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The Turn to Outcomes: A Revolution in Behavioral Health Practice

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Get ready.  The revolution is coming (if not already here).  Whether you are a direct service provider (psychologist, counselor, marriage and family therapist), agency, broker, or funder, you will be required to measure and likely report the outcomes of your clinical work.


Jay Lebow, Ph.D.

Just this month, Dr. Jay Lebow, a professor of psychology at the Family Institute at Northwestern University, published an article in the Psychotherapy Networker–the most widely circulated publication for practitioners in the world–where he claimed the field had reached a “tipping point.”  “Once a matter of interest only among a small circle of academics,” Dr. Lebow writes in his piece entitled, The Big Squeeze, “treatment outcome has now become a part of the national debate about healthcare reform.”


David Barlow, Ph.D.

The same sentiments were expressed in a feature article entitled, “Negative Effects from Psychological Treatments,” written by Dr. David Barlow in the January issue of the American Psychologist.  “Therapists,” he argues both eloquently and persuasively, “do not have to wait for the next clinical trial….[rather] clinicians [can act] as local clinical scientists…[using] outcome measures to track progress…rapidly becom[ing] aware of lack of progress or even deterioration” (p. 19).  What can I say, except that any practitioner with more than a few years to work before retirement, should read these articles and then forward them to every practitioner they know.

During the Holidays, and just before the turn of the New Year, I blogged about the trend toward outcome measurement.  As readers will recall, I talked about my experience on a panel at the Evolution of Psychotherapy conference where Dr. Barlow–who, in response to my brief remarks about the benefits of feedback– suprised me by stating unequivocally that all therapists would soon be required to measure and monitor the outcome of their clinical work. And even though my work has focused almost exclusively on measuring and using outcomes to improve both retention in and the results of behavioral health for the last 15 years, I said his pronouncement frightened me–which, by the way, reminds me of a joke.

A sheep farmer is out in the pasture tending his flock–I promise this is clean, so read on–when from over a small hill comes a man in a custom-tailored, three-piece business suit.  In one hand, the businessman holds a calculator; in the other, an expensive, leather brief case.  “I have a proposition for you,” the well-clad man says as he approaches the farmer, and then continues, “if I can tell you how many sheep are in your flock, to the exact number, may I have one of your sheep?”  Though initially startled by the stranger’s abrupt appearance and offer, the farmer quickly gathers his wits.  Knowing there is no way the man could know the actual number of sheep (since many in his flock were out of site in other pastures and several were born just that morning and still in the barn), the farmer quickly responded, “I’ll take that bet!”

Without a moment’s hesitation, the man calls out the correct number, “one thousand, three hundred and forty six,” then quickly adds, “…with the last three born this morning and still resting in the barn!”  Dumbfounded, the farmer merely motions toward his flock.  In response, the visitor stows his calculator, slings one of the animals up and across his shoulders and then, after retrieving his briefcase, begins making his way back up the hill.  Just as he nears the top of the embankment, the farmer finds his voice and calls out, “Sir, I have a counter proposal for you.”

“And what might that be?” the man replies, turning to face the farmer, who then asked, “If I can tell you, sir, what you do for a living, can I have my animal back?”

Always in the mood for a wager, the stranger replies, “I’ll take that bet!”  And then without a moment’s hesitation, the sheep farmer says, “You’re an accountant, a bureaucrat, a ‘bean-counter.'”  Now, it’s the businessman’s turn to be surprised.  “That’s right!” he says, and then asks, “How did you know?”

“Well,” the farmer answers, “because that’s my dog you have around your neck.”

The moral of the story?  Bureaucrats can count but they can’t tell the difference between what is and is not important.  In my blogpost on December 24th, I expressed concern about the explosion of “official interest” in measuring outcomes.  As the two articles mentioned above make clear, the revolution has started.  There’s no turning back now.  The only question that remains is whether behavioral health providers will be present to steer measurement toward what matters?  Here, our track record is less than impressive (remember the 80-90’s and the whole managed care revolution).  We had ample warning (and did, well, nothing.  If you don’t believe me, click here and read this article from 1986 by Dr. Nick Cummings).

As my colleague and friend Peter Albert is fond of saying, “If you’re not at the table, you’re likely to be on the menu.”  So, what can the average clinician do?  First of all, if you haven’t already done so, began tracking your outcomes.  Right here, on my website, you can download, free, simple-to use, valid and reliable measures.  Second, advocate for measures that are feasible, client-friendly, and have a empirical track record of improving retention and outcome.  Third, and lastly, join the International Center for Clinical Excellence.  Here, clinicians from all over the globe are connecting, learning, and sharing their experiences about how to use ongoing measures of progress and alliance.  Most importantly, all are determined to lead the revolution.

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

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

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

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

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

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

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

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Dateline: Mosjoen, Norway

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

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

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

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

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

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

Evidence-based practice or practice-based evidence? Article in the Los Angeles Times addresses the debate in behavioral health

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January 11th, 2010

“Debate over Cognitive & Traditional Mental Health Therapy” by Eric Jaffe

The fight debate between different factons, interest groups, scholars within the field of mental health hit the pages of the Los Angeles Times this last week. At issue?  Supposedly, whether the field will become “scientific” in practice or remain mired in traditions of the past.  On the one side are the enthusiastic supporters of cognitive-behavioral therapy (CBT) who claim that existing research provides overwhelming support for the use of CBT for the treatment of specific mental disorders.  On the other side are traditional, humanistic, “feel-your-way-as-you-go” practitioners who emphasize quality over the quantitative.

My response?  Spuds or potatoes.  Said another way, I can’t see any difference between the two warring factions.  Yes, research indicates the CBT works.  That exact same body of literature shows overwhelmingly, however, that any and all therapeutic approaches intended to be therapeutic are effective.  And yes, certainly, quality is important.  The question is, however, “what counts as quality?” and more importantly, “who gets to decide?”

In the Los Angeles Times article, I offer a third way; what has loosely been termed, “practice-based evidence.”  The bottom line?  Practitioners must seek and obtain valid, reliable, and ongoing feedback from consumers regarding the quality and effectiveness of the services they offer.  After all, what person following unsuccessful treatment would say, “well, at least I got CBT!” or, “I’m sure glad I got the quality treatment.”

"What Works" in Norway

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Dateline: Tromso, Norway
Place: Rica Ishavshotel

For the last two days, I’ve had the privilege of working with 125+ clinicians (psychotherapists, psychologists, social workers, psychiatrists, and addiction treatment professionals) in far northern Norway.  The focus of the two-day training was on “What Works” in treatment, in particular examining what constitutes “evidence-based practice” and how to seek and utilize feedback from consumers on an ongoing basis.  The crowd was enthusiastic, the food fantastic, and the location, well, simply inspiring.  Tomorrow, I’ll be working with a smaller group of practitioners, doing an advanced training.  More to come.

Are all treatments approaches equally effective?

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Bruce Wampold, Ph.D.

Late yesterday, I blogged about a soon-to-be published article in Clinical Psychology Review in which the authors argue that the finding by Benish, Imel, & Wamppold (2008) of equivalence in outcomes among treatments for PTSD was due to, “bias, over-generalization, lack of transparency, and poor judgement.”  Which interpretation of the evidence is correct?  Are there “specific approaches for specific disorders” that are demonstrably more effective than others?  Or does the available evidence show all approaches intended to be therapeutic to be equally effective?

History makes clear that science produces results in advance of understanding.  Until the response to Ehlers, Bisson, Clark, Creamer, Pilling, Richards, Schnurr, Turner, and Yule becomes available, I wanted to remind people of three prior blog posts that review the evidence regarding differential efficacy of competing therapeutic approaches.  The first (and I think most illuminating)–“The Debate of the Century“–appeared back in August.  The post featured a link to a debate between Bruce Wampold and enthusiastic proponent of “empirically supported treatments,” Steve Hollon.  Listen and then see if you agree with the large group of scientists and practitioners in attendance who thought–by a margin of 15:1–that Bruce carried the day.

The second post–Whoa Nellie!– commented on a 25 Million US$ research grant awarded by the US Department of Defense to study treatments for PTSD.  Why does this make me think of “deep throat’s” admonition to, “follow the money!”  Here you can read the study that is causing the uproar within the “specific treatments for specific disorders” gang.

Third, and finally, if you haven’t already read the post “Common versus Specific Factors and the Future of Psychotherapy,” I believe you’ll find the thorough review of the research done in response to an article by Siev and Chambless critical of the “dodo verdict” helpful.

DODO BIRD HYPOTHESIS PROVEN FALSE! Study of PTSD finally proves Wampold, Miller, and other "common factor" proponents wrong

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The Dodo Bird Researchers Anke Ehlers, Jonathon Bisson, David Clark, Mark Creamer, Steven Pilling, David Richards, Paula Schnurr, Stuart Turner, and William Yule have finally done it!  They slayed the “dodo.” Not the real bird of course–that beast has been extinct since the mid to late 17th century but rather the “dodo bird” conjecture first articulated by Saul Rozenzweig, Ph.D. in 1936.  The idea that all treatment approaches work about equally well has dogged the field–and driven proponents of  “specific treatments for specific disorders” positively mad.  In a soon to be published article in Clinical Psychology Review, the authors claim that bias, overgeneralization, lack of transparency, and poor judgement account for the finding that “all therapeutic approaches work equally well for people with a diagnosis of PTSD” reported in a meta-analysis by Benish, Imel, & Wampold (2008).

I guess this means that a public admission by me, Wampold, and other common factors researchers is in order…or maybe not!  Right now, we are writing a response to the article.  All I can say at this point is, “unbelievable!”  As soon as it becomes available, you’ll find it right here on this blog.  I’ll be drawing inspiration from Saul Rosenzweig who passed away in 2004.  It was such an honor to meet him.  Still working at 96 years of age.

Research on the Outcome Rating Scale, Session Rating Scale & Feedback

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PCOMS - Partners for change outcome management system Scott D Miller - SAMHSA - NREPP“How valid and reliable are the ORS and SRS?”  “What do the data say about the impact of routine measurement and feedback on outcome and retention in behavioral health?”  “Are the ORS and SRS ‘evidence-based?'”

These and other questions regarding the evidence supporting the ORS, SRS, and feedback are becoming increasingly common in the workshops I’m teaching in the U.S. and abroad.

As indicated in my December 24th blogpost, routine outcome monitoring (PROMS) has even been endorsed by “specific treatments for specific disorders” proponent David Barlow, Ph.D., who stated unequivocally that “all therapists would soon be required to measure and monitor the outcome of their clinical work.”  Clearly, the time has come for all behavioral health practitioners to be aware of the research regarding measurement and feedback.

Over the holidays, I updated a summary of the data to date that has long been available to trainers and associates of the International Center for Clinical Excellence.  The PDF reviews all of the research on the psychometric properties of the outcome and session ratings scales as well as the studies using these and other formal measures of progress and the therapeutic relationship to improve outcome and retention in behavioral health services.  The topics is so important, that I’ve decide to make the document available to everyone.  Feel free to distribute the file to any and all colleagues interested in staying up to date on this emerging mega-trend in clinical practice.

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

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

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

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

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

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

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

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

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

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

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

The Evolution of Psychotherapy: Meeting Michael Hoyt

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I’m still reeling from the experience in Anaheim this last week.  I met so many leaders in the field, heard so many presentations on cutting edge clinical practice–as well as was reminded of some “classic” principles of effective psychotherapy.

One of the people I met was colleague and friend, Michael F. Hoyt, Ph.D.  Michael and I go back 15+ years, having met–I believe–the first time at a workshop I was giving in Northern California (somewhere in the Bay Area where Michael works and resides).  Since that time, we chatted regularly, and written editorials and book chapters together.  His books (The First Session in Brief Therapy, Brief Therapy & Managed Care, The Handbook of Constructive Therapies, Some Stories are Better than Others) always balance theory and practice and are among my favorites.

My two favorite books are also his most recent: The Present is a Gift and Brief Psychotherapies: Principles & Practice (Hint: his chapters on couples therapy are among the best I’ve ever read).  Anyway, the two of us caught up at the ICCE booth this last week at the Evolution conference.

Five Incredible Days in Anaheim

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From December 9-13th, eight thousand five hundred mental health practitioners, from countries around the globe, gathered in Anaheim, California to attend the “Evolution of Psychotherapy” conference.  Held every five years since 1985, the conference started big and has grown only larger.  “Only a few places in the US can accommodate such a large gathering,” says Jeffrey K. Zeig, Ph.D., who has organized the conference since the first.

The event, held every five years, brings together 40 of the field’s leading researchers, practitioners, trend setters, and educators to deliver keynote addresses and workshops, host discussion panels, and offer clinical demonstrations on every conceivable subject related to clinical practice.  Naturally, I spoke about my current work on “Achieving Clinical Excellence” as well as served on several topical panels, including “evidence based practice” (with Don Meichenbaum), “Research on Psychotherapy” (with Steven Hayes and David Barlow), and “Severe and Persistent Mental Illness (with Marsha Linnehan and Jeff Zeig).

Most exciting of all, the Evolution of Psychotherapy conference also served as the official launching point for the International Center for Clinical Excellence.  Here I am pictured with long-time colleague and friend, Jeff Zeig, and psychologist and ICCE CEO, Brendan Madden, in front of the ICCE display in the convention center hall.

Over the five days, literally hundreds of visitors stopped by booth #128 chat with me, Brendan, and Senior ICCE Associates and Trainers, Rob Axsen, Jim Walt, Cynthia Maeschalck, Jason Seidel, Bill Andrews, Gunnar Lindfeldt, and Wendy Amey.  Among other things, a cool M and M dispenser passed out goodies to folks (if they pressed the right combination of buttons), we also talked about and handed out leaflets advertising the upcoming “Achieving Clinical Excellence” conference, and finally people watched a brief video introducing the ICCE community.  Take a look yourself:.


More to come from the week in Anaheim….

Climate Change in Denmark

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

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

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

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

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

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

 

Where is Scott Miller going? The Continuing Evolution

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I’ve just returned from a week in Denmark providing training for two important groups.  On Wednesday and Thursday, I worked with close to 100 mental health professionals presenting the latest information on “What Works” in Therapy at the Kulturkuset in downtown Copenhagen.  On Friday, I worked with a small group of select clinicians working on implementing feedback-informed treatment (FIT) in agencies around Denmark.  The day was organized by Toftemosegaard and held at the beautiful and comfortable Imperial Hotel.

In any event, while I was away, I received a letter from my colleague and friend, M. Duncan Stanton.  For many years, “Duke,” as he’s known, has been sending me press clippings and articles both helping me stay “up to date” and, on occasion, giving me a good laugh.  Enclosed in the envelope was the picture posted above, along with a post-it note asking me, “Are you going into a new business?!”

As readers of my blog know, while I’m not going into the hair-styling and spa business, there’s a grain of truth in Duke’s question.  My work is indeed evolving.  For most of the last decade, my writing, research, and training 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 (e.g., the therapeutic alliance, placebo/hope/expectancy, structure and techniques, extratherapeutic factors).  As first spelled out in Escape from Babel: Toward a Unifying Language for Psychotherapy Practice, the idea was that effectiveness could be enhanced by practitioners purposefully working to enhance the contribution of these pantheoretical ingredients.  Ultimately though, I realized the ideas my colleagues and I were proposing came dangerously close to a new model of therapy.  More importantly, there was (and is) no evidence that teaching clinicians a “common factors” perspective led to improved outcomes–which, by the way, had been my goal from the outset.

The measurable improvements in outcome and retention–following my introduction of the Outcome and Session Rating Scales to the work being done by me and my colleagues at the Institute for the Study of Therapeutic Change–provided the first clues to the coming evolution.  Something happened when formal feedback from consumers was provided to clinicians on an ongoing basis–something beyond either the common or specific factors–a process I believed held the potential for clarifying how therapists could improve their clinical knowledge and skills.  As I began exploring, I discovered an entire literature of which I’d previously been unaware; that is, the extensive research on experts and expert performance.  I wrote about our preliminary thoughts and findings together with my colleagues Mark Hubble and Barry Duncan in an article entitled, “Supershrinks” that appeared in the Psychotherapy Networker.

Since then, I’ve been fortunate to be joined by an internationally renowned group of researchers, educators, and clinicians, in the formation of the International Center for Clinical Excellence (ICCE).  Briefly, the ICCE is a web-based community where participants can connect, learn from, and share with each other.  It has been specifically designed using the latest web 2.0 technology to help behavioral health practitioners reach their personal best.  If you haven’t already done so, please visit the website at www.iccexcellence.com to register to become a member (its free and you’ll be notified the minute the entire site is live)!

As I’ve said before, I am very excited by this opportunity to interact with behavioral health professionals all over the world in this way.  Stay tuned, after months of hard work and testing by the dedicated trainers, associates, and “top performers” of ICCE, the site is nearly ready to launch.

Whoa Nellie! A 25 Million Dollar Study of Treatments for PTSD

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I have in my hand a frayed and yellowed copy of observations once made by a well known trainer of horses. The trainer’s simple message for leading a productive and successful professional life was, “If the horse you’re riding dies, get off.”

You would think the advice straightforward enough for all to understand and benefit.  And yet, the trainer pointed out, “many professionals don’t always follow it.”  Instead, they choose from an array of alternatives, including:

  1. Buying a strong whip
  2. Switching riders
  3. Moving the dead horse to a new location
  4. Riding the dead horse for longer periods of time
  5. Saying things like, “This is the way we’ve always ridden the horse.”
  6. Appointing a committee to study the horse
  7. Arranging to visit other sites where they ride dead horses more efficiently
  8. Increasing the standards for riding dead horses
  9. Creating a test for measuring our riding ability
  10. Complaining about how the state of the horse the days
  11. Coming up with new styles of riding
  12. Blaming the horse’s parents as the problem is often in the breeding.
When it comes to the treatment of post traumatic stress disorder, it appears the Department of Defense is applying all of the above.  Recently, the DoD awarded the largest grant ever awarded to “discover the best treatments for combat-related post-traumatic stress disorder” (APA Monitor).  Beneficiaries of the award were naturally ecstatic, stating “The DoD has never put this amount of money to this before.”
Missing from the announcements was any mention of research which clearly shows no difference in outcome between approaches intended to be therapeutic—including, the two approaches chosen for comparison in the DoD study!  In June 2008, researchers Benish, Imel, and Wampold, conducted a meta-analysis of all studies in which two or more treatment approaches were directly compared.  The authors conclude, “Given the lack of differential efficacy between treatments, it seems scientifically questionable to recommend one particular treatment over others that appear to be of comparable effectiveness. . . .keeping patients in treatment would appear to be more important in achieving desired outcomes than would prescribing a particular type of psychotherapy” (p. 755).
Ah yes, the horse is dead, but proponents of “specific treatments for specific disorders” ride on.  You can hear their rallying cry, “we will find a more efficient and effective way to ride this dead horse!” My advice? Simple: let’s get off this dead horse. There are any number of effective treatments for PTSD.  The challenge is decidedly not figuring out which one is best for all but rather “what works” for the individual. In these recessionary times, I can think of far better ways to spend 25 million than on another “horse race” between competing therapeutic approaches.  Evidence based methods exist for assessing and adjusting both the “fit and effect” of clinical services—the methods described, for instance, in the scholarly publications sections of my website.  Such methods have been found to improve both outcome and retention by as much as 65%.  What will happen? Though I’m hopeful, I must say that the temptation to stay on the horse you chose at the outset of the race is a strong one.

Achieving Clinical Excellence: The Conference

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

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

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

The Crown Jewel of Research on CDOI: Professor Jan Blomqvist receives 2.9 million crown grant for RCT on feedback in Sweden

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If you’ve been following me on Twitter, then you know that last week I was touring and teaching in different spots around Europe.  First, I presented two days in Copenhagen.  Then I keynoted the British Association of Counseling and Psychotherapy Conference in Newcastle, England.  Early Saturday morning, I flew from London to Stockholm.  My long time friend and associate, Gunnar Lindfelt picked me up at Arlanda airport and drove me back to his lovely home in the city.  There, we gorged on smoked salmon, “svensk godies” (small candies, my favorite of which is “skum bananer”–dark chocolate covered marshmellow in the shape of a banana) and Cider–a non-alcoholic fizzy apple drink that is an old time Swedish favorite.

It was Gunnar Lindfeldt, a gifted clinician and expert in the treatment of drug and alcohol problems, who first introduced me to the work of Swedish psychologist Jan Blomqvist.  In 1998, Blomqvist published a book entitled, “Beyond Treatment? Widening the Approach to Alcohol Problems and Solutions“ in which he made the provocative argument that common rather than specific factors held the key to effective care.  Since writing the book, Jan Blomqvist has continued his research and is currently a full professor at SORAD, the Centre for Social Research on Alcohol and Drugs at Stockholm University.

Anyway, I had the pleasure of meeting with Professor Blomqvist at his home in Uppsala, Sweden this last week.  Over homemade spinach soup, freshly-baked bread and cheese, we chatted about the state of the field.  The pièce de résistance, however, was hearing about the 2.9 million Swedish crown grant he had just been awarded for a 4 year long study of outcome-informed treatment of alcohol problems, called “Putting the Client in the Driver’s Seat.”

The study to be conducted by Professor Blomqvist will be the largest, most comprehensive, randomized clinical trial on client-directed outcome informed clinical work.  A centerpience of the study will be the routine use of the ORS and SRS and provision of feedback in the delivery of treatment services.  Importantly, unlike all other studies to date, this project completely avoids claims of “allegiance effects” as no developers of measures or supporters of CDOI are participating.  Stay tuned to the “Top Performance” blog for additional updates!  While you are waiting, take a moment and read Professor Blomqvist’s provocative take on “addiction” in slide viewer below.

International Center for Clinical Excellence: Update and Announcement

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On August 25th, right here on the “Top Performance” blog, I announced the formation of the International Center for Clinical Excellence.  As anyone who has been reading my recent posts or publication knows, my work is evolving; specifically, putting prior research on the common factors, measurement of outcome and alliance, and feedback to work in helping diverse providers improve their effectiveness and the services they offer consumers.

Since the announcement, my colleagues and I have been busy at work creating the ICCE web platform.  Based on the latest Web2.0 technology,  the site is specifically designed to support clinical excellence through creating virtual clinical networks, groups and clinical communities where clinicians can be supported in eveloping clinical excellence. We are in the second round of beta-testing right now and are expecting to go live in a very short while. So, stay tuned!  And if you haven’t already done so, please visit the ICCE site and register.  There’s no obligation or cost, and you’ll also be among the first to know when the site is officially lanuched.

In the meantime, I wanted to call attention to the talented and diverse group of clinicians who will be working with the ICCE as “Associates” and “Trainers.”  Included among them are representatives from every discipline within behavioral healthcare (psychology, psychiatry, social work, marriage and family therapy, addictions, criminal justice) and from countries all over the globe.  They are:  William Andrews, Susanne Bargmann, Jim Walt, Reg Fleming, Cynthia Maeschalck, Michael Clark, Alan Scheuermann, Rob Axsen, Stephen Michael, William Plum, Bill Robinson, Michael Hutchison, Jason Seidel, Michelle Sanders, Von Borg, Dave Nylund, Magnus Johannsen, Dave Green, Gunnar Lindfeldt, Gun Eva Langdahl, Wendy Amey, Luci Doppler, Megan Boylan, Melissa Newland, Amanda Pardue, Flip Van Oenen, Mark Crouzen, Frank Asmus, Dee Dee Stout, and Robbie Babins-Wagner. Consistent with the latest web 2.0 technology, each of these ICCE Trainers will have be blogging, uploading short, instructional videos and other content, and providing supervision and consultation to ICCE members.

Membership is easy, by the way, and free.  For now, just register online and we’ll notify you when the site goes live.  Then you can enter, create your own professional profile and begin tapping into the international network of providers and experts that make up the ICCE community.

How NOT to Achieve Clinical Excellence: The Sorry State of Continuing Professional Education

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Greg Neimeyer, Ph.D., is causing quite a stir in continuing education circles.  What has he done?  In several scholarly publications, he’s reviewed the existing empirical literature and found that continuing professional education in heavioral health is not particularly, well, …educational.  Indeed, in a soon-to-be published piece in the APA journal, Professional Psychology, he notes, “While the majority of studies report high levels of participants’ satisfaction with their CE experiences, little attention has been paid to assessing actual levels of learning, the translation of learning into practice, or the impact of CE on actual professional service delivery outcomes.”   Neimeyer then goes on to cite a scholarly review published in 2002 by Daniels and Walter which pointed out that “a search [of the research literature] revealed no controlled studies of the impact of continuing education in the…behavioral health disciplines” (p. 368).  Said another way, the near ubiguitous mandate that clinicians attend so many hours per year of approved “CE” events in order to further their knowledge and skill base has no empirical support.

Personally, my guess is that any study that might be done on CE in Behavioral Health would show little or no impact on performance anyway.  Why?  Studies in other fields (i.e., medicine, flight training) have long documented that traditional CE activities (i.e., attending conferences, lectures, reading articles) have no demonstrable effect.  So, what does work?  The same research that calls the efficacy of current CE activities into questions provide clear guidance: namely, brief, circumscribed, skill-based training, followed by observed practice, real-time feedback, and performance measurement. Such characteristics are, in fact, part and parcel of expert performance in any field.  And yet, it is virutally non-existent in behavioral health.

Let me give you an example of a CE offering that arrived in my box just this week.  The oversized, multi-color, tri-fold brochure boldly asserts a workshop on CBT featuring the “top evidence-based techniques.”  Momentarily setting aside the absolute lack of evidence in support of such trainings, consider the promised content–and I’m not kidding: clinical applications of cognitive behavior therapy, motivational interviewing, cognitive therapy, mindfulness and acceptance based therapies, and behavior therapy.  As if that were not enough, the outline for the training indicates that participants will learn 52 other bulleted points, including but not limited to: why CBT, integration of skills intro practice, identifying brain-based CBT strategies, the latest research on CBT, the stages of change, open-ended and reflective listening, behavioral activiation, acceptance and commitment, emotional regulation and distrss tolerance skills, the ABC technique to promote rational beliefs, homework assignments that test core beliefs, rescripting techniques for disturbing memories and images…and so on…AND ALL IN A SINGLE 6 HOUR DAY!  You say you have no money? Your agency has suffered budget cuts?  No worries, the ad states in giant print, as the same content is available via CD, web and podcast.

Such an agenda defies not only the evidence but strains credulity to the breaking point.  Could anyone accomplish so much in so little time?  Clinicians deserve and should demand more from the CE events they register for and, in many instances, are mandated to attend in order to maintain licensure and certification.  The International Center for Clinical Excellence web platform will soon be launched.  The mission of the site, as indicated in my blog post of August 25th, is to “support clinical excellence through creating virtual clinical networks, groups and clinical communities where clinicians can be supported in the key behavior changes required for developing clinical excellence.”  Members of the site will use a variety of social networking and collaborative tools to learn skills, obtain real-time feedback, and measure their performance.    Anyway, kudos to Dr. Greg Neimeyer for confronting the ugly truth about CE in behavioral health and saying it out loud!

Top Resources for Top Performers

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Since the 1960’s, over 10,000 “how-to” book on psychotherapy have been published.  I joke about this fact at my workshops, stating “Any field that needs ten thousand books to describe what it’s doing…surely doesn’t know what its doing!” I continue, pointing out that, “There aren’t 10,000 plus books on ‘human anatomy,’ for example.  There are a handful!  And the content of each is remarkably similar.”  The mere existence of so many, divergent points of view makes it difficult for any practitioner to sort the proverbial “wheat from the chaff.”

Over the last 100 years or so, the field has employed three solutions to deal with the existence of so many competing theories and approaches.  First, ignore the differences and continue with “business as usual”– this, in fact, is the approach thats been used for most of the history of the field.  Second, force a consolidation or reduction by fiat–this, in my opinion, is what is being attempted with much of the current evidence-based practice (“specific treatments for specific disorders”) movement.  And third, and finally, respect the field’s diverse nature and approaches, while attempting to understand the “DNA” common to all–said another way, identify and train clinicians in the factors common to all approaches so that they can tailor their work to their clients.

Let’s face it: option one is no longer viable.  Changes in both policy and funding make clear that ignoring the problem will result in further erosion of clinical autonomy.  For anyone choosing option two–either enthusistically or by inaction–I will blog later this week about developments in the United States and U.K. on the “evidence-based practice” front that I’m sure will give you pause.  Finally, for those interested in movng beyond the rival factions and delivering the best clinical service to clients, I want to recommend two resources.  First, Derek Truscott’s, Becoming an Effective Psychotherapist.  The title says it all.  Whether you are new to the field or an experienced clinician, this book will help you sort through the various and competing psychotherapy approaches and find a style that works for you and the people you work with.  The second volume, is Mick Cooper’s Essential Research Findings in Counselling and Psychotherapy.  What can I say about this book?  It is a gem.  Thorough, yet readable.  Empirical in nature, but clinically relevant.  When I’m out and about teaching around the globe and people ask me what to read in order to understand the empirical literature on psychotherapy, I recommend this book.

OK, enough for now.  Stay tuned for further updates this week. In the meantime, I did manage to find a new technique making the rounds on the workshop circuit.  Click on the video below.

Announcement: Evolving in a new direction

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As those of you who have followed my work and blog know, my perspective is evolving.  The direction I’m heading builds on all of the work done to date including the common factors, measurement of outcome and alliance, and feedback.  Crucially, however, it goes one step further; bridging the common and specific factors divide that has long dominated and splintered the field, and identifying the concrete steps that diverse providers can take to improve their effectiveness and the services they offer consumers.

For the past 10 years much of my work has been available through the Institute for the Study of Therapeutic Change (ISTC) and featured on its website.  In line with the evolution in my perspective my work is now increasingly centered on a new organization, the International Center for Clinical Excellence (ICCE), an international consortium of researchers, educators, and clinicians dedicated to understanding and promoting excellence in behavior healthcare.  My colleague Barry Duncan, co-founder of the ISTC, is also developing his work in new directions and we have therefore decided that the time is now right to dissolve our long-term partnership in the ISTC.  I recognise that for many of you, who have followed my work over the years, that this may come as a surprising development and I am hoping that this post and others to follow will provide guidance, reassurance and most importantly continuity.

Central to the mission of the International Center for Clinical Excellence (ICCE) is the creation of a web-based community of clinicians using the latest Web 2.0 technology where participants can learn from and share with each other.  Based on the principles of Clinical Community Social Software (CCSS) it is specifically designed to support clinical excellence through creating virtual clinical networks, groups and clinical communities where clinicians can be supported in the key behavior changes required for developing clinical excellence.  Participants can, using a variety of social networking and collaborative tools, share clinical insights through discussion forums and video posts as well as improve client outcomes through learning the skills of clinical excellence.

We have finished our first round of beta-testing for the site and you can go to the website at: www.centerforclinicalexcellence.com to register to become a member (its free and you’ll be notified the minute the entire site is live)!

For those of you new to the tremendous opportunities for web-based collaborative social software, let me reassure you that the site will permit access and use at whatever level you desire (everything from the familiar email, to online posts and discussions in real time).  It will provide lots of help to learn how to explore the information and resources on offer as well as the support of colleagues in the community.  I am very excited by this opportunity to interact with behavioral health professionals all over the world in this way. Over the next few days, I’ll be posting more information about the ICCE and our first International Conference on Excellence in Behavioral Health on my blog at www.scottdmiller.com.   I encourage you to follow the updates on my blog and post any questions or comments.