Not long ago, my friend and colleague Dr. Rick Kamins was on vacation in Hawaii. He was walking along the streets of a small village, enjoying the warm weather and tropical breezes, when the sign on a storefront caught his eye. Healing Arts Alliance, it read. The proprieter? None other than, “Scott Miller, Master of Oriental Medicine.”
“With all the talking you do about the alliance,” Rick emailed me later, ”I wondered, could it be the same guy?!”
I responded, “Ha, the story of my life. You go to Hawaii and all I get is this photo!”
Seriously though, I do spend a fair bit of time when I’m out and about talking about the therapeutic alliance. As reviewed in the revised edition of The Heart and Soul of Change there are over 1100 studies documenting the importance of the alliance in successful psychotherapy. Simply put, it is the most evidence-based concept in the treatment literature.
At the same time, whenever I’m presenting, I go to great lengths to point out that I’m not teaching an “alliance-based approach” to treatment. Indeed–and this can be confusing–I’m not teaching any treatment approach whatsoever. Why would I? The research literature is clear: all approaches work equally well. So, when it comes to method, I recommend that clinicians choose the one that fits their core values and preferences. Critically, however, the approach must also fit and work for the person in care–and this is where research on the alliance and feedback can inform and improve retention and outcome.
Back in 1994, my long time mentor Dr. Lynn Johnson encouraged me to begin using a simple scale he’d developed. It was called…(drum roll here)…”The Session Rating Scale!” The brief, 10-item measure was specifically designed to obtain feedback on a session by session basis regarding the quality of the therapeutic alliance. “Regular use of [such] scales,” he argued in his book Psychotherapy in the Age of Accountability, “enables patients to be the judge of the…relationship. The approach is…egalitarian and respectful, supporting and empowering the client” (Johnson, 1995, p. 44).
Some 17 years later, research has now firmly validated Lynn’s idea: formally seeking feedback improves both retention and outcome in behavioral health. How does it work? Unfortunately science, as Malcoln Gladwell astutely observes, “all too often produces progress in advance of understanding.” That said, recent evidence indicates that routinely monitoring outcome and alliance establishes and serves to maintain a higher level of baseline performance. In other words, regularly seeking feedback helps clinicians attend to core therapeutic principles and pocesses easily lost in the complex give-and-take of the treatment hour.
Such findings are echoed in the research literature on expertise which shows that superior performers across a variety of domains (physics, computer programming, medicine, etc.) spend more time than average performers reviewing basic core principles and practice.
At an intensive training in Antwerp, Belgium
The implications for improving practice are clear: before reaching for the stars, we should attend to the ground we stand on. It’s so simple, some might think it stupid. How can a four item scale given at the end of a session improve anything? And yet, in medicine, construction, and flight training, there is a growing reliance on such “checklists” to insure
With all the workshops and trainings on “advanced techniques,” I wonder will practitioners interested in the basics?
Rarely does a day go by without hearing about another “advance” in the neurobiology of human behavior. Suddenly, it seems, the world of psychotherapy has discovered that people have brains! And now where the unconscious, childhood, emotions, behaviors, and cognitions once where…neurons, plasticity, and magnetic resonance imagining now is. Alas, we are a field forever in search of legitimacy. My long time colleague and friend, Mark Hubble, Ph.D., sent me the following review of recent developments. I think you’ll enjoy it, along with video by comedian John Cleese on the same subject.
Mark Hubble, Ph.D.
Today, while contemplating the numerous chemical imbalances that are unhinging the minds of Americans — notwithstanding the longstanding failure of the left brain to coach the right with reason, and the right to enlighten the left with intuition — I unleashed the hidden power of my higher cortical functioning to the more pressing question of how to increase the market share for practicing therapists. As research has dismantled once and for all the belief that specific treatments exist for specific disorders, the field is left, one might say, in an altered state of consciousness. If we cannot hawk empirically supported therapies or claim any specialization that makes any real difference in treatment outcome, we are truly in a pickle. All we have is ourselves, the relationships we can offer to our clients, and the quality of their participation to make it all work. This, of course, hardly represents a propitious proposition for a business already overrun with too many therapists, receiving too few dollars.
Fortunately, the more energetic and enterprising among us, undeterred by the demise of psychotherapy as we know it, are ushering the age of neuro-mythology and the new language of neuro-babble. Seemingly accepting wholesale the belief that the brain is the final frontier, some are determined to sell us the map thereto and make more than a buck while they are at it. Thus, we see terms such as “Somatic/sensorimotor Psychotherapy,” “Interpersonal Neurobiology,” “Neurogenesis and Neuroplasticity,” “Unlocking the Emotional Brain,” “NeuroTherapy,” “Neuro Reorganization,” and so on. A moment’s look into this burgeoning literature quickly reveals the existence of an inverse relationship between the number of scientific sounding assertions and actual studies proving the claims made. Naturally, this finding is beside the point, because the purpose is to offer the public sensitive, nuanced brain-based solutions for timeless problems. Traditional theories and models, are out, psychotherapies-informed-by-neuroscience, with the aura of greater credibility, are in.
Neurology and neuroscience are worthy pursuits. To suggest, however, that the data emerging from these disciplines have reached the stage of offering explanatory mechanisms for psychotherapy, including the introduction of “new” technical interventions, is beyond the pale. Metaphor and rhetoric, though persuasive, are not the same as evidence emerging from rigorous investigations establishing and validating cause and effect, independently verified, and subject to peer review.
Without resorting to obfuscation and pseudoscience, already, we have a pretty good idea of how psychotherapy works and what can be done now to make it more effective for each and every client. From one brain to another, to apply that knowledge, is a good case of using the old noggin.
There’s a feeling I get whenever I’m learning something new. It’s a combination of wonder and possibility. Even though I’ve been traveling and teaching full time for over 18 years, I still feel that get that feeling of excitement whenever I step on a plane: What will I see? Who will I meet? What will I learn? Move over Indiana Jones, you’ve got nothing on me!
On the floor, arranged in neat little piles, are reams of research articles, newspaper clipplings, and pages torn out of magazines. Literally, all on the same subject: how can we clinicians reliably achieve better results?
I’ve never been one to “settle” for very long. It’s the journey not the destination I find appealing. Thus, I began exploring the common factors when it became clear that treatment models contributed little if anything to outcome (click here to read the history of this transition). When I became convinced that the common factors held little promise for improving results in psychotherapy, I followed the lead of two my mentors, professor Michael Lambert (who I worked with as an undergraduate) and psychologist Lynn Johnson (who trained and supervised me), and began measuring outcome and seeking feedback. Now that research has firmly established that using measures of the alliance and outcome to guide service delivery significantly enhances performance (see the comprehensive summary of research to date below), I’ve grown restless again.
In truth, I find discussions about the ORS and SRS a bit, well, boring. That doesn’t mean that I’m not using or teaching others to use the measures. Learning about the tools is an important first step. Getting clinicians to actually use them is also important. And yet, there is a danger if we stop there.
Right now, we have zero evidence that measurement and feedback improves the performance of clinicians over time. More troubling, the evidence we do have strongly suggests that clinicians do not learn from the feedback they receive from outcome and alliance measures. Said another way, while the outcome of each particular episode of care improves, clinicians overall ability does not. And that’s precisely why I’m feeling excited–the journey is beginning…
…and leads directly to Kansas City where, on October 20-22nd, 2010, leading researchers and clinicians will gather to learn the latest, evidence-based information and skills for improving performance in the field of behavioral health. As of today, talented professionals from Australia, Sweden, Norway, Denmark, Germany, England, Israel, and the United States have registered for the international “Achieving Clinical Excellence” conference. Some common questions about the event include:
1. What will I learn?
The entire agenda for the three day conference can be found here.
2. Is the content new?
Entirely. This is no repeat of a basic workshop or prior conferences. You won’t hear the same presentations on the common factors, dodo verdict, or ORS and SRS. You will learn the skills necessary to achieve your personal best.
3. Are continuing education credits available?
Absolutely–up to 18 hours depending on whether you attend the pre-conference ”law and ethics” training. By the way, if you register now, you’ll get the pre-conference workshop essentially free! Three days for one low price.
4. Will I have fun?
Guaranteed. In between each plenary address and skill building workshop, we’ve invited superior performers from sports, music, and entertainment to perform and inspire . If you’ve never been to Kansas City, you’ll enjoy the music, food, attractions, and architecture.
Feel free to email me with any questions or click here to register for the conference. Want a peak at some of what will be covered? Watch the video below, which I recorded last week in Sweden while “trapped” behind the cloud of volcanic ash. In it, I talk about the “Therapists Most Likely to Succeed.”
Dateline: Tuesday, 8:21pm, April 20th, 2010, Skellefteå, Sweden
What an incredible week. Spent the day today working with 250 social workers, case managers, psychologists, psychiatrists, and agency directors in the far nothern town of SkellefteÃ¥, Sweden. Many practitioners here are already measuring outcomes on an ongoing basis and using the information to improve the results of their work with consumers of behavioral health services. Today, I presented the latest findings from ICCE’s ongoing research on “Achieving Clinical Excellence.”
I’ve been coming to the area to teach and consult since the early 1990’s, when I was first invited to work with Gun-Eva Langdahl and the rest of the talented crew at RÃ¥dgivningen Oden (RO). As in previous years, I spent my first day (Monday) in SkellefteÃ¥ watching sessions and working with clients at RO clinic. Frankly, getting to SkellefteÃ¥ from Goteborg had been a bit of ordeal. What usually took a little over an hour by plane ended up being a 12-hour combination of cars, trains, and buses–all due to volcanic eruptions on Iceland. (I shudder to think of how I will get from SkellefteÃ¥ to Amsterdam on Wednesday evening if air travel doesn’t resume).
Anyway, the very first visit of the day at RÃ¥dgivningen Oden was with an adolescent and her parents. Per usual, the session started with the everyone completing and discussing the Outcome Rating Scale. The latest research reported in the April 2010 edition of Journal of Consulting and Clinical Psychology(JCCP)confirms the wisdom of this practice: measuring and discussing progress with consumers at every visit results in better outcomes.
It turns out that adolescents are at greater risk for deterioting in treatment than adults (20% versus 10%). Importantly, the study in JCCP by Warren, Nelson, Mondragon, Baldwin, and Burlingame found that the more frequently measures are used the less likely adolescents are to worsen in care. Indeed, as ICCE Senior Associate Susanne Bargmann pointed out in a series of excited emails about this important study, “routinely tracking and discussing progress led to 37% higher recovery rates and 38% lower rates of deterioration!”
Skellefteå is a hotbed of outcome-informed practice in Sweden. Accompanying the family at Rådgivningen Oden, for example, were professionals from a number of other agencies involved in the treatment and wanting to learn more about outcome-informed practice. As already noted, 250 clinicians took time away from their busy schedules to hear the latest information and finese their use of the measures. And tomorrow, Wednesday, I meet with managers and directors of behavioral health agencies to discuss steps for successfully implementing routine measurement of progress and feedback in their settings.
Stay tuned for more. If all goes well, I’ll be in Amsterdam by Wednesday evening.
Today I was supposed to fly from Stockholm, Sweden to the far northern town of Skelleftea–a flight that takes a little over an hour. Instead, I’m sitting on a train headed for Sundsvall, the first leg of a 12 hour trip that will include a 6 hour bus ride and then a short stint in a taxi.
If you’ve been following the news coming out of Europe, you know that all flights into, out of, and around Europe have been stopped. Eyjafjallajokull–an Iceland volcano–erupted the day after I landed in Goteborg spewing an ash cloud that now covers most of Europe disrupting millions of travellers. People are making due, sleeping on cots in airline, train, and bus terminals and using Facebook and Twitter to connect and arrange travel alternative.
In the meantime, another eruption has taken place with the publication of the latest issue of the Journal of Consulting and Clinical Psychology that threatens to be equally disruptive to the field of psychotherapy–and to proponents of the narrow, specific-treatments-for-specific-disorders or “evidence-based treatments” movement. Researchers Webb, DeRubeis, and Barber conducted a meta-analysis of studies examining the relationship between adherence to and competence in delivering a particular approach and outcome. The authors report finding that, “neither adherence nor competence was…related to patient (sic) outcome and indeed that the aggregate estimates of their effects were very close to zero.”
Zero! I’m not sure what zero means to everyone else, but where I come from it’s pretty close to nothing. And yet, the romance with the EBT movement continues among politicians, policy makers, and proponents of specific treatment models. Each year, millions and millions of dollars of scarce resources are poured into an approach to behavioral health that accounts for exactly 0% of the results.
Although it was not a planned part of their investigation, the must-read study by Webb, DeRubeis, and Barber also points to the ”magma” at the heart of effective psychotherapy: the alliance, or quality of the relationship between consumer and provider. The authors report, for example, finding ”larger competence-outcome effect size estimates [in studies that]…did not control for the influence of the alliance.”
The alliance will take center stage at the upcoming, “Achieving Clinical Excellence” and “Training of Trainers” events. Whatever you thought you knew about effective therapeutic relationships will be challenged by the lastest research from our study of top performing clinicians worldwide. I hope you’ll join our international group of trainers, researchers, and presenters by clicking on either of the links above. And, if you’ve not already done so, be sure and visit the International Center for Clinical Excellence home page and request an invitation to join the community of practitioners and researchers who are learning and sharing their expertise.
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 nearly three 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.
Obesity is a large and growing problem in the United States and elswhere. Data gathered by the National Center for Health Statistics indicate that 33% Americans are obese. When overweight people are added to the mix, the figure climbs to a staggering 66%! The problem is not likely to go away soon or on its own as the same figures apply to children.
Researchers estimate that weight problems are responsible for over 300,000 deaths annually and account for 12% of healthcare costs or 100 billion–that’s right, $100,000,000,000–in the United States alone. The overweight and obese have higher incidences of arthrisis, breast cancer, heart disease, colorectal cancer, diabetes, endometrial cancer, gallbladder disease, hypertentsion, liver disease, back pain, sleeping problems, and stroke–not to mention the tremendous emotional, relational, and social costs. The data are clear: the overweight are the target of discrimination in education, healthcare, and employment. A study by Brownell and Puhl (2003), for example, found that: (1) a significant percentage of healthcare professionals admit to feeling “repulsed” by obese person, even among those who specialize in bariatric treatment; (2) parents provide less college support to their overweight compared to “thin” children; and (3) 87% of obese individuals reported that weight prevented them from being hired for a job.
Sadly, available evidence indicates that while weight problems are “among the easiest conditions to recognize,” they remain one of the “most difficult to treat.” Weight loss programs abound. When was the last time you watched television and didn’t see an ad for a diet pill, program, or exercise machine? Many work. Few, however, lead to lasting change.
What might help?
More than a decade ago, I met Dr. Paul Faulkner, the founder and then Chief Executive Officer of Resources for Living (RFL), an innovative employee assistance program located in Austin, Texas. I was teaching a week-long course on outcome-informed work at the Cape Cod Institute in Eastham, Massachusetts. Paul had long searched for a way of improving outcomes and service delivery that could simultanesouly be used to provide evidence of the value of treatment to purchasers–in the case of RFL, the large, multinational companies that were paying him to manage their employee assistance programs. Thus began a long relationship between me and the management and clinical staff of RFL. I was in Austin, Texas dozens of times providing training and consultation as well as setting up the original ORS/SRS feedback system known as ALERT, which is still in use at the organization today. All of the original reliability, validity, norming, and response trajectories were done together with the crew at RFL.
Along the way, RFL expanded services to disease management, including depression, chronic obstructive pulminary disease, diabetes, and obesity. The “weight management” program delivered coaching and nutritional consultation via the telephone informed by ongoing measurement of outcomes and the therapeutic alliance using the SRS and ORS. The results are impressive. The study by Ryan Sorrell, a clinician and researcher at RFL, not only found that the program and feedback led to weight loss, but also significant improvements in distress, health eating behaviors (70%), exercise (65%), and presenteeism on the job (64%)–the latter being critical to the employers paying for the service.
Such research adds to the growing body of literature documenting the importance of “practice-based” evidence, making clear that finding the “right” or “evidence-based” approach for obesity (or any problem for that matter) is less important than finding out “what works” for each person in need of help. With challenging, “life-style” problems, this means using ongoing feedback to inform whatever services may be deemed appropriate or necessary. Doing so not only leads to better outcomes, but also provides real-time, real-world evidence of return on investment for those footing the bill.
Last week, my long time colleague and friend, Dr. Mark Hubble blogged about the current interest of non-medically trained therapists in the so-called “neurobiology of human behavior.” In my intro to his post, I “worried” out loud about the field’s tendency to search for legitimzing foundational metaphors. Over the years, psychotherapy has flirted with biology, physics, religion, philosophy, chaos, and “energy meridians” as both the cause of what ails people and and the source of psychotherapy’s effectiveness.
For whatever reason, biological explanations have always had particular cachet in the world of psychotherapy. When I first entered the field, the “dexamethasone suppression test” was being touted as the first “blood test” for depression. Some twenty years on, its hard to remember the hope and excitement surrounding the DST.
Another long-time friend and colleague, psychologist Michael Valentine is fond of citing the many problems–social, physical, and otherwise–attributed to genetics (including but not limited to: anxiety, depression, addictions, promicuity, completed suicides, thrill seeking obscene phone calls, smoking, gambling, and the amount of time one spends watching TV) for which there is either: (a) precious little or inconsistent evidence; or (b) the variance attributable to genetics is small and insigificant compared to size and scope of the problem.
In any event, I wanted to let readers know that response to Mark’s post has been unusually strong. The numerous comments can be found on the syndicated version of my blog at the International Center for Clinical Excellence. Don’t miss them!
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