Day1Heart&SoulDuncan

www.heartandsoulofchange.com June 17, 2010 The Heart and Soul of Change Becoming Better at What We Do Barry Duncan, Psy.D. www.heartandsoulofchange.com 954.721.2981 www.whatsrighwithyou.com barrylduncan@comcast.net 1

www.heartandsoulofchange.com June 17, 2010 Mission from Obama 2

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www.heartandsoulofchange.com June 17, 2010 A Story about Research • Two Evidence Based Practice Researchers • Went on a hot-air balloon ride Feedback Improves Effectiveness • An unexpected fog rolled in…hopelessly lost. • Finally, a small clearing appeared… •Since the 60’s, the # of models has grown from 60 to over 400… •Each claims superiority in conceptualization and outcome The result is fragmentation along theoretical and disciplinary lines Now over 100 so called evidence based treatments--effectiveness treatments--effectiveness not increased in 40 years… 4

www.heartandsoulofchange.com June 17, 2010 The Dodo Verdict •With few exceptions, partisan studies designed to prove the unique effects of a given model have found no differences— differences—nor has recent meta- meta- analyses…The analyses…The Dodo Verdict—the Verdict— most replicated finding in the psychological literature “Everybody has won and all must have prizes.” Rosenzweig, S. (1936). Some implicit common factors in diverse methods in psychotherapy. Journal of Orthopsychiatry, 6, 412-15. Wampold, B.E. et al. (1997). A meta-analysis of outcome studies comparing bona fide psychotherapies: Empirically, "All must have prizes." Psychological Bulletin, 122(3), 203-215. TDCRP The Alliance •Considered most sophisticated comparative clinical trial ever: •CBT, IPT, Drug, Placebo •No difference in outcome •The client’s rating of the alliance at the second session the best predictor of outcome across conditions. Elkin, I. Et al. (1989). The NIMH TDCRP: General effectiveness of treatments. Archives of General Psychiatry, 46, 971-82. 5

www.heartandsoulofchange.com June 17, 2010 Project MATCH The Alliance •CBT, 12-step, & Motivational 12- Interviewing •NO difference in outcome •The client’s rating of the alliance the best predictor of: Treatment participation; Drinking behavior during treatment; Drinking at 12-month FU 12- Project MATCH Group (1997). Matching alcoholism treatment to client heterogeneity. Journal of Studies on Alcohol, 58, 7-29. Babor, T.F., & Del Boca, F.K. (eds.) (2003). Treatment matching in Alcoholism. Cambridge University Press: Cambridge, UK. Connors, G.J., & Carroll, K.M. (1997). The therapeutic alliance and its relationship to alcoholism treatment participation and outcome. Journal of Consulting and Clinical Psychology, 65(4), 588-98. The Dodo Also Rules Family Therapy Cannabis Youth Treatment Project •600 Adolescents marijuana users: •Significant co-morbidity (3-12 problems). co- (3- •Two arms (dose, type) and one of three types of treatment in each arm: •Dose arm: MET+CBT (5 wks), MET+CBT (12 wks), Family Support Network (12 wks)+MET+CBT; •Type arm: MET/CBT (5 wks), ACRT (12 weeks), MDFT (12 wks). Approach accounted for 0% of the variance in outcome. Ratings of the alliance predicted: Premature drop-out; Substance abuse and dependency drop- symptoms post-treatment, and cannabis use at 3 and 6 month follow-up. post- follow- 6

www.heartandsoulofchange.com June 17, 2010 What About PTSD? • Many effective: EMDR, CT w/o exp., hypnotherapy, PDT, PCT. • MA found no difference • CT w/o exposure & PCT excluded any exposure • The 2 txs w/o exp. as effective as those w/exposure incidental Benish, S., Imel, Z. E., & Wampold, B. E. (PDT) or central (CBT (2007). The relative efficacy of bona fide psychotherapies for treating post- traumatic stress disorder: A meta- w/prolonged & in-vivo exp.) analysis of direct comparisons. Clinical Psychology Review, 28, 746-759. What About Evidenced Based Practice •Dodo highlights fatal flaw: Efficacy over placebo or TAU is not efficacy over other approaches & not saying much— much—if a friend went out on a date, you asked about the guy, your friend replied, “He was better than nothing—he was unequivocally better than watching TV or washing my hair.” How impressed? •And the conclusion… Rosenzweig, S. (1936). Some implicit common factors in diverse methods in psychotherapy. Journal of Orthopsychiatry, 6, 412-15. 7

www.heartandsoulofchange.com June 17, 2010 But Reason Prevails APA New Definition of EBP Evidence-based practice is the integration of the best available research with clinical expertise in the context of client characteristics, culture, and preferences (American Psychologist, May 2006). APA Recommendations • Decisions should be made in collaboration with the client, based on the best evidence • Most effective when responsive to the client’s strengths, cultural context, and preferences. • Responses are variable. Therefore, ongoing monitoring of client progress and adjusting as needed is essential 8

www.heartandsoulofchange.com June 17, 2010 Implication of the Dodo Bird Verdict All 400 approaches work because: Of factors common to all therapies So what are the factors? Factors Accounting for Successful Outcome 40.0% Spontaneous Remission Client/Extratherapeutic Common Factors Relationship Models/Techniques 30.0% 15.0% Placebo/Hope/Expectancy 15.0% Lambert, M. (1986). Implications of Psychotherapy Outcome Research for Eclectic Psychotherapy. In J. Norcross (Ed.) Handbook of Eclectic Psychotherapy. New York: Brunner/Mazel. 9

www.heartandsoulofchange.com June 17, 2010 Becoming Better More Satisfying Picture • Recent findings from meta- analytic studies paint a more complicated but satisfying picture of the factors, their effects, & relationship to each other. • Factors are interdependent, fluid, dynamic, & dependent on who the players are & their interactions…drugs Client/Extratherapeutic Factors (87%) Feedback Effects 15-31% Alliance Effects Treatment Effects 38-54% 13% Model/Technique 8% Model/Technique Delivered: Therapist Effects Expectancy/Allegiance 46-69% Rationale/Ritual (General Effects) Duncan, B. (2010). On becoming a better therapist. 30-?% Washington DC: American Psychological Association 10

www.heartandsoulofchange.com June 17, 2010 Bottom Line “The quality of • Suggests the patient's something different participation . . . [emerges] as • Privilege clients’ the most experience & rally important their resources to determinant of the cause outcome." Orlinsky, D. E., Rønnestad, M. H., & Willutzki, U. (2004). Fifty years of process -outcome research: In M. J. Lambert (Ed.), Bergin and Garfield’s handbook of psychotherapy and behavior change (5th ed., pp. 307-390). New York: Wiley. Translating Research into Practice •How do traditional theories and models marginalize the role of clients? •How can research showing the impact of the client be utilized; how can the client be recast in heroic roles? 11

www.heartandsoulofchange.com June 17, 2010 The Killer D’s of Client Diminishment Dysfunction Disorder Disability Disease Deficit Damaged Not Reliable or Valid None ever related to outcome Diagnosis “I have found little that is good about human beings. In my experience, most of them are trash.” --Sigmund Freud, M.D. 12

www.heartandsoulofchange.com June 17, 2010 Diagnostic Screening Test 1. Lift your right foot off the floor and make clockwise circles. 2. Now, while doing this, draw the number "6" in the air with your right hand. 3. If your foot changes direction, you need drugs or therapy or both. Diagnostic Dys-Order Poor Reliability Unknown Validity…Bipolar Dx Does not predict LOS or outcome Little help in treatment selection Surveys consistently find that MHPs do not like it or find it useful… Kirk, S.A., & Kutchins, H. (1992). The selling of DSM: The rhetoric of science in psychiatry. New York: Aldine Duncan, B., Miller, S., & Sparks, J. (2004). The Heroic Client. San Francisco: Jossey-Bass. 13

www.heartandsoulofchange.com June 17, 2010 Clients Are the Lions of Change Until lions have their historians, tales of hunting will always glorify the hunter. African Proverb Casting the Client in Heroic Roles • No formula here, more of an attitude requiring a balance between listening empathically with mindfulness toward resources that you know are there. • Identify not what clients need, but what they already have in their world that can be put to use in reaching their goals 14

www.heartandsoulofchange.com June 17, 2010 Finding the Heroic Client What are the qualities that describe you when you are your very best? What were you doing when these aspects became apparent to you? What kind of person do these aspects describe? Or, What kind of person do these aspects show an aspiration toward? What are the qualities that others would describe In you when you are at your very best? What were you doing when they noticed these aspects? What kind of person do these aspects describe? Or, what kind of person do these aspects show an aspiration toward? Finding the Heroic Client • Who was the first person to tell you that they noticed the best of you in action? What were you doing when they noticed these aspects? • Who was the last person to tell you that they noticed the best of you in action? What were you doing when they noticed these aspects? • Who in your life wouldn’t be surprised to see you stand up to these situations and prevail? What experiences would they draw upon to make these conclusions about you? What “quintessentially you” stories would they tell?...Kim • When I am at my very best, I am _____________. 15

www.heartandsoulofchange.com June 17, 2010 Telling Heroic Stories • What are the obvious and hidden strengths, resources, resiliencies, and competences contained in the client’s story? • What are the competing stories—the stories of clarity, coping, endurance, and desire that exist simultaneously with the confusion, pain, suffering, and desperation? • What is already there to be recruited for change? The Heroic Client Dale—the Violent Suicidal Man • Story of “Threats” • Story of “Suicide” • Story of “Strange Beliefs”…wants an apocalypse 16

www.heartandsoulofchange.com June 17, 2010 Dale’s Heroic Story • Story of a man with a warrior inside. • Story of a man who controls his rage. • Story of a natural born leader wanting to do some good in the world. The Heroic Client • The Client: • Change is a potent client factor, weaving in and out clients’ lives creating many therapeutic opportunities. • Chance events: • Things that simply happen while the person happens to be in therapy… 17

www.heartandsoulofchange.com June 17, 2010 Change in Treatment Source: Howard, et al (1986). The dose effect response in psychotherapy. American Psychologist, 41(2), 159-164. Maintaining Change •Strong correlation between the maintenance of change and the degree to which clients attribute it to their own efforts. •Participants who attribute changes to a med or therapist are less likely to maintain gains than those who viewed the improvement resulting from their own efforts. •Those who attribute changes to their own efforts rather than chance more likely to maintain gains regardless of the cause. Frank, J.D. (1976). Psychotherapy and the sense of mastery. In R.L. Spitzer et al. (eds). Evaluation of Psychotherapies. Baltimore, MD: Johns Hopkins. Liberman, B. (1978). The maintenance and persistence of change. In J.D. Frank et al. (eds). Effective ingredients of effective psychotherapy. New York: Brunner Mazel. 18

www.heartandsoulofchange.com June 17, 2010 Translating Research into Practice •How have traditional theories and models minimized the role of chance/change-producing events? •How can research showing the impact of chance events on the change process be utilized? “Chance favors the prepared mind.” Louis Pasteur December 7, 1854 19

www.heartandsoulofchange.com June 17, 2010 Becoming Change Focused • Listen for a change! Ask about and be curious about change: How did you do that? Where did that idea come from? • Validate the clients contribution to change. How is (drug/tx program) helping access strengths and resources that have always been there but were just beyond your grasp? Encourage Before and After Distinctions • How did you decide that now was the time for action? • What insights have you gained that you were finally able to put into action? • What insights have you gained from this change that will help you in the future? • What does this say about you, the kind of person that took the bull by the horns at this time? • How did you do it? How will you maintain the gains you have made? • How are you different now that you have realized this change? • Ponder the difference in your self-image before you changed and now….Ashley 20

www.heartandsoulofchange.com June 17, 2010 The Treatment of Depression Collaborative Research Project (TDCRP) •Considered to be the most sophisticated comparative clinical trial ever conducted: •Four approaches (CBT, IPT, Drug, Placebo). •No difference in outcome between approaches •The client’s rating of the alliance at the second session the best predictor of outcome across conditions. •Tx model accounted for 0-2% of the variance… 0- Elkin, I. Et al. (1989). The NIMH TDCRP: General effectiveness of treatments. Archives of General Psychiatry, 46, 971-82. Client/Extratherapeutic Factors (87%) Feedback Effects 15-31% Alliance Effects Treatment Effects 38-54% 13% Model/Technique 8% Model/Technique Delivered: Therapist Effects Expectancy/Allegiance 46-69% Rationale/Ritual (General Effects) Duncan, B. (2010). On becoming a better therapist. 30-?% Washington DC: American Psychological Association 21

www.heartandsoulofchange.com June 17, 2010 Therapist Differences Incredible Variation Among Providers TDCRP: top third psychiatrists giving placebo bested bottom third giving meds; clients of best therapists improve 50% more & dropped out 50% less; meds useful for clients of more effective therapists, not for less--What accounts Wampold, B., & Brown, J. (2006). Estimating variability in for the variability? outcomes attributable to therapists: A naturalistic study of outcomes in managed care. Journal of Consulting and Clinical Psychology, 73 (5), 914-923. Successful V. Unsuccessful Providers Focus on Strengths Studied videos of 120 sessions of 30 clients • Unsuccessful providers focused on problems, neglected strengths. • Successful providers focused on strengths before moving to problems…. Gassman, D. & Grawe, K. (2006). General change mechanisms: The relation between problem activation and resource activation in successful and unsuccessful therapeutic interactions. Clinical Psychology and Psychotherapy, 13, 1-11. 22

www.heartandsoulofchange.com June 17, 2010 Provider Variables that Predict Change Therapists with the best results: • Emphasize the relationship; are better at the alliance across clients Baldwin et al. (2007). Untangling the alliance-outcome correlation. Journal of Consulting and Clinical Psychology, • 40% therapist variance 75(6), 842-852.; Vocisano et al. (2004). Therapist variables that predict symptom change in psychotherapy with chronically accounted for by depressed outpatients. Psychotherapy, 41(3), 255-265. Owen, Anker, Duncan, & Sparks (2010). Therapist variance alliance in last session in couple therapy. Manuscript submitted for publication. Client/Extratherapeutic Factors (87%) Feedback Effects 15-31% Alliance Effects Treatment Effects 38-54% 13% Model/Technique 8% Model/Technique Delivered: Therapist Effects Expectancy/Allegiance 46-69% Rationale/Ritual (General Effects) Duncan, B. (2010). On becoming a better therapist. 30-?% Washington DC: American Psychological Association 23

www.heartandsoulofchange.com June 17, 2010 Relationship Factors The Alliance: • Relational Bond • Agreement on goals 38- 38-54% • Agreement on tasks Seven Times the Impact of Model/Technique…Accounts for Most of Therapist Variance Duncan, B., Miller, S., & Sparks, J. (2004). The Heroic Client. San Francisco: Jossey-Bass The Therapeutic Alliance The Alliance Goals, Means or Meaning Methods: or Theory of Purpose Change Client’s View of the Relationship 24

www.heartandsoulofchange.com June 17, 2010 The Alliance: Over 1000 Research Findings  Quality of the alliance more potent predictor of outcome than orientation, experience, or professional discipline-- recall TDCRP, MATCH, CYT.  Clients rarely report negative reactions before deciding to terminate.  Same holds true for youth and family therapy Project MATCH What about the mandated clients? •No difference in outcome between voluntary and mandated clients. •The only reliable predictor? •The Alliance Project MATCH Group (1997). Matching alcoholism treatment to client heterogeneity. Journal of Studies on Alcohol, 58, 7- 29. Connors, G.J., & Carroll, K.M. (1997). The therapeutic alliance and its relationship to alcoholism treatment participation and outcome. Journal of Consulting and Clinical Psychology, 65(4), 588-98. 25

www.heartandsoulofchange.com June 17, 2010 Translating Research into Practice •How have traditional theories and models minimized the role of the alliance and client engagement? •How can research showing the importance of the therapeutic alliance and client engagement be utilized? Research into Practice The Alliance •Increasingly, the relationship is viewed as merely “setting the stage” for the “real” treatment: •Confronting distorted thoughts; •Recovering forgotten memories; •Asking special questions; •Tapping on or waving fingers in front of the face…but the data say: •The alliance deserves far more RESPECT… Duncan, B. (2010). On becoming a better therapist. Washington, DC: APA. 26

www.heartandsoulofchange.com June 17, 2010 Reliance on the Alliance • Be friendly, responsive, and flexible (like a first date); stay close to client’s experience. • Empathy and Positive Regard: Validate. Legitimize the client’s concerns/basic worth and the importance of their struggle. • Work on client’s goals period. • Fit the client’s theory of change. Empathy Carl Rogers Was On To Something • Empathy. A meta-analysis of 47 studies: r of .26 between therapist empathy and psychotherapy outcome, translating to ES of .32. • ES of model and technique differences is but .20; Client’s perception of empathy more powerful than any technique you can ever wield. 27

www.heartandsoulofchange.com June 17, 2010 Empathy Plus Positive Regard Equals Validation • Positive Regard: warm acceptance w/o conditions. • When outcome & positive regard were both rated by clients, 88% of studies found sig. relationship. Critical that clients think we view them positively. • Appreciation: appreciation of people in general, their struggles, and of their humanity and innate goodness. The Rubber Hose of Doubt and the Bright Light of Blame You are the problem! You are to blame! • Validation doesn’t mean you agree with what the client has done; means that you acknowledge the rest of the story! • Puts client’s actions in a context that legitimizes him/her as a human being. No wonder… • Clears a path for change because it diffuses self doubt and dissipates self loathing…Dale 28

www.heartandsoulofchange.com June 17, 2010 Reliance on the Alliance • Be friendly, responsive, and flexible (like a first date); stay close to client’s experience. • Empathy and Positive Regard: Validate. Legitimize the client’s concerns/basic worth and the importance of their struggle. • Work on client’s goals period. • Fit the client’s theory of change. The Client’s Theory of Change Pre- Pre-existing beliefs about the problem and change Duncan, B., Solovey, A., & Rusk, G. (1992). Changing the Rules. New York: Guilford. 29

www.heartandsoulofchange.com June 17, 2010 The Client’s Theory of Change: Empirical Findings In the TDCRP, congruence between the clients TOC and tx resulted in: Stronger therapeutic alliances; Longer duration in treatment; and Improved treatment outcomes. Elkin, I. (1999). “Patient-treatment fit" and early engagement in therapy. Psychotherapy Research. 9(4) 437-451. Plurality Pays Off Differential Efficacy with Current Client • Q: Does it resonate; does it fit client preferences; can both get behind it? • Alliance skills: explore client ideas, discuss options, collaboratively plan, and negotiate changes if benefit not forthcoming. • Alliance in action. Litmus test: whether it engages client in purposive work. 30

www.heartandsoulofchange.com June 17, 2010 When the alliance is in trouble… Consider… Molly 31

www.heartandsoulofchange.com June 17, 2010 The Alliance and Model/Technique Not Disembodied Parts • Alliance dependent on delivery of some “treatment;” bond, goals, and tasks • Technique is an activity; the alliance characterizes the activity, the purpose of the activity—to engage the client in the work Alliance As An Overarching Framework The Alliance Filter • Transcends any beh & is a property of all—from tech. to scheduling an appt • Engage in purposive work • Requires utmost attention & best clinical skills: proactive, conscience, hard work • Have to earn it each & every time; alliance is our craft; practice elevates to art 32

www.heartandsoulofchange.com June 17, 2010 Attitude Important Alliance is Central Filter • Is what I am doing and saying now building or risking the alliance? • Doesn’t mean you can’t challenge but rather that you have to earn the right and, consider the alliance consequences The Alliance Bottom Line • The Alliance Matters— Big Time • TDCRP: alliance accounted for up to 21% of the variance, • Real-time Feedback about the Alliance Critical to Success 33

www.heartandsoulofchange.com June 17, 2010 Client/Extratherapeutic Factors (87%) Feedback Effects 15-31% Alliance Effects Treatment Effects 38-54% 13% Model/Technique 8% Model/Technique Delivered: Therapist Effects Expectancy/Allegiance 46-69% Rationale/Ritual (General Effects) Duncan, B. (2010). On becoming a better therapist. 30-?% Washington DC: American Psychological Association Model/Technique Delivered Allegiance and Expectancy • General effects: all models have a rationale and ritual—both client and therapist must believe . • Delivering a tx—carries allegiance & placebo effects in addition to the small specific effects of any approach 34

www.heartandsoulofchange.com June 17, 2010 Expectancy (Placebo) TDCRP • Across conditions, client expectation of improvement predicted outcome • An inspection of the BDI reveals that the placebo plus CM condition accounted for nearly 93% of the mean response to the active treatment conditions. But What About This Client? • While the data give general guidance, it does little to inform what will help a particular client. • To know what is therapeutic, the client’s view regarding both the alliance and outcome is key. • The real question: Does this client experience this interaction at this time and place to be therapeutic? And the only way to do this is via client feedback 35

www.heartandsoulofchange.com June 17, 2010 Bottom Line  Feedback is essential for clinical decision making.  Do not need to know what tx to use for a given dx as much as whether the relationship is a good fit and providing benefit. Psychotherapy The Good… Study after study, and studies of studies show the average treated client is better off than 80% of the untreated sample. 36

www.heartandsoulofchange.com June 17, 2010 Counseling Works As Good As RCTs • Recent study: – 2,000+ providers – 6,000+ clients – Outcomes equivalent to RCTs for depression, specifically the TDCRP. Minami, T., Wampold, B., Serlin, R. Hamilton, E., Brown, J., Kircher, J. (2008). Benchmarking the effectiveness of psychotherapy treatment for adult depression in a managed care environment. Journal of Consulting and Clinical Psychology, 76(1), 116-24. Psychotherapy The Bad… • Drop out rates average 47% • Therapists vary… a lot 37

www.heartandsoulofchange.com June 17, 2010 And the Ugly Providers Don’t Know • 20-70% range • Graded their effectiveness, A+ to F— 67% said A or better; none rated below average. Hansen, N., Lambert, M., Forman, E. (2002). The psychotherapy dose-response effect and its • Counselors don’t know implications for treatment delivery services. Clinical Psychology: Science and Practice, 9, 329-343. Sapyta, J., Riemer, M., & Bickman, L. Feedback to how effective they are clinicians: Theory, research, and practice. Journal of Clinical Psychology: In Session, 61, 145-153 Becoming Better More on Provider Differences •Least effective therapists believe they are as helpful as most effective. •In the absence of reliable information about outcome, what do we expect? 38

www.heartandsoulofchange.com June 17, 2010 The Result: Consumer Confidence Troubling • APA asked: “Is this an important reason why you might choose not to seek help?” • The highest % responses were lack of ins. (87%) & cost (81%). • The 3rd was a lack of confidence in the outcome of tx (77%). • Despite tx efficacy, DOs are a problem, many do not benefit, therapists vary in effectiveness and & there is a crisis of confidence among consumers. Outcome: How do therapists compare? In a survey on how much consumers trusted various professionals…. The consumer Therapists Psychotherapy in Australia (2001). Trust in therapists? 7(1), 4. 39

www.heartandsoulofchange.com June 17, 2010 To The Rescue Consumer Driven Outcomes Management • Howard et al. (1996) advocated for the systematic eval. of client response during treatment to “determine the appropriateness of the current tx…the need for further tx…[and] prompt a clinical consultation for patients who [were] not progressing at expected rates” Feedback and Outcome Lambert’s Five Trials • All 5 sig. gains for feedback • 22% of TAU at-risk cases at- improved compared with 33% for feedback to therapists, 39% for feedback to therapists & clients, & 45% when supplemented with support tools • A strong case for routine measurement of outcome in everyday clinical practice 40

www.heartandsoulofchange.com June 17, 2010 Becoming Better Isn’t It Good, Norwegian Wood • Feedback v TAU; Both persons reliable or sig. change—50.5% v. 22.6%; ES: .50; 4 xs # of clin. sig. change • FU: TAU-34.2% v. 18.4% Feedback Anker, M., Duncan, B., & Sparks, J. (2009). Using client feedback to improve couple therapy outcomes: A randomized clinical trial in a sep./divorce rate naturalistic setting. Journal of Consulting and Clinical Psychology, 77(4), 693-704. Barry Finds the Spot in the Norway Picture By Coincidence 41

www.heartandsoulofchange.com June 17, 2010 Reese, Norsworthy, & Rowlands (2009) First Independent Study • N=148: Feedback group doubled controls (10.4 Reese, R., Norsworthy, L., & vs. 5.1 pts); ES: .48 Rowlands, S. (2009). Does a continuous feedback model • Like Norway study, improve psychotherapy outcomes? Psychotherapy,46, 418-431. clients, regardless of risk status, benefit from continuous feedback • And the replication study now in press Effects on Efficiency Cancellations, No Shows, LOS • Claude (reported in Bohanske & Franczak) compared ave. # of sessions, canc., no shows, and % of long-term cases before and after OM in 2130 closed cases in a CMHC. • Ave. # of sessions dropped 40% (10 to 6) while outcomes improved by 7%; canc. and no show rates were reduced by 40% and 25%; and % of Bohanske, R., & Franczak, M. (2010). long term null cases diminished by Transforming public behavioral healthcare: A case example of consumer directed services, 80% (10% to 2%). recovery, and the common factors. In B. Duncan et al. (Eds.) The Heart and Soul of Change: Delivering What Works, 2nd Ed. Washington, DC: American • An estimated savings of $489,600. Psychological Association. 42

www.heartandsoulofchange.com June 17, 2010 Becoming Better Recapture Your At Risk Clients • Feedback tailors therapy based on response, provides an early warning system to prevents drop- outs & negative outcomes, & solves therapist variability—feedback improves performance period. First Things First Why You Might Be Reluctant • You might be thinking that you need more paperwork like a hole in the head. Therapists can get really worked up over anything that adds paperwork, especially when they don’t see it as clinically useful. 43

www.heartandsoulofchange.com June 17, 2010 When PacifiCare Introduced 30 Item Measure Practitioners complained: • About length & freq. admin. • Cut into sessions & increased workload • Was intrusive • Exec. Dir. of MPA said: “I have never seen such negative reaction from providers.” Hanlon, P. (2005). PacifiCare screening tool, policies raise concerns. New England Psychologist, 13, 1,11-12. First Things First Why You Might Be Reluctant • Feedback about the benefit & fit need not be cumbersome or intrusive. Only a couple of minutes & no intrusive questions. • Feedback the best hope to improve, clients appreciate your dedication to getting it right, & it is painless and can fit your natural way. 44

www.heartandsoulofchange.com June 17, 2010 Getting Started Just the Facts Ma’am • The nuts & bolts, not for starting next month, or even next week—but with your next client • Feedback is the way to transcend average. The First Session All Aboard • Have to be on board with two things: have to think privileging the client is a good idea; and have to want to be accountable. 45

www.heartandsoulofchange.com June 17, 2010 Client Privilege and Social Justice Clients Have Been Missing Persons Despite well-intentioned efforts, the infrastructure of therapy (paperwork, policies, procedures, and professional language) can reify non-contextualized descriptions of client problems and silence client views, goals, and preferences. The Measures and Social Justice “Leveling” the Counseling Process • Invites clients into inner circle of decision making • Available in multiple languages • Voice to diversity and the disenfranchised • Local culture and context over privileged knowledge 46

www.heartandsoulofchange.com June 17, 2010 Starting With the Predictors Change and the Alliance •Client’s rating of the alliance the best predictor of engagement and outcome. •Client’s subjective experience of change early in the process the best predictor of success for any particular pairing. Sooner Rather Than Later Who drops out? B •The bulk of change A occurs sooner rather than latter Howard, K. et al. (1986). The dose-effect response in psychotherapy. American Psychologist, 41, 159-164. 47

www.heartandsoulofchange.com June 17, 2010 Some clients do take longer, but the mythology never dies N=4676; 77% attended 8 or less, and 91% 12 or less Note that even for the clients who take longer, change starts early…just is flatter Baldwin, S., Berkeljon, A., Atkins, D., Olsen, J., & Nielsen, S. (2009). Rates of change in naturalistic psychotherapy: Contrasting dose-effect and good-enough level models of change. Journal of Consulting and Clinical Psychology, 77(2), 203-211. It’s A Fact Early Change is The Rule Cannabis Youth Treatment Project Early change in treatment is a robust predictor of outcome and retention in Project MATCH treatment. Gotta measure outcome! http://www.chestnut.org/LI/Posters/CYT_%20MF_APA.pdf Babor, T.F., & DelBoca, F.K. (eds.) (2003). Treatment Matching in Alcoholism. United Kingdom: Cambridge, 113. 48

www.heartandsoulofchange.com June 17, 2010 Early Change is the Rule TDCRP Conclusions: Early change is an important factor for the prediction of short- and long-term outcome in therapy. Lutz, W., Stulz, N., & Köck, K. (2009). Patterns of early change and their relationship to outcome and follow-up among patients with major depressive disorders. Journal of Affective Disorders 118(1), 60-68. Becoming Better Measuring Outcome •Give at the beginning of the visit; Client •Scored to the places a mark nearest millimeter. on the line. •Add the four •Each line 10 scales together cm (100 mm) in for the total score. length. •Reliable, valid, feasible 49

www.heartandsoulofchange.com June 17, 2010 CORS •Give at the beginning of the visit •Scored to the •Client clicks nearest a mark on millimeter the line •Four •Each line 10 scales cm (100 mm) added in length for the total score 50

www.heartandsoulofchange.com June 17, 2010 •Under 6 •Involves all members of the family, even the youngest •Have crayons and places to color ready Becoming Better Creating A Culture of Feedback •When scheduling, provide rationale for seeking feedback; convey commitment to their goals and highest quality of service…in your own words •Work a little differently; •If we are going to be helpful should see signs sooner rather than later; If not helpful, we’ll seek consultation & consider a referral. •No one has ever said: Bad idea! 51

www.heartandsoulofchange.com June 17, 2010 The First Session Whatever It Takes • You can’t over-explain… • Clients get this. Face validity. • Whatever explanation the client gives is ok. Some will say: “You mean like poor to well?” or “Like 1 to 10?” • It’s their subjective experience that matters so their understanding of the measure is paramount. Looking Like a Klutz We All Bozos on the Bus • Score the marks. Need a cm ruler. Many will not try—fear of looking like a bozo. • Worry about measuring marks & adding the scores. 4 marks & 4 scores, not regression equations. Practice until you feel confident. • But, it’s okay to look inept from time to time with clients. And believe me, however you do it won’t be as bad as I’ve done it. 52

www.heartandsoulofchange.com June 17, 2010 Becoming Better Graphing: A Helpful Visual • Adds a visual component— another way to focus tx • At a glance tells the story of the client’s progress. • Allows you to dispense of the previous measures. • Indispensable with couples & families, helps discuss multiple viewpoints The First Meeting The “Clinical Cutoff” •The dividing line between a 40 clinical & “non-clinical” 35 population (25). For children O u tc o m e S c o r e 30 25 (32) & adolescents (28); 20 caretakers (28) 15 •Between 25-33% score in 10 5 the “non-clinical” range. 0 1st 2nd 3rd 4th •The slope of change Session Number decreases as clients approach Actual Score Line 2 25th % 75th % the cutoff. 53

www.heartandsoulofchange.com June 17, 2010 The Clinical Cutoff Only 2 Choices • Either above or below. • Mention client score as it relates to the cutoff & have the client make sense of it. • Scores under cutoff may seem more straightforward • Reporting distress similar to others seeking services— the lower the score, the higher the distress. Looking for a change. Initial Information… 40 •Client’s score is within the 30 clinical range. s c o re ORS 20 •Scoring more 10 like people in therapy and 0 wanting 1 2 3 4 5 6 7 8 9 10 Session number something to change…wavy Projected change 75th percentile ORS Scores Estimated Clinical Cutoff 25th percentile 54

www.heartandsoulofchange.com June 17, 2010 ORS: An Example •What can we glean clinically from this 7.8 client’s scores in 8.1 addition to being above the clinical cut off? 5.4 •How could we use this 8.0 information to begin or focus the session? Total = 29.3 The First Meeting Over the Clinical Cutoff •Explore why the client entered therapy…two reasons: circumscribed problem or mandated/coerced •If mandated, ask for the referral’s rating as a catalyst for conversation… doesn’t mean they are lying •Focus on circumscribed problems or issues at hand •Avoid exploratory or “depth- oriented” techniques or stirring the cauldron 55

www.heartandsoulofchange.com June 17, 2010 Over the Cutoff The Wicked Witch • People over cutoff are a higher risk of deterioration. • Why? • We don our Wicked Witch costume, growing warts & a humongous nose, and we stir the cauldron. Laughing devilishly we shriek, “Oh you think things are going okay do you, we’ll see about that, my pretty!” First Session: Connect ORS to the Client’s Described Experience • At some point, connect the client’s described experience of their lives to the marks on the scales 56

www.heartandsoulofchange.com June 17, 2010 The ORS The Bare Bones • No specific content other than domains—a skeleton to which clients add the flesh & blood of their experiences. • At the moment clients connect the marks with what they find distressing, the ORS becomes a meaningful measure of their progress and potent clinical tool. Get A Good Rating Make Sure • Transparency is the rule, not confrontation or judgment • Darrell and Angelina Jolie • Ray 57

www.heartandsoulofchange.com June 17, 2010 40 Years of Data say… •Client’s rating of the alliance the best predictor of engagement and outcome. •Client’s subjective experience of change early in the process the best predictor of success for any particular pairing. Quickest Way Prevent Drop Out Clients drop out for 2 reasons: therapy is not helping (monitor outcome) & alliance problems—not engaged or turned on. Direct way to improve effectiveness is to keep people engaged in therapy. Gotta measure the alliance 58

www.heartandsoulofchange.com June 17, 2010 The Session Rating Scale Measuring the Alliance •Score in cm to •Give at the end the nearest mm; of session; •Discuss with •Each line 10 cm client anytime in length; total score falls below 36 59

www.heartandsoulofchange.com June 17, 2010 •Scored to the nearest mm •Give at the end of •Discuss each with session; client anytime •Each line total 10 cm in score length; falls below 36 Becoming Better A Culture of Feedback with the SRS •When scheduling a first appointment, provide a rationale for seeking feedback regarding the alliance. •Work a little differently; •Want to make sure that you are getting what you need; •Take the “temperature” at the end of each visit; •Feedback is critical to success. •Restate the rationale prior to administering the scale. •How not to do the SRS 60

www.heartandsoulofchange.com June 17, 2010 Make My Day 61

www.heartandsoulofchange.com June 17, 2010 The Session Rating Scale Traditionally • Told us with their feet • Will let us know on SRS before telling/bolting. • Takes work for candor. • Disparity in power & socio- economic, ethnic, or racial diff., can make it tough. When was the last time you told your physician, “You're making a big mistake"? But Don’t Stress It’s Okay • Keep encouraging client to let you know… • Have to KNOW: No bad news. Not a measure of competence or anything negative about you or the client. Gift from the client that helps you to be better. • Unless you really want it, you are unlikely to get it. • You won’t get it from everyone. 62

www.heartandsoulofchange.com June 17, 2010 The Session Rating Scale A Quick Visual Check • Scores < 36 or 9cms should be discussed. • SRS is good or its not. Either thank the client for the feedback, & invite them to share future concerns; or thank client & explore why their ratings are lower so that you can fix the concern. • Building the Alliance Thanks and Exploring What About Below 36 or 9cm? • Don’t expect specifics or revelations—any feedback is a godsend • Is there anything else I could have done, something I should have done more of or less of, some question or topic I should have asked? 63

www.heartandsoulofchange.com June 17, 2010 The SRS Graceful Acceptance • And a willingness to be flexible usually turn things around. • Clients reporting alliance problems more likely for success. Lower scores on the SRS should be celebrated. • If clients are comfortable enough to express something isn’t right, then you are doing something great. X X X X Now we’re ready to be better therapists, but first we must heed the words of a noted psychotherapy scholar 64

www.heartandsoulofchange.com June 17, 2010 Sage Psychotherapy Scholar: Mae West? Granted, at first When I’m blush, these good, hardly seem like I’m very words for good, but when therapists to live I’m bad, by—but, as it I’m better. turns out, they are. Becoming Better Helping Every Single Client • When clients are not benefiting provides the opportunity to do your best work—gives you the possibility of being helpful to everyone you see. Sound too good to be true? It’s not. 65

www.heartandsoulofchange.com June 17, 2010 Becoming Better Identifying Clients Not Responding • When outcome is bad in other words, you can make it better by changing something about the therapy to turns things around; and if things don’t turn around, by moving the client on to a different provider or service Becoming Better Two Choices: Not Rocket Science • Either the client is improving or not. If not, the client is at risk. • Engage client in discussion about progress, and what should be done differently if there isn’t any. • Keeps clients engaged so that a new direction can be planned. 66

www.heartandsoulofchange.com June 17, 2010 Becoming Better When I’m Good, I’m Very Good • When ORS scores increase, when you’re good, a crucial step to be very good is help clients see gains as a consequence of their own efforts and make sense of its meaning so repeat in the future. Becoming Better Linking Outcome to Treatment •See clients more frequently when the slope of change is steep. •Begin to space the visits as the rate of change lessens. •See clients as long as there is meaningful change & they desire to continue. 67

www.heartandsoulofchange.com June 17, 2010 Becoming Better Doesn’t Mean All Therapy Should Be Brief • Au contraire, research suggests that more is better than less for clients who progress early & want to continue. • When little or change, however, same data indicates that therapy should, indeed, be as brief as possible. Becoming Better What to Do Next • Involve the client in monitoring progress & the decision about what to do next, to elicit ideas & formulate a plan. • Repeated in all meetings, but later ones gain significance and warrant additional action: Checkpoint and Last Chance Discussions. 68

www.heartandsoulofchange.com June 17, 2010 Becoming Better When to Say When • Stimulates both client & therapist to struggle with continuing a process yielding little or no benefit. • To support what is working & challenge what is not. Urgency increases over time Checkpoint Session: An Opportunity to Be Better • Be transparent— comment about the lack of progress and seek feedback from the client about what he/she thinks it means 69

www.heartandsoulofchange.com June 17, 2010 Becoming Better First, the Alliance • “It doesn’t look like we are getting anywhere. Let’s go over the SRS to make sure you are getting exactly what you are looking for.” Going thru SRS and eliciting client responses in detail can help you & the client get a better sense of what may not be working. • Looking at SRS pattern may be instructive Checkpoint Conversation Do Something Different • Nothing may come of talk about the alliance. Don’t worry. Making effort helps. • Invite others from support system, use a team or co- therapist, a different approach; referral to another therapist, religious advisor, or self-help group—whatever seems of value. • Any ideas are implemented, and progress is monitored. 70

www.heartandsoulofchange.com June 17, 2010 Becoming Better The Last Chance Discussion • Driving into desert running on empty, “last chance for gas.” • Depicts the necessity of stopping and discussing the implications of continuing w/o change. Becoming Better Never the LAST CHANCE • Doesn’t mean the “last chance” for your client—but rather the last chance of a change plan or pairing. No last chance for your client—referral can make the difference! 71

www.heartandsoulofchange.com June 17, 2010 Becoming Better Helping Every Single Client • All clients can’t benefit. Still a way to be helpful. • Might have felt like a failure. But when I’m bad, I’m better. Now successful when client achieves change & when, in the absence of change, I get out of the way. Becoming Better The Last Chance Discussion • At the least, consultation • Referral seriously discussed. • Rarely justified to continue past typical period. • Rarely is not never. Highly idiosyncratic & uniquely negotiated. Keeps us honest, addresses the lack of change transparently—new for me. 72

www.heartandsoulofchange.com June 17, 2010 Becoming Better Guard Against Finger Pointing • Guard against explaining client response thru theoretical filters & folklore— puts us right back where we have traditionally been— attributing lack of change to the client. Client non- response means something else should be done. When I’m Bad, I’m Better Failing Successfully • Repeat commitment to help them achieve goals. • Failure says nothing about them or their potential. • If client wants, meet until arrangements are made. • But rarely continue with clients who show no improvement. 73

www.heartandsoulofchange.com June 17, 2010 My Data 100 90 Percent reaching target 80 70 60 50 98% 40 30 75% 20 10 0 1 2 3 4 5 6 7 Failing Successfully Change of Therapist 74

www.heartandsoulofchange.com June 17, 2010 Watershed Client Failing Successfully I wish my helper had failed successfully • I believed in PBE, but… • Awakened me to the pitfalls; taught me to fail successfully. • Avoid “chronic” client—the client— iatrongenic effects of continuing w/o benefit. • ORS allows us to ask ourselves hard questions. Being Bad Can Make You Better • Helps clients you are already effective with by empowering change—helps those not benefiting by enabling other options and, in absence of change, the ability to move the client on. • When we’re good, we’re very good, but when we’re bad, we can be even better. 75

Day1Heart&SoulDuncan

by Barry Duncan on Jun 04, 2010

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Day1Heart&SoulDuncan — Document Transcript