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 5th and expanded edition).
Here’s a riddle for you:
What do therapists, researchers, case managers, magicians, surgeons, award winning musicians, counselors, jugglers, behavioral health agency directors, and balloon twisting artists have in common?
They all participated in the first “Achieving Clinical Excellence” held last week in Kansas City, Missouri.
It’s true. The “motley” crew of presenters, entertainers, and attendees came to Kansas City learn the latest, evidence-based strategies for helping clinicians achieve their “personal best” and, in the process, improve the quality and outcome of behavioral health services. Not only did participants and presenters come from all over the globe–Australia, New Zealand, Norway, Sweden, Denmark, Austria, the UK, Ireland, Scotland, Germany, Canada, Holland, and elsewhere–but ICCE web 2.0 technology was used to stream many of the presentations live to a worldwide audience (click on the link to watch the recordings).
“The atmosphere was positively electric,” one participant remarked to me on break, “and so friendly. First, I was inspired. Each presentation contained something new, a take-away. Then I wanted to sit with other attendees and discuss the content.”
And thanks to “Gillis for Children and Families,” who not only sponsored and ran the event, but provided a full breakfast and lunch each day of the conference, participants had ample opportunity to meet, process, and network with each other.
Rich Simon Anders Ericsson Michael Ammar
Rich Simon, Ph.D., the editor of the Psychotherapy Networker, kicked off the event using his time at the podium to place the conference’s emphasis on excellence within the broader history of the field of psychotherapy. He was followed by K. Anders Ericsson, the editor of the influential Cambridge Handbook of Expertise and Expert Performance, reviewed research on expert performance gathered over the last 3 decades. Scott D. Miller, Ph.D., translated existing research on expert performance into steps for improving outcomes in behavioral health. On day 2, professional magician Michael Ammar delivered a stunning performance of close up magic while teaching a specific method of deliberate practice that clinicians can use to improve their skills. Meanwhile, break out sessions led by psychologists, physicians, counselors, pharmacists, and agency directors addressed “nuts and bolts” applications.
Rachel Hsu Roger Shen
In between each plenary and breakout session, top performers from a variety of fields entertained and inspired. Moving performances on the violin and piano by nine year old Rachel Hsu and eleven year old Roger Shen amazed and challenged everyone in attendance. “It is not talent,” Rachel told me, “It’s a lot of hard work–4 to 5 hours a day, everyday of the week, including weekends.” The take home lesson from these exception kids was clear: there are no short cuts when it comes to top performance. If you want to achieve your personal best you must work hard. Promises otherwise are so much more snake oil.
On Thursday evening, the Australian classical pianist, David Helfott, whose lifestory was the subject of the award winning film, “Shine” entertained conference attendees. His partner, Gillian, introduced and provided the audience with a brief history of David’s life, unfortunate treatment in the mental health system, and their long marriage. The audience rose to their feet in a standing ovation at the conclusion of the performance. There were few dry eyes in the house. Afterwards, the two spent nearly an hour meeting and greeting attendees personally. Once again, portions of the performance were broadcast live via ICCE web 2.0 technology to a world wide audience.
The inspiration that conference attendees felt continues on the International Center for Clinical Excellence web-based community. Join us as we work to help each other achieve our personal best. Still looking for inspiration? Take a look at the following two videos; first, a montage of events at ACE; and second, Mr. Ah’ Lee Robinson, the director of the Kansas City Boys Choir, whose story and performance brought the conference to a moving conclusion.
September 7, 2010
Chicago, Illinois USA
I can’t believe it. Summer is over. Kids are back in school. And, the International Center for Clinical Excellence (ICCE) is celebrating its one year anniversary! Time passes so quickly.
On August 25th, 2009, I blogged about the creation of a web-based community of clinicians using the latest Web2.0 technology where participants could learn from and share with each other. The ICCE website and community was officially launched the following December at the Evolution of Psychotherapy conference. In a few short months, ICCE had become the largest, international online community of professionals, researchers, and policy makers working to improve the quality and outcome of behavioral health services.
So much more has happened over the last year, including the development and standardization of a training package for clinicians and agencies interested in streamlining the implementation of Feedback-Informed Treatment (FIT), the annual “training of trainers” conference, and much more. Take a look at the video and see for yourself, and if you are not already a member, join us online today at: www.centerforclinicalexcellence.com.
“Hope Transcends” was the theme of the 39th Annual Summer Institute on Substance Abuse and Mental Health held in Newark, Delaware this last week. I had the honor of working with 60+ clinicians, agency managers, peer supports, and consumers of mental health services presenting a two-day, intensive training on “feedback-informed clinical work.” I met so many talented and dedicated people over the two days and even had a chance to reconnect with a number of folks I’d met at previous trainings– both at the Institute and elsewhere.
One person I knew but never had the privilege of meeting before was psychologist Ronald Bassman. A few years back, he’d written a chapter that was included in my book, The Heroic Client. His topic at the Summer Institute was similar to what he’d written for the book: harmful treatment. Research dating back decades documents that approximately 10% of people deteriorate while in psychotherapy. The same body of evidence shows that clinicians are not adept at identifying: (a) people who are likely to drop out of care; or (b) people who are deteriorating while in care.
Anyway, you can read about Ron on his website or pick up his gripping book A Fight to Be. Briefly, at age 22 Ron was committed to a psychiatric hospital. Over the next several years, he was diagnosed with paranoid schizophrenia and forcefully subjected to a series of humiliating, painful, degrading and ultimately unhelpful “treatments.” Eventually, he escaped his own and the systems’ madness and became a passionate advocate for improving mental health services. His message is simple: “we can and must do better.” And, he argues persuasively, the process begins with building better partnerships with consumers.
One way to build bridges with consumers is routinely seeking their feedback regarding the status of the therapeutic relationship and progress of any services offered. Indeed, the definition of “evidence-based practice” formally adopted by the American Psychological Association mandates that the clinician “monitor…progress…[and] If progress is not proceeding adequately…alters or addresses problematic aspects of the treatment (e.g., problems in the therapeutic relationship or the implementation of the goals of treatment)” (pp. 276-277, APA, 2006). Research reviewed in detail on this blog documents significant improvement in both retention and outcome when clinicians use the Outcome and Session Rating Scales to solicit feedback from consumers. Hope really does transcend. Thank you Ron and thank you clinicians and organizers at the Institute.
And now, just for fun. Check out these two new videos:
Brendan Madden Scott D. Miller Jeffrey K. Zeig
A little over month ago, I blogged about how the outcome and session rating scales were originally conceived of and developed. A few days prior to that, I wrote about where the whole idea of using measures to solicit feedback had started. In both instances, my teachers and supervisors played a significant role. Immediately following a two day workshop I’d given in Israel, psychologist Haim Omer suggested developing a visual analog scale that could be used in lieu of the longer Outcome Questionnaire 45.2–an idea that literally changed the entire arc of my professional career. Drs. Lynn Johnson and Michael Lambert–a supervisor and professor I met and worked with as a graduate student–were the first to pioneer feedback-informed treatment (FIT). Some twenty plus years into my career, I remain in contact with both, calling, seeking input, discussing ideas, and soliciting feedback.
“Professional coaches,” says the noted “expert on experts” K. Anders Erickson, “…play an essential role in guiding…future experts in a safe and effective manner” (p. 698). Needless to say, I’ve been very fortunate to have such visionary mentors. One more story.
In 1984, I wrote a letter to Dr. Jeffrey K. Zeig, the director of the Milton H. Erickson Institute. I was in my second year of a Ph.D. program in psychology and, like many graduate students, dead broke. While taking a course on hypnosis as part of my studies, I’d become interested in the work of Milton Erickson.
“I’d like to learn more,” I wrote at the time, “Would it be possible for me to visit the Institute, watch some videos and have a chance to talk with you?” I wasn’t too far away. I could drive to Phoenix where the Institute was located. I could even arrange to stay with friends to save money. “Dr. Zeig,” I continued, “I’m a graduate student and don’t have much money, but I’d be willing to do some work in kind.” I’d pasted mailing labels on thousands of brochures for the local hypnosis and therapy organizations, for example, in exchange for being able to attend professional continuing education events. “I’ll vacuum and clean the office, wash vehicles, do filing. Whatever might be helpful to you or the Institute.”
Within a couple of weeks, an envelop from the Milton H. Erickson Institute arrived. In it was a letter that was brief and to the point. “Please call me,” it said, and was signed Jeffrey K. Zeig, Ph.D. Needless to say, I called straight away. We chatted for a few minutes. He told me that I was welcome to visit the Institute, watch videos, talk with some of the staff and even spend some time with him. And then he asked, “Do you think you could afford five dollars?” I was floored.
Ever since meeting him on that hot summer day in Phoenix, he’s been an important teacher and mentor. It’s particularly noteworthy that whenever we talk–by phone, email, or in chance meetings on airplanes while criss-crossing the globe–he invariably asks, “What are you learning?” And then he listens, intently.
Last week, we were catching up on the phone and Jeff told me that his long-held desire to open an international psychotherapy training and research facility had finally been fulfilled. Briefly, The Institute for Applied Therapeutic Change is a real clinic where professionals and students can learn the latest in behavioral healthcare from leading experts in the field and while working with real clients (click on the text above for the complete press release).
“I can hardly wait to attend some of the events,” I said. “And when are you available to teach?” he responded. Stunned again. I’m so fortunate and can hardly wait to participate in the Institute activities as both a presenter and student. Stay tuned to the Foundation website for more details!
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.
Last week, I received an email from David Claud. I’ve known Dave for the better part of a decade, having met–I believe–at a Ericksonian Conference in Florida where he lives and works. He and the crew at the Center for Family Service in Palm Beach County figure prominently in the history of routine outcome measure and feedback. After hearing me speak, Dave took the measures back to the center and, together with the staff, became one of the first agencies in the country to formally adopt and use the ORS and SRS. Additionally, data gathered at CFS was used in some of the initial validation studies of the measures. Finally, their own research, cited in the second edition of The Heart and Soul of Change document dramatic improvements in outcome as well as decreased lengths of stay, cancellation and no show rates (40, 40, and 25% respectively).
Anyway, in his email, Dave included a link to a recent article by Ann Hulbert in Slate magazine. I’m lucky to have friends like Dave and others who keep me informed and up-to-date. The title of the piece certainly got my attention: “The Dark Side of the New Theories of Success: What the New Success Books Don’t tell you about Superachievement.”
As readers of my blog know, I’ve been pouring through the literature on excellence over this last year in an attempt to understand why some clinicians achieve reliably better outcomes than others. I first wrote about our findings in an article titled, “Supershrinks: Learning from the Field’s Most Effective Practitioners” that appeared in the Psychotherapy Networker. Since then, I’ve continued to work and research, together with senior associates at the International Center for Clinical Excellence, to deepen and refine the “steps to clinical excellence” that any therapist could follow to improve performance.
Alas, I’m not alone in my interest in the literature on expertise. A number of books, starting with Gladwell’s delightfully engaging Outliers, have appeared in the last year or so on the subject, including: The Talent Code, Bounce: The Science of Success, The Genius in All of Us: Why Everything You’ve Been Told About Genetics, Talent, and IQ Is Wrong and my personal favorite Talent Is Overrated: What Really Separates World-Class Performers from Everybody Else. The appearance of so many books is interesting. With few exceptions (i.e., sports psychology), K. Anders Erickson and colleagues labored in viritual academic obscurity for decades formulating hypotheses, conducting research and assembling evidence. And then suddenly: boom! EVERYBODY is talking about their work.
Always wanting to “hear” both sides of the story, I immediately clicked on the link in Dave’s email and read the article. I was dumbfounded. Hulbert’s gripe about the recent spate of books is in fact the central point of each: achieving superior performance in any field is bloody hard work. “They don’t always do realistic justice to the grunt work they champion,” whines Hulbert, tending instead to, “gloss over the sweaty specifics….distracting us from how arduous, tedious, and dependent on adult pushiness it can be…[and] glamorizing its intensity.”
My response: “Oh, contraire mon fraire!”
All of the books and research studies point to the years of dedicated and painstaking work involved in achieving world class levels of performance across a variety of domains (sports, music, medicine, computer programming, and psychology). K. Ander’s Erickson–who will, by the way, be one of the keynote presenters at the upcoming “Achieving Clinical Excellence” conference–is fond of saying, “Unlike play, deliberate practice is not inherently motivating; and unlike work, it does not lead to immediate social and monetary rewards…and actually generates costs…”. Little wonder few of us–myself included–engage in it on any regular basis.
The question that begs an answer is, “why would anyone do it?” Consider the brief video clip below:
Impressive, huh? I can’t imagine the amount of time it must have taken to master such a performance. No camera tricks. Just plain old fashioned trial-and-error, practice, and hard work.
We are finding the same pattern among top performing therapists. In short, they have an “error-centric” approach to practice–constantly looking for what they do that doesn’t work and taking time to plan, identify and try alternatives, and then reflect and refine their process-improvement efforts. Such activity is cognitively taxing and, in most instances, not immediately rewarding (financially or otherwise). But there is more to the story. It turns out that superior performance is not a matter of working harder. Most of us work hard at our jobs. Rather, becoming a better clinician is about working smarter. Here, the literature on expertise provides clear, empirically-supported guidelines.
If you’re feeling inspired, why not pick up one of the books? Also, be sure and join us at the upcoming “Achieving Clinical Excellence” conference where the ideas and steps will be discussed in detail.
Helsingor Castle (the setting for Shakespeare’s Hamlet)
Dateline: May 8th, 2010, Helsingor, Denmark
This weekend I’m in Denmark doing a two-day workshop on “Supershrinks” sponsored by Danish psychologist and ICCE Senior Associate and Trainer Susanne Bargmann. Just finished the first day with a group of 30 talented clinicians working diligently to achieve their personal best. The challenge, I’m increasingly aware, is sustaining a commitment to seeking client feedback over time once the excitement of a workshop is over. On the surface, the idea seems simple: ask the consumer. In practice however, it’s not easy. The result is that many practitioners who are initially enthusiastic lose steam, eventually setting aside the measures. It’s a serious concern given that available evidence documents the dramatic impact of routine outcome and alliance monitoring on outcome and retention in behavioral health.
Support of like-minded colleagues is one critical key for sustaining commitment “after the thrill is gone.” Where can you find such people? As I blogged about last week, over a thousand clinicians are connecting, sharing, and supporing each other on the web-based community of the International Center for Clinical Excellence (If you’re not already a member, click here to request your own personal (and free) invitation to join the conversation).
In the brief interview above, Susanne identifies a few additional steps that practitioners and agencies can take for making the process of seeking feedback successful over the long haul. By the way, she’ll be covering these principles and practices in detail in an afternoon workshop at the upcoming Achieving Clinical Excellence conference. Don’t miss it!
Let’s face it. Clinicians are tired. Tired of paperwork (electronic or othrwise). When I’m out and about training–which is every week by the way–and encouraging therapists to monitor and measure outcomes in their daily work few disagree in principle. The pain is readily apparent however, the minute the paper version of the Outcome Rating Scale flashes on the screen of my PowerPoint presentation.
It’s not uncommon nowadays for clinicians to spend 30-50% of their time completing intake, assessment, treatment planning, insurance, and other regulatory forms. Recently, I was in Buffalo, New York working with a talented team of children’s mental health professionals. It was not uncommon, I learned, to spend most of two outpatient visits doing the required paperwork. When one considers that the modal number of sessions consumers attend is 1 and the average approximately 5 its hard not to conclude that something is seriously amiss.
Much of the “fear and loathing” dissipates when I talk about the time it usually takes to complete the Outcome and Session Ratings Scales. On average, filling out and scoring the measures takes about a minute a piece. Back in January, I blogged about research on the ORS and SRS, including a summary in PDF format of all studies to date. The studies make clear that the scales are valid and reliable. Most important, however, for day-to-day clinical practice, the ORS and SRS are also the most clinically feasible measures available.
Unfortunately, many of the measures currently in use were never designed for routine clinical practice–certainly few therapists were consulted. In order to increase “complaince” with such time consuming outcome tools, many agencies advise clinicians to complete the scales occasionally (e.g., “prime numbers” [5,7, 11 and so on]) or only at the beginning and end of treatment. The very silliness of such ideas will be immediately apparent to anyone who ever actually conducted treatment. Who can predict a consumer’s last session? Can you imagine a similar policy ever flying in medicine? Hey Doc, just measure your patient’s heart rate at the beginning and end of the surgery! Inbetween? Fahgetabotit. Moreover, as I blogged about from behind the Icelandic ash plume, the latest research strongly favors routine measurement and feedback. In real-world clinical settings feasibility is every bit as important as reliability and validity. Agency managers, regulators, and policy makers ignore it at their own (and their data’s) peril.
How did the ORS and SRS end up so brief and without any numbers? When asked at workshops, I usually respond, “That’s an interesting story.” And then continue, “I was in Israel teaching. I’d just finished a two day workshop on ‘What Works.'” (At the time, I was using and recommending the 10-item SRS and 45-item OQ).
“The audience was filing out of the auditorium and I was shutting down my laptop when the sponsor approached the dais. ‘Scott,’ she said, ‘one of the participants has a last question…if you don’t mind.'”
“Of course not,” I immediately replied.
“His name is Haim Omer. Do you know of him?”
“Know him?” I responded, “I’m a huge fan!” And then, feeling a bit weak in the knees asked, “Has he been here the w h o l e time?”
Haim was as gracious as ever when he finally made it to the front of the room. “Great workshop, Scott. I’ve not laughed so hard in a long time!” But then he asked me a very pointed question. “Scott,” he said and then paused before continuing, “you complained a bit about the length of the two measures you are using. Why don’t you use a visual analog scale?”
“That’s simple Haim,” I responded, “It’s because I don’t know what a visual analog measure is!”
Haim described such scales in detail, gave me some examples (e.g., smiley and frowny faces), and even provided references. My review on the flight home reminded me of a simple neuropsychological assessment scale I used on internship called “The Line Bisection Task”–literally a straight line (a measure developed by my neuropsych supervisor, Dr. Tom Schenkenberg). And the rest is, as they say, history.
Made it back to Chicago after a week in New Zealand providing training and consultation. As I blogged about last Thursday, the last two days of my trip were spent in Christchurch providing a two-day training on “What Works” for Te Pou–New Zealand’s National Centre of Mental Health Research, Information, and Workforce Development. Last year around this same time, I provided a similar training for Te Pou for managers and policy makers in Auckland. News spread and this year my contact at Te Pou, Emma Wood brought the training to the south island. It is such a pleasure to be involved with such a forward thinking organization.
Long before I arrived, leadership at Te Pou were promoting outcome measurement and feedback. Here’s a direct quote from their website:
Outcomes information can assist:
- service users to use their own outcomes data to reflect on their wellbeing and circumstances, talk to clinicians about their support needs and inform their recovery plans
- clinicians to use outcomes information to support their decision-making in day-to-day practice, monitoring change, better understanding the needs of the service user, and also to begin evaluating the effectiveness of different interventions
- planners and funders to assess population needs for mental health services and assist with allocation of resources policy and mental health strategy developments through nationally aggregated data.
Indeed, using outcome to inform mental health service delivery is a key aspect of the Past, Present, and Future: Vision Paper–a review of “what works” in care and a plan for improving treatment in the future. The site even publishes a quarterly newsletter Outcomes Matter. Take a few minutes and explore the Te Pou website. While you are there, be sure and download the pamphlet entitled, “A Guide to Talking Therapies.” As the title implies, this brief, easy-to-read text provides a non-nonsense guide to the various “talk therapies” for consumers (I took several copies home with me from the workshop).
Before ending, let me say a brief hello to the Clinical Practice Leaders from the Problem Gambling Foundation of New Zealand who attended the two-day training in Christchurch. The dedicated staff use an integrated public health and clinical model and are working to implement ongoing measurement of outcome and consumer feedback into service delivery. The website contains a free online library including fact sheets, research, and books on the issue of problem gambling that is an incredible resource to professionals and the public. Following the workshop, the group sent a photo that was taken of us together. From left to right, they are Wenli Zhang, me, Margaret Sloan, and Jude West.
If you are following me on Twitter (and I hope you are), you know the last month has been extremely busy. This week I worked with clinicians in Peterborough, Ontario Canada. Last week, I was in Nashville, Tennessee and Richmond Virginia. Prior to that, I spent nearly two weeks in Europe, providing training and consultations in the Netherlands and Belgium.
It was, as always, a pleasure meeting and working with clinicians representing a wide range of disciplines (social workers, case managers, psychologists, psychiatrists, professional counselors, alcohol and drug treatment professionals, etc.) and determined to provide the best service possible. As tiring as “road work” can sometimes be, my spirits are always buoyed by the energy of the individuals, groups, and agencies I meet and work with around the world.
At the same time, I’d be remiss if I didn’t acknowledge the fear and hardship I’m witnessing among providers and treatment agencies each week as I’m out and about. Frankly, I’ve never seen anything like it in my seventeen years “on the road.” Being able to say that we predicted the current situation nearly 6 years ago provides little comfort (see The Heroic Client, 2004).
While nearly all are suffering, the economic crisis in the United States is hitting public behavioral health particularly hard. In late January I blogged about the impact of budget cuts in Ohio. Sadly, the situations in Virginia and Tennessee are no different. Simply put, public behavioral health agencies are expected to do more with less, and most often with fewer providers. What can be done?
Enter Chesterfield Community Service Board. Several years ago, I met and began working with Larry Barnett, Lyn Hill, and the rest of the talented clinical staff at this forward thinking public behavioral health agency. Their goal? According to the agency mission statement, “to promote improved quality of life…through exceptional and comprehensive mental health, mental retardation, substance abuse, and early intervention services.” Their approach? Measure and monitor the process and outcome of service delivery and use the resulting information to improve productivity and performance.
As Larry and Lynn report in the video below, the process was not easy. Indeed, it was damn difficult–full of long hours, seemingly endless discussions, and tough, tough choices. But that was then. Some three years later, the providers at Chesterfield CSB are serving 70% more people than they did in 2007 despite there being no increase in available staff resources in the intervening period. That’s right, 70%! And that’s not all. While productivity rates soared, clinician caseloads were reduced by nearly 30%. As might be expected, the time consumers in need of services had to wait was also significantly reduced.
In short, everybody won: providers, agency managers, funders, and consumers. And thanks to the two days of intensive training in Richmond, Virginia organized by Arnold Woodruff, many additional public behavioral health agencies have the information needed to get started. It won’t be easy. However, as the experience in Chesterfield demonstrates, it is possible to survive and thrive during these tumultuous times. But don’t take my word for it, listen to how Larry and Lynn describe the process–warts and all–and the results:
Later today, I board United flight 908 on my way to workshops scheduled in Holland and Belgium. My routine in the days leading up to an international trip is always the same. I slowly gather together the items I’ll need while away: computer (check); european electric adapter (check); presentation materials (check); clothes (check). And, oh yeah, two decks of playing cards and close up performance mat.
That’s me (pictured above) practicing a “ribbon spread” in my hotel room following a day of training in Marion, Ohio. It’s a basic skill in magic and I’ve been working hard on this (and other moves using cards) since last summer. Along the way, I’ve felt both hopeful and discouraged. But I’ve kept on nonetheless taking heart from what I’m reading about skill acquisition.
Research on expertise indicates that the best performers (in chess, medicine, music, sports, etc.) practice every day of the week (including weekends) for up to four hours a day. Sounds tiring for sure. And yet, the same body of evidence shows that world class performers are able to sustain such high levels of practice because they view the acquisition of expertise as a long-term process. Indeed, in a study of children, researcher Gary McPherson found that the answer to a simple question determined the musical ability of kids a year later: “how long do you think you’ll play your instrument?” The factors that were shown to be irrelevant to performance level were: initial musical ability, IQ, aural sensitivity, math skills, sense of rhythm, income level, and sensorimotor skills.
The type of practice also matters. When researchers Kitsantas and Zimmerman studied the skill acquisition of experts, they found that 90% of the variation in ability could be accounted for by how the performers described their practice; the types of goals they set, how they planned and executed strategies, self-monitored, and adapted their performance in response to feedback.
So, I take my playing cards and close-up mat with me on all of my trips (both domestic and international). I don’t practice on planes. Gave that up after getting some strange stares from fellow passengers as they watched me repeat, in obsessive fashion, the same small segment of my performance over, and over, and over again. It only made matters worse if they found out I was a psychologist. I’d get that “knowing look,” that seemed to say, “Oh yeah.” Anyway, I also managed to lose a fair number of cards when the deck–because of my inept handling while trying to master some particular move–went flying all over the cabin (You can imagine why I’ve been less successful in keeping last year’s New Year resolution to learn to play the ukelele).
Once I’m comfortably situated in my room, the mat and cards come out and I work, practice a specific handling for up to 30 minutes followed by a 15-20 minute break. Believe it or not, learning–or perhaps better said, attempting to learn–magic has really been helpful in understanding the acquisition of expertise in my chosen field: psychology and psychotherapy. Together with my colleagues, we are translating our experience and the latest research on expertise into steps for improving the performance and outcome of behavioral health services. This is, in fact, the focus of the newest workshop I’m teaching, “Achieving Clinical Excellence.” It’s also the organizing theme of the ICCE Achieving Clinical Excellence conference that will be held in Kansas City, Kansas in October 2010. Click on the photo below for more information.
In the meantime, check out the two videos I’ve uploaded to ICCETV featuring two fun magic effects. And yes, of course, feedback is always appreciated!
Nicholas Cummings, Ph.D.
Sometime in late 1986 I wrote a letter to Dr. Nicholas Cummings. As a then student-member of the American Psychological Association (APA), I was automatically subscribed to and receiving the American Psychologist. In the April issue, Dr. Cummings published an article, provocatively titled, “The Dismantling of Our Health System: Strategies for the Survival of Psychological Practice.” Change was in the air. “Traditional psychology practice is both inefficient and ineffective,” he argued, and a “growing revolution in heath care” was a clear and present danger to the very survival of the field.
What can I say? As someone at the beginning of his career (with large student loans to repay and a long time to go before retirement), the five page article spooked me. So I did what I’d done before: I wrote a letter. I’d been writing and calling prominent researchers and clinicians ever since I was an undergraduate. During the 70’s, I’d exchanged letters and even phone calls with B.F. Skinner!
In all honesty, I didn’t know anything about Dr. Cummings–for example, that he was a former president of the APA, launched the Professional Schools of Psychology movement and founded four campuses of the California School of Professional Psychology, wrote the freedom-of-choice legislation requiring insurers to reimburse non-medical, behavioral health providers, and started American Biodyne in the hopes that psychologists could own rather than be owned–as eventually happened–by managed care (read a history here). Neither did I know that he was a member of Psychology’s famed “Dirty Dozen.” Without a doubt, however, the decision to write him, changed the arc of my career.
Fast forward 25 years, and 86-year-old Nicholas Cummings is at it again–not only sounding a warning klaxon but identifying the opportunities available in the dramatically changing healthcare environment. Sadly, the field (and professional psychology in particular) ignored the counsel he’d given back in 1986. As a result, business interests took over managed care, resulting–just as he predicted–in low wages and the near complete lack of professional autonomy.
So, what can clinicians do now to survive and thrive? According to Dr. Cummings, two words best capture the future of behavioral health: (1) integrated care; and (2) entrepreneurship. Let’s face the unpleasant reality and say it out loud: independent practice is on life support. Agency work is no picnic either given the constant threats to funding and never ending amount of regulation and paperwork. Finally, when it comes to practitioner income, its a buyer’s market.
That said, it’s not all doom and gloom. Far from it. There is a tremendous need (and opportunity) in the present reform-driven healthcare marketplace for clinicians who are able to blend behavioral interventions, medical literacy, knowledge about healthcare delivery systems, and entrepreneurship skills. Possibilities do exist. The real question is, “Do we have the will to change?” Here’s where the power of one simple action–in this instance, a phone call–can have such a profound effect on one’s life and success.
Though we never formally worked together, I’ve been calling and writing Nick off and on for the two and a half decades. Late last fall, my partners and co-creators of the International Center for Clinical Excellence, Brendan Madden and Enda Madden, flew to Reno to seek his advice on our business plan. We simply called him. He said, “When can you get here?” The result? His sage counsel helped us win the InterTrade Seedcorn Regional Prize for “Best Emerging Company” as well as secure investors in the most restrictive venture capital environment since the Great Depression. And that’s not all…
Chief Technology Officer Enda Madden Chief Executive Officer Brendan Madden
Just last week, I flew to Phoenix, Arizona to give a presentation on using outcomes to improve behavioral healthcare service delivery at Arizona State University. Nick was there to meet me, along with the director of an entirely new program for behavioral health entrepreneurs, Dr. Ron O’Donnell. Briefly, the “Doctor of Behavioral Health” is the culmination of Nick’s vision of creating a doctoral training program tailored to the emerging need for innovative behavioral clinicians to practice in primary care and medical settings. Response has been overwhelming to say the least. Fifty plus post-graduate clinicians are enrolled. That’s right, post-graduate. In other words, these are practicing clinicians returning to add “integrated care expert and behavioral health entrepreneur” to their resume.
As it turns out, I’ll be traveling from Chicago to Phoenix a fair amount in the future. When he stood to introduce me, Nick announced that I’d be filling the “Cummings Professor of Behavioral Health” faculty position at ASU. The power of a single call.
Get ready. The revolution is coming (if not already here). Whether you are a direct service provider (psychologist, counselor, marriage and family therapist), agency, broker, or funder, you will be required to measure and likely report the outcomes of your clinical work.
Jay Lebow, Ph.D.
Just this month, Dr. Jay Lebow, a professor of psychology at the Family Institute at Northwestern University, published an article in the Psychotherapy Networker–the most widely circulated publication for practitioners in the world–where he claimed the field had reached a “tipping point.” “Once a matter of interest only among a small circle of academics,” Dr. Lebow writes in his piece entitled, The Big Squeeze, “treatment outcome has now become a part of the national debate about healthcare reform.”
David Barlow, Ph.D.
The same sentiments were expressed in a feature article entitled, “Negative Effects from Psychological Treatments,” written by Dr. David Barlow in the January issue of the American Psychologist. “Therapists,” he argues both eloquently and persuasively, “do not have to wait for the next clinical trial….[rather] clinicians [can act] as local clinical scientists…[using] outcome measures to track progress…rapidly becom[ing] aware of lack of progress or even deterioration” (p. 19). What can I say, except that any practitioner with more than a few years to work before retirement, should read these articles and then forward them to every practitioner they know.
During the Holidays, and just before the turn of the New Year, I blogged about the trend toward outcome measurement. As readers will recall, I talked about my experience on a panel at the Evolution of Psychotherapy conference where Dr. Barlow–who, in response to my brief remarks about the benefits of feedback– suprised me by stating unequivocally that all therapists would soon be required to measure and monitor the outcome of their clinical work. And even though my work has focused almost exclusively on measuring and using outcomes to improve both retention in and the results of behavioral health for the last 15 years, I said his pronouncement frightened me–which, by the way, reminds me of a joke.
A sheep farmer is out in the pasture tending his flock–I promise this is clean, so read on–when from over a small hill comes a man in a custom-tailored, three-piece business suit. In one hand, the businessman holds a calculator; in the other, an expensive, leather brief case. “I have a proposition for you,” the well-clad man says as he approaches the farmer, and then continues, “if I can tell you how many sheep are in your flock, to the exact number, may I have one of your sheep?” Though initially startled by the stranger’s abrupt appearance and offer, the farmer quickly gathers his wits. Knowing there is no way the man could know the actual number of sheep (since many in his flock were out of site in other pastures and several were born just that morning and still in the barn), the farmer quickly responded, “I’ll take that bet!”
Without a moment’s hesitation, the man calls out the correct number, “one thousand, three hundred and forty six,” then quickly adds, “…with the last three born this morning and still resting in the barn!” Dumbfounded, the farmer merely motions toward his flock. In response, the visitor stows his calculator, slings one of the animals up and across his shoulders and then, after retrieving his briefcase, begins making his way back up the hill. Just as he nears the top of the embankment, the farmer finds his voice and calls out, “Sir, I have a counter proposal for you.”
“And what might that be?” the man replies, turning to face the farmer, who then asked, “If I can tell you, sir, what you do for a living, can I have my animal back?”
Always in the mood for a wager, the stranger replies, “I’ll take that bet!” And then without a moment’s hesitation, the sheep farmer says, “You’re an accountant, a bureaucrat, a ‘bean-counter.'” Now, it’s the businessman’s turn to be surprised. “That’s right!” he says, and then asks, “How did you know?”
“Well,” the farmer answers, “because that’s my dog you have around your neck.”
The moral of the story? Bureaucrats can count but they can’t tell the difference between what is and is not important. In my blogpost on December 24th, I expressed concern about the explosion of “official interest” in measuring outcomes. As the two articles mentioned above make clear, the revolution has started. There’s no turning back now. The only question that remains is whether behavioral health providers will be present to steer measurement toward what matters? Here, our track record is less than impressive (remember the 80-90’s and the whole managed care revolution). We had ample warning (and did, well, nothing. If you don’t believe me, click here and read this article from 1986 by Dr. Nick Cummings).
As my colleague and friend Peter Albert is fond of saying, “If you’re not at the table, you’re likely to be on the menu.” So, what can the average clinician do? First of all, if you haven’t already done so, began tracking your outcomes. Right here, on my website, you can download, free, simple-to use, valid and reliable measures. Second, advocate for measures that are feasible, client-friendly, and have a empirical track record of improving retention and outcome. Third, and lastly, join the International Center for Clinical Excellence. Here, clinicians from all over the globe are connecting, learning, and sharing their experiences about how to use ongoing measures of progress and alliance. Most importantly, all are determined to lead the revolution.
Registrations are already coming in for the first International Conference on “Achieving Clinical Excellence.”
Not too long ago, I announced that internationally known researcher K. Anders Erickson, Ph.D.–the “expert on experts”–had agreed to present at the event. At that time, I also indicated that a number of internationally accomplished performers from a variety of professions (including psychology, business, medicine, science, music, entertainment, and sports) would be with us in Kansas City to teach and inspire. Attendees will learn the science and skills for achieving their personal best as a behavioral health practitioner by literally learning from the best.
Practice, as anyone who has been reading my recent blogosts and publications knows, is key for achieving excellence–and not just any old kind will do. To be effective, it must be deliberate, reflective, and ongoing. What’s more, it must be accompanied with high levels of support and detailed instruction from exceptional teachers.
No performer embodies these two principles–dedicated practice and exceptional teaching–better than FISM gold-medial winning magician, Michael Ammar. Magic magazine named him one of the 100 most influential magicians of the century.
Michael will open the second day of the the conference. First, he’ll perform. What can I say? You’ll be astonished and amazed. After that, Michael will talk about the role of practice in achieving excellence. He’s a master teacher who has spent years studying the elements of successful practice. He’ll not only inspire you, he will provide you with the means to excel.
Join us for three action packed days of fun, science and skill building. In the meantime, if you have a spare moment, watch Michael Ammar perform one of the classics of magic: the cups and balls.
One year ago today, I blogged about my New Year’s resolution to “take up the study of expertise and expert performance.” The promise marked a significant departure from my work up to that point in time and was not without controversy:
“Was I no longer interested in psychotherapy?”
“Had I given up on the common factors?
“What about the ORS and SRS?” and was I abandoning the field and pursue magic as a profession?”
The answer to all of the questions was, of course, an emphatic “NO!” At the same time, I recognized that I’d reached an empirical precipice–or, stated more accurately, dead end. The common factors, while explaining why therapy works did not and could never tell us how to work. And while seeking and obtaining ongoing feedback (via the ORS and SRS) had proven successful in boosting treatment outcomes, there was no evidence that the practice had a lasting impact on the professionals providing the service.
Understanding how to improve my performance as a clinician has, as is true of many therapists, been a goal and passion from the earliest days of my career. The vast literature on expertise and expert performance appeared to provide the answers I’d long sought. In fields as diverse as music and medicine, researchers had identified specific principles and methods associated with superior performance. On January 2nd, 2009, I vowed to apply what I was learning to, “a subject I know nothing about…put[ting] into practice the insights gleaned from the study of expertise and expert performance.”
The subject? Magic (and the ukulele).
How have I done? Definitely better than average I can say. In a column written by Barbara Brotman in today’s Chicago Tribune, psychologist Janine Gauthier notes that while 45% of people make New Year’s resolutions, only 8% actually keep them! I’m a solid 50%. I am still studying and learning magic–as attendees at the 2009 “Training of Trainers” and my other workshops can testify. The uke is another story, however. To paraphrase 1988 Democratic vice-presidential candidate, Lloyd Bentsen , “I know great ukulele players, and Scott, you are no Jake Shimabukuro.”
I first saw Jake Shimabukuro play the ukulele at a concert in Hawaii. I was in the islands working with behavioral health professionals in the military (Watch the video below and tell me if it doesn’t sound like more than one instrument is playing even though Jake is the only one pictured).
Interestingly, the reasons for my success with one and failure with the other are as simple and straightforward as the principles and practices that researchers say account for superior (and inferior) performance. I promise to lay out these findings, along with my experiences, over the next several weeks. If you are about to make a New Year’s resolution, let me give you step numero uno: make sure your goal/resolution is realistic. I know, I know…how mundane. And yet, while I’ve lectured extensively about the relationship between goal-setting and successful psychotherapy for over 15 years, my reading about expert performance combined with my attempts to master two novel skills, has made me aware of aspects I never knew about or considered before.
Anyway, stay tuned for more. In the meantime, just for fun, take a look at the video below from master magician Bill Malone. The effect he is performing is called, “Sam the Bellhop.” I’ve been practicing this routine since early summer, using what I’ve learned from my study of the literature on expertise to master the effect (Ask me to perform it for you on break if you happen to be in attendance at one of my upcoming workshops).
“What works” in therapy? Believe it or not, that question–as simple as it is–has and continues to spark considerable debate. For decades, the field has been divided. On one side are those who argue that the efficacy of psychological treatments is due to specific factors (e.g., changing negative thinking patterns) inherent in the model of treatment (e.g., cognitive behavioral therapy) remedial to the problem being treated (i.e., depression); on the other, is a smaller but no less committed group of researchers and writers who posit that the general efficacy of behavioral treatments is due to a group of factors common to all approaches (e.g., relationship, hope, expectancy, client factors).
While the overall effectiveness of psychological treatment is now well established–studies show that people who receive care are better off than 80% of those who do not regardless of the approach or the problem treated–one fact can not be avoided: outcomes have not improved appreciably over the last 30 years! Said another way, the common versus specific factor battle, while generating a great deal of heat, has not shed much light on how to improve the outcome of behavioral health services. Despite the incessant talk about and promotion of “evidence-based” practice, there is no evidence that adopting “specific methods for specific disorders” improves outcome. At the same time, as I’ve pointed out in prior blogposts, the common factors, while accounting for why psychological therapies work, do not and can not tell us how to work. After all, if the effectiveness of the various and competing treatment approaches is due to a shared set of common factors, and yet all models work equally well, why learn about the common factors? More to the point, there simply is no evidence that adopting a “common factors” approach leads to better performance.
The problem with the specific and common factor positions is that both–and hang onto your seat here–have the same objective at heart; namely, contextlessness. Each hopes to identify a set of principles and/or practices that are applicable across people, places, and situations. Thus, specific factor proponents argue that particular “evidence-based” (EBP) approaches are applicable for a given problem regardless of the people or places involved (It’s amazing, really, when you consider that various approaches are being marketed to different countries and cultures as “evidence-based” when there is in no evidence that these methods work beyond their very limited and unrepresentative samples). On the other hand, the common factors camp, in place of techniques, proffer an invariant set of, well, generic factors. Little wonder that outcomes have stagnated. Its a bit like trying to learn a language either by memorizing a phrase book–in the case of EBP–or studying the parts of speech–in the case of the common factors.
What to do? For me, clues for resolving the impasse began to appear when, in 1994, I followed the advice of my friend and long time mentor, Lynn Johnson, and began formally and routinely monitoring the outcome and alliance of the clinical work I was doing. Crucially, feedback provided a way to contextualize therapeutic services–to fit the work to the people and places involved–that neither a specific or common factors informed approach could.
Numerous studies (21 RCT’s; including 4 studies using the ORS and SRS) now document the impact of using outcome and alliance feedback to inform service delivery. One study, for example, showed a 65% improvement over baseline performance rates with the addition of routine alliance and outcome feedback. Another, more recent study of couples therapy, found that divorce/separation rates were half (50%) less for the feedback versus no feedback conditions!
Such results have, not surprisingly, led the practice of “routine outcome monitoring” (PROMS) to be deemed “evidence-based.” At the recent, Evolution of Psychotherapy conference I was on a panel with David Barlow, Ph.D.–a long time proponent of the “specific treatments for specific disorders” (EBP)–who, in response to my brief remarks about the benefits of feedback, stated unequivocally that all therapists would soon be required to measure and monitor the outcome of their clinical work. Given that my work has focused almost exclusively on seeking and using feedback for the last 15 years, you would think I’d be happy. And while gratifying on some level, I must admit to being both surprised and frightened by his pronouncement.
My fear? Focusing on measurement and feedback misses the point. Simply put: it’s not seeking feedback that is important. Rather, it’s what feedback potentially engenders in the user that is critical. Consider the following, while the results of trials to date clearly document the benefit of PROMS to those seeking therapy, there is currently no evidence of that the practice has a lasting impact on those providing the service. “The question is,” as researcher Michael Lambert notes, “have therapists learned anything from having gotten feedback? Or, do the gains disappear when feedback disappears? About the same question. We found that there is little improvement from year to year…” (quoted in Miller et al. ).
Research on expertise in a wide range of domains (including chess, medicine, physics, computer programming, and psychotherapy) indicates that in order to have a lasting effect feedback must increase a performer’s “domain specific knowledge.” Feedback must result in the performer knowing more about his or her area and how and when to apply than knowledge to specific situations than others. Master level chess players, for example, have been shown to possess 10 to 100 times more chess knowledge than “club-level” players. Not surprisingly, master players’ vast information about the game is consilidated and organized differently than their less successful peers; namely, in a way that allows them to access, sort, and apply potential moves to the specific situation on the board. In other words, their immense knowledge is context specific.
A mere handful studies document similar findings among superior performing therapists: not only do they know more, they know how, when, and with whom o apply that knowledge. I noted these and highlighted a few others in the research pipeline during my workshop on “Achieving Clinical Excellence” at the Evolution of Psychotherapy conference. I also reviewed what 30 years of research on expertise and expert performance has taught us about how feedback must be used in order to insure that learning actually takes place. Many of those in attendance stopped by the ICCE booth following the presentation to talk with our CEO, Brendan Madden, or one of our Associates and Trainers (see the video below).
Such research, I believe, holds the key to moving beyond the common versus specific factor stalemate that has long held the field in check–providing therapists with the means for developing, organizing, and contextualizing clinical knowledge in a manner that leads to real and lasting improvements in performance.
I’m still reeling from the experience in Anaheim this last week. I met so many leaders in the field, heard so many presentations on cutting edge clinical practice–as well as was reminded of some “classic” principles of effective psychotherapy.
One of the people I met was colleague and friend, Michael F. Hoyt, Ph.D. Michael and I go back 15+ years, having met–I believe–the first time at a workshop I was giving in Northern California (somewhere in the Bay Area where Michael works and resides). Since that time, we chatted regularly, and written editorials and book chapters together. His books (The First Session in Brief Therapy, Brief Therapy & Managed Care, The Handbook of Constructive Therapies, Some Stories are Better than Others) always balance theory and practice and are among my favorites.
My two favorite books are also his most recent: The Present is a Gift and Brief Psychotherapies: Principles & Practice (Hint: his chapters on couples therapy are among the best I’ve ever read). Anyway, the two of us caught up at the ICCE booth this last week at the Evolution conference.
From December 9-13th, eight thousand five hundred mental health practitioners, from countries around the globe, gathered in Anaheim, California to attend the “Evolution of Psychotherapy” conference. Held every five years since 1985, the conference started big and has grown only larger. “Only a few places in the US can accommodate such a large gathering,” says Jeffrey K. Zeig, Ph.D., who has organized the conference since the first.
The event, held every five years, brings together 40 of the field’s leading researchers, practitioners, trend setters, and educators to deliver keynote addresses and workshops, host discussion panels, and offer clinical demonstrations on every conceivable subject related to clinical practice. Naturally, I spoke about my current work on “Achieving Clinical Excellence” as well as served on several topical panels, including “evidence based practice” (with Don Meichenbaum), “Research on Psychotherapy” (with Steven Hayes and David Barlow), and “Severe and Persistent Mental Illness (with Marsha Linnehan and Jeff Zeig).
Most exciting of all, the Evolution of Psychotherapy conference also served as the official launching point for the International Center for Clinical Excellence. Here I am pictured with long-time colleague and friend, Jeff Zeig, and psychologist and ICCE CEO, Brendan Madden, in front of the ICCE display in the convention center hall.
Over the five days, literally hundreds of visitors stopped by booth #128 chat with me, Brendan, and Senior ICCE Associates and Trainers, Rob Axsen, Jim Walt, Cynthia Maeschalck, Jason Seidel, Bill Andrews, Gunnar Lindfeldt, and Wendy Amey. Among other things, a cool M and M dispenser passed out goodies to folks (if they pressed the right combination of buttons), we also talked about and handed out leaflets advertising the upcoming “Achieving Clinical Excellence” conference, and finally people watched a brief video introducing the ICCE community. Take a look yourself:.
More to come from the week in Anaheim….
Dateline: Chicago, Illinois
December 7, 2009
I’ve just finished packing my bags and am heading for the airport. Tomorrow the “Evolution of Psychotherapy” begins. Nearly 25 years after volunteering at the first “Evolution” conference, I’m back a second time to present. Tomorrow, I’ll be talking about “Achieving Clinical Excellence.” On the days that follow, I’m on panels with my friend Don Meichenbaum, as well as David Barlow, Marsha Linnehan, and others. I’m really looking forward to the four days in Anaheim.
Of everything going on in sunny southern California, I have to say that I’m most excited about the launch of the International Center for Clinical Excellence. We have a booth (#128) in the exhibitor hall where folks can stop by, talk, and peruse our new website. As promised, it is a true web 2.0 experience, enabling clinicians researchers. and educators around the world to connect, share, and learn from each other.
Hans Christian Andersen, the author of such classic stories as The Ugly Duckling and the Emperor’s New Clothes, once wrote, “Life itself is the most wonderful fairy tale of all.” That sentiment is certainly true of my own life. For the last 16 years, I’ve been privileged to travel around the world conducting training and providing consultation. Each year, I meet literally thousands of therapists and I’m consistently impressed and inspired by their dedication and persistence. Truth be told, that “spirit”–for lack of a better word–is actually what keeps me in the field.
This last year, I’ve spent a considerable amount of time working with practitioners in Denmark. Interest in Feedback-Informed Treatment has taken off–and I have the frequent flyer miles to prove it! While I’ve been traveling to the homeland of Hans Christian Andersen for many years (actually my maternal grandfather and his family immigrated to the United States from a small town just outside Copenhagen), momentum really began building following several years of workshops arranged by Henrik and Mette Petersen who run Solution–a top notch organization providing both workshops and year-long certification courses in short-term, solution-focused, and systemic therapies.
In October, I worked with 100+ staff who work at Psykoterapeutisk Center Stolpegård–a large outpatient center just outside of Copenhagen. For two days, we talked about research and practice in psychotheapy, focusing specifically on using outcome to inform and improve clinical services. Peter Koefoed, chief psychologist and head of Training organized the event. I was back in Denmark not quite one month later for two days with Henrik and Mette Petersen and a then third day for a small, intensive training with Toftemosegaard–a center for growth and change–smack dab in the middle of Copenhagen.
At each event, I was honored to be accompanied by Danish psychologist Susanne Bargmann, who is an Associate and Certified Trainer for the Center for Clinical Excellence (ICCE). I first met Susanne at a two-day workshop sponsored by Solutions a number of years ago. Her attitude and drive is infectious. She attended the Training of Trainer’s event in Chicago and now runs a listserve for Danish practitioners interested in feedback-informed treatment (FIT) (by the way, if you are interested in joining the group simply click on her name above to send an email).
Recently, she published an important article in Psycholog Nyt–the official magazine for the Danish Psychological Association. The article is really the first written in Danish by a Danish practitioner to suggest “practice-based evidence” as a scientifically credible alternative to the narrow “specific treatments for specific problems” paradigm that has come to dominate professional discourse and practice the world over.
Anyway, I’ll be back in Denmark several times in 2010. In May, I’ll be teaching “Supershrinks: Learning from the Field’s Most Effective Practitioners.” The course, as I understand it, is already sold out. No worries though as the workshop is being offered again in November–so sign up early (click here to access my workshop calendar). Also, in September, Susanne and I will jointly teach a course for psychologists on research entitled, “Forskning og Formidling”–a required training for those seeking specialist approval by the Danish Psychological Association. Finally, as I’ve done for the last several years, I’m scheduled to do two days for Solution as well. If you live and work in Denmark, I truly hope to see you at one of these events.
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.
I’ve just returned from a week in Denmark providing training for two important groups. On Wednesday and Thursday, I worked with close to 100 mental health professionals presenting the latest information on “What Works” in Therapy at the Kulturkuset in downtown Copenhagen. On Friday, I worked with a small group of select clinicians working on implementing feedback-informed treatment (FIT) in agencies around Denmark. The day was organized by Toftemosegaard and held at the beautiful and comfortable Imperial Hotel.
In any event, while I was away, I received a letter from my colleague and friend, M. Duncan Stanton. For many years, “Duke,” as he’s known, has been sending me press clippings and articles both helping me stay “up to date” and, on occasion, giving me a good laugh. Enclosed in the envelope was the picture posted above, along with a post-it note asking me, “Are you going into a new business?!”
As readers of my blog know, while I’m not going into the hair-styling and spa business, there’s a grain of truth in Duke’s question. My work is indeed evolving. For most of the last decade, my writing, research, and training focused on factors common to all therapeutic approaches. The logic guiding these efforts was simple and straightforward. The proven effectiveness of psychotherapy, combined with the failure to find differences between competing approaches, meant that elements shared by all approaches accounted for the success of therapy (e.g., the therapeutic alliance, placebo/hope/expectancy, structure and techniques, extratherapeutic factors). As first spelled out in Escape from Babel: Toward a Unifying Language for Psychotherapy Practice, the idea was that effectiveness could be enhanced by practitioners purposefully working to enhance the contribution of these pantheoretical ingredients. Ultimately though, I realized the ideas my colleagues and I were proposing came dangerously close to a new model of therapy. More importantly, there was (and is) no evidence that teaching clinicians a “common factors” perspective led to improved outcomes–which, by the way, had been my goal from the outset.
The measurable improvements in outcome and retention–following my introduction of the Outcome and Session Rating Scales to the work being done by me and my colleagues at the Institute for the Study of Therapeutic Change–provided the first clues to the coming evolution. Something happened when formal feedback from consumers was provided to clinicians on an ongoing basis–something beyond either the common or specific factors–a process I believed held the potential for clarifying how therapists could improve their clinical knowledge and skills. As I began exploring, I discovered an entire literature of which I’d previously been unaware; that is, the extensive research on experts and expert performance. I wrote about our preliminary thoughts and findings together with my colleagues Mark Hubble and Barry Duncan in an article entitled, “Supershrinks” that appeared in the Psychotherapy Networker.
Since then, I’ve been fortunate to be joined by an internationally renowned group of researchers, educators, and clinicians, in the formation of the International Center for Clinical Excellence (ICCE). Briefly, the ICCE is a web-based community where participants can connect, learn from, and share with each other. It has been specifically designed using the latest web 2.0 technology to help behavioral health practitioners reach their personal best. If you haven’t already done so, please visit the website at www.iccexcellence.com to register to become a member (its free and you’ll be notified the minute the entire site is live)!
As I’ve said before, I am very excited by this opportunity to interact with behavioral health professionals all over the world in this way. Stay tuned, after months of hard work and testing by the dedicated trainers, associates, and “top performers” of ICCE, the site is nearly ready to launch.
A few weeks ago, I announced the first International “Achieving Clinical Excellence” (ACE) conference to be held at the Westin Hotel in Kansas City, Missouri on October 20-22nd, 2010. You can now register for this and all other ICCE events, by clicking here. Through a variety of keynote addresses and workshops, participants will learn the “science and steps” to excellence in clinical practice. Attendees will also meet and learn directly from internationally ranked performers from a variety of professions, including medicine, science, music, entertainment, and sports. I do hope you’ll join us in Kansas City for three days of science, skill building, and inspiration.
In the meantime, I wanted to tell you a bit about one of the conference’s keynote speakers, K. Anders Ericsson, Ph.D. As anyone who has been following my blog knows, Dr. Ericsson is the editor of the massive and influential “Cambridge Handbook of Expertise and Expert Performance.” He is an internationally known writer, researcher, and speaker who is commonly referred to as “the expert on experts.”
There is an old (but in many ways sad) joke about two clinicians–actually, the way I first heard the story, it was two psychiatrists. The point of the story is the same regardless of the discipline of the provider. Anyway, two therapists meet in the hallway after a long day spent meeting clients. One, the younger of the two, is tired and bedraggled. The other, older and experienced, looks the same as s/he did at the start of the day: eyes bright and attentive, hair perfectly groomed, clothes and appearance immaculate. Taken aback by the composure of the more experienced colleague, the younger therapist asks, “How do you do it? How do you listen to the trials and tribulations, the problem and complaints, the dire lives and circumstances of your clients, minute and minute, hour upon hour…and yet emerge at the end of the day in such good shape?” Slowly shaking his head from left to right, the older and more experienced clinician immediately reached out, tapping the less experienced colleague gently on the shoulder, and then after removing the thick plugs stuffed into both of his years, said, “Excuse me, what did you say?”
Let’s face it: healthcare is in trouble. Behavioral healthcare in particular is in even worse shape. And while solutions from politicians, pundits, industry insiders and professionals are circulating in Washington with all the sound and fury of a hurricane, the voice of consumers is largely absent. Why? Of course, many of the barriers between providers and consumers are systemic in nature and as such, out of the control of average clinicians and consumers. Others, however, are local and could be addressed in an instance with a modicum of interest and attention on the part of professionals.
Chief among the steps practitioners could take to bridge to chasm between them and consumers is the adoption of routine, ongoing feedback. Seeking and utlizing real-time feedback from consumers has the added advantage of significantly boosting outcomes and increasing retention in services (several studies documenting the impact of feedback are available in the “Scholarly publications and Handouts” section of my website). Healthcare providers can download two well validated and easy-to-use scales right now for free by clicking on the Performance Metrics tab to the left.
So far, however, few in healthcare seem interested and others are downright hostile to the idea of asking consumers for input. Consider the following story by reporter Lindsey Tanner entitled, “Take two, call me in the morning…and keep it quiet.” Tanner discovered that some in healthcare are demanding that people (patients. clients, consumers) sign “gag orders” prior to being treated–agreeing in effect not to post comments about the provider (negative and otherwise) to online sites such as Zagats.com, Angieslist.com, and RateMds.com. According to the article, a Greensboro, N.C. company, ironically called “Medical Justice” is, for a fee, now providing physicians with standardized waiver agreements and advising all doctors to have patients sign on the dotted line. And if the patient refuses? Simple: find another doctor.
Can you imagine a hotel chain or restaurant asking you to sign a legally-binding agreement not to disclose your experience prior to booking your room or handing you the menu? Anyone who has travelled lately knows the value of the information contained on consumer-driven websites such as TripAdvisor.com. It’s outlandish really–except in healthcare.
To be sure, there is at least one important difference between healthcare and other service industries. Specifically, healthcare providers, unlike business owners and service managers, are prevented from responding to online complaints by existing privacy laws. However, even if this problem were insurmountable–which it is not–how then can one explain the continuing reluctance on the part of professionals to give people access to their own healthcare records? And this despite federal regulations under the Health Insurance Portability and Accountability Act (HIPAA) permitting complete and unfettered access (click here to read the recent NPR story on this subject). Clearly, the problem is not legal but rather cultural in nature. Remember when Elaine from Seinfeld asked to see her chart?
Earlier this summer, my family and I were vacationing in Southwest Michigan. One day, after visiting the beach and poking around the shops in the lakeside town of South Haven, we happened on a small Italian bistro named,Tello. Being from a big city famous for its good eats, I’ll admit I wasn’t expecting much. The food was delicious. More surprising, was the service. Not only were the staff welcoming and attentive, but at the end of the meal, when I thought the time had come to pay the bill, the folder I was given contained a small PDA rather than the check. I was being asked for my feedback.Answering the questions took less than a minute and the manager, Mike Sheedy, appeared at our table within moments of my hitting the “send” button. He seemed genuinely surprised when I asked if he felt uncomfortable seeking feedback so directly. “Have you learned anything useful?” I then inquired. “Of course,” he answered immediately, “just last week a customer told us that it would be nice to have a children’s menu posted in the window alongside the standard one.” I was dumbstruck as one of the main reasons we had decided to go into the restaurant rather than others was because the children’s menu was prominently displayed in the front window!
Mark your calendars! The International Center for Clinical Excellence is pleased to announce the “Achieving Clinical Excellence” (ACE) conference to be held at the Westin Hotel in Kansas City, Missouri on October 20-22nd, 2010.
K. Anders Erickson, Ph.D., the editor of The Cambridge Handbook of Expertise and Expert Performance and recognized “expert on experts,” will keynote the event. Through a combination of plenary presentations and intensive workshops, an internationally renowned faculty of researchers and educators, including Scott D. Miller, Ph.D. and John Norcross, Ph.D., will help participants discover the means to achieve excellence in clinical practice, leadership, ethics, and personal care.
Attendees will also meet and learn directly from internationally ranked performers from a variety of professions, including medicine, science, music, entertainment, and sports. As just one example, the Head Coach of the Olympic, Gold-Medal-winning Women’s volleyball team, Hugh McCutcheon, will present at the conference. In addition to a pre-conference day on ethics and law, internationally renowned concert pianist David Helfgott, whose heart-warming story was featured in the award winning film Shine, will perform on Thursday evening, October 21st. Join us in Kansas City for three days of science, skill building, and inspiration.
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)…
For those of you are friends with me on Facebook (and if you’re not already, please do as it’s a blast), you know I was teaching at the 41st Annual Southwestern School for Behavioral Health Studies.
First, let me express my appreciation to the Board and Michelle Brown for bringing me to Tucson to present on “Achieving Clinical Excellence.” If you’ve never attended this particular event, mark your calendar for next year.
This year, the conference theme was “Staying relevant in the 21st Century.” By the time I took the microphone to speak, 350 dedicated professionals from all around the country were on their fifth and last day of the conference. What a crowd! Excited, energized, and dedicated to doing their personal best for consumers of behavioral health services.
I’ve already heard from several folks who were in attendance, relating a personal or clinical story illustrating the principles and practices I talked about during my presentations. Thanks very much for sharing these stories with me.
Meanwhile, you can find the slides I used yesterday below. Feel free to download, use, and forward them to interested friends and colleagues.
In parting, I thought I’d relate one of my own experiences of excellence. It happened two years ago when I was presenting at this same conference. That morning, as I reached into my suitcase to get my clothes, I quickly discovered I’d left my slacks at home! Like this year, I’d worn shorts, a T-shirt, and flip flops on the plane, so no help there. Panicked, I called my co-presenter, Dr. David Mee-Lee—after all, he is a psychiatrist. He offered me an extra pair he had. It was a great idea that we both knew would never work since David is about 8” shorter than me. So I called the front desk. Now, the venue for the SWS for Behavioral Health is at the beautiful Loews Ventana Canyon Resort. It’s nestled in the mountains, miles from the city. Plus it was 7 am. My presentation started in an hour. No store was open at this hour, not even the resort gift shop. But that didn’t stop the dedicated staff at Loews. Within minutes, the manager of the resort shop was at the hotel. We found some pants and a shirt to match but the pants were 6 inches too long. “Not to worry,” the store manager said, she’d take care of it. Within minutes someone from the housekeep staff—not a tailor or seamstress, just a kind, dedicated person—was cutting and sewing the hem on the pants. I made it to the conference hall to present with 5 minutes to spare! I’ve never forgotten their kindness and dedication.
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.
If you’ve been following my website and the Top Performance Blog you know that my professional interests over the last couples of years have been shifting, away from psychotherapy, the common factors, and feedback and toward the study of expertise and excellence.
Studying this literature (click here for an interesting summary), makes clear that the factors responsible for superior performance are the same regardless of the specific endeavor one sets out to master. The chief principle will come as no surprise: You have to work harder than everyone else at whatever you want to be best at.
In other words, you have to practice.
Hard work is not enough, however. Research shows that few attain international status as superior performers without access to high levels of support and detailed instruction from exceptional teachers over sustained periods of time. In the massive “Cambridge Handbook of Expertise and Expert Performance,” Feltovich et al. note, “Research on what enabled some individuals to reach expert performance, rather than mediocre achievement, revealed that expert and elite performers seek out teachers and engage in specifically designed training activities…that provide feedback on performance, as well as opportunities for repetition and gradual refinement” (p. 61).
What makes for a “good” teacher? Well, in essence, that is what the “Top Performance” blog is all about. I’m going on a journey, a quest really. I’ve decided to take up two hoppies–activities I’ve always had a interest in but never had to the time to study seriously–magic and the ukelele.
Practicing is already proving challenging. Indeed, the process reminds me a lot of when I started out in the field of psychology. In a word, its daunting. There are literally thousands of “tricks” and “songs,” (as there are 100’s of treatment models), millions of how-to books, videos, and other instructional media (just as in the therapy world), as well as experts (who, similar to the field of psychotherapy, offer a wide and bewildering array of different and oftentimes contractory opinions).
By starting completely over with subjects I know nothing about, I hope to put into practice the insights gleaned from our study of expertise and expert performance, along the way reporting the challenges, triumphs and failures associated with learning to master new skills. I’ll review performances, instructional media (live, printed, DVD, etc), and the teachers I met. Stay tuned.