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Is Psychotherapy Getting Better?

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This last month, I spent a significant amount of time traveling around Europe and Scandanavia (Germany, Sweden, Denmark, the Netherlands) working with clinicians and mental health agencies implementing Feedback-Informed Treatment.  Not infrequently, people ask me, “doesn’t all the travel wear you out?”  My pat response is, “No, not at all!  The worst part is being away from my family.  But, meeting with practitioners and agency managers always buoys my spirits.”  I mean it.  I miss my family and the airlines (and airport food) are a real drag.  Practitioners are, on the other hand, a different story.  Despite the numerous challenges (funding, documentation, regulatory demands, etc.), they persist, working to improve their skills and provide effective help to their clients.

As happened a few months ago, I was in the SAS lounge at the Copenhagen airport, waiting for a flight, enjoying a cup of coffee, and catching up on the news, when I ran across another article by Thomas Friedman that caught my eye.  “The plan,” he said, “to work hard and play by the rules to get ahead is now outdated.  It takes much more than that.”

Wow, I thought, he’s so right–especially when it comes to the field of mental health.  I was raised in an era when “working hard at your job” was the formula for success, the pathway to a fruitful and enjoyable career.  As I travel the world, however, I see just how little reason there is to believe in this ideal any longer.  The rules have changed.  The world, observed Friedman, “is now a more open system.  Technology and globalization are wiping out lower-skilled jobs faster, while raising the skill level required for new jobs.  More than ever now, lifelong learning is the key to getting into and staying in the middle class.”

As I said earlier, the therapists I meet are working very hard–harder than either I or they ever anticipated.  They are putting in more hours and, in many cases, making less money than they did a few years earlier.  It’s true!  Did you know, psychologists incomes are down 17% in the last decade?  Simply put, working hard is a recipe for…eventual failure.  If we are to survive and thrive, a change of order–not magnitude–is required.

Recently, Diane Cole addressed the challenges facing practitioners in a special issue of the Psychotherapy Networker.  It’s worth a read (click here).  Importantly, she doesn’t just bemoan the problems currently facing the field, but provides crucial information for helping each and every one of us take charge of our fate.

Looking for Results in All the Wrong Places: What Makes Feedback Work?

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As anyone knows who reads this blog or has been to one of my workshops, I am a fan of feedback.  Back in the mid-1990’s, I began using Lynn Johnson’s 10-item Session Rating Scale in my clinical work.  His book, Psychotherapy in the Age of Accountability, and our long relationship, convinced me that I needed to check in regularly with my clients.  At the same time, I started using the Outcome Questionnaire (OQ-45).  The developer, Michael Lambert, a professor and mentor, was finding that routinely measuring outcome helped clinicians catch and prevent deterioration in treatment.  In time, I worked with colleagues to develop a set of tools, the brevity of which made the process of asking for and receiving feedback about the relationship and outcome of care, feasible.

Initial research on the measures and feedback process was promising.   Formally and routinely asking for feedback was associated with improved outcomes, decreased drop-out rates, and cost savings in service delivery!  As I warned in my blogpost last February, however, such results, while important, were merely “first steps” in a scientific journey.  Most importantly, the research to date said nothing about why the use of the measures improved outcomes.  Given the history of our field, it would be easy to begin thinking of the measures as an “intervention” that, if faithfully adopted and used, would result in better outcomes.  Not surprisingly, this is exactly what has happened, with some claiming that the measures improve outcomes more than anything since the beginning of psychotherapy.  Sadly, such claims rarely live up to their initial promise.  For decades the quest for the holy grail has locked the field into a vicious cycle of hope and despair, one that ultimately eclipses the opportunity to conduct the very research needed to facilitate understanding of the complex processes at work in any intervention.

In February, I wrote about several indirect, but empirically robust, avenues of evidence indicating that another variable might be responsible for the effect found in the initial feedback research.  Now, before I go on, let me remind you that I’m a fan of feedback, a big fan.  At the same time, its important to understand why it works and, specifically, what factors are responsible for the effect.  Doing otherwise risks mistaking method with cause, what we believe with reality.  Yes, it could be the measures.  But, the type research conducted at the time did not make it possible to reach that conclusion.  Plus, it seemed to me, other data pointed elsewhere; namely to the therapist.  Consider, for example, the following findings: (1) therapists did not appear to learn from the feedback provided by measures of the alliance and outcome; (2) therapists did not become more effective over time as a result of being exposed to feedback.  In other words, as with every other “intervention” in the history of psychotherapy, the effect of routinely monitoring the alliance and outcome seems to vary by therapist.

Such results, if true, would have significant implications for the feedback movement (and the field of behavioral health in general).  Instead of focusing on methods and interventions, efforts to improve the outcome of behavioral health practice should focus on those providing the service.  And guess what?  This is precisely what the latest research on routine outcome measurement (ROM) has now found. Hot off the press, in the latest issue of the journal, Psychotherapy Research, Dutch investigators de Jong, van Sluis, Nugter, Heiser, and Spinhoven (2012) found that feedback was not effective under all circumstances.  What variable was responsible for the difference?  You guessed it: the therapist–in particular, their interest in receiving feedback, sense of self-efficacy, commitment to use the tools to receive feedback, and…their gender (with women being more willing to use the measures).  Consistent with ICCE’s emphasis on supporting organizations with implementation, other research points to the significant role setting and structure plays in success.  Simon, Simon, Harris and Lambert (2011), Reimer and Bickman (2012), and de Jong (2012) have all found that organizational and administrative issues loom large in mediating the use and impact of feedback in care.

Together with colleagues, we are currently investigating both the individual therapist and contextual variables that enable clinicians to benefit from feedback.  The results are enticing.  The first will be presented at the upcoming Achieving Clinical Excellence conference in Holland, May 16-18th.  Other results will be reported in the 50th anniversayry issue of the journal, Psychotherapy, to which we’ve been asked to contribute.  Stay tuned.

More from Sweden

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sweden-mapThree short weeks ago, I was in Stockholm, Sweden talking about “what works” in clinical practice.  As I announced at the time, my visit coincided with an announcement by the organization governing mental health practice in the country.  For the better part of a decade, CBT enjoyed near exclusive status as “evidence-based.”  Indeed, payment for training of clinicians and treatment of clients in other approaches disappeared as over two billion Swedish crowns were spent on in CBT. 

The result? The widespread adoption of the method had no effect whatsoever on the outcome of people disabled by depression and anxiety.  The conclusion?  Guidelines for clinical practice were reviewed and expanded.  Research on feedback is in full swing in the largest randomized clinical trial on FIT in history.

More news…

Today, I received notice from Swedish clinician and publisher, Bengt Weine, that my article, “The Road to Mastery” (written together with my long friend and collaborator, Mark A. Hubble, Ph.D.), had been translated into Swedish and accepted for publication in SFT, the Swedish Family Therapy journal.  If you understand the language, click here to access a copy.

Helping clinicians and agencies along the “road to mastery” is what the upcoming Advanced Intensive and Training of Trainers events are all about.  Join colleagues from around the globe for these fun, intense days of training in Chicago.

The Achieving Clinical Excellence Conference CALL FOR PAPERS

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In October 2010, the first annual “Achieving Clinical Excellence” was held in Kansas City, Missouri.  A capacity crowd joined leading experts on the subject of top performance for three days worth of training and inspiration.  K. Anders Ericsson reviewed his groundbreaking research, popularized by Malcolm Gladwell and others.  ICCE Director, Scott D. Miller translated the research into speciific steps for improving clinical performance.  Finally, classical piansts David Helfgott, Rachel Hsu, and Roger Chen, demonstrated what can be accomplished when such evidence-based strategies are applied to the process of learning specific skills.

The ICCE is proud to announce the 2nd “ACE” conference to be held May 16th-18th, 2013 in Amsterdam, Holland.  Join us for three educational, inspiring, and fun-filled days.  Register today and receive a significant “Early Bird” discount.  The ACE conference committee is also issuing an international “Call for Papers.”  If you, your agency, or practice are committed to excellence, using outcomes to inform practice, or have published research on the subject, please visit the conference website to submit a proposal.

Here’s what attendees said about the last event:

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

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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!

Are Mental Health Practioners Afraid of Research and Statistics?

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A few weeks back I received an email from Dr. Kevin Carroll, a marriage and family therapist in Iowa.  Attached were the findings from his doctoral dissertation.  The subject was near and dear to my heart: the measurement of outcome in routine clinical practice.  The findings were inspiring.  Although few graduate level programs include training on using outcome measures to inform clinical practice, Dr. Carroll found that 64% of those surveyed reporting utilizing such scales with about 70% of their clients!  It was particularly rewarding for me to learn that the most common measures employed were the…Outcome and Session Rating Scales (ORS & SRS)

As readers of this blog know, there are multiple randomized clinical trials documenting the impact that routine use of the ORS and SRS has on retention, quality, and outcome of behavioral health services.  Such scales also provide direct evidence of effectiveness.  Last week, I posted a tongue-in-cheek response to Alan Kazdin’s broadside against individual psychotherapy practitioners.  He was bemoaning the fact that he could not find clinicians who utilized “empirically supported treatments.”  Such treatments when utilized, it is assumed, lead to better outcomes.  However, as all beginning psychology students know, there is a difference between “efficacy” and “effectiveness” studies.  The former tell us whether a treatment has an effect, the latter looks at how much benefit actual people gain from “real life” therapy.  If you were a client which kind of study would you prefer?  Unfortunately, most of the guidelines regarding treatment models are based on efficacy rather than effectiveness research.  The sine qua non of effectiveness research is measuring the quality and outcome of psychotherapy locally.  After all, what client, having sought out but ultimately gained nothing from psychotherapy, would say, “Well, at least the treatment I got was empircally supported.”  Ludicrous.

Dr. Carroll’s research clearly indicates that clinicians are not afraid of measurement, research, and even statistics.  In fact, this last week, I was in Denmark teaching a specialty course in research design and statistics for practitioners.  That’s right.  Not a course on research in psychotherapy or treatment.  Rather, measurement, research design, and statistics.  Pure and simple.  Their response convinces me even more that the much talked about “clinician-researcher” gap is not due to a lack of interest on practitioners’ parts but rather, and most often, a result of different agendas.  Clinicians want to know “what will work” for this client.  Research rarely address this question and the aims and goals of some in the field remain hopelessly far removed from day to day clinical practice.  Anyway, watch the video yourself:

Achieving Clinical Excellence Conference 2013: CALL FOR PAPERS

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Horsholm, Denmark

Spent the weekend with the planning committe for the 2013 Achieving Clinical Excellence Conference.  Committee members came in from all over the world–the USA, Romania, Holland, the UK, and Denmark–to finalize speakers, the conference venue, and mock up the logo for the conference brochure and advertizing.  Like last time, we are not only bringing in the top researchers to present the latest scientific findings, but also superior performers from a variety of vocations to inspire all of us to achieve our personal best.

Despite all the effort, a significant part of the program remains incomplete.  That part involves YOU!  The conference committee is issuing a formal “call for papers”on expertise and expert performance in the field of behavioral health.  In keeping with the theme of the conference–“Putting the Pieces Together: The Fragile Balance”–the committe is looking for presentations on:

  • Innovative strategies for improving the quality and outcome of behavioral health;
  • Research and experiences of using routine monitoring of progress and the alliance to improve retention and outcome of treatment services;
  • Principles, practices, and experiences regarding maintaining balance between professional and personal life in the achievement of clinical excellence;
  • Implementation of strategies for improving performance in agencies and systems of care
  • How professional development can improve performance of behavioral health professionals;
  • Management and leadership practices associated with superior performance in behavioral health;

Any and all papers may be submitted directly to: info@scottdmiller.com.  The conference website is also available for earlybird registration.

There are so many other developments that I hope to blog in detail about in the coming days.  In the meantime, here’s a short summary of what’s in store:

The World Did Not End: What it a Bad Thing?

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May 25th, 2011

Chicago, Illinois

On Saturday the 21st of May, 2011 the world was supposed to come to an end.  It did not.  My question: was that a bad thing?  Would it have been better if, as the now twice wrong Prophet Harold Camping predicted, the world had ended.

In the world of public behavioral health, the answer is perhaps. Since the crash of the United States economy in 2008, funding for public behavioral health has been on the chopping block.  It’s not the “end of world in one fell swoop.”  Rather, its more like slowly having the life strangled out of you.  And unlike teachers and prison guards, public behavioral health doesn’t have a strong and vocal lobby.

“It’s sad,” says the director of one agency in the midwest, “I come to work every day feeling weighed down.  We are going to experience very close to another one mission dollar cut, that is, on topic of the same cut last year.”

Agencies are doing everything they can to continue to provide effective treatment in the current environment.  Here’s what the staff and management in Marion-Crawford county, Ohio have done:

As Bob and Shirley make clear, routinely monitoring outcome and alliance and using the information to inform service delivery is a key to survival in these challenging economic times.

At ICCE, we are working with hundreds of agencies around the US and abroad to improve quality, effectiveness, and efficiency.  Soon, we’ll be gathering in Chicago for our annual “Training of Trainers” event.  The hands-on, intensive training is the first step to acquiring the skills necessary for navigatng the troubled waters ahead.  Here’s what attendee’s from last year said about the event:

Read more about the event or register online by clicking here.

The "Fragile Balance": Putting the Pieces together at the 2013 Achieving Clinical Excellence Conference in Amsterdam, Holland

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Dateline: May 8th, 2011

Copenhagen, Denmark

It is with great pleasure and high expectations that I announce the second “Achieving Excellence Conference” to be held in Amsterdam, Holland on May 16th-18th, 2013.

The title of the 2013 ACE conference is, “Putting the Pieces Together: The ‘Fragile Balance,'” emphasizing the steps, practices, and supports required for excellence in the field of behavioral health.

This last weekend, the organizing committe met in Horsholm, Denmark to begin planning the event.  The 2013 conference chair is Dutch psychologist Rick Plutt (pictured on the left in the photo to the right).  Committee members flew in from all over Europe and include ICCE associates (from left to right in the photo on the left) Liz Plutt (Holland), Rick Plutt (Holland), Anthony Jordan (Sweden), Bogdan Ion (Romania), Bill Andrews (UK), and Susanne Bargmann (Denmark).

Information about the event is already available on the official ACE 2013 Conference website.  Registration will soon be available.

The committee has also issued a “Call for Papers” from clinicians, researchers, and policy makers interested in presenting at the event.  Guidelines for submitting a proposal to present at the conference can be obtained by sending an email to:  info@centerforclinicalexcellence.com.

Details regarding the event, including keynote presenters will be released shortly so stay tuned.  In the meantime, make sure you watch the video highlights from the 2010 conference in Kansas City, Missouri:

More videos from the conference are available on the International Center for Clinical Excellence video channel.

Don’t wait until 2013 to begin improving the quality and outcome of your clinical work.  The one and only, official “Training of Trainers” is open for registration.  This hands on event is conducted by me and other ICCE Senior Associates.  Space is limited to 35 participants.  You can register by clicking the icon below.

Here’s what last year’s participants said about the “Training of Trainers”:

The Cryptonite of Behavioral Health: Making Mistakes

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Most people readily agree that its important to “learn from mistakes.”  In truth, however, few actually believe it.  Mistakes are like cryptonite, making us feel and, more importantly, look stupid and weak.  As a result, despite what we might advise others, we do our best to avoid making and admitting them.  Such avoidance comes with a big cost: personal and professional growth stalls and even atrophies.  We take on less challenging tasks, avoid taking risks, and give up more easily when confronted with situations that might expose our weaknesses.  Far all that, falling a bit on “error-phobic” side of life is hardly an instance of  irrationality.  As Alina Tugend, author of Better by Mistake points out, “As much as people hate to make mistakes, they love pointing out the ones others have made.”  Indeed, for most of us, the glee others take in pointing out our shortcomings only serves to compound our avoidance and deepen our public denial.  And that’s what makes Tony Rousmaniere’s recent blogpost so unusual.

Briefly, Tony is a psychologist in private practice in San Francisco and Palo Alto.  As he tells the story, he was riding in his car, listening to a recording of my presentation at the 2009 Evolution of Psychotherapy conference.  The subject was “Achieving Clinical Excellence.”  The message: routinely seeking feedback from clients about our mistakes decreases dropout rates and improves outcomes in psychotherapy.  Tony took the message to heart.  Unlike many of our peers who say they routinely ask clients for feedback, Tony actually downloaded the outcome and session rating scales and began formally asking his clients for feedback.

The story he relates makes for compelling reading, most of all because the feedback he received was not always easy to hear.  And yet, he persisted, not only asking clients, but recording his work and then seeking input from colleagues.  In the article, he gives step-by-step instructions for making use of the painful and sometimes confusing and contradictory feedback one receives.

Tony’s willingness to share his experience makes it tempting to say he is one brave soul.  In actuality, he’s pragmatic.  He placed outcomes over image.  As he reports in the article, his dropout rate has plummeted and his outcomes improved.  I say, “Bravo!”
________________________

Addendum

If you are thinking of writing to tell me that I misspelled the word, “cyptonite” (the accepted spelling is kryptonite), don’t bother.  I know.  I did it on purpose.  See what I mean?!

Why is this man laughing?

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May 4th, 2011
Copenhagen, Denmark

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

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

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

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

The "F" Word in Behavioral Health

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Since the 1960’s, over 10,000 how-to books on psychotherapy/counseling have been published—everything from nude marathon group therapy to the most recent “energy-based treatments.”  Clinicians have at their disposal literally hundreds of methods to apply to an ever growing list of diagnoses as codified in the Diagnostic and Statistical Manual of Mental Disorders (soon available in its 5th and expanded edition).

Conspicuously absent from the psychological cornucopia of diagnoses and treatments is the “F” word: FAILURE. A quick search of Amazon.com led to 32,670 results for the term, “psychotherapy,” 1,393 hits for “psychotherapy and depression,” and a mere 85 citations for “psychotherapy and failure.” Of the latter 85, less than 20 dealt with the topic of failure directly. There are some notable exceptions. The work of psychologist Jeffrey Kottler, for example. The dearth of information and frank discussion points to a glaring fact: behavioral health has a problem with failure.
The research literature is clear on the subject: we fail. Dropout rates have remained embarrassingly high over the last two and a half decades—hovering around 47%. At the same time, 10% of those who stay in services deteriorate while in care. Also troubling, despite the expansion of treatment modalities and diagnoses, the outcome of treatment (while generally good) has not improved appreciably over the last 30 or so years.  Finally, as reviewed recently on this blog, available evidence indicates that clinicians, despite what many believe, do not improve with experience.
In short, behavioral health is failing when it comes to failure. As a group, we do rarely address the topic. Even when we directly addressed, we find it hard to learn from our mistakes.
Our study of top performing clinicians and agencies documents that the best have an entirely different attitude toward failure than the rest. They work at failing. Everyday, quickly, and in small ways. In the lead article of upcoming Psychotherapy Networker, “The Path to Mastery” we review our findings and provide step-by-step, evidence-based directions for using failure to improve the quality and outcome of behavioral health. As we say in the article, “more than a dozen clinical trials, involving thousands of clients and numerous therapists, have established that excellence isn’t reserved for a select few. Far from it: it’s within the reach of all.” Getting there, however, requires that we embrace failure like never before.
At this year’s “Training of Trainers” (TOT) conference, building “mindful infrastructures” capable of identifying and using failure at the individual practitioner, supervisor, and agency level will be front and center. Please note: this is not an “advanced workshop” on client-directed, feedback-informed clinical work (CDOI/FIT). No lectures or powerpoint presentations. Participants get hands on experience learning to provide training, consultation, and supervision to therapists, agencies, and healthcare systems.
But, don’t take our word for it.  Listen to what attendees from the 2010 TOT said. Be sure and register soon as space is limited.

Cha-cha-cha-changes on a Grand Scale: Think Tank Meets in Chicago

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David Mee-Lee, MD     Bill Miller, Ph.D.     Scott D. Miller, Ph.D.

Jim Prochaska, Ph.D.                                    Don Kuhl, CEO

Whether in the United States or Europe, Asia or Australia, the field of behavioral health is undergoing a period of dramatic change–some would say, “transformation.”  At least that’s the verdict of the group bought together by the CEO of The Change Companies, Don Kuhl, who brought together some of the leading figures in behavioral health for two days of discussion and brainstorming last week in Chicago.

Chief on the list of issues to be discussed was bringing “scale” to the provision of mental health and substance abuse services.  Let’s face it, the current service provision model is broken: many people in need of help, do not get it.  The care that is provided is often limited in scope and does not address the “whole person.”  And finally, healthcare costs are soaring–particularly among those with longstanding, chronic problems requiring ongoing care.

In spite of 40 years of research support, behavioral health–that is, psychological interventions–are losing ground to other approaches to change.  Consider the following data published by Katherine Nordal: “the percentage of Americans who receive outpatient mental health care…is very similar to the proportion of those receiving such treatment in 1998.”

Let’s see, that’s two decades of no growth!  None. Zero. Zip. Nada.

Dr. Nordal continues, “Overall, there has been a decrease in the use of psychotherapy, a decrease in the use of psychotherapy in conjunction with medication and a big increase in the use of medication only.”  The question that begs to be answered is why, especially when one considers that psychological intervention (whether face to face, on the phone, in a book or together with peers in a group) has a side effect profile that is the envy of the pharmaceutical industry: no weight gain, no sexual dysfunction, no sleep disturbance or dry mouth.

Many factors are, of course, responsible for the demise of behavioral health (By the way, have you noticed the size of the psychology section of your local bookstore.  Its miniscule compared to what it was a decade ago, and the majority of the titles that are available praise neuroscience over human connection, and drugs over talk).  Dr. Nordal cites the rise of managed care and gargantuan advertizing budgets of the pharmaceutical industry.  Others cite cultural changes including a “short-term fix” mentality and the increasingly frenetic pace of life.

Whatever the cause, the problem is not the lack of effective psychological treatments.  Rather, the issue is that more people need to be helped, more quickly and efficiently.  “Helping people make behavioral change,” Dr. Jim Prochaska argued, “is at the center of  healthcare reform.”  Bringing scale to behavioral health, the group agreed, requires a radical revision of the current service delivery model.

In truth, many of the ideas discussed are already underway, including the move toward “integrated care” and ongoing measurement and use of feedback to improve the quality and outcome of treatment.  Other ideas discussed included methods for putting the principles of behavior change directly into the hands of the consumer.  But there’s more.  Stay tuned.  The group has big plans.  Announcements will soon be made right here on the “Top Performance” blog.

Am-ACE-ing Events in Kansas City: The First International Achieving Clinical Excellence Conference

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Here’s a riddle for you:

What do therapists, researchers, case managers, magicians, surgeons, award winning musicians, counselors, jugglers, behavioral health agency directors, and balloon twisting artists have in common?

Answer:

They all participated in the first “Achieving Clinical Excellence” held last week in Kansas City, Missouri.

It’s true. The “motley” crew of presenters, entertainers, and attendees came to Kansas City learn the latest, evidence-based strategies for helping clinicians achieve their “personal best” and, in the process, improve the quality and outcome of behavioral health services.  Not only did participants and presenters come from all over the globe–Australia, New Zealand, Norway, Sweden, Denmark, Austria, the UK, Ireland, Scotland, Germany, Canada, Holland, and elsewhere–but ICCE web 2.0 technology was used to stream many of the presentations live to a worldwide audience (click on the link to watch the recordings).

“The atmosphere was positively electric,” one participant remarked to me on break, “and so friendly.   First, I was inspired.  Each presentation contained something new, a take-away.  Then I wanted to sit with other attendees and discuss the content.”

And thanks to “Gillis for Children and Families,” who not only sponsored and ran the event, but provided a full breakfast and lunch each day of the conference, participants had ample opportunity to meet, process, and network with each other.


Rich Simon                       Anders Ericsson                     Michael Ammar

Rich Simon, Ph.D., the editor of the Psychotherapy Networker, kicked off the event using his time at the podium to place the conference’s emphasis on excellence within the broader history of the field of psychotherapy.  He was followed by K. Anders Ericsson, the editor of the influential Cambridge Handbook of Expertise and Expert Performance, reviewed research on expert performance gathered over the last 3 decades.  Scott D. Miller, Ph.D., translated existing research on expert performance into steps for improving outcomes in behavioral health. On day 2, professional magician Michael Ammar delivered a stunning performance of close up magic while teaching a specific method of deliberate practice that clinicians can use to improve their skills.  Meanwhile, break out sessions led by psychologists, physicians, counselors, pharmacists, and agency directors addressed “nuts and bolts” applications.

Rachel Hsu                                                  Roger Shen

In between each plenary and breakout session, top performers from a variety of fields entertained and inspired.  Moving performances on the violin and piano by nine year old Rachel Hsu and eleven year old Roger Shen amazed and challenged everyone in attendance.  “It is not talent,” Rachel told me, “It’s a lot of hard work–4 to 5 hours a day, everyday of the week, including weekends.”  The take home lesson from these exception kids was clear: there are no short cuts when it comes to top performance.  If you want to achieve your personal best you must work hard.  Promises otherwise are so much more snake oil.

On Thursday evening, the Australian classical pianist, David Helfott, whose lifestory was the subject of the award winning film, “Shine” entertained conference attendees.  His partner, Gillian, introduced and provided the audience with a brief history of David’s life, unfortunate treatment in the mental health system, and their long marriage.  The audience rose to their feet in a standing ovation at the conclusion of the performance.  There were few dry eyes in the house.  Afterwards, the two spent nearly an hour meeting and greeting attendees personally.  Once again, portions of the performance were broadcast live via ICCE web 2.0 technology to a world wide audience.

The inspiration that conference attendees felt continues on the International Center for Clinical Excellence web-based community.  Join us as we work to help each other achieve our personal best.  Still looking for inspiration?  Take a look at the following two videos; first, a montage of events at ACE; and second, Mr. Ah’ Lee Robinson, the director of the Kansas City Boys Choir, whose story and performance brought the conference to a moving conclusion.

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

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

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

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

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

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This week I’m in Calgary, Canada. Last week, I was in Charleston, South Carolina. Next week, I’ll be in Marion, Ohio and Bay City, Michigan. In each instance, I’m working with the management and staff of public behavioral health agencies that are busy implementing consumer-driven, outcome-informed clinical work.

Some of the groups are just beginning the process.  Others, as reported here on my blog, have been at it long enough to document significant improvements in outcome, retention, and productivity (i.e., in Ohio and Virginia).  All have told me that implementing the seemingly simple ideas of outcome-informed practice is incredibly hard work–impacting nearly every aspect of agency life.  Being able to access the expertise and experience of fellow clinicians and agency directors in real time when questions and challenges arise is, I’ve also learned, critical in maintaining the momentum necessary for successful implementation.

Enter the ICCE: The International Center for Clinical Excellence.  Briefly, the ICCE is a web-based community of clinicians, researchers, agency managers, and policy makers dedicated to excellence in behavioral health.  Many of the groups I’m working with have joined the site providing them with 24/7/365 access to a deeply knowledgeable world-wide community.  In addition to the numerous topic-specific discussion groups and member-generated videos, organizations can set up private forums where management and clinicians can have confidential discussions and coordinate implementation efforts.

If you are a clinician or agency director and are not already a member, you and/or your organization can access the ICCE community today by visiting the website at: www.centerforclinicalexcellence.com.  Membership is free.  In the video below, I talk with Arjan Van der Weijde, about groups in Holland that are meeting on on the ICCE for practitioners to discuss their implementation of feedback-informed work in the Netherlands.  Check it out.

I’ve also included a brief video about the upcoming “Training of Trainers” course, held each year in August in Chicago.  As in prior years, professionals from all over the world will be joining me and the state-of-the-art faculty for four intensive days of training.  Agencies both public and private, in the U.S. and abroad, are sending staff to the event to learn the skills necessary to lead transformation projects.  Space is already limited so register soon.

The Training of Trainers

Feedback, Friends, and Outcome in Behavioral Health

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

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


Michael J. Lambert, Ph.D.

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

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

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

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

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


Lynn D. Johnson, Ph.D.

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

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

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

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

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

Learning, Mastery, and Achieving One’s Personal Best

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

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

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

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

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

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

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

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

1. What will I learn?

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

2. Is the content new?

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

3. Are continuing education credits available?

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

4. Will I have fun?

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

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

"What Works" in Holland: The Cenzo Experience

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When it comes to healthcare, it can be said without risk of exaggeration that “revolution is in the air.”  The most sweeping legislation in history has just been passed in the United States.  Elsewhere, as I’ve been documenting in my blogs, countries, states, provinces, and municipalities are struggling to maintain quality while containing costs of the healthcare behemoth.

Back in January, I talked about the approach being taken in Holland where, in contrast to many countries, the healthcare system was jettisoning their government-run system in favor of private insurance reimbursement.  Believe me, it is a change no less dramatic in scope and impact than what is taking place in the U.S.  At the time, I noted that Dutch practitioners were, in response “’thinking ahead’, preparing for the change—in particular, understanding what the research literature indicates works as well as adopting methods for documenting and improving the outcome of treatment.” As a result, I’ve been traveling back and forth—at least twice a quarter–providing trainings to professional groups and agencies across the length and breadth of the country.

Not long ago, I was invited to speak at the 15th year anniversary of Cenzo—a franchise organization with 85 registered psychologist members.  Basically, the organization facilitates—some would say “works to smooth”–the interaction between practitioners and insurance companies.  In addition to helping with contracts, paperwork, administration, and training, Cenzo also has an ongoing “quality improvement” program consisting of routine outcome monitoring and feedback as well as client satisfaction metrics.  Everything about this forward-thinking group is “top notch,” including a brief film they made about the day and the workshop.  Whether you work in Holland or not, I think you’ll find the content interesting!  If you understand the language, click here to download the 15th year Anniversary Cenzo newsletter.

Is Professional Training a Waste of Time?

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

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

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

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

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

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

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

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

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

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

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

While on the subject of training, let me share the brochure for this year’s “Training of Trainers” event in Chicago, Illinois during the second week of August.  As in prior years, professionals from all over the world will be joining me and the state-of-the-art faculty for four intensive days of training on feedback-informed treatment (FIT).  Please note: this is not an “advanced training” in FIT where time is spent reviewing the basics or covering content.  Rather, the TOT curriculum has been designed to prepare participants to train others.  Every day of the training, you will learn specific skills for training others, have an opportunity to practice those skills, and then receive detailed feedback from ICCE Senior Associates and Trainers Rob Axsen, Cynthia Maeschalck, and Jason Seidel.  Anyway, read for yourself.  Agencies both public and private, in the U.S. and abroad, are sending staff to the event to learn the skills necessary to lead transformation projects.  Space is already limited so register soon.

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

Addressing the Financial Crisis in Public Behavioral Healthcare Head On in Chesterfield, Virginia

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If you are following me on Twitter (and I hope you are), you know the last month has been extremely busy.  This week I worked with clinicians in Peterborough, Ontario Canada.  Last week, I was in Nashville, Tennessee and Richmond Virginia.  Prior to that, I spent nearly two weeks in Europe, providing training and consultations in the Netherlands and Belgium.

It was, as always, a pleasure meeting and working with clinicians representing a wide range of disciplines (social workers, case managers, psychologists, psychiatrists, professional counselors, alcohol and drug treatment professionals, etc.) and determined to provide the best service possible.  As tiring as “road work” can sometimes be, my spirits are always buoyed by the energy of the individuals, groups, and agencies I meet and work with around the world.

At the same time, I’d be remiss if I didn’t acknowledge the fear and hardship I’m witnessing among providers and treatment agencies each week as I’m out and about.  Frankly, I’ve never seen anything like it in my seventeen years “on the road.”  Being able to say that we predicted the current situation nearly 6 years ago provides little comfort (see The Heroic Client, 2004).

While nearly all are suffering, the economic crisis in the United States is hitting public behavioral health particularly hard.  In late January I blogged about the impact of budget cuts in Ohio.   Sadly, the situations in Virginia and Tennessee are no different.  Simply put, public behavioral health agencies are expected to do more with less, and most often with fewer providers.  What can be done?

Enter Chesterfield Community Service Board.  Several years ago, I met and began working with Larry Barnett,  Lyn Hill, and the rest of the talented clinical staff at this forward thinking public behavioral health agency.  Their goal?  According to the agency mission statement, “to promote improved quality of life…through exceptional and comprehensive mental health, mental retardation, substance abuse, and early intervention services.”  Their approach?  Measure and monitor the process and outcome of service delivery and use the resulting information to improve productivity and performance.

As Larry and Lynn report in the video below, the process was not easy.  Indeed, it was damn difficult–full of long hours, seemingly endless discussions, and tough, tough choices.  But that was then.  Some three years later, the providers at Chesterfield CSB are serving 70% more people than they did in 2007 despite there being no increase in available staff resources in the intervening period.  That’s right, 70%!  And that’s not all.  While productivity rates soared, clinician caseloads were reduced by nearly 30%.  As might be expected, the time consumers in need of services had to wait was also significantly reduced.

In short, everybody won: providers, agency managers, funders, and consumers.  And thanks to the two days of intensive training in Richmond, Virginia organized by Arnold Woodruff, many additional public behavioral health agencies have the information needed to get started.  It won’t be easy.  However, as the experience in Chesterfield demonstrates, it is possible to survive and thrive during these tumultuous times.  But don’t take my word for it, listen to how Larry and Lynn describe the process–warts and all–and the results:

Deliberate Practice, Expertise, & Excellence

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

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

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

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

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

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

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

Behavioral Healthcare in Holland: The Turn Away from the Single-payer, Government-Based Reimbursement System

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Several years ago I was contacted by a group of practitioners located in the largest city in the north of the Netherlands–actually the capital of the province known as Groningen.  The “Platform,” as they are known, were wondering if I’d be willing to come and speak at one of their upcoming conferences.  The practice environment was undergoing dramatic change, the group’s leadership (Dorti Been & Pico Tuene) informed me.  Holland would soon be switching from government to a private insurance reimbursement system.  Dutch practitioners were “thinking ahead,” preparing for the change–in particular, understanding what the research literature indicates works in clinical practice as well as learning methods for documenting and improving the outcome of treatment.

I was then, and remain now, deeply impressed with the abilities and dedication of Dutch practitioners.  During that visit to Groningen, and the many that have followed (to Amsterdam, Rotterdam, Beilen, etc.), its clear that clinicians in the Netherlands are determined to lead rather than be led.  I’ve been asked to meet with university professors, practitioner organizations, training coordinators, and insurance company executives.  In a very short period of time, two Dutch therapists–physician Flip Van Oenen and psychologist Mark Crouzen–have completed the “Training of Trainers” course and become recognized trainers and associates for the International Center for Clinical Excellence.  And finally, a study will soon be published showing sound psychometric properties of the Dutch translations of the ORS and SRS.

I’ve also been working closely with the Dutch company Reflectum–a group dedicated to supporting outcome-informed healthcare and clinical excellence.  Briefly, Reflectum has organized several conferences and expert meetings between me and clinicians, agency managers, and insurance companies.  One thing for sure: we will be working closely together to train a network of trainers and consultants to promote, support, and train agencies and practitioners in outcome-informed methods in order to meet the demands of the changing practice climate.

Check out the videobelow filmed at Schipol airport during one of my recent trips to Holland:

The Field, the Future, and Feedback

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There is an old (but in many ways sad) joke about two clinicians–actually, the way I first heard the story, it was two psychiatrists.  The point of the story is the same regardless of the discipline of the provider.  Anyway, two therapists meet in the hallway after a long day spent meeting clients.  One, the younger of the two, is tired and bedraggled.  The other, older and experienced, looks the same as s/he did at the start of the day: eyes bright and attentive, hair perfectly groomed, clothes and appearance immaculate.  Taken aback by the composure of the more experienced colleague, the younger therapist asks, “How do you do it?  How do you listen to the trials and tribulations, the problem and complaints, the dire lives and circumstances of your clients, minute and minute, hour upon hour…and yet emerge at the end of the day in such good shape?”  Slowly shaking his head from left to right, the older and more experienced clinician immediately reached out, tapping the less experienced colleague gently on the shoulder, and then after removing the thick plugs stuffed into both of his years, said, “Excuse me, what did you say?”

Let’s face it: healthcare is in trouble.  Behavioral healthcare in particular is in even worse shape.  And while solutions from politicians, pundits, industry insiders and professionals are circulating in Washington with all the sound and fury of a hurricane, the voice of consumers is largely absent.  Why?  Of course, many of the barriers between providers and consumers are systemic in nature and as such, out of the control of average clinicians and consumers.  Others, however, are local and could be addressed in an instance with a modicum of interest and attention on the part of professionals.

Chief among the steps practitioners could take to bridge to chasm between them and consumers is the adoption of routine, ongoing feedback.  Seeking and utlizing real-time feedback from consumers has the added advantage of significantly boosting outcomes and increasing retention in services (several studies documenting the impact of feedback are available in the “Scholarly publications and Handouts” section of my website). Healthcare providers can download two well validated and easy-to-use scales right now for free by clicking on the Performance Metrics tab to the left.

So far, however, few in healthcare seem interested and others are downright hostile to the idea of asking consumers for input.  Consider the following story by reporter Lindsey Tanner entitled, “Take two, call me in the morning…and keep it quiet.” Tanner discovered that some in healthcare are demanding that people (patients. clients, consumers) sign “gag orders” prior to being treated–agreeing in effect not to post comments about the provider (negative and otherwise) to online sites such as Zagats.com, Angieslist.com, and RateMds.com.  According to the article, a Greensboro, N.C. company, ironically called “Medical Justice” is, for a fee, now providing physicians with standardized waiver agreements and advising all doctors to have patients sign on the dotted line.  And if the patient refuses?  Simple: find another doctor.

Can you imagine a hotel chain or restaurant asking you to sign a legally-binding agreement not to disclose your experience prior to booking your room or handing you the menu?  Anyone who has travelled lately knows the value of the information contained on consumer-driven websites such as TripAdvisor.com.  It’s outlandish really–except in healthcare.

To be sure, there is at least one important difference between healthcare and other service industries.  Specifically, healthcare providers, unlike business owners and service managers, are prevented from responding to online complaints by existing privacy laws.  However, even if this problem were insurmountable–which it is not–how then can one explain the continuing reluctance on the part of professionals to give people access to their own healthcare records?  And this despite federal regulations under the Health Insurance Portability and Accountability Act (HIPAA) permitting complete and unfettered access (click here to read the recent NPR story on this subject).  Clearly, the problem is not legal but rather cultural in nature.  Remember when Elaine from Seinfeld asked to see her chart?

Earlier this summer, my family and I were vacationing in Southwest Michigan.  One day, after visiting the beach and poking around the shops in the lakeside town of South Haven, we happened on a small Italian bistro named,Tello.  Being from a big city famous for its good eats, I’ll admit I wasn’t expecting much.  The food was delicious.  More surprising, was the service.  Not only were the staff welcoming and attentive, but at the end of the meal, when I thought the time had come to pay the bill, the folder I was given contained a small PDA rather than the check.  I was being asked for my feedback.Answering the questions took less than a minute and the manager, Mike Sheedy, appeared at our table within moments of my hitting the “send” button.  He seemed genuinely surprised when I asked if he felt uncomfortable seeking feedback so directly.  “Have you learned anything useful?” I then inquired.  “Of course,” he answered immediately, “just last week a customer told us that it would be nice to have a children’s menu posted in the window alongside the standard one.” I was dumbstruck as one of the main reasons we had decided to go into the restaurant rather than others was because the children’s menu was prominently displayed in the front window!