Routine Outcome Monitoring and Deliberate Practice: Fad or Phenomenon?

March 26, 2019 By scottdm 1 Comment

Would you believe me if I told you there was a way you could more than double the chances of helping your clients? Probably not, eh? As I’ve documented previously, claims abound regaring new methods for improving the outcome of psychotherapy. It’s easy to grow cynical.

And yet, findings from a recent study document when clinicians add this particular practice to their clinical work, clients are actually 2.5 times more likely to improve. The impact is so significant, a review of research emerging from a task force of the American Psychological Association concluded, “it is among the most effective ways available to services to improve outcomes.”

That said, there’s a catch.

The simple nature of this “highly rated,” transtheoretical method belies a steep learning curve. In truth, experience shows you can learn to do it — the mechanics — in a few minutes.

But therein lies the problem. The empirical evidence makes clear successful implementation often takes several years. This latter fact explains, in part, why surveys of American, Canadian, and Australian practitioners reveal that, while being aware of the method, they rarely integrate it into their work.

What exactly is the “it” being referred to?

Known by the acronym FIT, feedback-informed treatment (FIT) involves using standardized measures to formally and routinely solicit feedback from clients regarding progress and the quality of the therapeutic relationship, and then using the resulting information to inform and improve care.

The ORS and SRS are examples of two simple feedback scales used in more than a dozen randomized controlled trials as well as vetted and deemed “evidence-based” by the Substance Abuse and Mental Health Services Administration. Together, the forms take less than 3 minutes to administer, score and interpret (less if one of the web-based scoring systems is used).

So why, you might wonder, would it take so long to put such tools into practice?

As paradoxical as it may sound, because FIT is really not about using measures — any more say than making a home is about erecting four walls and a roof. While the structure is the most visible aspect — a symbol or representation — we all know it’s what’s inside that counts; namely, the people and their relationships.

On this score, it should come as no surprise that a newly released study has found a significant portion of the impact of FIT is brought about by the alliance or relationship between client and therapist. It’s the first study in history to look at how the process actually works and I’m proud to have been involved.

Of course, all practitioners know relationships skills are not only central to effective psychotherapy, but require lifelong learning. With time, and the right kind of support, using measurement tools facilitates both responsiveness to individual clients and continuous professional development.

Here’s the rub. Whenever I respond to inquiries about the tools — in particular, suggesting it takes time for the effects to manifest, and that the biggest benefit lies beyond the measurement of alliance and outcome — interest in FIT almost always disappears. “We already know how to do therapy,” a manager replied just over a week ago, “We only want the measures, and we like yours because they are the simplest and fastest to administer.”

Every so often, however, the reply is different. “What do we have to do to make this work to improve the effectiveness of our clinical work and clinicians?” asked Thomas Haastrup, the Coordinator of Family Services for Odense Municipality in Denmark. When I advised, planning and patience, with an emphasis on helping individual practitioners learn to use feedback to foster professional development versus simply measuring their results, he followed through. “We adopted the long view,” Thomas recounts, “and it’s paid off.” Now in their 5th year, outcomes are improving at both the program and provider level across services aimed at helping adults, children, and families.

In addition to the Manual 6 in the ICCE Treatment and Training manuals, the ICCE Summer Intensives offer several opportunities for helping you or your agency to succeed in implementing FIT. First, the 2-day FIT Implementation Training — the only workshop offering in-depth, evidence-based training in the steps for integrating FIT into clinical practice at the individual, agency, and system-of-care level. Second, the Deliberate Practice Intensive — here you not only learn the steps, but begin to set up a professional develop plan designed to enhance your effectiveness.

To help out, I’d like to offer a couple of discounts:

Purchase Manual 6 at 70% off the regular price. Click here to order. Enter the word IMPLEMENTATION at checkout to receive the discount (If you want to purchase the entire set, I’m making them available at 50% off the usual price. Enter IMPLEMENTATION2 at checkout).
Register for any or all of the summer intensives by May 1st and receive an additional discount off the early bird price. Simple enter the code FITPROMOAPRIL at checkout. Please note, registration MUST occur before May 1st. Generally, we sell out 6 to 8 weeks in advance.

Feel free to email me with any questions. In the meantime, as always, I’m interested in your thoughts about FIT and DP.

Until next time,

Scott

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

Time for a New Paradigm? Psychotherapy Outcomes Stagnant for 40 years

February 1, 2019 By scottdm 8 Comments

You’ve heard it said before. Flying is the safest form of transportation.

Facts back up the claim. In fact, it’s not even close. In terms of distance traveled, the fatality rate per billion kilometers is .003, improving dramatically over the years. Cars, by contrast, are almost 1,000 times more dangerous. Still, since 1923, the fatality rate in motor vehicle accidents has declined an eye-popping 93%.

How about psychotherapy? Have outcomes improved? Judging by the size of the Diagnostic and Statistical Manual and growth in the number of treatment approaches, one would expect success rates to have climbed significantly, if not exponentially. Not so, as I first presented at the Evolution of Psychotherapy Conference five years ago, and later on this blog, the empirical evidence clearly shows NO improvement.

And now a new study, this time reviewing the evidence regarding treatments for children and adolescents. Using sophisticated statistical analyses, the researchers examined 453 RCT’s spanning 53 years, involving nearly 32,000 kids treated for anxiety, depression, attention deficit/hyperactivity, and conduct problems. With the rising popularity of “evidence-based practice,” those conducting the study wanted to know whether “… our methods of developing and testing youth psychological therapies [are] producing improvement” (p. 2).

Can you guess what they found?

Outcomes have not changed (much less improved) over the last five decades–that’s 351 in dog years!

Can you imagine the outcry had similar results been published about automobiles or planes? You would fully expect hearings to be held, and leaders to be called called to account. The lives of children are on the line.

Nope. Instead, facing the supersized differences between promises made every year about “advances” in psychotherapy, and the results realized and reported in research studies, the authors meekly call for, “new approaches to treatment design and intervention science” (p. 1).

Really? Is that what’s required? Researchers going back to the drawing board of “treatment and intervention?”

No, what’s needed is an entirely different view of what clinicians actually do — and it starts by giving up the idea that psychotherapy is a form of treatment similar to antibiotics or angioplasty. Let’s face it. Psychotherapy is no more a medical treatment than are the facials, salt glows and body wraps one receives at the local spa. Which is not to say, it doesn’t work.

Outside the halls of academia, millions of therapists worldwide are helping people on a daily basis to live happier, more meaningful and functional lives. Dozens of studies of real world practitioners document outcomes that meet or exceed benchmarks established in tightly controlled, model-driven, randomized trials — all without following a particular, “evidence-based” protocol (see 1, 2, 3,4).

So, how best to conceptualize the effective work clinicians do? And, importantly, what could researchers offer that would be of real help to therapists?

That psychotherapy works, says more about humans and our need for connection, meaning, and purpose, than it does about the particulars of any given model or approach. And that our methods focus on thoughts, feelings, behaviors, and brain chemistry, says more about our Western values and beliefs, than about the ingredients necessary for successful healing.

Simply put, the field does not need to, as the authors of the study argue, “intensify the search for mechanisms of change [and] transdiagnostic … treatments” (p. 1). Doing so is merely a recipe for “more of the same.” Rather, to move forward, it should abandon the medical paradigm that has long had a stranglehold on our research and professional discourse, choosing instead to reconnect with the larger, worldwide family of healers, one that has existed since the dawn of history and which, from the outset, has been deeply engaged in the values and beliefs of those they treat, using whatever means necessary, consistent with the culture, to engender change.

What might that look like in practice?

As already documented, practicing clinicians already do a pretty darn good job helping their clients. There’s nothing wrong with our Westernized approaches when they work. At the same time, we don’t succeed with everyone. The problem, studies show, is we’re not particularly good at knowing when we’re not being helpful, when clients are at risk for dropping out or are actually deteriorating while in our care (1, 2). On this score, research has already provided a solution. Dozens of studies document, for example, using simple measures at the beginning and end of each visit not only provides clinicians with an opportunity to intervene more successfully with “at risk” clients, but also helps identify opportunities for their own growth and development (1, 2). If you’re not routinely and formally measuring the quality and outcome of your work, you can get started by accessing two simple tools here.

With outcome as our guide, all that remains is being willing to look outside the profession for possibilities for healing and change unbound by convention and the medical view. That’s happening already, by the way, in the world’s two most populous countries, India and China, with professionals learning the ways of indigenous healers and government officials tapping local shaman to meet citizen’s mental health and well being needs.

So, what about you? What you are doing to extend your healing reach?

And, in case you haven’t seen it, the video below is from the most recent Evolution of Psychotherapy conference, where I talk about new research documenting psychics achieving the same or better results as psychotherapists.

Until next time,

Scott

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

P.S.: Want to learn more about using outcome to inform and improve your effectiveness? Join me and an international group of teachers and researchers in Chicago for our Summer Intensives. For detailed information and to register, click on the banners below.

Just how good are our theories about the causes and alleviation of mental and emotional suffering?

July 12, 2018 By scottdm 7 Comments

Does the name Barry Marshall ring a bell?

Probably not if you are a mental health professional.

For decades, the Australian physician was persona non grata in the field of medicine — or perhaps stated more accurately, persona sciocca, a fool.

Beginning in the early 1980’s, Marshall, together with colleague Robin Warren, advanced the hypothesis that the bacteria heliobacter pylori was at root of most stomach ulcers. That idea proved exceptionally controversial flying, as it did, in the face of years of accepted practice and wisdom. Ulcers caused by something as simple and obvious as a bacterial infection? Bunk, the medical community responded, in the process lampooning the two researchers. After all, everyone knew stress was the culprit. The also knew the cure: certainly not antibiotics. Rather, antacids, sedatives, therapy and, in the more chronic and serious cases, gastrectomy–a surgical procedure involving the removal of the lower third of the stomach.

The textbook used in my Introduction to Psychology course in my first year at University boldly declared, “Emotional stress is now known to relate to … such illnesses as … peptic ulcers” (p. 343, Psychology Today: An Introduction 4th Edition [Braun and Linder, 1979]). The chapter on the subject was full of stories of people whose busy, emotionally demanding lives were clearly the cause of their stomach problems. I dutifully overlined all the relevant sections with my orange highlighter. Later, in my clinical career, whenever I saw a person with an ulcer, I told them it was caused by stress and, not surprisingly, taught them “stress-management” strategies.

The only problem is the field, my textbook, and I were wrong, seriously wrong. Stress was not responsible for stomach ulcers. And no, antacids, sedatives, and psychotherapy, were not the best treatments. The problem could be cured much more efficiently and effectively with a standard course of antibiotics, many of which had been available since the 1960’s! In other words, the cure had been within reach all along. Which begs the question, how could the field have missed it? Not only that, even after conclusively demonstrating the link between ulcers and the h.pylori bacterium, the medical community continued to reject Marshall and Warren’s papers and evidence for another 10 years (Klein, 2013)!

So what was it? Money, ignorance, hubris–even the normal process by which new scientific findings are disseminated–have all been offered as explanations. The truth is, however, the field of medicine, and mental health in particular, has a weakness–to paraphrase Mark Twain–for “knowing with certainty things that just ain’t so.”

How about these?

Structural abnormalities in the ovaries cause neurosis in women;
Psychopathology results from unconscious dynamics originating in childhood;
Optimism, anger control, and the expression of emotion reduces the risk of developing cancer;
Negative thinking, “cognitive distortions,” and/or a chemical imbalance cause depression;
Some psychotherapeutic approaches are more effective than others.

The list is extensive and dates all the way back to the field’s founding nearly 150 years ago. All, at one point or another, deeply believed and passionately advocated. All false.

Looking back, its easy to see that we therapists are suckers for a good story–especially those that appear to offer scientific confirmation of strongly held cultural beliefs and values.

Nowadays, for example, it simply sounds better to say that our work targets, “abnormal activation patterns in dlPFC and amygdala that underlie the cognitive control and emotion regulation impairments observed in Major Depressive Disorder” than, “Hey, I listened attentively and offered some advice which seemed to help.” And while there’s a mountain of evidence confirming the effectiveness of the latter, and virtually none supporting the former, proponents tell us it’s the former that “holds the promise” (Alvarez & Icoviello, 2015).

What to do? Our present “neuroenchantment” notwithstanding, is there anything we practitioners and the field can learn from more than 150 years of theorizing?

Given our history, it’s easy to become cynical, either coming to doubt the very existence of Truth or assuming that it’s relative to a particular individual, time, or culture. The other choice, it seems to me, is humility–not the feigned ignorance believed by some to be a demonstration of respect for individual differences–but rather what results when we closely and carefully examine our actual work.

Take empathy, for example. Not only do most practitioners consider the ability to understand and share the feelings of another an “essential” clinical skill, it is one of the most frequently studied aspects of therapeutic work (Norcross, 2011). And, research shows therapists, when asked, generally give themselves high marks in this area (c.f., Orlinksky & Howard, 2005). My colleagues, Daryl Chow, Sharon Lu, Geoffrey Tan, and I encountered the same degree of confidence when working with therapists in our recent, Difficult Conversations in Therapy study. Briefly, therapists were asked to respond empathically to a series of vignettes depicting challenging moments in psychotherapy (e.g., a client expressing anger at them). Each time, their responses were rated on standardized scale and individualized feedback for improving was provided.

Now, here is the absolutely cool part. The longer therapists participated in the research, the less confident but more demonstrably empathic they became! The process is known as “The Illusion of Explanatory Depth.” Simply put, most of us feel we understand the world and our work with far greater detail, coherence, and depth than we really do. Only when we are forced ourselves to grapple with the details, does this illusion give way to reality, and the possibility of personal and professional growth become possible.