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Questions and Answers about Feedback Informed Treatment and Deliberate Practice: Another COVID-19 Resource

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Since they were developed and tested back in the late 90’s, the Outcome and Session Rating Scales have been downloaded by practitioners more than 100,000 times!  Judging by the number of cases entered into the three authorized software applications, the tools have been used inform service delivery for millions of clients seeking care for different problems in diverse treatment settings.  The number of books, manuals, and “how to” videos describing how to use the tools has continued to grow dramatically.  And most weeks, I’m traveling somewhere to provide training or consultation on feedback informed treatment (FIT) — that is, until the COVID-19 outbreak.

Wanting to stay in touch, I offered to meet people online to connect and answer any FIT-related questions.  When all 100 spots for the first webinar filled within two hours, we scheduled another.  It’s also full to capacity.  We are planning more such free events in the future.

In the meantime, I’m making the recordings for each available here.  While I know its not the same as being together live, I think you’ll be surprised by the depth and breadth of the information covered.  Below you will find the first.  You can listen to the entire broadcast or use the guide below to jump directly to the questions that matter most to you.  In the meantime, be on the lookout for the announcement of the next live broadcast!

  1. How to get started with FIT? (2:23)
  2. How can I encourage my clients to provide open, honest feedback? (10:30; revisited 36:15)
  3. Should I start using the measures with established clients? (13:18, revisited 17:05)
  4. How do I know how effective I am? (14:45)
  5. How to interpret ORS and SRS feedback (18:10)
  6. How to use the scales online/on the phone? (22:00)
  7. How effective is supervision? (26:58)
  8. How to work with mandated clients? (31:30)
  9. Why do some clients not give feedback? (37:00)
  10. What is deliberate practice and how to apply it for improving therapist effectiveness? (46:00)

Until next time,

Scott

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

Improving the Odds: Implementing FIT in Care for Problem Gamblers and their Families

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spiraling roulette

Quick Healthcare Quiz

What problem in the U.S. costs the government approximately $274 per adult annually?

If you guessed gambling, give yourself one point.  According to the latest research, nearly 6 million Americans have a serious gaming problem—a number that is on the rise.  One-third of the Nation’s adults visit a Casino every year, losing according to the latest figures an estimated 100 billion dollars.

Which problem is more common?  Substance abuse or problem gambling?

If you guessed the former, give yourself another point.  Problems related to alcohol and drug use are about 3.5 times more common than gambling.  At the same time, 281 times more funding is devoted to treating drug and alcohol problems.  In March 2014, the National Council on Problem Gambling reported that government-funded treatment was provided to less than one quarter of one percent of those in need.

Does psychotherapy work for problem gambling?

If you answered “yes,” add one to your score.  Research not only indicates that psychological treatment approaches are effective, but that changes are maintained at follow up.  As with other presenting problems (e.g., anxiety and depression), more therapy is associated with better outcomes than less.

What is the key to successful treatment of problem gambling?

If you answered, “funding and getting people into treatment,” or some variation thereof, take away three points!

So, how many points do you have left?  If you are at or near zero, join the club.

Healthcare is obsessed with treatment.  A staggering 99% of resources are invested in interventions.  Said another way, practitioners and healthcare systems love solutions.  The problem is that research shows this investment, “does not result in positive implementation outcomes (changes in practitioner behavior) or intervention outcomes (benefits to consumers).”  Simply put, it’s not enough to know “what works.”  You have to be able to put “what works” to work.

BCRPGP

Enter the BC Responsible and Problem Gambling Program—an agency that provides free support and treatment services aimed at reducing and preventing the harmful impacts of excessive or uncontrolled gaming.  Clinicians working for the program not only sought to provide cutting-edge services, they wanted to know if they were effective and what they could do to continuously improve.

Five years ago, the organization adopted feedback-informed treatment (FIT)—routinely and formally seeking feedback from clients regarding the quality and outcome of services offered.    A host of studies documents that FIT improves retention in and outcome of psychotherapy.  Like all good ideas, however, the challenge of FIT is implementation.

Last week, I interviewed Michael Koo, the clinical coordinator of the BCRPGP.  Listen in as he discusses the principles and challenges of their successful implementation.  Learn also how the talented and devoted crew achieve outcomes on par with randomized controlled trials in an average of 7 visits while working with a culturally and clinically diverse clientele.

As you’ll hear, implementation is difficult, but doable.  More, you don’t have to reinvent the wheel or do it alone.  When FIT was reviewed and deemed “evidence-based” by the Substance Abuse and Mental Health Services organization in 2013, it received perfect scores for “implementation, training, support, and quality assurance” resources.  Regardless of the population you serve, you can:

  • Join a free, online, international community of nearly 10,000 like-minded professionals using FIT in diverse settings (www.iccexcellence.com).  Every day, members connect and share their knowledge and experience with each other;
  • Access a series of “how to” manuals and free, gap assessment tool (FRIFM) to aid in planning, guiding progress, and identifying common blind spots in implementation.
  • Attend the upcoming, 2-day FIT Implementation workshop.  Held once a year in August, this event provides an in-depth, evidence-based training based on the latest findings from the field of implementation science.

Come meet managers, supervisors, practitioners, and team leaders from around the world. You will leave the tools necessary to “put ‘what works’ to work.”

FIT IMP 2016
Until next time,

Scott

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

 

Are you Better? Improving Effectiveness One Therapist at a Time

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IMG_20160121_122453Greetings from snowy Sweden.  I’m in the beautiful city of Gothenburg this week, working with therapists and administrators on implementing Feedback-Informed Treatment (FIT).

I’m always impressed by the dedication of those who attend the intensive workshops.  More, I feel responsible for providing a training that not only results in mastery of the material, but also leads to better outcomes.

As commonsensical as it may seem to expect that training should foster better results, it’s not.  Consider a recent study out of the United Kingdom.  There, massive amounts of money have been spent over the last five years training clinicians to use cognitive behavioral therapy (CBT).  The expenditure is part of a well-intentioned government program aimed at improving access to effective mental health services.

Anyway, in the study, clinicians participated in a year-long “high-intensity” course that included more than 300 hours of training, supervision, and practice—a tremendous investment of time, money, and resources.  Competency in delivering CBT was assessed at regular intervals and shown to improve significantly throughout the training.

2a-we-are-all-the-same-problemThe only problem?  Training therapists in CBT did not result in better outcomes.

While one might hope such findings would cause the researchers to rethink the training program, they chose instead to question whether “patient outcome should … be used as a metric of competence…” (p. 27).  Said another way, doing treatment the right way was more important than whether it actually worked!  One is left to wonder whether the researchers would have reached a similar conclusion had the study gone the other way.  Most certainly, the headline would then have been, “Empirical Research Establishes Connection between Competence in CBT and Treatment Outcome!”

Attempts to improve the effectiveness of treatment via the creation of a psychological formulary—official lists of specific treatments for specific disorders—have persisted, and even intensified, despite consistent evidence that the methods clinicians use contribute little to outcome.  Indeed, neither clinicians’ competence in conducting specific types of therapy nor adherence to evidence-based protocols have been “found to be related to patient outcome and indeed . . . estimates of their effects [are] very close to zero” (p. 207, Webb, DeRubeis, & Barber, 2010).

So, what gives?

There are two reasons why such efforts have failed:

  • First, they do not focus on helping therapists develop the skills that account for the lion’s share of variability in treatment outcome.

Empathy, for example, has a greater impact than the combined effect sizes of therapist competence, adherence to protocol, specific ingredients within and differences between various treatment approaches.  Still, most, like the present study, continue to focus on method.

  • Second, they ignore the extensive scientific literature on expertise and expert performance.

Here, research has identified a universal set of processes, and step-by-step directions, anyone can follow to improve performance within a particular discipline.  To improve, training must be highly individualized, focused on helping performers reach for objectives just beyond their current ability.

“Deliberate Practice,” as it has been termed, requires grit and determination.  “Nobody is allowed to stagnate,” said one clinician when asked to describe what it was like to work at a clinic that had implemented the steps, adding, “Nobody is allowed to stay put in their comfort zone.”  The therapist works at Stangehjelpa, a community mental health service located an hour north of Oslo, Norway.

BirgitvidereThe director of the agency is psychologist, Birgit Valla (left), author of visionary book, Further: How Mental Services Can Be Better.   Birgit is on a mission to improve outcomes—not by dictating the methods staff are allowed to use but by focusing on their individual development.

It starts with measuring outcomes.  All therapists at Stangehjelpa know exactly how effective they are and, more importantly, when they are not helpful.  “It’s not about the measures,” Birgit is quick to point out, “It´s about the therapist, and how the service can support that therapist getting better.”  She continues, “It´s like if you want improve your time in the 100 meter race, you need a stopwatch.  It would be absurd to think, however, that the stopwatch is responsible for running faster.  Rather, it’s how one chooses to practice in relation to the results.”

Recently, researcher Siri Vikrem Austdal interviewed staff members at the clinic about their experience applying deliberate practice in their work.  Says one, ““It is strenuous. You are expected to deliver all the time. But being part of a team that dare to have new thoughts, and that wants something, is really exciting. I need it, or I would grow tired. It is demanding, but then there is that feeling we experience when we have climbed a mountain top. Then it is all worthwhile. It is incredibly fun to make new discoveries and experience mastery.”

So, what exactly are they doing at Stangehjelp?

You can read the entire report here (Norwegian), or the abbreviated version here (English).  Why not join Birgit this summer at the FIT Professional Development training in Chicago, Illinois.  Together with Dr. Daryl Chow, we will teach participants how to incorporate deliberate practice into an individualized, evidence-based plan for continuous professional development.  Click on the icon below to reserve your spot now.

FitProfessionalDevelopmentIntensiveAug8th2016 Until next time,

Scott

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

 

 

Intake: A Mistake

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bad idea

 

 

 

 

Available evidence leaves little doubt.  As I’ve blogged about previously, separating intake from treatment results in:

• Higher dropout rates;
• Poorer outcomes;
• Longer treatment duration; and
• Higher costs

And yet, in many public behavioral health agencies, the practice is commonplace. What else can we expect?

Chronically underfunded, and perpetually overwhelmed by mindless paperwork and regulation, agencies and practitioners are left with few options to meet the ever-rising number of people in need of help. Between 2009 and 2012, for example, the number of people receiving mental health services increased by 10%. During the same period, funding to state agencies decreased $4.35 billion. Not long ago, in my own home town of Chicago, the city shuttered half—50%–of the city’s mental health clinics, forcing the remaining, already burdened, agencies to absorb an additional 5,000 people in need of care.

crowd

 

 

 

Simply put, the practice of separating intake from treatment is little more than a form of “crowd management”–and an ineffective one at that.

feedback keyboard

 

 

 

 

Adding to the growing body of evidence is a new study investigating the impact of computerized intake on the consumer’s experience of the therapeutic relationship and continuation in care. Not only did researchers find that therapist use of a computer had a negative impact on the quality of the working relationship—one of the best predictors of outcome–but clients were between 62 and 97% less likely to continue in care!

domino

 

 

 

 

It’s not hard to see how these well-intentioned—some would argue, absolutely necessary—solutions actually end up exacerbating the problem. Money is wasted when the paperwork is completed but people don’t come back; money that would be better spent providing treatment. Those who do not return don’t disappear, they simply access services in other ways (e.g., the E.R., police and social services, etc.)—after all, they need help! The ones who do continue after intake, experience poorer outcomes and stay longer in care, a cost to both the consumer and the system.

What to do?

solution

 

 

 

 

In addition to pushing back against the mindless regulation and paperwork, there are several steps practitioners and agency managers can take:

  • Stop separating intake from treatment

The practices does not save time and actually increases costs. Consider having consumers complete as much of the paperwork as possible before the session begins. The first visit is critical. It determines whether people continue or drop pout. Listen first. At the end of the visit, review the paperwork, filling in missing data, and completing any remaining forms.

  • Begin monitoring outcome

Research to date shows that routinely monitoring progress reduces dropout rates and the length of time spent in treatment while simultaneously improving outcome. Combined, such results work to alleviate the bottleneck at the entry point of services.

  • Begin monitoring the quality of the therapeutic relationship:

Engagement and outcomes are improved when problems in the relationship are identified and openly discussed. Even when intake is separated from treatment, feedback should be sought. Data to date indicate that the most effective clinicians seek and more often receive negative feedback, a skill that enables them to better meet the needs of those they serve.

Getting started is not difficult. Indeed, there’s an entire community of professionals just a click away who are working with and learning from one another. The International Center for Clinical Excellence is the largest, web based community of mental health professionals in the world. It’s ad free and costs nothing to join.

Sign up for the ICCE Fall Webinar. You will learn:

  • The Empirical Basis for Feedback Informed Treatment
  • Basics of Outcome and Alliance Measurement
  • Integrating Feedback into Practice & Creating a Culture of Feedback
  • Understanding Outcome and Alliance Data

Register online at: https://www.eventbrite.ie/e/fall-2015-feedback-informed-treatment-webinar-series-tickets-17502143382. CE’s are available.

Finally, join colleagues and friends from around the world for the Advanced and FIT Supervision courses are held in March in Chicago. We work and play hard. You will leave with a thorough grounding in feedback-informed principles and practice. Registration is limited, and the courses tend to sell out several month in advance.

Until then,

Scott

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

Scott D. Miller - Australian Drug and Alcohol Symposium

 

Room for Improvement: Feedback Informed Treatment and the Therapeutic Relationship

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My Scandinavian Grandmother Christina was fond of saying, “The room for improvement…is the biggest one in our house.”

Turns out, when it comes to engaging people in physical and mental health services, Grandma was right.  We healthcare professionals can do better—and recent research points the way.

Stanford psychologists Sims and Tsai found that recipients of care both choose, and are more likely to follow the recommendations of, healthcare providers who match how they ideally want to feel.   People who valued feeling excitement, for example, were more likely to choose a professional who promoted excitement and vice versa.

Bottom line?  Making the helping relationship FIT how people want to feel—their goals, values, and preferences—improves engagement and effectiveness.

Tailoring services in the manner suggested by Sims and Tsai is precisely what Feedback-Informed Treatment (FIT) is all about.  Two simple scales—the Outcome and Session Ratings Scales—facilitate this process, enabling helping professionals to assess and adjust treatment in real time to improve the FIT.

Overwhelmed by paperwork?  No worries.  As I have written about in previous blogposts (1, 2), several web-based and electronic solutions exist that make integration a snap.  The pioneer–the very first to come online–is MyOutcomes.

MYO

Since coming on the scene, the owners have doggedly sought feedback from users, working steadily to provide a system that maximizes practitioners’ effectiveness.  The latest version is packed full of goodies, including a mobile app and the ability to have clients provide feedback remotely (e.g., home, between visits, etc.).  Watch the video below to get a more comprehensive overview of its many features.

I’m also proud to say that the parent company of MyOutcomes has partnered with the International Center for Clinical Excellence to create the first online training on Feedback-Informed Treatment.   Importantly, the FIT E-learning program is not another webinar.  It is a true online classroom, complete with video instruction and an intuitive software interface that tailors learning and mastery to the individual user.

Together, the ORS and SRS, FIT E-learning, and MyOutcomes make “the room for improvement” a much less daunting, even enjoyable, undertaking.

I can almost see my Granma Stina smiling!

Until next time,

Scott

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

P.S.:  We still have a few spots open for our FIT Implementation and FIT Ethics courses coming up in August. Don’t wait.  The number of participants is limited and both courses fill about two months in advance!

ethical 2Fit IMP

 

Something New

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something new ICCE

Actually, it’s more accurate to say, “Everything is new!”  The International Center for Clinical Excellence is coming up on its fifth birthday!   Since its launch in 2010, the ICCE has become the largest, online community of behavioral health practitioners and researchers in the world.  To celebrate, we are launching an entirely new web platform.   All the features you’ve come to expect remain—the discussions with colleagues, the document library, the commercial free atmosphere.   At the same time, everything has been streamlined, made faster, easier, and more intuitive.  Log in today!   Join a forum.  Start a conversation.  Share a presentation or paper with others. As you can see my own website has been completely redone.  The “Top Performance” blog is now front and center.  Plug in your email address and you’ll get regular updates regarding how to improve your effectiveness.   As always, my articles, books, video and audio materials are available with the click of a button.  You can also find an up-to-date schedule of workshops and intensive trainings in feedback informed treatment (FIT).

PCOMS - Partners for change outcome management system Scott D Miller - SAMHSA - NREPP Speaking of FIT, have you visited the www.whatispcoms.com website?  It’s the official website for ICCE’s Partners for Change Outcome Management System.  Here you can learn everything you need to know to get started using the feedback process documented to improve effectiveness and approved by SAMHSA as an evidence-based practice.  What’s new?  Thanks to ICCE members around the world, the site is available in five different languages, including: English, Dutch, Swedish, Norwegian, and Danish.   Until next time!

Excellence in Amsterdam: The 2013 ACE Conference

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My how time flies!  Nearly three weeks have passed since hundreds of clinicians, researchers, and educators met in Amsterdam, Holland for the 2013 “Achieving Clinical Excellence.”  Participants came from around the globe–Holland, the US, Germany, Denmark, Italy, Russia, Norway, Sweden, Denmark, New Zealand, Romania, Australia, France–for three days of presentations on improving the quality and outcome of behavioral healthcare.  Suffice it to say, we had a blast!

The conference organizers, Dr. Liz Pluut and Danish psychologist Susanne Bargmann did a fantastic job planning the event, organizing a beautiful venue (the same building where the plans for New York City were drafted back in the 17th century), coordinating speakers (36 from around the globe), arranging meals, hotel rooms, and handouts.

Dr. Pluut opened the conference and introduced the opening plenary speaker, Dr. K. Anders Ericsson, the world’s leading researcher and “expert on expertise.”  Virtually all of the work being done by me and my colleagues at the ICCE on the study of excellence and expertise among therapists is based on the three decades of pioneering work done by Dr. Ericsson.  You can read about our work, of course, in several recent articles: Supershrinks, The Road to Mastery, or the latest The Outcome of Psychotherapy: Past, Present and Future (which appeared in the 50th anniversary edition of the journal, Psychotherapy).

Over the next several weeks, I’ll be posting summaries and videos of many of the presentations, including Dr. Ericsson.  One key aspect of his work is the idea of “Deliberate Practice.”  Each of the afternoon sessions on the first day focused on this important topic, describing how clinicians, agency managers, and systems of care can apply it to improve their skills and outcome.

The first of these presentations was by psychologist Birgit Valla–the leader of Family Help, a mental health agency in Stange, Norway–entitled, “Unreflectingly Bad or Deliberately Good: Deciding the Future of Mental Health Services.”  Grab a cup of coffee and listen in…

Oh, yeah…while on the subject of excellence, here’s an interview that just appeared in the latest issue of the UK’s Therapy Today magazine:

It starts on page 32.

The Revolution in Sweden: More Evidence and A Brief Follow Up

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On May 13th, I blogged about a change in guidelines for clinical practice in Sweden.  As in many other countries, CBT enjoyed near exclusive status as “evidence-based” on most official lists of approved treatments. Billions of Swedish crowns were spent on the approach that ultimately had no effect on the outcome of people treated for depression and anxiety.  As a result, guidelines for clinical practice were reviewed and expanded.

Judging by the flood of comments, the news stirred considerable debate.  Indeed, the managers of several list-serves wrote to me indicating that the post had generated heated discussions among their members. Several mental professionals wrote to me directly asking for references in English.  Unfortunately, none to my knowledge exist.  That said, if and when one becomes available, I will post the article or link here.

In the meantime, two developments.  First, the Swedish Family Therapy Association posted a link for the translation of my article, “The Road to Mastery,” which originally appeared in the May-June 2012 issue of the Psychotherapy Networker.  Anyone who reads and understands Swedish, can fine the article by clicking here.  I am deeply grateful for the hard work that went into translating the piece and the attention giving to the topic by the leadership of SFFT.

OK.  One more important research development of which every practicing clinician should be aware.  Research, like the broader world of clinical practice, goes through fads and fashions.  Methods and designs “catch on,” capturing attention, and subsequently emulated by others.  Currently, one of the trends is comparing a particular treatment approach to “treatment as usual.”  However, as my professor and mentor Bruce Wampold observes, “design is destiny.”  Said another way: how you ask is what you get.

Attend a workshop or training and you’ll often hear presenters claiming that their preferred approach has proven more effective than “treatment as usual” (TAU) in randomized clinicial trials.  Sounds impressive.  It is, in fact, meant to impress.  And yet, “how you ask is what you get.”  As the study below documents, some TAU’s are destined to fail, purposefully employing TAU’s that are not designed to be therapeutic.  Importantly, when a treatment approach is compared to a “treatment-as-usual-that-is-actually-a-real-bona fide-therapeutic approach” no differences in efficacy are found.

The implication?  When considering whether to adopt a new method, or when claims are made regarding the superiority of a particular approach, clinicians need to ask, “what is being compared?”  A long trail of evidence documents that, in general, all approaches work well.  The challenge is finding “what works” for the individual client and practitioner.  Adopting new approaches, available research makes clear, is no guarantee of improved outcomes.  As is made clear in The Road to Mastery, time and resources are better spent determining one’s baseline level of performance.  From there, practitioners can both identify when their current skills fall short and the training necessary to improve their individual performance.

The International Center for Clinical Excellence: Using Social Networks for "Real Time" Research

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The International Center for Clinical Excellence was officially lauched at the Evolution of Psychotherapy Conference in December 2009.  Since that time, membership has grown steadily.  With over 3800 members, the ICCE is the largest, web-based community of behavioral health professionals dedicated to improving the quality and outcome of service delivery.  The site features nearly a hundred discussion forums, taking place in a number of languages, on topics specific to treatment and research.

Many agencies and systems of care are using the site to coordinate implementation of feedback-informed treatment.  Of course, those attending ICCE training events (e.g., the Advanced Intensive, Training of Trainers, and Achieving Clinical Excellence conference), use the site for both pre and post training support and continuing education.

And now, the site is being used for a new purpose: research.  ICCE member and associate Wendy Amey was the first.  She used the site successfully for her dissertation, surveying members about how they work with trauma.  I am pleased to announce two new research projects that will access the ICCE community.

The first is being conducted by McGill University counseling psychology doctoral candidate Ionita Gabriela.  Her study focuses on clinicians’ experiences with using measures to monitor client progress in the services they offer.  Implementation is the challenge most clinician and agencies face when incorporating routine outcome monitoring into practice.  All participants will be entered into a drawing for a $100 Amazon gift certificate.  More importantly, participants will contribute to the expanding knowledge base on feedback informed treatment.  Whether or not you are a member of ICCE, you can contribute by taking part in the study.  Click here to send an email to Ionita to complete the interview (it only takes about 15 minutes).

The second study is being conducted by me and ICCE Associate Daryl Chow as part of ICCE’s continuing emphasis on clinical excellence.  The study builds on groundbreaking research by Ronnestad and Orlinksy on the subject of therapist development.  Particpants are asked to complete a brief (8-12 minutes), online survey with questions pertaining to your development as a clinician.   All participants will be entered into a drawing, the winner receiving all 6 of the newly released FIT Treatment and Training Manuals (valued at $100).  Again, you can participant whether or not you are currently a member of the ICCE.  In fact, please ask your colleagues to participate as well!  Click here to complete the secure, online survey (no identifying information will be sought).

Mental Health Practice in a Global Economy

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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.

Looking Back, Looking Forward

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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 19-22nd 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=9th, 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.

Optum Health and the ICCE: Partnering to Achieve Excellence in Behavioral Health

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Monday, November 28th, 2011
Chicago, IL & Goldern Valley, MN

The members, associaties, and directors of the International Center for Clinical Excellence are proud to announce a partnership with Optum Health’s Campaign for Excellence.  Optum Health works with employers, payers, and providers serving nearly 60,000,000 people.  Their “Campaign for Excellence (CFE)” was specifically designed to enhance the quality and outcome of behavioral health services by recognizing top performing clinicians.  To date, over 4,000 providers spread across the United States are participating in the CFE, which involves ongoing measurement and benchmarking of client outcome and satisfaction.  CFE clinicians are not only provided with feedback regarding the outcome of the individuals they meet and work with but able to compare their overall effectiveness to other providers in the Optum Health network.  Performance research makes clear that such comparisons are a necessary first step in the development of expertise.  The second?  As Miller and Hubble point out in The Road to Mastery, c-o-m-m-u-n-i-t-y.  Top performers do not exist in a vacuum.  Across a number of domains–chess, mathematics, medicine, or psychotherapy–the “best of the best” benefit from a complex and interlocking network of people, places, resources, and circumstances without which excellence remains out of reach.

And now, we are pleased to welcome these CFE providers to the ICCE community.   In December 2009, the International Center for Clinical Excellence was launched and since then, it has grown into the largest, global, web-based network of clinicians, researchers, administrators, and policymakers dedicated to excellence in behavioral health.  Clinicians can choose to participate in any of the 100-plus forums, create their own discussion groups, immerse themselves in a library of documents and how-to-videos, and most importantly meet with and consult with peers.  Indeed, with the addition of clinicians from Optum Health, total ICCE membership will exceed 5000!

ICCE members will most certainly benefit from the knowledge and experience of the CFE clinicians.  And if experience of members to date is any indication, CFE providers will find the community helpful in nurturning their continued professional growth.  Indeed, what has been so striking about ICCE is that it transcends its online limitations–which often reinforce anonymity and invisibility–to provide members with the same complex norms of personal connection, openness, and honesty, mutual trust and support, challenge and accountability, that any “land-based” community of excellence offers.

Optum Health is providing CFE clinicians with a unique URL for joining the ICCE.  Don’t despair if you are not a provider for Optum Health or participant in the CFE.  You too can join the ICCE by going to: http://centerforclinicalexcellence.com/register.  Look forward to meeting you online!

Feedback-Informed Treatment as Evidence-based Practice: APA, SAMSHA, and NREPP

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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.

Changing Home-Based Mental Health Care for Good: Using Feedback Informed Treatment

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Some teach.  Some write.  Some publish research.  Arnold Woodruff and Kathy Levenston work for a living!  Kathy Levenston specializes in working with foster and adopted children.

Arnold Woodruff developed the first intensive in-home program run by a community services board in Virginia. He has over 30 years of experience, and has served as the President of the Virginia Association for Marriage and Family Therapy.  And now, these two dedicated professionals, certified trainers and associates of the International Center for Clinical Excellence, have just purchased Home for Good, the first home-based mental health program in the Richmond, VA area to use Feedback-Informed Treatment (FIT).

The program is now a 100% employee-owned company and part of a larger vision the two have for establishing customer-friendly mental health care to people in the Richmond area. Home for Good has been providing Intensive In-home Services (counseling, case management, and crisis support) to children, adolescents, and their families for the past two years. Home for Good has achieved superior results compared to other mental health programs, based on an analysis of data genderated from routine administration of the Outcome Rating Scale in clinical practice. Home for Good’s results are continuing to improve with the use of Feedback-Informed Treatment. Home for Good will soon be offering additional services, including outpatient individual, family, and group therapy.

Becoming FIT: Simple but not Easy

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Becoming FIT (feedback informed in treatment).  Ask any experienced practitioner and they will tell you, “it’s such a simple idea, but it’s not easy.”  In addition to the time it takes to master the administration and interpretation of formal feedback, special skills are required for using the information to guide service delivery.

Implementation in agencies and large healthcare settings is even more challenging.  “What,” you may wonder, “is so difficult?”  All that appears to be involved is the administration of two simple scales: a 4-item outcome and a 4-item alliance measure.  Would that the process were as easy as the forms are simple.

On the International Center for Clinical Excellence community, an international group of supervisors, agency directors, and officers of large healthcare organizations meet routinely to discuss, plan, and help support one another in efforts to develop a feedback-friendly workplace culture.  Ask any and they will tell you that a key element of successful implementation is: communication.  It is also one of the biggest challenges.  Rising case loads, increased documentation requirements, and tight budgets all conspire to keep people chained to their desks, interacting with their desktop computer, and straining just to keep up with the work load.  The proverbial “water-cooler” conversations are, for many, a thing of the past–along with clinical supervision and “advanced training.”

Here’s where ICCE is helping.   The peer-to-peer, web-based community is available to clinicians, managers, researchers, and policy makers 24/7/365.  Signing up is simple and free–and you simply won’t believe the resources available.  Access to an experienced group of professionals ready, willing, and able to answer questions related to FIT.  Discussion groups on everything from using FIT in supervision to the latest research on evidence-based practice.  Training videos, research papers, policy statements, and other documents uploaded by ICCE certified trainers and associates.

In the video below, psychologist and ICCE community manager, Susanne Bargmann describes the community and available resources.  As I blogged about recently, the community is growing at a rapid rate.  We will soon hit 2000 members–and all in less than one year.  So….join us.  And if you are already a member, log onto the site now.  One cool new feature is live chat!  That right.  When you log on, look down in the left hand corner of your screen.  There you’ll be able to see everyone who is “live” on the site at that moment.  With a simple click of the button, you could be chatting with a professional in Washington or Wollongong!

Join us for the upcoming “Advanced Intensive” training in Chicago!  If you are looking for in-depth training in the “how-to” of CDOI/FIT, this is the training for you.  When you leave, you will be on your way to mastering:

  • The empirical foundations of feedback-informed clinical work (i.e., empirically supported factors underlying successful clinical work, the impact of feedback on performance)
  • Clinical skills for enhancing client engagement that cut across different therapeutic orientations and diverse treatment populations
  • How to integrate outcome management tools (including one or more of the following: ORS, SRS, CORE, and OQ 45) into clinical practice
  • How to use the outcome management tools to inform and improve service delivery
  • How to significantly improve your clinical skills and outcomes via feedback and deliberate practice
  • How to use data generated from outcome measures to inform management, supervision, and training decisions
  • Strategies for successful implementation of CDOI and FIT in your organization or practice

Registration is strictly limited to 35 participants.  To reserve your place, click on the icon below!

Growing by Leaps and Bounds: ICCE Membership Nearing 2000!

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In December 2009, the International Center for Clinical Excellence was officially launched.  From our booth at the Evolution of Psychotherapy conference, the international web-based community “went live,” adding hundreds of members in a few days.  By April, as I reported in my blog, over 1000 clinicians, researchers, policy makers, and adminsitrators had joined the site, making it the largest organization in the world dedicated to improving the quality and outcome of behavioral healthcare.  And now, just shy of a year, the ICCE community is fast approaching 2000 members!

Unlike traditional list-serves dependent on email, limited to a single topic, and often hobbled by irrelevant chatter between participants, the ICCE community uses the latest web 2.0 technology to connect behavioral health practitioners from around the globe.  On the site, clinicians can start a discussion group, upload documents, view videos by the field’s most effective practitioners, and seek counsel regarding their most difficult and challenging questions from a group of experts from around the world.

Right now, members are discussing the recent ACE conference, research on the therapeutic alliance, what the literature says about achieving one’s personal best as a clinician, plus much, much more.  If you’re not yet a member, nows the time to join.  It’s free.  No cost whatsoever to join and you won’t be bombarded with adds for books, webinars, videos, or training.  Look forward to meeting you online!

What is "Best Practice?"

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You have to admit the phrase “best practice” is the buzzword of late. Graduate school training programs, professional continuing education events, policy and practice guidelines, and funding decisions are tied in some form or another to the concept. So, what exactly is it? At the State and Federal level, lists of so-called “evidence-based” interventions have been assembled and are being disseminated. In lockstep, as I reviewed recently, are groups like NICE. Their message is simple and straightforward: best practice is about applying specific treatments to specific disorders.
Admittedly, the message has a certain “common sense” appeal.    The problem, of course, is that behavioral health interventions are not the psychological equivalent of penicillin. In addition to the numerous studies highlighted on this blog documenting the failure of the “specific treatments for specific disorders” perspective, consider research published in the Spring 2010 edition of the Journal of Counseling and Development by Scott Nyman, Mark Nafziger, and Timothy Smith. Briefly, the authors examined outcome data to “evaluate treatment effectiveness across counselor training level [and found] no significant outcome differences between professional staff and …. interns, and practicum students” (p. 204). Although the researchers are careful to make all the customary prevarications, the conclusion—especially when combined with years of similar findings reported in the literature– is difficult to escape: counseling and psychotherapy are highly regulated activities requiring years of expensive professional training that ultimately fails to make the practitioner any better than they were at the outset.
What gives? Truth is, the popular conceptualization of “best practice” as a “specific treatment for a specific disorder” is hopelessly outdated. In a report few have read, the American Psychological Association (following the lead of the Institute of Medicine) redefined evidence-based, or best practice, as, “the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences.” Regarding the phrase “clinical expertise” in this definition, the Task Force stated, “Clinical expertise…entails the monitoring of 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 (Lambert, Bergin, & Garfield, 2004a). 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” (p. 273; emphasis included in the original text).
Said another way, instead of choosing the “specific treatment for the specific disorder” from a list of approved treatments, best practice is:
·         Integrating the best evidence into ongoing clinical practice;
·         Tailoring services to the consumer’s characteristics, culture, and preferences;
·         Formal, ongoing, real-time monitoring of progress and the therapeutic relationship.
In sum, best practice is Feedback Informed Treatment (FIT)—the vision of the International Center for Clinical Excellence. And right now, clinicians, researchers and policy makers are learning, sharing, and discussion implementing FIT in treatment settings around the globe on the ICCE web-based community.
Word is getting out. As just one example, consider Accreditation Canada, which recently identified FIT as a “leading practice” for use in behavioral health services. According to the website, leading practices are defined as “creative, evidence-based innovations [that] are commendable examples of high quality leadership and service delivery.” The accreditation body identified FIT as a “simple, measurable, effective, and feasible outcome-based accountability process,” stating that the approach is a model for the rest of the country! You can read the entire report here.
How exactly did this happen? Put bluntly, people and hard work. ICCE senior associates and certified trainers, Rob Axsen and Cynthia Maeschalck, with the support and backing of Vancouver Coast Health, worked tirelessly over the last 5 years both implementing and working to gain recognition for FIT. Similar recognition is taking place in the United States, Denmark, Sweden, England, and Norway.
You can help. Next time someone—be it colleague, trainer, or researcher—equates “best practice” with using a particular model or list of “approved treatment approaches” share the real, official, “approved” definition noted above.  Second, join Rob, Cynthia, and the hundreds of other practitioners, researchers, and policy makers on the ICCE helping to reshape the behavioral health practice worldwide.

No Therapist Left Behind: Improving the Quality and Outcome of Behavioral Health Services One Practitioner at a Time

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Staying “up-to-date” isn’t easy in today’s practice environment. In these lean economic times, training budgets are often the first to be cut. On the other hand, trying to separate the “important” from “irrelevant” in our information-rich age can be, as Mitchell Kapor once observed, “a bit like trying to get a drink from a fire hydrant.”

Enter the ICCE—a web-based community of professionals dedicated to improving the quality and outcome of behavioral health services worldwide.  Every day, in forums ranging from “research on psychotherapy” to “marketing and media,” members from around the world meet to learn from and share with each other.   What’s more, groups have been created for practitioners working in specific countries (Sweden, Denmark, Norway, Poland, Netherlands, and so on).  Crucially, in these forums members are able to address issues relevant to the specific environment in which they work and do so in their own language.
In the latest issue of the Psychotherapy Networker, internet and media consultant Elizabeth Doherty Thomas, identified ICCE as one of the “best clinical resources on the internet”—high praise when one considers the tens of thousands of websites featuring content related to behavioral health practice.
So, what are you waiting for?  If you’re not a member, you can request an invitation to join by clicking here. Tapping into the rich knowledge base of clinicians around the globe will insure that you are not “left behind.”

Implementing Consumer-Driven, Outcome-Informed (CDOI) Behavioral Health Services: The ICCE and 2010 Training of Trainers Event

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This week I’m in Calgary, Canada. Last week, I was in Charleston, South Carolina. Next week, I’ll be in Marion, Ohio and Bay City, Michigan. In each instance, I’m working with the management and staff of public behavioral health agencies that are busy implementing consumer-driven, outcome-informed clinical work.

Some of the groups are just beginning the process.  Others, as reported here on my blog, have been at it long enough to document significant improvements in outcome, retention, and productivity (i.e., in Ohio and Virginia).  All have told me that implementing the seemingly simple ideas of outcome-informed practice is incredibly hard work–impacting nearly every aspect of agency life.  Being able to access the expertise and experience of fellow clinicians and agency directors in real time when questions and challenges arise is, I’ve also learned, critical in maintaining the momentum necessary for successful implementation.

Enter the ICCE: The International Center for Clinical Excellence.  Briefly, the ICCE is a web-based community of clinicians, researchers, agency managers, and policy makers dedicated to excellence in behavioral health.  Many of the groups I’m working with have joined the site providing them with 24/7/365 access to a deeply knowledgeable world-wide community.  In addition to the numerous topic-specific discussion groups and member-generated videos, organizations can set up private forums where management and clinicians can have confidential discussions and coordinate implementation efforts.

If you are a clinician or agency director and are not already a member, you and/or your organization can access the ICCE community today by visiting the website at: www.centerforclinicalexcellence.com.  Membership is free.  In the video below, I talk with Arjan Van der Weijde, about groups in Holland that are meeting on on the ICCE for practitioners to discuss their implementation of feedback-informed work in the Netherlands.  Check it out.

I’ve also included a brief video about the upcoming “Training of Trainers” course, held each year in August in Chicago.  As in prior years, professionals from all over the world will be joining me and the state-of-the-art faculty for four intensive days of training.  Agencies both public and private, in the U.S. and abroad, are sending staff to the event to learn the skills necessary to lead transformation projects.  Space is already limited so register soon.

The Training of Trainers

Five Incredible Days in Anaheim

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From December 9-13th, eight thousand five hundred mental health practitioners, from countries around the globe, gathered in Anaheim, California to attend the “Evolution of Psychotherapy” conference.  Held every five years since 1985, the conference started big and has grown only larger.  “Only a few places in the US can accommodate such a large gathering,” says Jeffrey K. Zeig, Ph.D., who has organized the conference since the first.

The event, held every five years, brings together 40 of the field’s leading researchers, practitioners, trend setters, and educators to deliver keynote addresses and workshops, host discussion panels, and offer clinical demonstrations on every conceivable subject related to clinical practice.  Naturally, I spoke about my current work on “Achieving Clinical Excellence” as well as served on several topical panels, including “evidence based practice” (with Don Meichenbaum), “Research on Psychotherapy” (with Steven Hayes and David Barlow), and “Severe and Persistent Mental Illness (with Marsha Linnehan and Jeff Zeig).

Most exciting of all, the Evolution of Psychotherapy conference also served as the official launching point for the International Center for Clinical Excellence.  Here I am pictured with long-time colleague and friend, Jeff Zeig, and psychologist and ICCE CEO, Brendan Madden, in front of the ICCE display in the convention center hall.

Over the five days, literally hundreds of visitors stopped by booth #128 chat with me, Brendan, and Senior ICCE Associates and Trainers, Rob Axsen, Jim Walt, Cynthia Maeschalck, Jason Seidel, Bill Andrews, Gunnar Lindfeldt, and Wendy Amey.  Among other things, a cool M and M dispenser passed out goodies to folks (if they pressed the right combination of buttons), we also talked about and handed out leaflets advertising the upcoming “Achieving Clinical Excellence” conference, and finally people watched a brief video introducing the ICCE community.  Take a look yourself:.


More to come from the week in Anaheim….

Evolution of Psychotherapy and the International Center for Clinical Excellence

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evolution-2005

Dateline: Chicago, Illinois
December 7, 2009

I’ve just finished packing my bags and am heading for the airport.  Tomorrow the “Evolution of Psychotherapy” begins.  Nearly 25 years after volunteering at the first “Evolution” conference, I’m back a second time to present.  Tomorrow, I’ll be talking about “Achieving Clinical Excellence.”  On the days that follow, I’m on panels with my friend Don Meichenbaum, as well as David Barlow, Marsha Linnehan, and others.  I’m really looking forward to the four days in Anaheim.

Of everything going on in sunny southern California, I have to say that I’m most excited about the launch of the International Center for Clinical Excellence.  We have a booth (#128) in the exhibitor hall where folks can stop by, talk, and peruse our new website.  As promised, it is a true web 2.0 experience, enabling clinicians researchers. and educators around the world to connect, share, and learn from each other.

We’ll be streaming video to facebook and twitter. Stay tuned to my blog and twitter accounts as well for updates, videos, and pictures from the conference.

International Center for Clinical Excellence: Update and Announcement

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On August 25th, right here on the “Top Performance” blog, I announced the formation of the International Center for Clinical Excellence.  As anyone who has been reading my recent posts or publication knows, my work is evolving; specifically, putting prior research on the common factors, measurement of outcome and alliance, and feedback to work in helping diverse providers improve their effectiveness and the services they offer consumers.

Since the announcement, my colleagues and I have been busy at work creating the ICCE web platform.  Based on the latest Web2.0 technology,  the site is specifically designed to support clinical excellence through creating virtual clinical networks, groups and clinical communities where clinicians can be supported in eveloping clinical excellence. We are in the second round of beta-testing right now and are expecting to go live in a very short while. So, stay tuned!  And if you haven’t already done so, please visit the ICCE site and register.  There’s no obligation or cost, and you’ll also be among the first to know when the site is officially lanuched.

In the meantime, I wanted to call attention to the talented and diverse group of clinicians who will be working with the ICCE as “Associates” and “Trainers.”  Included among them are representatives from every discipline within behavioral healthcare (psychology, psychiatry, social work, marriage and family therapy, addictions, criminal justice) and from countries all over the globe.  They are:  William Andrews, Susanne Bargmann, Jim Walt, Reg Fleming, Cynthia Maeschalck, Michael Clark, Alan Scheuermann, Rob Axsen, Stephen Michael, William Plum, Bill Robinson, Michael Hutchison, Jason Seidel, Michelle Sanders, Von Borg, Dave Nylund, Magnus Johannsen, Dave Green, Gunnar Lindfeldt, Gun Eva Langdahl, Wendy Amey, Luci Doppler, Megan Boylan, Melissa Newland, Amanda Pardue, Flip Van Oenen, Mark Crouzen, Frank Asmus, Dee Dee Stout, and Robbie Babins-Wagner. Consistent with the latest web 2.0 technology, each of these ICCE Trainers will have be blogging, uploading short, instructional videos and other content, and providing supervision and consultation to ICCE members.

Membership is easy, by the way, and free.  For now, just register online and we’ll notify you when the site goes live.  Then you can enter, create your own professional profile and begin tapping into the international network of providers and experts that make up the ICCE community.

How NOT to Achieve Clinical Excellence: The Sorry State of Continuing Professional Education

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Greg Neimeyer, Ph.D., is causing quite a stir in continuing education circles.  What has he done?  In several scholarly publications, he’s reviewed the existing empirical literature and found that continuing professional education in heavioral health is not particularly, well, …educational.  Indeed, in a soon-to-be published piece in the APA journal, Professional Psychology, he notes, “While the majority of studies report high levels of participants’ satisfaction with their CE experiences, little attention has been paid to assessing actual levels of learning, the translation of learning into practice, or the impact of CE on actual professional service delivery outcomes.”   Neimeyer then goes on to cite a scholarly review published in 2002 by Daniels and Walter which pointed out that “a search [of the research literature] revealed no controlled studies of the impact of continuing education in the…behavioral health disciplines” (p. 368).  Said another way, the near ubiguitous mandate that clinicians attend so many hours per year of approved “CE” events in order to further their knowledge and skill base has no empirical support.

Personally, my guess is that any study that might be done on CE in Behavioral Health would show little or no impact on performance anyway.  Why?  Studies in other fields (i.e., medicine, flight training) have long documented that traditional CE activities (i.e., attending conferences, lectures, reading articles) have no demonstrable effect.  So, what does work?  The same research that calls the efficacy of current CE activities into questions provide clear guidance: namely, brief, circumscribed, skill-based training, followed by observed practice, real-time feedback, and performance measurement. Such characteristics are, in fact, part and parcel of expert performance in any field.  And yet, it is virutally non-existent in behavioral health.

Let me give you an example of a CE offering that arrived in my box just this week.  The oversized, multi-color, tri-fold brochure boldly asserts a workshop on CBT featuring the “top evidence-based techniques.”  Momentarily setting aside the absolute lack of evidence in support of such trainings, consider the promised content–and I’m not kidding: clinical applications of cognitive behavior therapy, motivational interviewing, cognitive therapy, mindfulness and acceptance based therapies, and behavior therapy.  As if that were not enough, the outline for the training indicates that participants will learn 52 other bulleted points, including but not limited to: why CBT, integration of skills intro practice, identifying brain-based CBT strategies, the latest research on CBT, the stages of change, open-ended and reflective listening, behavioral activiation, acceptance and commitment, emotional regulation and distrss tolerance skills, the ABC technique to promote rational beliefs, homework assignments that test core beliefs, rescripting techniques for disturbing memories and images…and so on…AND ALL IN A SINGLE 6 HOUR DAY!  You say you have no money? Your agency has suffered budget cuts?  No worries, the ad states in giant print, as the same content is available via CD, web and podcast.

Such an agenda defies not only the evidence but strains credulity to the breaking point.  Could anyone accomplish so much in so little time?  Clinicians deserve and should demand more from the CE events they register for and, in many instances, are mandated to attend in order to maintain licensure and certification.  The International Center for Clinical Excellence web platform will soon be launched.  The mission of the site, as indicated in my blog post of August 25th, is 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.”  Members of the site will use a variety of social networking and collaborative tools to learn skills, obtain real-time feedback, and measure their performance.    Anyway, kudos to Dr. Greg Neimeyer for confronting the ugly truth about CE in behavioral health and saying it out loud!

Announcement: Evolving in a new direction

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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.