONLINE.

 Dr. Scott D. Miller  and the ICCE professional development team will lead participants through 3 intensive days of didactic presentations and skill building exercises designed to give participants the tools needed to provide top Feedback Informed Treatment (FIT) training events and transformational presentations. 

The TOT focuses exclusively on the process of training and supporting others in their use of FIT, therefore participants of the TOT should be well versed in FIT.

The Training of Trainers is a required course for all ICCE Certified FIT Trainer candidates. Other requirements include the FIT Intensive, FIT Supervision Intensive, and FIT Implementation Intensive. ICCE Certified FIT Trainers must also pass a competency exam and provide a video demonstrating their knowledge of FIT and skills as a FIT Trainer. 

Scott D. Miller, PhD, is a co-founder of the Center for Clinical Excellence, an international consortium of clinicians, researchers, and educators dedicated to promoting excellence in behavior health. Dr. Miller conducts workshops and training in the United States and abroad, helping hundreds of agencies and organizations, both public and private, to achieve superior results. He is one of a handful of “invited faculty” whose work, thinking, and research is featured at the prestigious “Evolution of Psychotherapy Conference.” His humorous and engaging presentation style and command of the research literature consistently inspires practitioners, administrators, and policy makers to make effective changes in service delivery.

Scott is the author of numerous articles and co-author of Working with the Problem Drinker: A Solution Focused Approach (with Insoo Berg [Norton, 1992]), The “Miracle” Method: A Radically New Approach to Problem Drinking (with Insoo Kim Berg [Norton, 1995]), Finding the Adult Within: A Solution-Focused Self-Help Guide (with Barbara McFarland [Brief Therapy Center Press, 1995]), Handbook of Solution-Focused Brief Therapy: Foundations, Applications, and Research (with Mark Hubble and Barry Duncan [Jossey-Bass, 1996]), Escape from Babel: Toward a Unifying Language for Psychotherapy Practice (with Barry Duncan and Mark Hubble [Norton, 1997]), Psychotherapy with Impossible Cases: Efficient Treatment of Therapy Veterans (with Barry Duncan and Mark Hubble [Norton, 1997]), The Heart and Soul of Change (with Mark Hubble and Barry Duncan [APA Press, 1999] and Bruce Wampold [2nd Edition, 2009]), The Heroic Client: A Revolutionary Way to Improve Effectiveness through Client-Directed, Outcome-Informed Therapy (with Barry Duncan [Jossey-Bass, 2000], and Jacqueline Sparks [Revised, 2004]), The Cycle of Excellence: Using Deliberate Pratice to Improve Supervison and Training (with Tony Rousmaniere, Rodney Goodyear and Bruce Wampold [Wiley, 2017]), Feedback Informed Treatment in Clincial Practice: Reaching for Excellence (with David Prescott and Cynthia Maeschalck [APA Press, 2017]), Better Results: Using Deliberate Practice to Improve Therapeutic Effectiveness (with Mark Hubble and Daryl Chow [APA Press, 2020])

For more information about this event contact events@centerforclinicalexcellence.com or follow us on Twitter and Facebook.

CANCELLATION POLICY

To insure an optimal learning environment, registration for this event is limited in number. The quality of the training depends on all registrants attending and preparing for the event by completing the pre-conference reading assignments. A 50% refund will be made if requested 75 days or more prior to the first day of the scheduled event. After that, 50% of the tuition portion of registration fees will be applied toward the next available training.

Feedback Informed Treatment (FIT) Intensive ONLINE

March 7, 2021 By Yas h

FIT Intensive Training with Dr. Scott Miller and colleagues

The 2021 FIT Intensive (level 1) Training will be ONLINE via Zoom from March 17th – March 19th 2021. If you’ve read the books, watched the FIT Webinar series or attended a one or two day introductory workshop and want to delve deeper in your understanding and use of the principles and practices of FIT, this is the training for you! Three intensive days focused on skill development. Participants will receive a thorough grounding in:

  • The empirical foundations of FIT (i.e., research supporting the common factors, outcome and alliance measures, and feedback)
  • Alliance building skills that cut across different therapeutic orientations and diverse client populations
  • How to use outcome management tools to inform and improve treatment
  • How to determine your overall clinical success rates
  • How to significantly improve your outcome and retention rate via feedback and deliberate practice
  • How to use technology for support and to improve the services you offer clients and payers

The training will be facilitated by Scott Miller, Ph.D. , ICCE Director along with International Center for Clinical Excellence faculty .

Be sure and sign up early as spots are limited and this event sells several months in advance.

Continuing Education (CE’s) can be purchased upon registration. Changes to CE’s will be subject to an additional $50 administration fee. CE’s are provided by CEUnits.com®, the leading nationally accredited provider of continuing education for healthcare professionals in North America.

Interested in becoming a Certified FIT Trainer? The FIT Intensive level 1 and FIT Supervision Intensive courses are two of the courses required to become a Certified FIT Trainer. Other required courses include the FIT Implementation Intensive and Training of Trainers Intensive. In addition, applicants must pass an on-line exam and submit a suitable video demonstrating their ability to teach FIT.

For more information please send us an email to events@centerforclinicalexcellence.com.

CANCELLATION POLICY

To insure an optimal learning environment, registration for this event is limited in number. The quality of the training depends on all registrants attending and preparing for the event by completing the pre-conference reading assignments. A 50% refund or 100% of tuition will be applied toward the next available training will be made if requested if cancellation occurs 75 days or more prior to the first day of the scheduled event. If cancellation occurs 74-31 days prior to the first day of the event there will be no refund but a 50% of the tuition portion of registration fees will be applied toward the next available training if requested. If cancellation occurs 30 days or less before the event there will be no refunds or deferral of tuition. CE fees will not be refunded.

In the unlikely event the workshop is cancelled (e.g., weather, death, natural or human caused disasters, or other “Acts of God”) participants will be automatically registered for the next available training. No liability is assumed or coverage offered for any costs incurred resulting from cancellation.

Scott D. Miller, PhD, is a co-founder of the Center for Clinical Excellence, an international consortium of clinicians, researchers, and educators dedicated to promoting excellence in behavior health. Dr. Miller conducts workshops and training in the United States and abroad, helping hundreds of agencies and organizations, both public and private, to achieve superior results. He is one of a handful of “invited faculty” whose work, thinking, and research is featured at the prestigious “Evolution of Psychotherapy Conference.” His humorous and engaging presentation style and command of the research literature consistently inspires practitioners, administrators, and policy makers to make effective changes in service delivery.

Scott is the author of numerous articles and co-author of Working with the Problem Drinker: A Solution Focused Approach (with Insoo Berg [Norton, 1992]), The “Miracle” Method: A Radically New Approach to Problem Drinking (with Insoo Kim Berg [Norton, 1995]), Finding the Adult Within: A Solution-Focused Self-Help Guide (with Barbara McFarland [Brief Therapy Center Press, 1995]), Handbook of Solution-Focused Brief Therapy: Foundations, Applications, and Research (with Mark Hubble and Barry Duncan [Jossey-Bass, 1996]), Escape from Babel: Toward a Unifying Language for Psychotherapy Practice (with Barry Duncan and Mark Hubble [Norton, 1997]), Psychotherapy with Impossible Cases: Efficient Treatment of Therapy Veterans (with Barry Duncan and Mark Hubble [Norton, 1997]), The Heart and Soul of Change (with Mark Hubble and Barry Duncan [APA Press, 1999] and Bruce Wampold [2nd Edition, 2009]), The Heroic Client: A Revolutionary Way to Improve Effectiveness through Client-Directed, Outcome-Informed Therapy (with Barry Duncan [Jossey-Bass, 2000], and Jacqueline Sparks [Revised, 2004]), The Cycle of Excellence: Using Deliberate Pratice to Improve Supervison and Training (with Tony Rousmaniere, Rodney Goodyear and Bruce Wampold [Wiley, 2017]), Feedback Informed Treatment in Clincial Practice: Reaching for Excellence (with David Prescott and Cynthia Maeschalck [APA Press, 2017])

Do We Learn from Our Clients? Yes, No, Maybe So …

March 2, 2021 By scottdm Leave a Comment

LearningWhen it comes to professional development, we therapists are remarkably consistent in opinion about what matters.  Regardless of experience level, theoretical preference, professional discipline, or gender identity, large, longitudinal studies show “learning from clients” is considered the most important and influential contributor (1, 2).  Said another way, we believe clinical experience leads to better, increasingly effective performance in the consulting room.

As difficult as it may be to accept, the evidence shows we are wrong.  Confidence, proficiency, even knowledge about clinical practice, may improve with time and experience, but not our outcomes.  Indeed, the largest study ever published on the topic — 6500 clients treated by 170 practitioners whose results were tracked for up to 17 years — found the longer therapists were “in practice,” the less effective they became (3)!  Importantly, this result remained unchanged even after researchers controlled for several patient, caseload, and therapist-level characteristics known to have an impact effectiveness.

Only two interpretations are possible, neither of them particularly reassuring.  Either we are not learning from our clients, or what we claim to be learning doesn’t improve our ability to help them.  Just to be clear, the problem is not a lack of will.   Therapists, research shows, devote considerable time, effort, and resources to professional development efforts (4).  Rather, it appears the way we’ve approached the subject is suspect.

Consider the following provocative, but evidence-based idea.  Most of the time, there simply is nothing to learn from a particular client rabbits footabout how to improve our craft.  Why?  Because so much of what affects the outcome of individual clients at any given moment in care is random — that is, either outside of our direct control or not part of a recurring pattern of therapist errors.  Extratherapeutic factors, as influences are termed, contribute a whopping 87% to outcome of treatment (5, 6).   Let that sink in.

The temptation to draw connections between our actions and particular therapeutic results is both strong and understandable.  We want to improve.  To that end, the first step we take — just as we counsel clients — is to examine our own thoughts and actions in an attempt to extract lessons for the future.  That’s fine, unless no causal connection exists between what we think and do, and the outcomes that follow … then, we might as well add “rubbing a rabbit’s foot” to our professional development plans.

So, what can we to do?   Once more, the answer is as provocative as it is evidence-based.  Recognizing the large role randomness plays in the outcome of clinical work, therapists can achieve better results by improving their ability to respond in-the-moment to the individual and their unique and unpredictable set of circumstances.  Indeed, uber-researchers Stiles and Horvath note, research indicates, “Certain therapists are more effective than others … because [they are] appropriately responsive … providing each client with a different, individually tailored treatment” (7, p. 71).

FIT BookWhat does improving responsiveness look like in real world clinical practice?  In a word, “feedback.”  A clever study by Jeb Brown and Chris Cazauvielh found, for example, average therapists who were more engaged with the feedback their clients provided — as measured by the number of times they logged into a computerized data gathering program to view their results — in time became more effective than their less engaged peers (8).  How much more effective you ask?  Close to 30% — not a bad “return on investment” for asking clients to answer a handful of simple questions and then responding to the information they provide!

If you haven’t already done so, click here to access and begin using two, free, standardized tools for gathering feedback from clients.  Next, ioin our free, online community to get the support and inspiration you need to act effectively and creatively on the feedback your clients provide — hundreds and hundreds of dedicated therapists working in diverse settings around the world support each other daily on the forum and are available regardless of time zone.

And here’s a bonus.  Collecting feedback, in time, provides the very data therapists need to be able to sort random from non-random in their clinical work, to reliably identify when they need to respond and when a true opportunity for learning exists.  Have you heard or read anything about “deliberate practice?”  Since first introducing the term to the field in our 2007 article, Supershrinks, it’s become a hot topic among researchers and trainers.  If you haven’t yet, chances are you will soon be seeing books and videos offering to teach how to use deliberate practice for mastering any number of treatment methods.  The promise, of course, is better outcomes.  Critically, however, if training is not targeted directly to patterns of action or inaction that reliably impact the effectiveness of your individual clinical performance in negative ways, such efforts will, like clinical experience in general, make little difference.

If you are already using standardized tools to gather feedback from clients, you might be interested in joining me and my colleague Dr. Daryl Chow Better Results Coverfor upcoming, web-based workshop.  Delivered weekly in bite-sized bits, we’ll not only help you use your data to identify your specific learning edge, but work with you to develop an individualized deliberate practice plan.  You go at your own pace as access to the course and all training materials are available to you forever.  Interested?  Click here to read more or sign up.

OK, that’s it for now.  Until next time, wishes of health and safety, to you, your colleagues, and family.

Scott

Scott D. Miller, Ph.D.
Director, International Center for Clinical Excellence
FIT Implementation Intensive 2021Training of Trainers 2021

 

Filed Under: Behavioral Health, deliberate practice, evidence-based practice, Feedback Informed Treatment - FIT, FIT

Making Sense of Client Feedback

January 4, 2021 By scottdm Leave a Comment

Kitchen NightmaresI have a guilty confession to make.  I really like Kitchen Nightmares.  Even though the show finished its run six L O N G years ago, I still watch it in re-runs.  The concept was simple.  Send one of the world’s best known chefs to save a failing restaurant.

Each week a new disaster establishment was featured.  A fair number were dives — dirty, disorganized messes with all the charm and quality of a gas station lavatory.  It wasn’t hard to figure out why these spots were in trouble.  Others, by contrast, were beautiful, high-end eateries whose difficulties were not immediately obvious.

Of course, I have no idea how much of what we viewers saw was real versus contrived.  Regardless, the answers owners gave whenever Ramsey asked for their assessment of the restaurant never failed to surprise and amuse.   I don’t recall a single episode where the owners readily acknowledged having any problems, other than the lack of customers!  In fact, most often they defended themselves, typically rating their fare “above average,” — a 7 or higher on a scale from 1 to 10.

Contrast the attitude of these restaurateurs with pop music icon Billy Joel.  When journalist Steve Croft asked him why he Billy Joelthought he’d been so successful, Joel at first balked, eventually answering, “Well, I have a theory, and it may sound a little like false humility, but … I actually just feel that I’m competent.”  Whether or not you are a fan of Joel’s sound, you have to admit the statement is remarkable.   He is one of the most successful music artists in modern history, inducted into the Rock and Roll Hall of Fame, winning a Grammy Legend Award, earning four number one albums on the Billboard 200, and consistently filling stadiums of adoring fans despite not having released a new album since 1993!  And yet, unlike those featured on Kitchen Nightmares, he sees himself as merely competent, adding “when .. you live in an age where there’s a lot of incompetence, it makes you appear extraordinary.”

Is humility associated with success?  Well, turns out, it is a quality possessed by highly effective effective therapists.  Studies not only confirm “professional self-doubt” is a strong predictor of both alliance and outcome in psychotherapy but actually a prerequisite for acquiring therapeutic expertise (1, 2).  To be clear, I’m not talking about debilitating diffidence or, as is popular in some therapeutic circles, knowingly adopting a “not-knowing” stance.  As researchers Hook, Watkins, Davis, and Owen describe, its about feedback — specifically, “valuing input from the other (or client) … and [a] willingness to engage in self-scrutiny.”

Low humility, research shows, is associated with compromised openness (3).  Sound familiar?  It is the most common reaction of owners featured on Kitchen Nightmares.  Season 5 contained two back-to-back episodes featuring Galleria 33, an Italian restaurant in Boston, Massachusetts.  As is typical, the show starts out with management expressing bewilderment about their failing business.  According to them, they’ve tried everything — redecorating, changing the menu, lowering prices.  Nothing has worked.  To the viewer, the problem is instantly obvious: they don’t take kindly to feedback.  When one customer complains their meal is “a little cold,” one of the owners becomes enraged.  She first argues with Ramsey, who agrees with the customer’s assessment, and then storms over to the table to confront the diner.  Under the guise of “just being curious and trying to understand,” she berates and humiliates them.  It’s positively cringeworthy.  After numerous similar complaints from other customers — and repeated, uncharacteristically calm, corrective feedback from Ramsey — the owner experiences a moment of uncertainty.  Looking directly into the camera she asks, “Am I in denial?”  The thought is quickly dismissed.  The real problem, she and the co-owner decide, is … (wait for it) …

Ramsey and their customers!   Is anyone surprised the restaurant didn’t survive?

closed for businessSuch dramatic examples aside, few therapists would dispute the importance of feedback in psychotherapy.  How do I know?  I’ve meet thousands over the last two decades as I traveled the world teaching about feedback-informed treatment (FIT).  Research on implementation indicates a far bigger challenge is making sense of the feedback one receives (4, 5, 6)  Yes, we can (and should) speak with the client — research shows therapists do that about 60% of the time when they receive negative feedback.  However, like an unhappy diner in an episode of Kitchen Nightmares, they may not know exactly what to do to fix the problem.  That’s where outside support and consultation can be critical.  Distressingly, research shows, even when clients are deteriorating, therapists consult with others (e.g., supervisors, colleagues, expert coaches) only 7% of time.

Since late summer, my colleagues and I at the International Center for Clinical Excellence have offered a series of intimate, virtual gatherings of mental health professionals.  Known as the FIT Cafe, the small group (10 max) gets together once a week to finesse their FIT-related skills and process client feedback.  It’s a combination of support, sharing, tips, strategizing, and individual consultation.  As frequent participant, psychologist Claire Wilde observes, “it has provided critical support for using the ORS and SRS to improve my therapeutic effectiveness with tricky cases, while also learning ways to use collected data to target areas for professional growth.”FIT Winter Cafe 2021

The next series is fast approaching, a combination of veterans and newbies from the US, Canada, Europe, Scandinavia, and Australia.  Learn more or register by clicking here or on the icon to the right.

Not ready for such an “up close and personal” experience?  Please join the ICCE online discussion forum.  It’s free.  You can connect with knowledgeable and considerate colleagues working to implement FIT and deliberate practice in their clinical practice in diverse settings around the world.

OK, that’s it for now.  Until next time,

Scott

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

 

Filed Under: deliberate practice, excellence, Feedback, Feedback Informed Treatment - FIT, FIT, Therapeutic Relationship

Umpires and Psychotherapists

December 9, 2020 By scottdm Leave a Comment

umpireCriticizing umpires is as much a part of watching baseball as eating hotdogs and wearing team jerseys on game day.  The insults are legion, whole websites are dedicated to cataloging them:

“Open your eyes!”

“Wake up, you are missing a great game!”

“Your glasses fogged up?”

“Have you tried eating more carrots?”

“I’ve seen potatoes with better eyes!”

“Hey Ump, how many fingers am I holding up?

Are you “seeing” a common theme here?

And interestingly, the evidence indicates fans have reason to question the judgement and visual acuity of most umpires.  A truly massive study of nearly 4 million pitches examined the accuracy of their calls over 11 regular seasons.  I didn’t know this, but it turns out, all major league stadiums are equipped with fancy cameras which track every ball thrown from mound to home plate.  Using this data, researchers found “botched calls and high error rates are rampant.”   How many you ask?  A staggering 34,246 incorrect calls in the 2018 season alone!  It gets worse.  When the pressure was on — a player at bat, for example, with two strikes — umpire errors skyrocket, occurring nearly one-third of the time.  Surely, the “umps” improve with time an experience?  Nope.  In terms of accuracy, youth and inexperienced win out every time!therapists and horses

Now, let me ask, are your “ears burning” yet?

Turns out, umpires and psychotherapists share some common traits.  So, for example, despite widespread belief to the contrary, clinicians are not  particularly good at detecting deterioration in clients.  How bad are we?  In one study, therapists correctly identified clients who worsen in their care a mere two-and-a-half percent of the time (1)!  Like umpires, “we call ’em as we see ’em.”  We just don’t see them.  And if you believe we improve with experience, think again.  The largest study in the history of research on the subject — 170 practitioners treating 6500 clients over a 5 year period — reveals that what is true of umpires applies equally to clinicians.  Simply put, on average, our outcomes decline the longer we are in the field.

If you are beginning to feel discouraged, hold on a minute.  While the data clearly show umpires make mistakes, the same evidence documents most of their calls are correct.  Similarly, therapists working in real world settings help the majority of their clients achieve meaningful change — between 64 and 74% in our database of thousands of clinicians and several million completed treatment episodes.

Still, you wouldn’t be too far “off base” were you to conclude, “room for improvement exists.”

Truth is, umpires and therapists are calling “balls and strikes” much the same way they did when Babe Ruth and Alfred Alder were key players.  Solutions do exist.  As you might guess, they are organized around using feedback to augment and improve individual judgement ability.  So far, major league baseball (and its umpires) has resisted.  In psychotherapy, evidence shows clients of therapists who formally and routinely solicit feedback regarding the quality of the therapeutic relationship and progress over time are twice as likely to experience improvement in treatment.

The measures are free for practitioners to use and available in 25+ languages.  If you don’t have them, click here to register.   You’ll likely need some support in understanding how to use them effectively.  Please join the conversation with thousands of colleagues from around the world in the ICCE Discussion Forum.  If you find yourself wanting to learn more, click on the icon below my name for information about our next upcoming intensive — online, by the way!

What more is there to say, except: BATTER UP!

Until next time, wishes for a safe and healthy Holiday season,

Scott

Scott D. Miller, Ph.D.
Director, International Center for Clinical Excellence
ICCE FIT Intensive Online Scott D Miller

Filed Under: Feedback Informed Treatment - FIT

BAD THERAPY

July 28, 2020 By scottdm 5 Comments

bad dogBad therapy.

Are you guilty of it?  A quick internet search turned up only 15 books on the subject.  It’s strange, especially when you consider that between 5 and 10% of clients are actually worse off following treatment and an additional 35-40% experience no benefit whatsoever!  (Yep, that’s nearly 50%)

And what about those numerous “micro-failures.”  You know the ones I’m talking about?  Those miniature ruptures, empathic missteps, and outright gaffs committed during the therapy hour.  For example, seated opposite your client, empathic look glued to your face and suddenly you cannot remember your client’s name?  Or worse, you call them by someone else’s.  The point is, there’s a lot of bad therapy.

Why don’t we therapists talk about these experiences more often?  Could it possibly be that we don’t know?  Four years on, I can still remember the surprise I felt when Norwegian researcher, Jorgen Flor, found most therapists had a hard time recalling any clients they hadn’t helped.

One group does know — and recently, they’ve been talking their experiences!  The Very Bad Therapy podcast is one of my favorites.  After listening to sixty-some-odd episodes of clients exposing our shortcomings, I reached out to the podcast’s two fearless interviewers, clinicians Ben Fineman and Carrie Wiita, to learn what had motivated them to start the series in the first place and what, if anything, they’d learned along the way.  Here’s what I promise: they have no shame (and its a good thing for us they don’t)!

OK, that’s it for now.  Until next time, all the best,

Scott

Scott D. Miller, Ph.D.
Director, International Center for Clinical Excellence
FIT IMP 2020

 

 

 

 

P.S.: For the first time ever, we’re offering the FIT Implementation Intensive Online.  It’s one of the four courses required for certification as an ICCE FIT Trainer.  As with our “in-person” events, we have an international faculty and strictly limit the number of participants to 40 to ensure the highest quality experience.  Click here for more information or to register.

Filed Under: Feedback Informed Treatment - FIT

Does Teletherapy Work?

July 22, 2020 By scottdm Leave a Comment

teletherapyWith the outbreak of the coronavirus, much of mental health service delivery shifted online. Regulations regarding payment and confidentiality were scaled back in an effort to deal with the unprecedented circumstances, allowing clinicians and their clients to meet virtually in order to reduce the spread of the illness.
 
But is teletherapy helpful?
 
Listening to discussions among therapists on social media, the assessment is decidedly mixed.  Almost all are grateful for the opportunity online platforms provide to meet with clients.  On the other hand, many question its effectiveness relative to in person services.  At a minimum, challenges exist.  
 
So, what does the research indicate?
Drum roll please …
no difference in outcome for adults, adolescents and children being treated for the most common concerns addressed in psychotherapy (e.g., depression, anxiety, trauma, eating problems, substance abuse).  What’s more, online services are associated with greater utilization of and less dropout from mental health care.squeeze head
That said, challenges are evident.  For most clinicians and clients, teletherapy is an entirely new enterprise requiring a period of learning and adjustment.  Critically, the sensory input clinicians rely upon to make clinical judgments is also restricted — all the more reason to make “Feedback-Informed Treatment (FIT) a routine part of the services you provide.  Even if you’re regularly seeking feedback from clients using standardized measures like the Outcome and Session Rating Scales, doing so virtually will be new for most.
It’s why many of my posts since mid-March have provided detailed information using the measures online (read them by clicking: 1, 2, 3, 4, 5, 6, 7, 8, 9).  Below you’ll finds links to all the “how-to” videos FIT Certified Trainers created over the last four months.  No need to re-invent the wheel –and, no, if you’ve downloaded paper and pencil copies, digitizing the measures is not allowed — but there’s really no need.  Three authorized systems are available that administer, score, and most importantly, provide access to real time feedback and a series of evidence-based metrics for assessing your performance and developing deliberate practice objectives.
Until next time,
Scott
Scott D. Miller, Ph.D.
Director, International Center for Clinical Excellence
 FIT IMP 2020




Filed Under: Feedback Informed Treatment - FIT

Getting Beyond the “Good Idea” Phase in Evidence-based Practice

July 9, 2020 By scottdm 2 Comments

lit match

The year is 1846.  Hungarian-born physician Ignaz Semmelweis is in his first month of employment at Vienna General hospital when he notices a troublingly high death rate among women giving birth in the obstetrics ward.  Medical science at the time attributes the problem to “miasma,” an invisible, poison gas believed responsible for a variety of illnesses.

Semmelweis has a different idea.  Having noticed midwives at the hospital have a death rate six times lower than physicians, he concludes the prevailing theory cannot possibly be correct.  The final breakthrough comes when a male colleague dies after puncturing his finger while performing an autopsy.  Reasoning that contact with corpses is somehow implicated in the higher death rate among physicians, he orders all to wash their hands prior to interacting with patients.   The rest is, as they say, history.  In no time, the mortality rate on the maternity ward plummets, dropping to the same level as that of midwives.

Nowadays, of course, handwashing is considered a “best practice.”  Decades of research show it to be the single most effective way to prevent the spread of infections.  And yet, nearly 200 years after Semmewies’s life-saving discovery, compliance with hand hygiene among healthcare professionals remains shockingly low, with figures consistently ranging between 40 and 60% (1, 2).  Bottom line: a vast gulf exists between sound scientific practices and their implementation in real world settings.  Indeed, the evidence shows 70 to 95% of attempts to implement evidence-based strategies fail.

To the surprise of many, successful implementation depends less on disseminating “how to” information to practitioners thanburned out match on establishing a culture supportive of new practices.  In one study of hand washing, for example, when Johns Hopkins Hospital administrators put policies and structures in place facilitating an open, collaborative, and transparent culture among healthcare staff (e.g., nurses, physicians, assistants), compliance rates soared and infections dropped to zero!

Feedback Informed Treatment (FIT) — soliciting and using formal client feedback to guide mental health service delivery — is another sound scientific practice.  Scores of randomized clinical trials and naturalistic studies show it improves outcomes while simultaneously reducing drop out and deterioration rates.  And while literally hundreds of thousands of practitioners and agencies have downloaded the Outcome and Session Rating Scales — my two, brief, feedback tools — since they were developed nearly 20 years ago, I know most will struggle to put them into practice in a consistent and effective way.

To be clear, the problem has nothing to do with motivation or training.  Most are enthusiastic to start.  Many invest significant time and money in training.  Rather, just as with hand washing, the real challenge is creating the open, collaborative, and transparent workplace culture necessary to sustain FIT in daily practice.  What exactly does such a culture look like and what actions can practitioners, supervisors, and managers take to facilitate its development?  That’s the subject of our latest “how to” video by ICCE Certified Trainer, Stacy Bancroft.  It’s packed with practical strategies tested in real world clinical settings.

FIT IMP 2020We’ll cover the subject in even greater detail in the upcoming FIT Implementation Intensive — the only evidence-based training on implementing routine outcome monitoring available.

For the first time ever, the training will be held ONLINE, so you can learn from the comfort and safety of your home.  As with all ICCE events, we limit the number of participants to 40 to ensure each gets personalized attention.  For more information or to register, click here.

OK, that’s it for now.

Until next time,

Scott

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

P.S.: Want to interact with FIT Practitioners around the world?  Join the conversation here.

Filed Under: evidence-based practice, Feedback Informed Treatment - FIT, FIT, Implementation

The Expert on Expertise: An Interview with K. Anders Ericsson

June 23, 2020 By scottdm 13 Comments

Anders and ScottI can remember exactly where I was when I first “met” Swedish psychologist, K. Anders Ericsson.  Several hours into a long, overseas flight, I discovered someone had left a magazine in the seat pocket.  I never would have even given the periodical a second thought had I not seen all the movies onboard — many twice.  Its target audience wasn’t really aimed at mental health professionals: Fortune.  

Bored, I mindlessly thumbed through the pages. Then, between articles about investing and pictures of luxury watches, was an article that addressed a puzzle my colleagues and I had been struggling to solve for some time: why were some therapists more consistently effective than others?

In 1974, psychologist David F. Ricks published the first study documenting the superior outcomes of a select group of practitioners he termed, “supershrinks.”  Strangely, thirty-years would pass before another empirical analysis appeared in the literature.

The size and scope of the study by researchers Okiishi, Lambert, Nielsen, and Ogles (2003), dwarfed Rick’s, examining results from standardized measures Fortuneadministered on an ongoing basis to over 1800 people treated by 91 therapists.  The findings not only confirmed the existence of “supershrinks,” but showed exactly just how big the difference was between them and average clinicians.  Clients of the most effective experienced a rate of improvement 10 times greater than the average.  Meanwhile, those treated by the least effective, ended up feeling the same or worse than when they’d started — even after attending 3 times as many sessions!   How did the best work their magic?  The researchers were at a loss to explain, ending their article calling it a “mystery” (p. 372).

By this point, several years into the worldwide implementation of the outcome and session rating scales, we’d noticed (and, as indicated, were baffled by) the very same phenomenon.  Why were some more effective?  We pursued several lines of inquiry.  Was it their technique?  Didn’t seem to be.  What about their training?  Was it better or different in some way?  Frighteningly, no.  Experience level?  Didn’t matter.  Was it the clients they treated?  No, in fact, their outcomes were superior regardless of who walked through their door.  Could it be that some were simply born to greatness?  On this question, the article in Fortune, was clear, “The evidence … does not support the [notion that] excelling is a consequence of possessing innate gifts.”

So what was it?

Enter K. Anders Ericsson.  His life had been spent studying great performers in many fields, including medicine, mathematics, music, computer programming, chess, and sports.  The best, he and his team had discovered, spent more time engaged in an activity they termed, “deliberate practice” (DP).  Far from mindless repetition, it involved: (1) establishing a reliable and valid assessment of performance; (2) the identification of objectives just beyond an individual’s current level of ability; (3) development and engagement in exercises specifically designed to reach new performance milestones; (4) ongoing corrective feedback; and (5) successive refinement over time via repetition.

I can remember how excited I felt on finishing the article.  The ideas made so much intuitive sense.  Trapped in a middle seat, my row-mates on either side fast asleep, I resolved to contact Dr. Ericsson as soon as I got home.

Anders replied almost immediately, giving rise to a decade and a half of correspondence, mentoring, co-presenting, and friendship.  And now he is gone.  To say I am shocked is an understatement.  I’d just spoken with him a few days prior to his death.  He was in great spirits, forever helpful and supportive, full of insights and critical feedback.  I will miss him — his warmth, encouragement, humility, and continuing curiosity.  If you never met him, you can get a good sense of who he was from the interview I did with him two weeks ago.  Let me know your thoughts in the comments below.

Until next time, I wish you health, peace, and progress.

Scott

 

Filed Under: deliberate practice, excellence, Feedback, Feedback Informed Treatment - FIT

Far from Normal: More Resources for Feedback Informed Treatment in the Time of COVID-19

March 31, 2020 By scottdm 4 Comments

covid wrecking ballI hope this post finds you, your loved ones, and colleagues, safe and healthy.

What an amazing few weeks this has been.  Daily life, as most of us know it, has been turned upside down.  The clinicians I’ve spoken with are working frantically to adjust to the new reality, including staying abreast of rapidly evolving healthcare regulation and learning how to provide services online.

I cannot think of a time in recent memory when the need to adapt has more pressing.  As everyone knows, feedback plays a crucial role in this process.

Last week, I reported a surge in downloads of the Outcome and Session Rating Scales (ORS & SRS), up 21% over the preceding three months.  Independent, randomized controlled trials document clients are two and a half times more likely to benefit from therapy when their feedback is solicited via the measures and used to inform care.   Good news, eh? Practitioners are looking for methods to enhance their work in these new and challenging circumstances.   Only problem is the same research shows it takes time to learn to use the measures effectively — and that’s under the best or, at least, most normal of circumstances!

Given that we are far from normal, the team at the International Center for Clinical Excellence, in combination with longtime technology and continuing education partners, have been working to provide the resources necessary for practitioners to make the leap to online services.  In my prior post, a number of tips were shared, including empirically-validating scripts for oral administration of the ORS and SRS as well as instructional videos for texting, email, and online use via the three, authorized FIT software platforms.

We are not done.  Below, you will find two, new instructional videos from ICCE Certified Trainers, Stacy Bancroft and Brooke Mathewes.  They provide step-by-step instructions and examples of how to administer the measures orally —  a useful skill if you are providing services online or via the telephone.

Two additional resources:

  1. On April 15th at 5:00 p.m. CENTRAL time, I will be hosting a second, free online discussion for practitioners interested in feedback informed treatment and deliberate practice.  Although all are welcome to join, the particular time has been chosen to accommodate colleagues in Australia, New Zealand, and Asia.  To join, you must register.  Here’s the link: https://zoom.us/webinar/register/WN_c5eousjqQRChSSQSj3AQZg.
  2. My dear colleague, Elizabeth Irias at Clearly Clinical, has made a series of podcasts about the COVID-19 pandemic available for free (including CE’s).  What could be better than “earning while you are learning,” with courses about transitioning to online services and understanding the latest research on the psychological impact of the virus on clients.

OK, that’s it for now.

Until next time,

Scott

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


Filed Under: Feedback Informed Treatment - FIT, FIT

Final Making Sense of Making Sense of Negative Research Results about Feedback Informed Treatment

February 19, 2020 By scottdm 21 Comments

toilet 2“Everyone understands how a toilet works, don’t you?” ask cognitive scientists Sloman and Fernbach.

The answer, according to their research, is likely no.  Turns out, peoples’ confidence in their knowledge far outstrips their ability to explain how any number of simple, every day items work — a coffeemaker, zipper, bicycle and yes, a toilet.   More troubling, as complexity increases, the problem only worsens.  Thus, if you struggle to explain how glue holds two pieces of paper together — and most, despite being certain they can, cannot — good luck accounting for how an activity as complicated as psychotherapy works.

So pronounced is our inability to recognize the depth of our ignorance, the two researchers have given the phenomenon a name: the “Illusion of Explanatory Depth.”  To be sure, in most instances, not being able to adequately and accurately explain isn’t a problem.  Put simply, knowing how to make something work is more important in everyday life than knowing how it actually works:

  • Push the handle on the toilet and the water goes down the drain, replaced by fresh water from the tank;
  • Depress the lever on the toaster, threads of bare wire heat up, and the bread begins to roast;
  • Replace negative cognitions with positive ones and depression lifts.

Simple, right?

Our limited understanding serves us well until we need to build or improve upon any one of the foregoing.  In those instances, lacking true understanding, I know itwe could literally believe anything — in the case of the toilet, a little man in the rowboat inside the tank makes it flush — and be just as successful.   While such apparent human frailty might, at first pass, arouse feelings of shame or stupidity, truth is operating on a “need to know” basis makes good sense.  It’s both pragmatic and economical.  In life, you cannot possibly, and don’t really need to know everything.

And yet, therein lies the paradox: we passionately believe we do.  That is, until we are asked to provide a detailed, step-by-step, scientifically sound accounting — only then, does humility and the potential for learning enter the picture.

When research on routine outcome monitoring (ROM) first began to appear, the reported impact on outcomes was astonishing.  Some claimed it was the most important development in the field since the invention of psychotherapy!  They were also quite certain how it worked: like a blood test, outcome and alliance measures enabled clinicians to check progress and make adjustments when needed.  Voila!

Eight years ago, I drew attention to the assertions being made about ROM, warning “caution was warranted. ” It was not a bold statement, rather a reasoned one.   After all, throughout the waning decades of the last millennium and into the present, proponents of cognitive (CT) and cognitive behavioral therapy (CBT) had similarly overreached, claiming not only that their methods were superior in effect to all others, but that the mechanisms responsible were well understood.  Both proved false.  As I’ve written extensively on my blog, CT and CBT are no more effective in head to head comparisons with other approaches.  More, studies dating back to 1996 have not found any of the ingredients, touted by experts as critical, necessary to success (1, 2, 3).

ToiletThat’s why I was excited when researchers Mikeal, Gillaspy, Scoles, and Murphy (2016) published the first dismantling study of the Outcome and Session Rating Scales, showing that using the measures in combination, or just one or the other, resulted in similar outcomes.  Some were dismayed by these findings.  They wrote to me questioning the value of the tools.  For me, however, it proved what I’d said back in 2012, “focusing on the measures misses the point.”  Figure out why their use improves outcomes and we stop conflating features with causes, and are poised to build on what most matters.

On this score, what do the data say?  When it comes to feedback informed treatment, two key factors count:

  1. The therapist administering the measures; and
  2. The quality of the therapeutic relationship.

As is true of psychotherapy-in-general, the evidence indicates that who uses the scales is more important that what measures are used (1, 2).  Here’s what we know:

  • Therapists with an open attitude towards getting feedback reach faster progress with their patients;
  • Clinicians able to create an environment in which clients provide critical (e.g., negative) feedback in the form of lower alliance scores early on in care have better outcomes (1, 2); and
  • The more time a therapists spend consulting the data generated by routinely administering outcome and alliance measures, the greater their growth in effectiveness over time.

In terms of how FIT helps, two lines of research are noteworthy:

  • In a “first of its kind” study, psychologist Heidi Brattland found that the strength of the therapeutic relationship improvedThe Therapeutic Relationship more over the course of care when clinicians used the Outcome and Session Rating Scales (ORS & SRS) compared to when they did not.  Critically, such improvements resulted in better outcomes for clients, ultimately accounting for nearly a quarter of the effect of FIT.
  • Brattland also found therapists, “significantly differed in the influence of … [FIT] on the alliance, in the influence of the alliance on outcomes, and the residual direct effect of [FIT] … posttreatment” (p. 10).  Consistent with other studies, such findings indicate routine measurement can be used to identify a clinician’s “growth edge” — what, where, and with whom — they might improve their ability to relate to and help the diverse clients met in daily work.  Indeed, the combination of FIT, use of aggregate data to identify personal learning objectives, and subsequent engagement in deliberate practice has, in the only study in history of psychotherapy to date, been shown to improve effectiveness at the individual practitioner level.

“Inch by inch, centimeter by centimeter,” I wrote back in 2012, “the results of [new] studies will advance our understanding and effectiveness.”  I’m hopeful that the discussion in this and my two prior posts (1, 2) will help those interested in improving their results avoid the vicious cycle of hope and despair that frequently accompanies new ideas in our field, embracing the findings and what they can teach us rather than looking for the next best thing.

Until next time,

Scott

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

P.S: The March Intensives are sold out.  Register now for the summer trainings to ensure your spot:
ICCE FIT Implementation Intensive 2020Picture1ICCE FIT Deliberate Practice Intensive 2020

Filed Under: Feedback Informed Treatment - FIT

More Making Sense of Negative Research Results about Feedback Informed Treatment

January 30, 2020 By scottdm 17 Comments

outrageIs it just me or has public discourse gone mad?

A brief perusal of social media largely finds accusation, name calling, and outrage instead of exploration, dialogue and debate.  Not that any of the latter options were ever simple, straightforward, or successful, but somehow, somewhere, taking a stand has replaced extending a hand.

Thus, slightly more than a year ago, I was compared to an ignorant, cult leader by a person — a researcher and proponent of CBT — who’d joined an open discussion about a post of mine on Facebook.  From there, the tone of the exchange only worsened.  Ironically, after lecturing participants about their “ethical duties” and suggesting we needed to educate ourselves, he labelled the group “hostile” and left, saying he was going to “unfriend and block” me.

As I wrote about in my last blogpost, I recently received an email from someone accusing me of “hiding” research studies that failed to support feedback informed treatment (FIT).  Calling it “scandalous,” and saying I “should be ashamed,” they demanded I remove them from my mailing list.  I did, of course, but without responding to the email.

And, therein lies the problem: no dialogue. 

For me, no dialogue means no possibility of growth or change — on my part or other’s.  To be sure, when you are public person, you have to choose cult memberto what and whom you respond.  Otherwise, you could spend every waking moment either feeling bad or defending yourself.  Still, I always feel a loss when this happens.  I like talking, am curious about and energized by different points of view.

That’s why when my Dutch colleague, Kai Hjulsted, posted a query about the same study I’d been accused of hiding, I decided to devote several blogposts to the subject of “negative research results.”  Last time, I pointed out that some studies were confounded by the stage of implementation clinicians were in at the time the research was conducted.  Brattland et al.’s results indicate, consistent with findings from the larger implementation literature, it takes between two and four years to begin seeing results.  Why?  Because becoming feedback-informed is not about administering the ORS and SRS — that can be taught in a manner of minutes — rather, FIT is about changing practice and agency culture.

(By the way, today I heard through the grapevine that a published study of a group using FIT that found no effect has, in its fourth and fifth years of implementation, started to experience fairly dramatic improvements in outcome and retention)

As critical as time and ongoing support are to successful use of FIT, these two variables alone are insufficient for making sense of emerging, apparently unsupportive studies.  Near the end of my original post, I noted needing to look at the the type of design used in most research; namely, the randomized controlled trial or RCT.

RCTIn the evaluation of health care outcomes , the RCT is widely considered the “gold standard” — the best way for discovering the truth.   Thus, when researcher Annika Davidsen published her carefully designed and executed study showing that adding FIT to the standard treatment of people with eating disorders made no difference in terms of retention or outcome, it was entirely understandable some concluded the approach did not work with this particular population.  After all, that’s exactly what the last line of the abstract said, “Feedback neither increased attendance nor improved outcomes for outpatients in group psychotherapy for eating disorders.”

But what exactly was “tested” in the study?

Read a bit further, and you learn participating “therapists … did not use feedback as intended, that is, to individualize the treatment by adjusting or altering treatment length or actions according to client feedback” (p. 491).  Indeed, when critical feedback was provided by the clients via the measures, the standardization of services took precedence, resulting in therapists routinely responding, “the type of treatment, it’s length and activities, is a non-negotiable.”  From this, can we really conclude FIT was ineffective?

More, unlike studies in medicine, which test pills containing a single active ingredient against others that are similar in every way except they are missing that key ingredient, RCTs of psychotherapy test whole treatment packages (e.g., CBT, IPT, EMDR, etc.).  Understanding this difference is critical when trying to make sense of psychotherapy research.

When what is widely recognized as the first RCT in medicine was published in 1948, practitioners could be certain streptomycin caused the loveimprovement in pulmonary tuberculosis assessed in the study.  By contrast, an investigation showing one psychotherapeutic approach works better than a no treatment control does nothing to establish which, if any of, the ingredients in the method are responsible for change.  Consider cognitive therapy (CT).  Many, many RCTs show the approach works.  On this score, there is no doubt.  People who receive it are much better off than those placed on a waiting list or in control groups.  That said, how cognitive therapy works is another question entirely.  Proponents argue its efficacy results from targeting the patterns of “distorted thinking” causally responsible for maladapative emotions and behaviors.  Unfortunately, RCTs were never designed and are not equipped to test such assumptions.  Other research methods must be used — and when they have been, the results have been surprising to say the least.

In my next post, I will address those findings, both as they apply to popular treatment models such as CT and CBT but also, and more importantly, to FIT.

Stay tuned.  In the meantime, I’m interested in your thoughts thus far.

Until then,

Scott

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

ICCE FIT Implementation Intensive 2020ICCE FIT Masters 2020ICCE FIT Deliberate Practice Intensive 2020

 

 

 

 

 

Filed Under: Feedback Informed Treatment - FIT

Making Sense of Negative Research Results about Feedback Informed Treatment

January 16, 2020 By scottdm 10 Comments

blindfolded-professionalA ship’s captain who successfully sails through a strait at night learns nothing, and adds nothing, to their knowledge of the world.

(Please hang with me.  I promise this post will not be a long, metaphysical rant).

Returning to the example.  As paradoxical as it may strike one at first blush, a captain whose ship founders on the rocks while sailing through the strait both learns and adds to their knowledge.  As philosopher Ernst von Glasersfeld once opined, “The only aspect of that ‘real’ world that actually enters into the realm of experience is its constraints.”dart

The principle identified by von Glasersfeld applies not only to life lessons, but also to scientific advancement and, of course, feedback informed treatment (FIT).  Indeed, identifying and learning from “constraints” — that is, when things go wrong — is the very purpose of FIT.

It’s why, for example, when a client refuses to complete the outcome and alliance measures, my first impulse is to “lean in” and explore their reasons, rather than instantly set the scales aside.   It’s also why I’m most intrigued by studies which find that FIT fails to improve outcome (1, 2).  In both instances, my curiosity is piqued.  “Finally,” I think, “a chance to learn something …”.   Doing so, cognitive science has long shown, is not as easy or straightforward as simply adjusting our beliefs in light of new facts.  Quite to the contrary.

blindersWe are prone to see what we expect, fit the “different” into our current way of viewing the world or ignore it altogether.  One brief example before turning attention to FIT (aka Routine Outcome Monitoring [ROM]).  For most of the history of the field, the failure to engage in and respond to psychological intervention has been attributed to a host of client variables (e.g., degree or type of dysfunction, poor attachment history, IQ, etc.).  Therapists, for their part, have been held accountable for making the correct diagnosis and administering the right treatment.

And yet, despite continuous growth in the size of the DSM, and number of treatment approaches, no improvement in the outcome of psychotherapy has occurred in the last 50 years — a fact I first talked publicly about in 2014 and which über-researchers James Prochaska and John Norcross finally acknowledged in the most recent issue of the American Psychologist.  While some have argued that the field’s flat outcomes indicate the effectiveness therapy has reached a natural limit, an alternate point of view is that we should consider looking beyond the current ways of thinking about what matters most in successful treatment.

On this score, one possibility has been staring the field ninetysevenin the face for decades: the impact of the individual therapist on outcome.  Research has long shown, for example, that who does the treatment contributes 5 to 9 times more to outcome than the type of therapy, psychiatric diagnosis, or client history.  The same body of evidence documents some practitioners are consistently more effective than others.  When researcher Scott Baldwin and colleagues looked into why, they found 97% of the difference was attributable to therapist variability in the alliance.  Said another way, more effective therapists are able to establish a strong working relationship with a broader and more diverse group of clients.  I hope you’re seeing new possibilities for improving effectiveness.  If you’re a regular reader of my blog, you already know my colleagues and I published the only study to date documenting that a focus on therapist development via routine outcome measurement, feedback, and deliberate practice improves both agency and individual practitioner outcomes.

Turning to FIT, in my first post of the New Year, I talked about the strong sense of “anticipointment” I felt when thinking about the future of our field.  A colleague from the Netherlands, Kai Hjulsted, responded, saying he’d been having the same feeling about FIT!  The source, he said, was a study by a Dutch researcher conducted in a crisis intervention setting which, “contrary to expectations,” found, “Patients with psychiatric problems and severe distress seeking emergency psychiatric help did not benefit from direct feedback.”

I was well aware of this study, having served on the researcher’s dissertation committee.  And over the last decade, multiple studies have been published showing little or no benefit from feedback (e.g., 1, 2, 3).

How to make sense of such findings?  Having spoken with numerous practitioners (and even some researchers), I can tell you the tendency is to fit the results into our current way of viewing the world.  So, seen through a traditional medicopsychiatric lens, the inevitable conclusion is FIT does not work with people with certain, specific diagnosis (e.g., severe distress, in crisis, or those with eating disorders).  Such a conclusion makes no sense, however, if the totality of evidence is considered.  Why?  Because the results are decidedly mixed.  Thus, in one study, FIT makes a difference with people in crisis, in another it does not.  With one group of “severely distressed” clients, feedback appears to make matters worse, with another, chances of improvement increase 2.5 times.

Making SenseWhat then can we conclude?

An answer begins to emerge as soon as we’re able to get beyond thinking of FIT as just one more in a long list of treatment methods rather than a fundamental, organizing principle of agency and practice culture.  As is hopefully obvious, learning to administer measurement scales takes little time.

Cultural change, by contrast, is a much longer process.  How long?  Norwegian researcher Heidi Brattland and colleagues found it took three years ongoing training and support to successfully implement FIT.  Had they stopped to evaluate, like all other studies to date, after an average of 4 hours of instruction, no impact on outcomes would have been recorded.

While its now clear that time and support are critical to keep-calm-there-s-more-to-comesuccessful implementation, these two variables alone are not sufficient to make sense of emerging, apparently unsupportive studies of FIT.  Addressing such findings requires we look at the type of design used in most research: the randomized controlled trial.   That I’ll do in my next post, in particular addressing two, top notch, well-executed studies many have assumed show FIT is not effective in psychological care for people with eating disorders and severe distress.

And so, as I asked at the outset, please “hang with me.”

Until next time,

Scott

Scott D. Miller, Ph.D.
Director, International Center for Clinical Excellence
March 2020

 

 

 

Filed Under: Feedback Informed Treatment - FIT

Where did you get that idea?

December 22, 2019 By scottdm 4 Comments

mindblown“I heard Scott Miller say it,” the man sitting next to me said.

“Really?” I responded, somewhat incredulous.  After all, I didn’t recall ever saying such a thing.  More to the point, it’s just not something I would say.  Its wrong.  Then again, it was clear he didn’t know that I was Scott Miller.  Not wanting to disrupt the presenter before me at the conference, I’d quietly snuck into the room, dressed in my “civies,” shortly after the meeting had started.

“Yep,” he replied, his voice full of certainty, “as I understand it, he says it all the time.”  Making “air” quote marks with his fingers, “If the client is not changing within three visits, you should terminate the treatment.”

You should have seen the look on his face when later our eyes met as I took to the stage to do my presentation.

On many occasions over the years, I’ve heard people quote me saying things I’ve never said.  Here’s a common one:

“Scott Miller says all you need for successful treatment is a good therapeutic relationship.”

Just so you know, I’ve never said this.  Ever. And yet, once, after I corrected a nationally known practitioner in front of a large audience, he nonetheless repeated it in his newsletter.  Here’s what I have said and continue to say:

  • All treatment models work equally well.  All.
  • Of all the factors affecting outcome, the specific approach used has the smallest impact.  By comparison, the relationship between client and therapist contributes eight to nine times more. 

Another:

“Scott Miller says therapists help 80% of their clients.”gossip

Once again, I’ve never said this.  In this instance, the misquote is more understandable.  Here’s what I do say at almost every workshop:

  • Decades of research and hundreds of study document psychotherapy works.
  • The effectiveness of psychotherapy has remained fairly stable over the years.
  • In most studies, the average treated client is better off than 80% of the untreated comparison sample.

I’m certain it’s the last of these statements that causes problems.  Presented, as it, is in “researchspeak,” it’s easy to misunderstand.  Read it again and you’ll see it does not mean we help 80% of our clients.  Rather, its about the advantage therapy offers relative to receiving no treatment at all.  By contrast, the percentage we help — as I’ve blogged about on numerous occasions — is actually around 50%.

Now, in the interest of fairness, let me mention something I often say but have never heard misquoted.  At nearly of all my workshops, I joke, “The ORS and SRS may not be the best scales ever developed … but they are free!”  The latter part of that statement is absolutely true.  Clinicians wishing to solicit feedback from clients about their progress and the quality of the therapeutic relationship simply need to register for a free paper and pencil license.  That said, recent research out of the University of Nottingham is giving me pause about the other half.

bustedJust last week, I interviewed Professor Sam Malins who, together with a team of others, has been studying the use of the scales in real world clinical settings for a number of years.  In addition to replicating a number of important findings (e.g., the longer you use the ORS and SRS, the more impact they have on retention and effectiveness; spending time gathering information for diagnosis and treatment planning results in poorer outcomes, the scales can be used to identify skill development opportunities), he also found the Outcome Rating Scale predicted …  oh, just watch the video yourself.  That way, I won’t be misquoted!

Until next time,

Scott

Scott D. Miller, Ph.D.
Director, International Center for Clinical Excellence
March 2020

 

 

 

 

 

Filed Under: Feedback Informed Treatment - FIT

Please, don’t use my scales…

December 12, 2019 By scottdm 3 Comments

stopOr, at least that’s what I said in response to his question.  The look on his face made clear my words caused more confusion than clarity.

“But then, how will I found out which of the therapists at my agency are effective?” he asked.

“The purpose of FIT,” I replied, “is not to profile, but rather help clinicians respond more effectively to their clients.”

And I’ve found myself giving similar advise of late —  in particular, actively counseling practitioners and clinic directors against using the ORS and SRS.

Here’s another:

“We need a way to meet the new Joint Comission/SAMHSA requirement to use a standardized outcome measure in all therapeutic work.”

My reply?

FIT is purposefully designed — and a significant body of evidence indicates it does — help those in treatment achieve the best results possible.  Thus, while integrating measures into care has, in some countries, because a standard of care, using them merely to meet regulatory requirements is de facto unethical.  Please don’t use my scales.

One more?

“I don’t (or won’t) use the scales with all my clients, just those I decide it will be clinically useful with.”

What do I think?

The evidence clearly shows stop 2clinicians often believe they are effective or aligned with clients when they are not.  The whole purpose of routinely using outcome and alliance measures is to fill in these gaps in clinical judgement.  Please don’t use my scales. 

Last, as I recently blogged about, “The scales are really very simple and self-explanatory so I don’t think we really need much in the way of training or support materials.”

My response?

We have substantial evidence to the contrary.  In sharp contrast to the mere minutes involved in downloading and learning to administer measures, actual implemention of FIT takes considerable time and support —  more than most seem aware of or willing to invest.

PLEASE DON’T USE MY SCALES!

While I could cite many more examples of when not to use routine outcome measures (e.g., “we need a way to identify clients we aren’t helping so we can terminate services with them and free up scarce clinical resources” or “I want to have data to provide evidence of effectiveness to funding sources”) — I will refrain.

As one dedicated FIT practitioner recently wrote, “Using FIT is brutal. Without it, it’s the patients’ fault. With fit, it’s mine. Grit your way through . . . because it’s good and right.”

I could not have said it any better.

Until next time,

Scott

Scott D. Miller, Ph.D.
Director, International Center for Clinical Excellence
ICCE Advanced FIT Intensive 2020 Scott D MillerICCE Fit Supervision Intensive 2020 Scott D Miller

Filed Under: Feedback, Feedback Informed Treatment - FIT, FIT

Feedbak Informed Treatment: Game Changer or Another Therapeutic Fad?

December 4, 2019 By scottdm 1 Comment

FadsRemember these?

Did you ever own or try one?

Remember Beanie Babies?  According to one news story, interest was such, “People neglected other areas of their lives to spend all day trading, and some even invested their children’s college funds in toys that they believed would bring an astronomical return on investment.”

And how about advertising executive Gary Dahl’s product?  You remember him, right?  In the 1970’s, he became an overnight millionaire selling rocks marketed as pets.  Rocks!  Waterbeds, Crocs, cause-branded plastic wristbands, oxygen bars, Pogs, Silly Bandz, and the Macarena — the list is as endless as our attention span is short.

If you’ve been in practice for a while, you know the field of mental health is not immune to fad and fashion.  Like past diet crazes, the drugs, diagnoses, and treatment methods that capture professional interest and then quickly disappear can be hard to remember.  Thus, in the 1980’s it was Xanax, multiple personality disorder, and satanic cult abuse.  The 1990’s brought us the “decade of the brain,” borderline personality disorder, and a flood of Prozac and cognitive-behavior therapy knockoffs.  More recently, mindfulness, energy meridians, and trauma have become the objets de grand intérêt.

One more trend is Feedback-Informed Treatment (FIT).  Known also as Routine Outcome Monitoring, Patient Focused Research, and Measurement-based care, it involves using scales to solicit feedback from clients regarding their experience in treatment and using the resulting information in real time to improve quality and outcome.  The weight of the scientific evidence is such that professional and regulatory bodies in the U.S. and abroad have already deemed ROM a “standard” of care in the delivery of psychological services and clinical supervision (American Psychological Association Presidential Task Force on Evidence-based Practice, 2006; Association of State and Provincial Psychology Boards, 2019; Joint Commission, 2018; Tasca et al., 2019).

But is it just another fad?Karsten

Data from two recent surveys suggest FIT is moving beyond the “innovation” to the “mass adoption” phase among mental health providers and treatment agencies.  The study conducted by Myoutcomes® targeted members of Facebook-related psychotherapy interest groups and other sources, finding fairly dramatic growth in: (1) awareness of the empirical support for using measures to assess progress and the quality of the therapeutic relationship; and (2) experience with standardized measurement tools in psychotherapy.

Whether such results indicate FIT will stick around long enough to be the “game changer” remains to be seen.  What is known for sure is that, while important, awareness of, experience with, and research support for the process are insufficient to sustain the interest.  Research shows, for instance, successful implementation of FIT takes significant time, planning, and support, without which between 70 and 95% of efforts fail.  Why?  Because working feedback-informed is about changing culture, not using measurement scales in treatment.  Success requires that all members of management — from administration to clinical supervisors — understand and are actively involved in implementation.  Indeed, when practitioners rather than a team led by a manager are held accountable, the likelihood of FIT being a game changer plummets (80% versus 14 %).

Bottom line?  PLEASE don’t download the ORS and SRS and begin experimenting — testing it out to see “if it works.”  As I blogged about last week, the likelihood of failure is simply too high.   Instead, bring your team to our upcoming Spring intensives in Chicago.  You’ll not only “rub shoulders” with colleagues from around the world and our international faculty, but also leave with a thorough grounding in FIT, as well as skills for transforming the culture in which you work.

Until next time,

Scott

Director, International Center for Clinical Excellence
ICCE Advanced FIT Intensive 2020 Scott D MillerICCE Fit Supervision Intensive 2020 Scott D Miller

Filed Under: Feedback Informed Treatment - FIT

Can you help me understand this?

November 25, 2019 By scottdm 1 Comment

dear johnA couple of weeks ago I received an email from the leader of a group asking me to send them copies of the ORS and SRS. “We are to start using these straight away,” the person wrote.

I replied, of course, providing a link to my website where the scales could be downloaded along with a brief note, highlighting the Feedback Informed Treatment (FIT) Manuals and the upcoming March Intensives in Chicago.  “Both are great resources,” I said, “for learning how to use the measures to improve the quality and outcome of behavioral health services.”

I received a quick and polite response, thanking me for the links but going on to say, “I’ve seen the scales. They are really very simple and self-explanatory so I don’t think we really need much in the way of training or support materials.”stethoscope

I’d like to say I was surprised. After all, what medical professional would say something similar?  Say, about a stethoscope?  To wit, “No thanks, seems pretty simple, stick these thingies in my ears, and the other end on the patient’s chest and listen…”.

But I was not — surprised, that is. Why?  Of the several hundred downloads of the measures from my website per week, and the more than 200,000 over the last decade, very few practitioners have sought or received any training.  Indeed, most have never even read the FIT manuals!

The impact on those who are initially enthusiastic about seeking formal feedback from their clients is as predictable as it is sad: they quickly give up.  How do I know, you ask?  Every week, as I’m out and about, training and consulting, I run into practitioners who say:

“Yeah, I heard of FIT, I even tried the scales…but they didn’t work…”

“I tried the ORS and SRS scales for a while, but I didn’t get any clinically useful information from them…”

“My clients weren’t honest … so I stopped using them”

And so I ask, what does it take to help people get the information and training they need to succeed?  The question is far from trivial or self-serving.  The measures are free to download and the latest research shows using them more than doubles the chances of helping clients experience meaningful change.  The only caveat is that, despite their simplicity, learning to employ the tools effectively takes time and support.  How do I know that?  Research, of course!

If you have thoughts about what I can do to address this problem, please let me know. In the meantime, in an effort to help, here are several offers:

1. For the time being, get the FIT Treatment and Training Manuals for 50% off;

2. Register for the combined FIT Advanced and Supervision Intensive now using the code FIT-Promo at checkout and get an additional discount off the early bird rate;

3. Sign up for the cutting-edge FIT e-learning program — where you can learn at your own pace from the comfort of your home — and receive the new, deliberate practice module, for free (if interested, email me for details about this offer).

Yes, please feel free to share these links and codes with your colleagues.  And, once more, if you have additional suggestions, I’m interested in hearing them.  Please post a comment below.

That’s it for now.

All the best for the Holidays,

Scott

Scott D. Miller, Ph.D.
Director, International Center for Clinical Excellence
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Filed Under: Feedback Informed Treatment - FIT

Responsiveness is “Job One” in Becoming a More Effective Therapist

June 28, 2019 By scottdm 4 Comments

face in cloudsLook at the picture to the left.  What do you see?

In no time at all, most report a large face with deep set eyes and slight frown.  

Actually, once seen, it’s difficult, if not impossible to unsee.  Try it.  Look away momentarily then back again.

Once set in motion, the process tends to take on a life of its own, with many other items coming into focus. 

Do you see the ghostly hand?  Skeletonized spine and rib cage?  Other eyes and faces?  A clown hat?

From an evolutionary perspective, the tendency to find patterns — be it in clouds, polished marble surfaces, burn marks on toast, or tea leaves in a cup — is easy to understand.  For our earliest ancestors, seeing eyes in the underbrush, whether real or illusory, had obvious survival value.   Whether or not the perceptions or predictions were accurate mattered less than the consequences of being wrong.   

In short, we are hardwired to look for and find patterns.  And, as researchers Foster and Kokko (2008) point out, “natural selection … favour[s] strategies that make many incorrect causal associations in order to establish those that are essential for survival …” (p. 36).   

As proof of the tendency to draw incorrect causal associations,flying couch one need only look at the field’s most popular beliefs and practices, many of which, the evidence shows, have little or no relationship to outcome.  These include:

  • Training in or use of evidence-based treatment approaches;
  • Participation in clinical supervision;
  • Attending continuing education workshops;
  • Professional degree, licensure, or amount of clinical experience;

Alas, all of the above, and more, are mere “faces in the clouds” — compelling to be sure, but more accurately seen as indicators of our desire to improve than reliable pathways to better results.  They are not.

So, what, if anything, can we do to improve our effectiveness?

According to researchers Stiles and Horvath (2017), “Certain therapists are more effective than others … because [they are] appropriately responsive … providing each client with a different, individually tailored treatment” (p. 71).   

Sounds good, right?  The recommendation that one should “fit the therapy to the person” is as old as the profession.   The challenge, of course, is knowing when to respond as well as whether any of the myriad “in-the-moment” adjustments we make in a given therapy hour actually help. 

That is until now.

EngagementConsider a new study involving 100’s real world therapists and more than 10,000 of their clients (Brown and Cazauvielh, 2019).  Intriguingly, the researchers found, therapists who were more “engaged” in formally seeking and utilizing feedback from their clients regarding progress and quality of care — as measured by the frequency with which they logged in to a computerized outcome management system to check their results — were significantly more effective. 

How much, you ask? 

Look at the graph above.  With an effect size difference of .4 σ, the feedback-informed practitioners (green curve) were on average more effective than 70% of their less engaged, less responsive peers (the red).

Such findings confirm and extend results from another study I blogged about back in May documenting that feedback-informed treatment, or FIT, led to significant improvements in the quality and strength of the therapeutic alliance.fitbit

Why some choose to actively utilize feedback to inform and improve the quality and outcome of care, while others dutifully administer measurement scales but ignore the results is currently unknown — that is, scientifically.  Could it really be that mysterious, however?  Many of us have exercise equipment stuffed into closets bought in the moment but never used.  In time, I suspect research will eventually point to the same factors responsible for implementation failures in other areas of life, both personal and professional (e.g., habit, lack of support, contextual barriers, etc.).

Until then, one thing we know helps is community.  Having like-minded to interact with and share experiences makes a difference when it comes to staying on track.  The International Center for Clinical Excellence is a free, social network with thousands of members around the world.  Every day, practitioners, managers, and supervisors meet to address questions and provide support to one another in their efforts to implement feedback-informed treatment.  Click on the link to connect today.

Still wanting more?  Listen to my interview with Gay Barfield, Ph.D., a colleague of Carl Rogers, with whom she co-directed the Carl Rogers Institute for Peace –an organization that applied person-centered principles to real and potential international crisis situations, and for which Dr. Rogers was nominated for the Nobel Peace Prize in 1987.  I know her words and being will inspire you to seek and use client feedback on a more regular basis…

OK, done for now,

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

P.S.: Registration for the Spring 2020 Advanced and Supervision Intensives is open!  Both events sold out months in advance this year.  Click on the icons below for more information or to register.
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Filed Under: evidence-based practice, Feedback Informed Treatment - FIT, Practice Based Evidence

Therapeutic Nudging: How Very Little Can Mean a Lot

May 13, 2019 By scottdm 2 Comments

nudgeIt was a curious finding.  One we stumbled on quite by accident.  Highly effective therapists were more likely to contact their clients between visits than their more average peers.  We wondered whether such behavior might account, at least in part, for their superior retention rates and outcomes?

Turns out, our serendipitous finding fit nicely with results from the field of behavioral economics documenting how very simple actions can have a dramatic impact on people’s behavior.   In one well known example, a study showed the way food is displayed in school cafeterias –it’s location and prominence–significantly impacts whether students make healthy or unhealthy eating choices.  Similar results have been recorded in other areas, such as saving for retirement, choosing the best health insurance plan, deciding whether to exercise or make positive lifestyle changes.

In all cases, the “nudge” –as researchers call such interventions — are simple, inexpensive, and require little time and effort to deliver.  A recent report in The Chronicle of Higher Education found, for example, a single email expressing compassion and support to students who had failed their first semester exam led to better classroom performance and less school drop out.  And since our original discovery, psychotherapy researchers have confirmed what highly effective practitioners have known all along.  The study by Flükiger, Del Re, Wampold, Znoj, Caspar, and Jörg found that clients who were sent a brief letter and had one follow up call between visits experienced significant and lasting improvements in the quality of the therapeutic relationship over the course of care.

Clearly, a little can go a long way.  But where to start?littlegoesalong

It would be wrong to conclude that we should start phoning (or sending emails) to all of our clients between visits.  The research cited above and findings from our interviews with highly effective therapists show, to be effective, therapeutic nudges must interrupt “business-as-usual.”  The default choice for most practitioners is not to engage in extratherapeutic contact with clients.  We are busy enough and reaching out crosses a boundary.  Additionally, and importantly, any such efforts need to show our interest in the client while simultaneously leaving them free not to comply.  Simply put, nudges can not be shoves.  

Evidence shows using simple measurement scales on an ongoing basis to  assess progress and the quality of the therapeutic relationship can augment our ability to identify and time these types of interventions.  Indeed, as I posted last week, clients whose therapists do so are less likely to dropout and 2.5 times more like to experience benefit from treatment.   Actually, 10’s of thousands of clinicians around the world are using the tools I created nearly 20 years ago to inform their work.  If you aren’t, click here to download them for free.

In the meantime, if you are looking for new and creative ways to nudge your therapeutic effectiveness upwards, join me in Chicago for one or more of our Summer workshops:

  • The two-day “FIT Implementation intensive” is the only evidence-based workshop in the U.S. designed to help you implement feedback informed treatment in your agency or healthcare system.
  • The three-day “Training of Trainers” will enhance your presentation and training skills.  It’s a blast, the most fun workshop we do.
  • Last but not least, the two-day “Deliberate Practice” workshop will, as the name implies, help you use deliberate practice to improve your clinical effectiveness.  We help you identify the targets and develop a plan.

All the best,

Scott

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

 

Filed Under: Feedback Informed Treatment - FIT

How Does Feedback Informed Treatment Work? I’m Not Surprised

May 6, 2019 By scottdm Leave a Comment

ShellGameFeedback-Informed Treatment (FIT) — using measures to solicit feedback about progress and the quality of the therapeutic relationship — is a transtheoretical, evidence-based approach.  The most recent research shows clients whose therapists use FIT on an ongoing basis are 2.5 times more like to experience benefit from treatment.

But how does it work?

Quick.  Take a guess.

Under the first shell: FIT works because clinicians use measures to monitor their performance.  The second: Feedback helps clinicians select the most effective treatment methods.  Third: FIT enhances the therapeutic relationship.

If you guessed the “proverbial pea” was under the third shell, you’re right.  Hard to believe given: (1) the emphasis placed on measurement and treatment methods by researchers and advocates of various scales; and (2) concerns expressed by some clinicians that using measures will negatively impact the relationship.

In a “first of its kind” study, psychologist Heidi Brattland found that the strength of the therapeutic relationship improved more over the course of care when clinicians used the Outcome and Session Rating Scales (ORS & SRS) compared to when they did not.  Critically, such improvements resulted in better outcomes for clients, ultimately accounting for nearly a quarter of the effect of FIT.

Below, you will find a link to an interview I did with Heidi this week about the study. The Therapeutic Relationship It’s really worth watching, and it underscores the main point of her findings.  Bottom line: FIT is not about measures and methods.  True, the tools provide form and structure, but their purpose is to facilitate connection.  So, when therapists in the study used the ORS and SRS, their client’s first session alliance scores tended to be lower, indicating the process facilitated the development of a “culture of feedback” early on in care.  As the researchers note, “having been invited to reflect on any negative aspects of the alliance with a responsive therapist in the first session … clients had a more considered and realistic view of the early … [that] facilitated the communication about the treatment process from the first session onward” (p. 10).

That said, Brattland and her colleagues did not find clinicians were equally effective in their use of FIT.  Indeed, as detailed in the report, therapists, “significantly differed in the influence of … [FIT] on the alliance, in the influence of the alliance on outcomes, and the residual direct effect of [FIT] … posttreatment” (p. 10).  On this score, one advantage of using scales to routinely measure our work, is that doing so enables us to identify our personal “growth edge” — what, where, and how we might improve our ability to relate to and help the diverse clients we meet in our daily work.

Using the tools to facilitate professional growth and development is the focus of this summer’s “Deliberate Practice Intensive.”  Together with my colleague, Dr. Daryl Chow, we’ll translate the latest research showing that deliberate practice leads to steady improvements in effectiveness into step-by-step instructions for improving your clinical performance.  Click here for more information or to register!

Until next time,

Scott

Scott D. Miller, Ph.D.
Director, International Center for Clinical Excellence
FIT Implementation Intensive Aug 2019 - ICCEFIT Training of Trainers Aug 2019 - ICCE

 

 

 

 

 

 

Filed Under: Feedback Informed Treatment - FIT, PCOMS, Therapeutic Relationship

What does losing your keys have in common with the treatment of trauma?

April 24, 2019 By scottdm 9 Comments

keysLast week, I was preparing to leave the house and could not locate my keys.  Trust me when I say, it’s embarrassing to admit this is not an infrequent occurrence.

Logic and reason are always my first problem solving choices.  That’s why I paused after looking in the kitchen drawer where I am supposed to keep them, along with my wallet and glasses, and found it empty.  When did I last have them?  Not finding them there, the “search” began.

Upstairs to the bedroom to check my pants pockets.  No.  Downstairs to the front closet to look in my coat.  No.  Back upstairs to the hamper in the laundry room.  No.  Once more, down the stairs to the kitchen hutch.  I sometimes leave them there.  This time, however, no.  I then headed back up the stairs to the master bathroom — my pace now a bit frantic — and rummaged through my clothing.  No.  They’ve gotta be on my office desk.  Down two flights of stairs to the basement.  Not there either.

In a fit of pique, I stormed over to the landing, and yelled at the top of my voice, “DID SOMEONE TAKE MY KEYS?” the accusation barely concealed.  Although my head knew this was nuts, my heart was certain it was true. They’ve hidden them!

“No,” my family members kindly reply, then ask, “Have you lost them again?”

“Arrgh,” I mutter under my breath.  And that’s when I do something that, in hindsight, make no sense.  I wonder if you do the same?  Streetlight EffectNamely, I start the entire search over from the beginning — pants, coat, hamper, closet, hutch, office — often completing the exact same cycle several times.  Pants, coat, hamper, closet, hutch, office.   Pants, coat, hamper, closet, hutch, office.  Pants, coat, hamper, closet, hutch, office.

I can’t explain the compulsion, other than, by this point, I’ve generally lost my mind.  More, I can’t think of anything else do.  My problem: I have somewhere to go!  The solution: Keep looking (and it goes without saying, of course, in the same places).

(I did eventually locate my keys.  More on that in a moment)

Yesterday, I was reminded of my experience while reading a newly released study on the treatment of trauma.   Bear with me as I explain. Over a decade ago, I blogged about the U.S. Veteran’s Administration spending $25,000,000 aimed at “discover[ing] the best treatments for PTSD” despite a virtual mountain of evidence showing no difference in outcome between various therapy approaches.

Since that original post, the evidence documenting equivalence between competing methods has only increased (1, 2).  The data are absolutely clear.  Meta-analyses of studies in which two or more approaches intended to be therapeutic are directly compared, consistently find no difference in outcome between methods – importantly, whether the treatments are designated “trauma-focused” or not.   More, other highly specialized studies – known as dismantling research – fail to provide any evidence for the belief that specialized treatments contain ingredients specifically remedial to the diagnosis!  And yes, that includes the ingredient most believe essential to therapeutic success in the treatment of PTSD; namely, exposure (1, 2).

The new study confirms and extends such findings.  Briefly, using data drawn from 39 V.A. treatment centers, researchers examined the relationship between outcome and the degree of adoption of two so-called “evidence-based,” trauma-informed psychotherapy approaches — prolonged exposure and cognitive processing therapy.  If method mattered, of course, then a greater degree of adoption would be associated with better results.  It was not.  As the authors of the study conclude, “programs that used prolonged exposure and cognitive processing therapy with most or all patients did not see greater reductions in PTSD or depression symptoms or alcohol use, compared with programs that did not use these evidence-based psychotherapies.”

Winston Churchill Quote About History Repeating Itself History Doesn't Repeat Itself But It Rhymes | Quote"history Does - QUOTES BY PEOPLE

So what happens now?  If history, and my own behavior whenever I lose my keys, is any indication, we’ll start the process of looking all over again.  Instead of accepting the key is not where we’ve been looking, the field will continue it’s search.  After all, we have somewhere to go — and right back to the search for the next method, model, or treatment approach, we go.

It’s worse than that, actually, as looking over and again in the same place, keeps us from looking elsewhere.  That’s how I generally find my keys.  As simple and perhaps dumb as it sounds, I find them someplace I had not looked.

And where is the field not looking?  As Norcross and Wampold point out in an article published this week, “relationships and responsiveness” are the key ingredients in successful psychological care for people who are suffering as a result of traumatic experiences, going on to say that the emphasis on model or method is actually harmful, as it “squanders a vital opportunity to identify what actually heals.”

Improving our ability to connect with and respond effectively to the diverse people we meet in therapy is the focus on Deliberate Practice Intensive, held this August in Chicago, Illinois.  Unlike training in protocol-driven treatments, studies to date show learning the skills taught at the workshop result in steady improvements in clinicians’ facilitative interpersonal skills and outcomes commensurate with the rate of improvement seen in elite athletes.  For more information or to register, click here.

Until next time,

Scott

Scott D. Miller, Ph.D.
International Center for Clinical Excellence
FIT Deliberate Practice Aug 2019 - ICCEFIT Training of Trainers Aug 2019 - ICCEFIT Implementation Intensive Aug 2019 - ICCE

Filed Under: evidence-based practice, Feedback, Feedback Informed Treatment - FIT, Therapeutic Relationship

It’s Time to Abandon the “Mean” in Psychotherapy Practice and Research

April 8, 2019 By scottdm 7 Comments

car seatRecognize this?  Yours will likely look at bit different.  If you drive an expensive car, it may be motorized, with buttons automatically set to your preferences.  All, however, serve the same purpose.

Got it?

It’s the lever for adjusting your car seat.

I’m betting you’re not impressed.   Believe it or not though, this little device was once considered an amazing innovation — a piece of equipment so disruptive manufacturers balked at producing it, citing “engineering challenges” and fear of cost overruns.

For decades, seats in cars came in a fixed position.  You could not move them forward or back.  For that Plane-Crash-04022016-2matter, the same was the case with seats in the cockpits of airplanes.  The result?  Many dead drivers and pilots.

The military actually spent loads of time and money during the 1940’s and 50’s looking for the source of the problem.  Why, they wondered, were so many planes crashing?  Investigators were baffled.

Every detail was checked and rechecked.  Electronic and mechanical systems tested out.  Pilot training was reviewed and deemed exceptional.  Systematic review of accidents ruled out human error.   Finally, the equipment was examined.  Nothing, it was determined, could not have been more carefully designed — the size and shape of the seat, distance to the controls, even the shape of the helmet, were based on measurements of 140 dimensions of 4,000 pilots (e.g., thumb length, hand size, waist circumference, crotch height, distance from eye to ear, etc.).

It was not until a young lieutenant, Gilbert S. Daniels, intervened that the problem was solved.  Turns out, despite of the careful measurements, no pilot fit the average of the various dimensions used to design the cockpit and flight equipment.  Indeed, his study found, even when “the average” was defined as the middle 30 percent of the range of values on any given indice, no actual pilot fell within the range!

The conclusion was as obvious as it was radical.  Instead of fitting pilot into planes, planes needed to be designed to fit pilots.  Voila!   The adjustable seat was born.

round-head-square-holeNow, before you scoff — wisecracking, perhaps, about “military intelligence” being the worst kind of oxymoron — beware.  The very same “averagarianism” that gripped leaders and engineers in the armed services is still in full swing today in the field of mental health.

Perhaps the best example is the randomized controlled trial (RCT) — deemed the “gold standard” for identifying “best practices” by professional bodies, research scientists, and governmental regulatory bodies.  t-test

However sophisticated the statistical procedures may appear to the non-mathematically inclined, they are nothing more than mean comparisons.

Briefly, participants are recruited and then randomly assigned to one of two groups (e.g., Treatment A or a Control group; Treatment A or Treatment as Usual; and more rarely, Treatment A versus Treatment B).  A measure of some kind is administered to everyone in both groups at the beginning and the end of the study.   Should the mean response of one group prove statistically greater than the other, that particular treatment is deemed “empirically supported” and recommended for all.

The flaw in this logic is hopefully obvious: no individual fits the average.  More, as any researcher will tell you, the variability between individuals within groups is most often greater than variability between groups being compared.

in boxBottom line:  instead of fitting people into treatments, mental health care should be to made to fit the person.  Doing so is referred to, in the psychotherapy outcome literature, as responsiveness  — that is, “doing the right thing at the right time with the right person.”  And while the subject receives far less attention in professional discourse and practice than diagnostic-specific treatment packages, evidence indicates it accounts for why, “certain therapists are more effective than others…” (p. 71, Stiles & Horvath, 2017). 

I’m guessing you’ll agree it’s time for the field to make an “adjustment lever” a core standard of therapeutic practice — I’ll bet it’s what you try to do with the people you care for anyway.on box

Turns out, a method exists that can aid in our efforts to adjust services to the individual client.  It involves routinely and formally soliciting feedback from the people we treat.  That said, not all feedback is created equal.  With a few notable exceptions, all routine outcome monitoring systems (ROM) in use today suffer from the same problem that dogs the rest of the field.  In particular, all generate feedback by comparing the individual client to an index of change based on an average of a large sample (e.g., reliable change index, median response of an entire sample).

By contrast, three computerized outcome monitoring systems use cutting edge technology to provide feedback about progress and the quality of the therapeutic alliance unique to the individual client.  Together, they represent a small step in providing an evidence-based alternative to the “mean” approaches traditionally used in psychotherapy practice and research.

Interested in your thoughts,

Scott

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

PS: Want to learn more?  Join me and colleagues from around the world for any or all three, intensive workshops being offered this August in Chicago, IL (USA).

  1. The FIT Implementation Intensive: the only workshop in the US to provide an in depth training in the evidence-based steps for successful integration of Feedback Informed Treatment (FIT) into your agency or clinical practice.
  2. The Training of Trainers: a 3-day workshop aimed at enhancing your presentation and training skills.
  3. The Deliberate Practice Intensive: a 2-day training on using deliberate practice to improve your clinical effectiveness.

Click on the title of the workshop for more information or to register.

 

 

Filed Under: Behavioral Health, evidence-based practice, Feedback, Feedback Informed Treatment - FIT, FIT, FIT Software Tools

Routine Outcome Monitoring and Deliberate Practice: Fad or Phenomenon?

March 26, 2019 By scottdm 1 Comment

new-improved-newspaper-headline-better-product-update-upgrad-headlines-announcements-upgrade-60079897Would you believe me if I told you there was a way you could more than double the chances of helping your clients?  Probably not, eh?  As I’ve documented previously, claims abound regaring new methods for improving the outcome of psychotherapy.  It’s easy to grow cynical.

And yet, findings from a recent study document when clinicians add this particular practice to their clinical work, clients are actually 2.5 times more likely to improve.  The impact is so significant, a review of research emerging from a task force of the American Psychological Association concluded, “it is among the most effective ways available to services to improve outcomes.”feedback effects

That said, there’s a catch.

The simple nature of this “highly rated,” transtheoretical method belies a steep learning curve.  In truth, experience shows you can learn  to do it — the mechanics — in a few minutes.

But therein lies the problem.  The empirical evidence makes clear successful implementation often takes several years.  This latter fact explains, in part, why surveys of American, Canadian, and Australian practitioners reveal that, while being aware of the method, they rarely integrate it into their work.

What exactly is the “it” being referred to?

Known by the acronym FIT,  feedback-informed treatment (FIT) involves using standardized measures to formally and routinely solicit feedback from clients regarding progress and the quality of the therapeutic relationship, and then using the resulting information to inform and improve care.

The ORS and SRS are examples of two simple feedback scales used in more than a dozen randomized controlled trials as well as vetted and deemed “evidence-based” by the Substance Abuse and Mental Health Services Administration.  Together, the forms take less than 3 minutes to administer, score and interpret (less if one of the web-based scoring systems is used).

So why, you might wonder, would it take so long to put such tools into practice?

As paradoxical as it may sound, because FIT is really not about using measures — any more say than making a home is about erecting four walls and a roof.  While the structure is the most visible aspect — a symbol or representation — we all know it’s what’s inside that counts; namely, the people and their relationships.

On this score, it should come as no surprise that a newly released study has found a significant portion of the impact of FIT is brought about by the alliance or relationship between client and therapist.   It’s the first study in history to look at how the process actually works and I’m proud to have been involved.

Of course, all practitioners know relationships skills are not only central to effective psychotherapy, but require lifelong learning.   With time, and the right kind of support, using measurement tools facilitates both responsiveness to individual clients and continuous professional development.

Here’s the rub.  Whenever I respond to inquiries about the tools — in particular, suggesting it takes time for the effects to manifest, and that the biggest benefit lies beyond the measurement of alliance and outcome — interest in FIT almost always disappears.  “We already know how to do therapy,” a manager  replied just over a week ago, “We only want the measures, and we like yours because they are the simplest and fastest to administer.”fit training

Every so often, however, the reply is different.  “What do we have to do to make this work to improve the effectiveness of our clinical work and clinicians?” asked Thomas Haastrup, the Coordinator of Family Services for Odense Municipality in Denmark.  When I advised, planning and patience, with an emphasis on helping individual practitioners learn to use feedback to foster professional development versus simply measuring their results, he followed through.  “We adopted the long view,” Thomas recounts, “and it’s paid off.”  Now in their 5th year, outcomes are improving at both the program and provider level across services aimed at helping adults, children, and families.

In addition to the Manual 6 in the ICCE Treatment and Training manuals, the ICCE Summer Intensives offer several opportunities for helping you or your agency to succeed in implementing FIT.  First, the 2-day FIT Implementation Training — the only workshop offering in-depth, evidence-based training in the steps for integrating FIT into clinical practice at the individual, agency, and system-of-care level.  Second, the Deliberate Practice Intensive — here you not only learn the steps, but begin to set up a professional develop plan designed to enhance your effectiveness.

To help out, I’d like to offer a couple of discounts:

  1. Purchase Manual 6 at 70% off the regular price.  Click here to order.  Enter the word IMPLEMENTATION at checkout to receive the discount  (If you want to purchase the entire set, I’m making them available at 50% off the usual price.  Enter IMPLEMENTATION2 at checkout).
  2. Register for any or all of the summer intensives by May 1st and receive an additional discount off the early bird price.  Simple enter the code FITPROMOAPRIL at checkout.  Please note, registration MUST occur before May 1st.  Generally, we sell out 6 to 8 weeks in advance.

Feel free to email me with any questions.  In the meantime, as always, I’m interested in your thoughts about FIT and DP.

Until next time,

Scott

Scott D. Miller, Ph.D.
Director, International Center for Clinical Excellence
FIT Implementation Intensive Aug 2019 - ICCEFIT Training of Trainers Aug 2019 - ICCEFIT Deliberate Practice Aug 2019 - ICCE

Filed Under: evidence-based practice, excellence, Feedback, Feedback Informed Treatment - FIT, FIT

Good Intentions or The Proverbial “Road to Hell?”: Trying to Understand the APA guidelines for Men and Boys

March 8, 2019 By scottdm 9 Comments

Clinical Practice GuidelinesSeveral weeks ago, the American Psychological Association (APA) released its latest in a series of practice guidelines for psychologists – this time for “Psychological Practice with Boys and Men.”  Prior years had seen guidelines focused on ethnicity, older adults, girls and women, LGBT, and “transgender and gender-non-conforming” persons.

Curiously, despite claiming to be based on 40 years of research, and the product of 12 years of intensive study, the latest release attracted little attention.  More, the responses that have appeared in print and other media have largely been negative (1, 2, 3, 4, 5). question

What happened?

At first blush, the development and dissemination practice guidelines for psychologists would seem a failsafe proposition.  What possibly could go wrong with providing evidence-based information for improving clinical work?  And yet, time and again, guidelines released by APA end up not just attracting criticism, but deep concern.   Already, for example, a Title IX complaint has been filed against the new guidelines at Harvard.

Consider others released in late 2017 for the treatment of trauma.  Coming in at just over 700 pages ensured few, if any, actual working professionals would read the complete document and supportive appendices.  Beyond length, the way the information was presented–especially the lack of hypertext for cross referencing of the studies cited–seriously compromised any straightforward effort to review and verify evidentiary claims.  Nevertheless, digging into the details revealed a serious problem:  a discontinuity between the evidence reviewed and the conclusions reached.  For example, despite “strongly recommending” certain approaches over others, none that topped the list had actually been shown by research to be more effective than any other.

Guidelines are far from benign.  They are meant to shape practice, establishing a “standard of care” — one that will be used, as the name implies to guide training and treatment.  As such, the stakes are high, potentially life altering for both practitioners and those they serve.

bad manAnd so, on reading the latest release from the APA, we wonder about the consequences for men and boys.  Even a superficial reading leaves little to recommend “being male.”  Gone are any references to the historical or current contributions of men — to their families, communities, marginalized peoples, culture, or civilization.  In their place, are a host of sweeping generalizations often wrapped in copious amounts of political, progressive jargon on a wide variety of subjects, many of which are the focus of research and debate by serious scientists (e.g., the connection between media violence and male aggression, socialization as a primary cause of gender and behavior, the existence of a singular versus multiple masculine ideal, etc.).

Cutting to the chase, when viewed in this way, is it any wonder really, that many men – as the document accurately points out – “do not seek help from mental health professionals when they need it?” (p. 1).

And lest there be any doubt, men as a group, are in need help.  Concern-sign

You’ve likely read the statistics, seen examples in your practice, perhaps in the life of your family or friends.   It starts young, with boys accounting for 90% of discipline problems in schools, and continues to the end of life, with women living 5 to 10 years longer on average.  The “in between” years are not any better, with men significantly more likely to be incarcerated, addicted to drugs, drop and fail out of school, and end their lives by suicide.

To be clear, the document is not overarchingly negative.  At the same time, if our goal, as a profession, is to reduce stigma — which previous, and even the present, guidelines do for other groups and “non-traditional” males — then the latest release risks perpetuating stereotypes and prejudices of “traditional” men and the people in their orbit.

caringSticking to the science of helping, instead of conforming to popular standards of public discourse, would have lead to a very different document – one containing a more nuanced and appreciative understanding of the boys and men who are reluctant to seek our care.  In the fractious times in which we find ourselves, perhaps it’s time for guidelines on how to live and work together, as individuals and as a species.

As always, interested in your thoughts,

Scott & David

Scott D. Miller, Ph.D. & David Prescott, LICSW
International Center for Clinical Excellence

P.S.: Registration for our Summer Intensives on Implementing Feedback Informed Treatment and Deliberate Practice is now open — two clinical practices research shows improves retention and outcome in behavioral health care.   For more information, click here.

Filed Under: Feedback Informed Treatment - FIT

Surfing and Psychotherapy (or, How Two of My “Love Affairs” in Life are Alike)

February 26, 2019 By scottdm 2 Comments

blogpost

I’m neither a great psychotherapist or surfer.  I love doing both, however.

Turns out, the two share a fundamental similarity critical to successful execution; in a word, responsiveness.

/rəˈspänsivnəs/
NOUN
The quality of reacting quickly and positively.

In surfing, you take advantage of the waves coming your way.  In psychotherapy, you utilize and react to what the client presents.  In both activities, trying to force matters spoils, if not altogether thwarts, the experience.

Recent research actually shows “certain therapists are more effective than others … because [they are] appropriately responsive … providing each client with a different, individually tailored treatment” (1).

How best to improve this key skill?

Having just returned from a week surfing in Hawaii, I can definitely say “patience and persistence” are key.  I spent a lot of time sitting on my board scanning the surrounding water for incoming waves.  If not that, I was paddling like mad to get in front of a swell I hoped would turn into a good ride.

Sometimes I was ahead of the curve, other times behind.  Even when my timing was right, some waves quickly “fell apart” leaving me slowly sinking into the surrounding water.  Often enough though, it all came together, and what a high.   Soon, and without thinking, I was laying astride my board paddling back out for more.

I’m sure you’ve had similar experiences in psychotherapy.  At times, you are too early; at others, too late.  With some, you are helpful; others, not so much.  For most of the history of the field, patience and endurance, combined with training, supervision, and trial and error, are the ways by which we’ve learned to respond to and tailor the work to the individual.  That is, until recently.engagement

Consider the bar graph displayed on the right.  It shows the results of a brand new study just released by my colleague Jeb Brown tracking the impact Feedback Informed Treatment (FIT)  — the process of using formal measures to track progress and the quality of the therapeutic relationship — has on the outcome of psychotherapy.  Importantly, the data used were drawn from a super-large, real world sample of working clinicians.

Here’s what Jeb found.  Therapists who were more “engaged” in seeking and processing performance feedback were significantly more effective than their peers (an average effect size difference of .2 σ).  In short, FIT improved clinical responsiveness, increasing the odds of practitioners “doing the right thing at the right time.”

If you’re not already using the two FIT scales, you can download and start them using them for free by clicking here.  Several cutting edge software programs are also available that will administer and score the tools, as well as provide you with evidence-based feedback delivered at the point of service delivery.  “Epic!” is likely what a Surfer would say if they to had access to similar tools for enhancing their responsiveness to local surf conditions.

Which reminds me …

StayingA few years back, Mark Hubble and I, together with our surfer bro, Seth Houdeshell, wrote a book about surfing.  Actually, its an inspirational, “how to” volume about living the good life based on the principles of surfing.   Jack Canfield, author of the Chicken Soup of the Soul books, described it “Like a warm sunny day at the beach,” promising  it “would brighten your spirits and put a smile on your face.”

It’s a fun read that won’t strain your brain.  Young or old, surfer or wannabe, I know you’d enjoy it.  Click here if you’re interested.  You can have it at my cost ($4.95 plus shipping) until my supply runs out.

Until next time,

Scott

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

P.S: Registration is open for the FIT Summer Intensive Trainings.  Click on the icons below for more information or to register.

FIT Implementation Intensive Aug 2019 - ICCEFIT Training of Trainers Aug 2019 - ICCEFIT Deliberate Practice Aug 2019 - ICCE

 

Filed Under: Feedback Informed Treatment - FIT

Time for a New Paradigm? Psychotherapy Outcomes Stagnant for 40 years

February 1, 2019 By scottdm 9 Comments

airplane in treeYou’ve heard it said before.  Flying is the safest form of transportation.

Facts back up the claim.  In fact, it’s not even close.  In terms of distance traveled, the fatality rate per billion kilometers is .003, improving dramatically over the years.  Cars, by contrast, are almost 1,000 times more dangerous.  Still, since 1923, the fatality rate in motor vehicle accidents has declined an eye-popping 93%.

How about psychotherapy?  Have outcomes improved?  Judging by the size of the Diagnostic and Statistical Manual and growth in the number of treatment approaches, one would expect success rates to have climbed significantly, if not exponentially.  Not so, as I first presented at the Evolution of Psychotherapy Conference five years ago, and later on this blog, the empirical evidence clearly shows NO improvement.

And now a new study, this time reviewing the evidence regarding treatments for children and adolescents.  Using sophisticated statistical analyses, the researchers examined 453 RCT’s spanning 53 years, involving nearly 32,000 kids treated for anxiety, depression, attention deficit/hyperactivity, and conduct problems.  With the rising popularity of “evidence-based practice,” those conducting the study wanted to know whether “… our methods of developing and testing youth psychological therapies [are] producing improvement” (p. 2).

Can you guess what they found?Books in tree

Outcomes have not changed (much less improved) over the last five decades–that’s 351 in dog years!

Can you imagine the outcry had similar results been published about automobiles or planes?  You would fully expect hearings to be held, and leaders to be called called to account.  The lives of children are on the line.

Nope.  Instead, facing the supersized differences between promises made every year about “advances” in psychotherapy, and the results realized and reported in research studies, the authors meekly call for, “new approaches to treatment design and intervention science” (p. 1).

Really?  Is that what’s required?  Researchers going back to the drawing board of “treatment and intervention?”

No, what’s needed is an entirely different view of what clinicians actually do  — and it starts by giving up the idea that psychotherapy is a form of treatment similar to antibiotics or angioplasty.  Let’s face it.  Psychotherapy is no more a medical treatment than are the facials, salt glows and body wraps one receives at the local spa.  Which is not to say, it doesn’t work.

Eva-Strauss-Ivory-Tower

Outside the halls of academia, millions of therapists worldwide are helping people on a daily basis to live happier, more meaningful and functional lives.  Dozens of studies of real world practitioners document outcomes that meet or exceed benchmarks established in tightly controlled, model-driven, randomized trials — all without following a particular, “evidence-based” protocol (see 1, 2, 3,4).

So, how best to conceptualize the effective work clinicians do?  And, importantly, what could researchers offer that would be of real help to therapists?

That psychotherapy works, says more about humans and our need for connection, meaning, and purpose, than it does about the particulars of any given model or approach.  And that our methods focus on thoughts, feelings, behaviors, and brain chemistry, says more about our Western values and beliefs, than about the ingredients necessary for successful healing.

Simply put, the field does not need to, as the authors of the study argue, “intensify the search for mechanisms of change [and] transdiagnostic … treatments” (p. 1).  Doing so is merely a recipe for “more of the same.”  Rather, to move forward, it should abandon the medical paradigm that has long had a stranglehold on our research and professional discourse, choosing instead to reconnect with the larger, worldwide family of healers, one that has existed since the dawn of history and which, from the outset, has been deeply engaged in the values and beliefs of those they treat, using whatever means necessary, consistent with the culture, to engender change.

What might that look like in practice?

As already documented, practicing clinicians already do a pretty darn good job helping their clients.  There’s nothing wrong with our Westernized approaches when they work.  At the same time, we don’t succeed with everyone.  The problem, studies show, is we’re not particularly good at knowing when we’re not being helpful, when clients are at risk for dropping out or are actually deteriorating while in our care (1, 2).  On this score, research has already provided a solution.  Dozens of studies document, for example, using simple measures at the beginning and end of each visit not only provides clinicians with an opportunity to intervene more successfully with “at risk” clients, but also helps identify opportunities for their own growth and development (1, 2).  If you’re not routinely and formally measuring the quality and outcome of your work, you can get started by accessing two simple tools here.

With outcome as our guide, all that remains is being willing to look outside the profession for possibilities for healing and change unbound by convention and the medical view.  That’s happening already, by the way, in the world’s two most populous countries, India and China, with professionals learning the ways of indigenous healers and government officials tapping local shaman to meet citizen’s mental health and well being needs.

So, what about you?  What you are doing to extend your healing reach?

And, in case you haven’t seen it, the video below is from the most recent Evolution of Psychotherapy conference, where I talk about new research documenting psychics achieving the same or better results as psychotherapists.

Until next time,

Scott

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

P.S.: Want to learn more about using outcome to inform and improve your effectiveness?  Join me and an international group of teachers and researchers in Chicago for our Summer Intensives.  For detailed information and to register, click on the banners below.
FIT Implementation Intensive Aug 2019 - ICCEFIT Training of Trainers Aug 2019 - ICCEFIT Deliberate Practice Aug 2019 - ICCE

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