Leading Outcomes in Vermont: The Brattleboro Retreat and Primarilink Project

November 8, 2009 By scottdm 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

October 30, 2009 By scottdm 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

October 27, 2009 By scottdm 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:

Buying a strong whip
Switching riders
Moving the dead horse to a new location
Riding the dead horse for longer periods of time
Saying things like, “This is the way we’ve always ridden the horse.”
Appointing a committee to study the horse
Arranging to visit other sites where they ride dead horses more efficiently
Increasing the standards for riding dead horses
Creating a test for measuring our riding ability
Complaining about how the state of the horse the days
Coming up with new styles of riding
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

October 20, 2009 By scottdm 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.

J Blomqvist 3 from Scott Miller

The Field, the Future, and Feedback

October 2, 2009 By scottdm Leave a 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

August 25, 2009 By scottdm 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.