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Implementing Feedback Informed Treatment

April 1, 2015 By scottdm 1 Comment

bigdigSOHeurofighter

What do the Sydney Opera House, Boston Central Artery Tunnel, and Eurozone Typhoon Defense Project all have in common?   In each case, their developers suffered from, “The Planning Fallacy” (PF). First recognized in 1979 by Nobel Prize winning psychologists Daniel Kahneman and Amos Tversky, the planning fallacy is the all too human tendency to underestimate the amount of time and money projects will require for completion. The impact is far from trivial, especially if you are footing the bill. The Sydney Opera House, for example, took ten years longer and cost nearly 15 times more money than originally planned (102 versus 7 million). The tunnel project in Boston ran over budget to the tune of 12 billion dollars—a figure equivalent to 19,000 dollars for man, woman, and child living in the city!

Research documents that the same shortsightedness plagues implementation of new best practices in mental healthcare. As I blogged about previously, available data indicate that between 70 and 95 percent of such efforts fail. The same body of evidence shows that prior experience with similar projects offers no protection. Indeed, regardless of experience, when planners are asked to provide a “best” and “worst” case estimate, the vast majority fail to meet even their most dire predictions.

planning fallacy

The impact of a failed implementation on staff morale can be devastating—not to mention the waste of precious time and resources, and missed opportunity to provide more effective services to consumers. I’ve seen it first hand, had it whispered to me on breaks at workshops, as I crisscross the globe teaching about Feedback-Informed Treatment (FIT). At a workshop in Ohio, a woman approached me saying, “So, you are the guy that developed the Outcome and Session Rating Scales?” When I answered yes, she leaned in, and in a quiet voice, asked, “Will you be telling us how to use them? ‘Cause we’ve been using them at my agency for about a year, but no one knows what they’re for.” More recently, at a training on the west coast, a participant told me he and his colleagues started using the scales following a two- day workshop at his agency, but eventually stopped. “Initially, there was a lot of excitement,” he said, “We really bought in. All of us were all doing it, or at least trying. Then, it just kind of fizzled.” I nodded in recognition. The planning fallacy strikes again!

Since first being reviewed and listed on SAMHSA’s National Registry of Evidence Based Programs and Practices, interest in the proven approach to improving the outcome and retention of mental health services has exploded.  More than 100,000 practitioners have downloaded the ORS and SRS.   Given the brevity and simplicity of scales, it is easy to assume that implementation will be quick and relatively easy. Ample evidence, as well as experience in diverse settings around the world, strongly suggests otherwise.

It goes without saying that getting started is not the problem.   Fully implementing FIT is another story. It takes time and careful planning—for most, between five and seven years. Along the way, there’s plenty of support to aid in success:

  • Managers, supervisors, and clinicians can join a free, online, international community of nearly 10,000 like-minded professionals using FIT in diverse settings (www.iccexcellence.com). Every day, members connect and share their knowledge and experience with each other;
  • A series of “how to” manuals and free, gap assessment tool (FRIFM) are available to aid in planning, guiding progress, and identifying common blind spots in implementation; ,
  • The 2-day FIT Implementation workshop provides an in-depth, evidence-based training based on the latest findings from the field of implementation science. Over the last few years, we’ve learned a great deal about what leads to success. Immunize yourself against the planning fallacy by joining colleagues from around the world for this event.
  • Finally, there’s technology.  Last blogpost, I introduce PragmaticTracker.com, a system for administering the ORS and SRS.  The video below introduces www.fit-outcomes.com, a simple, easy-to-use website with a clean, Apple-like interface that makes gathering and interpreting outcome and alliance data a snap.

That’s it for now.

Until next time, best wishes,

Scott Miller (Evolution 2014)

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

 

 

 

Filed Under: Conferences and Training, Feedback, Feedback Informed Treatment - FIT, FIT Software Tools Tagged With: feedback informed treatment

Want to be more effective? Point North!

July 24, 2014 By scottdm Leave a Comment

2014-06-25 14.22.57

In June, I spent several days in the air traveling to and from Perth, Australia for a conference.  Too tired to read anymore, I turned on the video system and began watching a program from the Discovery Channel about the North American red fox. 

red fox

The furry little creatures were shown hunting rodents hidden under three feet of snow.  Three feet!  Up in the air the foxes would hop, thrusting their noses deep into the drifts.  Most of the time, they came up with nothing.  That is, unless they were facing north.  Then the odds changed considerably.  Seventy-five percent of the time, the fox was guaranteed a meal.  Scientists believe the animal uses the planet’s magnetic field to more accurately calculate and plot it’s trajectory–the same principle as the GPS in your car.  Watch the video.  It’s incredible.

In a similar way, the odds of successful treatment increase considerably when clinicians incorporate feedback into their work.  Asking consumers to assess their progress and the quality of the therapeutic relationship is the “North Pole” of behavioral health services.  Available evidence documents that when providers ask for and accommodate such feedback, dropout and deterioration rates plummet, and effectiveness doubles.  Without it, the same body of evidence shows that likelihood of recovery for consumers is about 15-20%, roughly equivalent to foxes who hunt pointing in the wrong direction.

The process, known as Feedback-Informed Treatment (FIT), is being used around the globe to improve the quality and outcome of therapy.  It’s also listed on SAMHSA’s National Registry of Evidence-Based Programs and Practices.

I have a brand new DVD demonstrating how to introduce, administer, and deal effectively with the feedback consumers provide.  It was filmed live at the most recent Evolution of Psychotherapy Conference.  Thanks to the Erickson Foundation, for a limited time, you can get it here for 29.95 (that’s 50% off the regular price).

2014-07-24 11.01.58

More information about FIT is available at: www.whatispcoms.com.  You can also access the free outcome and alliance tools there.  Gotta go.  I’m re-arranging my office furniture…

Filed Under: Feedback Informed Treatment - FIT Tagged With: evidence based practice, feedback informed treatment

Is Supervision Important to you?

June 20, 2014 By scottdm 1 Comment

How valuable is clinical supervision to you?  In their massive, long-term international study of therapist development, researchers Orlinsky and Rønnestad (2005) found that “practitioners at all experience levels, theoretical orientations, professions, and nationalities report that supervised client experience is highly important for their current and career development” (p. 188).

Despite the value most of us place on the process, the latest review of the literature found no empirical evidence, “that psychotherapy supervision contributes to patient outcome” (Watkins, 2011).  Said another way, supervision does not produce more effective clinicians.  The result?  In the US, at least, opportunities for clinical supervision are in the decline, replaced by growing documentation requirements and administrative oversight–a trend destined to continue if the dearth of evidence persists.

What can be done?  Simply put, solicit formal feedback from clients regarding their experience of progress and the therapeutic relationship.  Such information, in turn, can be used to guide supervision, providing both a focus for the consultation and data supporting its effectiveness.  After all, multiple studies already document that the process improves outcomes while simultaneously decreasing drop out and deterioration rates (Miller, 2013 ).

Getting started is not difficult.  First, access two, free, easy-to-use scales for monitoring client progress and the relationship.   Second, join colleagues in the largest, online community of behavioral health professionals in the world.  It’s free–no hidden costs or secret levels of premium content.  On the ICCE, you can connect and consult with practitioners who are using feedback to improve the quality and outcome of treatment and supervision.  If you are new to feedback-informed work (FIT)–a SAMHSA certified evidence-based practice–you can get a thorough introduction at: www.whatispcoms.com .

Finally, get the  Feedback-Informed supervision manual and newly released, two-hour DVD.  Both provide step-by step instructions and examples of integrating feedback into supervision.  While you are at it, join us for our Feedback-Informed Supervision Intensive.  Last time around, it sold out months advance.  Registration is now open for our next training in March 2015.

Filed Under: Feedback Informed Treatment - FIT Tagged With: clinical supervision, feedback informed treatment, icce, international center for cliniclal excellence, Orlinsky, ors, outcome rating scale, PCOMS, psychotherapy supervision, Rønnestad, SAMHSA, session rating scale, srs

What’s in an Acronym? CDOI, FIT, PCOMS, ORS, SRS … all BS?

June 7, 2014 By scottdm Leave a Comment

“What’s in a name?”

–William Shakespeare

A little over a week ago, I received an email from Anna Graham Anderson, a graduate student in psychology at Aarhus University in Denmark.  “I’m writing,” she said, “in hopes of receiving some clarifications.”

Anna Graham Anderson
Anna Graham Anderson

Without reading any further, I knew exactly where Anna was going.  I’d fielded the same question before.  As interest in measurement and feedback has expanded, it comes up more and more frequently.

Anna continued,  “I cannot find any literature on the difference between CDOI, FIT, PCOMS, ORS, and SRS.  No matter where I search, I cannot find any satisfying clues.  Is it safe to say they are the same?”  Or, as another asked more pointedly, “Are all these acronyms just a bunch of branding B.S.?”

I answered, “B.S.?  No.  Confusing?  Absolutely.  So, what is the difference?”

As spelled out in each of the six treatment and training manuals, FIT, or feedback-informed treatment, is, “a panetheoretical approach for evaluating and improving the quality and effectiveness of behavioral health services.  It involves routinely and formally soliciting feedback from consumers regarding the therapeutic relationship and outcome of care and using the resulting information to inform and tailor service deliver.”

Importantly, FIT is agnostic regarding both the method of treatment and the particular measures a practitioner may employ.  Some practitioners use the ORS and SRS, two brief, simple-to-use, and free measures of progress and the therapeutic relationship–but any other valid and reliable scales could be used.

Of all the acronyms associated with my work, CDOI is the one I no longer use.  For me, it had always problematic as it came precariously close to being a treatment model, a way of doing therapy.  I wasn’t  interested in creating a new therapeutic approach.  My work and writing on the common factors had long ago convinced me the field needed no more therapeutic schools.  The phrase, “client-directed, outcome-informed”  described the team’s position at the time, with one foot in the past (how to do therapy), the other in the future (feedback).

And PCOMS?  A long time ago, my colleagues and I had a dream of launching a web-based “system for both monitoring and improving the effectiveness of treatment” (Miller et. al, 2005).  We did some testing at an employee assistance program in located in Texas, formed a corporation called PCOMS (Partners for Change Outcome Management System), and even hired a developer to build the site.  In the end, nothing happened.  Overtime, the acronym, PCOMS, began to be used as an overall term referring to the ORS, SRS, and norms for interpreting the scores.  In February 2013, the Substance Abuse and Mental Health Service Adminstration (SAMHSA) formally recognized PCOMS as an evidence-based practice.  You can read more about PCOMS at: www.whatispcoms.com.

I expect there will be new names and acronyms as the work evolves.  While some remain, others, like fossils, are left behind; evidence of what has come before, their sum total a record of development over time.

Filed Under: Feedback Informed Treatment - FIT Tagged With: cdoi, evidence based medicine, evidence based practice, feedback informed treatment, FIT, ors, outcome measurement, outcome rating scale, PCOMS, SAMHSA, session rating scale, srs, Substance Abuse and Mental Health Service Adminstration

What can therapists learn from the CIA? Experts versus the "Wisdom of the Crowd"

May 6, 2014 By scottdm Leave a Comment

Central psychotherapy agency

What can we therapists learn from the CIA?  In a phrase, “When it comes to making predictions about important future events, don’t rely on experts!”

After a spate of embarrassing, high-profile intelligence failures, a recent story showed how a relatively small group of average people made better predictions about critical world events than highly-trained analysts with access to classified information.  The four-year study, known as the Good Judgment Project, adds to mounting evidence regarding the power of aggregating independent guesses of regular folks–or what is known as, “the wisdom of the crowd.”

When it comes to therapy, multiple scientific studies show that inviting the “wisdom of the crowd” into treatment as much as doubles effectiveness, while simultaneously cutting drop out and deterioration rates.

Whatever your profession, work setting, or preferred therapeutic approach, the process involves formally soliciting feedback from clients and then comparing the results to empirically established benchmarks.   Getting started is easy:

  • Download and  begin using two free, easy to use tools–one that charts progress, the other the quality of the therapeutic relationship–both of which are listed on SAMHSA’s National Registry of Evidence Based Programs and Practices.
  • Next, access cutting edge technology available on the web, smartphones, and tablets, that makes it easy to anonymously compare the progress of  your clients to effective patterns of practice worldwide.

You can learn more at: www.whatispcoms.com.  Plus, the ICCE–the world’s largest online community of professionals using feedback to enhance clinical judgment–is available at no cost to support you in your efforts.

While you’re at it, be sure and join fellow practitioners from the US, Canada, Europe, and Australia for the “Training of Trainers” or two-day FIT Implementation Intensive coming up this August in Chicago.  You’ll not only learn how to use the measures, but also tap into the collective wisdom of clients and practitioners around the globe.   Space is limited, and we are filling up quickly, so don’t wait to register.

Filed Under: Feedback, Feedback Informed Treatment - FIT Tagged With: feedback, feedback informed treatment, icce, international center for cliniclal excellence, National Registry of Evidence Based Programs and Practices, NREPP, PCOMS, SAMHSA, therapy, Training

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

April 20, 2014 By scottdm Leave a Comment

fail2

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

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

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

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

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

Fit Imp 2014

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

What does Golf have to do with Feedback-Informed Treatment? Watch the video!

July 11, 2013 By scottdm 1 Comment

Summer is finally here.  The snow and rain has been replaced by warm, humid days here in Chicago.  The team at ICCE is awaiting the arrival of practitioners from all around the world to participate in the FIT Supervision Intensive training scheduled for August 6-9th.  We have a full house, the event selling out ages ago.  No reason to fret though as a second course has been scheduled for March 2014.  Register now by clicking here.

Soon, more videos of presentations from the 2013 Achieving Clinical Excellence conference will be posted here.  In the meantime, you can find handouts from all the plenary and break out sessions on the official conference website: www.ace2013amsterdam.com.  Once again, a BIG thanks to Dr. Liz Pluut, and the members of the organizing committee for pulling together such a fantastic event!

(Susanne Bargmann, Liz Pluut, Scott Miller, Rick Pluut, and Bogdan Ion)

Speaking of summer, have you been golfing yet?  What, you might ask, has golfing to do with “top performance” as a behavioral health practitioner.  Well, that was the subject of a thought-provoking and engaging presentation delivered by ICCE Associate Jim Walt at the CAMFT Annual meeting.  Lucky for us, the entire thing was caught on tape.  I know you’ll enjoy it!

Filed Under: Feedback Informed Treatment - FIT Tagged With: feedback informed treatment

Resources on Feedback-Informed Treatment, Training, & Research

January 24, 2013 By scottdm Leave a Comment

Last week, I spent a day in London working with the clinical staff of the Hertfordshire Partnership NHS Foundation Trust.  The subject?  Feedback, of course!  As soon as I stepped off my transcontinental flight, I knew it was going to be a fun day.  Every way I turned at the Heathrow airport I was greeted by a machine asking for feedback about my experience: after exiting customs, at the baggage claim area, at the duty free shops.  Amazing!

The process was as engaging as it was efficient.  Tell us about your experience…by pressing a button bearing one of four different faces.  The similarity to the ICCE Young Child Outcome Rating Scale was striking (to say the least).  I felt compelled to register my feedback at every opportunity.

From London, I travelled to Gotheburg, Sweden for the first Scandanavian Advanced Intensive Training in Feedack Informed Treatment.  The event, organized by GCK, Gothenburg’s Center for Competence Development, sold out in a week with participants coming from all over Scandanavia.  I taught the course together with ICCE Senior Associate Susanne Bargmann using a curriculum based on the FIT Treatment and Training Manuals.  The series was developed to support, in part, ICCE’s application to the US Substance Abuse and Mental Health Services Administration (SAMSHA) for designation of FIT as an evidence-based practice.  Together with the Training of Trainers (TOT) and Supervision Intensive workshops, the manuals and Advanced Intensive training provides participants with the latest, cutting-edge, evidence-based information and skills in FIT.

Back in October, I blogged about an article that reviewed the evidence regarding psychotherapy training.   In it, the author John Malouff concluded, “There appears to be no evidence that coursework and research completion…have any value to future psychotherapy clients…”.  He continued, “Training programs…carry the responsibility to show that the training they provide have positive benefits for future clients.”

Well…on that score, learning FIT, available evidence shows, leads to direct benefits to consumers of behavioral health services.  Together with New Zealand based psychologist and ICCE Senior Associate Eeuwe Schuckard, I’ve updated the review of the research supporting FIT practice (click here).

Don’t wait to learn about or deepen your understanding of and skills in feedback informed treatment.  The Advanced Intensive scheduled for March 18-321st has a few spots left.  You can register online by clicking here.

By the way, shortly after the publication of Malouff’s review in Psychotherapy in Australia, I wrote to the editor, Liz Sheehan, and asked for permission to reprint the article.  Click here to read it.

Filed Under: Conferences and Training Tagged With: feedback informed treatment, icce, New Zealand, NHS, sweden

Feedback in Groups: New Tools, New Evidence

December 29, 2012 By scottdm Leave a Comment

 

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

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

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

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

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

Advanced FIT Training - March 2013

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

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

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

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

A Lotta Help from One’s Friends: The Role of Community in the Pursuit of Excellence

August 3, 2012 By scottdm Leave a Comment

Dateline: Chicago, IL USA

Hard not to be impressed with the USA Women’s Gymnastic team.  What skill, percision, expertise, and excellence.

By now, I’m sure you’ve seen the interviews.  In all instances, each and every one has focused on the team.  Despite some in the media attempting to make stars out of the individual members, the atheletes have continually highlighted, “The Team.”  When asked to account for their success or the source of their ambition, the reason cited has been: THE TEAM.

Sixteen year old McKayla Maroney said, “I think we’re as close as we can be.  We’ve all been working and training together for a long time…I’ve known (fellow team member) Kyla since I was 6 years old.  We are all best of friends.  They did so great today and I just love this team so much.”

As highlighted in our recent article, “The Road to Mastery,” excellence does not occur in a vacuum.  Surrounding every great performer is a community (teachers, coaches, mentors, and peers).  In the busy world that is modern clinical practice, where can practitioners finda trsutworthy and supportive community of peers?  A group of colleagues that will challenge them to keep growing as professionals and people?

In a word, the ICCE.  In December 2009, the International Center for Clinical Excellence was launched and since them become the largest, global, web-based community of clinicians, researchers, administrators, and policy makers dedicated to excellence in behavioral health.  The ICCE has it’s own gold-medal winning team!  Practitioners working together in locations around the globe.

Practitioners like Jason Seidel, Psy.D., who represented ICCE at last week’s meeting of the American Psychological Association.  Jason presented on Feedback Informed Treatment (FIT) and then participated in a panel discussion on Practice Based Evidence together with Paul Clement, Michael Lambert, Bill Stiles, Carol Goodheart, and David Barlow.  Jason rocked the packed house with his tight summary of the empirical support for FIT and argument in favor of practice-based evidence!

Then there’s Daryl Chow, a psychologist from Singapore, who is currently finishing up a quantitative study of “Supershrinks.” His research is the first to employ a sophisticated statistical analysis of therapists practices related to superior outcomes.  Suffice it to say, his results are mind blowing.  Daryl’s work won him a scholarship to this year’s “Training of Trainers” course.  If you’re not signed up for that event, you can meet him today by joining the ICCE and looking him up!

There are many, many other dedicated and supportive members.  Join and share your expertise with the community today!

Filed Under: excellence, Top Performance Tagged With: cdoi, continuing education, feedback informed treatment, icce

Feedback Informed Treatment as Evidence-Based Practice

May 23, 2012 By scottdm Leave a Comment

Back in November, I blogged about the ICCE application to SAMSHA’s National Registry for consideration of FIT as an official evidence-based approach (EBP).  Given the definition of EBP by the Institute of Medicine and the American Psychological Association, Feedback Informed Treatment seems a perfect, well, FIT.  According to the IOM and APA, evidence-based practice means using the best evidence and tailoring services to the client, their preferences, culture, and circumstances.  Additionally, when evidence-based, clinicians must monitor “patient progress (and of changes in the patient’s circumstances—e.g.,job loss, major illness) that may suggest the need to adjust the treatment. If progress is not proceeding adequately, the psychologist alters or addresses problematic aspects of the treatment (e.g., problems in the therapeutic relationship or in the implementation of the goals of the treatment) as appropriate.”

In late Summer 2011, ICCE submitted 1000’s of pages of supporting documents, research studies, as well as video in support of the application.  This week, we heard that FIT passed the “Quality of Research” phase of the review.  Now, the committee is looking at the “Readiness for Dissemination” materials, including the six detailed treatment and implementation manuals on feedback informed treatment.  Keep your fingers crossed.  We’ve been told that the entire process should be completed sometime in late fall.

In the meantime, we are preparing for this summer’s Advanced Intensive and Training of Trainer workshops.  Once again, clinicians, educators, and researchers from around the world will be coming together for cutting edge training.  Only a few spots remain, so register now.

Filed Under: Feedback Informed Treatment - FIT Tagged With: American Psychological Association, evidence based medicine, evidence based practice, feedback informed treatment, FIT, icce, Institute of Medicine, NREPP, practice-based evidence, SAMHSA, Training

A Handy "Little Helper" for the Outcome Rating Scale: A Freebie from the ACE Conference Committee

April 24, 2012 By scottdm Leave a Comment

This last week the planning committee for the upcoming Achieving Clinical Excellence (ACE) conference meet once again in Horsholm, Denmark.  In the picture from left to right: Liz Plutt, Bill Andrews, myself, Rick Plutt (Conference Chair), and Bogdan Ion.  Taking the photo was Susanne Bargmann.

The agenda for the three day event is now set: (1) one day pre-conference on feedback informed treatment (FIT); (2) two days of plenaries and presentations by an international group of clinicians, researchers, and educators.

On day one, the conference kicks off with a keynote address by the world’s “expert on expertise,” Dr. K. Anders Ericsson.  Throughout the day, other speakers will translate Dr. Ericsson’s research into practical steps for enhancing the performance of mental health professionals, agencies, and systems of care.

Day two kicks off with a keynote address by Dr. Robbie Wagner addressing the question, “what barriers stand in the way of improving our effectiveness?”  Once again, the rest of the day will be spent identifying solutions for the problems standing in the way of expertise and expert performance.

We still have several openings for presentations at the conference.  If you have experiences or data related to: (1) measuring outcomes; (2) implementing feedback informed treatment; (3) the qualities of super effective clinicians or treatment approaches, then PLEASE click go to the ICCE website and submit a description for consideration.

It’ll be a fun, inspiring, and rewarding three days in Amsterdam.  Don’t miss it!  Register today and get the early bird special, saving you 100’s of dollars!

In the meantime, click on the link below to download a handy little tool for scoring the Outcome and Session Rating Scales.  It’s a combination bookmark and 10 centimeter ruler.

Ace Ruler (PDF Format)

Filed Under: Conferences and Training, excellence Tagged With: cdoi, denmark, feedback informed treatment, icce, ors, outcome rating scale, session rating scale, srs, Therapist Effects

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

February 12, 2012 By scottdm 3 Comments

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

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

What can be done?

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

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

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

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

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

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

Getting FIT: Another Opportunity

February 4, 2012 By scottdm Leave a Comment

The March Advanced Intensive in Feedback Informed Treatment is full!  Not a single space left.  For several weeks, we put folks on a waiting list.  When that reached nearly 20, we told most they’d probably have to wait until next year to attend.

Wait no more!

The ICCE is pleased to announce a second, “Advanced Intensive” Training schedule for July 30th through August 2nd, 2012 in Chicago, IL, USA.  If you’ve read the books and attended a one or two day introductory workshop and want to delve deeper in your understanding and use of the principles and practices of FIT, this is the training for you!  Multiple randomized clinical trials document that FIT improves outcomes and retention rates while decreasing costs of behavioral health.

Four intensive days focused on skill development. Participants will receive a thorough grounding in:

  • The empirical foundations of FIT (i.e., research supporting the common factors, outcome and alliance measures, and feedback)
  • Alliance building skills that cut across different therapeutic orientations and diverse client populations
  • How to use outcome management tools (including one or more of the following: ORS, SRS, CORE, and OQ 45 to inform and improve treatment)
  • How to determine your overall clinical success rates
  • How to significantly improve your outcome and retention rate via feedback and deliberate practice
  • How to use technology for support and improvement of the services you offer clients and payers
  • How to implement FIT in your setting or agency

The training venue is situated along the beautiful “Magnificent Mile,” near Northwestern hospital, atop a beautiful tall building steps from the best retail therapy and jazz clubs in Chicago. As always, the conference features continental breakfast every morning, a night of Blues at one of Scott’s favorite haunts and dinner at arguably the best Italian restaurant in Chicago.

Unlike any other training, the ICCE “Advanced Intensive” offers both pre and post attendance support to enhance learning and retention.  All participants are provided with memberships to the ICCE Trainers Forum where they can interact with the course instructors and participants, download coarse readings, view “how-to” videos, and reach out to and learn from the thousands of other member-clinicians around the world.

Don’t wait.  Register today here.

If you are interested in hanging out in Chicago a few extra days, why not register for both the “Advanced Intensive” and the 2012 “Training of Trainers” workshop?  Thanks to the demand, for the first time ever, the two events are being held back to back. Sign up for both events by May 31st and receive 25% off for the trainings!  To obtain your discount code for both events, email: events@centerforclinicalexcellence.com today.

Filed Under: Conferences and Training, Feedback Informed Treatment - FIT Tagged With: cdoi, feedback informed treatment

Looking Back, Looking Forward

January 6, 2012 By scottdm Leave a Comment

Bidding goodbye to last year and welcoming the new always puts me in a reflective frame of mind.  How did my life, work, and relationships go?  What are my hopes for the future?

Just two short years ago, together with colleagues from around the world, the International Center for Clinical Excellence (ICCE) was launched.  Today, the ICCE is the largest, global, web-based community of providers, educators, researchers, and policy makers dedicated to improving the quality and outcome of behavioral health services.  Clinicians can choose to participate in any of the 100-plus forums, create their own discussion group, immerse themselves in a library of documents and how-to videos, and consult directly with peers. Membership costs nothing and the site is free of the advertising.  With just a few clicks, practitioners are able to plug into a group of like-minded clinicians whose sole reason for being on the site is to raise everyone’s performance level.  I have many people to thank for the success of ICCE: senior associates and trainers, our community manager Susanne Bargmann, director of training Julie Tilsen, and our tech wizard Enda Madden. 

As membership in ICCE has grown from a few hundred to well over 3000, many in the community have worked together to translate research on excellence into standards for improving clinical practice.  Routine outcome monitoring (ROM) has grown in popularity around the world.  As a result, new measures and trainings have proliferated.  In order to insure quality and consistency, a task force was convened within ICCE in 2010 to develop a list of “Core Competencies”—a document establishing the empirical and practice foundations for outcome-informed clinical work.  In 2011, the ICCE Core Competencies were used to develop and standardize the curricula for the “Advanced Intensive” and “Training-of-Trainers” workshops as well as the exam all attendees must pass to achieve certification as an ICCE Trainer.   As if these accomplishments were not enough, a small cadre of ICCE associates banded together to compose the Feedback Informed Treatment and Training Manuals—six practical, “how-to”volumes covering everything from empirical foundations to implementation.  None of this would have been possible without the tireless contributions of Bob Bertolino, Jason Seidel, Cynthia Maeschalck, Rob Axsen, Susanne Bargmann, Bill Robinson, Robbie Wagner, and Julie Tilsen.

Looking back, I feel tremendous gratitude–both for the members, associates, and trainers of ICCE as well as the many people who have supported my professional journey.  This year, two of those mentors passed away: Dick Fisch and James Hillman.   During my graduate school years, I read James Hillman’s book, Suicide and the Soul.  Many years later, I had the opportunity to present alongside him at the “Evolution of Psychotherapy” conference.  Dick, together with his colleagues from MRI, had a great influence on my work, especially during the early years when I was in Milwaukee with Insoo Berg and Steve de Shazer in Milwaukee doing research and writing about brief therapy.  Thinking about Dick reminded me of two other teachers and mentors from that period in my life; namely, John Weakland and Jay Haley.


Looking forward, I am filled with hope and high expectations.  The “Advanced Intensive” training scheduled for March 19-22nd is booked to capacity—not a single spot left.  Registrations for this summer’s “Training of Trainers” course are coming in at a record pace (don’t wait if you are thinking about joining me, Cynthia and Rob).  Currently, I am awaiting word from the National Registry of Evidence Based Programs and Practices (NREPP) formally recognizing “Feedback Informed Treatment” (FIT) as an evidence-based approach.  The application process has been both rigorous and time-consuming.  It’s worth it though.  Approval by this department within the federal government would instantly raise awareness about as well as increased access to funding for implementing FIT.  Keep your fingers crossed!

There’s so much more:

  • Professor Jan Blomqvist, a researcher at the Center for Alcohol and Drug Research at Stockholm University (SoRAD) launched what will be the largest, independent evaluation of feedback informed treatment to date, involving 80+ clinicians and 100’s of clients located throughout Sweden.   I provided the initial training to clinicians in October of last year.  ICCE Certified Trainers Gunnar Lindfeldt and Magnus Johansson are providing ongoing logistic and supervisory support.
  • The most sophisticated and empirically robust interpretive algorithms for the Outcome Rating Scale (based on a sample of 427,744 administrations of the ORS, in 95,478 unique episodes of care, provided by 2,354 different clinicians) have been developed and are now available for integration into software and web based applications.  Unlike the prior formulas–which plotted the average progress of all consumers successful and not–the new equations provide benchmarks for comparing individual consumer progress to both successful and unsuccessful treatment episodes.
  • The keynote speakers and venue for the Second Achieving Clinical Excellence Conference have been secured.  We’ll be meeting at one of the nicest hotels in Amsterdam, Holland, May 16-18=9th, 2013.  Thanks go to the planning committee: Bill Andrews, Susanne Bargmann, Liz Plutt, Rick Plutt, Tony Jordan, and Bogdan Ion.  Please visit the conference website and submit a proposal for a workshop or presentation.
  • Finally, I’ve been asked to deliver the lunchtime keynote at the upcoming Psychotherapy Networker Conference scheduled on March 23, 2012.  The topic?  Achieving excellence as a behavioral health practitioner.  Last year, my colleague Mark Hubble and I published the lead article in the May-June issue of the magazine, describing the latest research on top performing clinicians.  I’m deeply honored by the opportunity to speak at this prestigious event.

More coming in the weeks ahead.  Until then, look forward to connecting on ICCE.

Filed Under: Behavioral Health, Conferences and Training, excellence, Feedback Informed Treatment - FIT, ICCE, PCOMS Tagged With: cdoi, feedback informed treatment, HHS, Insoo Berg, NREPP, ors, outcome rating scale, session rating scale, srs, Steve de Shazer

Making History in Delft, Holland: The Launch of the first Consumer-Driven Outcome Management App

October 18, 2011 By scottdm Leave a Comment

Dateline: October 18, 2011
Chicago, Illinois USA

Last week I was in Europe: three days in Norway, a week in Sweden, and a day in Holland.  In a day or two, I’ll say more about developments in Norway and the launch of the largest study in history on FIT in Sweden.  Meanwhile, I’m pleased to announce the lauch of the first, truly “consumer-driven” outcome management application: M2FIT. Briefly, this smart phone based technology empowers consumers of behavioral health services to provide feedback to clinicians regarding the quality and outcome of treatment services.  Unlike existing applications, M2FIT is owned, operated, and managed by the consumer.  It’s on their phone–not the therapists.  The application further provides tips and encouragement between visits as well as appointment reminders.

As the pictures above indicate, the M2FIT application is simple, straightforward, and intuitive.   Most important, it puts the power of feedback in consumers’ hands.

For more information, or to obtain a copy, visit the M2FIT website at: www.M2FIT.com.  In the meantime, here’s a brief video shot during my visit!

Filed Under: FIT Software Tools Tagged With: feedback informed treatment, FIT Software Tools, holland, M2FIT

Getting FIT: The Advanced Intensive Training

January 19, 2011 By scottdm Leave a Comment

Dateline: January 19, 2011
Buffalo, New York

The New Year is here and travel/training season is in full swing.  Last week, I was in Ohio and Virginia.  This week New York and Idaho (keep your weather fingers crossed, it’s going to be dicey getting from here to there and home again).

Interest in “Feedback Informed Treatment” continues to grow.  Agencies across the United States and abroad–as my travel schedule attests–are implementing the ORS and SRS in routine clinical practice.  Clinicians are finding the support they need on the International Center for Clinical Excellence web-based community.  As I blogged about a while back, the ICCE is the largest and most diverse group of practitioners working to improve the quality and outcome of behavioral health services.  Many will soon be joining me in Chicago for the 2011 “Advanced Intensive” training.  Once again, clinicians from all over the world will be in attendance–Sweden, Holland, England, Australia and so on.  Interest is high as participants receive a thorough, state-of-the-art grounding in the principles and practice of FIT.  I look forward to meeting everyone soon.

Last summer, I videoblogged about the event.  Ah, summer!   With everything my co-teacher, psychologist Susanne Bargmann, and I have planned, we promise a warm and rewarding event.

Filed Under: Behavioral Health, Conferences and Training, Feedback Informed Treatment - FIT Tagged With: feedback informed treatment, icce, ors, outcome rating scale, session rating scale, srs, Training

Hope Transcends: Learning from our Clients

July 30, 2010 By scottdm Leave a Comment

“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:


Filed Under: Behavioral Health, excellence, Feedback, Feedback Informed Treatment - FIT Tagged With: American Psychological Society APA, cdoi, feedback informed treatment, meta-analysis, ors, out rating scale, Outcome, psychology, public behavioral health, randomized clinical trial, schizophrenia, session rating scale, srs, the heroic client

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

July 14, 2010 By scottdm Leave a Comment

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

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

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

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

 

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

O Canada! Leading the Way to Improved Behavioral Health Services

June 23, 2010 By scottdm Leave a Comment

Last month, I traveled back and forth between the United States and Canada several times.  First, I was in Edmonton working with several hundred dedicated social workers, case managers, and therapists at The Family Centre.  A week later I traveled to Saskatoon, spending two days talking about outcome-informed clinical work at the Addiction Professionals Association of Saskatchewan annual conference (Photos below are from the APASK meeting.  The first during the presentation, the second with Ruth and Laurel).

The evening following this event, I flew to Calgary where I spent the day with the clinical crew at Calgary Counseling Center.  I caught a red-eye home to Chicago and then returned to Canada the following week stopping over first in Vancouver for a workshop on drug and alcohol treatment sponsored by Jack Hirose & Associates and then continued on to Calgary where I met with the staff and managers of each program that comprises Aspen Family and Community Network Society.

The reason for all the frenetic activity?  A perfect storm has been brewing for some time that is culminating in a tidal wave of interest in using outcomes to inform and improve behavioral health services.  First and foremost: vision.  Specifically, key thought and action leaders not only embraced the idea of seeking feedback from consumers but worked hard to implement outcome-informed work in the settings in which they work: Bill Smiley at  The Family Centre, Robbie Babbins-Wagner at Calgary Counseling Center, and Kim Ruse at Aspen Family and Community Network Society.  Second, as I’ve been warning about for over a decade, one province in Canada–Alberta–passed an initiative which links future agency funding to “the achievement of outcomes.”  Indeed, “outcome” is identified as “the central driver for both case work practice and allocation of resources.”  Third, and finally, economic times are tough.  Payers–be they clients, insurance companies, or government bodies–want proof of a “return on investment” for the money spent on behavioral health services.

Needless to say, it was an inspiring month.  I managed to capture some of that in an interview I did with the director of the Calgary Counseling Center, Robbie Babbins-Wagner.  In it, she describes “why” she and CCC staff are committed to measuring outcomes as well as reviews the challenges involved.  Take a look:

Filed Under: Behavioral Health, evidence-based practice, Feedback Informed Treatment - FIT, PCOMS Tagged With: Canada, feedback informed treatment

My New Year’s Resolution: The Study of Expertise

January 2, 2009 By scottdm Leave a Comment

Most of my career has been spent providing and studying psychotherapy.  Together with my colleagues at the Institute for the Study of Therapeutic Change, I’ve now published 8 books and many, many articles and scholarly papers.  If you are interested you can read more about and even download many of my publications here.

Like most clinicians, I spent the early part of my career focused on how to do therapy.  To me, the process was confusing and the prospect of sitting opposite a real, suffering, client, daunting.  I was determined to understand and be helpful so I went graduate school, read books, and attended literally hundreds of seminars.

Unfortunately, as detailed in my article, Losing Faith, written with Mark Hubble, the “secret” to effective clinical practice always seemed to elude me.  Oh, I had ideas and many of the people I worked with claimed our work together helped.  At the same time, doing the work never seemed as simple or effortless as professional books and training it appear.

Each book and paper I’ve authored and co-authored over the last 20 years has been an attempt to mine the “mystery” of how psychotherapy actually works.  Along the way, my colleagues and I have paradoxically uncovered a great deal about what contributes little or nothing to treatment outcome! Topping the list, of course, are treatment models.  In spite of the current emphasis on “evidence-based” practice, there is no evidence that using particular treatment models for specific diagnostic groups improves outcome.  It’s also hugely expensive!  Other factors that occupy a great deal of professional attention but ultimately make little or no difference include: client age, gender, DSM diagnosis, prior treatment history; additionally, therapist age, gender, years of experience, professional discipline, degree, training, amount of supervision, personal therapy, licensure, or certification.

In short, we spend a great deal of time, effort, and money on matters that matter very little.

For the last 10 years, my work has focused on factors common to all therapeutic approaches. The logic guiding these efforts was simple and straightforward. The proven effectiveness of psychotherapy, combined with the failure to find differences between competing approaches, meant that elements shared by all approaches accounted for the success of therapy. And make no mistake, treatment works. The average person in treatment is better off than 80% of those with similar problems that do not get professional help.

In the Heart and Soul of Change, my colleagues and I, joined by some of the field’s leading researchers, summarized what was known about the effective ingredients shared by all therapeutic approaches. The factors included the therapeutic alliance, placebo/hope/expectancy, structure and techniques in combination with a huge, hairy amount of unexplained “stuff” known as “extratherapeutic factors.”

Our argument, at the time, was that effectiveness could be enhanced by practitioners purposefully working to enhance the contribution of these pantheoretical ingredients.  At a minimum, we believed that working in this manner would help move professional practice beyond the schoolism that had long dominated the field.

Ultimately though, we were coming dangerously close to simply proposing a new model of therapy–this one based on the common factors.  In any event, practitioners following the work treated our suggestions as such.  Instead of say, “confronting dysfunctional thinking,” they understood us to be advocating for a “client-directed” or strength-based approach.  Discussion of particular “strategies” and “skills” for accomplishing these objectives did not lag far behind.  Additionally, while the common factors enjoyed overwhelming empirical support (especially as compared to so-called specific factors), their adoption as a guiding framework was de facto illogical.  Think about it.  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 would anyone need to learn about the common factors?

Since the publication of the first edition of the Heart and Soul of Change in 1999 I’ve struggled to move beyond this point. I’m excited to report that in the last year our understanding of effective clinical practice has taken a dramatic leap forward.  All hype aside, we discovered the reason why our previous efforts had long failed: our research had been too narrow.  Simply put, we’d been focusing on therapy rather than on expertise and expert performance.  The path to excellence, we have learned, will never be found by limiting explorations to the world of psychotherapy, with its attendant theories, tools, and techniques.  Instead, attention needs to be directed to superior performance, regardless of calling or career.

A significant body of research shows that the strategies used by top performers to achieve superior success are the same across a wide array of fields including chess, medicine, sales, sports, computer programming, teaching, music, and therapy!  Not long ago, we published our initial findings from a study of 1000’s of top performing clinicians in an article titled, “Supershrinks.”  I must say, however, that we have just “scratched the surface.”  Using outcome measures to identify and track top performing clinicians over time is enabling us, for the first time in the history of the profession, to “reverse engineer” expertise.  Instead of assuming that popular trainers (and the methods they promote) are effective, we are studying clinicians that have a proven track record.  The results are provocative and revolutionary, and will be reported first here on the Top Performance Blog!  So, stay tuned.  Indeed, why not subscribe? That way, you’ll be among the first to know.

Filed Under: Behavioral Health, excellence, Top Performance Tagged With: behavioral health, cdoi, DSM, feedback informed treatment, mental health, ors, outcome measurement, psychotherapy, routine outcome measurement, srs, supervision, therapeutic alliance, therapy

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