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National Psychotherapy Day: A Recognition, Celebration, and Call for Action

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With all the challenges facing the profession, it is important to highlight people and organizations that are working hard to make a difference.  On that note, tomorrow, Tuesday the 25th of September 2012 is the very first National Psychotherapy Day.  Having a day of unified, active promotion of psychotherapy is the brain child of psychologist Ryan Howes.  At his side is the Psychotherapy Foundation (PF), a nonprofit foundation, dedicated to promoting the therapeutic relationship as an “effective, long-lasting, collaborative approach” to resolving emotional, behavioral, and relational problems.  What’s not to like?  Dr. Howes and the PF are encouraging people who have seen a therapist to talk or blog about their experience.  They are calling on therapists to commit to sharing research documenting the effectiveness of psychotherapy with the public (write a letter to the editor of your local paper, offer to do an interview, give a brief presentation at the Chamber of Commerce).

Surveys show that the two primary barriers to seeking the help of a therapist are: (1) cost of the service (cited by 81%); and (2) lack of confidence in the outcome of therapy (78%).  Of these two barriers, the first is entirely understandable.  Times are tough and treatment costs money.  It is for these this reason that Dr. Howe and the PF are asking all who participate in the day to support their local, low-fee counseling centers in whatever way possible.

The second barrier is more troubling and, frankly, difficult to understand and address.  Research overwhelmingly supports the efficacy of psychological treatment.  Indeed, the American Psychological Association issued a rare, formal resolution this last month recognizing the effectiveness of psychotherapy!  Listen to the language:

  • Whereas the effects of psychotherapy …are widely accepted to be significant and large;
  • Whereas the results of psychotherapy tend to last long and be less liely to equire additional treatment courses than psychopharmacological treatments;
  • Whereas comparisons of different forms of psychotherapy most often result in relatively nonsignificant difference, and contextual and relationship factors (not captured by a patient’s diagnosis or by the therapists use of a specific psychotherapy) mediate or moderate outcomes;
  • Whereas the best research evidence conclusively shows that individual, group, and couple/family psychotherapy are effective for a broad range of…problems with children, adolescents, adults, and older adults;
  • THEREFORE be it resolved that, as a healing practice and professional service, psychotherapy is effective and highly cost effective…and should be included in the health care system as an established evidence-based practice.

Strong words, right?  Even so, it’s very clear that the public’s lingering doubts about effectiveness will require than a proclamation.  It is for this reason that Dr. Howes and PF are asking all those currently in care to provide constructive feedback to their therapist.  Therapists, in turn, are encouraged to seek and respond to feedback from their clients.   As reviewed here on this blog, numerous studies document the positive impact that routine feedback from clients has on retention and outcome of service.  Free evidence-based tools are available for download from this website for soliciting formal feedback from consumers.  Plus, the International Center for Clinical Excellence web-based community–the largest group of clinicians and researchers dedicated to improving the quality and outcome of psychotherapy via the use of ongoing feedback–stands ready and willing to be of support.

So, why the turquoise?  Well, its’ the official color of National Psychotherapy Day.  To show your support, Dr. Howes and PF are asking all to wear something with that color tomorrow.

Mental Health Practice in a Global Economy

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Did you feel it?  The seismic shift that occurred in field of mental health just a little over a month ago?  No?  Nothing?  Well, in truth, it wasn’t so much a rip in the space-time continuum as a run.  That “run,” however, promises to forever alter the fabric of clinical practice–in particular how clinicians earn and maintain a certain standard of living.

For decades, licensing statutes have protected behavioral health professionals from competing with providers living outside of their state and local jurisdiction.  In order to bill or receive reimbursement, mental health professionals needed to be licensed in the state in which treatment services were offered.  Over the years, the various professional organizations have worked to make it easier for professionals to become licensed when they move from one state to the another.  Still, it ain’t easy and, some practitioners and professional groups would argue, for good reason.  Such laws, to some extent, insure that fees charged for services are commensurate with the cost of living in the place where therapists live and work.  The cost of therapy in Manhattan varies considerably, for example, depending on whether one is talking about the city located in state of New York or Kansas.

As far as outcomes are concerned, however, there is no evidence that people who pay more necessarily get better results.  Indeed, as reviewed here on this blog, available evidence indicates little or no difference in outcome between highly trained (and expensive) clinicians and minimally trained (and less expensive) para-professionals and students.  If the traditional geographic (licensing) barriers were reduced or eliminated, consumers would with few exceptions gravitate to the best value for their money.  In the 1980’s and 90’s, for example, comsumers deserted small, Main Street retailers when big box stores opened on the outskirts of town offering the same merchandise at a lower price.  Now, big box retailers are closing en masse as consumers shift their purchases to less expensive, web based outlets.

And that’s precisely the shift that began a little over a month ago in the field of mental health.  The U.S. Military eliminated the requirement that civilian providers be licensed in the same jurisdiction or state in which treatment is offered.  The new law allows care to be provided wherever the receipient of services lives and regardless of where the provider is licensed.  Public announcements argued that the change was needed to make services available to service members and veterans living in isolated or rural areas where few providers may be available.  Whatever the reason, the implications are profound: in the future, clinicians, like Main Street retailers, will be competing with geographically distant providers.

Just one week prior to the announcement by the U.S. Military, I posted a blogpost highlighting a recent New York Times column by author and trend watcher, Thomas Friedman.  In it, I argued that “Globalization and advances in information technology were…challenging the status quo…access. At one time, being average enabled one to live an average life, live in an average neighborhood and, most importantly, earn an average living.  Not so anymore.  Average is now plentiful, easily accessible, and cheap. What technology can’t do in either an average or better way, a younger, less-trained but equally effective provider can do for less. A variety of computer programs and web-based systems provide both psychological advice and treatment.”

Truth is, the change is likely to be a boon to consumers of mental health services: easier access to services at a better price.  What can clinicians do?  First, begin measuring outcome.  Without evidence of their effectiveness, individual providers will lose out to the least expensive provider.  No matter how much people complain about “big box and internet retailers,” most use them.  The savings are too great to ignore.

What else can clinicians do?  The advice of Friedman, which I quoted in my recent blogpost, applies, “everyone needs to find their extra–their unique value contribution that makes them stand out in whatever is their field.” Measuring outcome and finding that “something special” is what the International Center for Clinical Excellence is all about.  If you are not a member, please join the thousands of other professionals online today.   After that, why not spend time with peers and cutting edge instructors at the upcoming “advanced intensive” or “training of trainers” workshops this summer.

Excellence "Front and Center" at the Psychotherapy Networker Conference

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This year, the Psychotherapy Networker is celebrating it’s 35th anniversary.  I’m not going to let on how long I’ve been a reader and subscriber, but I can say that I eagerly anticipate each issue.  Rich Simon and his incredibly dedicated and talented crew always seem to have their fingers on the pulse of the profession.

It is no accident that our most recent work on achieving excellence in behavioral health appeared in the pages of the Networker–in 2007, our study of top performing clinicians, “Supershrinks,” and then last year, “The Road to Mastery” which layed out the most recent findings as well as identified the resources necessary for the development of therapeutic expertise.

I was deeply honored when Rich Simon asked me to give one of the plenary addresses at this year’s Networker Symposium, March 22-25th, 2012.  The theme of this year’s event is, “Creating a New Wisdom: The Art and Science of Optimal Well Being” and I’ll be delivering Friday’s luncheon address on applying the science of expertise to the world of clinical practice.

Click here to register online and join me for 3 fantastic days at this historic meeting.

Psychologist Alan Kazdin Needs Help: Please Give

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Look at this picture.  This man needs help.  He is psychologist, Alan Kazdin, former president of the American Psychological Association, and current Professor of Psychology at Yale University.  A little over a week ago, to the surprise and shock of many in the field, he disclosed a problem in his professional life.  In an interview that appeared online at TimeHealthland Dr. Kazdin reported being unable to find a therapist or treatment program to which he could refer clients–even in Manhattan, New York, the nation’s largest city!

After traveling the length and breadth of the United States for the last decade, and meeting and working with hundreds of agencies and tens of thousands of therapists, I know there are many clinicians that can help Dr. Kazdin with his problem.  Our group has been tracking the outcome of numerous practitioners over the last decade and found average outcomes to be on par with those obtained in tightly controlled randomized clinical trails!  That’s good news for Dr. Kazdin.

Now, just to be sure, it should be pointed out that Dr. Kazdin is asking for practitioners who adhere to the Cochrane Review’s and the American Psychological Association’s definition of evidence-based practice (EBP)–or, I should say, I believe that is what he is asking for as the interview is not entirely clear on this point and appears to imply that EBP is about using specific treatment methods (the most popular, of course, being CBT).  The actual definition contains three main points, and clearly states that EBP is the integration of:

  1. The best available research;
  2. Clinical expertise; and
  3. The client’s culture, values, and preferences.

Interestingly, the official APA policy on evidence-based practice further defines clinical expertise as the “monitoring of patient progress (and of changes in the patient’s circumstances)…that may suggest the need to adjust the treatment.  If progress is not proceeding adequately, the psychologist alters or addresses problematic aspects of the treatment (e.g., problems in the therapeutic relationship or in the implementation of the goals of the treatment) as appropriate.”

I say “interestingly” for two reasons.  First, the definition of EBP clearly indicates that clinicians must tailor psychotherapy to the individual client.  And yet, the interview with Dr. Kazdin specifically quotes him as saying, “That’s a red herring. The research shows that no one knows how to do that. [And they don’t know how to monitor your progress].”   Now, admittedly, the research is new and, as Dr. Kazdin says, “Most people practicing who are 50 years or older”–like himself–may not know about it, but there are over a dozen randomized clinical trials documenting how routinely monitoring progress and the relationship and adjusting accordingly improves outcome.  The interview also reports him saying that “there is no real evidence” that the relationship (aka alliance) between the therapist and client matters when, in fact, the APA Interdivisional Task Force on Evidence-Based Therapy Relationships concluded that there is abundant evidence that “the therapy relationship accounts for substantial and consistent contributions to…outcome….at least as much as the particular method.”  (Incidently, the complete APA policy statement on EBP can be found in the May-June 2006 issue of the American Psychologist).

Who knows how these two major bloopers managed to slip through the editing process?  I sure know I’d be embarrased and immediately issue a clarification if I’d been misquoted making statements so clearly at odds with the facts.  Perhaps Dr. Kazdin is still busy looking for someone to whom he can refer clients.  If you are a professional who uses your clinical expertise to tailor the application of scientifically sound psychotherapy practices to client preferences, values, and culture, then you can help.

Is Psychotherapy Dead?

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“AMERICANS PREFER DRUGS” screams the headline posted by the Reuters news service and attributed to Consumer Reports–one of the most respected periodical for the average American reader.  “NEARLY 80 PERCENT TAKE A PILL FOR DEPRESSION,” the article continues.  Read a little further and do some searching around on the internet and a different story emerges.  Americans it turns out don’t necessarily prefer drugs but rather, “78 percent of those seeking treatment for depression or anxiety were prescribed antidepressants.”

With respected news agencies advertizing for the pharaceutical companies, is it any wonder why the practice of “talk therapy” is suffering?  AA’s Executive Director for Professional Practice, Dr. Kaherine Nordal, in a recent editorial asked, “Where has all the psychotherapy gone?”  The percentage of Americans who receive outpatinet mental health care has remained unchanged over the last several decades.  Moreover, as Dr. Mark Hubble and I point out in the lead article in the May-June issue of the Psychotherapy Networker, “median incomes for psychologists, both applied and academic, have dropped between 17 and 33 percent at the same time that workloads have increaed, profssional autonomy has been subverted, and funding for public behavioral healthcare has all but disappeared.”

In a recent, highly publicized exchange on psychotherapy that appeared on Medscape: Psychiatry and Health, panel participants (all psychiatrists) repeated the same, old, tired argument about the field.  To wit, “the research base is insufficient.”   How such statements can be made with a straight face, much less by mental health professionals, on a public website, defies explanation.   The truth is, the evidence-base for psychological treatments is as large and robust as any.  What’s more, seeing a talk therapist does not require invasive surgery or a black box warning.  Clearly, the issue is not research.  It is about awareness.

The members and associates of the International Center for Clinical Excellence (ICCE) are working diligently to raise consciousness among the public and policy makers.  Every day, 1000’s of professionals connect to, learn from, and share with colleagues around the world.  The mission of the organization?  To use community to improve the quality and outcome of behavioral health services.  On the ICCE web-based community, clinicians share experiences and real world data regarding the effectiveness of talk therapy.  For example, ICCE associate Dan Buccino shared outcomes from a 7 year project aimed at “promoting recovery and accountability.”  Using the Outcome and Session Ratings Scales, Dan documented effectiveness levels that far exceeded national benchmarks for clinical practice.  Why not email him for a copy of the report?  Meanwhile, providers serving US Airforce personnel began using the same measures in early 2010 and have reported very similar findings.  Finally, to date, more than a dozen randomized clinical trials, involving thousands of clients and numerous therapists, have established that using feedback to inform services increases effectiveness of individual practitioners three fold, cuts dropout rates by 50 percent, reduces the rate of deterioration by 33 percent, and speeds recovery by 66 percent, while simultaensouly improving client satisfaction and reducing the cost of care.

To paraphrase Mark Twain, the rumored death of psychotherapy has been greatly exaggerated.  Now is not the time, however, to merely hope for a better future.  Join the discussion taking place on ICCE  right now.  Membership is free and a strong, supportive community just a few clicks away.

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

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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.

The "F" Word in Behavioral Health

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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.

Cha-cha-cha-changes on a Grand Scale: Think Tank Meets in Chicago

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David Mee-Lee, MD     Bill Miller, Ph.D.     Scott D. Miller, Ph.D.

Jim Prochaska, Ph.D.                                    Don Kuhl, CEO

Whether in the United States or Europe, Asia or Australia, the field of behavioral health is undergoing a period of dramatic change–some would say, “transformation.”  At least that’s the verdict of the group bought together by the CEO of The Change Companies, Don Kuhl, who brought together some of the leading figures in behavioral health for two days of discussion and brainstorming last week in Chicago.

Chief on the list of issues to be discussed was bringing “scale” to the provision of mental health and substance abuse services.  Let’s face it, the current service provision model is broken: many people in need of help, do not get it.  The care that is provided is often limited in scope and does not address the “whole person.”  And finally, healthcare costs are soaring–particularly among those with longstanding, chronic problems requiring ongoing care.

In spite of 40 years of research support, behavioral health–that is, psychological interventions–are losing ground to other approaches to change.  Consider the following data published by Katherine Nordal: “the percentage of Americans who receive outpatient mental health care…is very similar to the proportion of those receiving such treatment in 1998.”

Let’s see, that’s two decades of no growth!  None. Zero. Zip. Nada.

Dr. Nordal continues, “Overall, there has been a decrease in the use of psychotherapy, a decrease in the use of psychotherapy in conjunction with medication and a big increase in the use of medication only.”  The question that begs to be answered is why, especially when one considers that psychological intervention (whether face to face, on the phone, in a book or together with peers in a group) has a side effect profile that is the envy of the pharmaceutical industry: no weight gain, no sexual dysfunction, no sleep disturbance or dry mouth.

Many factors are, of course, responsible for the demise of behavioral health (By the way, have you noticed the size of the psychology section of your local bookstore.  Its miniscule compared to what it was a decade ago, and the majority of the titles that are available praise neuroscience over human connection, and drugs over talk).  Dr. Nordal cites the rise of managed care and gargantuan advertizing budgets of the pharmaceutical industry.  Others cite cultural changes including a “short-term fix” mentality and the increasingly frenetic pace of life.

Whatever the cause, the problem is not the lack of effective psychological treatments.  Rather, the issue is that more people need to be helped, more quickly and efficiently.  “Helping people make behavioral change,” Dr. Jim Prochaska argued, “is at the center of  healthcare reform.”  Bringing scale to behavioral health, the group agreed, requires a radical revision of the current service delivery model.

In truth, many of the ideas discussed are already underway, including the move toward “integrated care” and ongoing measurement and use of feedback to improve the quality and outcome of treatment.  Other ideas discussed included methods for putting the principles of behavior change directly into the hands of the consumer.  But there’s more.  Stay tuned.  The group has big plans.  Announcements will soon be made right here on the “Top Performance” blog.

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

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

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

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

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

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

The Training of Trainers

Eruptions in Europe and in Research

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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.

Neurobabble Redux: Comments from Dr. Mark Hubble on the Latest Fad in the World of Therapy Spark Comment and Controversy

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Last week, my long time colleague and friend, Dr. Mark Hubble blogged about the current interest of non-medically trained therapists in the so-called “neurobiology of human behavior.”  In my intro to his post, I “worried” out loud about the field’s tendency to search for legitimacy by aligning with the medical model.  Over the years, psychotherapy has flirted with biology, physics, religion, philosophy, chaos, and “energy meridians” as both the cause of what ails people and and the source of psychotherapy’s effectiveness.

For whatever reason, biological explanations have always had particular cachet in the world of psychotherapy.  When I first entered the field, the “dexamethasone suppression test” was being touted as the first “blood test” for depression.  Some twenty years on, its hard to remember the hope and excitement surrounding the DST.

Another long-time friend and colleague, psychologist Michael Valentine is fond of citing the many problems–social, physical, and otherwise–attributed to genetics (including but not limited to: anxiety, depression, addictions, promiscuity, completed suicides, thrill seeking obscene phone calls, smoking, gambling, and the amount of time one spends watching TV) for which there is either: (a) precious little or inconsistent evidence; or (b) the variance attributable to genetics is small and insignificant compared to size and scope of the problem.

In any event, I wanted to let readers know that response to Mark’s post has been unusually strong.  The numerous comments can be found on the syndicated version of my blog at the International Center for Clinical Excellence.  Don’t miss them!

Neurobabble: Comments from Dr. Mark Hubble on the Latest Fad in the World of Therapy

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Rarely does a day go by without hearing about another “advance” in the neurobiology of human behavior.  Suddenly, it seems, the world of psychotherapy has discovered that people have brains!  And now where the unconscious, childhood, emotions, behaviors, and cognitions once where…neurons, plasticity, and magnetic resonance imagining now is.  Alas, we are a field forever in search of legitimacy.  My long time colleague and friend, Mark Hubble, Ph.D., sent me the following review of recent developments.  I think you’ll enjoy it, along with video by comedian John Cleese on the same subject.

Mark Hubble, Ph.D.

Today, while contemplating the numerous chemical imbalances that are unhinging the minds of Americans — notwithstanding the longstanding failure of the left brain to coach the right with reason, and the right to enlighten the left with intuition — I unleashed the hidden power of my higher cortical functioning to the more pressing question of how to increase the market share for practicing therapists. As research has dismantled once and for all the belief that specific treatments exist for specific disorders, the field is left, one might say, in an altered state of consciousness. If we cannot hawk empirically supported therapies or claim any specialization that makes any real difference in treatment outcome, we are truly in a pickle. All we have is ourselves, the relationships we can offer to our clients, and the quality of their participation to make it all work. This, of course, hardly represents a propitious proposition for a business already overrun with too many therapists, receiving too few dollars.

Fortunately, the more energetic and enterprising among us, undeterred by the demise of psychotherapy as we know it, are ushering the age of neuro-mythology and the new language of neuro-babble.   Seemingly accepting wholesale the belief that the brain is the final frontier, some are determined to sell us the map thereto and make more than a buck while they are at it. Thus, we see terms such as “Somatic/sensorimotor Psychotherapy,” “Interpersonal Neurobiology,” “Neurogenesis and Neuroplasticity,”  “Unlocking the Emotional Brain,” “NeuroTherapy,” “Neuro Reorganization,” and so on.  A moment’s look into this burgeoning literature quickly reveals the existence of an inverse relationship between the number of scientific sounding assertions and actual studies proving the claims made. Naturally, this finding is beside the point, because the purpose is to offer the public sensitive, nuanced brain-based solutions for timeless problems. Traditional theories and models, are out, psychotherapies-informed-by-neuroscience, with the aura of greater credibility, are in.

Neurology and neuroscience are worthy pursuits. To suggest, however, that the data emerging from these disciplines have reached the stage of offering explanatory mechanisms for psychotherapy, including the introduction of “new” technical interventions, is beyond the pale. Metaphor and rhetoric, though persuasive, are not the same as evidence emerging from rigorous investigations establishing and validating cause and effect, independently verified, and subject to peer review.

Without resorting to obfuscation and pseudoscience, already, we have a pretty good idea of how psychotherapy works and what can be done now to make it more effective for each and every client. From one brain to another, to apply that knowledge, is a good case of using the old noggin.

Addressing the Financial Crisis in Public Behavioral Healthcare Head On in Chesterfield, Virginia

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If you are following me on Twitter (and I hope you are), you know the last month has been extremely busy.  This week I worked with clinicians in Peterborough, Ontario Canada.  Last week, I was in Nashville, Tennessee and Richmond Virginia.  Prior to that, I spent nearly two weeks in Europe, providing training and consultations in the Netherlands and Belgium.

It was, as always, a pleasure meeting and working with clinicians representing a wide range of disciplines (social workers, case managers, psychologists, psychiatrists, professional counselors, alcohol and drug treatment professionals, etc.) and determined to provide the best service possible.  As tiring as “road work” can sometimes be, my spirits are always buoyed by the energy of the individuals, groups, and agencies I meet and work with around the world.

At the same time, I’d be remiss if I didn’t acknowledge the fear and hardship I’m witnessing among providers and treatment agencies each week as I’m out and about.  Frankly, I’ve never seen anything like it in my seventeen years “on the road.”  Being able to say that we predicted the current situation nearly 6 years ago provides little comfort (see The Heroic Client, 2004).

While nearly all are suffering, the economic crisis in the United States is hitting public behavioral health particularly hard.  In late January I blogged about the impact of budget cuts in Ohio.   Sadly, the situations in Virginia and Tennessee are no different.  Simply put, public behavioral health agencies are expected to do more with less, and most often with fewer providers.  What can be done?

Enter Chesterfield Community Service Board.  Several years ago, I met and began working with Larry Barnett,  Lyn Hill, and the rest of the talented clinical staff at this forward thinking public behavioral health agency.  Their goal?  According to the agency mission statement, “to promote improved quality of life…through exceptional and comprehensive mental health, mental retardation, substance abuse, and early intervention services.”  Their approach?  Measure and monitor the process and outcome of service delivery and use the resulting information to improve productivity and performance.

As Larry and Lynn report in the video below, the process was not easy.  Indeed, it was damn difficult–full of long hours, seemingly endless discussions, and tough, tough choices.  But that was then.  Some three years later, the providers at Chesterfield CSB are serving 70% more people than they did in 2007 despite there being no increase in available staff resources in the intervening period.  That’s right, 70%!  And that’s not all.  While productivity rates soared, clinician caseloads were reduced by nearly 30%.  As might be expected, the time consumers in need of services had to wait was also significantly reduced.

In short, everybody won: providers, agency managers, funders, and consumers.  And thanks to the two days of intensive training in Richmond, Virginia organized by Arnold Woodruff, many additional public behavioral health agencies have the information needed to get started.  It won’t be easy.  However, as the experience in Chesterfield demonstrates, it is possible to survive and thrive during these tumultuous times.  But don’t take my word for it, listen to how Larry and Lynn describe the process–warts and all–and the results:

The Turn to Outcomes: A Revolution in Behavioral Health Practice

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Get ready.  The revolution is coming (if not already here).  Whether you are a direct service provider (psychologist, counselor, marriage and family therapist), agency, broker, or funder, you will be required to measure and likely report the outcomes of your clinical work.


Jay Lebow, Ph.D.

Just this month, Dr. Jay Lebow, a professor of psychology at the Family Institute at Northwestern University, published an article in the Psychotherapy Networker–the most widely circulated publication for practitioners in the world–where he claimed the field had reached a “tipping point.”  “Once a matter of interest only among a small circle of academics,” Dr. Lebow writes in his piece entitled, The Big Squeeze, “treatment outcome has now become a part of the national debate about healthcare reform.”


David Barlow, Ph.D.

The same sentiments were expressed in a feature article entitled, “Negative Effects from Psychological Treatments,” written by Dr. David Barlow in the January issue of the American Psychologist.  “Therapists,” he argues both eloquently and persuasively, “do not have to wait for the next clinical trial….[rather] clinicians [can act] as local clinical scientists…[using] outcome measures to track progress…rapidly becom[ing] aware of lack of progress or even deterioration” (p. 19).  What can I say, except that any practitioner with more than a few years to work before retirement, should read these articles and then forward them to every practitioner they know.

During the Holidays, and just before the turn of the New Year, I blogged about the trend toward outcome measurement.  As readers will recall, I talked about my experience on a panel at the Evolution of Psychotherapy conference where Dr. Barlow–who, in response to my brief remarks about the benefits of feedback– suprised me by stating unequivocally that all therapists would soon be required to measure and monitor the outcome of their clinical work. And even though my work has focused almost exclusively on measuring and using outcomes to improve both retention in and the results of behavioral health for the last 15 years, I said his pronouncement frightened me–which, by the way, reminds me of a joke.

A sheep farmer is out in the pasture tending his flock–I promise this is clean, so read on–when from over a small hill comes a man in a custom-tailored, three-piece business suit.  In one hand, the businessman holds a calculator; in the other, an expensive, leather brief case.  “I have a proposition for you,” the well-clad man says as he approaches the farmer, and then continues, “if I can tell you how many sheep are in your flock, to the exact number, may I have one of your sheep?”  Though initially startled by the stranger’s abrupt appearance and offer, the farmer quickly gathers his wits.  Knowing there is no way the man could know the actual number of sheep (since many in his flock were out of site in other pastures and several were born just that morning and still in the barn), the farmer quickly responded, “I’ll take that bet!”

Without a moment’s hesitation, the man calls out the correct number, “one thousand, three hundred and forty six,” then quickly adds, “…with the last three born this morning and still resting in the barn!”  Dumbfounded, the farmer merely motions toward his flock.  In response, the visitor stows his calculator, slings one of the animals up and across his shoulders and then, after retrieving his briefcase, begins making his way back up the hill.  Just as he nears the top of the embankment, the farmer finds his voice and calls out, “Sir, I have a counter proposal for you.”

“And what might that be?” the man replies, turning to face the farmer, who then asked, “If I can tell you, sir, what you do for a living, can I have my animal back?”

Always in the mood for a wager, the stranger replies, “I’ll take that bet!”  And then without a moment’s hesitation, the sheep farmer says, “You’re an accountant, a bureaucrat, a ‘bean-counter.'”  Now, it’s the businessman’s turn to be surprised.  “That’s right!” he says, and then asks, “How did you know?”

“Well,” the farmer answers, “because that’s my dog you have around your neck.”

The moral of the story?  Bureaucrats can count but they can’t tell the difference between what is and is not important.  In my blogpost on December 24th, I expressed concern about the explosion of “official interest” in measuring outcomes.  As the two articles mentioned above make clear, the revolution has started.  There’s no turning back now.  The only question that remains is whether behavioral health providers will be present to steer measurement toward what matters?  Here, our track record is less than impressive (remember the 80-90’s and the whole managed care revolution).  We had ample warning (and did, well, nothing.  If you don’t believe me, click here and read this article from 1986 by Dr. Nick Cummings).

As my colleague and friend Peter Albert is fond of saying, “If you’re not at the table, you’re likely to be on the menu.”  So, what can the average clinician do?  First of all, if you haven’t already done so, began tracking your outcomes.  Right here, on my website, you can download, free, simple-to use, valid and reliable measures.  Second, advocate for measures that are feasible, client-friendly, and have a empirical track record of improving retention and outcome.  Third, and lastly, join the International Center for Clinical Excellence.  Here, clinicians from all over the globe are connecting, learning, and sharing their experiences about how to use ongoing measures of progress and alliance.  Most importantly, all are determined to lead the revolution.

Behavioral Healthcare in Holland: The Turn Away from the Single-payer, Government-Based Reimbursement System

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Several years ago I was contacted by a group of practitioners located in the largest city in the north of the Netherlands–actually the capital of the province known as Groningen.  The “Platform,” as they are known, were wondering if I’d be willing to come and speak at one of their upcoming conferences.  The practice environment was undergoing dramatic change, the group’s leadership (Dorti Been & Pico Tuene) informed me.  Holland would soon be switching from government to a private insurance reimbursement system.  Dutch practitioners were “thinking ahead,” preparing for the change–in particular, understanding what the research literature indicates works in clinical practice as well as learning methods for documenting and improving the outcome of treatment.

I was then, and remain now, deeply impressed with the abilities and dedication of Dutch practitioners.  During that visit to Groningen, and the many that have followed (to Amsterdam, Rotterdam, Beilen, etc.), its clear that clinicians in the Netherlands are determined to lead rather than be led.  I’ve been asked to meet with university professors, practitioner organizations, training coordinators, and insurance company executives.  In a very short period of time, two Dutch therapists–physician Flip Van Oenen and psychologist Mark Crouzen–have completed the “Training of Trainers” course and become recognized trainers and associates for the International Center for Clinical Excellence.  And finally, a study will soon be published showing sound psychometric properties of the Dutch translations of the ORS and SRS.

I’ve also been working closely with the Dutch company Reflectum–a group dedicated to supporting outcome-informed healthcare and clinical excellence.  Briefly, Reflectum has organized several conferences and expert meetings between me and clinicians, agency managers, and insurance companies.  One thing for sure: we will be working closely together to train a network of trainers and consultants to promote, support, and train agencies and practitioners in outcome-informed methods in order to meet the demands of the changing practice climate.

Check out the videobelow filmed at Schipol airport during one of my recent trips to Holland:

The Evolution of Psychotherapy: Meeting Michael Hoyt

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I’m still reeling from the experience in Anaheim this last week.  I met so many leaders in the field, heard so many presentations on cutting edge clinical practice–as well as was reminded of some “classic” principles of effective psychotherapy.

One of the people I met was colleague and friend, Michael F. Hoyt, Ph.D.  Michael and I go back 15+ years, having met–I believe–the first time at a workshop I was giving in Northern California (somewhere in the Bay Area where Michael works and resides).  Since that time, we chatted regularly, and written editorials and book chapters together.  His books (The First Session in Brief Therapy, Brief Therapy & Managed Care, The Handbook of Constructive Therapies, Some Stories are Better than Others) always balance theory and practice and are among my favorites.

My two favorite books are also his most recent: The Present is a Gift and Brief Psychotherapies: Principles & Practice (Hint: his chapters on couples therapy are among the best I’ve ever read).  Anyway, the two of us caught up at the ICCE booth this last week at the Evolution conference.

The Crown Jewel of Research on CDOI: Professor Jan Blomqvist receives 2.9 million crown grant for RCT on feedback in Sweden

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If you’ve been following me on Twitter, then you know that last week I was touring and teaching in different spots around Europe.  First, I presented two days in Copenhagen.  Then I keynoted the British Association of Counseling and Psychotherapy Conference in Newcastle, England.  Early Saturday morning, I flew from London to Stockholm.  My long time friend and associate, Gunnar Lindfelt picked me up at Arlanda airport and drove me back to his lovely home in the city.  There, we gorged on smoked salmon, “svensk godies” (small candies, my favorite of which is “skum bananer”–dark chocolate covered marshmellow in the shape of a banana) and Cider–a non-alcoholic fizzy apple drink that is an old time Swedish favorite.

It was Gunnar Lindfeldt, a gifted clinician and expert in the treatment of drug and alcohol problems, who first introduced me to the work of Swedish psychologist Jan Blomqvist.  In 1998, Blomqvist published a book entitled, “Beyond Treatment? Widening the Approach to Alcohol Problems and Solutions“ in which he made the provocative argument that common rather than specific factors held the key to effective care.  Since writing the book, Jan Blomqvist has continued his research and is currently a full professor at SORAD, the Centre for Social Research on Alcohol and Drugs at Stockholm University.

Anyway, I had the pleasure of meeting with Professor Blomqvist at his home in Uppsala, Sweden this last week.  Over homemade spinach soup, freshly-baked bread and cheese, we chatted about the state of the field.  The pièce de résistance, however, was hearing about the 2.9 million Swedish crown grant he had just been awarded for a 4 year long study of outcome-informed treatment of alcohol problems, called “Putting the Client in the Driver’s Seat.”

The study to be conducted by Professor Blomqvist will be the largest, most comprehensive, randomized clinical trial on client-directed outcome informed clinical work.  A centerpience of the study will be the routine use of the ORS and SRS and provision of feedback in the delivery of treatment services.  Importantly, unlike all other studies to date, this project completely avoids claims of “allegiance effects” as no developers of measures or supporters of CDOI are participating.  Stay tuned to the “Top Performance” blog for additional updates!  While you are waiting, take a moment and read Professor Blomqvist’s provocative take on “addiction” in slide viewer below.

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

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

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

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

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

On the Path of the Supershrinks: An Article by Bill Robinson

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Not too long ago, my colleagues and I published some preliminary thoughts and findings from our research into “Supershrinks.”

That differences in effectiveness exist between clinicians is neither surprising or new.  Indeed, “therapist effects”–as they are referred to in the research literature–have been documented for decades and rival the contribution of factors long known to influence successful psychotherapy (e.g., the therapeutic alliance, hope and expectancy, etc.).  Personally, I believe that studying these super-effective clinicians will help practitioners improve the outcome of their clinical work.

Aside from research documenting the existence of “supershrinks,” and our own articles on the subject, little additional information exists documenting how superior performing clinicians achieve the results they do.

Enter Bill Robinson, manager, counselor, and a senior supervsor with Relationships Australia based in Mandurah, Western Australia.  I’m also proud to say that Bill is one of a highly select group of clinicians that have completed the necessary training to be designated an ICCE Certified Trainer.

In any event, in the last issue of Psychotherapy in Australia–a treasure of a publication that every clinician dedicated to improving their work should subscribe to–Bill explores the topic of therapist effects, suggesting possible links between effectiveness and clinicians’ abilities to connect with the phenomenological worlds of the people they work with.  Trust me, this peer reviewed article is worth reading.  Don’t forget to post a comment, by the way, once you’ve finished!

 

Excellence in Behavioral Health in Arizona

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For those of you are friends with me on Facebook (and if you’re not already, please do as it’s a blast), you know I was teaching at the 41st Annual Southwestern School for Behavioral Health Studies.

First, let me express my appreciation to the Board and Michelle Brown for bringing me to Tucson to present on “Achieving Clinical Excellence.”  If you’ve never attended this particular event, mark your calendar for next year.

This year, the conference theme was “Staying relevant in the 21st Century.”  By the time I took the microphone to speak, 350 dedicated professionals from all around the country were on their fifth and last day of the conference.  What a crowd!  Excited, energized, and dedicated to doing their personal best for consumers of behavioral health services.

I’ve already heard from several folks who were in attendance, relating a personal or clinical story illustrating the principles and practices I talked about during my presentations.  Thanks very much for sharing these stories with me.

Meanwhile, you can find the slides I used yesterday below.  Feel free to download, use, and forward them to interested friends and colleagues.

In parting, I thought I’d relate one of my own experiences of excellence.  It happened two years ago when I was presenting at this same conference. That morning, as I reached into my suitcase to get my clothes, I quickly discovered I’d left my slacks at home!  Like this year, I’d worn shorts, a T-shirt, and flip flops on the plane, so no help there. Panicked, I called my co-presenter, Dr. David Mee-Lee—after all, he is a psychiatrist.  He offered me an extra pair he had. It was a great idea that we both knew would never work since David is about 8” shorter than me.  So I called the front desk.  Now, the venue for the SWS for Behavioral Health is at the beautiful Loews Ventana Canyon Resort.  It’s nestled in the mountains, miles from the city.  Plus it was 7 am. My presentation started in an hour.  No store was open at this hour, not even the resort gift shop.  But that didn’t stop the dedicated staff at Loews.  Within minutes, the manager of the resort shop was at the hotel.  We found some pants and a shirt to match but the pants were 6 inches too long. “Not to worry,” the store manager said, she’d take care of it.  Within minutes someone from the housekeep staff—not a tailor or seamstress, just a kind, dedicated person—was cutting and sewing the hem on the pants.  I made it to the conference hall to present with 5 minutes to spare! I’ve never forgotten their kindness and dedication.