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What's New?

This topic is devoted to emerging research related to feedback informed treatment along with research activities of ACORN member organizations. The topic is now 10 years old, so some posts are not so new....in which case, enjoy the retrospective look at what was once new.

ACORN Scientific Advisory Committee

  • The committee was organized in June of 2017 to helps guide the ongoing research activities of the ACORN Collaboration.
  • Follow the discussions and findings of the ACORN research community at: Scientific Advisory Committee

The evidence show we can improve outcomes....Here's how.

  • Improving_Outcomes-ACORN_Results_and_QA_initiative-BriefReport.pdf
  • This report provides the strongest evidence to date that therapists can significantly increase the effect size using feedback informed treatment
  • The magnitude of effect size increase is strongly associated with the amount of time therapist spend reviewing their results.
  • Implications for quality improvement are discussed.

What your therapist doesn't know

This a great article on feedback informed treatment that appears in the Atlantic.

What Barack Obama's high school math teacher has to say about psychotherapy.

More evidence that therapists can improve their outcomes...

This is a case study of one agency that set up to improve their outcomes. While this agency wasn't a part of the ACORN collaboration, there are certainly valuable lessons to be learned from this case study.

Humana providers increased effect size

The report shows changes effect size for 19 large practices/agencies participating in the Humana Feedback Informed Treatment Initiative. The effect sizes for a baseline period (the first 6 months of participation) are compared to the effect sizes during the follow-up period (first 6 months of 2016). Twelve (63%) of the practices/agencies showed an increased effect size.

During the baseline period, 4 sites (21%) has a effect size of .8 or greater. At follow-up, 13 (63%) of the sites has an effect size of .8 or higher. The average gain in effect size for all sites combined was over 15% (.71 effect size at baseline, .82 effect size at follow-up).

For more information, go to: Humana Results for FIT Initiative

Are therapist effective across multiple domains, or is their effectiveness more specific?

ACORN generated data suggests that therapists' effectiveness is global rather than specific. This recently published article using data from different sources and different questionnaires comes to the same conclusion.

Eating disorders program reports dramatic improvement in outcomes after joining the ACORN collaboration.

The Columbus Park eating disorders treatment center in New York City reports dramatic improvement in their outcomes over the past year. They are using their results to market their services.

What do we know about psychotherapy and what is the left to debate?

Many ACORN users are familiar with the work of Bruce Wampold, Ph.D and the impact he has had on the development of ACORN and the underlying assumptions and statistical procedures built into the Decision Support Toolkit. He is a co-author on many of the articles describing the methodology for benchmarking outcomes. His recent book, along with co-author Zac Imel Ph.D. provides a compelling and comprehensive review of what we have learned from over 40 years of psychotherapy research. The article summarizes their findings.

The Relationship of Decline in Spiritual Struggles to Psychotherapy Outcomes

A number of sites in the ACORN collaboration have been exploring the relationship between spiritual issues and psychotherapy outcomes. The results are now published. This has major implications for faith based counseling services.

Scale Survey of Psychotherapy Clients

Should we aim for cured, doing better or still working on it?

Long time ACORN collaborator and supporter Ed Jones, Ph.D. recently published a piece of the changing demands on behavioral health providers.

Use mobile forms for rapid viewing of data.

Almost all of the ACORN questionnaires can now be completed on any device with a browser...smart phone, tablet, you name it. When questionnaires are completed in this way, you can view the completed questionnaire immediately in your Toolkit. Within 4 to 8 minutes, you can also viewed the scored results, including the change graphs.

How is the accomplished, with so many different questionnaire and so many different norms including norms for different diagnostic groups?

Every 4 minutes, the ACORN system reads in all of the data... over 830,000 cases and 2,250,000 questionnaires, employing a server with 12 processors and 68 gigabytes of RAM. Everything is recalculated, including using multivariate statistics to calculate projected change and severity adjusted effective. The ACORN clinical algorithms to generate the clinical messages are then applied. Then all new data is output to the Toolkit for your use. At which point, the cycle begins again.

Are you any good... as a therapist?

Bruce Wampold and others have argued that therapist have an ethical obligation to know their own results. The ACORN Toolkit provides therapists with this information, and automatically provides reports which adjust for both case mix and sample size. This article described the distribution of Severity Adjusted Effect Size for a sample of 2820 therapists using the ACORN Toolkit. This article allows ACORN users to estimate their percentile rank bases on their average Severity Adjusted Effect Size.

Three ways to improve out psychotherapy effectiveness

Bruce Wampold, PhD, one of the best known psychotherapy researchers of the past two decades has recently published this article on how to improve psychotherapy outcomes.

Article describing the ACORN collaboration

The APA journal Psychotherapy devoted an entire issue to advances in systems for measuring and improving outcomes. Here is the link to the article on ACORN. This not only describes ACORN, but presents information on factors associated with improved outcomes.

Second Edition of the Great Psychotherapy Debate is available!

The second edition of Bruce Wampold's game changing the Great Psychotherapy Debate is now available. Withe the help of co-author Zac Imel, new edition incorporates findings from the explosion of studies in the last decade, and provides the most comprehensive and up to date summary of what we have learned from 40 years of psychotherapy research. This book is a must read for any serious student of psychotherapy research, yet is also written in a manner accessible to the average clinician.

New ACORN Well-being Questionnaire

ACORN participated in an exciting project to develop a new Well-being & Life Satisfaction questionnaire in collaboration with the Institue for Health and Productivity Management (IHPM). The questionnaire is designed for use in the workplace, and IHPM is presently approaching a number of large employers internally to begin using the new questionnaires.

For more information on the development of the questionnaires, its psychometric properties, a link to the journal article describing the new measure see: New Quality of Life/Well-being Questionnaire

Evolution of psychotherapy: An Oxymoron?

This is a video of Scott Miller's address at the 2013 Evolution of Psychotherapy Conference.

What predicts improved outcomes for individual clinicians?

They ACORN system has collected outcomes for hundreds of therapists over multiple years. This analysis looks at what behaviors predicts improvement in results from one year to the next. This data indicates that clinicians can show significant gains in effective from one year to the next.

Upward trend in outcomes for ACORN participants!

This brief report summarizes the outcomes patients using the ACORN questionnaires based on the number of years the organization providing care has utilized the ACORN tools. Factors associated with improved outcomes include consistency of use of the questionnaires and the frequency with which clinicians log into the ACORN Decision Support Toolkit.

You don't have to believe for the magic to work!

We all know that placebos are effective for a wide range of medical problems, but do they work if the patient is told that they are taking a "sugar pill" with no active ingredients? Apparently that depends on how you explain it, as this novel studies demonstrates. This is a study that begs to be replicated!

For more on this study and related articles, and to play an audio tape by the primary author, Ted J. Kaptchuk, OMD of Harvard Medical School go to:

Newsweek Cover Story: The Depressing News About Antidepressants

The title says it all. The secret is out in the open and we can no longer ignore the fact that the scientific evidence for the efficacy of the antidepressants is nowhere near as strong as commonly believed by patients and doctors. For many patients, it appears that the risk may well outweigh the benefits. Every clinician should be familiar with this research and know how to respond factually to their patients' questions about antidepressants.

We have strong evidence that psychotherapy works, even for patients with severe depression. We also know that the relationship with the treating clinician is critical to the outcome, whether the treatment is pharmacological, psychological, or some combination of the two. We also have strong evidence that the routine use of outcome and alliance questionnaires, combined with continuous feedback to the clinician, results in better outcomes for patients.

The demonstrated benefits from outcomes informed care can be an antidote for any despair resulting from loss of faith in the medications.

For more on this subject, see the new edition of the Heart & Soul of Change.

Heart & Soul of Change

The new edition of Heart & Soul Change from APA Books is now available. Edited by Duncan, Miller, Wampold and Hubble (2009), the 2nd edition of this landmark book provides an updated review of the literature on what really makes a difference in behavioral health outcomes, with contributions from many of the leading researchers in the country. The book provides a compelling case for the benefits of outcomes informed care.

  • �when effects of treatments are noted, who provides the treatment, the quality of the alliance, and the clinician and recipient's expectations for success provide a far better explanation of the results than any presumed specific effects due to the medications.� - Jacqueline Sparks et al.; page 221

  • �The use of outcomes management systems is ushering in a significant change in how psychotherapy is conducted. This review underscores the value of monitoring treatment response, applying statistical algorithms for identifying problematic cases, providing timely feedback to therapists (and clients), and providing therapists with problem-solving strategies. It is becoming clear that such procedures are well substantiated, not just matters for debate or equivocation. When implemented, these procedures enhance client outcome and improve quality of care.� - Michael Lambert; page 259

Placebos Are Getting More Effective. Drugmakers Are Desperate to Know Why.

  • Brief summary: The title says it all. This Wired Magazine article by By Steve Silberman (08.24.09) provides a concise and fascinating summary of the history of placebos in clinical trials, and the awkward fact that placebos appear to be getting more effective while the new investigational drugs are not. The "placebo problem" is costing big pharma potentially billions of dollars in lost revenues and stock value due to "promising new drugs" which never make it to the market because they can't beat the growing effect size for placebos. It is possible that big pharma created this problem for themselves through effective marketing of the idea that there is an exciting new drug for everything. It's a serious enough problem that the pharmacuetical industry is getting very serious about collaborating on placebo research. Secretly, of course.

Depression drugs don�t work, finds data review

The Times (UK) February 26, 2008
  • Brief summary: News report of new study by Irvin Kirsch, Ph.D., who is now at the University of Hull. This study is one of a number he has published based on analyzes of the actual FDA data on antidepressants, as opposed to what gets published in peer reviewed journals (see the following article). Essentially, the finding is that SSRIs are nowhere near as effective as claimed by the pharmaceutical industry, and for most patients are probably no better than placebo.

Selective Publication of Antidepressant Trials and Its Influence on Apparent Efficacy

New England Journal of Medicine, Volume 358:252-260, January 17, 2008.
  • Erick H. Turner, M.D.
  • Annette M. Matthews, M.D.
  • Eftihia Linardatos, B.S.
  • Robert A. Tell, L.C.S.W.
  • Robert Rosenthal, Ph.D.

  • Brief summary: Evidence-based medicine is valuable to the extent that the evidence base is complete and unbiased. Selective publication of clinical trials � and the outcomes within those trials � can lead to unrealistic estimates of drug effectiveness and alter the apparent risk�benefit ratio. In other words, don't necessarily trust the results that get published. This is the most recent analysis of FDA data on antidepressants that finds that the effect sizes reported in peer reviewed journals significantly misrepresent the true efficacy of the medications. This is due to publication bias in favor of studies with large effect sizes. From a review of published clinical trials for 12 antidepressant agents, it appears that over 94% of the trials were positive for the medication. However, among 74 FDA registered studies, only 51% were positive for the drug. Out of 38 registered studies with positive effects, 37 were published. Of the 36 studies with negative or questionable outcomes, only 3 were published in a manner that accurately reflected the findings of the study.

Psychiatrist effects in the psychopharmacological treatment of depression.

Journal of Affective Disorders, Vol 92(2-3), Jun 2006. pp. 287-290.
  • McKay, Kevin M., University of Wisconsin, Madison, WI, US, kmmckay@wisc.edu
  • Imel, Zac E., University of Wisconsin, Madison, WI, US
  • Wampold, Bruce E., University of Wisconsin, Madison, WI, US

  • Brief summary: This study performed a reanalysis of the the National Institute of Mental Health Treatment of Depression Collaborative Research Program study data to determine if the subjects' response to medication was dependent on which psychiatrist prescribed the medication. Data from 112 patients seen by 9 psychiatrists from the NIMH TDCRP study was reanalyzed using HLM. The percentage of variance in the BDI scores due to medication was 3.4% (p<.05), while the percentage of variance due to psychiatrists was 9.1% (p<.05). The percentage of variance in the HAM-D scores due to medication was 5.9% (p<.05), while the percentage of variance in HAM-D scores due to psychiatrist was 6.7% (p=.053). Psychiatrist effects were greater than the treatment effects. In this study, both psychiatrists and treatments contributed to outcomes in the treatment of depression. Given the fact that psychiatrists were responsible for more of the variance in outcomes than the medications, the authors concluded that effective psychiatrists can augment the effects of the active ingredients of anti-depressant medication as well as placebo.

Supershrinks: What is the secret of their success?

Psychotherapy Networker; November/December, 2007
  • Scott Miller, Ph.D.
  • Mark Hubble, Ph.D.
  • Barry Duncan, Ph.D.

  • Brief summary: This provocative article takes a fresh look at how a therapist can become a "supershrink" by drawing from other research on how top performers in other fields achieve their results. Is it talent or hard work? In any case, performance feedback is critical.

To Reap Psychotherapy�s Benefits, Get a Good Fit

New York Times, August 20, 2007
  • RICHARD A. FRIEDMAN, M.D.

  • Brief summary: This article summarizes findings of a recently published article by Micheal Lambert, Ph.D. and colleagues regarding the role of outcomes measurement and feedback in improving treatment outcomes.

Monitoring patient improvement and treatment outcomes in managed behavioral healthcare

Journal for Healthcare Quality, March-April 2007
  • Francisca Azocar
  • Brian Cuffel
  • Joyce McCulloch
  • John McCabe
  • Shanna Tani
  • Benjamin Brodey

  • Brief summary: This study examined the use of outcomes reports sent to clinicians by a managed behavioral healthcare organization to monitor patient progress and its relation to treatment outcomes. Results showed that clinicians who reported using outcome information had patients who also reported greater improvement at 6 months from baseline. Let's hear it for outcomes informed clinicians!!

Abandoning our Utopian fantasies

Behavioral Healthcare, June 2007
  • Ed Jones, Ph.D.; Senior Vice President of National and Health Plan Accounts, ValueOptions

  • Brief summary: This is one of the most cogent articles presenting the business argument for the importance of outcomes informed care that I have encountered.

Ed Jones is on the Advisory Board of ACORN, and while Executive Director of Summit Centers utilized ACORN as part of their outcomes management program.

A Review of Methods to Measure Health Related Productivity Loss

American Journal of Managed Care, April, 2007.

  • Soeren, Mattke, MD
  • Aruna Balakrishnan, BS
  • Giacomo Bergamo, BS
  • Sydne Newburry, Ph.D.

  • Brief summary: This review article is based on a systematic search of published and grey-market research literature between 1995 and 2005 on methods of estimating and monitoring productivity loss. This is an excellent article for anyone interested in how to measure productivity gains resulting from mental health treatment. The whole article is available on line (click on the title above).

Therapist Effects in Outpatient Psychotherapy: A Three-Level Growth Curve Approach.

Journal of Counseling Psychology, Vol 54(1), Jan 2007. pp. 32-39.
  • Lutz, Wolfgang, Department of Psychology, University of Berne, Berne, Switzerland, wolfgang.lutz@psy.unibe.ch
  • Leon, Scott C., Department of Psychology, Loyola University, Chicago, IL, US
  • Martinovich, Zoran, Department of Psychiatry and Behavioral Sciences, Northwestern University Medical School, Chicago, IL, US
  • Lyons, John S., Department of Psychiatry and Behavioral Sciences, Northwestern University Medical School, Chicago, IL, US
  • Stiles, William B., Department of Psychology, Miami University, Oxford, OH, US

  • Brief Summary: This study assessed the amount of variance in change in symptom intensity scores in a large naturalistic data set (1,198 patients and 60 therapists, who each treated 10-77 of the patients). Results indicated that approximately 8% of the total variance and approximately 17% of the variance in rates of patient improvement could be attributed to the therapists.

An Analysis of Therapist Treatment Effects: Toward Providing Feedback to Individual Therapists on Their Clients' Psychotherapy Outcome.

Journal of Clinical Psychology, Vol 62(9), Sep 2006. pp. 1157-1172.
  • Okiishi, John C., Brigham Young University, Provo, UT, US
  • Lambert, Michael J., Brigham Young University, Provo, UT, US, michael_lambert@byu.edu
  • Eggett, Dennis, Brigham Young University, Provo, UT, US
  • Nielsen, Lars, Brigham Young University, Provo, UT, US
  • Dayton, David D., Brigham Young University, Provo, UT, US
  • Vermeersch, David A., Loma Linda University, Loma Linda, CA, US

  • Brief Summary: This exciting new study analyzed outcomes from over 5,000 clients seen by 71 therapists over a 6-year period at the Brigham Young University Counseling Center. Data was analyzed using hierarchical linear modeling (HLM) to see if general therapist traits (i.e., theoretical orientation, type of training) accounted for differences in clients' rate of improvement and then again using HLM with therapists as a fixed effect, to evaluate if therapists differed in the efficiency of treatment. General therapist traits did not account for differences in outcome, while a significant amount of variation was found among therapists' clients' rates of improvement. Therapist received feedback on their outcomes as compared to center averages in an attempt to improve client outcome.

Therapist effects in psychotherapy: A random-effects modeling of the National Institute of Mental Health Treatment of Depression Collaborative Research Program data.

Psychotherapy Research, Vol 16(2), Mar 2006. pp. 161-172.
  • Kim, Dong-Min, University of Wisconsin-Madison, Madison, WI, US
  • Wampold, Bruce E., University of Wisconsin-Madison, Madison, WI, US, wampold@education.wisc.edu
  • Bolt, Daniel M., University of Wisconsin-Madison, Madison, WI, US

  • Brief summary: Data from the two psychotherapy conditions of the National Institute of Mental Health Treatment of Depression Collaborative Research Program was analyzed to estimate the proportion of variability in outcomes resulting from therapists. The results indicated that about 8% of the variance in outcomes was attributable to therapists, whereas 0% was due to the particular treatment delivered. In contrast to previously reported results, when therapist effects were appropriately modeled, differences in efficacy between the two psychotherapy conditions for more severely depressed patients disappeared, as predicted by methodological considerations.

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