The Verdict is “In”: Feedback is NOT enough to Improve Outcome

September 21, 2015 By scottdm 17 Comments

Nearly three years have passed since I blogged about claims being made about the impact of routine outcome monitoring (ROM) on the quality and outcome of mental health services. While a small number of studies showed promise, others results indicated that therapists did not learn from nor become more effective over time as a result of being exposed to ongoing feedback. Such findings suggested that the focus on measures and monitoring might be misguided–or at least a “dead end.”

Well, the verdict is in: feedback is not enough to improve outcomes. Indeed, researchers are finding it hard to replicate the medium to large effects sizes enthusiastically reported in early studies, a well-known phenomenon called the “decline effect,” observed across a wide range of scientific disciplines.

In a naturalistic multisite randomized clinical trial (RCT) in Norway, for example, Amble, Gude, Stubdal, Andersen, and Wampold (2014) found the main effect of feedback to be much smaller (d = 0.32), than the meta-analytic estimate reported by Lambert and Shimokawa (2011 [d = 0.69]). A more recent study (Rise, Eriksen, Grimstad, and Steinsbeck, 2015) found that routine use of the ORS and SRS had no impact on either patient activation or mental health symptoms among people treated in an outpatient setting. Importantly, the clinicians in the study were trained by someone with an allegiance to the use of the scales as routine outcome measures.

Fortunately, a large and growing body of literature points in a more productive direction. Consider the recent study by De Jong, van Sluis, Nugter, Heiser, and Spinhoven (2012), which found that a variety of therapist factors moderated the effect ROM had on outcome. Said another way, in order to realize the potential of feedback for improving the quality and outcome of psychotherapy, emphasis must shift away from measurement and monitoring and toward the development of more effective therapists.

What’s the best way to enhance the effectiveness of therapists? Studies on expertise and expert performance document a single, underlying trait shared by top performers across a variety of endeavors: deep domain-specific knowledge. In short, the best know more, see more and, accordingly, are able to do more. The same research identifies a universal set of processes that both account for how domain-specific knowledge is acquired and furnish step-by-step directions anyone can follow to improve their performance within a particular discipline. Miller, Hubble, Chow, & Seidel (2013) identified and provided detailed descriptions of three essential activities giving rise to superior performance. These include: (1) determining a baseline level of effectiveness; (2) obtaining systematic, ongoing feedback; and (3) engaging in deliberate practice.

I discussed these three steps and more, in a recent interview for the IMAGO Relationships Think Tank. Although intended for their members, the organizers graciously agreed to allow me to make the interview available here on my blog. Be sure and leave a comment after you’ve had a chance to listen!

Until next time,

Scott

Scott D. Miller, Ph.D.
www.whatispcoms.com
www.iccexcellence.com

Intake: A Mistake

September 4, 2015 By scottdm 1 Comment

Available evidence leaves little doubt. As I’ve blogged about previously, separating intake from treatment results in:

• Higher dropout rates;
• Poorer outcomes;
• Longer treatment duration; and
• Higher costs

And yet, in many public behavioral health agencies, the practice is commonplace. What else can we expect?

Chronically underfunded, and perpetually overwhelmed by mindless paperwork and regulation, agencies and practitioners are left with few options to meet the ever-rising number of people in need of help. Between 2009 and 2012, for example, the number of people receiving mental health services increased by 10%. During the same period, funding to state agencies decreased $4.35 billion. Not long ago, in my own home town of Chicago, the city shuttered half—50%–of the city’s mental health clinics, forcing the remaining, already burdened, agencies to absorb an additional 5,000 people in need of care.

Simply put, the practice of separating intake from treatment is little more than a form of “crowd management”–and an ineffective one at that.

Adding to the growing body of evidence is a new study investigating the impact of computerized intake on the consumer’s experience of the therapeutic relationship and continuation in care. Not only did researchers find that therapist use of a computer had a negative impact on the quality of the working relationship—one of the best predictors of outcome–but clients were between 62 and 97% less likely to continue in care!

It’s not hard to see how these well-intentioned—some would argue, absolutely necessary—solutions actually end up exacerbating the problem. Money is wasted when the paperwork is completed but people don’t come back; money that would be better spent providing treatment. Those who do not return don’t disappear, they simply access services in other ways (e.g., the E.R., police and social services, etc.)—after all, they need help! The ones who do continue after intake, experience poorer outcomes and stay longer in care, a cost to both the consumer and the system.

What to do?

In addition to pushing back against the mindless regulation and paperwork, there are several steps practitioners and agency managers can take:

Stop separating intake from treatment

The practices does not save time and actually increases costs. Consider having consumers complete as much of the paperwork as possible before the session begins. The first visit is critical. It determines whether people continue or drop pout. Listen first. At the end of the visit, review the paperwork, filling in missing data, and completing any remaining forms.

Begin monitoring outcome

Research to date shows that routinely monitoring progress reduces dropout rates and the length of time spent in treatment while simultaneously improving outcome. Combined, such results work to alleviate the bottleneck at the entry point of services.

Begin monitoring the quality of the therapeutic relationship:

Engagement and outcomes are improved when problems in the relationship are identified and openly discussed. Even when intake is separated from treatment, feedback should be sought. Data to date indicate that the most effective clinicians seek and more often receive negative feedback, a skill that enables them to better meet the needs of those they serve.

Getting started is not difficult. Indeed, there’s an entire community of professionals just a click away who are working with and learning from one another. The International Center for Clinical Excellence is the largest, web based community of mental health professionals in the world. It’s ad free and costs nothing to join.

The Empirical Basis for Feedback Informed Treatment
Basics of Outcome and Alliance Measurement
Integrating Feedback into Practice & Creating a Culture of Feedback
Understanding Outcome and Alliance Data

Register online at: https://www.eventbrite.ie/e/fall-2015-feedback-informed-treatment-webinar-series-tickets-17502143382. CE’s are available.

Finally, join colleagues and friends from around the world for the Advanced and FIT Supervision courses are held in March in Chicago. We work and play hard. You will leave with a thorough grounding in feedback-informed principles and practice. Registration is limited, and the courses tend to sell out several month in advance.

Until then,

Scott

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

Dinner with Paul McCartney (and others)

December 11, 2014 By scottdm 7 Comments

McCartney

Growing up, my family had a game we frequently played around the dining room table. “If you could invite anyone to dinner,” it always started,”who would it be?” Invariably, my father chose historical figures: Abraham Lincoln, Mark Twain, Leonardo Da Vinci. My mom was more inclined toward the living: Jackie O., J.D. Salinger, Lucille Ball. My brothers, Marc and Doug, usually went for sports figures. I recall Wilt Chamberlain and Willie Mays being popular choices–although there were many others whose names I’ve now forgotten.

Me? Always the same answer: Paul McCartney.

Of course, the “name game” didn’t end there. Whatever your choice, you also had to state why. Here, my answer didn’t vary either. “He’s one of the Beatles!” I’d say, frustrated whenever my family acted as though my statement needed further clarification.

To this date, I’ve never had a chance to met much less have dinner with Paul McCartney. Seen him in concert a number of times but always from a distance. Last week, however, I did have the opportunity to meet and spend time with a number of my heroes from the field of psychotherapy–and go to dinner together, not once, but twice!

We were together at the first ever Calgary Counseling Center Outcomes conference. Thanks to Center’s director, Dr. Robbie Wagner, a small group of practitioners, policy makers, and agency managers were invited to spend two, intimate days learning from the field’s leading thinkers and researchers. The Beatles of outcome research: Michael J. Lambert, Bruce E. Wampold, Michael Barkham, Wolfgang Lutz, and Gary Burlingame. I presented the latest results on our studies of top performing therapists.

It was every bit a rock concert–exciting, controversial, and cutting edge. Below, I summarize the “greatest hits.” I’ve also included the slides from each presentation for those who like to read the details contained in the “liner notes!”

Let me know what you think…here goes:

The burden born by people with mental health problems is second only to cancer (Depression alone results in a 70% loss of productivity)

Bottom line: People need the skills mental health professional have to offer

Treatment is effective. However, therapists believe they help far more people than they do (85% versus 20%);
Approximately 10% of adults deteriorate in care;
Between 14 and 25% of children are worse off following treatment;
Serious deterioration recognized in only one-third of cases;

Bottom Line: Mental health professionals overestimate their effectiveness and miss deterioration

Multiple, sophisticated, real world studies find no difference in outcome between people treated with different therapeutic approaches;
Factors related to the therapeutic relationship (i.e., empathy, collaboration, affirmation, genuineness) have a far greater impact on outcome (7:1) than treatment approach, adherence to treatment protocol, or rated competence.

Bottom Line: The pathway to improved effectiveness is not adopting new treatment approaches

Rapid and dramatic change (first 5 visits) occurs in as many as 40% of people and is maintained at two year follow up;
90% chance of failure if there is no change between the 2nd and 8th visit;
As many as 25% of people remain in treatment while experiencing no measurable benefit;

Bottom Line: A large number of people need very little treatment to achieve lasting benefit

Separating intake from treatment results in higher drop out, lower and longer treatment response, and higher costs;

Bottom Line: Any barrier to establishing a relationship with a specific provider has a negative impact on outcome

The majority of individual practitioners are effective;
Around 16% of practitioners achieve outcomes significantly below average;
Less effective practitioners rate empathic understanding more highly as a professional/personal attribute than more effective practitioners;
The clients of the least effective clinicians were assigned to average practitioners, an additional 15% of clients would achieve clinical recovery;
Around 16% of practitioners consistently achieve outcomes significantly above average;
More effective practitioners rate resilience and mindfulness more highly as a professional/personal attribute;
Professional self-doubt and an “error-centric attitude” are associated with better outcomes.

Bottom Line: Choose your therapist carefully as they determine the outcome of care

When therapists receive feedback that clients are deteriorating, they: discuss it with clients about 60% of the time; make efforts to assist with other resources about 27% of the time; adjust therapeutic interventions 30% of the time; vary intensity or dose of services 9% of the time; consult with others (supervision, education, etc.) 7% of the time;
Therapist attitude toward soliciting and using feedback vary and influence results;
Therapists who value feedback achieve better outcomes;
Professional self-doubt and an “error-centric attitude” are associated with better outcomes;

Bottom Line: Regular, formal feedback from clients to therapists improves outcomes (as long as the therapist listens and acts on the feedback)

When asked, 92% of clients say they like the use of outcome measures in care.

Bottom Line: An overwhelming majority of clients endorse progress monitoring or providing feedback

The economic value of monitoring patient treatment response (Lambert, 2014)

How to double client outcomes in 18 seconds (Lambert, 2014)

Practice-based Evidence (Michael Barkham, 2014)

How to Improve Quality of Services by Integrating Common Factors into Treatment Protocols

When & How do Patients Change? Wolfgang Lutz Outcome Presentation

Reach: Pushing Your Clinical Effectiveness to the Next Level

Is Documentation Helping or Hindering Mental Health Care? Please Let me know.

November 23, 2014 By scottdm 44 Comments

So, how much time do you spend doing paperwork? Assessments, progress notes, treatment plans, billing, updates, etc.–the lot?

When I asked the director of the agency I was working at last week, it took him no time to respond. “Fifty percent,” he said, then added without the slightest bit of irony, “It’s a clinic-wide goal, keeping it to 50% of work time.”

Truth is, it’s not the first time I’ve heard this figure. Wherever I travel–whether in the U.S. or abroad–practitioners are spending more and more time “feeding the bureaucratic beast.” Each state or federal agency, regulatory body, and payer wants a form of some kind. Unchecked, regulation has lost touch with reality.

Just a few short years ago, the figure commonly cited was 30%. In the last edition of The Heart and Soul of Change, published in 2009, we pointed out that in one state, “The forms needed to obtain a marriage certificate, buy a new home, lease an automobile, apply for a passport, open a bank account, and die of natural causes were assembled … altogether weighed 1.4 ounces. By contrast, the paperwork required for enrolling a single mother in counseling to talk about difficulties her child was experiencing at school came in at 1.25 pounds” (p. 300).

Research shows that a high documentation to clinical service ratio leads to higher rates of:

Burnout and job dissatisfaction among clinical staff;
Fewer scheduled treatment appointments;
No shows, cancellations, and disengagement among consumers.

Some potential solutions have emerged. “Concurrent ,” a.k.a., “collaborative documentation.” It’s a great idea: completing assessments, treatment plans, and progress notes together with clients during rather than after the session. We started doing this to improve transparency and engagement at the Brief Family Therapy Center in Milwaukee, Wisconsin back in the late 1980’s. At the same time, it’s chief benefit to date seems to be that it saves time on documentation–as though filling out paperwork is an end in and of itself!

Ostensibly, the goal of paperwork and oversight procedures is to improve accountability. In these evidence-based times, that leads me to say, “show me the data.” Consider the wide-spread practice–mandate, in most instances–of treatment planning. Simply put, it is less science than science fiction. Perhaps this practice improves outcomes in a galaxy far, far away but on planet Earth, supporting evidence is spare to non-existent. Where is the evidence that any of the other documentation improves accountability, benefits consumers, or results in better outcomes?

Put bluntly, the field needs an alternative. What practice not only insures accountability but simultaneously improves the quality and outcome of behavioral health services? Routinely and formally seeking feedback from consumers about how they are treated and their progress.

Soliciting feedback need not be time consuming nor difficult. Last year, two brief, easy-to-use scales were deemed “evidence-based” by the Substance Abuse and Mental Health Services Administration (SAMHSA). The International Center for Clinical Excellence received perfect scores for the materials, training, and quality assurance procedures it makes available for implementing the measures into routine clinical practice:

Then again, these two forms add to the paperwork already burdening clinicians. The main difference? Unlike everything else, numerous RCT’s document that using these forms increases effectiveness and efficiency while decreasing both cost and risk of deterioration.

Learn more at the official website: www.whatispcoms.com. Better yet, join us in Chicago for our upcoming intensives in Feedback Informed Treatment and Supervision:

In the meantime, would you please let me know your thoughts? To paraphrase Goldilocks, is the amount of documentation you are required to complete, “Too much,” Too little,” or “Just about Right!” Type in your reply below!

What articles have 140,000 of your colleagues read to improve their practice?

November 21, 2014 By scottdm 1 Comment

Each week, I upload articles to the web about how to improve effectiveness. There are a lot to choose from, but here are the top ones read by behavioral health professionals around the world:

Measures and Feedback 2014

This is the latest version of the most widely-read upload on the site. It summarizes all of the available research about using feedback to improve retention in and outcome of care, including studies using the ORS and SRS.

How to Improve your Effectiveness

A short, fun article that highlights the evidence-based steps for improving one’s effectiveness as a behavioral health provider. Feedback, it turns out, is not enough. This article reviews the crucial step that makes all the difference.

Finally, here’s a link to a simple-to-use tool for interpreting scores on the ORS:

ORS Reliable Change Chart

That’s it for now. Best wishes in your work. Stay in touch.

Scott D. Miller, Ph.D.
Director, International Center for Clinical Excellence
info@scottdmiller.com

Registration is open for the Advanced Training in Feedback-Informed Treatment (FIT). Learn how to integrate this SAMHSA certified evidence-based practice into your work or agency. We promise you three comprehensive, yet fun-filled days of learning together with colleagues from around the world.

Is Psychotherapy Getting Better?

October 11, 2012 By scottdm Leave a Comment

This last month, I spent a significant amount of time traveling around Europe and Scandanavia (Germany, Sweden, Denmark, the Netherlands) working with clinicians and mental health agencies implementing Feedback-Informed Treatment. Not infrequently, people ask me, “doesn’t all the travel wear you out?” My pat response is, “No, not at all! The worst part is being away from my family. But, meeting with practitioners and agency managers always buoys my spirits.” I mean it. I miss my family and the airlines (and airport food) are a real drag. Practitioners are, on the other hand, a different story. Despite the numerous challenges (funding, documentation, regulatory demands, etc.), they persist, working to improve their skills and provide effective help to their clients.

As happened a few months ago, I was in the SAS lounge at the Copenhagen airport, waiting for a flight, enjoying a cup of coffee, and catching up on the news, when I ran across another article by Thomas Friedman that caught my eye. “The plan,” he said, “to work hard and play by the rules to get ahead is now outdated. It takes much more than that.”

Wow, I thought, he’s so right–especially when it comes to the field of mental health. I was raised in an era when “working hard at your job” was the formula for success, the pathway to a fruitful and enjoyable career. As I travel the world, however, I see just how little reason there is to believe in this ideal any longer. The rules have changed. The world, observed Friedman, “is now a more open system. Technology and globalization are wiping out lower-skilled jobs faster, while raising the skill level required for new jobs. More than ever now, lifelong learning is the key to getting into and staying in the middle class.”

As I said earlier, the therapists I meet are working very hard–harder than either I or they ever anticipated. They are putting in more hours and, in many cases, making less money than they did a few years earlier. It’s true! Did you know, psychologists incomes are down 17% in the last decade? Simply put, working hard is a recipe for…eventual failure. If we are to survive and thrive, a change of order–not magnitude–is required.

Recently, Diane Cole addressed the challenges facing practitioners in a special issue of the Psychotherapy Networker. It’s worth a read (click here). Importantly, she doesn’t just bemoan the problems currently facing the field, but provides crucial information for helping each and every one of us take charge of our fate.

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.

The Revolution in Sweden: More Evidence and A Brief Follow Up

August 14, 2012 By scottdm 1 Comment

On May 13th, I blogged about a change in guidelines for clinical practice in Sweden. As in many other countries, CBT enjoyed near exclusive status as “evidence-based” on most official lists of approved treatments. Billions of Swedish crowns were spent on the approach that ultimately had no effect on the outcome of people treated for depression and anxiety. As a result, guidelines for clinical practice were reviewed and expanded.

Judging by the flood of comments, the news stirred considerable debate. Indeed, the managers of several list-serves wrote to me indicating that the post had generated heated discussions among their members. Several mental professionals wrote to me directly asking for references in English. Unfortunately, none to my knowledge exist. That said, if and when one becomes available, I will post the article or link here.

In the meantime, two developments. First, the Swedish Family Therapy Association posted a link for the translation of my article, “The Road to Mastery,” which originally appeared in the May-June 2012 issue of the Psychotherapy Networker. Anyone who reads and understands Swedish, can fine the article by clicking here. I am deeply grateful for the hard work that went into translating the piece and the attention giving to the topic by the leadership of SFFT.

OK. One more important research development of which every practicing clinician should be aware. Research, like the broader world of clinical practice, goes through fads and fashions. Methods and designs “catch on,” capturing attention, and subsequently emulated by others. Currently, one of the trends is comparing a particular treatment approach to “treatment as usual.” However, as my professor and mentor Bruce Wampold observes, “design is destiny.” Said another way: how you ask is what you get.

Attend a workshop or training and you’ll often hear presenters claiming that their preferred approach has proven more effective than “treatment as usual” (TAU) in randomized clinicial trials. Sounds impressive. It is, in fact, meant to impress. And yet, “how you ask is what you get.” As the study below documents, some TAU’s are destined to fail, purposefully employing TAU’s that are not designed to be therapeutic. Importantly, when a treatment approach is compared to a “treatment-as-usual-that-is-actually-a-real-bona fide-therapeutic approach” no differences in efficacy are found.

The implication? When considering whether to adopt a new method, or when claims are made regarding the superiority of a particular approach, clinicians need to ask, “what is being compared?” A long trail of evidence documents that, in general, all approaches work well. The challenge is finding “what works” for the individual client and practitioner. Adopting new approaches, available research makes clear, is no guarantee of improved outcomes. As is made clear in The Road to Mastery, time and resources are better spent determining one’s baseline level of performance. From there, practitioners can both identify when their current skills fall short and the training necessary to improve their individual performance.

Revolution in Swedish Mental Health Practice: The Cognitive Behavioral Therapy Monopoly Gives Way

May 13, 2012 By scottdm 34 Comments

Sunday, May 13th, 2012
Arlanda Airport, Sweden

Over the last decade, Sweden, like most Western countries, embraced the call for “evidence-based practice.” Socialstyrelsen, the country’s National Board of Health and Welfare, developed and disseminated a set of guidelines (“riktlinger”) for mental health practice. Topping the list of methods was, not surprisingly, cognitive-behavioral therapy.

The Swedish State took the list seriously, restricting payment for training of clinicians and treatment of clients to cognitive behavioral methods. In the last three years, a billion Swedish crowns were spent on training clinicians in CBT. Another billion was spent on providing CBT to people with diagnoses of depression and anxiety. No funding was provided for training or treatment in other methods.

The State’s motives were pure: use the best methods to decrease the number of people who become disabled as result of depression and anxiety. Like other countries, the percentage of people in Sweden who exit the work force and draw disability pensions has increased dramatically. As a result, costs skyrocketed. Even more troubling, far too many became permanently disabled.

The solution? Identify methods which have scientific support, or what some called, “evidence-based practice.” The result? Despite substantial evidence that all methods work equally well, CBT became the treatment of choice throughout the country. In point of fact, CBT became the only choice.

As noted above, Sweden is not alone in embracing practice guidelines. The U.K. and U.S. have charted similar paths, as have many professional organizations. Indeed, the American Psychological Association has now resurrected its plan to develop and disseminate a series of guidelines advocating specific treatments for specific disorders. Earlier efforts by Division 12 (“Clinical Psychology”) met with resistance from the general membership as well as scientists who pointed to the lack of evidence for differential effectiveness among treatment approaches.

Perhaps APA and other countries can learn from Sweden’s experience. The latest issue of Socionomen, the official journal for Swedish social workers, reported the results of the government’s two billion Swedish crown investment in CBT. The widespread adoption of the method has had no effect whatsoever on the outcome of people disabled by depression and anxiety. Moreover, a significant number of people who were not disabled at the time they were treated with CBT became disabled, costing the government an additional one billion Swedish crowns. Finally, nearly a quarter of those who started treatment, dropped out, costing an additional 340 million!

In sum, billions training therapists in and treating clients with CBT to little or no effect.

Since the publication of Escape from Babel in 1995, my colleagues and I at the International Center for Clinical Excellence have gathered, summarized, published, and taught about research documenting little or no difference in outcome between treatment approaches. All approaches worked about equally well, we argued, suggesting that efforts to identify specific approaches for specific psychiatric diagnoses were a waste of precious time and resources. We made the same argument, citing volumes of research in two editions of The Heart and Soul of Change.

Yesterday, I presented at Psykoterapi Mässan, the country’s largest free-standing mental health conference. As I have on previous visits, I talked about “what works” in behavioral health, highlighting data documenting that the focus of care should shift away from treatment model and technique, focusing instead on tailoring services to the individual client via ongoing measurement and feedback. My colleague and co-author, Bruce Wampold had been in the country a month or so before singing the same tune.

One thing about Sweden: the country takes data seriously. As I sat down this morning to eat breakfast at the home of my long-time Swedish friend, Gunnar Lindfeldt, the newscaster announced on the radio that Socialstyrelsen had officially decided to end the CBT monopoly (listen here). The experiment had failed. To be helped, people must have a choice.

“What have we learned?” Rolf Holmqvist asks in Socionomen, “Treatment works…at the same time, we have the possibility of exploring…new perspectives. First, getting feedback during treatment…taking direction from the patient at every session while also tracking progress and the development of the therapeutic relationship!”

“Precis,” (exactly) my friend Gunnar said.

And, as readers of my blog know, using the best evidence, informed by clients’ preferences and ongoing monitoring of progress and alliance is evidence-based practice. However the concept ever got translated into creating lists of preferred treatment is anyone’s guess and, now, unimportant. Time to move forward. The challenge ahead is helping practitioners learn to integrate client feedback into care—and here, Sweden is leading the way.

“Skål Sverige!”

The Achieving Clinical Excellence Conference CALL FOR PAPERS

March 13, 2012 By scottdm Leave a Comment

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

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

Here’s what attendees said about the last event:

Implementation Science, FIT, and the Training of Trainers

March 8, 2012 By scottdm Leave a Comment

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

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

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

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

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

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

November 26, 2011 By scottdm Leave a Comment

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

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

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

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

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

Cutting Edge Feedback

November 22, 2011 By scottdm Leave a Comment

Earth | Time Lapse View from Space, Fly Over | NASA, ISS

Using feedback to guide and improve the quality and outcome of behavioral health services is growing in popularity. The number of systems available for measuring, aggregating, and interpreting the feedback provided by consumers is increasing. The question, of course, is, “which is best?” And the answer is, “it depends on the algorithms being used.”

Over a decade ago, my colleagues and I developed a set of mathematic equations that enabled us to plot the “expected treatment response” or ETR of a client based on their first session Outcome Rating Scale (ORS) score. Although the math was complicated, the idea was not: therapists and clients could compare outcomes from session to session to the benchmark provided by the ETR. If too much or too little progress were being made, client and therapist could discuss what changes might be made to the services being offered in order to insure more effective or durable progress. It was a bold idea and definately “cutting edge” at the time–after all, 10 years ago, few people were even measuring outcomes let alone trying to provide benchmarks for guiding clinical practice. The formulas developed at that time for plotting change in treatmentare still being used by many around the world with great effect. At the same time, it was merely a first attempt.

I am proud and excited to be able to announce the development and launch of a new set of algorithms–the largest and most sophisticated to date–based on a sample of 427,744 administrations of the ORS, in 95,478 unique episodes of care, provided by 2,354 different clinicians. Unlike the prior formulas–which plotted the average progress of all consumers successful and not–the new equations provide benchmarks for comparing individual consumer progress to both successful and unsuccessful treatment episodes. Consider an analogy to the field of medicine. No one would be interested in a test for the effectiveness of a particular cancer treatment that compared an individual’s progress to to the average of all patients whether they lived or died. People want to know, “will I live?” And in order to answer that question, the ETR of both successful and ultimately unsuccessful treatments must be determined and the individual clients progress compared to both benchmarks. Adjustments can be made to the services offered when the client’s session by session outcomes fit the ETR of treatments that ended unsuccessfully.

An example of the type of feedback provided by the new algorithms is found below. The graph displays three zones of potential progress (or ETR’s) for a client scoring 15 on the ORS at intake. Scores falling in the “green” area from session to session are similar to treatments that ended successfully. As might be expected, those in the “red” zone, ended unsuccessfully. Finally, scores in the “yellow” zone had mixed results. In each instance, both the client and therapist are provided with instant feedback: green = on track, red = off track, yellow = concern.

The new algorithms will be a major focus of the upcoming “Advanced Intensive in Feedback-Informed Treatment (FIT)” scheduled for March 19th-22nd, 2012. All those subscribing to the event also receive the newly released series of FIT treatment manuals. Space is limited, as always, to 35 people and we are filling fast so please don’t wait. So many exciting developments!

Now, if you haven’t already done so, click on the video at the start of this post. I was floored by these satellite images. In some way, I hope that the new algorithms, FIT training manuals, and the ICCE community can inspire a similar sense of perspective!

Psychologist Alan Kazdin Needs Help: Please Give

September 25, 2011 By scottdm Leave a Comment

Look at this picture. This man needs help. He is psychologist, Alan Kazdin, former president of the American Psychological Association, and current Professor of Psychology at Yale University. A little over a week ago, to the surprise and shock of many in the field, he disclosed a problem in his professional life. In an interview that appeared online at TimeHealthland Dr. Kazdin reported being unable to find a therapist or treatment program to which he could refer clients–even in Manhattan, New York, the nation’s largest city!

After traveling the length and breadth of the United States for the last decade, and meeting and working with hundreds of agencies and tens of thousands of therapists, I know there are many clinicians that can help Dr. Kazdin with his problem. Our group has been tracking the outcome of numerous practitioners over the last decade and found average outcomes to be on par with those obtained in tightly controlled randomized clinical trails! That’s good news for Dr. Kazdin.

Now, just to be sure, it should be pointed out that Dr. Kazdin is asking for practitioners who adhere to the Cochrane Review’s and the American Psychological Association’s definition of evidence-based practice (EBP)–or, I should say, I believe that is what he is asking for as the interview is not entirely clear on this point and appears to imply that EBP is about using specific treatment methods (the most popular, of course, being CBT). The actual definition contains three main points, and clearly states that EBP is the integration of:

The best available research;
Clinical expertise; and
The client’s culture, values, and preferences.

Interestingly, the official APA policy on evidence-based practice further defines clinical expertise as the “monitoring of patient progress (and of changes in the patient’s circumstances)…that may suggest the need to adjust the treatment. If progress is not proceeding adequately, the psychologist alters or addresses problematic aspects of the treatment (e.g., problems in the therapeutic relationship or in the implementation of the goals of the treatment) as appropriate.”

I say “interestingly” for two reasons. First, the definition of EBP clearly indicates that clinicians must tailor psychotherapy to the individual client. And yet, the interview with Dr. Kazdin specifically quotes him as saying, “That’s a red herring. The research shows that no one knows how to do that. [And they don’t know how to monitor your progress].” Now, admittedly, the research is new and, as Dr. Kazdin says, “Most people practicing who are 50 years or older”–like himself–may not know about it, but there are over a dozen randomized clinical trials documenting how routinely monitoring progress and the relationship and adjusting accordingly improves outcome. The interview also reports him saying that “there is no real evidence” that the relationship (aka alliance) between the therapist and client matters when, in fact, the APA Interdivisional Task Force on Evidence-Based Therapy Relationships concluded that there is abundant evidence that “the therapy relationship accounts for substantial and consistent contributions to…outcome….at least as much as the particular method.” (Incidently, the complete APA policy statement on EBP can be found in the May-June 2006 issue of the American Psychologist).

Who knows how these two major bloopers managed to slip through the editing process? I sure know I’d be embarrased and immediately issue a clarification if I’d been misquoted making statements so clearly at odds with the facts. Perhaps Dr. Kazdin is still busy looking for someone to whom he can refer clients. If you are a professional who uses your clinical expertise to tailor the application of scientifically sound psychotherapy practices to client preferences, values, and culture, then you can help.

The Cryptonite of Behavioral Health: Making Mistakes

May 7, 2011 By scottdm Leave a Comment

Most people readily agree that its important to “learn from mistakes.” In truth, however, few actually believe it. Mistakes are like cryptonite, making us feel and, more importantly, look stupid and weak. As a result, despite what we might advise others, we do our best to avoid making and admitting them. Such avoidance comes with a big cost: personal and professional growth stalls and even atrophies. We take on less challenging tasks, avoid taking risks, and give up more easily when confronted with situations that might expose our weaknesses. Far all that, falling a bit on “error-phobic” side of life is hardly an instance of irrationality. As Alina Tugend, author of Better by Mistake points out, “As much as people hate to make mistakes, they love pointing out the ones others have made.” Indeed, for most of us, the glee others take in pointing out our shortcomings only serves to compound our avoidance and deepen our public denial. And that’s what makes Tony Rousmaniere’s recent blogpost so unusual.

Briefly, Tony is a psychologist in private practice in San Francisco and Palo Alto. As he tells the story, he was riding in his car, listening to a recording of my presentation at the 2009 Evolution of Psychotherapy conference. The subject was “Achieving Clinical Excellence.” The message: routinely seeking feedback from clients about our mistakes decreases dropout rates and improves outcomes in psychotherapy. Tony took the message to heart. Unlike many of our peers who say they routinely ask clients for feedback, Tony actually downloaded the outcome and session rating scales and began formally asking his clients for feedback.

The story he relates makes for compelling reading, most of all because the feedback he received was not always easy to hear. And yet, he persisted, not only asking clients, but recording his work and then seeking input from colleagues. In the article, he gives step-by-step instructions for making use of the painful and sometimes confusing and contradictory feedback one receives.

Tony’s willingness to share his experience makes it tempting to say he is one brave soul. In actuality, he’s pragmatic. He placed outcomes over image. As he reports in the article, his dropout rate has plummeted and his outcomes improved. I say, “Bravo!”
________________________

Addendum

If you are thinking of writing to tell me that I misspelled the word, “cyptonite” (the accepted spelling is kryptonite), don’t bother. I know. I did it on purpose. See what I mean?!

Why is this man laughing?

May 4, 2011 By scottdm 3 Comments

May 4th, 2011
Copenhagen, Denmark

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

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

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

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

The "F" Word in Behavioral Health

April 20, 2011 By scottdm Leave a Comment

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

Conspicuously absent from the psychological cornucopia of diagnoses and treatments is the “F” word: FAILURE. A quick search of Amazon.com led to 32,670 results for the term, “psychotherapy,” 1,393 hits for “psychotherapy and depression,” and a mere 85 citations for “psychotherapy and failure.” Of the latter 85, less than 20 dealt with the topic of failure directly. There are some notable exceptions. The work of psychologist Jeffrey Kottler, for example. The dearth of information and frank discussion points to a glaring fact: behavioral health has a problem with failure.

The research literature is clear on the subject: we fail. Dropout rates have remained embarrassingly high over the last two and a half decades—hovering around 47%. At the same time, 10% of those who stay in services deteriorate while in care. Also troubling, despite the expansion of treatment modalities and diagnoses, the outcome of treatment (while generally good) has not improved appreciably over the last 30 or so years. Finally, as reviewed recently on this blog, available evidence indicates that clinicians, despite what many believe, do not improve with experience.

In short, behavioral health is failing when it comes to failure. As a group, we do rarely address the topic. Even when we directly addressed, we find it hard to learn from our mistakes.

Our study of top performing clinicians and agencies documents that the best have an entirely different attitude toward failure than the rest. They work at failing. Everyday, quickly, and in small ways. In the lead article of upcoming Psychotherapy Networker, “The Path to Mastery” we review our findings and provide step-by-step, evidence-based directions for using failure to improve the quality and outcome of behavioral health. As we say in the article, “more than a dozen clinical trials, involving thousands of clients and numerous therapists, have established that excellence isn’t reserved for a select few. Far from it: it’s within the reach of all.” Getting there, however, requires that we embrace failure like never before.

At this year’s “Training of Trainers” (TOT) conference, building “mindful infrastructures” capable of identifying and using failure at the individual practitioner, supervisor, and agency level will be front and center. Please note: this is not an “advanced workshop” on client-directed, feedback-informed clinical work (CDOI/FIT). No lectures or powerpoint presentations. Participants get hands on experience learning to provide training, consultation, and supervision to therapists, agencies, and healthcare systems.

But, don’t take our word for it. Listen to what attendees from the 2010 TOT said. Be sure and register soon as space is limited.

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

November 5, 2010 By scottdm Leave a Comment

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

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

What is "Best Practice?"

October 20, 2010 By scottdm Leave a Comment

You have to admit the phrase “best practice” is the buzzword of late. Graduate school training programs, professional continuing education events, policy and practice guidelines, and funding decisions are tied in some form or another to the concept. So, what exactly is it? At the State and Federal level, lists of so-called “evidence-based” interventions have been assembled and are being disseminated. In lockstep, as I reviewed recently, are groups like NICE. Their message is simple and straightforward: best practice is about applying specific treatments to specific disorders.

Admittedly, the message has a certain “common sense” appeal. The problem, of course, is that behavioral health interventions are not the psychological equivalent of penicillin. In addition to the numerous studies highlighted on this blog documenting the failure of the “specific treatments for specific disorders” perspective, consider research published in the Spring 2010 edition of the Journal of Counseling and Development by Scott Nyman, Mark Nafziger, and Timothy Smith. Briefly, the authors examined outcome data to “evaluate treatment effectiveness across counselor training level [and found] no significant outcome differences between professional staff and …. interns, and practicum students” (p. 204). Although the researchers are careful to make all the customary prevarications, the conclusion—especially when combined with years of similar findings reported in the literature– is difficult to escape: counseling and psychotherapy are highly regulated activities requiring years of expensive professional training that ultimately fails to make the practitioner any better than they were at the outset.

What gives? Truth is, the popular conceptualization of “best practice” as a “specific treatment for a specific disorder” is hopelessly outdated. In a report few have read, the American Psychological Association (following the lead of the Institute of Medicine) redefined evidence-based, or best practice, as, “the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences.” Regarding the phrase “clinical expertise” in this definition, the Task Force stated, “Clinical expertise…entails the monitoring of patient progress (and of changes in the patient’s circumstances—e.g., job loss, major illness) that may suggest the need to adjust the treatment (Lambert, Bergin, & Garfield, 2004a). If progress is not proceeding adequately, the psychologist alters or addresses problematic aspects of the treatment (e.g., problems in the therapeutic relationship or in the implementation of the goals of the treatment) as appropriate” (p. 273; emphasis included in the original text).

Said another way, instead of choosing the “specific treatment for the specific disorder” from a list of approved treatments, best practice is:

· Integrating the best evidence into ongoing clinical practice;

· Tailoring services to the consumer’s characteristics, culture, and preferences;

· Formal, ongoing, real-time monitoring of progress and the therapeutic relationship.

In sum, best practice is Feedback Informed Treatment (FIT)—the vision of the International Center for Clinical Excellence. And right now, clinicians, researchers and policy makers are learning, sharing, and discussion implementing FIT in treatment settings around the globe on the ICCE web-based community.

Word is getting out. As just one example, consider Accreditation Canada, which recently identified FIT as a “leading practice” for use in behavioral health services. According to the website, leading practices are defined as “creative, evidence-based innovations [that] are commendable examples of high quality leadership and service delivery.” The accreditation body identified FIT as a “simple, measurable, effective, and feasible outcome-based accountability process,” stating that the approach is a model for the rest of the country! You can read the entire report here.

How exactly did this happen? Put bluntly, people and hard work. ICCE senior associates and certified trainers, Rob Axsen and Cynthia Maeschalck, with the support and backing of Vancouver Coast Health, worked tirelessly over the last 5 years both implementing and working to gain recognition for FIT. Similar recognition is taking place in the United States, Denmark, Sweden, England, and Norway.

You can help. Next time someone—be it colleague, trainer, or researcher—equates “best practice” with using a particular model or list of “approved treatment approaches” share the real, official, “approved” definition noted above. Second, join Rob, Cynthia, and the hundreds of other practitioners, researchers, and policy makers on the ICCE helping to reshape the behavioral health practice worldwide.

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

September 25, 2010 By scottdm Leave a Comment

“Studies show…”

“Available data indicate…”

“This method is evidence-based…”

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

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

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

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

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

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

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

· The empirical foundations of feedback-informed clinical work (i.e., empirically supported factors underlying successful clinical work, the impact of feedback on performance)

· Clinical skills for enhancing client engagement that cut across different therapeutic orientations and diverse treatment populations

· How to integrate outcome management tools (including one or more of the following: ORS, SRS, CORE, and OQ 45) into clinical practice

· How to use the outcome management tools to inform and improve service delivery

· How to significantly improve your clinical skills and outcomes via feedback and deliberate practice

· How to use data generated from outcome measures to inform management, supervision, and training decisions

· Strategies for successful implementation of CDOI and FIT in your organization or practice

Need more information about the course? Email us or click on the video below to hear more about the course. In the meantime, space is limited so register early at: http://www.eventbrite.ie/o/the-international-centre-for-clinical-excellence-298540255.

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

July 16, 2010 By scottdm Leave a Comment

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

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

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

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

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

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

O Canada! Leading the Way to Improved Behavioral Health Services

June 23, 2010 By scottdm Leave a Comment

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:

More Eruptions (in Europe and in Research)

April 20, 2010 By scottdm Leave a Comment

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.

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:

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

January 19, 2010 By scottdm Leave a Comment

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.

"What Works" in Norway

January 13, 2010 By scottdm 1 Comment

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?

January 9, 2010 By scottdm Leave a Comment

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.

Research on the Outcome Rating Scale, Session Rating Scale & Feedback

January 7, 2010 By scottdm Leave a Comment

“How valid and reliable are the ORS and SRS?” “What do the data say about the impact of routine measurement and feedback on outcome and retention in behavioral health?” “Are the ORS and SRS ‘evidence-based?'”

These and other questions regarding the evidence supporting the ORS, SRS, and feedback are becoming increasingly common in the workshops I’m teaching in the U.S. and abroad.

As indicated in my December 24th blogpost, routine outcome monitoring (PROMS) has even been endorsed by “specific treatments for specific disorders” proponent David Barlow, Ph.D., who stated unequivocally that “all therapists would soon be required to measure and monitor the outcome of their clinical work.” Clearly, the time has come for all behavioral health practitioners to be aware of the research regarding measurement and feedback.

Over the holidays, I updated a summary of the data to date that has long been available to trainers and associates of the International Center for Clinical Excellence. The PDF reviews all of the research on the psychometric properties of the outcome and session ratings scales as well as the studies using these and other formal measures of progress and the therapeutic relationship to improve outcome and retention in behavioral health services. The topics is so important, that I’ve decide to make the document available to everyone. Feel free to distribute the file to any and all colleagues interested in staying up to date on this emerging mega-trend in clinical practice.

Measures And Feedback from Scott Miller

Outcomes in OZ III

December 4, 2009 By scottdm Leave a Comment

Dateline: November 28, 2009 Brisbane, Australia

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.

Outcomes in Oz

November 20, 2009 By scottdm Leave a Comment

Greetings from beautiful Melbourne, Australia! For the next couple of weeks, I’ll be traveling the up and down the east coast of this captivating country, conducting workshops and providing consultations on feedback-informed clinical work.

Actually, I’ve had the privilege of visiting and teaching in Australia about once a year beginning in the late 1990’s. Back then, Liz Sheehan, the editor of the “must read” journal Psychotherapy in Australiabrought me in to speak about the then recently published first edition of the Heart and Soul of Change. By the way, if you are not from Australia, and are unfamiliar with the journal, please do visit the website. Liz makes many of the articles that appear in the print version available online. I’ve been a subscriber for years now and await the arrival of each issue with great anticipation. I’m never disappointed.

In any event, on Wednesday this week, I spent the entire day with Mark Buckingham, Fiona Craig, and the clinical staff of Kedesh Rehabilitation Services in Wollongong, Australia–a scenic sea-side location about 45 minutes south of Sydney. Briefly, Kedesh is a residential treatment facility providing cutting-edge, consumer driven, outcome-informed services to people with drug, alcohol, and mental health problems. The crew at Kedesh is using the ORS and SRS to guide service delivery and is, in fact, one of the first to fully implement CDOI in the country.

I’ll be back with more soon, so please check back tomorrow. In the meantime, check out the video with Mark and Fiona.