Top Performance Blog

Several years ago I was contacted by a group of practitioners located in the largest city in the north of the Netherlands–actually the capital of the province known as Groningen.  The "Platform," as they are known, were wondering if I’d be willing to come and speak at one of their upcoming conferences.  The practice environment was undergoing dramatic change, the group’s leadership (Dorti Been & Pico Tuene) informed me.  Holland would soon be switching from government to a private insurance reimbursement system.  Dutch practitioners were "thinking ahead," preparing for the change–in particular, understanding what the research literature indicates works in clinical practice as well as learning methods for documenting and improving the outcome of treatment.

I was then, and remain now, deeply impressed with the abilities and dedication of Dutch practitioners.  During that visit to Groningen, and the many that have followed (to Amsterdam, Rotterdam, Beilen, etc.), its clear that clinicians in the Netherlands are determined to lead rather than be led.  I’ve been asked to meet with university professors, practitioner organizations, training coordinators, and insurance company executives.  In a very short period of time, two Dutch therapists–physician Flip Van Oenen and psychologist Mark Crouzen–have completed the "Training of Trainers" course and become recognized trainers and associates for the International Center for Clinical Excellence.  And finally , professor Anton Hafkenscheid has completed and will soon publish data showing sound psychometric properties of the Dutch translations of the ORS and SRS.

I’ve also been working closely with the Dutch company Reflectum–a group dedicated to supporting outcome-informed healthcare and clinical excellence.  Briefly, Reflectum has organized several conferences and expert meetings between me and clinicians, agency managers, and insurance companies.  One thing for sure: we will be working closely together to train a network of trainers and consultants to promote, support, and train agencies and practitioners in outcome-informed methods in order to meet the demands of the changing practice climate.

Check out the videobelow filmed at Schipol airport during one of my recent trips to Holland:

As anyone who follows me on Twitter knows, I get around.  In the past few months, I visited Australia, Norway, Sweden, Denmark (to name but a few countries) as well as criss-crossed the United States.  If I were asked to sum up the state of public behavioral health agencies in a single word, the word–with very few exceptions–would be: desperate.  Between the unfunded mandates and funding cutbacks, agencies are struggling. 

Not long ago, I blogged about the challenges facing agencies and providers in Ohio.  In addition to reductions in staffing, those in public behavioral health are dealing with increasing oversight and regulation, rising caseloads, unrelenting paperwork, and demands for accountability.  The one bright spot in this otherwise frightening climate is: outcomes.  Several counties in Ohio have adopted the ORS and SRS and been using them to improve the effectiveness and efficiency of behavioral health services.

I’ve been working with the managers and providers in both Marion and Crawford counties for a little over two years.  Last year, the agencies endured significant cuts in funding.  As a result, they were forced to eliminate a substantial number of positions.  Needless to say, it was a painful process with no upsides–except that, as a result of using the measures, the dedicated providers had so improved the effectiveness and efficiency of treatment they were able to absorb the loss of staff without having to cut on services to clients.

The agencies cite four main findings resulting from the work we’ve done together over the last two years.  In their own words:

"1. Use of CDOI has enabled us to be more efficient, which is particularly important given Ohio’s economic picture and the impact of State budget cuts. Specifically, CDOI is enabling service providers and supervisors to identify consumers much earlier who are not progressing in the treatment process. This allows us to change course sooner when treatment is not working, to know if changes work, to identify consumers in need of a different level of care, etc.  CDOI also provides data on which the provider and consumer can base decisions about the intensity of treatment and treatment continuation (i.e. when to extend time between services or when the episode of service should end). In short, our staff and consumers are spending much less time “spinning their wheels” in unproductive activities.  As a result, we have noticed more “planned discharges versus clients just dropping out of treatment.

Dateline: Mosjoen, Norway

The last stop on my training tour around northern Norway was Mosjoen.  The large group of psychologists, social workers, psychiatrists, case managers, and physicians laughed uproariously when I talked about the bumpy, "white-knuckler" ride aboard the small twin-engine airplane that delivered me to the snowy, mountain-rimmed town. They were all to familiar with the peculiar path pilots must follow to navigate safely between the sharp, angular peaks populating the region.

Anyway, I’d been invited nearly two years earlier to conduct the day-long training on "what works in treatment." The event was sponsored by Helgelandssykehuset-Mosjoen and organized by Norwegian practitioner Konrad Kummernes.  I first met Konrad at a conference held in another beautiful location in Norway (is there any other type in this country?!), Stavanger–best known for its breathtaking Fjordes.  The goal for the day in Mosjeon?  Facilitate the collaboration between the many different services providers and settings thereby enabling the delivery of the most effective and comprehensive clinical services.  Meeting Konrad again and working with the many dedicated professionals in Mosjoen was an inspiration. Here’s Konrad:

For those of you following me on Twitter–and if you’re not, click here to start–you know that I was traveling above the artic circle in Norway last week.  I always enjoy visiting the Scandanavia countries.  My grandparents immigrated from nearby Sweden.  I lived there myself for a number of years (and speak the language).  And I am married to a Norwegian!  So, I consider Scandanavia to be my second home.

In a prior post, I talked a bit about the group I worked with during my three day stay in Tromso.  Here, I briefly interview psychologist Mikael Aagard, the organizer of the conference.  Mikael works at KORUS Nord, an addiction technology transfer center, which sponsored the training.  His mission? To help clinicians working in the trenches stay up-to-date with the research on "what works" in behavioral health.  Judging by the tremendous response–people came from all over the disparate regions of far northern Norway to attend the conference–he is succeeding. 

Listen as he describes the challenges facing practitioners in Norway and the need to balance the "evidence-based practice" movement with "practice-based evidence."  If you’d like any additional information regarding KORUS, feel free to email Mikael by clicking on his name above.  Information about the activities of the International Center for Clinical Excellence in Scandanavia can be found at: www.centerforclinicalexcellence.org or by emailing ICCE Senior Associate in Denmark, psychologist Susanne Bargmann.

January 11th, 2010

"Debate over Cognitive & Traditional Mental Health Therapy" by Eric Jaffe

The fight debate between different factons, interest groups, scholars within the field of mental health hit the pages of the Los Angeles Times this last week. At issue?  Supposedly, whether the field will become "scientific" in practice or remain mired in traditions of the past.  On the one side are the enthusiastic supporters of cognitive-behavioral therapy (CBT) who claim that existing research provides overwhelming support for the use of CBT for the treatment of specific mental disorders.  On the other side are traditional, humanistic, "feel-your-way-as-you-go" practitioners who emphasize quality over the quantitative.

My response?  Spuds or potatoes.  Said another way, I can’t see any difference between the two warring factions.  Yes, research indicates the CBT works.  That exact same body of literature shows overwhelmingly, however, that any and all therapeutic approaches intended to be therapeutic are effective.  And yes, certainly, quality is important.  The question is, however, "what counts as quality?" and more importantly, "who gets to decide?"

In the Los Angeles Times article, I offer a third way; what has loosely been termed, "practice-based evidence."  The bottom line?  Practitioners must seek and obtain valid, reliable, and ongoing feedback from consumers regarding the quality and effectiveness of the services they offer.  After all, what person following unsuccessful treatment would say, "well, at least I got CBT!" or, "I’m sure glad I got the quality treatment."

Dateline: Tromsø, Norway
Place: Rica Ishavshotel

For the last two days, I’ve had the privilege of working with 125+ clinicians (psychotherapists, psychologists, social workers, psychiatrists, and addiction treatment professionals) in far northern Norway.  The focus of the two-day training was on "What Works" in treatment, in particular examining what constitutes "evidence-based practice" and how to seek and utilize feedback from consumers on an ongoing basis.  The crowd was enthusiastic, the food fantastic, and the location, well, simply inspiring.  Tomorrow, I’ll be working with a smaller group of practitioners, doing an advanced training.  More to come.

Bruce Wampold, Ph.D.

Late yesterday, I blogged about a soon-to-be published article in Clinical Psychology Review in which the authors argue that the finding by Benish, Imel, & Wampold (2008) of equivalence in outcomes among treatments for PTSD was due to, "bias, overgeneralization, lack of transparency, and poor judgement."  Which interpretation of the evidence is correct?  Are there "specific approaches for specific disorders" that are demonstrably more effective than others?  Or does the available evidence show all approaches intended to be therapeutic to be equally effective?

History makes clear that science produces results in advance of understanding.  Until the response to Ehlers, Bisson, Clark, Creamer, Pilling, Richards, Schnurr, Turner, and Yule becomes available, I wanted to remind people of three prior blogposts that review the evidence regarding differential efficacy of competing therapeutic approaches.  The first (and I think most illuminating)–The Debate of the Century–appeared back in August.  The post featured a link to a debate between Bruce Wampold and enthusiastic proponent of "empirically supported treatments" Steve Hollon.  Listen and then see if you agree with the large group of scientists and practitioners in attendance who thought–by a margin of 15:1–that Bruce carried the day.

The second post–Whoa Nellie!– commented on a 25 Million US$ research grant awarded by the US Department of Defense to study treatments for PTSD.  Why does this make me think of "deep throat’s" admonition to, "follow the money!"  Here you can read the study that is causing the uproar within the "specific treatments for specific disorders" gang.

Third, and finally, if you haven’t already read the post "Common versus Specific Factors and the Future of Psychotherapy," I believe you’ll find the thorough review of the research done in response to an article by Siev and Chambless critical of the "dodo verdict" helpful.

Researchers Anke Ehlers, Jonathon Bisson, David Clark, Mark Creamer, Steven Pilling, David Richards, Paula Schnurr, Stuart Turner, and William Yule have finally done it!  They slayed the "dodo." Not the real bird of course–that beast has been extinct since the mid to late 17th century but rather the "dodo bird" conjecture first articulated by Saul Rozenzweig, Ph.D. in 1936.  The idea that all treatment approaches work about equally well has dogged the field–and driven proponents of  "specific treatments for specific disorders" positively mad.

In a soon to be published article in Clinical Psychology Review, the authors claim that bias, overgeneralization, lack of transparency, and poor judgement account for the finding that "all therapeutic approaches work equally well for people with a diagnosis of PTSD" reported in a meta-analysis by Benish, Imel, & Wampold (2008).

Barry Duncan, Saul Rosenzweig, Scott Miller
 

I guess this means that a public admission by me, Wampold, and other common factors researchers is in order…or maybe not!  Right now, we are writing a response to the article.  All I can say at this point is, "unbelievable!"  As soon as it becomes available, you’ll find it right here.

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 frightenly 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."  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 outcome-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.

"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 evidentiary support for 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 unequivolcally 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