Routine Outcome Monitoring and Deliberate Practice: Fad or Phenomenon?

March 26, 2019 By scottdm 1 Comment

Would you believe me if I told you there was a way you could more than double the chances of helping your clients? Probably not, eh? As I’ve documented previously, claims abound regaring new methods for improving the outcome of psychotherapy. It’s easy to grow cynical.

And yet, findings from a recent study document when clinicians add this particular practice to their clinical work, clients are actually 2.5 times more likely to improve. The impact is so significant, a review of research emerging from a task force of the American Psychological Association concluded, “it is among the most effective ways available to services to improve outcomes.”

That said, there’s a catch.

The simple nature of this “highly rated,” transtheoretical method belies a steep learning curve. In truth, experience shows you can learn to do it — the mechanics — in a few minutes.

But therein lies the problem. The empirical evidence makes clear successful implementation often takes several years. This latter fact explains, in part, why surveys of American, Canadian, and Australian practitioners reveal that, while being aware of the method, they rarely integrate it into their work.

What exactly is the “it” being referred to?

Known by the acronym FIT, feedback-informed treatment (FIT) involves using standardized measures to formally and routinely solicit feedback from clients regarding progress and the quality of the therapeutic relationship, and then using the resulting information to inform and improve care.

The ORS and SRS are examples of two simple feedback scales used in more than a dozen randomized controlled trials as well as vetted and deemed “evidence-based” by the Substance Abuse and Mental Health Services Administration. Together, the forms take less than 3 minutes to administer, score and interpret (less if one of the web-based scoring systems is used).

So why, you might wonder, would it take so long to put such tools into practice?

As paradoxical as it may sound, because FIT is really not about using measures — any more say than making a home is about erecting four walls and a roof. While the structure is the most visible aspect — a symbol or representation — we all know it’s what’s inside that counts; namely, the people and their relationships.

On this score, it should come as no surprise that a newly released study has found a significant portion of the impact of FIT is brought about by the alliance or relationship between client and therapist. It’s the first study in history to look at how the process actually works and I’m proud to have been involved.

Of course, all practitioners know relationships skills are not only central to effective psychotherapy, but require lifelong learning. With time, and the right kind of support, using measurement tools facilitates both responsiveness to individual clients and continuous professional development.

Here’s the rub. Whenever I respond to inquiries about the tools — in particular, suggesting it takes time for the effects to manifest, and that the biggest benefit lies beyond the measurement of alliance and outcome — interest in FIT almost always disappears. “We already know how to do therapy,” a manager replied just over a week ago, “We only want the measures, and we like yours because they are the simplest and fastest to administer.”

Every so often, however, the reply is different. “What do we have to do to make this work to improve the effectiveness of our clinical work and clinicians?” asked Thomas Haastrup, the Coordinator of Family Services for Odense Municipality in Denmark. When I advised, planning and patience, with an emphasis on helping individual practitioners learn to use feedback to foster professional development versus simply measuring their results, he followed through. “We adopted the long view,” Thomas recounts, “and it’s paid off.” Now in their 5th year, outcomes are improving at both the program and provider level across services aimed at helping adults, children, and families.

In addition to the Manual 6 in the ICCE Treatment and Training manuals, the ICCE Summer Intensives offer several opportunities for helping you or your agency to succeed in implementing FIT. First, the 2-day FIT Implementation Training — the only workshop offering in-depth, evidence-based training in the steps for integrating FIT into clinical practice at the individual, agency, and system-of-care level. Second, the Deliberate Practice Intensive — here you not only learn the steps, but begin to set up a professional develop plan designed to enhance your effectiveness.

To help out, I’d like to offer a couple of discounts:

Purchase Manual 6 at 70% off the regular price. Click here to order. Enter the word IMPLEMENTATION at checkout to receive the discount (If you want to purchase the entire set, I’m making them available at 50% off the usual price. Enter IMPLEMENTATION2 at checkout).
Register for any or all of the summer intensives by May 1st and receive an additional discount off the early bird price. Simple enter the code FITPROMOAPRIL at checkout. Please note, registration MUST occur before May 1st. Generally, we sell out 6 to 8 weeks in advance.

Feel free to email me with any questions. In the meantime, as always, I’m interested in your thoughts about FIT and DP.

Until next time,

Scott

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

Just how good are our theories about the causes and alleviation of mental and emotional suffering?

July 12, 2018 By scottdm 7 Comments

Does the name Barry Marshall ring a bell?

Probably not if you are a mental health professional.

For decades, the Australian physician was persona non grata in the field of medicine — or perhaps stated more accurately, persona sciocca, a fool.

Beginning in the early 1980’s, Marshall, together with colleague Robin Warren, advanced the hypothesis that the bacteria heliobacter pylori was at root of most stomach ulcers. That idea proved exceptionally controversial flying, as it did, in the face of years of accepted practice and wisdom. Ulcers caused by something as simple and obvious as a bacterial infection? Bunk, the medical community responded, in the process lampooning the two researchers. After all, everyone knew stress was the culprit. The also knew the cure: certainly not antibiotics. Rather, antacids, sedatives, therapy and, in the more chronic and serious cases, gastrectomy–a surgical procedure involving the removal of the lower third of the stomach.

The textbook used in my Introduction to Psychology course in my first year at University boldly declared, “Emotional stress is now known to relate to … such illnesses as … peptic ulcers” (p. 343, Psychology Today: An Introduction 4th Edition [Braun and Linder, 1979]). The chapter on the subject was full of stories of people whose busy, emotionally demanding lives were clearly the cause of their stomach problems. I dutifully overlined all the relevant sections with my orange highlighter. Later, in my clinical career, whenever I saw a person with an ulcer, I told them it was caused by stress and, not surprisingly, taught them “stress-management” strategies.

The only problem is the field, my textbook, and I were wrong, seriously wrong. Stress was not responsible for stomach ulcers. And no, antacids, sedatives, and psychotherapy, were not the best treatments. The problem could be cured much more efficiently and effectively with a standard course of antibiotics, many of which had been available since the 1960’s! In other words, the cure had been within reach all along. Which begs the question, how could the field have missed it? Not only that, even after conclusively demonstrating the link between ulcers and the h.pylori bacterium, the medical community continued to reject Marshall and Warren’s papers and evidence for another 10 years (Klein, 2013)!

So what was it? Money, ignorance, hubris–even the normal process by which new scientific findings are disseminated–have all been offered as explanations. The truth is, however, the field of medicine, and mental health in particular, has a weakness–to paraphrase Mark Twain–for “knowing with certainty things that just ain’t so.”

How about these?

Structural abnormalities in the ovaries cause neurosis in women;
Psychopathology results from unconscious dynamics originating in childhood;
Optimism, anger control, and the expression of emotion reduces the risk of developing cancer;
Negative thinking, “cognitive distortions,” and/or a chemical imbalance cause depression;
Some psychotherapeutic approaches are more effective than others.

The list is extensive and dates all the way back to the field’s founding nearly 150 years ago. All, at one point or another, deeply believed and passionately advocated. All false.

Looking back, its easy to see that we therapists are suckers for a good story–especially those that appear to offer scientific confirmation of strongly held cultural beliefs and values.

Nowadays, for example, it simply sounds better to say that our work targets, “abnormal activation patterns in dlPFC and amygdala that underlie the cognitive control and emotion regulation impairments observed in Major Depressive Disorder” than, “Hey, I listened attentively and offered some advice which seemed to help.” And while there’s a mountain of evidence confirming the effectiveness of the latter, and virtually none supporting the former, proponents tell us it’s the former that “holds the promise” (Alvarez & Icoviello, 2015).

What to do? Our present “neuroenchantment” notwithstanding, is there anything we practitioners and the field can learn from more than 150 years of theorizing?

Given our history, it’s easy to become cynical, either coming to doubt the very existence of Truth or assuming that it’s relative to a particular individual, time, or culture. The other choice, it seems to me, is humility–not the feigned ignorance believed by some to be a demonstration of respect for individual differences–but rather what results when we closely and carefully examine our actual work.

Take empathy, for example. Not only do most practitioners consider the ability to understand and share the feelings of another an “essential” clinical skill, it is one of the most frequently studied aspects of therapeutic work (Norcross, 2011). And, research shows therapists, when asked, generally give themselves high marks in this area (c.f., Orlinksky & Howard, 2005). My colleagues, Daryl Chow, Sharon Lu, Geoffrey Tan, and I encountered the same degree of confidence when working with therapists in our recent, Difficult Conversations in Therapy study. Briefly, therapists were asked to respond empathically to a series of vignettes depicting challenging moments in psychotherapy (e.g., a client expressing anger at them). Each time, their responses were rated on standardized scale and individualized feedback for improving was provided.

Now, here is the absolutely cool part. The longer therapists participated in the research, the less confident but more demonstrably empathic they became! The process is known as “The Illusion of Explanatory Depth.” Simply put, most of us feel we understand the world and our work with far greater detail, coherence, and depth than we really do. Only when we are forced ourselves to grapple with the details, does this illusion give way to reality, and the possibility of personal and professional growth become possible.

If this makes your head spin, get a cup of coffee and watch the video below in which Dr. Daryl Chow explains these intriguing results.

Until next time,

Scott

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

P.S. Marshall and Warren were awarded the Nobel Prize for their research in 2005. Better late than never.

Finding Meaning in Psychotherapy Amidst the Trivia and Trivial

April 1, 2018 By scottdm 11 Comments

I don’t know if you feel the same way I do. Looking back, I’m pretty sure its been going on for a while, but somehow I didn’t notice.

Professional books and journals fill my bookshelves and are stacked around my desk. I am, and always have been, a voracious–even compulsive–reader. In the last couple of years, the volume of material has only increased–exponentially so, if I include digital items saved to my desktop.

Now, I’ll be the first to admit: it’s hard keeping up. But that’s really not my problem.

The issue is: I feel like I’m drowning in trivia and the trivial.

How about you? When was the last time you read something truly meaningful?

Increasingly, research journals are filled with studies that are either so narrow in focus as to defy any real world application, or simply revisit the same questions over and over. Just how many more studies does the field need, for example, on cognitive-behavioral therapy? A Google Scholar search on the subject, crossed with the term, “randomized controlled trial,” returns over a million hits!

In terms of translating research into practice, here’s a sample of articles sure to appeal to almost every clinician (and I didn’t have to “dig deep” to find these, by the way, as all were in journals neatly stacked on my desk):

I didn’t make these up. All are real articles in real research journals. If you don’t believe me, click on the links to see for yourself.

Neologisms (#1) and cuteness (#2) aside, their titles often belie a mind-numbing banality in both scope and findings. Take the last study. Can you guess what its about? Satisfaction with life moderates the indirect effect of pain intensity on pain interference through pain catastrophizing. And what findings do you think the authors spent 10 double-column, 10-point font pages relating in one of psychology’s most prestigious journals?

“Satisfaction with life appears to buffer the effect of pain.”

Hmm. Not particularly earth-shattering. And, based on these results, what do the authors recommend? Of course: “Further evaluation in longitudinal and interventional studies” (I foresee another study on cognitive-behavioral therapy in the near future).

Purpose, belonging, sense-making, transcendence, and growth are the foundations of meaning. Most of what shows up in my inbox, is taught at professionals workshops, and appears in scholarly publications has, or engenders, none of those qualities. The cost to our field and the people we serve is staggering. Worldwide, rates of depression, anxiety, and suicide continue to rise. At the same time, fewer and fewer people are seeking psychotherapy–34% fewer according to the latest findings. It is important to note that even when extensive efforts are made, and significant financial support is provided, 85% of those who could benefit choose not go. I just can’t believe its because therapists haven’t attended the latest “amygdala retraining” workshop, or do not know how to “psychodynamize” their cognitive-behavioral interventions.

This last week, I had the pleasure of interviewing Dr. Ben Caldwell. His book, Saving Psychotherapy: Bringing the Talking Cure Back from the Brink, speaks directly to the challenges facing the field as well as steps every clinician can take to restore meaning to both research and practice. Take listen, and then be sure to leave a comment.

Until next time,

Scott

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