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The Importance of "Whoops" in Improving Treatment Outcome

December 2, 2012 By scottdm Leave a Comment

“Ring the bells that still can ring,
Forget your perfect offering
There is a crack in everything,
That’s how the light gets in.”

Leonard Cohen, Anthem

Making mistakes.  We all do it, in both our personal and professional lives.  “To err is human…,” the old saying goes.  And most of us say, if asked, that we agree whole heartedly with the adage–especially when it refers to someone else!  When the principle becomes personal, however, its is much more difficult to be so broad-minded.

Think about it for a minute: can you name five things you are wrong about?  Three?  How about the last mistake you made in your clinical work?  What was it?  Did you share it with the person you were working with?  With your colleagues?

Research shows there are surprising benefits to being wrong, especially when the maker views such errors differently.  As author Alina Tugend points out in her fabulous book, Better by Mistake, custom wrongly defines a mistake as ” the failure of a planned sequence of mental or physical activities to achieve its intended outcome.”  When you forget a client’s name during a session or push a door instead of pull, that counts as  slip or lapse.  A mistake, by contrast, is when “the plan itself is inadequate to achieve it’s objectives” (p. 11).  Knowing the difference, she continues, “can be very helpful in avoiding mistakes in the future” because it leads exploration away from assigning blame to the exploring systems, processes, and conditions that either cause mistakes or thwart their detection.

Last week, I was working with a talented and energetic group of helping professionals in New Bedford, Massachusetts.  The topic was, “Achieving Excellence: Pushing One’s Clinical Performance to the Next Level of Effectiveness.”  As part of my presentation, I talked about becoming more, “error-centric” in our work; specifically, using ongoing measurement of the alliance to identify opportunities for improving our connection with consumers of behavioral health services.  As an example of the benefits of making mistakes the focus of professional development efforts, I showed a brief video of Rachel Hsu and Roger Chen, two talented musicians who performed at the last Achieving Clinical Excellence (ACE) conference.  Rachel plays a piece by Liszt, Roger one by Mozart.  Both compositions are extremely challenging to play.  You tell me how they did (by the way, Rachel is 8 years old, Roger. 9):

Following her performance, I asked Rachel if she’d made any mistakes during her performance.  She laughed, and then said, “Yes, a lot!”  When I asked her what she did about that, she replied, “Well, its impossible to learn from my mistakes while I’m playing.  So I note them and then later practice those small bits, over and over, slow at first, then speeding up, until I get them right.”

After showing the video in New Bedford, a member of the audience raised his hand, “I get it but that whole idea makes me a bit nervous.”  I knew exactly what he was thinking.  Highlighting one’s mistakes in public is risky business.  Studies documenting that the most effective clinicians experience more self-doubt and are more willing to admit making mistakes is simply not convincing when one’s professional self-esteem or job may be on the line.  Neither is research showing that health care professionals who admit making mistakes and apologize to consumers are significantly less likely to be sued.  Becoming error centric, requires a change in culture, one that not only invites discloure but connects it with the kind of support and structure that leads to superior results.

Creating a “whoops-friendly” culture will be a focus of the next Achieving Clinical Excellence conference, scheduled for May 16-18th, 2013 in Amsterdam, Holland.  Researchers and clinicians from around the world will gather to share their data and experience at this unique event.  I promise you don’t want to miss it.  Here’s a short clip of highlights from the last one:

My colleague, Susanne Bargmann and I will also be teaching the latest research and evidence based methods for transforming mistakes into improved clinical performance at the upcoming FIT Advanced Intensive training in Chicago, Illinois.   I look forward to meeting you at one of these upcoming events.  In the meantime, here’s a fun, brief but informative video from the TED talks series on mistakes:

By the way, the house pictured above is real.  My family and I visited it while vacationing in Niagara Falls, Canada in October.  It’s a tourist attraction actually.  Mistakes, it seems, can be profitable.

Filed Under: Feedback Informed Treatment - FIT Tagged With: accountability, Alliance, behavioral health, cdoi, conferences, continuing education, deliberate practice, evidence based practice, feedback, mental health, Therapist Effects, top performance

What is the Real Source of Effectiveness in Smoking Cessation Treatment? New Research on Feedback Informed Treatment

November 24, 2012 By scottdm Leave a Comment

When it rains, it pours!  So much news to relay regarding recent research on Feedback Informed Treatment (FIT).  Just received news this week from ICCE Associate Stephen Michaels that research using the ORS and SRS in smoking cessation treatment is in print!   A few days prior to that, Kelley Quirk sent a copy of our long-awaited article on the validity and reliability of the Group Session Rating Scale.  On that very same day, the editors from the journal Psychotherapy sent proofs of an article written by me, Mark Hubble, Daryl Chow, and Jason Seidel for the 50th anniversary issue of the publication.

Let’s start with the validity and reliability study.  Many clinicians have already downloaded and been using Group Session Rating Scale.  The measure is part of the packet of FIT tools available in 20+ languages on both my personal and the International Center for Clinical Excellence websites.   The article presents the first research on the validity and reliability of the measure.  The data for the study was gathered at two sites I’ve worked with for many years.   Thanks to Kelley Quirk and Jesse Owen for crunching the numbers and writing up the results!   Since the alliance is one of the most robust predictors of outcome, the GSRS provides yet another method for helping therapists obtain feedback from consumers of behavior health services.

Moving on, if there were a Nobel Prize for patience and persistence, it would have to go to Stephen Michaels, the lead author of the study, Assessing Counsellor Effects on Quit Rates and Life Satisfactions Scores at a Tobacco Quitline” (Michael, Seltzer, Miller, and Wampold, 2012).  Over the last four years, Stephen has trained Quitline staff in FIT, implemented the ORS and SRS in Quitline tobacco cessation services, gathered outcome and alliance data on nearly 3,000 Quitline users, completed an in-depth review of the available smoking cessation literature, and finally, organized, analyzed, and written up the results.

What did he find?  Statistically significant differences in quit rates attributable to counselor effects.  In other words, as I’ve been saying for some time, some helpers are more helpful than others–even when the treatment provided is highly manualized and structured.  In short, it’s not the method that matters (including the use of the ORS and SRS), it’s the therapist.

What is responsible for the difference in effectiveness among therapists?  The answer to that question is the subject of the article, “The Outcome of Psychotherapy: Yesterday, Today, and Tomorrow” slated to appear in the 50th anniversary issue of Psychotherapy.  In it, we review controversies surround the question, “What makes therapy work?” and tip findings from another, soon-to-be-published empirical analysis of top performing clinicians.  Stay tuned.

Filed Under: Feedback Informed Treatment - FIT Tagged With: addiction, behavioral health, cdoi, Certified Trainers, evidence based practice, excellence, feedback, healthcare, icce, Smoking cessation, Therapist Effects

Clinical Support Tools for the ORS and SRS

November 20, 2012 By scottdm 1 Comment

I have so much to be grateful for at this time.  Most of all, I’m happy to be home with my family.  As we have in the past, this year we’ll be spending the holiday at the home of our long time friends John and Renee Dalton.  The two always put out a fantastic spread and our son, Michael, is fast friends with their two kids.

I’m also grateful for the International Center for Clinical Excellence (ICCE) community.  Currently, ICCE has over 4200 members located around the world, making the organization the largest, web-based community of professionals, educators, managers, and clinicians dedicated to using feedback to pursue excellence in the delivery of behavioral health services.  Recently, the site was highlighted as one of the best resources for practitioners available on the web.  Articles, how-to videos, and discussion forums are available everyday, all day–and for free!  No come-ons for books or webinars and no “cult of personality”–just sharing among peers.  If you are not a member, you can join at: www.centerforclinicalexcellence.com

A special thanks goes to several ICCE senior advisors and associates, including Susanne Bargmann, Jason Seidel, Cynthia Maeschalck, Bob Bertolino, Bill Plum, Julie Tilsen, and Robbie Babbins-Wagner.  These folks are the backbone of the organization.  Together, they make it work.  Most recently, we all joined together to create the ICCE Feedback Informed Treatment and Training Manuals, a cutting edge series covering every aspect of FIT–from the empirical foundations to implementation–in support of our application to SAMSHA for recognition as an “evidence-based practice.”

As a way of supporting everyone using the ORS and SRS, I wanted to make a couple of clinical support tools available.  If you are using the measures, the first item will need no introduction.  It’s a 10 cm ruler!  Save the file and print it off and you also have a ready reminder of the upcoming Achieving Clinical Excellence conference, coming up in May 2013.  Like last time, this will feature the latest inforamtion about feedback informed practice!  The second item is a reliable change graph.  If you are using the paper and pencil measures, rather than one of the existing web based systems (www.fit-outcomes.com, www.myoutcomes.com), you can use this tool to determine whether a change in scores from session to session is reliable (that is, greater than chance, the passage of time, and measurement error [and therefore, due to the care being provided]) or even clinically significant (that is, both reliable and indicating recovered).  The last item is an impressive summary of various systems for monitoring progress in treatment.

In addition ACE Health have developed openFIT, a plug-in which seamlessly integrates the ORS, SRS and associated algorithms into any existing Electronic Health Record, Case Management System of eMental Health application.

I wish everyone a peaceful and rewarding Thanksgiving holiday.

 

Filed Under: FIT Software Tools Tagged With: behavioral health, cdoi, excellence, feedback, healthcare, icce, mental health, ors, Outcome, practice-based evidence, srs

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