Day2JeffReeseMortenAnkerJesseOwen

www.heartandsoulofchange.com June 18, 2010 Research Can Be Sexy – Like When it Changes the Way a Country Provides Services Your not so sexy presenters: Jeff Reese Morten Anker Jesse Owen Heart and Soul of Change Conference New Orleans, LA June 18, 2010 Overview of Session • Share the latest, greatest client feedback research. • Provide evidence of how client feedback can make you a better therapist. Morten & Jesse• Demonstrate how practical research can “Revenge of the address the scientist-practitioner gap Research and help shape both the practice of Nerds” training of psychotherapy. 1

www.heartandsoulofchange.com June 18, 2010 Inside the Research Lab: Investigating the Effects of Client Feedback in Psychotherapy and Supervision Jeff Reese, PhD University of Kentucky Heart and Soul of Change Conference New Orleans, LA June 18, 2010 Overview of Presentation 1. Share results of client feedback studies within: a. Individual therapy b. Couple therapy c. Supervision and Training 2. Discuss future ideas for client feedback research 2

www.heartandsoulofchange.com June 18, 2010 But first, let’s talk about my initial… Feedback & Individual Therapy We asked the following questions: • Can PCOMS research be replicated? • Specifically, we asked: 1. Does PCOMS lead to increased effectiveness? 2. What is the dose-response curve? Reese, R. J., Norsworthy, L. A., & Rowlands, S. R. (2009). Does a continuous feedback system improve psychotherapy outcome? Psychotherapy: Theory, Research, Practice, Training, 46, 418-431. 3

www.heartandsoulofchange.com June 18, 2010 Sample & Methodology Sample • Clients (N = 148) randomly assigned to client feedback or no-feedback condition at two sites Univ. Counseling Center (UCC) – 74 Participants MFT Training Clinic (MFT) – 74 Participants Methodology • Feedback Condition - completed ORS before each session and SRS at end of each session • No-Feedback Condition - “Treatment as Usual” completed ORS at first and last session (UCC) completed ORS each session (MFT) 1. Does PCOMS increase effectiveness? Uh…yes. Feedback No-Feedback Double the M SD M SD Effectiveness!! Study 1 ORS Total (Pre) 18.59 7.60 22.71 9.70 (Post) 31.28 6.63 29.53 7.26 12.69 6.82 d = .55 Study 2 ORS Total (Pre) 18.68 10.39 19.64 6.46 (Post) 29.51 9.58 24.33 7.51 10.83 4.69 d = .67 4

www.heartandsoulofchange.com June 18, 2010 1. Does PCOMS increase effectiveness? Yes, again… Feedback No-Feedback Classification n % n % Study 1 1. Deteriorated 2 4.00% 3 12.50% 2. No Change 8 16.00% 8 33.30% 3. Reliable Change 40 80.00% 13 54.20% Study 2 1. Deteriorated 2 4.44% 1 3.44% 2. No Change 13 28.89% 16 55.16% 3. Reliable Change 30 66.67% 12 41.40% Note. χ2 = 4.60, p < .05 (Study 1); χ2 = 16.67, p < .01 (Study 2). 2. What is the Dose-Response Curve? (Study 1) 1.0 Staff Student 0.8 therapist Percentage of Clients Improved staff intern staff-censored intern-censored 0.6 0.4 0.2 0.0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Session 5

www.heartandsoulofchange.com June 18, 2010 2. What is the Dose-Response Curve? (Study 2) 1.0 Feedback TAU Percentage of Clients Improved 0.8 group experiemental control experiemental- censored control-censored 0.6 0.4 0.2 0.0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Session Summary of Findings 1. Both the feedback and no-feedback groups experienced statistically significant change as a result of psychotherapy. 2. Those in the client feedback condition experienced more improvement, about double, in fewer sessions. 3. Findings of the dose-response curve tend to reflect those found in the literature, with more change occurring early. 4. Study 1: 50% of those in the client feedback condition experienced reliable change by the 7th (staff) or 12th (practicum student) session. Study 2: 50% in the feedback condition experienced reliable change by the 7th session compared to 10th session for no-feedback condition. 6

www.heartandsoulofchange.com June 18, 2010 Feedback & Couple Therapy • Evaluated if client feedback effects extended to couple therapy. • Specifically we asked: 1. Do couples in a feedback condition demonstrate more improvement? 2. Do couples in a feedback condition improve more quickly? Reese, R. J., Toland, M. T., Slone, N. C., & Norsworthy, L. A.. (in press). Effect of client feedback on couple psychotherapy outcomes. Psychotherapy: Theory, Research, Practice, Training. Sample & Methodology Sample • 46 heterosexual couples from MFT Training Clinic • 74% White, 4.3% was African American, 16.3% Hispanic/Latino, 3.2% multiracial, and 2.2% did not indicate ethnicity. • Mean age was 30.18 (SD = 9.71), ages from 19 to 56. Methodology • Therapists & couples randomly assigned to the client feedback or TAU conditions. • Mean number of sessions attended by couples in the feedback (6.06) and TAU (5.13) conditions were not significantly different, t (90) = 1.48, p > .05. 7

www.heartandsoulofchange.com June 18, 2010 1. Does PCOMS increase effectiveness? Looks Familiar… Client Feedback TAU M SD M SD Pre-ORS Score 23.34 9.15 24.03 9.47 Post-ORS Score 31.92 7.15 27.67 9.53 8.58 3.64 Effect Size .94 .38 More than 50% !! 1. Does PCOMS increase effectiveness? Look if you must… Two-Level HLM Parameter Model 1 Model 2 Fixed effects Intercept 30.17***(0.99) 27.56*** (1.46) Client pre ORS .26** (.09) .27** (.09) Feedback 4.44* (1.9) Random effects Client Intercept Variance 33.27***(7.04) 33.48***(7.1) Couple Intercept Variance 27.51** (10.31) 22.52** (9.35) Therapist Intercept Variance 1.14 (--) .99 (--) 8

www.heartandsoulofchange.com June 18, 2010 1. Does PCOMS increase effectiveness? Yip, Yip, Yip… Feedback TAU (n = 27 couples) (n = 19 couples) Classification n % n % 1. Deteriorated 1 6.3 1 8.3 2. No change 3 18.8 9 69.2 3. Reliable change 4 25.0 1 8.3 4. Clin. Sig. change 8 50.0* 2 2 6.7 2. Did couples in the feedback condition improve faster? 40 35 30 Feedback ORS 25 TAU 20 15 10 1 2 3 4 5 Session 9

www.heartandsoulofchange.com June 18, 2010 Summary of Findings • Couples in feedback condition demonstrated more improvement (8.58) than couples in a TAU condition (3.64) • 4X as many couples in the feedback condition experienced clinically significant change • Couples in the client feedback condition improved more quickly Feedback in Supervision and Training • Do benefits of client feedback extend to supervision? • Specifically, we asked if using client feedback data in supervision: 1. led to better outcomes? 2. enhanced counseling self- efficacy? 3. influenced the supervisory alliance & supervision satisfaction? Reese, R. J., Usher, E. L., Bowman, D., Norsworthy, L., Halstead, J., Rowlands, S., & Chisholm, R. (2009). Using client feedback in psychotherapy training: An analysis of its influence on supervision and counselor self-efficacy. Training and Education in Professional Psychology, 3, 157-168. 10

www.heartandsoulofchange.com June 18, 2010 Sample and Methodology Sample • Trainees (N = 28; 10 men and 18 women; 79% White, 10.5% African American, 10.5% Asian American; Mean age = 25.14, SD = 3.49) • Supervisors (N = 9; 5 men & 4 women; 100% White) • Client participants (N = 110) Sample and Methodology Methodology • MFT supervisees and supervisors were randomly assigned • Clinical/Counseling supervisees and supervisors were not.  • Supervisees in feedback condition used ORS/SRS with clients and provided data to supervisor. Supervisors followed a protocol for using data. • Supervisees in no-feedback condition provided TAU and supervisors provided SAU. 11

www.heartandsoulofchange.com June 18, 2010 Sample and Methodology Measures: 1. Counseling Self-Estimate Inventory (COSE): start & end of semesters 2. Supervisory Working Alliance (SWAI-T): end of each semester 3. Supervision Outcomes Survey (SOS): end of each semester 1. Better Outcomes? • Feedback condition = clients showed improvement of 8.90 points from pretest to posttest (19.25 to 28.15) • No-feedback condition = clients had a mean gain of 4.00 points (18.56 to 22.56) 12

www.heartandsoulofchange.com June 18, 2010 1. Better Outcomes? 0.97 1.00 0.92 0.80 0.70 Effect Size 0.60 0.37 Feedback 0.40 0.30 0.23 No-Feedback 0.20 0.00 Fall Spring Overall 2. Enhanced Counseling Self-Efficacy? No. COSE Condition Start of Year End of Year M SD M SD Feedback 140.90 (17.32) 167.78 (13.71) No-Feedback 143.23 (15.82) 165.71 (16.65) 13

www.heartandsoulofchange.com June 18, 2010 What we did find… Trainee Outcome Scale Feedback No-Feedback COSE (Start of Year) -.04 .06 COSE (End of Year) .51 - .38 3. Influenced Supervisory Alliance & Satisfaction? No. SWAI-T Condition End of Fall End of Spring M SD M SD Feedback 95.57 (14.54) 100.00 (27.96) No-Feedback 99.10 (19.08) 106.45 (24.02) SOS Feedback 98.28 (20.66) 118.40 (21.15) No-Feedback 109.50 (23.27) 115.36 (26.13) 14

www.heartandsoulofchange.com June 18, 2010 Summary of Findings • Using Client Feedback is useful for trainees – how sexy is that? • Trainees in both conditions demonstrated improvement across the academic year • Using PCOMS data in supervision did not influence, positively or negatively, the supervisory relationship or satisfaction with supervision • Outcome was positively related to counseling self-efficacy for the feedback condition, but not the no-feedback condition What’s Next? • Multi-site (4) supervision study - all supervisees use ORS/SRS • PCOMS at OLOP - use of feedback with an inpatient sample • Process Studies with PCOMS - social desirability study associated with the SRS - Why does PCOMS work with all clients? 15

www.heartandsoulofchange.com June 18, 2010 Conclusions • Evidence has led the University of Kentucky to require students in practicum to use PCOMS. • Privileging the client’s voice in therapy and in supervision results in better outcomes and better therapists! THE NORWAY FEEDBACK STUDY Anker, Duncan & Sparks Psykolog Morten Anker 16

www.heartandsoulofchange.com June 18, 2010 First Act: Using Feedback in Couple Therapy Second Act: Does it work? Third Act: The implementation First Act: Using Feedback in Couple Therapy Video: The Norwegian Couple 17

www.heartandsoulofchange.com June 18, 2010 USING FEEDBACK IN THERAPY Intergration of ORS/SRS in clinical practice. FEEDBACK CATALYST SYSTEM FOR DIALOGUE Second Act: Does it work? 18

www.heartandsoulofchange.com June 18, 2010 224 couples Therapists get 235 couples education in using and Office: A integrating ORS/SRS Office: B feedback Randomly assigned CDOI. Office A. CDOI. Office B. Treatment As 10 therapists who 10 therapists who systematically 1.session: 1.Session: systematically integrate Usual. Office B. integrate feedback about alliance Couples mark their goal. Couples mark their goal. feedback about alliance Same 10 therapists and outcome Wallace Marital Locke (SRS/ORS) in and outcome (SRS/ORS) Wallace do treatment as Locke Marital couple therapy. Therapists get adjustment test. in couple therapy. adjustment test. usual. Outcome is outcome and alliance feedback in ORS/SRS. all sessions. Carried get outcome Therapists ORS/SRS and alliance feedback in registered in all sessions but through all sessions. therapists have no access to the scores. 2½ years Follow-up after 6 months. Questions about change. up ORS Psykolog Morten Anker Lock Wallace Marital Adjustment Test. ORS- ORS-CHANGE SCORES, DO THEY REVEAL THE FUTURE? Both ETR One ETR None ETR Follow- Follow-up ½ year ORS ORS ORS Follow- Follow-up: Development of the problems you sought help for. 56% 45.8% 33% N=167 N=107 N=68 Better/Much better Mean ORS Follow- Follow-up 30.12 25.37 23.82 SD=7.36 SD=10.3 SD=7.09 N=165 N=103 N=68 Follow- Follow-up: Percentage of couples where both score 25 65.8% 38.1% 30.8% (cut- (cut-of) or above. N=73 N=42 N=26 couples couples couples Mean LW Follow- Follow-up 91.28 86.24 81.12 SD=26.6 SD=28.38 SD=29.9 N=166 N=106 N=67 Relationship status: Separated at follow-up follow- 15% 29.9% 40% N=109 couples N=87 couples N=70 couples Psykolog Morten Anker 19

www.heartandsoulofchange.com June 18, 2010 DOES IT WORK ? 69,1% score 30 above 25 50,0% ORS 25 score above 25 20 FEEDBACK N=84 15 TAU N=64 10 Pre-post N=410, Follow-up N=148 (intact 5 couples, with LW ORS pre-post-follow-up, biased toward TAU differential numbers of separated that is not in the follow-up) 0 First session Last session Follow-up Psykolog Morten Anker DOES IT WORK: RESULTS PRE-POST PRE- ORS TAU Feedback Clinical significant change+ reliable change. Both in couple change 5 22.6% 50.5% points or more. p<.001 Clinical significant change: Ends over cut of (25) and both have at 10.8% 40.8% least 5 points change. Either one or both at risk compared to their ETR. 74.5% 54.4% p<.001 Sub- Sub-group: At risk couples. Clinical significant change for 9.2% 28.6% both. p<.01 Psykolog Morten Anker 20

www.heartandsoulofchange.com June 18, 2010 DOES IT WORK: RESULTS FOLLOW-UP FOLLOW- ORS TAU Feedback Clinical significant change+ reliable change. Both in couple change 5 18.8 % 47.6 % points or more. p=.01 Clinical significant change: Ends over cut of 12.5 % 35.7 % (25) and both have at least 5 points change. Psykolog Morten Anker DOES IT WORK: RESULTS FOLLOW-UP FOLLOW- ORS/LW/ TAU Feedback separation At least two sessions for both. Mean ORS. 24,6 28,28 Subgroup: stil in the relationship. Lock 83.06 (27.42) 91.16 (28.48) Wallace ES 0.21 0.52 Separation 34.25 % 18.41 % A difference of 46.25 % P=0.014 Psykolog Morten Anker 21

www.heartandsoulofchange.com June 18, 2010 DOES IT WORK: Variability in the Effects of Feedback across Therapists  Nine out of ten therapists benefited from feedback.  The effect of feedback varied significantly across therapists; less A contribution to: effective therapists (without feedback) Just services. benefited more from feedback than the most effective therapists. Psykolog Morten Anker DOES IT WORK: CONCLUSIONS • Feedback has a general positive effect on outcome. • Feedback has a preventive effect on at Can be Duncan, & Sparks (2009) Anker, risk cases. downloaded for free at: Using Client Feedback to Improve Couple Therapy Outcomes: Better therapies with A Randomized Clinical Trial in a Naturalistic Setting. • Feedback has andpositive effect in at Journal of Consulting a Clinical Psychology, 77, 696-704. www.heartandsoulofchange.com feedback !!! risk cases. • Feedback has a positive long term effect. Psykolog Morten Anker 22

www.heartandsoulofchange.com June 18, 2010 THE IMPLEMENTATION THE IMPLEMENTATION Royal Proposition (St.prp. nr. 1 (2008-2009) (p.44-45) (translated) : " Consumer directed quality development: Bufdir has continued the task of developing a model for consumer directed quality development in the family counseling offices, in this way it can be utilized in the task to improve the service systematically. To ensure high quality services for the consumers, it is under development a system for consumer inquiries and guidelines for systematic use of feedback from the clients." 23

www.heartandsoulofchange.com June 18, 2010 THE IMPLEMENTATION Bufdir (Norwegian Directorate for Children, Youth and Family Affairs), has decided to use and integrate the Partners for Change Outcome Management System (PCOMS) (Duncan, et al., 2004; Miller, et al., 2005) which utilizes the ORS and SRS, in their computer progress note system for the family counseling offices. SUCCESSFUL CDOI IMPLEMENTATION CDOI Office culture Progress-note Supervision system Therapist development 24

www.heartandsoulofchange.com June 18, 2010 THE IMPLEMENTATION Results: You are reporting a great deal of progress since the last visit. Activity: Explore: (1) what you are doing to make progress possible; (2) how you can build on and continue your success; and (3) any concerns you have about maintaining progress. Consider whether longer time between visits will build your confidence. Do not be surprised if the pace of change slows or a minor setback occurs. THE IMPLEMENTATION 25

www.heartandsoulofchange.com June 18, 2010 Thank you ! The Empirically Supported Something likeFactors Common this Barry ? Chicken and the Egg The Role of the therapist Jesse Owen, PhD. Licensed Psychologist Research Director: Heart & Soul of Change Associate Editor: Psychotherapy Assistant Professor: University of Louisville 26

www.heartandsoulofchange.com June 18, 2010 Act 1: Getting Specific with Common Factors Act 2: The Chicken & The Egg: Early-change & Alliance Act 3: The Putting the Therapist in Therapy Common Factors: • There are over 90 documented common factors (and counting) • Which leads to me think… 27

www.heartandsoulofchange.com June 18, 2010 Expert Therapists say… • Structural Components: – Theoretically consistent – Therapist is seen as a healer – Therapist uses techniques – Positive expectations Tracey et al. (2003) 28

www.heartandsoulofchange.com June 18, 2010 Expert Therapists say… • Feeling Processes (hot, not sexy hot, but hot): – Tension reduction – Partner in change – Warmth Alliance – Emotional learning Tracey et al. (2003) Expert Therapists say… • Thinking Processes (cool) – Client is persuaded – Advice or psycho-education – Client is given feedback about self/life situation Tracey et al. (2003) But what do clients say? 29

www.heartandsoulofchange.com June 18, 2010 • 161 Clients treated by 40 therapists – 114 female, 47 male (22 yrs old) – 53.4% White, 1.2% African American, 0.6% Native American, 16.8% Asian American, 11.2% Hispanic, 14.9% multi- ethnic, and 2% did not indicate their ethnicity. – Median # of sessions: 5 • “Please describe what your therapist did (e.g., action, way of being, etc) that helped you change” • “How did it help you change?” Clients’ View of Helpful Common Factors Owen et al (2010) Relationship: Insight: Information: Alliance Warmth Learning Feedback Providing Info Partnership Insight Advice (see handout for specific examples) 30

www.heartandsoulofchange.com June 18, 2010 Who Likes What? • Clients who are more Emotionally Controlled, Self-Reliant, & Driven preferred: – Relationship & Insight Factors • Ah, the balance in life… – Approach & Avoidance motivational processes (Holtforth et al., 2007) • What tools do you have in your tool box? – My favorite tool… Act 2: Chicken or Egg • 118 couples, 19 therapists • All had 4 sessions or more • Remember what Morten said about the process…similar deal here • We will focus on the ORS/SRS Anker, Owen, Duncan, & Sparks (in press) 31

www.heartandsoulofchange.com June 18, 2010 The Debate: Alliance is the by-product of a successful therapy vs. Alliance is a active mechanism to assist therapy outcomes Barber (2009)’s review found a mix of findings to support both sides Step 1. Calculate Early Change = 5 pt change on the ORS (reliable change index) Step 2. Predict Therapy outcomes based on Alliance and Early Change Step 3. Alliance is different from Early Change in therapy Alliance predicted therapy outcomes of couples over and above early change 32

www.heartandsoulofchange.com June 18, 2010 Take Home Messages: • 1. Early Change—within the first 3 sessions—is a powerful predictor therapy outcome • 2. Alliance: The work of therapy • Working on Goal Agreement • Promoting & understanding clients’ confidence in the method, and • Knowing what is emotionally relevant connectedness mean for the work of therapy Act 3: The Putting the Therapist in Therapy Not all therapists are equally effective! Therapists account for 5-10% of variance in outcomes So what? It is only 5-10% 33

www.heartandsoulofchange.com June 18, 2010 • Owen, Anker, Duncan, & Sparks (under review) • Same data from chicken and egg study, but included all clients (2 sessions or more) • 250 couples, 20 therapists • We will focus on the ORS/SRS Percent of Couples Reaching Clinically Significant Change 34

www.heartandsoulofchange.com June 18, 2010 What Makes Effective Therapists? Therapist Alliance Quality “Alliance describes the degree to which the therapy dyad [triad] is engaged in collaborative, purposive work” Hatcher & Barends (2006) Extension: Therapists’ ability to consistently establish a facilitative environment that promotes the process of therapy 35

www.heartandsoulofchange.com June 18, 2010 Hatred Of Marriage Counselor Brings Couple Together "At the time, we could barely make eye contact," Tom said. "But about halfway through the first session, we started casting these sideways glances, because we just hated this guy. We could both feel it.“ The Onion Who were the more effective therapists in Norway study? • Therapists who were better at forming alliances, had couples who did better… • Also, therapists with more experience conducting couples therapy, had couples who did better… – Interesting… 36

www.heartandsoulofchange.com June 18, 2010 What about those RCTs? • Owen, Rhoades, Stanley, Markman (under review) • 118 Couples were treated by 31 leaders • Treatments: – Prevention and Relationship Enhancement Program (PREP) – TAU • Outcomes: Positive & Negative Communication – Based on Observational Coding – 15 min discussion – Similar results, so we will highlight Positive Comm. 37

www.heartandsoulofchange.com June 18, 2010 Positive Communication Therapist Effect 5.2% 34.3% Individual Effect 60.4% Couples Effect 38

www.heartandsoulofchange.com June 18, 2010 What Makes Effective Therapists? Therapist Alliance Ability vs. Being PREP Trained They all win and must win prizes Both Alliance Ability and being PREP trained accounted for nearly all of variance in therapy outcomes attributed to the therapist 39

Day2JeffReeseMortenAnkerJesseOwen

by Barry Duncan on Jun 05, 2010

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