~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
TIPS & TOPICS from David Mee-Lee, M.D.
Volume 5, No.6
October 2007
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
In this issue
-- SAVVY and STUMP THE SHRINK
-- SATIRE
-- SOUL
-- SHAMELESS SELLING
-- Until Next Time
Thanks
for joining us for the October edition of TIPS and
TOPICS (TNT). Welcome to all the new readers.
SAVVY
and STUMP THE SHRINK
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
In the July/August edition of TNT, the focus was
on Evidence-Based Practice (EBP). A number of readers
sent me comments on that issue. At the risk of boring
you with more discussion about EBPs, we'll share
comments from two readers. The first response I
am calling a "Stump the Shrink" because
it got me thinking how best to explain more about
my views about EBPs and the relationship to therapeutic
alliance.
With Dr. Brian Miller's permission, here are his
comments and my response right next to each section
of the full message:
"Dr.
Mee-Lee:
Comment:
I hope you can stand just a few more thoughts about
evidence-based practices-I had a strong reaction
to your July/August Tips-both positive and negative-
and wanted to reply:
I
am hopeful that the paradigm wars between the orthodoxy
of the "nothing but EBPs" advocates and
the "nothing but the relationship matters"
advocates is reaching its acme.
My
Response:
I re-read the July/August TIPS and TOPICS to
see what it was you read that made it seem that
Scott Miller and I are advocating: "nothing
but the relationship matters". I did not see
where we said that. In fact Scott said that "For
the record, our team has never said that the therapeutic
relationship is the only important variable in psychological
treatments. It is, however, the most evidence-based
finding in the literature, with over 1000 findings
published to date. Study after study show that it
contributes 4-8 times more to treatment outcome
than treatment approach. As such, its absence in
most professional discourse and the EBP movement
is nothing short of stunning." If you read
his section again and the SKILLS section, I was
explicit that EBPs have a role to play. Our concern
is that research, training funds and fidelity efforts
have been centered on what contributes less to the
outcome (EBPs) with far less resources spent on
helping clinicians, programs and systems to focus
on measuring the quality of engagement and tracking
of real-time outcomes.
Comment:
I feel that a new dialectic is becoming clear that
synthesizes the sides into what, I hope, will be
a new paradigm. This new paradigm distinguishes
between evidence-based practice and the evidence-based
practices.
My
Response:
I agree and hope you are right. Scott referred
to the new APA definition on EBP that takes this
in the right direction.
Comment:
In your and Miller's deconstruction of the evidence-
based practices, you create the straw man argument
in the form of the practitioner who is rigidly adhering
to a treatment manual without any consideration
of relationship or client factors.
My
Response:
I didn't see what you were reading where either
Scott or I created such a straw man. But maybe I
missed something. It would help if you could paste
in where we said anything that sounded like practitioners
are "rigidly adhering to a treatment manual
without any consideration of relationship or client
factors." Perhaps you are referring to comments
of Norman G Hoffmann, Ph.D. in TNT. But again on
re-reading his section, I still didn't see where
any of us created such a straw man. But I remain
open to your feedback on any sections if you wouldn't
mind including those in a response back.
Comment:
Such practitioners may exist, but no one I know
is arguing that what they are doing is "evidence-based
practice." Evidence-based practice (again,
distinguished from the evidence based practices)
is best defined by Eamon Armstrong in the context
of evidence-based medicine: "Evidence-based
medicine is a process of problem-based learning
and informational mastery that enables physicians
to keep up to date while improving their clinical
behavior and patient outcomes."
My
Response:
I am comfortable with this definition and the
APA one. In fact "improving their clinical
behavior and patient outcomes" is precisely
what Scott Miller and his associates and also I
are all advocating. Scott Miller and Barry Duncan's
Session Rating Scale (SRS) focuses on engagement
and the quality of the alliance so that the clinician
can change the style, method, fit of their treatment
approach to better meet the desires and direction
of the client. The Outcome Rating Scale (ORS) specifically
measures patient outcomes in real- time to improve
outcomes by a change in approach and treatment plan
negotiated with the client. This is akin to the
management of hypertension where the outcome is
measured in real time and the clinical behavior
changes to adjust treatment to be more effective,
acceptable and engaging. You can see these instruments
on www.talkingcure.com. I have seen now a number
of programs using these instruments and am impressed
how client and clinician-friendly they are and how
it helps clinicians focus on outcomes and engagement
and individualized treatment. I hope Utah will consider
the ORS and SRS rather than, as I understand it,
Mike Lambert's OQ 45 and the Clinical Support Tools
that from my observation are not as clinician and
client- friendly. By the way, I have no financial
stake in the ORS or SRS or the ASIST software. If
you know of programs that are using real-time feedback
tools to track outcome and alliance that are as
client and clinician-friendly, efficient, effective
and time-feasible, please give me contact information.
I would like to contact them and learn what they
are doing. I would be happy to connect you with
both mental health and addiction programs who are
using ASAM multidimensional assessment in conjunction
with ORS/SRS; or ORS/SRS alone.
Comment:
Nothing in that definition suggests rigid adherence
to a manual or fidelity measures. Rather, the emphasis
in evidence-based practice is upon the scientific
method, wherein everything is open to question as
the evidence appears. Who can argue against the
emphasis upon problem-based learning-another way
of describing attention to client-level data-- and
informational mastery? Thus, the new paradigm is
not one of rigid adherence to anything, but emphasizes
objective evidence and the scientific method over
traditional views and theory-and places the emphasis
on what works rather than on defending what
we have always done. Viewed this way, evidence-based
practice is flexible and open, but non-evidence-based
practice is rigid adherence to what we already think
we know-including the belief that only the treatment
relationship matters.
My
Response:
I agree with you on this paragraph. Again, neither
Scott nor I believe that "only the treatment
relationship matters". We are concerned about
the lopsided emphasis that is placed on the EBPs
as you say, and the stunning neglect of helping
clinicians measure and manage the therapeutic relationship
and patient outcomes. A doctor manages and changes
the treatment in real-time based on measurement
of outcome. More training and resources need to
be focused on helping clinicians change their behavior
based on real-time, during- treatment feedback on
the quality of the alliance, engagement and patient
outcomes.
Comment:
What is missing in both sides' arguments is that,
although it is true that no one model has shown
clear superiority in clinical trials against any
or all other models, there is good evidence that
there is a difference between high quality and low
quality treatment. Miller's MATCH study, often used
to argue against the evidence-based practices, also
made clear that it is well-implemented treatment
that is effective. What is the basic stuff of "well-
implemented" treatment? When "fidelity
measures" are nothing more than arbitrary rules
that define the "religion" of a particular
model, they are meaningless and may be counterproductive.
When, however, the fidelity measures define the
essential elements of a well-implemented program,
however, they become something more: They become
definitions of quality treatment.
My
Response:
I agree. In the SKILLS section,
I said: "By all means learn about EBPs and
become proficient enough to confidently include
a greater variety of methods and techniques in your
clinical toolkit. But don't let self- consciousness
over fidelity to a model dilute any natural and
effective style that engages people in a good working
alliance."
Comment:
In our rush to defend against the evidence-based
practices, we must be careful to realize that the
genuine benefit to effectiveness research is not
to prove which model has God on their side. The
real value of this research is in beginning to learn
what quality in treatment means. There is a difference
whether you have 8 or 28 clients in your treatment
group. There is a difference in whether a peer advocate
is available only in the clinic during working hours,
or is available 24/7 anywhere she is needed. There
is a difference in whether the counselor is confrontational
or is accepting, and there is a difference between
quality and poor treatment. This difference shouldn't
be lost in the academic argument about the proportion
of variation that can be attributed to model versus
relationship factors.
My
Response:
I agree we should look at what quality treatment
is. The evidence is that we already know a lot about
what contributes most to effective treatment outcomes.
Rather than focus on chart audits to track compliance
with process measures that have limited relationship
to effective outcome (e.g., to what degree clinicians
are adhering to a specific model; or whether there
are signed consents that clients were explained
their medications; or whether the treatment plan
is worded with the right goals and objectives that
the auditor feels is individualized enough etc.,)
I'd suggest that we should focus on tracking client
outcomes in real time; decrease drop-out rates by
engaging clients more effectively; and audit whether
clinicians measure outcomes and do anything different
to improve the outcomes. You might be interested
in "Making Treatment Count" that we wrote
and can be accessed on www.talkingcure.com. It outlines
in more detail what we are proposing. What is more
fascinating to me, is that in programs that are
taking this approach, we are seeing impressive clinician
and client acceptance and far better individualized,
client- directed care than all my years of training
people on individualized treatment.
Comment:
I hope I am right in suggesting that evidence-based
practice, as defined by Armstrong, will be the new
paradigm, and that the argument between the old
paradigms will become a unified focus on learning
what works. Then we can focus on information mastery
and applying that information in a problem- solving
process with each individual client.
My
Response:
Yes, I agree. We need to focus on what works
for this client at this point in time, in this program,
with this clinician, using what methods, working
on what goals towards what outcome. The emphasis
we would put then is on real-time, specific client
feedback on alliance, engagement and treatment outcome.
By having a range of EBPs in one's toolkit, the
clinician can move quickly and flexibly to change
approaches if the outcomes and client preferences
require a different approach.
Brian
C. Miller, Ph.D.
Salt Lake County Mental Health Director
Salt Lake County Government Center
2001 South State Street
Salt Lake City, UT 84190-2000
(801) 468-2186
SATIRE
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Just for this edition of TIPS and TOPICS, we've
added a new "S" category that will substitute
this month for the SKILLS section. I think you will
enjoy a couple of comments from two readers. In
the first, I know Bonnie Malek from Oregon is very
supportive of 12 Step programs, so take this in
the light-hearted manner it was intended. In the
second comment, Bill Garrett from Alabama shares
some humorous thoughts on what might be the real
purpose of documentation (who would have thought
documentation had anything to do with flies?)
Hi
David:
It's been a LONG time since we've been in contact
and this issue inspired me to touch base. I thought
you might get a kick out of the 12 Steps of Evidence
Based Practice. Feel free to share it if you're
so inclined.
THE
12 STEPS OF EVIDENCE BASED PRACTICE
1.
We admitted we were powerless over *Senate Bill
267 and that our information technology (IT) needs
had become unmanageable.
2.
Came to believe that the right set of manuals could
restore us to pre-morbid functioning.
3.
Made a decision to turn our program development
and training resources over to the Substance Abuse
and Mental Health Services Administration (SAMHSA)
before we understood why.
4.
Took the inventories of everyone that voted for
this bill (and in some cases their mothers and their
dogs).
5.
Admitted to the Office of Mental Health and Addiction
Services (OMHAS) and the Oregon legislature that
for the past 70 years, we've been running on sweat
equity, imagination and rubber bands.
6.
Grudgingly agreed to do some reading and to keep
an open mind.
7.
Swore all the way to the dumpster with our favorite
handouts and films.
8.
Made a list of all the practices that made sense
to us and became willing to check at least some
of them out.
9.
Agreed to learn one new thing this year as long
as it didn't add to our caseloads or paperwork.
10.
Continued to work on doing the impossible with no
new resources and dreamed of deleting databases
when no one was looking.
11.
Sought through outcomes data and specific serotonin
reuptake inhibitors (SSRIs) medication to improve
our conscious contact with the legislature, praying
only to prove that treatment works and we're truly
not sleeping at our desks.
12.
Having had a rude awakening as the result of these
steps, we vowed to share our retention data with
programs that were still pre-contemplative and to
practice fidelity in all of our affairs.
By
Bonnie Malek, MS, QMHP III, CDS III
E-mail : bmalek@co.marion.or.us
* Overview of Oregon Senate Bill 267
The
2003 Legislature passed ORS 182.525 (Senate Bill
267). This bill requires that increasing amounts
of Oregon state funds be focused on Evidence-Based
Practices (EBP). For 2005-07, the statute requires
that at least 25 percent of state funds used to
treat people with substance abuse problems who have
a propensity to commit crimes be used for the provision
of Evidence-Based Practices. The statute also requires
that 25 percent of state fund be used to treat people
with mental illness who use or have a propensity
to use emergency mental health services. In 2007-09,
the percentage of funds to be spent on EBPs increases
to 50 percent and in 2009-2011 to 75 percent.
The
shift to the delivery of services based on scientific
evidence of effectiveness is a major shift for both
the mental health and addiction treatment systems.
This shift includes a focus on lifelong recovery
for person with mental illness as well as those
with substance abuse disorders.
As
part of an effort to meet requirements outlined
in ORS 182.525 (Senate Bill 267) from the 2003 Legislative
Session, the Office of Mental Health and Addiction
Services (OMHAS) developed an operational definition
of evidence-based practices. The definition was
developed with broad community input before being
officially adopted by the office.
http://www.oregon.gov/DHS/mentalhealth/ebp/main.
shtml
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Comment:
Dr. Mee-Lee:
Your September '07 Tips & Topics focus on rote
documentation to please the overseers was dead on.
The issue to me seems to be to look at the purpose
of any particular paperwork and how is it facilitating
patient care. Often in site visits I'll come upon
a form or some other sort of spurious documentation
and ask "What's it for" and be told, "Don't
know. On our last survey they said to do it so we
just do it and they don't bother us about that anymore."
I started calling this superstitious documentation.
Once
on a bike ride I noticed some baggies of water stapled
to the rafters of a porch at a rural store. I was
staring up at them and the owner came out and I
asked, "What are those for?" He replied,
"Keeps the flies away." I asked how. He
responded: "We don't know, but it works."
"Earl has some at his BBQ and they don't never
get pestered by 'em, so we put 'em up."
I
think putting up baggies of water is what many of
us as treatment providers are doing in our documentation
in order to keep the flies away, or in our case,
not be pestered by surveyors. Hanging baggies of
water and filling out meaningless forms both seem
to qualify as superstitious behaviors. Then again,
maybe not as they are both effective in keeping
the flies away.
Bill
Garrett, MPH
Shoals Treatment Center
Muscle Shoals, Alabama
SOUL
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
I was listening to a report about the Tokyo Auto
Show and some of the concept cars Honda, Nissan
and others were showing. Nissan featured a car with
a little robot on the dashboard which speaks to
you and keeps you company. Apparently, people have
fewer accidents and are less likely to fall asleep
or have other tragic mishaps. The robot uses several
video cameras checking the driver's eyes, head movements,
body posture etc. to employ "mood recognition
technology". The robot processes this data
and "senses" whether you are falling asleep
at the wheel; or are building up to "road rage"
or some other potentially dangerous mood.
I guess this is not all that ridiculous. I just
started using one of those Global Positioning System
(GPS) gadgets in the car. It calculates and plots
out every turn to get you to your destination; and
"holds your hand" all the way until you
arrive safely. It not only anticipates and alerts
you to every turn of the way, but lovingly, without
scolding you, adjusts if you make a wrong turn and
gets you back on track. None of "I told you
so"; or "You just don't listen";
or "Dummy, what do you think you are doing?".
No wonder the guy in the funny car rental TV ads
tries to date and hook up with the "women"
in the GPS dashboard gadget. He is just so impressed
with how she is consistently there to guide his
every step, calmly speaking to him at every turn.
Perhaps it is a sorry commentary
on our lives that we could relate to talking robots
and machines even better than to a talking real
live human being. But then again, it would really
be nice to get a real live person to answer the
phone sometimes, especially if an intoxicated and/or
psychotic person calls to try to get some help.
That "your call is very important to us"
message doesn't seem very inviting or genuine.
I don't know what right balance
of technology and human contact is best. I would
rather use an ATM to deposit and get money than
stand in line to complete my transaction with a
live bank teller. But then it is really frustrating
to have to go through ten voice mail prompts in
order to talk to a real person. As I said, I don't
know what the right balance is and I don't have
time to ponder that any more deeply now---I've got
to go and check my voice mail and e-mail.
SHAMELESS
SELLING
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
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Until
Next Time
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
See you for the November issue.
David
Contact Information
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
email: info@dmlmd.com
phone: 530-753-4300 PACIFIC
web: http://www.dmlmd.com
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Copyright
2006 DML Training & Consulting | 4228 Boxelder
Place | Davis | CA | 95616
