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The ICCE Feedback-Informed Treatment Manuals

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September 12, 2011
Copenhagen, Denmark

Fall is in the air.  For me, that means the start of the travel season.  For the next two weeks, I’ll be traveling throughout Scandanavia–this week in Denmark and Norway.  It’s great to be back on the road meeting clinicians and consulting with agencies about feedback-informed treatment (FIT).

On this trip, I’m finally able to announce the publication of the Feedback-Informed Treatment Manuals.  Over the summer, senior associates of the International Center for Clinical Excellence, together with the talented artists and graphic designers at The Change Companies, worked hard to complete the series.

The six manuals cover every aspect of feedback-informed practice including: empirical foundations, basic and advanced applications (including FIT in groups, couples, and with special populations), supervision, data analysis, and agency implementation.  Each manual is written in clear, step-by-step, non-technical language, and is specifically designed to help practitioners and agencies integrate FIT into routine clinical practice.   Indeed, the manuals were submitted as part of ICCE’s application for consideration of FIT as an “evidence-based practice” to the National Registry of Evidence-Based Programs and Practices.  The manuals may be purchased separately or as a series in the bookstore.

While on the subject of registries, mention should be made that over the summer the American Psychological Association  contacted me about listing the Outcome and Session Rating Scales in their official database of outcome tools for clinical practice (click here to see the listing).  Taken together, the manuals, NREPP application, listing, and growing body of research evidence provide a compelling case for feedback-informed work.

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

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

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

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

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

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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.

Deliberate Practice, Expertise, & Excellence

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

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

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

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

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

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

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

The Future of Behavioral Health: Integrated Care & Entrepreneurship

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Nicholas Cummings, Ph.D.

Sometime in late 1986 I wrote a letter to Dr. Nicholas Cummings.  As a then student-member of the American Psychological Association (APA), I was automatically subscribed to and receiving the American Psychologist.  In the April issue, Dr. Cummings published an article, provocatively titled, “The Dismantling of Our Health System: Strategies for the Survival of Psychological Practice.”  Change was in the air. “Traditional psychology practice is both inefficient and ineffective,” he argued, and a “growing revolution in heath care” was a clear and present danger to the very survival of the field.

What can I say?  As someone at the beginning of his career (with large student loans to repay and a long time to go before retirement), the five page article spooked me.  So I did what I’d done before: I wrote a letter.  I’d been writing and calling prominent researchers and clinicians ever since I was an undergraduate.  During the 70’s, I’d exchanged letters and even phone calls with B.F. Skinner!

In all honesty, I didn’t know anything about Dr. Cummings–for example, that he was a former president of the APA, launched the Professional Schools of Psychology movement and founded four campuses of the California School of Professional Psychology, wrote the freedom-of-choice legislation requiring insurers to reimburse non-medical, behavioral health providers, and started American Biodyne in the hopes that psychologists could own rather than be owned–as eventually happened–by managed care (read a history here).  Neither did I know that he was a member of Psychology’s famed “Dirty Dozen.” Without a doubt, however, the decision to write him, changed the arc of my career.

Fast forward 25 years, and 86-year-old Nicholas Cummings is at it again–not only sounding a warning klaxon but identifying the opportunities available in the dramatically changing healthcare environment.  Sadly, the field (and professional psychology in particular) ignored the counsel he’d given back in 1986.  As a result, business interests took over managed care, resulting–just as he predicted–in low wages and the near complete lack of professional autonomy.

So, what can clinicians do now to survive and thrive?  According to Dr. Cummings, two words best capture the future of behavioral health: (1) integrated care; and (2) entrepreneurship.  Let’s face the unpleasant reality and say it out loud: independent practice is on life support.  Agency work is no picnic either given the constant threats to funding and never ending amount of regulation and paperwork.  Finally, when it comes to practitioner income, its a buyer’s market.

That said, it’s not all doom and gloom.  Far from it.  There is a tremendous need (and opportunity) in the present reform-driven healthcare marketplace for clinicians who are able to blend behavioral interventions, medical literacy, knowledge about healthcare delivery systems, and entrepreneurship skills.  Possibilities do exist.  The real question is, “Do we have the will to change?”  Here’s where the power of one simple action–in this instance, a phone call–can have such a profound effect on one’s life and success.

Though we never formally worked together, I’ve been calling and writing Nick off and on for the two and a half decades.  Late last fall, my partners and co-creators of the International Center for Clinical Excellence, Brendan Madden and Enda Madden, flew to Reno to seek his advice on our business plan.  We simply called him.  He said, “When can you get here?”  The result?  His sage counsel helped us win the InterTrade Seedcorn Regional Prize for “Best Emerging Company” as well as secure investors in the most restrictive venture capital environment since the Great Depression.  And that’s not all…

Chief Technology Officer Enda Madden    Chief Executive Officer Brendan Madden

Just last week, I flew to Phoenix, Arizona to give a presentation on using outcomes to improve behavioral healthcare service delivery at Arizona State University.  Nick was there to meet me, along with the director of an entirely new program for behavioral health entrepreneurs, Dr. Ron O’Donnell.  Briefly, the “Doctor of Behavioral Health” is the culmination of Nick’s vision of creating a doctoral training program tailored to the emerging need for innovative behavioral clinicians to practice in primary care and medical settings.  Response has been overwhelming to say the least.  Fifty plus post-graduate clinicians are enrolled.   That’s right, post-graduate.  In other words, these are practicing clinicians returning to add “integrated care expert and behavioral health entrepreneur” to their resume.


School of Letters and Sciences

As it turns out, I’ll be traveling from Chicago to Phoenix a fair amount in the future.  When he stood to introduce me, Nick announced that I’d be filling the “Cummings Professor of Behavioral Health” faculty position at ASU.  The power of a single call.

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:

"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.

Why ongoing, formal feedback is critical for improving outcomes in healthcare

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researchNot long ago, I had a rather lengthy email exchange with a well-known, high profile psychotherapist in the United States.  Feedback was the topic.  We both agreed that feedback was central to successful psychotherapy.   We differed, however, in terms of method.  I argued for the use of simple, standardized measures of progress and alliance (e.g., ORS and SRS).  In support of my opinion, I pointed to several randomized clinical trials documenting the impact of routine outcome monitoring on retention and progress.  I also cited studies showing traditionally low correlations between consumers and clinician’s rating of outcome and alliance and clinicians frighteningly frequent inability to predict deterioration and drop out in treatment.  He responded that such measures were an “unnecessary intrusion,” indicating that he’d always sought feedback from his clients albeit on an “informal basis.”  television-reception

When I mentioned our own research which had found that clinicians believed they asked consumers for feedback more often than they actually did, he finally seemed to agree with me.  “Of course,” he said immediately–but then he added, “I don’t need to ask in order to get feedback.”  In response to my query about how he managed to get feedback without asking, he responded (without a hint of irony), “I have unconditional empathic reception.”  Needless to say, the conversation ended there.

It’s a simple idea, feedback.  Yet, as I jet around the globe teaching about feedback-informed clinical practice, I’m struck by how hard it seems for many in healthcare to adopt.  Whatever the reason for the resistance–fear, hubris, or inertia–the failure to seek out valid and reliable feedback is a conceit that the field can no longer afford.  Simply stated, no one has “unconditional empathic reception.”  As the video below makes clear, we all need help seeing what is right before our eyes.