Outcomes in Ohio: The Ohio Council of Behavioral Health & Family Service Providers

October 30, 2009 By scottdm Leave a Comment

Ohio is experiencing the same challenges faced by other states when it comes to behavioral health services: staff and financial cutbacks, increasing oversight and regulation, rising caseloads, unrelenting paperwork, and demands for accountability. Into the breach, the Ohio Council of Behavioral Health & Family Service Providers organized their 30th annual conference, focused entirely on helping their members meet the challenges and provide the most effective services possible.

On Tuesday, I presented a plenary address summarizing 40 years of research on “What Works” in clinical practice as well as strategies for documenting and improving retention and outcome of behavioral health services. What can I say? It was a real pleasure working with the 200+ clinicians, administrators, payers, and business executives in attendance. Members of OCBHFSP truly live up to their stated mission of, “improving the health of Ohio’s communities and the well-being of Ohio’s families by promoting effective, efficient, and sufficient behavioral health and family services through member excellence and family advocacy.”

For a variety of reasons, the State of Ohio has recently abandoned the outcome measure that had been in use for a number of years. In my opinion, this is a “good news/bad news” situation. The good news is that the scale that was being used was neither feasible or clinically useful. The bad news, at least at this point in time, is that state officials opted for no measure rather than another valid, reliable, and feasible outcome tool. This does not mean that agencies and providers are not interested in outcome. Indeed, as I will soon blog about, a number of clinics and therapists in Ohio are using the Outcome and Session Rating Scales to inform and improve service delivery. At the conference, John Blair and Jonathon Glassman from Myoutcomes.com demonstrated the web-based system for administering, scoring, and interpreting the scales to many attendees. I caught up with them both in the hall outside the exhibit room.

Anyway, thanks go to the members and directors of OCBHFSP for inviting me to present at the conference. I look forward to working with you in the future.

The Crown Jewel of Research on CDOI: Professor Jan Blomqvist receives 2.9 million crown grant for RCT on feedback in Sweden

October 20, 2009 By scottdm 2 Comments

If you’ve been following me on Twitter, then you know that last week I was touring and teaching in different spots around Europe. First, I presented two days in Copenhagen. Then I keynoted the British Association of Counseling and Psychotherapy Conference in Newcastle, England. Early Saturday morning, I flew from London to Stockholm. My long time friend and associate, Gunnar Lindfelt picked me up at Arlanda airport and drove me back to his lovely home in the city. There, we gorged on smoked salmon, “svensk godies” (small candies, my favorite of which is “skum bananer”–dark chocolate covered marshmellow in the shape of a banana) and Cider–a non-alcoholic fizzy apple drink that is an old time Swedish favorite.

It was Gunnar Lindfeldt, a gifted clinician and expert in the treatment of drug and alcohol problems, who first introduced me to the work of Swedish psychologist Jan Blomqvist. In 1998, Blomqvist published a book entitled, “Beyond Treatment? Widening the Approach to Alcohol Problems and Solutions“ in which he made the provocative argument that common rather than specific factors held the key to effective care. Since writing the book, Jan Blomqvist has continued his research and is currently a full professor at SORAD, the Centre for Social Research on Alcohol and Drugs at Stockholm University.

Anyway, I had the pleasure of meeting with Professor Blomqvist at his home in Uppsala, Sweden this last week. Over homemade spinach soup, freshly-baked bread and cheese, we chatted about the state of the field. The pièce de résistance, however, was hearing about the 2.9 million Swedish crown grant he had just been awarded for a 4 year long study of outcome-informed treatment of alcohol problems, called “Putting the Client in the Driver’s Seat.”

The study to be conducted by Professor Blomqvist will be the largest, most comprehensive, randomized clinical trial on client-directed outcome informed clinical work. A centerpience of the study will be the routine use of the ORS and SRS and provision of feedback in the delivery of treatment services. Importantly, unlike all other studies to date, this project completely avoids claims of “allegiance effects” as no developers of measures or supporters of CDOI are participating. Stay tuned to the “Top Performance” blog for additional updates! While you are waiting, take a moment and read Professor Blomqvist’s provocative take on “addiction” in slide viewer below.

J Blomqvist 3 from Scott Miller

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.