Top Performance Blog

Greg Neimeyer, Ph.D., is causing quite a stir in continuing education circles.  What has he done?  In several scholarly publications, he’s reviewed the existing empirical literature and found that continuing professional education in heavioral health is not particularly, well, …educational.  Indeed, in a soon-to-be published piece in the APA journal, Professional Psychology, he notes, "While the majority of studies report high levels of

participants’ satisfaction with their CE experiences, little attention has been paid to assessing actual levels of learning, the translation of learning into practice, or the impact of CE on actual professional service delivery outcomes."   Neimeyer then goes on to cite a scholarly review published in 2002 by Daniels and Walter which pointed out that "a search [of the research literature] revealed no controlled studies of the impact of continuing education in the…behavioral health disciplines" (p. 368).  Said another way, the near ubiguitous mandate that clinicians attend so many hours per year of approved "CE" events in order to further their knowledge and skill base has no empirical support.

Personally, my guess is that any study that might be done on CE in Behavioral Health would show little or no impact on performance anyway.  Why?  Studies in other fields (i.e., medicine, flight training) have long documented that traditional CE activities (i.e., attending conferences, lectures, reading articles) have no demonstrable effect. So, what does work?  The same research that calls the efficacy of current CE activities into questions provide clear guidance: namely, brief, circumscribed, skill-based training, followed by observed practice, real-time feedback, and performance measurement. Such characteristics are, in fact, part and parcel of expert performance in any field.  And yet, it is virutally non-existent in behavioral health.

Let me give you an example of a CE offering that arrived in my box just this week.  The oversized, multi-color, tri-fold brochure boldly asserts a workshop on CBT featuring the "top evidence-based techniques."  Momentarily setting aside the absolute lack of evidence in support of such trainings, consider the promised content–and I’m not kidding: clinical applications of cognitive behavior therapy, motivational interviewing, cognitive therapy, mindfulness and acceptance based therapies, and behavior therapy.  As if that were not enough, the outline for the training indicates that participants will learn 52 other bulleted points, including but not limited to: why CBT, integration of skills intro practice, identify brain-based CBT strategies, latest research on CBT, the stages of change, open-ended and reflective listening, behavioral activiation, acceptance and commitment, emotional regulation and distrss tolerance skills, the ABC technique to promote rational beliefs, homework assignments that test core beliefs, rescripting techniques for disturbing memories and images…and so on…AND ALL IN A SINGLE 6 HOUR DAY!  You say you have no money? Your agency has suffered budget cuts?  No worries, the ad states in giant print, as the same content is available via CD, web and podcast. 

Such an agenda defies not only the evidence but strains credulity to the breaking point.  Could anyone accomplish so much in so little time?  Clinicians deserve and should demand more from the CE events they register for and, in many instances, are mandated to attend in order to maintain licensure and certification.  The International Center for Clinical Excellence web platform will soon be launched.  The mission of the site, as indicated in my blog post of August 24th, is to "support clinical excellence through creating virtual clinical networks, groups and clinical communities where clinicians can be supported in the key behavior changes required for developing clinical excellence."  Members of the site will use a variety of social networking and collaborative tools to learn skills, obtain real-time feedback, and measure their performance.    Anyway, kudos to Gre Neimeyer for confronting the ugly truth about CE in behavioral health and saying it out loud!

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.
 

Not too long ago, my colleagues and I published some preliminary thoughts and findings from our research into "Supershrinks."  That differences in effectiveness exist between clinicians is neither surprising or new.  Indeed, "therapist effects"–as they are referred to in the research literature–have been documented for decades and rival the contribution of factors long known to influence successful psychotherapy (e.g., the therapeutic alliance, hope and expectancy, etc.).  Personally, I believe that studying these super-effective clinicians will help practitioners improve the outcome of their clinical work.  Aside from research documenting the existence of "supershrinks," and our own articles on the subject, little additional information exists documenting how superior performing clinicians achieve the results they do.

Enter Bill Robinson,manager, counsellor and a senior supervisor with Relationships Australia based in Mandurah, Western Australia. I am also proud to say that Bill is one of a highly select group of clinicians that have completed the necessary training and been invited to work as certified trainers for the International Center for Clinical Excellence.

In any event, in the last issue of Psychotherapy in Australia–a treasure of a publication that every clinician dedicated to improving their work should subscribe to–Bill explores the topic of therapist effects, suggesting possible links between effectiveness and clinicians’ abilities to connect with the phenomenological worlds of the people they work with.  Trust me, this peer reviewed article is worth reading.  Don’t forget to post a comment, by the way, once you’ve finished!

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 "History doesn’t repeat itself," the celebrated American author, Mark Twain once observed, "but it does rhyme."  No better example of Twain’s wry comment than recurring claims about specifc therapeutic approaches.  As any clinician knows, every year witnesses the introduction of new treatment models.  Invariably, the developers and proponents claim superior effectivess of the approach over existing treatments.  In the last decade or so, such claims, and the publication of randomized clinical trials, has enabled some to assume the designation of an "evidence-based practice" or "empirically supported treatment."  Training, continuing education, funding, and policy changes follow.  

Without exception, in a few short years, other research appears showing the once widely heralded "advance" to be no more effective than what existed at the time.  Few notice, however, as professional attention is once again captured by a "newer" and "more improved" treatment model.  Studies conducted by my colleagues and I (downloadable from the "scholarly publications" are of my website), document this pattern with treatments for kids, alcohol abuse and dependence, and PTSD over the last 30 plus years.  
As folks who’ve attended my recent workshops know, I’ve been using DBT as an example of approaches that have garnered significant professional attention (and funding) despite a relatively small number of studies (and participants) and no evidence of differential effectiveness.

In any event, the American Journal of Psychiatry will soon publish, "A Randomized Trial of Dialectical Behavior Therapy versus General Psychiatric Management for Borderline Personality Disorder." As described by the authors, this study is "the largest clinical trial comparing dialectical behavior therapy and an
active high-standard, coherent, and principled approach derived from APA
guidelines and delivered by clinicians with expertise in treating borderline personality disorder."  And what did these researchers find?  "Dialectical behavior therapy was not superior to general psychiatric management with both intent-to-treat and per-protocol analyses; the two were equally effective across a range of outcomes."  Interested readers can request a copy of the paper from the lead investigator, Shelley McMain at: Shelley_McMain@camh.net.  Below, readers can also find a set of slides summarizing and critiquing the current research on DBT. In reviewing the slides, ask yourself, "how could an approach based on such a limited and narrow sample of clients and no evidence of differential effectives achieved worldwide prominence?"

Of course, the results summarized here do not mean that there is nothing of value in the ideas and skills associated with DBT.  Rather, it suggests that the field, including clinicians, researchers, and policy makers, needs to adopt a different approach when attempting to improve the process and outcome of behavioral health practices.  Rather than continuously searching for the "specific treatment" for a "specific diagnosis," research showing the general equivalence of competing therapeutic approaches indicates that emphasis needs to be placed on: (1) studying factors shared by all approaches that account for success; and (2) developing methods for helping clinicians identify what works for individual clients. This is, in fact, the mission of the International Center for Clinical Excellence (www.centerforclinicalexcellence.com): identifying the empirical evidence most likely to lead to superior outcomes in behavioral health.

Mark your calendars!  The International Center for Clinical Excellence is pleased to announce the “Achieving Clinical Excellence” (ACE) conference to be held at the Westin Hotel in Kansas City, Missouri on October 20-22nd, 2010.  K. Anders Erickson, Ph.D., the editor of The Cambridge Handbook of Expertise and Expert Performance and recognized “expert on experts,” will keynote the event. Through a combination of plenary presentations and intensive workshops, an internationally renowned faculty of researchers and educators, including Scott D. Miller, Ph.D. and John Norcross, Ph.D., will help participants discover the means to achieve excellence in clinical practice, leadership, ethics, and personal care.  Attendees will also meet and learn directly from internationally ranked performers from a variety of professions, including medicine, science, music, entertainment, and sports.  As just one example, the Head Coach of the Olympic, Gold-Medal-winning Women’s volleyball team, Hugh McCutcheon, will present at the conference.  In addition to a pre-conference day on ethics and law, internationally renowned concert pianist Daivd Helfgott, whose heart-warming story was featured in the award winning film Shine, will perform on Thursday evening, October 21st. Join us in Kansas City for three days of science, skill building, and inspiration.

For years, my colleagues and I have been using the phrase "practice-based evidence" to refer to clinicians’ use of real-time feedback to develop, guide, and evaluate behavioral health services. Against a tidal wave of support from professional and regulatory bodies, we argued that the "evidence-based practice"–the notion that certain treatments work best for certain diagnosis–was not supported by the evidence. Along the way, I published, along with my colleagues, several meta-analytic studies, showing that all therapies worked about equally well (click here to access recent studies children, alcohol abuse and dependence, and post-traumatic stress disorder). The challenge, it seemed to me, was not finding what worked for a particular disorder or diagnosis, but rather what worked for a particular individual–and that required ongoing monitoring and feedback. In 2006, following years of controversy and wrangling, the American Psychological Association, finally revised the official definition to be consistent with "practice-based evidence." You can read the definition in the May-June issue of the American Psychologist, volume 61, pages 271-285.

Now, a recent report on the Medscape journal of medicine channel provides further evidence that practice-based evidence is going mainstream. I think you’ll find the commentary interesting. Together with the link to the "debate of the century" posted below, it provides compelling evidence that an alternative to the dominent paradigm currently guiding professional discourse is taking hold.
 

I’m still reeling from the experience in Anaheim this last week.  I met so many leaders in the field, heard so many presentations on cutting edge clinical practice–as well as was reminded of some "classic" principles of effective psychotherapy.

One of the people I met was colleague and friend, Michael F. Hoyt, Ph.D.  Michael and I go back 15+ years, having met–I believe–the first time at a workshop I was giving in Northern California (somewhere in the Bay Area where Michael works and resides).  Since that time, we chatted regularly, and written editorials and book chapters together.  His books (The First Session in Brief Therapy, Brief Therapy & Managed Care, The Handbook of Constructive Therapies, Some Stories are Better than Others) always balance theory and practice and are among my favorites.

My two favorite books are also his most recent: The Present is a Gift and Brief Psychotherapies: Principles & Practice (Hint: his chapters on couples therapy are among the best I’ve ever read). Anyway, the two of us caught up at the ICCE booth this last week at the Evolution conference.