Please, don’t use my scales…

December 12, 2019 By scottdm 3 Comments

Or, at least that’s what I said in response to his question. The look on his face made clear my words caused more confusion than clarity.

“But then, how will I found out which of the therapists at my agency are effective?” he asked.

“The purpose of FIT,” I replied, “is not to profile, but rather help clinicians respond more effectively to their clients.”

And I’ve found myself giving similar advise of late — in particular, actively counseling practitioners and clinic directors against using the ORS and SRS.

Here’s another:

“We need a way to meet the new Joint Comission/SAMHSA requirement to use a standardized outcome measure in all therapeutic work.”

My reply?

FIT is purposefully designed — and a significant body of evidence indicates it does — help those in treatment achieve the best results possible. Thus, while integrating measures into care has, in some countries, because a standard of care, using them merely to meet regulatory requirements is de facto unethical. Please don’t use my scales.

One more?

“I don’t (or won’t) use the scales with all my clients, just those I decide it will be clinically useful with.”

What do I think?

The evidence clearly shows clinicians often believe they are effective or aligned with clients when they are not. The whole purpose of routinely using outcome and alliance measures is to fill in these gaps in clinical judgement. Please don’t use my scales.

Last, as I recently blogged about, “The scales are really very simple and self-explanatory so I don’t think we really need much in the way of training or support materials.”

My response?

We have substantial evidence to the contrary. In sharp contrast to the mere minutes involved in downloading and learning to administer measures, actual implemention of FIT takes considerable time and support — more than most seem aware of or willing to invest.

PLEASE DON’T USE MY SCALES!

While I could cite many more examples of when not to use routine outcome measures (e.g., “we need a way to identify clients we aren’t helping so we can terminate services with them and free up scarce clinical resources” or “I want to have data to provide evidence of effectiveness to funding sources”) — I will refrain.

As one dedicated FIT practitioner recently wrote, “Using FIT is brutal. Without it, it’s the patients’ fault. With fit, it’s mine. Grit your way through . . . because it’s good and right.”

I could not have said it any better.

Until next time,

Scott

Scott D. Miller, Ph.D.
Director, International Center for Clinical Excellence
ICCE Fit Supervision Intensive 2020 Scott D Miller

What does losing your keys have in common with the treatment of trauma?

April 24, 2019 By scottdm 9 Comments

Last week, I was preparing to leave the house and could not locate my keys. Trust me when I say, it’s embarrassing to admit this is not an infrequent occurrence.

Logic and reason are always my first problem solving choices. That’s why I paused after looking in the kitchen drawer where I am supposed to keep them, along with my wallet and glasses, and found it empty. When did I last have them? Not finding them there, the “search” began.

Upstairs to the bedroom to check my pants pockets. No. Downstairs to the front closet to look in my coat. No. Back upstairs to the hamper in the laundry room. No. Once more, down the stairs to the kitchen hutch. I sometimes leave them there. This time, however, no. I then headed back up the stairs to the master bathroom — my pace now a bit frantic — and rummaged through my clothing. No. They’ve gotta be on my office desk. Down two flights of stairs to the basement. Not there either.

In a fit of pique, I stormed over to the landing, and yelled at the top of my voice, “DID SOMEONE TAKE MY KEYS?” the accusation barely concealed. Although my head knew this was nuts, my heart was certain it was true. They’ve hidden them!

“No,” my family members kindly reply, then ask, “Have you lost them again?”

“Arrgh,” I mutter under my breath. And that’s when I do something that, in hindsight, make no sense. I wonder if you do the same? Namely, I start the entire search over from the beginning — pants, coat, hamper, closet, hutch, office — often completing the exact same cycle several times. Pants, coat, hamper, closet, hutch, office. Pants, coat, hamper, closet, hutch, office. Pants, coat, hamper, closet, hutch, office.

I can’t explain the compulsion, other than, by this point, I’ve generally lost my mind. More, I can’t think of anything else do. My problem: I have somewhere to go! The solution: Keep looking (and it goes without saying, of course, in the same places).

(I did eventually locate my keys. More on that in a moment)

Yesterday, I was reminded of my experience while reading a newly released study on the treatment of trauma. Bear with me as I explain. Over a decade ago, I blogged about the U.S. Veteran’s Administration spending $25,000,000 aimed at “discover[ing] the best treatments for PTSD” despite a virtual mountain of evidence showing no difference in outcome between various therapy approaches.

Since that original post, the evidence documenting equivalence between competing methods has only increased (1, 2). The data are absolutely clear. Meta-analyses of studies in which two or more approaches intended to be therapeutic are directly compared, consistently find no difference in outcome between methods – importantly, whether the treatments are designated “trauma-focused” or not. More, other highly specialized studies – known as dismantling research – fail to provide any evidence for the belief that specialized treatments contain ingredients specifically remedial to the diagnosis! And yes, that includes the ingredient most believe essential to therapeutic success in the treatment of PTSD; namely, exposure (1, 2).

The new study confirms and extends such findings. Briefly, using data drawn from 39 V.A. treatment centers, researchers examined the relationship between outcome and the degree of adoption of two so-called “evidence-based,” trauma-informed psychotherapy approaches — prolonged exposure and cognitive processing therapy. If method mattered, of course, then a greater degree of adoption would be associated with better results. It was not. As the authors of the study conclude, “programs that used prolonged exposure and cognitive processing therapy with most or all patients did not see greater reductions in PTSD or depression symptoms or alcohol use, compared with programs that did not use these evidence-based psychotherapies.”

So what happens now? If history, and my own behavior whenever I lose my keys, is any indication, we’ll start the process of looking all over again. Instead of accepting the key is not where we’ve been looking, the field will continue it’s search. After all, we have somewhere to go — and right back to the search for the next method, model, or treatment approach, we go.

It’s worse than that, actually, as looking over and again in the same place, keeps us from looking elsewhere. That’s how I generally find my keys. As simple and perhaps dumb as it sounds, I find them someplace I had not looked.

And where is the field not looking? As Norcross and Wampold point out in an article published this week, “relationships and responsiveness” are the key ingredients in successful psychological care for people who are suffering as a result of traumatic experiences, going on to say that the emphasis on model or method is actually harmful, as it “squanders a vital opportunity to identify what actually heals.”

Improving our ability to connect with and respond effectively to the diverse people we meet in therapy is the focus on Deliberate Practice Intensive, held this August in Chicago, Illinois. Unlike training in protocol-driven treatments, studies to date show learning the skills taught at the workshop result in steady improvements in clinicians’ facilitative interpersonal skills and outcomes commensurate with the rate of improvement seen in elite athletes. For more information or to register, click here.

Until next time,

Scott

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

It’s Time to Abandon the “Mean” in Psychotherapy Practice and Research

April 8, 2019 By scottdm 7 Comments

Recognize this? Yours will likely look at bit different. If you drive an expensive car, it may be motorized, with buttons automatically set to your preferences. All, however, serve the same purpose.

Got it?

It’s the lever for adjusting your car seat.

I’m betting you’re not impressed. Believe it or not though, this little device was once considered an amazing innovation — a piece of equipment so disruptive manufacturers balked at producing it, citing “engineering challenges” and fear of cost overruns.

For decades, seats in cars came in a fixed position. You could not move them forward or back. For that matter, the same was the case with seats in the cockpits of airplanes. The result? Many dead drivers and pilots.

The military actually spent loads of time and money during the 1940’s and 50’s looking for the source of the problem. Why, they wondered, were so many planes crashing? Investigators were baffled.

Every detail was checked and rechecked. Electronic and mechanical systems tested out. Pilot training was reviewed and deemed exceptional. Systematic review of accidents ruled out human error. Finally, the equipment was examined. Nothing, it was determined, could not have been more carefully designed — the size and shape of the seat, distance to the controls, even the shape of the helmet, were based on measurements of 140 dimensions of 4,000 pilots (e.g., thumb length, hand size, waist circumference, crotch height, distance from eye to ear, etc.).

It was not until a young lieutenant, Gilbert S. Daniels, intervened that the problem was solved. Turns out, despite of the careful measurements, no pilot fit the average of the various dimensions used to design the cockpit and flight equipment. Indeed, his study found, even when “the average” was defined as the middle 30 percent of the range of values on any given indice, no actual pilot fell within the range!

The conclusion was as obvious as it was radical. Instead of fitting pilot into planes, planes needed to be designed to fit pilots. Voila! The adjustable seat was born.

Now, before you scoff — wisecracking, perhaps, about “military intelligence” being the worst kind of oxymoron — beware. The very same “averagarianism” that gripped leaders and engineers in the armed services is still in full swing today in the field of mental health.

Perhaps the best example is the randomized controlled trial (RCT) — deemed the “gold standard” for identifying “best practices” by professional bodies, research scientists, and governmental regulatory bodies.

However sophisticated the statistical procedures may appear to the non-mathematically inclined, they are nothing more than mean comparisons.

Briefly, participants are recruited and then randomly assigned to one of two groups (e.g., Treatment A or a Control group; Treatment A or Treatment as Usual; and more rarely, Treatment A versus Treatment B). A measure of some kind is administered to everyone in both groups at the beginning and the end of the study. Should the mean response of one group prove statistically greater than the other, that particular treatment is deemed “empirically supported” and recommended for all.

The flaw in this logic is hopefully obvious: no individual fits the average. More, as any researcher will tell you, the variability between individuals within groups is most often greater than variability between groups being compared.

Bottom line: instead of fitting people into treatments, mental health care should be to made to fit the person. Doing so is referred to, in the psychotherapy outcome literature, as responsiveness — that is, “doing the right thing at the right time with the right person.” And while the subject receives far less attention in professional discourse and practice than diagnostic-specific treatment packages, evidence indicates it accounts for why, “certain therapists are more effective than others…” (p. 71, Stiles & Horvath, 2017).

I’m guessing you’ll agree it’s time for the field to make an “adjustment lever” a core standard of therapeutic practice — I’ll bet it’s what you try to do with the people you care for anyway.

Turns out, a method exists that can aid in our efforts to adjust services to the individual client. It involves routinely and formally soliciting feedback from the people we treat. That said, not all feedback is created equal. With a few notable exceptions, all routine outcome monitoring systems (ROM) in use today suffer from the same problem that dogs the rest of the field. In particular, all generate feedback by comparing the individual client to an index of change based on an average of a large sample (e.g., reliable change index, median response of an entire sample).

By contrast, three computerized outcome monitoring systems use cutting edge technology to provide feedback about progress and the quality of the therapeutic alliance unique to the individual client. Together, they represent a small step in providing an evidence-based alternative to the “mean” approaches traditionally used in psychotherapy practice and research.

Interested in your thoughts,

Scott

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

PS: Want to learn more? Join me and colleagues from around the world for any or all three, intensive workshops being offered this August in Chicago, IL (USA).

The FIT Implementation Intensive: the only workshop in the US to provide an in depth training in the evidence-based steps for successful integration of Feedback Informed Treatment (FIT) into your agency or clinical practice.
The Training of Trainers: a 3-day workshop aimed at enhancing your presentation and training skills.
The Deliberate Practice Intensive: a 2-day training on using deliberate practice to improve your clinical effectiveness.

Click on the title of the workshop for more information or to register.