Client-Directed, Recovery-Oriented Practice: Feedback-Informed Treatment to Improve Consumer Participation
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This 90-minute workshop was delivered at the at the 5th Rural and Remote Mental Health Symposium in Kingscliff, New South Wales on the 2nd of November 2016.
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Client-Directed, Recovery-Oriented Practice: Feedback-Informed Treatment to Improve Consumer Participation
- 1. Will Dobud Charles Sturt University Consumer-Driven, Recovery-Oriented Practice: Using Feedback-Informed Treatment to Improve Consumer Participation
- 13. Consumer-Driven, Recovery Oriented Practice • The Business of It All – Consumers, Professionals, & Service Delivery • Finding What Works – Research & Practice • Feedback-Informed Treatment & Continuous Quality Improvement 8th Australian Rural & Remote Mental Health Symposium www.anzmh.asn.au/rrmh
- 14. “The therapist is a co-adventurer, exploring the landscape and encountering multiple vantage points while crossing the terrain of the client’s theory of change. When stuck along the way, we join clients in looking for and exploring alternate routes on their own maps. In the process clients uncover trails we never dreamed existed.” (Duncan, Miller, & Sparks, 2004, p. 136) 8th Australian Rural & Remote Mental Health Symposium www.anzmh.asn.au/rrmh
- 15. My Name is Will & I’m a Social Worker Education BSW - University of Maryland – Baltimore County MSW[AP] - Charles Sturt University v Run a small adventure therapy program in SA Awarded Australian Postgraduate Award by CSU Australian Association for Bush Adventure Therapy 8th Australian Rural & Remote Mental Health Symposium www.anzmh.asn.au/rrmh
- 16. Business, Mental Health & Wellbeing • Our services are purchased services • We’re worth investing in: We’re well trained and our services are effective • Those who do engage are better off than 80% who do not • Our services are cost effective (i.e. Reduction in Hospital Stays) • Depression is the leading cause of disability in western countries 8th Australian Rural & Remote Mental Health Symposium www.anzmh.asn.au/rrmh
- 17. Who has confidence in our services? • Behind cost and insurance, lack of confidence is #3 reason for not engaging • Stigma does not break the Top 10 • More money is spent on stigma in mental health then improving public confidence • Dropouts are an issue: Adults = 47% Children/Adolescents = 25% to 85% 8th Australian Rural & Remote Mental Health Symposium www.anzmh.asn.au/rrmh
- 18. Table 1 Factor Loadings for Varimax Six-Factor Solution Factor and item Factor, loading Eigenvalue % Variance Mean factor score Factor 1: Therapeutic Relationship Problems 6.46 15.72 .27 33. The therapist didn’t seem to be doing the right things. .90 31. The therapist didn’t seem to understand. .83 30. The therapist didn’t talk about the right problems. .77 35. My child’s treatment was not clearly explained to me. .73 32. My child or I didn’t like the therapist. .70 34. The therapist didn’t seem to be helping. .69 36. One or more of the staff members did not seem competent. .65 28. There was something we did not like about one or more of the staff members. .55 40. I felt that the therapist or staff did not spend enough time with my child alone. .55 41. I felt that the therapist or staff did not spend enough time with my child and other family members together. .54 39. I felt that the therapist or staff did not spend enough time with me alone. .54 16. I decided that going to the clinic would not help my child. .51 29. There was something about the clinic that my child or I did not like. .45 37. We waited too long at appointments. .45 38. No one would see us at our appointments. .42 Factor 2: Family and Clinic Practical Problems 2.96 7.22 .13 26. We had family problems that prevented us from going. .59 2. Someone in the family got sick. .47 38. No one would see us at our appointments. .46 21. We moved away from the area. .42 41. Therapist didn’t spend enough time with the family. .41 37. We waited too long at appointments. .41 39. The therapist didn’t spend enough time with us alone. .37 4. We didn’t know how to get to the clinic. .37 18. We had transportation problems. .35 22. It was too hard to make babysitting arrangements for my other children. .35 Factor 3: Staff and Appointment Problems 2.44 5.96 .26 14. The staff member I talked to on the phone did not seem very nice, or did not seem interested in helping. .80 15. The staff member I talked to on the phone did not seem very competent. .72 28. There was something we did not like about one or more of the staff members. .43 5. The appointment they gave us was too far in the future. .42 13. I found another counselor or clinic to help my child. .39 7. The appointment they gave us interfered with my work schedule. .36 6. The appointment they gave us interfered with my child’s school. .36 Factor 4: Time and Effort Concerns 1.94 4.74 .19 24. We didn’t have enough time. .79 3. I felt that too much travel time was involved. .66 23. It took too much effort to go. .57 7. The appointment interfered with my work schedule. .35 Factor 5: Treatment Not Needed 1.79 4.38 .30 25. We decided that things were ok after all—that my child didn’t really need to change. .74 10. I felt that help was no longer necessary because my child got better. .63 12. I didn’t really feel that my child had a problem. .58 Factor 6: Money Issues 1.38 3.38 .17 27. I had a misunderstanding with the clinic over the payment of fees. .75 17. The services cost too much. .49 441BRIEF REPORTS Garcia & Weisz (2002): When Youth Mental Health Care Stops Therapist didn’t do the right things My child and I didn’t like the therapist One or more staff members did not seem competent Family Issues prevented us from going (i.e. Sickness, babysitter, transport) The staff member I talked to on the phone did not seem very nice or interested in helping I found another counselor or clinic to help The services cost too much We decided things were ok after all 8th Australian Rural & Remote Mental Health Symposium www.anzmh.asn.au/rrmh
- 19. “Connection Before Correction” • Agreement on Goals – What the consumer wants? • Agreement on Therapeutic Tasks – How we will go about getting it? • A Relational Bond – Our relationship 8th Australian Rural & Remote Mental Health Symposium www.anzmh.asn.au/rrmh
- 20. Exercise 1: Relationship & Rapport • Circle Up • Get a name and some information • Get Mouse Trap & Set It! ------- • Build trust and relationship • What’s our goal? • How will we achieve it? 8th Australian Rural & Remote Mental Health Symposium www.anzmh.asn.au/rrmh
- 21. Becoming Consumer-Driven “Clients are not inert objects or diagnostic categories on whom techniques are administered. They are not dependent variables on which independent variables operate…people are agentive being who are effective forces in the complex of causal events.” (Lambert, Garfield, & Begin, 2004, p. 814) 8th Australian Rural & Remote Mental Health Symposium www.anzmh.asn.au/rrmh
- 22. Process-Oriented Proper Diagnosis + Prescriptive Intervention = Effective Treatment Targeted Diagnostic Groups + Evidenced Based Treatments = Symptom Reduction 8th Australian Rural & Remote Mental Health Symposium www.anzmh.asn.au/rrmh
- 23. First Step: The Killer D’s • Most mental illnesses in the DSM have no boundaries (i.e. Depression) • They’re Socially Constructed: The Story of Homosexuality • Attribution Creep – Rosenhan Experiment (1973) 'On Being Sane in Insane Places’ • Project MATCH - $33 million dollar study, no differences in approach 8th Australian Rural & Remote Mental Health Symposium www.anzmh.asn.au/rrmh
- 24. Next: Empirically-Supported Treatments • How do we find the best treatments? • Treatment vs. Control or TAU • Human Affairs International Study • What all therapies have in common? • Why are some therapists better? 8th Australian Rural & Remote Mental Health Symposium www.anzmh.asn.au/rrmh
- 25. The Therapeutic Factors Theory 8th Australian Rural & Remote Mental Health Symposium www.anzmh.asn.au/rrmh Reprinted from On becoming a better therapist, by B. Duncan, 2010, Washington, DC, American Psychological Association.
- 26. The New Equation 8th Australian Rural & Remote Mental Health Symposium www.anzmh.asn.au/rrmh Client Resources and Resilience + Client Theories of Change + Client Feedback about the Fit & Benefit of the Service = Client Perceptions of Preferred Outcomes
- 27. Feedback Factors 8th Australian Rural & Remote Mental Health Symposium www.anzmh.asn.au/rrmh • Routinely Monitor Outcomes – Practice-Based Evidence • Began with Lambert’s self-report Outcome Questionnaire – 45 (OQ-45) • Reduce deterioration, dropouts, and doubles effectiveness • Long measures leads to low adherence
- 35. Warning Signs & Failing Successfully 8th Australian Rural & Remote Mental Health Symposium www.anzmh.asn.au/rrmh • No Improvement by Session 3 • Deterioration – Client’s who are showing decreasing scores • SRS Scores below the Clinical Cutoff (Any score under 9)
- 36. Clinical Excellence & Quality Development 8th Australian Rural & Remote Mental Health Symposium www.anzmh.asn.au/rrmh • Who are the Supershrinks? • What do the highest achieving therapists do to achieve their outcomes? • More time completing “Deliberate Practice”
- 37. Exercise 2: Culture of Feedback • Pick a partner • Invite them to complete the ORS • Measure it ------- • Get feedback from your partner • How comfortable were you? • Any feedback from your partner? 8th Australian Rural & Remote Mental Health Symposium www.anzmh.asn.au/rrmh
- 38. 8th Australian Rural & Remote Mental Health Symposium www.anzmh.asn.au/rrmh The Victor Harbor Flexible Learning Options Project
- 39. 8th Australian Rural & Remote Mental Health Symposium www.anzmh.asn.au/rrmh Initial Meetings & Program Structure • Met the 8 young people and parents to discuss the program • Administered the ORS at first meeting without much discussion • Alert Cases: Two participants reported an initial score of 40 • Baseline Mean = 28.7 Collateral Score Mean = 25.5 • 11 Day Program funded through DECD and Local Rotary Club
- 40. 8th Australian Rural & Remote Mental Health Symposium www.anzmh.asn.au/rrmh Implementing FIT Practice • ORS and GSRS administered every 3 days • Progress Report created after measurement to discuss changes in scores • Discussion about GSRS Scores to address potential issues in the group
- 41. 8th Australian Rural & Remote Mental Health Symposium www.anzmh.asn.au/rrmh Results of the Program 0 5 10 15 20 25 30 35 40 P16F S15S S16F D16M J16M M15M J17F L17M
- 42. 8th Australian Rural & Remote Mental Health Symposium www.anzmh.asn.au/rrmh Stacked ORS and GSRS Scores 0 5 10 15 20 25 30 35 40 ORS GSRS
- 43. 8th Australian Rural & Remote Mental Health Symposium www.anzmh.asn.au/rrmh A 17 Year Old Male 0 5 10 15 20 25 30 35 40 ORS GSRS