Feedback-Informed Treatment as Evidence-based Practice: APA, SAMSHA, and NREPP

November 1, 2011 By scottdm 1 Comment

What is evidence-based practice? Visit the UK-based NICE website, or talk to proponents of particular theoretical schools or therapeutic models, and they will tell you that being “evidence-based” means using the approach research has deemed effective for a particular diagnosis (e.g., CBT for depression, EMDR for trauma). Over the last two decades, numerous organizations and interest groups have promoted lists of “approved” treatment approaches–guidelines that clinicians and funding bodies should follow when making practice decisions. Throughout the 1990’s, for example, division 12 within the American Psychological Association (APA) promoted the idea of “empirically supported treatments.”

However, when one considers the official definition of evidence-based practice offered by the Institute of Medicine and the APA, it is hard to fathom how anyone could come to such a conclusion. According to the APA, evidence-based practice is, “the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences.” (see American Psychologist, May 2006). Nothing here about “empirically supported treatments” or the mindless application of specific treatment protocols. Rather, according to the APA and IOM, clinicians must FIT the treatment to the client, their preferences, culture, and circumstances. And how can one do that? Well, conspicuously absent from the definition is, “consult a set of treatment guidelines.” Rather, when evidence-based, clinicians must monitor “patient progress (and of changes in the patient’s circumstances—e.g.,job loss, major illness) that may suggest the need to adjust the treatment. If progress is not proceeding adequately, the psychologist alters or addresses problematic aspects of the treatment (e.g., problems in the therapeutic relationship or in the implementation of the goals of the treatment) as appropriate.”

The principles and practices of feedback-informed treatment (FIT) are not only consistent with but operationalize the American Psychological Association’s (APA) definition of evidence-based practice. 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. And indeed, over the last 9 months, together with Senior Associates, I completed and submitted an application for FIT to be reviewed by NREPP–SAMSHA’s National Registry of Evidence-based Practices and Approaches! As part of that application and ICCE’s commitment to improving the quality and outcome of behavioral health, we developed a list of “core competencies” for FIT practice, a series of six detailed treatment and implementation manuals, a gap assessment tool that organizations can use to quickly and expertly assess implementation and fidelity problems, and supportive documentation and paperwork. Finally, we developed and rigorously tested training curricula and administered the first standardized exam for certifying FIT practitioners and trainers. We are in the final stages of that review process soon and I’m sure I’ll be making a major announcement right here on this blog shortly. So, stay tuned.

In the meantime, this last Saturday, clinicians located the globe–Canada, New Zealand, Australia, the US,a nd Romania–sat for the first administration of ICCE “Core Competency” Exam. Taking the test is the last step in becoming an ICCE “Certified Trainer.” The other requirements include: (1) attending the “Advanced Intensive” and “Training of Trainers” workshops; and (2) submitting a training video on FIT for review. The exam was administered online using the latest technology.

The members, directors, and senior associates of ICCE want to congratulate (from top left):

Eeuwe Schuckard, Psychologist, Wellington, New Zealand;
Aaron Frost, Psychologist, Brisbane, Australia;
Cindy Hansen, BA-Psych, HHP, Manager Myoutcomes;
David Prescott, Director of Professional Development, Becket Family of Services, Portland, Maine;
Arnold Woodruff, LMFT, Clinical Director, Home for Good, Richmond, Virginia;
Bogdan, Ion, Ph.D., Bucharest University, Bucharest, Romania;
Daniel Buccino, Clinical Supervisor, Community Psychiatry Program. Johns Hopkins;
Dwayne Cameron, Outreach Counselor, Prince Albert, Saskatoon, Canada;
Mark Goheen, the Clinical Practice Lead at Fraser Health, British Columbia.

If you are not yet a member of the ICCE community, please join the largest, fastest growing, and friendly group of behavioral health professionals today at: www.centerforclinicalexcellence.com.

Making History in Delft, Holland: The Launch of the first Consumer-Driven Outcome Management App

October 18, 2011 By scottdm Leave a Comment

Dateline: October 18, 2011
Chicago, Illinois USA

Last week I was in Europe: three days in Norway, a week in Sweden, and a day in Holland. In a day or two, I’ll say more about developments in Norway and the launch of the largest study in history on FIT in Sweden. Meanwhile, I’m pleased to announce the lauch of the first, truly “consumer-driven” outcome management application: M2FIT. Briefly, this smart phone based technology empowers consumers of behavioral health services to provide feedback to clinicians regarding the quality and outcome of treatment services. Unlike existing applications, M2FIT is owned, operated, and managed by the consumer. It’s on their phone–not the therapists. The application further provides tips and encouragement between visits as well as appointment reminders.

As the pictures above indicate, the M2FIT application is simple, straightforward, and intuitive. Most important, it puts the power of feedback in consumers’ hands.

For more information, or to obtain a copy, visit the M2FIT website at: www.M2FIT.com. In the meantime, here’s a brief video shot during my visit!

Are Mental Health Practioners Afraid of Research and Statistics?

September 30, 2011 By scottdm Leave a Comment

A few weeks back I received an email from Dr. Kevin Carroll, a marriage and family therapist in Iowa. Attached were the findings from his doctoral dissertation. The subject was near and dear to my heart: the measurement of outcome in routine clinical practice. The findings were inspiring. Although few graduate level programs include training on using outcome measures to inform clinical practice, Dr. Carroll found that 64% of those surveyed reporting utilizing such scales with about 70% of their clients! It was particularly rewarding for me to learn that the most common measures employed were the…Outcome and Session Rating Scales (ORS & SRS)

As readers of this blog know, there are multiple randomized clinical trials documenting the impact that routine use of the ORS and SRS has on retention, quality, and outcome of behavioral health services. Such scales also provide direct evidence of effectiveness. Last week, I posted a tongue-in-cheek response to Alan Kazdin’s broadside against individual psychotherapy practitioners. He was bemoaning the fact that he could not find clinicians who utilized “empirically supported treatments.” Such treatments when utilized, it is assumed, lead to better outcomes. However, as all beginning psychology students know, there is a difference between “efficacy” and “effectiveness” studies. The former tell us whether a treatment has an effect, the latter looks at how much benefit actual people gain from “real life” therapy. If you were a client which kind of study would you prefer? Unfortunately, most of the guidelines regarding treatment models are based on efficacy rather than effectiveness research. The sine qua non of effectiveness research is measuring the quality and outcome of psychotherapy locally. After all, what client, having sought out but ultimately gained nothing from psychotherapy, would say, “Well, at least the treatment I got was empircally supported.” Ludicrous.

Dr. Carroll’s research clearly indicates that clinicians are not afraid of measurement, research, and even statistics. In fact, this last week, I was in Denmark teaching a specialty course in research design and statistics for practitioners. That’s right. Not a course on research in psychotherapy or treatment. Rather, measurement, research design, and statistics. Pure and simple. Their response convinces me even more that the much talked about “clinician-researcher” gap is not due to a lack of interest on practitioners’ parts but rather, and most often, a result of different agendas. Clinicians want to know “what will work” for this client. Research rarely address this question and the aims and goals of some in the field remain hopelessly far removed from day to day clinical practice. Anyway, watch the video yourself: