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

May 6, 2014 By scottdm Leave a Comment

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:

Download and begin using two free, easy to use tools–one that charts progress, the other the quality of the therapeutic relationship–both of which are listed on SAMHSA’s National Registry of Evidence Based Programs and Practices.
Next, access cutting edge technology available on the web, smartphones, and tablets, that makes it easy to anonymously compare the progress of your clients to effective patterns of practice worldwide.

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.

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

April 20, 2014 By scottdm Leave a Comment

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!

Do you do psychotherapy?

September 26, 2013 By scottdm 1 Comment

You know psychotherapy works. Forty years of research evidence backs up your faith in the process. And yet, fewer and fewer people are seeking out the services of professionals. Between 1998 and 2007, psychotherapy use decreased by 35%. People still sought help, they just went elsewhere to get it. For instance, use of psychotropic drugs is up 40% over the last decade.

A recent article in Popular Science traced the decline and outlined 3 provocative steps for saving the field. If you provide psychotherapy, it’s worth a read. The article is dead serious when recommending:

1. It’s time to GO BIG;

2. Getting a cute commercial; and

3. Dropping the biology jargon.

You’ve got to admit that the field’s fascination with biology is curious. A mountain of evidence points instead to the relationship between the provider and recipient of care. Other research shows that psychotherapy promotes more lasting change, at less cost and with fewer side effects than medication.

How to get the message out?

Many people and organizations are making a valiant effort. Ryan Howe almost single-handedly established today, September 25, as National Psychotherapy Day. The American Psychological Association published a rare, formal resolution on the efficacy of psychotherapy.

Frankly though, the best commercial for psychotherapy is our results. Consider the approach taken by the Colorado Center for Clinical Excellence. They don’t merely cite studies supporting psychotherapy in general, they report their actual results!

You can begin doing the same by downloading two free, simple to use measures here.

Then, learn how to use the scales to determine your effectiveness at an upcoming Feedback Informed Treatment Intensive (FIT) training.

There, you’ll also learn how to use the data to improve both the quality and outcome of your services. That’s why the Substance Abuse and Mental Health Services Administration (SAMHSA) recently listed FIT on the National Registry of Evidence Based Programs and Practices!

So, now is the time GO BIG by joining us. The next training is coming up in March! Register now at: http://ai2014.eventbrite.ie/.

Evidence-based Practice is a Verb not a Noun

April 8, 2013 By scottdm 1 Comment

Evidence-based practice (EBP). What is it? Take a look at the graphic above. According to American Psychological Association and the Institute of Medicine, there are three components: (1) the best evidence; in combination with (2) individual clinical expertise; and consistent with (3) patient values and expectations. Said another way, EBP is a verb. Why then do so many treat it as a noun, continually linking the expression to the use of specific treatment approaches? As just one example, check out guidelines published for the treatment of people with PTSD by the National Institute for Clinical Excellence (NICE)–the U.K.’s equivalent to the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA). Despite the above noted definition, and the lack of evidence favoring one treatment over another, the NICE equates EBP with the use of specific treatment approaches and boldly recommends certain methods over others.

Not long ago, ICCE Senior Associate, and U.K.-based researcher and clinician, Bill Andrews, addressed the problems with the guidelines in a presentation to an audience of British practitioners. He not only addresses the inconsistent use of the term, evidence-based practice, in the development of guidelines by governing bodies but also the actual research on PTSD. After watching the clip, take some time to review the articles assembled below, which Bill cites during his presentation. The main point here is that clinicians need not be afraid of EBP. Instead, they need to insist that leaders and officials stick to the stated definition–a definition I’m perfectly content to live with mas are most practitioners I meet. To wit, know what the evidence says “works,” use my expertise to translate such findings into practices that fit with the values, preferences, and expectations of the individual consumers I treat.

Click here to read the meta-analysis that started it all. Don’t stop there, however, make sure and read the response to that study written by proponents of the NICE guideliness. You’ll be completely up-to-date if you finish with our response to that critique.

What to Pay Attention to in Therapy?

March 15, 2013 By scottdm Leave a Comment

A week or so ago, I received an email from my friend, colleague, and mentor Joe Yeager. He runs a small listserve that sends out interesting and often provocative information. The email contained pictures from a new and, dare I say, ingenious advertising campaign for Colgate brand dental floss. Before I give you any of further details, however, take a look at the images yourself:

All right. So what caught your attention? If you’re like most people–including me–you probably found yourself staring at the food stuck in the teeth of the men in all three images. If so, the ad achieved its purpose. Take a look at the pictures one more time. In the first, the woman has one too many fingers on her left hand. The second image has a “phamtom arm” around the man’s shoulder. Can you see the issue in the third?

The anomalies in the photos are far from minor! And yet, most of us, captured by the what initially catches our eye, miss them.

Looking beyond the obvious is what Feedback Informed Treatment (FIT) is all about. Truth is, much of the time therapy works. What we do pay attention to gets results–except when it doesn’t! At those times, two things must happen: (1) we have to know when what we usually do isn’t working with a given person; and (2) look beyond the obvious and see a bigger picture. Doing this takes effort and support. What can you do?

1. Download two free, brief, simple to use tools for tracking outcome and engagement in care (the ORS and SRS) and begin using them in your work;

2. Join the International Center for Clinical Excellence, the world’s largest, free, online, non-denominational organization of behavioral health professionals;

3. Read the six cutting-edge treatment and training manuals on feedback-informed treatment–a series which helped earn FIT the highest ratings from the Substance Abuse and Mental Health Services Administration (SAMHSA);

4. Attend a training in Chicago or abroad.

S.A.M.S.H.A. designates Feedback-Informed Treatment an "Evidence-based Practice"

February 2, 2013 By scottdm Leave a Comment

February 2, 2013
Chicago, Illinois USA

I am honored to announce that Feedback-Informed Treatment (FIT) has been added to SAMSHA’s official database of evidence-based practices (EBP) known as NREPP (the National Registry of Evidence-based Programs and Practices). Briefly, NREPP is a searchable online registry of behavioral health interventions that have been reviewed and rated by independent reviewers. The purpose of the registry is to assist the public, payers, and practitioners in identifying approaches that have both empirical support and materials available to facilitate implementation.

The Institute of Medicine and American Psychological Association define EBP as, “the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences (see American Psychologist, May 2006). The principles and practices of feedback-informed treatment (FIT) are not only consistent with but provide practitioners with a simple and practical method for operationalizing EBP in their daily work. To wit, routinely and formally soliciting feedback from consumers regarding the therapeutic alliance and outcome of care and using the resulting information to inform and tailor service delivery. As reviewed many times on this blog, multiple, carefully-controlled, randomized clinical trials document that FIT improves outcomes while simultaneously decreasing the risk of drop out and deterioration in care.

Scientific evidence is one matter; being able to support practitioners, agencies, and systems of care in implementing an EBP is another. On this subject, I am proud to say that FIT received perfect ratings (see, “Readiness for Dissemination” tab). Unlike other similar approaches, “no weaknesses” were identified by reviewers. Instead, the summary noted, “ICCE…has an array of comprehensive, well-organized, and high-quality materials to support…implementation…The steps for successful implementation are clear and accompanied by tools and guidance to support the entire process, from the determination of organizations readiness through evaluation.”

Such high marks would not been possible without the contribution of ICCE Senior Associates who worked tirelessly to create the materials and complete the application. A big thanks to Jason Seidel, Psy.D., Bob Bertolino, Ph.D., Susanne Bargmann, Cynthia Maeschalck, Rox Axsen, Bill Robinson, Robbie Babbins-Wagner, Ph.D., and Julie Tilsen, Ph.D..

The formal recognition of FIT as an EBP is a watershed moment in the history of the International Center for Clinical Excellence, further enabling the organization to achieve it’s mission of improving the quality and outcome of behavioral health services.

Feedback Informed Treatment as Evidence-Based Practice

May 23, 2012 By scottdm Leave a Comment

Back in November, I blogged about the ICCE application to SAMSHA’s National Registry for consideration of FIT as an official evidence-based approach (EBP). Given the definition of EBP by the Institute of Medicine and the American Psychological Association, Feedback Informed Treatment seems a perfect, well, FIT. According to the IOM and APA, evidence-based practice means using the best evidence and tailoring services to the client, their preferences, culture, and circumstances. Additionally, when evidence-based, clinicians must monitor “patient progress (and of changes in the patient’s circumstances—e.g.,job loss, major illness) that may suggest the need to adjust the treatment. If progress is not proceeding adequately, the psychologist alters or addresses problematic aspects of the treatment (e.g., problems in the therapeutic relationship or in the implementation of the goals of the treatment) as appropriate.”

In late Summer 2011, ICCE submitted 1000’s of pages of supporting documents, research studies, as well as video in support of the application. This week, we heard that FIT passed the “Quality of Research” phase of the review. Now, the committee is looking at the “Readiness for Dissemination” materials, including the six detailed treatment and implementation manuals on feedback informed treatment. Keep your fingers crossed. We’ve been told that the entire process should be completed sometime in late fall.

In the meantime, we are preparing for this summer’s Advanced Intensive and Training of Trainer workshops. Once again, clinicians, educators, and researchers from around the world will be coming together for cutting edge training. Only a few spots remain, so register now.

The Outcome and Session Rating Scales: Support Tools

March 30, 2012 By scottdm 6 Comments

Japan, Sweden, Norway, Denmark, Germany, France, Israel, Poland, Chile, Guam, Finland, Hungary, Mexico, Australia, China, the United States…and many, many more. What do all these countries have in common? In each, clinicians and agencies are using the ORS and SRS scales to inform and improve behavioral health services. Some are using web-based systems for administration, scoring, interpretation and data aggregation (e.g., myoutcomes.com and fit-outcomes), many are accessing paper and pencil versions of the measures for free and then administering and scoring by hand.

Even if one is not using a web-based system to compare individual client progress to cutting edge norms, practitioners can still determine simply and easily whether reliable change is being made by using the “Reliable Change Chart” below. Recall, a change on the ORS is considered reliable when the difference in scores exceeds the contribution attributable to chance, maturation, and measurement error. Feel free to print out the graph and use it in your practice.

To learn how to get the most out of the measures, be sure and download the six FIT Treatment and Training Manuals. 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

ORS Reliable Change Chart

Looking Back, Looking Forward

January 6, 2012 By scottdm Leave a Comment

Bidding goodbye to last year and welcoming the new always puts me in a reflective frame of mind. How did my life, work, and relationships go? What are my hopes for the future?

Just two short years ago, together with colleagues from around the world, the International Center for Clinical Excellence (ICCE) was launched. Today, the ICCE is the largest, global, web-based community of providers, educators, researchers, and policy makers dedicated to improving the quality and outcome of behavioral health services. Clinicians can choose to participate in any of the 100-plus forums, create their own discussion group, immerse themselves in a library of documents and how-to videos, and consult directly with peers. Membership costs nothing and the site is free of the advertising. With just a few clicks, practitioners are able to plug into a group of like-minded clinicians whose sole reason for being on the site is to raise everyone’s performance level. I have many people to thank for the success of ICCE: senior associates and trainers, our community manager Susanne Bargmann, director of training Julie Tilsen, and our tech wizard Enda Madden.

As membership in ICCE has grown from a few hundred to well over 3000, many in the community have worked together to translate research on excellence into standards for improving clinical practice. Routine outcome monitoring (ROM) has grown in popularity around the world. As a result, new measures and trainings have proliferated. In order to insure quality and consistency, a task force was convened within ICCE in 2010 to develop a list of “Core Competencies”—a document establishing the empirical and practice foundations for outcome-informed clinical work. In 2011, the ICCE Core Competencies were used to develop and standardize the curricula for the “Advanced Intensive” and “Training-of-Trainers” workshops as well as the exam all attendees must pass to achieve certification as an ICCE Trainer. As if these accomplishments were not enough, a small cadre of ICCE associates banded together to compose the Feedback Informed Treatment and Training Manuals—six practical, “how-to”volumes covering everything from empirical foundations to implementation. None of this would have been possible without the tireless contributions of Bob Bertolino, Jason Seidel, Cynthia Maeschalck, Rob Axsen, Susanne Bargmann, Bill Robinson, Robbie Wagner, and Julie Tilsen.

Looking back, I feel tremendous gratitude–both for the members, associates, and trainers of ICCE as well as the many people who have supported my professional journey. This year, two of those mentors passed away: Dick Fisch and James Hillman. During my graduate school years, I read James Hillman’s book, Suicide and the Soul. Many years later, I had the opportunity to present alongside him at the “Evolution of Psychotherapy” conference. Dick, together with his colleagues from MRI, had a great influence on my work, especially during the early years when I was in Milwaukee with Insoo Berg and Steve de Shazer in Milwaukee doing research and writing about brief therapy. Thinking about Dick reminded me of two other teachers and mentors from that period in my life; namely, John Weakland and Jay Haley.

Looking forward, I am filled with hope and high expectations. The “Advanced Intensive” training scheduled for March 19-22^nd is booked to capacity—not a single spot left. Registrations for this summer’s “Training of Trainers” course are coming in at a record pace (don’t wait if you are thinking about joining me, Cynthia and Rob). Currently, I am awaiting word from the National Registry of Evidence Based Programs and Practices (NREPP) formally recognizing “Feedback Informed Treatment” (FIT) as an evidence-based approach. The application process has been both rigorous and time-consuming. It’s worth it though. Approval by this department within the federal government would instantly raise awareness about as well as increased access to funding for implementing FIT. Keep your fingers crossed!

There’s so much more:

Professor Jan Blomqvist, a researcher at the Center for Alcohol and Drug Research at Stockholm University (SoRAD) launched what will be the largest, independent evaluation of feedback informed treatment to date, involving 80+ clinicians and 100’s of clients located throughout Sweden. I provided the initial training to clinicians in October of last year. ICCE Certified Trainers Gunnar Lindfeldt and Magnus Johansson are providing ongoing logistic and supervisory support.
The most sophisticated and empirically robust interpretive algorithms for the Outcome Rating Scale (based on a sample of 427,744 administrations of the ORS, in 95,478 unique episodes of care, provided by 2,354 different clinicians) have been developed and are now available for integration into software and web based applications. Unlike the prior formulas–which plotted the average progress of all consumers successful and not–the new equations provide benchmarks for comparing individual consumer progress to both successful and unsuccessful treatment episodes.
The keynote speakers and venue for the Second Achieving Clinical Excellence Conference have been secured. We’ll be meeting at one of the nicest hotels in Amsterdam, Holland, May 16-18=9^th, 2013. Thanks go to the planning committee: Bill Andrews, Susanne Bargmann, Liz Plutt, Rick Plutt, Tony Jordan, and Bogdan Ion. Please visit the conference website and submit a proposal for a workshop or presentation.
Finally, I’ve been asked to deliver the lunchtime keynote at the upcoming Psychotherapy Networker Conference scheduled on March 23, 2012. The topic? Achieving excellence as a behavioral health practitioner. Last year, my colleague Mark Hubble and I published the lead article in the May-June issue of the magazine, describing the latest research on top performing clinicians. I’m deeply honored by the opportunity to speak at this prestigious event.

More coming in the weeks ahead. Until then, look forward to connecting on ICCE.

Feedback-Informed Treatment as Evidence-based Practice: APA, SAMSHA, and NREPP

November 1, 2011 By scottdm 1 Comment

What is evidence-based practice? Visit the UK-based NICE website, or talk to proponents of particular theoretical schools or therapeutic models, and they will tell you that being “evidence-based” means using the approach research has deemed effective for a particular diagnosis (e.g., CBT for depression, EMDR for trauma). Over the last two decades, numerous organizations and interest groups have promoted lists of “approved” treatment approaches–guidelines that clinicians and funding bodies should follow when making practice decisions. Throughout the 1990’s, for example, division 12 within the American Psychological Association (APA) promoted the idea of “empirically supported treatments.”

However, when one considers the official definition of evidence-based practice offered by the Institute of Medicine and the APA, it is hard to fathom how anyone could come to such a conclusion. According to the APA, evidence-based practice is, “the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences.” (see American Psychologist, May 2006). Nothing here about “empirically supported treatments” or the mindless application of specific treatment protocols. Rather, according to the APA and IOM, clinicians must FIT the treatment to the client, their preferences, culture, and circumstances. And how can one do that? Well, conspicuously absent from the definition is, “consult a set of treatment guidelines.” Rather, when evidence-based, clinicians must monitor “patient progress (and of changes in the patient’s circumstances—e.g.,job loss, major illness) that may suggest the need to adjust the treatment. If progress is not proceeding adequately, the psychologist alters or addresses problematic aspects of the treatment (e.g., problems in the therapeutic relationship or in the implementation of the goals of the treatment) as appropriate.”

The principles and practices of feedback-informed treatment (FIT) are not only consistent with but operationalize the American Psychological Association’s (APA) definition of evidence-based practice. To wit, routinely and formally soliciting feedback from consumers regarding the therapeutic alliance and outcome of care and using the resulting information to inform and tailor service delivery. And indeed, over the last 9 months, together with Senior Associates, I completed and submitted an application for FIT to be reviewed by NREPP–SAMSHA’s National Registry of Evidence-based Practices and Approaches! As part of that application and ICCE’s commitment to improving the quality and outcome of behavioral health, we developed a list of “core competencies” for FIT practice, a series of six detailed treatment and implementation manuals, a gap assessment tool that organizations can use to quickly and expertly assess implementation and fidelity problems, and supportive documentation and paperwork. Finally, we developed and rigorously tested training curricula and administered the first standardized exam for certifying FIT practitioners and trainers. We are in the final stages of that review process soon and I’m sure I’ll be making a major announcement right here on this blog shortly. So, stay tuned.

In the meantime, this last Saturday, clinicians located the globe–Canada, New Zealand, Australia, the US,a nd Romania–sat for the first administration of ICCE “Core Competency” Exam. Taking the test is the last step in becoming an ICCE “Certified Trainer.” The other requirements include: (1) attending the “Advanced Intensive” and “Training of Trainers” workshops; and (2) submitting a training video on FIT for review. The exam was administered online using the latest technology.

The members, directors, and senior associates of ICCE want to congratulate (from top left):

Eeuwe Schuckard, Psychologist, Wellington, New Zealand;
Aaron Frost, Psychologist, Brisbane, Australia;
Cindy Hansen, BA-Psych, HHP, Manager Myoutcomes;
David Prescott, Director of Professional Development, Becket Family of Services, Portland, Maine;
Arnold Woodruff, LMFT, Clinical Director, Home for Good, Richmond, Virginia;
Bogdan, Ion, Ph.D., Bucharest University, Bucharest, Romania;
Daniel Buccino, Clinical Supervisor, Community Psychiatry Program. Johns Hopkins;
Dwayne Cameron, Outreach Counselor, Prince Albert, Saskatoon, Canada;
Mark Goheen, the Clinical Practice Lead at Fraser Health, British Columbia.

If you are not yet a member of the ICCE community, please join the largest, fastest growing, and friendly group of behavioral health professionals today at: www.centerforclinicalexcellence.com.