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The Illness and the Cure: Two Free, Evidence-based Resources for What Ails and Can Heal Serious Psychological Distress

April 18, 2017 By scottdm 14 Comments

141030125424-mental-illness-hands-on-head-live-videoFindings from several recent studies are sobering. Depression is now the leading cause of ill-health and disability worldwide–more than cancer, heart disease, respiratory problems, and accidents.  Yesterday, researchers reported that serious psychological distress is at an all-time high, significantly affecting not only quality but actual life expectancy.  And who has not heard about the opioid crisis–33,000 deaths in the U.S. in 2015 and rising?

The research is clear:  psychotherapy helps.  Indeed, its effectiveness is on par with coronary artery bypass surgery.  Despite such results, availability of mental health services in the U.S. and other Westernized nations has seriously eroded over the last decade.   Additionally, modern clinical practice is beset by regulation and paperwork, much of which gets in the way of treatment’s most important healing ingredient: the relationship.

What can practitioners do?Students Taking Notes at Desks by VCU_Brandcenter

Completing paperwork together with clients during the visit–a process termed, “collaborative (or concurrent) documentation”–has been shown to save full-time practitioners between 6 and 8 hours per week, thereby improving capacity up to 20%.

It’s a great idea: completing assessments, treatment plans, and progress notes together with clients during rather than after the session. Unfortunately, it’s chief selling point to date seems to be that it saves time on documentation–as though filling out paperwork is an end in and of itself!  Clearly, the real challenges facing mental health services are getting people into and keeping them in care.   Here, the research literature is clear, people are more likely to stay engaged in care that is: (1) organized around their goals; and (2) works.  Collaborating on and coming to a consensus regarding the goals for treatment, for example, has the largest impact on outcome among all of the relationship factors in psychotherapy, including empathy!  Additionally, when documentation FITs the clients’ view of the process and is deemed transparent and respectful, trust–another essential ingredient of the therapeutic relationship–improves.

For the last several years, practitioners and agencies around the world have been using the ICCE “Service Delivery Agreement” and “Progress Note” as part of their documentation of clinical services.  Both were specifically designed to be completed collaboratively with clients at the time the service is provided and both are focused on documenting what matters to people in treatment.  Most important of all, however, both are part of an evidence-based process documented to improve engagement and effectiveness listed on SAMHSA’s National Registry of Evidence-based Programs and Practices.

For the next short while, I’ll send you the forms for free, along with a detailed instruction booklet for incorporating them into your clinical work.  Reduce the “paper curtain” in your practice.  Just email me at scottdmiller@talkingcure.com.   Better yet, register for our upcoming intensive trainings this summer in Chicago.  Click on any of the course icons to the right for detailed information.

Until next time,

Scott

Scott D. Miller, Ph.D.
Director, International Center for Clinical Excellence
Scott D. Miller - Australian Drug and Alcohol Symposium

Filed Under: Behavioral Health, CDOI, Conferences and Training, excellence, Feedback Informed Treatment - FIT, FIT, Implementation

Does practice make perfect?

August 30, 2016 By scottdm 1 Comment

michael ammart“Practice does not make perfect,” my friend, and award-winning magician, Michael Ammar, is fond of saying.  “Rather,” he observes, “practice makes permanent.”

Thus, if we are not getting better as we work, our work will simply insure our current performance stays the same.

Now, before reading any further, watch a bit of the video below.  It features Diana Damrau singing one of the most recognizable arias from Mozart’s, “The Magic Flute.”  Trust me, even if you don’t like opera, this performance will make the hair on your neck stand on end.

All right, now click on the video below (and listen for as long as you can stand it).

No, the latter recording is not a joke.  Neither is it a reject from one of the “GOT TALENT” shows so popular on TV at present.  It’s none other than Florence Jenkins—an American socialite and heiress who was, according to Wikipedia, “a prominent musical cult figure…during the 1920’s, ‘30’s, and 40’s.”

Florence Jenkins

How could that be, you may well wonder?  Her pitch is off, and there are so many mistakes in terms of rhythm, tempo, and phrasing in the first 30 seconds, one quickly loses count.

The problem?  In a word, feedback—more specifically, the lack of critical feedback extending over many years.

For most of her career, Lady Florence, as she liked to be called, performed to “select audiences” in her home or small clubs. Attendance was invitation-only–and Jenkins controlled the list.  Her guests did their best not to let on what they tought of her abilities.  Instead, they smiled approvingly and applauded–loudly as it turns out, in an attempt to cover the laughter that invariably accompanied her singing!

Jenkins performanceEverything changed in 1944 when Jenkins booked Carnegie Hall for a public performance. This time, the applause was not sufficient to cover the laughter.  If anything, it followed, treating the performance as a comedy act, and encouraging the singer to continue the frivolity.

The reviews were scathing.  The next morning, the critic for the New York Sun, wrote, Lady Florence, “…can sing everything…except notes…”

The moral of the story?  Practice is not enough.  To improve, feedback is required.  Honest feedback–and the earlier in the process, the better.  Research indicates the keys to success are: (1) identifying performance objectives that lie just beyond an individuals current level of reliable achievement; (2) immediate feedback; and (3) continuous effort aimed at gradually refining and improving one’s performance.

Here’s the parallel with psychotherapy: the evidence shows therapist self-appraisal is not a reliable measure of either the quality or effectiveness of their work.  Indeed, a number of studies have found that, when asked, the least effective clinicians rate themselves on par with the most effective–a finding that could well be labelled, “Jenkin’s Paradox.”

Evidence-based measures exists which can help therapists avoid the bias inherent in self-assessment as well as aid in the identification of small, achievable performance improvement objectives.  A recent study documented, for example, how therapists can use such tools, in combination with immediate feedback and practice, to gradually yet significantly improve the quality and effectiveness of their therapeutic relationships–arguably, the most important contributor to treatment outcome.  Using the tools to improve outcome and engagement in psychotherapy will be the focus of the upcoming ICCE webinar.  It’s a simply way to get started, or to refine your existing knowledge.  Learn more or register online by clicking here.

Let me leave you with one last video.  It’s an interview I did with Danish psychologist Susanne Bargmann.  Over the last 5 years, she’s applied the principles described here in an attempt to not only improve her effectiveness as a clinician, but also in music.  Recently, her efforts came to the attention of the folks at Freakonomics radio.  As was the case when you listened to Diana Damrau, you’ll come away inspired!

Until next time,

Scott

Scott D. Miller, Ph.D.
Director, International Center for Clinical Excellence
ICCE Fall WEbinar

 

 

 

Filed Under: CDOI, evidence-based practice, Feedback Informed Treatment - FIT, FIT, Top Performance

Making the Impossible, Possible: The Fragile Balance

July 25, 2016 By scottdm 1 Comment

Trip-Advisor scores it # 11 out of 45 things to do Sausalito, California.  No, it not’s the iconic Golden Gate Bridge or Point Bonita Lighthouse.  Neither is it one of the fantastic local restaurants or bars.  What’s more, in what can be a fairly pricey area, this attraction won’t cost you a penny.   It’s the gravity-defying rock sculptures of local performance artist, Bill Dan.

bill dan

So impossible his work seems, most initially assume there’s a trick: magnets, hooks, cement, or pre-worked or prefab construction materials.

Dan 1

Watch for a while, get up close, and you’ll see there are no tricks or shortcuts.  Rather, Bill Dan has vision, a deep understanding of the materials he works with, and perseverance.  Three qualities that, it turns out, are essential in any implementation.

Over the last decade, I’ve had the pleasure of working with agencies and healthcare systems around the world as they work to implement Feedback-Informed Treatment (FIT).  Not long ago, FIT–that is, formally using measures of progress and the therapeutic alliance to guide care–was deemed an evidence-based practice by SAMHSA, and listed on the official NREPP website.  Research to date shows that FIT makes the impossible, possible, improving the effectiveness of behavioral health services, while simultaneously decreasing costs, deterioration and dropout rates.

Dan 2

 

Over the last decade, a number of treatment settings and healthcare systems have beaten the odds.  Together with insights gleaned from the field of Implementation Science, they are helping us understand what it takes to be successful.

One such group is Prairie Ridge, an integrated behavioral healthcare agency located in Mason City, Iowa.  Recently, I had the privilege of speaking with the clinical leadership and management team at this cutting-edge agency.

Click on the video below to listen in as they share the steps for successfully implementing FIT that have led to improved outcomes and satisfaction across an array of treatment programs, including residential, outpatient, mental health, and addictions.

Until next time,

Scott D. Miller, Ph.D.
Director, International Center for Clinical Excellence
Scott D Miller Symposium bg3

P.S.: Looking for a way to learn the principles and practice of Feedback Informed Treatment?  No need to leave home.  You can learn and earn CE’s at the ICCE Fall FIT Webinar.  Register today at: https://www.eventbrite.ie/e/fall-2016-feedback-informed-treatment-webinar-series-tickets-26431099129.

ICCE Fall WEbinar

 

Filed Under: behavioral health, CDOI, evidence-based practice, Feedback Informed Treatment - FIT, Practice Based Evidence

Why aren’t therapists talking about this?

June 20, 2016 By scottdm 8 Comments

shhTurns out, every year, for the last several years, and right around this time, I’ve done a post on the subject of deterioration in psychotherapy.  In June 2014, I was responding to yet another attention-grabbing story published in The Guardian, one of the U.K.’s largest daily newspapers. “Misjudged counselling and therapy can be harmful,” the headline boldly asserted, citing results from “a major new analysis of outcomes.” The article was long on warnings to the public, but short on details about the study.  In fact, there wasn’t anything about the size, scope, or design.  Emails to the researchers were never answered.  As of today, no results have appeared in print.

One year later, I was at it again—this time after seeing the biopic Love & Mercy, a film about the relationship LOVE-MERCY-POSTER-1308x1940 between psychologist Eugene Landy and his famous client, Beach Boy Brian Wilson. In a word, it was disturbing.  The psychologist did “24-hour-a-day” therapy, as he termed it, living full time with the singer-songwriter, keeping Wilson isolated from family and friends, and on a steady dose of psychotropic drugs while simultaneously taking ownership of Wilson’s songs, and charging $430,000 in fees annually. Eventually, the State of California intervened, forcing the psychologist to surrender his license to practice.  As egregious as the behavior of this practitioner was, the problem of deterioration in psychotherapy goes beyond the field’s “bad apples.”

bad-appleDo some people in therapy get worse? The answer is, most assuredly, “Yes.” Research dating back several decades puts the figure at about 10% (Lambert, 2010). Said another way, at termination, roughly one out of ten people are functioning more poorly than they were at the beginning of treatment. Despite claims to the contrary (e.g., Lilenfeld, 2007), no psychotherapy approach tested in a clinical trial has ever been shown to reliably lead to or increase the chances of deterioration. NONE. Scary stories about dangerous psychological treatments are limited to a handful of fringe therapies–approaches that have been never vetted scientifically and which all practitioners, but a few, avoid.

So, what is the chief cause of deterioration in treatment?norw-MMAP-md Norwegian psychologist Jørgen A. Flor just completed a study on the subject. We’ve been corresponding for a number  of year as he worked on the project.  Given the limited information available, I was interested.

What he found may surprise you. Watch the video or click here to read his entire report (in Norwegian).  Be sure and leave a comment!

Until next time,

Scott

Scott D. Miller, Ph.D.
Director, International Center for Clinical Excellence

Scott Abbey Road.jpg

Filed Under: Behavioral Health, CDOI, Conferences and Training, evidence-based practice

Something New

October 8, 2014 By scottdm 1 Comment

something new ICCE

Actually, it’s more accurate to say, “Everything is new!”  The International Center for Clinical Excellence is coming up on its fifth birthday!   Since its launch in 2010, the ICCE has become the largest, online community of behavioral health practitioners and researchers in the world.  To celebrate, we are launching an entirely new web platform.   All the features you’ve come to expect remain—the discussions with colleagues, the document library, the commercial free atmosphere.   At the same time, everything has been streamlined, made faster, easier, and more intuitive.  Log in today!   Join a forum.  Start a conversation.  Share a presentation or paper with others. As you can see my own website has been completely redone.  The “Top Performance” blog is now front and center.  Plug in your email address and you’ll get regular updates regarding how to improve your effectiveness.   As always, my articles, books, video and audio materials are available with the click of a button.  You can also find an up-to-date schedule of workshops and intensive trainings in feedback informed treatment (FIT).

PCOMS - Partners for change outcome management system Scott D Miller - SAMHSA - NREPP Speaking of FIT, have you visited the www.whatispcoms.com website?  It’s the official website for ICCE’s Partners for Change Outcome Management System.  Here you can learn everything you need to know to get started using the feedback process documented to improve effectiveness and approved by SAMHSA as an evidence-based practice.  What’s new?  Thanks to ICCE members around the world, the site is available in five different languages, including: English, Dutch, Swedish, Norwegian, and Danish.   Until next time!

Filed Under: CDOI, Feedback Informed Treatment - FIT, FIT, ICCE Tagged With: icce, top performance

Did you know your clients can tell if you are happy?

January 19, 2014 By scottdm 3 Comments

Are_You_Happy

It’s true.  Adding to a growing literature showing that the person of the therapist is more important than theoretical orientation, years of experience, or discipline, a new study documents that clients are sensitive to the quality of their therapist’s life outside of treament.  In short, they can tell when you are happy or not.  Despite our best efforts to conceal it, they see it in how we interact with them in therapy.  By contrast, therapists’ judgements regarding the quality of the therapy are biased by their own sense of personal well-being. The solution?  Short of being happy, it means we need to check in with our clients on a regular basis regarding the quality of the therapeutic relationship.  Multiple randomized clinical trials show that formally soliciting feedback regarding progress and the alliance improves outcome and continued engagement in treatment.  One approach, “Feedback-Informed Treatment” is now listed on SAMHSA’s National Registry of Evidence-Based Programs and Practices.  Step-by-step instructions and videos for getting started are available on a new website: www.pcomsinternational.com. Seeking feedback from clients not only helps to identify and correct potential problems in therapy, but is also the first step in pushing one’s effectiveness to the next level.  In case you didn’t see it, I review the research and steps for improving performance as a therapist in an article/interview on the Psychotherapy.net website.  It’s sure to make you happy!

Filed Under: CDOI, Feedback, Feedback Informed Treatment - FIT, PCOMS Tagged With: behavioral health, common factors, evidence based practice, excellence, healthcare, productivity, Therapist Effects

Feedback Informed Treatment: Update

August 16, 2012 By scottdm Leave a Comment

Chicago, IL (USA)

The last two weeks have been a whirlwind of activity here in Chicago.  First, the “Advanced Intensive.”  Next came the annual “Training of Trainers.”  Each week, the room was filled to capacity with practitioners, researchers, supervisors, and agency directors from around the globe receiving in-depth training in feedback-informed practice.  It was a phenomenal experience.  As the video below shows, we worked and played hard!

Already, people are signing up for the next “Advanced Intensive” scheduled for the third week of March 2013 and the new three-day intensive training on FIT supervision scheduled for the 6-9th of August 2013.   Both events follow and are designed to complement the newly released ICCE FIT Treatment and Training Manuals.  In fact, all participants receive copies of the 6 manuals, covering every detail of FIT practice, from the empirical evidence to implementation.  The manuals were developed and submitted to support ICCE’s submission of FIT to the National Registry of Evidence Based Practices (NREPP).  As I blogged about last March, ICCE trainings fill up early.  Register today and get the early bird discount.

Filed Under: CDOI, Conferences and Training, evidence-based practice, Feedback Informed Treatment - FIT, FIT Tagged With: cdoi, icce

Getting FIT in the New Year: The Latest Evidence

January 18, 2011 By scottdm Leave a Comment

 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.

Filed Under: Behavioral Health, CDOI, Feedback, PCOMS Tagged With: cdoi, continuing education, icce, randomized clinical trial

Learning, Mastery, and Achieving One’s Personal Best

April 25, 2010 By scottdm Leave a Comment


Dateline: Sunday, April 25th, 2010 Chicago, IL

There’s a feeling I get whenever I’m learning something new.  It’s a combination of wonder and possibility.  Even though I’ve been traveling and teaching full time for over 18 years, I still feel that get that feeling of excitement whenever I step on a plane: What will I see?  Who will I meet?  What will I learn?  Move over Indiana Jones, you’ve got nothing on me!

On my desk right now are stacks of books on the subject of expertise and expert performance: The Talent Code: Greatness Isn’t Born. It’s Grown. Here’s How, The Genius in All of Us: Why Everything You’ve Been Told About Genetics, Talent, and IQ Is Wrong, The Cambridge Handbook of Creativity, The Psychology of Abilities, Competencies, and Expertise, Why We Make Mistakes: How We Look Without Seeing, Forget Things in Seconds, and Are All Pretty Sure We Are Way Above Average, and many, many more.

On the floor, arranged in neat little piles, are reams of research articles, newspaper clippings, and pages torn out of magazines.  Literally, all on the same subject: how can we clinicians reliably achieve better results?

I’ve never been one to “settle” for very long.  It’s the journey not the destination I find appealing.  Thus, I began exploring the common factors when it became clear that treatment models contributed little if anything to outcome (click here to read the history of this transition).  When I became convinced that the common factors held little promise for improving results in psychotherapy, I followed the lead of two my mentors, professor Michael Lambert (who I worked with as an undergraduate) and psychologist Lynn Johnson (who trained and supervised me), and began measuring outcome and seeking feedback.  Now that research has firmly established that using measures of the alliance and outcome to guide service delivery significantly enhances performance (see the comprehensive summary of research to date below), I’ve grown restless again.

In truth, I find discussions about the ORS and SRS a bit, well, boring.  That doesn’t mean that I’m not using or teaching others to use the measures.  Learning about the tools is an important first step.  Getting clinicians to actually use them is also important.  And yet, there is a danger if we stop there.

Right now, we have zero evidence that measurement and feedback improves the performance of clinicians over time.  More troubling, the evidence we do have strongly suggests that clinicians do not learn from the feedback they receive from outcome and alliance measures.  Said another way, while the outcome of each particular episode of care improves, clinicians overall ability does not.   And that’s precisely why I’m feeling excited–the journey is beginning…

…and leads directly to Kansas City where, on October 20-22nd, 2010, leading researchers and clinicians will gather to learn the latest, evidence-based information and skills for improving performance in the field of behavioral health.  As of today, talented professionals from Australia, Sweden, Norway, Denmark, Germany, England, Israel, and the United States have registered for the international “Achieving Clinical Excellence” conference.  Some common questions about the event include:

1. What will I learn?

How to determine your overall effectiveness and what specifically you can do to improve your outcomes.

2. Is the content new?

Entirely.  This is no repeat of a basic workshop or prior conferences.  You won’t hear the same presentations on the common factors, dodo verdict, or ORS and SRS.   You will learn the skills necessary to achieve your personal best.

3. Are continuing education credits available?

Absolutely–up to 18 hours depending on whether you attend the pre-conference “law and ethics” training.  By the way, if you register now, you’ll get the pre-conference workshop essentially free!  Three days for one low price.

4. Will I have fun?

Guaranteed.  In between each plenary address and skill building workshop, we’ve invited superior performers from sports, music, and entertainment to perform and inspire .  If you’ve never been to Kansas City, you’ll enjoy the music, food, attractions, and architecture.

Feel free to email me with any questions or click here to register for the conference.  Want a peak at some of what will be covered?  Watch the video below, which I recorded last week in Sweden while “trapped” behind the cloud of volcanic ash.  In it, I talk about the “Therapists Most Likely to Succeed.”

Measures and feedback 2016 from Scott Miller

Filed Under: CDOI, Conferences and Training, deliberate practice, Feedback Informed Treatment - FIT Tagged With: achieving clinical excellence, Carl Rogers, holland, psychometrics, Therapist Effects

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

March 9, 2010 By scottdm Leave a Comment

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

Filed Under: Behavioral Health, CDOI, Conferences and Training, Feedback Informed Treatment - FIT Tagged With: behavioral health, Canada, Carl Rogers, cdoi, holland, Therapist Effects, TOT

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

March 5, 2010 By scottdm Leave a Comment

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:

Filed Under: Behavioral Health, CDOI, excellence, Feedback Informed Treatment - FIT Tagged With: behavioral health, brief therapy, cdoi, clinician caseloads, evidence based practice, healthcare, holland, Hyperlipidemia, meta-analysis, public behavioral health, randomized clinical trial

The Turn to Outcomes: A Revolution in Behavioral Health Practice

February 1, 2010 By scottdm Leave a Comment

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.

Filed Under: Behavioral Health, CDOI, excellence, Feedback Informed Treatment - FIT Tagged With: brief therapy, evidence based practice, icce, Jay Lebow, medicine, post traumatic stress, psychotherapy networker, public behavioral health

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

January 26, 2010 By scottdm Leave a Comment

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:

Filed Under: Behavioral Health, CDOI, Conferences and Training, evidence-based practice, Feedback Informed Treatment - FIT Tagged With: brief therapy, cdoi, common factors, holland, meta-analysis, ors, outcome rating scale, public behavioral health, reflectum, session rating scale, srs

Outcomes in OZ III

December 4, 2009 By scottdm Leave a Comment

Dateline: November 28, 2009 Brisbane, Australia

accor

Crown Plaza Hotel
Pelican Waters Golf Resort & Spa

As their name implies, LifeLine Australia is the group people call when they need a helping hand.  During the last leg of my tour of eastern Australia, I was lucky enough to spend two days working with Lifeline’s dedicated and talented clinicians on improving the retention and outcome of clinical services they offer.

The two-day conference was the kick off for a “transformation project,” as Trevor Carlyon, the executive director of Lifeline Community Care points out in the video segment below, the stated goal of which is “putting clients back at the center of care.”   Nearly 200 clinicians working with a diverse clientele located throughout northern Queensland gathered for the event.  I look forward to returning in the future as the ideas are implemented across services throughout the system.

 

Filed Under: Behavioral Health, CDOI, evidence-based practice, Feedback Informed Treatment - FIT, Implementation Tagged With: australia, lifeline community care, mental health

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