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Feedback Informed Treatment (FIT): A Worldwide Trend in Behavioral Health

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In my prior blogpost, I reviewed exciting developments taking place throughout Canada regarding “feedback-informed treatment” (FIT).  For those following me on Twitter–and if you’re not, please do so by clicking on the link–you already know that last week I was in Tunbridge, England for a two day training sponsored by the Kent-Medway National Healthcare Trust on “Supershrinks: Learning from the Fields Most Effective Practitioners.”  Interest in outcomes is growing exponentially, becoming a worldwide phenomenon.

It was a real pleasure being asked to work with the dedicated–and I must say, long-suffering–physicians, psychologists, counselors, social workers, and nurses of the NHS Trust.  I say “long-suffering” because these healthcare professionals, like others around the globe, are laboring to provide effective services while contending with a back breaking amount of paperwork, oversight, mandated treatment protocols, and regulation.

Much of the mess that behavioral health practitioners find themselves in is due to the way “good practice” is and has been conceptualized.  Simply put, the field–it’s researchers, visionaries, policy makers and sadly, many clinicians–are still stuck in the penicillin era, promoting specific treatments for specific disorders.  The result has been a growing list of protocols, fidelity and adherence measures, and other documentation requirements.  As pointed Bohanske and Franzcak point out in their excellent chapter on transforming behavioral health in the latest edition of The Heart and Soul of Change: Delivering What Works in Therapy, “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…altogether…weigh 1.4 ounces.  By contrast, the paperwork required for enrolling a single mother in counseling to talk about difficulties her child [is] experiencing [weigh] 1.25 pounds” (p. 300).

Something has to change, and that something is the incessant focus on controlling the process–or “how”– of treatment.  Instead, as the video interview below illustrates, emphasis can be placed on outcome.  Doing so will not only simplify oversight and regulation but, as an increasing number of studies show, result in improved “FIT” and effect of services offered.

 

O Canada! Leading the Way to Improved Behavioral Health Services

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Last month, I traveled back and forth between the United States and Canada several times.  First, I was in Edmonton working with several hundred dedicated social workers, case managers, and therapists at The Family Centre.  A week later I traveled to Saskatoon, spending two days talking about outcome-informed clinical work at the Addiction Professionals Association of Saskatchewan annual conference (Photos below are from the APASK meeting.  The first during the presentation, the second with Ruth and Laurel).

The evening following this event, I flew to Calgary where I spent the day with the clinical crew at Calgary Counseling Center.  I caught a red-eye home to Chicago and then returned to Canada the following week stopping over first in Vancouver for a workshop on drug and alcohol treatment sponsored by Jack Hirose & Associates and then continued on to Calgary where I met with the staff and managers of each program that comprises Aspen Family and Community Network Society.

The reason for all the frenetic activity?  A perfect storm has been brewing for some time that is culminating in a tidal wave of interest in using outcomes to inform and improve behavioral health services.  First and foremost: vision.  Specifically, key thought and action leaders not only embraced the idea of seeking feedback from consumers but worked hard to implement outcome-informed work in the settings in which they work: Bill Smiley at  The Family Centre, Robbie Babbins-Wagner at Calgary Counseling Center, and Kim Ruse at Aspen Family and Community Network Society.  Second, as I’ve been warning about for over a decade, one province in Canada–Alberta–passed an initiative which links future agency funding to “the achievement of outcomes.”  Indeed, “outcome” is identified as “the central driver for both case work practice and allocation of resources.”  Third, and finally, economic times are tough.  Payers–be they clients, insurance companies, or government bodies–want proof of a “return on investment” for the money spent on behavioral health services.

Needless to say, it was an inspiring month.  I managed to capture some of that in an interview I did with the director of the Calgary Counseling Center, Robbie Babbins-Wagner.  In it, she describes “why” she and CCC staff are committed to measuring outcomes as well as reviews the challenges involved.  Take a look:

Implementing Consumer-Driven, Outcome-Informed (CDOI) Behavioral Health Services: The ICCE and 2010 Training of Trainers Event

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This week I’m in Calgary, Canada. Last week, I was in Charleston, South Carolina. Next week, I’ll be in Marion, Ohio and Bay City, Michigan. In each instance, I’m working with the management and staff of public behavioral health agencies that are busy implementing consumer-driven, outcome-informed clinical work.

Some of the groups are just beginning the process.  Others, as reported here on my blog, have been at it long enough to document significant improvements in outcome, retention, and productivity (i.e., in Ohio and Virginia).  All have told me that implementing the seemingly simple ideas of outcome-informed practice is incredibly hard work–impacting nearly every aspect of agency life.  Being able to access the expertise and experience of fellow clinicians and agency directors in real time when questions and challenges arise is, I’ve also learned, critical in maintaining the momentum necessary for successful implementation.

Enter the ICCE: The International Center for Clinical Excellence.  Briefly, the ICCE is a web-based community of clinicians, researchers, agency managers, and policy makers dedicated to excellence in behavioral health.  Many of the groups I’m working with have joined the site providing them with 24/7/365 access to a deeply knowledgeable world-wide community.  In addition to the numerous topic-specific discussion groups and member-generated videos, organizations can set up private forums where management and clinicians can have confidential discussions and coordinate implementation efforts.

If you are a clinician or agency director and are not already a member, you and/or your organization can access the ICCE community today by visiting the website at: www.centerforclinicalexcellence.com.  Membership is free.  In the video below, I talk with Arjan Van der Weijde, about groups in Holland that are meeting on on the ICCE for practitioners to discuss their implementation of feedback-informed work in the Netherlands.  Check it out.

I’ve also included a brief video about the upcoming “Training of Trainers” course, held each year in August in Chicago.  As in prior years, professionals from all over the world will be joining me and the state-of-the-art faculty for four intensive days of training.  Agencies both public and private, in the U.S. and abroad, are sending staff to the event to learn the skills necessary to lead transformation projects.  Space is already limited so register soon.

The Training of Trainers

The Road to Clinical Excellence is Paved with Practice, Mistakes, & Hard Work

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Last week, I received an email from David Claud.  I’ve known Dave for the better part of a decade, having met–I believe–at a Ericksonian Conference in Florida where he lives and works.  He and the crew at the Center for Family Service in Palm Beach County figure prominently in the history of routine outcome measure and feedback.  After hearing me speak, Dave took the measures back to the center and, together with the staff, became one of the first agencies in the country to formally adopt and use the ORS and SRS.  Additionally, data gathered at CFS was used in some of the initial validation studies of the measures.  Finally, their own research, cited in the second edition of The Heart and Soul of Change document dramatic improvements in outcome as well as decreased lengths of stay, cancellation and no show rates (40, 40, and 25% respectively).

Anyway, in his email, Dave included a link to a recent article by Ann Hulbert in Slate magazine.  I’m lucky to have friends like Dave and others who keep me informed and up-to-date.  The title of the piece certainly got my attention: “The Dark Side of the New Theories of Success: What the New Success Books Don’t tell you about Superachievement.”

As readers of my blog know, I’ve been pouring through the literature on excellence over this last year in an attempt to understand why some clinicians achieve reliably better outcomes than others.  I first wrote about our findings in an article titled, “Supershrinks: Learning from the Field’s Most Effective Practitioners” that appeared in the Psychotherapy Networker.  Since then, I’ve continued to work and research, together with senior associates at the International Center for Clinical Excellence, to deepen and refine the “steps to clinical excellence” that any therapist could follow to improve performance.

Alas, I’m not alone in my interest in the literature on expertise.  A number of books, starting with Gladwell’s delightfully engaging Outliers, have appeared in the last year or so on the subject, including: The Talent Code, Bounce: The Science of Success, The Genius in All of Us: Why Everything You’ve Been Told About Genetics, Talent, and IQ Is Wrong and my personal favorite Talent Is Overrated: What Really Separates World-Class Performers from Everybody Else.  The appearance of so many books is interesting.  With few exceptions (i.e., sports psychology), K. Anders Erickson and colleagues labored in viritual academic obscurity for decades formulating hypotheses, conducting research and assembling evidence.  And then suddenly: boom!  EVERYBODY is talking about their work.

Always wanting to “hear” both sides of the story, I immediately clicked on the link in Dave’s email and read the article.  I was dumbfounded.  Hulbert’s gripe about the recent spate of books is in fact the central point of each: achieving superior performance in any field is bloody hard work.  “They don’t always do realistic justice to the grunt work they champion,” whines Hulbert, tending instead to, “gloss over the sweaty specifics….distracting us from how arduous, tedious, and dependent on adult pushiness it can be…[and] glamorizing its intensity.”

My response: “Oh, contraire mon fraire!”

All of the books and research studies point to the years of dedicated and painstaking work involved in achieving world class levels of performance across a variety of domains (sports, music, medicine, computer programming, and psychology).  K. Ander’s Erickson–who will, by the way, be one of the keynote presenters at the upcoming “Achieving Clinical Excellence” conference–is fond of saying, “Unlike play, deliberate practice is not inherently motivating; and unlike work, it does not lead to immediate social and monetary rewards…and actually generates costs…”.  Little wonder few of us–myself included–engage in it on any regular basis.

The question that begs an answer is, “why would anyone do it?”  Consider the brief video clip below:

Impressive, huh?  I can’t imagine the amount of time it must have taken to master such a performance.  No camera tricks. Just plain old fashioned trial-and-error, practice, and hard work.

We are finding the same pattern among top performing therapists.  In short, they have an “error-centric” approach to practice–constantly looking for what they do that doesn’t work and taking time to plan, identify and try alternatives, and then reflect and refine their process-improvement efforts.  Such activity is cognitively taxing and, in most instances, not immediately rewarding (financially or otherwise).  But there is more to the story.  It turns out that superior performance is not a matter of working harder.  Most of us work hard at our jobs.  Rather, becoming a better clinician is about working smarter.   Here, the literature on expertise provides clear, empirically-supported guidelines.

If you’re feeling inspired, why not pick up one of the books?  Also, be sure and join us at the upcoming “Achieving Clinical Excellence” conference where the ideas and steps will be discussed in detail.

More Eruptions (in Europe and in Research)

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Dateline: Tuesday, 8:21pm, April 20th, 2010, Skellefteå, Sweden

What an incredible week.  Spent the day today working with 250 social workers, case managers, psychologists, psychiatrists, and agency directors in the far nothern town of Skellefteå, Sweden.  Many practitioners here are already measuring outcomes on an ongoing basis and using the information to improve the results of their work with consumers of behavioral health services.  Today, I presented the latest findings from ICCE’s ongoing research on “Achieving Clinical Excellence.”

I’ve been coming to the area to teach and consult since the early 1990’s, when I was first invited to work with Gun-Eva Langdahl and the rest of the talented crew at Rådgivningen Oden (RO).  As in previous years, I spent my first day (Monday) in Skellefteå watching sessions and working with clients at RO clinic.  Frankly, getting to Skellefteå from Goteborg had been a bit of ordeal.  What usually took a little over an hour by plane ended up being a 12-hour combination of cars, trains, and buses–all due to volcanic eruptions on Iceland.  (I shudder to think of how I will get from Skellefteå to Amsterdam on Wednesday evening if air travel doesn’t resume).

Anyway, the very first visit of the day at Rådgivningen Oden was with an adolescent and her parents.  Per usual, the session started with the everyone completing and discussing the Outcome Rating Scale.  The latest research reported in the April 2010 edition of Journal of Consulting and Clinical Psychology (JCCP) confirms the wisdom of this practice: measuring and discussing progress with consumers at every visit results in better outcomes.

It turns out that adolescents are at greater risk for deteriorating in treatment than adults (20% versus 10%).  Importantly, the study in JCCP by Warren, Nelson, Mondragon, Baldwin, and Burlingame found that the more frequently measures are used the less likely adolescents are to worsen in care.  Indeed, as ICCE Senior Associate Susanne Bargmann pointed out in a series of recent emails about this important study, “routinely tracking and discussing progress led to 37% higher recovery rates and 38% lower rates of deterioration!”

Skellefteå is a hotbed of feedback-informed practice in Sweden.  Accompanying the family at Rådgivningen Oden, for example, were professionals from a number of other agencies involved in the treatment and wanting to learn more about outcome-informed practice.  As already noted, 250 clinicians took time away from their busy schedules to hear the latest information and finesse their use of the measures.  And tomorrow, Wednesday, I meet with managers and directors of behavioral health agencies to discuss steps for successfully implementing routine measurement of progress and feedback in their settings.  You can download a video discussing the work being done by the team at Odin in Northern Sweden, by clicking here.

Stay tuned for more.  If all goes well, I’ll be in Amsterdam by Wednesday evening.

Eruptions in Europe and in Research

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Dateline: 11:20 am, April 18th, 2010

Today I was supposed to fly from Stockholm, Sweden to the far northern town of Skelleftea–a flight that takes a little over an hour.  Instead, I’m sitting on a train headed for Sundsvall, the first leg of a 12 hour trip that will include a 6 hour bus ride and then a short stint in a taxi.

If you’ve been following the news coming out of Europe, you know that all flights into, out of, and around Europe have been stopped. Eyjafjallajokull–an Icelandic volcano–erupted the day after I landed in Goteborg spewing an ash cloud that now covers most of Europe disrupting millions of travellers.  People are making due, sleeping on cots in airline, train, and bus terminals and using Facebook and Twitter to connect and arrange travel alternative.

In the meantime, another eruption has taken place with the publication of the latest issue of the Journal of Consulting and Clinical Psychology that threatens to be equally disruptive to the field of psychotherapy–and to proponents of the narrow, specific-treatments-for-specific-disorders or “evidence-based treatments” movement.   Researchers Webb, DeRubeis, and Barber conducted a meta-analysis of studies examining the relationship between adherence to and competence in delivering a particular approach and outcome.  The authors report finding that, “neither adherence nor competence was…related to patient (sic) outcome and indeed that the aggregate estimates of their effects were very close to zero.”

Zero!  I’m not sure what zero means to everyone else, but where I come from it’s pretty close to nothing.  And yet, the romance with the EBT movement continues among politicians, policy makers, and proponents of specific treatment models.  Each year, millions and millions of dollars of scarce resources are poured into an approach to behavioral health that accounts for exactly 0% of the results.

Although it was not a planned part of their investigation, the must-read study by Webb, DeRubeis, and Barber also points to the “magma” at the heart of effective psychotherapy: the alliance, or quality of the relationship between consumer and provider.  The authors report, for example, finding “larger competence-outcome effect size estimates [in studies that]…did not control for the influence of the alliance.”

The alliance will take center stage at the upcoming, “Achieving Clinical Excellence” and “Training of Trainers” events.  Whatever you thought you knew about effective therapeutic relationships will be challenged by the latest research from our study of top performing clinicians worldwide.  I hope you’ll join our international group of trainers, researchers, and presenters by clicking on either of the links above.  And, if you’ve not already done so, be sure and visit the International Center for Clinical Excellence home page and request an invitation to join the community of practitioners and researchers who are learning and sharing their expertise.

Where Necessity is the Mother of Invention: Forming Alliances with Consumers on the Margins

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Spring of last year, I traveled to Gothenburg, Sweden to provide training GCK–an top notch organization led by Ulla Hansson and Ulla Westling-Missios providing cutting-edge training on “what works” in psychotherapy.  I’ll be back this week again doing an open workshop and an advanced training for the group.

While I’m always excited to be out and about traveling and training, being in Sweden is special for me.  It’s like my second home.  My family roots are Swedish and Danish and, it just so happens, I speak the language.  Indeed, I lived and worked in the country for two years back in the late seventies.  If you’ve never been, be sure and put it on your short list of places to visit…

AND IMPORTANTLY, go in the Summer!  (Actually, the photos above are from the famous “Ice Hotel”–that’s right, a hotel completely made of icc.  The lobby, bar, chairs, beds.  Everything!  If you find yourself in Sweden during the winter months, it’s a must see.  I promise you’ll never forget the experience).

Anyway, the last time I was in Gothenburg, I met a clinician whose efforts to deliver consumer-driven and outcome-informed services to people on the margins of society were truly inspiring.   During one of the breaks at the training, therapist Jan Larsson introduced himself, told me he had been reading my books and articles, and then showed me how he managed to seek and obtain feedback from the people he worked with on the streets.  “My work does not look like ‘traditional’ therapeutic work since I do not meet clients at an office.  Rather, I meet them where they live: at home, on a bench in the park, or sitting in the library or local activity center.”

Most of Jan’s clients have been involved with the “psychiatric system” for years and yet, he says, continue to struggle and suffer with many of the same problems they entered the system with years earlier.  “Oftentimes,” he observed, “a ‘treatment plan’ has been developed for the person that has little to do with what they think or want.”

So Jan began asking.  And each time they met, they also completed the ORS and SRS–“just to be sure,” he said.  No computer.  No I-phone app.  No sophisticated web-based adminsitration system.  With a pair of scissors, he simply trimmed copies of the measures to fit in his pocket-sized appointment book.

His experience thusfar?  In Swedish Jan says, “Det finns en livserfarenhet hos klienterna som bara väntar på att bli upptäckt och bli lyssnad till. Klienterna är så mycket mer än en diagnos. Frågan är om vi är nyfikna på den eftersom diagnosen har stulit deras livberättelse.”  Translated: “There is life experience with clients that is just waiting to be noticed and listened to.  Clients are so much more than their diagnosis.  The question is whether we are curious about them because the diagnosis has stolen their life story.”

I look forward to catching up Jan and the crew at GKC this coming week.  I also be posting interviews with Ulla and Ulla as well as ICCE certified trainers Gun-Eva Langdahl (who I’ll be working with in Skelleftea) and Gunnar Lindfeldt (who I’ll be meeting in Stockholm).  In the meantime, let me post several articles he sent by Swedish research Alain Topor on developing helpful relationships with people on the margins.  Dr. Topor was talking about the “recovery model” among people considered “severely and persistently mentally ill long before it became popular here in the States. Together with others, such as psychologist Jan Blomqvist (who I blogged about late last year), Alain’s work is putting the consumer at the center of service delivery.

Improving Outcomes in the Treatment of Obesity via Practice-Based Evidence: Weight Loss, Nutrition, and Work Productivity

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Obesity is a large and growing problem in the United States and elsewhere.  Data gathered by the National Center for Health Statistics indicate that 33% Americans are obese.  When overweight people are added to the mix, the figure climbs to a staggering 66%!   The problem is not likely to go away soon or on its own as the same figures apply to children.

Researchers estimate that weight problems are responsible for over 300,000 deaths annually and account for 12% of healthcare costs or 100 billion–that’s right, $100,000,000,000–in the United States alone.   The overweight and obese have higher incidences of arthritis, breast cancer, heart disease, colorectal cancer, diabetes, endometrial cancer, gallbladder disease, hypertension, liver disease, back pain, sleeping problems, and stroke–not to mention the tremendous emotional, relational, and social costs.  The data are clear: the overweight are the target of discrimination in education, healthcare, and employment.  A study by Brownell and Puhl (2003), for example, found that: (1) a significant percentage of healthcare professionals admit to feeling  “repulsed” by obese person, even among those who specialize in bariatric treatment; (2) parents provide less college support to their overweight compared to “thin” children; and (3) 87% of obese individuals reported that weight prevented them from being hired for a job.

Sadly, available evidence indicates that while weight problems are “among the easiest conditions to recognize,” they remain one of the “most difficult to treat.”  Weight loss programs abound.  When was the last time you watched television and didn’t see an ad for a diet pill, program, or exercise machine?  Many work.  Few, however, lead to lasting change.

What might help?

More than a decade ago, I met Dr. Paul Faulkner, the founder and then Chief Executive Officer of Resources for Living (RFL), an innovative employee assistance program located in Austin, Texas.  I was teaching a week-long course on outcome-informed work at the Cape Cod Institute in Eastham, Massachusetts.  Paul had long searched for a way of improving outcomes and service delivery that could simultaneously be used to provide evidence of the value of treatment to purchasers–in the case of RFL, the large, multinational companies that were paying him to manage their employee assistance programs.  Thus began a long relationship between me and the management and clinical staff of RFL.  I was in Austin, Texas dozens of times providing training and consultation as well as setting up the original ORS/SRS feedback system known as ALERT, which is still in use at the organization today.  All of the original reliability, validity, norming, and response trajectories were done together with the crew at RFL.

Along the way, RFL expanded services to disease management, including depression, chronic obstructive pulmonary disease, diabetes, and obesity.  The “weight management” program delivered coaching and nutritional consultation via the telephone informed by ongoing measurement of outcomes and the therapeutic alliance using the SRS and ORS.  The results are impressive.  The study by Ryan Sorrell, a clinician and researcher at RFL, not only found that the program and feedback led to weight loss, but also significant improvements in distress, health eating behaviors (70%), exercise (65%), and presenteeism on the job (64%)–the latter being critical to the employers paying for the service.

Such research adds to the growing body of literature documenting the importance of “practice-based” evidence, making clear that finding the “right” or “evidence-based” approach for obesity (or any problem for that matter) is less important than finding out “what works” for each person in need of help.  With challenging, “life-style” problems, this means using ongoing feedback to inform whatever services may be deemed appropriate or necessary.  Doing so not only leads to better outcomes, but also provides real-time, real-world evidence of return on investment for those footing the bill.

Neurobabble Redux: Comments from Dr. Mark Hubble on the Latest Fad in the World of Therapy Spark Comment and Controversy

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Last week, my long time colleague and friend, Dr. Mark Hubble blogged about the current interest of non-medically trained therapists in the so-called “neurobiology of human behavior.”  In my intro to his post, I “worried” out loud about the field’s tendency to search for legitimacy by aligning with the medical model.  Over the years, psychotherapy has flirted with biology, physics, religion, philosophy, chaos, and “energy meridians” as both the cause of what ails people and and the source of psychotherapy’s effectiveness.

For whatever reason, biological explanations have always had particular cachet in the world of psychotherapy.  When I first entered the field, the “dexamethasone suppression test” was being touted as the first “blood test” for depression.  Some twenty years on, its hard to remember the hope and excitement surrounding the DST.

Another long-time friend and colleague, psychologist Michael Valentine is fond of citing the many problems–social, physical, and otherwise–attributed to genetics (including but not limited to: anxiety, depression, addictions, promiscuity, completed suicides, thrill seeking obscene phone calls, smoking, gambling, and the amount of time one spends watching TV) for which there is either: (a) precious little or inconsistent evidence; or (b) the variance attributable to genetics is small and insignificant compared to size and scope of the problem.

In any event, I wanted to let readers know that response to Mark’s post has been unusually strong.  The numerous comments can be found on the syndicated version of my blog at the International Center for Clinical Excellence.  Don’t miss them!

Outcomes in New Zealand

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Made it back to Chicago after a week in New Zealand providing training and consultation.  As I blogged about last Thursday, the last two days of my trip were spent in Christchurch providing a two-day training on “What Works” for Te Pou–New Zealand’s National Centre of Mental Health Research, Information, and Workforce Development.  Last year around this same time, I provided a similar training for Te Pou for managers and policy makers in Auckland.  News spread and this year my contact at Te Pou, Emma Wood brought the training to the south island.  It is such a pleasure to be involved with such a forward thinking organization.

Long before I arrived, leadership at Te Pou were promoting outcome measurement and feedback.  Here’s a direct quote from their website:

Outcomes information can assist:

  • service users to use their own outcomes data to reflect on their wellbeing and circumstances, talk to clinicians about their support needs and inform their recovery plans
  • clinicians to use outcomes information to support their decision-making in day-to-day practice, monitoring change, better understanding the needs of the service user, and also to begin evaluating the effectiveness of different interventions
  • planners and funders to assess population needs for mental health services and assist with allocation of resources policy and mental health strategy developments through nationally aggregated data.

Indeed, using outcome to inform mental health service delivery is a key aspect of the Past, Present, and Future: Vision Paper–a review of “what works” in care and a plan for improving treatment in the future.  The site even publishes a quarterly newsletter Outcomes Matter.  Take a few minutes and explore the Te Pou website.  While you are there, be sure and download the pamphlet entitled, “A Guide to Talking Therapies.”  As the title implies, this brief, easy-to-read text provides a non-nonsense guide to the various “talk therapies” for consumers (I took several copies home with me from the workshop).

Before ending, let me say a brief hello to the Clinical Practice Leaders from the Problem Gambling Foundation of New Zealand who attended the two-day training in Christchurch.    The dedicated staff use an integrated public health and clinical model and are working to implement ongoing measurement of outcome and consumer feedback into service delivery.  The website contains a free online library including fact sheets, research, and books on the issue of problem gambling that is an incredible resource to professionals and the public.  Following the workshop, the group sent a photo that was taken of us together.  From left to right, they are Wenli Zhang, me, Margaret Sloan, and Jude West.

Excellence on a Shoestring: The “Home for Good” Program

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Today I’m teaching in Christchurch, New Zealand. For the last two days, I’ve been in Nelson, a picturesque coastal town opposite Abel Tasman, working with the local DHB (District Health Board). If you’ve never visited, make a point of adding the country to your list of top travel destinations. The landscape and the people are second to none. (In Nelson, be sure and visit The Swedish Bakery. My 8-year old son, Michael, unequivocally states it has the best hot chocolate in the world—and, believe me, he’s an expert).

I’ve been traveling to New Zealand at least once a year for the last several years to provide training on using outcomes to inform behavioral healthcare. Interest is keen and providers and managers are working hard to deliver top-notch services. However, like many other places around the globe, economic factors are taking a toll.   On the day I arrived, one of the lead stories in the local paper (The Nelson Mail) focused on the economic crisis in healthcare.   “Complaints about money, shortages, overwork, stress and unsympathetic management…in the always-stretched hospital service,” the story began, “[indicate] a rapidly worsening situation” (p. 5, News Extra). Today, the headline of an article in section A5 of The Press Christchurch warns, “Health Ministry staff brace for job losses.”

A little over two weeks ago, I was in Richmond, Virginia working with managers and providers of public behavioral health agencies. There too, economic problems loom large. Over the last two years, for example, agencies have had to absorb across-the-board, double-digit cuts in funding. The result, in many instances, has been layoffs and the elimination of services and programs—with a few prominent exceptions.

On March 5th, I blogged about the crew at Chesterfield CSB in Virginia that were serving 70% more people than they did in 2007 despite there being no increase in available staff resources in the intervening period and, at the same time, decreasing clinician caseloads by nearly 30%.  In January, I posted text and video about agencies in Ohio that had managed to improve outcome, retention, and productivity at the same time that cutbacks had forced the furlough of staff! The common denominator in both instances is outcomes; that is, measuring the “fit and effect” of treatment on an ongoing basis and then using the data in consultation with consumers to improve service delivery.

If you’re not yet convinced, I have one more example to add to the mix: the “Home for Good” program.  Vision, commitment, and drive are words that best capture the management and staff who work at this Richmond, Virginia-based in-home behavioral health services program. Some might question the wisdom of starting a private, primarily Medicaid-funded treatment program in the worst economic climate since the Great Depression. A commitment to helping families keep their children at home—preventing placement in residential treatment centers, foster care, and detention—is what drove founder and director Kathy Levenston to take up the challenge. The key to their success says Kathy is that “we take responsibility for the results.” As in Ohio and Chesterfield, Kathy and her crew routinely monitor the alliance and results of the work they do and then use the data to enhance retention and outcome. Listen to Kathy as she describes the “Home for Good” program. I’m sure her story will inspire you to push for excellence whatever the “shoestring” budget you may be surviving on at the moment.

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

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

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

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

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

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

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

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

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

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

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

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

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

The Future of Behavioral Health: Integrated Care & Entrepreneurship

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Nicholas Cummings, Ph.D.

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

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

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

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

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

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

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

Chief Technology Officer Enda Madden    Chief Executive Officer Brendan Madden

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


School of Letters and Sciences

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

The Turn to Outcomes: A Revolution in Behavioral Health Practice

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


Jay Lebow, Ph.D.

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


David Barlow, Ph.D.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Dateline: Mosjoen, Norway

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

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

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

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

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

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

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

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January 11th, 2010

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

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

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

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

"What Works" in Norway

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Dateline: Tromso, Norway
Place: Rica Ishavshotel

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

Are all treatments approaches equally effective?

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Bruce Wampold, Ph.D.

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

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

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

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

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

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

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

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

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

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

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

Magical Moments in Kansas

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

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

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

michael ammart

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

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

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

 

New Year’s Resolutions: Progress Report and Future Plans

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

“Was I no longer interested in psychotherapy?”

“Had I given up on the common factors?

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

Seriously.

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

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

The subject? Magic (and the ukulele).

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Holidays and Suicide: Tis’ the Season NOT!

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

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

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

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

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

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

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

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

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

Stay tuned for more…

The Evolution of Psychotherapy: Meeting Michael Hoyt

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

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

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