Implementation Science, FIT, and the Training of Trainers

March 8, 2012 By scottdm Leave a Comment

The International Center for Clinical Excellence (ICCE) is pleased to announce the 6th annual Training of Trainers event to be held in Chicago, Illinois August 6th-10th, 2012. As always, the ICCE TOT prepares participants provide training, consultation, and supervision to therapists, agencies, and healthcare systems in Feedback-Informed Treatment (FIT). Attendees leave the intensive, hands-on training with detailed knowledge and skills for:

Training clinicians in the Core Competencies of Feedback Informed Treatment (FIT/CDOI);
Using FIT in supervision;
Methods and practices for implementing FIT in agencies, group practices, and healthcare settings;.
Conducting top training sessions, learning and mastery exercises, and transformational presentations.

Multiple randomized clinical trials document that implementing FIT leads to improved outcomes and retention rates while simultanesouly decreasing the cost of services.

This year’s “state of the art” faculty include: ICCE Director, Scott D. Miller, Ph.D., ICCE Training Director, Julie Tilsen, Ph.D., and special guest lecturer and ICCE Coordinator of Professional Development, Cynthia Maeschalck, M.A.

Join colleagues from around the world who are working to improve the quality and outcome of behavioral healthcare via the use of ongoing feedback. Space is limited. Click here to register online today. Last year, one participants said the training was, “truly masterful. Seeing the connection between everything that has been orchestrated leaves me amazed at the thought, preparation, and talent that has cone into this training.” Here’s what others had to say:

Psychologist Alan Kazdin Needs Help: Please Give

September 25, 2011 By scottdm Leave a Comment

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:

The best available research;
Clinical expertise; and
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.

Why is this man laughing?

May 4, 2011 By scottdm 3 Comments

May 4th, 2011
Copenhagen, Denmark

Just finished my first day of a two week trip covering spots in Denmark and Holland. Yesterday, I traveled to Copenhagen from Hilo, Hawaii where I was presenting for the Hawaiian Association of Marriage and Family Therapy. Dr. Gay Barflied (pictured on the far left above) spent years lobbying to bring me to the “Big Island” for the conference, where I spoke about the latest research on expertise and excellence in the field of behavioral health. I met so many dedicated and talented clinicians in Hilo, including marriage and family therapist, Makela Bruno-Kidani (pictured in the middle photo above) who started the day off with a traditional Hawaiian chant and then presented me with two beautiful lei to wear during the event.

On a break, Gay mentioned an article that appeared in the May/June 1995 issue of AHP Perspective. In it, she said, Maureen O’Hara, president of the Association for Humanistic Psychology, quoted one of the first articles me and my colleagues wrote on the common factors, “No More Bells and Whistles” (I’ll upload a copy to the “publications and handouts” section of the website as soon as I’m back in the States). Carl Rogers, she said, would have been laughing (happily, that is) had he read the findings we cited documented the lack of differential efficacy of competing treatment approaches. We had, in essence, proved him right!

“It turns out,” OHara wrote, “that Miller, Hubble, and Duncan come to similar conclusions. Carl Rogers was right. After all our forays into the dizzing arcana of paradoxical interventions, inner children, narrative therapy, EMDR, behaviorism, psychopharmacology, bioenergetics, TA, Jungian analysis, psychodrama, Gestalt, and so on down the entire list of hundred brand named therapies, what actually creates change is the…creation of a relationship between client and therapist…”.

I’d never seen the article before. It brought back very positive memories about the journey that has led most recently to the study of excellence. Indeed, as we point out in the lead article in the upcoming May/June 2011 issue of the Psychotherapy Networker, relationships are not only the “sine qua non” of healing for clients but are responsible for the professional growth for therapists.

What Works in the Treatment of Post Traumatic Stress Disorder? The Definitive Study

September 15, 2010 By scottdm 1 Comment

What works in the treatment of people with post-traumatic stress? The influential Cochrane Collaboration–an “independent network of people” whose self-professed mission is to help “healthcare providers, policy makers, patients, their advocates and carers, make well-informed decisions, concludes that, “non trauma-focused psychological treatments [do] not reduce PTSD symptoms as significantly…as individual trauma focused cognitive-behavioral therapy (TFCBT), eye movement desensitization and reprocessing, stress mamangement and group TFCBT.” The same conclusion was reached by the National Institute for Health and Clinical Excellence (or NICE) in the United Kingdom which has developed and disseminated practice guidelines that unequivocally state that , “all people with PTSD should be offered a course of trauma focused psychological treatment (TFCBT) or eye movement desensitization and reprocessing (EMDR).” And they mean all: adults and kids, young and old. Little room for left for interpretation here. No thinking is required. Like the old Nike ad, you should: “Just do it.”

Wait a minute though…what do the data say? Apparently, the NICE and Cochrane recommendations are not based on, well…the evidence–at least, that is, the latest meta-analytic research! Meta-analysis, you will recall, is a procedure for aggregating results from similar studies in order to test a hypothesis, such as, “are certain approaches for the treatment of post traumatic stress more effective than others?” A year ago, I blogged about the publication of a meta-analysis by Benish, Imel, & Wampold which clearly showed that there was no difference in outcome between treatments for PTSD and that the designation of some therapies as “trauma-focused” was devoid of empirical support, a fiction.

So, how to account for the differences? In a word, allegiance. Although written by scientists, so-called “scholarly” reviews of the literature and “consensus panel” opinions inevitably reflect the values, beliefs, and theoretical predilections of the authors. NICE guidelines, for example, read like a well planned advertising campaign for single psychotherapeutic modality: CBT. Indeed, the organization is quite explicit in it’s objective: “provide support for the local implementation of…appropriate levels of cognitive beheavioral therapy.” Astonishingly, no other approach is accorded the same level of support or endorsement despite robust evidence of the equivalence of outcomes among treatment approaches. Meanwhile, the review of the PTSD literature and treatment recommendations published by the Cochrane Collaboration has not been updated since 2007–a full two years following the publication of the Benish et al. (2008) meta-analysis–and that was penned by a prominent advocate of…CBT…Trauma-focused CBT.

As I blogged about back in January, researchers and prominent CBT proponents, published a critique of the Benish et al. (2008) meta-analysis in the March 2010 issue of Clinical Psychology Review (Vol. 30, No. 2, pages 269-76). Curiously, the authors chose not to replicate the Benish et al. study, but rather claim that bias, arbitrariness, lack of transparency, and poor judgement accounted for the findings. As I promised at the time, I’m making the response we wrote–which appeared in the most recent issue of Clinical Psychology Review—available here.

Of course, the most important finding of the Benish et al. (2008) and our later response (Wampold et al. 2010) is that mental health treatments work for people with post traumatic stress. Such a conclusion is unequivocal. At the same time, as we state in our response to the critique of Benish et al. (2008), “there is little evidence to support the conclusion…that one particular treatment for PTSD is superior to others or that some well defined ingredient is crucial to successful treatments of PTSD.” Saying otherwise, belies the evidence and diverts attention and scarce resources away from efforts likely to improve the quality and outcome of behavioral health services.

View more documents from Scott Miller.

The Impact of Mentors

July 20, 2010 By scottdm Leave a Comment

Brendan Madden Scott D. Miller Jeffrey K. Zeig

A little over month ago, I blogged about how the outcome and session rating scales were originally conceived of and developed. A few days prior to that, I wrote about where the whole idea of using measures to solicit feedback had started. In both instances, my teachers and supervisors played a significant role. Immediately following a two day workshop I’d given in Israel, psychologist Haim Omer suggested developing a visual analog scale that could be used in lieu of the longer Outcome Questionnaire 45.2–an idea that literally changed the entire arc of my professional career. Drs. Lynn Johnson and Michael Lambert–a supervisor and professor I met and worked with as a graduate student–were the first to pioneer feedback-informed treatment (FIT). Some twenty plus years into my career, I remain in contact with both, calling, seeking input, discussing ideas, and soliciting feedback.

“Professional coaches,” says the noted “expert on experts” K. Anders Erickson, “…play an essential role in guiding…future experts in a safe and effective manner” (p. 698). Needless to say, I’ve been very fortunate to have such visionary mentors. One more story.

In 1984, I wrote a letter to Dr. Jeffrey K. Zeig, the director of the Milton H. Erickson Institute. I was in my second year of a Ph.D. program in psychology and, like many graduate students, dead broke. While taking a course on hypnosis as part of my studies, I’d become interested in the work of Milton Erickson.

“I’d like to learn more,” I wrote at the time, “Would it be possible for me to visit the Institute, watch some videos and have a chance to talk with you?” I wasn’t too far away. I could drive to Phoenix where the Institute was located. I could even arrange to stay with friends to save money. “Dr. Zeig,” I continued, “I’m a graduate student and don’t have much money, but I’d be willing to do some work in kind.” I’d pasted mailing labels on thousands of brochures for the local hypnosis and therapy organizations, for example, in exchange for being able to attend professional continuing education events. “I’ll vacuum and clean the office, wash vehicles, do filing. Whatever might be helpful to you or the Institute.”

Within a couple of weeks, an envelop from the Milton H. Erickson Institute arrived. In it was a letter that was brief and to the point. “Please call me,” it said, and was signed Jeffrey K. Zeig, Ph.D. Needless to say, I called straight away. We chatted for a few minutes. He told me that I was welcome to visit the Institute, watch videos, talk with some of the staff and even spend some time with him. And then he asked, “Do you think you could afford five dollars?” I was floored.

Ever since meeting him on that hot summer day in Phoenix, he’s been an important teacher and mentor. It’s particularly noteworthy that whenever we talk–by phone, email, or in chance meetings on airplanes while criss-crossing the globe–he invariably asks, “What are you learning?” And then he listens, intently.

Last week, we were catching up on the phone and Jeff told me that his long-held desire to open an international psychotherapy training and research facility had finally been fulfilled. Briefly, The Institute for Applied Therapeutic Change is a real clinic where professionals and students can learn the latest in behavioral healthcare from leading experts in the field and while working with real clients (click on the text above for the complete press release).

“I can hardly wait to attend some of the events,” I said. “And when are you available to teach?” he responded. Stunned again. I’m so fortunate and can hardly wait to participate in the Institute activities as both a presenter and student. Stay tuned to the Foundation website for more details!

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

June 8, 2010 By scottdm Leave a Comment

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

Learning, Mastery, and Achieving One’s Personal Best

April 25, 2010 By scottdm Leave a Comment

Dateline: Sunday, April 25th, 2010 Chicago, IL

There’s a feeling I get whenever I’m learning something new. It’s a combination of wonder and possibility. Even though I’ve been traveling and teaching full time for over 18 years, I still feel that get that feeling of excitement whenever I step on a plane: What will I see? Who will I meet? What will I learn? Move over Indiana Jones, you’ve got nothing on me!

On my desk right now are stacks of books on the subject of expertise and expert performance: The Talent Code: Greatness Isn’t Born. It’s Grown. Here’s How, The Genius in All of Us: Why Everything You’ve Been Told About Genetics, Talent, and IQ Is Wrong, The Cambridge Handbook of Creativity, The Psychology of Abilities, Competencies, and Expertise, Why We Make Mistakes: How We Look Without Seeing, Forget Things in Seconds, and Are All Pretty Sure We Are Way Above Average, and many, many more.

On the floor, arranged in neat little piles, are reams of research articles, newspaper clippings, and pages torn out of magazines. Literally, all on the same subject: how can we clinicians reliably achieve better results?

I’ve never been one to “settle” for very long. It’s the journey not the destination I find appealing. Thus, I began exploring the common factors when it became clear that treatment models contributed little if anything to outcome (click here to read the history of this transition). When I became convinced that the common factors held little promise for improving results in psychotherapy, I followed the lead of two my mentors, professor Michael Lambert (who I worked with as an undergraduate) and psychologist Lynn Johnson (who trained and supervised me), and began measuring outcome and seeking feedback. Now that research has firmly established that using measures of the alliance and outcome to guide service delivery significantly enhances performance (see the comprehensive summary of research to date below), I’ve grown restless again.

In truth, I find discussions about the ORS and SRS a bit, well, boring. That doesn’t mean that I’m not using or teaching others to use the measures. Learning about the tools is an important first step. Getting clinicians to actually use them is also important. And yet, there is a danger if we stop there.

Right now, we have zero evidence that measurement and feedback improves the performance of clinicians over time. More troubling, the evidence we do have strongly suggests that clinicians do not learn from the feedback they receive from outcome and alliance measures. Said another way, while the outcome of each particular episode of care improves, clinicians overall ability does not. And that’s precisely why I’m feeling excited–the journey is beginning…

…and leads directly to Kansas City where, on October 20-22nd, 2010, leading researchers and clinicians will gather to learn the latest, evidence-based information and skills for improving performance in the field of behavioral health. As of today, talented professionals from Australia, Sweden, Norway, Denmark, Germany, England, Israel, and the United States have registered for the international “Achieving Clinical Excellence” conference. Some common questions about the event include:

1. What will I learn?

How to determine your overall effectiveness and what specifically you can do to improve your outcomes.

2. Is the content new?

Entirely. This is no repeat of a basic workshop or prior conferences. You won’t hear the same presentations on the common factors, dodo verdict, or ORS and SRS. You will learn the skills necessary to achieve your personal best.

3. Are continuing education credits available?

Absolutely–up to 18 hours depending on whether you attend the pre-conference “law and ethics” training. By the way, if you register now, you’ll get the pre-conference workshop essentially free! Three days for one low price.

4. Will I have fun?

Guaranteed. In between each plenary address and skill building workshop, we’ve invited superior performers from sports, music, and entertainment to perform and inspire . If you’ve never been to Kansas City, you’ll enjoy the music, food, attractions, and architecture.

Feel free to email me with any questions or click here to register for the conference. Want a peak at some of what will be covered? Watch the video below, which I recorded last week in Sweden while “trapped” behind the cloud of volcanic ash. In it, I talk about the “Therapists Most Likely to Succeed.”

Measures and feedback 2016 from Scott Miller

Is Professional Training a Waste of Time?

March 18, 2010 By scottdm 6 Comments

Every year, thousands of students graduate from professional programs with degrees enabling them to work in the field of behavioral health. Many more who have already graduated and are working as a social worker, psychologist, counselor, or marriage and family therapist attend—often by legal mandate—continuing education events. The costs of such training in terms of time and money are not insignificant.

Most graduates enter the professional world in significant debt, taking years to pay back student loans and recoup income that was lost during the years they were out of the job market attending school. Continuing professional education is also costly for agencies and individuals in practice, having to arrange time off from work and pay for training.

To most, the need for training seems self-evident. And yet, in the field of behavioral health the evidence is at best discouraging. While in traveling in New Zealand this week, my long-time colleague and friend, Dr. Bob Bertolino forwarded an article on the subject appearing in the latest issue of the Journal of Counseling and Development (volume 88, number 2, pages 204-209). In it, researchers Nyman and Nafziger reported results of their study on the relationship between therapist effectiveness and level of training.

First, the good news: “clients who obtained services…experienced moderate symptom relief over the course of six sessions.” Now the bad news: it didn’t matter if the client was “seen by a licensed doctoral –level counselor, a pre-doctoral intern, or a practicum student” (p. 206, emphasis added). The authors conclude, “It may be that researchers are loathe to face the possibility that the extensive efforts involved in educating graduate students to become licensed professionals result in no observable differences in client outcome” (p. 208, emphasis added).

In case you were wondering, such findings are not an anomaly. Not long ago, Atkins and Christensen (2001) reviewed the available evidence in an article published in the Australian Psychologist and concluded much the same (volume 36, pages 122-130); to wit, professional training has little if any impact on outcome. As for continuing professional education, you know if you’ve been reading my blog that there is not a single supportive study in the literature.

“How,” you may wonder, “could this be?” The answer is: content and methods. First of all, training at both the graduate and professional level continues to focus on the weakest link in the outcome chain—that is, model and technique. Recall, available evidence indicates that the approach used accounts for 1% or less of the variance in treatment outcome (see Wampold’s chapter in the latest edition of the Heart and Soul of Change). As just one example, consider workshops being conduced around the United States using precious resources to train clinicians in the methods studied in the “Cannabis Youth Treatment” (CYT) project–a study which found that the treatment methods used contributed zero to the variance in treatment outcome. Let me just say, where I come from zero is really close to nothing!

Second, and even more important, traditional methods of training (i.e., classroom lecture, reading, attending conferences) simply do not work. And sadly, behavioral health is one of the few professions that continue to rely on such outdated and ineffective training methods.

The literature on expertise and expert performance provides clear, compelling, and evidence-based guidelines about the qualities of effective training. I’ve highlighted such data in a number of recent blogposts. The information has already had a profound impact on the way how the ICCE organizes and conducts trainings. Thanks to Cynthia Maeschalck, Rob Axsen, and Bob, the entire curriculum and methods used for the annual “Training of Trainers” event have been entirely revamped. Suffice it to say, agencies and individuals who invest precious time and resources attending the training will not only learn but be able to document the impact of the training on performance. More later.

Leading for a Change: The Training of Trainer’s (TOT) Chicago

March 9, 2010 By scottdm Leave a Comment

I’m writing tonight from my hotel room at the River Rock Inn in Rockland, Ontario, Canada. For those of you who are not familiar with the area, it is a bilingual (French & English) community of around 9,000 located about 25 km west of Ottawa.

Today through Thursday, I’m working with the staff, supervisors, and agency administrators of Prescott-Russell Services to Children and Adults. The goal? Introduce the latest “cutting-edge” research on “what works” in behavioral health and initiate a system transformation project for this group that provides child protection, mental health, family violence, and development services in the area. The time spent with the first cohort of 125 direct services providers and supervisors went by, as they say, in “the blink of an eye.” Tomorrow, I’ll be repeating the same training for the rest of the crew. On Wednesday and Thursday I’ll meet with supervisors and administrators. Suffice it to say, it’s an incredible opportunity for me to take part in such a large and well executed service improvement project. In these lean economic times, I’m inspired by both the time and resources being directed at improving services offered to this area’s most needy. By the end of the week, I hope to have interviews posted with some of the providers and leaders working in the project.

While on the subject of training, let me share the brochure for this year’s “Training of Trainers” event in Chicago, Illinois during the second week of August. 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 on feedback-informed treatment (FIT). Please note: this is not an “advanced training” in FIT where time is spent reviewing the basics or covering content. Rather, the TOT curriculum has been designed to prepare participants to train others. Every day of the training, you will learn specific skills for training others, have an opportunity to practice those skills, and then receive detailed feedback from ICCE Senior Associates and Trainers Rob Axsen, Cynthia Maeschalck, and Jason Seidel. Anyway, read for yourself. 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.

Click here to download the brochure to review or forward to colleagues

Deliberate Practice, Expertise, & Excellence

February 3, 2010 By scottdm 2 Comments

Later today, I board United flight 908 on my way to workshops scheduled in Holland and Belgium. My routine in the days leading up to an international trip is always the same. I slowly gather together the items I’ll need while away: computer (check); european electric adapter (check); presentation materials (check); clothes (check). And, oh yeah, two decks of playing cards and close up performance mat.

That’s me (pictured above) practicing a “ribbon spread” in my hotel room following a day of training in Marion, Ohio. It’s a basic skill in magic and I’ve been working hard on this (and other moves using cards) since last summer. Along the way, I’ve felt both hopeful and discouraged. But I’ve kept on nonetheless taking heart from what I’m reading about skill acquisition.

Research on expertise indicates that the best performers (in chess, medicine, music, sports, etc.) practice every day of the week (including weekends) for up to four hours a day. Sounds tiring for sure. And yet, the same body of evidence shows that world class performers are able to sustain such high levels of practice because they view the acquisition of expertise as a long-term process. Indeed, in a study of children, researcher Gary McPherson found that the answer to a simple question determined the musical ability of kids a year later: “how long do you think you’ll play your instrument?” The factors that were shown to be irrelevant to performance level were: initial musical ability, IQ, aural sensitivity, math skills, sense of rhythm, income level, and sensorimotor skills.

The type of practice also matters. When researchers Kitsantas and Zimmerman studied the skill acquisition of experts, they found that 90% of the variation in ability could be accounted for by how the performers described their practice; the types of goals they set, how they planned and executed strategies, self-monitored, and adapted their performance in response to feedback.

So, I take my playing cards and close-up mat with me on all of my trips (both domestic and international). I don’t practice on planes. Gave that up after getting some strange stares from fellow passengers as they watched me repeat, in obsessive fashion, the same small segment of my performance over, and over, and over again. It only made matters worse if they found out I was a psychologist. I’d get that “knowing look,” that seemed to say, “Oh yeah.” Anyway, I also managed to lose a fair number of cards when the deck–because of my inept handling while trying to master some particular move–went flying all over the cabin (You can imagine why I’ve been less successful in keeping last year’s New Year resolution to learn to play the ukelele).

Once I’m comfortably situated in my room, the mat and cards come out and I work, practice a specific handling for up to 30 minutes followed by a 15-20 minute break. Believe it or not, learning–or perhaps better said, attempting to learn–magic has really been helpful in understanding the acquisition of expertise in my chosen field: psychology and psychotherapy. Together with my colleagues, we are translating our experience and the latest research on expertise into steps for improving the performance and outcome of behavioral health services. This is, in fact, the focus of the newest workshop I’m teaching, “Achieving Clinical Excellence.” It’s also the organizing theme of the ICCE Achieving Clinical Excellence conference that will be held in Kansas City, Kansas in October 2010. Click on the photo below for more information.

In the meantime, check out the two videos I’ve uploaded to ICCETV featuring two fun magic effects. And yes, of course, feedback is always appreciated!

The Future of Behavioral Health: Integrated Care & Entrepreneurship

February 2, 2010 By scottdm Leave a Comment

Nicholas Cummings, Ph.D.

Sometime in late 1986 I wrote a letter to Dr. Nicholas Cummings. As a then student-member of the American Psychological Association (APA), I was automatically subscribed to and receiving the American Psychologist. In the April issue, Dr. Cummings published an article, provocatively titled, “The Dismantling of Our Health System: Strategies for the Survival of Psychological Practice.” Change was in the air. “Traditional psychology practice is both inefficient and ineffective,” he argued, and a “growing revolution in heath care” was a clear and present danger to the very survival of the field.

What can I say? As someone at the beginning of his career (with large student loans to repay and a long time to go before retirement), the five page article spooked me. So I did what I’d done before: I wrote a letter. I’d been writing and calling prominent researchers and clinicians ever since I was an undergraduate. During the 70’s, I’d exchanged letters and even phone calls with B.F. Skinner!

In all honesty, I didn’t know anything about Dr. Cummings–for example, that he was a former president of the APA, launched the Professional Schools of Psychology movement and founded four campuses of the California School of Professional Psychology, wrote the freedom-of-choice legislation requiring insurers to reimburse non-medical, behavioral health providers, and started American Biodyne in the hopes that psychologists could own rather than be owned–as eventually happened–by managed care (read a history here). Neither did I know that he was a member of Psychology’s famed “Dirty Dozen.” Without a doubt, however, the decision to write him, changed the arc of my career.

Fast forward 25 years, and 86-year-old Nicholas Cummings is at it again–not only sounding a warning klaxon but identifying the opportunities available in the dramatically changing healthcare environment. Sadly, the field (and professional psychology in particular) ignored the counsel he’d given back in 1986. As a result, business interests took over managed care, resulting–just as he predicted–in low wages and the near complete lack of professional autonomy.

So, what can clinicians do now to survive and thrive? According to Dr. Cummings, two words best capture the future of behavioral health: (1) integrated care; and (2) entrepreneurship. Let’s face the unpleasant reality and say it out loud: independent practice is on life support. Agency work is no picnic either given the constant threats to funding and never ending amount of regulation and paperwork. Finally, when it comes to practitioner income, its a buyer’s market.

That said, it’s not all doom and gloom. Far from it. There is a tremendous need (and opportunity) in the present reform-driven healthcare marketplace for clinicians who are able to blend behavioral interventions, medical literacy, knowledge about healthcare delivery systems, and entrepreneurship skills. Possibilities do exist. The real question is, “Do we have the will to change?” Here’s where the power of one simple action–in this instance, a phone call–can have such a profound effect on one’s life and success.

Though we never formally worked together, I’ve been calling and writing Nick off and on for the two and a half decades. Late last fall, my partners and co-creators of the International Center for Clinical Excellence, Brendan Madden and Enda Madden, flew to Reno to seek his advice on our business plan. We simply called him. He said, “When can you get here?” The result? His sage counsel helped us win the InterTrade Seedcorn Regional Prize for “Best Emerging Company” as well as secure investors in the most restrictive venture capital environment since the Great Depression. And that’s not all…

Chief Technology Officer Enda Madden Chief Executive Officer Brendan Madden

Just last week, I flew to Phoenix, Arizona to give a presentation on using outcomes to improve behavioral healthcare service delivery at Arizona State University. Nick was there to meet me, along with the director of an entirely new program for behavioral health entrepreneurs, Dr. Ron O’Donnell. Briefly, the “Doctor of Behavioral Health” is the culmination of Nick’s vision of creating a doctoral training program tailored to the emerging need for innovative behavioral clinicians to practice in primary care and medical settings. Response has been overwhelming to say the least. Fifty plus post-graduate clinicians are enrolled. That’s right, post-graduate. In other words, these are practicing clinicians returning to add “integrated care expert and behavioral health entrepreneur” to their resume.

School of Letters and Sciences

As it turns out, I’ll be traveling from Chicago to Phoenix a fair amount in the future. When he stood to introduce me, Nick announced that I’d be filling the “Cummings Professor of Behavioral Health” faculty position at ASU. The power of a single call.