scottdm's blog

Feedback Informed Treatment as Evidence-Based Practice

scottdm — Wed, 23 May 2012 17:47:26 +0000

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

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

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

Revolution in Swedish Mental Health Care: Brief Update

scottdm — Mon, 14 May 2012 19:04:27 +0000

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.

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

scottdm — Sun, 13 May 2012 19:42:13 +0000

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!”

A Handy "Little Helper" for the Outcome Rating Scale: A Freebie from the ACE Conference Committee

scottdm — Tue, 24 Apr 2012 17:00:32 +0000

This last week the planning committee for the upcoming Achieving Clinical Excellence (ACE) conference meet once again in Horsholm, Denmark. In the picture from left to right: Liz Plutt, Bill Andrews, myself, Rick Plutt (Conference Chair), and Bogdan Ion. Taking the photo was Susanne Bargmann.

The agenda for the three day event is now set: (1) one day pre-conference on feedback informed treatment (FIT); (2) two days of plenaries and presentations by an international group of clinicians, researchers, and educators.

On day one, the conference kicks off with a keynote address by the world's "expert on expertise," Dr. K. Anders Ericsson. Throughout the day, other speakers will translate Dr. Ericsson's research into practical steps for enhancing the performance of mental health professionals, agencies, and systems of care.

Day two kicks off with a keynote address by Dr. Carol Dweck addressing the question, "what barriers stand in the way of improving our effectiveness?" Once again, the rest of the day will be spent identifying solutions for the problems standing in the way of expertise and expert performance.

We still have several openings for presentations at the conference. If you have experiences or data related to: (1) measuring outcomes; (2) implementing feedback informed treatment; (3) the qualities of super effective clinicians or treatment approaches, then PLEASE click go to the ace2013amsterdam.com website and submit a description for consideration.

It'll be a fun, inspiring, and rewarding three days in Amsterdam. Don't miss it! You can register online at: www.ace2013amsterdam.com. Do it today and get the early bird special, saving you 100's of dollars!

In the meantime, click on the link below to download a handy little tool for scoring the Outcome and Session Rating Scales. It's a combination bookmark and 10 centimeter ruler.

Ace Ruler (PDF Format)

View more documents from Scott Miller.

Mental Health Practice in a Global Economy

scottdm — Tue, 17 Apr 2012 19:25:34 +0000

Did you feel it? The seismic shift that occurred in field of mental health just a little over a month ago? No? Nothing? Well, in truth, it wasn't so much a rip in the space-time continuum as a run. That "run," however, promises to forever alter the fabric of clinical practice--in particular how clinicians earn and maintain a certain standard of living.

For decades, licensing statutes have protected behavioral health professionals from competing with providers living outside of their state and local jurisdiction. In order to bill or receive reimbursement, mental health professionals needed to be licensed in the state in which treatment services were offered. Over the years, the various professional organizations have worked to make it easier for professionals to become licensed when they move from one state to the another. Still, it ain't easy and, some practitioners and professional groups would argue, for good reason. Such laws, to some extent, insure that fees charged for services are commensurate with the cost of living in the place where therapists live and work. The cost of therapy in Manhattan varies considerably, for example, depending on whether one is talking about the city located in state of New York or Kansas.

As far as outcomes are concerned, however, there is no evidence that people who pay more necessarily get better results. Indeed, as reviewed here on this blog, available evidence indicates little or no difference in outcome between highly trained (and expensive) clinicians and minimally trained (and less expensive) para-professionals and students. If the traditional
geographic (licensing) barriers were reduced or eliminated, consumers would with few exceptions gravitate to the best value for their money. In the 1980's and 90's, for example, comsumers deserted small, Main Street retailers when big box stores opened on the outskirts of town offering the same merchandise at a lower price. Now, big box retailers are closing en masse as consumers shift their purchases to less expensive, web based outlets.

And that's precisely the shift that began a little over a month ago in the field of mental health. The U.S. Military eliminated the requirement that civilian providers be licensed in the same jurisdiction or state in which treatment is offered. The new law allows care to be provided wherever the receipient of services lives and regardless of where the provider is licensed. Public announcements argued that the change was needed to make services available to service members and veterans living in isolated or rural areas where few providers may be available. Whatever the reason, the implications are profound: in the future, clinicians, like Main Street retailers, will be competing with geographically distant providers.

Just one week prior to the announcement by the U.S. Military, I posted a blogpost highlighting a recent New York Times column by author and trend watcher, Thomas Friedman. In it, I argued that "Globalization and advances in information technology were...challenging the status quo...access. At one time, being average enabled one to live an average life, live in an average neighborhood and, most importantly, earn an average living. Not so anymore. Average is now plentiful, easily accessible, and cheap. What technology can't do in either an average or better way, a younger, less-trained but equally effective provider can do for less. A variety of computer programs and web-based systems provide both psychological advice and treatment."

Truth is, the change is likely to be a boon to consumers of mental health services: easier access to services at a better price. What can clinicians do? First, begin measuring outcome. Without evidence of their effectiveness, individual providers will lose out to the least expensive provider. No matter how much people complain about "big box and internet retailers," most use them. The savings are too great to ignore.

What else can clinicians do? The advice of Friedman, which I quoted in my recent blogpost, applies, "everyone needs to find their extra--their unique value contribution that makes them stand out in whatever is their field." Measuring outcome and finding that "something special" is what the International Center for Clinical Excellence is all about. If you are not a member, please join the thousands of other professionals online today. After that, why not spend time with peers and cutting edge instructors at the upcoming "advanced intensive" or "training of trainers" workshops this summer.

The Outcome and Session Rating Scales: Support Tools

scottdm — Thu, 29 Mar 2012 23:06:05 +0000

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

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

To learn how to get the most out of the measures, be sure and download the six FIT Treatment and Training Manuals. The six manuals cover every aspect of feedback-informed practice including: empirical foundations, basic and advanced applications (including FIT in groups, couples, and with special populations), supervision, data analysis, and agency implementation. Each manual is written in clear, step-by-step, non-technical language, and is specifically designed to help practitioners and agencies integrate FIT into routine clinical practice. Indeed, the manuals were submitted as part of ICCE's application for consideration of FIT as an "evidence-based practice" to the National Registry of Evidence-Based Programs and Practices

ORS Reliable Change Chart

View more documents from Scott Miller.

Is the "Summer of Love" Over? Positive Publication Bias Plagues Pharmaceutical Research

scottdm — Tue, 27 Mar 2012 15:22:22 +0000

Evidence-based practice is only as good as the available "evidence"--and on this subject, research points to a continuing problem with both the methodology and type of studies that make it into the professional literature. Last week, PloS Medicine, a peer-reviewed, open access journal of the Public Library of Science, published a study showing a positive publication bias in research on so-called atypical antipsychotic drugs. In comparing articles appearing in journals to the FDA database, researchers found that almost all postive studies were published while clinical trials with negative or questionable results were not or--and get this--were published as having positive results!

Not long ago, similar yet stronger results appeared in the same journal on anti-depressants. Again, in a comparison with the FDA registry, researchers found all postive studies were published while clinical trials with negative or questionable results were not or--and get this--were published as having positive results! The problem is far from insignificant. Indeed, a staggering 46% of studies with negative results were not published or published but reported as positive.

Maybe the "summer of love" is finally over for the field and broader American public. Today's Chicago Tribune has a story by Kate Kelland and Ben Hirschler reporting data about sagging sales of anti-depressants and multiple failures to bring new, "more effective" drug therapies to market. Taken together, robust placebo effects, the FDA mandate to list all trials (positive and negative), and an emphasis in research on conducting fair comparisons (e.g., comparing any new "products" to existing ones) make claims about "new and improved" effectiveness challenging.

Still one sees ads on TV making claims about the biological basis of depression--the so called, "biochemical imbalance." Perhaps this explains why a recent study of Medicaid clients found that costs of treating depression rose by 30% over the last decade while the outcomes did not improve at all during the same period. The cause for the rise in costs? Increased use of psychiatric drugs--in particular, anti-psychotics in cases of depression.

"It's a great time for brain science, but at the same time a poor time for drug discovery for brain disorders," says David Nutt, professor of neuropsychopharmacology, cited in the Chicago Tribune, "That's an amazing paradox which we need to do something about."

Here's an idea: how about not assuming that problems in living are reduceable to brain chemistry? That the direction of causality for much of what ails people is not brain to behavior but perhaps behavior to brain? On this note, it is sad to note that while the percentage of clients prescribed drugs rose from 81 to 87%--with no improvement in effect--the number of those receiving psychotherapy dropped from 57 to 38%.

Here's what we know about psychotherapy: it works and it has a far less troublesome side effect profile than psychotropic drugs. No warnings needed for dry mouth, dizziness, blood and liver problems, or sexual dysfunction. The time has come to get over the collective 1960's delusion of better living through chemistry.

A Progress Report on the Science (and Art ) of Psychotherapy: The Psychotherapy Networker 30th Anniversary Edition

scottdm — Sun, 18 Mar 2012 13:40:09 +0000

The 30th Anniversary Edition of the Psychotherapy Networker has hit newsstands. In it, is an article by Diane Cole taking the measure of psychotherapy. Her question? Has the field gotten any better over the last three decades? The entire issue is a "must read," starting with editor Rich Simon's lengthy and thought provoking editorial, "Still Crazy After All These Years."

Even if you are not a subscriber, much of the current edition is available FOR FREE online at the Networker website. It is an honor that the work that I have been doing on excellence and expert performance, together with many Senior Associates at ICCE (Susanne Bargman, Cynthia Maeschalck, Julie Tilsen, Rob Axsen, Jason Seidel, and Bob Bertolino) is featured prominently in this special issue magazine.

Don't miss it! And don't miss the Networker conference scheduled this week in Washington, D.C. I'll be there on Friday delivering the luncheon keynote address and a workshop on pushing your clinical performance to the next level of effectiveness!

NEWSFLASH: The Advanced Intensive and Training of Trainers in Feedback Informed Therapy (FIT)

scottdm — Sat, 17 Mar 2012 21:59:23 +0000

Dateline: March 17th, 2012, Chicago, Illinois USA

Barely a month ago, I announced the addition of a second "Advanced Intensive" (AI) course in Feedback Informed Treatment (FIT). The original March training filled really early this year and a long waiting list formed. Now the second Advanced Intensive training in FIT scheduled for July 30th through August 1st is nearly full. Register now and you can still receive the early bird price. Additionally, we're offering a super special discount for people attending both the AI and the ICCE Training of Trainers. Don't wait though, only a handful of spaces remain. If you would like to attend both courses, drop me an email straight away and I'll send you the special registration code.

We look forward to meeting everyone attending the AI this week. Stay tuned for tweets and video from the training.

The Achieving Clinical Excellence Conference CALL FOR PAPERS

scottdm — Tue, 13 Mar 2012 13:04:20 +0000

In October 2010, the first annual "Achieving Clinical Excellence" was held in Kansas City, Missouri. A capacity crowd joined leading experts on the subject of top performance for three days worth of training and inspiration. K. Anders Ericsson reviewed his groundbreaking research, popularized by Malcolm Gladwell and others. ICCE Director, Scott D. Miller translated the research into speciific steps for improving clinical performance. Finally, classical piansts David Helfgott, Rachel Hsu, and Roger Chen, demonstrated what can be accomplished when such evidence-based strategies are applied to the process of learning specific skills.

The ICCE is proud to announce the 2nd "ACE" conference to be held May 16th-18th, 2013 in Amsterdam, Holland. Join us for three educational, inspiring, and fun-filled days. Register online today and receive a significant "Early Bird" discount. The ACE conference committee is also issuing an international "Call for Papers." If you, your agency, or practice are committed to excellence, using outcomes to inform practice, or have published research on the subject, please visit the conference website to submit a proposal.

Here's what attendees said about the last event: