Implementing Feedback Informed Treatment

April 1, 2015 By scottdm 1 Comment

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.

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

Want to be more effective? Point North!

July 24, 2014 By scottdm Leave a Comment

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.

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).

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…

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.