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How Does Feedback Informed Treatment Work? I’m Not Surprised

May 6, 2019 By scottdm 2 Comments

Feedback-Informed Treatment (FIT) — using measures to solicit feedback about progress and the quality of the therapeutic relationship — is a transtheoretical, evidence-based approach.  The most recent research shows clients whose therapists use FIT on an ongoing basis are 2.5 times more like to experience benefit from treatment.

But how does it work?

Quick.  Take a guess.

Under the first shell: FIT works because clinicians use measures to monitor their performance.  The second: Feedback helps clinicians select the most effective treatment methods.  Third: FIT enhances the therapeutic relationship.

If you guessed the “proverbial pea” was under the third shell, you’re right.  Hard to believe given: (1) the emphasis placed on measurement and treatment methods by researchers and advocates of various scales; and (2) concerns expressed by some clinicians that using measures will negatively impact the relationship.

In a “first of its kind” study, psychologist Heidi Brattland found that the strength of the therapeutic relationship improved more over the course of care when clinicians used the Outcome and Session Rating Scales (ORS & SRS) compared to when they did not.  Critically, such improvements resulted in better outcomes for clients, ultimately accounting for nearly a quarter of the effect of FIT.

Below, you will find a link to an interview I did with Heidi this week about the study. The Therapeutic Relationship It’s really worth watching, and it underscores the main point of her findings.  Bottom line: FIT is not about measures and methods.  True, the tools provide form and structure, but their purpose is to facilitate connection.  So, when therapists in the study used the ORS and SRS, their client’s first session alliance scores tended to be lower, indicating the process facilitated the development of a “culture of feedback” early on in care.  As the researchers note, “having been invited to reflect on any negative aspects of the alliance with a responsive therapist in the first session … clients had a more considered and realistic view of the early … [that] facilitated the communication about the treatment process from the first session onward” (p. 10).

That said, Brattland and her colleagues did not find clinicians were equally effective in their use of FIT.  Indeed, as detailed in the report, therapists, “significantly differed in the influence of … [FIT] on the alliance, in the influence of the alliance on outcomes, and the residual direct effect of [FIT] … posttreatment” (p. 10).  On this score, one advantage of using scales to routinely measure our work, is that doing so enables us to identify our personal “growth edge” — what, where, and how we might improve our ability to relate to and help the diverse clients we meet in our daily work.

Filed Under: Feedback Informed Treatment - FIT, PCOMS, Therapeutic Relationship

Ho, Ho, Oh No! Science, politics, and the demise of the National Registry of Evidence-based Programs and Practices

February 7, 2018 By scottdm 13 Comments

End of NREPPWhile you were celebrating the Holidays–shopping and spending time with family–government officials were busy at work.  On December 28th, the Substance Abuse and Mental Health Services (SAMHSA) sent a formal termination notice to the National Registry of Evidence-based Programs and Practices (NREPP).

Ho, ho, oh no…!

Briefly, NREPP is “an evidence-based repository and review system designed to provide the public with reliable information on mental health and substance use interventions.”  In plain English, it’s a government website listing treatment approaches that have scientific support.  SAMHSA is the Federal Agency overseeing behavior health policy.

Back in November, I’d responded to a request from NREPP to update research on the Outcome and Session Rating Scales, two routine outcome measures currently listed on the registry website site.  All’s well until January 4th, when I received a short email stating that “no further review activities will occur” because the program was being ended “for the convenience of the government.”Danger

Like much that comes from our Nation’s capitol, the reason given for the actions taken depends entirely on who you ask.  Democrats are blaming Trump.   Republicans, and the new SAMHSA director, blame the system, calling the registry not only flawed, but potentially dangerous.   As is typical nowadays, everyone is outraged!

As someone whose work was vetted by NREPP, I can personally vouch for the thoroughness of the process and the integrity of the reviewers.  No favors were sought and none were given.  More, while no one knows exactly what will happen in the future, I sincerely believe officials leading the change have the best of intentions.  What I am much less certain of is whether science will finally prevail in communicating “what works” in mental health and substance abuse to the public.

Bottom line: psychological approaches for alleviating human suffering are remarkably effective–on par or better than most medical treatments.  That said, NONE work like a medicine.

salespersonYou have a bacterial infection, antibiotics are the solution.  A virus?  Well, you are just going to have to tough it out.  Take an aspirin and get some rest–and no, the brand you choose doesn’t really matter.   Ask a friend or relative, and they likely have a favorite.  The truth is, however, it doesn’t matter which one you take: Bayer, Econtin, Bufferin, Alka-Selzter, Anacin, a hundred other names, they’re all the same!

Four decades of research shows psychotherapy works much more like aspirin than an antibiotic.  Despite claims, its effects are not targeted nor specific to particular diagnoses.  Ask a friend, relative, your therapist or workshop presenter, and they all have their favorite: CBT, IPT, DBT, PD, TFT, CRT, EMDR, four-hundred additional names.  And yet, meta-analytic studies of head-to-head comparisons find no meaningful difference in outcome between approaches.

What does all this mean for the future of NREPP and SAMHSA?  The evidence makes clear that, when it comes to psychotherapy, any “list” of socially sanctioned approaches is not only unscientific, but seriously misleading.  Would it be too much to hope that future governmental efforts stop offering a marketplace for manufacturers of different brands of aspirin and focus instead on fostering evidence-based practice (EBP)?

Really, it’s not a bridge too far.  bridge too farIt merely means putting policies in place that help practitioners and agencies live up to the values inherent in the definition of EBP accepted by all professional organizations and regulatory bodies; namely, “the integration of the best available research with with clinical expertise in the context of patient characteristics, culture, and preferences” (pp. 273, APA, 2006).

Until next time,

Scott

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

P.S.: Every other year, the ICCE sponsors the “Training of Trainers” intensive.  Over three days, we focus on helping you become a world class presenter and trainer.  Join me, and colleagues from around the world for this transformational event.
FIT Training of Trainers 2018

 

 

Filed Under: Behavioral Health, evidence-based practice, Feedback Informed Treatment - FIT, PCOMS

Joint Commission and SAMHSA Set New Standard of Care for Measurement Based Care

January 29, 2018 By scottdm 1 Comment

TJCLogo

The Joint Commission has recently revised their standards of care.  To maintain accreditation, organizations are now required to assess outcomes with a standardized measurement tool. main_logo

The Substance Abuse and Mental Health Services Administration is moving in the same direction.

Two scales I developed met the new standard.  Both are listed on the Joint Commission and SAMSHA websites.  The Outcome and Session Rating Scales (ORS, SRS) are brief, well-validated tools in use in clinical settings around the world.

The new standard has the potential to significantly improve the effectiveness and efficiency of care. Studies also show, however, that implementation is a complex process with many challenges. Indeed, despite significant investment of time and resources, many organizations fail.

PCOMS - Partners for change outcome management system Scott D Miller - SAMHSA - NREPPClick here for a free handout to assess the readiness of your agency.  It’s one of the many resources provided at the ICCE Feedback-Informed Treatment Implementation workshop—the only evidence-based implementation training on measurement-based care to receive perfect marks for implementation materials, training and support resources, and quality assurance procedures by the National Registry of Evidence-based Programs and Practices (NREPP).

As always, feel free to email me with any questions.

All the best,

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

Filed Under: Conferences and Training, Feedback Informed Treatment - FIT, Implementation, PCOMS

Something BIG is Happening: The Demand for Routine Outcome Measurement from Funders

October 16, 2017 By scottdm 2 Comments

Something in the air

Something is happening.  Something big.

Downloads of the Outcome and Session Rating Scales have skyrocketed.

The number of emails I receive has been steadily increasing.

The subject?  Routine outcome measurement.  The questions:

  • Where can I get copies of your measures?person asking question

Paper and pencil versions are available on my website.

  • What is the cost?

Individual practitioners can access the tools for free.  Group licenses are available for agencies and healthcare systems.

  • Can we incorporate the tools into our electronic healthcare record (E.H.R.)?

Three companies are licensed and authorized to provide an “Application Program Interface” (or API) for integrating the ORS, SRS, data aggregation formulas, and feedback signals directly into your E.H.R.  Detailed information and contact forms are available in a special page on my website.

  • What evidence is available for the validity, reliability, and effectiveness of the measures?

evidenceAlways a good question!  Since the tools were published seventeen years ago, studies have multiplied.  Keeping up with the data can be challenging as the tools are being used in different settings and with diverse clinical populations around the world.

Each year, together with my colleague, New Zealand psychologist, Eeuwe Schuckard, we add the latest research to a comprehensive document available for free online, titled “Measures and Feedback.”

Additionally, the tools have been vetted by an independent group of research scientists and are listed on the Substance Abuse and Mental Health Administration’s National Registry of Evidence-based Programs and Practices.

  • How can I (or my agency) get started?

Although it may sound simple and straightforward, this is the hardest question to answer.  There is often a tone of urgency in the emails I receive, “We need to measure outcomes now,” they say.tortoise-hare1

I nearly always respond with the same advice: the fastest way to succeed is to go slow.

We’ve learned a great deal about implementation over the last 10 years.  Getting practitioners to administer outcome measures is easy.  I can teach them how in less than three minutes.  Making the process more than just another, dreary “administrative task” takes time, patience, and persistence.

I caution against purchasing licenses, software, or onsite training.  Instead, I recommend taking time to explore.  It’s why the reviewers at SAMHSA gave our application for evidence-based status the highest ratings on “implementation support.”

ICCE ImplementationTo succeed, start with:

  1. Accessing a set of the ICCE Feedback Informed Treatment Manuals–the single, most comprehensive resource available on using the ORS and SRS.  Read and discuss them together with colleagues.
  2. Connect with practitioners and agencies around the world who have already implemented.  It’s easy.  Join the International Center for Clinical Excellence–the world’s largest online community dedicated to routine outcome measurement.
  3. Send a few key staff–managers, supervisors, implementation team leaders–to the Feedback-Informed Treatment Intensives.   The Advanced and Supervision workshops are held back-to-back each March in Chicago.  Participants not only leave with a thorough understanding of the ORS and SRS, but ready to kick off a successful implementation at home.  I tell people to sign up early as the courses are limited to 35 participants and always sell out a couple of months in advance.

Feel free to email me with any questions.

Until next time,

Scott

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

 

Filed Under: Behavioral Health, evidence-based practice, Feedback Informed Treatment - FIT, FIT, FIT Software Tools, Implementation, PCOMS

Did you know your clients can tell if you are happy?

January 19, 2014 By scottdm 3 Comments

Are_You_Happy

It’s true.  Adding to a growing literature showing that the person of the therapist is more important than theoretical orientation, years of experience, or discipline, a new study documents that clients are sensitive to the quality of their therapist’s life outside of treament.  In short, they can tell when you are happy or not.  Despite our best efforts to conceal it, they see it in how we interact with them in therapy.  By contrast, therapists’ judgements regarding the quality of the therapy are biased by their own sense of personal well-being. The solution?  Short of being happy, it means we need to check in with our clients on a regular basis regarding the quality of the therapeutic relationship.  Multiple randomized clinical trials show that formally soliciting feedback regarding progress and the alliance improves outcome and continued engagement in treatment.  One approach, “Feedback-Informed Treatment” is now listed on SAMHSA’s National Registry of Evidence-Based Programs and Practices.  Step-by-step instructions and videos for getting started are available on a new website: www.pcomsinternational.com. Seeking feedback from clients not only helps to identify and correct potential problems in therapy, but is also the first step in pushing one’s effectiveness to the next level.  In case you didn’t see it, I review the research and steps for improving performance as a therapist in an article/interview on the Psychotherapy.net website.  It’s sure to make you happy!

Filed Under: CDOI, Feedback, Feedback Informed Treatment - FIT, PCOMS Tagged With: behavioral health, common factors, evidence based practice, excellence, healthcare, productivity, Therapist Effects

Looking Back, Looking Forward

January 6, 2012 By scottdm Leave a Comment

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

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

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

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


Looking forward, I am filled with hope and high expectations.  The “Advanced Intensive” training scheduled for March 19-22nd 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.

Filed Under: Behavioral Health, Conferences and Training, excellence, Feedback Informed Treatment - FIT, ICCE, PCOMS Tagged With: cdoi, feedback informed treatment, HHS, Insoo Berg, NREPP, ors, outcome rating scale, session rating scale, srs, Steve de Shazer

Becoming FIT: The 2011 Training of Trainers

August 10, 2011 By scottdm 1 Comment

August 10th, 2011

Chicago, IL

The first week of August was one of the hottest weeks on record in Chicago.  It was also the location of the hottest training on “feedback-informed treatment” (FIT)–the 5th Annual “Training of Trainers” weeklong intensive training.  We worked intensively over 5 days preparing an international group of administrators, supervisors, researchers, and clinicians to train others in the principles and practices of FIT.  We also played hard: dinners, music, magic, and more.  Here’s what attendee’s said about this years event:

Be sure and join us for the 4-day “Advanced Intensive” scheduled in March.  More information can be found at: scottdmiller.com.

 

Filed Under: Conferences and Training, Feedback Informed Treatment - FIT, PCOMS Tagged With: cdoi, evidence based practice, icce

Yes, More Evidence: Spanish version of the ORS Validated by Chilean Researchers

June 16, 2011 By scottdm Leave a Comment

Last week, Chile.  This week, Perth, Australia.  Yesterday, I landed in Sydney following a 30 hour flight from the United States.  I managed to catch the last flight out to Perth before all air travel was grounded due to another ash clound–this time coming from Chile!  I say “another” as just over a year ago, I was trapped behind the cloud of ash from the Icelandic eruption!  So far so good.  Today, I’ll spend the day talking about “excellence” in behavioral healthcare.

Before heading out to teach for the day, I wanted to upload a report from a recent research project conducted in Chile investigating the statistical properties of the ORS.  I’ve attached the report here so you can read for yourself.  That said, let me present the highlights:

  • The spanish version of the ORS is reliable (alpha coefficients .90-.95).
  • The spanish version of the ORS shows good construct and convergent validity (correlations with the OQ45 .5, .58).
  • The spanish version of the ORS is sensitive to change in a treated population.

The authors of the report that was presented at the Society for Psychotherapy Research meeting conclude, “The ORS is a valid instrument to be used with the Chilean population.”

As asked in my blogpost last week, “how much more evidence is needed?”  Now, more than ever, clinicians needs simple, valid, reliable, and feasible tools for evaluating the process and outcome of behavioral healthcare.  The ORS and SRS FITS the bill!

Filed Under: FIT, PCOMS, Practice Based Evidence Tagged With: behavioral health, cdoi, Chile, evidence based practice, mental health, ors, outcome rating scale, session rating scale, srs

Getting FIT in the New Year: The Latest Evidence

January 18, 2011 By scottdm Leave a Comment

 John Norcross, Ph.D.  is without a doubt the researcher that has done the most to highlight the evidence-base supporting the importance of the relationship between clinician and consumer in successful behavioral healthcare.   The second edition of his book, Psychotherapy Relationships that Work, is about to be released. Like the last edition, this volume is a virtual treasure trove of research findings and empirically supported practices.

Among the many gems in the book is a chapter by Michael J. Lambert, Ph.D–pioneering researcher on “feedback-informed treatment” (FIT).  As usual, he does a masterful job summarizing the existing research on the subject. The data are overwhelmingly positive: seeking and using standardized feedback regarding the progress and outcome of treatment cuts drop out and deterioration rates and significantly improves outcome.

Lambert also reports the results of two meta-analyses. One performed on studies using his own OQ System family of measures, the other based on research using the ORS and SRS. Not only did he find ample empirical support for the two systems, but in the case of the ORS and SRS those therapies informed by feedback, “had 3.5 times higher odds of experiencing reliable change.”  Additionally, and importantly, the brief, 4-item ORS and SRS scales performed the same as the longer and more detailed OQ 45.2.

What can you do? First, order John’s book. Second, if you are not FIT, now is the time to register to use the measures.  And if you need support, why not join the International Center for Clinical Excellence? Like the measures, there is no cost. Right now, professionals from different disciplines, working in diverse settings are connecting with and learning from each other. Here’s a nudge: you’ll be able to reach John Norcross there—he’s one of ICCE’s newest members.

Filed Under: Behavioral Health, CDOI, Feedback, PCOMS Tagged With: cdoi, continuing education, icce, randomized clinical trial

O Canada! Leading the Way to Improved Behavioral Health Services

June 23, 2010 By scottdm Leave a Comment

Last month, I traveled back and forth between the United States and Canada several times.  First, I was in Edmonton working with several hundred dedicated social workers, case managers, and therapists at The Family Centre.  A week later I traveled to Saskatoon, spending two days talking about outcome-informed clinical work at the Addiction Professionals Association of Saskatchewan annual conference (Photos below are from the APASK meeting.  The first during the presentation, the second with Ruth and Laurel).

The evening following this event, I flew to Calgary where I spent the day with the clinical crew at Calgary Counseling Center.  I caught a red-eye home to Chicago and then returned to Canada the following week stopping over first in Vancouver for a workshop on drug and alcohol treatment sponsored by Jack Hirose & Associates and then continued on to Calgary where I met with the staff and managers of each program that comprises Aspen Family and Community Network Society.

The reason for all the frenetic activity?  A perfect storm has been brewing for some time that is culminating in a tidal wave of interest in using outcomes to inform and improve behavioral health services.  First and foremost: vision.  Specifically, key thought and action leaders not only embraced the idea of seeking feedback from consumers but worked hard to implement outcome-informed work in the settings in which they work: Bill Smiley at  The Family Centre, Robbie Babbins-Wagner at Calgary Counseling Center, and Kim Ruse at Aspen Family and Community Network Society.  Second, as I’ve been warning about for over a decade, one province in Canada–Alberta–passed an initiative which links future agency funding to “the achievement of outcomes.”  Indeed, “outcome” is identified as “the central driver for both case work practice and allocation of resources.”  Third, and finally, economic times are tough.  Payers–be they clients, insurance companies, or government bodies–want proof of a “return on investment” for the money spent on behavioral health services.

Needless to say, it was an inspiring month.  I managed to capture some of that in an interview I did with the director of the Calgary Counseling Center, Robbie Babbins-Wagner.  In it, she describes “why” she and CCC staff are committed to measuring outcomes as well as reviews the challenges involved.  Take a look:

Filed Under: Behavioral Health, evidence-based practice, Feedback Informed Treatment - FIT, PCOMS Tagged With: Canada, feedback informed treatment

Outcomes in Oz

November 20, 2009 By scottdm Leave a Comment

Greetings from beautiful Melbourne, Australia!   For the next couple of weeks, I’ll be traveling the up and down the east coast of this captivating country, conducting workshops and providing consultations on feedback-informed clinical work.

Actually, I’ve had the privilege of visiting and teaching in Australia about once a year beginning in the late 1990’s. Back then, Liz Sheehan, the editor of the “must read” journal Psychotherapy in Australiabrought me in to speak about the then recently published first edition of the Heart and Soul of Change.  By the way, if you are not from Australia, and are unfamiliar with the journal, please do visit the website.  Liz makes many of the articles that appear in the print version available online.  I’ve been a subscriber for years now and await the arrival of each issue with great anticipation.  I’m never disappointed.

In any event, on Wednesday this week, I spent the entire day with Mark Buckingham, Fiona Craig, and the clinical staff of Kedesh Rehabilitation Services in Wollongong, Australia–a scenic sea-side location about 45 minutes south of Sydney.  Briefly, Kedesh is a residential treatment facility providing cutting-edge, consumer driven, outcome-informed services to people with drug, alcohol, and mental health problems.  The crew at Kedesh is using the ORS and SRS to guide service delivery and is, in fact, one of the first to fully implement CDOI in the country.

I’ll be back with more soon, so please check back tomorrow.  In the meantime, check out the video with Mark and Fiona.

Filed Under: Behavioral Health, evidence-based practice, excellence, Feedback Informed Treatment - FIT, PCOMS Tagged With: australia, kedesh, liz sheehan, psychotherapy

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