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The Revolution in Swedish Mental Health Services: UPDATE on the CBT Monopoly

April 5, 2013 By scottdm Leave a Comment

No blogpost I’ve ever published received the amount of attention as the one on May 13th, 2012 detailing changes to Swedish Mental Health practice.  At the time, I reported about research results showing that the massive investment of resources in training therapists in CBT had not translated into improved outcomes or efficiency in the treatment of people with depression and anxiety.  In short, the public experiment of limiting training and treatment to so called, “evidence-based methods” had failed to produce tangible results.  The findings generated publications in Swedish journals as merited commentary in Swedish newspapers and on the radio.

I promised to keep people updated if and when research became available in languages other than Swedish.  This week, the journal Psychotherapy, published an article comparing outcomes of three different treatment approaches, including CBT, psychodynamic, and integrative-eclectic psychotherapy.  Spanning a three year period, the results gathered at 13 outpatient clinics, found that psychotherapy was remarkably effective regardless of the type of treatment offered!  Read the study yourself and then ask yourself: when will a simpler, less expensive, and more client-centered approach to insuring effective and efficient behavioral health services be adopted?  Routinely seeking feedback from consumers regarding the process and outcome of care provides such an alternative.  The failure to find evidence that adopting specific models for specific disorders improves outcomes indicates the time has come.  You can learn more about feedback-informed treatment (FIT), a practice recently designed “evidence-based” by the Substance Abuse and Mental Health Services Administration (SAMHSA), by visiting the International Center for Clinical Excellence web-based community or attending an upcoming training with me in Chicago or on the road.

  • Learn more about what is going on in Sweden by reading:

Everyday evidence outcomes of psychotherapies in swedish public health services (psychotherapy werbart et al 2013)

  • Here’s one additional reference for those of you who read Swedish.  It’s the official summary of the results from the study that started this entire thread:
Delrapport ii slutversion

Filed Under: Practice Based Evidence Tagged With: CBT, evidence based practice, ors, outcome rating scale, psychotherapy, session rating scale, srs, sweden

Resources on Feedback-Informed Treatment, Training, & Research

January 24, 2013 By scottdm Leave a Comment

Last week, I spent a day in London working with the clinical staff of the Hertfordshire Partnership NHS Foundation Trust.  The subject?  Feedback, of course!  As soon as I stepped off my transcontinental flight, I knew it was going to be a fun day.  Every way I turned at the Heathrow airport I was greeted by a machine asking for feedback about my experience: after exiting customs, at the baggage claim area, at the duty free shops.  Amazing!

The process was as engaging as it was efficient.  Tell us about your experience…by pressing a button bearing one of four different faces.  The similarity to the ICCE Young Child Outcome Rating Scale was striking (to say the least).  I felt compelled to register my feedback at every opportunity.

From London, I travelled to Gotheburg, Sweden for the first Scandanavian Advanced Intensive Training in Feedack Informed Treatment.  The event, organized by GCK, Gothenburg’s Center for Competence Development, sold out in a week with participants coming from all over Scandanavia.  I taught the course together with ICCE Senior Associate Susanne Bargmann using a curriculum based on the FIT Treatment and Training Manuals.  The series was developed to support, in part, ICCE’s application to the US Substance Abuse and Mental Health Services Administration (SAMSHA) for designation of FIT as an evidence-based practice.  Together with the Training of Trainers (TOT) and Supervision Intensive workshops, the manuals and Advanced Intensive training provides participants with the latest, cutting-edge, evidence-based information and skills in FIT.

Back in October, I blogged about an article that reviewed the evidence regarding psychotherapy training.   In it, the author John Malouff concluded, “There appears to be no evidence that coursework and research completion…have any value to future psychotherapy clients…”.  He continued, “Training programs…carry the responsibility to show that the training they provide have positive benefits for future clients.”

Well…on that score, learning FIT, available evidence shows, leads to direct benefits to consumers of behavioral health services.  Together with New Zealand based psychologist and ICCE Senior Associate Eeuwe Schuckard, I’ve updated the review of the research supporting FIT practice (click here).

Don’t wait to learn about or deepen your understanding of and skills in feedback informed treatment.  The Advanced Intensive scheduled for March 18-321st has a few spots left.  You can register online by clicking here.

By the way, shortly after the publication of Malouff’s review in Psychotherapy in Australia, I wrote to the editor, Liz Sheehan, and asked for permission to reprint the article.  Click here to read it.

Filed Under: Conferences and Training Tagged With: feedback informed treatment, icce, New Zealand, NHS, sweden

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.

Filed Under: evidence-based practice, Top Performance Tagged With: denmark, Germany, holland, icce, psychotherapy networker, randomized clinical trial, sweden, Thomas Friedman

More from Sweden

June 4, 2012 By scottdm Leave a Comment

sweden-mapThree short weeks ago, I was in Stockholm, Sweden talking about “what works” in clinical practice.  As I announced at the time, my visit coincided with an announcement by the organization governing mental health practice in the country.  For the better part of a decade, CBT enjoyed near exclusive status as “evidence-based.”  Indeed, payment for training of clinicians and treatment of clients in other approaches disappeared as over two billion Swedish crowns were spent on in CBT. 

The result? The widespread adoption of the method had no effect whatsoever on the outcome of people disabled by depression and anxiety.  The conclusion?  Guidelines for clinical practice were reviewed and expanded.  Research on feedback is in full swing in the largest randomized clinical trial on FIT in history.

More news…

Today, I received notice from Swedish clinician and publisher, Bengt Weine, that my article, “The Road to Mastery” (written together with my long friend and collaborator, Mark A. Hubble, Ph.D.), had been translated into Swedish and accepted for publication in SFT, the Swedish Family Therapy journal.  If you understand the language, click here to access a copy.

Helping clinicians and agencies along the “road to mastery” is what the upcoming Advanced Intensive and Training of Trainers events are all about.  Join colleagues from around the globe for these fun, intense days of training in Chicago.

Filed Under: Conferences and Training Tagged With: CBT, continuing education, FIT, holland, mark hubble, sweden

Revolution in Swedish Mental Health Care: Brief Update

May 14, 2012 By scottdm 1 Comment

In April 2010, I blogged about Jan Larsson, a Swedish clinician who works with people on the margins of the mental health system.  Jan was dedicated to seeking feedback, using the ORS and SRS to tailor services to the individuals he met.  It wasn’t easy.  Unilke most, he did not meet his clients in an office or agency setting.  Rather, he met them where they were: in the park, on the streets, and in their one room aparments.  Critically, wherever they met, Jan had them complete the two measures–“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! I’ve been following his creative application of the scales ever since.

Not surprisingly, Jan was on top of the story I blogged about yesterday regarding changes in the guidelines governing Swedish mental health care practice.  He emailed me as I was writing my post, including the link to the Swedish Radio program about the changes.  Today, he emailed again, sending along links to stories appearing in two Swedish newspapers: Dagens Nyheter and Goteborg Posten.

Thanks Jan!

And to everyone else, please continue to send any new links, videos, and comments.

Filed Under: behavioral health, excellence, Feedback Informed Treatment - FIT, Top Performance Tagged With: continuing education, Dagens Nyheter, evidence based practice, Goteborg Posten, icce, ors, outcome rating scale, session rating scale, srs, sweden

Revolution in Swedish Mental Health Practice: The Cognitive Behavioral Therapy Monopoly Gives Way

May 13, 2012 By scottdm 34 Comments

Sunday, May 13th, 2012
Arlanda Airport, Sweden

Over the last decade, Sweden, like most Western countries, embraced the call for “evidence-based practice.”  Socialstyrelsen, the country’s National Board of Health and Welfare, developed and disseminated a set of guidelines (“riktlinger”) for mental health practice.  Topping the list of methods was, not surprisingly, cognitive-behavioral therapy. 

The Swedish State took the list seriously, restricting payment for training of clinicians and treatment of clients to cognitive behavioral methods.  In the last three years, a billion Swedish crowns were spent on training clinicians in CBT.  Another billion was spent on providing CBT to people with diagnoses of depression and anxiety.  No funding was provided for training or treatment in other methods. 

The State’s motives were pure: use the best methods to decrease the number of people who become disabled as result of depression and anxiety.  Like other countries, the percentage of people in Sweden who exit the work force and draw disability pensions has increased dramatically.  As a result, costs skyrocketed.  Even more troubling, far too many became permanently disabled. 

The solution?  Identify methods which have scientific support, or what some called, “evidence-based practice.” The result?  Despite substantial evidence that all methods work equally well, CBT became the treatment of choice throughout the country.  In point of fact, CBT became the only choice.

As noted above, Sweden is not alone in embracing practice guidelines.  The U.K. and U.S. have charted similar paths, as have many professional organizations.  Indeed, the American Psychological Association has now resurrected its plan to develop and disseminate a series of guidelines advocating specific treatments for specific disorders.  Earlier efforts by Division 12 (“Clinical Psychology”) met with resistance from the general membership as well as scientists who pointed to the lack of evidence for differential effectiveness among treatment approaches. 

Perhaps APA and other countries can learn from Sweden’s experience.  The latest issue of Socionomen, the official journal for Swedish social workers, reported the results of the government’s two billion Swedish crown investment in CBT.  The widespread adoption of the method has had no effect whatsoever on the outcome of people disabled by depression and anxiety.  Moreover, a significant number of people who were not disabled at the time they were treated with CBT became disabled, costing the government an additional one billion Swedish crowns.  Finally, nearly a quarter of those who started treatment, dropped out, costing an additional 340 million!

In sum, billions training therapists in and treating clients with CBT to little or no effect.  

Since the publication of Escape from Babel in 1995, my colleagues and I at the International Center for Clinical Excellence have gathered, summarized, published, and taught about research documenting little or no difference in outcome between treatment approaches.  All approaches worked about equally well, we argued, suggesting that efforts to identify specific approaches for specific psychiatric diagnoses were a waste of precious time and resources.  We made the same argument, citing volumes of research in two editions of The Heart and Soul of Change.

Yesterday, I presented at Psykoterapi Mässan, the country’s largest free-standing mental health conference.  As I have on previous visits, I talked about “what works” in behavioral health, highlighting data documenting that the focus of care should shift away from treatment model and technique, focusing instead on tailoring services to the individual client via ongoing measurement and feedback.  My colleague and co-author, Bruce Wampold had been in the country a month or so before singing the same tune.

One thing about Sweden:  the country takes data seriously.  As I sat down this morning to eat breakfast at the home of my long-time Swedish friend, Gunnar Lindfeldt, the newscaster announced on the radio that Socialstyrelsen had officially decided to end the CBT monopoly (listen here).  The experiment had failed.  To be helped, people must have a choice. 

“What have we learned?” Rolf Holmqvist asks in Socionomen, “Treatment works…at the same time, we have the possibility of exploring…new perspectives.  First, getting feedback during treatment…taking direction from the patient at every session while also tracking progress and the development of the therapeutic relationship!”

“Precis,” (exactly) my friend Gunnar said. 

And, as readers of my blog know, using the best evidence, informed by clients’ preferences and ongoing monitoring of progress and alliance is evidence-based practice.  However the concept ever got translated into creating lists of preferred treatment is anyone’s guess and, now, unimportant.  Time to move forward.  The challenge ahead is helping practitioners learn to integrate client feedback into care—and here, Sweden is leading the way.

“Skål Sverige!”

Filed Under: Behavioral Health, evidence-based practice, Feedback Informed Treatment - FIT, Practice Based Evidence Tagged With: CBG, continuing education, evidence based practice, icce, Socialstyrelsen, sweden

Feedback informed treatment (FIT) takes center stage in Sweden

November 23, 2010 By scottdm Leave a Comment

Just sweden-mapa short entry to highlight recent developments in Sweden…

On November 17th and 18th, over 500 politicians, agency directors, and service managers gathered together to discuss “the future of alcohol and drug treatment” in Sweden.  High on the agenda?  Feedback Informed Treatment!

Psychologist and ICCE Associate, Gun-Eva Langdahl and the rest of the talented crew at Radgivingen Oden, were featured in a video documenting the impact of feedback on retention and outcome of drug and alcohol treatment services.

You may recall, last spring I was on my way to visit this talented group of practitioners when the volcano in Iceland erupted, forcing me to take a long and complicated series of “trains, buses, and automobiles” to get to the beautiful, northern Swedish town of Skelleftea.

Anyway, thanks to the work of the team, the town and surrounding area are something of a hotbed of feedback informed treatment.  For those practitioners, policy makers, and agency directors living and working in Scandinavia, the professionally produced video provides an excellent introduction to the process and benefits of feedback informed work.  You can also read about the work in a feature article that appeared in the daily newspaper, Folkbladet.

In the meantime, take a look at these videos where Gun-Eva Langdahl explains both why clinicians should begin seeking feedback from their clients as well as how to get started.

Filed Under: Feedback Informed Treatment - FIT Tagged With: addiction, icce, sweden

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.

Filed Under: Behavioral Health, Feedback Informed Treatment - FIT Tagged With: evidence based practice, Hypertension, Jan Blomqvist, ors, outcome rating scale, Pharmacology, psychotherapy, randomized clinical trial, recovery model, session rating scale, srs, sweden, Training

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

Filed Under: Drug and Alcohol, evidence-based practice, Feedback, Feedback Informed Treatment - FIT Tagged With: addiction, behavioral health, brief therapy, cdoi, continuing education, evidence based practice, icce, Jan Blomqvist, ors, post traumatic stress, randomized clinical trial, SORAD, srs, sweden

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