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Featured Expert Review
Feedback Informed Treatment (FIT): Achieving Clinical
Excellence One Person at a Time
— Scott D.Mil...
cally significant change, decreases drop-out rates by as
much as 50%, and cuts deterioration rates by one-third
(Miller, 20...
Such programs are especially useful in large and busy
group practices and agencies. Detailed descriptions
of the other app...
simple. Using the ORS and SRS, the outcomes and alli-
ance ratings of 205 couples in therapy were gathered
during each tre...
talent (Ericsson, Nandagopal, & Roring, 2005; Erics-
son, Roring, & Nandagopal, 2007), nor is it reflected
by degrees earne...
OneTherapist at aTime
“A man walking is never in balance, but always
correcting for imbalance.”
Gregory Bateson
Taken toge...
Ericsson, K. A. (2007). An expert-performance perspective
of research on medical expertise: the study of clini-
cal perfor...
Nissen-Lie, H. A., Monsen, J. T., & Ronnestad, M. H. (2010).
Therapist predictors of early patient-rated working alli-
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Feedback informed treatment (fit) achieving(apa ip miller hubble seidel chow bargmann 2014

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Feedback informed treatment (fit) achieving(apa ip miller hubble seidel chow bargmann 2014

  1. 1. Featured Expert Review Feedback Informed Treatment (FIT): Achieving Clinical Excellence One Person at a Time — Scott D.Miller,Mark A.Hubble,Jason A.Seidel,Daryl Chow,& Susanne Bargmann “It is the big choices we make that set our direction. It is the smallest choices we make that get us to the destination.” —Shad Helmstetter Clinical psychology outcomes research and stud- ies of high performance in other fields indicate that the critical factors separating high-per- forming psychotherapists from average therapists have little to do with experience or the use of empirically- supported treatments. Instead, there appear to be systematic differences in how practitioners implement the tools of their trade (regardless of their therapeu- tic orientation). As therapists shift their focus from traditional methods of accumulating knowledge and experience toward a more empirically-supported meth- odology for improving performance (including the formal collection of feedback, a stance of non-defensive openness, and individually tuned programs of delib- erate practice), evidence suggests that the individual practitioner will be able to achieve superior outcomes, measure these outcomes, and compete more effectively in the behavioral healthcare marketplace. A “great debate” is raging in the field of psychotherapy (Wampold, 2001). On one side are those who hold that behavioral health interventions are similar to medi- cal treatments (Barlow, 2004). Therapies work, they believe, because like penicillin they contain specific ingredients remedial to the disorder being treated. Consistent with this perspective, emphasis is placed on diagnosis, treatment plans, and adherence to so-called “validated” treatments (Siev, Huppert, & Chambless, 2009; Huppert, Fabbro, & Barlow, 2006; Chambless & Ollendick, 2001). The “medical model,” as it is termed, is arguably the dominant view of how psychotherapy works. It is also the view held by most people who seek behavioral health treatment. On the other side of the debate are those who argue that improvements in effectiveness, and ultimately, clinical excellence, will not be achieved by mimick- ing the practices of medicine. In fact, they hold that psychotherapy is fundamentally incompatible with the medical view (Wampold, 2001; Duncan, Miller, Wampold, & Hubble, 2010; Hubble, Duncan, & Miller, 1999). Proponents of what has been termed the “con- textual” perspective highlight the evidence for the lack of differential effectiveness among the 250 compet- ing psychological treatments, suggesting instead that the efficacy of psychotherapy is more parsimoniously accounted for by a handful of curative factors shared by all (Lambert, 1992; Miller, Duncan, & Hubble, 1997). While each therapist offers their own particular frame- work for treatment, of particular importance from this contextual point of view are extratherapeutic factors and the therapeutic relationship. The former refer to strengths, resources, life-circumstances—variables that clients bring to treatment. The therapeutic relationship includes the emotional bond between the participants and agreements on goals and tasks. The challenge for practitioners striving to achieve excellence—given the sharply diverging points of view and dizzying array of treatments available—is know- ing what to do, when to do it, and with whom. For the independent practitioner, these questions are especially pressing as therapists continue to lose their share of a market that increasingly looks for faster, cheaper, more effective solutions to psychological and rela- tional problems. Thankfully, recent developments are on track to providing an empirically robust and clini- cally feasible answer to the question of “What works for whom?” Based on the pioneering work of Howard, Moras, Brill, Martinovich, and Lutz (1996) and others (c.f., Lambert, 2010; Brown, Dries, & Nace, 1999; Miller, Duncan, & Hubble, 2005; Duncan et al., 2010), this approach transcends the “medical versus contextual” debate by focusing on routine, ongoing monitoring of engagement in and progress of therapy (Lambert, 2010). Such data, in turn, are utilized to inform decisions about the kind of treatment offered as well as whether to continue, modify, or even end services. Indeed, multiple, independent randomized clinical trials now show that formally and routinely assessing and discuss- ing clients’ experience of the process and outcome of care effectively doubles the rate of reliable and clini-
  2. 2. cally significant change, decreases drop-out rates by as much as 50%, and cuts deterioration rates by one-third (Miller, 2010). Excellence is within the reach of all clinicians, whether aligned primarily with the medical or contextual views of psychotherapy. In short, they can benefit by using feedback to improve the outcome of the services they offer one person at a time. What Kind of Feedback Matters? “If we don’t change direction, we’ll end up where we’re going.” Professor Irwin Corey Feedback-informed treatment or FIT is based on several well-established findings from the outcome literature. The first is: psychotherapy works. Studies dating back over 35 years document that the average treated person is better off than 80% of the untreated sample in most studies (Duncan et al., 2010; Smith & Glass, 1977; Wampold, 2001). Second, the general trajectory of change in successful treatment is pre- dictable, with the majority of measured progress occurring earlier rather than later (Brown, Dreis, and Nace, 1999; Hansen, Lambert & Forman 2002). Third, despite the proven efficacy of psychotherapy, there is considerable variation in both the engagement in and outcome of individual episodes of care. With regard to the former, for example, available evidence indicates that as many as 50% of those who initiate treatment drop out before achieving a reliable improvement in functioning (Bohanske & Franczak, 2010; Kazdin, 1996; Garcia & Weisz, 2002; Swift & Greenberg, 2012; Wierzbicki & Pekarik, 1993). With regard to the latter, significant differences in outcome exist between prac- titioners. Indeed, a large body of evidence shows that “who” provides a treatment contributes 8 to 9 times more to outcome than “what” particular treatment is offered (Wampold, 2005; Miller, Hubble, & Duncan, 2007). Such findings indicate that people seeking treat- ment would do well to choose their provider carefully as it is the therapist – not the treatment approach—that matters most in terms of results. Fourth, and finally, a sizable portion of the variability in outcome among clinicians is attributable to the therapeutic alliance. For example, in a study involving 80 clinicians and 331 clients, Baldwin, Wampold, and Imel (2007) reported that it was therapist variability in the alliance, rather than client variability, that predicted outcome. In other words, therapists who on average, formed stronger alli- ances, performed better than therapists who did not form as strong a therapeutic engagement with their clients. Taken together, the foregoing findings indicate that real-time monitoring and utilization of outcome and alliance data can maximize the “fit” between client, therapist, and treatment. With so many factors at play influencing outcome at the time of service delivery, it is practically impossible to know a priori what treat- ment or treatments delivered by a particular therapist will reliably work with a specific client. Regardless of discipline or theoretical orientation, clinicians must determine if the services being offered are working and adjust accordingly. Two simple scales that have proven useful for monitor- ing the status of the relationship and progress in care are the Session Rating Scale (SRS [Miller, Duncan, & Johnson, 2000]), and the Outcome Rating Scale (ORS, [Miller & Duncan, 2000]). The SRS and ORS measure alliance and outcome, respectively. Both scales are short, 4-item, self-report instruments that have been tested in numerous studies and shown to have solid reliability and validity (Miller, 2010). Most importantly perhaps, the brevity of the two measures insures they are also feasible for use in everyday clinical practice. After having experimented with other tools, the devel- opers, along with others (i.e., Brown et al., 1999), found that “any measure or combination of measures that [take] more than five minutes to complete, score, and interpret [are] not considered feasible by the majority of clinicians” (Duncan & Miller, 2000, p. 96). Indeed, available evidence indicates that routine use of the ORS and SRS is high compared to other, longer measures (e.g., 99% utilization rates of the ORS & SRS, versus 25% utilization rate of the Outcome Questionnaire-45 [Miller, Duncan, Brown, Sparks, & Claud, 2003]). Administering and scoring the measures is simple and straightforward. The ORS is administered at the beginning of the session. The scale asks consumers of therapeutic services to think back over the prior week (or since the last visit) and place a hash mark (or “x”) on four different lines, each representing a differ- ent area of functioning (e.g., individual, interpersonal, social, and overall well being). The SRS, by contrast, is completed at the end of each visit. Here again, the consumer places a hash mark on four different lines, each corresponding to a different and important qual- ity of the therapeutic alliance (e.g., relationship, goals and tasks, approach and method, and overall). On both measures, the lines are ten centimeters in length. Scoring is a simple matter of determining the distance in centimeters (to the nearest millimeter) between the left pole and the client’s hash mark on each indi- vidual item and then adding the four numbers together to obtain the total score (the scales are available in numerous languages at www.scottdmiller.com/perfor- mance-metrics). In addition to hand scoring, a growing number of computer-based applications are available which can simplify the process of administering, scoring, inter- preting, and aggregating data from the ORS and SRS.
  3. 3. Such programs are especially useful in large and busy group practices and agencies. Detailed descriptions of the other applications can be found online at www. scottdmiller.com. Creating a“Culture of Feedback” “My priority is to encourage openness and a culture that is willing to acknowledge when things have gone wrong.” John F. Kennedy Of course, soliciting clinically meaningful feedback from consumers of therapeutic services requires more than administering two scales. Clinicians must work at creating an atmosphere where clients feel free to rate their experience of the process and outcome of services: (1) without fear of retaliation; and (2) with a hope of having an impact on the nature and quality of services delivered. Interestingly, empirical evidence from both business and healthcare demonstrates that consumers who are happy with the way failures in service delivery are handled are generally more satisfied at the end of the process than those who experience no problems along the way (Fleming & Asplund, 2007). The most effec- tive clinicians, it turns out, consistently achieve lower scores on standardized alliance measures at the outset of therapy thereby providing an opportunity to discuss and address problems in the working relationship—a finding that has now been confirmed in numerous, independent, real-world clinical samples (Miller, Hubble, & Duncan, 2007). Beyond displaying an attitude of openness and receptiv- ity, creating a “culture of feedback” involves taking time to introduce the measures in a thoughtful and thorough manner. Providing the client with a rationale for using the tools is critical, as is including a description of how the feedback will be used to guide service delivery (e.g., enabling the therapist to catch and repair alliance breaches, prevent dropout, correct deviations from optimal treatment experiences, etc). Additionally, it is important that the client understands that the therapist will not be offended or become defensive in response to feedback given. Instead, therapists must take clients’ concerns regarding the treatment process seriously and avoid the temptation to interpret feedback solely in clinical terms. When introducing the measures at the beginning of a therapy, the therapist might say: “(I/We) work a little differently in this (agency/prac- tice). (My/Our) first priority is making sure that you get the results you want. For this reason, it is very important that you are involved in monitoring our prog- ress throughout therapy. (I/We) like to do this formally by using a short paper and pencil measure called the Outcome Rating Scale. It takes about a minute. Basi- cally, you fill it out at the beginning of each session and then we talk about the results. A fair amount of research shows that if we are going to be successful in our work together, we should see signs of improvement earlier rather than later. If what we’re doing works, then we’ll continue. If not, however, then I’ll try to change or modify the treatment. If things still don’t improve, then I’ll work with you to find someone or someplace else for you to get the help you want. Does this make sense to you?” (Miller & Duncan, 2004; Miller & Bargmann, 2011). At the end of each session, the therapist administers the SRS, emphasizing the importance of the relation- ship in successful treatment and encouraging negative feedback: “I’d like to ask you to fill out one additional form. This is called the Session Rating Scale. Basically, this is a tool that you and I will use at the end of each session to adjust and improve the way we work together. A great deal of research shows that your experience of our work together—did you feel understood, did we focus on what was important to you, did the approach I’m taking make sense and feel right—is a good predictor of whether we’ll be successful. I want to emphasize that I’m not aiming for a perfect score—a 10 out of 10. Life isn’t perfect and neither am I. What I’m aiming for is your feedback about even the smallest things—even if it seems unimportant—so we can adjust our work and make sure we don’t steer off course. Whatever it might be, I promise I won’t take it personally. I’m always learning, and am curious about what I can learn from getting this feedback from you that will in time help me improve my skills. Does this make sense?” (Miller & Bargmann, 2011). Free copies of the ORS and SRS measures are available at: www.scottdmiller.com/performance-metrics.com. The ORS and SRS are collectively called the Partners for Change Outcome Management System (PCOMS) which has been certified as an evidence-based practice by the Substance Abuse and Mental Health Services Adminis- tration (SAMHSA). A copy of the SAMHSA report can be found at: http://www.nrepp.samhsa.gov/ViewIn- tervention.aspx?id=249. Instructional manuals for the implementation of FIT and the PCOMS are available at www.scottdmiller.com and further training materials, articles, networking and educational opportunities, and instructional videos are available at the International Center for Clinical Excellence website: http://www. centerforclinicalexcellence.com. In one example of how FIT can alter practitioners’ outcomes, Anker, Duncan, & Sparks (2009) conducted the largest randomized clinical trial in the history of couples therapy research. The design of the study was
  4. 4. simple. Using the ORS and SRS, the outcomes and alli- ance ratings of 205 couples in therapy were gathered during each treatment session. In half of the cases, clinicians received feedback about the couples’ experi- ence of the therapeutic relationship and progress in treatment; in the other half, none. At the conclusion of the study, couples whose therapist received feedback experienced twice the rate of reliable and clinically sig- nificant change as those in the non-feedback condition. At 6-month follow-up, couples treated by therapists not receiving feedback had nearly twice the rate of separa- tion and divorce. The research evidence is clear: psychotherapy is effective for a wide range of presenting concerns and problems. At the same time, too many clients dete- riorate while in care, an even larger number drop out before experiencing a reliable improvement in function- ing, and outcomes vary widely and consistently among clinicians. FIT enables practitioners to achieve excellence by routinely soliciting feedback regarding the client’s per- ception of the therapeutic alliance and progress and using the information to guide and improve service delivery. A significant and growing body of research documents that, regardless of theoretical orientation or preferred treatment approach, employing FIT improves outcome and retention rates and reduces deterioration. In short, FIT can systematically improve the effective- ness of independent practitioners of psychotherapy, one person and one therapy session at a time. From Feedback to Excellence “...[E]xperts are always made not born.” K. Anders Ericsson (2007) As crucial as the use of feedback measures may be in delivering better outcomes, their use is not enough to develop expertise. Our attitudinal perspective plays a significant influence in our adoption of feedback. For instance, De Jong, van Sluis, Nugter, Heiser, and Spin- hoven (2012) found that not every therapist benefits from the use of formal feedback measures. Only thera- pists who were committed and held an open attitude towards the use of feedback benefited from the utiliza- tion of feedback mechanisms. In other words, feedback functions like tuning equipment for a musical instru- ment. It indicates when a note is out of tune, but it does not necessarily improve the musician’s sense of pitch. Needless to say, it does not inform the user about how to compose a classic. Another issue that hinders the adoption of feedback measures is attributed to self-assessment bias, also coined as the “Lake Wobegon” effect (Kruger, 1999). The phenomenon of self-assessment bias is not uncommon. Kahneman (2011) termed this “the illusion of valid- ity,” describing the fallacy of judgments about one’s own abilities, especially without any feedback from external sources to confirm or disconfirm one’s intui- tive responses. For example, Kahneman (2011) found that experts making political judgments, stock trad- ers, and financial advisors were not only inaccurate in their predictions, but also over-confident in their judgments. Similar self-assessment biases have also been found with physicians (Davis et al., 2006). Simi- lar to studies of physicians, self-assessment reports by psychotherapists have revealed that the least effective therapists rate themselves as highly as the most effec- tive therapists (Brown et al., 2006; Hiatt & Hargrave, 1995). Therapists are also more likely to overestimate their rates of client improvement and underestimate their rates of client deterioration (Walfish, McAlister, O’Donnell, & Lambert, 2012). In our recent investiga- tion with a sub-sample of therapists who have been routinely measuring their own outcomes over a 5-year period (Andrews, Wislocki, Short, Chow, & Minami, 2013), their self-assessment of their effectiveness did not predict actual client outcomes (Chow, 2013; Chow, Miller, Kane, Thornton, Andrews, n.d.). In fact, the majority of therapists optimistically viewed that they have improved over the years. As such, it remains questionable if self-reported effectiveness actually does represent actual levels of competency. Feedback can be helpful when an additional step is in place: engaging in deliberate practice (Ericsson, 1996; Ericsson, 2006; Ericsson, 2009; Ericsson, Krampe, & Tesch-Romer, 1993). Deliberate practice is defined as: …Individualized training activities especially designed by a coach or teacher to improve specific aspects of an individual’s performance through repetition and suc- cessive refinement. To receive maximal benefit from feedback, individuals have to monitor their training with full concentration, which is effortful and limits the duration of daily training. (Ericsson & Lehmann, 1996, pp. 278-279) This type of practice is often focused, systematic, carried out over extended periods of time, guided by conscious monitoring of outcomes, and evaluated by analyses of levels of expertise acquired, identification of errors, and procedures implemented at reducing errors (Ericsson, 1996; Ericsson, 2006; Ericsson et al., 1993). In a study of violinists, for example, “best” and “good” violinists spent almost three times longer than music teachers in solitary practice with their instrument, averaging 3.5 hours per day for each day of the week including weekends, compared with 1.3 hours per day for the music teachers (Ericsson et al., 1993). Based on research in the field of expertise and expert performance, Ericsson and colleagues noted that superior performance is not a function of any innate
  5. 5. talent (Ericsson, Nandagopal, & Roring, 2005; Erics- son, Roring, & Nandagopal, 2007), nor is it reflected by degrees earned, professional title, or experience. Rather, it comes from the incremental development of extended deliberate practice. Deliberate practice was found to mediate performance in multiple areas of expertise, such as music (Ericsson et al., 1993; Krampe & Ericsson, 1996), chess (Gobet & Charness, 2006), sports (Cote, Ericsson, & Law, 2005), business (Son- nentag & Kleine, 2000), and medicine and surgery (Ericsson, 2007b; Mamede et al., 2007; Norman, Eva, Brooks, & Hamstra, 2006; Schmidt & Rikers, 2007). Ericsson and colleagues (1993) argue, “The search for stable heritable characteristics that could predict or at least account for superior performance of eminent individuals has been surprisingly unsuccessful” (p. 365), with the exception of certain sporting activities (e.g., ballet, basketball) that require a specific physical endowment. In psychotherapy, neither training clinicians to improve the alliance nor greater experience conducting ther- apy have predicted clinical outcomes (Horvath, 2001; Anderson, Ogles, Patterson, Lambert, and Vermeersch, 2009). As described above, some therapists are consis- tently better at establishing and maintaining helpful relationships than others. Evidence that the difference is attributable to their possession of deeper domain-spe- cific knowledge (the kind of therapeutic resource that is attained by deliberate practice) was demonstrated by Anderson et al. (2009). In that study, differences in client outcomes between therapists were found to be unrelated to therapist gender, theoretical orienta- tion, professional experience, and overall social skills. Rather, the therapists who exhibited deeper, broader, and interpersonally nuanced knowledge obtained the best results. Regardless of presenting problem or client’s relational style, top-performing therapists were able to respond collaboratively and empathically, and far less likely to make remarks or comments that distanced or offended a client. Acquiring this kind of understanding, perception, and sensitivity is a common goal for clinicians from the full range of theoretical orientations; yet the data from Anderson et al. (2009) and the broader evidence from Ericsson and colleagues suggest that some end up having such knowledge and using it effectively, while others (of equal experience and social ability), do not. A recent research study investigated the contribution of therapist variables, their professional work prac- tices, professional development activities, and beliefs regarding learning and personal appraisals of thera- peutic effectiveness (Chow, 2013; Chow et al., n.d.). Although preliminary, results from this study are in line with earlier research on the factors that account for expertise. Similar to Anderson et al. (2009) and others (Wampold & Brown, 2005), therapist gender, qualifi- cations, professional discipline, years of experience, and time spent conducting therapy were unrelated to outcome. Similar to findings reported by Walfish et al. (2012), therapist self-appraisal was not a reliable mea- sure of effectiveness. Consistent with results obtained in other professional domains (e.g., Charness, Tuffiash, Krampe, Reingold, & Vasyukova, 2005; Duckworth, Kirby, Tsukayama, Berstein, & Ericsson, 2011; Ericsson et al., 1993; Keith & Ericsson, 2007; Krampe & Ericsson, 1996; Starkes, Deakin, Allard, Hodges, & Hayes, 1996), the findings by Chow and colleagues (n.d.) provide preliminary support for the significant role of deliber- ate practice in the development of expertise among highly effective therapists. In sum, the amount of time therapists reported being engaged in solitary activities intended to improve their skills was related to outcome. Seventeen therapists were asked, “How many hours per week (on average) do you spend alone seriously engaging in activities related to improving your therapy skills in the current year?” The top quartile (in terms of clinical outcomes) group of therapists invested about 1.8 times more time on “deliberate practice alone” com- pared with the second quartile group of therapists. The top quartile group spent about 3.7 times more time on “deliberate practice alone” than the third quartile group. Chow and colleagues (n.d.) also found that compared to other therapists in their cohort, highly effective therapists were more likely to report being surprised by their clients’ feedback. This surprise may signify qualities about the therapist’s openness, receptivity, and willingness to receive negative and positive feedback consistent with the concept of therapists taking a “not- knowing” stance to the dialogical process of therapy (Anderson, 1990, 2005; Anderson & Goolishian, 1988). That is, while the therapist uses his or her expertise in creating a facilitative environment for the client, the therapist adopts a responsive and tentative posture, while conveying a sense of openness and newness towards the client’s unfolding narrative. Providing further converging evidence for the delib- erate and error-centric practice of more effective practitioners of both psychotherapy and other profes- sional fields, Najavits and Strupp (1994) found that effective therapists were more self-critical and reported making more mistakes then less effective therapists. In a more recent study, among other predictors, therapist- reported professional self-doubt (PSD) had a positive effect on client ratings of working alliance, with higher levels of PSD suggesting an open attitude towards admitting their own shortcomings (Nissen-Lie, Monsen, & Ronnestad, 2010). Taken together, these studies sug- gest that highly effective therapists’ willingness to evaluate their contribution to the psychotherapeutic process, and emphasis on self-correction were associ- ated with their better performance.
  6. 6. OneTherapist at aTime “A man walking is never in balance, but always correcting for imbalance.” Gregory Bateson Taken together, the findings above point to a viable and hopeful journey ahead for the field of psychotherapy. The three key features of knowing one’s performance baseline, obtaining feedback, and engaging in deliber- ate practice provide a practical framework for clinicians who seek to improve their craft of therapy (Miller, Hubble, Chow, & Seidel, 2013; Tracey, Wampold, Lich- tenber, & Goodyear, 2014). A craft is defined as “a collection of learned skills accompanied by experienced judgment” (Moore, 1994; p. 1). Psychologists who want to improve at their craft of therapy must continously reach for objectives just beyond their level of current ability (Miller, Hubble, & Duncan, 2007). For independent practitioners to thrive in a market- place increasingly driven by demands for quality and accountability, they must evolve beyond the study of psychotherapies in general (i.e., premises, models, pro- cedures, and techniques), and beyond the accumulation of credentials and years of experience. Instead, evi- dence points to the likely necessity (and certainly to the necessity of further research) of working to improve the outcome of each and every therapist, one client at a time. References Anderson, H. (2005). Myths about “not-knowing”. Family Pro- cess, 44(4), 497-504. doi:10.1111/j.1545-5300.2005.00074.x Anderson, H., & Goolishian, H. A. (1988). Human systems as linguistic systems: Preliminary and evolving ideas about the implications for clinical theory. Family Process, 27(4), 371-393. doi:10.1111/j.1545-5300.1988.00371.x Anderson, T., Ogles, B. M., Patterson, C. L., Lambert, M. J., & Vermeersch, D. A. (2009). Therapist effects: Facilitative interpersonal skills as a predictor of therapist success. Journal of Clinical Psychology, 65(7), 755-768. doi:10.1002/ jclp.20583 Andrews, W., Wislocki, A. P., Short, F., Chow, D. L., & Minami, T. (2013). A 5-year evaluation of the human givens therapy using a practice research network. Mental Health Review Journal, 18(3), 165-176. doi:10.1108/MHRJ-04-2013- 0011 Anker, M., Duncan, B., & Sparks, J. (2009). Using client feed- back to improve couple therapy outcomes: A randomized clinical trial in a naturalistic setting. Journal of Consulting and Clinical Psychology, 77, 693-704. Baldwin, S., Wampold, B., & Imel, Z. (2007). Untangling the alliance-outcome correlation: Exploring the relative importance of therapist and patient variability in the alliance. Journal of Consulting and Clinical Psychology, 75, 842-852. Barlow, D. (2004). Psychological treatments. American Psy- chologist, 59, 869-878. Bohanske, B., & Franczak, M. (2010). Transforming public behavioral health care: A case example of consumer- directed services, recovery, and the common factors (pp. 299-322). In B. Duncan, S. Miller, B. Wampold, & M. Hubble (Eds.). The Heart and Soul of Change. Washington, D. C.: APA Press. Brown, G., Dreis, S., & Nace, D. (1999). What really makes a difference in psychotherapy outcome? Why does man- aged care want to know? In M. Hubble, D. Duncan, & S. Miller (eds). The Heart and Soul of Change: What Really Works in Therapy (389-406). Washington, D.C.: APA Press. Chambless, D. & Ollendick, T. (2001). Empirically-supported psychological interventions: Controversies and evidence. Annual Review of Psychology, 52, 685-716. Charness, N., Tuffiash, M., Krampe, R., Reingold, E., & Vasyu- kova, E. (2005). The role of deliberate practice in chess expertise. Applied Cognitive Psychology, 19(2), 151-165. doi:http://dx.doi.org/10.1002/acp.1106 Chow, D. L. (2013). The study of supershrinks: Development and deliberate practices of highly effective psychotherapists. Paper presented at the Achieving Clinical Excellence (ACE) Conference, May 16-18, 2013, Amsterdam, Holland. Chow, D., Miller, S. D., Kane, R., Thornton, J., & Andrews, W. (n.d.). The study of supershrinks: Development and deliberate practices of highly effective psychotherapists. Manuscript in preparation. Cote, J., Ericsson, K., & Law, M. P. (2005). Tracing the Devel- opment of Athletes Using Retrospective Interview Methods: A Proposed Interview and Validation Procedure for Reported Information. Journal of Applied Sport Psychol- ogy, 17(1), 1-19. doi:10.1080/10413200590907531 Davis, D. A., Mazmanian, P. E., Fordis, M., Van Harrison, R., Thorpe, K. E., & Perrier, L. (2006). Accuracy of physician self-assessment compared with observed measures of competence: A systematic review. 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In the process of mediation, parties may negotiate any aspect of the termination of their marriage including child custody, child support, and property distribution. Parties can enter mediation either privately or through a court-ordered process. In some jurisdictions, courts will mandate that par- ties who file a petition for child custody or visitation attend mediation, with the goal of resolv- ing their dispute before the court makes a ruling on their custody matter. Court-ordered mediations are one way in which courts have attempted to relieve the court of the endless backlog of custody cases that flow through the family court system. In jurisdictions that contain court-ordered mediations, courts will typically maintain a list of mediators. There are varying requirements for getting placed on a court list. For example, as a mediator in Chester County Pennsylvania, I was required to have both basic and advanced mediation training. Additionally, the court required a specified number of supervised mediation cases prior to being placed on the court list. Once placed on the court list, the court then sets the fee for those court ordered mediations. Additionally, I was required to conduct a court-specified number of pro-bono mediations each year. Divorce and custody mediation are typically governed by state statute, which provides the minimum qualifi-