My how time flies!  Nearly three weeks have passed since hundreds of clinicians, researchers, and educators met in Amsterdam, Holland for the 2013 “Achieving Clinical Excellence.”  Participants came from around the globe–Holland, the US, Germany, Denmark, Italy, Russia, Norway, Sweden, Denmark, New Zealand, Romania, Australia, France–for three days of presentations on improving the quality and outcome of behavioral healthcare.  Suffice it to say, we had a blast!

The conference organizers, Dr. Liz Pluut and Danish psychologist Susanne Bargmann did a fantastic job planning the event, organizing a beautiful venue (the same building where the plans for New York City were drafted back in the 17th century), coordinating speakers (36 from around the globe), arranging meals, hotel rooms, and handouts.

Dr. Pluut opened the conference and introduced the opening plenary speaker, Dr. K. Anders Ericsson, the world’s leading researcher and “expert on expertise.”  Virtually all of the work being done by me and my colleagues at the ICCE on the study of excellence and expertise among therapists is based on the three decades of pioneering work done by Dr. Ericsson.  You can read about our work, of course, in several recent articles: Supershrinks, The Road to Mastery, or the latest The Outcome of Psychotherapy: Past, Present and Future (which appeared in the 50th anniversary edition of the journal, Psychotherapy).

Over the next several weeks, I’ll be posting summaries and videos of many of the presentations, including Dr. Ericsson.  One key aspect of his work is the idea of “Deliberate Practice.”  Each of the afternoon sessions on the first day focused on this important topic, describing how clinicians, agency managers, and systems of care can apply it to improve their skills and outcome.

The first of these presentations was by psychologist Birgit Valla–the leader of Family Help, a mental health agency in Stange, Norway–entitled, “Unreflectingly Bad or Deliberately Good: Deciding the Future of Mental Health Services.”  Grab a cup of coffee and listen in…

Oh, yeah…while on the subject of excellence, here’s an interview that just appeared in the latest issue of the UK’s Therapy Today magazine:

Almost a year ago, I blogged about results from field trials of the soon-to-be-released, fifth edition of the Diagnostic and Statistical Manual of Mental Disorders.  Turns out, many of the diagnoses in the “new and improved” version were simply unreliable.  In fact, the likelihood of two clinicians, applying the same criteria to assess the same person for the two most common mental health conditions—anxiety and depression—and agreeing, was worse than it was with DSM IV, the ICD-10, or the DSM-III!

The question of validity, that is how well the diagnoses relate to real world phenomena, has never been addressed empirically in any edition.  Essentially, DSM is a collection of symptom clusters, not too dissimilar from categorizing people according to the four humours—and, it turns out, about as helpful in determining the appropriate or likely outcome of any treatment provided.

Despite these serious shortcomings, the volume exerted tremendous power and influence over research and practice for the last three decades.  Nearly all graduate programs teach it, research is organized around its content, and insurance companies and payers (including the Federal government) demand it for reimbursement.  In short, everyone acted “as if” it were true—that is, until last week when NIMH Director, Thomas Insel, announced the organization was abandoning the DSM.  As if having woken up from a thirty-year- nap the reason given was the volume’s lack of validity!  Really?

The day the announcement was made, I received a bunch of emails.   Most of the writers were elated.  They knew I’d been critical of the volume for many years.  “Finally,” one said, “a return to sanity.”  My response?  Not so fast.

To begin, DSM is not going away any time soon.  Sorry, but if you want to be paid, keep your trusty copy nearby.

More troubling— if you read the fine print—NIMH is promising a better system, based on “a new idea everyone should welcome.”   Just what is that idea?   Mental health problems are biological in origin.  To achieve better outcomes, NIMH funded researchers need to map the “cognitive, circuit, and genetic aspects of mental disorders” so as to identify “new and better targets for treatment.”  Insel calls it, “precision medicine.”

Now, I don’t know about you, but the new idea sounds a heck of a lot like the old one to me!  Psychiatry’s biological bandwagon blew into town last century and has been playing the same tune ever since.  Remember the “dexamethasone suppression test” for differentiating endogenous from non-endogenous depression?  How about the claims made about Xanax in the treatment of panic or the “new” anti-psychotics?   There’s always prefrontal lobotomy which like the DSM, proponents continued to use and promote long after its lack of efficacy and brain disabling side effects were known.  Heck, the originator won a Nobel Prize!

As far the promise of something better is concerned, history should chasten any hope one might feel.  Honestly, when was the last time the field failed to claim significant progress was being made?  Each new treatment approach is pitched as a vast improvement over “old ideas.”  CBT is better than psychodynamic,   specific is better than eclectic, evidence-based treatments are better than routine clinical practice, and so on—except none of these widely promulgated notions holds empirical water.

If “news” = new + different, then the NIMH announcement, like so much of what you find on TV and other social media, is definitely not news.  It’s more of the same.  Precision medicine in mental health is: 90% promise + 10% hyperbole, or marketing.

Here are a couple of newsworthy facts with immediate implications for mental health policy, practice, and research:

1. Treatment works.  Evidence gathered over the last four decades documents that people who receive therapy are better off than 80% of those (with the same problem or concern) as those without the benefit of treatment.
2. A majority of potential consumers (78%) cite “lack of confidence” in the outcome of treatment as a barrier to seeking help from a mental health professional.
3. Tracking a consumer’s engagement and progress during treatment enables clinicians to tailor services to the individual, resulting in lower costs, fewer drop outs, and as much as three times the effects!

Just a thought—if we really want to step into the future, rather than geneticists, neurologists, and radiologists perhaps the field could start by listening to consumers.  That’s exactly the point Ernesto Sirolli made at a recent TED talk.  If you haven’t seen it, here it is:

This week, my colleague and friend, Dr. David Mee-Lee, sent me a link to a blogpost written by Don Kuhl.  Actually, I was already a subscriber to Don’s Minful MIDweek blog (you should be too), but my travel this week had prevented me from reading his latest installment.  His posts always leave me inspired and give me something to think about.  This week was no different.  More on that in a moment.

In the meantime, let me tell you about Don.  He is the founder and CEO of The Change Companies, a company whose mission is to create tailored materials and programs to support behavioral change for special populatons.  And create they do.  Hundreds of bright, attractive, highly readable publications and guided workbooks for use by professionals and the people they serve.  Their material is exhaustive and comprehensive, including adult behavioral health, criminal justice, education and prevention, clinical assessment, and faith-based programs.  A side note, it was Don and his skillful team at The Change Companies that produced the ICCE Feedback Informed Treatment and Training Manuals.  If you’ve not seen them, you should.  They are the cutting edge of information about FIT.

What is most striking about Don, however, is his passion.  I met him at a conference in San Francisco nearly a decade ago.  On several occasions, he flew to Chicago from his home base in Carson City, Nevada just to meet, talk, and share ideas.  The photo above is from one of the meetings he arranged.  Don is devoted to improving the quality and experience of behavioral health services for professionals and clients alike.  Simply said, Don Kuhl is cool.

In his blogpost this week, Don wrote about that meeting with Jim Prochaska, David Mee-Lee, me, and Bill Miller.  He referred to it as a ”highlight” of his recent professional life, a lucky event resulting from his mindful pursuit of relationships with “people who have smiles on their faces and goodness in their hearts.”

My thought?  I was and am the lucky one.  Thanks Don.  Thanks Change Companies.  Keep up the good work.

Evidence-based practice (EBP).  What is it?  Take a look at the graphic above.  According to American Psychological Association and the Institute of Medicine, there are three components: (1) the best evidence; in combination with (2) individual clinical expertise; and consistent with (3) patient values and expectations.  Said another way, EBP is a verb.  Why then do so many treat it as a noun, continually linking the expression to the use of specific treatment approaches?  As just one example, check out guidelines published for the treatment of people with PTSD by the National Institute for Clinical Excellence (NICE)–the U.K.’s equivalent to the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA).  Despite the above noted definition, and the lack of evidence favoring one treatment over another, the NICE equates EBP with the use of specific treatment approaches and boldly recommends certain methods over others.

Not long ago, ICCE Senior Associate, and U.K.-based researcher and clinician, Bill Andrews, addressed the problems with the guidelines in a presentation to an audience of British practitioners.  He not only addresses the inconsistent use of the term, evidence-based practice, in the development of guidelines by governing bodies but also the actual research on PTSD.  After watching the clip, take some time to review the articles assembled below, which Bill cites during his presentation.  The main point here is that clinicians need not be afraid of EBP.  Instead, they need to insist that leaders and officials stick to the stated definition–a definition I’m perfectly content to live with mas are most practitioners I meet.  To wit, know what the evidence says “works,” use my expertise to translate such findings into practices that fit with the values, preferences, and expectations of the individual consumers I treat.

Here’s the Meta-analysis that started it all:

Benish Et Al 08a from Scott Miller

Here’s the response to the Benish Meta-analysis written by proponents of the NICE guideliness:

Ehlers et al. 2010 Critique of Benish from Scott Miller

Here’s the response to the Ehler’s et al. critique:

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.

All right.  So what caught your attention?  If you’re like most people–including me–you probably found yourself staring at the food stuck in the teeth of the men in all three images.  If so, the ad achieved its purpose.  Take a look at the pictures one more time.  In the first, the woman has one too many fingers on her left hand.  The second image has a “phamtom arm” around the man’s shoulder.  Can you see the issue in the third?

The anomalies in the photos are far from minor!  And yet, most of us, captured by the what initially catches our eye, miss them.

Looking beyond the obvious is what Feedback Informed Treatment (FIT) is all about.  Truth is, much of the time therapy works.  What we do pay attention to gets results–except when it doesn’t!  At those times, two things must happen: (1) we have to know when what we usually do isn’t working with a given person; and (2) look beyond the obvious and see a bigger picture.  Doing this takes effort and support.    What can you do?

1. Download two free, brief, simple to use tools for tracking outcome and engagement in care (the ORS and SRS) and begin using them in your work;

2. Join the International Center for Clinical Excellence, the world’s largest, free, online, non-denominational organization of behavioral health professionals;

3. Read the six cutting-edge treatment and training manuals on feedback-informed treatment–a series which helped earn FIT the highest ratings from the Substance Abuse and Mental Health Services Administration (SAMHSA);

4. Attend a training in Chicago or abroad.

“Could we talk?” she wanted to know.  After sorting the time difference between New Zealand and Chicago and working around my crazy travel schedule, we connected via Skype.  I learned that her interest in the subject of treatment outcome began when she heard fellow kiwi, and counselor, Steve Taylor, being interviewed on radio about the effectiveness of Social Services.

Over the last few years, Steve had given a number of such interviews, pointedly criticizing the system for failing to measure results.  Time and again, he highlighted popular programs for which there was either no empirical support or which the available evidence indicated did not work.

These gibes did not go unnoticed.  Once he was anonymously attacked on air while commenting on Family Court outcomes in New Zealand.  Throughout, Steve stuck to his stance, using research to make his point, arguing that providers and systems of care needed to produce evidence of real outcomes via the use of routine outcome measurement.

The article Donna wrote appeared in print this week, entitled, “Counselling: Cure or Con?”  Provocative and well-written, the piece puts “Feedback-Informed Treatment (FIT) front and center, concluding that “a profession whose practitioners spend their days analysing others, its about time they started examining themselves.”  It also provides practical, research-based advice for anyone thinking about seeing a therapist.  Anyway, read it for yourself:

February 2, 2013
Chicago, Illinois USA

I am honored to announce that Feedback-Informed Treatment (FIT) has been added to SAMSHA’s official database of evidence-based practices (EBP) known as NREPP (the National Registry of Evidence-based Programs and Practices).  Briefly, NREPP is a searchable online registry of behavioral health interventions that have been reviewed and rated by independent reviewers.  The purpose of the registry is to assist the public, payers, and practitioners in identifying approaches that have both empirical support and materials available to facilitate implementation.

The Institute of Medicine and American Psychological Association define EBP as, “the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences (see American Psychologist, May 2006).  The principles and practices of feedback-informed treatment (FIT) are not only consistent with but provide practitioners with a simple and practical method for operationalizing EBP in their daily work.  To wit, routinely and formally soliciting feedback from consumers regarding the therapeutic alliance and outcome of care and using the resulting information to inform and tailor service delivery.  As reviewed many times on this blog, multiple, carefully-controlled, randomized clinical trials document that FIT improves outcomes while simultaneously decreasing the risk of drop out and deterioration in care.

Scientific evidence is one matter; being able to support practitioners, agencies, and systems of care in implementing an EBP is another.  On this subject, I am proud to say that FIT received perfect ratings (see, “Readiness for Dissemination” tab).  Unlike other similar approaches, “no weaknesses” were identified by reviewers.  Instead, the summary noted, “ICCE…has an array of comprehensive, well-organized, and high-quality materials to support…implementation…The steps for successful implementation are clear and accompanied by tools and guidance to support the entire process, from the determination of organizations readiness through evaluation.”

Such high marks would not been possible without the contribution of ICCE Senior Associates who worked tirelessly to create the materials and complete the application.   A big thanks to Jason Seidel, Psy.D., Bob Bertolino, Ph.D., Susanne Bargmann, Cynthia Maeschalck, Rox Axsen, Bill Robinson, Robbie Babbins-Wagner, Ph.D., and Julie Tilsen, Ph.D..

The formal recognition of FIT as an EBP is a watershed moment in the history of the International Center for Clinical Excellence, further enabling the organization to achieve it’s mission of improving the quality and outcome of behavioral health services.

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.  Here it is:

Measures and feedback 2013 [compatibility mode] from Scott Miller

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 here.  You will find it below:

Overconfidence.  It’s a problem that leads to systematic errors in judgement.   Long thought to arise out of hubris or the corrupting effects of the emotion, the evidence actually shows it to be built into humans’ evolved cognitive machinery.  Existimo ergo certus sum (I think, therefore I am…certain).

Behavioral health professionals are not immune.  A recently published study by Walfish, McAlister, O’Donnell, and Lambert (2012) asked clinicians how their effectiveness rates compared to other professionals.  Turns out, clinicians, on average, believed their results were better than 80% of their peers.  Not a single practitioner surveyed viewed themselves as below average and a full quarter (25%) thought they fell at the 90th percentile or higher in skill level and effectiveness!

It’s true that we are not alone in this tendency.  As indicated above, it’s how our brains work.  The typical driver, for example, believes themselves to be better than 80% of others on the road.  University professors, it appears, suffer from the most inflated levels of self-esteem, ranking themselves at the 94th percentile on average.

When it comes to learning, the consequences are significant.  Why change, after all, if you’re already pretty darn good and if the real problem is obvious: other drivers, poor students, etc., difficult life circumstances or the complex nature of some mental disorders?

Researchers have discovered a relatively simple solution to overconfidence: frowning.  That’s right.  Turning that smile upside down short circuits our reptilian wiring, making us more analytical and vigilant in our thinking, in the process enabling us to “question stories that we would otherwise unreflectively accept as true because they are facile and coherent” ( Holt, 2011).

What else can clinicians do?  Do something to gain perspective.  Take on another, divergent point of view, for example.  Practically speaking, scan rather than fix your gaze.  Literally, move your eyes.

Everyone has heard of “tunnel vision.”  Turns out, despite pledges to remain open and flexible, it ain’t so easy.  If you don’t agree, try a little experiment.    Fix your eyes on the flashing red and/or green dot at the center of the graphic and notice what happens to the surrounding yellow ones.  Be patient if the image hasn’t loaded.  It can take a minute or two.

They either blinked on and off or disappeared completely.  Interesting enough but here’s what’s really strange: the yellow dots actually never disappear.  They are always there despite what you see.  And no, the computer did not scan your visual field and cause the yellow dots to blink.  Neither is this an optical illusion.  Once again, it’s the way we are wired.  We think we are seeing everything…but we are not.  The result: overconfidence.  It’s why, following an automobile accident, people will say, “the other driver came out of nowhere.”  It’s why surgeons leave sponges inside their patients or miss seeing bleeds or small nicks of the scalpel.  It’s also why behavioral health practitioners routinely fail to detect deterioration and people at risk for dropping out of services (Hannan, et al. 2005).

Now, look again.  This time, however, shift your eyes about while watching the flashing dot in the center.  In other words, don’t fix your gaze.  If that doesn’t change what you see, then step back from the image and view it from a distance.  There, see!  The yellow dots are present the entire time.

Helping busy practitioners step back, shift their gaze, and otherwise improve their critical faculties and skills is the mission of ICCE.  Members connect, learn from, and share with the largest online community of mental health professionals in the world.  Thousands of members, hundreds of discussion forums, a massive and every growing library of research and other supportive documents, and how-to videos are available for free 24-7-365.

Many of the members and associates will be meeting in Amsterdam, Holland for the Achieving Clinical Excellence conference on May 16-18th.  Conference coordinator, Liz Pluut, has organized an line-up of international speakers, researchers, and practitioners that is guaranteed to push your clinical performance to the next level!  Participants are coming from all over Europe, the US, Canada, Asia, Australia, and more.  Don’t wait to register.  Space is limited and the response has been amazing.

OK, here’s something fun.  Take a look at the video below.  Oh yeah, make sure you smile and keep your eyes fixed on my hands!