SCOTT D Miller - For the latest and greatest information on Feedback Informed Treatment

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Clinician Beware: Ignoring Research Can be Hazardous to Your Professional (and Economic) Health

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“Studies show…”
“Available data indicate…”
“This method is evidence-based…”
My how things have changed. Twenty years ago when I entered the field, professional training, continuing education events, and books rarely referred to research or evidence. Now, everyone refers to the “data.”  The equation is simple: no research = no money.  Having “an evidence-base” increasingly determines book sales, attendance at continuing education events, and myriad other funding and reimbursement decisions.

So what do the data actually say? S adly, the answer is often, “it depends on who you ask.”  If you read the latest summary and treatment recommendations for post-traumatic stress disorder (PTSD) posted by the Cochrane Collaboration, you are told that TFCBT and EMDR are the most effective, “state of the art” treatments on offer.  Other summaries, as I recently blogged about, arrive at very—even opposite—conclusions; namely, all psychotherapies (trauma-focused and otherwise) work equally well in the treatment of PTSD.  For the practicing clinician (as well as other consumers of research), the end result is confusion and, dare I say, despair.

Unable to resolve the discrepant findings, the research is either rejected out of hand (“it’s all crap anyway”) or cherry-picked (“your research is crap, mine is good”).  In a world where experts disagree–and vehemently–what is the average Joe or Jane therapist to do?

Fortunately, there is another way, beyond agnosticism and instead of fundamentalism.   In a word, it is engagement. This last week, I spent 5 days teaching an intensive workshop with ICCE Senior Associate Susanne Bargmann to a group of Danish psychologists on “Statistics and Research Design.”  That’s right.  Five days, 6 hours a day spent away from work and clients learning how to understand, read, and conduct research.

The goal of the training was simple and straight-forward: help practitioners learn to evaluate the methods and meanings, strengths and weaknesses, and political and paradigmatic influences associated with research and evidentiary claims. At the conclusion of the five days, none of those assembled had difficulty engaging with and understanding the reasons for the seemingly discrepant findings noted above. As a result, they could state with confidence “what works” with PTSD, helping clarify this not only to colleagues, payers, and policy members but also to consumers of behavioral health services.

The “Statistics and Research Design” course will be held again in Denmark in 2011.  If the experience of this year’s participants proves anything, it is that, “The only thing therapists have to fear about statistics and research design, is fear itself.”  Please contact Vinther and Mosgaard directly for more information.

Finally, as part of the International Center for Clinical Excellence (ICCE) efforts to improve the quality and outcome of behavioral health services worldwide, two additional intensive trainings will be offered in Chicago, Illinois (USA). First, the “Advanced Training in Feedback-Informed Treatment (FIT).”  And second, the annual “Training of Trainers.”   In the Advanced Training, participants learn:

·         The empirical foundations of feedback-informed clinical work (i.e., empirically supported factors underlying successful clinical work, the impact of feedback on performance)
·         Clinical skills for enhancing client engagement that cut across different therapeutic orientations and diverse treatment populations
·         How to integrate outcome management tools (including one or more of the following: ORS, SRS, CORE, and OQ 45) into clinical practice
·         How to use the outcome management tools to inform and improve service delivery
·         How to significantly improve your clinical skills and outcomes via feedback and deliberate practice
·         How to use data generated from outcome measures to inform management, supervision, and training decisions
·         Strategies for successful implementation of CDOI and FIT in your organization or practice
Need more information about the course?  Email us or click on the video below to hear more about the course.  In the meantime, space is limited so register early at: http://www.eventbrite.ie/o/the-international-centre-for-clinical-excellence-298540255.

Goodbye Freud, Hello Common Factors

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Gary Greenberg certainly has a way with words.  In his most recent article, The War on Unhappiness, published in the August issue of Harper‘s magazine, Greenberg focuses on the “helping profession”–its colorful characters, constantly shifting theoretical landscape, and claims and counterclaims regarding “best practice.”  He also gives prominence to the most robust and replicated finding in psychotherapy outcome research: the “dodo bird verdict.”  Simply put, the finding that all approaches developed over the last 100 years–now numbering in the thousands–work about equally well.   Several paragraphs are devoted to my own work; specifically, research documenting the relatively inconsequential role that particular treatment approaches play in successful treatment and the importance of using ongoing feedback to inform and improve mental health services.  In any event, Greenberg’s review of current and historical trends is sobering to say the least–challenging mental health professionals to look in the mirror and question what we really know for certain–and a must read for any practitioner hoping to survive and thrive in the current practice environment.  OK.  Enough said.  Read it yourself here.

View more documents from Scott Miller.

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

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

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

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

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

Connecting, Learning, and Sharing: The ICCE at One Year

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September 7, 2010
Chicago, Illinois USA

I can’t believe it. Summer is over. Kids are back in school.  And, the International Center for Clinical Excellence (ICCE) is celebrating its one year anniversary!  Time passes so quickly.

On August 25th, 2009, I blogged about the creation of a web-based community of clinicians using the latest Web2.0 technology where participants could learn from and share with each other.  The ICCE website and community was officially launched the following December at the Evolution of Psychotherapy conference.  In a few short months, ICCE had become the largest, international online community of professionals, researchers, and policy makers working to improve the quality and outcome of behavioral health services.

So much more has happened over the last year, including the development and standardization of a training package for clinicians and agencies interested in streamlining the implementation of Feedback-Informed Treatment (FIT), the annual “training of trainers” conference, and much more.  Take a look at the video and see for yourself, and if you are not already a member, join us online today at: www.centerforclinicalexcellence.com.

A week or so ago, I received an email from Susanne Helfgott, the sister of concert pianist David Helfgott who, as you know, will be performing at the upcoming “Achieving Clinical Excellence” conference in Kansas City.  She sent me a link to an interview with David that appeared on Australian morning TV.  David is a perfect example of the theme of the conference: achieving superior performance under challenging circumstances.  Check it out:

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

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

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

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

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

Hope Transcends: Learning from our Clients

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“Hope Transcends” was the theme of the 39th Annual Summer Institute on Substance Abuse and Mental Health held in Newark, Delaware this last week.  I had the honor of working with 60+ clinicians, agency managers, peer supports, and consumers of mental health services presenting a two-day, intensive training on “feedback-informed clinical work.”  I met so many talented and dedicated people over the two days and even had a chance to reconnect with a number of folks I’d met at previous trainings– both at the Institute and elsewhere.

One person I knew but never had the privilege of meeting before was psychologist Ronald Bassman.  A few years back, he’d written a chapter that was included in my book, The Heroic Client.  His topic at the Summer Institute was similar to what he’d written for the book: harmful treatment.  Research dating back decades documents that approximately 10% of people deteriorate while in psychotherapy.  The same body of evidence shows that clinicians are not adept at identifying: (a) people who are likely to drop out of care; or (b) people who are deteriorating while in care.

Anyway, you can read about Ron on his website or pick up his gripping book A Fight to Be.  Briefly, at age 22 Ron was committed to a psychiatric hospital.  Over the next several years, he was diagnosed with paranoid schizophrenia and forcefully subjected to a series of humiliating, painful, degrading and ultimately unhelpful “treatments.”  Eventually, he escaped his own and the systems’ madness and became a passionate advocate for improving mental health services.  His message is simple: “we can and must do better.”  And, he argues persuasively, the process begins with building better partnerships with consumers.

One way to build bridges with consumers is routinely seeking their feedback regarding the status of the therapeutic relationship and progress of any services offered.  Indeed, the definition of “evidence-based practice” formally adopted by the American Psychological Association mandates that the clinician “monitor…progress…[and] If progress is not proceeding adequately…alters or addresses problematic aspects of the treatment (e.g., problems in the therapeutic relationship or the implementation of the goals of treatment)” (pp. 276-277, APA, 2006).  Research reviewed in detail on this blog documents significant improvement in both retention and outcome when clinicians use the Outcome and Session Rating Scales to solicit feedback from consumers.  Hope really does transcend.  Thank you Ron and thank you clinicians and organizers at the Institute.

And now, just for fun.  Check out these two new videos:


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

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

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

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

The Impact of Mentors

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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!

So you want to be a better therapist? Take a hike!

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How best to improve your performance as a clinician?  Take the continuing education multiple-choice quiz:

a. Attend a two-day training;
b. Have an hour of supervision from a recognized expert in a particular treatment approach;
c. Read a professional book, article, or research study;
d. Take a walk or nap.

If you chose a, b, or c, welcome to the world of average performance!  As reviewed on my blog (March 2010), there is exactly zero evidence that attending a continuing education event improves performance.  Zero.  And supervision?  In the most recent review of the research, researchers Beutler et al. (2005) concluded, “Supervision of psychotherapy cases has been the major method of ensuring that therapists develop proficiency and skill…unfortunately, studies are sparse…and apparently, supervisors tend to rate highly the performance of those who agree with them” (p. 246).  As far as professional books, articles, and studies are concerned–including those for which a continuing education or “professional development” point may be earned–the picture is equally grim.  No evidence.  That leaves taking a walk or nap!

K. Anders Ericsson–the leading researcher in the area of expertise and expert performance–points out the type and intensity of practice required to improve performance, “requires concentration that can be maintained only for limited periods of time.”  As a result, he says, “expert performers from many domains engage in practice without rest for only around an hour…The limit…holds true for a wide range of elite performers in difference domains…as does their increased tendency to recperative take naps”  (p.699, Erickson, 2006).  By the way, Ericsson will deliver a keynote address at the upcoming “Achieving Clinical Excellence” conference.  Sign up now for this event to reserve your space!


Two recently released studies add to the evidence base on rest and expertise.  The first, conducted at the University of California, Berkeley by psychologist Matthew Walker found that a midday nap markedly improved the brain’s learning capacity.  The second, published last week in the European Journal of Developmental Psychology, found that simply taking a walk–one where you are free to choose the speed–similarly improved performance on complex cognitive tasks.

So, there you go.  I’d say more but I’m feeling sleepy.

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

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

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

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

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

 

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

Feedback, Friends, and Outcome in Behavioral Health

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

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


Michael J. Lambert, Ph.D.

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

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

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

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

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


Lynn D. Johnson, Ph.D.

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

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

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

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

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

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

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

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

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

What might help?

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

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

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

Problems in Evidence-Based Land: Questioning the Wisdom of "Preferred Treatments"

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This last week, Jeremy Laurance, Health Editor for the U.K. Independent published an article entitled, “The big question: Does cognitive therapy work? And should the NHS (National Health Service) provide more of it?” Usually such questions are limited to professional journals and trade magazines. Instead, it ran in the “Life and Style” section of one of Britain’s largest daily newspapers. Why?

In 2007, the government earmarked £173,000,000 (approximately 260,000,000 U.S. dollars) to train up an army of new therapists. Briefly, the money was allocated following an earlier report by Professor Richard Layard of the London School of Economics which found that a staggering 38% of illness and disability claims were accounted for by “mental disorders.” The sticking point—and part of the reason for the article by Laurance—is that training was largely limited to a single treatment approach: cognitive-behavioral therapy (CBT).  And research released this week indicates that the efficacy of the method has been seriously overestimated due to “publication bias.”
Researchers Cuijpers, Smith, Bohlmeijer, Hollon, and Andersson (2010) examined the “effect sizes” of 117 trials and found that the tendency of journals to accept trials that showed positive results and reject those with null or negative findings reduced the reported effectiveness of CBT by as much as 33 percent!
Combine such findings with evidence from multiple meta-analyses showing no difference in outcome between treatment approaches intended to be therapeutic and one has to wonder why CBT continues to enjoy a privileged position among policy makers and regulatory bodies.  Despite the evidence, the governmental body in the UK that is responsible for reviewing research and making policy recommendations—National Institute for Health and Clinical Excellence (NICE)–continues to advocate for CBT.  It’s not only unscientific, its bad policy. Alas, when it comes to treatment methods, CBT enjoys what British psychologist Richard Wiseman calls, the “get out of a null effect free” card.
What would work? If the issue is truly guaranteeing effective treatment, the answer is measurement and feedback.  The single largest contributor to outcome is who provides the treatment and not what treatment approach is employed.  More than a dozen randomized clinical trials—the design of choice of NICE and SAMSHA—indicate that outcomes and retention rates are improved while costs are decreased—in many cases dramatically so.
I respectfully ask, “What is the hold up?”

Is Professional Training a Waste of Time?

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readerEvery 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.

Excellence on a Shoestring: The “Home for Good” Program

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Today I’m teaching in Christchurch, New Zealand. For the last two days, I’ve been in Nelson, a picturesque coastal town opposite Abel Tasman, working with the local DHB (District Health Board). If you’ve never visited, make a point of adding the country to your list of top travel destinations. The landscape and the people are second to none. (In Nelson, be sure and visit The Swedish Bakery. My 8-year old son, Michael, unequivocally states it has the best hot chocolate in the world—and, believe me, he’s an expert).

I’ve been traveling to New Zealand at least once a year for the last several years to provide training on using outcomes to inform behavioral healthcare. Interest is keen and providers and managers are working hard to deliver top-notch services. However, like many other places around the globe, economic factors are taking a toll.   On the day I arrived, one of the lead stories in the local paper (The Nelson Mail) focused on the economic crisis in healthcare.   “Complaints about money, shortages, overwork, stress and unsympathetic management…in the always-stretched hospital service,” the story began, “[indicate] a rapidly worsening situation” (p. 5, News Extra). Today, the headline of an article in section A5 of The Press Christchurch warns, “Health Ministry staff brace for job losses.”

A little over two weeks ago, I was in Richmond, Virginia working with managers and providers of public behavioral health agencies. There too, economic problems loom large. Over the last two years, for example, agencies have had to absorb across-the-board, double-digit cuts in funding. The result, in many instances, has been layoffs and the elimination of services and programs—with a few prominent exceptions.

On March 5th, I blogged about the crew at Chesterfield CSB in Virginia that were serving 70% more people than they did in 2007 despite there being no increase in available staff resources in the intervening period and, at the same time, decreasing clinician caseloads by nearly 30%.  In January, I posted text and video about agencies in Ohio that had managed to improve outcome, retention, and productivity at the same time that cutbacks had forced the furlough of staff! The common denominator in both instances is outcomes; that is, measuring the “fit and effect” of treatment on an ongoing basis and then using the data in consultation with consumers to improve service delivery.

If you’re not yet convinced, I have one more example to add to the mix: the “Home for Good” program.  Vision, commitment, and drive are words that best capture the management and staff who work at this Richmond, Virginia-based in-home behavioral health services program. Some might question the wisdom of starting a private, primarily Medicaid-funded treatment program in the worst economic climate since the Great Depression. A commitment to helping families keep their children at home—preventing placement in residential treatment centers, foster care, and detention—is what drove founder and director Kathy Levenston to take up the challenge. The key to their success says Kathy is that “we take responsibility for the results.” As in Ohio and Chesterfield, Kathy and her crew routinely monitor the alliance and results of the work they do and then use the data to enhance retention and outcome. Listen to Kathy as she describes the “Home for Good” program. I’m sure her story will inspire you to push for excellence whatever the “shoestring” budget you may be surviving on at the moment.

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

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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

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:

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:

Accountability in Behavioral Health: Steps for Dealing with Cutbacks, Shortfalls, and Tough Economic Conditions

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As anyone who follows me on Facebook knows, I get around.  In the past few months, I visited Australia, Norway, Sweden, Denmark (to name but a few countries) as well as criss-crossed the United States.  If I were asked to sum up the state of public behavioral health agencies in a single word, the word–with very few exceptions–would be: desperate.  Between the unfunded mandates and funding cutbacks, agencies are struggling.

Not long ago, I blogged about the challenges facing agencies and providers in Ohio.  In addition to reductions in staffing, those in public behavioral health are dealing with increasing oversight and regulation, rising caseloads, unrelenting paperwork, and demands for accountability.  The one bright spot in this otherwise frightening climate is: outcomes.  Several counties in Ohio have adopted the ORS and SRS and been using them to improve the effectiveness and efficiency of behavioral health services.

I’ve been working with the managers and providers in both Marion and Crawford counties for a little over two years.  Last year, the agencies endured significant cuts in funding.  As a result, they were forced to eliminate a substantial number of positions.  Needless to say, it was a painful process with no upsides–except that, as a result of using the measures, the dedicated providers had so improved the effectiveness and efficiency of treatment they were able to absorb the loss of staff without having to cut on services to clients.

The agencies cite four main findings resulting from the work we’ve done together over the last two years.  In their own words:

  1.  Use of FIT has enabled us to be more efficient, which is particularly important given Ohio’s economic picture and the impact of State budget cuts. Specifically, FIT is enabling service providers and supervisors to identify consumers much earlier who are not progressing in the treatment process. This allows us to change course sooner when treatment is not working, to know if changes work, to identify consumers in need of a different level of care, etc.  FIT also provides data on which the provider and consumer can base decisions about the intensity of treatment and treatment continuation (i.e. when to extend time between services or when the episode of service should end). In short, our staff and consumers are spending much less time “spinning their wheels” in unproductive activities.  As a result, we have noticed more “planned discharges versus clients just dropping out of treatment.
  2. FIT provides aggregate effect size data for individual service providers, for programs, and for services, based on data from a valid and reliable outcome scale. Effect sizes are calculated by comparing our outcome data to a large national data base. Progress achieved by individual consumers is also compared to this national data base. For the first time, we can “prove” to referral sources and funding sources that our treatment works, using data from a valid and reliable scale. Effect size data also has numerous implications for supervision, and supervision sessions are more focused and productive.
  3.  Use of the SRS (session rating scale) is helping providers attend to the therapeutic alliance in a much more deliberate manner. As a result, we have noticed increased collaboration between consumer and provider, less resistance and more partnership, and greater openness from consumers about their treatment experience. Consumer satisfaction surveying has revealed increased satisfaction by consumers. The implications for consumers keeping appointments and actually implementing what is learned in treatment are clear. The Session Rating Scale is also yielding some unexpected feedback from clients and has caused us to rethink what we assume about clients and their treatment experience.
  4. Service providers, especially those who are less experienced, appear to be more confident and purposeful when providing services. The data provides a basis for clinical work and there is much less ‘flying by the seat of their pants.’”Inspiring, eh?  And now, listen to Community Counseling Services Director Bob Moneysmith and Crawford-Marion ADAMH Board Associate Director Shirley Galdys describe the implementation:

Outcomes in the Artic: An Interview with Norwegian Practitioner Konrad Kummernes

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Dateline: Mosjoen, Norway

The last stop on my training tour around northern Norway was Mosjoen.  The large group of psychologists, social workers, psychiatrists, case managers, and physicians laughed uproariously when I talked about the bumpy, “white-knuckler” ride aboard the small twin-engine airplane that delivered me to the snowy, mountain-rimmed town. They were all to familiar with the peculiar path pilots must follow to navigate safely between the sharp, angular peaks populating the region.

Anyway, I’d been invited nearly two years earlier to conduct the day-long training on “what works in treatment.” The event was sponsored by Helgelandssykehuset-Mosjoen and organized by Norwegian practitioner Konrad Kummernes.  I first met Konrad at a conference held in another beautiful location in Norway (is there any other type in this country?!), Stavanger–best known for its breathtaking Fjordes.  The goal for the day in Mosjoen?  Facilitate the collaboration between the many different services providers and settings thereby enabling the delivery of the most effective and comprehensive clinical services.  Meeting Konrad again and working with the many dedicated professionals in Mosjoen was an inspiration. Here’s Konrad:

Practice-Based Evidence in Norway: An Interview with Psychologist Mikael Aagard

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For those of you following me on Facebook–and if you’re not, click here to start–you know that I was traveling above the arctic circle in Norway last week.  I always enjoy visiting the Scandinavian countries.  My grandparents immigrated from nearby Sweden.  I lived there myself for a number of years (and speak the language).  And I am married to a Norwegian!  So, I consider Scandinavia to be my second home.

In a prior post, I talked a bit about the group I worked with during my three day stay in Tromso.  Here, I briefly interview psychologist Mikael Aagard, the organizer of the conference.  Mikael works at KORUS Nord, an addiction technology transfer center, which sponsored the training.  His mission?  To help clinicians working in the trenches stay up-to-date with the research on “what works” in behavioral health.  Judging by the tremendous response–people came from all over the disparate regions of far northern Norway to attend the conference–he is succeeding.

Listen as he describes the challenges facing practitioners in Norway and the need to balance the “evidence-based practice” movement with “practice-based evidence.”  If you’d like any additional information regarding KORUS, feel free to connect with Mikael and his colleagues by visiting their website.  Information about the activities of the International Center for Clinical Excellence in Scandinavia can be found at: www.centerforclinicalexcellence.org.

Why ongoing, formal feedback is critical for improving outcomes in healthcare

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researchNot long ago, I had a rather lengthy email exchange with a well-known, high profile psychotherapist in the United States.  Feedback was the topic.  We both agreed that feedback was central to successful psychotherapy.   We differed, however, in terms of method.  I argued for the use of simple, standardized measures of progress and alliance (e.g., ORS and SRS).  In support of my opinion, I pointed to several randomized clinical trials documenting the impact of routine outcome monitoring on retention and progress.  I also cited studies showing traditionally low correlations between consumers and clinician’s rating of outcome and alliance and clinicians frighteningly frequent inability to predict deterioration and drop out in treatment.  He responded that such measures were an “unnecessary intrusion,” indicating that he’d always sought feedback from his clients albeit on an “informal basis.”  television-reception

When I mentioned our own research which had found that clinicians believed they asked consumers for feedback more often than they actually did, he finally seemed to agree with me.  “Of course,” he said immediately–but then he added, “I don’t need to ask in order to get feedback.”  In response to my query about how he managed to get feedback without asking, he responded (without a hint of irony), “I have unconditional empathic reception.”  Needless to say, the conversation ended there.

It’s a simple idea, feedback.  Yet, as I jet around the globe teaching about feedback-informed clinical practice, I’m struck by how hard it seems for many in healthcare to adopt.  Whatever the reason for the resistance–fear, hubris, or inertia–the failure to seek out valid and reliable feedback is a conceit that the field can no longer afford.  Simply stated, no one has “unconditional empathic reception.”  As the video below makes clear, we all need help seeing what is right before our eyes.

New Year’s Resolutions: Progress Report and Future Plans

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One year ago today, I blogged about my New Year’s resolution to “take up the study of expertise and expert performance.”  The promise marked a significant departure from my work up to that point in time and was not without controversy:

“Was I no longer interested in psychotherapy?”

“Had I given up on the common factors?

“What about the ORS and SRS?” and was I abandoning the field and pursue magic as a profession?”

Seriously.

The answer to all of the questions was, of course, an emphatic “NO!”  At the same time, I recognized that I’d reached an empirical precipice–or, stated more accurately, dead end.  The common factors, while explaining why therapy works did not and could never tell us how to work.  And while seeking and obtaining ongoing feedback (via the ORS and SRS) had proven successful in boosting treatment outcomes, there was no evidence that the practice had a lasting impact on the professionals providing the service.

Understanding how to improve my performance as a clinician has, as is true of many therapists, been a goal and passion from the earliest days of my career.  The vast literature on expertise and expert performance appeared to provide the answers I’d long sought.   In fields as diverse as music and medicine, researchers had identified specific principles and methods associated with superior performance.  On January 2nd, 2009, I vowed to apply what I was learning to, “a subject I know nothing about…put[ting] into practice the insights gleaned from the study of expertise and expert performance.”

The subject? Magic (and the ukulele).

How have I done?  Definitely better than average I can say.  In a column written by Barbara Brotman in today’s Chicago Tribune, psychologist Janine Gauthier notes that while 45% of people make New Year’s resolutions, only 8% actually keep them!  I’m a solid 50%.  I am still studying and learning magic–as attendees at the 2009 “Training of Trainers” and my other workshops can testify.  The uke is another story, however.  To paraphrase 1988 Democratic vice-presidential candidate, Lloyd Bentsen , “I know great ukulele players, and Scott, you are no Jake Shimabukuro.”

I first saw Jake Shimabukuro play the ukulele at a concert in Hawaii.  I was in the islands working with behavioral health professionals in the military (Watch the video below and tell me if it doesn’t sound like more than one instrument is playing even though Jake is the only one pictured).

Interestingly, the reasons for my success with one and failure with the other are as simple and straightforward as the principles and practices that researchers say account for superior (and inferior) performance.  I promise to lay out these findings, along with my experiences, over the next several weeks.  If you are about to make a New Year’s resolution, let me give you step numero uno: make sure your goal/resolution is realistic.  I know, I know…how mundane.  And yet, while I’ve lectured extensively about the relationship between goal-setting and successful psychotherapy for over 15 years, my reading about expert performance combined with my attempts to master two novel skills, has made me aware of aspects I never knew about or considered before.

Anyway, stay tuned for more.  In the meantime, just for fun, take a look at the video below from master magician Bill Malone.  The effect he is performing is called, “Sam the Bellhop.”  I’ve been practicing this routine since early summer, using what I’ve learned from my study of the literature on expertise to master the effect (Ask me to perform it for you on break if you happen to be in attendance at one of my upcoming workshops).

The Study of Excellence: A Radically New Approach to Understanding "What Works" in Behavioral Health

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“What works” in therapy?  Believe it or not, that question–as simple as it is–has and continues to spark considerable debate.  For decades, the field has been divided.  On one side are those who argue that the efficacy of psychological treatments is due to specific factors (e.g., changing negative thinking patterns) inherent in the model of treatment (e.g., cognitive behavioral therapy) remedial to the problem being treated (i.e., depression); on the other, is a smaller but no less committed group of researchers and writers who posit that the general efficacy of behavioral treatments is due to a group of factors common to all approaches (e.g., relationship, hope, expectancy, client factors).

While the overall effectiveness of psychological treatment is now well established–studies show that people who receive care are better off than 80% of those who do not regardless of the approach or the problem treated–one fact can not be avoided: outcomes have not improved appreciably over the last 30 years!  Said another way, the common versus specific factor battle, while generating a great deal of heat, has not shed much light on how to improve the outcome of behavioral health services.  Despite the incessant talk about and promotion of “evidence-based” practice, there is no evidence that adopting “specific methods for specific disorders” improves outcome.  At the same time, as I’ve pointed out in prior blogposts, the common factors, while accounting for why psychological therapies work, do not and can not tell us how to work.  After all, if the effectiveness of the various and competing treatment approaches is due to a shared set of common factors, and yet all models work equally well, why learn about the common factors?  More to the point, there simply is no evidence that adopting a “common factors” approach leads to better performance.

The problem with the specific and common factor positions is that both–and hang onto your seat here–have the same objective at heart; namely, contextlessness.  Each hopes to identify a set of principles and/or practices that are applicable across people, places, and situations.  Thus, specific factor proponents argue that particular “evidence-based” (EBP) approaches are applicable for a given problem regardless of the people or places involved (It’s amazing, really, when you consider that various approaches are being marketed to different countries and cultures as “evidence-based” when there is in no evidence that these methods work beyond their very limited and unrepresentative samples).  On the other hand, the common factors camp, in place of techniques, proffer an invariant set of, well, generic factors.  Little wonder that outcomes have stagnated.  Its a bit like trying to learn a language either by memorizing a phrase book–in the case of EBP–or studying the parts of speech–in the case of the common factors.

What to do?  For me, clues for resolving the impasse began to appear when, in 1994, I followed the advice of my friend and long time mentor, Lynn Johnson, and began formally and routinely monitoring the outcome and alliance of the clinical work I was doing.  Crucially, feedback provided a way to contextualize therapeutic services–to fit the work to the people and places involved–that neither a specific or common factors informed approach could.

Numerous studies (21 RCT’s; including 4 studies using the ORS and SRS) now document the impact of using outcome and alliance feedback to inform service delivery.  One study, for example, showed a 65% improvement over baseline performance rates with the addition of routine alliance and outcome feedback.  Another, more recent study of couples therapy, found that divorce/separation rates were half (50%) less for the feedback versus no feedback conditions!

Such results have, not surprisingly, led the practice of “routine outcome monitoring” (PROMS) to be deemed “evidence-based.” At the recent, Evolution of Psychotherapy conference I was on a panel with David Barlow, Ph.D.–a long time proponent of the “specific treatments for specific disorders” (EBP)–who, in response to my brief remarks about the benefits of feedback, stated unequivocally that all therapists would soon be required to measure and monitor the outcome of their clinical work.  Given that my work has focused almost exclusively on seeking and using feedback for the last 15 years, you would think I’d be happy.  And while gratifying on some level, I must admit to being both surprised and frightened by his pronouncement.

My fear?  Focusing on measurement and feedback misses the point.  Simply put: it’s not seeking feedback that is important.  Rather, it’s what feedback potentially engenders in the user that is critical.  Consider the following, while the results of trials to date clearly document the benefit of PROMS to those seeking therapy, there is currently no evidence of that the practice has a lasting impact on those providing the service.  “The question is,” as researcher Michael Lambert notes, “have therapists learned anything from having gotten feedback? Or, do the gains disappear when feedback disappears? About the same question. We found that there is little improvement from year to year…” (quoted in Miller et al. [2004]).

Research on expertise in a wide range of domains (including chess, medicine, physics, computer programming, and psychotherapy) indicates that in order to have a lasting effect feedback must increase a performer’s “domain specific knowledge.”   Feedback must result in the performer knowing more about his or her area and how and when to apply than knowledge to specific situations than others.  Master level chess players, for example, have been shown to possess 10 to 100 times more chess knowledge than “club-level” players.  Not surprisingly, master players’ vast information about the game is consilidated and organized differently than their less successful peers; namely, in a way that allows them to access, sort, and apply potential moves to the specific situation on the board.  In other words, their immense knowledge is context specific.

A mere handful studies document similar findings among superior performing therapists: not only do they know more, they know how, when, and with whom o apply that knowledge.  I noted these and highlighted a few others in the research pipeline during my workshop on “Achieving Clinical Excellence” at the Evolution of Psychotherapy conference.  I also reviewed what 30 years of research on expertise and expert performance has taught us about how feedback must be used in order to insure that learning actually takes place.  Many of those in attendance stopped by the ICCE booth following the presentation to talk with our CEO, Brendan Madden, or one of our Associates and Trainers (see the video below).

Such research, I believe, holds the key to moving beyond the common versus specific factor stalemate that has long held the field in check–providing therapists with the means for developing, organizing, and contextualizing clinical knowledge in a manner that leads to real and lasting improvements in performance.

Holidays and Suicide: Tis’ the Season NOT!

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The notion that suicides increase during the holiday season is as traditional as “Santa Claus”–and, according to statistics dating back at least a decade, just as illusory.  In fact, research actually shows suicide rates to be the lowest in December!  According to Dan Romer, a researcher at the Annenberg Public Policy Center at the University of Pennsylvania, the holidays are simply not a time for suicide.  If you are trying to peg the rate to a particular month during the year, try May.  Moreover, even suicide attempts decline during the holiday season!  At Cuyahoga County Mental health, a group I’ve worked closely with over the last three years implementing Feedback Informed Treatment (FIT), the director of crisis services, Rick Oliver, says that reviews done by the agency show that calls from suicidal people actually drop off during this time of year.

The culprit for the lingering misconception?  The media and–hold onto your candy cane–healthcare professionals!  That’s right.  In a study published this month in the British Medical Journal, researchers Vreeman and Carroll, found that healthcare professionals believe in the suicide-holiday connection along with a number of other dubious ideas (including sugar leads to hyperactivity, poinsettias are poisonous, and people lose heat through their head).stop-it-sign

So, the advice to the media and healthcare professionals, given the evidence, can only be: STOP IT!  Stop associating the holiday season with increased risk of suicide.

Clearly, suicide can happen at any time and none of the foregoing implies that people can’t and don’t feel blue.  At the same time, the decrease in suicides during this period suggests a possible course of action: connection and generosity.  If you are feeling down, do your best to reach out.  And if you’re not, then extend your hand.

Climate Change in Denmark

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hans_christian_andersen_gbHans Christian Andersen, the author of such classic stories as The Ugly Duckling and the Emperor’s New Clothes, once wrote, “Life itself is the most wonderful fairy tale of all.”  That sentiment is certainly true of my own life.  For the last 16 years, I’ve been privileged to travel around the world conducting training and providing consultation.  Each year, I meet literally thousands of therapists and I’m consistently impressed and inspired by their dedication and persistence.  Truth be told, that “spirit”–for lack of a better word–is actually what keeps me in the field.

This last year, I’ve spent a considerable amount of time working with practitioners in Denmark.  Interest in Feedback-Informed Treatment has taken off–and I have the frequent flyer miles to prove it! While I’ve been traveling to the homeland of Hans Christian Andersen for many years (actually my maternal grandfather and his family immigrated to the United States from a small town just outside Copenhagen), momentum really began building following several years of workshops arranged by Henrik and Mette Petersen who run Solution–a top notch organization providing both workshops and year-long certification courses in short-term, solution-focused, and systemic therapies.

In October, I worked with 100+ staff who work at Psykoterapeutisk Center Stolpegård–a large outpatient center just outside of Copenhagen.  For two days, we talked about research and practice in psychotheapy, focusing specifically on using outcome to inform and improve clinical services.  Peter Koefoed, chief psychologist and head of Training organized the event.   I was back in Denmark not quite one month later for two days with Henrik and Mette Petersen and a then third day for a small, intensive training with Toftemosegaard–a center for growth and change–smack dab in the middle of Copenhagen.

At each event, I was honored to be accompanied by Danish psychologist Susanne Bargmann, who is an Associate and Certified Trainer for the Center for Clinical Excellence (ICCE).  I first met Susanne at a two-day workshop sponsored by Solutions a number of years ago.  Her attitude and drive is infectious.  She attended the Training of Trainer’s event in Chicago and now runs a listserve for Danish practitioners interested in feedback-informed treatment (FIT) (by the way, if you are interested in joining the group simply click on her name above to send an email).

Recently, she published an important article in Psycholog Nyt–the official magazine for the Danish Psychological Association. The article is really the first written in Danish by a Danish practitioner to suggest “practice-based evidence” as a scientifically credible alternative to the narrow “specific treatments for specific problems” paradigm that has come to dominate professional discourse and practice the world over.

Anyway, I’ll be back in Denmark several times in 2010.  In May, I’ll be teaching “Supershrinks: Learning from the Field’s Most Effective Practitioners.”  The course, as I understand it, is already sold out.  No worries though as the workshop is being offered again in November–so sign up early (click here to access my workshop calendar).  Also, in September, Susanne and I will jointly teach a course for psychologists on research entitled, “Forskning og Formidling”–a required training for those seeking specialist approval by the Danish Psychological Association. Finally, as I’ve done for the last several years, I’m scheduled to do two days for Solution as well.  If you live and work in Denmark, I truly hope to see you at one of these events.

 

Achieving Clinical Excellence: The Conference

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A few weeks ago, I announced the first International “Achieving Clinical Excellence” (ACE) conference to be held at the Westin Hotel in Kansas City, Missouri on October 20-22nd, 2010.  You can now register for this and all other ICCE events, by clicking here.  Through a variety of keynote addresses and workshops, participants will learn the “science and steps” to excellence in clinical practice.  Attendees will also meet and learn directly from internationally ranked performers from a variety of professions, including medicine, science, music, entertainment, and sports.  I do hope you’ll join us in Kansas City for three days of science, skill building, and inspiration.

In the meantime, I wanted to tell you a bit about one of the conference’s keynote speakers, K. Anders Ericsson, Ph.D. As anyone who has been following my blog knows, Dr. Ericsson is the editor of the massive and influential “Cambridge Handbook of Expertise and Expert Performance.”  He is an internationally known writer, researcher, and speaker who is commonly referred to as “the expert on experts.”

 At the ACE conference, Dr. Ericsson will bring his knowledge and experience to bear on the subject of expertise in behavioral health.  I promise you won’t want to miss it. For a flavor, give his recent article from the Harvard Business Review a read.

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.