Improving the Odds: Implementing FIT in Care for Problem Gamblers and their Families

April 17, 2016 By scottdm 1 Comment

Quick Healthcare Quiz

What problem in the U.S. costs the government approximately $274 per adult annually?

If you guessed gambling, give yourself one point. According to the latest research, nearly 6 million Americans have a serious gaming problem—a number that is on the rise. One-third of the Nation’s adults visit a Casino every year, losing according to the latest figures an estimated 100 billion dollars.

Which problem is more common? Substance abuse or problem gambling?

If you guessed the former, give yourself another point. Problems related to alcohol and drug use are about 3.5 times more common than gambling. At the same time, 281 times more funding is devoted to treating drug and alcohol problems. In March 2014, the National Council on Problem Gambling reported that government-funded treatment was provided to less than one quarter of one percent of those in need.

Does psychotherapy work for problem gambling?

If you answered “yes,” add one to your score. Research not only indicates that psychological treatment approaches are effective, but that changes are maintained at follow up. As with other presenting problems (e.g., anxiety and depression), more therapy is associated with better outcomes than less.

What is the key to successful treatment of problem gambling?

If you answered, “funding and getting people into treatment,” or some variation thereof, take away three points!

So, how many points do you have left? If you are at or near zero, join the club.

Healthcare is obsessed with treatment. A staggering 99% of resources are invested in interventions. Said another way, practitioners and healthcare systems love solutions. The problem is that research shows this investment, “does not result in positive implementation outcomes (changes in practitioner behavior) or intervention outcomes (benefits to consumers).” Simply put, it’s not enough to know “what works.” You have to be able to put “what works” to work.

Enter the BC Responsible and Problem Gambling Program—an agency that provides free support and treatment services aimed at reducing and preventing the harmful impacts of excessive or uncontrolled gaming. Clinicians working for the program not only sought to provide cutting-edge services, they wanted to know if they were effective and what they could do to continuously improve.

Five years ago, the organization adopted feedback-informed treatment (FIT)—routinely and formally seeking feedback from clients regarding the quality and outcome of services offered. A host of studies documents that FIT improves retention in and outcome of psychotherapy. Like all good ideas, however, the challenge of FIT is implementation.

Last week, I interviewed Michael Koo, the clinical coordinator of the BCRPGP. Listen in as he discusses the principles and challenges of their successful implementation. Learn also how the talented and devoted crew achieve outcomes on par with randomized controlled trials in an average of 7 visits while working with a culturally and clinically diverse clientele.

As you’ll hear, implementation is difficult, but doable. More, you don’t have to reinvent the wheel or do it alone. When FIT was reviewed and deemed “evidence-based” by the Substance Abuse and Mental Health Services organization in 2013, it received perfect scores for “implementation, training, support, and quality assurance” resources. Regardless of the population you serve, you can:

Join a free, online, international community of nearly 10,000 like-minded professionals using FIT in diverse settings (www.iccexcellence.com). Every day, members connect and share their knowledge and experience with each other;
Access a series of “how to” manuals and free, gap assessment tool (FRIFM) to aid in planning, guiding progress, and identifying common blind spots in implementation.
Attend the upcoming, 2-day FIT Implementation workshop. Held once a year in August, this event provides an in-depth, evidence-based training based on the latest findings from the field of implementation science.

Come meet managers, supervisors, practitioners, and team leaders from around the world. You will leave the tools necessary to “put ‘what works’ to work.”

FIT IMP 2016
Until next time,

Scott

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

Do you know Norman Malone? FIT, Grit, and Grace Personified

March 27, 2016 By scottdm 1 Comment

At the tender age of 10, Norman Malone’s father attacked him and his two younger brothers with a hammer while they slept. Their mother, drugged into unconsciousness by her husband the prior evening, found the children the next morning. Each had suffered grave head wounds, but were alive. Later, all would learn the senior Malone had taken his life shortly after the attack, throwing himself in front of a suburban train.

A long recovery followed, months spent in a hospital learning to walk again. Despite steady and dramatic improvement, Norman never regained the use of his right hand. With his single functioning hand, he spent the next seven decades following a dream he’d had since he was five: to become a concern pianist.

It has been a solitary journey throughout. In his youth, kids made fun of his damaged skull. Teachers and advisors consistently advised him to give up his quest, deeming it “ludicrous.” Thinking he must be “crazy,” they even sent him for a psychological evaluation. Wittgenstein

Sustained and focused application, or “grit,” research indicates is key for achieving difficult goals. Norman Malone is grit and grace personified. He persisted, eventually meeting a willing teacher at the Chicago Musical College. That teacher knew the story of another famous left-handed pianist, Paul Wittgenstein—brother of the celebrated philosopher, Ludwig—who following the loss of his right hand in World War 1, used his family’s wealth to commission Ravel, Prokofiev, and other famous composers to write music for him.

Last week, I had the opportunity to meet Norman Malone. Now 78 years of age, he graciously accepted an invitation to play at my home for participants attending the ICCE Intensive Trainings in Chicago. Forty-five participants from around the world (US, Canada, the Netherlands, Sweden, Denmark, Finland, Australia) crowded into my living room. You could hear a pin drop as he spoke.

It started Malone at home with his story. Then, he played—doing with one hand what many would think impossible with two. When asked what drove him to continue in the face of so many challenges, he said, in a quiet yet confident voice, “Because there is so much to learn!”

Mr. Malone will be back in August to perform for participants in the FIT Implementation, Training of Trainers, and FIT Professional Development Intensives. Come and get inspired!

You can get a taste of his performance at the training, and a watch a video of his life story, by clicking on the videos below.

Until next time,

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

Love, Mercy, & Adverse Events in Psychotherapy

July 9, 2015 By scottdm 10 Comments

Just over a year ago, I blogged about an article that appeared in one of the U.K.’s largest daily newspapers, The Guardian. Below a picture of an attractive, yet dejected looking woman (reclined on a couch), the caption read, “Major new study reveals incorrect…care can do more harm than good.”

I was interested.

As I often do in such cases, I wrote directly to the researcher cited in the article asking for a reprint or pre-publication copy of the study. No reply. One month later, I wrote again. Still, no reply. Two months after my original email, I received a brief note thanking me for my interest in the study and offering to share any results once they became available.

“Wait a minute,” I immediately thought, “The results of this ‘major new study’ about the harmful effects of psychotherapy had already been announced in a leading newspaper. How could they not be available?” Then I wondered, “If there are no actual results to share, what exactly was the article in The Guardian based on?”

So-called “adverse events” are a hot topic at the moment. That some people deteriorate while in care is not in question. Research dating back several decades puts the figure at about 10%, on average (Lambert, 2010). When those being treated are adolescents or children, the rates are twice as high (Warren et al., 2009).

Putting this in context, compared to medical procedures with effect sizes similar to psychotherapy (e.g., coronary artery bypass surgery, stages II and III breast cancer, stroke), the rate is remarkably low. Nonetheless, it is a matter of concern–especially given research showing that therapists are not particularly adept at recognizing when those they serve deteriorate in their care (Hannan et al., 2005)

The question, of course, is the cause?

To date, whenever the question of adverse events is raised, two “usual suspects” are trotted out: (1) the method of treatment used; and (2) the therapist. Let’s take a closer look at each.

In an October 2914 article published in World Psychiatry, Linden and Schermuly-Haupt wrote about estimates of side effects associated with specific methods of treatment that had been reported in an earlier study by Swiss researchers. The numbers were shocking. Patient reported “burdens caused by therapy” were 19.7% with CBT, 20.4% for systemically oriented treatments, 64.8% with humanistic approaches, and a staggering 94.1% with psychodynamic psychotherapy.

Based on such results, one could only conclude that anyone seeking anything other than CBT should have their head examined.

There is only one problem. The figures reported were wrong. Completely and utterly wrong. Linden and Schermuly-Haupt made an arithmetic error and, as a result, totally misinterpreted the Swiss findings. Read the study for yourself. When it comes to adverse events in psychotherapy, CBT–the fair-haired child of the evidence-based practice movement–is not better. Indeed, as the study clearly shows, people treated with humanistic and systemic approaches suffered fewer “burdens” than expected, while those in CBT had a slightly higher, although not statistically significant, level. More, the observed percentage of people in care who perceived the quality of the therapeutic relationship–the single most potent predictor of engagement and outcome–as poor was significantly higher than expected in CBT and lower for both humanistic and systemic approaches.

How could the researchers have gotten it so wrong?

As I pointed out in my blog over year ago, 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. In short, its not about the method.

(By the way, over a month ago, I wrote to the lead author of the paper that appeared in World Psychiatry via the ResearchGate portal–a site where scholars meet and share their publications–providing a detailed breakdown of the statistical errors in the publication. No response thusfar)

With only one suspect left, attention naturally turns to the therapist–you know, the “bad apple” in the bunch. Here’s what we know. That some practitioners do more harm than others is not exactly news. Have you seen the new biopic Love & Mercy, about the life of Beach Boy Brian Wilson? You should. The acting is superb.

Wilson’s therapist, psychologist Eugene Landy (chillingly recreated by actor Paul Giamatti), is a prime example of an adverse event. See the film and you’ll most certainly wonder how the guy kept his license to practice so long. And yet, as I also pointed out in my blog last year, there are too few such practitioners to account for the total number of clients who worsen. Consider this unsettling fact: beyond the 10% of those who deteriorate in psychotherapy, an additional 30 and 50% experience no benefit whatsoever!

Where does this leave us when it comes to adverse events in psychotherapy?

Whatever the cause, lack of progress and risk of deterioration are issues for all clinicians and clients. The key to addressing these problems is tracking progress from visit to visit so that those not improving, or getting worse, can be identified and offered alternatives. It’s that simple.

Right now, practitioners can access two simple, easy-to-use scales for free at: www.whatispcoms.com. Both have been tested in multiple, randomized, clinical trials and deemed evidence-based by the Federal Substance Abuse and Mental Health Services Administration (SAMHSA).

Learning to use the tools isn’t difficult. It costs nothing to join the International Center for Clinical Excellence and begin interacting with professionals around the world who are using the measures to improve the quality and outcome of behavioral health services. More detailed instruction is available at the upcoming webinar:

Join us in tackling the issue of adverse events in psychotherapy. In the meantime, be sure and leave a comment below.

Best wishes for the summer,

Scott

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

P .S.: On the one year anniversary of my original email to the reseacher cited in the Guardian, I sent another. That’s over a month ago. So far, no reply. By contrast, the reporter who broke the story, Sarah Boseley , wrote back within a half hour! She’s following up her sources. I’ll let you know if she gets a response.