Day2DavidClaud

www.heartandsoulfchange.com June 18, 2010 Heart & Soul of Change: Becoming Better at this BarryDo Something like What You ? Putting Addicts In Charge of Their Treatment. Are You Crazy? David A. Claud, MS, LMHC, LPC, CAP Chief Operating Officer Center for Family Services of Palm Beach County, Inc. Clinical Supervisor – Partners for Change CDOI Project My BIO Something like this Barry ? 1. Worked w/brain injuries & “OBS” @ CMHC with Music Therapy early 70’s 2. BA in Biological Science – Psychology 3. Masters in Counseling Psychology 4. LMHC, LPC, CAP 5. Came up through the ranks 6. Public & private sector SA Tx.& dual diagnosis 8. Family Services non-profit agency since 1997 9. Private practice 10. Began Using CDOI in 2000 1

www.heartandsoulfchange.com June 18, 2010 My Agency Something like this Barryin ? 1. Private, nonprofit, social services agency founded 1961 2. Originally a mental health counseling agency 3. Programs for substance use and employee assistance 4. Program for sexually abused kids; victims of trauma 5. Serve the homeless and other vulnerable populations 6. Began CDOI dual diagnosis project in 2007 - State funded 7. Agency is funded by county, state and federal grants some insurance and Medicare; some pay OOP sliding scale fees 8. Nationally accredited by Council on Accreditation 1985 Experience with CDOI Something like this Barry ? • Began using ORS in 2000 in various counseling programs (individual/family counseling, child abuse treatment, substance use/DUI counseling) • Jacqueline Sparks, Ph.D. on staff from Oct. 2002- Dec. 2003 • CFS data used in standardization of ORS/SRS and CORS • ORS/SRS published in JBT in 2003 & CORS 2006 • Presented efficiency data at Heart & Soul 2,3,4 • 2007 Awarded $1.2 million State contract for CDOI Project 2

www.heartandsoulfchange.com June 18, 2010 Our Results with CDOI Something like this Barry ? Increased client engagement as evidenced by: • Reduced “drop outs” by 50% • Reduced No shows for appointments by 25% • Reduced cancellations of appointments by 40% Increase efficiency as evidenced by: • Using 40% fewer sessions to achieve program goals at the same or higher level • Use of fewer resources w/o sacrificing client satisfaction; satisfaction actually increased; reduce # sessions by 40% • Decreased by 80% the number of long term therapy cases where no benefit was being achieved • Decreased the number and frequency of client grievances and complaints to almost zero over the past 3-4 years Consumer Something like this Barry ? Driven Services 3

www.heartandsoulfchange.com June 18, 2010 Consumer Driven Treatment Something like this Barry ? Federal, State & Local funding require it. Some private MCO’s as well. Concept language includes: -Consumer driven services -Client or family centered treatment -Self directed care -Client choice -Client directed -Menu driven -Self selected Where did these ideas originate? Something like this Barry ? Harvard Business School Research 1980’s •Consumer driven healthcare saves money •Improves access to care •Increases value for consumers •Increases customer satisfaction •Increases quality & improves outcomes •2003 legislation tax incentives for CDHC plans •Government support for these concepts (SAMSHA, NIAA, NIDA, NIH, NIMH, etc.) 4

www.heartandsoulfchange.com June 18, 2010 How did these ideas gain a foothold in the SAMH treatment industry? Something like this Barry ? 1. Studies on client motivation, engagement, retention in Tx. all support client choice as a key factor in positive outcomes (William Miller, Ph.D., U of NM) 2. Studies on SA TX outcome show client’s perception of change and alliance do predict long term outcome (Project MATCH 1993) 3. Increased emphasis on civil rights & patient rights 4. Effective legal challenges have been made to coerced “religious” based SA treatments (AA/NA). * Clients have a choice under US constitutional law! 5. Research on treatment outcomes reveals what works and what does not. Consumer choice is in! If Addicts Were this Barry ?of Something like In Charge Their Treatment…. What would that look like? 5

www.heartandsoulfchange.com June 18, 2010 Addicts in Charge of Their Tx. Something like this Barry ? Me My Own Therapist? Like Putting Kids In Charge of Painting The House? Something like this Barry ? 6

www.heartandsoulfchange.com June 18, 2010 They’ll Want Long Coffee Breaks! Something like this Barry ? They’ll Want Frequent Something like this Barry ? Smoke Breaks! 7

www.heartandsoulfchange.com June 18, 2010 The Inner Child Will Escape! Something like this Barry ? Who Will Diagnose? Something like this Barry ? 8

www.heartandsoulfchange.com June 18, 2010 Who Would Do The Something like this Barry ? Paperwork? Make Him Do it! Something like this Barry ? 9

www.heartandsoulfchange.com June 18, 2010 Something like this Barry ? What Do We Think About Something Their this Barry “Addicts” and like Treatment? ? • What are the stereotypes? • What’s the public view? • How do the media portray them? • Have we as professionals come to tolerate or accept as “truth” a certain view of clients who have substance use problems? 10

www.heartandsoulfchange.com June 18, 2010 Exercise # 1 Something like this Barry ? Addicts are __________________! Addicts are __________________! Addicts are __________________! Addicts are __________________! Addicts are __________________! Addicts are __________________! Addicts are __________________! Exercise # 2 • SUD treatment must ________________. • SUD treatment must ________________. • SUD treatment must ________________. • SUD treatment must ________________. • SUD treatment must ________________. • SUD treatment must ________________. • SUD treatment must ________________. 11

www.heartandsoulfchange.com June 18, 2010 Some Familiar Ideas from the SA Treatment Culture Something like this Barry ? •How do you know when an addict is lying? •Take the cotton out of your ears and stick it in your mouth • Shut up and listen! •Your best thinking got you here! •Keep it simple stupid! •An addict alone is in bad company! History & Traditions Are Changing • Something like this Barry ? It takes one to know one. • Self-help AA and the 12 steps, The only way! • AA Not Religion but…. • “Spiritual” Program or Solution • “illness” – allergy/craving • Jellinek/AMA/WHO – 1950’s Disease Model • SA and MH Tx. and funding separate • Dual Dx.Tx. separate not integrated • Program driven vs. clinically driven; 28 days • Expert driven vs. consumer driven • One size fits all treatment; canned Tx., ? • Confrontational therapies still commonplace…. • (1950s) Treatment designed to break down the narcissistic, sociopathic personality and rebuild 12

www.heartandsoulfchange.com June 18, 2010 Confrontational Approaches Something like this Barry ? Effective or ineffective? What does the research say? Excerpts from “Confrontation Something likeTreatment”? in Addiction this Barry A Review of Four Decades of Outcome Research Literature on Substance Abuse Treatments Published in Counselor Magazine October 2007 By William R. Miller, PhD and William White, MA http://www.counselormagazine.com/columns-mainmenu-55/27-treatment- strategies-or-protocols/608-confrontation-in-addiction-treatment 13

www.heartandsoulfchange.com June 18, 2010 Confrontational Approaches Something like this Barry direct, Defined as “the process by which a therapist provides ? reality-oriented feedback to a client regarding the client's own thoughts, feelings or behavior.” Ranged from frank feedback to profanity laden indictments, screamed denunciations of character, challenges and ultimatums, intense argumentation, ridicule, and purposeful humiliation. Premise: If you make an addict feel bad enough about their behavior then they will stop doing it. Do Confrontational Approaches Something like SAT? Barry ? Work in this “Four decades of research have failed to yield a single clinical trial showing efficacy of confrontational counseling, whereas a number have documented harmful effects, particularly for more vulnerable populations.” William R. Miller, Ph.D. and William White, MA Confrontation In Addiction Treatment, Counselor Magazine, October 2007 14

www.heartandsoulfchange.com June 18, 2010 Treatments/Approaches Proven Ineffective or Iatrogenic Something like this Barry ? 1. Synanon Type TCs – ego deflation 2. Tough love and “Stop enabling” 3. Group confrontation; the Hot seat 4. Repeaters program – for hard cases 5. Derogatory statements and labels 6. Boot camps & prisons, “Scared Straight” 7. Intervention – 71% failed to enter Tx. 8. “Cinematic psycho-shock” – aversion 1950s 9. MADD Victim Impact Panels – 2x more likely to be re-arrested for DUI 10.One size fits all approach William R. Miller, Ph.D. and William White, MA Confrontation In Addiction Treatment, Counselor Magazine, October 20 Language and Stigma Something like this Barry ? Mass General Hospital’s Center for Addiction Medicine Surveyed 700+ MH Professionals @ Addictions Conference Findings: “Referring to people with addictions as “substance abusers” was more likely to evoke punitive responses to drug use than those who referred to individuals with “substance use disorders.” Note: The World Health Organization declared the term "abuser" as stigmatizing three decades ago. John F. Kelly and Cassandra M. Westerhoff Does it matter how we refer to individuals with substance- related conditions? A randomized study of two commonly used terms . (In press) International Journal of Drug Policy 2009 15

www.heartandsoulfchange.com June 18, 2010 Information, Not Scare Tactics, Helps Smokers Quit: Study Something like this Barry ? A new study finds that “smokers who called a tobacco quit line were twice as likely to experience short-term success in quitting if they heard positive messages rather than negative ones.” The positive messages were more effective in the short run, although the effects were not sustained, with abstinence rates evening out among the two groups after three months. "Multiple messages may be necessary for longer-term impact," the study noted. Randomized Trial: Quitline Specialist Training in Gain-Framed vs Standard-Care Messages for Smoking Cessation Toll, Benjamin A., Martino, Steve, Latimer, Amy, Salovey, Peter , O'Malley, Stephanie, Carlin- Menter, Shannon, Hopkins, Jessica, Wu, Ran, Celestino, Paula, Cummings, K. Michael. Journal of the National Cancer Institute 2010 102(2):96-106; doi:10.1093/jnci/djp468 So Where Are We Going? Something like this Barry ? Consumer Driven Client Directed Results Oriented Outcome Informed Accountability Measureable Evidenced-based 16

www.heartandsoulfchange.com June 18, 2010 National Consensus Statement on Something like Recovery ? Mental Health this Barry “Mental Health recovery is a journey of healing and transformation enabling a person with a mental health problem to live a meaningful life in a community of his or her choice while striving to achieve his or her full potential.” US Department of Health & Human Services SAMHSA Center for Mental Health Services 10 Fundamental Components of Recovery Something like this Barry ? 1. Self Direction 2. Individualized and Person-Centered 3. Empowerment 4. Holistic 5. Non-linear 6. Strengths-based 7. Peer Support 8. Respect 9. Responsibility 10.Hope US Department of Health & Human Services SAMHSA Center for Mental Health Services 17

www.heartandsoulfchange.com June 18, 2010 Principles of Effective Addiction Treatment (NIDA) Something like this Barry ? • No single treatment is appropriate for everyone. • Treatment needs to be readily available. • Effective treatment attends to multiple needs of the individual, not just his or her drug abuse. • Remaining in treatment for an adequate period of time is critical. • Counseling—individual and/or group—and other behavioral therapies are the most commonly used forms of drug abuse treatment. • An individual's treatment and services plan must be assessed continually and modified as necessary to ensure that it meets his or her changing needs. Something like this Barry ? The need for effective treatments for substance use problems has never been greater! 18

www.heartandsoulfchange.com June 18, 2010 Something like this Barry ? SUP Prevalence and the Need For Effective Treatment Something like this Barry ? 1. 23.2 million people ages 12 & up need treatment – 2007 2. Over 100,000 deaths annually due to problem drinking 3. $467.7 million cost to federal, state and local government 4. SA the #1 health problem in the US – 2000-2001 5. 40% of traffic fatalities are alcohol related – 2006 6. 25% of US children are exposed to SU in the family – 2000 7. Up to 80% of incidents of familial violence are SU related 19

www.heartandsoulfchange.com June 18, 2010 The Need For Effective SUD Tx. Something like this Barry ? 1. By 2010 we will need 35% more addictions professionals in order to meet the need 2. In 2006 providers already understaffed & with low recruiting of qualified professionals unable to meet need 3. Less than 10% of those in need of SUD Tx. are able to receive those kinds of services 4. The majority of those in SUD treatment do not complete treatment – SAMHSA 2008 5. 50%+ of Tx. completers resume problematic use within six months following discharge 6. Despite this SA Tx. has not appreciably changed in 75 years Four Macro Approaches to Something like this Barry ? SUD Treatment 1. Complications driven treatment 2. Diagnosis & problem driven treatment 3. Individualized, assessment driven treatment 4. Outcome Informed treatment The first 2 types predominate the SUD treatment industry 20

www.heartandsoulfchange.com June 18, 2010 Approaches to SUD Tx. Today Something like this Barry ? Complications Driven Care 1. Attention to treating the presenting complaints such as the medical and psychiatric complications of substance use. 2. Continuing care is typically superficial or nonexistent Diagnosis and Program Driven Care 1. Substance use and dependence take center stage 2. Programs are structured around this with fixed LOS 3. Aftercare is common & dedicated to reinforcing program goals & objectives Newest Approaches to SUD Tx. Something like this Barry ? Individualized Assessment Driven Treatment 1. Tailor services to the individual (ASI, ASAM, etc.) 2. Broad continuum of care to accommodate diverse needs 3. Placement criteria for multiple levels of treatment (ASAM) Outcome Informed Treatment 1. Uses feedback from clients to enhance fit and effectiveness of services 2. An extension of assessment driven treatment but … 3. Except client assessments rather than clinician’s assessments drive the service plan and delivery 21

www.heartandsoulfchange.com June 18, 2010 Are we there yet? Something like this Barry ? 1. Assessment driven care not yet fully implemented 2. Still have programmatic, fixed lengths of stay and canned treatment plans 3. Minnesota model is still the predominant approach or philosophy of care for addictions 4. Confrontational approaches still remain in use 5. The “medical model” of therapy still dominates 6. Anecdotal accounts and client testimonials tend to weigh in over good objective research data or practice based evidence re: effectiveness 7. Drop outs and relapse rates remain high on average Something like thisSeries ? IOM Quality Chasm Barry “Successful quality improvement requires that quality measurement be linked with activities at the locus of care to effect change and that understanding and use of these techniques be woven into the day to day of healthcare organizations and provider practices.” 22

www.heartandsoulfchange.com June 18, 2010 Factors Now Coming Together Something like this Barry ? 1. Rise of Consumerism – People less inclined to assume the patient role. Consumers want an active part in their care. 2. Payers and stakeholders demanding accountability, transparency and evidence of return on investment 3. A new generation of researchers and clinicians now in charge, with 40 years of research evidence about what works and pushing for a paradigm shift Where Does CDOI Come in? Something like this Barry ? 23

www.heartandsoulfchange.com June 18, 2010 How Has CDOI Changed Something like this Barry ? Assessment and Treatment Planning of Substance Users? • Focus on the client’s view as primary • Emphasize client strengths • Explore extra-therapeutic factors • Clarify goals: what do they want to change? • Tie the plan into the ORS • Assess risk on multiple dimensions: ASAM • Establish the baseline to measure change • Keep the Client's theory of change up front ASAM SomethingRisk Tothis Barry ? Assess for like Clients Goals Multidimensional Assessment 1. Acute Intoxication and/or Withdrawal Potential 2. Biomedical conditions and complications 3. Emotional/Behavioral/Cognitive conditions and complications 4. Readiness to Change 5. Relapse/Continued Use/Continued Problem potential 6. Recovery Environment 24

www.heartandsoulfchange.com June 18, 2010 Managing Residential SU Something like this Barry ? Treatment within a CDOI Clinical Framework ? Managing Residential SU Something like this CDOI ? Treatment within a Barry Clinical Framework ? • Establish Your Core Values • Clarify Management and Clinical Issues • Prioritize and Use as Guidelines • Think About the Group as a Client • Talk about rules vs. principals • Plan for Scenarios • Revisit Old Ideas About Do’s & Don’ts • Be Willing to Take Measured Risks 25

www.heartandsoulfchange.com June 18, 2010 Something like this Barry ? Remember the Common Factors! 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 26

www.heartandsoulfchange.com June 18, 2010 Something like this Barry ? Remember Early Change! Change in Treatment Source: Howard, et al (1986). The dose effect response in psychotherapy. American Psychologist, 41(2), 159-164. 27

www.heartandsoulfchange.com June 18, 2010 Project MATCH The Results Babor, T.F., & DelBoca, F.K. (eds.) (2003). Treatment Matching in Alcoholism. United Kingdom: Cambridge, 113. Cannabis Youth Treatment RCT Treatment Approach Results © http://www.chestnut.org/LI/Posters/CYT_%20MF_APA.pdf 20MF_APA.pdf 28

www.heartandsoulfchange.com June 18, 2010 Translating Research into Practice •How has the field typically diminished the role of clients in change? •How can research showing the impact of the client be utilized? The Killer D’s of Client Diminishment Diagnosis Dysfunction Disorder Disability Disease Deficit Damaged Delinquent 29

www.heartandsoulfchange.com June 18, 2010 Casting the Client in Heroic Roles Listening for Heroic Stories • No formula here, more of an attitude requiring a balance between listening empathically with mindfulness toward resources that you know are there. • Tap into the client’s world. Identify not what clients need, but what they already have in their world that can be put to use in reaching their goals 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 already exists that can be used in service of the client’s goals? The Heroic Client 30

www.heartandsoulfchange.com June 18, 2010 Conclusions From This Research  Feedback about outcome is essential for clinical decision making.  The diverse approaches in these studies suggests that the type of therapy is of less importance.  Do not need to know what tx to use for a given diagnosis as much as whether the current relationship is a good fit and providing benefit, and, if not, to adjust early to maximize the chances of success.  And the major conclusion that we reached… Shifting from EBP to PBE The EBP View: The PBE View: What treatment, by Is this relationship whom, is most effective between this client for this individual with and this therapist that specific problem, working for this under which set of individual at this time circumstances, and and place? how does it come about? 31

www.heartandsoulfchange.com June 18, 2010 Shift Happens! Something like this Barry ? 40 Years of Data say… •Client’s rating of the alliance the best predictor of engagement and outcome. •The client’s subjective experience of change early in the process the best predictor of success for any particular pairing. 32

www.heartandsoulfchange.com June 18, 2010 •Assesses individual, relational, and social functioning. •Validity: Correlates .6 with the OQ-45.2. OQ- •Reliability in the .8’s. •Feasibility: Takes less than a minute; compliance rates in the 90’s (v. 14%) The Outcome Rating Scale •Client places a mark •Add the four scales on the line. together for the total score. •Each line 10 cm in length. •Give at the beginning of each session or “point of service.” 33

www.heartandsoulfchange.com June 18, 2010 Introducing the ORS/SRS: Building A Culture of Feedback and Client Privilege • Start with the first phone call • Emphasize importance of client voice and feedback • Better to know sooner than later • Continue focus in first session ORS: An Example •What can we glean clinically from this 7.8 client’s scores in addition to being 8.1 above the clinical cut off? 5.4 •How could we use 8.0 this information to Total = 29.3 begin or focus the session? 34

www.heartandsoulfchange.com June 18, 2010 BECAUSE THESE CLIENTS GET WORSE WITH TREATMENT •Explore why the client entered therapy •Use referral source’s rating •Identify and reinforce strengths and resources, successful problem solving patterns, plans for the future •Avoid exploratory or depth-oriented techniques •Adopt a “check-in/check up”/PRN approach when scheduling Initial Information… •Client’s score is 40 within the clinical range. 30 •Scoring more like people in treatment s c o re ORS 20 and wanting something to change; 10 0 1 2 3 4 5 6 7 8 9 10 Session number •Within range of Projected change 75th percentile ORS Scores experience. Estimated Clinical Cutoff 25th percentile 35

www.heartandsoulfchange.com June 18, 2010 Connecting to the Client’s Described Experience • At some point, connect the client’s described experience of their lives to the marks on the scales • At that moment, both therapist and client know what the marks mean and how success will be measured Assessing The Alliance • Adds time, but assessing the alliance identifies weaknesses in the delivery of services before any negative effect on outcome. Clients do not typically report negative alliances; when they do, enjoy more progress. 36

www.heartandsoulfchange.com June 18, 2010 The Therapeutic Alliance Alliance Goals, Meaning Means or or Methods Purpose Client’s View of the Therapeutic Relationship •Assesses the four components of the alliance. •Validity: Correlates .5 with the HAQ-II. HAQ- •Reliability of .83. •Feasibility: Takes less than a minute; compliance in the 90’s. 37

www.heartandsoulfchange.com June 18, 2010 The Session Rating Scale •Client places a mark •Give at the end of each on the line. session or “point of service.” •Each line 10 cm •Before the client leaves, length. discuss their responses any time the total score falls at 36 •Add the four scales or below. together for the total score. SRS Guidelines • SRS score: 0-34 Reflects a Poor Alliance • SRS Score: 35-38 Reflects a Fair Alliance • SRS Score: 39-40 Reflects a Good Alliance 38

www.heartandsoulfchange.com June 18, 2010 SRS Example: Interpretation? •Because most people score high on such measures: 9.5 •You can’t interpret high ratings 9.7 (trying to please, etc.) 10.0 •Thank the person for completing the measure and 9.8 maintain an openness to Total = 39 feedback. •Most useful if negative! SRS scores are under 36, even though the client expresses satisfaction • Build culture of feedback…clients really have to know that you want it • Go over each item of SRS and discuss • Only a problem if ORS shows no change 39

www.heartandsoulfchange.com June 18, 2010 The Benefits of Outcome Management • One study of 6224 clients, Miller, Duncan, Brown, Sorrell, & Chalk (2004) provided therapists with 1.00 0.90 real-time feedback using 0.80 the ORS and SRS. Effect size 0.70 0.60 0.50 • This “practice-based 0.40 0.30 evidence” resulted in 0.20 higher retention rates and 2nd 3 ua 4thqu r 1st q rter 2n 3 uarter 4thq arte 1 q rter rdq rter arte ua d rdq u r st ua qu r arte 20 02 2002 2 3 00 qu r arte 2003 2003 2004 doubled the overall effect 2002 (n=7 ) (n 2 22 =7 3) (n=8 ) 45 2 3 (n=1 0 (n=9 ) (n 5) 00 02 ) 45 =86 (n 9) =52 (n=8 2 8) size (baseline ES = .37 v. final phase ES = .79; p < .001). The Revolutionary Benefits • As incredible as the results may appear, they are entirely consistent with other findings. • Lambert et al. (2003) reported that those relationships at risk for a negative outcome which received formal feedback were, at the end of therapy, better off than 65% of those without feedback (Average ES = .39, p < .05). • Whipple et al. (2003) found that clients whose therapists had access to outcome and alliance information were less likely to deteriorate, more likely to stay longer, and twice as likely to achieve a clinically significant change. 40

www.heartandsoulfchange.com June 18, 2010 SRS Results so far… •Cases in which therapists “opted out” of assessing the alliance at the end of a session: •Two times more likely for the client to drop out; •Three to four times more likely to have a negative or null outcome. Miller, S.D., Duncan, B.L., Sorrell, R., & Brown, G.S. (February, 2005). The Partners for Change Outcome Management System. Journal of Clinical Psychology, 61(2), 199-208. More SRS Results • Poor and remains poor predicts negative outcome • Good and remains good predicts positive outcome • Poor or fair and improves predicts positive outcome even more • Good and decreases predicts negative outcome 41

www.heartandsoulfchange.com June 18, 2010 Something like this Barry ? Different Strokes for Different Folks The Individual Nature of Clients Something like this Barry ? 42

www.heartandsoulfchange.com June 18, 2010 43

www.heartandsoulfchange.com June 18, 2010 Something like this Barry ? Working with Clients Scenes from the Coal Face 44

www.heartandsoulfchange.com June 18, 2010 What about Dual Diagnosis or Co-Occuring like this Barry ? Something SAMH Problems? 46

www.heartandsoulfchange.com June 18, 2010 Principles of Dual Diagnosis Treatment Something like this Barry ? Dr. Kenneth Minkoff WE NEED…… COMPREHENSIVE, CONTINUOUS, INTEGRATED, SYSTEMS OF CARE FOR INDIVDIUALS WITH CO-OCCURRING DISORDERS Dr. Kenneth Minkoff Eight Principles of Dual Dx. Treatment Something like this Barry ? Research-based and consensus-derived! Empathic, hopeful, integrated treatment relationships are one of the most important contributors to treatment success in any setting. There is no single correct intervention. For each individual interventions must be individualized 47

www.heartandsoulfchange.com June 18, 2010 Something like this Barry ? Outcome Measures Got Data? 48

www.heartandsoulfchange.com June 18, 2010 Something likeVariance ? Therapist this Barry Mean # Mean LOS in Clients To Effect Size Sessions Months Benchmark 10.9 5 78% .69 8.1 2.8 78% .72 6.7 2.3 68% .43 11.4 3.5 72% .45 Where To Start Something like this Barry ? 1. Work Within The System 2. Start Small if You Have To (Pilot) 3. Gradually Integrate Into Existing Structures 4. Change Policy & Procedure When Possible 5. Collect Data and Show Results 6. Talk to Colleagues and Stakeholders 7. Create opportunities to Influence the System 8. Train Others 9. Change the World 50

Day2DavidClaud

by Barry Duncan on Jun 05, 2010

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