Day2MichaelLambert

www.heartandsoulofchange.com June 18, 2010 Implementing the OQ SYSTEM: An Evidence- Based Practice Michael J. Lambert, Ph.D. Brigham Young University www.OQMeasures.com michael_lambert@byu.edu Overview 1. Monitoring client treatment response and providing alerts for off-track cases is an evidence- based practice 2. It takes us WELL beyond accountability by surpassing administrative solutions such as provider profiling and benchmarking 1

www.heartandsoulofchange.com June 18, 2010 OQ-Analyst Solution: An evidence-based practice • A family of measures that are sensitive to treatment effects across a wide variety of clients • Automated method to repeatedly assess clients without involving clinician time • Immediate graph of client change in relation to scientifically derived expectations • Immediate feedback to therapists and consumers that improves outcomes Measure of Outcome: OQ-45 • 45 items across 4 domains • Yields a total score reflecting amount of distress a person has been experiencing during the last 7 days • Scores range from 0 to 180 • Higher scores signify more distress • 64 represents the cutoff between functional and dysfunctional populations 2

www.heartandsoulofchange.com June 18, 2010 OQ-45 Domain and Sample Questions Measures SELF-REPORTED CHANGES IN: – Symptoms-anxiety, depression, somatic • I feel hopeless about the future. • I feel no interest in things. • I have thoughts of ending my life. • Disturbing thoughts come into my mind that I cannot get rid of. OQ-45 Domain and Sample Questions Measures SELF-REPORTED CHANGES IN: – Interpersonal Problems • I feel lonely. • I have frequent arguments. • I have an unfulfilling sex life. • I have trouble getting along with friends and close acquaintances. 3

www.heartandsoulofchange.com June 18, 2010 There are two very important clinical problems that clinicians need help with • 1. A portion of clients (5%-24%) are worse at the end of treatment and many fail to benefit • 2. Clinicians are overly optimistic and fail to recognize who is deteriorating 4

www.heartandsoulofchange.com June 18, 2010 Identifying Cases for Review Little or No Need (50%) Moderate Need (43%) Great Need (7%) How well do practitioners predict treatment failure? • Final outcome was predicted for 550 Clients • 3 were predicted to have a negative outcome • 40 had a negative outcome • Staff were accurate 1 time • Algorithms identified 85% of those who deteriorated, but over predicted deterioration Hannan, Lambert, Harmon, Nielsen, Smart, Shimokawa, Sutton (2005) 5

www.heartandsoulofchange.com June 18, 2010 Hatfield, et al. (2010) • Examined case notes of patients who deteriorated to see if therapists noted worsening at the session it occurred. • If the patient got 14 points worse was there any recognition? 21% • If the patient got 30 points worse was there recognition? 32% Case Note Recognition Case Note Recognition Reliably worse Worsening Recognized 6

www.heartandsoulofchange.com June 18, 2010 Clinician Report Red Alert – Part 1 Clinician Report Red Alert – Part 2 7

www.heartandsoulofchange.com June 18, 2010 OQ-A provides Clinical Decision Support Tools for failure risk cases Consumer report of: 1.THERAPEUTIC RELATIONSHIP (I was willing to share my innermost thoughts with my therapist) 2.SOCIAL SUPPORT (I felt accepted by someone other than my therapist) 3.MOTIVATION FOR THERAPY (Honestly, I really don’t understand what I can get from therapy) 4.RECENT LIFE EVENTS (I had difficulty adjusting to an occurrence in my life) Clinical Support Decision Tree Assess therapeutic alliance. Does the client report concerns with the therapeutic See Therapeutic Alliance Interventions YES handout. alliance? NO Assess motivation. Does the client report See Readiness to Change Interventions being in a precontemplation or YES handout. contemplation stage of readiness to change NO Assess social support resources. Does the See Social Support Interventions handout. YES client report low social support? NO Reassess the diagnostic formulation. Is there an Consult relevant resources and alter the effective treatment option that has not been YES treatment plan. attempted? NO Is medication an effective treatment Refer for psychiatric consultation. YES option? 8

www.heartandsoulofchange.com June 18, 2010 What Accounts for Improvement in Psychotherapy Outcomes? TA 30.0% External 40.0% Placebo 15.0% Technique (Lambert, 1992) 8 9

www.heartandsoulofchange.com June 18, 2010 Assessment for Signal Cases • My therapist seems glad to see me • At times the tone of my therapist’s voice seems critical • I could count on friendships when something went wrong • I had thoughts of quitting therapy Research Program • Six CLINICAL TRIALS IN WHICH WE ATTEMPTED TO REDUCE DETERIORATION RATES BY PROVIDING PROGRESS FEEDBACK TO PSYCHOTHERAPISTS Lambert, et al. 2001 Lambert, et al. 2002 Whipple, et al. 2003 Hawkins, et al. 2005 Harmon, et al. 2007 Slade, et al. 2008 • Random assignment of patients to experimental condition blocked on therapist (every therapist had patients for whom they received feedback and were denied feedback) N = 4,000 10

www.heartandsoulofchange.com June 18, 2010 Results-CST Feedback 95 90 85 Not on Track- Treatment as Usual O Q T o ta l S c o r e 80 75 Not on Track-OQ 70 Feedback only (No 65 CST) 60 Not on Track-OQ Feedback + CST 55 50 45 Pre-test Feedback Post-test Recovered or No Change Deteriorated Improved NOT-NFb 71 (22.3%) 183 (57.5%) 64 (20.1%) (n = 318) NOT-Fb 99 (37.6%) 140 (53.2%) 24 (9.1%) (n = 263) NOT-Fb+CST 91 (41.9%) 114 (52.5%) 12 (5.5%) (n = 217) 15 11

www.heartandsoulofchange.com June 18, 2010 Table 9.1 Effect Sizes of Feedback Interventions in Comparison to TAU (Efficacy Analysis) Post-Treatment Score Reliable Improvement Deterioration Feedback System k Hedges’s g [95% CI] OR OR r r rb [95% CI] [95% CI] OQ Systema NOT Fb 4 0.53*** 0.25 2.55*** 0.23 0.44* -0.21 [0.28, 0.78] [1.64, 3.98] [0.23, 0.85] NOT P/T Fb 3c 0.55*** 0.25 2.87*** 0.27 0.68 -0.10 [0.36, 0.73] [1.93, 4.27] [0.42, 1.13] CST Fb 3d 0.70*** 0.33 3.85*** 0.34 0.23*** -0.37 [0.52, 0.88] [2.65, 5.60] [0.12, 0.44] PCOMS Feedback 3 0.48*** 0.23 3.52*** 0.32 0.44* -0.22 [0.31, 0.65] [2.08, 5.96] [0.14, 1.35] Clinical Value : Provider Profile • Providers can profile real time change metrics for themselves—percent of cases recovered, improved, no change & deteriorated—to determine strengths & areas for improvement • Providers can view aggregate cases by diagnosis, gender, etc. for differential effectiveness in case load • Providers contrast differential effectiveness (e.g., diagnosis) with peers 12

www.heartandsoulofchange.com June 18, 2010 80 70 60 O Q T o ta l S c o r e 50 Whole Center 40 Therapist #1 30 Therapist#56 20 10 0 0 1 2 3 4 5 6 7 8 9 Session # Experienced Therapist Specializing in Brief Therapy 50 45 40 % Recovered 35 30 25 20 15 10 5 0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 Number of Sessions Training Clinic Dr. L. J. 13

www.heartandsoulofchange.com June 18, 2010 Harmon, S.C., Lambert M.J., Smart, D.W., Hawkins, E.J., Nielsen, S.L., Slade, K, et al. (2007). Enhancing outcome for potential treatment failures: Therapist-client feedback and clinical support tools. Psychotherapy Research, 17, 379-392. Hawkins, E. J., Lambert, M. J., Vermeersch, D. A., Slade, K., & Tuttle, K. (2004). The effects of providing patient progress information to therapists and patients. Psychotherapy Research, 31, 308-327. Lambert, M. J., Whipple, J. L., Smart, D. W., Vermeersch, D. A., Nielsen, S. L., & Hawkins, E. J. (2001). The effects of providing therapists with feedback on client progress during psychotherapy: Are outcomes enhanced? Psychotherapy Research, 11, 49-68. Lambert, M. J., Whipple, J. L., Vermeersch, D. A., Smart, D. W., Hawkins, E. J., Nielsen, S. L., Et al. (2002). Enhancing psychotherapy outcomes via providing feedback on client progress: A replication. Clinical Psychology and Psychotherapy, 9, 91-103. Slade, K., Lambert, M. J., Harmon, S. C., Smart, D. M., & Bailey, R. (2008). Enhancing psychotherapy outcomes: The effects of immediate electronic feedback and Clinical Support Tools. Clinical Psychology & Psychotherapy, 15, 287-303. Whipple, J. L., Lambert, M. J., Vermeersch, D. A., Smart, D. W., Nielsen, S. L., & Hawkins, E. J. (2003). Improving the effects of psychotherapy: The use of early identification of treatment failure and problem solving strategies in routine practice. Journal of Counseling Psychology, 58, 59-68. 14

Day2MichaelLambert

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