Feedback Informed Treatment: Update

August 16, 2012 By scottdm Leave a Comment

Chicago, IL (USA)

The last two weeks have been a whirlwind of activity here in Chicago. First, the “Advanced Intensive.” Next came the annual “Training of Trainers.” Each week, the room was filled to capacity with practitioners, researchers, supervisors, and agency directors from around the globe receiving in-depth training in feedback-informed practice. It was a phenomenal experience. As the video below shows, we worked and played hard!

Already, people are signing up for the next “Advanced Intensive” scheduled for the third week of March 2013 and the new three-day intensive training on FIT supervision scheduled for the 6-9th of August 2013. Both events follow and are designed to complement the newly released ICCE FIT Treatment and Training Manuals. In fact, all participants receive copies of the 6 manuals, covering every detail of FIT practice, from the empirical evidence to implementation. The manuals were developed and submitted to support ICCE’s submission of FIT to the National Registry of Evidence Based Practices (NREPP). As I blogged about last March, ICCE trainings fill up early. Register today and get the early bird discount.

The DSM 5: Mental Health’s "Disappointingly Sorry Manual" (Fifth Edition)

June 11, 2012 By scottdm 2 Comments

Have you seen the results from the field trials for the fifth edition of the Diagnostic and Statistical Manual? The purpose of the research was to test the reliability of the diagnoses contained in the new edition. Reliable (ri-lahy–uh-buhl), meaning “trustworthy, dependable, consistent.”

Before looking at the data, consider the following question: what are the two most common mental health problems in the United States (and, for that matter, most of the Western world)? If you answered depression and anxiety, you are right. The problem is that the degree of agreement between experts trained to used the criteria is unacceptably low.

Briefly, reliability is estimated using what statisticians call the Kappa (k) coefficient, a measure of inter-rater agreement. Kappa is thought to be a more robust measure than simple percent agreement as it takes into account the likelihood of raters agreeing by chance.

The results? The likelihood of two clinicians, applying the same criteria to assess the same person, was poor for both depression and anxiety. Although there is no set standard, experts generally agree that kappa coefficients that fall lower that .40 can be considered poor; .41-.60, fair; .61-.75, good; and .76 and above, excellent. Look at the numbers below and judge for yourself:

Diagnosis	DSM-5	DSM4	ICD-10	DSM-3
Major Depressive Disorder	.32	.59	.53	.80
Generalized Anxiety Disorder	.20	.65	.30	.72

Now, is it me or do you notice a trend? The reliability for the two most commonly diagnosed and treated “mental health disorders” has actually worsened over time! The same was found for a number of the disorders, including schizophrenia (.46, .76, .81), alcohol use disorder (.40, .71, .80), and oppositional defiant disorder (.46, .51., .66). Antisocial and Obsessive Personality Disorders were so variable as to be deemed unreliable.

Creating a manual of “all known mental health problems” is a momumental (and difficult) task to be sure. Plus, not all the news was bad. A number of diagnoses demonstrated good reliability (autism spectrum disorder, posttraumatic stress disorder (PTSD), and attention-deficit/hyperactivity disorder (ADHD) in children (.69, .67, .61, respectively). Still, the overall picture is more than a bit disconcerting–especially when one considers that the question of the manual’s validity has never been addressed. Validity (vuh–lid-i-tee), meaning literally, “having some foundation; based on truth.” Given the lack of any understanding of or agreement on the pathogenesis or etiology of the 350+ diagnoses contained in the manual, the volume ends up being, at best, a list of symptom clusters–not unlike categorizing people according to the four humours (e.g., phlegmatic, choleric, melancholy, sanquine).

Personally, I’ve always been puzzled by the emphasis placed on psychiatric diagnoses, given the lack of evidence of diagnostic specific treatment effects in psychotherapy outcome research. Additionally, a increasing number of randomized clinical trials has provided solid evidence that simply monitoring alliance and progress during care significantly improves both quality and outcome of the services delivered. Here’s the latest summary of feedback-related research.

Feedback Informed Treatment as Evidence-Based Practice

May 23, 2012 By scottdm Leave a Comment

Back in November, I blogged about the ICCE application to SAMSHA’s National Registry for consideration of FIT as an official evidence-based approach (EBP). Given the definition of EBP by the Institute of Medicine and the American Psychological Association, Feedback Informed Treatment seems a perfect, well, FIT. According to the IOM and APA, evidence-based practice means using the best evidence and tailoring services to the client, their preferences, culture, and circumstances. Additionally, 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.”

In late Summer 2011, ICCE submitted 1000’s of pages of supporting documents, research studies, as well as video in support of the application. This week, we heard that FIT passed the “Quality of Research” phase of the review. Now, the committee is looking at the “Readiness for Dissemination” materials, including the six detailed treatment and implementation manuals on feedback informed treatment. Keep your fingers crossed. We’ve been told that the entire process should be completed sometime in late fall.

In the meantime, we are preparing for this summer’s Advanced Intensive and Training of Trainer workshops. Once again, clinicians, educators, and researchers from around the world will be coming together for cutting edge training. Only a few spots remain, so register now.

Revolution in Swedish Mental Health Care: Brief Update

May 14, 2012 By scottdm 1 Comment

In April 2010, I blogged about Jan Larsson, a Swedish clinician who works with people on the margins of the mental health system. Jan was dedicated to seeking feedback, using the ORS and SRS to tailor services to the individuals he met. It wasn’t easy. Unilke most, he did not meet his clients in an office or agency setting. Rather, he met them where they were: in the park, on the streets, and in their one room aparments. Critically, wherever they met, Jan had them complete the two measures–“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! I’ve been following his creative application of the scales ever since.

Not surprisingly, Jan was on top of the story I blogged about yesterday regarding changes in the guidelines governing Swedish mental health care practice. He emailed me as I was writing my post, including the link to the Swedish Radio program about the changes. Today, he emailed again, sending along links to stories appearing in two Swedish newspapers: Dagens Nyheter and Goteborg Posten.

Thanks Jan!

And to everyone else, please continue to send any new links, videos, and comments.

Revolution in Swedish Mental Health Practice: The Cognitive Behavioral Therapy Monopoly Gives Way

May 13, 2012 By scottdm 34 Comments

Sunday, May 13th, 2012
Arlanda Airport, Sweden

Over the last decade, Sweden, like most Western countries, embraced the call for “evidence-based practice.” Socialstyrelsen, the country’s National Board of Health and Welfare, developed and disseminated a set of guidelines (“riktlinger”) for mental health practice. Topping the list of methods was, not surprisingly, cognitive-behavioral therapy.

The Swedish State took the list seriously, restricting payment for training of clinicians and treatment of clients to cognitive behavioral methods. In the last three years, a billion Swedish crowns were spent on training clinicians in CBT. Another billion was spent on providing CBT to people with diagnoses of depression and anxiety. No funding was provided for training or treatment in other methods.

The State’s motives were pure: use the best methods to decrease the number of people who become disabled as result of depression and anxiety. Like other countries, the percentage of people in Sweden who exit the work force and draw disability pensions has increased dramatically. As a result, costs skyrocketed. Even more troubling, far too many became permanently disabled.

The solution? Identify methods which have scientific support, or what some called, “evidence-based practice.” The result? Despite substantial evidence that all methods work equally well, CBT became the treatment of choice throughout the country. In point of fact, CBT became the only choice.

As noted above, Sweden is not alone in embracing practice guidelines. The U.K. and U.S. have charted similar paths, as have many professional organizations. Indeed, the American Psychological Association has now resurrected its plan to develop and disseminate a series of guidelines advocating specific treatments for specific disorders. Earlier efforts by Division 12 (“Clinical Psychology”) met with resistance from the general membership as well as scientists who pointed to the lack of evidence for differential effectiveness among treatment approaches.

Perhaps APA and other countries can learn from Sweden’s experience. The latest issue of Socionomen, the official journal for Swedish social workers, reported the results of the government’s two billion Swedish crown investment in CBT. The widespread adoption of the method has had no effect whatsoever on the outcome of people disabled by depression and anxiety. Moreover, a significant number of people who were not disabled at the time they were treated with CBT became disabled, costing the government an additional one billion Swedish crowns. Finally, nearly a quarter of those who started treatment, dropped out, costing an additional 340 million!

In sum, billions training therapists in and treating clients with CBT to little or no effect.

Since the publication of Escape from Babel in 1995, my colleagues and I at the International Center for Clinical Excellence have gathered, summarized, published, and taught about research documenting little or no difference in outcome between treatment approaches. All approaches worked about equally well, we argued, suggesting that efforts to identify specific approaches for specific psychiatric diagnoses were a waste of precious time and resources. We made the same argument, citing volumes of research in two editions of The Heart and Soul of Change.

Yesterday, I presented at Psykoterapi Mässan, the country’s largest free-standing mental health conference. As I have on previous visits, I talked about “what works” in behavioral health, highlighting data documenting that the focus of care should shift away from treatment model and technique, focusing instead on tailoring services to the individual client via ongoing measurement and feedback. My colleague and co-author, Bruce Wampold had been in the country a month or so before singing the same tune.

One thing about Sweden: the country takes data seriously. As I sat down this morning to eat breakfast at the home of my long-time Swedish friend, Gunnar Lindfeldt, the newscaster announced on the radio that Socialstyrelsen had officially decided to end the CBT monopoly (listen here). The experiment had failed. To be helped, people must have a choice.

“What have we learned?” Rolf Holmqvist asks in Socionomen, “Treatment works…at the same time, we have the possibility of exploring…new perspectives. First, getting feedback during treatment…taking direction from the patient at every session while also tracking progress and the development of the therapeutic relationship!”

“Precis,” (exactly) my friend Gunnar said.

And, as readers of my blog know, using the best evidence, informed by clients’ preferences and ongoing monitoring of progress and alliance is evidence-based practice. However the concept ever got translated into creating lists of preferred treatment is anyone’s guess and, now, unimportant. Time to move forward. The challenge ahead is helping practitioners learn to integrate client feedback into care—and here, Sweden is leading the way.

“Skål Sverige!”

Mental Health Practice in a Global Economy

April 17, 2012 By scottdm 2 Comments

Did you feel it? The seismic shift that occurred in field of mental health just a little over a month ago? No? Nothing? Well, in truth, it wasn’t so much a rip in the space-time continuum as a run. That “run,” however, promises to forever alter the fabric of clinical practice–in particular how clinicians earn and maintain a certain standard of living.

For decades, licensing statutes have protected behavioral health professionals from competing with providers living outside of their state and local jurisdiction. In order to bill or receive reimbursement, mental health professionals needed to be licensed in the state in which treatment services were offered. Over the years, the various professional organizations have worked to make it easier for professionals to become licensed when they move from one state to the another. Still, it ain’t easy and, some practitioners and professional groups would argue, for good reason. Such laws, to some extent, insure that fees charged for services are commensurate with the cost of living in the place where therapists live and work. The cost of therapy in Manhattan varies considerably, for example, depending on whether one is talking about the city located in state of New York or Kansas.

As far as outcomes are concerned, however, there is no evidence that people who pay more necessarily get better results. Indeed, as reviewed here on this blog, available evidence indicates little or no difference in outcome between highly trained (and expensive) clinicians and minimally trained (and less expensive) para-professionals and students. If the traditional geographic (licensing) barriers were reduced or eliminated, consumers would with few exceptions gravitate to the best value for their money. In the 1980’s and 90’s, for example, comsumers deserted small, Main Street retailers when big box stores opened on the outskirts of town offering the same merchandise at a lower price. Now, big box retailers are closing en masse as consumers shift their purchases to less expensive, web based outlets.

And that’s precisely the shift that began a little over a month ago in the field of mental health. The U.S. Military eliminated the requirement that civilian providers be licensed in the same jurisdiction or state in which treatment is offered. The new law allows care to be provided wherever the receipient of services lives and regardless of where the provider is licensed. Public announcements argued that the change was needed to make services available to service members and veterans living in isolated or rural areas where few providers may be available. Whatever the reason, the implications are profound: in the future, clinicians, like Main Street retailers, will be competing with geographically distant providers.

Just one week prior to the announcement by the U.S. Military, I posted a blogpost highlighting a recent New York Times column by author and trend watcher, Thomas Friedman. In it, I argued that “Globalization and advances in information technology were…challenging the status quo…access. At one time, being average enabled one to live an average life, live in an average neighborhood and, most importantly, earn an average living. Not so anymore. Average is now plentiful, easily accessible, and cheap. What technology can’t do in either an average or better way, a younger, less-trained but equally effective provider can do for less. A variety of computer programs and web-based systems provide both psychological advice and treatment.”

Truth is, the change is likely to be a boon to consumers of mental health services: easier access to services at a better price. What can clinicians do? First, begin measuring outcome. Without evidence of their effectiveness, individual providers will lose out to the least expensive provider. No matter how much people complain about “big box and internet retailers,” most use them. The savings are too great to ignore.

What else can clinicians do? The advice of Friedman, which I quoted in my recent blogpost, applies, “everyone needs to find their extra–their unique value contribution that makes them stand out in whatever is their field.” Measuring outcome and finding that “something special” is what the International Center for Clinical Excellence is all about. If you are not a member, please join the thousands of other professionals online today. After that, why not spend time with peers and cutting edge instructors at the upcoming “advanced intensive” or “training of trainers” workshops this summer.

The Outcome and Session Rating Scales: Support Tools

March 30, 2012 By scottdm 6 Comments

Japan, Sweden, Norway, Denmark, Germany, France, Israel, Poland, Chile, Guam, Finland, Hungary, Mexico, Australia, China, the United States…and many, many more. What do all these countries have in common? In each, clinicians and agencies are using the ORS and SRS scales to inform and improve behavioral health services. Some are using web-based systems for administration, scoring, interpretation and data aggregation (e.g., myoutcomes.com and fit-outcomes), many are accessing paper and pencil versions of the measures for free and then administering and scoring by hand.

Even if one is not using a web-based system to compare individual client progress to cutting edge norms, practitioners can still determine simply and easily whether reliable change is being made by using the “Reliable Change Chart” below. Recall, a change on the ORS is considered reliable when the difference in scores exceeds the contribution attributable to chance, maturation, and measurement error. Feel free to print out the graph and use it in your practice.

To learn how to get the most out of the measures, be sure and download the six FIT Treatment and Training Manuals. 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

ORS Reliable Change Chart

NEWSFLASH: The Advanced Intensive and Training of Trainers in Feedback Informed Therapy (FIT)

March 17, 2012 By scottdm Leave a Comment

Dateline: March 17th, 2012, Chicago, Illinois USA

Barely a month ago, I announced the addition of a second “Advanced Intensive” (AI) course in Feedback Informed Treatment (FIT). The original March training filled really early this year and a long waiting list formed. Now the second Advanced Intensive training in FIT scheduled for July 30th through August 1st is nearly full. Register now and you can still receive the early bird price. Additionally, we’re offering a super special discount for people attending both the AI and the ICCE Training of Trainers. Don’t wait though, only a handful of spaces remain. If you would like to attend both courses, drop me an email straight away and I’ll send you the special registration code.

We look forward to meeting everyone attending the AI this week. Stay tuned for tweets and video from the training.

The Achieving Clinical Excellence Conference CALL FOR PAPERS

March 13, 2012 By scottdm Leave a Comment

In October 2010, the first annual “Achieving Clinical Excellence” was held in Kansas City, Missouri. A capacity crowd joined leading experts on the subject of top performance for three days worth of training and inspiration. K. Anders Ericsson reviewed his groundbreaking research, popularized by Malcolm Gladwell and others. ICCE Director, Scott D. Miller translated the research into speciific steps for improving clinical performance. Finally, classical piansts David Helfgott, Rachel Hsu, and Roger Chen, demonstrated what can be accomplished when such evidence-based strategies are applied to the process of learning specific skills.

The ICCE is proud to announce the 2nd “ACE” conference to be held May 16th-18th, 2013 in Amsterdam, Holland. Join us for three educational, inspiring, and fun-filled days. Register today and receive a significant “Early Bird” discount. The ACE conference committee is also issuing an international “Call for Papers.” If you, your agency, or practice are committed to excellence, using outcomes to inform practice, or have published research on the subject, please visit the conference website to submit a proposal.

Here’s what attendees said about the last event:

Implementation Science, FIT, and the Training of Trainers

March 8, 2012 By scottdm Leave a Comment

The International Center for Clinical Excellence (ICCE) is pleased to announce the 6th annual Training of Trainers event to be held in Chicago, Illinois August 6th-10th, 2012. As always, the ICCE TOT prepares participants provide training, consultation, and supervision to therapists, agencies, and healthcare systems in Feedback-Informed Treatment (FIT). Attendees leave the intensive, hands-on training with detailed knowledge and skills for:

Training clinicians in the Core Competencies of Feedback Informed Treatment (FIT/CDOI);
Using FIT in supervision;
Methods and practices for implementing FIT in agencies, group practices, and healthcare settings;.
Conducting top training sessions, learning and mastery exercises, and transformational presentations.

Multiple randomized clinical trials document that implementing FIT leads to improved outcomes and retention rates while simultanesouly decreasing the cost of services.

This year’s “state of the art” faculty include: ICCE Director, Scott D. Miller, Ph.D., ICCE Training Director, Julie Tilsen, Ph.D., and special guest lecturer and ICCE Coordinator of Professional Development, Cynthia Maeschalck, M.A.

Join colleagues from around the world who are working to improve the quality and outcome of behavioral healthcare via the use of ongoing feedback. Space is limited. Click here to register online today. Last year, one participants said the training was, “truly masterful. Seeing the connection between everything that has been orchestrated leaves me amazed at the thought, preparation, and talent that has cone into this training.” Here’s what others had to say:

Is the Research on Feedback too Good to be True? Better to UPOD than OPUD!

February 29, 2012 By scottdm 6 Comments

It is a standard maxim of good business practice: Under Promise, OverDeliver (or UPOD). As my father used to say, “Do your best, and then a little better.” Sadly, history shows that the field of behavioral health has followed a difference course: Over Promise, Under Deliver. The result? O, PUDs.

The most gripping account of the field’s failed promises is Robert Whitaker’s Mad in America: Mad Science, Bad Medicine, and Enduring Mistreatment of the Mentall Ill. In fact, Whitaker’s book inspired me to write what became my most popular article, downloaded from my website more often than any other: Losing Faith. In it, I document how, each year, new models, methods, and diagnoses appear promising to revolutionize mental health care, only later to be shown ineffective, wrong, and, in some instances, harmful. Remember Multiple Personality Disorder? Satanic Ritual Abuse? Xanax for panic disorder? Johnsonian-style Interventions for Addiction? Co-dependence? Thought Field Therapy? Rebirthing? How about SSRIs? Weren’t they supposed to be much better than those, you know, old-fashioned tricyclics? The list is endless.

“Not to worry,” current leaders and pundits advise, “We’ve made progress. We have a new idea. A much better idea than the old one. We promise!”

However, when it comes to claims about advances in the field of behavioral health, history indicates that caution is warranted. That includes, by the way, claims about the use of feedback tools in therapy. As readers of this blog know, I have, for several years, been championing the use of simple checklists for guiding and improving the quality and outcome of treatment. Several studies document–as reviewed here on this blog–improved outcomes and decreased drop out and deterioration rates. These studies are important first steps in the scientific process. I’ve been warning however that these studies are only, first steps. Why?

Studies to date, while important, suffer from the same allegiance effects and unfair comparisons of other RCT’s. With regard to the latter, no study compares feedback with an active control condition. Rather, all comparisons have been to “treatment as usual.” Such research, as a result, says nothing about why the use of the measures improves outcomes. At the same time, several indirect, but empirically robust, avenues of evidence indicate that another variable may be responsible for the effect! Consider, for example, the following findings: (1) therapists do not learn from the feedback provided by measures of the alliance and outcome; (2) therapists do not become more effective over time as a result of being exposed to feedback. Such research indicates that focus on the measures and outcome may be misguided–or at least a “dead end.”

Such shortcomings are why researchers and clinicians at ICCE are focused on the literature regarding expertise and expert performance. Focusing on measures misses the point. Already, there is talk about methods for insuring fidelity to a particular way of using feedback tools. Instead, the research on expertise indicates that we need to help clinicians develop practices which enable them to learn from the feedback they receive.

Several studies are in progress. In Trondheim, Norway, the first ever study to include an active control comparison for feedback is underway. I fully expect the control to be as effective as the simple use of checklists in treatment. In a joint research project being conducted at agencies in the US, UK, Canada, and Australia, research is underway investigating how top performing therapists use feedback to learn and improve compared to average and below average clinicians. Such studies are the necessary second step to insure that we understand the elements responsible for the effective use of feedback. Inch by inch, centimeter by centimeter, the results of such studies will advance our understanding and effectiveness. The gains I’m sure will be modest at best–and that’s just fine. In fact, the latest feedback research using the ORS and SRS found in small, largely insignificant effects! (I’m still waiting for permission to publish the entire article on this blog). Until then, interested readers can find a summary here). Such findings can be disturbing to those who have heard others claim that “feedback is the most effective method ever invented in the history of the field!” OPUD is dangerous. It keeps the field stuck in a vicious cycle of hope and despair, one that ultimately eclipses the opportunity to conduct the very research needed to facilitate understanding of the complex processes at work in any intervention. People loose faith until the “next best thing” comes along.

I’m excited about the research that is in process. Stay tuned for updates. Until then, let’s agree to UPOD.

Goodbye Mr. & Ms. Know-it-All: Redefining Competence in the Era of Increasing Complexity

February 12, 2012 By scottdm 3 Comments

Every day behavioral health professionals make hundreds of decisions. As experts in the field, they meet and work successfully with diverse clients presenting an array of different difficulties. Available evidence indicates that the average person who receives care is better off than 80% of those with similar problems that do not. Outcomes in mental health are on par or better than most medical treatments and, crucially, have far few side effects! Psychotherapy, for example, is equal in effect to coronary artery bypass surgery and three times more effective than flouride for cavities.

Not all the news is good, however. Drop out rates run around 25% or higher. Said another way, clinicians do great work with the people who stay. Unfortunately, many do not, resulting in increased costs and lost opportunities. Another problem is that therapists, the data indicate, are not particularly adept at identifying clients at risk for dropping out or deterioration. For decades, research has has shown that approximately 10% of people worsen while in treatment. Practitioners, despite what they may believe, are none the wiser. Finally, it turns out that a small percentage (between 10-20%) of people in care account for lion’s share of expenses in behavioral health service delivery (In case you are wondering, roughly the same figures apply in the field of medicine). Such people continue in care for long periods, often receiving an escalating and complicated array of services, without relief. At the same time, clinician caseloads and agency waiting lists grow.

What can be done?

At one time, being a professional meant that one possessed the knowledge, training, and skills to deliver the right services to the right people for the right problem in a consistent, correct, and safe manner. To that end, training requirements–including schooling, certification, and continuing professional development–expanded, exponentially so. Today’s behavioral health professionals spend more time training and are more highly specialized than ever before. And yet, the above noted problems persist.

Some call for more training, others for increasing standardization of treatment approaches, many for more rigorous licensing and accreditation standards. The emphasis on “empirically supported treatments”–specific methods for specific diagnoses–typify this approach. However, relying as these solutions do on an antiquated view of professional knowledge and behavior, each is doomed to fail.

In an earlier era, professionals were “masters of their domain.” Trained and skillful, the clinician diagnosed, developed a plan for treatment, then executed, evaluated, and tailored services to maximize the benefit to the individual client. Such a view assumes that problems are either simple or complicated, puzzles that are solvable if the process is broken down into a series of steps. Unfortunately, the shortcomings in behavioral health outcomes noted above (drop out rates, failure to identify deterioration and lack of progress) appear to be problems that are not so much simple or complicated but complex in nature. In such instances, outcomes are remain uncertain throughout the process. Getting things right is less about following the formula than continually making adjustments, as “what works” with one person or situation may not easily transfer to another time or place. Managing such complexity requires a change of heart and direction, a new professional identity. One in which the playing field between providers and clients is leveled, where power is moved to the center of the dyad and shared, where ongoing client feedback takes precedence over theory and protocol.

In his delightful and engaging book, The Checklist Manifesto, physician and surgeon Atul Gawande provides numerous examples in medicine, air travel, computer programming, and construction where simple feedback tools have resulted in dramatic improvements in efficiency, effectiveness, and safety. The dramatic decrease in airplane related disasters over the last three decades is one example among many–all due to the introduction of simple feedback tools. Research in the field of behavioral health documents similar improvements. Multiple studies document that routinely soliciting feedback regarding progress and the alliance results in significantly improved effectiveness, lower drop out rates, and less client deterioration–and all this while decreasing the cost of service delivery. The research and tools are described in detail in a new series of treatment manuals produced by the members and associates of the International Center for Clinical Excellence–six simple, straightforward, how-to guidebooks covering everything from the empirical foundations, administration and interpretation of feedback tools, to implementation in diverse practice settings. Importantly, the ICCE Manuals on Feedback Informed Treatment (FIT) are not a recipe or cookbook. They will teach not to you how to do treatment. You will learn, however, skills for managing the increasingly complex nature of modern behavioral health practice.

In the meantime, here’s a fantastic video of Dr. Gawande on the subject. Use the cursor to skip ahead to the 2:18 mark:

Getting FIT: Another Opportunity

February 4, 2012 By scottdm Leave a Comment

The March Advanced Intensive in Feedback Informed Treatment is full! Not a single space left. For several weeks, we put folks on a waiting list. When that reached nearly 20, we told most they’d probably have to wait until next year to attend.

Wait no more!

The ICCE is pleased to announce a second, “Advanced Intensive” Training schedule for July 30th through August 2nd, 2012 in Chicago, IL, USA. If you’ve read the books and attended a one or two day introductory workshop and want to delve deeper in your understanding and use of the principles and practices of FIT, this is the training for you! Multiple randomized clinical trials document that FIT improves outcomes and retention rates while decreasing costs of behavioral health.

Four intensive days focused on skill development. Participants will receive a thorough grounding in:

The empirical foundations of FIT (i.e., research supporting the common factors, outcome and alliance measures, and feedback)
Alliance building skills that cut across different therapeutic orientations and diverse client populations
How to use outcome management tools (including one or more of the following: ORS, SRS, CORE, and OQ 45 to inform and improve treatment)
How to determine your overall clinical success rates
How to significantly improve your outcome and retention rate via feedback and deliberate practice
How to use technology for support and improvement of the services you offer clients and payers
How to implement FIT in your setting or agency

The training venue is situated along the beautiful “Magnificent Mile,” near Northwestern hospital, atop a beautiful tall building steps from the best retail therapy and jazz clubs in Chicago. As always, the conference features continental breakfast every morning, a night of Blues at one of Scott’s favorite haunts and dinner at arguably the best Italian restaurant in Chicago.

Unlike any other training, the ICCE “Advanced Intensive” offers both pre and post attendance support to enhance learning and retention. All participants are provided with memberships to the ICCE Trainers Forum where they can interact with the course instructors and participants, download coarse readings, view “how-to” videos, and reach out to and learn from the thousands of other member-clinicians around the world.

Don’t wait. Register today here.

If you are interested in hanging out in Chicago a few extra days, why not register for both the “Advanced Intensive” and the 2012 “Training of Trainers” workshop? Thanks to the demand, for the first time ever, the two events are being held back to back. Sign up for both events by May 31st and receive 25% off for the trainings! To obtain your discount code for both events, email: events@centerforclinicalexcellence.com today.

Excellence "Front and Center" at the Psychotherapy Networker Conference

January 30, 2012 By scottdm Leave a Comment

This year, the Psychotherapy Networker is celebrating it’s 35th anniversary. I’m not going to let on how long I’ve been a reader and subscriber, but I can say that I eagerly anticipate each issue. Rich Simon and his incredibly dedicated and talented crew always seem to have their fingers on the pulse of the profession.

It is no accident that our most recent work on achieving excellence in behavioral health appeared in the pages of the Networker–in 2007, our study of top performing clinicians, “Supershrinks,” and then last year, “The Road to Mastery” which layed out the most recent findings as well as identified the resources necessary for the development of therapeutic expertise.

I was deeply honored when Rich Simon asked me to give one of the plenary addresses at this year’s Networker Symposium, March 22-25th, 2012. The theme of this year’s event is, “Creating a New Wisdom: The Art and Science of Optimal Well Being” and I’ll be delivering Friday’s luncheon address on applying the science of expertise to the world of clinical practice.

Click here to register online and join me for 3 fantastic days at this historic meeting.

Looking Back, Looking Forward

January 6, 2012 By scottdm Leave a Comment

Bidding goodbye to last year and welcoming the new always puts me in a reflective frame of mind. How did my life, work, and relationships go? What are my hopes for the future?

Just two short years ago, together with colleagues from around the world, the International Center for Clinical Excellence (ICCE) was launched. Today, the ICCE is the largest, global, web-based community of providers, educators, researchers, and policy makers dedicated to improving the quality and outcome of behavioral health services. Clinicians can choose to participate in any of the 100-plus forums, create their own discussion group, immerse themselves in a library of documents and how-to videos, and consult directly with peers. Membership costs nothing and the site is free of the advertising. With just a few clicks, practitioners are able to plug into a group of like-minded clinicians whose sole reason for being on the site is to raise everyone’s performance level. I have many people to thank for the success of ICCE: senior associates and trainers, our community manager Susanne Bargmann, director of training Julie Tilsen, and our tech wizard Enda Madden.

As membership in ICCE has grown from a few hundred to well over 3000, many in the community have worked together to translate research on excellence into standards for improving clinical practice. Routine outcome monitoring (ROM) has grown in popularity around the world. As a result, new measures and trainings have proliferated. In order to insure quality and consistency, a task force was convened within ICCE in 2010 to develop a list of “Core Competencies”—a document establishing the empirical and practice foundations for outcome-informed clinical work. In 2011, the ICCE Core Competencies were used to develop and standardize the curricula for the “Advanced Intensive” and “Training-of-Trainers” workshops as well as the exam all attendees must pass to achieve certification as an ICCE Trainer. As if these accomplishments were not enough, a small cadre of ICCE associates banded together to compose the Feedback Informed Treatment and Training Manuals—six practical, “how-to”volumes covering everything from empirical foundations to implementation. None of this would have been possible without the tireless contributions of Bob Bertolino, Jason Seidel, Cynthia Maeschalck, Rob Axsen, Susanne Bargmann, Bill Robinson, Robbie Wagner, and Julie Tilsen.

Looking back, I feel tremendous gratitude–both for the members, associates, and trainers of ICCE as well as the many people who have supported my professional journey. This year, two of those mentors passed away: Dick Fisch and James Hillman. During my graduate school years, I read James Hillman’s book, Suicide and the Soul. Many years later, I had the opportunity to present alongside him at the “Evolution of Psychotherapy” conference. Dick, together with his colleagues from MRI, had a great influence on my work, especially during the early years when I was in Milwaukee with Insoo Berg and Steve de Shazer in Milwaukee doing research and writing about brief therapy. Thinking about Dick reminded me of two other teachers and mentors from that period in my life; namely, John Weakland and Jay Haley.

Looking forward, I am filled with hope and high expectations. The “Advanced Intensive” training scheduled for March 19-22^nd is booked to capacity—not a single spot left. Registrations for this summer’s “Training of Trainers” course are coming in at a record pace (don’t wait if you are thinking about joining me, Cynthia and Rob). Currently, I am awaiting word from the National Registry of Evidence Based Programs and Practices (NREPP) formally recognizing “Feedback Informed Treatment” (FIT) as an evidence-based approach. The application process has been both rigorous and time-consuming. It’s worth it though. Approval by this department within the federal government would instantly raise awareness about as well as increased access to funding for implementing FIT. Keep your fingers crossed!

There’s so much more:

Professor Jan Blomqvist, a researcher at the Center for Alcohol and Drug Research at Stockholm University (SoRAD) launched what will be the largest, independent evaluation of feedback informed treatment to date, involving 80+ clinicians and 100’s of clients located throughout Sweden. I provided the initial training to clinicians in October of last year. ICCE Certified Trainers Gunnar Lindfeldt and Magnus Johansson are providing ongoing logistic and supervisory support.
The most sophisticated and empirically robust interpretive algorithms for the Outcome Rating Scale (based on a sample of 427,744 administrations of the ORS, in 95,478 unique episodes of care, provided by 2,354 different clinicians) have been developed and are now available for integration into software and web based applications. 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.
The keynote speakers and venue for the Second Achieving Clinical Excellence Conference have been secured. We’ll be meeting at one of the nicest hotels in Amsterdam, Holland, May 16-18=9^th, 2013. Thanks go to the planning committee: Bill Andrews, Susanne Bargmann, Liz Plutt, Rick Plutt, Tony Jordan, and Bogdan Ion. Please visit the conference website and submit a proposal for a workshop or presentation.
Finally, I’ve been asked to deliver the lunchtime keynote at the upcoming Psychotherapy Networker Conference scheduled on March 23, 2012. The topic? Achieving excellence as a behavioral health practitioner. Last year, my colleague Mark Hubble and I published the lead article in the May-June issue of the magazine, describing the latest research on top performing clinicians. I’m deeply honored by the opportunity to speak at this prestigious event.

More coming in the weeks ahead. Until then, look forward to connecting on ICCE.

What’s disturbing Mental Health? Opportunities Lost

November 29, 2011 By scottdm Leave a Comment

In a word, paperwork. Take a look at the book pictured above. That massive tome on the left is the 2011 edition of “Laws and Regulations” governing mental health practice in the state of California. Talk about red tape! Hundreds and hundreds of pages of statutes informing, guiding, restricting, and regulating the “talking cure.” Now, on top of that, layer federal and third party payer policies and paperwork and you end up with…lost opportunities. Many lost opportunities. Indeed, as pointed out in our recent article, The Road to Mastery, as much as 30% of clinicians time is spent completing paperwork required by various funding bodies and regulatory agencies. THIRTY PERCENT. Time and money that could be spent much more productively serving people with mental health needs. Time and money that could be spent on improving treatment facilities and training of behavioral health professionals. In the latest edition of our book, The Heart and Soul of Change, authors Bob Bohanske and Michael Franczak described their struggle to bring sanity to the paperwork required in public mental health service settings in the state of Arizona. “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 were assembled,” they wrote, “…and altogether weighed 1.4 ounces. By contrast, the paperwork required for enrolling a single mother in counseling to talk about difficulties her child was experiencing at school came in at 1.25 pounds” (p. 300). What gives?

The time has come to confront the unpleasant reality and say it outloud: regulation has lost touch with reality. Ostensibly, the goal of paperwork and oversight procedures is to improve accountability. In these evidence-based times, that leads me to say, “show me the data.” Consider the wide-spread practice–mandate, in most instances–of treatment planning. Simply put, it is less science than science fiction. Perhaps this practice improves outcomes in a galaxy far, far away but on planet Earth, supporting evidence is spare to non-existent (see the review in The Heart and Soul of Change, 2nd Edition).

No amount of medication will resolve this craziness. Perhaps a hefty dose of CBT might do some good identifying and correcting the distoreted thinking that has led to this current state of affairs. Whatever happens, the field needs an alternative. What practice not only insures accountability but simultaneously improves the quality and outcome of behavioral health services? Routine outcome measurement and feedback (ROM^Fb). As I’ve blogged about several times, numerous RCT’s document increased effectiveness and efficiency and decreased costs and rates of deterioration. Simply put, as the slide below summarizes, everybody wins. Clinicians. Consumers. Payers.
Everybody wins

Learn about or deepen your knowledge of feedback-informed treatment (FIT) by attending the upcoming “Advanced Intensive” workshop in March 2012; specfically, the 19th-22nd. We will have four magical days together. Space is filling rapidly, so register now. And then, at the end of the last day of the training, fly to Washington, D.C. to finish off the week by attending the Psychotherapy Networker conference. Excellence is front and center at the event and I’ve been asked to do the keynote on the subject on the first day!

Cutting Edge Feedback

November 22, 2011 By scottdm Leave a Comment

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

November 1, 2011 By scottdm 1 Comment

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?

September 30, 2011 By scottdm Leave a Comment

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

September 12, 2011 By scottdm 3 Comments

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

August 10, 2011 By scottdm 1 Comment

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

June 9, 2011 By scottdm 1 Comment

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

May 7, 2011 By scottdm 2 Comments

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!”
________________________

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?

May 4, 2011 By scottdm 3 Comments

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)

January 25, 2011 By scottdm Leave a Comment

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.

Measures and feedback 2016 from Scott Miller

Getting FIT: The Advanced Intensive Training

January 19, 2011 By scottdm Leave a Comment

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

November 23, 2010 By scottdm Leave a Comment

Just a 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

November 11, 2010 By scottdm Leave a Comment

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

November 5, 2010 By scottdm Leave a Comment

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

September 8, 2010 By scottdm 2 Comments

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: