SCOTT D Miller - For the latest and greatest information on Feedback Informed Treatment

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Cutting Edge Feedback

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Earth | Time Lapse View from Space, Fly Over | NASA, ISS

Using feedback to guide and improve the quality and outcome of behavioral health services is growing in popularity.  The number of systems available for measuring, aggregating, and interpreting the feedback provided by consumers is increasing.  The question, of course, is, “which is best?”  And the answer is, “it depends on the algorithms being used.”

Over a decade ago, my colleagues and I developed a set of mathematic equations that enabled us to plot the “expected treatment response” or ETR of a client based on their first session Outcome Rating Scale (ORS) score.  Although the math was complicated, the idea was not: therapists and clients could compare outcomes from session to session to the benchmark provided by the ETR.  If too much or too little progress were being made, client and therapist could discuss what changes might be made to the services being offered in order to insure more effective or durable progress.  It was a bold idea and definately “cutting edge” at the time–after all, 10 years ago, few people were even measuring outcomes let alone trying to provide benchmarks for guiding clinical practice.  The formulas  developed at that time for plotting change in treatmentare still being used by many around the world with great effect.  At the same time, it was merely a first attempt.

I am proud and excited to be able to announce the development and launch of a new set of algorithms–the largest and most sophisticated to date–based on a sample of 427,744 administrations of the ORS, in 95,478 unique episodes of care, provided by 2,354 different clinicians.  Unlike the prior formulas–which plotted the average progress of all consumers successful and not–the new equations provide benchmarks for comparing individual consumer progress to both successful and unsuccessful treatment episodes. Consider an analogy to the field of medicine.  No one would be interested in a test for the effectiveness of a particular cancer treatment that compared an individual’s progress to to the average of all patients whether they lived or died.  People want to know, “will I live?”  And in order to answer that question, the ETR of both successful and ultimately unsuccessful treatments must be determined and the individual clients progress compared to both benchmarks.  Adjustments can be made to the services offered when the client’s session by session outcomes fit the ETR of treatments that ended unsuccessfully.

An example of the type of feedback provided by the new algorithms is found below.  The graph displays three zones of potential progress (or ETR’s) for a client scoring 15 on the ORS at intake.  Scores falling in the “green” area from session to session are similar to treatments that ended successfully.  As might be expected, those in the “red” zone, ended unsuccessfully.  Finally, scores in the “yellow” zone had mixed results.  In each instance, both the client and therapist are provided with instant feedback: green = on track, red = off track, yellow = concern.


The new algorithms will be a major focus of the upcoming “Advanced Intensive in Feedback-Informed Treatment (FIT)” scheduled for March 19th-22nd, 2012.  All those subscribing to the event also receive the newly released series of FIT treatment manuals.  Space is limited, as always, to 35 people and we are filling fast so please don’t wait.  So many exciting developments!

Now, if you haven’t already done so, click on the video at the start of this post.  I was floored by these satellite images.  In some way, I hope that the new algorithms, FIT training manuals, and the ICCE community can inspire a similar sense of perspective!

Feedback-Informed Treatment as Evidence-based Practice: APA, SAMSHA, and NREPP

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What is evidence-based practice?  Visit the UK-based NICE website, or talk to proponents of particular theoretical schools or therapeutic models, and they will tell you that being “evidence-based” means using the approach research has deemed effective for a particular diagnosis  (e.g., CBT for depression, EMDR for trauma).  Over the last two decades, numerous organizations and interest groups have promoted lists of “approved” treatment approaches–guidelines that clinicians and funding bodies should follow when making practice decisions.  Throughout the 1990’s, for example, division 12 within the American Psychological Association (APA) promoted the idea of “empirically supported treatments.”

However, when one considers the official definition of evidence-based practice offered by the Institute of Medicine and the APA, it is hard to fathom how anyone could come to such a conclusion.  According to the APA, evidence-based practice is, “the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences.” (see American Psychologist, May 2006).  Nothing here about “empirically supported treatments” or the mindless application of specific treatment protocols.  Rather, according to the APA and IOM, clinicians must FIT the treatment to the client, their preferences, culture, and circumstances.  And how can one do that?  Well, conspicuously absent from the definition is, “consult a set of treatment guidelines.”  Rather, when evidence-based, clinicians must monitor “patient progress (and of changes in the patient’s circumstances—e.g.,job loss, major illness) that may suggest the need to adjust the treatment. If progress is not proceeding adequately, the psychologist alters or addresses problematic aspects of the treatment (e.g., problems in the therapeutic relationship or in the implementation of the goals of the treatment) as appropriate.”

The principles and practices of feedback-informed treatment (FIT) are not only consistent with but operationalize the American Psychological Association’s (APA) definition of evidence-based practice.  To wit, routinely and formally soliciting feedback from consumers regarding the therapeutic alliance and outcome of care and using the resulting information to inform  and tailor service delivery.  And indeed, over the last 9 months, together with Senior Associates, I completed and submitted an application for FIT to be reviewed by NREPP–SAMSHA’s National Registry of Evidence-based Practices and Approaches!  As part of that application and ICCE’s commitment to improving the quality and outcome of behavioral health, we developed a list of “core competencies” for FIT practice, a series of six detailed treatment and implementation manuals, a gap assessment tool that organizations can use to quickly and expertly assess implementation and fidelity problems, and supportive documentation and paperwork.  Finally, we developed and rigorously tested training curricula and administered the first standardized exam for certifying FIT practitioners and trainers.  We are in the final stages of that review process soon and I’m sure I’ll be making a major announcement right here on this blog shortly.  So, stay tuned.

In the meantime, this last Saturday, clinicians located the globe–Canada, New Zealand, Australia, the US,a nd Romania–sat for the first administration of ICCE “Core Competency” Exam.  Taking the test is the last step in becoming an ICCE “Certified Trainer.”   The other requirements include: (1) attending the “Advanced Intensive” and “Training of Trainers” workshops; and (2) submitting a training video on FIT for review.  The exam was administered online using the latest technology.


The members, directors, and senior associates of ICCE want to congratulate (from top left):

  • Eeuwe Schuckard, Psychologist, Wellington, New Zealand;
  • Aaron Frost, Psychologist, Brisbane, Australia;
  • Cindy Hansen, BA-Psych, HHP, Manager Myoutcomes;
  • David Prescott, Director of Professional Development, Becket Family of Services, Portland, Maine;
  • Arnold Woodruff, LMFT, Clinical Director, Home for Good, Richmond, Virginia;
  • Bogdan, Ion, Ph.D., Bucharest University, Bucharest, Romania;
  • Daniel Buccino, Clinical Supervisor, Community Psychiatry Program. Johns Hopkins;
  • Dwayne Cameron, Outreach Counselor, Prince Albert, Saskatoon, Canada;
  • Mark Goheen, the Clinical Practice Lead at Fraser Health, British Columbia.

If you are not yet a member of the ICCE community, please join the largest, fastest growing, and friendly group of behavioral health professionals today at: www.centerforclinicalexcellence.com.

Are Mental Health Practioners Afraid of Research and Statistics?

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A few weeks back I received an email from Dr. Kevin Carroll, a marriage and family therapist in Iowa.  Attached were the findings from his doctoral dissertation.  The subject was near and dear to my heart: the measurement of outcome in routine clinical practice.  The findings were inspiring.  Although few graduate level programs include training on using outcome measures to inform clinical practice, Dr. Carroll found that 64% of those surveyed reporting utilizing such scales with about 70% of their clients!  It was particularly rewarding for me to learn that the most common measures employed were the…Outcome and Session Rating Scales (ORS & SRS)

As readers of this blog know, there are multiple randomized clinical trials documenting the impact that routine use of the ORS and SRS has on retention, quality, and outcome of behavioral health services.  Such scales also provide direct evidence of effectiveness.  Last week, I posted a tongue-in-cheek response to Alan Kazdin’s broadside against individual psychotherapy practitioners.  He was bemoaning the fact that he could not find clinicians who utilized “empirically supported treatments.”  Such treatments when utilized, it is assumed, lead to better outcomes.  However, as all beginning psychology students know, there is a difference between “efficacy” and “effectiveness” studies.  The former tell us whether a treatment has an effect, the latter looks at how much benefit actual people gain from “real life” therapy.  If you were a client which kind of study would you prefer?  Unfortunately, most of the guidelines regarding treatment models are based on efficacy rather than effectiveness research.  The sine qua non of effectiveness research is measuring the quality and outcome of psychotherapy locally.  After all, what client, having sought out but ultimately gained nothing from psychotherapy, would say, “Well, at least the treatment I got was empircally supported.”  Ludicrous.

Dr. Carroll’s research clearly indicates that clinicians are not afraid of measurement, research, and even statistics.  In fact, this last week, I was in Denmark teaching a specialty course in research design and statistics for practitioners.  That’s right.  Not a course on research in psychotherapy or treatment.  Rather, measurement, research design, and statistics.  Pure and simple.  Their response convinces me even more that the much talked about “clinician-researcher” gap is not due to a lack of interest on practitioners’ parts but rather, and most often, a result of different agendas.  Clinicians want to know “what will work” for this client.  Research rarely address this question and the aims and goals of some in the field remain hopelessly far removed from day to day clinical practice.  Anyway, watch the video yourself:

The ICCE Feedback-Informed Treatment Manuals

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September 12, 2011
Copenhagen, Denmark

Fall is in the air.  For me, that means the start of the travel season.  For the next two weeks, I’ll be traveling throughout Scandanavia–this week in Denmark and Norway.  It’s great to be back on the road meeting clinicians and consulting with agencies about feedback-informed treatment (FIT).

On this trip, I’m finally able to announce the publication of the Feedback-Informed Treatment Manuals.  Over the summer, senior associates of the International Center for Clinical Excellence, together with the talented artists and graphic designers at The Change Companies, worked hard to complete the series.

The six manuals cover every aspect of feedback-informed practice including: empirical foundations, basic and advanced applications (including FIT in groups, couples, and with special populations), supervision, data analysis, and agency implementation.  Each manual is written in clear, step-by-step, non-technical language, and is specifically designed to help practitioners and agencies integrate FIT into routine clinical practice.   Indeed, the manuals were submitted as part of ICCE’s application for consideration of FIT as an “evidence-based practice” to the National Registry of Evidence-Based Programs and Practices.  The manuals may be purchased separately or as a series in the bookstore.

While on the subject of registries, mention should be made that over the summer the American Psychological Association  contacted me about listing the Outcome and Session Rating Scales in their official database of outcome tools for clinical practice (click here to see the listing).  Taken together, the manuals, NREPP application, listing, and growing body of research evidence provide a compelling case for feedback-informed work.

Becoming FIT: The 2011 Training of Trainers

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August 10th, 2011

Chicago, IL

The first week of August was one of the hottest weeks on record in Chicago.  It was also the location of the hottest training on “feedback-informed treatment” (FIT)–the 5th Annual “Training of Trainers” weeklong intensive training.  We worked intensively over 5 days preparing an international group of administrators, supervisors, researchers, and clinicians to train others in the principles and practices of FIT.  We also played hard: dinners, music, magic, and more.  Here’s what attendee’s said about this years event:

Be sure and join us for the 4-day “Advanced Intensive” scheduled in March.  More information can be found at: scottdmiller.com.

 

How Much More Evidence Is Needed? A New Meta-Analysis on Feedback-Informed Treatment

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Received an email from friend and colleague John Norcross, Ph.D.  Attached were the results of a meta-analysis completed by Michael Lambert and Kenichi Shimokawa on Feedback-Informed Treatment (FIT) which will appear in the second edition of his book, Psychotherapy Relationships that Work (Oxford University Press).  For those who cannot wait, you can access the same results in the lastest issue of the APA journal Psychotherapy (Volume 48, Number 1, March 2011, pages 72-79).

Briefly, the chapter begins with a review of the literature on feedback–a body of evidence that, by the way, dates back to 1930’s and has always shown small to moderate effects on the outcome of treatment.  In reviewing studies specific to the ORS and SRS, the authors conclude, “”>the results indicated that those in the feedback group ha[ve] 3.5 times higher odds of experiencing reliable change while having less than half the odds of experiencing deterioration.”  Additionally, Lambert and Shimokawa report few if any meaningful differences between therapies informed by the ORS and SRS and those using the well-established and widely used Outcome Questionnaire (OQ).   Finally, and importantly, the authors note that in “busy practices…the brevity of the [ORS and SRS]…expedite and ease practical difficulties” thereby decreasing barriers to implementation.

How much more evidence will it take before feedback informed treatment becomes standard practice?  All of the available data is summarized in the materials below.

Measures and Feedback January 2011

View more documents from Scott Miller

Be sure and join other clinicians and researchers who are discussing FIT at the International Center for Clinical Excellence–the largest, free, web-based community dedicated to improving the quality and outcome of behavioral health.

Finally, if you are in thinking about or in the process of becoming FIT in your agency or practice, please join us at the upcoming “Training of Trainers” workshop held the first week of August.  Registration is limited to 35 participants and we have only a few spots left!  Here’s what attendees from last year had to say about the event…

The Cryptonite of Behavioral Health: Making Mistakes

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Most people readily agree that its important to “learn from mistakes.”  In truth, however, few actually believe it.  Mistakes are like cryptonite, making us feel and, more importantly, look stupid and weak.  As a result, despite what we might advise others, we do our best to avoid making and admitting them.  Such avoidance comes with a big cost: personal and professional growth stalls and even atrophies.  We take on less challenging tasks, avoid taking risks, and give up more easily when confronted with situations that might expose our weaknesses.  Far all that, falling a bit on “error-phobic” side of life is hardly an instance of  irrationality.  As Alina Tugend, author of Better by Mistake points out, “As much as people hate to make mistakes, they love pointing out the ones others have made.”  Indeed, for most of us, the glee others take in pointing out our shortcomings only serves to compound our avoidance and deepen our public denial.  And that’s what makes Tony Rousmaniere’s recent blogpost so unusual.

Briefly, Tony is a psychologist in private practice in San Francisco and Palo Alto.  As he tells the story, he was riding in his car, listening to a recording of my presentation at the 2009 Evolution of Psychotherapy conference.  The subject was “Achieving Clinical Excellence.”  The message: routinely seeking feedback from clients about our mistakes decreases dropout rates and improves outcomes in psychotherapy.  Tony took the message to heart.  Unlike many of our peers who say they routinely ask clients for feedback, Tony actually downloaded the outcome and session rating scales and began formally asking his clients for feedback.

The story he relates makes for compelling reading, most of all because the feedback he received was not always easy to hear.  And yet, he persisted, not only asking clients, but recording his work and then seeking input from colleagues.  In the article, he gives step-by-step instructions for making use of the painful and sometimes confusing and contradictory feedback one receives.

Tony’s willingness to share his experience makes it tempting to say he is one brave soul.  In actuality, he’s pragmatic.  He placed outcomes over image.  As he reports in the article, his dropout rate has plummeted and his outcomes improved.  I say, “Bravo!”
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Addendum

If you are thinking of writing to tell me that I misspelled the word, “cyptonite” (the accepted spelling is kryptonite), don’t bother.  I know.  I did it on purpose.  See what I mean?!

Why is this man laughing?

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May 4th, 2011
Copenhagen, Denmark

Just finished my first day of a two week trip covering spots in Denmark and Holland.  Yesterday, I traveled to Copenhagen from Hilo, Hawaii where I was presenting for the Hawaiian Association of Marriage and Family Therapy.  Dr. Gay Barflied (pictured on the far left above) spent years lobbying to bring me to the “Big Island” for the conference, where I spoke about the latest research on expertise and excellence in the field of behavioral health.  I met so many dedicated and talented clinicians in Hilo, including marriage and family therapist, Makela Bruno-Kidani (pictured in the middle photo above) who started the day off with a traditional Hawaiian chant and then presented me with two beautiful lei to wear during the event.

On a break, Gay mentioned an article that appeared in the May/June 1995 issue of AHP Perspective.  In it, she said, Maureen O’Hara, president of the Association for Humanistic Psychology, quoted one of the first articles me and my colleagues wrote on the common factors, “No More Bells and Whistles” (I’ll upload a copy to the “publications and handouts” section of the website as soon as I’m back in the States).  Carl Rogers, she said, would have been laughing (happily, that is) had he read the findings we cited documented the lack of differential efficacy of competing treatment approaches.  We had, in essence, proved him right!

“It turns out,” OHara wrote, “that Miller, Hubble, and Duncan come to similar conclusions.  Carl Rogers was right.  After all our forays into the dizzing arcana of paradoxical interventions, inner children, narrative therapy, EMDR, behaviorism, psychopharmacology, bioenergetics, TA, Jungian analysis, psychodrama, Gestalt, and so on down the entire list of hundred brand named therapies, what actually creates change is the…creation of a relationship between client and therapist…”.

I’d never seen the article before.  It brought back very positive memories about the journey that has led most recently to the study of excellence.  Indeed, as we point out in the lead article in the upcoming May/June 2011 issue of the Psychotherapy Networker, relationships are not only the “sine qua non” of healing for clients but are responsible for the professional growth for therapists.

The Growing Evidence Base for Feedback-Informed Treatment (FIT)

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Dateline: February 2, 2011
Location: Anchorage, AK
Greetings from Anchorage, Alaska where I’ve been traveling and teaching about feedback-informed treatment (FIT).  On Monday, I worked with dedicated behavioral health professionals living and working in Barrow–the northern most point in the United States.  FIT has literally reached the “top of the world.”  How incredible is that?

Here I am pictured in front of a sign which locals told me would prove I’d made the long journey to the village of 5,000.  I look forward to returning soon to help the group with the “nuts and bolts” of implementing FIT across various behavioral health services–practitoners were keen to get started.

As I’ve crisscrossed the state, I’ve been proud to share the growing evidence-base for feedback informed work.  Below, the data is summarized in a free, downloadable PDF file, “Measures and Feedback,” which has been updated to include the latest research using the ORS and SRS to improve the quality and outcome of treatment.  If you accessed this file back in 2010, be sure to get this updated version.

Getting FIT: The Advanced Intensive Training

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Dateline: January 19, 2011
Buffalo, New York

The New Year is here and travel/training season is in full swing.  Last week, I was in Ohio and Virginia.  This week New York and Idaho (keep your weather fingers crossed, it’s going to be dicey getting from here to there and home again).

Interest in “Feedback Informed Treatment” continues to grow.  Agencies across the United States and abroad–as my travel schedule attests–are implementing the ORS and SRS in routine clinical practice.  Clinicians are finding the support they need on the International Center for Clinical Excellence web-based community.  As I blogged about a while back, the ICCE is the largest and most diverse group of practitioners working to improve the quality and outcome of behavioral health services.  Many will soon be joining me in Chicago for the 2011 “Advanced Intensive” training.  Once again, clinicians from all over the world will be in attendance–Sweden, Holland, England, Australia and so on.  Interest is high as participants receive a thorough, state-of-the-art grounding in the principles and practice of FIT.  I look forward to meeting everyone soon.

Last summer, I videoblogged about the event.  Ah, summer!   With everything my co-teacher, psychologist Susanne Bargmann, and I have planned, we promise a warm and rewarding event.

Feedback informed treatment (FIT) takes center stage in Sweden

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Just sweden-mapa short entry to highlight recent developments in Sweden…

On November 17th and 18th, over 500 politicians, agency directors, and service managers gathered together to discuss “the future of alcohol and drug treatment” in Sweden.  High on the agenda?  Feedback Informed Treatment!

Psychologist and ICCE Associate, Gun-Eva Langdahl and the rest of the talented crew at Radgivingen Oden, were featured in a video documenting the impact of feedback on retention and outcome of drug and alcohol treatment services.

You may recall, last spring I was on my way to visit this talented group of practitioners when the volcano in Iceland erupted, forcing me to take a long and complicated series of “trains, buses, and automobiles” to get to the beautiful, northern Swedish town of Skelleftea.

Anyway, thanks to the work of the team, the town and surrounding area are something of a hotbed of feedback informed treatment.  For those practitioners, policy makers, and agency directors living and working in Scandinavia, the professionally produced video provides an excellent introduction to the process and benefits of feedback informed work.  You can also read about the work in a feature article that appeared in the daily newspaper, Folkbladet.

In the meantime, take a look at these videos where Gun-Eva Langdahl explains both why clinicians should begin seeking feedback from their clients as well as how to get started.

Cha-cha-cha-changes on a Grand Scale: Think Tank Meets in Chicago

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David Mee-Lee, MD     Bill Miller, Ph.D.     Scott D. Miller, Ph.D.

Jim Prochaska, Ph.D.                                    Don Kuhl, CEO

Whether in the United States or Europe, Asia or Australia, the field of behavioral health is undergoing a period of dramatic change–some would say, “transformation.”  At least that’s the verdict of the group bought together by the CEO of The Change Companies, Don Kuhl, who brought together some of the leading figures in behavioral health for two days of discussion and brainstorming last week in Chicago.

Chief on the list of issues to be discussed was bringing “scale” to the provision of mental health and substance abuse services.  Let’s face it, the current service provision model is broken: many people in need of help, do not get it.  The care that is provided is often limited in scope and does not address the “whole person.”  And finally, healthcare costs are soaring–particularly among those with longstanding, chronic problems requiring ongoing care.

In spite of 40 years of research support, behavioral health–that is, psychological interventions–are losing ground to other approaches to change.  Consider the following data published by Katherine Nordal: “the percentage of Americans who receive outpatient mental health care…is very similar to the proportion of those receiving such treatment in 1998.”

Let’s see, that’s two decades of no growth!  None. Zero. Zip. Nada.

Dr. Nordal continues, “Overall, there has been a decrease in the use of psychotherapy, a decrease in the use of psychotherapy in conjunction with medication and a big increase in the use of medication only.”  The question that begs to be answered is why, especially when one considers that psychological intervention (whether face to face, on the phone, in a book or together with peers in a group) has a side effect profile that is the envy of the pharmaceutical industry: no weight gain, no sexual dysfunction, no sleep disturbance or dry mouth.

Many factors are, of course, responsible for the demise of behavioral health (By the way, have you noticed the size of the psychology section of your local bookstore.  Its miniscule compared to what it was a decade ago, and the majority of the titles that are available praise neuroscience over human connection, and drugs over talk).  Dr. Nordal cites the rise of managed care and gargantuan advertizing budgets of the pharmaceutical industry.  Others cite cultural changes including a “short-term fix” mentality and the increasingly frenetic pace of life.

Whatever the cause, the problem is not the lack of effective psychological treatments.  Rather, the issue is that more people need to be helped, more quickly and efficiently.  “Helping people make behavioral change,” Dr. Jim Prochaska argued, “is at the center of  healthcare reform.”  Bringing scale to behavioral health, the group agreed, requires a radical revision of the current service delivery model.

In truth, many of the ideas discussed are already underway, including the move toward “integrated care” and ongoing measurement and use of feedback to improve the quality and outcome of treatment.  Other ideas discussed included methods for putting the principles of behavior change directly into the hands of the consumer.  But there’s more.  Stay tuned.  The group has big plans.  Announcements will soon be made right here on the “Top Performance” blog.

Pushing the Research Envelope: Getting Researchers to Conduct Clinically Meaningful Research

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ACE Health Innovations - Developers of openFIT and mFIT

At the recent ACE conference, I had the pleasure of learning from the world’s leading experts on expertise and top performance.  Equally stimulating were conversations in the hallways between presentations with clinicians, policy makers, and researchers attending the event.  One of those was Bill Andrews, the director of the HGI Practice Research Network in the UK who work over the last 3+ years has focused on clinicians whose outcomes consistently fall in the top quartile of effectiveness.

In this brief interview, Bill talks about the “new direction” his research on top performing clinicians is taking.  He is truly “pushing the research envelope, challenging the field to move beyond the simplistic randomized clinical trials comparing different treatment packages.  Take a look:

Connecting, Learning, and Sharing: The ICCE at One Year

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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.

A week or so ago, I received an email from Susanne Helfgott, the sister of concert pianist David Helfgott who, as you know, will be performing at the upcoming “Achieving Clinical Excellence” conference in Kansas City.  She sent me a link to an interview with David that appeared on Australian morning TV.  David is a perfect example of the theme of the conference: achieving superior performance under challenging circumstances.  Check it out:

Ohio Update: Use of CDOI improves outcome, retention, and decreases "board-level" complaints

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A few days ago, I received an email from Shirley Galdys, the Associate Director of the Crawford-Marion Alcohol and Drug/Mental Health Services Board in Marion, Ohio.  Back in January, I blogged about the steps the group had taken to deal with the cutbacks, shortfalls, and all around tough economic circumstances facing agencies in Ohio.  At that time, I noted that the dedicated administrators and clinicians had improved the effectiveness and efficiency of treatment so much by their systematic use of Feedback-Informed Treatment (FIT) that they were able to absorb cuts in funding and loss of staff without having to cut services to their consumers.

Anyway, Shirley was writing because she wanted to share some additional good news.  She’d just seen an advance copy of the group’s annual report.  “Since we began using FIT over two years ago,” she wrote, “board level complaints and grievances have decreased!”

In the past, the majority of such complaints have centered on client rights.  “Because of FIT,” she continued, “we are making more of an effort to explain to people what we can and cannot do for them as part of the ‘culture of feedback’….we took a lot for granted about what people understood about behavioral health care prior to FIT.”

The Crawford-Marion Alcohol and Drug/Mental Health Services Board is now into the second full year of implementation.  They are not merely surviving, they are thriving!  In the video below, directors Shirley Galdys, Bob Moneysmith, and Elaine Ring talk about the steps for a successful implementation.

Hope Transcends: Learning from our Clients

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“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:


Error-centric Practice: How Getting it Wrong can Help you Get it Right

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It’s an idea that makes intuitive sense but is simultanesouly unappealing to most people. I, for one, don’t like it.  What’s more, it flies in the face of the “self-esteem” orientation that has dominated much of educational theory and practice over the last several decades.  And yet, research summarized in a recent issue of Scientific American Mind is clear: people learn the most when conditions are arranged so that they have to make mistakes.   Testing prior to learning, for example, improves recall of information learned after failing the pre-test regarding that same information.  As is well known, frequent testing following learning and/or skill acquisition significantly enhances retention of knowledge and abilities.  In short, getting it wrong can help you get it right more often in the future.

So, despite the short term risk to my self-esteem, “error-centric learning” is an evidence-based practice that I’m taking to heart.  I’m not only applying the approach in the trainings I offer to mental health professionals–beginning all of my workshop with a fun, fact-filled quiz–but in my attempts to master a completely new skill in my personal life: magic and mind reading.  And if the number of mistakes I routinely make in these pursuits is a reliable predictor of future success, well…I should be a master mind reading magician in little more than a few days.

Enough for now–back to practicing.  Tonight, in my hotel room in Buffalo, New York, I’m working on a couple of new card tricks.  Take a look at the videos of two new effects I recorded over the weekend.  Also, don’t miss the interview with Cindy Voelker and John Catalino on the implementation of Feedback-Informed Treatment (FIT) at Spectrum Human Services here in Buffalo.

The Impact of Mentors

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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!

Feedback Informed Treatment (FIT): A Worldwide Trend in Behavioral Health

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In my prior blogpost, I reviewed exciting developments taking place throughout Canada regarding “feedback-informed treatment” (FIT).  For those following me on Twitter–and if you’re not, please do so by clicking on the link–you already know that last week I was in Tunbridge, England for a two day training sponsored by the Kent-Medway National Healthcare Trust on “Supershrinks: Learning from the Fields Most Effective Practitioners.”  Interest in outcomes is growing exponentially, becoming a worldwide phenomenon.

It was a real pleasure being asked to work with the dedicated–and I must say, long-suffering–physicians, psychologists, counselors, social workers, and nurses of the NHS Trust.  I say “long-suffering” because these healthcare professionals, like others around the globe, are laboring to provide effective services while contending with a back breaking amount of paperwork, oversight, mandated treatment protocols, and regulation.

Much of the mess that behavioral health practitioners find themselves in is due to the way “good practice” is and has been conceptualized.  Simply put, the field–it’s researchers, visionaries, policy makers and sadly, many clinicians–are still stuck in the penicillin era, promoting specific treatments for specific disorders.  The result has been a growing list of protocols, fidelity and adherence measures, and other documentation requirements.  As pointed Bohanske and Franzcak point out in their excellent chapter on transforming behavioral health in the latest edition of The Heart and Soul of Change: Delivering What Works in Therapy, “The forms needed to obtain a marriage certificate, buy a new home, lease an automobile, apply for a passport, open a bank account, and die of natural causes…altogether…weigh 1.4 ounces.  By contrast, the paperwork required for enrolling a single mother in counseling to talk about difficulties her child [is] experiencing [weigh] 1.25 pounds” (p. 300).

Something has to change, and that something is the incessant focus on controlling the process–or “how”– of treatment.  Instead, as the video interview below illustrates, emphasis can be placed on outcome.  Doing so will not only simplify oversight and regulation but, as an increasing number of studies show, result in improved “FIT” and effect of services offered.

 

O Canada! Leading the Way to Improved Behavioral Health Services

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Last month, I traveled back and forth between the United States and Canada several times.  First, I was in Edmonton working with several hundred dedicated social workers, case managers, and therapists at The Family Centre.  A week later I traveled to Saskatoon, spending two days talking about outcome-informed clinical work at the Addiction Professionals Association of Saskatchewan annual conference (Photos below are from the APASK meeting.  The first during the presentation, the second with Ruth and Laurel).

The evening following this event, I flew to Calgary where I spent the day with the clinical crew at Calgary Counseling Center.  I caught a red-eye home to Chicago and then returned to Canada the following week stopping over first in Vancouver for a workshop on drug and alcohol treatment sponsored by Jack Hirose & Associates and then continued on to Calgary where I met with the staff and managers of each program that comprises Aspen Family and Community Network Society.

The reason for all the frenetic activity?  A perfect storm has been brewing for some time that is culminating in a tidal wave of interest in using outcomes to inform and improve behavioral health services.  First and foremost: vision.  Specifically, key thought and action leaders not only embraced the idea of seeking feedback from consumers but worked hard to implement outcome-informed work in the settings in which they work: Bill Smiley at  The Family Centre, Robbie Babbins-Wagner at Calgary Counseling Center, and Kim Ruse at Aspen Family and Community Network Society.  Second, as I’ve been warning about for over a decade, one province in Canada–Alberta–passed an initiative which links future agency funding to “the achievement of outcomes.”  Indeed, “outcome” is identified as “the central driver for both case work practice and allocation of resources.”  Third, and finally, economic times are tough.  Payers–be they clients, insurance companies, or government bodies–want proof of a “return on investment” for the money spent on behavioral health services.

Needless to say, it was an inspiring month.  I managed to capture some of that in an interview I did with the director of the Calgary Counseling Center, Robbie Babbins-Wagner.  In it, she describes “why” she and CCC staff are committed to measuring outcomes as well as reviews the challenges involved.  Take a look:

Implementing Consumer-Driven, Outcome-Informed (CDOI) Behavioral Health Services: The ICCE and 2010 Training of Trainers Event

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This week I’m in Calgary, Canada. Last week, I was in Charleston, South Carolina. Next week, I’ll be in Marion, Ohio and Bay City, Michigan. In each instance, I’m working with the management and staff of public behavioral health agencies that are busy implementing consumer-driven, outcome-informed clinical work.

Some of the groups are just beginning the process.  Others, as reported here on my blog, have been at it long enough to document significant improvements in outcome, retention, and productivity (i.e., in Ohio and Virginia).  All have told me that implementing the seemingly simple ideas of outcome-informed practice is incredibly hard work–impacting nearly every aspect of agency life.  Being able to access the expertise and experience of fellow clinicians and agency directors in real time when questions and challenges arise is, I’ve also learned, critical in maintaining the momentum necessary for successful implementation.

Enter the ICCE: The International Center for Clinical Excellence.  Briefly, the ICCE is a web-based community of clinicians, researchers, agency managers, and policy makers dedicated to excellence in behavioral health.  Many of the groups I’m working with have joined the site providing them with 24/7/365 access to a deeply knowledgeable world-wide community.  In addition to the numerous topic-specific discussion groups and member-generated videos, organizations can set up private forums where management and clinicians can have confidential discussions and coordinate implementation efforts.

If you are a clinician or agency director and are not already a member, you and/or your organization can access the ICCE community today by visiting the website at: www.centerforclinicalexcellence.com.  Membership is free.  In the video below, I talk with Arjan Van der Weijde, about groups in Holland that are meeting on on the ICCE for practitioners to discuss their implementation of feedback-informed work in the Netherlands.  Check it out.

I’ve also included a brief video about the upcoming “Training of Trainers” course, held each year in August in Chicago.  As in prior years, professionals from all over the world will be joining me and the state-of-the-art faculty for four intensive days of training.  Agencies both public and private, in the U.S. and abroad, are sending staff to the event to learn the skills necessary to lead transformation projects.  Space is already limited so register soon.

The Training of Trainers

After the Thrill is Gone: Sustaining a Commitment to Routinely Seeking Feedback

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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!

Finding Feasible Measures for Practice-Based Evidence

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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?”


Dr. Haim Omer

“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.

Feedback, Friends, and Outcome in Behavioral Health

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My first year in college, my declared major was accounting.  What can I say?  My family didn’t have much money and my mother–who chose my major for me–thought that the next best thing to wealth was being close to money.

Much to her disappointment I switched from accounting to psychology in my sophomore year.  That’s when I first met Dr. Michael Lambert.


Michael J. Lambert, Ph.D.

It was 1979 and I was enrolled in a required course taught by him on “tests and measures.”  He made an impression to be sure.  He was young and hip–the only professor I met while earning my Bachelor’s degree who insisted the students call him by his first name.  What’s more, his knowledge and passion made what everyone considered the “deadliest” class in the entire curriculum seem positively exciting.  (The text, Cronbach’s classic Essentials of Psychological Testing, 3rd Edition, still sits on my bookshelf–one of the few from my undergraduate days).  Within a year, I was volunteering as a “research assistant,” reading and then writing up short summaries of research articles.

Even then, Michael was concerned about deterioration in psychotherapy.  “There is ample evidence,” he wrote in his 1979 book, The Effects of Psychotherapy (Volume 1), “that psychotherapy can and does cause harm to a portion of those it is intended to help” (p. 6).  And where the entire field was focused on methods, he was hot on the trail of what later research would firmly establish as the single largest source of variation in outcome: the therapist.  “The therapist’s contribution to effective psychotherapy is evident,” he wrote, “…training and selection on dimensions of…empathy, warmth, and genuineness…is advised, although little research supports the efficacy of current training procedures.”  In a passage that would greatly influence the arc of my own career, he continued, “Client perception…of the relationship correlate more highly with outcome that objective judges’ ratings” (Lambert, 1979, p. 32).

Fast forward 32 years.  Recently, Michael sent me a pre-publication copy of a mega-analysis of his work on using feedback to improve outcome and reduce deterioration in psychotherapy.  Mega-analysis combines original, raw data from multiple studies–in this case 6–to create a large, representative data set of the impact of feedback on outcome.  In his accompanying email, he said, “our new study shows what the individual studies have shown.”  Routine, ongoing feedback from consumers of behavioral health services not only improves overall outcome but reduces risk of deterioration by nearly two thirds!    The article will soon appear in the Journal of Consulting and Clinical Psychology.

Such results were not available when I first began using Lambert’s measure–the OQ 45–in my clinical work.  It was late 1996.  My colleagues and I had just put the finishing touches on Escape from Babel, our first book together on the “common factors.”

That’s when I received a letter from my colleague and mentor, Dr. Lynn Johnson.


Lynn D. Johnson, Ph.D.

In the envelop was a copy of an article Lynn had written for the journal, Psychotherapy entitled, “Improving Quality in Psychotherapy” in which he argued for the routine measurement of outcome in psychotherapy.  He cited three reasons: (1) providing proof of effectiveness to payers; (2) enabling continuous analysis and improvement of service delivery; and (3) giving consumers voice and choice in treatment.  (If you’ve never read the article, I highly recommend it–if for no other reason than its historical significance.  I’m convinced that the field would be in far better shape now had Lynn’s suggestions been heeded then).

Anyway, I was hooked.  I soon had a bootleg copy of the OQ and was using it in combination with Lynn’s Session Rating Scale with every person I met.

It wasn’t always easy.  The measure took time and more than a few of my clients had difficulty reading and comprehending the items on the measure.  I was determined however, and so persisted, occasionally extending sessions to 90 minutes so the client and I could read and score the 45-items together.

Almost immediately, routinely measuring and talking about the alliance and outcome had an impact on my work.  My average number of sessions began slowly “creeping up” as the number of single-session therapies, missed appointments, and no shows dropped.  For the first time in my career, I knew when I was and was not effective.  I was also able to determine my overall success rate as a therapist.  These early experiences also figured prominently in development of the Outcome Rating Scale and revision of the Session Rating Scale.

More on how the two measures–the OQ 45 and original 10-item SRS–changed from lengthy Likert scales to short, 4-item visual analog measures later.  At this point, suffice it to say I’ve been extremely fortunate to have such generous and gifted teachers, mentors, and friends.

Bringing up Baseline: The Effect of Alliance and Outcome Feedback on Clinical Performance

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Not long ago, my friend and colleague Dr. Rick Kamins was on vacation in Hawaii.  He was walking along the streets of a small village, enjoying the warm weather and tropical breezes, when the sign on a storefront caught his eye.  Healing Arts Alliance, it read.  The proprietor?  None other than, “Scott Miller, Master of Oriental Medicine.”

“With all the talking you do about the alliance,” Rick emailed me later, “I wondered, could it be the same guy?!”

I responded, “Ha, the story of my life.  You go to Hawaii and all I get is this photo!”

Seriously though, I do spend a fair bit of time when I’m out and about talking about the therapeutic alliance.  As reviewed in the revised edition of The Heart and Soul of Change there are over 1100 studies documenting the importance of the alliance in successful psychotherapy.  Simply put, it is the most evidence-based concept in the treatment literature.

At the same time, whenever I’m presenting, I go to great lengths to point out that I’m not teaching an “alliance-based approach” to treatment.  Indeed–and this can be confusing–I’m not teaching any treatment approach whatsoever.  Why would I?  The research literature is clear: all approaches work equally well.  So, when it comes to method, I recommend that clinicians choose the one that fits their core values and preferences.  Critically, however, the approach must also fit and work for the person in care–and this is where research on the alliance and feedback can inform and improve retention and outcome.


Lynn D. Johnson, Ph.D.

Back in 1994, my long time mentor Dr. Lynn Johnson encouraged me to begin using a simple scale he’d developed.  It was called…(drum roll here)…”The Session Rating Scale!”  The brief, 10-item measure was specifically designed to obtain feedback on a session by session basis regarding the quality of the therapeutic alliance.  “Regular use of [such] scales,” he argued in his book Psychotherapy in the Age of Accountability, “enables patients to be the judge of the…relationship.  The approach is…egalitarian and respectful, supporting and empowering the client” (Johnson, 1995, p. 44).  If you look at the current version of the SRS, you will see Lynn is listed on the copyright line–as Paul Harvey would say, “And now you know…the rest of the story.”  Soon, I’ll tell you how the measure went from a 10-item, Likert scale to a 4-item visual analog scale.

Anyway, some 17 years later, research has now firmly validated Lynn’s idea: formally seeking feedback improves both retention and outcome in behavioral health.  How does it work?  Unfortunately science, as Malcoln Gladwell astutely observes, “all too often produces progress in advance of understanding.”  That said, recent evidence indicates that routinely monitoring outcome and alliance establishes and serves to maintain a higher level of baseline performance.   In other words, regularly seeking feedback helps clinicians attend to core therapeutic principles and processes easily lost in the complex give-and-take of the treatment hour.

Such findings are echoed in the research literature on expertise which shows that superior performers across a variety of domains (physics, computer programming, medicine, etc.) spend more time than average performers reviewing basic core principles and practice.


At an intensive training in Antwerp, Belgium

The implications for improving practice are clear: before reaching for the stars, we should attend to the ground we stand on.  It’s so simple, some might think it stupid.  How can a four item scale given at the end of a session improve anything?  And yet, in medicine, construction, and flight training, there is a growing reliance on such “checklists” to insure that proven steps to success are not overlooked.  Atul Gawande reviews this practice in his new and highly readable book, The Checklist Manifesto: How to Get Things Right.  Thanks go to Dan Buccino, member of the International Center for Clinical Excellence, for bringing this work to my attention.  (By the way, you can connect with Dan and Lynn in the ICCE community.  If you’re not a member, click here to join.  It’s free).

The only question that remains is, I suppose, with all the workshops and training on “advanced methods and specialized techniques,” will practitioners interested in bringing up baseline?

Learning, Mastery, and Achieving One’s Personal Best

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Dateline: Sunday, April 25th, 2010 Chicago, IL

There’s a feeling I get whenever I’m learning something new.  It’s a combination of wonder and possibility.  Even though I’ve been traveling and teaching full time for over 18 years, I still feel that get that feeling of excitement whenever I step on a plane: What will I see?  Who will I meet?  What will I learn?  Move over Indiana Jones, you’ve got nothing on me!

On my desk right now are stacks of books on the subject of expertise and expert performance: The Talent Code: Greatness Isn’t Born. It’s Grown. Here’s How, The Genius in All of Us: Why Everything You’ve Been Told About Genetics, Talent, and IQ Is Wrong, The Cambridge Handbook of Creativity, The Psychology of Abilities, Competencies, and Expertise, Why We Make Mistakes: How We Look Without Seeing, Forget Things in Seconds, and Are All Pretty Sure We Are Way Above Average, and many, many more.

On the floor, arranged in neat little piles, are reams of research articles, newspaper clippings, and pages torn out of magazines.  Literally, all on the same subject: how can we clinicians reliably achieve better results?

I’ve never been one to “settle” for very long.  It’s the journey not the destination I find appealing.  Thus, I began exploring the common factors when it became clear that treatment models contributed little if anything to outcome (click here to read the history of this transition).  When I became convinced that the common factors held little promise for improving results in psychotherapy, I followed the lead of two my mentors, professor Michael Lambert (who I worked with as an undergraduate) and psychologist Lynn Johnson (who trained and supervised me), and began measuring outcome and seeking feedback.  Now that research has firmly established that using measures of the alliance and outcome to guide service delivery significantly enhances performance (see the comprehensive summary of research to date below), I’ve grown restless again.

In truth, I find discussions about the ORS and SRS a bit, well, boring.  That doesn’t mean that I’m not using or teaching others to use the measures.  Learning about the tools is an important first step.  Getting clinicians to actually use them is also important.  And yet, there is a danger if we stop there.

Right now, we have zero evidence that measurement and feedback improves the performance of clinicians over time.  More troubling, the evidence we do have strongly suggests that clinicians do not learn from the feedback they receive from outcome and alliance measures.  Said another way, while the outcome of each particular episode of care improves, clinicians overall ability does not.   And that’s precisely why I’m feeling excited–the journey is beginning…

…and leads directly to Kansas City where, on October 20-22nd, 2010, leading researchers and clinicians will gather to learn the latest, evidence-based information and skills for improving performance in the field of behavioral health.  As of today, talented professionals from Australia, Sweden, Norway, Denmark, Germany, England, Israel, and the United States have registered for the international “Achieving Clinical Excellence” conference.  Some common questions about the event include:

1. What will I learn?

How to determine your overall effectiveness and what specifically you can do to improve your outcomes.

2. Is the content new?

Entirely.  This is no repeat of a basic workshop or prior conferences.  You won’t hear the same presentations on the common factors, dodo verdict, or ORS and SRS.   You will learn the skills necessary to achieve your personal best.

3. Are continuing education credits available?

Absolutely–up to 18 hours depending on whether you attend the pre-conference “law and ethics” training.  By the way, if you register now, you’ll get the pre-conference workshop essentially free!  Three days for one low price.

4. Will I have fun?

Guaranteed.  In between each plenary address and skill building workshop, we’ve invited superior performers from sports, music, and entertainment to perform and inspire .  If you’ve never been to Kansas City, you’ll enjoy the music, food, attractions, and architecture.

Feel free to email me with any questions or click here to register for the conference.  Want a peak at some of what will be covered?  Watch the video below, which I recorded last week in Sweden while “trapped” behind the cloud of volcanic ash.  In it, I talk about the “Therapists Most Likely to Succeed.”

More Eruptions (in Europe and in Research)

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Dateline: Tuesday, 8:21pm, April 20th, 2010, Skellefteå, Sweden

What an incredible week.  Spent the day today working with 250 social workers, case managers, psychologists, psychiatrists, and agency directors in the far nothern town of Skellefteå, Sweden.  Many practitioners here are already measuring outcomes on an ongoing basis and using the information to improve the results of their work with consumers of behavioral health services.  Today, I presented the latest findings from ICCE’s ongoing research on “Achieving Clinical Excellence.”

I’ve been coming to the area to teach and consult since the early 1990’s, when I was first invited to work with Gun-Eva Langdahl and the rest of the talented crew at Rådgivningen Oden (RO).  As in previous years, I spent my first day (Monday) in Skellefteå watching sessions and working with clients at RO clinic.  Frankly, getting to Skellefteå from Goteborg had been a bit of ordeal.  What usually took a little over an hour by plane ended up being a 12-hour combination of cars, trains, and buses–all due to volcanic eruptions on Iceland.  (I shudder to think of how I will get from Skellefteå to Amsterdam on Wednesday evening if air travel doesn’t resume).

Anyway, the very first visit of the day at Rådgivningen Oden was with an adolescent and her parents.  Per usual, the session started with the everyone completing and discussing the Outcome Rating Scale.  The latest research reported in the April 2010 edition of Journal of Consulting and Clinical Psychology (JCCP) confirms the wisdom of this practice: measuring and discussing progress with consumers at every visit results in better outcomes.

It turns out that adolescents are at greater risk for deteriorating in treatment than adults (20% versus 10%).  Importantly, the study in JCCP by Warren, Nelson, Mondragon, Baldwin, and Burlingame found that the more frequently measures are used the less likely adolescents are to worsen in care.  Indeed, as ICCE Senior Associate Susanne Bargmann pointed out in a series of recent emails about this important study, “routinely tracking and discussing progress led to 37% higher recovery rates and 38% lower rates of deterioration!”

Skellefteå is a hotbed of feedback-informed practice in Sweden.  Accompanying the family at Rådgivningen Oden, for example, were professionals from a number of other agencies involved in the treatment and wanting to learn more about outcome-informed practice.  As already noted, 250 clinicians took time away from their busy schedules to hear the latest information and finesse their use of the measures.  And tomorrow, Wednesday, I meet with managers and directors of behavioral health agencies to discuss steps for successfully implementing routine measurement of progress and feedback in their settings.  You can download a video discussing the work being done by the team at Odin in Northern Sweden, by clicking here.

Stay tuned for more.  If all goes well, I’ll be in Amsterdam by Wednesday evening.

Where Necessity is the Mother of Invention: Forming Alliances with Consumers on the Margins

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Spring of last year, I traveled to Gothenburg, Sweden to provide training GCK–an top notch organization led by Ulla Hansson and Ulla Westling-Missios providing cutting-edge training on “what works” in psychotherapy.  I’ll be back this week again doing an open workshop and an advanced training for the group.

While I’m always excited to be out and about traveling and training, being in Sweden is special for me.  It’s like my second home.  My family roots are Swedish and Danish and, it just so happens, I speak the language.  Indeed, I lived and worked in the country for two years back in the late seventies.  If you’ve never been, be sure and put it on your short list of places to visit…

AND IMPORTANTLY, go in the Summer!  (Actually, the photos above are from the famous “Ice Hotel”–that’s right, a hotel completely made of icc.  The lobby, bar, chairs, beds.  Everything!  If you find yourself in Sweden during the winter months, it’s a must see.  I promise you’ll never forget the experience).

Anyway, the last time I was in Gothenburg, I met a clinician whose efforts to deliver consumer-driven and outcome-informed services to people on the margins of society were truly inspiring.   During one of the breaks at the training, therapist Jan Larsson introduced himself, told me he had been reading my books and articles, and then showed me how he managed to seek and obtain feedback from the people he worked with on the streets.  “My work does not look like ‘traditional’ therapeutic work since I do not meet clients at an office.  Rather, I meet them where they live: at home, on a bench in the park, or sitting in the library or local activity center.”

Most of Jan’s clients have been involved with the “psychiatric system” for years and yet, he says, continue to struggle and suffer with many of the same problems they entered the system with years earlier.  “Oftentimes,” he observed, “a ‘treatment plan’ has been developed for the person that has little to do with what they think or want.”

So Jan began asking.  And each time they met, they also completed the ORS and SRS–“just to be sure,” he said.  No computer.  No I-phone app.  No sophisticated web-based adminsitration system.  With a pair of scissors, he simply trimmed copies of the measures to fit in his pocket-sized appointment book.

His experience thusfar?  In Swedish Jan says, “Det finns en livserfarenhet hos klienterna som bara väntar på att bli upptäckt och bli lyssnad till. Klienterna är så mycket mer än en diagnos. Frågan är om vi är nyfikna på den eftersom diagnosen har stulit deras livberättelse.”  Translated: “There is life experience with clients that is just waiting to be noticed and listened to.  Clients are so much more than their diagnosis.  The question is whether we are curious about them because the diagnosis has stolen their life story.”

I look forward to catching up Jan and the crew at GKC this coming week.  I also be posting interviews with Ulla and Ulla as well as ICCE certified trainers Gun-Eva Langdahl (who I’ll be working with in Skelleftea) and Gunnar Lindfeldt (who I’ll be meeting in Stockholm).  In the meantime, let me post several articles he sent by Swedish research Alain Topor on developing helpful relationships with people on the margins.  Dr. Topor was talking about the “recovery model” among people considered “severely and persistently mentally ill long before it became popular here in the States. Together with others, such as psychologist Jan Blomqvist (who I blogged about late last year), Alain’s work is putting the consumer at the center of service delivery.

Improving Outcomes in the Treatment of Obesity via Practice-Based Evidence: Weight Loss, Nutrition, and Work Productivity

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Obesity is a large and growing problem in the United States and elsewhere.  Data gathered by the National Center for Health Statistics indicate that 33% Americans are obese.  When overweight people are added to the mix, the figure climbs to a staggering 66%!   The problem is not likely to go away soon or on its own as the same figures apply to children.

Researchers estimate that weight problems are responsible for over 300,000 deaths annually and account for 12% of healthcare costs or 100 billion–that’s right, $100,000,000,000–in the United States alone.   The overweight and obese have higher incidences of arthritis, breast cancer, heart disease, colorectal cancer, diabetes, endometrial cancer, gallbladder disease, hypertension, liver disease, back pain, sleeping problems, and stroke–not to mention the tremendous emotional, relational, and social costs.  The data are clear: the overweight are the target of discrimination in education, healthcare, and employment.  A study by Brownell and Puhl (2003), for example, found that: (1) a significant percentage of healthcare professionals admit to feeling  “repulsed” by obese person, even among those who specialize in bariatric treatment; (2) parents provide less college support to their overweight compared to “thin” children; and (3) 87% of obese individuals reported that weight prevented them from being hired for a job.

Sadly, available evidence indicates that while weight problems are “among the easiest conditions to recognize,” they remain one of the “most difficult to treat.”  Weight loss programs abound.  When was the last time you watched television and didn’t see an ad for a diet pill, program, or exercise machine?  Many work.  Few, however, lead to lasting change.

What might help?

More than a decade ago, I met Dr. Paul Faulkner, the founder and then Chief Executive Officer of Resources for Living (RFL), an innovative employee assistance program located in Austin, Texas.  I was teaching a week-long course on outcome-informed work at the Cape Cod Institute in Eastham, Massachusetts.  Paul had long searched for a way of improving outcomes and service delivery that could simultaneously be used to provide evidence of the value of treatment to purchasers–in the case of RFL, the large, multinational companies that were paying him to manage their employee assistance programs.  Thus began a long relationship between me and the management and clinical staff of RFL.  I was in Austin, Texas dozens of times providing training and consultation as well as setting up the original ORS/SRS feedback system known as ALERT, which is still in use at the organization today.  All of the original reliability, validity, norming, and response trajectories were done together with the crew at RFL.

Along the way, RFL expanded services to disease management, including depression, chronic obstructive pulmonary disease, diabetes, and obesity.  The “weight management” program delivered coaching and nutritional consultation via the telephone informed by ongoing measurement of outcomes and the therapeutic alliance using the SRS and ORS.  The results are impressive.  The study by Ryan Sorrell, a clinician and researcher at RFL, not only found that the program and feedback led to weight loss, but also significant improvements in distress, health eating behaviors (70%), exercise (65%), and presenteeism on the job (64%)–the latter being critical to the employers paying for the service.

Such research adds to the growing body of literature documenting the importance of “practice-based” evidence, making clear that finding the “right” or “evidence-based” approach for obesity (or any problem for that matter) is less important than finding out “what works” for each person in need of help.  With challenging, “life-style” problems, this means using ongoing feedback to inform whatever services may be deemed appropriate or necessary.  Doing so not only leads to better outcomes, but also provides real-time, real-world evidence of return on investment for those footing the bill.

"What Works" in Holland: The Cenzo Experience

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When it comes to healthcare, it can be said without risk of exaggeration that “revolution is in the air.”  The most sweeping legislation in history has just been passed in the United States.  Elsewhere, as I’ve been documenting in my blogs, countries, states, provinces, and municipalities are struggling to maintain quality while containing costs of the healthcare behemoth.

Back in January, I talked about the approach being taken in Holland where, in contrast to many countries, the healthcare system was jettisoning their government-run system in favor of private insurance reimbursement.  Believe me, it is a change no less dramatic in scope and impact than what is taking place in the U.S.  At the time, I noted that Dutch practitioners were, in response “’thinking ahead’, preparing for the change—in particular, understanding what the research literature indicates works as well as adopting methods for documenting and improving the outcome of treatment.” As a result, I’ve been traveling back and forth—at least twice a quarter–providing trainings to professional groups and agencies across the length and breadth of the country.

Not long ago, I was invited to speak at the 15th year anniversary of Cenzo—a franchise organization with 85 registered psychologist members.  Basically, the organization facilitates—some would say “works to smooth”–the interaction between practitioners and insurance companies.  In addition to helping with contracts, paperwork, administration, and training, Cenzo also has an ongoing “quality improvement” program consisting of routine outcome monitoring and feedback as well as client satisfaction metrics.  Everything about this forward-thinking group is “top notch,” including a brief film they made about the day and the workshop.  Whether you work in Holland or not, I think you’ll find the content interesting!  If you understand the language, click here to download the 15th year Anniversary Cenzo newsletter.