An interview with Jason Seidel: Measuring outcomes in psychotherapy

The Paubox Encrypted Interview Series allows us to chat with leaders in healthcare IT, compliance and cybersecurity to pick their brains on trends and best practices. In this Encrypted Interview, we chat with Jason Seidel, Director of the Colorado Center for Clinical Excellence , a group of Denver psychologists and psychotherapists who provide exceptional therapy by measuring their outcomes using diverse treatment approaches and honoring their client’s preferences.

Early career and professional growth

Rick Kuwahara: So what attracted you to the field of psychology?

Jason Seidel: The combination of a crazy family and a really horrible therapist when I was a kid. 

I had asked my parents to send me to a therapist when I was 11. Because my sister had had a lot of psychological problems from an early age, I had some vague sense as a kid about what psychologists were because of her seeing them. 

And there was a lot of chaos and some violence, and my parents agreed this would be a way for me to get some support. 

So I asked them to send me to someone, and in those years, this was the late 70s, there was still a really good amount of insurance coverage for any therapists you'd want to see. 

Basically, if you had a job that had insurance coverage, you could pretty much see any therapist. At least in Maryland where I grew up. So my parents were able to get me into one of the best in the DC area--a child psychiatrist with a great reputation. And he was horrible. 

And I wound up going to see him weekly for a couple of years. And it was really depressing. Although at that point, I would say I was more angry than depressed. I wound up lying to the guy about all kinds of things just to have a sense of power, given the powerlessness I felt as a kid.

And I remember pretty early on having this thought, while I was sitting on his couch, that I could do better than this jerk--because I had a sense even at 11 or 12 that I needed help. I knew I needed someone to just care and listen.

This therapist seemed so smug, and sure of himself. He thought he was funny, but he was really out of touch with how I felt and what I needed. 

So that was really, believe it or not, the first time I had this thought of, "I know what I need and I wish there was someone who could who could give it to me." 

I knew there was something important and powerful and helpful that's needed in the world, and I knew what it meant to need that.

Rick: You started the Colorado Center for Clinical Excellence back in 2011. What was the reason you wanted to start a group practice versus staying in like private practice? And, you know, how did your time with the International Center for Clinical Excellence (ICCE) influence you?

Jason: At that point I had been in private practice around 12 years when I started really putting together the idea for the group practice. 

For most of the time I was in private practice, I had been involved in one way or another with the field of outcomes measurement. 

Because just as I was starting my practice, I had come across the pioneers who are really making outcomes measurement happen in our field. 

Scott Miller, Barry Duncan, and Mark Hubbell were really the first ones to popularize the idea of outcomes measurement in a session-by-session way that was practical and had some validity to it. 

And so partly drawing on my fear around becoming the therapist that I had first had as a kid, I was really drawn to the idea of having accountability beyond my intuition of how I thought I was doing. Or my selective memory of how my clients told me I was doing.

Because I know that we all have this self enhancement bias. And we are going to tend to remember the feedback that enhances our idea of how we're doing. 

And so that fear of becoming this guy who thinks he knows what he's doing, but is really screwing up left and right, made the whole idea of outcomes measurement make some sense to me, although I was really skeptical. 

So I did it on my own, in my own practice for years and had also become certified as a trainer for agencies who were starting to take this on. 

It was really agencies that were at the forefront of doing outcomes measurement because they tended to have more motivation, more of a sense of accountability, or funders and third parties who wanted to know that their money was going someplace useful. 

They tend to be the ones, and still are the ones, who tend to do more of this outcomes measurement. 

So I had been doing this consultation and training for these agencies and for my own private practice, and I was getting really depressed because I'd go in to do these trainings and I knew from the way that clinicians were responding in the audience, that they were not getting support, by and large, from their administration. 

That they were feeling very anxious about how they were going to be judged, potentially fired, from what their outcomes showed. There was a lot of fear and not a lot of support for their work. 

So I would leave the training already feeling really worried about whether this was really going to go anywhere. Then I just stopped doing them because it was too depressing. 

I felt too much like the enemy when I'd walk into a room of 100 clinicians who are scowling at me, who hadn't really been prepared for what I was going to train them on. 

So I decided, you know, this is really valuable stuff. I'm using it a lot in my own practice and I'm finding it helpful. If not daily, then at least on a weekly basis, something will happen that reminds me why it's important. 

And I thought, “Well, why not just train my own people and build a practice around this where I can hire into this.” Rather than freaking out clinicians by changing things up on them when they've been working at a place for 10 years. I'll hire based on people's willingness and openness to doing this and make this the cornerstone of what we do as a practice.

So that was really the beginning where forming the group came from, my experience with the ICCE, and doing this training that felt like was really not getting a lot of traction because of the resistance and sometimes the act of sabotage from clinicians who were worried it was gonna be used in a bad way.

Jason: I think one of the challenges that we have is finding clinicians whose desire to do really phenomenal work is greater than their fear of what they find out if they measure their outcomes over time. There's still a lot of fear among clinicians.

So the idea that we're measuring outcomes, it's really scary. It's scary for all of us to start measuring how we are actually doing. 

And then there's probably going to be some fear in clinicians about how the data will be used. 

Will it be abused in a bad way by the administrator of the practice? 

So we really do have a big filter for people coming in of self selection, and that reduces our pool of good candidates. And I'm sure we're missing out on some really great clinicians who are just freaked out by the idea of this. 

Then on the other hand, it's also honestly finding clients who still value the richness and depth of what psychotherapy can provide. 

Because the culture as a whole has moved so much more into a very quick-fix orientation, almost seeing therapy as just a functional enhancement. You know: "I need a pill; I need some sort of technique, exercise, podcasts I can listen to, a YouTube video I can watch--something that I can consume and will fix some problem I have."

And the background I come from in psychotherapy is much more focused on developing one's self or a philosophy of life, the depth of one's spirituality, or the richness of one's relationships.

So it's almost more like an art than a technology. And it's becoming harder and harder in the culture to find people who really hunger for that depth and want that kind of richness versus just being stressed out and wanting to feel better.

Measuring outcomes in psychotherapy

Rick: Obviously, a huge focus you have is on measuring outcomes. Can you tell me more about how you do that and why it's important?

Jason: Yeah, so we measure outcomes really on two different levels. We’re measuring the outcomes for each client so we could think of that as the client level, where we’re interested from session to session, whether our patients are getting better over time.

And not that it would go in a straight line, but just to see overall, whether people are improving. And so that’s a way we’re using it on a clinical level, just to adjust if we need to, how we’re doing the therapy with this particular client.

And then we also are measuring outcomes on the clinician level.

So we’re looking at each of us as a therapist in our group to see overall what do our data look like. Are there areas that we’re weak in that we need to do more continuing education?

Are we getting certain patterns of feedback from our clients about the way we’re engaging with them that we need to look at as therapists? So I might talk too much, or I might stir people up too much, or be too focused on the past.

And if I’m getting feedback from an individual client about that, I can adjust that for that client, but if I’m getting consistent feedback from a number of clients that I’m doing something in a way that’s getting in the way or that just doesn’t feel very useful, then that really can direct me to do more of my own training and development as a therapist.

So we’re looking at the statistics much more on the therapist level. We don’t want to over-interpret on the client level because it can be so variable on the client level.

We just use it on the client level to adjust with that client, how we’re working together and whether we’re doing the best work we can with that person.

Rick: Great, and we talked a little about this before, maybe we can go into it a little bit more, how different that really is, that approach to measure outcomes for the therapists and using that to improve how you’re delivering care. Can you talk a little bit about how that kind of shift is and why you think that it can be so helpful?

Jason: Yeah. And, I mean, this is such a big topic because there’s such a movement right now both in medicine and psychotherapy toward outcomes-oriented care or patient-reported outcomes as a way of measuring quality, and there are so many landmines in this field.

And so in my world of psychotherapy outcomes, one of the biggest difficulties in getting clinicians to do this is the fear of what’s gonna happen if your outcomes aren’t so good? Because we can’t all be above average, right? So the idea is, if you’re a below-average clinician, what do you do with that? Or worse than that, what would insurance company do with that?

So there’s a lot of fear around just knowing how we’re doing and then making adjustments along the way.

What I do as a practice owner, first of all, is make sure that my therapists know that we’re using the data about how we’re doing as therapists to support them, to not punish anybody or bonus people for doing really good work.

And so not tying it to some sort of punishment or reward, but rather using it to improve their training or direct their continued education efforts.

So there’s a sense of support around it, rather than using it as a carrot or a stick.

And I will tell you that there’s been a number of insurance companies and agencies who’ve tried to use it as a carrot or a stick or both, and it blows up in their face every time because clinicians don’t like that.

None of us are in this to make money. There’s a lot easier ways to make money than being a therapist.

We’re in it because we really care about helping people. And when you have someone saying, “Well, if you’re not doing a good enough job then it could hurt your pay" or something like that, it really hurts people’s morale.

And all therapists really want is to be supported to do the best work they can because that’s really all we’re in this for.

So having this as a tool to do that, and when therapists really truly can believe that that’s what it’s being used for, then they tend to be a little less scared and more willing to jump on board and make use of the feedback they’re getting.

Jason: Yeah, exactly.

COVID-19 impact on telehealth & future of psychotherapy

Rick: So obviously, a big thing in the news right now is COVID-19 and it’s a big concern, and we’ve seen a lot of shifts in how technology can help you with still delivering care, even though people are having to stay at home and shelter in place. So how are you utilizing technology to help you achieve your outcomes?

Jason: Well, we have definitely made the shift to doing teletherapy or tele-mental health with all of our patients, so we’re not doing any in-person work right now, it’s all by video and some folks actually do prefer phone rather than video, so they will do that with those people.

And so right now what we’re really focused on is how to use the video technology in a way that still allows us to feel connected with our patients and do good work.

One of the things about doing therapy is we’re really using a person’s body in the room. In other words, we’re reading their body language, and you can get so much of a sense of someone being in the same room with them in terms of just how people are breathing, if they’re tensing, we’re constantly using that feedback, and with a screen, that is so limited.

And so what we have to rely on much more is facial expression and also asking more questions than we might have to ask if we were in-person.

So I might notice that something seems to be happening where I’m looking on my screen and I see someone seems to be breathing in a more shallow way, but I can’t quite tell, I think I’m seeing it.

So I might not be able to rely on my intuition about what I’m picking up, I might actually have to come out and ask, “Hey, I’m noticing your breathing seems a little different. Am I seeing that right?” So more checking in.

But on the other hand, with a video, we also often, if the quality is good enough, we sometimes can see more in terms of a little micro-expressions on people’s faces, and that can make our job even easier.

So, we’re just adjusting a lot to how to balance out the information we’re losing with information we’re gaining by doing the video and just again, continuing every session to get feedback to make sure we’re staying on track.

Rick: Very cool. So now looking into the future like in 10 years, how do you see more data being utilized to help specifically in your area, psychotherapy or mental health? How do you kinda see data being utilized?

Jason: Well, that’s a good question. Because I started doing this one way or another about 20 years ago, and I was sure that in 20 years, it would all be ironed out and being done. And we are still super far away from this being used throughout mental health.

And so I guess… What I’m thinking is that we’re gonna continue to stumble through as an industry, where I imagine that insurance companies and third-party payers and folks who are driving the desire for the data, because frankly, those are mostly the folks who are driving it, are going to get smarter about how they train clinicians and how they support clinicians to get clinicians to do this.

Because over the last 20 years often they just, with varying degrees, they’ve tried to support or educate, but still there is a sense of real fear among clinicians who will continue to sabotage it because they don’t believe it’s gonna be used in a good way.

There’s ways of using the data in very helpful human ways, and there’s ways of using the data in really stupid and dehumanizing ways.

And people rightly worry that the data are gonna be used in dehumanizing ways that are gonna water down the effectiveness of therapy, cause people potentially to fake data, things like that. So these are all very real concerns.

So I think it’s really gonna be a much slower slog up and down to find our way through to a method of doing this that still has a lot of integrity and honesty, and real use for the consumer to improve the quality of the care they’re getting.

Final Thoughts

Rick: How do you keep up with industry trends? Any good podcasts, blogs, influencers or newsletters that we should be following?

Jason: So I think in terms of industry trends, I read a lot of peer reviewed research on psychotherapy and outcomes measurement. 

I keep up with colleagues in the field as much as I can informally, but mostly I'm reading their work and keeping tabs that way. 

I don't follow any particular blogs or influencers except for, again, some of my colleagues like Scott Miller who has a blog that I keep up with. 

But otherwise I kind of dabble and I'll find things on TED talks or TEDx talks, or if someone sends me a link for a blog or a podcast they like, I tend to discover things that way.

Rick: What do you do to de-stress and relax?

Jason: Lately, I seem to watch a lot of films and TV. 

I listen to the music that my kids like, I really like to explore newer music that otherwise I would not have a clue what's out there and what's going on. I find it really enjoyable and it's a way for me to connect with them. 

I read mostly nonfiction and these days, mostly on my phone. And I fix things. 

I used to do a lot of woodworking and remodeling, but I don't have time for that now. 

So I find it really therapeutic just to fix things that are broken around the house or at work to get a concrete sense of satisfaction to balance the complexity of the emotional work that I'm doing.

Things like fixing a broken faucet or rewiring an electrical outlet is really satisfying and relaxing. In some ways because it's so concrete.