Wednesday, May 9, 2018

How do we get better, really? The Achieving Clinical Excellence 2018 Conference in Östersund, Sweden

By David S. Prescott, LICSW

The evidence is in, and there’s no doubt. Psychotherapy works for a wide range of conditions and behaviors. People can and do change, often suddenly and unpredictably. Among the most effective mechanisms for change is the most ancient and fundamental approach: the human conversation. 

Why even mention this? Those working in the fields of violence and trauma (including sexual abuse) too often believe that people who harm others are either unwilling or unable to change, despite decades of evidence. Too many professionals argue over lesser findings or ask the wrong questions. While searching for the randomized controlled trial showing that treatment can reduce risk, we overlook other findings, such as that people who complete programs very commonly have lower rates of re-offense. What can we learn from these studies? And more importantly, from the clients that can inform our approaches? There are entire bodies of research in psychotherapy, criminology, and education that go unnoticed and under-discussed.

The research points to greater differences between the least and most effective therapists within treatment methods than differences between the methods themselves. This uncomfortable truth is that we may be looking in the wrong place for success when we pin our hopes on trainings about the latest technique or model. Instead, we might want to look inward at what we can do to become more effective, one client at a time.

One path to professional development is feedback-informed treatment (FIT), which we have discussed in previous blogs. Critical to understanding FIT is that it is not enough to engage in routine outcome monitoring through the use of measures such as the Outcome Rating Scale (ORS) and Session Rating Scale (SRS). Practitioners don’t always respond with adequate professional self-development based on the feedback they’ve received. This has led to a movement within psychotherapy aimed at focusing on specific steps clinicians can take to become more effective and involves solitary, deliberate practice between sessions.

As revolutionary as much of this information may seem, the ACE 2018 Conference took the discussion to a new level. Routine outcome monitoring cannot result in actual improvement without the clinician actively working to improve performance based on the results. Some measures of outcome (such as the ORS) can provide benchmarks of success in performance, while others (such as the SRS) yield insights for practice aimed at improvement.

At the start of the conference, researchers Bruce Wampold and Scott Miller reviewed the evidence for what works in treatment. Wampold took careful note of emerging evidence that the effects of cognitive-behavioral therapy (CBT) may have declined over the years, and wondered aloud if that isn’t a natural part of the evolution of methods. That is, that the pioneers of CBT had started out as highly trained therapists in general, whereas therapists are now trained more in the methods than in the core conditions of effective therapy. Also significantly, Wampold noted that therapists often overlook the most important therapist skills (e.g., the effective demonstration of empathy) in favor of novel techniques. He emphasized that “basic counseling skills” should be re-framed as “critical counseling skills.”

Birgit Valla, the director of Stangejelpa in Norway, provided a narrative of how her agency became demonstrably more effective in helping clients. She took issue with approaches to mental health agency development based on the traditional medical model. Valla described differences between how successful business and mental health agencies operate in designing actions that will be useful and effective for their customers. Her agency has defined the development of wellbeing as its primary product rather than over-emphasizing diagnoses and focusing exclusively on problems. She further described an agency culture in which “helping people is a team sport” and that before starting employees understand they will be expected to practice deliberately in response to client feedback.

Scott Miller gave a keynote address that reflected his recent provocative article titled “How Psychotherapy Lost its Magick.” In his address, he noted that in recent years, more people have visited psychics than have seen therapists. He concluded that, in part, this was because too often therapists practice within a narrow framework of models and techniques that may look impressive, but are not actually as helpful to clients as they could be.

Ultimately, there is a difference between models and techniques as developed and intended versus how they get applied in actual practice.  Implementation and integration of models can bring many challenges. Perhaps the most heartfelt example of this at the ACE 2018 Conference was Heidi Brattland. In her keynote address, she described going to see a therapist as part of her training to become a psychologist. By her account, the biggest lesson she learned was the resolve never to become the kind of psychologist she had gone to see.

Finally, Daryl Chow urged every professional to develop a broader view of the work we do. He is the first researcher to have published on deliberate practice approaches in psychotherapy.

Where does this leave the rest of us? Take-home messages include:

·    Basic counseling skills are only basic in theory. Combining them in actual practice is an advanced skill.
·       Conversation can be curative.
·     The most effective professionals in our field engage in solitary, often very difficult practice between sessions.
·    Treatment sessions are best thought of as performance that is different from the practice aimed at improving performance.
·       Clinicians in our field can learn from trends happening elsewhere.

I hope that the links provided throughout this post offer ideas for the way forward for readers.

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