Do you know who said, "Sometimes the magic works, sometimes it doesn’t"?

April 30, 2014 By scottdm Leave a Comment

Chief Dan George playing the role of Old Lodge Skins in the 1970 movie, “Little Big Man.” Whether or not you’ve seen or remember the film, if you’re a practicing therapist, you know the wisdom contained in that quote. No matter how skilled the clinician or devoted the client, “sometimes therapy works, sometimes it doesn’t.”

Evidence from randomized clinical trials indicates that, on average, clinicians achieve a reliable change–that is, a difference not attributable to chance, maturation, or measurement error–with approximately 50% of people treated. For the most effective therapists, it’s about 70%. Said another way, all of us fail between 30-50% of the time.

Of greater concern, however, is the finding that we don’t see the failure coming. Hannan and colleagues (2005) found, for example, that therapists correctly predicted deterioration in only 1 of 550 people treated, despite having been told beforehand the likely percentage of their clients that would worsen and knowing they were participating in a study on the subject!

It’s one thing when “the magic doesn’t work”–nothing is 100%–but it’s an entirely different matter when we go on believing that something is working, when it’s not. Put bluntly, we are a terminally, and forever hopeful group of professionals!

What to do? Hannan et al. (2005) found that simple measures of progress in therapy correctly identified 90% of clients “at risk” for a negative outcome or dropout. Other studies have found that routinely soliciting feedback from people in treatment regarding progress and their experience of the therapeutic relationship as much as doubles effectiveness while simultaneously reducing dropout and deterioration rates.

You can get two, simple, evidence-based measures for free here. Get started by connecting with and learning from colleagues on the world’s largest, online network of clinicians: The International Center for Clinical Excellence. It’s free and signing up takes only a minute or two.

Finally, take advantage of a special offer for the 6 Feedback Informed Treatment and Training Manuals, containing step by step instructions for using the scales to guide and improve the services you offer. These manuals are the reason the ICCE received the perfect scores when SAMHSA reviewed and approved our application for evidence-based status.

Here’s to knowing when our “magic” is working, and when it’s not!

Is Psychotherapy Getting Better?

October 11, 2012 By scottdm Leave a Comment

This last month, I spent a significant amount of time traveling around Europe and Scandanavia (Germany, Sweden, Denmark, the Netherlands) working with clinicians and mental health agencies implementing Feedback-Informed Treatment. Not infrequently, people ask me, “doesn’t all the travel wear you out?” My pat response is, “No, not at all! The worst part is being away from my family. But, meeting with practitioners and agency managers always buoys my spirits.” I mean it. I miss my family and the airlines (and airport food) are a real drag. Practitioners are, on the other hand, a different story. Despite the numerous challenges (funding, documentation, regulatory demands, etc.), they persist, working to improve their skills and provide effective help to their clients.

As happened a few months ago, I was in the SAS lounge at the Copenhagen airport, waiting for a flight, enjoying a cup of coffee, and catching up on the news, when I ran across another article by Thomas Friedman that caught my eye. “The plan,” he said, “to work hard and play by the rules to get ahead is now outdated. It takes much more than that.”

Wow, I thought, he’s so right–especially when it comes to the field of mental health. I was raised in an era when “working hard at your job” was the formula for success, the pathway to a fruitful and enjoyable career. As I travel the world, however, I see just how little reason there is to believe in this ideal any longer. The rules have changed. The world, observed Friedman, “is now a more open system. Technology and globalization are wiping out lower-skilled jobs faster, while raising the skill level required for new jobs. More than ever now, lifelong learning is the key to getting into and staying in the middle class.”

As I said earlier, the therapists I meet are working very hard–harder than either I or they ever anticipated. They are putting in more hours and, in many cases, making less money than they did a few years earlier. It’s true! Did you know, psychologists incomes are down 17% in the last decade? Simply put, working hard is a recipe for…eventual failure. If we are to survive and thrive, a change of order–not magnitude–is required.

Recently, Diane Cole addressed the challenges facing practitioners in a special issue of the Psychotherapy Networker. It’s worth a read (click here). Importantly, she doesn’t just bemoan the problems currently facing the field, but provides crucial information for helping each and every one of us take charge of our fate.

National Psychotherapy Day: A Recognition, Celebration, and Call for Action

September 24, 2012 By scottdm Leave a Comment

With all the challenges facing the profession, it is important to highlight people and organizations that are working hard to make a difference. On that note, tomorrow, Tuesday the 25th of September 2012 is the very first National Psychotherapy Day. Having a day of unified, active promotion of psychotherapy is the brain child of psychologist Ryan Howes. At his side is the Psychotherapy Foundation (PF), a nonprofit foundation, dedicated to promoting the therapeutic relationship as an “effective, long-lasting, collaborative approach” to resolving emotional, behavioral, and relational problems. What’s not to like? Dr. Howes and the PF are encouraging people who have seen a therapist to talk or blog about their experience. They are calling on therapists to commit to sharing research documenting the effectiveness of psychotherapy with the public (write a letter to the editor of your local paper, offer to do an interview, give a brief presentation at the Chamber of Commerce).

Surveys show that the two primary barriers to seeking the help of a therapist are: (1) cost of the service (cited by 81%); and (2) lack of confidence in the outcome of therapy (78%). Of these two barriers, the first is entirely understandable. Times are tough and treatment costs money. It is for these this reason that Dr. Howe and the PF are asking all who participate in the day to support their local, low-fee counseling centers in whatever way possible.

The second barrier is more troubling and, frankly, difficult to understand and address. Research overwhelmingly supports the efficacy of psychological treatment. Indeed, the American Psychological Association issued a rare, formal resolution this last month recognizing the effectiveness of psychotherapy! Listen to the language:

Whereas the effects of psychotherapy …are widely accepted to be significant and large;
Whereas the results of psychotherapy tend to last long and be less liely to equire additional treatment courses than psychopharmacological treatments;
Whereas comparisons of different forms of psychotherapy most often result in relatively nonsignificant difference, and contextual and relationship factors (not captured by a patient’s diagnosis or by the therapists use of a specific psychotherapy) mediate or moderate outcomes;
Whereas the best research evidence conclusively shows that individual, group, and couple/family psychotherapy are effective for a broad range of…problems with children, adolescents, adults, and older adults;
THEREFORE be it resolved that, as a healing practice and professional service, psychotherapy is effective and highly cost effective…and should be included in the health care system as an established evidence-based practice.

Strong words, right? Even so, it’s very clear that the public’s lingering doubts about effectiveness will require than a proclamation. It is for this reason that Dr. Howes and PF are asking all those currently in care to provide constructive feedback to their therapist. Therapists, in turn, are encouraged to seek and respond to feedback from their clients. As reviewed here on this blog, numerous studies document the positive impact that routine feedback from clients has on retention and outcome of service. Free evidence-based tools are available for download from this website for soliciting formal feedback from consumers. Plus, the International Center for Clinical Excellence web-based community–the largest group of clinicians and researchers dedicated to improving the quality and outcome of psychotherapy via the use of ongoing feedback–stands ready and willing to be of support.

So, why the turquoise? Well, its’ the official color of National Psychotherapy Day. To show your support, Dr. Howes and PF are asking all to wear something with that color tomorrow.

REACHing the Next Level of Clinical Performance: What it Really Takes

September 1, 2012 By scottdm 2 Comments

Do any of these people look familiar? Well, of course, I’m the guy in the middle pointing. To my left is the rock and roll guitarist Joe Walsh. On my right is world-renowned, card mechanic Richard Turner. Why have I pictured myself sandwiched between these two? Because they are both inspiring examples of what can be accomplished when individuals push beyond the “tried and true,” to reach the next level of performance.

Back in June, I read an article about Joe Walsh in the Chicago Tribune. Buried deep in the piece was a brief biography of the guitarist that exemplifies what it takes to achieve excellence. Walsh, who is 67 years old, began playing back in the late 1960’s. Like many of his generation, he was inspired by the Beatles. One day, he was listening to the band’s song, “And Your Bird can Sing,” which contains a “ridiculously finger stretching George Harrison guitar solo.” According to the article, Walsh worked tirelessly until he mastered the riff. It was only years later, long after he’d become famous, that he met Ringo Starr. Walsh related the story to the drummer who “looked at Walsh like he was nuts.” Harrison, Ringo told him, had played two guitar parts separately and tracked them on top of each other and later tracked them together in the studio.

Good thing no one told Walsh the truth. As a result, he did what no one–even now–thought posssible.

On to Richard Turner. Unless you are into magic or gambling, this may be the first time you’ve ever heard of this person. Author Alex Stone, in his phenomenally fun and informative book, Fooling Houdini, describes him as “a card handler without equal, a man whose prowess with a deck borders on the supernatural.” The supernaturnal? Really? I would have deemd such praise so much more hype, typical of “hollywood” and the media, if I hadn’t meet Turner personally and seen him work. Simply put, there’s nothing he can’t do with a deck of cards.

Watch the brief video below filmed at this year’s “Training of Trainers” event in Chicago. At all training events, we bring in top performers to entertain, inspire, and inform participants about what it takes to achieve excellence.

Not bad eh? Especially when one considers that Turner is blind. And the video above is only the tiniest snippet of his performance. At one point, he dealt out hands of poker and black jack, asking audience members which position they would like to have dealt the winning cards. Sure enough, whatever position was called, luck struck there and only there. “Give me a number between 1 and 52,” he asked. Whatever number was called out, he cut the cards to that exact position in the deck. Did I mention he’s also a 6th degree black belt? Simply put, Turner is a performer that is always pushing the limits. Once he was cited for a driving motor cycle while blind! How does he do it? Practice. Yep, seventeen hours a day! For years, he slept with a deck of cards. Like Walsh, he persisted until he mastered moves that no one considered possible or, more accurately, no one ever even imagined.

So, what can mental health professionals do to REACH the next level of clinical performance? Over the last few years, together with my colleagues, we’ve been writing about the steps thrapists can take to achieving excellence. This year, I was privileged to summarize the current state of the research on the subject in a keynote address at the Psychotherapy Networker conference in Washington, DC. Here, for the first time, is “Part 1” of that address (the second half will follow soon). In it, I lay out what the evidence says it takes to excel.

Cutting Edge Feedback

November 22, 2011 By scottdm Leave a Comment

Earth | Time Lapse View from Space, Fly Over | NASA, ISS

Using feedback to guide and improve the quality and outcome of behavioral health services is growing in popularity. The number of systems available for measuring, aggregating, and interpreting the feedback provided by consumers is increasing. The question, of course, is, “which is best?” And the answer is, “it depends on the algorithms being used.”

Over a decade ago, my colleagues and I developed a set of mathematic equations that enabled us to plot the “expected treatment response” or ETR of a client based on their first session Outcome Rating Scale (ORS) score. Although the math was complicated, the idea was not: therapists and clients could compare outcomes from session to session to the benchmark provided by the ETR. If too much or too little progress were being made, client and therapist could discuss what changes might be made to the services being offered in order to insure more effective or durable progress. It was a bold idea and definately “cutting edge” at the time–after all, 10 years ago, few people were even measuring outcomes let alone trying to provide benchmarks for guiding clinical practice. The formulas developed at that time for plotting change in treatmentare still being used by many around the world with great effect. At the same time, it was merely a first attempt.

I am proud and excited to be able to announce the development and launch of a new set of algorithms–the largest and most sophisticated to date–based on a sample of 427,744 administrations of the ORS, in 95,478 unique episodes of care, provided by 2,354 different clinicians. 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. Consider an analogy to the field of medicine. No one would be interested in a test for the effectiveness of a particular cancer treatment that compared an individual’s progress to to the average of all patients whether they lived or died. People want to know, “will I live?” And in order to answer that question, the ETR of both successful and ultimately unsuccessful treatments must be determined and the individual clients progress compared to both benchmarks. Adjustments can be made to the services offered when the client’s session by session outcomes fit the ETR of treatments that ended unsuccessfully.

An example of the type of feedback provided by the new algorithms is found below. The graph displays three zones of potential progress (or ETR’s) for a client scoring 15 on the ORS at intake. Scores falling in the “green” area from session to session are similar to treatments that ended successfully. As might be expected, those in the “red” zone, ended unsuccessfully. Finally, scores in the “yellow” zone had mixed results. In each instance, both the client and therapist are provided with instant feedback: green = on track, red = off track, yellow = concern.

The new algorithms will be a major focus of the upcoming “Advanced Intensive in Feedback-Informed Treatment (FIT)” scheduled for March 19th-22nd, 2012. All those subscribing to the event also receive the newly released series of FIT treatment manuals. Space is limited, as always, to 35 people and we are filling fast so please don’t wait. So many exciting developments!

Now, if you haven’t already done so, click on the video at the start of this post. I was floored by these satellite images. In some way, I hope that the new algorithms, FIT training manuals, and the ICCE community can inspire a similar sense of perspective!

Is Psychotherapy Dead?

August 26, 2011 By scottdm 1 Comment

“AMERICANS PREFER DRUGS” screams the headline posted by the Reuters news service and attributed to Consumer Reports–one of the most respected periodical for the average American reader. “NEARLY 80 PERCENT TAKE A PILL FOR DEPRESSION,” the article continues. Read a little further and do some searching around on the internet and a different story emerges. Americans it turns out don’t necessarily prefer drugs but rather, “78 percent of those seeking treatment for depression or anxiety were prescribed antidepressants.”

With respected news agencies advertizing for the pharaceutical companies, is it any wonder why the practice of “talk therapy” is suffering? AA’s Executive Director for Professional Practice, Dr. Kaherine Nordal, in a recent editorial asked, “Where has all the psychotherapy gone?” The percentage of Americans who receive outpatinet mental health care has remained unchanged over the last several decades. Moreover, as Dr. Mark Hubble and I point out in the lead article in the May-June issue of the Psychotherapy Networker, “median incomes for psychologists, both applied and academic, have dropped between 17 and 33 percent at the same time that workloads have increaed, profssional autonomy has been subverted, and funding for public behavioral healthcare has all but disappeared.”

In a recent, highly publicized exchange on psychotherapy that appeared on Medscape: Psychiatry and Health, panel participants (all psychiatrists) repeated the same, old, tired argument about the field. To wit, “the research base is insufficient.” How such statements can be made with a straight face, much less by mental health professionals, on a public website, defies explanation. The truth is, the evidence-base for psychological treatments is as large and robust as any. What’s more, seeing a talk therapist does not require invasive surgery or a black box warning. Clearly, the issue is not research. It is about awareness.

The members and associates of the International Center for Clinical Excellence (ICCE) are working diligently to raise consciousness among the public and policy makers. Every day, 1000’s of professionals connect to, learn from, and share with colleagues around the world. The mission of the organization? To use community to improve the quality and outcome of behavioral health services. On the ICCE web-based community, clinicians share experiences and real world data regarding the effectiveness of talk therapy. For example, ICCE associate Dan Buccino shared outcomes from a 7 year project aimed at “promoting recovery and accountability.” Using the Outcome and Session Ratings Scales, Dan documented effectiveness levels that far exceeded national benchmarks for clinical practice. Why not email him for a copy of the report? Meanwhile, providers serving US Airforce personnel began using the same measures in early 2010 and have reported very similar findings. Finally, to date, more than a dozen randomized clinical trials, involving thousands of clients and numerous therapists, have established that using feedback to inform services increases effectiveness of individual practitioners three fold, cuts dropout rates by 50 percent, reduces the rate of deterioration by 33 percent, and speeds recovery by 66 percent, while simultaensouly improving client satisfaction and reducing the cost of care.

To paraphrase Mark Twain, the rumored death of psychotherapy has been greatly exaggerated. Now is not the time, however, to merely hope for a better future. Join the discussion taking place on ICCE right now. Membership is free and a strong, supportive community just a few clicks away.

The Cryptonite of Behavioral Health: Making Mistakes

May 7, 2011 By scottdm Leave a Comment

Most people readily agree that its important to “learn from mistakes.” In truth, however, few actually believe it. Mistakes are like cryptonite, making us feel and, more importantly, look stupid and weak. As a result, despite what we might advise others, we do our best to avoid making and admitting them. Such avoidance comes with a big cost: personal and professional growth stalls and even atrophies. We take on less challenging tasks, avoid taking risks, and give up more easily when confronted with situations that might expose our weaknesses. Far all that, falling a bit on “error-phobic” side of life is hardly an instance of irrationality. As Alina Tugend, author of Better by Mistake points out, “As much as people hate to make mistakes, they love pointing out the ones others have made.” Indeed, for most of us, the glee others take in pointing out our shortcomings only serves to compound our avoidance and deepen our public denial. And that’s what makes Tony Rousmaniere’s recent blogpost so unusual.

Briefly, Tony is a psychologist in private practice in San Francisco and Palo Alto. As he tells the story, he was riding in his car, listening to a recording of my presentation at the 2009 Evolution of Psychotherapy conference. The subject was “Achieving Clinical Excellence.” The message: routinely seeking feedback from clients about our mistakes decreases dropout rates and improves outcomes in psychotherapy. Tony took the message to heart. Unlike many of our peers who say they routinely ask clients for feedback, Tony actually downloaded the outcome and session rating scales and began formally asking his clients for feedback.

The story he relates makes for compelling reading, most of all because the feedback he received was not always easy to hear. And yet, he persisted, not only asking clients, but recording his work and then seeking input from colleagues. In the article, he gives step-by-step instructions for making use of the painful and sometimes confusing and contradictory feedback one receives.

Tony’s willingness to share his experience makes it tempting to say he is one brave soul. In actuality, he’s pragmatic. He placed outcomes over image. As he reports in the article, his dropout rate has plummeted and his outcomes improved. I say, “Bravo!”
________________________

Addendum

If you are thinking of writing to tell me that I misspelled the word, “cyptonite” (the accepted spelling is kryptonite), don’t bother. I know. I did it on purpose. See what I mean?!

Changing Home-Based Mental Health Care for Good: Using Feedback Informed Treatment

February 8, 2011 By scottdm Leave a Comment

Some teach. Some write. Some publish research. Arnold Woodruff and Kathy Levenston work for a living! Kathy Levenston specializes in working with foster and adopted children.

Arnold Woodruff developed the first intensive in-home program run by a community services board in Virginia. He has over 30 years of experience, and has served as the President of the Virginia Association for Marriage and Family Therapy. And now, these two dedicated professionals, certified trainers and associates of the International Center for Clinical Excellence, have just purchased Home for Good, the first home-based mental health program in the Richmond, VA area to use Feedback-Informed Treatment (FIT).

The program is now a 100% employee-owned company and part of a larger vision the two have for establishing customer-friendly mental health care to people in the Richmond area. Home for Good has been providing Intensive In-home Services (counseling, case management, and crisis support) to children, adolescents, and their families for the past two years. Home for Good has achieved superior results compared to other mental health programs, based on an analysis of data genderated from routine administration of the Outcome Rating Scale in clinical practice. Home for Good’s results are continuing to improve with the use of Feedback-Informed Treatment. Home for Good will soon be offering additional services, including outpatient individual, family, and group therapy.

Getting FIT in the New Year: The Latest Evidence

January 18, 2011 By scottdm Leave a Comment

John Norcross, Ph.D. is without a doubt the researcher that has done the most to highlight the evidence-base supporting the importance of the relationship between clinician and consumer in successful behavioral healthcare. The second edition of his book, Psychotherapy Relationships that Work, is about to be released. Like the last edition, this volume is a virtual treasure trove of research findings and empirically supported practices.

Among the many gems in the book is a chapter by Michael J. Lambert, Ph.D–pioneering researcher on “feedback-informed treatment” (FIT). As usual, he does a masterful job summarizing the existing research on the subject. The data are overwhelmingly positive: seeking and using standardized feedback regarding the progress and outcome of treatment cuts drop out and deterioration rates and significantly improves outcome.

Lambert also reports the results of two meta-analyses. One performed on studies using his own OQ System family of measures, the other based on research using the ORS and SRS. Not only did he find ample empirical support for the two systems, but in the case of the ORS and SRS those therapies informed by feedback, “had 3.5 times higher odds of experiencing reliable change.” Additionally, and importantly, the brief, 4-item ORS and SRS scales performed the same as the longer and more detailed OQ 45.2.

What can you do? First, order John’s book. Second, if you are not FIT, now is the time to register to use the measures. And if you need support, why not join the International Center for Clinical Excellence? Like the measures, there is no cost. Right now, professionals from different disciplines, working in diverse settings are connecting with and learning from each other. Here’s a nudge: you’ll be able to reach John Norcross there—he’s one of ICCE’s newest members.

The Effects of Feedback on Medication Compliance and Outcome: Follow Up on The University of Pittsburgh Study

September 9, 2010 By scottdm Leave a Comment

Late last year, I blogged about a study being conducted at the University of Pittsburgh by Dr. Jan Pringle, the director of the Program Evaluation Research Unit in the School of Pharmacology and her colleague, Dr. Michael Melczak. You’ll recall, there were two conditions in the study. In the first, pharmacists–the practitioner most likely to interact with patients about prescriptions–engaged in “practice as usual.” In the second condition, pharmacists used the ORS and the SRS to chart, discuss, and guide patient progress and the pharmacist-patient alliance. At the time, I reported that initial findings showed that patients of pharmacists who used the measures to solicit feedback “were significantly more likely to take their medications at the levels that would be likely to result in clinical impact than the patients who saw a pharmacists who did not use the scales…for hypertensive and hyperlipidemia drugs especially.” Well, the official results are finally available.

After controlling for age, gender, and other individual and control conditions (including measures of interactions with pharmacies), patients in the feedback condition increased their rate of “percent of days covered”–that is, taking the medication as prescribed–significantly (average 11%, a result considered “impressive” when compared to other, traditional efforts aimed at improving compliance). Interestingly, additional analyses showed that the impact of the SRS–a measure of the therapeutic alliance–was greatest for the hyplipidemia and hypertensive medications (as opposed to the anti-diabetic medications).

Drs. Pringle and Melczak are currently in the process of planning a series of additional studies involving a larger number of patients and pharmacists. Both will be presenting at the upcoming Achieving Clinical Excellence conference.

Finally, take a look at the video that was developed to begin training pharmacists to use the measures with customers filling prescriptions at local pharmacies. According to Dr. Pringle, “we expect to training about 240 pharmacists across 118 pharmacies in the western and central portions of Pennsylvania how to use the ORS and SRS…the program represents a collaboration between the University of Pittsburgh, CECity (a technology company), RiteAid, and Highmark ( a Blues insurer).” Exciting stuff, eh?

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:

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

July 22, 2010 By scottdm 1 Comment

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.

Feedback Informed Treatment (FIT): A Worldwide Trend in Behavioral Health

July 14, 2010 By scottdm Leave a Comment

In my prior blogpost, I reviewed exciting developments taking place throughout Canada regarding “feedback-informed treatment” (FIT). For those following me on Twitter–and if you’re not, please do so by clicking on the link–you already know that last week I was in Tunbridge, England for a two day training sponsored by the Kent-Medway National Healthcare Trust on “Supershrinks: Learning from the Fields Most Effective Practitioners.” Interest in outcomes is growing exponentially, becoming a worldwide phenomenon.

It was a real pleasure being asked to work with the dedicated–and I must say, long-suffering–physicians, psychologists, counselors, social workers, and nurses of the NHS Trust. I say “long-suffering” because these healthcare professionals, like others around the globe, are laboring to provide effective services while contending with a back breaking amount of paperwork, oversight, mandated treatment protocols, and regulation.

Much of the mess that behavioral health practitioners find themselves in is due to the way “good practice” is and has been conceptualized. Simply put, the field–it’s researchers, visionaries, policy makers and sadly, many clinicians–are still stuck in the penicillin era, promoting specific treatments for specific disorders. The result has been a growing list of protocols, fidelity and adherence measures, and other documentation requirements. As pointed Bohanske and Franzcak point out in their excellent chapter on transforming behavioral health in the latest edition of The Heart and Soul of Change: Delivering What Works in Therapy, “The forms needed to obtain a marriage certificate, buy a new home, lease an automobile, apply for a passport, open a bank account, and die of natural causes…altogether…weigh 1.4 ounces. By contrast, the paperwork required for enrolling a single mother in counseling to talk about difficulties her child [is] experiencing [weigh] 1.25 pounds” (p. 300).

Something has to change, and that something is the incessant focus on controlling the process–or “how”– of treatment. Instead, as the video interview below illustrates, emphasis can be placed on outcome. Doing so will not only simplify oversight and regulation but, as an increasing number of studies show, result in improved “FIT” and effect of services offered.

Where Necessity is the Mother of Invention: Forming Alliances with Consumers on the Margins

April 11, 2010 By scottdm 3 Comments

Spring of last year, I traveled to Gothenburg, Sweden to provide training GCK–an top notch organization led by Ulla Hansson and Ulla Westling-Missios providing cutting-edge training on “what works” in psychotherapy. I’ll be back this week again doing an open workshop and an advanced training for the group.

While I’m always excited to be out and about traveling and training, being in Sweden is special for me. It’s like my second home. My family roots are Swedish and Danish and, it just so happens, I speak the language. Indeed, I lived and worked in the country for two years back in the late seventies. If you’ve never been, be sure and put it on your short list of places to visit…

AND IMPORTANTLY, go in the Summer! (Actually, the photos above are from the famous “Ice Hotel”–that’s right, a hotel completely made of icc. The lobby, bar, chairs, beds. Everything! If you find yourself in Sweden during the winter months, it’s a must see. I promise you’ll never forget the experience).

Anyway, the last time I was in Gothenburg, I met a clinician whose efforts to deliver consumer-driven and outcome-informed services to people on the margins of society were truly inspiring. During one of the breaks at the training, therapist Jan Larsson introduced himself, told me he had been reading my books and articles, and then showed me how he managed to seek and obtain feedback from the people he worked with on the streets. “My work does not look like ‘traditional’ therapeutic work since I do not meet clients at an office. Rather, I meet them where they live: at home, on a bench in the park, or sitting in the library or local activity center.”

Most of Jan’s clients have been involved with the “psychiatric system” for years and yet, he says, continue to struggle and suffer with many of the same problems they entered the system with years earlier. “Oftentimes,” he observed, “a ‘treatment plan’ has been developed for the person that has little to do with what they think or want.”

So Jan began asking. And each time they met, they also completed the ORS and SRS–“just to be sure,” he said. No computer. No I-phone app. No sophisticated web-based adminsitration system. With a pair of scissors, he simply trimmed copies of the measures to fit in his pocket-sized appointment book.

His experience thusfar? In Swedish Jan says, “Det finns en livserfarenhet hos klienterna som bara väntar på att bli upptäckt och bli lyssnad till. Klienterna är så mycket mer än en diagnos. Frågan är om vi är nyfikna på den eftersom diagnosen har stulit deras livberättelse.” Translated: “There is life experience with clients that is just waiting to be noticed and listened to. Clients are so much more than their diagnosis. The question is whether we are curious about them because the diagnosis has stolen their life story.”

I look forward to catching up Jan and the crew at GKC this coming week. I also be posting interviews with Ulla and Ulla as well as ICCE certified trainers Gun-Eva Langdahl (who I’ll be working with in Skelleftea) and Gunnar Lindfeldt (who I’ll be meeting in Stockholm). In the meantime, let me post several articles he sent by Swedish research Alain Topor on developing helpful relationships with people on the margins. Dr. Topor was talking about the “recovery model” among people considered “severely and persistently mentally ill long before it became popular here in the States. Together with others, such as psychologist Jan Blomqvist (who I blogged about late last year), Alain’s work is putting the consumer at the center of service delivery.

Improving Outcomes in the Treatment of Obesity via Practice-Based Evidence: Weight Loss, Nutrition, and Work Productivity

April 9, 2010 By scottdm 4 Comments

Obesity is a large and growing problem in the United States and elsewhere. Data gathered by the National Center for Health Statistics indicate that 33% Americans are obese. When overweight people are added to the mix, the figure climbs to a staggering 66%! The problem is not likely to go away soon or on its own as the same figures apply to children.

Researchers estimate that weight problems are responsible for over 300,000 deaths annually and account for 12% of healthcare costs or 100 billion–that’s right, $100,000,000,000–in the United States alone. The overweight and obese have higher incidences of arthritis, breast cancer, heart disease, colorectal cancer, diabetes, endometrial cancer, gallbladder disease, hypertension, liver disease, back pain, sleeping problems, and stroke–not to mention the tremendous emotional, relational, and social costs. The data are clear: the overweight are the target of discrimination in education, healthcare, and employment. A study by Brownell and Puhl (2003), for example, found that: (1) a significant percentage of healthcare professionals admit to feeling “repulsed” by obese person, even among those who specialize in bariatric treatment; (2) parents provide less college support to their overweight compared to “thin” children; and (3) 87% of obese individuals reported that weight prevented them from being hired for a job.

Sadly, available evidence indicates that while weight problems are “among the easiest conditions to recognize,” they remain one of the “most difficult to treat.” Weight loss programs abound. When was the last time you watched television and didn’t see an ad for a diet pill, program, or exercise machine? Many work. Few, however, lead to lasting change.

What might help?

More than a decade ago, I met Dr. Paul Faulkner, the founder and then Chief Executive Officer of Resources for Living (RFL), an innovative employee assistance program located in Austin, Texas. I was teaching a week-long course on outcome-informed work at the Cape Cod Institute in Eastham, Massachusetts. Paul had long searched for a way of improving outcomes and service delivery that could simultaneously be used to provide evidence of the value of treatment to purchasers–in the case of RFL, the large, multinational companies that were paying him to manage their employee assistance programs. Thus began a long relationship between me and the management and clinical staff of RFL. I was in Austin, Texas dozens of times providing training and consultation as well as setting up the original ORS/SRS feedback system known as ALERT, which is still in use at the organization today. All of the original reliability, validity, norming, and response trajectories were done together with the crew at RFL.

Along the way, RFL expanded services to disease management, including depression, chronic obstructive pulmonary disease, diabetes, and obesity. The “weight management” program delivered coaching and nutritional consultation via the telephone informed by ongoing measurement of outcomes and the therapeutic alliance using the SRS and ORS. The results are impressive. The study by Ryan Sorrell, a clinician and researcher at RFL, not only found that the program and feedback led to weight loss, but also significant improvements in distress, health eating behaviors (70%), exercise (65%), and presenteeism on the job (64%)–the latter being critical to the employers paying for the service.

Such research adds to the growing body of literature documenting the importance of “practice-based” evidence, making clear that finding the “right” or “evidence-based” approach for obesity (or any problem for that matter) is less important than finding out “what works” for each person in need of help. With challenging, “life-style” problems, this means using ongoing feedback to inform whatever services may be deemed appropriate or necessary. Doing so not only leads to better outcomes, but also provides real-time, real-world evidence of return on investment for those footing the bill.

Problems in Evidence-Based Land: Questioning the Wisdom of "Preferred Treatments"

March 29, 2010 By scottdm Leave a Comment

This last week, Jeremy Laurance, Health Editor for the U.K. Independent published an article entitled, “The big question: Does cognitive therapy work? And should the NHS (National Health Service) provide more of it?” Usually such questions are limited to professional journals and trade magazines. Instead, it ran in the “Life and Style” section of one of Britain’s largest daily newspapers. Why?

In 2007, the government earmarked £173,000,000 (approximately 260,000,000 U.S. dollars) to train up an army of new therapists. Briefly, the money was allocated following an earlier report by Professor Richard Layard of the London School of Economics which found that a staggering 38% of illness and disability claims were accounted for by “mental disorders.” The sticking point—and part of the reason for the article by Laurance—is that training was largely limited to a single treatment approach: cognitive-behavioral therapy (CBT). And research released this week indicates that the efficacy of the method has been seriously overestimated due to “publication bias.”

Researchers Cuijpers, Smith, Bohlmeijer, Hollon, and Andersson (2010) examined the “effect sizes” of 117 trials and found that the tendency of journals to accept trials that showed positive results and reject those with null or negative findings reduced the reported effectiveness of CBT by as much as 33 percent!

Combine such findings with evidence from multiple meta-analyses showing no difference in outcome between treatment approaches intended to be therapeutic and one has to wonder why CBT continues to enjoy a privileged position among policy makers and regulatory bodies. Despite the evidence, the governmental body in the UK that is responsible for reviewing research and making policy recommendations—National Institute for Health and Clinical Excellence (NICE)–continues to advocate for CBT. It’s not only unscientific, its bad policy. Alas, when it comes to treatment methods, CBT enjoys what British psychologist Richard Wiseman calls, the “get out of a null effect free” card.

What would work? If the issue is truly guaranteeing effective treatment, the answer is measurement and feedback. The single largest contributor to outcome is who provides the treatment and not what treatment approach is employed. More than a dozen randomized clinical trials—the design of choice of NICE and SAMSHA—indicate that outcomes and retention rates are improved while costs are decreased—in many cases dramatically so.

I respectfully ask, “What is the hold up?”

Outcomes in New Zealand

March 23, 2010 By scottdm Leave a Comment

Made it back to Chicago after a week in New Zealand providing training and consultation. As I blogged about last Thursday, the last two days of my trip were spent in Christchurch providing a two-day training on “What Works” for Te Pou–New Zealand’s National Centre of Mental Health Research, Information, and Workforce Development. Last year around this same time, I provided a similar training for Te Pou for managers and policy makers in Auckland. News spread and this year my contact at Te Pou, Emma Wood brought the training to the south island. It is such a pleasure to be involved with such a forward thinking organization.

Long before I arrived, leadership at Te Pou were promoting outcome measurement and feedback. Here’s a direct quote from their website:

Outcomes information can assist:

service users to use their own outcomes data to reflect on their wellbeing and circumstances, talk to clinicians about their support needs and inform their recovery plans
clinicians to use outcomes information to support their decision-making in day-to-day practice, monitoring change, better understanding the needs of the service user, and also to begin evaluating the effectiveness of different interventions
planners and funders to assess population needs for mental health services and assist with allocation of resources policy and mental health strategy developments through nationally aggregated data.

Indeed, using outcome to inform mental health service delivery is a key aspect of the Past, Present, and Future: Vision Paper–a review of “what works” in care and a plan for improving treatment in the future. The site even publishes a quarterly newsletter Outcomes Matter. Take a few minutes and explore the Te Pou website. While you are there, be sure and download the pamphlet entitled, “A Guide to Talking Therapies.” As the title implies, this brief, easy-to-read text provides a non-nonsense guide to the various “talk therapies” for consumers (I took several copies home with me from the workshop).

Before ending, let me say a brief hello to the Clinical Practice Leaders from the Problem Gambling Foundation of New Zealand who attended the two-day training in Christchurch. The dedicated staff use an integrated public health and clinical model and are working to implement ongoing measurement of outcome and consumer feedback into service delivery. The website contains a free online library including fact sheets, research, and books on the issue of problem gambling that is an incredible resource to professionals and the public. Following the workshop, the group sent a photo that was taken of us together. From left to right, they are Wenli Zhang, me, Margaret Sloan, and Jude West.

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:

Deliberate Practice, Expertise, & Excellence

February 3, 2010 By scottdm 2 Comments

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!

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

January 8, 2010 By scottdm 3 Comments

Not 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.

Research on the Outcome Rating Scale, Session Rating Scale & Feedback

January 7, 2010 By scottdm Leave a Comment

“How valid and reliable are the ORS and SRS?” “What do the data say about the impact of routine measurement and feedback on outcome and retention in behavioral health?” “Are the ORS and SRS ‘evidence-based?'”

These and other questions regarding the evidence supporting the ORS, SRS, and feedback are becoming increasingly common in the workshops I’m teaching in the U.S. and abroad.

As indicated in my December 24th blogpost, routine outcome monitoring (PROMS) has even been endorsed by “specific treatments for specific disorders” proponent David Barlow, Ph.D., who stated unequivocally that “all therapists would soon be required to measure and monitor the outcome of their clinical work.” Clearly, the time has come for all behavioral health practitioners to be aware of the research regarding measurement and feedback.

Over the holidays, I updated a summary of the data to date that has long been available to trainers and associates of the International Center for Clinical Excellence. The PDF reviews all of the research on the psychometric properties of the outcome and session ratings scales as well as the studies using these and other formal measures of progress and the therapeutic relationship to improve outcome and retention in behavioral health services. The topics is so important, that I’ve decide to make the document available to everyone. Feel free to distribute the file to any and all colleagues interested in staying up to date on this emerging mega-trend in clinical practice.

Measures And Feedback from Scott Miller

The Crown Jewel of Research on CDOI: Professor Jan Blomqvist receives 2.9 million crown grant for RCT on feedback in Sweden

October 20, 2009 By scottdm 2 Comments

If you’ve been following me on Twitter, then you know that last week I was touring and teaching in different spots around Europe. First, I presented two days in Copenhagen. Then I keynoted the British Association of Counseling and Psychotherapy Conference in Newcastle, England. Early Saturday morning, I flew from London to Stockholm. My long time friend and associate, Gunnar Lindfelt picked me up at Arlanda airport and drove me back to his lovely home in the city. There, we gorged on smoked salmon, “svensk godies” (small candies, my favorite of which is “skum bananer”–dark chocolate covered marshmellow in the shape of a banana) and Cider–a non-alcoholic fizzy apple drink that is an old time Swedish favorite.

It was Gunnar Lindfeldt, a gifted clinician and expert in the treatment of drug and alcohol problems, who first introduced me to the work of Swedish psychologist Jan Blomqvist. In 1998, Blomqvist published a book entitled, “Beyond Treatment? Widening the Approach to Alcohol Problems and Solutions“ in which he made the provocative argument that common rather than specific factors held the key to effective care. Since writing the book, Jan Blomqvist has continued his research and is currently a full professor at SORAD, the Centre for Social Research on Alcohol and Drugs at Stockholm University.

Anyway, I had the pleasure of meeting with Professor Blomqvist at his home in Uppsala, Sweden this last week. Over homemade spinach soup, freshly-baked bread and cheese, we chatted about the state of the field. The pièce de résistance, however, was hearing about the 2.9 million Swedish crown grant he had just been awarded for a 4 year long study of outcome-informed treatment of alcohol problems, called “Putting the Client in the Driver’s Seat.”

The study to be conducted by Professor Blomqvist will be the largest, most comprehensive, randomized clinical trial on client-directed outcome informed clinical work. A centerpience of the study will be the routine use of the ORS and SRS and provision of feedback in the delivery of treatment services. Importantly, unlike all other studies to date, this project completely avoids claims of “allegiance effects” as no developers of measures or supporters of CDOI are participating. Stay tuned to the “Top Performance” blog for additional updates! While you are waiting, take a moment and read Professor Blomqvist’s provocative take on “addiction” in slide viewer below.

J Blomqvist 3 from Scott Miller

The Field, the Future, and Feedback

October 2, 2009 By scottdm 1 Comment

There is an old (but in many ways sad) joke about two clinicians–actually, the way I first heard the story, it was two psychiatrists. The point of the story is the same regardless of the discipline of the provider. Anyway, two therapists meet in the hallway after a long day spent meeting clients. One, the younger of the two, is tired and bedraggled. The other, older and experienced, looks the same as s/he did at the start of the day: eyes bright and attentive, hair perfectly groomed, clothes and appearance immaculate. Taken aback by the composure of the more experienced colleague, the younger therapist asks, “How do you do it? How do you listen to the trials and tribulations, the problem and complaints, the dire lives and circumstances of your clients, minute and minute, hour upon hour…and yet emerge at the end of the day in such good shape?” Slowly shaking his head from left to right, the older and more experienced clinician immediately reached out, tapping the less experienced colleague gently on the shoulder, and then after removing the thick plugs stuffed into both of his years, said, “Excuse me, what did you say?”

Let’s face it: healthcare is in trouble. Behavioral healthcare in particular is in even worse shape. And while solutions from politicians, pundits, industry insiders and professionals are circulating in Washington with all the sound and fury of a hurricane, the voice of consumers is largely absent. Why? Of course, many of the barriers between providers and consumers are systemic in nature and as such, out of the control of average clinicians and consumers. Others, however, are local and could be addressed in an instance with a modicum of interest and attention on the part of professionals.

Chief among the steps practitioners could take to bridge to chasm between them and consumers is the adoption of routine, ongoing feedback. Seeking and utlizing real-time feedback from consumers has the added advantage of significantly boosting outcomes and increasing retention in services (several studies documenting the impact of feedback are available in the “Scholarly publications and Handouts” section of my website). Healthcare providers can download two well validated and easy-to-use scales right now for free by clicking on the Performance Metrics tab to the left.

So far, however, few in healthcare seem interested and others are downright hostile to the idea of asking consumers for input. Consider the following story by reporter Lindsey Tanner entitled, “Take two, call me in the morning…and keep it quiet.” Tanner discovered that some in healthcare are demanding that people (patients. clients, consumers) sign “gag orders” prior to being treated–agreeing in effect not to post comments about the provider (negative and otherwise) to online sites such as Zagats.com, Angieslist.com, and RateMds.com. According to the article, a Greensboro, N.C. company, ironically called “Medical Justice” is, for a fee, now providing physicians with standardized waiver agreements and advising all doctors to have patients sign on the dotted line. And if the patient refuses? Simple: find another doctor.

Can you imagine a hotel chain or restaurant asking you to sign a legally-binding agreement not to disclose your experience prior to booking your room or handing you the menu? Anyone who has travelled lately knows the value of the information contained on consumer-driven websites such as TripAdvisor.com. It’s outlandish really–except in healthcare.

To be sure, there is at least one important difference between healthcare and other service industries. Specifically, healthcare providers, unlike business owners and service managers, are prevented from responding to online complaints by existing privacy laws. However, even if this problem were insurmountable–which it is not–how then can one explain the continuing reluctance on the part of professionals to give people access to their own healthcare records? And this despite federal regulations under the Health Insurance Portability and Accountability Act (HIPAA) permitting complete and unfettered access (click here to read the recent NPR story on this subject). Clearly, the problem is not legal but rather cultural in nature. Remember when Elaine from Seinfeld asked to see her chart?

Earlier this summer, my family and I were vacationing in Southwest Michigan. One day, after visiting the beach and poking around the shops in the lakeside town of South Haven, we happened on a small Italian bistro named,Tello. Being from a big city famous for its good eats, I’ll admit I wasn’t expecting much. The food was delicious. More surprising, was the service. Not only were the staff welcoming and attentive, but at the end of the meal, when I thought the time had come to pay the bill, the folder I was given contained a small PDA rather than the check. I was being asked for my feedback.Answering the questions took less than a minute and the manager, Mike Sheedy, appeared at our table within moments of my hitting the “send” button. He seemed genuinely surprised when I asked if he felt uncomfortable seeking feedback so directly. “Have you learned anything useful?” I then inquired. “Of course,” he answered immediately, “just last week a customer told us that it would be nice to have a children’s menu posted in the window alongside the standard one.” I was dumbstruck as one of the main reasons we had decided to go into the restaurant rather than others was because the children’s menu was prominently displayed in the front window!

Top Resources for Top Performers

September 28, 2009 By scottdm 1 Comment

Since the 1960’s, over 10,000 “how-to” book on psychotherapy have been published. I joke about this fact at my workshops, stating “Any field that needs ten thousand books to describe what it’s doing…surely doesn’t know what its doing!” I continue, pointing out that, “There aren’t 10,000 plus books on ‘human anatomy,’ for example. There are a handful! And the content of each is remarkably similar.” The mere existence of so many, divergent points of view makes it difficult for any practitioner to sort the proverbial “wheat from the chaff.”

Over the last 100 years or so, the field has employed three solutions to deal with the existence of so many competing theories and approaches. First, ignore the differences and continue with “business as usual”– this, in fact, is the approach thats been used for most of the history of the field. Second, force a consolidation or reduction by fiat–this, in my opinion, is what is being attempted with much of the current evidence-based practice (“specific treatments for specific disorders”) movement. And third, and finally, respect the field’s diverse nature and approaches, while attempting to understand the “DNA” common to all–said another way, identify and train clinicians in the factors common to all approaches so that they can tailor their work to their clients.

Let’s face it: option one is no longer viable. Changes in both policy and funding make clear that ignoring the problem will result in further erosion of clinical autonomy. For anyone choosing option two–either enthusistically or by inaction–I will blog later this week about developments in the United States and U.K. on the “evidence-based practice” front that I’m sure will give you pause. Finally, for those interested in movng beyond the rival factions and delivering the best clinical service to clients, I want to recommend two resources. First, Derek Truscott’s, Becoming an Effective Psychotherapist. The title says it all. Whether you are new to the field or an experienced clinician, this book will help you sort through the various and competing psychotherapy approaches and find a style that works for you and the people you work with. The second volume, is Mick Cooper’s Essential Research Findings in Counselling and Psychotherapy. What can I say about this book? It is a gem. Thorough, yet readable. Empirical in nature, but clinically relevant. When I’m out and about teaching around the globe and people ask me what to read in order to understand the empirical literature on psychotherapy, I recommend this book.

OK, enough for now. Stay tuned for further updates this week. In the meantime, I did manage to find a new technique making the rounds on the workshop circuit. Click on the video below.