GoodBadUglyMyOutcomes
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This first of six webinars addresses the pitfalls of providing mental health and substance abuse services and the number one way you can improve your outcomes: systematic collection of client ...

This first of six webinars addresses the pitfalls of providing mental health and substance abuse services and the number one way you can improve your outcomes: systematic collection of client feedback. Despite overall effectiveness, drop outs are a problem, many clients do not benefit, and therapists significantly vary in effectiveness. And even worse, therapists do not know how effective or not, they really are. The Partners for Change Outcome Management System (PCOMS) offers a viable solution by identifying at risk clients before they drop out or realize a negative outcome while simultaneously raising the bar of all therapists’ performance.

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GoodBadUglyMyOutcomes Document Transcript

  • 1. www.heartandsoulofchange.com July, 2012 The Art & Science Of Becoming a Better Therapist Barry Duncan, Psy.D. Psy.D. www.heartandsoulofchange.com 561.239.3640 barrylduncan@comcast.netbarrylduncan@comcast.net 1
  • 2. www.heartandsoulofchange.com July, 2012 Psychotherapy The Good… Study after study study, and studies of studies show the average treated client is better off than 80% of the untreated sample.barrylduncan@comcast.net 2
  • 3. www.heartandsoulofchange.com July, 2012 Psychotherapy The Bad… Drop out rates average 47%, 60% with adol. adol. & SA clients Therapists vary… a lot 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 d d 50% less; meds useful for clients of more effective Wampold, B., & Brown, J. (2006). Estimating variability in therapists, not for less. outcomes attributable to therapists: A naturalistic study of outcomes in managed care. Journal of Consulting and Clinical Psychology, 73 (5), 914-923.barrylduncan@comcast.net 3
  • 4. www.heartandsoulofchange.com July, 2012 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  Providers don’t know psychotherapy dose-response effect and its implications for treatment delivery services. Clinical Psychology: Science and Practice, 9, 329-343. how effective they are Sapyta, J., Riemer, M., & Bickman, L. Feedback to clinicians: Theory, research, and practice. Journal of Clinical Psychology: In Session, 61, 145-153 To The Rescue Consumer-Driven Outcome Management  Howard et al. (1996) advocated for the f th systematic eval. of client t ti l f li t 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”barrylduncan@comcast.net 4
  • 5. www.heartandsoulofchange.com July, 2012 Feedback and Outcome Lambert’s Six Trials  All 6 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 h l t d ith support tools  A strong case for routine measurement of outcome in everyday clinical practice Client Based Outcome Feedback Offers a Solution The O.R.S The S.R.S Download free working copies at: http://www.heartandsoulofchange.combarrylduncan@comcast.net 5
  • 6. www.heartandsoulofchange.com July, 2012 •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 SRS •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 36barrylduncan@comcast.net 6
  • 7. www.heartandsoulofchange.com July, 2012 Becoming Better Two Choices: Not Rocket Science  Either the client is improving or not. If not, i i t t 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. PCOMS 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 li i h  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.barrylduncan@comcast.net 7
  • 8. www.heartandsoulofchange.com July, 2012 Reese, Norsworthy, & Rowlands (2009) First Independent Study Reese, R., Norsworthy, L., &  N=148: Feedback group Rowlands, S. (2009) Ro lands S (2009). Does a continuous feedback model doubled d bl d controls (10.4 t l (10 4 vs. 5.1 pts); ES: .48 improve psychotherapy outcomes? Psychotherapy,46, 418-431. Reese, R., Toland, M., Slone, N.,  Like Norway study, clients, regardless of risk & Norsworthy, L. (2010). Effect of client feedback on couple status, b t t benefit f fit from psychotherapy outcomes. Psychotherapy, 47, 616-630. continuous feedback  And also a replication study published Meta-analysis by Lambert & Shimokawa (2011) of PCOMS (the ORS and SRS) Those in feedback group had 3.5 higher odds of experiencing reliable change Those in feedback group had less than half the odds of experiencing deterioration Feedback attained .48 ES Lambert, M. J., & Shimokawa, K. (2011). Collecting client feedback. Psychotherapy, 48, 72-79.barrylduncan@comcast.net 8
  • 9. www.heartandsoulofchange.com July, 2012 Regarding Therapist Variability Feedback Improves Outcomes  Norway: 9 of 10 got better o tcomes bette outcomes  Feedback raised effectiveness of the lower ones to their more successful colleagues colleagues.  Therapist in low effectiveness group became the BEST with feedback! Provider Variation Feedback Improves Effectiveness C ounselors O utcom es (n= 30 o r mo re case s) 1 .8 M ean E ffec t S iz e for all C as es 1 .6 1 .4 Effect size 1 .2 1 0 .8 0 .6 0 .4 0 .2 2 0 (n ) 4) (n ) (n ) (n ) (n ) 5) (n ) (n ) (n ) (n ) (n ) (n ) (n ) (n ) (n ) (n ) (n ) (n ) (n ) (n ) 0) 4 7 5 9 8 0 8 11 48 12 47 13 47 1 15 41 16 40 9 18 37 19 35 20 34 1 22 31 =9 =7 =6 =6 =5 =5 =5 =5 =4 =4 =3 =3 =3 = = = = = = = = = (n (n (n 1 2 3 4 5 6 7 8 9 10 14 17 21 C ounselor 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. 61(2), 199-barrylduncan@comcast.net 9
  • 10. www.heartandsoulofchange.com July, 2012 Becoming Better Recapture Your At Risk Clients  Feedback tailors therapy based on response, provides an early warning system to prevents drop- outs & negative outcomes, g , & solves therapist variability—feedback improves performance In Fact, Client Based Outcome Feedback  Improves outcomes more than So there is lot to get excited about! anything since the i th beginning of therapybarrylduncan@comcast.net 10
  • 11. www.heartandsoulofchange.com July, 2012 And…Finally  Puts the client’s voice center stage t t  Allows services to be client and family driven  Brings consumers into the inner circle of decisions  Partners in monitoring the benefit and fit of services Answers the Call Consumer-Centered, Recovery-Based  New Freedom Commission: Care is consumer-centered, 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 consumersbarrylduncan@comcast.net 11
  • 12. www.heartandsoulofchange.com July, 2012 The Partners for Change Outcome Management System PCOMS First implemented in 2000; now p ; used by 100s of organizations, public and private, by 1000s of behavioral healthcare professionals around the world, in all 50 states and 20 countries numbering over 100 clients a 100K year. EBT status in 2 states and under review by SAMSHA for EBP designation But What Else Can We Do What Else Accounts for Variability One Possibility One No- Brainerbarrylduncan@comcast.net 12
  • 13. www.heartandsoulofchange.com July, 2012 Client/Extratherapeutic Factors (87%) Feedback Effects 15‐31% Alliance Effects ll ff 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 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.barrylduncan@comcast.net 13
  • 14. www.heartandsoulofchange.com July, 2012 Therapists Variables that Predict Change Therapists with the best results:  Are better at the alliance across clients; alliance ability accounts for Baldwin et al. (2007). Untangling the alliance-outcome correlation. Journal of Consulting and Clinical Psychology, 75(6), 842-852.; therapist differences Anker, Owen, Duncan, & Sparks (2010). The alliance in couple therapy. Journal of Consulting and Clinical Psychology, 78(5), 635-645. Relationship Factors The Alliance: • Relational Bond • Agreement on goals 38- 38-54% • Agreement on tasks Seven Times th I S Ti the Impact of t f Model/Technique…Accounts for Most of Therapist Variance Duncan, B., Miller, S., & Sparks, J. (2004). The Heroic Client. San Francisco: Jossey-Bassbarrylduncan@comcast.net 14
  • 15. www.heartandsoulofchange.com July, 2012 The Alliance: Over 1000 Research Findings  Q Quality of the alliance more y potent predictor of outcome than orientation, experience, or professional training.  Same holds true for youth and f il services d family i  Clients rarely report negative reactions before deciding to terminate. The Alliance The of Change Alliance feedback enables a fit between client expectations, preferences, and services Does not leave the alliance to chance—applying over 1000 studies showing the relationship of the alliance to positive outcomesbarrylduncan@comcast.net 15
  • 16. www.heartandsoulofchange.com July, 2012 What Separates The Best? Barry’s Recipe  1. Client Feedback Improves Outcomes More than Anything since the Beginning of Psychotherapy  2. Clients Account for Most of the Variance: Rally, Recruit Rally Harvest Resources for Change  3. Rely on the Tried & True Old Friend, the Alliancebarrylduncan@comcast.net 16