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The Most Important Psychotherapy Book

June 14, 2022 By scottdm Leave a Comment

Late last year, I began a project I’d been putting off for a long while: culling my professional books. I had thousands. They filled the shelves in both my office and home. To be sure, I did not collect for the sake of collecting. Each had been important to me at some time, served some purpose, be it a research or professional development project — or so I thought.

I contacted several local bookstores. I live in Chicago — a big city with many interesting shops and loads of clinicians. I also posted on social media. “Surely,” I was convinced, “someone would be interested.” After all, many were classics and more than a few had been signed by the authors.

I wish I had taken a selfie when the manager of one store told me, “These are pretty much worthless.” And no, they would not take them in trade or as a donation. “We’d just put them in the dumpster out back anyway,” they said with a laugh, “no one is interested.”

Honestly, I was floored. I couldn’t even give the books away!

The experience gave me pause. However, over a period of several months, and after much reflection, I gradually (and grudgingly) began to agree with the manager’s assessment. The truth was very few — maybe 10 to 20 — had been transformative, becoming the reference works I returned to time and again for both understanding and direction in my professional career.

Among that small group, one volume clearly stands out. A book I’ve considered my “secret source” of knowledge about psychotherapy, The Handbook of Psychotherapy and Behavior Change. Beginning in the 1970’s, every edition has contained the most comprehensive, non-ideological, scientifically literate review of “what works” in our field.

Why secret? Because so few practitioners have ever heard of it, much less read it. Together with my colleague Dr. Dan Lewis, we review the most current, 50th anniversary edition. We also cover Ghost Hunter, a book about William James’ investigation of psychics and mediums.

What do these two books have in common? In a word, “science.” Don’t take my word for it, however. Listen to the podcast or video yourself!

Until next time, all the best!

Scott

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

Filed Under: Feedback Informed Treatment - FIT Tagged With: behavioral health, psychotherapy

How not to be among the 70-95% of practitioners and agencies that fail

April 20, 2014 By scottdm Leave a Comment

fail2

Our field is full of good ideas, strategies that work.  Each year, practitioners and agencies devote considerable time and resources to staying current with new developments.  What does the research say about such efforts?  When it comes to the implementation of new, evidence-based practices, traditional training strategies routinely produce only 5% to 30% success rates.  Said another way, 70-95% of training fails (Fixsen, Blase, Van Dyke, & Metz, 2013).  

In 2013, Feedback Informed Treatment (FIT)–that is, formally using measures of progress and the therapeutic alliance to guide care–was deemed an evidence-based practice by SAMHSA, and listed on the official NREPP website.  It’s one of those good ideas.  Research to date shows that FIT as much as doubles the effectiveness of behavioral health services, while decreasing costs, deterioration and dropout rates. 

As effective as FIT has proven to be in scientific studies, the bigger challenge is helping clinicians and agencies implement the approach in real world clinical settings.  Simply put, it’s not enough to know “what works.”  You have to be able to put “what works” to work.  On this subject, researchers have identified five, evidence-based steps associated with the successful implementation of any evidence-based practice.  The evidence is summarized in a free, manual available online.  You can avoid the 70-95% failure rate by reading it before attending another training, buying that new software, or hiring the latest consultant.

At the International Center for Clinical Excellence, we’ve integrated the research on implementation into all training events, including a special, two-day intensive workshop on implementing Feedback-Informed Treatment (FIT).  Based on the five, scientifically-established steps, clinicians, supervisors, and agency directors will learn how to both plan and execute a successful implementation of this potent evidence-based practice. 

You can register today by clicking on the link above or the “FIT for Management” icon below.  Feel free to e-mail me with any questions.  In the meantime, hope to see you this summer in Chicago!

Fit Imp 2014

Filed Under: Conferences and Training Tagged With: behavioral health, dropout rates, evidence based medicine, evidence based practice, feedback informed treatment, FIT, icce, implementation, international center for cliniclal excellence, NREPP, SAMHSA, Training

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

Excellence in Amsterdam: The 2013 ACE Conference

June 6, 2013 By scottdm Leave a Comment

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:

Excellence in therapy: An Interview with Scott D. Miller, Ph.D. by Colin Feltham. 
It starts on page 32.

Filed Under: Conferences and Training, ICCE Tagged With: accountability, behavioral health, conference, conferences, continuing education, evidence based practice, excellence, feedback

How Cool is Kuhl? A Man with Vision on a Mission

April 19, 2013 By scottdm Leave a Comment

This week, my colleague and friend, Dr. David Mee-Lee, sent me a link to a blogpost written by Don Kuhl.  Actually, I was already a subscriber to Don’s Minful MIDweek blog (you should be too), but my travel this week had prevented me from reading his latest installment.  His posts always leave me inspired and give me something to think about.  This week was no different.  More on that in a moment.

In the meantime, let me tell you about Don.  He is the founder and CEO of The Change Companies, a company whose mission is to create tailored materials and programs to support behavioral change for special populatons.  And create they do.  Hundreds of bright, attractive, highly readable publications and guided workbooks for use by professionals and the people they serve.  Their material is exhaustive and comprehensive, including adult behavioral health, criminal justice, education and prevention, clinical assessment, and faith-based programs.  A side note, it was Don and his skillful team at The Change Companies that produced the ICCE Feedback Informed Treatment and Training Manuals.  If you’ve not seen them, you should.  They are the cutting edge of information about FIT.

What is most striking about Don, however, is his passion.  I met him at a conference in San Francisco nearly a decade ago.  On several occasions, he flew to Chicago from his home base in Carson City, Nevada just to meet, talk, and share ideas.  The photo above is from one of the meetings he arranged.  Don is devoted to improving the quality and experience of behavioral health services for professionals and clients alike.  Simply said, Don Kuhl is cool.

In his blogpost this week, Don wrote about that meeting with Jim Prochaska, David Mee-Lee, me, and Bill Miller.  He referred to it as a “highlight” of his recent professional life, a lucky event resulting from his mindful pursuit of relationships with “people who have smiles on their faces and goodness in their hearts.”

My thought?  I was and am the lucky one.  Thanks Don.  Thanks Change Companies.  Keep up the good work.

Filed Under: Top Performance Tagged With: addiction, behavioral health, books, Change Companies, continuing education, Don Kuhl, evidence based practice, excellence, icce

What to Pay Attention to in Therapy?

March 15, 2013 By scottdm Leave a Comment

A week or so ago, I received an email from my friend, colleague, and mentor Joe Yeager.  He runs a small listserve that sends out interesting and often provocative information.  The email contained pictures from a new and, dare I say, ingenious advertising campaign for Colgate brand dental floss.  Before I give you any of further details, however, take a look at the images yourself:

All right.  So what caught your attention?  If you’re like most people–including me–you probably found yourself staring at the food stuck in the teeth of the men in all three images.  If so, the ad achieved its purpose.  Take a look at the pictures one more time.  In the first, the woman has one too many fingers on her left hand.  The second image has a “phamtom arm” around the man’s shoulder.  Can you see the issue in the third?

The anomalies in the photos are far from minor!  And yet, most of us, captured by the what initially catches our eye, miss them.

Looking beyond the obvious is what Feedback Informed Treatment (FIT) is all about.  Truth is, much of the time therapy works.  What we do pay attention to gets results–except when it doesn’t!  At those times, two things must happen: (1) we have to know when what we usually do isn’t working with a given person; and (2) look beyond the obvious and see a bigger picture.  Doing this takes effort and support.    What can you do?

1. Download two free, brief, simple to use tools for tracking outcome and engagement in care (the ORS and SRS) and begin using them in your work;

2. Join the International Center for Clinical Excellence, the world’s largest, free, online, non-denominational organization of behavioral health professionals;

3. Read the six cutting-edge treatment and training manuals on feedback-informed treatment–a series which helped earn FIT the highest ratings from the Substance Abuse and Mental Health Services Administration (SAMHSA);

4. Attend a training in Chicago or abroad.

 

Filed Under: Feedback Informed Treatment - FIT Tagged With: accountability, Alliance, behavioral health, deliberate practice, evidence based practice, feedback, NREPP, SAMHSA

Curing Clinician Overconfidence: Try Darting and Frowning

January 10, 2013 By scottdm Leave a Comment

Overconfidence.  It’s a problem that leads to systematic errors in judgement.   Long thought to arise out of hubris or the corrupting effects of the emotion, the evidence actually shows it to be built into humans’ evolved cognitive machinery.  Existimo ergo certus sum (I think, therefore I am…certain).

Behavioral health professionals are not immune.  A recently published study by Walfish, McAlister, O’Donnell, and Lambert (2012) asked clinicians how their effectiveness rates compared to other professionals.  Turns out, clinicians, on average, believed their results were better than 80% of their peers.  Not a single practitioner surveyed viewed themselves as below average and a full quarter (25%) thought they fell at the 90th percentile or higher in skill level and effectiveness!

It’s true that we are not alone in this tendency.  As indicated above, it’s how our brains work.  The typical driver, for example, believes themselves to be better than 80% of others on the road.  University professors, it appears, suffer from the most inflated levels of self-esteem, ranking themselves at the 94th percentile on average.

When it comes to learning, the consequences are significant.  Why change, after all, if you’re already pretty darn good and if the real problem is obvious: other drivers, poor students, etc., difficult life circumstances or the complex nature of some mental disorders?

Researchers have discovered a relatively simple solution to overconfidence: frowning.  That’s right.  Turning that smile upside down short circuits our reptilian wiring, making us more analytical and vigilant in our thinking, in the process enabling us to “question stories that we would otherwise unreflectively accept as true because they are facile and coherent” ( Holt, 2011).

What else can clinicians do?  Do something to gain perspective.  Take on another, divergent point of view, for example.  Practically speaking, scan rather than fix your gaze.  Literally, move your eyes.

Everyone has heard of “tunnel vision.”  Turns out, despite pledges to remain open and flexible, it ain’t so easy.  If you don’t agree, try a little experiment.    Fix your eyes on the flashing red and/or green dot at the center of the graphic and notice what happens to the surrounding yellow ones.  Be patient if the image hasn’t loaded.  It can take a minute or two.

They either blinked on and off or disappeared completely.  Interesting enough but here’s what’s really strange: the yellow dots actually never disappear.  They are always there despite what you see.  And no, the computer did not scan your visual field and cause the yellow dots to blink.  Neither is this an optical illusion.  Once again, it’s the way we are wired.  We think we are seeing everything…but we are not.  The result: overconfidence.  It’s why, following an automobile accident, people will say, “the other driver came out of nowhere.”  It’s why surgeons leave sponges inside their patients or miss seeing bleeds or small nicks of the scalpel.  It’s also why behavioral health practitioners routinely fail to detect deterioration and people at risk for dropping out of services (Hannan, et al. 2005).

Now, look again.  This time, however, shift your eyes about while watching the flashing dot in the center.  In other words, don’t fix your gaze.  If that doesn’t change what you see, then step back from the image and view it from a distance.  There, see!  The yellow dots are present the entire time.

Helping busy practitioners step back, shift their gaze, and otherwise improve their critical faculties and skills is the mission of ICCE.  Members connect, learn from, and share with the largest online community of mental health professionals in the world.  Thousands of members, hundreds of discussion forums, a massive and every growing library of research and other supportive documents, and how-to videos are available for free 24-7-365.

Many of the members and associates will be meeting in Amsterdam, Holland for the Achieving Clinical Excellence conference on May 16-18th.  Conference coordinator, Liz Pluut, has organized an line-up of international speakers, researchers, and practitioners that is guaranteed to push your clinical performance to the next level!  Participants are coming from all over Europe, the US, Canada, Asia, Australia, and more.  Don’t wait to register.  Space is limited and the response has been amazing.

OK, here’s something fun.  Take a look at the video below.  Oh yeah, make sure you smile and keep your eyes fixed on my hands!

Filed Under: Conferences and Training, Feedback Informed Treatment - FIT Tagged With: behavioral health, icce

Feedback in Groups: New Tools, New Evidence

December 29, 2012 By scottdm Leave a Comment

 

Groups are an increasingly popular mode for delivering behavioral health services.  Few would deny that using the same hour to treat mutliple people is more cost effective.  A large body of research shows it to be as effective in general as individually delivered treatments.

Now clinicians can incorporate feedback into the group therapy using a brief, scientifically validated measurement scale: the Group Session Rating Scale.  The measure is part of the packet of FIT tools available in 20+ languages on both my personal and the International Center for Clinical Excellence websites.   Since the alliance is one of the most robust predictors of outcome, the GSRS provides yet another method for helping therapists obtain feedback from consumers of behavior health services.  As readers of this blog know, over a dozen randomized clinical trials document the positive impact of routinely assessing consumers’ experience of progress and the alliance on both retention and outcome of treatment.

The most up-to-date information about incorporating the GSRS into group therapy is covered in Manual 5: Feedback Informed Clinical Work: Specific Populations and Service Settings written together with ICCE Senior Associates Julie Tilsen, Cynthia Maeschalck, Jason Seidel, and Bill Robinson.

Manual 5 is one of six, state-of-the-art, how-to volumes on Feedback-Informed Treatment.  The series covers every aspect of FIT, from supporting research to implementation in agencies and larger systems of care.  The were developed and submitted in partial support of ICCE’s application to SAMSHA for designation as an evidence-based practice.

These popular e-books are being used in agencies and by practitioners around the world.  Right now, they are also available on a limited edition, searchable CD at 50% off the regular price.  As always, individual clinicians can download the GSRS and begin using it in their work for free.  

Advanced FIT Training - March 2013

Using the GSRS to inform and improve the effectiveness of group therapy will also be a focus on the ICCE Advanced Intensive training scheduled for March 18th-21st in Chicago, Illinois (USA).  Registration is simple and easy.  Click here to get started.  Participants from all over the United States, Canada, Europe and elsewhere are already registered to attend.

Click on the link below to read the validation article on the GSRS:

The Group Session Rating Scale (Quirk, Miller, Duncan, Owen, 2013)

Filed Under: Feedback Informed Treatment - FIT Tagged With: behavioral health, feedback informed treatment, ors, outcome rating scale, session rating scale, srs

Dealing with Scientific Objections to the Outcome and Session Rating Scales: Real and Bogus

December 15, 2012 By scottdm Leave a Comment

The available evidence is clear: seeking formal feedback from consumers of behavioral health services decreases drop out and deterioration while simultanesouly improving effectiveness.  When teaching practitioners how to use the ORS and SRS to elicit feedback regarding progress and the therapeutic relationship,  three common and important concerns are raised:

  1. How can such simple and brief scales provide meaningful information?
  2. Are consumers going to be honest?
  3. Aren’t these measures merely assessing satisfaction rather than anything meaninful?

Recently, I was discussing these concerns with ICCE Associate and Certified Trainer, Dan Buccino.

Briefly, Dan is a clinical supervisor and student coordinator in the Adult Outpatience Community Psychiatry program at Johns Hopkins.  He’d not only encountered the concerns noted above but several additional objections.  As he said in his email, “they were at once baffling and yet exciting, because they were so unusal and rigorous.”

“It’s a sign of the times,” I replied, “As FIT (feedback informed treatment) becomes more widespread, the supporting evidence will be scrutinized more carefully.  It’s a good sign.”

Together with Psychologist and ICCE Senior Associate and Trainer, Jason Seidel, Dan crafted detailed response.  When I told them that I believed the ICCE community would value having access to the document they created, both agreed to let me publish it on the Top Performance blog.  So…here it is.  Please read and feel free to pass it along to others.

 

 

 

Filed Under: Feedback Informed Treatment - FIT Tagged With: accountability, behavioral health, Certified Trainers, evidence based practice, feedback, interviews, mental health, ors, practice-based evidence, psychometrics, research, srs

The Importance of "Whoops" in Improving Treatment Outcome

December 2, 2012 By scottdm Leave a Comment

“Ring the bells that still can ring,
Forget your perfect offering
There is a crack in everything,
That’s how the light gets in.”

Leonard Cohen, Anthem

Making mistakes.  We all do it, in both our personal and professional lives.  “To err is human…,” the old saying goes.  And most of us say, if asked, that we agree whole heartedly with the adage–especially when it refers to someone else!  When the principle becomes personal, however, its is much more difficult to be so broad-minded.

Think about it for a minute: can you name five things you are wrong about?  Three?  How about the last mistake you made in your clinical work?  What was it?  Did you share it with the person you were working with?  With your colleagues?

Research shows there are surprising benefits to being wrong, especially when the maker views such errors differently.  As author Alina Tugend points out in her fabulous book, Better by Mistake, custom wrongly defines a mistake as ” the failure of a planned sequence of mental or physical activities to achieve its intended outcome.”  When you forget a client’s name during a session or push a door instead of pull, that counts as  slip or lapse.  A mistake, by contrast, is when “the plan itself is inadequate to achieve it’s objectives” (p. 11).  Knowing the difference, she continues, “can be very helpful in avoiding mistakes in the future” because it leads exploration away from assigning blame to the exploring systems, processes, and conditions that either cause mistakes or thwart their detection.

Last week, I was working with a talented and energetic group of helping professionals in New Bedford, Massachusetts.  The topic was, “Achieving Excellence: Pushing One’s Clinical Performance to the Next Level of Effectiveness.”  As part of my presentation, I talked about becoming more, “error-centric” in our work; specifically, using ongoing measurement of the alliance to identify opportunities for improving our connection with consumers of behavioral health services.  As an example of the benefits of making mistakes the focus of professional development efforts, I showed a brief video of Rachel Hsu and Roger Chen, two talented musicians who performed at the last Achieving Clinical Excellence (ACE) conference.  Rachel plays a piece by Liszt, Roger one by Mozart.  Both compositions are extremely challenging to play.  You tell me how they did (by the way, Rachel is 8 years old, Roger. 9):

Following her performance, I asked Rachel if she’d made any mistakes during her performance.  She laughed, and then said, “Yes, a lot!”  When I asked her what she did about that, she replied, “Well, its impossible to learn from my mistakes while I’m playing.  So I note them and then later practice those small bits, over and over, slow at first, then speeding up, until I get them right.”

After showing the video in New Bedford, a member of the audience raised his hand, “I get it but that whole idea makes me a bit nervous.”  I knew exactly what he was thinking.  Highlighting one’s mistakes in public is risky business.  Studies documenting that the most effective clinicians experience more self-doubt and are more willing to admit making mistakes is simply not convincing when one’s professional self-esteem or job may be on the line.  Neither is research showing that health care professionals who admit making mistakes and apologize to consumers are significantly less likely to be sued.  Becoming error centric, requires a change in culture, one that not only invites discloure but connects it with the kind of support and structure that leads to superior results.

Creating a “whoops-friendly” culture will be a focus of the next Achieving Clinical Excellence conference, scheduled for May 16-18th, 2013 in Amsterdam, Holland.  Researchers and clinicians from around the world will gather to share their data and experience at this unique event.  I promise you don’t want to miss it.  Here’s a short clip of highlights from the last one:

My colleague, Susanne Bargmann and I will also be teaching the latest research and evidence based methods for transforming mistakes into improved clinical performance at the upcoming FIT Advanced Intensive training in Chicago, Illinois.   I look forward to meeting you at one of these upcoming events.  In the meantime, here’s a fun, brief but informative video from the TED talks series on mistakes:

By the way, the house pictured above is real.  My family and I visited it while vacationing in Niagara Falls, Canada in October.  It’s a tourist attraction actually.  Mistakes, it seems, can be profitable.

Filed Under: Feedback Informed Treatment - FIT Tagged With: accountability, Alliance, behavioral health, cdoi, conferences, continuing education, deliberate practice, evidence based practice, feedback, mental health, Therapist Effects, top performance

What is the Real Source of Effectiveness in Smoking Cessation Treatment? New Research on Feedback Informed Treatment

November 24, 2012 By scottdm Leave a Comment

When it rains, it pours!  So much news to relay regarding recent research on Feedback Informed Treatment (FIT).  Just received news this week from ICCE Associate Stephen Michaels that research using the ORS and SRS in smoking cessation treatment is in print!   A few days prior to that, Kelley Quirk sent a copy of our long-awaited article on the validity and reliability of the Group Session Rating Scale.  On that very same day, the editors from the journal Psychotherapy sent proofs of an article written by me, Mark Hubble, Daryl Chow, and Jason Seidel for the 50th anniversary issue of the publication.

Let’s start with the validity and reliability study.  Many clinicians have already downloaded and been using Group Session Rating Scale.  The measure is part of the packet of FIT tools available in 20+ languages on both my personal and the International Center for Clinical Excellence websites.   The article presents the first research on the validity and reliability of the measure.  The data for the study was gathered at two sites I’ve worked with for many years.   Thanks to Kelley Quirk and Jesse Owen for crunching the numbers and writing up the results!   Since the alliance is one of the most robust predictors of outcome, the GSRS provides yet another method for helping therapists obtain feedback from consumers of behavior health services.

Moving on, if there were a Nobel Prize for patience and persistence, it would have to go to Stephen Michaels, the lead author of the study, Assessing Counsellor Effects on Quit Rates and Life Satisfactions Scores at a Tobacco Quitline” (Michael, Seltzer, Miller, and Wampold, 2012).  Over the last four years, Stephen has trained Quitline staff in FIT, implemented the ORS and SRS in Quitline tobacco cessation services, gathered outcome and alliance data on nearly 3,000 Quitline users, completed an in-depth review of the available smoking cessation literature, and finally, organized, analyzed, and written up the results.

What did he find?  Statistically significant differences in quit rates attributable to counselor effects.  In other words, as I’ve been saying for some time, some helpers are more helpful than others–even when the treatment provided is highly manualized and structured.  In short, it’s not the method that matters (including the use of the ORS and SRS), it’s the therapist.

What is responsible for the difference in effectiveness among therapists?  The answer to that question is the subject of the article, “The Outcome of Psychotherapy: Yesterday, Today, and Tomorrow” slated to appear in the 50th anniversary issue of Psychotherapy.  In it, we review controversies surround the question, “What makes therapy work?” and tip findings from another, soon-to-be-published empirical analysis of top performing clinicians.  Stay tuned.

Filed Under: Feedback Informed Treatment - FIT Tagged With: addiction, behavioral health, cdoi, Certified Trainers, evidence based practice, excellence, feedback, healthcare, icce, Smoking cessation, Therapist Effects

Clinical Support Tools for the ORS and SRS

November 20, 2012 By scottdm 1 Comment

I have so much to be grateful for at this time.  Most of all, I’m happy to be home with my family.  As we have in the past, this year we’ll be spending the holiday at the home of our long time friends John and Renee Dalton.  The two always put out a fantastic spread and our son, Michael, is fast friends with their two kids.

I’m also grateful for the International Center for Clinical Excellence (ICCE) community.  Currently, ICCE has over 4200 members located around the world, making the organization the largest, web-based community of professionals, educators, managers, and clinicians dedicated to using feedback to pursue excellence in the delivery of behavioral health services.  Recently, the site was highlighted as one of the best resources for practitioners available on the web.  Articles, how-to videos, and discussion forums are available everyday, all day–and for free!  No come-ons for books or webinars and no “cult of personality”–just sharing among peers.  If you are not a member, you can join at: www.centerforclinicalexcellence.com

A special thanks goes to several ICCE senior advisors and associates, including Susanne Bargmann, Jason Seidel, Cynthia Maeschalck, Bob Bertolino, Bill Plum, Julie Tilsen, and Robbie Babbins-Wagner.  These folks are the backbone of the organization.  Together, they make it work.  Most recently, we all joined together to create the ICCE Feedback Informed Treatment and Training Manuals, a cutting edge series covering every aspect of FIT–from the empirical foundations to implementation–in support of our application to SAMSHA for recognition as an “evidence-based practice.”

As a way of supporting everyone using the ORS and SRS, I wanted to make a couple of clinical support tools available.  If you are using the measures, the first item will need no introduction.  It’s a 10 cm ruler!  Save the file and print it off and you also have a ready reminder of the upcoming Achieving Clinical Excellence conference, coming up in May 2013.  Like last time, this will feature the latest inforamtion about feedback informed practice!  The second item is a reliable change graph.  If you are using the paper and pencil measures, rather than one of the existing web based systems (www.fit-outcomes.com, www.myoutcomes.com), you can use this tool to determine whether a change in scores from session to session is reliable (that is, greater than chance, the passage of time, and measurement error [and therefore, due to the care being provided]) or even clinically significant (that is, both reliable and indicating recovered).  The last item is an impressive summary of various systems for monitoring progress in treatment.

In addition ACE Health have developed openFIT, a plug-in which seamlessly integrates the ORS, SRS and associated algorithms into any existing Electronic Health Record, Case Management System of eMental Health application.

I wish everyone a peaceful and rewarding Thanksgiving holiday.

 

Filed Under: FIT Software Tools Tagged With: behavioral health, cdoi, excellence, feedback, healthcare, icce, mental health, ors, Outcome, practice-based evidence, srs

An Easy Way to Improve Our Schools (and Psychotherapy)

November 13, 2012 By scottdm Leave a Comment

If you didn’t see the October Atlantic Monthly, you really missed a great issue.  In it, Amanda Ripley wrote a delightful and informative article about a simple and straightforward method for improving the performance of the public schools: have kids grade teachers.   What kind of grades you ask?   Not those on standardized achievement tests, and certainly not measures of a teacher’s popularity.  Although both of those methods are widely advocated and used, neither has proven particularly predictive of student performance.  Rather, grades should be based on how well teachers engage students; particularly whether the kids believe the teacher makes them want to work hard, pay attention, understand the course material, and identify and correct their mistakes.  Indeed, in thousands of surveys, kids as young as kindergartners “can identify with uncanny accuracy, their most–and least effective teachers.”

The findings stood out for me not only because I am a parent but also because they mirror results from psychotherapy research.  First, data gathered over the last three decades documents that client engagement is the number one process-related predictor of treatment outcome.  Second, a growing number of studies indicates that clients can identify “with uncanny accuracy” the most and least effective treatment services and providers.  Importantly, this same body of evidence shows that client assessments of their sessions and progress can be used to enhance treatment results in general as well as the effectiveness and skill level of individual clinicians.

Viewpoint clearly matters–and in the case of schools and psychotherapy, it is the recipient of the service whose opinion we should be seeking.  In her article, Ripley identifies the types of questions that can be used in schools.  If you are a therapist, two brief, simple-to-use scales are available for free.  Research has shown that regularly using the measures to solicit client feedback improves both retention in and outcome of psychotherapy.  The largest, international professional community dedicated to enhancing the quality and outcome of behavioral healthcare is available to support you in your use of the tools.  There, you will find a wealth of information, discussion forums, and how-to videos available at no charge 24 hours a day, 7 days a week, 365 days a year.

In March, many members from around the world will be joining colleagues from around the world for four days of intensive training.  Why not join us?  We work and play hard.  Rest assured that by the end of the four days, you’ll be playing an “A” game.  Click here to register today.  In the meantime, here’s what participants from last year said about the event.

Filed Under: Top Performance Tagged With: Alliance, behavioral health, cdoi, evidence based practice, excellence, feedback

Mental Health Practice in a Global Economy

April 17, 2012 By scottdm 2 Comments

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.

Filed Under: Behavioral Health, Feedback Informed Treatment - FIT, ICCE Tagged With: behavioral health, brief therapy, cdoi, evidence based practice, mental health, Thomas Friedman

Is the "Summer of Love" Over? Positive Publication Bias Plagues Pharmaceutical Research

March 27, 2012 By scottdm Leave a Comment


Evidence-based practice is only as good as the available “evidence”–and on this subject, research points to a continuing problem with both the methodology and type of studies that make it into the professional literature.  Last week, PloS Medicine, a peer-reviewed, open access journal of the Public Library of Science, published a study showing a positive publication bias in research on so-called atypical antipsychotic drugs.  In comparing articles appearing in journals to the FDA database, researchers found that almost all postive studies were published while clinical trials with negative or questionable results were not or–and get this–were published as having positive results!

Not long ago, similar yet stronger results appeared in the same journal on anti-depressants.  Again, in a comparison with the FDA registry, researchers found all postive studies were published while clinical trials with negative or questionable results were not or–and get this–were published as having positive results!  The problem is far from insignificant.  Indeed, a staggering 46% of studies with negative results were not published or published but reported as positive.

Maybe the “summer of love” is finally over for the field and broader American public.  Today’s Chicago Tribune has a story by Kate Kelland and Ben Hirschler reporting data about sagging sales of anti-depressants and multiple failures to bring new, “more effective” drug therapies to market.  Taken together, robust placebo effects, the FDA mandate to list all trials (positive and negative), and an emphasis in research on conducting fair comparisons (e.g., comparing any new “products” to existing ones) make claims about “new and improved” effectiveness challenging.

Still one sees ads on TV making claims about the biological basis of depression–the so called, “biochemical imbalance.”  Perhaps this explains why a recent study of Medicaid clients found that costs of treating depression rose by 30% over the last decade while the outcomes did not improve at all during the same period.  The cause for the rise in costs?    Increased use of psychiatric drugs–in particular, anti-psychotics in cases of depression.

“It’s a great time for brain science, but at the same time a poor time for drug discovery for brain disorders,” says David Nutt, professor of neuropsychopharmacology, cited in the Chicago Tribune, “That’s an amazing paradox which we need to do something about.”

Here’s an idea: how about not assuming that problems in living are reduceable to brain chemistry?   That the direction of causality for much of what ails people is not brain to behavior but perhaps behavior to brain?  On this note, it is sad to note that while the percentage of clients prescribed drugs rose from 81 to 87%–with no improvement in effect–the number of those receiving psychotherapy dropped from 57 to 38%.

Here’s what we know about psychotherapy: it works and it has a far less troublesome side effect profile than psychotropic drugs.  No warnings needed for dry mouth, dizziness, blood and liver problems, or sexual dysfunction.  The time has come to get over the collective 1960’s delusion of better living through chemistry.

Filed Under: Practice Based Evidence Tagged With: behavioral health, continuing education, depression, evidence based practice, icce, Medicaid, mental health, psychotherapy

Goodbye Mr. & Ms. Know-it-All: Redefining Competence in the Era of Increasing Complexity

February 12, 2012 By scottdm 3 Comments

Every day behavioral health professionals make hundreds of decisions.  As experts in the field, they meet and work successfully with diverse clients presenting an array of different difficulties.  Available evidence indicates that the average person who receives care is better off than 80% of those with similar problems that do not.  Outcomes in mental health are on par or better than most medical treatments and, crucially, have far few side effects!  Psychotherapy, for example, is equal in effect to coronary artery bypass surgery and three times more effective than flouride for cavities.

Not all the news is good, however.  Drop out rates run around 25% or higher.  Said another way, clinicians do great work with the people who stay.  Unfortunately, many do not, resulting in increased costs and lost opportunities.  Another problem is that therapists, the data indicate, are not particularly adept at identifying clients at risk for dropping out or deterioration.  For decades, research has has shown that approximately 10% of people worsen while in treatment.  Practitioners, despite what they may believe, are none the wiser.  Finally, it turns out that a small percentage (between 10-20%) of people in care account for lion’s share of expenses in behavioral health service delivery (In case you are wondering, roughly the same figures apply in the field of medicine).  Such people continue in care for long periods, often receiving an escalating and complicated array of services, without relief.  At the same time, clinician caseloads and agency waiting lists grow.

What can be done?

At one time, being a professional meant that one possessed the knowledge, training, and skills to deliver the right services to the right people for the right problem in a consistent, correct, and safe manner.  To that end, training requirements–including schooling, certification, and continuing professional development–expanded, exponentially so.  Today’s behavioral health professionals spend more time training and are more highly specialized than ever before.  And yet, the above noted problems persist.

Some call for more training, others for increasing standardization of treatment approaches, many for more rigorous licensing and accreditation standards.  The emphasis on “empirically supported treatments”–specific methods for specific diagnoses–typify this approach.  However, relying as these solutions do on an antiquated view of professional knowledge and behavior, each is doomed to fail.

In an earlier era, professionals were “masters of their domain.”  Trained and skillful, the clinician diagnosed, developed a plan for treatment, then executed, evaluated, and tailored services to maximize the benefit to the individual client.  Such a view assumes that problems are either simple or complicated, puzzles that are solvable if the process is broken down into a series of steps.  Unfortunately, the shortcomings in behavioral health outcomes noted above (drop out rates, failure to identify deterioration and lack of progress) appear to be problems that are not so much simple or complicated but complex in nature.  In such instances, outcomes are remain uncertain throughout the process.  Getting things right is less about following the formula than continually making adjustments, as “what works” with one person or situation may not easily transfer to another time or place.  Managing such complexity requires a change of heart and direction, a new professional identity.  One in which the playing field between providers and clients is leveled, where power is moved to the center of the dyad and shared, where ongoing client feedback takes precedence over theory and protocol.

In his delightful and engaging book, The Checklist Manifesto, physician and surgeon Atul Gawande provides numerous examples in medicine, air travel, computer programming, and construction where simple feedback tools have resulted in dramatic improvements in efficiency, effectiveness, and safety.  The dramatic decrease in airplane related disasters over the last three decades is one example among many–all due to the introduction of simple feedback tools.  Research in the field of behavioral health documents similar improvements.  Multiple studies document that routinely soliciting feedback regarding progress and the alliance results in significantly improved effectiveness, lower drop out rates, and less client deterioration–and all this while decreasing the cost of service delivery.  The research and tools are described in detail in a new series of treatment manuals produced by the members and associates of the International Center for Clinical Excellence–six simple, straightforward, how-to guidebooks covering everything from the empirical foundations, administration and interpretation of feedback tools, to implementation in diverse practice settings.  Importantly, the ICCE Manuals on Feedback Informed Treatment (FIT) are not a recipe or cookbook.  They will teach not to you how to do treatment.  You will learn, however, skills for managing the increasingly complex nature of modern behavioral health practice.

In the meantime, here’s a fantastic video of Dr. Gawande on the subject.  Use the cursor to skip ahead to the 2:18 mark:

Filed Under: Behavioral Health, Feedback Informed Treatment - FIT, Practice Based Evidence Tagged With: Atul Gawande, behavioral health, feedback informed treatment, icce, The Checklist Manifesto

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

The World Did Not End: What it a Bad Thing?

May 25, 2011 By scottdm Leave a Comment

May 25th, 2011

Chicago, Illinois

On Saturday the 21st of May, 2011 the world was supposed to come to an end.  It did not.  My question: was that a bad thing?  Would it have been better if, as the now twice wrong Prophet Harold Camping predicted, the world had ended.

In the world of public behavioral health, the answer is perhaps. Since the crash of the United States economy in 2008, funding for public behavioral health has been on the chopping block.  It’s not the “end of world in one fell swoop.”  Rather, its more like slowly having the life strangled out of you.  And unlike teachers and prison guards, public behavioral health doesn’t have a strong and vocal lobby.

“It’s sad,” says the director of one agency in the midwest, “I come to work every day feeling weighed down.  We are going to experience very close to another one mission dollar cut, that is, on topic of the same cut last year.”

Agencies are doing everything they can to continue to provide effective treatment in the current environment.  Here’s what the staff and management in Marion-Crawford county, Ohio have done:

As Bob and Shirley make clear, routinely monitoring outcome and alliance and using the information to inform service delivery is a key to survival in these challenging economic times.

At ICCE, we are working with hundreds of agencies around the US and abroad to improve quality, effectiveness, and efficiency.  Soon, we’ll be gathering in Chicago for our annual “Training of Trainers” event.  The hands-on, intensive training is the first step to acquiring the skills necessary for navigatng the troubled waters ahead.  Here’s what attendee’s from last year said about the event:

Read more about the event or register online by clicking here.

Filed Under: Conferences and Training Tagged With: behavioral health, brief therapy, holland, icce

The "F" Word in Behavioral Health

April 20, 2011 By scottdm Leave a Comment

Since the 1960’s, over 10,000 how-to books on psychotherapy/counseling have been published—everything from nude marathon group therapy to the most recent “energy-based treatments.”  Clinicians have at their disposal literally hundreds of methods to apply to an ever growing list of diagnoses as codified in the Diagnostic and Statistical Manual of Mental Disorders (soon available in its 5th and expanded edition).

Conspicuously absent from the psychological cornucopia of diagnoses and treatments is the “F” word: FAILURE. A quick search of Amazon.com led to 32,670 results for the term, “psychotherapy,” 1,393 hits for “psychotherapy and depression,” and a mere 85 citations for “psychotherapy and failure.” Of the latter 85, less than 20 dealt with the topic of failure directly. There are some notable exceptions. The work of psychologist Jeffrey Kottler, for example. The dearth of information and frank discussion points to a glaring fact: behavioral health has a problem with failure.
The research literature is clear on the subject: we fail. Dropout rates have remained embarrassingly high over the last two and a half decades—hovering around 47%. At the same time, 10% of those who stay in services deteriorate while in care. Also troubling, despite the expansion of treatment modalities and diagnoses, the outcome of treatment (while generally good) has not improved appreciably over the last 30 or so years.  Finally, as reviewed recently on this blog, available evidence indicates that clinicians, despite what many believe, do not improve with experience.
In short, behavioral health is failing when it comes to failure. As a group, we do rarely address the topic. Even when we directly addressed, we find it hard to learn from our mistakes.
Our study of top performing clinicians and agencies documents that the best have an entirely different attitude toward failure than the rest. They work at failing. Everyday, quickly, and in small ways. In the lead article of upcoming Psychotherapy Networker, “The Path to Mastery” we review our findings and provide step-by-step, evidence-based directions for using failure to improve the quality and outcome of behavioral health. As we say in the article, “more than a dozen clinical trials, involving thousands of clients and numerous therapists, have established that excellence isn’t reserved for a select few. Far from it: it’s within the reach of all.” Getting there, however, requires that we embrace failure like never before.
At this year’s “Training of Trainers” (TOT) conference, building “mindful infrastructures” capable of identifying and using failure at the individual practitioner, supervisor, and agency level will be front and center. Please note: this is not an “advanced workshop” on client-directed, feedback-informed clinical work (CDOI/FIT). No lectures or powerpoint presentations. Participants get hands on experience learning to provide training, consultation, and supervision to therapists, agencies, and healthcare systems.
But, don’t take our word for it.  Listen to what attendees from the 2010 TOT said. Be sure and register soon as space is limited.

Filed Under: Behavioral Health, evidence-based practice, excellence, FIT Tagged With: behavioral health, brief therapy, Failure, holland, Jeffrey Kottler, meta-analysis, psychotherapy networker

Pushing the Research Envelope: Getting Researchers to Conduct Clinically Meaningful Research

November 5, 2010 By scottdm Leave a Comment

ACE Health Innovations - Developers of openFIT and mFIT

At the recent ACE conference, I had the pleasure of learning from the world’s leading experts on expertise and top performance.  Equally stimulating were conversations in the hallways between presentations with clinicians, policy makers, and researchers attending the event.  One of those was Bill Andrews, the director of the HGI Practice Research Network in the UK who work over the last 3+ years has focused on clinicians whose outcomes consistently fall in the top quartile of effectiveness.

In this brief interview, Bill talks about the “new direction” his research on top performing clinicians is taking.  He is truly “pushing the research envelope, challenging the field to move beyond the simplistic randomized clinical trials comparing different treatment packages.  Take a look:

Filed Under: Behavioral Health, Conferences and Training, evidence-based practice, Feedback Informed Treatment - FIT, Practice Based Evidence Tagged With: behavioral health, cdoi, continuing education, evidence based practice, icce

The Effects of Feedback on Medication Compliance and Outcome: Follow Up on The University of Pittsburgh Study

September 9, 2010 By scottdm Leave a Comment

Late last year, I blogged about a study being conducted at the University of Pittsburgh by Dr. Jan Pringle, the director of the Program Evaluation Research Unit in the School of Pharmacology and her colleague, Dr. Michael Melczak.  You’ll recall, there were two conditions in the study.   In the first, pharmacists–the practitioner most likely to interact with patients about prescriptions–engaged in “practice as usual.”  In the second condition, pharmacists used the ORS and the SRS to chart, discuss, and guide patient progress and the pharmacist-patient alliance.  At the time, I reported that initial findings showed that patients of pharmacists who used the measures to solicit feedback “were significantly more likely to take their medications at the levels that would be likely to result in clinical impact than the patients who saw a pharmacists who did not use the scales…for hypertensive and hyperlipidemia drugs especially.”  Well, the official results are finally available.

After controlling for age, gender, and other individual and control conditions (including measures of interactions with pharmacies), patients in the feedback condition increased their rate of “percent of days covered”–that is, taking the medication as prescribed–significantly (average 11%, a result considered “impressive” when compared to other, traditional efforts aimed at improving compliance).  Interestingly, additional analyses showed that the impact of the SRS–a measure of the therapeutic alliance–was greatest for the hyplipidemia and hypertensive medications (as opposed to the anti-diabetic medications).

Drs. Pringle and Melczak are currently in the process of planning a series of additional studies involving a larger number of patients and pharmacists.  Both will be presenting at the upcoming Achieving Clinical Excellence conference.

Finally, take a look at the video that was developed to begin training pharmacists to use the measures with customers filling prescriptions at local pharmacies.  According to Dr. Pringle, “we expect to training about 240 pharmacists across 118 pharmacies in the western and central portions of Pennsylvania how to use the ORS and SRS…the program represents a collaboration between the University of Pittsburgh, CECity (a technology company), RiteAid, and Highmark ( a Blues insurer).”  Exciting stuff, eh?

Filed Under: Behavioral Health, medication adherence Tagged With: behavioral health, blue cross, cdoi, highmark, Hyperlipidemia, Hypertension, medication adherence, Pharmacology, randomized clinical trial, riteaid

Ohio Update: Use of CDOI improves outcome, retention, and decreases "board-level" complaints

August 5, 2010 By scottdm Leave a Comment

A few days ago, I received an email from Shirley Galdys, the Associate Director of the Crawford-Marion Alcohol and Drug/Mental Health Services Board in Marion, Ohio.  Back in January, I blogged about the steps the group had taken to deal with the cutbacks, shortfalls, and all around tough economic circumstances facing agencies in Ohio.  At that time, I noted that the dedicated administrators and clinicians had improved the effectiveness and efficiency of treatment so much by their systematic use of Feedback-Informed Treatment (FIT) that they were able to absorb cuts in funding and loss of staff without having to cut services to their consumers.

Anyway, Shirley was writing because she wanted to share some additional good news.  She’d just seen an advance copy of the group’s annual report.  “Since we began using FIT over two years ago,” she wrote, “board level complaints and grievances have decreased!”

In the past, the majority of such complaints have centered on client rights.  “Because of FIT,” she continued, “we are making more of an effort to explain to people what we can and cannot do for them as part of the ‘culture of feedback’….we took a lot for granted about what people understood about behavioral health care prior to FIT.”

The Crawford-Marion Alcohol and Drug/Mental Health Services Board is now into the second full year of implementation.  They are not merely surviving, they are thriving!  In the video below, directors Shirley Galdys, Bob Moneysmith, and Elaine Ring talk about the steps for a successful implementation.

Filed Under: Behavioral Health, Feedback Informed Treatment - FIT, FIT, Implementation Tagged With: addiction, behavioral health, cdoi, mental health, shirley galdys

Error-centric Practice: How Getting it Wrong can Help you Get it Right

July 22, 2010 By scottdm 1 Comment

It’s an idea that makes intuitive sense but is simultanesouly unappealing to most people. I, for one, don’t like it.  What’s more, it flies in the face of the “self-esteem” orientation that has dominated much of educational theory and practice over the last several decades.  And yet, research summarized in a recent issue of Scientific American Mind is clear: people learn the most when conditions are arranged so that they have to make mistakes.   Testing prior to learning, for example, improves recall of information learned after failing the pre-test regarding that same information.  As is well known, frequent testing following learning and/or skill acquisition significantly enhances retention of knowledge and abilities.  In short, getting it wrong can help you get it right more often in the future.

So, despite the short term risk to my self-esteem, “error-centric learning” is an evidence-based practice that I’m taking to heart.  I’m not only applying the approach in the trainings I offer to mental health professionals–beginning all of my workshop with a fun, fact-filled quiz–but in my attempts to master a completely new skill in my personal life: magic and mind reading.  And if the number of mistakes I routinely make in these pursuits is a reliable predictor of future success, well…I should be a master mind reading magician in little more than a few days.

Enough for now–back to practicing.  Tonight, in my hotel room in Buffalo, New York, I’m working on a couple of new card tricks.  Take a look at the videos of two new effects I recorded over the weekend.  Also, don’t miss the interview with Cindy Voelker and John Catalino on the implementation of Feedback-Informed Treatment (FIT) at Spectrum Human Services here in Buffalo.

Filed Under: deliberate practice, Feedback Informed Treatment - FIT, Practice Based Evidence Tagged With: Alliance, behavioral health, cdoi, holland, Norway, randomized clinical trial, scientific american

Feedback Informed Treatment (FIT): A Worldwide Trend in Behavioral Health

July 14, 2010 By scottdm Leave a Comment

In my prior blogpost, I reviewed exciting developments taking place throughout Canada regarding “feedback-informed treatment” (FIT).  For those following me on Twitter–and if you’re not, please do so by clicking on the link–you already know that last week I was in Tunbridge, England for a two day training sponsored by the Kent-Medway National Healthcare Trust on “Supershrinks: Learning from the Fields Most Effective Practitioners.”  Interest in outcomes is growing exponentially, becoming a worldwide phenomenon.

It was a real pleasure being asked to work with the dedicated–and I must say, long-suffering–physicians, psychologists, counselors, social workers, and nurses of the NHS Trust.  I say “long-suffering” because these healthcare professionals, like others around the globe, are laboring to provide effective services while contending with a back breaking amount of paperwork, oversight, mandated treatment protocols, and regulation.

Much of the mess that behavioral health practitioners find themselves in is due to the way “good practice” is and has been conceptualized.  Simply put, the field–it’s researchers, visionaries, policy makers and sadly, many clinicians–are still stuck in the penicillin era, promoting specific treatments for specific disorders.  The result has been a growing list of protocols, fidelity and adherence measures, and other documentation requirements.  As pointed Bohanske and Franzcak point out in their excellent chapter on transforming behavioral health in the latest edition of The Heart and Soul of Change: Delivering What Works in Therapy, “The forms needed to obtain a marriage certificate, buy a new home, lease an automobile, apply for a passport, open a bank account, and die of natural causes…altogether…weigh 1.4 ounces.  By contrast, the paperwork required for enrolling a single mother in counseling to talk about difficulties her child [is] experiencing [weigh] 1.25 pounds” (p. 300).

Something has to change, and that something is the incessant focus on controlling the process–or “how”– of treatment.  Instead, as the video interview below illustrates, emphasis can be placed on outcome.  Doing so will not only simplify oversight and regulation but, as an increasing number of studies show, result in improved “FIT” and effect of services offered.

 

Filed Under: Behavioral Health, Feedback Informed Treatment - FIT Tagged With: behavioral health, bohanske, Canada, cdoi, England, evidence based practice, feedback informed treatment, franzcak, icce, Kent-Medway National Healthcare Trust, randomized clinical trial

After the Thrill is Gone: Sustaining a Commitment to Routinely Seeking Feedback

May 8, 2010 By scottdm Leave a Comment


Helsingor Castle (the setting for Shakespeare’s Hamlet)

Dateline: May 8th, 2010, Helsingor, Denmark

This weekend I’m in Denmark doing a two-day workshop on “Supershrinks” sponsored by Danish psychologist and ICCE Senior Associate and Trainer Susanne Bargmann.  Just finished the first day with a group of 30 talented clinicians working diligently to achieve their personal best.  The challenge, I’m increasingly aware, is sustaining a commitment to seeking client feedback over time once the excitement of a workshop is over.  On the surface, the idea seems simple: ask the consumer.  In practice however, it’s not easy.  The result is that many practitioners who are initially enthusiastic lose steam, eventually setting aside the measures.  It’s a serious concern given that available evidence documents the dramatic impact of routine outcome and alliance monitoring on outcome and retention in behavioral health.

Support of like-minded colleagues is one critical key for sustaining commitment “after the thrill is gone.”  Where can you find such people?  As I blogged about last week, over a thousand clinicians are connecting, sharing, and supporing each other on the web-based community of the International Center for Clinical Excellence (If you’re not already a member, click here to request your own personal (and free) invitation to join the conversation).

In the brief interview above, Susanne identifies a few additional steps that practitioners and agencies can take for making the process of seeking feedback successful over the long haul.  By the way, she’ll be covering these principles and practices in detail in an afternoon workshop at the upcoming Achieving Clinical Excellence conference.  Don’t miss it!

Filed Under: Conferences and Training, excellence, Feedback Informed Treatment - FIT Tagged With: addiction, behavioral health, evidence based practice, Therapist Effects

Feedback, Friends, and Outcome in Behavioral Health

May 1, 2010 By scottdm Leave a Comment


My first year in college, my declared major was accounting.  What can I say?  My family didn’t have much money and my mother–who chose my major for me–thought that the next best thing to wealth was being close to money.

Much to her disappointment I switched from accounting to psychology in my sophomore year.  That’s when I first met Dr. Michael Lambert.


Michael J. Lambert, Ph.D.

It was 1979 and I was enrolled in a required course taught by him on “tests and measures.”  He made an impression to be sure.  He was young and hip–the only professor I met while earning my Bachelor’s degree who insisted the students call him by his first name.  What’s more, his knowledge and passion made what everyone considered the “deadliest” class in the entire curriculum seem positively exciting.  (The text, Cronbach’s classic Essentials of Psychological Testing, 3rd Edition, still sits on my bookshelf–one of the few from my undergraduate days).  Within a year, I was volunteering as a “research assistant,” reading and then writing up short summaries of research articles.

Even then, Michael was concerned about deterioration in psychotherapy.  “There is ample evidence,” he wrote in his 1979 book, The Effects of Psychotherapy (Volume 1), “that psychotherapy can and does cause harm to a portion of those it is intended to help” (p. 6).  And where the entire field was focused on methods, he was hot on the trail of what later research would firmly establish as the single largest source of variation in outcome: the therapist.  “The therapist’s contribution to effective psychotherapy is evident,” he wrote, “…training and selection on dimensions of…empathy, warmth, and genuineness…is advised, although little research supports the efficacy of current training procedures.”  In a passage that would greatly influence the arc of my own career, he continued, “Client perception…of the relationship correlate more highly with outcome that objective judges’ ratings” (Lambert, 1979, p. 32).

Fast forward 32 years.  Recently, Michael sent me a pre-publication copy of a mega-analysis of his work on using feedback to improve outcome and reduce deterioration in psychotherapy.  Mega-analysis combines original, raw data from multiple studies–in this case 6–to create a large, representative data set of the impact of feedback on outcome.  In his accompanying email, he said, “our new study shows what the individual studies have shown.”  Routine, ongoing feedback from consumers of behavioral health services not only improves overall outcome but reduces risk of deterioration by nearly two thirds!    The article will soon appear in the Journal of Consulting and Clinical Psychology.

Such results were not available when I first began using Lambert’s measure–the OQ 45–in my clinical work.  It was late 1996.  My colleagues and I had just put the finishing touches on Escape from Babel, our first book together on the “common factors.”

That’s when I received a letter from my colleague and mentor, Dr. Lynn Johnson.


Lynn D. Johnson, Ph.D.

In the envelop was a copy of an article Lynn had written for the journal, Psychotherapy entitled, “Improving Quality in Psychotherapy” in which he argued for the routine measurement of outcome in psychotherapy.  He cited three reasons: (1) providing proof of effectiveness to payers; (2) enabling continuous analysis and improvement of service delivery; and (3) giving consumers voice and choice in treatment.  (If you’ve never read the article, I highly recommend it–if for no other reason than its historical significance.  I’m convinced that the field would be in far better shape now had Lynn’s suggestions been heeded then).

Anyway, I was hooked.  I soon had a bootleg copy of the OQ and was using it in combination with Lynn’s Session Rating Scale with every person I met.

It wasn’t always easy.  The measure took time and more than a few of my clients had difficulty reading and comprehending the items on the measure.  I was determined however, and so persisted, occasionally extending sessions to 90 minutes so the client and I could read and score the 45-items together.

Almost immediately, routinely measuring and talking about the alliance and outcome had an impact on my work.  My average number of sessions began slowly “creeping up” as the number of single-session therapies, missed appointments, and no shows dropped.  For the first time in my career, I knew when I was and was not effective.  I was also able to determine my overall success rate as a therapist.  These early experiences also figured prominently in development of the Outcome Rating Scale and revision of the Session Rating Scale.

More on how the two measures–the OQ 45 and original 10-item SRS–changed from lengthy Likert scales to short, 4-item visual analog measures later.  At this point, suffice it to say I’ve been extremely fortunate to have such generous and gifted teachers, mentors, and friends.

Filed Under: Feedback Informed Treatment - FIT Tagged With: behavioral health, cdoi, continuing education, evidence based practice, holland, icce, Michael Lambert, Paychotherapy, public behavioral health

ICCE Membership Hits 1000!

April 28, 2010 By scottdm Leave a Comment

Just yesterday, the membership of the International Center for Clinical Excellence burst through the 1000 mark, making it the largest community of behavioral health professionals dedicated to excellence and feedback informed treatment (FIT).  And there’s more news…click on the video below.

Filed Under: ICCE Tagged With: addiction, behavioral health, cdoi, common factors, psychotherapy, Therapist Effects

More Eruptions (in Europe and in Research)

April 20, 2010 By scottdm Leave a Comment

Dateline: Tuesday, 8:21pm, April 20th, 2010, Skellefteå, Sweden

What an incredible week.  Spent the day today working with 250 social workers, case managers, psychologists, psychiatrists, and agency directors in the far nothern town of Skellefteå, Sweden.  Many practitioners here are already measuring outcomes on an ongoing basis and using the information to improve the results of their work with consumers of behavioral health services.  Today, I presented the latest findings from ICCE’s ongoing research on “Achieving Clinical Excellence.”

I’ve been coming to the area to teach and consult since the early 1990’s, when I was first invited to work with Gun-Eva Langdahl and the rest of the talented crew at Rådgivningen Oden (RO).  As in previous years, I spent my first day (Monday) in Skellefteå watching sessions and working with clients at RO clinic.  Frankly, getting to Skellefteå from Goteborg had been a bit of ordeal.  What usually took a little over an hour by plane ended up being a 12-hour combination of cars, trains, and buses–all due to volcanic eruptions on Iceland.  (I shudder to think of how I will get from Skellefteå to Amsterdam on Wednesday evening if air travel doesn’t resume).

Anyway, the very first visit of the day at Rådgivningen Oden was with an adolescent and her parents.  Per usual, the session started with the everyone completing and discussing the Outcome Rating Scale.  The latest research reported in the April 2010 edition of Journal of Consulting and Clinical Psychology (JCCP) confirms the wisdom of this practice: measuring and discussing progress with consumers at every visit results in better outcomes.

It turns out that adolescents are at greater risk for deteriorating in treatment than adults (20% versus 10%).  Importantly, the study in JCCP by Warren, Nelson, Mondragon, Baldwin, and Burlingame found that the more frequently measures are used the less likely adolescents are to worsen in care.  Indeed, as ICCE Senior Associate Susanne Bargmann pointed out in a series of recent emails about this important study, “routinely tracking and discussing progress led to 37% higher recovery rates and 38% lower rates of deterioration!”

Skellefteå is a hotbed of feedback-informed practice in Sweden.  Accompanying the family at Rådgivningen Oden, for example, were professionals from a number of other agencies involved in the treatment and wanting to learn more about outcome-informed practice.  As already noted, 250 clinicians took time away from their busy schedules to hear the latest information and finesse their use of the measures.  And tomorrow, Wednesday, I meet with managers and directors of behavioral health agencies to discuss steps for successfully implementing routine measurement of progress and feedback in their settings.  You can download a video discussing the work being done by the team at Odin in Northern Sweden, by clicking here.

Stay tuned for more.  If all goes well, I’ll be in Amsterdam by Wednesday evening.

Filed Under: Behavioral Health, evidence-based practice, Feedback Informed Treatment - FIT Tagged With: behavioral health, continuing education, Journal of Consulting and Clinical Psychology, medicine, meta-analysis, public behavioral health

Eruptions in Europe and in Research

April 18, 2010 By scottdm 3 Comments

Dateline: 11:20 am, April 18th, 2010

Today I was supposed to fly from Stockholm, Sweden to the far northern town of Skelleftea–a flight that takes a little over an hour.  Instead, I’m sitting on a train headed for Sundsvall, the first leg of a 12 hour trip that will include a 6 hour bus ride and then a short stint in a taxi.

If you’ve been following the news coming out of Europe, you know that all flights into, out of, and around Europe have been stopped. Eyjafjallajokull–an Icelandic volcano–erupted the day after I landed in Goteborg spewing an ash cloud that now covers most of Europe disrupting millions of travellers.  People are making due, sleeping on cots in airline, train, and bus terminals and using Facebook and Twitter to connect and arrange travel alternative.

In the meantime, another eruption has taken place with the publication of the latest issue of the Journal of Consulting and Clinical Psychology that threatens to be equally disruptive to the field of psychotherapy–and to proponents of the narrow, specific-treatments-for-specific-disorders or “evidence-based treatments” movement.   Researchers Webb, DeRubeis, and Barber conducted a meta-analysis of studies examining the relationship between adherence to and competence in delivering a particular approach and outcome.  The authors report finding that, “neither adherence nor competence was…related to patient (sic) outcome and indeed that the aggregate estimates of their effects were very close to zero.”

Zero!  I’m not sure what zero means to everyone else, but where I come from it’s pretty close to nothing.  And yet, the romance with the EBT movement continues among politicians, policy makers, and proponents of specific treatment models.  Each year, millions and millions of dollars of scarce resources are poured into an approach to behavioral health that accounts for exactly 0% of the results.

Although it was not a planned part of their investigation, the must-read study by Webb, DeRubeis, and Barber also points to the “magma” at the heart of effective psychotherapy: the alliance, or quality of the relationship between consumer and provider.  The authors report, for example, finding “larger competence-outcome effect size estimates [in studies that]…did not control for the influence of the alliance.”

The alliance will take center stage at the upcoming, “Achieving Clinical Excellence” and “Training of Trainers” events.  Whatever you thought you knew about effective therapeutic relationships will be challenged by the latest research from our study of top performing clinicians worldwide.  I hope you’ll join our international group of trainers, researchers, and presenters by clicking on either of the links above.  And, if you’ve not already done so, be sure and visit the International Center for Clinical Excellence home page and request an invitation to join the community of practitioners and researchers who are learning and sharing their expertise.

Filed Under: Behavioral Health, Practice Based Evidence Tagged With: behavioral health, brief therapy, continuing education, icce, Journal of Consulting and Clinical Psychology, Outcome, public behavioral health

Improving Outcomes in the Treatment of Obesity via Practice-Based Evidence: Weight Loss, Nutrition, and Work Productivity

April 9, 2010 By scottdm 4 Comments

Obesity is a large and growing problem in the United States and elsewhere.  Data gathered by the National Center for Health Statistics indicate that 33% Americans are obese.  When overweight people are added to the mix, the figure climbs to a staggering 66%!   The problem is not likely to go away soon or on its own as the same figures apply to children.

Researchers estimate that weight problems are responsible for over 300,000 deaths annually and account for 12% of healthcare costs or 100 billion–that’s right, $100,000,000,000–in the United States alone.   The overweight and obese have higher incidences of arthritis, breast cancer, heart disease, colorectal cancer, diabetes, endometrial cancer, gallbladder disease, hypertension, liver disease, back pain, sleeping problems, and stroke–not to mention the tremendous emotional, relational, and social costs.  The data are clear: the overweight are the target of discrimination in education, healthcare, and employment.  A study by Brownell and Puhl (2003), for example, found that: (1) a significant percentage of healthcare professionals admit to feeling  “repulsed” by obese person, even among those who specialize in bariatric treatment; (2) parents provide less college support to their overweight compared to “thin” children; and (3) 87% of obese individuals reported that weight prevented them from being hired for a job.

Sadly, available evidence indicates that while weight problems are “among the easiest conditions to recognize,” they remain one of the “most difficult to treat.”  Weight loss programs abound.  When was the last time you watched television and didn’t see an ad for a diet pill, program, or exercise machine?  Many work.  Few, however, lead to lasting change.

What might help?

More than a decade ago, I met Dr. Paul Faulkner, the founder and then Chief Executive Officer of Resources for Living (RFL), an innovative employee assistance program located in Austin, Texas.  I was teaching a week-long course on outcome-informed work at the Cape Cod Institute in Eastham, Massachusetts.  Paul had long searched for a way of improving outcomes and service delivery that could simultaneously be used to provide evidence of the value of treatment to purchasers–in the case of RFL, the large, multinational companies that were paying him to manage their employee assistance programs.  Thus began a long relationship between me and the management and clinical staff of RFL.  I was in Austin, Texas dozens of times providing training and consultation as well as setting up the original ORS/SRS feedback system known as ALERT, which is still in use at the organization today.  All of the original reliability, validity, norming, and response trajectories were done together with the crew at RFL.

Along the way, RFL expanded services to disease management, including depression, chronic obstructive pulmonary disease, diabetes, and obesity.  The “weight management” program delivered coaching and nutritional consultation via the telephone informed by ongoing measurement of outcomes and the therapeutic alliance using the SRS and ORS.  The results are impressive.  The study by Ryan Sorrell, a clinician and researcher at RFL, not only found that the program and feedback led to weight loss, but also significant improvements in distress, health eating behaviors (70%), exercise (65%), and presenteeism on the job (64%)–the latter being critical to the employers paying for the service.

Such research adds to the growing body of literature documenting the importance of “practice-based” evidence, making clear that finding the “right” or “evidence-based” approach for obesity (or any problem for that matter) is less important than finding out “what works” for each person in need of help.  With challenging, “life-style” problems, this means using ongoing feedback to inform whatever services may be deemed appropriate or necessary.  Doing so not only leads to better outcomes, but also provides real-time, real-world evidence of return on investment for those footing the bill.

Filed Under: Behavioral Health, Feedback Informed Treatment - FIT, Practice Based Evidence Tagged With: behavioral health, cdoi, cognitive-behavioral therapy, conferences, continuing education, diabetes, disease management, Dr. Paul Faulkner, evidence based medicine, evidence based practice, Hypertension, medicine, obesity, ors, outcome rating scale, practice-based evidence, public behavioral health, randomized clinical trial, session rating scale, srs, Training

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