Looking for Results in All the Wrong Places: What Makes Feedback Work?

September 16, 2012 By scottdm Leave a Comment

As anyone knows who reads this blog or has been to one of my workshops, I am a fan of feedback. Back in the mid-1990’s, I began using Lynn Johnson’s 10-item Session Rating Scale in my clinical work. His book, Psychotherapy in the Age of Accountability, and our long relationship, convinced me that I needed to check in regularly with my clients. At the same time, I started using the Outcome Questionnaire (OQ-45). The developer, Michael Lambert, a professor and mentor, was finding that routinely measuring outcome helped clinicians catch and prevent deterioration in treatment. In time, I worked with colleagues to develop a set of tools, the brevity of which made the process of asking for and receiving feedback about the relationship and outcome of care, feasible.

Initial research on the measures and feedback process was promising. Formally and routinely asking for feedback was associated with improved outcomes, decreased drop-out rates, and cost savings in service delivery! As I warned in my blogpost last February, however, such results, while important, were merely “first steps” in a scientific journey. Most importantly, the research to date said nothing about why the use of the measures improved outcomes. Given the history of our field, it would be easy to begin thinking of the measures as an “intervention” that, if faithfully adopted and used, would result in better outcomes. Not surprisingly, this is exactly what has happened, with some claiming that the measures improve outcomes more than anything since the beginning of psychotherapy. Sadly, such claims rarely live up to their initial promise. For decades the quest for the holy grail has locked the field into a vicious cycle of hope and despair, one that ultimately eclipses the opportunity to conduct the very research needed to facilitate understanding of the complex processes at work in any intervention.

In February, I wrote about several indirect, but empirically robust, avenues of evidence indicating that another variable might be responsible for the effect found in the initial feedback research. Now, before I go on, let me remind you that I’m a fan of feedback, a big fan. At the same time, its important to understand why it works and, specifically, what factors are responsible for the effect. Doing otherwise risks mistaking method with cause, what we believe with reality. Yes, it could be the measures. But, the type research conducted at the time did not make it possible to reach that conclusion. Plus, it seemed to me, other data pointed elsewhere; namely to the therapist. Consider, for example, the following findings: (1) therapists did not appear to learn from the feedback provided by measures of the alliance and outcome; (2) therapists did not become more effective over time as a result of being exposed to feedback. In other words, as with every other “intervention” in the history of psychotherapy, the effect of routinely monitoring the alliance and outcome seems to vary by therapist.

Such results, if true, would have significant implications for the feedback movement (and the field of behavioral health in general). Instead of focusing on methods and interventions, efforts to improve the outcome of behavioral health practice should focus on those providing the service. And guess what? This is precisely what the latest research on routine outcome measurement (ROM) has now found. Hot off the press, in the latest issue of the journal, Psychotherapy Research, Dutch investigators de Jong, van Sluis, Nugter, Heiser, and Spinhoven (2012) found that feedback was not effective under all circumstances. What variable was responsible for the difference? You guessed it: the therapist–in particular, their interest in receiving feedback, sense of self-efficacy, commitment to use the tools to receive feedback, and…their gender (with women being more willing to use the measures). Consistent with ICCE’s emphasis on supporting organizations with implementation, other research points to the significant role setting and structure plays in success. Simon, Simon, Harris and Lambert (2011), Reimer and Bickman (2012), and de Jong (2012) have all found that organizational and administrative issues loom large in mediating the use and impact of feedback in care.

Together with colleagues, we are currently investigating both the individual therapist and contextual variables that enable clinicians to benefit from feedback. The results are enticing. The first will be presented at the upcoming Achieving Clinical Excellence conference in Holland, May 16-18th. Other results will be reported in the 50th anniversayry issue of the journal, Psychotherapy, to which we’ve been asked to contribute. Stay tuned.

What Works in the Treatment of Post Traumatic Stress Disorder? The Definitive Study

September 15, 2010 By scottdm 1 Comment

What works in the treatment of people with post-traumatic stress? The influential Cochrane Collaboration–an “independent network of people” whose self-professed mission is to help “healthcare providers, policy makers, patients, their advocates and carers, make well-informed decisions, concludes that, “non trauma-focused psychological treatments [do] not reduce PTSD symptoms as significantly…as individual trauma focused cognitive-behavioral therapy (TFCBT), eye movement desensitization and reprocessing, stress mamangement and group TFCBT.” The same conclusion was reached by the National Institute for Health and Clinical Excellence (or NICE) in the United Kingdom which has developed and disseminated practice guidelines that unequivocally state that , “all people with PTSD should be offered a course of trauma focused psychological treatment (TFCBT) or eye movement desensitization and reprocessing (EMDR).” And they mean all: adults and kids, young and old. Little room for left for interpretation here. No thinking is required. Like the old Nike ad, you should: “Just do it.”

Wait a minute though…what do the data say? Apparently, the NICE and Cochrane recommendations are not based on, well…the evidence–at least, that is, the latest meta-analytic research! Meta-analysis, you will recall, is a procedure for aggregating results from similar studies in order to test a hypothesis, such as, “are certain approaches for the treatment of post traumatic stress more effective than others?” A year ago, I blogged about the publication of a meta-analysis by Benish, Imel, & Wampold which clearly showed that there was no difference in outcome between treatments for PTSD and that the designation of some therapies as “trauma-focused” was devoid of empirical support, a fiction.

So, how to account for the differences? In a word, allegiance. Although written by scientists, so-called “scholarly” reviews of the literature and “consensus panel” opinions inevitably reflect the values, beliefs, and theoretical predilections of the authors. NICE guidelines, for example, read like a well planned advertising campaign for single psychotherapeutic modality: CBT. Indeed, the organization is quite explicit in it’s objective: “provide support for the local implementation of…appropriate levels of cognitive beheavioral therapy.” Astonishingly, no other approach is accorded the same level of support or endorsement despite robust evidence of the equivalence of outcomes among treatment approaches. Meanwhile, the review of the PTSD literature and treatment recommendations published by the Cochrane Collaboration has not been updated since 2007–a full two years following the publication of the Benish et al. (2008) meta-analysis–and that was penned by a prominent advocate of…CBT…Trauma-focused CBT.

As I blogged about back in January, researchers and prominent CBT proponents, published a critique of the Benish et al. (2008) meta-analysis in the March 2010 issue of Clinical Psychology Review (Vol. 30, No. 2, pages 269-76). Curiously, the authors chose not to replicate the Benish et al. study, but rather claim that bias, arbitrariness, lack of transparency, and poor judgement accounted for the findings. As I promised at the time, I’m making the response we wrote–which appeared in the most recent issue of Clinical Psychology Review—available here.

Of course, the most important finding of the Benish et al. (2008) and our later response (Wampold et al. 2010) is that mental health treatments work for people with post traumatic stress. Such a conclusion is unequivocal. At the same time, as we state in our response to the critique of Benish et al. (2008), “there is little evidence to support the conclusion…that one particular treatment for PTSD is superior to others or that some well defined ingredient is crucial to successful treatments of PTSD.” Saying otherwise, belies the evidence and diverts attention and scarce resources away from efforts likely to improve the quality and outcome of behavioral health services.

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The Turn to Outcomes: A Revolution in Behavioral Health Practice

February 1, 2010 By scottdm Leave a Comment

Get ready. The revolution is coming (if not already here). Whether you are a direct service provider (psychologist, counselor, marriage and family therapist), agency, broker, or funder, you will be required to measure and likely report the outcomes of your clinical work.

Jay Lebow, Ph.D.

Just this month, Dr. Jay Lebow, a professor of psychology at the Family Institute at Northwestern University, published an article in the Psychotherapy Networker–the most widely circulated publication for practitioners in the world–where he claimed the field had reached a “tipping point.” “Once a matter of interest only among a small circle of academics,” Dr. Lebow writes in his piece entitled, The Big Squeeze, “treatment outcome has now become a part of the national debate about healthcare reform.”

David Barlow, Ph.D.

The same sentiments were expressed in a feature article entitled, “Negative Effects from Psychological Treatments,” written by Dr. David Barlow in the January issue of the American Psychologist. “Therapists,” he argues both eloquently and persuasively, “do not have to wait for the next clinical trial….[rather] clinicians [can act] as local clinical scientists…[using] outcome measures to track progress…rapidly becom[ing] aware of lack of progress or even deterioration” (p. 19). What can I say, except that any practitioner with more than a few years to work before retirement, should read these articles and then forward them to every practitioner they know.

During the Holidays, and just before the turn of the New Year, I blogged about the trend toward outcome measurement. As readers will recall, I talked about my experience on a panel at the Evolution of Psychotherapy conference where Dr. Barlow–who, in response to my brief remarks about the benefits of feedback– suprised me by stating unequivocally that all therapists would soon be required to measure and monitor the outcome of their clinical work. And even though my work has focused almost exclusively on measuring and using outcomes to improve both retention in and the results of behavioral health for the last 15 years, I said his pronouncement frightened me–which, by the way, reminds me of a joke.

A sheep farmer is out in the pasture tending his flock–I promise this is clean, so read on–when from over a small hill comes a man in a custom-tailored, three-piece business suit. In one hand, the businessman holds a calculator; in the other, an expensive, leather brief case. “I have a proposition for you,” the well-clad man says as he approaches the farmer, and then continues, “if I can tell you how many sheep are in your flock, to the exact number, may I have one of your sheep?” Though initially startled by the stranger’s abrupt appearance and offer, the farmer quickly gathers his wits. Knowing there is no way the man could know the actual number of sheep (since many in his flock were out of site in other pastures and several were born just that morning and still in the barn), the farmer quickly responded, “I’ll take that bet!”

Without a moment’s hesitation, the man calls out the correct number, “one thousand, three hundred and forty six,” then quickly adds, “…with the last three born this morning and still resting in the barn!” Dumbfounded, the farmer merely motions toward his flock. In response, the visitor stows his calculator, slings one of the animals up and across his shoulders and then, after retrieving his briefcase, begins making his way back up the hill. Just as he nears the top of the embankment, the farmer finds his voice and calls out, “Sir, I have a counter proposal for you.”

“And what might that be?” the man replies, turning to face the farmer, who then asked, “If I can tell you, sir, what you do for a living, can I have my animal back?”

Always in the mood for a wager, the stranger replies, “I’ll take that bet!” And then without a moment’s hesitation, the sheep farmer says, “You’re an accountant, a bureaucrat, a ‘bean-counter.'” Now, it’s the businessman’s turn to be surprised. “That’s right!” he says, and then asks, “How did you know?”

“Well,” the farmer answers, “because that’s my dog you have around your neck.”

The moral of the story? Bureaucrats can count but they can’t tell the difference between what is and is not important. In my blogpost on December 24th, I expressed concern about the explosion of “official interest” in measuring outcomes. As the two articles mentioned above make clear, the revolution has started. There’s no turning back now. The only question that remains is whether behavioral health providers will be present to steer measurement toward what matters? Here, our track record is less than impressive (remember the 80-90’s and the whole managed care revolution). We had ample warning (and did, well, nothing. If you don’t believe me, click here and read this article from 1986 by Dr. Nick Cummings).

As my colleague and friend Peter Albert is fond of saying, “If you’re not at the table, you’re likely to be on the menu.” So, what can the average clinician do? First of all, if you haven’t already done so, began tracking your outcomes. Right here, on my website, you can download, free, simple-to use, valid and reliable measures. Second, advocate for measures that are feasible, client-friendly, and have a empirical track record of improving retention and outcome. Third, and lastly, join the International Center for Clinical Excellence. Here, clinicians from all over the globe are connecting, learning, and sharing their experiences about how to use ongoing measures of progress and alliance. Most importantly, all are determined to lead the revolution.