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    Good Bad Ugly Webinar Good Bad Ugly Webinar Presentation Transcript

    • The Heart and Soul of Change: Becoming Better At What We Do June 17-19 New Orleans Featuring: Barry Duncan, Jacqueline Sparks, Makungu Akinyela, Michael Lambert, Lori Ashcraft, Bob Bohanske, John Murphy Sponsored by the Louisiana Counseling Association Save the dates! Registration information forthcoming at www.lacounseling.org and www.heartandsoulofchange.com Learn: What Works and How to Deliver It How to Improve Your Outcomes and Accelerate Your Development How to “Level” the Counseling Process How to Join Forces with the Recovery and Social Justice Movements
    • The Good, the Bad, & the Ugly of Psychotherapy Barry Duncan, Psy.D. www.heartandsoulofchange.com 954.721.2981 www.whatsrighwithyou.com [email_address] Consumer Driven Outcomes Management
    •  
    •  
    • What’s Up Three Rationales
      • Solves inconsistency in outcomes among therapists & treatments; improves outcomes…period
      • Based in research
      • about what works (the common factors)
      • Based on known predictors of outcome
      • I love this work
    • Consumer Driven Outcomes Management Long Ago in a Galaxy Far Away
      • Before the validation studies demonstrated the psychometrics
      • Before RCTs demonstrated the power of feedback to improve outcomes
      • Before the science…
      • There was the desire to give consumers a voice in their own care, to bring them into the inner circle—that’s what started what you will hear about today
    • Psychotherapy The Good…
      • Study after study, and studies of studies show the average treated client is better off than 80% of the untreated sample.
      • Recent study:
        • 2,000+ providers
        • 6,000+ clients
        • Outcomes equivalent to RCTs for depression, specifically the TDCRP.
      Therapy Works As Good As RCTs 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
        • TDCRP: top third psychiatrists giving placebo bested bottom third giving meds; clients of best therapists improve 50% more and dropped out 50% less; medication useful for clients of more effective therapists and not for less
      Wampold, B., & Brown, J. (2006). Estimating variability in outcomes attributable to therapists: A naturalistic study of outcomes in managed care. Journal of Consulting and Clinical Psychology, 73 (5), 914-923. The Bad Incredible Variation Among Therapists
    • Client/Extratherapeutic Factors (87%) Treatment Effects 13% Feedback Effects 15-31 % Alliance Effects 38-54% Model/Technique 8% Model/Technique Delivered : Expectancy/Allegiance Rationale/Ritual (General Effects) 30-?% Therapist Effects 4 6-69%
    • And the Ugly Providers Don’t Know
      • 20-70% range
      • Therapists graded their effectiveness, A+ to F—67% said A or better; none rated below average.
      • Therapists don’t know how effective they are
      Hansen, N., Lambert, M., Forman, E. (2002). The psychotherapy dose-response effect and its implications for treatment delivery services. Clinical Psychology: Science and Practice, 9, 329-343. Sapyta, J., Riemer, M., & Bickman, L. Feedback to clinicians: Theory, research, and practice. Journal of Clinical Psychology: In Session, 61, 145-153
      • Least effective therapists believe they are as helpful as most effective.
      • In the absence of reliable information about outcome, what do we expect?
      On Becoming A Better Therapist More on Provider Differences Hiatt, D. & Hargrave, G. (1995). Characteristics of highly effective therapists in managed behavioral provider networks. Behavioral Healthcare Tomorrow , July August, 19-22
    • 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 3 rd was a lack of confidence in the outcome of tx (77%).
      • Despite tx efficacy, DOs are a problem, many do not benefit, therapists vary, don’t know about effectiveness, & there is a crisis of confidence among consumers .
    • To The Rescue Consumer Driven Outcomes Management
      • Can alleviate these problems.
      • 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 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
      • Feedback v TAU; Over doubled effectiveness; ES: .50; 4 times # of clients reached clinically sig. change
      • FU: TAU-34.2% v. 18.4% Feedback sep./divorce rate
      Anker, M., Duncan, B., & Sparks, J. (2009). Using client feedback to improve couple therapy outcomes: A randomized clinical trial in a naturalistic setting. Journal of Consulting and Clinical Psychology, 77, 693-704. On Becoming A Better Therapist Isn’t It Good, Norwegian Wood
    • Reese et al (in press, Psychotherapy ) First Independent Study
      • N=148: Feedback group doubled controls (10.4 vs. 5.1 pts); ES: .48
      • Like Norway study, clients, regardless of risk status, benefit from continuous feedback
      • Norway: 9 of 10 got better outcomes
      • Feedback raised effectiveness of the lower ones to their more successful colleagues.
      • Therapist in low effectiveness group became the BEST with feedback!
      Regarding Therapist Variability Feedback Improves Outcomes
    • 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. Provider Variation Feedback Improves Effectiveness
    • Effects on Efficiency Cancellations, No Shows, LOS
      • Claude (2004) compared the ave. # of sessions, canc., no shows, and % of long-term cases before and after OM. Sample: 2130 closed cases seen in a public 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 long term null cases diminished by 80% (10% to 2%).
      • An estimated savings of $489,600. Such cost savings did not come at the expense of client satisfaction with services—during the same period satisfaction rates improved significantly.
    • Addiction Services: Retention Before and After
      • Improved Completion Rates:
        • 50% or Less Before
        • 82% After
        • With Improved Outcomes, Increased Satisfaction, and Decreased Complaints
      Bohanske, R., & Franczak, M. (in press). Transforming public behavioral healthcare: A case example of consumer directed services, recovery, and the common factors. In B. Duncan et al. (Eds.) The Heart and Soul of Change: Delivering What Works , 2 nd Ed. Washington, DC: American Psychological Association.
    • Arizona Length of Stay 138 88 Bohanske, R., & Franczak, M. (in press). Transforming public behavioral healthcare: A case example of consumer directed services, recovery, and the common factors. In B. Duncan et al. (Eds.) The Heart and Soul of Change: Delivering What Works , 2 nd Ed. Washington, DC: American Psychological Association.
    • “ Severely and Persistently Mentally Ill” Services in a CMHC
      • Reduced LOS in CM, therapy, & residential services by 72, 59, & 47% respectively
      • No shows & canc. reduced by 30%.
      Bohanske, R., & Franczak, M. (in press). Transforming public behavioral healthcare: A case example of consumer directed services, recovery, and the common factors. In B. Duncan et al. (Eds.) The Heart and Soul of Change: Delivering What Works , 2 nd Ed. Washington, DC: American Psychological Association.
    • Client/Extratherapeutic Factors (87%) Treatment Effects 13% Feedback Effects 15-31 % Alliance Effects 38-54% Model/Technique 8% Model/Technique Delivered : Expectancy/Allegiance Rationale/Ritual (General Effects) 30-?% Therapist Effects 4 6-69%
    • 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.
    • On Becoming A Better Therapist Bottom Line
      • Privilege clients’ experience & rally their resources to the cause….what ORS is all about
      “ The quality of the patient's participation . . . [emerges] as the most important determinant of 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.
    • Therapists Variables that Predict Change
      • Therapists with the best results :
      • Emphasize the therapist-client relationship
      • Are better at the alliance across clients
      Baldwin, S. A., Wampold, B. E., & Imel, Z. E. (2007). Untangling the alliance-outcome correlation: Exploring the relative importance of therapist and patient variability in the alliance. Journal of Consulting and Clinical Psychology, 75 (6), 842-852.; Vocisano et al. (2004). Therapist variables that predict symptom change in psychotherapy with chronically depressed outpatients. Psychotherapy , 41(3), 255-265.
    • Client/Extratherapeutic Factors (87%) Treatment Effects 13% Feedback Effects 15-31 % Alliance Effects 38-54% Model/Technique 8% Model/Technique Delivered : Expectancy/Allegiance Rationale/Ritual (General Effects) 30-?% Therapist Effects 4 6-69%
    • The Norway Feedback Project (n=500) Therapist Variability and the Alliance
      • Therapists accounted for 9% of the variability
      • Alliance at last session accounted for 40% of that variability
      • Implication: Continuous alliance monitoring is essential; need to focus on the alliance as job 1
      • Considered to be the most sophisticated comparative
      • clinical trial ever conducted:
        • Four approaches (CBT, IPT, Drug, Placebo).
      Elkin, I. Et al. (1989). The NIMH TDCRP: General effectiveness of treatments. Archives of General Psychiatry, 46 , 971-82.
      • No difference in outcome between approaches
      • The client’s rating of the alliance at the second session the best predictor of outcome across conditions.
      TDCRP The Alliance
      • The largest study ever conducted on the treatment of problem drinking:
        • Three different treatment approaches studied (CBT, 12-step, and Motivational Interviewing).
      • NO difference in outcome between approaches.
      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 client’s rating of the therapeutic alliance the best predictor of:
          • Treatment participation;
          • Drinking behavior during treatment;
          • Drinking at 12-month follow-up.
      Project MATCH The Alliance
      • 600 Adolescents marijuana users:
        • Significant co-morbidity (3-12 problems).
      • 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).
      • Alliance predicted: Premature drop-out; Substance abuse post-treatment, and cannabis use at 3 and 6 month follow-up.
      Dennis, M.,et al. (2004). The Cannabis Youth Treatment (CYT) Study: Main findings from two randomized trials. Journal of Substance Abuse Treatment, 27, 197-213. Cannabis Youth Treatment Project The Alliance
    • The Alliance Bottom Line
      • The Alliance Matters—Big Time
      • TDCRP : alliance accounted for up to 21% of the variance…what the SRS is all about
    • The Predictors What Really Predicts Outcome? Client variables: Demographics, etc Diagnosis Treatment Models & Techniques
      • 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.
      Starting With the Predictors Gifts to Improve Outcomes
    • Howard, K. et al. (1986). The dose-effect response in psychotherapy. American Psychologist, 41 , 159-164. ? A B
      • The bulk of change occurs sooner rather than latter
      Who drops out? Sooner Rather Than Later
    • 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. 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
    • Cannabis Youth Treatment Project Project MATCH 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. Early change in treatment is a robust predictor of outcome and retention in treatment. Gotta measure outcome! It’s A Fact Early Change is The Rule
      • But any measurement system that takes more than 5 minutes will never happen. Therapists can get really worked up over anything that adds paperwork, especially when they don’t see the clinical usefulness.
      Feasibility First Like I Need A Hole in the Head
    • When PacifiCare Introduced 30 Item Measure
      • Practitioners complained:
      • About the length & frequent administration
      • 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.
      • Scored to the nearest millimeter.
      • Add the four scales together for the total score.
      • Give at the beginning of the visit; Client places a mark on the line.
      • Each line 10 cm (100 mm) in length.
      • Reliable, valid, feasible
      Becoming Better Measuring Outcome
    • The Session Rating Scale Measuring the Alliance
      • Give at the end of session;
      • Each line 10 cm in length;
      • Reliable, valid, feasible
      • Score in cm to the nearest mm;
      • Discuss with client anytime total score falls below 36
    • A.S.I.S.T: Automated Scoring, Interpretation, and data Storage Tool
      • Give at the beginning of the visit
      • Client clicks a mark on the line
      • Each line 10 cm (100 mm) in length
      • Scored to the nearest millimeter
      • Four scales added for the total score
    • SRS
      • Give at the end of each session;
      • Each line 10 cm in length;
      • Scored to the nearest mm
      • Discuss with client anytime total score falls below 36
    • Answers the Call Consumer-Centered, Recovery-Based
      • New Freedom Commission : Care is consumer-centered, with providers working in full partnership with the consumers they serve to develop individualized plans of care.
      • SAMHSA and Partners : National Consensus Statement on Mental Health Recovery
      • PCOMS only system that partners with consumers
      • Partners with consumers to tailor services based on response & fit, provides an early warning system
      • to prevent drop-outs & negative outcomes, & solves helper variability—feedback improves performance based on factors accounting for and predicting positive outcomes
      Consumer Driven Outcomes Management