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Excellence in Amsterdam: The 2013 ACE Conference

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My how time flies!  Nearly three weeks have passed since hundreds of clinicians, researchers, and educators met in Amsterdam, Holland for the 2013 “Achieving Clinical Excellence.”  Participants came from around the globe–Holland, the US, Germany, Denmark, Italy, Russia, Norway, Sweden, Denmark, New Zealand, Romania, Australia, France–for three days of presentations on improving the quality and outcome of behavioral healthcare.  Suffice it to say, we had a blast!

The conference organizers, Dr. Liz Pluut and Danish psychologist Susanne Bargmann did a fantastic job planning the event, organizing a beautiful venue (the same building where the plans for New York City were drafted back in the 17th century), coordinating speakers (36 from around the globe), arranging meals, hotel rooms, and handouts.

Dr. Pluut opened the conference and introduced the opening plenary speaker, Dr. K. Anders Ericsson, the world’s leading researcher and “expert on expertise.”  Virtually all of the work being done by me and my colleagues at the ICCE on the study of excellence and expertise among therapists is based on the three decades of pioneering work done by Dr. Ericsson.  You can read about our work, of course, in several recent articles: Supershrinks, The Road to Mastery, or the latest The Outcome of Psychotherapy: Past, Present and Future (which appeared in the 50th anniversary edition of the journal, Psychotherapy).

Over the next several weeks, I’ll be posting summaries and videos of many of the presentations, including Dr. Ericsson.  One key aspect of his work is the idea of “Deliberate Practice.”  Each of the afternoon sessions on the first day focused on this important topic, describing how clinicians, agency managers, and systems of care can apply it to improve their skills and outcome.

The first of these presentations was by psychologist Birgit Valla–the leader of Family Help, a mental health agency in Stange, Norway–entitled, “Unreflectingly Bad or Deliberately Good: Deciding the Future of Mental Health Services.”  Grab a cup of coffee and listen in…

Oh, yeah…while on the subject of excellence, here’s an interview that just appeared in the latest issue of the UK’s Therapy Today magazine:

It starts on page 32.

The Importance of "Whoops" in Improving Treatment Outcome

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

Leonard Cohen, Anthem

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

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

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

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

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

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

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

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

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

Becoming FIT: Simple but not Easy

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Becoming FIT (feedback informed in treatment).  Ask any experienced practitioner and they will tell you, “it’s such a simple idea, but it’s not easy.”  In addition to the time it takes to master the administration and interpretation of formal feedback, special skills are required for using the information to guide service delivery.

Implementation in agencies and large healthcare settings is even more challenging.  “What,” you may wonder, “is so difficult?”  All that appears to be involved is the administration of two simple scales: a 4-item outcome and a 4-item alliance measure.  Would that the process were as easy as the forms are simple.

On the International Center for Clinical Excellence community, an international group of supervisors, agency directors, and officers of large healthcare organizations meet routinely to discuss, plan, and help support one another in efforts to develop a feedback-friendly workplace culture.  Ask any and they will tell you that a key element of successful implementation is: communication.  It is also one of the biggest challenges.  Rising case loads, increased documentation requirements, and tight budgets all conspire to keep people chained to their desks, interacting with their desktop computer, and straining just to keep up with the work load.  The proverbial “water-cooler” conversations are, for many, a thing of the past–along with clinical supervision and “advanced training.”

Here’s where ICCE is helping.   The peer-to-peer, web-based community is available to clinicians, managers, researchers, and policy makers 24/7/365.  Signing up is simple and free–and you simply won’t believe the resources available.  Access to an experienced group of professionals ready, willing, and able to answer questions related to FIT.  Discussion groups on everything from using FIT in supervision to the latest research on evidence-based practice.  Training videos, research papers, policy statements, and other documents uploaded by ICCE certified trainers and associates.

In the video below, psychologist and ICCE community manager, Susanne Bargmann describes the community and available resources.  As I blogged about recently, the community is growing at a rapid rate.  We will soon hit 2000 members–and all in less than one year.  So….join us.  And if you are already a member, log onto the site now.  One cool new feature is live chat!  That right.  When you log on, look down in the left hand corner of your screen.  There you’ll be able to see everyone who is “live” on the site at that moment.  With a simple click of the button, you could be chatting with a professional in Washington or Wollongong!

Join us for the upcoming “Advanced Intensive” training in Chicago!  If you are looking for in-depth training in the “how-to” of CDOI/FIT, this is the training for you.  When you leave, you will be on your way to mastering:

  • 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

Registration is strictly limited to 35 participants.  To reserve your place, click on the icon below!

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?”

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

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

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

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

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

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