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Mental Health Practice in a Global Economy

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Did you feel it?  The seismic shift that occurred in field of mental health just a little over a month ago?  No?  Nothing?  Well, in truth, it wasn’t so much a rip in the space-time continuum as a run.  That “run,” however, promises to forever alter the fabric of clinical practice–in particular how clinicians earn and maintain a certain standard of living.

For decades, licensing statutes have protected behavioral health professionals from competing with providers living outside of their state and local jurisdiction.  In order to bill or receive reimbursement, mental health professionals needed to be licensed in the state in which treatment services were offered.  Over the years, the various professional organizations have worked to make it easier for professionals to become licensed when they move from one state to the another.  Still, it ain’t easy and, some practitioners and professional groups would argue, for good reason.  Such laws, to some extent, insure that fees charged for services are commensurate with the cost of living in the place where therapists live and work.  The cost of therapy in Manhattan varies considerably, for example, depending on whether one is talking about the city located in state of New York or Kansas.

As far as outcomes are concerned, however, there is no evidence that people who pay more necessarily get better results.  Indeed, as reviewed here on this blog, available evidence indicates little or no difference in outcome between highly trained (and expensive) clinicians and minimally trained (and less expensive) para-professionals and students.  If the traditional geographic (licensing) barriers were reduced or eliminated, consumers would with few exceptions gravitate to the best value for their money.  In the 1980’s and 90’s, for example, comsumers deserted small, Main Street retailers when big box stores opened on the outskirts of town offering the same merchandise at a lower price.  Now, big box retailers are closing en masse as consumers shift their purchases to less expensive, web based outlets.

And that’s precisely the shift that began a little over a month ago in the field of mental health.  The U.S. Military eliminated the requirement that civilian providers be licensed in the same jurisdiction or state in which treatment is offered.  The new law allows care to be provided wherever the receipient of services lives and regardless of where the provider is licensed.  Public announcements argued that the change was needed to make services available to service members and veterans living in isolated or rural areas where few providers may be available.  Whatever the reason, the implications are profound: in the future, clinicians, like Main Street retailers, will be competing with geographically distant providers.

Just one week prior to the announcement by the U.S. Military, I posted a blogpost highlighting a recent New York Times column by author and trend watcher, Thomas Friedman.  In it, I argued that “Globalization and advances in information technology were…challenging the status quo…access. At one time, being average enabled one to live an average life, live in an average neighborhood and, most importantly, earn an average living.  Not so anymore.  Average is now plentiful, easily accessible, and cheap. What technology can’t do in either an average or better way, a younger, less-trained but equally effective provider can do for less. A variety of computer programs and web-based systems provide both psychological advice and treatment.”

Truth is, the change is likely to be a boon to consumers of mental health services: easier access to services at a better price.  What can clinicians do?  First, begin measuring outcome.  Without evidence of their effectiveness, individual providers will lose out to the least expensive provider.  No matter how much people complain about “big box and internet retailers,” most use them.  The savings are too great to ignore.

What else can clinicians do?  The advice of Friedman, which I quoted in my recent blogpost, applies, “everyone needs to find their extra–their unique value contribution that makes them stand out in whatever is their field.” Measuring outcome and finding that “something special” is what the International Center for Clinical Excellence is all about.  If you are not a member, please join the thousands of other professionals online today.   After that, why not spend time with peers and cutting edge instructors at the upcoming “advanced intensive” or “training of trainers” workshops this summer.

The Outcome and Session Rating Scales: Support Tools

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Japan, Sweden, Norway, Denmark, Germany, France, Israel, Poland, Chile, Guam, Finland, Hungary, Mexico, Australia, China, the United States…and many, many more.  What do all these countries have in common?  In each, clinicians and agencies are using the ORS and SRS scales to inform and improve behavioral health services.  Some are using web-based systems for administration, scoring, interpretation and data aggregation (e.g., myoutcomes.com and fit-outcomes), many are accessing paper and pencil versions of the measures for free and then administering and scoring by hand.

Even if one is not using a web-based system to compare individual client progress to cutting edge norms, practitioners can still determine simply and easily whether reliable change is being made by using the “Reliable Change Chart” below.  Recall, a change on the ORS is considered reliable when the difference in scores exceeds the contribution attributable to chance, maturation, and measurement error. Feel free to print out the graph and use it in your practice.

To learn how to get the most out of the measures, be sure and download the six FIT Treatment and Training Manuals.  The six manuals cover every aspect of feedback-informed practice including: empirical foundations, basic and advanced applications (including FIT in groups, couples, and with special populations), supervision, data analysis, and agency implementation. Each manual is written in clear, step-by-step, non-technical language, and is specifically designed to help practitioners and agencies integrate FIT into routine clinical practice. Indeed, the manuals were submitted as part of ICCE’s application for consideration of FIT as an “evidence-based practice” to the National Registry of Evidence-Based Programs and Practices

ORS Reliable Change Chart

The Achieving Clinical Excellence Conference CALL FOR PAPERS

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In October 2010, the first annual “Achieving Clinical Excellence” was held in Kansas City, Missouri.  A capacity crowd joined leading experts on the subject of top performance for three days worth of training and inspiration.  K. Anders Ericsson reviewed his groundbreaking research, popularized by Malcolm Gladwell and others.  ICCE Director, Scott D. Miller translated the research into speciific steps for improving clinical performance.  Finally, classical piansts David Helfgott, Rachel Hsu, and Roger Chen, demonstrated what can be accomplished when such evidence-based strategies are applied to the process of learning specific skills.

The ICCE is proud to announce the 2nd “ACE” conference to be held May 16th-18th, 2013 in Amsterdam, Holland.  Join us for three educational, inspiring, and fun-filled days.  Register today and receive a significant “Early Bird” discount.  The ACE conference committee is also issuing an international “Call for Papers.”  If you, your agency, or practice are committed to excellence, using outcomes to inform practice, or have published research on the subject, please visit the conference website to submit a proposal.

Here’s what attendees said about the last event:

Implementation Science, FIT, and the Training of Trainers

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

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

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

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

Scott Miller (Evolution 2014)

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

 

Goodbye Mr. & Ms. Know-it-All: Redefining Competence in the Era of Increasing Complexity

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Every day behavioral health professionals make hundreds of decisions.  As experts in the field, they meet and work successfully with diverse clients presenting an array of different difficulties.  Available evidence indicates that the average person who receives care is better off than 80% of those with similar problems that do not.  Outcomes in mental health are on par or better than most medical treatments and, crucially, have far few side effects!  Psychotherapy, for example, is equal in effect to coronary artery bypass surgery and three times more effective than flouride for cavities.

Not all the news is good, however.  Drop out rates run around 25% or higher.  Said another way, clinicians do great work with the people who stay.  Unfortunately, many do not, resulting in increased costs and lost opportunities.  Another problem is that therapists, the data indicate, are not particularly adept at identifying clients at risk for dropping out or deterioration.  For decades, research has has shown that approximately 10% of people worsen while in treatment.  Practitioners, despite what they may believe, are none the wiser.  Finally, it turns out that a small percentage (between 10-20%) of people in care account for lion’s share of expenses in behavioral health service delivery (In case you are wondering, roughly the same figures apply in the field of medicine).  Such people continue in care for long periods, often receiving an escalating and complicated array of services, without relief.  At the same time, clinician caseloads and agency waiting lists grow.

What can be done?

At one time, being a professional meant that one possessed the knowledge, training, and skills to deliver the right services to the right people for the right problem in a consistent, correct, and safe manner.  To that end, training requirements–including schooling, certification, and continuing professional development–expanded, exponentially so.  Today’s behavioral health professionals spend more time training and are more highly specialized than ever before.  And yet, the above noted problems persist.

Some call for more training, others for increasing standardization of treatment approaches, many for more rigorous licensing and accreditation standards.  The emphasis on “empirically supported treatments”–specific methods for specific diagnoses–typify this approach.  However, relying as these solutions do on an antiquated view of professional knowledge and behavior, each is doomed to fail.

In an earlier era, professionals were “masters of their domain.”  Trained and skillful, the clinician diagnosed, developed a plan for treatment, then executed, evaluated, and tailored services to maximize the benefit to the individual client.  Such a view assumes that problems are either simple or complicated, puzzles that are solvable if the process is broken down into a series of steps.  Unfortunately, the shortcomings in behavioral health outcomes noted above (drop out rates, failure to identify deterioration and lack of progress) appear to be problems that are not so much simple or complicated but complex in nature.  In such instances, outcomes are remain uncertain throughout the process.  Getting things right is less about following the formula than continually making adjustments, as “what works” with one person or situation may not easily transfer to another time or place.  Managing such complexity requires a change of heart and direction, a new professional identity.  One in which the playing field between providers and clients is leveled, where power is moved to the center of the dyad and shared, where ongoing client feedback takes precedence over theory and protocol.

In his delightful and engaging book, The Checklist Manifesto, physician and surgeon Atul Gawande provides numerous examples in medicine, air travel, computer programming, and construction where simple feedback tools have resulted in dramatic improvements in efficiency, effectiveness, and safety.  The dramatic decrease in airplane related disasters over the last three decades is one example among many–all due to the introduction of simple feedback tools.  Research in the field of behavioral health documents similar improvements.  Multiple studies document that routinely soliciting feedback regarding progress and the alliance results in significantly improved effectiveness, lower drop out rates, and less client deterioration–and all this while decreasing the cost of service delivery.  The research and tools are described in detail in a new series of treatment manuals produced by the members and associates of the International Center for Clinical Excellence–six simple, straightforward, how-to guidebooks covering everything from the empirical foundations, administration and interpretation of feedback tools, to implementation in diverse practice settings.  Importantly, the ICCE Manuals on Feedback Informed Treatment (FIT) are not a recipe or cookbook.  They will teach not to you how to do treatment.  You will learn, however, skills for managing the increasingly complex nature of modern behavioral health practice.

In the meantime, here’s a fantastic video of Dr. Gawande on the subject.  Use the cursor to skip ahead to the 2:18 mark:

The New Average: Meeting the Need to Exceed

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No matter where you look,good is no longer “good enough.”  In a recent article in the New York Times, author and trend watcher, Thomas L. Friedman, declared, “Average is Over.”  It’s an argument similar to the one made over a decade ago by Robert Reich, former Secretary of Labor under Bill Clinton, in his phenomenally prescient book The Future of Success.  I read it at the time with a mixture of apprehension and anticipation.  Globalization and advances in information technology were then and are now challenging the status quo.  At one time, being average enabled one to live an average life, live in an average neighborhood and, most importantly, earn an average living.  Not so anymore.

Average is now plentiful, easily accessible, and cheap.  What technology can’t do in either an average or better way, a younger, less-trained but equally effective provider can do for less. A variety of computer programs and web-based systems provide both psychological advice and treatment.  (By the way, studies to date document outcomes equal to face-to-face services for at least the most common mental health related issues).  At the same time, as reviewed here previously on this blog, the evidence again and again shows no difference in outcome between professionally trained clinicians and students or paraprofessionals.  Uh-oh.

What is the solution?  Friedman says, “everyone needs to find their extra–their unique value contribution that makes them stand out in whatever is their field.”  Yeah, exactly.  As my father used to say, “Do your best and then a little better.  What can behavioral health professionals do to stand out?  Well, if you are trained, licensed or certified, practicing evidence-based, know the latest methods and research findings, and understand how the brain works, then you are, in a word, average.  Going forward, standing out will require evidence that you are effective; measures documenting not only who you help but identifying those you do not.  Professional development will be less about learning a new method than documenting what you do to “do your best and then a little better.”

Helping clincians stand out is what the ICCE is all about.  Everyday, thousands meet online to learn, share, and support each other in both measuring and improving the impact of their clinical work.  Each year, the ICCE offers two intensive training opportunities: The Advanced Intensive and the Training of Trainers.  Both events are designed to help professionals achieve their personal best.  The Training of Trainers is specifically designed for participants, such as supervisors, managers, and agency directors, who wish to train others or transform public or private agencies for achieving success.   The Advanced Intensive scheduled for March is sold out.  By popular demand, we are offering an unprecedented second opportunity to attend the Advanced Intensive this summer.  Don’t wait to register.  Despite only announcing this event last week, half of the seats are already booked.  Either event will insure that you have the tools and skills necessary to meet the need to exceed.  Email us with any questions at: training@centerforclinicalexcellence.com.

(By the way, if you are interested, you catch watch a clip of Friedman delivering his message to the Hudson Society here).

Looking Back, Looking Forward

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Bidding goodbye to last year and welcoming the new always puts me in a reflective frame of mind.  How did my life, work, and relationships go?  What are my hopes for the future?

Just two short years ago, together with colleagues from around the world, the International Center for Clinical Excellence (ICCE) was launched.  Today, the ICCE is the largest, global, web-based community of providers, educators, researchers, and policy makers dedicated to improving the quality and outcome of behavioral health services.  Clinicians can choose to participate in any of the 100-plus forums, create their own discussion group, immerse themselves in a library of documents and how-to videos, and consult directly with peers. Membership costs nothing and the site is free of the advertising.  With just a few clicks, practitioners are able to plug into a group of like-minded clinicians whose sole reason for being on the site is to raise everyone’s performance level.  I have many people to thank for the success of ICCE: senior associates and trainers, our community manager Susanne Bargmann, director of training Julie Tilsen, and our tech wizard Enda Madden. 

As membership in ICCE has grown from a few hundred to well over 3000, many in the community have worked together to translate research on excellence into standards for improving clinical practice.  Routine outcome monitoring (ROM) has grown in popularity around the world.  As a result, new measures and trainings have proliferated.  In order to insure quality and consistency, a task force was convened within ICCE in 2010 to develop a list of “Core Competencies”—a document establishing the empirical and practice foundations for outcome-informed clinical work.  In 2011, the ICCE Core Competencies were used to develop and standardize the curricula for the “Advanced Intensive” and “Training-of-Trainers” workshops as well as the exam all attendees must pass to achieve certification as an ICCE Trainer.   As if these accomplishments were not enough, a small cadre of ICCE associates banded together to compose the Feedback Informed Treatment and Training Manuals—six practical, “how-to”volumes covering everything from empirical foundations to implementation.  None of this would have been possible without the tireless contributions of Bob Bertolino, Jason Seidel, Cynthia Maeschalck, Rob Axsen, Susanne Bargmann, Bill Robinson, Robbie Wagner, and Julie Tilsen.

Looking back, I feel tremendous gratitude–both for the members, associates, and trainers of ICCE as well as the many people who have supported my professional journey.  This year, two of those mentors passed away: Dick Fisch and James Hillman.   During my graduate school years, I read James Hillman’s book, Suicide and the Soul.  Many years later, I had the opportunity to present alongside him at the “Evolution of Psychotherapy” conference.  Dick, together with his colleagues from MRI, had a great influence on my work, especially during the early years when I was in Milwaukee with Insoo Berg and Steve de Shazer in Milwaukee doing research and writing about brief therapy.  Thinking about Dick reminded me of two other teachers and mentors from that period in my life; namely, John Weakland and Jay Haley.


Looking forward, I am filled with hope and high expectations.  The “Advanced Intensive” training scheduled for March 19-22nd is booked to capacity—not a single spot left.  Registrations for this summer’s “Training of Trainers” course are coming in at a record pace (don’t wait if you are thinking about joining me, Cynthia and Rob).  Currently, I am awaiting word from the National Registry of Evidence Based Programs and Practices (NREPP) formally recognizing “Feedback Informed Treatment” (FIT) as an evidence-based approach.  The application process has been both rigorous and time-consuming.  It’s worth it though.  Approval by this department within the federal government would instantly raise awareness about as well as increased access to funding for implementing FIT.  Keep your fingers crossed!

There’s so much more:

  • Professor Jan Blomqvist, a researcher at the Center for Alcohol and Drug Research at Stockholm University (SoRAD) launched what will be the largest, independent evaluation of feedback informed treatment to date, involving 80+ clinicians and 100’s of clients located throughout Sweden.   I provided the initial training to clinicians in October of last year.  ICCE Certified Trainers Gunnar Lindfeldt and Magnus Johansson are providing ongoing logistic and supervisory support.
  • The most sophisticated and empirically robust interpretive algorithms for the Outcome Rating Scale (based on a sample of 427,744 administrations of the ORS, in 95,478 unique episodes of care, provided by 2,354 different clinicians) have been developed and are now available for integration into software and web based applications.  Unlike the prior formulas–which plotted the average progress of all consumers successful and not–the new equations provide benchmarks for comparing individual consumer progress to both successful and unsuccessful treatment episodes.
  • The keynote speakers and venue for the Second Achieving Clinical Excellence Conference have been secured.  We’ll be meeting at one of the nicest hotels in Amsterdam, Holland, May 16-18=9th, 2013.  Thanks go to the planning committee: Bill Andrews, Susanne Bargmann, Liz Plutt, Rick Plutt, Tony Jordan, and Bogdan Ion.  Please visit the conference website and submit a proposal for a workshop or presentation.
  • Finally, I’ve been asked to deliver the lunchtime keynote at the upcoming Psychotherapy Networker Conference scheduled on March 23, 2012.  The topic?  Achieving excellence as a behavioral health practitioner.  Last year, my colleague Mark Hubble and I published the lead article in the May-June issue of the magazine, describing the latest research on top performing clinicians.  I’m deeply honored by the opportunity to speak at this prestigious event.

More coming in the weeks ahead.  Until then, look forward to connecting on ICCE.

What’s disturbing Mental Health? Opportunities Lost

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In a word, paperwork.  Take a look at the book pictured above.  That massive tome on the left is the 2011 edition of “Laws and Regulations” governing mental health practice in the state of California.  Talk about red tape!  Hundreds and hundreds of pages of statutes informing, guiding, restricting, and regulating the “talking cure.”  Now, on top of that, layer federal and third party payer policies and paperwork and you end up with…lost opportunities.  Many lost opportunities.  Indeed, as pointed out in our recent article, The Road to Mastery, as much as 30% of clinicians time is spent completing paperwork required by various funding bodies and regulatory agencies.  THIRTY PERCENT.  Time and money that could be spent much more productively serving people with mental health needs. Time and money that could be spent on improving treatment facilities and training of behavioral health professionals.  In the latest edition of our book, The Heart and Soul of Change, authors Bob Bohanske and Michael Franczak described their struggle to bring sanity to the paperwork required in public mental health service settings in the state of Arizona.  “The forms needed to obtain a marriage certificate, buy a new home, lease an automobile, apply for a passport, open a bank account, and die of natural causes were assembled,” they wrote, “…and altogether weighed 1.4 ounces.  By contrast, the paperwork required for enrolling a single mother in counseling to talk about difficulties her child was experiencing at school came in at 1.25 pounds” (p. 300).  What gives?

The time has come to confront the unpleasant reality and say it outloud: regulation has lost touch with reality.  Ostensibly, the goal of paperwork and oversight procedures is to improve accountability.  In these evidence-based times, that leads me to say, “show me the data.”  Consider the wide-spread practice–mandate, in most instances–of treatment planning. Simply put, it is less science than science fiction.  Perhaps this practice improves outcomes in a galaxy far, far away but on planet Earth, supporting evidence is spare to non-existent (see the review in The Heart and Soul of Change, 2nd Edition).

No amount of medication will resolve this craziness.  Perhaps a hefty dose of CBT might do some good identifying and correcting the distoreted thinking that has led to this current state of affairs.  Whatever happens, the field needs an alternative.  What practice not only insures accountability but simultaneously improves the quality and outcome of behavioral health services?  Routine outcome measurement and feedback (ROMFb).  As I’ve blogged about several times, numerous RCT’s document increased effectiveness and efficiency and decreased costs and rates of deterioration.   Simply put, as the slide below summarizes, everybody wins.  Clinicians.  Consumers.  Payers.
Everybody wins

Learn about or deepen your knowledge of feedback-informed treatment (FIT) by attending the upcoming “Advanced Intensive” workshop in March 2012; specfically, the 19th-22nd.  We will have four magical days together.  Space is filling rapidly, so register now.  And then, at the end of the last day of the training, fly to Washington, D.C. to finish off the week by attending the Psychotherapy Networker conference.  Excellence is front and center at the event and I’ve been asked to do the keynote on the subject on the first day!

Optum Health and the ICCE: Partnering to Achieve Excellence in Behavioral Health

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Monday, November 28th, 2011
Chicago, IL & Goldern Valley, MN

The members, associaties, and directors of the International Center for Clinical Excellence are proud to announce a partnership with Optum Health’s Campaign for Excellence.  Optum Health works with employers, payers, and providers serving nearly 60,000,000 people.  Their “Campaign for Excellence (CFE)” was specifically designed to enhance the quality and outcome of behavioral health services by recognizing top performing clinicians.  To date, over 4,000 providers spread across the United States are participating in the CFE, which involves ongoing measurement and benchmarking of client outcome and satisfaction.  CFE clinicians are not only provided with feedback regarding the outcome of the individuals they meet and work with but able to compare their overall effectiveness to other providers in the Optum Health network.  Performance research makes clear that such comparisons are a necessary first step in the development of expertise.  The second?  As Miller and Hubble point out in The Road to Mastery, c-o-m-m-u-n-i-t-y.  Top performers do not exist in a vacuum.  Across a number of domains–chess, mathematics, medicine, or psychotherapy–the “best of the best” benefit from a complex and interlocking network of people, places, resources, and circumstances without which excellence remains out of reach.

And now, we are pleased to welcome these CFE providers to the ICCE community.   In December 2009, the International Center for Clinical Excellence was launched and since then, it has grown into the largest, global, web-based network of clinicians, researchers, administrators, and policymakers dedicated to excellence in behavioral health.  Clinicians can choose to participate in any of the 100-plus forums, create their own discussion groups, immerse themselves in a library of documents and how-to-videos, and most importantly meet with and consult with peers.  Indeed, with the addition of clinicians from Optum Health, total ICCE membership will exceed 5000!

ICCE members will most certainly benefit from the knowledge and experience of the CFE clinicians.  And if experience of members to date is any indication, CFE providers will find the community helpful in nurturning their continued professional growth.  Indeed, what has been so striking about ICCE is that it transcends its online limitations–which often reinforce anonymity and invisibility–to provide members with the same complex norms of personal connection, openness, and honesty, mutual trust and support, challenge and accountability, that any “land-based” community of excellence offers.

Optum Health is providing CFE clinicians with a unique URL for joining the ICCE.  Don’t despair if you are not a provider for Optum Health or participant in the CFE.  You too can join the ICCE by going to: http://centerforclinicalexcellence.com/register.  Look forward to meeting you online!

The ICCE Feedback-Informed Treatment Manuals

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September 12, 2011
Copenhagen, Denmark

Fall is in the air.  For me, that means the start of the travel season.  For the next two weeks, I’ll be traveling throughout Scandanavia–this week in Denmark and Norway.  It’s great to be back on the road meeting clinicians and consulting with agencies about feedback-informed treatment (FIT).

On this trip, I’m finally able to announce the publication of the Feedback-Informed Treatment Manuals.  Over the summer, senior associates of the International Center for Clinical Excellence, together with the talented artists and graphic designers at The Change Companies, worked hard to complete the series.

The six manuals cover every aspect of feedback-informed practice including: empirical foundations, basic and advanced applications (including FIT in groups, couples, and with special populations), supervision, data analysis, and agency implementation.  Each manual is written in clear, step-by-step, non-technical language, and is specifically designed to help practitioners and agencies integrate FIT into routine clinical practice.   Indeed, the manuals were submitted as part of ICCE’s application for consideration of FIT as an “evidence-based practice” to the National Registry of Evidence-Based Programs and Practices.  The manuals may be purchased separately or as a series in the bookstore.

While on the subject of registries, mention should be made that over the summer the American Psychological Association  contacted me about listing the Outcome and Session Rating Scales in their official database of outcome tools for clinical practice (click here to see the listing).  Taken together, the manuals, NREPP application, listing, and growing body of research evidence provide a compelling case for feedback-informed work.

Is Psychotherapy Dead?

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“AMERICANS PREFER DRUGS” screams the headline posted by the Reuters news service and attributed to Consumer Reports–one of the most respected periodical for the average American reader.  “NEARLY 80 PERCENT TAKE A PILL FOR DEPRESSION,” the article continues.  Read a little further and do some searching around on the internet and a different story emerges.  Americans it turns out don’t necessarily prefer drugs but rather, “78 percent of those seeking treatment for depression or anxiety were prescribed antidepressants.”

With respected news agencies advertizing for the pharaceutical companies, is it any wonder why the practice of “talk therapy” is suffering?  AA’s Executive Director for Professional Practice, Dr. Kaherine Nordal, in a recent editorial asked, “Where has all the psychotherapy gone?”  The percentage of Americans who receive outpatinet mental health care has remained unchanged over the last several decades.  Moreover, as Dr. Mark Hubble and I point out in the lead article in the May-June issue of the Psychotherapy Networker, “median incomes for psychologists, both applied and academic, have dropped between 17 and 33 percent at the same time that workloads have increaed, profssional autonomy has been subverted, and funding for public behavioral healthcare has all but disappeared.”

In a recent, highly publicized exchange on psychotherapy that appeared on Medscape: Psychiatry and Health, panel participants (all psychiatrists) repeated the same, old, tired argument about the field.  To wit, “the research base is insufficient.”   How such statements can be made with a straight face, much less by mental health professionals, on a public website, defies explanation.   The truth is, the evidence-base for psychological treatments is as large and robust as any.  What’s more, seeing a talk therapist does not require invasive surgery or a black box warning.  Clearly, the issue is not research.  It is about awareness.

The members and associates of the International Center for Clinical Excellence (ICCE) are working diligently to raise consciousness among the public and policy makers.  Every day, 1000’s of professionals connect to, learn from, and share with colleagues around the world.  The mission of the organization?  To use community to improve the quality and outcome of behavioral health services.  On the ICCE web-based community, clinicians share experiences and real world data regarding the effectiveness of talk therapy.  For example, ICCE associate Dan Buccino shared outcomes from a 7 year project aimed at “promoting recovery and accountability.”  Using the Outcome and Session Ratings Scales, Dan documented effectiveness levels that far exceeded national benchmarks for clinical practice.  Why not email him for a copy of the report?  Meanwhile, providers serving US Airforce personnel began using the same measures in early 2010 and have reported very similar findings.  Finally, to date, more than a dozen randomized clinical trials, involving thousands of clients and numerous therapists, have established that using feedback to inform services increases effectiveness of individual practitioners three fold, cuts dropout rates by 50 percent, reduces the rate of deterioration by 33 percent, and speeds recovery by 66 percent, while simultaensouly improving client satisfaction and reducing the cost of care.

To paraphrase Mark Twain, the rumored death of psychotherapy has been greatly exaggerated.  Now is not the time, however, to merely hope for a better future.  Join the discussion taking place on ICCE  right now.  Membership is free and a strong, supportive community just a few clicks away.

How Much More Evidence Is Needed? A New Meta-Analysis on Feedback-Informed Treatment

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Received an email from friend and colleague John Norcross, Ph.D.  Attached were the results of a meta-analysis completed by Michael Lambert and Kenichi Shimokawa on Feedback-Informed Treatment (FIT) which will appear in the second edition of his book, Psychotherapy Relationships that Work (Oxford University Press).  For those who cannot wait, you can access the same results in the lastest issue of the APA journal Psychotherapy (Volume 48, Number 1, March 2011, pages 72-79).

Briefly, the chapter begins with a review of the literature on feedback–a body of evidence that, by the way, dates back to 1930’s and has always shown small to moderate effects on the outcome of treatment.  In reviewing studies specific to the ORS and SRS, the authors conclude, “”>the results indicated that those in the feedback group ha[ve] 3.5 times higher odds of experiencing reliable change while having less than half the odds of experiencing deterioration.”  Additionally, Lambert and Shimokawa report few if any meaningful differences between therapies informed by the ORS and SRS and those using the well-established and widely used Outcome Questionnaire (OQ).   Finally, and importantly, the authors note that in “busy practices…the brevity of the [ORS and SRS]…expedite and ease practical difficulties” thereby decreasing barriers to implementation.

How much more evidence will it take before feedback informed treatment becomes standard practice?  All of the available data is summarized in the materials below.

Measures and Feedback January 2011

View more documents from Scott Miller

Be sure and join other clinicians and researchers who are discussing FIT at the International Center for Clinical Excellence–the largest, free, web-based community dedicated to improving the quality and outcome of behavioral health.

Finally, if you are in thinking about or in the process of becoming FIT in your agency or practice, please join us at the upcoming “Training of Trainers” workshop held the first week of August.  Registration is limited to 35 participants and we have only a few spots left!  Here’s what attendees from last year had to say about the event…

The Mystery of Mastery: Excellence Takes Center Stage in the Psychotherapy Networker

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The Psychotherapy Networker has long been the most popular periodical among practicing clinicians.  Rumor has it that the magazine has 80,000+ subscribers and sells over 120,000 copies of each issue.  If you want to know what therapists are thinking and talking about, the Networker magazine is the place to look.  And in the May/June issue, the topic of excellence is front and center.

The reason is obvious: the field of psychotherapy is in trouble.  Think about it for a moment.  What real accomplishments can psychotherapy boast of in recent years? What was the last truly revolutionary discovery in the field of psychotherapy? What “treatment” (analogous to penicillin in medicine) has ever successfully eradicated a mental or emotional disorder? In fact, while we’ve been at our posts, provisioning and parading an army of techniques and methods, rates of depression and anxiety have soared.  Even if one disagrees with this grim assessment of the field’s contributions and influence, it’s hard to be sanguine about our status. Over the last decade, median incomes for psychologists, both applied and academic, have dropped by thousands of dollars. In the same period, workloads have increased, professional autonomy has been subverted, and funding for public behavioral healthcare has all but disappeared.  Meanwhile, the very relevance of psychotherapy is an open question in the minds of many current and prospective consumers. Despite overwhelming evidence that therapy works, and that more than 90 percent of people say they’d prefer to talk about their problems than take psychopharmacological drugs, most people doubt the efficacy of treatment. Perhaps this accounts for the fact that the use of medications has steadily increased, while visits to a psychotherapist have been decreasing.

What can be done?

In 2007, we wrote an article that appeared in the pages of the Networker on the subject of “top performing” clinicians–those that consistently achieve superior results with their clients.  Over the last four years, we’ve continued to research and write on the subject and in the latest issue of the Networker we review the latest findings.  ICCE Associate, Dr. Bob Bertolino, also has an article in the issue detailed the steps required to reac excellence in agencies and healthcare systems.

Scott Miller         Mark Hubble          Bob Bertolino

Never has a moment in the history of the field existed when the need for a “culture of excellence” has been more pressing or when the qualities of that culture are more unambiguous.  Seeing as we spend so much of our lives at work anyway—often more in total than with our families, friends, and in leisure—the question is, “why not?”   If not for ourselves, then for our clients, the very people the research shows benefit the most from top performance and on whom our livelihoods depend.  Don’t wait.  Click on the links above to read both articles.

Why is this man laughing?

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May 4th, 2011
Copenhagen, Denmark

Just finished my first day of a two week trip covering spots in Denmark and Holland.  Yesterday, I traveled to Copenhagen from Hilo, Hawaii where I was presenting for the Hawaiian Association of Marriage and Family Therapy.  Dr. Gay Barflied (pictured on the far left above) spent years lobbying to bring me to the “Big Island” for the conference, where I spoke about the latest research on expertise and excellence in the field of behavioral health.  I met so many dedicated and talented clinicians in Hilo, including marriage and family therapist, Makela Bruno-Kidani (pictured in the middle photo above) who started the day off with a traditional Hawaiian chant and then presented me with two beautiful lei to wear during the event.

On a break, Gay mentioned an article that appeared in the May/June 1995 issue of AHP Perspective.  In it, she said, Maureen O’Hara, president of the Association for Humanistic Psychology, quoted one of the first articles me and my colleagues wrote on the common factors, “No More Bells and Whistles” (I’ll upload a copy to the “publications and handouts” section of the website as soon as I’m back in the States).  Carl Rogers, she said, would have been laughing (happily, that is) had he read the findings we cited documented the lack of differential efficacy of competing treatment approaches.  We had, in essence, proved him right!

“It turns out,” OHara wrote, “that Miller, Hubble, and Duncan come to similar conclusions.  Carl Rogers was right.  After all our forays into the dizzing arcana of paradoxical interventions, inner children, narrative therapy, EMDR, behaviorism, psychopharmacology, bioenergetics, TA, Jungian analysis, psychodrama, Gestalt, and so on down the entire list of hundred brand named therapies, what actually creates change is the…creation of a relationship between client and therapist…”.

I’d never seen the article before.  It brought back very positive memories about the journey that has led most recently to the study of excellence.  Indeed, as we point out in the lead article in the upcoming May/June 2011 issue of the Psychotherapy Networker, relationships are not only the “sine qua non” of healing for clients but are responsible for the professional growth for therapists.

The "F" Word in Behavioral Health

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Since the 1960’s, over 10,000 how-to books on psychotherapy/counseling have been published—everything from nude marathon group therapy to the most recent “energy-based treatments.”  Clinicians have at their disposal literally hundreds of methods to apply to an ever growing list of diagnoses as codified in the Diagnostic and Statistical Manual of Mental Disorders (soon available in its 5th and expanded edition).

Conspicuously absent from the psychological cornucopia of diagnoses and treatments is the “F” word: FAILURE. A quick search of Amazon.com led to 32,670 results for the term, “psychotherapy,” 1,393 hits for “psychotherapy and depression,” and a mere 85 citations for “psychotherapy and failure.” Of the latter 85, less than 20 dealt with the topic of failure directly. There are some notable exceptions. The work of psychologist Jeffrey Kottler, for example. The dearth of information and frank discussion points to a glaring fact: behavioral health has a problem with failure.
The research literature is clear on the subject: we fail. Dropout rates have remained embarrassingly high over the last two and a half decades—hovering around 47%. At the same time, 10% of those who stay in services deteriorate while in care. Also troubling, despite the expansion of treatment modalities and diagnoses, the outcome of treatment (while generally good) has not improved appreciably over the last 30 or so years.  Finally, as reviewed recently on this blog, available evidence indicates that clinicians, despite what many believe, do not improve with experience.
In short, behavioral health is failing when it comes to failure. As a group, we do rarely address the topic. Even when we directly addressed, we find it hard to learn from our mistakes.
Our study of top performing clinicians and agencies documents that the best have an entirely different attitude toward failure than the rest. They work at failing. Everyday, quickly, and in small ways. In the lead article of upcoming Psychotherapy Networker, “The Path to Mastery” we review our findings and provide step-by-step, evidence-based directions for using failure to improve the quality and outcome of behavioral health. As we say in the article, “more than a dozen clinical trials, involving thousands of clients and numerous therapists, have established that excellence isn’t reserved for a select few. Far from it: it’s within the reach of all.” Getting there, however, requires that we embrace failure like never before.
At this year’s “Training of Trainers” (TOT) conference, building “mindful infrastructures” capable of identifying and using failure at the individual practitioner, supervisor, and agency level will be front and center. Please note: this is not an “advanced workshop” on client-directed, feedback-informed clinical work (CDOI/FIT). No lectures or powerpoint presentations. Participants get hands on experience learning to provide training, consultation, and supervision to therapists, agencies, and healthcare systems.
But, don’t take our word for it.  Listen to what attendees from the 2010 TOT said. Be sure and register soon as space is limited.

Changing Home-Based Mental Health Care for Good: Using Feedback Informed Treatment

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Some teach.  Some write.  Some publish research.  Arnold Woodruff and Kathy Levenston work for a living!  Kathy Levenston specializes in working with foster and adopted children.

Arnold Woodruff developed the first intensive in-home program run by a community services board in Virginia. He has over 30 years of experience, and has served as the President of the Virginia Association for Marriage and Family Therapy.  And now, these two dedicated professionals, certified trainers and associates of the International Center for Clinical Excellence, have just purchased Home for Good, the first home-based mental health program in the Richmond, VA area to use Feedback-Informed Treatment (FIT).

The program is now a 100% employee-owned company and part of a larger vision the two have for establishing customer-friendly mental health care to people in the Richmond area. Home for Good has been providing Intensive In-home Services (counseling, case management, and crisis support) to children, adolescents, and their families for the past two years. Home for Good has achieved superior results compared to other mental health programs, based on an analysis of data genderated from routine administration of the Outcome Rating Scale in clinical practice. Home for Good’s results are continuing to improve with the use of Feedback-Informed Treatment. Home for Good will soon be offering additional services, including outpatient individual, family, and group therapy.

Getting FIT: The Advanced Intensive Training

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Dateline: January 19, 2011
Buffalo, New York

The New Year is here and travel/training season is in full swing.  Last week, I was in Ohio and Virginia.  This week New York and Idaho (keep your weather fingers crossed, it’s going to be dicey getting from here to there and home again).

Interest in “Feedback Informed Treatment” continues to grow.  Agencies across the United States and abroad–as my travel schedule attests–are implementing the ORS and SRS in routine clinical practice.  Clinicians are finding the support they need on the International Center for Clinical Excellence web-based community.  As I blogged about a while back, the ICCE is the largest and most diverse group of practitioners working to improve the quality and outcome of behavioral health services.  Many will soon be joining me in Chicago for the 2011 “Advanced Intensive” training.  Once again, clinicians from all over the world will be in attendance–Sweden, Holland, England, Australia and so on.  Interest is high as participants receive a thorough, state-of-the-art grounding in the principles and practice of FIT.  I look forward to meeting everyone soon.

Last summer, I videoblogged about the event.  Ah, summer!   With everything my co-teacher, psychologist Susanne Bargmann, and I have planned, we promise a warm and rewarding event.

Getting FIT in the New Year: The Latest Evidence

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 John Norcross, Ph.D.  is without a doubt the researcher that has done the most to highlight the evidence-base supporting the importance of the relationship between clinician and consumer in successful behavioral healthcare.   The second edition of his book, Psychotherapy Relationships that Work, is about to be released. Like the last edition, this volume is a virtual treasure trove of research findings and empirically supported practices.

Among the many gems in the book is a chapter by Michael J. Lambert, Ph.D–pioneering researcher on “feedback-informed treatment” (FIT).  As usual, he does a masterful job summarizing the existing research on the subject. The data are overwhelmingly positive: seeking and using standardized feedback regarding the progress and outcome of treatment cuts drop out and deterioration rates and significantly improves outcome.

Lambert also reports the results of two meta-analyses. One performed on studies using his own OQ System family of measures, the other based on research using the ORS and SRS. Not only did he find ample empirical support for the two systems, but in the case of the ORS and SRS those therapies informed by feedback, “had 3.5 times higher odds of experiencing reliable change.”  Additionally, and importantly, the brief, 4-item ORS and SRS scales performed the same as the longer and more detailed OQ 45.2.

What can you do? First, order John’s book. Second, if you are not FIT, now is the time to register to use the measures.  And if you need support, why not join the International Center for Clinical Excellence? Like the measures, there is no cost. Right now, professionals from different disciplines, working in diverse settings are connecting with and learning from each other. Here’s a nudge: you’ll be able to reach John Norcross there—he’s one of ICCE’s newest members.

Growing by Leaps and Bounds: ICCE Membership Nearing 2000!

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In December 2009, the International Center for Clinical Excellence was officially launched.  From our booth at the Evolution of Psychotherapy conference, the international web-based community “went live,” adding hundreds of members in a few days.  By April, as I reported in my blog, over 1000 clinicians, researchers, policy makers, and adminsitrators had joined the site, making it the largest organization in the world dedicated to improving the quality and outcome of behavioral healthcare.  And now, just shy of a year, the ICCE community is fast approaching 2000 members!

Unlike traditional list-serves dependent on email, limited to a single topic, and often hobbled by irrelevant chatter between participants, the ICCE community uses the latest web 2.0 technology to connect behavioral health practitioners from around the globe.  On the site, clinicians can start a discussion group, upload documents, view videos by the field’s most effective practitioners, and seek counsel regarding their most difficult and challenging questions from a group of experts from around the world.

Right now, members are discussing the recent ACE conference, research on the therapeutic alliance, what the literature says about achieving one’s personal best as a clinician, plus much, much more.  If you’re not yet a member, nows the time to join.  It’s free.  No cost whatsoever to join and you won’t be bombarded with adds for books, webinars, videos, or training.  Look forward to meeting you online!

Pushing the Research Envelope: Getting Researchers to Conduct Clinically Meaningful Research

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ACE Health Innovations - Developers of openFIT and mFIT

At the recent ACE conference, I had the pleasure of learning from the world’s leading experts on expertise and top performance.  Equally stimulating were conversations in the hallways between presentations with clinicians, policy makers, and researchers attending the event.  One of those was Bill Andrews, the director of the HGI Practice Research Network in the UK who work over the last 3+ years has focused on clinicians whose outcomes consistently fall in the top quartile of effectiveness.

In this brief interview, Bill talks about the “new direction” his research on top performing clinicians is taking.  He is truly “pushing the research envelope, challenging the field to move beyond the simplistic randomized clinical trials comparing different treatment packages.  Take a look:

Am-ACE-ing Events in Kansas City: The First International Achieving Clinical Excellence Conference

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Here’s a riddle for you:

What do therapists, researchers, case managers, magicians, surgeons, award winning musicians, counselors, jugglers, behavioral health agency directors, and balloon twisting artists have in common?

Answer:

They all participated in the first “Achieving Clinical Excellence” held last week in Kansas City, Missouri.

It’s true. The “motley” crew of presenters, entertainers, and attendees came to Kansas City learn the latest, evidence-based strategies for helping clinicians achieve their “personal best” and, in the process, improve the quality and outcome of behavioral health services.  Not only did participants and presenters come from all over the globe–Australia, New Zealand, Norway, Sweden, Denmark, Austria, the UK, Ireland, Scotland, Germany, Canada, Holland, and elsewhere–but ICCE web 2.0 technology was used to stream many of the presentations live to a worldwide audience (click on the link to watch the recordings).

“The atmosphere was positively electric,” one participant remarked to me on break, “and so friendly.   First, I was inspired.  Each presentation contained something new, a take-away.  Then I wanted to sit with other attendees and discuss the content.”

And thanks to “Gillis for Children and Families,” who not only sponsored and ran the event, but provided a full breakfast and lunch each day of the conference, participants had ample opportunity to meet, process, and network with each other.


Rich Simon                       Anders Ericsson                     Michael Ammar

Rich Simon, Ph.D., the editor of the Psychotherapy Networker, kicked off the event using his time at the podium to place the conference’s emphasis on excellence within the broader history of the field of psychotherapy.  He was followed by K. Anders Ericsson, the editor of the influential Cambridge Handbook of Expertise and Expert Performance, reviewed research on expert performance gathered over the last 3 decades.  Scott D. Miller, Ph.D., translated existing research on expert performance into steps for improving outcomes in behavioral health. On day 2, professional magician Michael Ammar delivered a stunning performance of close up magic while teaching a specific method of deliberate practice that clinicians can use to improve their skills.  Meanwhile, break out sessions led by psychologists, physicians, counselors, pharmacists, and agency directors addressed “nuts and bolts” applications.

Rachel Hsu                                                  Roger Shen

In between each plenary and breakout session, top performers from a variety of fields entertained and inspired.  Moving performances on the violin and piano by nine year old Rachel Hsu and eleven year old Roger Shen amazed and challenged everyone in attendance.  “It is not talent,” Rachel told me, “It’s a lot of hard work–4 to 5 hours a day, everyday of the week, including weekends.”  The take home lesson from these exception kids was clear: there are no short cuts when it comes to top performance.  If you want to achieve your personal best you must work hard.  Promises otherwise are so much more snake oil.

On Thursday evening, the Australian classical pianist, David Helfott, whose lifestory was the subject of the award winning film, “Shine” entertained conference attendees.  His partner, Gillian, introduced and provided the audience with a brief history of David’s life, unfortunate treatment in the mental health system, and their long marriage.  The audience rose to their feet in a standing ovation at the conclusion of the performance.  There were few dry eyes in the house.  Afterwards, the two spent nearly an hour meeting and greeting attendees personally.  Once again, portions of the performance were broadcast live via ICCE web 2.0 technology to a world wide audience.

The inspiration that conference attendees felt continues on the International Center for Clinical Excellence web-based community.  Join us as we work to help each other achieve our personal best.  Still looking for inspiration?  Take a look at the following two videos; first, a montage of events at ACE; and second, Mr. Ah’ Lee Robinson, the director of the Kansas City Boys Choir, whose story and performance brought the conference to a moving conclusion.

What is "Best Practice?"

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You have to admit the phrase “best practice” is the buzzword of late. Graduate school training programs, professional continuing education events, policy and practice guidelines, and funding decisions are tied in some form or another to the concept. So, what exactly is it? At the State and Federal level, lists of so-called “evidence-based” interventions have been assembled and are being disseminated. In lockstep, as I reviewed recently, are groups like NICE. Their message is simple and straightforward: best practice is about applying specific treatments to specific disorders.
Admittedly, the message has a certain “common sense” appeal.    The problem, of course, is that behavioral health interventions are not the psychological equivalent of penicillin. In addition to the numerous studies highlighted on this blog documenting the failure of the “specific treatments for specific disorders” perspective, consider research published in the Spring 2010 edition of the Journal of Counseling and Development by Scott Nyman, Mark Nafziger, and Timothy Smith. Briefly, the authors examined outcome data to “evaluate treatment effectiveness across counselor training level [and found] no significant outcome differences between professional staff and …. interns, and practicum students” (p. 204). Although the researchers are careful to make all the customary prevarications, the conclusion—especially when combined with years of similar findings reported in the literature– is difficult to escape: counseling and psychotherapy are highly regulated activities requiring years of expensive professional training that ultimately fails to make the practitioner any better than they were at the outset.
What gives? Truth is, the popular conceptualization of “best practice” as a “specific treatment for a specific disorder” is hopelessly outdated. In a report few have read, the American Psychological Association (following the lead of the Institute of Medicine) redefined evidence-based, or best practice, as, “the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences.” Regarding the phrase “clinical expertise” in this definition, the Task Force stated, “Clinical expertise…entails the monitoring of 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 (Lambert, Bergin, & Garfield, 2004a). 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” (p. 273; emphasis included in the original text).
Said another way, instead of choosing the “specific treatment for the specific disorder” from a list of approved treatments, best practice is:
·         Integrating the best evidence into ongoing clinical practice;
·         Tailoring services to the consumer’s characteristics, culture, and preferences;
·         Formal, ongoing, real-time monitoring of progress and the therapeutic relationship.
In sum, best practice is Feedback Informed Treatment (FIT)—the vision of the International Center for Clinical Excellence. And right now, clinicians, researchers and policy makers are learning, sharing, and discussion implementing FIT in treatment settings around the globe on the ICCE web-based community.
Word is getting out. As just one example, consider Accreditation Canada, which recently identified FIT as a “leading practice” for use in behavioral health services. According to the website, leading practices are defined as “creative, evidence-based innovations [that] are commendable examples of high quality leadership and service delivery.” The accreditation body identified FIT as a “simple, measurable, effective, and feasible outcome-based accountability process,” stating that the approach is a model for the rest of the country! You can read the entire report here.
How exactly did this happen? Put bluntly, people and hard work. ICCE senior associates and certified trainers, Rob Axsen and Cynthia Maeschalck, with the support and backing of Vancouver Coast Health, worked tirelessly over the last 5 years both implementing and working to gain recognition for FIT. Similar recognition is taking place in the United States, Denmark, Sweden, England, and Norway.
You can help. Next time someone—be it colleague, trainer, or researcher—equates “best practice” with using a particular model or list of “approved treatment approaches” share the real, official, “approved” definition noted above.  Second, join Rob, Cynthia, and the hundreds of other practitioners, researchers, and policy makers on the ICCE helping to reshape the behavioral health practice worldwide.

Clinician Beware: Ignoring Research Can be Hazardous to Your Professional (and Economic) Health

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“Studies show…”
“Available data indicate…”
“This method is evidence-based…”
My how things have changed. Twenty years ago when I entered the field, professional training, continuing education events, and books rarely referred to research or evidence. Now, everyone refers to the “data.”  The equation is simple: no research = no money.  Having “an evidence-base” increasingly determines book sales, attendance at continuing education events, and myriad other funding and reimbursement decisions.

So what do the data actually say? S adly, the answer is often, “it depends on who you ask.”  If you read the latest summary and treatment recommendations for post-traumatic stress disorder (PTSD) posted by the Cochrane Collaboration, you are told that TFCBT and EMDR are the most effective, “state of the art” treatments on offer.  Other summaries, as I recently blogged about, arrive at very—even opposite—conclusions; namely, all psychotherapies (trauma-focused and otherwise) work equally well in the treatment of PTSD.  For the practicing clinician (as well as other consumers of research), the end result is confusion and, dare I say, despair.

Unable to resolve the discrepant findings, the research is either rejected out of hand (“it’s all crap anyway”) or cherry-picked (“your research is crap, mine is good”).  In a world where experts disagree–and vehemently–what is the average Joe or Jane therapist to do?

Fortunately, there is another way, beyond agnosticism and instead of fundamentalism.   In a word, it is engagement. This last week, I spent 5 days teaching an intensive workshop with ICCE Senior Associate Susanne Bargmann to a group of Danish psychologists on “Statistics and Research Design.”  That’s right.  Five days, 6 hours a day spent away from work and clients learning how to understand, read, and conduct research.

The goal of the training was simple and straight-forward: help practitioners learn to evaluate the methods and meanings, strengths and weaknesses, and political and paradigmatic influences associated with research and evidentiary claims. At the conclusion of the five days, none of those assembled had difficulty engaging with and understanding the reasons for the seemingly discrepant findings noted above. As a result, they could state with confidence “what works” with PTSD, helping clarify this not only to colleagues, payers, and policy members but also to consumers of behavioral health services.

The “Statistics and Research Design” course will be held again in Denmark in 2011.  If the experience of this year’s participants proves anything, it is that, “The only thing therapists have to fear about statistics and research design, is fear itself.”  Please contact Vinther and Mosgaard directly for more information.

Finally, as part of the International Center for Clinical Excellence (ICCE) efforts to improve the quality and outcome of behavioral health services worldwide, two additional intensive trainings will be offered in Chicago, Illinois (USA). First, the “Advanced Training in Feedback-Informed Treatment (FIT).”  And second, the annual “Training of Trainers.”   In the Advanced Training, participants learn:

·         The empirical foundations of feedback-informed clinical work (i.e., empirically supported factors underlying successful clinical work, the impact of feedback on performance)
·         Clinical skills for enhancing client engagement that cut across different therapeutic orientations and diverse treatment populations
·         How to integrate outcome management tools (including one or more of the following: ORS, SRS, CORE, and OQ 45) into clinical practice
·         How to use the outcome management tools to inform and improve service delivery
·         How to significantly improve your clinical skills and outcomes via feedback and deliberate practice
·         How to use data generated from outcome measures to inform management, supervision, and training decisions
·         Strategies for successful implementation of CDOI and FIT in your organization or practice
Need more information about the course?  Email us or click on the video below to hear more about the course.  In the meantime, space is limited so register early at: http://www.eventbrite.ie/o/the-international-centre-for-clinical-excellence-298540255.

What Works in the Treatment of Post Traumatic Stress Disorder? The Definitive Study

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What works in the treatment of people with post-traumatic stress?  The influential Cochrane Collaboration–an “independent network of people” whose self-professed mission is to help “healthcare providers, policy makers, patients, their advocates and carers, make well-informed decisions, concludes that, “non trauma-focused psychological treatments [do] not reduce PTSD symptoms as significantly…as individual trauma focused cognitive-behavioral therapy (TFCBT), eye movement desensitization and reprocessing, stress mamangement and group TFCBT.”  The same conclusion was reached by the National Institute for Health and Clinical Excellence (or NICE) in the United Kingdom which has developed and disseminated practice guidelines that unequivocally state that , “all people with PTSD should be offered a course of trauma focused psychological treatment (TFCBT) or eye movement desensitization and reprocessing (EMDR).”  And they mean all: adults and kids, young and old.  Little room for left for interpretation here.  No thinking is required.  Like the old Nike ad, you should: “Just do it.”

Wait a minute though…what do the data say? Apparently, the NICE and Cochrane recommendations are not based on, well…the evidence–at least, that is, the latest meta-analytic research!  Meta-analysis, you will recall, is a procedure for aggregating results from similar studies in order to test a hypothesis, such as, “are certain approaches for the treatment of post traumatic stress more effective than others?”  A year ago, I blogged about the publication of a meta-analysis by Benish, Imel, & Wampold which clearly showed that there was no difference in outcome between treatments for PTSD and that the designation of some therapies as “trauma-focused” was devoid of empirical support, a fiction.

So, how to account for the differences?  In a word, allegiance.  Although written by scientists, so-called “scholarly” reviews of the literature and “consensus panel” opinions inevitably reflect the values, beliefs, and theoretical predilections of the authors.  NICE guidelines, for example, read like a well planned advertising campaign for single psychotherapeutic modality: CBT.  Indeed, the organization is quite explicit in it’s objective: “provide support for the local implementation of…appropriate levels of cognitive beheavioral therapy.”   Astonishingly, no other approach is accorded the same level of support or endorsement despite robust evidence of the equivalence of outcomes among treatment approaches.  Meanwhile, the review of the PTSD literature and treatment recommendations published by the Cochrane Collaboration has not been updated since 2007–a full two years following the publication of the Benish et al. (2008) meta-analysis–and that was penned by a prominent advocate of…CBT…Trauma-focused CBT.

As I blogged about back in January, researchers and prominent CBT proponents, published a critique of the Benish et al. (2008) meta-analysis in the March 2010 issue of Clinical Psychology Review (Vol. 30, No. 2, pages 269-76).  Curiously, the authors chose not to replicate the Benish et al. study, but rather claim that bias, arbitrariness, lack of transparency, and poor judgement accounted for the findings.   As I promised at the time, I’m making the response we wrote–which appeared in the most recent issue of Clinical Psychology Review—available here.

Of course, the most important finding of the Benish et al. (2008) and our later response (Wampold et al. 2010) is that mental health treatments work for people with post traumatic stress.  Such a conclusion is unequivocal.  At the same time, as we state in our response to the critique of Benish et al. (2008), “there is little evidence to support the conclusion…that one particular treatment for PTSD is superior to others or that some well defined ingredient is crucial to successful treatments of PTSD.”  Saying otherwise, belies the evidence and diverts attention and scarce resources away from efforts likely to improve the quality and outcome of behavioral health services.

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Goodbye Freud, Hello Common Factors

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Gary Greenberg certainly has a way with words.  In his most recent article, The War on Unhappiness, published in the August issue of Harper‘s magazine, Greenberg focuses on the “helping profession”–its colorful characters, constantly shifting theoretical landscape, and claims and counterclaims regarding “best practice.”  He also gives prominence to the most robust and replicated finding in psychotherapy outcome research: the “dodo bird verdict.”  Simply put, the finding that all approaches developed over the last 100 years–now numbering in the thousands–work about equally well.   Several paragraphs are devoted to my own work; specifically, research documenting the relatively inconsequential role that particular treatment approaches play in successful treatment and the importance of using ongoing feedback to inform and improve mental health services.  In any event, Greenberg’s review of current and historical trends is sobering to say the least–challenging mental health professionals to look in the mirror and question what we really know for certain–and a must read for any practitioner hoping to survive and thrive in the current practice environment.  OK.  Enough said.  Read it yourself here.

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

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Late last year, I blogged about a study being conducted at the University of Pittsburgh by Dr. Jan Pringle, the director of the Program Evaluation Research Unit in the School of Pharmacology and her colleague, Dr. Michael Melczak.  You’ll recall, there were two 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.  At the time, I reported that initial findings showed that patients of pharmacists who used the measures to solicit feedback “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.”  Well, the official results are finally available.

After controlling for age, gender, and other individual and control conditions (including measures of interactions with pharmacies), patients in the feedback condition increased their rate of “percent of days covered”–that is, taking the medication as prescribed–significantly (average 11%, a result considered “impressive” when compared to other, traditional efforts aimed at improving compliance).  Interestingly, additional analyses showed that the impact of the SRS–a measure of the therapeutic alliance–was greatest for the hyplipidemia and hypertensive medications (as opposed to the anti-diabetic medications).

Drs. Pringle and Melczak are currently in the process of planning a series of additional studies involving a larger number of patients and pharmacists.  Both will be presenting at the upcoming Achieving Clinical Excellence conference.

Finally, take a look at the video that was developed to begin training pharmacists to use the measures with customers filling prescriptions at local pharmacies.  According to Dr. Pringle, “we expect to training about 240 pharmacists across 118 pharmacies in the western and central portions of Pennsylvania how to use the ORS and SRS…the program represents a collaboration between the University of Pittsburgh, CECity (a technology company), RiteAid, and Highmark ( a Blues insurer).”  Exciting stuff, eh?

Connecting, Learning, and Sharing: The ICCE at One Year

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September 7, 2010
Chicago, Illinois USA

I can’t believe it. Summer is over. Kids are back in school.  And, the International Center for Clinical Excellence (ICCE) is celebrating its one year anniversary!  Time passes so quickly.

On August 25th, 2009, I blogged about the creation of a web-based community of clinicians using the latest Web2.0 technology where participants could learn from and share with each other.  The ICCE website and community was officially launched the following December at the Evolution of Psychotherapy conference.  In a few short months, ICCE had become the largest, international online community of professionals, researchers, and policy makers working to improve the quality and outcome of behavioral health services.

So much more has happened over the last year, including the development and standardization of a training package for clinicians and agencies interested in streamlining the implementation of Feedback-Informed Treatment (FIT), the annual “training of trainers” conference, and much more.  Take a look at the video and see for yourself, and if you are not already a member, join us online today at: www.centerforclinicalexcellence.com.

A week or so ago, I received an email from Susanne Helfgott, the sister of concert pianist David Helfgott who, as you know, will be performing at the upcoming “Achieving Clinical Excellence” conference in Kansas City.  She sent me a link to an interview with David that appeared on Australian morning TV.  David is a perfect example of the theme of the conference: achieving superior performance under challenging circumstances.  Check it out:

Ohio Update: Use of CDOI improves outcome, retention, and decreases "board-level" complaints

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A few days ago, I received an email from Shirley Galdys, the Associate Director of the Crawford-Marion Alcohol and Drug/Mental Health Services Board in Marion, Ohio.  Back in January, I blogged about the steps the group had taken to deal with the cutbacks, shortfalls, and all around tough economic circumstances facing agencies in Ohio.  At that time, I noted that the dedicated administrators and clinicians had improved the effectiveness and efficiency of treatment so much by their systematic use of Feedback-Informed Treatment (FIT) that they were able to absorb cuts in funding and loss of staff without having to cut services to their consumers.

Anyway, Shirley was writing because she wanted to share some additional good news.  She’d just seen an advance copy of the group’s annual report.  “Since we began using FIT over two years ago,” she wrote, “board level complaints and grievances have decreased!”

In the past, the majority of such complaints have centered on client rights.  “Because of FIT,” she continued, “we are making more of an effort to explain to people what we can and cannot do for them as part of the ‘culture of feedback’….we took a lot for granted about what people understood about behavioral health care prior to FIT.”

The Crawford-Marion Alcohol and Drug/Mental Health Services Board is now into the second full year of implementation.  They are not merely surviving, they are thriving!  In the video below, directors Shirley Galdys, Bob Moneysmith, and Elaine Ring talk about the steps for a successful implementation.

Hope Transcends: Learning from our Clients

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“Hope Transcends” was the theme of the 39th Annual Summer Institute on Substance Abuse and Mental Health held in Newark, Delaware this last week.  I had the honor of working with 60+ clinicians, agency managers, peer supports, and consumers of mental health services presenting a two-day, intensive training on “feedback-informed clinical work.”  I met so many talented and dedicated people over the two days and even had a chance to reconnect with a number of folks I’d met at previous trainings– both at the Institute and elsewhere.

One person I knew but never had the privilege of meeting before was psychologist Ronald Bassman.  A few years back, he’d written a chapter that was included in my book, The Heroic Client.  His topic at the Summer Institute was similar to what he’d written for the book: harmful treatment.  Research dating back decades documents that approximately 10% of people deteriorate while in psychotherapy.  The same body of evidence shows that clinicians are not adept at identifying: (a) people who are likely to drop out of care; or (b) people who are deteriorating while in care.

Anyway, you can read about Ron on his website or pick up his gripping book A Fight to Be.  Briefly, at age 22 Ron was committed to a psychiatric hospital.  Over the next several years, he was diagnosed with paranoid schizophrenia and forcefully subjected to a series of humiliating, painful, degrading and ultimately unhelpful “treatments.”  Eventually, he escaped his own and the systems’ madness and became a passionate advocate for improving mental health services.  His message is simple: “we can and must do better.”  And, he argues persuasively, the process begins with building better partnerships with consumers.

One way to build bridges with consumers is routinely seeking their feedback regarding the status of the therapeutic relationship and progress of any services offered.  Indeed, the definition of “evidence-based practice” formally adopted by the American Psychological Association mandates that the clinician “monitor…progress…[and] If progress is not proceeding adequately…alters or addresses problematic aspects of the treatment (e.g., problems in the therapeutic relationship or the implementation of the goals of treatment)” (pp. 276-277, APA, 2006).  Research reviewed in detail on this blog documents significant improvement in both retention and outcome when clinicians use the Outcome and Session Rating Scales to solicit feedback from consumers.  Hope really does transcend.  Thank you Ron and thank you clinicians and organizers at the Institute.

And now, just for fun.  Check out these two new videos:


So you want to be a better therapist? Take a hike!

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How best to improve your performance as a clinician?  Take the continuing education multiple-choice quiz:

a. Attend a two-day training;
b. Have an hour of supervision from a recognized expert in a particular treatment approach;
c. Read a professional book, article, or research study;
d. Take a walk or nap.

If you chose a, b, or c, welcome to the world of average performance!  As reviewed on my blog (March 2010), there is exactly zero evidence that attending a continuing education event improves performance.  Zero.  And supervision?  In the most recent review of the research, researchers Beutler et al. (2005) concluded, “Supervision of psychotherapy cases has been the major method of ensuring that therapists develop proficiency and skill…unfortunately, studies are sparse…and apparently, supervisors tend to rate highly the performance of those who agree with them” (p. 246).  As far as professional books, articles, and studies are concerned–including those for which a continuing education or “professional development” point may be earned–the picture is equally grim.  No evidence.  That leaves taking a walk or nap!

K. Anders Ericsson–the leading researcher in the area of expertise and expert performance–points out the type and intensity of practice required to improve performance, “requires concentration that can be maintained only for limited periods of time.”  As a result, he says, “expert performers from many domains engage in practice without rest for only around an hour…The limit…holds true for a wide range of elite performers in difference domains…as does their increased tendency to recperative take naps”  (p.699, Erickson, 2006).  By the way, Ericsson will deliver a keynote address at the upcoming “Achieving Clinical Excellence” conference.  Sign up now for this event to reserve your space!


Two recently released studies add to the evidence base on rest and expertise.  The first, conducted at the University of California, Berkeley by psychologist Matthew Walker found that a midday nap markedly improved the brain’s learning capacity.  The second, published last week in the European Journal of Developmental Psychology, found that simply taking a walk–one where you are free to choose the speed–similarly improved performance on complex cognitive tasks.

So, there you go.  I’d say more but I’m feeling sleepy.