Feedback Informed Treatment Series

Note: This is a compilation of Frontier Friday, a weekly Substack published, originally released on 17 Apr. 2021

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PART I

1. Research: Science of FIT Implementation 
   Heidi Brattland, John Morten and colleagues did a good RCT study examining the implementation of FIT into their agency in Norway. They found that the feedback group were more than 2x likely to achieve improvement, compared to the no-feedback group.
   
   This finding was similar to the one that my colleague Sharon Lu and I did in naturalistic outpatient setting in Singapore, 2009 (Click here to see the poster.)
   
   (Watch this short interview my colleague/friend/mentor Scott Miler did with the lead researcher, Heidi Brattland.)
    
2. Research: Critique of FIT
   Ole Østergård did his doctoral work based on 3 publications examining the effectiveness and moderators of FIT. 
   In one of their meta-analysis, the researchers found that the “effects” of FIT is small.
   Take a look for yourself before moving on to the next recommendation. 
    
3. Read: Does This Mean That FIT is Not Working?
   My colleague Susanne Bargmann wrote a good blogpost addressing some of the implementation issues (e.g., some studies that were included in the meta-analysis had 1-12hrs of training, whereas studies like Brattland and colleagues indicate that proper implementation takes more time than simple learning to administer the measures).
   To read this blogpost in English, click here.
    
4. Research: Latest Meta-Analysis
   Can you believe it that there’s now nine meta-analyses being done on examining studies on the effects of feedback tools? 
   Just this year, a new one is being published by Kim de Jong and colleagues. They looked at 58 studies in total, using a broader inclusion criteria and more sophisticated statistical analysis (multi-level modeling)
   
   Here’s the key grafs of what they found: 
   – small positive effect on symptom reduction
   – reduction in dropout rates
   
   Once again, measurement by itself shouldn’t be seen as a silver bullet. It is what we do with the feedback to feed-forward into the treatment process that really counts.
    
5. Words Worth Contemplating: 
   The quality of your feedback determines the quality of your learning.

Reflection:

Do you use measures in therapy? If so, do you use them as an assessment tool or a conversational tool?

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PART II

1. From My Desk: Peak vs Typical Performance
   Peak performance is greatly admired. But I would argue that there are another group of people who deserves better recognition. They are not peak performers. In fact, what they do is considered ‘typical’.
   Read on to find out why this is highly relevant to you.
    
2. Read: Feedback-Informed Treatment in Clinical Practice: Reaching for Excellence
   A few years ago, colleagues from all over contributed to an excellence edited book on the use of implementing FIT in a variety of settings (e.g., agencies, private practice, child and adolescence, addiction). 
   This also included a final chapter from me on “The Practice and the Practical: Pushing Your Clinical Effectiveness to the Next Level.” 
    
3. Resources: FIT Manuals
   If you are new to the use of feedback measures, this 6 series of manuals by the International Center of Clinical Excellence (ICCE) is the nuts and bolts for understanding and using the tools.
    
4. Watch: FIT in Child Protection Statutory Services
   I first began as a youth worker before practicing as a psychologist since 2004. And in 2010, I moved to Australia to do my doctoral. While I was downunder, I was fortunate enough to link up with a team that did therapy in an unusual way. We worked with kids who were under  child protection. We worked with them on an outreach basis. In other words, they do not come to our office. We met them at skateparks, shopping malls, walking trails and hung out on park benches. 
   Given my background, I was delighted to watch this interview Scott Miller did with 3 practitioners from Denmark, Rasmus, Tine and Mette who implemented the ideas of FIT in their child protection services agency.
   
   Their key findings: 
   (1) 50% fewer kids placed outside the home;
   (2)100% decrease in complaints filed by families against social service agencies and staff;
   (3) 100% decrease in staff turnover and sick days.
    
5. Words Worth Contemplating (according to my Mrs.): 
   “The single biggest problem with communication is the illusion that it has taken place.” ~ George Bernard Shaw.

Reflections:

Instead of simply valuing what we are asked to measure, how do we get closer to measuring what we value?

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PART III

Since using measures in 2004 in therapy, I’ve thought long and hard about this, and I can’t see a viable alternative. In a sea of complexity, the numbers derived in measures tell me an important language alongside client’s qualitative descriptions. I can’t simply defer decision making to quantitative numerics, but the combination of clinical data + clinical intuition helps me to make better clinical decisions.
In our Part III about FIT, we are going to visit some practical bits about the nuance of how to integrate the use of measures in meaningful ways.

And in case you missed it, here’s FIT and from previous newsletters.

1. New From My Desk: Wait…Why Measure? 
   Short answer: to be adaptive.
   
   
   
   
   Long answer: Watch this video.
   
   
2. From The Same Desk: How to Receive Feedback & How to Get Better at Eliciting Feedback
    
3. Research: The Power of Feedback John Hattie and Helen Timperley (2007)
   One of my favorite “synthesiser” of the learning literature is John Hattie. 
   In this 2007 article with Helen Timperley, they examined the potency of feedback on the impact of learning. 
   Click on this link to see my highlights for this article. 
   One critical piece that we don’t often make the distinction is the difference between performance feedback and learning feedback. 
   
   Key feedback framework proposed in this article: 
   i. Feed-Back
   ii. Feed-Forward
   iii. Feed-Up
   
   (See also the book Visible Learning and the Science of How We Learn by John Hattie and Gregory Yates).
    
4. Tech Recommendations:
   There are a bunch of FIT systems that helps you track outcomes. Here are the ones I recommend that are worth checking out. 
   i. myoutcomes.com (this is one that I use)
   ii. fit-outcomes.com (many people I consult use this too)
   iii. Open-Fit
   iv. Pragmatic Tracker (I am also familiar with this as the hospital and group practice I previously worked in used this)
   
   The first three uses the outcome rating scale and session rating scales as part of the PCOMS system. They all have a fancy predictive algorithm running in the background that gives you hints if your client is on-track or off-track of a successful outcome, session by session. While Pragmatic Trackers doesn’t have this, PT is that allows you to use other outcome measures i.e., customisable. 
   
   Note: While I do use myoutcomes, I also have a manual “macro” spreadsheet to give me a bird’s eye view of my case load, as well as paper graphs for each client. This is overkill to many, but I simply love the flexibility and less “friction” involved in the use of a spreadsheet. Plus, I use other measures at regular intervals… I still trying to find a sweet spot of balance with the use of tech to manage my work.
    
5. Words Worth Contemplating (according to my Mrs.): 
   “If there is anything unique about the human animal, it is that it has the ability to grow knowledge at an accelerating rate while being chronically incapable of learning from experience.”
   ~ John Gray, The Silence of Animals.
   
    

Reflection:

Technology has advanced tremendously in recent decades. It’s there at the palm of our hands.

What does it take to deepen and evolve our conversations? How are we creating spaciousness, so as to listen to each other into speech?

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PART IV

1. From My Desk: To Get Useful Feedback, Seek Contrast
   
   This has been one tip that continues to pay dividends, so long as I keep the graphs visible to both my client and I. 
    
2. From the Same Desk: Value What We Measure Or Measure What We Value
   
   It’s much easier to simply compile with what we are asked to measured, then it is to think clearly about measuring what is of value. 
   
   
3. Research: Cost Effectiveness of Feedback Informed Treatment
   This is hot-off-the-press. A new study from the UK by Jamie Deligadillo and colleagues was just released about the economic evaluation of using a system like FIT to guide treatment. 
   
   Key grafs: 
   – Compared to usual care, FIT was associated with an increased probability of reliable symptomatic improvement by 8.09 percentage points (95% CI: 4.16% to 12.03%) which was statistically significant (as measured by patient-reported depression [PHQ-9] and anxiety [GAD-7] measures)
   – The incremental cost of FIT was £15.17 (95% CI: -£6.95 to £37.29) per patient and was not statistically significant.
    
4. Research: Beyond Measures and Monitoring (Miller, Hubble Chow & Seidel, 2015)
   Here’s one article from our team that might be useful to you as we explored the potentials of integrating FIT into practice.
   (This is available via ResearchGate)
    
5. Words Worth Contemplating: 
    “People are united by questions. It is the answers that divide them.”
   ~ Elie Wisel
   

Reflection:

An overemphasis on performance can impede learning (listen to this podcast episode)

Does the use of measure help you to perform or to learn?

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