How NOT to Achieve Clinical Excellence: The Sorry State of Continuing Professional Education

September 30, 2009 By scottdm 5 Comments

Greg Neimeyer, Ph.D., is causing quite a stir in continuing education circles. What has he done? In several scholarly publications, he’s reviewed the existing empirical literature and found that continuing professional education in heavioral health is not particularly, well, …educational. Indeed, in a soon-to-be published piece in the APA journal, Professional Psychology, he notes, “While the majority of studies report high levels of participants’ satisfaction with their CE experiences, little attention has been paid to assessing actual levels of learning, the translation of learning into practice, or the impact of CE on actual professional service delivery outcomes.” Neimeyer then goes on to cite a scholarly review published in 2002 by Daniels and Walter which pointed out that “a search [of the research literature] revealed no controlled studies of the impact of continuing education in the…behavioral health disciplines” (p. 368). Said another way, the near ubiguitous mandate that clinicians attend so many hours per year of approved “CE” events in order to further their knowledge and skill base has no empirical support.

Personally, my guess is that any study that might be done on CE in Behavioral Health would show little or no impact on performance anyway. Why? Studies in other fields (i.e., medicine, flight training) have long documented that traditional CE activities (i.e., attending conferences, lectures, reading articles) have no demonstrable effect. So, what does work? The same research that calls the efficacy of current CE activities into questions provide clear guidance: namely, brief, circumscribed, skill-based training, followed by observed practice, real-time feedback, and performance measurement. Such characteristics are, in fact, part and parcel of expert performance in any field. And yet, it is virutally non-existent in behavioral health.

Let me give you an example of a CE offering that arrived in my box just this week. The oversized, multi-color, tri-fold brochure boldly asserts a workshop on CBT featuring the “top evidence-based techniques.” Momentarily setting aside the absolute lack of evidence in support of such trainings, consider the promised content–and I’m not kidding: clinical applications of cognitive behavior therapy, motivational interviewing, cognitive therapy, mindfulness and acceptance based therapies, and behavior therapy. As if that were not enough, the outline for the training indicates that participants will learn 52 other bulleted points, including but not limited to: why CBT, integration of skills intro practice, identifying brain-based CBT strategies, the latest research on CBT, the stages of change, open-ended and reflective listening, behavioral activiation, acceptance and commitment, emotional regulation and distrss tolerance skills, the ABC technique to promote rational beliefs, homework assignments that test core beliefs, rescripting techniques for disturbing memories and images…and so on…AND ALL IN A SINGLE 6 HOUR DAY! You say you have no money? Your agency has suffered budget cuts? No worries, the ad states in giant print, as the same content is available via CD, web and podcast.

Such an agenda defies not only the evidence but strains credulity to the breaking point. Could anyone accomplish so much in so little time? Clinicians deserve and should demand more from the CE events they register for and, in many instances, are mandated to attend in order to maintain licensure and certification. The International Center for Clinical Excellence web platform will soon be launched. The mission of the site, as indicated in my blog post of August 25th, is to “support clinical excellence through creating virtual clinical networks, groups and clinical communities where clinicians can be supported in the key behavior changes required for developing clinical excellence.” Members of the site will use a variety of social networking and collaborative tools to learn skills, obtain real-time feedback, and measure their performance. Anyway, kudos to Dr. Greg Neimeyer for confronting the ugly truth about CE in behavioral health and saying it out loud!

Practice-Based Evidence Goes Mainstream

September 5, 2009 By scottdm 4 Comments

For years, my colleagues and I have been using the phrase “practice-based evidence” to refer to clinicians’ use of real-time feedback to develop, guide, and evaluate behavioral health services. Against a tidal wave of support from professional and regulatory bodies, we argued that the “evidence-based practice”–the notion that certain treatments work best for certain diagnosis–was not supported by the evidence.

Along the way, I published, along with my colleagues, several meta-analytic studies, showing that all therapies worked about equally well (click here to access recent studies children, alcohol abuse and dependence, and post-traumatic stress disorder). The challenge, it seemed to me, was not finding what worked for a particular disorder or diagnosis, but rather what worked for a particular individual–and that required ongoing monitoring and feedback. In 2006, following years of controversy and wrangling, the American Psychological Association, finally revised the official definition to be consistent with “practice-based evidence.” You can read the definition in the May-June issue of the American Psychologist, volume 61, pages 271-285.

Now, a recent report on the Medscape journal of medicine channel provides further evidence that practice-based evidence is going mainstream. I think you’ll find the commentary interesting as it provides compelling evidence that an alternative to the dominent paradigm currently guiding professional discourse is taking hold. Watch it here.

The Evolution of Psychotherapy: Twenty-Five Years On

September 1, 2009 By scottdm Leave a Comment

In 1985, I was starting my second year as a doctoral student at the University of Utah. Like thousands of other graduate students, I’d watched the “Gloria” films. Carl Roger, Albert Ellis, Fritz Perls were all impressive if not confusing given their radically different styles. I also knew that I would soon have the opportunity to meet each one live and in person. Thanks to Jeffrey K. Zeig, Ph.D. and the dedicated staff at the Milton H. Erickson Foundation, nearly every well known therapist, guru, and psychotherapy cult-leader would gather for the first mega-conference ever held, the field’s Woodstock: The Evolution of Psychotherapy.

Having zero resources at my disposal, I wrote to Jeff asking if I could volunteer for the event in exchange for the price of admission. Soon after completing the multiple-page application, I received notice that I had been chosen to work at event. I was ecstatic. When December finally came around, I loaded up my old car with food and a sleeping bag and, together with a long time friend Paul Finch, drove from Salt Lake City to Phoenix. What can I say? It was alternately inspiring and confusing. I learned so very much and also felt challenged to make sense of the disparate theories and approaches.

At that time, I had no idea that some twenty years later, I’d receive a call from Jeff Zeig asking me to participate as one of the “State of the Art” faculty for the 2005 Evolution Conference. Actually, I can remember where I was when my cell phone rang: driving on highway 12 on southwest Michigan toward Indian Lake, where my family has a small cottage. In any event, I’m looking forward to attending and presenting at the 2009 conference. I encourage all of the readers of my blog to attend. Registration information can be found at the conference website: www.evolutionofpsychotherapy.com. The highlight of the event for me is a debate/discussion I’ll be having with my friend and colleague, Don Meichenbaum, Ph.D. on the subject of “evidence-based practice.”

One more thing. To get a feel for the event, I included a clip of a panel discussion from the first Evolution conference featuring Carl Rogers. Not trying to be hyperbolic, but listening to Rogers speak changed my life. I won’t bore you with the details but the night following his presentation, I had a dream…(more later)…

Announcement: Evolving in a new direction

August 25, 2009 By scottdm Leave a Comment

As those of you who have followed my work and blog know, my perspective is evolving. The direction I’m heading builds on all of the work done to date including the common factors, measurement of outcome and alliance, and feedback. Crucially, however, it goes one step further; bridging the common and specific factors divide that has long dominated and splintered the field, and identifying the concrete steps that diverse providers can take to improve their effectiveness and the services they offer consumers.

For the past 10 years much of my work has been available through the Institute for the Study of Therapeutic Change (ISTC) and featured on its website. In line with the evolution in my perspective my work is now increasingly centered on a new organization, the International Center for Clinical Excellence (ICCE), an international consortium of researchers, educators, and clinicians dedicated to understanding and promoting excellence in behavior healthcare. My colleague Barry Duncan, co-founder of the ISTC, is also developing his work in new directions and we have therefore decided that the time is now right to dissolve our long-term partnership in the ISTC. I recognise that for many of you, who have followed my work over the years, that this may come as a surprising development and I am hoping that this post and others to follow will provide guidance, reassurance and most importantly continuity.

Central to the mission of the International Center for Clinical Excellence (ICCE) is the creation of a web-based community of clinicians using the latest Web 2.0 technology where participants can learn from and share with each other. Based on the principles of Clinical Community Social Software (CCSS) it is specifically designed to support clinical excellence through creating virtual clinical networks, groups and clinical communities where clinicians can be supported in the key behavior changes required for developing clinical excellence. Participants can, using a variety of social networking and collaborative tools, share clinical insights through discussion forums and video posts as well as improve client outcomes through learning the skills of clinical excellence.

We have finished our first round of beta-testing for the site and you can go to the website at: www.centerforclinicalexcellence.com to register to become a member (its free and you’ll be notified the minute the entire site is live)!

For those of you new to the tremendous opportunities for web-based collaborative social software, let me reassure you that the site will permit access and use at whatever level you desire (everything from the familiar email, to online posts and discussions in real time). It will provide lots of help to learn how to explore the information and resources on offer as well as the support of colleagues in the community. I am very excited by this opportunity to interact with behavioral health professionals all over the world in this way. Over the next few days, I’ll be posting more information about the ICCE and our first International Conference on Excellence in Behavioral Health on my blog at www.scottdmiller.com. I encourage you to follow the updates on my blog and post any questions or comments.