The Biggest Stumbling Block Towards Individualised Professional De ...

The biggest barrier towards your professional development is not on how to get from zero to 10, but from zero to one.[1]
Many therapists struggle with systematically measuring their outcomes.

Because of this, they lack a clear baseline performance.

Photo by Bethany Legg

While the interest continues to grow for therapists in deliberate practice, it is hard to appreciate the effort and tenacity it takes to consistently measure outcomes, one client at a time, in a systematic and reliable manner.

Even though in this Frontiers… blog, I’ve talked alot about ways for an individualised professional development (we even developed a taxonomy to deal with identifying the activities for therapists to work on[2]), one cannot truly begin the journey without a system of measuring results.

Management guru Peter Drucker points out that what gets measured, get managed.

Without the information of your baseline performance, it’s very easy to lose track. For starters, your assumption of what to work on is typically based on ideology rather than reality.

Measurement Precedes Professional Development

In workshops, I repeatedly hear practitioners ask the following question (see also a previous post on this):

What does improvement mean?

Simply, improvement means get better results with your clients compared to your baseline performance.
Without a baseline information, you would be on a hamster wheel. Traveling without moving. Without a reference point, though with the best of intentions, how would you know what you are doing makes a den of a difference to your overall outcomes?

“Am I Getting Any Better?”

Finally, one of the biggest source of therapist’s personal frustration and burnout —one that is often left unspoken— is the unanswered question “Am I get any better?” (This is an important question. Besides, real development is inoculative of burnout).

Recent studies suggest that on average, we do NOT get better over time.[3] Yes, that’s right. Experience is not predictor of better outcomes. And even though we hail clinical supervision as our “signature pedagogy,” our efforts in this tradition doesn’t help us improve on our outcomes.[4] I know, it’s not the most uplifting news.

What stands in the way of a concerted attempt at routine outcome monitoring, is not because of a lack of will, but a lack of a system.[5]

We need a system of practice in order for deliberate practice to happen.

A system of practice means:

1. Pre-commitment

Pre-decide what measures you are going to use, and use it with EVERY client at EVERY session. Remember, do not simply value what you measure, measure what is of value.

As a pre-commitment device[6], if you are starting out employing routine outcome monitoring (ROM) in your practice, suspend any judgement about the utility of the measures, until you have completed at least 20-30 closed cases using outcomes and alliance measures. Once you get to that phase, that is where the fun begins (and the road to a real personalised professional development). You can start to get an idea of your outcomes!
As a pre-commitment, you must trust the tangible BENEFITS. If you need to be convinced, read the evidence[7]. This not in short supply. Ultimately, committing to measuring your outcomes one-client-at-a-time, requires you to think the long-game.

2. Make it Easy on Yourself

Make sure the forms are readily available in your practice desk. Better yet, use some online tool to help you manage this.
Check out:

Myoutcomes.com
pragmatictracker.com
fit-outcomes.com
Open Fit

Test drive them. Myoutcomes.com, fit-outcomes.com and Open Fit provide the use of the Outcome Rating Scale (ORS) and Session Rating Scale, PLUS algorithms running at the back to compare with trends of “successful” and “unsuccessful” cases as you move from session to session. Pragmatictracker.com does not provide such algorithms, but the plus side for PT is that you can customise various type of measures you want to use in your clinical practice, alongside the ORS and SRS as well.

(I get asked a lot on what I use. I employ the ORS and SRS at every session, and I combine this with the Clinical Routine Outcome Evaluation-10 at the first, fifth and every five sessions onwards. The CORE-10 gives me quick valuable information that I consider important in my work, especially at the first session, such as risk, intrusive memories, and social support).

3. Make The Benefits Visible

Graph out the progress in each session. Make the graph visible to you and your client. Feed this back to your client, and make the information come alive into the flesh and bones of the therapy hour. Use this as a springboard. Let the feedback feed-forward. Use this not just as an assessment tool, but a conversational tool.

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Just like the GP’s use of a thermometer, there is nothing magical about the use of feedback tools. The use of feedback measures gives us the attentional cue on what to look out for.

Ultimately, remember this:

Professional Development = Evaluating + Improvement

While it’s not the most attractive, we often neglect the Evaluation component of the equation (Ironically, organisations tend to harp more on evaluation, and much less on helping therapists improve. You can tell when all they are insistent on capturing just the pre-post session outcomes, and not helping practitioners weave this piece of information into the sessions.)

So the question is, do you know how effective you are? If so, how do you get from zero to one?

I love to hear your thoughts about this. Send in your comments below.

Footnotes:
[1] I’ve borrowed this terminology from Peter Thiel’s book, Zero to One.
[2] Email me at daryl@darylchow.com to receive a copy of the Taxonomy of Deliberate Practice Activities (TDPA)

[3] Goldberg, S. B., Rousmaniere, T., Miller, S. D., Whipple, J., Nielsen, S. L., Hoyt, W. T., & Wampold, B. E. (in press). Do psychotherapists improve with time and experience? A longitudinal analysis of real world outcome data. Journal of Consulting and Clinical Psychology., 63(1), 1-11. doi:http://dx.doi.org/10.1037/cou0000131

[4] Rousmaniere, T. G., Swift, J. K., Babins-Wagner, R., Whipple, J. L., & Berzins, S. (2014). Supervisor variance in psychotherapy outcome in routine practice. Psychother Res, 1-10. doi:10.1080/10503307.2014.963730

[5] See Full Circles: Reflections on Living blog, When Someone Says “I Lack the Discipline.” 

[6] I highly recommend you listen to a Freakonomics podcast episode on this topic, http://freakonomics.com/podcast/when-willpower-isnt-enough-a-new-freakonomics-radio-podcast/

[7] For some examples, see the follow papers (many of the articles are downloadable here: https://independent.academia.edu/DarylChow)

Chow, D. (2017). The practice and the practical: Pushing your clinical performance to the next level. Prescott, David S [Ed]; Maeschalck, Cynthia L [Ed]; Miller, Scott D [Ed] (2017) Feedback-informed treatment in clinical practice: Reaching for excellence (pp 323-355) x, 368 pp Washington, DC, US: American Psychological Association; US, 323-355.

Chow, D. L., & Lu, S. (2015). The use of routine outcome monitoring in an asian outpatient psychiatric setting. Paper presented at the World Federal of Mental Health., Singapore.
Miller, S. D., Bargmann, S., Chow, D., Seidel, J., & Maeschalck, C. (2016). Feedback-informed treatment (FIT): Improving the outcome of psychotherapy one person at a time. O’Donohue, William [Ed]; Maragakis, Alexandros [Ed] (2016) Quality improvement in behavioral health (pp 247-262) ix, 327 pp Cham, Switzerland: Springer International Publishing; Switzerland, 247-262.
Miller, S. D., Hubble, M. A., Chow, D. L., & Seidel, J. A. (2015). Beyond measures and monitoring: Realizing the potential of feedback-informed treatment. Psychotherapy, 52(4), 449-457. doi:http://dx.doi.org/10.1037/pst0000031
Miller, S. D., Hubble, M. A., Seidel, J. A., Chow, D., & Bargmann, S. (2014). Feedback Informed Treatment (FIT): Achieving clinical excellence one person at a time. Independent Practitioner, 34(3), 78-84.
Miller, S. D., Hubble, M. A., Chow, D. L., & Seidel, J. A. (2013). The outcome of psychotherapy: Yesterday, today, and tomorrow. Psychotherapy, 50(1), 88-97. doi:10.1037/a0031097
Wampold, B. E., & Imel, Z. E. (2015). The great psychotherapy debate: The evidence for what makes psychotherapy work (2nd ed.). New York, NY: Routledge/Taylor & Francis Group; US.