Feedback to achieve clinical excellence (summer 2014 ind psy)

Independent
Practitioner
Summer 2014 • Volume 34 Number 3
Your Summer 2014 IP
Bulletin of
division42.org
Psychologists in Independent Practice
A Division of the American Psychological Association
President’s Column
Pat DeLeon
Duty to Protect Third Parties
Feedback to Achieve Clinical Excellence
Basics of Providing Diversity and Mediation Training
Holistic Team Approach to Divorce Mediation
An Attempt at Conducting a Group for Mothers of Young Children
From Research to Practice
Strategies for Identifying Cash Pay Services
Diversity and Disabilities
Free CEs!

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Table of Contents
Future Challenges to Independent Practice —Gordon Herz................................................................... 72
Opinions and Policy
It Always Seems Impossible Until it’s Done — Pat DeLeon.................................................................... 74
Liability, Malpractice and Risk Management
Misunderstandings Regarding Duty to Protect Third Parties — David Shapiro...................................... 76
Focus on Clinical Practice
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..................................................................................................... 78
Providing Divorce and Custody Mediation Services: The Basics — Lori C. Thomas.............................. 85
Divorce Mediation: A Holistic, Structured Team Approach — Crispino Pastore &
Sharon Pastore.................................................................................................................................... 87
An Attempt at Conducting a Group for Mothers of Young Children — Carrie R. King............................91
From Research to Practice — Andrea Peterson, Mattie McIntyre, and
Andrea Kozak Miller, Ph.D.................................................................................................................. 93
Focus on the Business of Practice
Strategies for Identifying Cash Pay Services — Mel Whitehurst.............................................................. 96
Focus on Diversity
Diversity and Disabilities — June W. J. Ching.......................................................................................... 99
Division Announcements for upcoming APA convention in Washington DC
Division 42 Supports Your Hard Work: Show It Off This Year At Convention Social Hour
Membership Committee..................................................................................................................102
Make Art with Your Peers — Alan Entin & Pamela McCrory..................................................................103
CE Quiz..................................................................................................................................................106
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Independent Practitioner Summer 2014 71

Future Challenges to Independent Practice
— Gordon I. Herz
I previously avoided the temptation
to write about how we can apply
our unique position as psycholo-gists
in independent practice to shape
and contribute to the future -- our
deep knowledge of all levels of human
systems, our skills as agents of growth
and change. I hope you will bear with
me if I take that opportunity now.
Much of what I write is not based
on expert training or understand-ing
of health care service delivery,
of health care economics or econom-ics
generally. But I do write from the
experience of having provided psycho-logical
and health services for 22 years
now since being licensed, and on a full time indepen-dent
basis for 14 years.
My introduction to being “managed” — even as an inde-pendent
— occurred the first year after I was licensed
and had taken a salaried position in a hospital. There,
I had no difficulty being credentialed to provide, and
have my home department reimbursed for, care I pro-vided
to the hospital’s patients, by the HMO allied with
the hospital. When I rented office space one block away
and began seeing clients independently evenings and
weekends, that same HMO would neither credential nor
reimburse me for the same care to the same sorts of cli-ents.
The lesson in who was attempting to control how I
practiced and how I made my living was invaluable.
I also write as an independent psychologist who has
been involved, to some extent, in activism to influ-ence
the system. Division 42 became a natural home
for me for this involvement, particularly through the
(now sunsetted) “Task Force on Managed Care” (which
soon expanded to “and Health Care Policy”). In 2007 we
were able to move through APA’s Council the adoption
of a “Statement of Principles for Health Care Reform,”
emphasizing access to affordable care, the insepara-bility
of mental and physical well being, prevention,
rehabilitation and improving quality of life as neces-sary
activities in a just and effective health system,
and the recognition of the role behavior plays in the
major causes of illness and death in our country. With
the seemingly “renewed’ emphasis on “integrated ser-vices”
as exemplified in even the most recent Special
Issue of the American Psychologist (“Primary care
and psychology”), we were either riding the crest of an
inevitable tsunami of change, were
already trained in and were providing
health services, or had some actual
foresight (most likely, some of each).
And in terms health care financing, as
we wrote in 2009, “A for-profit, managed
reimbursement financing system is
fundamentally incompatible with the
independent practice of psychology
and unfettered access by the public to
doctoral level psychological services.”
Given that we are now — in theory,
with “parity” — subject to no different
oversight in third party reimbursement
systems than our medical colleagues,
perhaps our practices will benefit and
the public will be better served. But this will require
holding payers accountable, and I urge all readers to
respond to the APA Practice Organization’s (APAPO) call to
report possible party violations.
In light of the history of independent practice and the cur-rent
environment, the following seem to me to be likely
future trends that will challenge independent practice.
• Downward pressure will almost certainly con-tinue
to occur in third party reimbursement for
services. There is nothing new about this trend,
with many contributing factors. Just one of these
variables may give a glimpse of the challenge.
Psychologists are greatly outnumbered by other
health professionals who can and do provide psy-chotherapy
and other mental health services on
an independent basis. For example, RNs, nurse
practitioners and nurse specialists outnumber psy-chologists
by a factor of almost 16 to 1 and social
workers outnumber psychologists by almost 4 to 1
(Robiner, Dixon, Miner & Hong, 2014, Figure 3, U.S.
Health Occupations Workforce).
• Models of reimbursement will change from fee-for-
service to other configurations, as witnessed
by the ongoing experiments in at least two models
within Medicare, the Medicare Shared Savings Pro-gram,
and the Advance Payment ACO Model.
• “Quality,” effectiveness and outcomes measure-ment
will become expected. For example, the
Physician Quality Reporting System (PQRS) — cur-rently
a voluntary program within Medicare that
operates on an “incentive” basis and is available to
psychologists — will become mandatory in 2015,
72 Summer 2014 Independent Practitioner

with financial penalties assessed for nonparticipa-tion
(in PQRS, not in Medicare). Are for-profit and
other third party payers far behind?
• Technology demands will continue to evolve.
Enforcement rules and other “incentives” (such as)
for the The Health Information Technology for Eco-nomic
and Clinical Health [HITECH] Act make it
likely the expectation of “meaningful use” of health
information technology and compliance with secu-rity
requirements will become a part of everyday
practice, even for the small group or solo indepen-dent
practitioner.
Note that none of these even begin to recognize the
need to keep up with an ever-growing body of clinical
knowledge and practical applications.
How does the independent psychologist evolve, adapt,
survive, thrive? I see at least two substantial trends in
our profession, and a third way I will call a “hybrid.”
First, many of our independent colleagues are already
used to “integrated care,” collaborating regularly
with a wide range of health professionals in a variety
of settings. While the current buzz phrase may be
“co-location,” in my view it is an empirical question
whether this actually will be necessary to improve
care and outcomes. It is possible that independents in
the future will maintain separate locations and use
technology to integrate care. These colleagues will
nevertheless be fully integrated into health care sys-tems
— in record keeping and information sharing
dimensions, as well as in reimbursement models, with
all the credentialing, outcomes measurement, busi-ness
and reimbursement structures that implies. Many
of our independent colleagues lament the perceived
and actual reduction in autonomy and control. But the
benefits of a “fully integrated” practice model include
a greatly increased and highly diverse base of consum-ers
of services. That, after all, was one of the principal
promises of ACA: more citizens covered. One great
additional risk to independent practice is that, as more
of our citizens have insured themselves for coverage
for health services, there is greater expectation to use
the coverage. The extent to which people be willing to
purchase services beyond those for which they have
“pre-paid” remains to be seen.
However, this does point to another possible future
model of independent practice. Many of our colleagues
will choose to function entirely outside of this system,
instead providing the full range of professional services
for which psychologists are uniquely trained. Locate a
human system and there is a need for applied psycho-logical
knowledge and skill. Undoubtedly, this model
also continues a longstanding tradition of psychological
services, one that even pre-dates the era when psycho-therapy
was not recognized (i.e., reimbursed) by health
insurance, through the period of efforts to break free of
constraints (e.g., Ackley, 1997 and many others) all the
way through our most current thinkers and leaders who
identify myriad ways to do work that matters and that
will be purchased (e.g., Walfish, 2010).
There is a third, “middle path.” My sense is that, given
the demands of the above two models I believe we are
likely to see, the challenges of this middle ground will
be substantial. Some of our colleagues will develop and
maintain involvement in both systems, responding to
practice structures, flows of consumers, services needed
and methods of reimbursement implied by both. The
benefits in this approach include the potential to have
a relatively predictable, even expanding, base of work,
while developing and applying expertise to a broad range
of individuals, systems and human problems.
My guess is this model will already seem familiar to
many. It should seem familiar to any of us who have pro-vided
standard services in the context of known referral
and reimbursement patterns, while simultaneously
developing specialty work. What remains unknown is
whether such a hybrid practice will be possible or practi-cal
in the future, given the likely commitment in time,
learning, expertise and other resources. Or, perhaps such
diversification will be just what is needed.
One thing does seem fairly sure to me. The challenge
for Division 42 will be to support our members however
they choose to maintain independence, in whatever
balance they find. There may well be stage-of-career
differences in choice. It is possible those who are early
in their careers and closer to their training experiences
may feel more comfortable with a more fully “inte-grated”
model, while those at later career stages may
want and be able to minimize third party intrusion in
practice structures or service delivery. We need to sup-port
our colleagues to pursue the joy and meaning this
profession brings.
References
Ackley, D. (1997). Breaking free of managed care: A step-by-step
guide to regaining control of your practice. New York: Guil-ford
Press.
American Psychologist (2014). Special issue: Primary care
and psychology. May-June, 69 (4).
APAPO Practice Update. (April 10, 2014). Mental health
parity: We need your help. Retrieved 4/25/2014 from
http://www.apapracticecentral.org/update/2014/04-10/
parity.aspx
Herz, G. (2009). Reimbursement for psychologists’ services:
Trends, impact on access to psychologists, and solutions.
Retrieved 5/19/2014 from http://www.drherz.us/
blog42/ReimbursementAccessSolutions.htm
Robiner, W., Dixon, K., Miner, J. & Hong, B. (2014). Psycholo-gists
in medical schools and academic medical centers:
Over 100 years of growth, influence, and partnership.
American Psychologist, 69 (3), 230-248.
Walfish, S. (2010). Earning a living outside of managed mental
health care: 50 ways to expand your practice. Washington
DC: APA Books.

Opinions and Policy
It Always Seems Impossible Until it’s Done
—Pat DeLeon
State Leadership Conference (SLC):
At this year’s exciting Practice
Directorate State Leadership Confer-ence
(SLC) titled “Creating Roadmaps for
Practice,” visionary Executive Director
Katherine Nordal emphasized: “The way
the Affordable Care Act [ACA] is unfold-ing
reminds us that no single advocacy
strategy for psychology can address the
diverse legislative, regulatory and mar-ketplace
environments we see from one
state to another. Meanwhile, our country
still doesn’t pay nearly enough attention
to mental health and substance use treat-ment.
We’ve carved out this treatment
from medical care and made people jump
through hoops to get the psychological services they
need. And mental health is chronically underfunded.
About 20% of our population experiences a mental
health disorder in any given year, compared to a life-time
incidence of 6% for adults with cancer. Yet, in
2012, the federal government invested more than 5
billion dollars in the National Cancer Institute but less
than 1.5 billion dollars in NIMH. Health care reform
implementation is a work in progress. There are hope-ful
signs, especially related to the goal of increasing the
ranks of Americans with health insurance coverage.
A combination of professional, marketplace, legisla-tive
and regulatory developments encourages more
collaborative, multi-disciplinary practice models. As
the landscape shifts towards more integrated care,
new reimbursement mechanisms will emerge. The
demand for evidence-based practices and use of quality
measures related to process and outcome, includ-ing
behavioral health measures, will grow. And the
increasing use of technology for electronic health
record keeping and telepsychology service delivery
will continue to evolve. Many of our members seem
attuned to this evolution.” As Katherine also indi-cated
at last year’s SLC conference: “Our practitioners
increasingly will need to promote the value and qual-ity
they can contribute to emerging models of care. If
we are not valued as a health profession, it will detract
from our value in other practice arenas as well. Health
care reform is a marathon – we’re in it for the long haul.
New models of care and changes in health care financ-ing
won’t take shape overnight.”
Integrated Care: Katherine’s description of the
“changing winds” of health care reform is extraor-dinarily
accurate. The Alliance for Health Reform
recently sponsored a Hill briefing – “Is the
Mind Part of the Body? The Challenge of
Integrating Behavioral Health and Primary
Care in a Reform Era.” “As more people
gain coverage that includes behavioral
health benefits, and given a limited supply
of mental health professionals, analysts
and advocates are raising concerns over
how and whether new laws and regulations
will be able to change that situation. One
option being explored in many settings is
the integration of behavioral health ser-vices
with primary care. There is early
evidence that coordinating care in this
manner may deliver high-quality care
more efficiently. For almost 20 years,
bipartisan majorities in Congress have been legislat-ing
ways of bringing behavioral health services to the
62 million Americans in need of them. Beginning
with the 1996 Mental Health Parity Act, Congress has
steadily broadened access to these services.
“All state Medicaid programs and plans sold on the
health insurance marketplaces cover behavioral health
services. Yet 60% of adults and 70% of children with
a mental health disorder do not receive treatment. In
children, the average time between onset and treat-ment
of mental illness is nine years. And one in six
adults has co-morbid mental health and medical con-ditions.
More commonly their medical condition is
being treated while their mental health condition goes
undiagnosed and untreated. Do current models of inte-grating
behavioral and physical health hold promise?
Are there enough providers to meet the demand of the
newly insured? What is needed to help primary care
fill the gap? How are the states meeting the budgetary
challenge in Medicaid programs? Is parity a reality?”
Our colleagues in the American Psychiatric Association
(ApA) would appear to agree with Katherine, recently
calling for much tighter integration of primary care and
mental health care, thereby providing better services
with a reduction in costs. “Studies have shown that
concurrently treating behavioral and physical condi-tions
leads to better control of the illness itself, but also
better patient satisfaction, quality of life, and reduced
costs [ApA President].” The ApA commissioned report
shows that effective integration could save $26 billion
to $48 billion a year in general medical care. Almost
half of people with a mental disorder first consult with
a primary care physician and approximately 50% of

the 38,000 individuals who commit suicide each year
have seen a primary care physician within a month of
the completed attempt. Their report, which drew on
claims data for 20 million enrollees, found that only
14% of those who had a mental disorder were receiv-ing
treatment but that they accounted for 30% of the
spending reviewed. “Even though they are insured and
are being treated for their mental illnesses, the lack
of coordinated care represents lost opportunities….
The higher costs were mostly attributable to patients
falling through the cracks or not getting proper care
– which showed up in more emergency room visits,
more hospitalizations, and hospital readmissions [ApA
President-Elect].”
In our judgment, critical to the success of Katherine’s
vision of psychology being recognized as a bona fide
“health care profession” is affirmatively embracing our
societal responsibility to provide proactive leadership
in addressing society’s most pressing needs. Psychol-ogy
is one of the “learned professions” and with that
comes a fundamental obligation to effectively utilize
our clinical skills, beyond the confines of traditional
practice. Last year we were very pleased to learn of
Gaby Toloza’s efforts on behalf of the Hawaii Psycholog-ical
Association (HPA) to address the needs of families
with an autistic child. Her “call to action” this year: “We
are in need of about 6-7 psychologists to volunteer ONE
hour of their time on Saturday at the Windward YMCA
to give an interactive psycho-educational talk about an
aspect of Self Care to a group of 15-20 parents of autistic
children. Some previous topics related to mind body
connection, achieving balance, how to change behavior,
role of nutrition, stress management, financial stress
management and relationship health. This is a wonder-ful
way to give back to the community and promote
psychology as a profession, but more importantly the
necessity of self-care and a wellness model. This sup-ports
HPA and APA initiatives for public education and
it’s just a fun, simple and meaningful experience for
both the families and providers. It is a collaborative
project with HPA, YMCA, Hawaii Autism Foundation
and Creative Connections Foundation, so it also rep-resents
yet another way that the work of psychologists
can be integrated and effectively used to support a
given population. Thank you for your time and hope I
hear back from many of you wonderful helping profes-sionals
(Yes, shameless positive feedback in hopes of
soliciting your time).”
Interdisciplinary Training For The Next Genera-tion:
The Robert Wood Johnson Foundation (RWJ)
Nursing and Health Policy Collaborative at the Univer-sity
of New Mexico reports that over 100 doctoral level
nursing programs have stand-alone, required courses
in health policy, with numerous other programs incor-porating
health policy content into related courses.
In sharp contrast, we have been able to find very few
related courses within psychology’ training programs.
An appreciation of the legislative and administrative
process is essential for all health professions. For
example, the Institute of Medicine (IOM) found that
although the primary purpose of a state licensing board
is specifically to protect the interests of the public, 52%
of dentists thought that the primary purpose of their
state dental board was to protect the interests of den-tists
and 32% thought they protected the interests of
both dentists and the general public. The IOM report
also concluded that publicly funded health programs
should not separate oral health from overall health.
The IOM President: “Can you imagine a time when we
fully incorporate mental and dental health into our
thinking about health? What is it about problems above
the neck that seems to exclude them so often from
policy about health care?”
At the Uniformed Services University of the Health
Sciences (USUHS), the next generation of psychologists
and doctors of nursing practice (DNP) train together in
a number of venues, including health policy. “My col-league,
CPT Kathleen Young and I had the pleasure of
attending the American Association of Colleges of Nurs-ing
(AACN) Student Policy Summit held in Washington,
DC. The Summit provided a panoply of distinguished
nursing professionals and activists committed to the
advancement of nursing and nursing practice that
bestowed upon us the importance of uniting as a profes-sion
to influence changes that affect our profession and
the care that we provide to our patients. Astonishingly
we have approximately 3.1 million nurses of which only
approximately 100,000 belong to the American Nurses
Association (ANA). While this statistic does not include
the many other nursing organizations that nurses may
be members of, it is nonetheless an astonishing fact that
nurses make up the majority of the healthcare industry,
yet we have the least amount of members participating
in organizations that influence the very policies that
impact our profession.
“The AACN Summit provided an opportunity to show
the ease with which nurses can become politically
involved to improve health status and the delivery of
healthcare. Mindful of relevant DoD Directives, my
colleague and I were graciously allowed to accompany
Dr. Jane Kirschling, President of the AACN and Dean
of the University of Maryland School of Nursing, as
well as several bright undergraduate and graduate nurs-ing
students from the State of Maryland as they were
welcomed by the offices and staff of the Maryland Sena-tors
and Congresspersons. The well-spoken students
impressed upon their Representatives the importance
for continued support for Title VIII funding for nursing
education, increased funding for nursing research, and
support for nursing practice bills designed to promote
the role of Advanced Practice Nurses in the healthcare
delivery system.

“The AACN Student Summit Policy Summit was an
extraordinary opportunity to network with nursing
leaders, advocates for the advancement of nursing prac-tice,
and colleagues with the common goal of imparting
change. In an era of unprecedented health care reform
nurses, one of the most trusted health professions in
the nation, have a unique opportunity and dare I say
obligation, to provide our expertise in matters that
affect the profession of nursing and the delivery of care
that we provide [Capt. Kellie Webb-Casero, USAF].”
Aloha,
Pat DeLeon, former APA President – Division 42 – May,
2014
Liability, Malpractice and Risk Management
Misunderstandings Regarding Duty to Protect Third
Parties
— David Shapiro
There is perhaps no other area of the
law that has engendered more mis-understandings
than the so called
“duty to warn/protect”. Many psycholo-gists
believe that the “duty to warn/protect”
demands an unquestioning, knee jerk, break-ing
of confidentiality when a patient makes
any threatening or potentially threatening
statement. This concept of course origi-nated
with the case of Tarasoff v. Regents of
the University of California. In fact, there
were two separate Tarasoff cases, the first in
1974 (Tarasoff I) and the second in 1976. The
concept of “duty to warn” third parties that was enunci-ated
in Tarasoff I was broadened in 1976 to include the
“duty to protect” third parties ; this was largely due to
a brief filed by the American Psychiatric Association
raising concerns about clinicians’ abilities to predict
future violence as well as their need to breach confi-dentiality.
The second Tarasoff case actually gave the
clinician greater discretion to utilize his or her clinical
judgment. Therapists mistakenly focus on the narrow
idea of “warning” third parties and therefore breaking
confidentiality, rather than listening to the words of the
second Tarasoff case, which spoke of “taking reasonable
steps to protect the intended victim”; warning might
have been one of those ‘reasonable steps “ but it was
not the only one.
A careful reading of the second Tarasoff case reveals
that the court discussed and concluded that clinicians
did not need to change the basic ways in which they
dealt with patients, but only needed to consider the
steps they might need to take if a third party were in
danger. The court did not specify what the steps had to
be, but rather left it to the discretion of the therapist to
determine what steps should be taken if he or she deter-mined
that a third party was in danger. These might
include (but are by no means limited to) increasing the
number of therapy sessions, putting the patient
on medication, (or if already on medication,
changing the medication or the dosage), vol-untarily
or involuntarily hospitalizing the
patient, giving the patient a way to contact the
therapist in an emergency( cell phone or pager
number) and , as a last resort, notifying the
police or the intended victim.
The misunderstandings had an immediate
impact. As early as 1978, in an article in the
Stanford Law Review (Simon & Sadoff, 1978)
, the authors noted that there had been an
increased number of unnecessary involuntary com-mitments,
and a general reluctance on the part of
therapists to see any patients who described problems
with controlling anger; thus, since many of the people
who were most in need of treatment were being denied
treatment, the potential for violent behavior increased
rather than decreased.
Leedy( 1989 ) in her doctoral dissertation surveyed
licensed psychologists in two states, one of which had
a mandatory duty to warn statute and another which
did not. Her results demonstrated that over 90% of
licensed psychologists misunderstood the law in their
own state. One would hope that with more cases devel-oping
over the years, and more attention being paid to
the issue, psychologists would have a better understand-ing.
However, subsequent studies continued to reveal
widespread misunderstanding of these laws.
In workshops that I have taught regarding malpractice
and risk management, another popular misconception
is that violent acting out by patients in psychotherapy
is a major cause of malpractice actions; workshop par-ticipants
estimate that between ten and fifteen percent
of such cases are due to the violent behavior of a psy-chotherapy
patient; in fact, the figures from the APA
Insurance Trust, consistently show that less than two

percent of successful malpractice actions have to do
with failure to protect third parties.
Given these misunderstandings, what are the best risk
management steps to take to guard against this area
of litigation? The simple answer is the same as in any
other area of risk management- informed consent,
documentation, and consultation. Underlying all of
these is the need for a careful and well documented
assessment, a carefully crafted informed consent that
is also fully documented, and consultation with col-leagues
when there are doubts about the proper course
of action to take. Givelber, Bowers, and Blitch (1984)
also reported that in cases where the central issue was
failure to protect third parties, none of the cases based
liability on a failure to predict the violent behavior, par-ticularly
if a careful assessment had been done in the
first place. Rather liability was found where therapists
failed to follow standard procedures, failed to consult
with colleagues, and failed to document what they did.
Gone is the day when a therapist would say “I do not
have to take notes; I am a superb clinician”( these were
the actual words stated by a therapist in response to an
ethics complaint filed with the APA.
This leads us to a discussion on the nature of risk
assessments; in fact, there is no one established proto-col
but a clinician would have to demonstrate that he
or she followed at least one documented approach to
risk assessment. There is currently an ongoing debate
among those who utilize a purely actuarial approach,
an adjusted actuarial approach, or what is called “struc-tured
professional judgment”. The idea of basing an
assessment of future violent behavior on unaided clini-cal
judgment is no longer recognized as an appropriate
way to handle such situations. Each of the other three
approaches will cite its own literature, and its own find-ings
to demonstrate the superiority of its approach;
nevertheless, each is a legitimate approach and no one
appears superior to the others. The important issue
is to find an approach with which one is comfortable,
and follow that procedure according to the established
manuals; that will be adhering to the appropriate stan-dard
of care. There will always be people who claim
to be able to predict future violent behavior with a
high degree of accuracy, some without even seeing the
person clinically, but an accumulation of empirical data
can help end the influence of this kind of irresponsible
testimony in court.
We should also note an encouraging trend in cases
where there is a question of whether a duty to warn/
protect existed. When the cases first started emerging,
in the 1970’s, there was an inherent assumption that we
as clinicians could make accurate predictions of future
violent behavior and therefore, should be held liable in
cases where our patients did act out violently. As the
empirical data have accumulated, demonstrating that
we do not have such clairvoyant abilities, and identi-fying
the limited parameters within which we could
predict certain types of violent behavior, cases seem to
have reversed direction, with a greater number noting
the limited ability to predict violence and therefore,
restricting liability only to those cases where there
were unambiguous warning signals and the clinician
failed to do anything about them. For example, in
the case of Brady v. Hopper (1983), the Tenth Circuit
Court of Appeals rendered a decision very supportive
of mental health professionals, and avoided the hind-sight
bias that often characterizes such cases. This was
the case against John Hinckley’s psychiatrist, Dr. John
Hopper, filed by press secretary James Brady who was
wounded in Hinckley’s attack on President Reagan. The
Court ruled that even if Dr. Hopper had known about
Hinckley’s infatuation with Jodi Foster, his fascina-tion
with the movie “Taxi Driver”, and his taking target
practice at pictures of Reagan, this still would not have
been considered a foreseeable risk; only if he had con-fided
to Dr. Hopper that he planned to attack Reagan
would there have been any potential liability and then,
only if the doctor had failed to do a careful assessment
of the threat. Therefore, the best risk management
strategy is to do a careful assessment, document it
carefully, include within the informed consent the pos-sibility
of needing to protect a third party if the harm is
imminent and cannot be handled by other means, and
consult with colleagues when the situation is ambigu-ous.
References
Brady v. Hopper 570 F. Supp.1333, 1339 (D.Colo.1983)
Givelber, Bowers, and Blitch (1984). Tarasoff: Myth and Real-ity.
Wisconsin Law Review, 2, 443-497.
Leedy, S. (1989) Unpublished doctoral dissertation. University
of Maryland, Baltimore County.
Simon, R., & Sadoff, R. (1978). Where the Public Peril Begins.
Stanford Law Review, 31(1), 165-190.
Correspondence regarding this article should be addressed to
David Shapiro, Ph.D. at psyfor@aol.com.

Focus on Clinical Practice
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
studies of high performance in other fields,
indicate that the critical factors separat-ing
high-performing 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
therapeutic orientation). As therapists shift their focus
from traditional methods of accumulating knowledge
and experience toward a more empirically-supported
methodology 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-

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 litera-ture.
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
(Duncan et al., 2010; Smith & Glass, 1977; Wampold,
2001). Second, the general trajectory of change in suc-cessful
treatment is predictable, 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 epi-sodes
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 achiev-ing
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 practitioners. 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 treatment would do well to choose their
provider carefully as it is the therapist - not the treat-ment
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 thera-peutic
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 aver-age
formed stronger alliances, performed better than
therapists who did not. Taken together, the foregoing
findings indicate that real-time monitoring and utiliza-tion
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 treatment or treatments delivered by a par-ticular
therapist will reliably work with a specific client.
Regardless of discipline or theoretical orientation, clini-cians
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 individual
item and then adding the four numbers together to
obtain the total score (the scales are available at no cost
to independent practitioners in numerous languages at
www.scottdmiller.com/performance-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.
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).
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
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. The attitude of practitioners has
been shown to play a significant role in their adoption
and integration of feedback. For instance, De Jong, van
Sluis, Nugter, Heiser, and Spinhoven (2012) found that
not every therapist benefits from the use of formal feed-back
measures. Only therapists who were committed
and held an open attitude towards the use of feedback
benefited from the utilization of feedback mechanisms.
In other words, feedback functions like tuning equip-ment
for a musical instrument. 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 validity,”
describing the fallacy of judgments about one’s own
abilities, especially without any feedback from exter-nal
sources to confirm or disconfirm one’s intuitive
responses. For example, Kahneman (2011) found that
experts making political judgments, stock traders, 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). Similar to studies of
physicians, self-assessment reports by psychotherapists
have revealed that the least effective therapists rate
themselves as highly as the most effective therapists
(Brown et al., 2006; Hiatt & Hargrave, 1995). Thera-pists
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 investigation 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 pre-dict
actual client outcomes (Chow, 2013; Chow, Miller,
Kane, Thornton, Andrews, n.d.). 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
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 (in press) also found that com-pared
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, recep-tivity,
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 & Gool-ishian,
1988). That is, 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 deliberate,
Najavits and Strupp (1994) found that effective thera-pists
were more self-critical and reported making more
mistakes then less effective therapists. In a more recent
study, among other predictors, therapist-reported pro-fessional
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 suggest that highly
effective therapists’ willingness to evaluate their contri-bution
to the psychotherapeutic process, and emphasis
on self-correction were associated with their better
performance.
One Therapist at a Time
“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 (Miller, Hubble, Chow,
& Seidel, 2013; Tracey, Wampold, Lichtenber, & Good-

year, 2014). A craft is defined as “a collection of learned
skills accompanied by experienced judgment” (Moore,
1994; p. 1). Psychologists who want to improve 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.
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Providing Divorce and Custody Mediation Services: The Basics
— Lori C. Thomas
Increasingly parties who are seeking to
avoid the financial and emotional, as well
as collateral damage to their children,
have steered away from traditional court-based
divorces process and have instead opted to
purse divorce mediation. In divorce media-tion,
the mediator serves as a neutral third
party who facilitates a discussion between
divorcing parties, as they negotiate a mutu-ally
acceptable agreement in the dissolution of
their marriage. As a neutral third party, the
mediator is not empowered to make decisions
for the parties.
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 resolving their
dispute before the court makes a ruling on their cus-tody
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 con-tain
court-ordered mediations, courts will typically
maintain a list of mediators. There are varying require-ments
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 mini-mum
qualifications mediators must have, the training
required, as well as, ethical standards to be followed by
mediators. Mediator qualifications typically include
psychologists, lawyers, social workers and others in the
behavioral health and social science fields. For exam-ple,
in Pennsylvania, Title 231, Rules of Civil Procedure,
Chapter 1940.4 provides the following:
a. (a) A mediator must have at least the following
qualifications:
(1) a bachelor’s degree and practical expe-rience
in law, psychiatry, psychology,
counseling, family therapy or any comparable
behavioral or social science field;
(2) successful completion of basic training in
domestic and family violence or child abuse
and a divorce and custody mediation program

approved by the Association for Conflict Reso-lution,
American Bar Association, American
Academy of Matrimonial Lawyers, or Adminis-trative
Office of Pennsylvania Courts;
(3) mediation professional liability insurance;
and
(4) additional mediation training consisting
of a minimum of 4 mediated cases totaling 10
hours under the supervision of a mediator who
has complied with subdivisions (1) through (3)
above and is approved by the court to super-vise
other mediators.
b. (b) The mediator shall comply with the ethi-cal
standards of the mediator profession as well
as those of his or her primary profession and
complete at least 20 hours of continuing educa-tion
every two years in topics related to family
mediation.
c. (c) A post-graduate student enrolled in a state
or federally accredited educational institution
in the disciplines of law, psychiatry, psychology,
counseling, family therapy or any comparable
behavioral or social science field may mediate
with direct and actual supervision by a quali-fied
mediator.
While many state statues provide minimum qualifica-tions
for the mediators, most states have not mandated
special certifications for engaging in the practice of
mediation (See mediation training institute inter-national
for a review of state requirements). One
exception is the Florida Supreme Court, which requires
that mediators to be certified through their court train-ing
program in order to become a family mediator with
the court.
There are a variety of mediation styles that mediators
can practice including but not limited to transfor-mative,
facilitative and evaluative. Over the years,
research has investigated the effectiveness of media-tion
and mediation styles (see e.g. Beck & Sales, 2000;
Emory, Sbarra, & Gover, 2005; and Baitar, Buysse,
Brondel, De Mol, & Rober, 2013). Psychologists wish-ing
to participate in mediation would of course need
to receive training and could obtain that training from
a number of non-profit organizations in their state.
Cost for mediation training may run upwards of $1000,
which includes basic and advance mediation training
along with supervised hours. Psychologists will also
have to check with their malpractice carrier to ensure
that they are covered for their work as a mediator.
However, in some cases, malpractice carriers may con-sider
mediation to fit within the auspices of the work of
a psychologist.
If a psychologist is not interested in pursuing training
as a mediator, there are other ways that psychologists
may be involved in the mediation process. The Holis-tic
Divorce Mediation model, proffered by Pastore and
Pastore, is one example of how multidisciplinary teams
of professionals may collaborate in providing compre-hensive
services to individuals who are endeavoring to
dissolve their marriage.
References
Baitar, R., Buysse, A., Brondeel, R., DeMol, J., & Rober, P.
(Fall, 2013). Styles and goals: Clarifying the professional
identity of divorce mediation. Conflict Resolution Quar-terly,
31(1), 57-77. doi# 10.1002/crq
Beck, C. J. A., & Sales, B. D. (2000). A critical reappraisal of
divorce mediation research and policy. Psychology, Public
Policy, and Law, 6, 989-1056. doi # 10.1037//1076-
8971.6.4.989
Emory, R. E., Sbarra, D., & Grover, T. (2005). Divorce media-tion:
Research and reflections. Family Court Review, 43(1),
22-37.
Mediation Training Institute International (n. d). State
requirements for mediators. Retrieved from http://www.
mediationworks.com/medcert3/staterequirements.htm
231 Pa Code Rule 1940 (1999)

Divorce Mediation: A Holistic, Structured Team Approach
— Crispino M. Pastore and Sharon Pastore
After much focus on reconciliation of the rela-tionship
and the marriage has clearly reached
a “point of no return,” it is not uncommon to
find yourself in a position where one or both parties is
asking you, their most trusted confidant, about what
steps they should take in the dissolution of their mar-riage.
How might you respond?
While you can certainly tell your client that this is not
your area of expertise and recommend they consult
an attorney for legal advice, you may consider another
option. The standard court contested divorce process
may be appropriate in some cases; however, the use of
the adversarial process in divorce proceedings, may
unnecessarily throw your clients straight into a “boxing
ring,” unraveling the important work they may have
done to preserve civility in their relationship and pre-serve
the family unit.
This article takes the position that mediation is a far
more effective option for clients to consider first, even
when they cannot agree or communicate well together.
Additionally, there is often a role that psychologists
may play as a member of a divorce team in helping
divorcing spouses successfully manage those emotions,
both prior to and throughout the mediation process.
Unintended Consequences in the Court-
Contested Divorce Process
It is important to take a moment to understand the
potential set of adversarial chain reactions that could
occur when your client retains a lawyer. When it comes
to custody, for example, your clients will be advised to
protect themselves, as well they should. However, liti-gation
tactics are centered on things like proving who
is the worse parent, and can cause a spouse to head
down an emotionally and financially draining path
of multiple hearings and court dates, sometimes even
subjecting their children to have to testify in court. A
custody trial alone often costs at least $15,000 in legal
fees on average, digging an even deeper financial hole
that has additional anger, shame and guilt attached.
Other protective tactics might also appear subversive,
such as withdrawing and shifting funds in and out of
joint accounts and redirecting paycheck deposits, set-ting
the tone for a long and bitter divorce.
From the divorce lawyer’s perspective, he or she is only
doing what they have been trained to do- to zealously
represent their client, regardless of the financial and
emotional fallout that occurs. Judges are also part of an
over-worked court system which often sadly does not
have the time to evaluate each case on its individual
merits with the level of attention that it deserves.
While it is true that most contested divorce matters
settle out of court, this is most typically at the eleventh
hour on the courthouse steps before trial, two to four
years may have past after numerous support, custody
and property distribution hearings have taken place,
and at a time when all the financial and emotional
damage has already been levied on the family unit.
How a Holistic Divorce Mediation Model
Works and the Psychologist’s Role
When spouses have decided that their marriage is over
and cannot agree, the psychologist can play a pivotal
role in steering clients toward the emotionally and
financially healthier option of divorce mediation, while
playing a vital role throughout the process. In our
practice, divorce is viewed as a change, neither positive
nor negative. Mediation is the process for managing
that change. As such, we have developed the following
model for divorce mediation (see, Figure). It is both
facilitative and holistic, and focuses on four key aspects
of divorce: legal, parenting, financial, and emotional.
Figure. Main Line Family Law Center Holistic Model
for Divorce Mediation
A Holistic Model for Divorce Mediation
Not a cookie cutter approach, the process is tailored
to the needs of each client. If minor children are
involved, for example, and concerns about parenting
separately are foremost, clients are advised to par-ticipate
in the full program and possibly referred for
co-parenting counseling. A child psychologist or thera-pist
is also recommended if parents notice any unusual
or prolonged changes in a child’s behavior that suggest
their difficulty in coping with the change.
Clients are also encouraged to use their own psycholo-gist
or therapist to recover from the overall trauma of
divorce, or to work with a divorce coach to help them
emotionally prepare for each mediation session. The
psychologist may also act as a project manager, help-

Table 1 Plan for Resolution Using a Facilitative Model
Process and Timeline
(Average 3- 7 months)
Step 1: Initial Consultation with Attorney-Mediator, Overview of
Process
Step 2: Emotional Preparation Holds either individual and or joint session with client(s) to focus
Step 3: Gather Financial Documents Works with client to relieve sense of overwhelm around docu-ment
Step 4: Parenting Mediation Works with one or both parents around decisions in a healthy
Step 5: Financial Mediation Works with client to understand emotional connections to
Step 6: Financial Planning and Analysis Reviews financial scenarios with client to sort through options
Step 7: Financial Mediation Same as step 6
Step 8: Draft Review Reinforce the careful selection of a mediation-friendly attorney
Week 10: Filing for Divorce Decree or Sign Separation Agreement Helps client adjust to finality, and use the mandatory 90-day wait
ing a client to get better organized and prepared in
planning for the change they are about to experience.
We have a network of psychologists and marriage and
family therapists who are oriented to this model as part
of the divorce mediation team, should clients need a
referral.
In addition, when clients submit to the mediation pro-cess,
they agree to trust the process and therefore,
agree not to retain lawyers. However, an independent
attorney may be used to review their marital settlement
agreement draft at the end of the mediation process.
Otherwise, the reason for abandoning lawyers is so
that spouses can demonstrate their commitment to
the process, even when the trust of a spouse is in ques-tion.
This “act of surrender” is critical to the good faith
peace-making that makes mediation so transformative
and relationship-preserving. Along with that commit-ment,
a stronger sense of vulnerability, or perhaps a
newfound voice of anger or resolve, can develop result-ing
in the need for added support.
In these situations of higher conflict couples who want
to mediate, we have found that the holistic, team facili-tative
approach lends itself especially well. There are
several reasons for this. First, this model is directed
primarily by an experienced attorney-mediator. While
Role of Psychologist
Similar to a coach, work with client(s) to review information
from consultation and come to a decision on whether/how to
move forward.
on intentions, managing anger, guilt, and effect on decisions in
mediation.
gathering, understand importance of full disclosure of
information and increased sense of vulnerability.
parenting plan, co-parenting, trust, telling the children. While
children are not involved in this process, parents are encouraged
to monitor children’s signs of difficulty coping, and work with
child psychologist.
money
and potential outcomes from an emotional perspective.
who will not derail the progress of mediation.
period as a time to rediscover and start anew.
he or she cannot give legal advice, per say, spouses tend
to feel they are still getting legally informed guidance,
and have access to a seasoned practitioner who also
has a keen sense of what is most fair for each divorce
situation. Second, while not all spouses are ready to
move quickly, they usually appreciate the ability to
clearly see “the way out,” especially after feeling stuck
in an unhappy marriage for so long. Third, clients
generally seem to prefer to use the law as a starting
point for their negotiations, as there is often a strong
belief of “should” and the need to understand “rights
and entitlements” when beginning the process. Stick-ing
with what the rules say is fair is often a comfortable
place for higher conflict couples to begin their negotia-tions.
Depending on the needs of the client, our team
of professionals includes any or all of the following: an
attorney-mediator, parenting mediator, psychologist/
therapist, divorce coach, draft review attorney, financial
planner, and/or estate planner. With permission of the
client (and when ethically appropriate), the attorney-mediator
may discuss any concerning issues with the
team to pave a smoother path toward resolution.
The process begins with parenting mediation, to allow
focus on children’s needs first, followed by one to two
financial mediations and a final agreement draft review
meeting. The process` takes as little as 3-7 months, and

Feedback to achieve clinical excellence (summer 2014 ind psy)

Feedback to achieve clinical excellence (summer 2014 ind psy)

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