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

info@scottdmiller.com 773.404.5130

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

By Leave a Comment


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

By Leave a Comment

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

By Leave a Comment


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

By 1 Comment

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

By Leave a Comment


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)

By Leave a Comment

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

By 3 Comments

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

By 4 Comments

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

By 1 Comment

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.

Outcomes in New Zealand

By Leave a Comment

Made it back to Chicago after a week in New Zealand providing training and consultation.  As I blogged about last Thursday, the last two days of my trip were spent in Christchurch providing a two-day training on “What Works” for Te Pou–New Zealand’s National Centre of Mental Health Research, Information, and Workforce Development.  Last year around this same time, I provided a similar training for Te Pou for managers and policy makers in Auckland.  News spread and this year my contact at Te Pou, Emma Wood brought the training to the south island.  It is such a pleasure to be involved with such a forward thinking organization.

Long before I arrived, leadership at Te Pou were promoting outcome measurement and feedback.  Here’s a direct quote from their website:

Outcomes information can assist:

  • service users to use their own outcomes data to reflect on their wellbeing and circumstances, talk to clinicians about their support needs and inform their recovery plans
  • clinicians to use outcomes information to support their decision-making in day-to-day practice, monitoring change, better understanding the needs of the service user, and also to begin evaluating the effectiveness of different interventions
  • planners and funders to assess population needs for mental health services and assist with allocation of resources policy and mental health strategy developments through nationally aggregated data.

Indeed, using outcome to inform mental health service delivery is a key aspect of the Past, Present, and Future: Vision Paper–a review of “what works” in care and a plan for improving treatment in the future.  The site even publishes a quarterly newsletter Outcomes Matter.  Take a few minutes and explore the Te Pou website.  While you are there, be sure and download the pamphlet entitled, “A Guide to Talking Therapies.”  As the title implies, this brief, easy-to-read text provides a non-nonsense guide to the various “talk therapies” for consumers (I took several copies home with me from the workshop).

Before ending, let me say a brief hello to the Clinical Practice Leaders from the Problem Gambling Foundation of New Zealand who attended the two-day training in Christchurch.    The dedicated staff use an integrated public health and clinical model and are working to implement ongoing measurement of outcome and consumer feedback into service delivery.  The website contains a free online library including fact sheets, research, and books on the issue of problem gambling that is an incredible resource to professionals and the public.  Following the workshop, the group sent a photo that was taken of us together.  From left to right, they are Wenli Zhang, me, Margaret Sloan, and Jude West.

Leading for a Change: The Training of Trainer’s (TOT) Chicago

By Leave a Comment

I’m writing tonight from my hotel room at the River Rock Inn in Rockland, Ontario, Canada.  For those of you who are not familiar with the area, it is a bilingual (French & English) community of around 9,000 located about 25 km west of Ottawa.

Today through Thursday, I’m working with the staff, supervisors, and agency administrators of Prescott-Russell Services to Children and Adults.  The goal?  Introduce the latest “cutting-edge” research on “what works” in behavioral health and initiate a system transformation project for this group that provides child protection, mental health, family violence, and development services in the area.  The time spent with the first cohort of 125 direct services providers and supervisors went by, as they say, in “the blink of an eye.”  Tomorrow, I’ll be repeating the same training for the rest of the crew.  On Wednesday and Thursday I’ll meet with supervisors and administrators.  Suffice it to say, it’s an incredible opportunity for me to take part in such a large and well executed service improvement project.  In these lean economic times, I’m inspired by both the time and resources being directed at improving services offered to this area’s most needy.  By the end of the week, I hope to have interviews posted with some of the providers and leaders working in the project.

While on the subject of training, let me share the brochure for this year’s “Training of Trainers” event in Chicago, Illinois during the second week of August.  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 on feedback-informed treatment (FIT).  Please note: this is not an “advanced training” in FIT where time is spent reviewing the basics or covering content.  Rather, the TOT curriculum has been designed to prepare participants to train others.  Every day of the training, you will learn specific skills for training others, have an opportunity to practice those skills, and then receive detailed feedback from ICCE Senior Associates and Trainers Rob Axsen, Cynthia Maeschalck, and Jason Seidel.  Anyway, read for yourself.  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.

Click here to download the brochure to review or forward to colleagues

Addressing the Financial Crisis in Public Behavioral Healthcare Head On in Chesterfield, Virginia

By Leave a Comment

If you are following me on Twitter (and I hope you are), you know the last month has been extremely busy.  This week I worked with clinicians in Peterborough, Ontario Canada.  Last week, I was in Nashville, Tennessee and Richmond Virginia.  Prior to that, I spent nearly two weeks in Europe, providing training and consultations in the Netherlands and Belgium.

It was, as always, a pleasure meeting and working with clinicians representing a wide range of disciplines (social workers, case managers, psychologists, psychiatrists, professional counselors, alcohol and drug treatment professionals, etc.) and determined to provide the best service possible.  As tiring as “road work” can sometimes be, my spirits are always buoyed by the energy of the individuals, groups, and agencies I meet and work with around the world.

At the same time, I’d be remiss if I didn’t acknowledge the fear and hardship I’m witnessing among providers and treatment agencies each week as I’m out and about.  Frankly, I’ve never seen anything like it in my seventeen years “on the road.”  Being able to say that we predicted the current situation nearly 6 years ago provides little comfort (see The Heroic Client, 2004).

While nearly all are suffering, the economic crisis in the United States is hitting public behavioral health particularly hard.  In late January I blogged about the impact of budget cuts in Ohio.   Sadly, the situations in Virginia and Tennessee are no different.  Simply put, public behavioral health agencies are expected to do more with less, and most often with fewer providers.  What can be done?

Enter Chesterfield Community Service Board.  Several years ago, I met and began working with Larry Barnett,  Lyn Hill, and the rest of the talented clinical staff at this forward thinking public behavioral health agency.  Their goal?  According to the agency mission statement, “to promote improved quality of life…through exceptional and comprehensive mental health, mental retardation, substance abuse, and early intervention services.”  Their approach?  Measure and monitor the process and outcome of service delivery and use the resulting information to improve productivity and performance.

As Larry and Lynn report in the video below, the process was not easy.  Indeed, it was damn difficult–full of long hours, seemingly endless discussions, and tough, tough choices.  But that was then.  Some three years later, the providers at Chesterfield CSB are serving 70% more people than they did in 2007 despite there being no increase in available staff resources in the intervening period.  That’s right, 70%!  And that’s not all.  While productivity rates soared, clinician caseloads were reduced by nearly 30%.  As might be expected, the time consumers in need of services had to wait was also significantly reduced.

In short, everybody won: providers, agency managers, funders, and consumers.  And thanks to the two days of intensive training in Richmond, Virginia organized by Arnold Woodruff, many additional public behavioral health agencies have the information needed to get started.  It won’t be easy.  However, as the experience in Chesterfield demonstrates, it is possible to survive and thrive during these tumultuous times.  But don’t take my word for it, listen to how Larry and Lynn describe the process–warts and all–and the results:

Deliberate Practice, Expertise, & Excellence

By 2 Comments

Later today, I board United flight 908 on my way to workshops scheduled in Holland and Belgium.  My routine in the days leading up to an international trip is always the same.  I slowly gather together the items I’ll need while away: computer (check); european electric adapter (check); presentation materials (check); clothes (check).   And, oh yeah, two decks of playing cards and close up performance mat.

That’s me (pictured above) practicing a “ribbon spread” in my hotel room following a day of training in Marion, Ohio.  It’s a basic skill in magic and I’ve been working hard on this (and other moves using cards) since last summer.  Along the way, I’ve felt both hopeful and discouraged.  But I’ve kept on nonetheless taking heart from what I’m reading about skill acquisition.

Research on expertise indicates that the best performers (in chess, medicine, music, sports, etc.) practice every day of the week (including weekends) for up to four hours a day.  Sounds tiring for sure.  And yet, the same body of evidence shows that world class performers are able to sustain such high levels of practice because they view the acquisition of expertise as a long-term process.  Indeed, in a study of children, researcher Gary McPherson found that the answer to a simple question determined the musical ability of kids a year later: “how long do you think you’ll play your instrument?”  The factors that were shown to be irrelevant to performance level were: initial musical ability, IQ, aural sensitivity, math skills, sense of rhythm, income level, and sensorimotor skills.

The type of practice also matters.  When researchers Kitsantas and Zimmerman studied the skill acquisition of experts, they found that 90% of the variation in ability could be accounted for by how the performers described their practice; the types of goals they set, how they planned and executed strategies, self-monitored, and adapted their performance in response to feedback.

So, I take my playing cards and close-up mat with me on all of my trips (both domestic and international).  I don’t practice on planes.  Gave that up after getting some strange stares from fellow passengers as they watched me repeat, in obsessive fashion, the same small segment of my performance over, and over, and over again.  It only made matters worse if they found out I was a psychologist.  I’d get that “knowing look,” that seemed to say, “Oh yeah.”  Anyway, I also managed to lose a fair number of cards when the deck–because of my inept handling while trying to master some particular move–went flying all over the cabin (You can imagine why I’ve been less successful in keeping last year’s New Year resolution to learn to play the ukelele).

Once I’m comfortably situated in my room, the mat and cards come out and I work, practice a specific handling for up to 30 minutes followed by a 15-20 minute break.  Believe it or not, learning–or perhaps better said, attempting to learn–magic has really been helpful in understanding the acquisition of expertise in my chosen field: psychology and psychotherapy.  Together with my colleagues, we are translating our experience and the latest research on expertise into steps for improving the performance and outcome of behavioral health services.  This is, in fact, the focus of the newest workshop I’m teaching, “Achieving Clinical Excellence.”   It’s also the organizing theme of the ICCE Achieving Clinical Excellence conference that will be held in Kansas City, Kansas in October 2010.  Click on the photo below for more information.

In the meantime, check out the two videos I’ve uploaded to ICCETV featuring two fun magic effects.  And yes, of course, feedback is always appreciated!

The Turn to Outcomes: A Revolution in Behavioral Health Practice

By Leave a Comment

Get ready.  The revolution is coming (if not already here).  Whether you are a direct service provider (psychologist, counselor, marriage and family therapist), agency, broker, or funder, you will be required to measure and likely report the outcomes of your clinical work.


Jay Lebow, Ph.D.

Just this month, Dr. Jay Lebow, a professor of psychology at the Family Institute at Northwestern University, published an article in the Psychotherapy Networker–the most widely circulated publication for practitioners in the world–where he claimed the field had reached a “tipping point.”  “Once a matter of interest only among a small circle of academics,” Dr. Lebow writes in his piece entitled, The Big Squeeze, “treatment outcome has now become a part of the national debate about healthcare reform.”


David Barlow, Ph.D.

The same sentiments were expressed in a feature article entitled, “Negative Effects from Psychological Treatments,” written by Dr. David Barlow in the January issue of the American Psychologist.  “Therapists,” he argues both eloquently and persuasively, “do not have to wait for the next clinical trial….[rather] clinicians [can act] as local clinical scientists…[using] outcome measures to track progress…rapidly becom[ing] aware of lack of progress or even deterioration” (p. 19).  What can I say, except that any practitioner with more than a few years to work before retirement, should read these articles and then forward them to every practitioner they know.

During the Holidays, and just before the turn of the New Year, I blogged about the trend toward outcome measurement.  As readers will recall, I talked about my experience on a panel at the Evolution of Psychotherapy conference where Dr. Barlow–who, in response to my brief remarks about the benefits of feedback– suprised me by stating unequivocally that all therapists would soon be required to measure and monitor the outcome of their clinical work. And even though my work has focused almost exclusively on measuring and using outcomes to improve both retention in and the results of behavioral health for the last 15 years, I said his pronouncement frightened me–which, by the way, reminds me of a joke.

A sheep farmer is out in the pasture tending his flock–I promise this is clean, so read on–when from over a small hill comes a man in a custom-tailored, three-piece business suit.  In one hand, the businessman holds a calculator; in the other, an expensive, leather brief case.  “I have a proposition for you,” the well-clad man says as he approaches the farmer, and then continues, “if I can tell you how many sheep are in your flock, to the exact number, may I have one of your sheep?”  Though initially startled by the stranger’s abrupt appearance and offer, the farmer quickly gathers his wits.  Knowing there is no way the man could know the actual number of sheep (since many in his flock were out of site in other pastures and several were born just that morning and still in the barn), the farmer quickly responded, “I’ll take that bet!”

Without a moment’s hesitation, the man calls out the correct number, “one thousand, three hundred and forty six,” then quickly adds, “…with the last three born this morning and still resting in the barn!”  Dumbfounded, the farmer merely motions toward his flock.  In response, the visitor stows his calculator, slings one of the animals up and across his shoulders and then, after retrieving his briefcase, begins making his way back up the hill.  Just as he nears the top of the embankment, the farmer finds his voice and calls out, “Sir, I have a counter proposal for you.”

“And what might that be?” the man replies, turning to face the farmer, who then asked, “If I can tell you, sir, what you do for a living, can I have my animal back?”

Always in the mood for a wager, the stranger replies, “I’ll take that bet!”  And then without a moment’s hesitation, the sheep farmer says, “You’re an accountant, a bureaucrat, a ‘bean-counter.'”  Now, it’s the businessman’s turn to be surprised.  “That’s right!” he says, and then asks, “How did you know?”

“Well,” the farmer answers, “because that’s my dog you have around your neck.”

The moral of the story?  Bureaucrats can count but they can’t tell the difference between what is and is not important.  In my blogpost on December 24th, I expressed concern about the explosion of “official interest” in measuring outcomes.  As the two articles mentioned above make clear, the revolution has started.  There’s no turning back now.  The only question that remains is whether behavioral health providers will be present to steer measurement toward what matters?  Here, our track record is less than impressive (remember the 80-90’s and the whole managed care revolution).  We had ample warning (and did, well, nothing.  If you don’t believe me, click here and read this article from 1986 by Dr. Nick Cummings).

As my colleague and friend Peter Albert is fond of saying, “If you’re not at the table, you’re likely to be on the menu.”  So, what can the average clinician do?  First of all, if you haven’t already done so, began tracking your outcomes.  Right here, on my website, you can download, free, simple-to use, valid and reliable measures.  Second, advocate for measures that are feasible, client-friendly, and have a empirical track record of improving retention and outcome.  Third, and lastly, join the International Center for Clinical Excellence.  Here, clinicians from all over the globe are connecting, learning, and sharing their experiences about how to use ongoing measures of progress and alliance.  Most importantly, all are determined to lead the revolution.

Behavioral Healthcare in Holland: The Turn Away from the Single-payer, Government-Based Reimbursement System

By Leave a Comment

Several years ago I was contacted by a group of practitioners located in the largest city in the north of the Netherlands–actually the capital of the province known as Groningen.  The “Platform,” as they are known, were wondering if I’d be willing to come and speak at one of their upcoming conferences.  The practice environment was undergoing dramatic change, the group’s leadership (Dorti Been & Pico Tuene) informed me.  Holland would soon be switching from government to a private insurance reimbursement system.  Dutch practitioners were “thinking ahead,” preparing for the change–in particular, understanding what the research literature indicates works in clinical practice as well as learning methods for documenting and improving the outcome of treatment.

I was then, and remain now, deeply impressed with the abilities and dedication of Dutch practitioners.  During that visit to Groningen, and the many that have followed (to Amsterdam, Rotterdam, Beilen, etc.), its clear that clinicians in the Netherlands are determined to lead rather than be led.  I’ve been asked to meet with university professors, practitioner organizations, training coordinators, and insurance company executives.  In a very short period of time, two Dutch therapists–physician Flip Van Oenen and psychologist Mark Crouzen–have completed the “Training of Trainers” course and become recognized trainers and associates for the International Center for Clinical Excellence.  And finally, a study will soon be published showing sound psychometric properties of the Dutch translations of the ORS and SRS.

I’ve also been working closely with the Dutch company Reflectum–a group dedicated to supporting outcome-informed healthcare and clinical excellence.  Briefly, Reflectum has organized several conferences and expert meetings between me and clinicians, agency managers, and insurance companies.  One thing for sure: we will be working closely together to train a network of trainers and consultants to promote, support, and train agencies and practitioners in outcome-informed methods in order to meet the demands of the changing practice climate.

Check out the videobelow filmed at Schipol airport during one of my recent trips to Holland:

Outcomes in the Artic: An Interview with Norwegian Practitioner Konrad Kummernes

By Leave a Comment

Dateline: Mosjoen, Norway

The last stop on my training tour around northern Norway was Mosjoen.  The large group of psychologists, social workers, psychiatrists, case managers, and physicians laughed uproariously when I talked about the bumpy, “white-knuckler” ride aboard the small twin-engine airplane that delivered me to the snowy, mountain-rimmed town. They were all to familiar with the peculiar path pilots must follow to navigate safely between the sharp, angular peaks populating the region.

Anyway, I’d been invited nearly two years earlier to conduct the day-long training on “what works in treatment.” The event was sponsored by Helgelandssykehuset-Mosjoen and organized by Norwegian practitioner Konrad Kummernes.  I first met Konrad at a conference held in another beautiful location in Norway (is there any other type in this country?!), Stavanger–best known for its breathtaking Fjordes.  The goal for the day in Mosjoen?  Facilitate the collaboration between the many different services providers and settings thereby enabling the delivery of the most effective and comprehensive clinical services.  Meeting Konrad again and working with the many dedicated professionals in Mosjoen was an inspiration. Here’s Konrad:

Why ongoing, formal feedback is critical for improving outcomes in healthcare

By 3 Comments

researchNot long ago, I had a rather lengthy email exchange with a well-known, high profile psychotherapist in the United States.  Feedback was the topic.  We both agreed that feedback was central to successful psychotherapy.   We differed, however, in terms of method.  I argued for the use of simple, standardized measures of progress and alliance (e.g., ORS and SRS).  In support of my opinion, I pointed to several randomized clinical trials documenting the impact of routine outcome monitoring on retention and progress.  I also cited studies showing traditionally low correlations between consumers and clinician’s rating of outcome and alliance and clinicians frighteningly frequent inability to predict deterioration and drop out in treatment.  He responded that such measures were an “unnecessary intrusion,” indicating that he’d always sought feedback from his clients albeit on an “informal basis.”  television-reception

When I mentioned our own research which had found that clinicians believed they asked consumers for feedback more often than they actually did, he finally seemed to agree with me.  “Of course,” he said immediately–but then he added, “I don’t need to ask in order to get feedback.”  In response to my query about how he managed to get feedback without asking, he responded (without a hint of irony), “I have unconditional empathic reception.”  Needless to say, the conversation ended there.

It’s a simple idea, feedback.  Yet, as I jet around the globe teaching about feedback-informed clinical practice, I’m struck by how hard it seems for many in healthcare to adopt.  Whatever the reason for the resistance–fear, hubris, or inertia–the failure to seek out valid and reliable feedback is a conceit that the field can no longer afford.  Simply stated, no one has “unconditional empathic reception.”  As the video below makes clear, we all need help seeing what is right before our eyes.

Research on the Outcome Rating Scale, Session Rating Scale & Feedback

By Leave a Comment

PCOMS - Partners for change outcome management system Scott D Miller - SAMHSA - NREPP“How valid and reliable are the ORS and SRS?”  “What do the data say about the impact of routine measurement and feedback on outcome and retention in behavioral health?”  “Are the ORS and SRS ‘evidence-based?'”

These and other questions regarding the evidence supporting the ORS, SRS, and feedback are becoming increasingly common in the workshops I’m teaching in the U.S. and abroad.

As indicated in my December 24th blogpost, routine outcome monitoring (PROMS) has even been endorsed by “specific treatments for specific disorders” proponent David Barlow, Ph.D., who stated unequivocally that “all therapists would soon be required to measure and monitor the outcome of their clinical work.”  Clearly, the time has come for all behavioral health practitioners to be aware of the research regarding measurement and feedback.

Over the holidays, I updated a summary of the data to date that has long been available to trainers and associates of the International Center for Clinical Excellence.  The PDF reviews all of the research on the psychometric properties of the outcome and session ratings scales as well as the studies using these and other formal measures of progress and the therapeutic relationship to improve outcome and retention in behavioral health services.  The topics is so important, that I’ve decide to make the document available to everyone.  Feel free to distribute the file to any and all colleagues interested in staying up to date on this emerging mega-trend in clinical practice.

The Effects of Feedback on Medication Compliance and Outcome: The University of Pittsburgh Study

By 1 Comment

A number of years ago, I was conducting a workshop in Pittsburgh.  At some point during the training, I met Dr. Jan Pringle, the director of the Program Evaluation Research Unit in the School of Pharmacy at the University of Pittsburgh.

Jan had an idea: use outcome feedback to improve pharmacy practice and outcome.  Every year, large numbers of prescriptions are written by physicians (and other practitioners) that are never filled.  Whats more, surprisingly large number of the scripts that are filled, are either: (a) not taken; or (b) not taken properly.  The result?  In addition to the inefficient use of scarce resources, the disconnect between prescribers, pharmacists, and patients puts people at risk for poor healthcare outcomes.

Together with project coordinator and colleague, Dr. Michael Melczak, Jan set up a study using the ORS and SRS.  Over the last 3 years, I’ve worked as a consultant to the project–providing training and addressing issues regarding application in this first ever study of pharmacy.

Anyway, there were two different conditions in the study.  In the first, pharmacists–the practitioner most likely to interact with patients about prescriptions–engaged in “practice as usual.”  In the second condition, pharmacists used the ORS and the SRS to chart, discuss, and guide patient progress and the pharmacist-patient alliance.  Although the manuscript is still in preparation, I’m pleased to be able to report here that, according to Drs. Pringle and Melczak, the results indicate, “that the patients who were seen by the pharmacists who used [the] scales were significantly more likely to take their medications at the levels that would be likely to result in clinical impact than the patients who saw a pharmacists who did not use the scales…for hypertensive and hyperlipidemia drugs especially.”

Stay tuned for more…

Climate Change in Denmark

By Leave a Comment

hans_christian_andersen_gbHans Christian Andersen, the author of such classic stories as The Ugly Duckling and the Emperor’s New Clothes, once wrote, “Life itself is the most wonderful fairy tale of all.”  That sentiment is certainly true of my own life.  For the last 16 years, I’ve been privileged to travel around the world conducting training and providing consultation.  Each year, I meet literally thousands of therapists and I’m consistently impressed and inspired by their dedication and persistence.  Truth be told, that “spirit”–for lack of a better word–is actually what keeps me in the field.

This last year, I’ve spent a considerable amount of time working with practitioners in Denmark.  Interest in Feedback-Informed Treatment has taken off–and I have the frequent flyer miles to prove it! While I’ve been traveling to the homeland of Hans Christian Andersen for many years (actually my maternal grandfather and his family immigrated to the United States from a small town just outside Copenhagen), momentum really began building following several years of workshops arranged by Henrik and Mette Petersen who run Solution–a top notch organization providing both workshops and year-long certification courses in short-term, solution-focused, and systemic therapies.

In October, I worked with 100+ staff who work at Psykoterapeutisk Center Stolpegård–a large outpatient center just outside of Copenhagen.  For two days, we talked about research and practice in psychotheapy, focusing specifically on using outcome to inform and improve clinical services.  Peter Koefoed, chief psychologist and head of Training organized the event.   I was back in Denmark not quite one month later for two days with Henrik and Mette Petersen and a then third day for a small, intensive training with Toftemosegaard–a center for growth and change–smack dab in the middle of Copenhagen.

At each event, I was honored to be accompanied by Danish psychologist Susanne Bargmann, who is an Associate and Certified Trainer for the Center for Clinical Excellence (ICCE).  I first met Susanne at a two-day workshop sponsored by Solutions a number of years ago.  Her attitude and drive is infectious.  She attended the Training of Trainer’s event in Chicago and now runs a listserve for Danish practitioners interested in feedback-informed treatment (FIT) (by the way, if you are interested in joining the group simply click on her name above to send an email).

Recently, she published an important article in Psycholog Nyt–the official magazine for the Danish Psychological Association. The article is really the first written in Danish by a Danish practitioner to suggest “practice-based evidence” as a scientifically credible alternative to the narrow “specific treatments for specific problems” paradigm that has come to dominate professional discourse and practice the world over.

Anyway, I’ll be back in Denmark several times in 2010.  In May, I’ll be teaching “Supershrinks: Learning from the Field’s Most Effective Practitioners.”  The course, as I understand it, is already sold out.  No worries though as the workshop is being offered again in November–so sign up early (click here to access my workshop calendar).  Also, in September, Susanne and I will jointly teach a course for psychologists on research entitled, “Forskning og Formidling”–a required training for those seeking specialist approval by the Danish Psychological Association. Finally, as I’ve done for the last several years, I’m scheduled to do two days for Solution as well.  If you live and work in Denmark, I truly hope to see you at one of these events.

 

Outcomes in OZ III

By Leave a Comment

Dateline: November 28, 2009 Brisbane, Australia

accor

Crown Plaza Hotel
Pelican Waters Golf Resort & Spa

As their name implies, LifeLine Australia is the group people call when they need a helping hand.  During the last leg of my tour of eastern Australia, I was lucky enough to spend two days working with Lifeline’s dedicated and talented clinicians on improving the retention and outcome of clinical services they offer.

The two-day conference was the kick off for a “transformation project,” as Trevor Carlyon, the executive director of Lifeline Community Care points out in the video segment below, the stated goal of which is “putting clients back at the center of care.”   Nearly 200 clinicians working with a diverse clientele located throughout northern Queensland gathered for the event.  I look forward to returning in the future as the ideas are implemented across services throughout the system.

 

Outcomes in Oz

By Leave a Comment

Greetings from beautiful Melbourne, Australia!   For the next couple of weeks, I’ll be traveling the up and down the east coast of this captivating country, conducting workshops and providing consultations on feedback-informed clinical work.

Actually, I’ve had the privilege of visiting and teaching in Australia about once a year beginning in the late 1990’s. Back then, Liz Sheehan, the editor of the “must read” journal Psychotherapy in Australiabrought me in to speak about the then recently published first edition of the Heart and Soul of Change.  By the way, if you are not from Australia, and are unfamiliar with the journal, please do visit the website.  Liz makes many of the articles that appear in the print version available online.  I’ve been a subscriber for years now and await the arrival of each issue with great anticipation.  I’m never disappointed.

In any event, on Wednesday this week, I spent the entire day with Mark Buckingham, Fiona Craig, and the clinical staff of Kedesh Rehabilitation Services in Wollongong, Australia–a scenic sea-side location about 45 minutes south of Sydney.  Briefly, Kedesh is a residential treatment facility providing cutting-edge, consumer driven, outcome-informed services to people with drug, alcohol, and mental health problems.  The crew at Kedesh is using the ORS and SRS to guide service delivery and is, in fact, one of the first to fully implement CDOI in the country.

I’ll be back with more soon, so please check back tomorrow.  In the meantime, check out the video with Mark and Fiona.

Where is Scott Miller going? The Continuing Evolution

By 2 Comments

I’ve just returned from a week in Denmark providing training for two important groups.  On Wednesday and Thursday, I worked with close to 100 mental health professionals presenting the latest information on “What Works” in Therapy at the Kulturkuset in downtown Copenhagen.  On Friday, I worked with a small group of select clinicians working on implementing feedback-informed treatment (FIT) in agencies around Denmark.  The day was organized by Toftemosegaard and held at the beautiful and comfortable Imperial Hotel.

In any event, while I was away, I received a letter from my colleague and friend, M. Duncan Stanton.  For many years, “Duke,” as he’s known, has been sending me press clippings and articles both helping me stay “up to date” and, on occasion, giving me a good laugh.  Enclosed in the envelope was the picture posted above, along with a post-it note asking me, “Are you going into a new business?!”

As readers of my blog know, while I’m not going into the hair-styling and spa business, there’s a grain of truth in Duke’s question.  My work is indeed evolving.  For most of the last decade, my writing, research, and training focused on factors common to all therapeutic approaches. The logic guiding these efforts was simple and straightforward. The proven effectiveness of psychotherapy, combined with the failure to find differences between competing approaches, meant that elements shared by all approaches accounted for the success of therapy (e.g., the therapeutic alliance, placebo/hope/expectancy, structure and techniques, extratherapeutic factors).  As first spelled out in Escape from Babel: Toward a Unifying Language for Psychotherapy Practice, the idea was that effectiveness could be enhanced by practitioners purposefully working to enhance the contribution of these pantheoretical ingredients.  Ultimately though, I realized the ideas my colleagues and I were proposing came dangerously close to a new model of therapy.  More importantly, there was (and is) no evidence that teaching clinicians a “common factors” perspective led to improved outcomes–which, by the way, had been my goal from the outset.

The measurable improvements in outcome and retention–following my introduction of the Outcome and Session Rating Scales to the work being done by me and my colleagues at the Institute for the Study of Therapeutic Change–provided the first clues to the coming evolution.  Something happened when formal feedback from consumers was provided to clinicians on an ongoing basis–something beyond either the common or specific factors–a process I believed held the potential for clarifying how therapists could improve their clinical knowledge and skills.  As I began exploring, I discovered an entire literature of which I’d previously been unaware; that is, the extensive research on experts and expert performance.  I wrote about our preliminary thoughts and findings together with my colleagues Mark Hubble and Barry Duncan in an article entitled, “Supershrinks” that appeared in the Psychotherapy Networker.

Since then, I’ve been fortunate to be joined by an internationally renowned group of researchers, educators, and clinicians, in the formation of the International Center for Clinical Excellence (ICCE).  Briefly, the ICCE is a web-based community where participants can connect, learn from, and share with each other.  It has been specifically designed using the latest web 2.0 technology to help behavioral health practitioners reach their personal best.  If you haven’t already done so, please visit the website at www.iccexcellence.com to register to become a member (its free and you’ll be notified the minute the entire site is live)!

As I’ve said before, I am very excited by this opportunity to interact with behavioral health professionals all over the world in this way.  Stay tuned, after months of hard work and testing by the dedicated trainers, associates, and “top performers” of ICCE, the site is nearly ready to launch.

Leading Outcomes in Vermont: The Brattleboro Retreat and Primarilink Project

By 4 Comments

For the last 7 years, I’ve been traveling to the small, picturesque village of Brattleboro, Vermont to work with clinicians, agency managers, and various state officials on integrating outcomes into behavioral health services.  Peter Albert, the director of Governmental Affairs and PrimariLink at the Brattleboro Retreat, has tirelessly crisscrossed the state, promoting outcome-informed clinical work and organizing the trainings and ongoing consultations.   Over time, I’ve done workshops on the common factors, “what works” in therapy, using outcome to inform treatment, working with challenging clinical problems and situations and, most recently, the qualities and practices of super effective therapists.  In truth, outcome-informed clinical work both grew up and “came of age” in Vermont.  Indeed, Peter Albert was the first to bulk-purchase the ASIST program and distribute it for free to any provider interested in tracking and improving the effectiveness of their clinical work.

If you’ve never been to the Brattleboro area, I can state without reservation that it is one of the most beautiful areas I’ve visited in the U.S.–particularly during the Fall, when the leaves are changing color.  If you are looking for a place to stay for a few days, the Crosy House is my first and only choice.  The campus of the Retreat is also worth visiting.  It’s no accident that the trainings are held there as it has been a place for cutting edge services since being founded in 1874.  The radical idea at that time?  Treat people with respect and dignity.  The short film below gives a brief history of the Retreat and a glimpse of the serene setting.

Anyway, this last week, I spent an entire day together with a select group of therapists dedicated to improving outcomes and delivering superior service to their clients.  Briefly, these clinicians have been volunteering their time to participate in a project to implement outcome-informed work in their clinical settings.  We met in the boardroom at the Retreat, discussing the principles and practices of outcome-informed work as well as reviewing graphs of their individual and aggregate ORS and SRS data.

It has been and continues to be an honor to work with each and every one in the PrimariLink project.  Together, they are making a real difference in the lives of those they work with and to the field of behavioral health in Vermont.  If you are a clinician located in Vermont or provide services to people covered by MVP or PrimariLink and would like to participate in the project, please email Peter Albert.  At the same time, if you are a person in need of behavioral health services and looking for a referral, you could do no better than contacting one of the providers in the project!

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

By Leave a Comment

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

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

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

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

Whoa Nellie! A 25 Million Dollar Study of Treatments for PTSD

By 1 Comment

I have in my hand a frayed and yellowed copy of observations once made by a well known trainer of horses. The trainer’s simple message for leading a productive and successful professional life was, “If the horse you’re riding dies, get off.”

You would think the advice straightforward enough for all to understand and benefit.  And yet, the trainer pointed out, “many professionals don’t always follow it.”  Instead, they choose from an array of alternatives, including:

  1. Buying a strong whip
  2. Switching riders
  3. Moving the dead horse to a new location
  4. Riding the dead horse for longer periods of time
  5. Saying things like, “This is the way we’ve always ridden the horse.”
  6. Appointing a committee to study the horse
  7. Arranging to visit other sites where they ride dead horses more efficiently
  8. Increasing the standards for riding dead horses
  9. Creating a test for measuring our riding ability
  10. Complaining about how the state of the horse the days
  11. Coming up with new styles of riding
  12. Blaming the horse’s parents as the problem is often in the breeding.
When it comes to the treatment of post traumatic stress disorder, it appears the Department of Defense is applying all of the above.  Recently, the DoD awarded the largest grant ever awarded to “discover the best treatments for combat-related post-traumatic stress disorder” (APA Monitor).  Beneficiaries of the award were naturally ecstatic, stating “The DoD has never put this amount of money to this before.”
Missing from the announcements was any mention of research which clearly shows no difference in outcome between approaches intended to be therapeutic—including, the two approaches chosen for comparison in the DoD study!  In June 2008, researchers Benish, Imel, and Wampold, conducted a meta-analysis of all studies in which two or more treatment approaches were directly compared.  The authors conclude, “Given the lack of differential efficacy between treatments, it seems scientifically questionable to recommend one particular treatment over others that appear to be of comparable effectiveness. . . .keeping patients in treatment would appear to be more important in achieving desired outcomes than would prescribing a particular type of psychotherapy” (p. 755).
Ah yes, the horse is dead, but proponents of “specific treatments for specific disorders” ride on.  You can hear their rallying cry, “we will find a more efficient and effective way to ride this dead horse!” My advice? Simple: let’s get off this dead horse. There are any number of effective treatments for PTSD.  The challenge is decidedly not figuring out which one is best for all but rather “what works” for the individual. In these recessionary times, I can think of far better ways to spend 25 million than on another “horse race” between competing therapeutic approaches.  Evidence based methods exist for assessing and adjusting both the “fit and effect” of clinical services—the methods described, for instance, in the scholarly publications sections of my website.  Such methods have been found to improve both outcome and retention by as much as 65%.  What will happen? Though I’m hopeful, I must say that the temptation to stay on the horse you chose at the outset of the race is a strong one.

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

By 2 Comments

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

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

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

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

The Field, the Future, and Feedback

By 1 Comment

There is an old (but in many ways sad) joke about two clinicians–actually, the way I first heard the story, it was two psychiatrists.  The point of the story is the same regardless of the discipline of the provider.  Anyway, two therapists meet in the hallway after a long day spent meeting clients.  One, the younger of the two, is tired and bedraggled.  The other, older and experienced, looks the same as s/he did at the start of the day: eyes bright and attentive, hair perfectly groomed, clothes and appearance immaculate.  Taken aback by the composure of the more experienced colleague, the younger therapist asks, “How do you do it?  How do you listen to the trials and tribulations, the problem and complaints, the dire lives and circumstances of your clients, minute and minute, hour upon hour…and yet emerge at the end of the day in such good shape?”  Slowly shaking his head from left to right, the older and more experienced clinician immediately reached out, tapping the less experienced colleague gently on the shoulder, and then after removing the thick plugs stuffed into both of his years, said, “Excuse me, what did you say?”

Let’s face it: healthcare is in trouble.  Behavioral healthcare in particular is in even worse shape.  And while solutions from politicians, pundits, industry insiders and professionals are circulating in Washington with all the sound and fury of a hurricane, the voice of consumers is largely absent.  Why?  Of course, many of the barriers between providers and consumers are systemic in nature and as such, out of the control of average clinicians and consumers.  Others, however, are local and could be addressed in an instance with a modicum of interest and attention on the part of professionals.

Chief among the steps practitioners could take to bridge to chasm between them and consumers is the adoption of routine, ongoing feedback.  Seeking and utlizing real-time feedback from consumers has the added advantage of significantly boosting outcomes and increasing retention in services (several studies documenting the impact of feedback are available in the “Scholarly publications and Handouts” section of my website). Healthcare providers can download two well validated and easy-to-use scales right now for free by clicking on the Performance Metrics tab to the left.

So far, however, few in healthcare seem interested and others are downright hostile to the idea of asking consumers for input.  Consider the following story by reporter Lindsey Tanner entitled, “Take two, call me in the morning…and keep it quiet.” Tanner discovered that some in healthcare are demanding that people (patients. clients, consumers) sign “gag orders” prior to being treated–agreeing in effect not to post comments about the provider (negative and otherwise) to online sites such as Zagats.com, Angieslist.com, and RateMds.com.  According to the article, a Greensboro, N.C. company, ironically called “Medical Justice” is, for a fee, now providing physicians with standardized waiver agreements and advising all doctors to have patients sign on the dotted line.  And if the patient refuses?  Simple: find another doctor.

Can you imagine a hotel chain or restaurant asking you to sign a legally-binding agreement not to disclose your experience prior to booking your room or handing you the menu?  Anyone who has travelled lately knows the value of the information contained on consumer-driven websites such as TripAdvisor.com.  It’s outlandish really–except in healthcare.

To be sure, there is at least one important difference between healthcare and other service industries.  Specifically, healthcare providers, unlike business owners and service managers, are prevented from responding to online complaints by existing privacy laws.  However, even if this problem were insurmountable–which it is not–how then can one explain the continuing reluctance on the part of professionals to give people access to their own healthcare records?  And this despite federal regulations under the Health Insurance Portability and Accountability Act (HIPAA) permitting complete and unfettered access (click here to read the recent NPR story on this subject).  Clearly, the problem is not legal but rather cultural in nature.  Remember when Elaine from Seinfeld asked to see her chart?

Earlier this summer, my family and I were vacationing in Southwest Michigan.  One day, after visiting the beach and poking around the shops in the lakeside town of South Haven, we happened on a small Italian bistro named,Tello.  Being from a big city famous for its good eats, I’ll admit I wasn’t expecting much.  The food was delicious.  More surprising, was the service.  Not only were the staff welcoming and attentive, but at the end of the meal, when I thought the time had come to pay the bill, the folder I was given contained a small PDA rather than the check.  I was being asked for my feedback.Answering the questions took less than a minute and the manager, Mike Sheedy, appeared at our table within moments of my hitting the “send” button.  He seemed genuinely surprised when I asked if he felt uncomfortable seeking feedback so directly.  “Have you learned anything useful?” I then inquired.  “Of course,” he answered immediately, “just last week a customer told us that it would be nice to have a children’s menu posted in the window alongside the standard one.” I was dumbstruck as one of the main reasons we had decided to go into the restaurant rather than others was because the children’s menu was prominently displayed in the front window!

Announcement: Evolving in a new direction

By Leave a Comment

As those of you who have followed my work and blog know, my perspective is evolving.  The direction I’m heading builds on all of the work done to date including the common factors, measurement of outcome and alliance, and feedback.  Crucially, however, it goes one step further; bridging the common and specific factors divide that has long dominated and splintered the field, and identifying the concrete steps that diverse providers can take to improve their effectiveness and the services they offer consumers.

For the past 10 years much of my work has been available through the Institute for the Study of Therapeutic Change (ISTC) and featured on its website.  In line with the evolution in my perspective my work is now increasingly centered on a new organization, the International Center for Clinical Excellence (ICCE), an international consortium of researchers, educators, and clinicians dedicated to understanding and promoting excellence in behavior healthcare.  My colleague Barry Duncan, co-founder of the ISTC, is also developing his work in new directions and we have therefore decided that the time is now right to dissolve our long-term partnership in the ISTC.  I recognise that for many of you, who have followed my work over the years, that this may come as a surprising development and I am hoping that this post and others to follow will provide guidance, reassurance and most importantly continuity.

Central to the mission of the International Center for Clinical Excellence (ICCE) is the creation of a web-based community of clinicians using the latest Web 2.0 technology where participants can learn from and share with each other.  Based on the principles of Clinical Community Social Software (CCSS) it is specifically designed to support clinical excellence through creating virtual clinical networks, groups and clinical communities where clinicians can be supported in the key behavior changes required for developing clinical excellence.  Participants can, using a variety of social networking and collaborative tools, share clinical insights through discussion forums and video posts as well as improve client outcomes through learning the skills of clinical excellence.

We have finished our first round of beta-testing for the site and you can go to the website at: www.centerforclinicalexcellence.com to register to become a member (its free and you’ll be notified the minute the entire site is live)!

For those of you new to the tremendous opportunities for web-based collaborative social software, let me reassure you that the site will permit access and use at whatever level you desire (everything from the familiar email, to online posts and discussions in real time).  It will provide lots of help to learn how to explore the information and resources on offer as well as the support of colleagues in the community.  I am very excited by this opportunity to interact with behavioral health professionals all over the world in this way. Over the next few days, I’ll be posting more information about the ICCE and our first International Conference on Excellence in Behavioral Health on my blog at www.scottdmiller.com.   I encourage you to follow the updates on my blog and post any questions or comments.