Public Attitudes Toward Mental Health Services: A Change for the Worse

July 3, 2014 By scottdm 1 Comment

The results are not encouraging. A recent meta-analysis found that public attitudes toward psychotherapy have become progressively more negative over the last 40 years. The impact on practitioners is staggering. Between 1997 and 2007, use of psychotherapy declined by 35%. Not surprisingly, clinicians’ incomes also suffered, dropping 15-20% over the last decade.

So, if not psychotherapy, what do consumers of mental health services really want?

Well, if you trust the study I’ve cited, the answer seems clear: drugs. During the same time period that talking fell out of favor, use of pharmaceuticals increased a whopping 75%! Some blame society’s short attention span and desire for a “quick fix.” Such an argument hardly seems credible, however, given that psychotherapy works to alleviate distress as fast or faster than most psychotropics.

Others, including the authors of the meta-analysis, blame public education campaigns and pharmacological marketing aimed at “convincing the public that mental disorders have a neurobiological etiology that require biological treatments” (p. 103). At first glance, this idea is compelling. After all, every year, the pharmaceutical industry spends $5 billion dollars on direct-to-consumer advertising.

And yet, what is it the drug companies are really selling in those ads? In one of the most well-known TV commercials for a popular antidepressant, less than 7 seconds is spent on the supposed neurobiological cause. Instead, the majority of the time is spent depicting the positive results one can expect from the product. It’s marketing 101: focus on the benefits not the features of whatever you’re selling.

What do consumers want? The answer is: results. Your training, degree, certification, and treatment approach are irrelevant, mere features most consumers could care less about. Your rate of effectiveness is another matter entirely–its the benefit people are looking for from working with you.

So, how effective are you? Do you know? Not a guess or a hunch, but the actual number of people you treat that are measurably improved? If not, its easy to get started. Start by downloading two, simple, free, SAMHSA-approved scales for measuring progress and quality of mental health services. Next, visit www.whatispcoms.com to learn how individual practitioners and agencies can use these tools to monitor and improve outcome and retention in treatment, as well as communicate results effectively to consumers.

To see how outcomes attract consumers, just take a look at the Colorado Center for Clinical Excellence website. This Denver-based group of practitioners is a model for the future of clinical practice.

Dumb and Dumber: Research and the Media

April 2, 2014 By scottdm 1 Comment

“Just when I thought you couldn’t get any dumber, you go and do something like this… and totally redeem yourself!”
– Harry in Dumb & Dumber

On January 25th, my inbox began filling with emails from friends and fellow researchers around the globe. “Have you seen the article in the Guardian?” they asked. “What do you make of it?” others inquired, “Have you read the study the authors are talking about? Is it true?!” A few of the messages were snarkier, even gloating, “Scott, research has finally proven the Dodo verdict is wrong!”

The article the emails referred to was titled, Are all psychological therapies equally effective? Don’t ask the dodo. The subtitle boldly announced, “The claim that all forms of psychotherapy are winners has been dealt a blow.”

Honestly, my first thought on reading the headline was, “Why is an obscure topic like the ‘Dodo verdict’ the subject of an article in a major newspaper?” Who in their right mind–outside of researchers and small cadre of psychotherapists–would care? What possible interest would a lengthy dissertation on the subject–including references to psychologist Saul Rozenzweig (who first coined the expression in the 1930’s) and researcher allegiance effects–hold for the average Joe or Jane reader of The Guardian. At a minimum, it struck me as odd.

And odd it stayed, until I glanced down to see who had written the piece. The authors were psychologist Daniel Freeman–a strong proponent of the empirically-supported treatments–and his journalist brother, Jason.

Briefly, advocates of EST’s hold that certain therapies are better than others in the treatment of specific disorders. Lists of such treatments are created–for example, the NICE Guidelines–dictating which of the therapies are deemed “best.” Far from innocuous, such lists are, in turn, used to direct public policy, including both the types of treatment offered and the reimbursement given.

Interestingly, in the article, Freeman and Freeman base their conclusion that “the dodo was wrong” on a single study. Sure enough, that one study comparing CBT to psychoanalysis, found that CBT resulted in superior effects in the treatment of bulimia. No other studies were mentioned to bolster this bold claim–an assertion that would effectively overturn nearly 50 years of robust research findings documenting no difference in outcome among competing treatment approaches.

In contrast to what is popularly believed extraordinary findings from single studies are fairly common in science. As a result, scientists have learned to require replication, by multiple investigators, working in different settings.

The media, they’re another story. They love such studies. The controversy generates interest, capturing readers attention. Remember cold fusion? In 1989, researchers Stanley Pons and Martin Fleischmann–then two of the world’s leading electrochemists–claimed that they had produced a nuclear reaction at room temperature–a finding that would, if true, not only overturn decades and decades of prior research and theory but, more importantly, revolutionize energy production.

The media went nuts. TV and print couldn’t get enough of it. The hope for a cheap, clean, and abundant source of energy was simply too much to ignore. The only problem was that, in the time that followed, no one could replicate Pons and Fleischmann’s results. No one. While the media ran off in search of other, more tantalizing findings to report, cold fusion quietly disappeared, becoming a footnote in history.

Back to The Guardian. Curiously, Freeman and Freeman did not mention the publication of another, truly massive study published in Clinical Psychology Review—a study available in print at the time their article appeared. In it, the researchers used the statistically rigorous method of meta-analysis to review results from 53 studies of psychological treatments for eating disorders. Fifty-three! Their finding? Confirming mountains of prior evidence: no difference in effect between competing therapeutic approaches. NONE!

Obviously, however, such results are not likely to attract much attention.

Sadly, the same day that the article appeared in The Guardian, John R. Huizenga passed away. Huizenga is perhaps best known as one of the physicists who helped build the atomic bomb. Importantly, however, he was also among the first to debunk the claims about cold fusion made by Pons and Fleischman. His real-world experience, and decades of research, made clear that the reports were a case of dumb (cold fusion) being followed by dumber (media reports about cold fusion).

“How ironic this stalwart of science died on this day,” I thought, “and how inspiring his example is of ‘good science.'”

I spent the rest of the day replying to my emails, including the link to study in Clinical Psychology Review (Smart). “Don’t believe the hype,” I advised, “stick to the data” (and smarter)!

The "F" Word in Behavioral Health

April 20, 2011 By scottdm Leave a Comment

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 5^th 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.

Hope Transcends: Learning from our Clients

July 30, 2010 By scottdm Leave a Comment

“Hope Transcends” was the theme of the 39th Annual Summer Institute on Substance Abuse and Mental Health held in Newark, Delaware this last week. I had the honor of working with 60+ clinicians, agency managers, peer supports, and consumers of mental health services presenting a two-day, intensive training on “feedback-informed clinical work.” I met so many talented and dedicated people over the two days and even had a chance to reconnect with a number of folks I’d met at previous trainings– both at the Institute and elsewhere.

One person I knew but never had the privilege of meeting before was psychologist Ronald Bassman. A few years back, he’d written a chapter that was included in my book, The Heroic Client. His topic at the Summer Institute was similar to what he’d written for the book: harmful treatment. Research dating back decades documents that approximately 10% of people deteriorate while in psychotherapy. The same body of evidence shows that clinicians are not adept at identifying: (a) people who are likely to drop out of care; or (b) people who are deteriorating while in care.

Anyway, you can read about Ron on his website or pick up his gripping book A Fight to Be. Briefly, at age 22 Ron was committed to a psychiatric hospital. Over the next several years, he was diagnosed with paranoid schizophrenia and forcefully subjected to a series of humiliating, painful, degrading and ultimately unhelpful “treatments.” Eventually, he escaped his own and the systems’ madness and became a passionate advocate for improving mental health services. His message is simple: “we can and must do better.” And, he argues persuasively, the process begins with building better partnerships with consumers.

One way to build bridges with consumers is routinely seeking their feedback regarding the status of the therapeutic relationship and progress of any services offered. Indeed, the definition of “evidence-based practice” formally adopted by the American Psychological Association mandates that the clinician “monitor…progress…[and] If progress is not proceeding adequately…alters or addresses problematic aspects of the treatment (e.g., problems in the therapeutic relationship or the implementation of the goals of treatment)” (pp. 276-277, APA, 2006). Research reviewed in detail on this blog documents significant improvement in both retention and outcome when clinicians use the Outcome and Session Rating Scales to solicit feedback from consumers. Hope really does transcend. Thank you Ron and thank you clinicians and organizers at the Institute.

And now, just for fun. Check out these two new videos:

More Eruptions (in Europe and in Research)

April 20, 2010 By scottdm Leave a Comment

Dateline: Tuesday, 8:21pm, April 20th, 2010, Skellefteå, Sweden

What an incredible week. Spent the day today working with 250 social workers, case managers, psychologists, psychiatrists, and agency directors in the far nothern town of Skellefteå, Sweden. Many practitioners here are already measuring outcomes on an ongoing basis and using the information to improve the results of their work with consumers of behavioral health services. Today, I presented the latest findings from ICCE’s ongoing research on “Achieving Clinical Excellence.”

I’ve been coming to the area to teach and consult since the early 1990’s, when I was first invited to work with Gun-Eva Langdahl and the rest of the talented crew at Rådgivningen Oden (RO). As in previous years, I spent my first day (Monday) in Skellefteå watching sessions and working with clients at RO clinic. Frankly, getting to Skellefteå from Goteborg had been a bit of ordeal. What usually took a little over an hour by plane ended up being a 12-hour combination of cars, trains, and buses–all due to volcanic eruptions on Iceland. (I shudder to think of how I will get from Skellefteå to Amsterdam on Wednesday evening if air travel doesn’t resume).

Anyway, the very first visit of the day at Rådgivningen Oden was with an adolescent and her parents. Per usual, the session started with the everyone completing and discussing the Outcome Rating Scale. The latest research reported in the April 2010 edition of Journal of Consulting and Clinical Psychology (JCCP) confirms the wisdom of this practice: measuring and discussing progress with consumers at every visit results in better outcomes.

It turns out that adolescents are at greater risk for deteriorating in treatment than adults (20% versus 10%). Importantly, the study in JCCP by Warren, Nelson, Mondragon, Baldwin, and Burlingame found that the more frequently measures are used the less likely adolescents are to worsen in care. Indeed, as ICCE Senior Associate Susanne Bargmann pointed out in a series of recent emails about this important study, “routinely tracking and discussing progress led to 37% higher recovery rates and 38% lower rates of deterioration!”

Skellefteå is a hotbed of feedback-informed practice in Sweden. Accompanying the family at Rådgivningen Oden, for example, were professionals from a number of other agencies involved in the treatment and wanting to learn more about outcome-informed practice. As already noted, 250 clinicians took time away from their busy schedules to hear the latest information and finesse their use of the measures. And tomorrow, Wednesday, I meet with managers and directors of behavioral health agencies to discuss steps for successfully implementing routine measurement of progress and feedback in their settings. You can download a video discussing the work being done by the team at Odin in Northern Sweden, by clicking here.

Stay tuned for more. If all goes well, I’ll be in Amsterdam by Wednesday evening.

Neurobabble Redux: Comments from Dr. Mark Hubble on the Latest Fad in the World of Therapy Spark Comment and Controversy

April 8, 2010 By scottdm 2 Comments

Last week, my long time colleague and friend, Dr. Mark Hubble blogged about the current interest of non-medically trained therapists in the so-called “neurobiology of human behavior.” In my intro to his post, I “worried” out loud about the field’s tendency to search for legitimacy by aligning with the medical model. Over the years, psychotherapy has flirted with biology, physics, religion, philosophy, chaos, and “energy meridians” as both the cause of what ails people and and the source of psychotherapy’s effectiveness.

For whatever reason, biological explanations have always had particular cachet in the world of psychotherapy. When I first entered the field, the “dexamethasone suppression test” was being touted as the first “blood test” for depression. Some twenty years on, its hard to remember the hope and excitement surrounding the DST.

Another long-time friend and colleague, psychologist Michael Valentine is fond of citing the many problems–social, physical, and otherwise–attributed to genetics (including but not limited to: anxiety, depression, addictions, promiscuity, completed suicides, thrill seeking obscene phone calls, smoking, gambling, and the amount of time one spends watching TV) for which there is either: (a) precious little or inconsistent evidence; or (b) the variance attributable to genetics is small and insignificant compared to size and scope of the problem.

In any event, I wanted to let readers know that response to Mark’s post has been unusually strong. The numerous comments can be found on the syndicated version of my blog at the International Center for Clinical Excellence. Don’t miss them!

Neurobabble: Comments from Dr. Mark Hubble on the Latest Fad in the World of Therapy

March 24, 2010 By scottdm Leave a Comment

Rarely does a day go by without hearing about another “advance” in the neurobiology of human behavior. Suddenly, it seems, the world of psychotherapy has discovered that people have brains! And now where the unconscious, childhood, emotions, behaviors, and cognitions once where…neurons, plasticity, and magnetic resonance imagining now is. Alas, we are a field forever in search of legitimacy. My long time colleague and friend, Mark Hubble, Ph.D., sent me the following review of recent developments. I think you’ll enjoy it, along with video by comedian John Cleese on the same subject.

Mark Hubble, Ph.D.

Today, while contemplating the numerous chemical imbalances that are unhinging the minds of Americans — notwithstanding the longstanding failure of the left brain to coach the right with reason, and the right to enlighten the left with intuition — I unleashed the hidden power of my higher cortical functioning to the more pressing question of how to increase the market share for practicing therapists. As research has dismantled once and for all the belief that specific treatments exist for specific disorders, the field is left, one might say, in an altered state of consciousness. If we cannot hawk empirically supported therapies or claim any specialization that makes any real difference in treatment outcome, we are truly in a pickle. All we have is ourselves, the relationships we can offer to our clients, and the quality of their participation to make it all work. This, of course, hardly represents a propitious proposition for a business already overrun with too many therapists, receiving too few dollars.

Fortunately, the more energetic and enterprising among us, undeterred by the demise of psychotherapy as we know it, are ushering the age of neuro-mythology and the new language of neuro-babble. Seemingly accepting wholesale the belief that the brain is the final frontier, some are determined to sell us the map thereto and make more than a buck while they are at it. Thus, we see terms such as “Somatic/sensorimotor Psychotherapy,” “Interpersonal Neurobiology,” “Neurogenesis and Neuroplasticity,” “Unlocking the Emotional Brain,” “NeuroTherapy,” “Neuro Reorganization,” and so on. A moment’s look into this burgeoning literature quickly reveals the existence of an inverse relationship between the number of scientific sounding assertions and actual studies proving the claims made. Naturally, this finding is beside the point, because the purpose is to offer the public sensitive, nuanced brain-based solutions for timeless problems. Traditional theories and models, are out, psychotherapies-informed-by-neuroscience, with the aura of greater credibility, are in.

Neurology and neuroscience are worthy pursuits. To suggest, however, that the data emerging from these disciplines have reached the stage of offering explanatory mechanisms for psychotherapy, including the introduction of “new” technical interventions, is beyond the pale. Metaphor and rhetoric, though persuasive, are not the same as evidence emerging from rigorous investigations establishing and validating cause and effect, independently verified, and subject to peer review.

Without resorting to obfuscation and pseudoscience, already, we have a pretty good idea of how psychotherapy works and what can be done now to make it more effective for each and every client. From one brain to another, to apply that knowledge, is a good case of using the old noggin.

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

March 5, 2010 By scottdm Leave a Comment

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:

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

January 26, 2010 By scottdm Leave a Comment

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:

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

January 19, 2010 By scottdm Leave a Comment

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

January 18, 2010 By scottdm Leave a Comment

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.”

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

January 8, 2010 By scottdm 3 Comments

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.

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

October 27, 2009 By scottdm 1 Comment

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:

Buying a strong whip
Switching riders
Moving the dead horse to a new location
Riding the dead horse for longer periods of time
Saying things like, “This is the way we’ve always ridden the horse.”
Appointing a committee to study the horse
Arranging to visit other sites where they ride dead horses more efficiently
Increasing the standards for riding dead horses
Creating a test for measuring our riding ability
Complaining about how the state of the horse the days
Coming up with new styles of riding
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.

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

September 30, 2009 By scottdm 5 Comments

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!