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Is Supervision Important to you?

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

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

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

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

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

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

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Central psychotherapy agency

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

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

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

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

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

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

Do you know who said, "Sometimes the magic works, sometimes it doesn’t"?

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Dan George

Chief Dan George playing the role of Old Lodge Skins in the 1970 movie, “Little Big Man.”  Whether or not you’ve seen or remember the film, if you’re a practicing therapist, you know the wisdom contained in that quote.  No matter how skilled the clinician or devoted the client, “sometimes therapy works, sometimes it doesn’t.”

Evidence from randomized clinical trials indicates that, on average, clinicians achieve a reliable change–that is, a difference not attributable to chance, maturation, or measurement error–with approximately 50% of people treated.  For the most effective therapists, it’s about 70%.  Said another way, all of us fail between 30-50% of the time.

Of greater concern, however, is the finding that we don’t see the failure coming.  Hannan and colleagues (2005) found, for example, that therapists correctly predicted deterioration in only 1 of 550 people treated, despite having been told beforehand the likely percentage of their clients that would worsen and knowing they were participating in a study on the subject!

It’s one thing when “the magic doesn’t work”–nothing is 100%–but it’s an entirely different matter when we go on believing that something is working, when it’s not.  Put bluntly, we are a terminally, and forever hopeful group of professionals!

What to do?  Hannan et al. (2005) found that simple measures of progress in therapy correctly identified 90% of clients “at risk” for a negative outcome or dropout.  Other studies have found that routinely soliciting feedback from people in treatment regarding progress and their experience of the therapeutic relationship as much as doubles effectiveness while simultaneously reducing dropout and deterioration rates.

You can get two, simple, evidence-based measures for free here.   Get started by connecting with and learning from colleagues on the world’s largest, online network of clinicians: The International Center for Clinical Excellence.  It’s free and signing up takes only a minute or two.

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Finally, take advantage of a special offer for the 6 Feedback Informed Treatment and Training Manuals, containing step by step instructions for using the scales to guide and improve the services you offer.  These manuals are the reason the ICCE received the perfect scores when SAMHSA reviewed and approved our application for evidence-based status.

Here’s to knowing when our “magic” is working, and when it’s not!

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

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

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

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

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

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

Fit Imp 2014

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.

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.

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.