Can you help me understand this?

November 25, 2019 By scottdm 1 Comment

A couple of weeks ago I received an email from the leader of a group asking me to send them copies of the ORS and SRS. “We are to start using these straight away,” the person wrote.

I replied, of course, providing a link to my website where the scales could be downloaded along with a brief note, highlighting the Feedback Informed Treatment (FIT) Manuals and the upcoming March Intensives in Chicago. “Both are great resources,” I said, “for learning how to use the measures to improve the quality and outcome of behavioral health services.”

I received a quick and polite response, thanking me for the links but going on to say, “I’ve seen the scales. They are really very simple and self-explanatory so I don’t think we really need much in the way of training or support materials.”

I’d like to say I was surprised. After all, what medical professional would say something similar? Say, about a stethoscope? To wit, “No thanks, seems pretty simple, stick these thingies in my ears, and the other end on the patient’s chest and listen…”.

But I was not — surprised, that is. Why? Of the several hundred downloads of the measures from my website per week, and the more than 200,000 over the last decade, very few practitioners have sought or received any training. Indeed, most have never even read the FIT manuals!

The impact on those who are initially enthusiastic about seeking formal feedback from their clients is as predictable as it is sad: they quickly give up. How do I know, you ask? Every week, as I’m out and about, training and consulting, I run into practitioners who say:

“Yeah, I heard of FIT, I even tried the scales…but they didn’t work…”

“I tried the ORS and SRS scales for a while, but I didn’t get any clinically useful information from them…”

“My clients weren’t honest … so I stopped using them”

And so I ask, what does it take to help people get the information and training they need to succeed? The question is far from trivial or self-serving. The measures are free to download and the latest research shows using them more than doubles the chances of helping clients experience meaningful change. The only caveat is that, despite their simplicity, learning to employ the tools effectively takes time and support. How do I know that? Research, of course!

If you have thoughts about what I can do to address this problem, please let me know. In the meantime, in an effort to help, here are several offers:

1. For the time being, get the FIT Treatment and Training Manuals for 50% off;

2. Register for the combined FIT Advanced and Supervision Intensive now using the code FIT-Promo at checkout and get an additional discount off the early bird rate;

3. Sign up for the cutting-edge FIT e-learning program — where you can learn at your own pace from the comfort of your home — and receive the new, deliberate practice module, for free (if interested, email me for details about this offer).

Yes, please feel free to share these links and codes with your colleagues. And, once more, if you have additional suggestions, I’m interested in hearing them. Please post a comment below.

That’s it for now.

All the best for the Holidays,

Scott

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

Some Common Questions (and Answers) about Feedback Informed Treatment

November 6, 2019 By scottdm 7 Comments

Mr. Gomm was my sixth grade teacher. Tall and angular, with a booming voice and stern demeanor, he remains a forbidding figure from my childhood.

I’ll never forget the day he slammed his open hand on my desk, bellowing “That, Mr. Miller, is an assumption!” Turning abruptly, he walked to the chalkboard, and began writing, one capital letter at a time: A, S, S, U, M, E.

“And do you know what happens when we assume, Mr. Miller?” he asked.

“Speak up!” I remember him commanding. But I just sat there, like a deer in the headlights.

I’m sure you know what happened next. Returning to the board, he quickly drew slash marks between the S and U, and U and M: ASS/U/ME.

For emphasis, he then tapped each section loudly with his chalk as he spoke, “Let me spell it out for you, Mr. Miller. To assume is to make an ass out of you and me!”

It’s a moment I recall with absolute clarity. Only later — much later — did I come to realize I’d not understood the point he’d been trying to make at the time. Indeed, at recess, all anyone could talk about was that Mr. Gomm said the word “ass” out loud in class. Soon, we were applying our new knowledge to anything anyone did on the playground that we didn’t like: butting in line, missing a critical shot in kick ball, or any of the other possible social faux pas among marginally pubescent adolescents.

“You just made an ass out of you and me!” we repeated with glee at the slightest provocation.

Beyond the obvious irony involved, it turns out tr. Gomm was only half right. Yes, assuming — supposing without proof — is fraught with risk. That said, presuming — taking something for granted based on probability — is, as the incident so clearly demonstrates, just as problematic. In his mind, he’d made a sensible presumption: we would get “it.” After all, he knew us. We were his students. We made the same mistake. Based on our experience of him, we figured he was teaching us another valuable lesson, and then assumed we’d understood what he’d said.

Prior to last week, I’d not thought of Mr. Gomm for ages. I was was reminded of him after puzzling over a slew of questions about feedback-informed treatment (FIT) posted on our online discussion forums at the International Center for Clinical Excellence. On the surface, all appeared to be straightforward requests for information, requiring nothing more than a simple and direct response. The trouble was that any answer one might give ended up confirming assumptions contained in the queries that were fundamentally untrue or inaccurate.

While the particulars varied, a theme shared by many of the posts was whether one could or should trust scores on the Outcome and Session Rating Scales (ORS & SRS) with certain clients — in particular, people who were shy, mandated into treatment, cognitively compromised, or emotionally disturbed.

To be sure, it’s not the first time I’d encountered such concerns. Indeed, they frequently come up at the beginning of introductory workshops on FIT:

“Court ordered clients won’t be truthful.”

“The feedback from client’s with (borderline personality disorder, bipolar, psychosis) won’t be reliable or valid.”

“People from this (age group, culture) are not (accustomed to or incapable of) providing feedback to professionals.”

When I have several hours to teach, interact, and illustrate, I usually ask people to wait with such observations, promising an answer will emerge in time. In the truncated, two-dimensional space of most social media interactions, however, I’ve found a similar evolution of understanding much more challenging. Hence this post.

Of course, in the best of all worlds, people would get more training. Answers are available. Given the simplicity of the scales — you can learn to administer and score the ORS and SRS in less than a minute — the temptation to dive in, presuming our existing clinical knowledge and experience applies to their use, is simply too great for most to resist. Consider this: several hundred thousand practitioners have download the measures from my website in just the last couple of years! Of these, fewer than 2 or 3% have had any training! In the end, the unquestioned assumptions brought to the process cause most to get stuck and eventually give up.

So, what about the concerns noted above?

All make perfect sense IF the ORS and SRS are thought of as assessments, the helpfulness of which depend on the accuracy of the data collected. By contrast, were the measures primarily seen as tools to help engage clients, an entirely different set of assumptions becomes possible. For example, rather than interpreting high ORS scores of a court-ordered client as evidence of dishonesty or denial that must be confronted or overcome, they could be treated as an opportunity to connect with, explore, and understand their experience and world view.

In practical terms that means taking client scores at face value. Leaving traditional assumptions aside, the clinician would first acknowledge and then respond logically to what is reported on the scale. “I see from your responses, you are doing quite well,” continuing, “So, why did you decide to come see me today?” Should the client say, as most readily do, they were sent by the courts (or employer, parents, or partner), the clinician responds by asking them to complete the measure as if they were the person who sent them. After all, from their perspective, that’s why they are there! The discussion can then turn to closing the gap between the client’s and referral source’s scores, beginning, for instance, with asking, “What have they missed about you that, once recognized, will lead them to score you higher?” Along the way, the result of this line of inquiry is greater participation of the client in treatment — the factor long ago established as the number one process-related predictor of outcome (see Orlinsky, Grawe, & Parks, 1994).

And what about the other questions?

As already stated, answers are available — ones that leave most thinking, “Duh, why didn’t I think of that?” To be blunt, we can’t so long as we are unaware we are thinking something else! That’s where a more in-depth training in FIT can prove helpful. Join colleagues from around the world and our international faculty this coming Spring in Chicago for the three-day, Advanced FIT Intensive. We’ll not only challenge your thinking, we’ll provide a thorough grounding in the principles and skills of using feedback to inform and improve the quality of mental health and substance abuse services with a broad and diverse clinical population — training which, research shows, improves therapist effectiveness. Registration is limited to 40 participants. Click either of the icons below for more information.

Until next time,

Scott

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

Is THAT true? Judging Evidence by How Often its Repeated

October 22, 2019 By scottdm 11 Comments

I’m sure you’ve heard it repeated many times:

The term, “evidence-based practice” refers to specific treatment approaches which have been tested in research and found to be effective;

CBT is the most effective form of psychotherapy for anxiety and depression;

Neuroscience has added valuable insights to the practice of psychotherapy in addition to establishing the neurological basis for many mental illnesses;

Training in trauma-informed treatments (EMDR, Exposure, CRT) improves effectiveness;

Adding mindfulness-based interventions to psychotherapy improves the outcome of psychotherapy;

Clinical supervision and personal therapy enhance clinicians’ ability to engage and help.

Only one problem: none of the foregoing statements are true. Taking each in turn:

As I related in detail in a blogpost some six years ago, evidence-based practice has nothing to do with specific treatment approaches. The phrase is better thought of as a verb, not a noun. According to the American Psychological Association and Institute of Medicine, there are three components: (1) the best evidence; in combination with (2) individual clinical expertise; and consistent with (3) patient values and expectations. Any presenter who says otherwise is selling something.
CBT is certainly the most tested treatment approach — the one employed most often in randomized controlled trials (aka, RCT’s). That said, studies which compare the approach with other methods find all therapeutic methods work equally well across a wide range of diagnoses and presenting complaints.
When it comes to neuroscience, a picture is apparently worth more than 1,000’s of studies. On the lecture circuit, mental illness is routinely linked to the volume, structure, and function of the hippocampus and amygdala. And yet, a recent review compared such claims to 19th-century phrenology. More to the point, no studies show that so-called, “neurologically-informed” treatment approaches improve outcome over and above traditional psychotherapy (Thanks to editor Paul Fidalgo for making this normally paywalled article available).
When I surveyed clinicians recently about the most popular subjects at continuing education workshops, trauma came in first place. Despite widespread belief to the contrary, there is no evidence that learning a “trauma-informed” improves a clinician’s effectiveness. More, consistent with the second bullet point about CBT, such approaches have not shown to produce better results than any other therapeutic method.
Next to trauma, the hottest topic on the lecture circuit is mindfulness. What do the data say? The latest meta-analysis found such interventions offer no advantage over other approaches.
The evidence clearly shows clinicians value supervision. In large, longitudinal studies, it is consistently listed in the top three, most influential experiences for learning psychotherapy. And yet, research fails to provide any evidence that supervision contributes to improved outcomes.

Are you surprised? If so, you are not alone.

The evidence notwithstanding, the important question is why these beliefs persist?

According to the research, a part of the answer is, repetition. Hear something often enough and eventually you adjust your “truth bar” — what you accept as “accepted” or established, settled fact. Of course, advertisers, propagandists and politicians have known this for generations — paying big bucks to have their message repeated over and over.

For a long while, researchers believed the “illusory truth effect,” as it has been termed, was limited to ambiguous statements; that is, items not easily checked or open to more than one interpretation. A recent study, however, shows repetition increases acceptance/belief of false statements even when they are unambiguous and simple- to-verify. Frightening to say the least.

A perfect example is the first item on the list above: evidence-based practice refers to specific treatment approaches which have been tested in research and found to be effective. Type the term into Google, and one of the FIRST hits you’ll get makes clear the statement is false. It, and other links, defines the term as “a way of approaching decision making about clinical issues.”

Said another way, evidence-based practice is a mindset — a way of approaching our work that has nothing to do with adopting particular treatment protocols.

Still, belief persists.

What can a reasonable person do to avoid falling prey to such falsehoods?

It’s difficult, to be sure. More, as busy as we are, and as much information as we are subjected to on a daily basis, the usual suggestions (e.g., read carefully, verify all facts independently, seek out counter evidence) will leave all but those with massive amounts of free time on their hands feeling overwhelmed.

And therein lies the clue — at least in part — for dealing with the “illusory truth effect.” Bottom line: if you try to assess each bit of information you encounter on a one-by-one basis, your chances of successfully sorting fact from fiction are low. Indeed, it will be like trying to quench your thirst by drinking from a fire hydrant.

To increase your chances of success, you must step back from the flood, asking instead, “what must I unquestioningly believe (or take for granted) in order to accept a particular assertion as true?” Then, once identified, ask yourself whether those assumptions are true?

Try it. Go back to the statements at the beginning of this post with this larger question in mind.

(Hint: they all share a common philosophical and theoretical basis that, once identified, makes verification of the specific statements much easier)

If you guessed the “medical model” (or something close), you are on the right track. All assume that helping relieve mental and emotional suffering is the same as fixing a broken arm or treating a bacterial infection — that is, to be successful a treatment containing the ingredients specifically remedial to the problem must be applied.

While mountains of research published over the last five decades document the effectiveness of the “talk therapies,” the same evidence conclusively shows “psychotherapy” does not work in the same way as medical treatments. Unlike medicine, no specific technique in any particular therapeutic approach has ever proven essential for success. None. Any claim based on a similar assumptive base should, therefore, be considered suspect.

Voila!

I’ve been applying the same strategy in the work my team and I have done on using measures and feedback — first, to show that therapists needed to do more than ask for feedback if they wanted to improve their effectiveness; and second, to challenge traditional notions about why, when, and with whom, the process does and doesn’t work. In these, and other instances, the result has been greater understanding and better outcomes.

So there you have it. Until next time,

Scott

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

P.S: Registration for the Spring Feedback Informed Treatment intensives is now open. In prior years, these two events have sold out several months in advance. For more information or to register, click here or on the images below.