S.A.M.S.H.A. designates Feedback-Informed Treatment an "Evidence-based Practice"

February 2, 2013 By scottdm Leave a Comment

(This post is included for historical purposes. Following the 2016 election, the NREPP registry was decommissioned)

February 2, 2013
Chicago, Illinois USA

I am honored to announce that Feedback-Informed Treatment (FIT) has been added to SAMSHA’s official database of evidence-based practices (EBP) known as NREPP (the National Registry of Evidence-based Programs and Practices). Briefly, NREPP is a searchable online registry of behavioral health interventions that have been reviewed and rated by independent reviewers. The purpose of the registry is to assist the public, payers, and practitioners in identifying approaches that have both empirical support and materials available to facilitate implementation.

The Institute of Medicine and American Psychological Association define EBP as, “the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences (see American Psychologist, May 2006). The principles and practices of feedback-informed treatment (FIT) are not only consistent with but provide practitioners with a simple and practical method for operationalizing EBP in their daily work. To wit, routinely and formally soliciting feedback from consumers regarding the therapeutic alliance and outcome of care and using the resulting information to inform and tailor service delivery. Multiple, carefully-controlled, randomized clinical trials document that FIT improves outcomes while simultaneously decreasing the risk of drop out and deterioration in care.

Scientific evidence is one matter; being able to support practitioners, agencies, and systems of care in implementing an EBP is another. On this subject, I am proud to say that FIT received perfect ratings. Unlike other similar approaches, “no weaknesses” were identified by reviewers. Instead, the summary noted, “ICCE…has an array of comprehensive, well-organized, and high-quality materials to support…implementation…The steps for successful implementation are clear and accompanied by tools and guidance to support the entire process, from the determination of organizations readiness through evaluation.”

Such high marks would not been possible without the contribution of ICCE Senior Associates who worked tirelessly to create the materials and complete the application. A big thanks to Jason Seidel, Psy.D., Bob Bertolino, Ph.D., Susanne Bargmann, Cynthia Maeschalck, Rox Axsen, Bill Robinson, Robbie Babbins-Wagner, Ph.D., and Julie Tilsen, Ph.D..

The formal recognition of FIT as an EBP is a watershed moment in the history of the International Center for Clinical Excellence, further enabling the organization to achieve it’s mission of improving the quality and outcome of behavioral health services.

Curing Clinician Overconfidence: Try Darting and Frowning

January 10, 2013 By scottdm Leave a Comment

Overconfidence. It’s a problem that leads to systematic errors in judgement. Long thought to arise out of hubris or the corrupting effects of the emotion, the evidence actually shows it to be built into humans’ evolved cognitive machinery. Existimo ergo certus sum (I think, therefore I am…certain).

Behavioral health professionals are not immune. The first article published on the subject (Walfish, McAlister, O’Donnell, and Lambert [2012]) asked clinicians how their effectiveness rates compared to other professionals. Turns out, clinicians, on average, believed their results were better than 80% of their peers. Not a single practitioner surveyed viewed themselves as below average and a full quarter (25%) thought they fell at the 90th percentile or higher in skill level and effectiveness!

It’s true that we are not alone in this tendency. As indicated above, it’s how our brains work. The typical driver, for example, believes themselves to be better than 80% of others on the road. University professors, it appears, suffer from the most inflated levels of self-esteem, ranking themselves at the 94th percentile on average.

When it comes to learning, the consequences are significant. Why change, after all, if you’re already pretty darn good and if the real problem is obvious: other drivers, poor students, etc., difficult life circumstances or the complex nature of some mental disorders?

Researchers have discovered a relatively simple solution to overconfidence: frowning. That’s right. Turning that smile upside down short circuits our reptilian wiring, making us more analytical and vigilant in our thinking, in the process enabling us to “question stories that we would otherwise unreflectively accept as true because they are facile and coherent” ( Holt, 2011).

What else can clinicians do? Do something to gain perspective. Take on another, divergent point of view, for example. Practically speaking, scan rather than fix your gaze. Literally, move your eyes.

Everyone has heard of “tunnel vision.” Turns out, despite pledges to remain open and flexible, it ain’t so easy. If you don’t agree, try a little experiment.

In the graphic below, fix your eyes on the flashing red and/or green dot at the center of the graphic and notice what happens to the surrounding yellow ones. Be patient if the image hasn’t loaded. It can take a minute or two.

They either blinked on and off or disappeared completely. Interesting enough but here’s what’s really strange: the yellow dots actually never disappear. They are always there despite what you see. And no, the computer did not scan your visual field and cause the yellow dots to blink. Neither is this an optical illusion. Once again, it’s the way we are wired. We think we are seeing everything…but we are not. The result: overconfidence. It’s why, following an automobile accident, people will say, “the other driver came out of nowhere.” It’s why surgeons leave sponges inside their patients or miss seeing bleeds or small nicks of the scalpel. It’s also why behavioral health practitioners routinely fail to detect deterioration and people at risk for dropping out of services (Hannan, et al. 2005).

Now, look again. This time, however, shift your eyes about while watching the flashing dot in the center. In other words, don’t fix your gaze. If that doesn’t change what you see, then step back from the image and view it from a distance. There, see! The yellow dots are present the entire time.

Helping busy practitioners step back, shift their gaze, and otherwise improve their critical faculties and skills is the mission of ICCE. Members can connect, learn from, and share with a large (and free) online community of mental health professionals in the world.

Believing is Seeing: How Wishing Makes Things So

January 3, 2013 By scottdm Leave a Comment

Yesterday evening, my family and I were watching a bit of T.V. My son, Michael commented about all the ads for nutrional supplements, juicing machines, weight loss programs and devices. “Oh yeah,” I thought, then explained to him, “It’s the start of a new year.” Following “spending more time with family,” available evidence shows exercise and weight loss top the bill of resolutions. Other research shows that a whopping 80% eventually break these well intentioned commitments. Fully a third won’t even make it to the end of the month! Most attribute the failure to being too busy, others to a lack of motivation. Whatever the cause, it’s clear that, when it comes to change, hope and belief will only take you so far.

What can help? More on that in a moment.

In the meantime, consider a recent study on the role of hope and belief in research on psychotherapy. Beginning in the 1970’s, study after study, and studies of studies, have found a substantial association between the effectiveness of particular treatment models and the beliefs of the researchers who conduct the specific investigations. In the literature, the findings are referred to under the generic label, “research allegiance” or R.A. Basically, psychotherapy outcome researchers tend to find in favor of the approach they champion, believe in, and have an affinity towards. Unlike New Year’s resolutions, it seems, the impact of hope and belief in psychotherapy outcome research is not limited; indeed, it carries investigators all the way to success–albeit a result that is completely “in the eye of the beholder.” That is, if one believes the research. Some don’t.

Hang with me now as I review the controversy about this finding. As robust as the results on researcher allegiance appear, an argument can be made that the phenomenon is a reflection rather than a cause of differences in treatment effectiveness. The argument goes: researcher allegiance is caused by the same factors that lead to differences in outcome between approaches: real differences in outcome betweepproaches. In short, researchers’ beliefs do not cause the effects, as much as the superior effects of the methods cause researchers to believe. Makes sense, right? And the matter has largely languished there, unresolved for decades.

That is, until recently. Turns out, believing is seeing. Using a sample of studies in which treatments with equivalent efficacy were directly compared within the same study, researchers Munder, Fluckiger, Gerger, Wampold, and Barth (2012) found that a researcher’s allegiance to a particular method systemically biases their results in favor of their chosen approach. The specific methods included in this study were all treatments designated as “trauma-focused” and deemed “equally effective” by panels of experts such as the U.K.’S National Institute for Clinical Excellence. Since the TFT approaches are equivalent in outcome, researcher allegiance should not have been predictive of outcome. Yet, it was–accounting for an incredible 12% of the variance. When it comes to psychotherapy outcome research, wishing makes it so.

What’s the “take-away” for practitioners? Belief is powerful stuff: it can either help you see possibilities or blind you to important realities. Moreover, you cannot check your beliefs at the door of the consulting room, nor would you want to. Everyday, therapists encourage people to take the first steps toward a happier, more meaningful life by rekindling hope. However, if researchers, bound by adherence to protocol and subject to peer review can be fooled, so can therapists. The potentially significant consequences of unchecked belief become apparent when one considers a recently published study by Walfish et al. (2012) which found that therapists on average overestimate their effectiveness by 65%.

When it comes to keeping New Year’s resolutions, experts recommend avoiding broad promises and grand commitments and instead advise setting small, concrete measureable objectives. Belief, it seems, is most helpful when its aims are clear and effects routinely verified. One simple way to implement this sage counsel in psychotherapy is to routinely solicit feedback from consumers about the process and outcome of the services offered. Doing so, research clearly shows, improves both retention and effectiveness. More, you can get two, simple, easy-to use scales for free by registering at: https://centerforclinicalexcellence.com/fit-software-tools/.