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Leading for a Change: The Training of Trainer’s (TOT) Chicago

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I’m writing tonight from my hotel room at the River Rock Inn in Rockland, Ontario, Canada.  For those of you who are not familiar with the area, it is a bilingual (French & English) community of around 9,000 located about 25 km west of Ottawa.

Today through Thursday, I’m working with the staff, supervisors, and agency administrators of Prescott-Russell Services to Children and Adults.  The goal?  Introduce the latest “cutting-edge” research on “what works” in behavioral health and initiate a system transformation project for this group that provides child protection, mental health, family violence, and development services in the area.  The time spent with the first cohort of 125 direct services providers and supervisors went by, as they say, in “the blink of an eye.”  Tomorrow, I’ll be repeating the same training for the rest of the crew.  On Wednesday and Thursday I’ll meet with supervisors and administrators.  Suffice it to say, it’s an incredible opportunity for me to take part in such a large and well executed service improvement project.  In these lean economic times, I’m inspired by both the time and resources being directed at improving services offered to this area’s most needy.  By the end of the week, I hope to have interviews posted with some of the providers and leaders working in the project.

While on the subject of training, let me share the brochure for this year’s “Training of Trainers” event in Chicago, Illinois during the second week of August.  As in prior years, professionals from all over the world will be joining me and the state-of-the-art faculty for four intensive days of training on feedback-informed treatment (FIT).  Please note: this is not an “advanced training” in FIT where time is spent reviewing the basics or covering content.  Rather, the TOT curriculum has been designed to prepare participants to train others.  Every day of the training, you will learn specific skills for training others, have an opportunity to practice those skills, and then receive detailed feedback from ICCE Senior Associates and Trainers Rob Axsen, Cynthia Maeschalck, and Jason Seidel.  Anyway, read for yourself.  Agencies both public and private, in the U.S. and abroad, are sending staff to the event to learn the skills necessary to lead transformation projects.  Space is already limited so register soon.

Click here to download the brochure to review or forward to colleagues

Addressing the Financial Crisis in Public Behavioral Healthcare Head On in Chesterfield, Virginia

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If you are following me on Twitter (and I hope you are), you know the last month has been extremely busy.  This week I worked with clinicians in Peterborough, Ontario Canada.  Last week, I was in Nashville, Tennessee and Richmond Virginia.  Prior to that, I spent nearly two weeks in Europe, providing training and consultations in the Netherlands and Belgium.

It was, as always, a pleasure meeting and working with clinicians representing a wide range of disciplines (social workers, case managers, psychologists, psychiatrists, professional counselors, alcohol and drug treatment professionals, etc.) and determined to provide the best service possible.  As tiring as “road work” can sometimes be, my spirits are always buoyed by the energy of the individuals, groups, and agencies I meet and work with around the world.

At the same time, I’d be remiss if I didn’t acknowledge the fear and hardship I’m witnessing among providers and treatment agencies each week as I’m out and about.  Frankly, I’ve never seen anything like it in my seventeen years “on the road.”  Being able to say that we predicted the current situation nearly 6 years ago provides little comfort (see The Heroic Client, 2004).

While nearly all are suffering, the economic crisis in the United States is hitting public behavioral health particularly hard.  In late January I blogged about the impact of budget cuts in Ohio.   Sadly, the situations in Virginia and Tennessee are no different.  Simply put, public behavioral health agencies are expected to do more with less, and most often with fewer providers.  What can be done?

Enter Chesterfield Community Service Board.  Several years ago, I met and began working with Larry Barnett,  Lyn Hill, and the rest of the talented clinical staff at this forward thinking public behavioral health agency.  Their goal?  According to the agency mission statement, “to promote improved quality of life…through exceptional and comprehensive mental health, mental retardation, substance abuse, and early intervention services.”  Their approach?  Measure and monitor the process and outcome of service delivery and use the resulting information to improve productivity and performance.

As Larry and Lynn report in the video below, the process was not easy.  Indeed, it was damn difficult–full of long hours, seemingly endless discussions, and tough, tough choices.  But that was then.  Some three years later, the providers at Chesterfield CSB are serving 70% more people than they did in 2007 despite there being no increase in available staff resources in the intervening period.  That’s right, 70%!  And that’s not all.  While productivity rates soared, clinician caseloads were reduced by nearly 30%.  As might be expected, the time consumers in need of services had to wait was also significantly reduced.

In short, everybody won: providers, agency managers, funders, and consumers.  And thanks to the two days of intensive training in Richmond, Virginia organized by Arnold Woodruff, many additional public behavioral health agencies have the information needed to get started.  It won’t be easy.  However, as the experience in Chesterfield demonstrates, it is possible to survive and thrive during these tumultuous times.  But don’t take my word for it, listen to how Larry and Lynn describe the process–warts and all–and the results:

Deliberate Practice, Expertise, & Excellence

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Later today, I board United flight 908 on my way to workshops scheduled in Holland and Belgium.  My routine in the days leading up to an international trip is always the same.  I slowly gather together the items I’ll need while away: computer (check); european electric adapter (check); presentation materials (check); clothes (check).   And, oh yeah, two decks of playing cards and close up performance mat.

That’s me (pictured above) practicing a “ribbon spread” in my hotel room following a day of training in Marion, Ohio.  It’s a basic skill in magic and I’ve been working hard on this (and other moves using cards) since last summer.  Along the way, I’ve felt both hopeful and discouraged.  But I’ve kept on nonetheless taking heart from what I’m reading about skill acquisition.

Research on expertise indicates that the best performers (in chess, medicine, music, sports, etc.) practice every day of the week (including weekends) for up to four hours a day.  Sounds tiring for sure.  And yet, the same body of evidence shows that world class performers are able to sustain such high levels of practice because they view the acquisition of expertise as a long-term process.  Indeed, in a study of children, researcher Gary McPherson found that the answer to a simple question determined the musical ability of kids a year later: “how long do you think you’ll play your instrument?”  The factors that were shown to be irrelevant to performance level were: initial musical ability, IQ, aural sensitivity, math skills, sense of rhythm, income level, and sensorimotor skills.

The type of practice also matters.  When researchers Kitsantas and Zimmerman studied the skill acquisition of experts, they found that 90% of the variation in ability could be accounted for by how the performers described their practice; the types of goals they set, how they planned and executed strategies, self-monitored, and adapted their performance in response to feedback.

So, I take my playing cards and close-up mat with me on all of my trips (both domestic and international).  I don’t practice on planes.  Gave that up after getting some strange stares from fellow passengers as they watched me repeat, in obsessive fashion, the same small segment of my performance over, and over, and over again.  It only made matters worse if they found out I was a psychologist.  I’d get that “knowing look,” that seemed to say, “Oh yeah.”  Anyway, I also managed to lose a fair number of cards when the deck–because of my inept handling while trying to master some particular move–went flying all over the cabin (You can imagine why I’ve been less successful in keeping last year’s New Year resolution to learn to play the ukelele).

Once I’m comfortably situated in my room, the mat and cards come out and I work, practice a specific handling for up to 30 minutes followed by a 15-20 minute break.  Believe it or not, learning–or perhaps better said, attempting to learn–magic has really been helpful in understanding the acquisition of expertise in my chosen field: psychology and psychotherapy.  Together with my colleagues, we are translating our experience and the latest research on expertise into steps for improving the performance and outcome of behavioral health services.  This is, in fact, the focus of the newest workshop I’m teaching, “Achieving Clinical Excellence.”   It’s also the organizing theme of the ICCE Achieving Clinical Excellence conference that will be held in Kansas City, Kansas in October 2010.  Click on the photo below for more information.

In the meantime, check out the two videos I’ve uploaded to ICCETV featuring two fun magic effects.  And yes, of course, feedback is always appreciated!

The Future of Behavioral Health: Integrated Care & Entrepreneurship

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Nicholas Cummings, Ph.D.

Sometime in late 1986 I wrote a letter to Dr. Nicholas Cummings.  As a then student-member of the American Psychological Association (APA), I was automatically subscribed to and receiving the American Psychologist.  In the April issue, Dr. Cummings published an article, provocatively titled, “The Dismantling of Our Health System: Strategies for the Survival of Psychological Practice.”  Change was in the air. “Traditional psychology practice is both inefficient and ineffective,” he argued, and a “growing revolution in heath care” was a clear and present danger to the very survival of the field.

What can I say?  As someone at the beginning of his career (with large student loans to repay and a long time to go before retirement), the five page article spooked me.  So I did what I’d done before: I wrote a letter.  I’d been writing and calling prominent researchers and clinicians ever since I was an undergraduate.  During the 70’s, I’d exchanged letters and even phone calls with B.F. Skinner!

In all honesty, I didn’t know anything about Dr. Cummings–for example, that he was a former president of the APA, launched the Professional Schools of Psychology movement and founded four campuses of the California School of Professional Psychology, wrote the freedom-of-choice legislation requiring insurers to reimburse non-medical, behavioral health providers, and started American Biodyne in the hopes that psychologists could own rather than be owned–as eventually happened–by managed care (read a history here).  Neither did I know that he was a member of Psychology’s famed “Dirty Dozen.” Without a doubt, however, the decision to write him, changed the arc of my career.

Fast forward 25 years, and 86-year-old Nicholas Cummings is at it again–not only sounding a warning klaxon but identifying the opportunities available in the dramatically changing healthcare environment.  Sadly, the field (and professional psychology in particular) ignored the counsel he’d given back in 1986.  As a result, business interests took over managed care, resulting–just as he predicted–in low wages and the near complete lack of professional autonomy.

So, what can clinicians do now to survive and thrive?  According to Dr. Cummings, two words best capture the future of behavioral health: (1) integrated care; and (2) entrepreneurship.  Let’s face the unpleasant reality and say it out loud: independent practice is on life support.  Agency work is no picnic either given the constant threats to funding and never ending amount of regulation and paperwork.  Finally, when it comes to practitioner income, its a buyer’s market.

That said, it’s not all doom and gloom.  Far from it.  There is a tremendous need (and opportunity) in the present reform-driven healthcare marketplace for clinicians who are able to blend behavioral interventions, medical literacy, knowledge about healthcare delivery systems, and entrepreneurship skills.  Possibilities do exist.  The real question is, “Do we have the will to change?”  Here’s where the power of one simple action–in this instance, a phone call–can have such a profound effect on one’s life and success.

Though we never formally worked together, I’ve been calling and writing Nick off and on for the two and a half decades.  Late last fall, my partners and co-creators of the International Center for Clinical Excellence, Brendan Madden and Enda Madden, flew to Reno to seek his advice on our business plan.  We simply called him.  He said, “When can you get here?”  The result?  His sage counsel helped us win the InterTrade Seedcorn Regional Prize for “Best Emerging Company” as well as secure investors in the most restrictive venture capital environment since the Great Depression.  And that’s not all…

Chief Technology Officer Enda Madden    Chief Executive Officer Brendan Madden

Just last week, I flew to Phoenix, Arizona to give a presentation on using outcomes to improve behavioral healthcare service delivery at Arizona State University.  Nick was there to meet me, along with the director of an entirely new program for behavioral health entrepreneurs, Dr. Ron O’Donnell.  Briefly, the “Doctor of Behavioral Health” is the culmination of Nick’s vision of creating a doctoral training program tailored to the emerging need for innovative behavioral clinicians to practice in primary care and medical settings.  Response has been overwhelming to say the least.  Fifty plus post-graduate clinicians are enrolled.   That’s right, post-graduate.  In other words, these are practicing clinicians returning to add “integrated care expert and behavioral health entrepreneur” to their resume.


School of Letters and Sciences

As it turns out, I’ll be traveling from Chicago to Phoenix a fair amount in the future.  When he stood to introduce me, Nick announced that I’d be filling the “Cummings Professor of Behavioral Health” faculty position at ASU.  The power of a single call.

The Turn to Outcomes: A Revolution in Behavioral Health Practice

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Get ready.  The revolution is coming (if not already here).  Whether you are a direct service provider (psychologist, counselor, marriage and family therapist), agency, broker, or funder, you will be required to measure and likely report the outcomes of your clinical work.


Jay Lebow, Ph.D.

Just this month, Dr. Jay Lebow, a professor of psychology at the Family Institute at Northwestern University, published an article in the Psychotherapy Networker–the most widely circulated publication for practitioners in the world–where he claimed the field had reached a “tipping point.”  “Once a matter of interest only among a small circle of academics,” Dr. Lebow writes in his piece entitled, The Big Squeeze, “treatment outcome has now become a part of the national debate about healthcare reform.”


David Barlow, Ph.D.

The same sentiments were expressed in a feature article entitled, “Negative Effects from Psychological Treatments,” written by Dr. David Barlow in the January issue of the American Psychologist.  “Therapists,” he argues both eloquently and persuasively, “do not have to wait for the next clinical trial….[rather] clinicians [can act] as local clinical scientists…[using] outcome measures to track progress…rapidly becom[ing] aware of lack of progress or even deterioration” (p. 19).  What can I say, except that any practitioner with more than a few years to work before retirement, should read these articles and then forward them to every practitioner they know.

During the Holidays, and just before the turn of the New Year, I blogged about the trend toward outcome measurement.  As readers will recall, I talked about my experience on a panel at the Evolution of Psychotherapy conference where Dr. Barlow–who, in response to my brief remarks about the benefits of feedback– suprised me by stating unequivocally that all therapists would soon be required to measure and monitor the outcome of their clinical work. And even though my work has focused almost exclusively on measuring and using outcomes to improve both retention in and the results of behavioral health for the last 15 years, I said his pronouncement frightened me–which, by the way, reminds me of a joke.

A sheep farmer is out in the pasture tending his flock–I promise this is clean, so read on–when from over a small hill comes a man in a custom-tailored, three-piece business suit.  In one hand, the businessman holds a calculator; in the other, an expensive, leather brief case.  “I have a proposition for you,” the well-clad man says as he approaches the farmer, and then continues, “if I can tell you how many sheep are in your flock, to the exact number, may I have one of your sheep?”  Though initially startled by the stranger’s abrupt appearance and offer, the farmer quickly gathers his wits.  Knowing there is no way the man could know the actual number of sheep (since many in his flock were out of site in other pastures and several were born just that morning and still in the barn), the farmer quickly responded, “I’ll take that bet!”

Without a moment’s hesitation, the man calls out the correct number, “one thousand, three hundred and forty six,” then quickly adds, “…with the last three born this morning and still resting in the barn!”  Dumbfounded, the farmer merely motions toward his flock.  In response, the visitor stows his calculator, slings one of the animals up and across his shoulders and then, after retrieving his briefcase, begins making his way back up the hill.  Just as he nears the top of the embankment, the farmer finds his voice and calls out, “Sir, I have a counter proposal for you.”

“And what might that be?” the man replies, turning to face the farmer, who then asked, “If I can tell you, sir, what you do for a living, can I have my animal back?”

Always in the mood for a wager, the stranger replies, “I’ll take that bet!”  And then without a moment’s hesitation, the sheep farmer says, “You’re an accountant, a bureaucrat, a ‘bean-counter.'”  Now, it’s the businessman’s turn to be surprised.  “That’s right!” he says, and then asks, “How did you know?”

“Well,” the farmer answers, “because that’s my dog you have around your neck.”

The moral of the story?  Bureaucrats can count but they can’t tell the difference between what is and is not important.  In my blogpost on December 24th, I expressed concern about the explosion of “official interest” in measuring outcomes.  As the two articles mentioned above make clear, the revolution has started.  There’s no turning back now.  The only question that remains is whether behavioral health providers will be present to steer measurement toward what matters?  Here, our track record is less than impressive (remember the 80-90’s and the whole managed care revolution).  We had ample warning (and did, well, nothing.  If you don’t believe me, click here and read this article from 1986 by Dr. Nick Cummings).

As my colleague and friend Peter Albert is fond of saying, “If you’re not at the table, you’re likely to be on the menu.”  So, what can the average clinician do?  First of all, if you haven’t already done so, began tracking your outcomes.  Right here, on my website, you can download, free, simple-to use, valid and reliable measures.  Second, advocate for measures that are feasible, client-friendly, and have a empirical track record of improving retention and outcome.  Third, and lastly, join the International Center for Clinical Excellence.  Here, clinicians from all over the globe are connecting, learning, and sharing their experiences about how to use ongoing measures of progress and alliance.  Most importantly, all are determined to lead the revolution.

Behavioral Healthcare in Holland: The Turn Away from the Single-payer, Government-Based Reimbursement System

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Several years ago I was contacted by a group of practitioners located in the largest city in the north of the Netherlands–actually the capital of the province known as Groningen.  The “Platform,” as they are known, were wondering if I’d be willing to come and speak at one of their upcoming conferences.  The practice environment was undergoing dramatic change, the group’s leadership (Dorti Been & Pico Tuene) informed me.  Holland would soon be switching from government to a private insurance reimbursement system.  Dutch practitioners were “thinking ahead,” preparing for the change–in particular, understanding what the research literature indicates works in clinical practice as well as learning methods for documenting and improving the outcome of treatment.

I was then, and remain now, deeply impressed with the abilities and dedication of Dutch practitioners.  During that visit to Groningen, and the many that have followed (to Amsterdam, Rotterdam, Beilen, etc.), its clear that clinicians in the Netherlands are determined to lead rather than be led.  I’ve been asked to meet with university professors, practitioner organizations, training coordinators, and insurance company executives.  In a very short period of time, two Dutch therapists–physician Flip Van Oenen and psychologist Mark Crouzen–have completed the “Training of Trainers” course and become recognized trainers and associates for the International Center for Clinical Excellence.  And finally, a study will soon be published showing sound psychometric properties of the Dutch translations of the ORS and SRS.

I’ve also been working closely with the Dutch company Reflectum–a group dedicated to supporting outcome-informed healthcare and clinical excellence.  Briefly, Reflectum has organized several conferences and expert meetings between me and clinicians, agency managers, and insurance companies.  One thing for sure: we will be working closely together to train a network of trainers and consultants to promote, support, and train agencies and practitioners in outcome-informed methods in order to meet the demands of the changing practice climate.

Check out the videobelow filmed at Schipol airport during one of my recent trips to Holland:

Accountability in Behavioral Health: Steps for Dealing with Cutbacks, Shortfalls, and Tough Economic Conditions

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As anyone who follows me on Facebook knows, I get around.  In the past few months, I visited Australia, Norway, Sweden, Denmark (to name but a few countries) as well as criss-crossed the United States.  If I were asked to sum up the state of public behavioral health agencies in a single word, the word–with very few exceptions–would be: desperate.  Between the unfunded mandates and funding cutbacks, agencies are struggling.

Not long ago, I blogged about the challenges facing agencies and providers in Ohio.  In addition to reductions in staffing, those in public behavioral health are dealing with increasing oversight and regulation, rising caseloads, unrelenting paperwork, and demands for accountability.  The one bright spot in this otherwise frightening climate is: outcomes.  Several counties in Ohio have adopted the ORS and SRS and been using them to improve the effectiveness and efficiency of behavioral health services.

I’ve been working with the managers and providers in both Marion and Crawford counties for a little over two years.  Last year, the agencies endured significant cuts in funding.  As a result, they were forced to eliminate a substantial number of positions.  Needless to say, it was a painful process with no upsides–except that, as a result of using the measures, the dedicated providers had so improved the effectiveness and efficiency of treatment they were able to absorb the loss of staff without having to cut on services to clients.

The agencies cite four main findings resulting from the work we’ve done together over the last two years.  In their own words:

  1.  Use of FIT has enabled us to be more efficient, which is particularly important given Ohio’s economic picture and the impact of State budget cuts. Specifically, FIT is enabling service providers and supervisors to identify consumers much earlier who are not progressing in the treatment process. This allows us to change course sooner when treatment is not working, to know if changes work, to identify consumers in need of a different level of care, etc.  FIT also provides data on which the provider and consumer can base decisions about the intensity of treatment and treatment continuation (i.e. when to extend time between services or when the episode of service should end). In short, our staff and consumers are spending much less time “spinning their wheels” in unproductive activities.  As a result, we have noticed more “planned discharges versus clients just dropping out of treatment.
  2. FIT provides aggregate effect size data for individual service providers, for programs, and for services, based on data from a valid and reliable outcome scale. Effect sizes are calculated by comparing our outcome data to a large national data base. Progress achieved by individual consumers is also compared to this national data base. For the first time, we can “prove” to referral sources and funding sources that our treatment works, using data from a valid and reliable scale. Effect size data also has numerous implications for supervision, and supervision sessions are more focused and productive.
  3.  Use of the SRS (session rating scale) is helping providers attend to the therapeutic alliance in a much more deliberate manner. As a result, we have noticed increased collaboration between consumer and provider, less resistance and more partnership, and greater openness from consumers about their treatment experience. Consumer satisfaction surveying has revealed increased satisfaction by consumers. The implications for consumers keeping appointments and actually implementing what is learned in treatment are clear. The Session Rating Scale is also yielding some unexpected feedback from clients and has caused us to rethink what we assume about clients and their treatment experience.
  4. Service providers, especially those who are less experienced, appear to be more confident and purposeful when providing services. The data provides a basis for clinical work and there is much less ‘flying by the seat of their pants.’”Inspiring, eh?  And now, listen to Community Counseling Services Director Bob Moneysmith and Crawford-Marion ADAMH Board Associate Director Shirley Galdys describe the implementation:

Outcomes in the Artic: An Interview with Norwegian Practitioner Konrad Kummernes

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Dateline: Mosjoen, Norway

The last stop on my training tour around northern Norway was Mosjoen.  The large group of psychologists, social workers, psychiatrists, case managers, and physicians laughed uproariously when I talked about the bumpy, “white-knuckler” ride aboard the small twin-engine airplane that delivered me to the snowy, mountain-rimmed town. They were all to familiar with the peculiar path pilots must follow to navigate safely between the sharp, angular peaks populating the region.

Anyway, I’d been invited nearly two years earlier to conduct the day-long training on “what works in treatment.” The event was sponsored by Helgelandssykehuset-Mosjoen and organized by Norwegian practitioner Konrad Kummernes.  I first met Konrad at a conference held in another beautiful location in Norway (is there any other type in this country?!), Stavanger–best known for its breathtaking Fjordes.  The goal for the day in Mosjoen?  Facilitate the collaboration between the many different services providers and settings thereby enabling the delivery of the most effective and comprehensive clinical services.  Meeting Konrad again and working with the many dedicated professionals in Mosjoen was an inspiration. Here’s Konrad:

Practice-Based Evidence in Norway: An Interview with Psychologist Mikael Aagard

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For those of you following me on Facebook–and if you’re not, click here to start–you know that I was traveling above the arctic circle in Norway last week.  I always enjoy visiting the Scandinavian countries.  My grandparents immigrated from nearby Sweden.  I lived there myself for a number of years (and speak the language).  And I am married to a Norwegian!  So, I consider Scandinavia to be my second home.

In a prior post, I talked a bit about the group I worked with during my three day stay in Tromso.  Here, I briefly interview psychologist Mikael Aagard, the organizer of the conference.  Mikael works at KORUS Nord, an addiction technology transfer center, which sponsored the training.  His mission?  To help clinicians working in the trenches stay up-to-date with the research on “what works” in behavioral health.  Judging by the tremendous response–people came from all over the disparate regions of far northern Norway to attend the conference–he is succeeding.

Listen as he describes the challenges facing practitioners in Norway and the need to balance the “evidence-based practice” movement with “practice-based evidence.”  If you’d like any additional information regarding KORUS, feel free to connect with Mikael and his colleagues by visiting their website.  Information about the activities of the International Center for Clinical Excellence in Scandinavia can be found at: www.centerforclinicalexcellence.org.

Evidence-based practice or practice-based evidence? Article in the Los Angeles Times addresses the debate in behavioral health

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January 11th, 2010

“Debate over Cognitive & Traditional Mental Health Therapy” by Eric Jaffe

The fight debate between different factons, interest groups, scholars within the field of mental health hit the pages of the Los Angeles Times this last week. At issue?  Supposedly, whether the field will become “scientific” in practice or remain mired in traditions of the past.  On the one side are the enthusiastic supporters of cognitive-behavioral therapy (CBT) who claim that existing research provides overwhelming support for the use of CBT for the treatment of specific mental disorders.  On the other side are traditional, humanistic, “feel-your-way-as-you-go” practitioners who emphasize quality over the quantitative.

My response?  Spuds or potatoes.  Said another way, I can’t see any difference between the two warring factions.  Yes, research indicates the CBT works.  That exact same body of literature shows overwhelmingly, however, that any and all therapeutic approaches intended to be therapeutic are effective.  And yes, certainly, quality is important.  The question is, however, “what counts as quality?” and more importantly, “who gets to decide?”

In the Los Angeles Times article, I offer a third way; what has loosely been termed, “practice-based evidence.”  The bottom line?  Practitioners must seek and obtain valid, reliable, and ongoing feedback from consumers regarding the quality and effectiveness of the services they offer.  After all, what person following unsuccessful treatment would say, “well, at least I got CBT!” or, “I’m sure glad I got the quality treatment.”

"What Works" in Norway

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Dateline: Tromso, Norway
Place: Rica Ishavshotel

For the last two days, I’ve had the privilege of working with 125+ clinicians (psychotherapists, psychologists, social workers, psychiatrists, and addiction treatment professionals) in far northern Norway.  The focus of the two-day training was on “What Works” in treatment, in particular examining what constitutes “evidence-based practice” and how to seek and utilize feedback from consumers on an ongoing basis.  The crowd was enthusiastic, the food fantastic, and the location, well, simply inspiring.  Tomorrow, I’ll be working with a smaller group of practitioners, doing an advanced training.  More to come.

Are all treatments approaches equally effective?

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Bruce Wampold, Ph.D.

Late yesterday, I blogged about a soon-to-be published article in Clinical Psychology Review in which the authors argue that the finding by Benish, Imel, & Wamppold (2008) of equivalence in outcomes among treatments for PTSD was due to, “bias, over-generalization, lack of transparency, and poor judgement.”  Which interpretation of the evidence is correct?  Are there “specific approaches for specific disorders” that are demonstrably more effective than others?  Or does the available evidence show all approaches intended to be therapeutic to be equally effective?

History makes clear that science produces results in advance of understanding.  Until the response to Ehlers, Bisson, Clark, Creamer, Pilling, Richards, Schnurr, Turner, and Yule becomes available, I wanted to remind people of three prior blog posts that review the evidence regarding differential efficacy of competing therapeutic approaches.  The first (and I think most illuminating)–“The Debate of the Century“–appeared back in August.  The post featured a link to a debate between Bruce Wampold and enthusiastic proponent of “empirically supported treatments,” Steve Hollon.  Listen and then see if you agree with the large group of scientists and practitioners in attendance who thought–by a margin of 15:1–that Bruce carried the day.

The second post–Whoa Nellie!– commented on a 25 Million US$ research grant awarded by the US Department of Defense to study treatments for PTSD.  Why does this make me think of “deep throat’s” admonition to, “follow the money!”  Here you can read the study that is causing the uproar within the “specific treatments for specific disorders” gang.

Third, and finally, if you haven’t already read the post “Common versus Specific Factors and the Future of Psychotherapy,” I believe you’ll find the thorough review of the research done in response to an article by Siev and Chambless critical of the “dodo verdict” helpful.

DODO BIRD HYPOTHESIS PROVEN FALSE! Study of PTSD finally proves Wampold, Miller, and other "common factor" proponents wrong

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The Dodo Bird Researchers Anke Ehlers, Jonathon Bisson, David Clark, Mark Creamer, Steven Pilling, David Richards, Paula Schnurr, Stuart Turner, and William Yule have finally done it!  They slayed the “dodo.” Not the real bird of course–that beast has been extinct since the mid to late 17th century but rather the “dodo bird” conjecture first articulated by Saul Rozenzweig, Ph.D. in 1936.  The idea that all treatment approaches work about equally well has dogged the field–and driven proponents of  “specific treatments for specific disorders” positively mad.  In a soon to be published article in Clinical Psychology Review, the authors claim that bias, overgeneralization, lack of transparency, and poor judgement account for the finding that “all therapeutic approaches work equally well for people with a diagnosis of PTSD” reported in a meta-analysis by Benish, Imel, & Wampold (2008).

I guess this means that a public admission by me, Wampold, and other common factors researchers is in order…or maybe not!  Right now, we are writing a response to the article.  All I can say at this point is, “unbelievable!”  As soon as it becomes available, you’ll find it right here on this blog.  I’ll be drawing inspiration from Saul Rosenzweig who passed away in 2004.  It was such an honor to meet him.  Still working at 96 years of age.

Why ongoing, formal feedback is critical for improving outcomes in healthcare

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researchNot long ago, I had a rather lengthy email exchange with a well-known, high profile psychotherapist in the United States.  Feedback was the topic.  We both agreed that feedback was central to successful psychotherapy.   We differed, however, in terms of method.  I argued for the use of simple, standardized measures of progress and alliance (e.g., ORS and SRS).  In support of my opinion, I pointed to several randomized clinical trials documenting the impact of routine outcome monitoring on retention and progress.  I also cited studies showing traditionally low correlations between consumers and clinician’s rating of outcome and alliance and clinicians frighteningly frequent inability to predict deterioration and drop out in treatment.  He responded that such measures were an “unnecessary intrusion,” indicating that he’d always sought feedback from his clients albeit on an “informal basis.”  television-reception

When I mentioned our own research which had found that clinicians believed they asked consumers for feedback more often than they actually did, he finally seemed to agree with me.  “Of course,” he said immediately–but then he added, “I don’t need to ask in order to get feedback.”  In response to my query about how he managed to get feedback without asking, he responded (without a hint of irony), “I have unconditional empathic reception.”  Needless to say, the conversation ended there.

It’s a simple idea, feedback.  Yet, as I jet around the globe teaching about feedback-informed clinical practice, I’m struck by how hard it seems for many in healthcare to adopt.  Whatever the reason for the resistance–fear, hubris, or inertia–the failure to seek out valid and reliable feedback is a conceit that the field can no longer afford.  Simply stated, no one has “unconditional empathic reception.”  As the video below makes clear, we all need help seeing what is right before our eyes.

Research on the Outcome Rating Scale, Session Rating Scale & Feedback

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PCOMS - Partners for change outcome management system Scott D Miller - SAMHSA - NREPP“How valid and reliable are the ORS and SRS?”  “What do the data say about the impact of routine measurement and feedback on outcome and retention in behavioral health?”  “Are the ORS and SRS ‘evidence-based?'”

These and other questions regarding the evidence supporting the ORS, SRS, and feedback are becoming increasingly common in the workshops I’m teaching in the U.S. and abroad.

As indicated in my December 24th blogpost, routine outcome monitoring (PROMS) has even been endorsed by “specific treatments for specific disorders” proponent David Barlow, Ph.D., who stated unequivocally that “all therapists would soon be required to measure and monitor the outcome of their clinical work.”  Clearly, the time has come for all behavioral health practitioners to be aware of the research regarding measurement and feedback.

Over the holidays, I updated a summary of the data to date that has long been available to trainers and associates of the International Center for Clinical Excellence.  The PDF reviews all of the research on the psychometric properties of the outcome and session ratings scales as well as the studies using these and other formal measures of progress and the therapeutic relationship to improve outcome and retention in behavioral health services.  The topics is so important, that I’ve decide to make the document available to everyone.  Feel free to distribute the file to any and all colleagues interested in staying up to date on this emerging mega-trend in clinical practice.

Magical Moments in Kansas

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Registrations are already coming in for the first International Conference on “Achieving Clinical Excellence.”

Not too long ago, I announced that internationally known researcher K. Anders Erickson, Ph.D.–the “expert on experts”–had agreed to present at the event.  At that time, I also indicated that a number of internationally accomplished performers from a variety of professions (including psychology, business, medicine, science, music, entertainment, and sports) would be with us in Kansas City to teach and inspire.  Attendees will learn the science and skills for achieving their personal best as a behavioral health practitioner by literally learning from the best.

Practice, as anyone who has been reading my recent blogosts and publications knows, is key for achieving excellence–and not just any old kind will do.  To be effective, it must be deliberate, reflective, and ongoing.   What’s more, it must be accompanied with high levels of support and detailed instruction from exceptional teachers.

michael ammart

No performer embodies these two principles–dedicated practice and exceptional teaching–better than FISM gold-medial winning magician, Michael Ammar.  Magic magazine named him one of the 100 most influential magicians of the century.

Michael will open the second day of the the conference.  First, he’ll perform. What can I say?  You’ll be astonished and amazed.  After that, Michael will talk about the role of practice in achieving excellence.  He’s a master teacher who has spent years studying the elements of successful practice.  He’ll not only inspire you, he will provide you with the means to excel.

Join us for three action packed days of fun, science and skill building.  In the meantime, if you have a spare moment, watch Michael Ammar perform one of the classics of magic: the cups and balls.

 

New Year’s Resolutions: Progress Report and Future Plans

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One year ago today, I blogged about my New Year’s resolution to “take up the study of expertise and expert performance.”  The promise marked a significant departure from my work up to that point in time and was not without controversy:

“Was I no longer interested in psychotherapy?”

“Had I given up on the common factors?

“What about the ORS and SRS?” and was I abandoning the field and pursue magic as a profession?”

Seriously.

The answer to all of the questions was, of course, an emphatic “NO!”  At the same time, I recognized that I’d reached an empirical precipice–or, stated more accurately, dead end.  The common factors, while explaining why therapy works did not and could never tell us how to work.  And while seeking and obtaining ongoing feedback (via the ORS and SRS) had proven successful in boosting treatment outcomes, there was no evidence that the practice had a lasting impact on the professionals providing the service.

Understanding how to improve my performance as a clinician has, as is true of many therapists, been a goal and passion from the earliest days of my career.  The vast literature on expertise and expert performance appeared to provide the answers I’d long sought.   In fields as diverse as music and medicine, researchers had identified specific principles and methods associated with superior performance.  On January 2nd, 2009, I vowed to apply what I was learning to, “a subject I know nothing about…put[ting] into practice the insights gleaned from the study of expertise and expert performance.”

The subject? Magic (and the ukulele).

How have I done?  Definitely better than average I can say.  In a column written by Barbara Brotman in today’s Chicago Tribune, psychologist Janine Gauthier notes that while 45% of people make New Year’s resolutions, only 8% actually keep them!  I’m a solid 50%.  I am still studying and learning magic–as attendees at the 2009 “Training of Trainers” and my other workshops can testify.  The uke is another story, however.  To paraphrase 1988 Democratic vice-presidential candidate, Lloyd Bentsen , “I know great ukulele players, and Scott, you are no Jake Shimabukuro.”

I first saw Jake Shimabukuro play the ukulele at a concert in Hawaii.  I was in the islands working with behavioral health professionals in the military (Watch the video below and tell me if it doesn’t sound like more than one instrument is playing even though Jake is the only one pictured).

Interestingly, the reasons for my success with one and failure with the other are as simple and straightforward as the principles and practices that researchers say account for superior (and inferior) performance.  I promise to lay out these findings, along with my experiences, over the next several weeks.  If you are about to make a New Year’s resolution, let me give you step numero uno: make sure your goal/resolution is realistic.  I know, I know…how mundane.  And yet, while I’ve lectured extensively about the relationship between goal-setting and successful psychotherapy for over 15 years, my reading about expert performance combined with my attempts to master two novel skills, has made me aware of aspects I never knew about or considered before.

Anyway, stay tuned for more.  In the meantime, just for fun, take a look at the video below from master magician Bill Malone.  The effect he is performing is called, “Sam the Bellhop.”  I’ve been practicing this routine since early summer, using what I’ve learned from my study of the literature on expertise to master the effect (Ask me to perform it for you on break if you happen to be in attendance at one of my upcoming workshops).

The Study of Excellence: A Radically New Approach to Understanding "What Works" in Behavioral Health

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“What works” in therapy?  Believe it or not, that question–as simple as it is–has and continues to spark considerable debate.  For decades, the field has been divided.  On one side are those who argue that the efficacy of psychological treatments is due to specific factors (e.g., changing negative thinking patterns) inherent in the model of treatment (e.g., cognitive behavioral therapy) remedial to the problem being treated (i.e., depression); on the other, is a smaller but no less committed group of researchers and writers who posit that the general efficacy of behavioral treatments is due to a group of factors common to all approaches (e.g., relationship, hope, expectancy, client factors).

While the overall effectiveness of psychological treatment is now well established–studies show that people who receive care are better off than 80% of those who do not regardless of the approach or the problem treated–one fact can not be avoided: outcomes have not improved appreciably over the last 30 years!  Said another way, the common versus specific factor battle, while generating a great deal of heat, has not shed much light on how to improve the outcome of behavioral health services.  Despite the incessant talk about and promotion of “evidence-based” practice, there is no evidence that adopting “specific methods for specific disorders” improves outcome.  At the same time, as I’ve pointed out in prior blogposts, the common factors, while accounting for why psychological therapies work, do not and can not tell us how to work.  After all, if the effectiveness of the various and competing treatment approaches is due to a shared set of common factors, and yet all models work equally well, why learn about the common factors?  More to the point, there simply is no evidence that adopting a “common factors” approach leads to better performance.

The problem with the specific and common factor positions is that both–and hang onto your seat here–have the same objective at heart; namely, contextlessness.  Each hopes to identify a set of principles and/or practices that are applicable across people, places, and situations.  Thus, specific factor proponents argue that particular “evidence-based” (EBP) approaches are applicable for a given problem regardless of the people or places involved (It’s amazing, really, when you consider that various approaches are being marketed to different countries and cultures as “evidence-based” when there is in no evidence that these methods work beyond their very limited and unrepresentative samples).  On the other hand, the common factors camp, in place of techniques, proffer an invariant set of, well, generic factors.  Little wonder that outcomes have stagnated.  Its a bit like trying to learn a language either by memorizing a phrase book–in the case of EBP–or studying the parts of speech–in the case of the common factors.

What to do?  For me, clues for resolving the impasse began to appear when, in 1994, I followed the advice of my friend and long time mentor, Lynn Johnson, and began formally and routinely monitoring the outcome and alliance of the clinical work I was doing.  Crucially, feedback provided a way to contextualize therapeutic services–to fit the work to the people and places involved–that neither a specific or common factors informed approach could.

Numerous studies (21 RCT’s; including 4 studies using the ORS and SRS) now document the impact of using outcome and alliance feedback to inform service delivery.  One study, for example, showed a 65% improvement over baseline performance rates with the addition of routine alliance and outcome feedback.  Another, more recent study of couples therapy, found that divorce/separation rates were half (50%) less for the feedback versus no feedback conditions!

Such results have, not surprisingly, led the practice of “routine outcome monitoring” (PROMS) to be deemed “evidence-based.” At the recent, Evolution of Psychotherapy conference I was on a panel with David Barlow, Ph.D.–a long time proponent of the “specific treatments for specific disorders” (EBP)–who, in response to my brief remarks about the benefits of feedback, stated unequivocally that all therapists would soon be required to measure and monitor the outcome of their clinical work.  Given that my work has focused almost exclusively on seeking and using feedback for the last 15 years, you would think I’d be happy.  And while gratifying on some level, I must admit to being both surprised and frightened by his pronouncement.

My fear?  Focusing on measurement and feedback misses the point.  Simply put: it’s not seeking feedback that is important.  Rather, it’s what feedback potentially engenders in the user that is critical.  Consider the following, while the results of trials to date clearly document the benefit of PROMS to those seeking therapy, there is currently no evidence of that the practice has a lasting impact on those providing the service.  “The question is,” as researcher Michael Lambert notes, “have therapists learned anything from having gotten feedback? Or, do the gains disappear when feedback disappears? About the same question. We found that there is little improvement from year to year…” (quoted in Miller et al. [2004]).

Research on expertise in a wide range of domains (including chess, medicine, physics, computer programming, and psychotherapy) indicates that in order to have a lasting effect feedback must increase a performer’s “domain specific knowledge.”   Feedback must result in the performer knowing more about his or her area and how and when to apply than knowledge to specific situations than others.  Master level chess players, for example, have been shown to possess 10 to 100 times more chess knowledge than “club-level” players.  Not surprisingly, master players’ vast information about the game is consilidated and organized differently than their less successful peers; namely, in a way that allows them to access, sort, and apply potential moves to the specific situation on the board.  In other words, their immense knowledge is context specific.

A mere handful studies document similar findings among superior performing therapists: not only do they know more, they know how, when, and with whom o apply that knowledge.  I noted these and highlighted a few others in the research pipeline during my workshop on “Achieving Clinical Excellence” at the Evolution of Psychotherapy conference.  I also reviewed what 30 years of research on expertise and expert performance has taught us about how feedback must be used in order to insure that learning actually takes place.  Many of those in attendance stopped by the ICCE booth following the presentation to talk with our CEO, Brendan Madden, or one of our Associates and Trainers (see the video below).

Such research, I believe, holds the key to moving beyond the common versus specific factor stalemate that has long held the field in check–providing therapists with the means for developing, organizing, and contextualizing clinical knowledge in a manner that leads to real and lasting improvements in performance.

Holidays and Suicide: Tis’ the Season NOT!

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The notion that suicides increase during the holiday season is as traditional as “Santa Claus”–and, according to statistics dating back at least a decade, just as illusory.  In fact, research actually shows suicide rates to be the lowest in December!  According to Dan Romer, a researcher at the Annenberg Public Policy Center at the University of Pennsylvania, the holidays are simply not a time for suicide.  If you are trying to peg the rate to a particular month during the year, try May.  Moreover, even suicide attempts decline during the holiday season!  At Cuyahoga County Mental health, a group I’ve worked closely with over the last three years implementing Feedback Informed Treatment (FIT), the director of crisis services, Rick Oliver, says that reviews done by the agency show that calls from suicidal people actually drop off during this time of year.

The culprit for the lingering misconception?  The media and–hold onto your candy cane–healthcare professionals!  That’s right.  In a study published this month in the British Medical Journal, researchers Vreeman and Carroll, found that healthcare professionals believe in the suicide-holiday connection along with a number of other dubious ideas (including sugar leads to hyperactivity, poinsettias are poisonous, and people lose heat through their head).stop-it-sign

So, the advice to the media and healthcare professionals, given the evidence, can only be: STOP IT!  Stop associating the holiday season with increased risk of suicide.

Clearly, suicide can happen at any time and none of the foregoing implies that people can’t and don’t feel blue.  At the same time, the decrease in suicides during this period suggests a possible course of action: connection and generosity.  If you are feeling down, do your best to reach out.  And if you’re not, then extend your hand.

The Effects of Feedback on Medication Compliance and Outcome: The University of Pittsburgh Study

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A number of years ago, I was conducting a workshop in Pittsburgh.  At some point during the training, I met Dr. Jan Pringle, the director of the Program Evaluation Research Unit in the School of Pharmacy at the University of Pittsburgh.

Jan had an idea: use outcome feedback to improve pharmacy practice and outcome.  Every year, large numbers of prescriptions are written by physicians (and other practitioners) that are never filled.  Whats more, surprisingly large number of the scripts that are filled, are either: (a) not taken; or (b) not taken properly.  The result?  In addition to the inefficient use of scarce resources, the disconnect between prescribers, pharmacists, and patients puts people at risk for poor healthcare outcomes.

Together with project coordinator and colleague, Dr. Michael Melczak, Jan set up a study using the ORS and SRS.  Over the last 3 years, I’ve worked as a consultant to the project–providing training and addressing issues regarding application in this first ever study of pharmacy.

Anyway, there were two different conditions in the study.  In the first, pharmacists–the practitioner most likely to interact with patients about prescriptions–engaged in “practice as usual.”  In the second condition, pharmacists used the ORS and the SRS to chart, discuss, and guide patient progress and the pharmacist-patient alliance.  Although the manuscript is still in preparation, I’m pleased to be able to report here that, according to Drs. Pringle and Melczak, the results indicate, “that the patients who were seen by the pharmacists who used [the] scales were significantly more likely to take their medications at the levels that would be likely to result in clinical impact than the patients who saw a pharmacists who did not use the scales…for hypertensive and hyperlipidemia drugs especially.”

Stay tuned for more…

The Evolution of Psychotherapy: Meeting Michael Hoyt

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I’m still reeling from the experience in Anaheim this last week.  I met so many leaders in the field, heard so many presentations on cutting edge clinical practice–as well as was reminded of some “classic” principles of effective psychotherapy.

One of the people I met was colleague and friend, Michael F. Hoyt, Ph.D.  Michael and I go back 15+ years, having met–I believe–the first time at a workshop I was giving in Northern California (somewhere in the Bay Area where Michael works and resides).  Since that time, we chatted regularly, and written editorials and book chapters together.  His books (The First Session in Brief Therapy, Brief Therapy & Managed Care, The Handbook of Constructive Therapies, Some Stories are Better than Others) always balance theory and practice and are among my favorites.

My two favorite books are also his most recent: The Present is a Gift and Brief Psychotherapies: Principles & Practice (Hint: his chapters on couples therapy are among the best I’ve ever read).  Anyway, the two of us caught up at the ICCE booth this last week at the Evolution conference.

Five Incredible Days in Anaheim

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From December 9-13th, eight thousand five hundred mental health practitioners, from countries around the globe, gathered in Anaheim, California to attend the “Evolution of Psychotherapy” conference.  Held every five years since 1985, the conference started big and has grown only larger.  “Only a few places in the US can accommodate such a large gathering,” says Jeffrey K. Zeig, Ph.D., who has organized the conference since the first.

The event, held every five years, brings together 40 of the field’s leading researchers, practitioners, trend setters, and educators to deliver keynote addresses and workshops, host discussion panels, and offer clinical demonstrations on every conceivable subject related to clinical practice.  Naturally, I spoke about my current work on “Achieving Clinical Excellence” as well as served on several topical panels, including “evidence based practice” (with Don Meichenbaum), “Research on Psychotherapy” (with Steven Hayes and David Barlow), and “Severe and Persistent Mental Illness (with Marsha Linnehan and Jeff Zeig).

Most exciting of all, the Evolution of Psychotherapy conference also served as the official launching point for the International Center for Clinical Excellence.  Here I am pictured with long-time colleague and friend, Jeff Zeig, and psychologist and ICCE CEO, Brendan Madden, in front of the ICCE display in the convention center hall.

Over the five days, literally hundreds of visitors stopped by booth #128 chat with me, Brendan, and Senior ICCE Associates and Trainers, Rob Axsen, Jim Walt, Cynthia Maeschalck, Jason Seidel, Bill Andrews, Gunnar Lindfeldt, and Wendy Amey.  Among other things, a cool M and M dispenser passed out goodies to folks (if they pressed the right combination of buttons), we also talked about and handed out leaflets advertising the upcoming “Achieving Clinical Excellence” conference, and finally people watched a brief video introducing the ICCE community.  Take a look yourself:.


More to come from the week in Anaheim….

Evolution of Psychotherapy and the International Center for Clinical Excellence

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evolution-2005

Dateline: Chicago, Illinois
December 7, 2009

I’ve just finished packing my bags and am heading for the airport.  Tomorrow the “Evolution of Psychotherapy” begins.  Nearly 25 years after volunteering at the first “Evolution” conference, I’m back a second time to present.  Tomorrow, I’ll be talking about “Achieving Clinical Excellence.”  On the days that follow, I’m on panels with my friend Don Meichenbaum, as well as David Barlow, Marsha Linnehan, and others.  I’m really looking forward to the four days in Anaheim.

Of everything going on in sunny southern California, I have to say that I’m most excited about the launch of the International Center for Clinical Excellence.  We have a booth (#128) in the exhibitor hall where folks can stop by, talk, and peruse our new website.  As promised, it is a true web 2.0 experience, enabling clinicians researchers. and educators around the world to connect, share, and learn from each other.

We’ll be streaming video to facebook and twitter. Stay tuned to my blog and twitter accounts as well for updates, videos, and pictures from the conference.

Climate Change in Denmark

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hans_christian_andersen_gbHans Christian Andersen, the author of such classic stories as The Ugly Duckling and the Emperor’s New Clothes, once wrote, “Life itself is the most wonderful fairy tale of all.”  That sentiment is certainly true of my own life.  For the last 16 years, I’ve been privileged to travel around the world conducting training and providing consultation.  Each year, I meet literally thousands of therapists and I’m consistently impressed and inspired by their dedication and persistence.  Truth be told, that “spirit”–for lack of a better word–is actually what keeps me in the field.

This last year, I’ve spent a considerable amount of time working with practitioners in Denmark.  Interest in Feedback-Informed Treatment has taken off–and I have the frequent flyer miles to prove it! While I’ve been traveling to the homeland of Hans Christian Andersen for many years (actually my maternal grandfather and his family immigrated to the United States from a small town just outside Copenhagen), momentum really began building following several years of workshops arranged by Henrik and Mette Petersen who run Solution–a top notch organization providing both workshops and year-long certification courses in short-term, solution-focused, and systemic therapies.

In October, I worked with 100+ staff who work at Psykoterapeutisk Center Stolpegård–a large outpatient center just outside of Copenhagen.  For two days, we talked about research and practice in psychotheapy, focusing specifically on using outcome to inform and improve clinical services.  Peter Koefoed, chief psychologist and head of Training organized the event.   I was back in Denmark not quite one month later for two days with Henrik and Mette Petersen and a then third day for a small, intensive training with Toftemosegaard–a center for growth and change–smack dab in the middle of Copenhagen.

At each event, I was honored to be accompanied by Danish psychologist Susanne Bargmann, who is an Associate and Certified Trainer for the Center for Clinical Excellence (ICCE).  I first met Susanne at a two-day workshop sponsored by Solutions a number of years ago.  Her attitude and drive is infectious.  She attended the Training of Trainer’s event in Chicago and now runs a listserve for Danish practitioners interested in feedback-informed treatment (FIT) (by the way, if you are interested in joining the group simply click on her name above to send an email).

Recently, she published an important article in Psycholog Nyt–the official magazine for the Danish Psychological Association. The article is really the first written in Danish by a Danish practitioner to suggest “practice-based evidence” as a scientifically credible alternative to the narrow “specific treatments for specific problems” paradigm that has come to dominate professional discourse and practice the world over.

Anyway, I’ll be back in Denmark several times in 2010.  In May, I’ll be teaching “Supershrinks: Learning from the Field’s Most Effective Practitioners.”  The course, as I understand it, is already sold out.  No worries though as the workshop is being offered again in November–so sign up early (click here to access my workshop calendar).  Also, in September, Susanne and I will jointly teach a course for psychologists on research entitled, “Forskning og Formidling”–a required training for those seeking specialist approval by the Danish Psychological Association. Finally, as I’ve done for the last several years, I’m scheduled to do two days for Solution as well.  If you live and work in Denmark, I truly hope to see you at one of these events.

 

Outcomes in OZ III

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Dateline: November 28, 2009 Brisbane, Australia

accor

Crown Plaza Hotel
Pelican Waters Golf Resort & Spa

As their name implies, LifeLine Australia is the group people call when they need a helping hand.  During the last leg of my tour of eastern Australia, I was lucky enough to spend two days working with Lifeline’s dedicated and talented clinicians on improving the retention and outcome of clinical services they offer.

The two-day conference was the kick off for a “transformation project,” as Trevor Carlyon, the executive director of Lifeline Community Care points out in the video segment below, the stated goal of which is “putting clients back at the center of care.”   Nearly 200 clinicians working with a diverse clientele located throughout northern Queensland gathered for the event.  I look forward to returning in the future as the ideas are implemented across services throughout the system.

 

Outcomes in Oz II

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Sitting in my hotel room in Brisbane, Australia.  It’s beautiful here: white, sandy beaches and temperatures hovering around 80 degrees.  Can’t say that I’ll be enjoying the sunny weather much.  Tomorrow I’ll be speaking to a group of 135+ practitioners about “Supershrinks.”  I leave for home on Saturday.  While it’s cold and overcast in Chicago, I’m really looking forward to seeing my family after nearly two weeks on the road.

I spent the morning talking to practitioners in New Zealand via satellite for a conference sponsored by Te Pou.  It was a completely new and exciting experience for me, seated in an empty television studio and talking to a camera.  Anyway, organizers of the conference are determined to avoid mistakes made in the U.S., Europe, and elsewhere with the adoption of “evidence-based practice.”  As a result, they organized the event around the therapeutic alliance–the most neglected, yet evidence-based concept in the treatment literature!  More later, including a link to the hour-long presentation.

On Friday and Saturday of this last week, I was in the classic Victorian city of Melbourne, Australia doing two days worth of training at the request of WorkSafe and the Traffic Accident Commission.  The mission of WorkSafe is, “Working with the community to deliver outstanding workplace safety, together with quality care and insurance protection to workers and employers.”  100+ clinicians dedicated to helping Australians recover from work and traffic-related injuries were present for the first day of training which focused on using formal client feedback to improve retention and outcome of psychological services.  On day 2, a smaller group met for an intensive day of training and consultation.  Thanks go to the sponsors and attendees for an exciting two days.  Learn more about how outcomes are being used to inform service delivery by watching the video below with Daniel Claire and Claire Amies from the Health Services Group.

 

Outcomes in Oz

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Greetings from beautiful Melbourne, Australia!   For the next couple of weeks, I’ll be traveling the up and down the east coast of this captivating country, conducting workshops and providing consultations on feedback-informed clinical work.

Actually, I’ve had the privilege of visiting and teaching in Australia about once a year beginning in the late 1990’s. Back then, Liz Sheehan, the editor of the “must read” journal Psychotherapy in Australiabrought me in to speak about the then recently published first edition of the Heart and Soul of Change.  By the way, if you are not from Australia, and are unfamiliar with the journal, please do visit the website.  Liz makes many of the articles that appear in the print version available online.  I’ve been a subscriber for years now and await the arrival of each issue with great anticipation.  I’m never disappointed.

In any event, on Wednesday this week, I spent the entire day with Mark Buckingham, Fiona Craig, and the clinical staff of Kedesh Rehabilitation Services in Wollongong, Australia–a scenic sea-side location about 45 minutes south of Sydney.  Briefly, Kedesh is a residential treatment facility providing cutting-edge, consumer driven, outcome-informed services to people with drug, alcohol, and mental health problems.  The crew at Kedesh is using the ORS and SRS to guide service delivery and is, in fact, one of the first to fully implement CDOI in the country.

I’ll be back with more soon, so please check back tomorrow.  In the meantime, check out the video with Mark and Fiona.

Where is Scott Miller going? The Continuing Evolution

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I’ve just returned from a week in Denmark providing training for two important groups.  On Wednesday and Thursday, I worked with close to 100 mental health professionals presenting the latest information on “What Works” in Therapy at the Kulturkuset in downtown Copenhagen.  On Friday, I worked with a small group of select clinicians working on implementing feedback-informed treatment (FIT) in agencies around Denmark.  The day was organized by Toftemosegaard and held at the beautiful and comfortable Imperial Hotel.

In any event, while I was away, I received a letter from my colleague and friend, M. Duncan Stanton.  For many years, “Duke,” as he’s known, has been sending me press clippings and articles both helping me stay “up to date” and, on occasion, giving me a good laugh.  Enclosed in the envelope was the picture posted above, along with a post-it note asking me, “Are you going into a new business?!”

As readers of my blog know, while I’m not going into the hair-styling and spa business, there’s a grain of truth in Duke’s question.  My work is indeed evolving.  For most of the last decade, my writing, research, and training focused on factors common to all therapeutic approaches. The logic guiding these efforts was simple and straightforward. The proven effectiveness of psychotherapy, combined with the failure to find differences between competing approaches, meant that elements shared by all approaches accounted for the success of therapy (e.g., the therapeutic alliance, placebo/hope/expectancy, structure and techniques, extratherapeutic factors).  As first spelled out in Escape from Babel: Toward a Unifying Language for Psychotherapy Practice, the idea was that effectiveness could be enhanced by practitioners purposefully working to enhance the contribution of these pantheoretical ingredients.  Ultimately though, I realized the ideas my colleagues and I were proposing came dangerously close to a new model of therapy.  More importantly, there was (and is) no evidence that teaching clinicians a “common factors” perspective led to improved outcomes–which, by the way, had been my goal from the outset.

The measurable improvements in outcome and retention–following my introduction of the Outcome and Session Rating Scales to the work being done by me and my colleagues at the Institute for the Study of Therapeutic Change–provided the first clues to the coming evolution.  Something happened when formal feedback from consumers was provided to clinicians on an ongoing basis–something beyond either the common or specific factors–a process I believed held the potential for clarifying how therapists could improve their clinical knowledge and skills.  As I began exploring, I discovered an entire literature of which I’d previously been unaware; that is, the extensive research on experts and expert performance.  I wrote about our preliminary thoughts and findings together with my colleagues Mark Hubble and Barry Duncan in an article entitled, “Supershrinks” that appeared in the Psychotherapy Networker.

Since then, I’ve been fortunate to be joined by an internationally renowned group of researchers, educators, and clinicians, in the formation of the International Center for Clinical Excellence (ICCE).  Briefly, the ICCE is a web-based community where participants can connect, learn from, and share with each other.  It has been specifically designed using the latest web 2.0 technology to help behavioral health practitioners reach their personal best.  If you haven’t already done so, please visit the website at www.iccexcellence.com to register to become a member (its free and you’ll be notified the minute the entire site is live)!

As I’ve said before, I am very excited by this opportunity to interact with behavioral health professionals all over the world in this way.  Stay tuned, after months of hard work and testing by the dedicated trainers, associates, and “top performers” of ICCE, the site is nearly ready to launch.

Leading Outcomes in Vermont: The Brattleboro Retreat and Primarilink Project

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For the last 7 years, I’ve been traveling to the small, picturesque village of Brattleboro, Vermont to work with clinicians, agency managers, and various state officials on integrating outcomes into behavioral health services.  Peter Albert, the director of Governmental Affairs and PrimariLink at the Brattleboro Retreat, has tirelessly crisscrossed the state, promoting outcome-informed clinical work and organizing the trainings and ongoing consultations.   Over time, I’ve done workshops on the common factors, “what works” in therapy, using outcome to inform treatment, working with challenging clinical problems and situations and, most recently, the qualities and practices of super effective therapists.  In truth, outcome-informed clinical work both grew up and “came of age” in Vermont.  Indeed, Peter Albert was the first to bulk-purchase the ASIST program and distribute it for free to any provider interested in tracking and improving the effectiveness of their clinical work.

If you’ve never been to the Brattleboro area, I can state without reservation that it is one of the most beautiful areas I’ve visited in the U.S.–particularly during the Fall, when the leaves are changing color.  If you are looking for a place to stay for a few days, the Crosy House is my first and only choice.  The campus of the Retreat is also worth visiting.  It’s no accident that the trainings are held there as it has been a place for cutting edge services since being founded in 1874.  The radical idea at that time?  Treat people with respect and dignity.  The short film below gives a brief history of the Retreat and a glimpse of the serene setting.

Anyway, this last week, I spent an entire day together with a select group of therapists dedicated to improving outcomes and delivering superior service to their clients.  Briefly, these clinicians have been volunteering their time to participate in a project to implement outcome-informed work in their clinical settings.  We met in the boardroom at the Retreat, discussing the principles and practices of outcome-informed work as well as reviewing graphs of their individual and aggregate ORS and SRS data.

It has been and continues to be an honor to work with each and every one in the PrimariLink project.  Together, they are making a real difference in the lives of those they work with and to the field of behavioral health in Vermont.  If you are a clinician located in Vermont or provide services to people covered by MVP or PrimariLink and would like to participate in the project, please email Peter Albert.  At the same time, if you are a person in need of behavioral health services and looking for a referral, you could do no better than contacting one of the providers in the project!

Common versus Specific Factors and the Future of Psychotherapy: A Response to Siev and Chambless

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Early last summer, I received an email from my long time friend and colleague Don Meichenbaum alerting me to an article published in the April 2009 edition of the Behavior Therapist–the official “newsletter” of the Association for Behavioral and Cognitive Therapies–critical of the work that I and others have done on the common factors.

Briefly, the article, written by two proponents of the “specific treatments for specific disorders” approach to “evidence-based practice” in psychology, argued that the common factors position–the idea that the efficacy of psychotherapy is largely due to shared rather than unique or model-specific factors–was growing in popularity despite being based on “fallacious reasoning” and a misinterpretation of the research.

Although the article claimed to provide an update on research bearing directly on the validity of the “dodo verdict”–the idea that all treatment approaches work equally well–it simply repeated old criticisms and ignored contradictory, and at times, vast evidence.  Said another way, rather than seizing the opportunity they were given to educate clinicians and address the complex issues involved in questions surrounding evidence-based practice, Siev and Chambless instead wrote to “shore up the faithful.”  “Do not doubt,” authors Siev and Chambless were counseling their adherents, “science is on our side.”

That differences and tensions exist in the interpretation of the evidence is clear and important.  At the same time, more should be expected from those who lead the field.  You read the articles and decide.  The issues at stake are critical to the future of psychotherapy.  As I will blog about next week, there are forces at work in the United States and abroad that are currently working to limit the types of approaches clinicians can employ when working with clients.  While well-intentioned, available evidence indicates they are horribly misguided.  Once again, the question clinicians and consumers face is not “which treatment is best for that problem,” but rather “which approach “fits with, engages, and helps” the particular consumer at this moment in time?”