Clinical Support Tools for the ORS and SRS

November 20, 2012 By scottdm 1 Comment

I have so much to be grateful for at this time. Most of all, I’m happy to be home with my family. As we have in the past, this year we’ll be spending the holiday at the home of our long time friends John and Renee Dalton. The two always put out a fantastic spread and our son, Michael, is fast friends with their two kids.

I’m also grateful for the International Center for Clinical Excellence (ICCE) community. Currently, ICCE has over 4200 members located around the world, making the organization the largest, web-based community of professionals, educators, managers, and clinicians dedicated to using feedback to pursue excellence in the delivery of behavioral health services. Recently, the site was highlighted as one of the best resources for practitioners available on the web. Articles, how-to videos, and discussion forums are available everyday, all day–and for free! No come-ons for books or webinars and no “cult of personality”–just sharing among peers. If you are not a member, you can join at: www.centerforclinicalexcellence.com

A special thanks goes to several ICCE senior advisors and associates, including Susanne Bargmann, Jason Seidel, Cynthia Maeschalck, Bob Bertolino, Bill Plum, Julie Tilsen, and Robbie Babbins-Wagner. These folks are the backbone of the organization. Together, they make it work. Most recently, we all joined together to create the ICCE Feedback Informed Treatment and Training Manuals, a cutting edge series covering every aspect of FIT–from the empirical foundations to implementation–in support of our application to SAMSHA for recognition as an “evidence-based practice.”

As a way of supporting everyone using the ORS and SRS, I wanted to make a couple of clinical support tools available. If you are using the measures, the first item will need no introduction. It’s a 10 cm ruler! Save the file and print it off and you also have a ready reminder of the upcoming Achieving Clinical Excellence conference, coming up in May 2013. Like last time, this will feature the latest inforamtion about feedback informed practice! The second item is a reliable change graph. If you are using the paper and pencil measures, rather than one of the existing web based systems (www.fit-outcomes.com, www.myoutcomes.com), you can use this tool to determine whether a change in scores from session to session is reliable (that is, greater than chance, the passage of time, and measurement error [and therefore, due to the care being provided]) or even clinically significant (that is, both reliable and indicating recovered). The last item is an impressive summary of various systems for monitoring progress in treatment.

In addition ACE Health have developed openFIT, a plug-in which seamlessly integrates the ORS, SRS and associated algorithms into any existing Electronic Health Record, Case Management System of eMental Health application.

I wish everyone a peaceful and rewarding Thanksgiving holiday.

Are Mental Health Practioners Afraid of Research and Statistics?

September 30, 2011 By scottdm Leave a Comment

A few weeks back I received an email from Dr. Kevin Carroll, a marriage and family therapist in Iowa. Attached were the findings from his doctoral dissertation. The subject was near and dear to my heart: the measurement of outcome in routine clinical practice. The findings were inspiring. Although few graduate level programs include training on using outcome measures to inform clinical practice, Dr. Carroll found that 64% of those surveyed reporting utilizing such scales with about 70% of their clients! It was particularly rewarding for me to learn that the most common measures employed were the…Outcome and Session Rating Scales (ORS & SRS)

As readers of this blog know, there are multiple randomized clinical trials documenting the impact that routine use of the ORS and SRS has on retention, quality, and outcome of behavioral health services. Such scales also provide direct evidence of effectiveness. Last week, I posted a tongue-in-cheek response to Alan Kazdin’s broadside against individual psychotherapy practitioners. He was bemoaning the fact that he could not find clinicians who utilized “empirically supported treatments.” Such treatments when utilized, it is assumed, lead to better outcomes. However, as all beginning psychology students know, there is a difference between “efficacy” and “effectiveness” studies. The former tell us whether a treatment has an effect, the latter looks at how much benefit actual people gain from “real life” therapy. If you were a client which kind of study would you prefer? Unfortunately, most of the guidelines regarding treatment models are based on efficacy rather than effectiveness research. The sine qua non of effectiveness research is measuring the quality and outcome of psychotherapy locally. After all, what client, having sought out but ultimately gained nothing from psychotherapy, would say, “Well, at least the treatment I got was empircally supported.” Ludicrous.

Dr. Carroll’s research clearly indicates that clinicians are not afraid of measurement, research, and even statistics. In fact, this last week, I was in Denmark teaching a specialty course in research design and statistics for practitioners. That’s right. Not a course on research in psychotherapy or treatment. Rather, measurement, research design, and statistics. Pure and simple. Their response convinces me even more that the much talked about “clinician-researcher” gap is not due to a lack of interest on practitioners’ parts but rather, and most often, a result of different agendas. Clinicians want to know “what will work” for this client. Research rarely address this question and the aims and goals of some in the field remain hopelessly far removed from day to day clinical practice. Anyway, watch the video yourself:

Why is this man laughing?

May 4, 2011 By scottdm 3 Comments

May 4th, 2011
Copenhagen, Denmark

Just finished my first day of a two week trip covering spots in Denmark and Holland. Yesterday, I traveled to Copenhagen from Hilo, Hawaii where I was presenting for the Hawaiian Association of Marriage and Family Therapy. Dr. Gay Barflied (pictured on the far left above) spent years lobbying to bring me to the “Big Island” for the conference, where I spoke about the latest research on expertise and excellence in the field of behavioral health. I met so many dedicated and talented clinicians in Hilo, including marriage and family therapist, Makela Bruno-Kidani (pictured in the middle photo above) who started the day off with a traditional Hawaiian chant and then presented me with two beautiful lei to wear during the event.

On a break, Gay mentioned an article that appeared in the May/June 1995 issue of AHP Perspective. In it, she said, Maureen O’Hara, president of the Association for Humanistic Psychology, quoted one of the first articles me and my colleagues wrote on the common factors, “No More Bells and Whistles” (I’ll upload a copy to the “publications and handouts” section of the website as soon as I’m back in the States). Carl Rogers, she said, would have been laughing (happily, that is) had he read the findings we cited documented the lack of differential efficacy of competing treatment approaches. We had, in essence, proved him right!

“It turns out,” OHara wrote, “that Miller, Hubble, and Duncan come to similar conclusions. Carl Rogers was right. After all our forays into the dizzing arcana of paradoxical interventions, inner children, narrative therapy, EMDR, behaviorism, psychopharmacology, bioenergetics, TA, Jungian analysis, psychodrama, Gestalt, and so on down the entire list of hundred brand named therapies, what actually creates change is the…creation of a relationship between client and therapist…”.

I’d never seen the article before. It brought back very positive memories about the journey that has led most recently to the study of excellence. Indeed, as we point out in the lead article in the upcoming May/June 2011 issue of the Psychotherapy Networker, relationships are not only the “sine qua non” of healing for clients but are responsible for the professional growth for therapists.

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:

Eruptions in Europe and in Research

April 18, 2010 By scottdm 3 Comments

Dateline: 11:20 am, April 18th, 2010

Today I was supposed to fly from Stockholm, Sweden to the far northern town of Skelleftea–a flight that takes a little over an hour. Instead, I’m sitting on a train headed for Sundsvall, the first leg of a 12 hour trip that will include a 6 hour bus ride and then a short stint in a taxi.

If you’ve been following the news coming out of Europe, you know that all flights into, out of, and around Europe have been stopped. Eyjafjallajokull–an Icelandic volcano–erupted the day after I landed in Goteborg spewing an ash cloud that now covers most of Europe disrupting millions of travellers. People are making due, sleeping on cots in airline, train, and bus terminals and using Facebook and Twitter to connect and arrange travel alternative.

In the meantime, another eruption has taken place with the publication of the latest issue of the Journal of Consulting and Clinical Psychology that threatens to be equally disruptive to the field of psychotherapy–and to proponents of the narrow, specific-treatments-for-specific-disorders or “evidence-based treatments” movement. Researchers Webb, DeRubeis, and Barber conducted a meta-analysis of studies examining the relationship between adherence to and competence in delivering a particular approach and outcome. The authors report finding that, “neither adherence nor competence was…related to patient (sic) outcome and indeed that the aggregate estimates of their effects were very close to zero.”

Zero! I’m not sure what zero means to everyone else, but where I come from it’s pretty close to nothing. And yet, the romance with the EBT movement continues among politicians, policy makers, and proponents of specific treatment models. Each year, millions and millions of dollars of scarce resources are poured into an approach to behavioral health that accounts for exactly 0% of the results.

Although it was not a planned part of their investigation, the must-read study by Webb, DeRubeis, and Barber also points to the “magma” at the heart of effective psychotherapy: the alliance, or quality of the relationship between consumer and provider. The authors report, for example, finding “larger competence-outcome effect size estimates [in studies that]…did not control for the influence of the alliance.”

The alliance will take center stage at the upcoming, “Achieving Clinical Excellence” and “Training of Trainers” events. Whatever you thought you knew about effective therapeutic relationships will be challenged by the latest research from our study of top performing clinicians worldwide. I hope you’ll join our international group of trainers, researchers, and presenters by clicking on either of the links above. And, if you’ve not already done so, be sure and visit the International Center for Clinical Excellence home page and request an invitation to join the community of practitioners and researchers who are learning and sharing their expertise.