HeartandSoulofChange

www.heartandsoulofchange.com 2011 The Heart & Soul of Change Delivering What Works In Therapy Barry Duncan, Psy.D. www.heartandsoulofchange.com Psy.D. 561.239.3640 www.whatsrightwithyou.com barrylduncan@comcast.net 1

www.heartandsoulofchange.com 2011 •Since the 60’s, the # of models has grown from 60 to over 400… •Each claims superiority in conceptualization and outcome The result is fragmentation along theoretical and disciplinary lines Now over 100 so called evidence based treatments--effectiveness treatments--effectiveness not increased in 40 years… 2

www.heartandsoulofchange.com 2011 The Dodo Verdict •With few exceptions, partisan studies designed to prove the unique effects of a given model have found no differences— differences—nor has recent meta- meta- analyses…The analyses…The Dodo Verdict—the Verdict— most replicated finding in the psychological literature “Everybody has won and all must have prizes.” Rosenzweig, S. (1936). Some implicit common factors in diverse methods in psychotherapy. Journal of Orthopsychiatry, 6, 412-15. Wampold, B.E. et al. (1997). A meta-analysis of outcome studies comparing bona fide psychotherapies: Empirically, "All must have prizes." Psychological Bulletin, 122(3), 203-215. TDCRP The Alliance •Considered most sophisticated comparative clinical trial ever: •CBT, IPT, Drug, Placebo •No difference in outcome •The client’s rating of the alliance at the second session the best predictor of outcome across conditions. Elkin, I. Et al. (1989). The NIMH TDCRP: General effectiveness of treatments. Archives of General Psychiatry, 46, 971-82. 3

www.heartandsoulofchange.com 2011 Project MATCH The Alliance •CBT, 12-step, & Motivational 12- Interviewing •NO difference in outcome •The client’s rating of the alliance the best predictor of: Treatment participation; Drinking behavior during Anton, S. et al., (2006). Combined treatment; pharmaceutical and behavioral interventions for alcohol Drinking at 12-month FU 12- dependence.. JAMA, 295, 203-217. COMBINE…same thing 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 Dodo Also Rules Family Therapy Cannabis Youth Treatment Project •600 Adolescents marijuana users: •Significant co-morbidity (3-12 problems). co- (3- •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). No Difference! Approach accounted for 0% of the variance in outcome. Alliance predicted: Premature drop-out; Substance abuse symptoms post- drop- post- treatment, and cannabis use at 3 and 6 month follow-up. follow- 4

www.heartandsoulofchange.com 2011 What About Evidenced Based Treatment •Dodo highlights fatal flaw: Efficacy over placebo or TAU is not efficacy over other approaches & not saying much— much—if a friend went out on a date, you asked about the guy, your friend replied, “He was better than nothing—he was unequivocally better than watching TV or washing my hair.” How impressed? Rosenzweig, S. (1936). Some implicit common factors in diverse methods in psychotherapy. •And the conclusion… Journal of Orthopsychiatry, 6, 412-15. 6, 412- Implication of the Dodo Bird Verdict All 400 approaches work because: Of factors common to all therapies So what are the factors? 5

www.heartandsoulofchange.com 2011 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 Becoming Better Bottom Line “The quality of  Suggests the patients participation . . . something different [emerges] as  Privilege clients’ the most experience & rally important determinant of their resources to outcome." the cause 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. 6

www.heartandsoulofchange.com 2011 The Killer D’s of Client Diminishment Dysfunction Disorder Disability Disease Deficit Damaged Not Reliable or Valid None ever related to outcome More Quotable Quotes about Diagnosis “Psychotherapy is the only form of treatment which, at least to some extent, appears to create the illness it treats” Jerome Frank (Frank, 1961, p. 7). Reliability: “To say that weve solved the reliability problem is just not true…Its been improved. But if youre in a situation with a general clinician its certainly not very good. Theres still a real problem, and its not clear how to solve the problem" Robert Spitzer, lead •Creates the Illness editor of DSM III (Spiegel, 2005, p. 63). •Reliability not good •It’s BS Validity: “There is no definition of a mental disorder. It’s bullshit. I mean, you just can’t define it… these concepts are virtually impossible to define precisely with bright lines at the boundaries.” Allen Francis, lead editor of DSM IV (Greenberg, 2010, p. 1). 7

www.heartandsoulofchange.com 2011 Casting the Client in Heroic Roles  No formula here, more of an attitude requiring a balance between listening empathically with mindfulness toward resources that you know are there.  Identify not what clients need, but what they already have in their world that can be put to use in reaching their goals Finding the Heroic Client What are the qualities that describe you when you are your very best? What were you doing when these aspects became apparent to you? What kind of person do these aspects describe? Or, What kind of person do these aspects show an aspiration toward? What are the qualities that others would describe In you when you are at your very best? What were you doing when they noticed these aspects? What kind of person do these aspects describe? Or, what kind of person do these aspects show an aspiration toward? 8

www.heartandsoulofchange.com 2011 Finding the Heroic Client  Who was the first person to tell you that they noticed the best of you in action? What were you doing when they noticed these aspects?  Who was the last person to tell you that they noticed the best of you in action? What were you doing when they noticed these aspects?  Who in your life wouldn’t be surprised to see you stand up to these situations and prevail? What experiences would they draw upon to make these conclusions about you? What “quintessentially you” stories would they tell?...Kim  When I am at my very best, I am _____________. 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 is already there to be recruited for change? The Heroic Client 9

www.heartandsoulofchange.com 2011 Think of a Time in Your Life  Think of a time in your life that was very difficult.  What problems did this situation create for your personal mental health as well as your family?  Did you use drugs or alcohol to get you through?  What pattern in your life does this story represent?  Who else knows this story about you?  What do you think they say this story says about what destructive patterns that you need to change?  Who wouldn’t be surprised that you are repeating this pattern now? Telling Heroic Stories…Imagine  Think of a time in your life that was very difficult, but you managed to get through it.  What personal resources did you draw on to get through this difficulty?  What family, spiritual, friend, or community support did you draw on to get through?  What does this story tell you about who you are and what you can do?  Who else knows this story about you?  What do you think they say this story says about who you are and what you are capable of?  Who wouldn’t be surprised to see you stand up to this problem and prevail? 10

www.heartandsoulofchange.com 2011 The Heroic Client • The Client: • Change is a potent client factor, weaving in and out clients’ lives creating many therapeutic opportunities. • Chance events: • Things that simply happen while the person happens to be in therapy… Change in Treatment Source: Howard, et al (1986). The dose effect response in psychotherapy. American Psychologist, 41(2), 159-164. 11

www.heartandsoulofchange.com 2011 Maintaining Change •Strong correlation between the maintenance of change and the degree to which clients attribute it to their own efforts. •Participants who attribute changes to a med or therapist are less likely to maintain gains than those who viewed the improvement resulting from their own efforts. •Those who attribute changes to their own efforts rather than chance more likely to maintain gains regardless of the cause. Frank, J.D. (1976). Psychotherapy and the sense of mastery. In R.L. Spitzer et al. (eds). Evaluation of Psychotherapies. Baltimore, MD: Johns Hopkins. Liberman, B. (1978). The maintenance and persistence of change. In J.D. Frank et al. (eds). Effective ingredients of effective psychotherapy. New York: Brunner Mazel. Becoming Change Focused  Listen for a change! Ask about and be curious about change: How did you do that? Where did that idea come from?  Validate the clients contribution to change. How is (drug/tx program) helping access strengths and resources that have always been there but were just beyond your grasp? 12

www.heartandsoulofchange.com 2011 Encourage Before and After Distinctions  How did you decide that now was the time for action?  What insights have you gained that you were finally able to put into action?  What insights have you gained from this change that will help you in the future?  What does this say about you, the kind of person that took the bull by the horns at this time?  How did you do it? How will you maintain the gains you have made?  How are you different now that you have realized this change?  Ponder the difference in your self-image before you changed and now….Chris Client is the of Change  Client’s Resources, Resiliencies, and Relational Support  Client’s View of the Alliance  Client’s View of Progress &Expectation of Success 13

www.heartandsoulofchange.com 2011 Clients The Heart of Change Client outcome feedback makes consumers the historians of their own change and recovery Partnering w/clients to monitor outcome engages most the potent factor of change The Treatment of Depression Collaborative Research Project (TDCRP) •Considered to be the most sophisticated comparative clinical trial ever conducted: •Four approaches (CBT, IPT, Drug, Placebo). •No difference in outcome between approaches •The client’s rating of the alliance at the second session the best predictor of outcome across conditions. •Tx model accounted for 0-2% of the variance… 0- Elkin, I. Et al. (1989). The NIMH TDCRP: General effectiveness of treatments. Archives of General Psychiatry, 46, 971-82. 14

www.heartandsoulofchange.com 2011 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 50% less; meds useful for clients of more effective therapists, not for less. What accounts for the Wampold, B., & Brown, J. (2006). Estimating variability in variability? outcomes attributable to therapists: A naturalistic study of outcomes in managed care. Journal of Consulting and Clinical Psychology, 73 (5), 914-923. 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. 15

www.heartandsoulofchange.com 2011 Therapists Variables that Predict Change Therapists with the best results:  Are better at the alliance across clients; alliance ability accounts for therapist differences Baldwin et al. (2007). Untangling the alliance-outcome correlation. Journal of Consulting and Clinical Psychology,  Alliance predicts change 75(6), 842-852.; Anker, Owen, Duncan, & Sparks (2010). The alliance in couple therapy. Journal of Consulting and Clinical over and above early Psychology, 78(5), 635-645. Owen, Duncan, Anker, & Sparks (2011). Therapist variability change in couple therapy. Manuscript submitted for publication. Relationship Factors The Alliance: • Relational Bond • Agreement on goals 38- 38-54% • Agreement on tasks Seven Times the Impact of Model/Technique…Accounts for Most of Therapist Variance Duncan, B., Miller, S., & Sparks, J. (2004). The Heroic Client. San Francisco: Jossey-Bass 16

www.heartandsoulofchange.com 2011 The Therapeutic Alliance The Alliance Goals, Means or Meaning Methods: or Theory of Purpose Change Client’s View of the Relationship The Alliance: Over 1000 Research Findings  Quality of the alliance more potent predictor of outcome than orientation, experience, or professional discipline-- recall TDCRP, MATCH, CYT.  Clients rarely report negative reactions before deciding to terminate.  Same holds true for youth and family therapy 17

www.heartandsoulofchange.com 2011 Project MATCH What about the mandated clients? •No difference in outcome between voluntary and mandated clients. •The only reliable predictor? •The Alliance Project MATCH Group (1997). Matching alcoholism treatment to client heterogeneity. Journal of Studies on Alcohol, 58, 7- 29. 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. Research into Practice The Alliance •Increasingly, the relationship is viewed as merely “setting the stage” for the “real” treatment: •Confronting distorted thoughts; •Recovering forgotten memories; •Asking special questions; •Tapping on or waving fingers in front of the face…but the data say: •The alliance deserves far more RESPECT… Duncan, B. (2010). On becoming a better therapist. Washington, DC: APA. 18

www.heartandsoulofchange.com 2011 Reliance on the Alliance • Be friendly, responsive, and flexible (like a first date); stay close to client’s experience. • Empathy and Positive Regard: Validate. Legitimize the client’s concerns/basic worth and the importance of their struggle. • Work on client’s goals period. • Fit the client’s theory of change. Empathy Carl Rogers Was On To Something  Empathy. A meta-analysis of 47 studies: r of .26 between therapist empathy and psychotherapy outcome, translating to ES of .32.  ES of model and technique differences is but .20; Client’s perception of empathy more powerful than any technique you can ever wield. 19

www.heartandsoulofchange.com 2011 Empathy Plus Positive Regard Equals Validation  Positive Regard: warm acceptance of client w/o conditions.  When outcome & positive regard were both rated by clients, 88% of studies found sig. relationship. Critical that clients think we view them positively.  Appreciation: appreciation of people in general, their struggles, and of their humanity and innate goodness…Lisbeth You Know It Ain’t Easy Why Do Think They Call It Work  Gotta try and understand the anger; gotta figure out a way for it all to make sense  Gotta find stuff about the client to like, to appreciate  Gotta validate her experience, work on her goals, and get her involved in purposeful work 20

www.heartandsoulofchange.com 2011 The Rubber Hose of Doubt and the Bright Light of Blame You are the problem! You are to blame!  Validation doesn’t mean you agree with what the client has done; means that you acknowledge the rest of the story!  Puts client’s actions in a context that legitimizes him/her as a human being. No wonder…  Clears a path for change because it diffuses self doubt and dissipates self loathing…Sam…Lisbeth The Client’s Theory of Change Pre- Pre-existing beliefs about the problem and change Source: Duncan, B., Solovey, A., & Rusk, G. (1992). Changing the Rules. New York: Guilford. 21

www.heartandsoulofchange.com 2011 The Client’s Theory of Change: Empirical Findings In the TDCRP, congruence between the clients TOC and tx resulted in: Stronger therapeutic alliances; Longer duration in treatment; and Improved treatment outcomes. Elkin, I. (1999). “Patient-treatment fit" and early engagement in therapy. Psychotherapy Research. 9(4) 437-451. Preferences Meta-Analysis of 35 Studies  Clients matched to preferred conditions were less likely to drop out & improved more.  Type of preference (role, therapist, or tx) not sig.  Results underscore centrality of incorporating client preferences Swift, J.K., Callahan, J.L. & Vollmer, B.M. Preferences. Journal of Clinical Psychology: In Session, 67, 155–165. 22

www.heartandsoulofchange.com 2011 Plurality Pays Off Differential Efficacy with Current Client  Q: Does it resonate; does it fit client preferences; can both get behind it?  Alliance skills: explore client ideas, discuss options, collaboratively plan, and negotiate changes if benefit not forthcoming.  Alliance in action. Litmus test: whether it engages client in purposive work. Attitude Important Alliance is Central Filter  Is what I am doing and saying now building or risking the alliance?  Doesn’t mean you can’t challenge but rather that you have to earn the right and, consider the alliance consequences 23

www.heartandsoulofchange.com 2011 Alliance As An Overarching Framework The Alliance is the Soul  Transcends any beh & is a property of all—from tech. to scheduling appt  Purpose is to engage in purposive work  Have to earn it each & every time; alliance is our craft; practice elevates to art 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 outcomes 24

www.heartandsoulofchange.com 2011 But What About This Client?  While the data give general guidance, it does little to inform what will help a particular client.  To know what is therapeutic, the client’s view regarding both the alliance and outcome is key.  The real question: Does this client experience this interaction at this time and place to be therapeutic? And the only way to do this is via client feedback Feedback As A Common Factor  Overlaps with & affects all factors—tie that binds  Soliciting feedback is a living, process that engages clients in monitoring outcome, heightens hope, fits client preferences, maximizes therapist-client fit, and is itself a core feature of change. 25

www.heartandsoulofchange.com 2011 40+ Years of Data Say… No one approach works better than another. Factors common across all approaches account for change— change—Feedback helps you integrate and enhance the effects of these factors Psychotherapy The Good… Study after study, and studies of studies show the average treated client is better off than 80% of the untreated sample. 26

www.heartandsoulofchange.com 2011 Counseling Works As Good As RCTs  Recent study:  2,000+ providers  6,000+ clients  Outcomes equivalent to RCTs for depression, specifically the TDCRP. 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. 116- Psychotherapy The Bad… Drop out rates average 47% Therapists vary… a lot 27

www.heartandsoulofchange.com 2011 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 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 3rd was a lack of confidence in the outcome of tx (77%).  Despite tx efficacy, DOs are a problem, many do not benefit, therapists vary in effectiveness and & there is a crisis of confidence among consumers. 28

www.heartandsoulofchange.com 2011 To The Rescue: Partners for Change Outcome Management System  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 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 support tools  A strong case for routine measurement of outcome in everyday clinical practice 29

www.heartandsoulofchange.com 2011 Becoming Better 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  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. Reese, Norsworthy, & Rowlands (2009) First Independent Study Reese, R., Norsworthy, L., &  N=148: Feedback group Rowlands, S. (2009). Does a continuous feedback model doubled controls (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, benefit from psychotherapy outcomes. Psychotherapy, 47, 616-630. continuous feedback  And also a replication study published 30

www.heartandsoulofchange.com 2011 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., & Shimokawa, K. (2011). Collecting client feedback. In J. Norcross (Ed.), Psychotherapy relationships that work, 2nd ed. New York: Oxford University Press Effects on Efficiency Cancellations, No Shows, LOS  Claude (reported in Bohanske & Franczak) compared ave. # of sessions, canc., no shows, and % of long-term cases before and after OM in 2130 closed cases in a 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 Bohanske, R., & Franczak, M. (2010). long term null cases diminished by Transforming public behavioral healthcare: A case example of consumer directed services, 80% (10% to 2%). recovery, and the common factors. In B. Duncan et al. (Eds.) The Heart and Soul of Change: Delivering What Works, 2nd Ed. Washington, DC: American  An estimated savings of $489,600. Psychological Association. 31

www.heartandsoulofchange.com 2011 Becoming Better Recapture Your At Risk Clients  Feedback tailors therapy based on response, provides an early warning system to prevents drop- outs & negative outcomes, & solves therapist variability—feedback improves performance And…Finally Operationalizes Recovery  Puts the client’s voice center stage  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 32

www.heartandsoulofchange.com 2011 First Things First Why You Might Be Reluctant  Finding out is risky  What if you find out that you are not so good? What if you are in the wrong profession?  The only way we improve is thru feedback. It takes courage. But so does walking in a room with someone in distress. Regarding Therapist Variability Feedback Improves Outcomes  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! 33

www.heartandsoulofchange.com 2011 Provider Variation Feedback Improves Effectiveness C ounselors O utcom es (n = 30 or more 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 0 4) 4) 7) 5) 9) 8) 5) 0) 8) 8) 7) 7) 1) 1) 0) 9) 7) 5) 4) 1) 1) 0) =9 n=7 n=6 n=6 n=5 n=5 n=5 n=5 n=4 n=4 n=4 n=4 n=4 n=4 n=4 n=3 n=3 n=3 n=3 n=3 n=3 n=3 (n ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 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- Many Believe They Already Know  The info the measures reveal—that are attuned to client’s experience & the forms superfluous.  Norway study: all therapists believed they already acquired outcome & alliance info—that formal feedback wouldn’t improve their effectiveness.  9 of 10 improved; only 1 correct. 34

www.heartandsoulofchange.com 2011 First Things First Why You Might Be Reluctant  You might be thinking that you need more paperwork like a hole in the head. Therapists can get really worked up over anything that adds paperwork, especially when they don’t see it as clinically useful. First Things First Why You Might Be Reluctant  Feedback about the benefit & fit need not be cumbersome or intrusive. Only a couple of minutes & no intrusive questions.  Feedback the best hope to improve, clients appreciate your dedication to getting it right, & it is painless and can fit your natural way. 35

www.heartandsoulofchange.com 2011 PCOMS: Getting Started Just the Facts Ma’am  The nuts & bolts, for starting PCOMS with your next client  Feedback is the way to transcend average. Skill Building: Partners for Change Outcome Management System 3 Skills of PCOMS (The Three I’s)  Introducing the Measures  Integrating Client Feedback into Practice  Informing and Tailoring Services Based on Client Feedback 36

www.heartandsoulofchange.com 2011 Nuances of the Measures Not a Perfunctory Piece of Paper  Administering But Don’t Get It. Clients Must Understand Purpose (monitoring outcome, privileging their perspective); Therapists Must Understand Same + Make Them Meaningful  Administering, Using Some, But Not the Clinical Cutoff or Numbers…Heuristic Clinical Use but No Continuity or Coherence  Administering, Using Some, But Not Connecting to Client’s Experience or Reasons for Service; Data Integrity Questionable  Administering the SRS, But Seeing as Reflective of Competence Rather than an Alliance Building Tool The First Session All Aboard  Have to be on board with two things: have to think privileging the client is a good idea; and have to want to be accountable. 37

www.heartandsoulofchange.com 2011 Client Privilege and Social Justice Clients Have Been Missing Persons Despite well-intentioned efforts, the infrastructure of therapy (paperwork, policies, procedures, and professional language) can reify non-contextualized descriptions of client problems and silence client views, goals, and preferences. The Measures and Social Justice “Leveling” the Counseling Process  Invites clients into inner circle of decision making  Available in multiple languages  Voice to diversity and the disenfranchised  Local culture and context over privileged knowledge 38

www.heartandsoulofchange.com 2011 Starting With the Predictors Change and the Alliance •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. Sooner Rather Than Later Who drops out? B •The bulk of change A occurs sooner rather than latter Howard, K. et al. (1986). The dose-effect response in psychotherapy. American Psychologist, 41, 159-164. 39

www.heartandsoulofchange.com 2011 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 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. It’s A Fact Early Change is The Rule Cannabis Youth Treatment Project Early change in treatment is a robust predictor of outcome and retention in Project MATCH treatment. Gotta measure outcome! 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. 40

www.heartandsoulofchange.com 2011 Early Change is the Rule TDCRP Conclusions: Early change is an important factor for the prediction of short- and long-term outcome in therapy. Lutz, W., Stulz, N., & Köck, K. (2009). Patterns of early change and their relationship to outcome and follow-up among patients with major depressive disorders. Journal of Affective Disorders 118(1), 60-68. Becoming Better Measuring Outcome •Give at the beginning of the visit; Client •Scored to the places a mark nearest millimeter. on the line. •Add the four •Each line 10 scales together cm (100 mm) in for the total score. length. •Reliable, valid, feasible 41

www.heartandsoulofchange.com 2011 CORS Becoming Better Creating A Culture of Feedback •When scheduling, provide rationale for seeking feedback; convey commitment to their goals and highest quality of service…in your own words •Work a little differently; •If we are going to be helpful should see signs sooner rather than later; If not helpful, we’ll seek consultation & consider a referral. •No one has ever said: Bad idea! 42

www.heartandsoulofchange.com 2011 The Outcome Rating Scale An Introduction  The ORS is an outcome measure that allows us to track where you’re at, how you’re doing, how things are changing or if they are not. It allows us to determine whether the therapy is being helpful so we can do something different if it’s not. It also is way to make sure that your perspective stays central here, that we are addressing what you think is most important. It only takes a minute to fill out and most clients find it to be very helpful. Would you give it a try? The First Session Whatever It Takes  You can’t over-explain…  Clients get this. Face validity.  Whatever explanation the client gives is ok. Some will say: “You mean like poor to well?” or “Like 1 to 10?”  It’s their subjective experience that matters so their understanding of the measure is paramount. 43

www.heartandsoulofchange.com 2011 Looking Like a Klutz We’re All Bozos on this Bus  Score the marks. Need a cm ruler. Many will not try—fear of looking like a bozo.  Worry about measuring marks & adding the scores. 4 marks & 4 scores, not regression equations. Practice until you feel confident.  But, it’s okay to look inept from time to time with clients. And believe me, however you do it won’t be as bad as I’ve done it. Becoming Better Graphing: A Helpful Visual  Adds a visual component— another way to focus tx  At a glance tells the story of the client’s progress.  Allows you to dispense of the previous measures.  Indispensable with couples & families, helps discuss multiple viewpoints 44

www.heartandsoulofchange.com 2011 Using Graphs With Families •Can easily see indv. & family progress from session to session •Can comment on other’s scores in relation to own •Invites family discussion about the next steps •A visual indication of the need for changing approach, continuing, or ending. The Three Ring Circus: Making Measures Work with Families •Invite all members of the family to participate. •When child is presented as the problem, use CORS with the child & parents •Invite all members of the family to interpret. •Summarize progress as entry point into the meeting. •Summarize alliance as exit out of the meeting. 45

www.heartandsoulofchange.com 2011 The First Meeting The “Clinical Cutoff” •The dividing line between a 40 clinical & “non-clinical” “non- 35 population (25). For children O u tc o m e S c o r e 30 25 (32) & adolescents (28); 20 caretakers (28) 15 •Between 25-33% score in 25- 10 5 the “non-clinical” range. “non- 0 1st 2nd 3rd 4th •The slope of change Session Number decreases as clients approach Actual Score Line 2 25th % 75th % the cutoff. The Clinical Cutoff Only 2 Choices  Either above or below.  Mention client score as it relates to the cutoff & have the client make sense of it.  Scores under cutoff may seem more straightforward  Reporting distress similar to others seeking services— the lower the score, the higher the distress. Looking for a change. 46

www.heartandsoulofchange.com 2011 Initial Information… 40 •Client’s score is within the 30 clinical range. s c o re ORS 20 •Scoring more 10 like people in therapy and 0 wanting 1 2 3 4 5 6 7 8 9 10 Session number something to change…wavy Projected change 75th percentile ORS Scores Estimated Clinical Cutoff 25th percentile ORS: An Example •What can we glean 7.6 clinically from this client’s scores in 5.7 addition to being above the clinical cut off? 8.0 •How could we use this information to begin or 7.5 focus the session? Total = 28.8 47

www.heartandsoulofchange.com 2011 The First Meeting Over the Clinical Cutoff •Explore why the client entered therapy…two reasons: circumscribed problem or mandated/coerced •If mandated, ask for the referral’s rating as a catalyst for conversation… doesn’t mean they are lying •Focus on circumscribed problems or issues at hand •Avoid exploratory or “depth- “depth- oriented” techniques or stirring the cauldron Over the Cutoff The Wicked Witch  People over cutoff are a higher risk of deterioration.  Why?  We don our Wicked Witch costume, growing warts & a humongous nose, and we stir the cauldron. Laughing devilishly we shriek, “Oh you think things are going okay do you, we’ll see about that, my pretty!” 48

www.heartandsoulofchange.com 2011 Take Clients at Face Value  Don’t interpret high scores as a misrepresentation  It is the way the client sees him or herself  Don’t have to see a problem to be helped  Other’s ratings important too First Session: Connect ORS to the Client’s Described Experience  Atsome point, connect the client’s described experience of their lives to the marks on the scales 49

www.heartandsoulofchange.com 2011 The ORS The Bare Bones  No specific content other than domains—a skeleton to which clients add the flesh & blood of their experiences.  At the moment clients connect the marks with what they find distressing, the ORS becomes a meaningful measure of their progress and potent clinical tool. Get A Good Rating Make Sure  Transparency is the rule, not confrontation or judgment  Darrell and Angelina Jolie  Brandy  Ray 50

www.heartandsoulofchange.com 2011 Integrating the Measures Problems and Challenges?  Has to be Relevant to the Work  OrBecomes an Emotional Thermometer of Day to Day Life 40 Years of Data say… •Client’s rating of the alliance the best predictor of engagement and outcome. outcome. •Client’s subjective experience of change early in the process the best predictor of success for any particular pairing. 51

www.heartandsoulofchange.com 2011 Quickest Way Prevent Drop Out Clients drop out for 2 reasons: therapy is not helping (monitor outcome) & alliance problems—not engaged or turned on. Direct way to improve effectiveness is to keep people engaged in therapy. Gotta measure the alliance The Session Rating Scale Measuring the Alliance •Score in cm to •Give at the end the nearest mm; of session; •Discuss with •Each line 10 cm client anytime in length; total score falls below 36 52

www.heartandsoulofchange.com 2011 Becoming Better A Culture of Feedback with the SRS •When scheduling a first appointment, provide a rationale for seeking feedback regarding the alliance. •Work a little differently; •Want to make sure that you are getting what you need; •Take the “temperature” at the end of each visit; •Feedback is critical to success. •Restate the rationale prior to administering the scale. •How not to do the SRS 53

www.heartandsoulofchange.com 2011 The Session Rating Scale An Introduction  Let’s take a minute and have you fill out the other form that asks your opinion about our work together. It’s kind of like taking the temperature of our relationship today. Are we too hot or too cold? Do I need to adjust the thermostat? This information helps me stay on track. The ultimate purpose of using these forms is to make every possible effort to make our work together beneficial. If something is amiss, you would be doing me the best favor if you let me know. Can you help me out? The Session Rating Scale Traditionally  Told us with their feet  Will let us know on SRS before telling/bolting.  Takes work for candor.  Disparity in power & socio- economic, ethnic, or racial diff., can make it tough. When was the last time you told your physician, “Youre making a big mistake"? 54

www.heartandsoulofchange.com 2011 But Don’t Stress It’s Okay  Keep encouraging client to let you know…  Have to KNOW: No bad news. Not a measure of competence or anything negative about you or the client. Gift from the client that helps you to be better.  Unless you really want it, you are unlikely to get it.  You won’t get it from everyone. The Session Rating Scale A Quick Visual Check  Scores < 36 or 9cms should be discussed.  SRS is good or its not. Either thank the client for the feedback, & invite them to share future concerns; or thank client & explore why their ratings are lower so that you can fix the concern.  Building the Alliance 55

www.heartandsoulofchange.com 2011 Thanking and Inviting  Let me just take a second here to look at this SRS—it’s kind of like a thermometer that takes the temperature of our meeting here today. Wow, great, looks like we are on the same page, that we are talking about what you think is important and you believe today’s meeting was right for you. Please let me know if I get off track, because letting me know would be the biggest favor you could do for me. Thanks and Exploring What About Below 36 or 9cm?  Don’t expect specifics or revelations—any feedback is a godsend  Is there anything else I could have done, something I should have done more of or less of, some question or topic I should have asked? 56

www.heartandsoulofchange.com 2011 Thanking and Exploring  Let me quickly look at this other form here that lets me know how you think we are doing. Okay, seems like I am missing the boat here. Thanks very much for your honesty and giving me a chance to address what I can do differently. Was there something else I should have asked you about or should have done to make this meeting work better for you? What was missing here? The Session Rating Scale Other Responses  When time an issue, set expectation that the SRS will increase over time.  Sometimes: “I don’t know” or “Nobody’s perfect.” Or will rate you low & never say why, or rate high all the way. It’s all ok.  Continue to leave space for feedback, to want it, and many clients will. Even if they don’t, your attention to the alliance will help. Get points for trying. 57

www.heartandsoulofchange.com 2011 The SRS Graceful Acceptance  And a willingness to be flexible usually turn things around.  Clients reporting alliance problems more likely for success. Lower scores on the SRS should be celebrated.  If clients are comfortable enough to express something isn’t right, then you are doing something great. X X X X Now we’re ready to be better therapists, but first we must heed the words of a noted psychotherapy scholar 58

www.heartandsoulofchange.com 2011 Sage Psychotherapy Scholar: Mae West? Granted, at first When I’m blush, these good, hardly seem like I’m very words for good, but when therapists to live I’m bad, by—but, as it I’m better. turns out, they are. Becoming Better Helping Every Single Client  When clients are not benefiting provides the opportunity to do your best work—gives you the possibility of being helpful to everyone you see. Sound too good to be true? It’s not. 59

www.heartandsoulofchange.com 2011 Becoming Better Identifying Clients Not Responding  When outcome is bad in other words, you can make it better by changing something about the therapy to turns things around; and if things don’t turn around, by moving the client on to a different provider or service Becoming Better Two Choices: Not Rocket Science  Either the client is improving or not. If not, 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. 60

www.heartandsoulofchange.com 2011 Becoming Better When I’m Good, I’m Very Good  When ORS scores increase, when you’re good, a crucial step to be very good is help clients see gains as a consequence of their own efforts and make sense of its meaning so repeat in the future. Becoming Better Linking Outcome to Treatment •See clients more frequently when the slope of change is steep. •Begin to space the visits as the rate of change lessens. •See clients as long as there is meaningful change & they desire to continue. 61

www.heartandsoulofchange.com 2011 Becoming Better Doesn’t Mean All Therapy Should Be Brief  Au contraire, research suggests that more is better than less for clients who progress early & want to continue.  When little or change, however, same data indicates that therapy should, indeed, be as brief as possible. Becoming Better What to Do Next  Involve the client in monitoring progress & the decision about what to do next, to elicit his or her ideas & formulate a plan.  The discussion repeated in all meetings, but later ones gain significance and warrant additional action: Checkpoint and Last Chance Discussions. 62

www.heartandsoulofchange.com 2011 Becoming Better When to Say When  Stimulates both client and therapist to struggle with continuing a process that is yielding little or no benefit.  To support what is working & challenge what is not. Urgency increases over time Checkpoint Session: An Opportunity to Be Better  Be transparent— comment about the lack of progress and seek feedback from the client about what he/she thinks it means 63

www.heartandsoulofchange.com 2011 Becoming Better Client Not Improving  Okay, so things haven’t changed since the last time we talked. How do you make sense of that? Should we be doing something different here, or should we continue on course steady as we go? If we are going to stay on the same track, how long should we go before getting worried? When will we know when to say “when?” Becoming Better First, the Alliance  “It doesn’t look like we are getting anywhere. Let’s go over the SRS to make sure you are getting exactly what you are looking for.” Going thru SRS and eliciting client responses in detail can help you & the client get a better sense of what may not be working. 64

www.heartandsoulofchange.com 2011 Checkpoint Conversation Further Considerations  Worth exploring fit of your approach with client’s sensibilities about what needs to happen—the client’s theory of change.  Ringing true with the client will increase expectation for change as well as participation.  Client’s TOC unfolds from a conversation structured by your curiosity about the client’s ideas, attitudes, and speculations about change. Checkpoint Conversation Do Something Different  Nothing may come of talk about the alliance. Don’t worry. Making effort helps.  Invite others from support system, use a team or co- therapist, a different approach; referral to another therapist, religious advisor, or self-help group—whatever seems of value.  Any ideas are implemented, and progress is monitored. 65

www.heartandsoulofchange.com 2011 Becoming Better Precipitous Drops  Get explanation: Is the drop related to the reason for service—a deterioration—or is a recent event holding sway over the client’s rating?  If deterioration, then a red flag, signals the necessity to have a heart to heart about what needs to happen different to quickly turn things around. Becoming Better Potholes Are Different  Hit a pot hole, etc. Events hold sway over rating.  If pothole, ask to redo looking at the whole week, related to reasons for tx.  If pothole trumps the orig. reasons for tx, then go with it. Reconnect new issues to ORS. Don’t turn life events into therapy issues. 66

www.heartandsoulofchange.com 2011 Becoming Better Zigzag  Sometimes scores, even when connected to the client’s problems go up and down over time—a zigzag pattern.  Of primary interest is whether there is an upward or downward trend—back to the basic question: Are things getting better or not? Becoming Better The Last Chance Discussion  Driving into desert running on empty, “last chance for gas.”  Depicts the necessity of stopping and discussing the implications of continuing w/o change. 67

www.heartandsoulofchange.com 2011 Becoming Better Never the LAST CHANCE  Doesn’t mean the “last chance” for your client—but rather the last chance of a change plan or pairing. No last chance for your client—referral can make the difference! Last Chance Thoughts The Longer w/o Change, the Quicker to #5 1.What does the client say? 2.What have you done differently? 3.What can be done differently now? 4.What other resources can be rallied? 5.Is it time to fail successfully? 68

www.heartandsoulofchange.com 2011 Becoming Better Helping Every Single Client  All clients can’t benefit. Still a way to be helpful.  Might have felt like a failure. But when I’m bad, I’m better. Now successful when client achieves change & when, in the absence of change, I get out of the way. Becoming Better The Last Chance Discussion  At the least, consultation  Referral seriously discussed.  Rarely justified to continue past typical period.  Rarely is not never. Highly idiosyncratic & uniquely negotiated. Keeps us honest, addresses the lack of change transparently—new for me. 69

www.heartandsoulofchange.com 2011 Becoming Better Guard Against Finger Pointing  Guard against explaining client response thru theoretical filters & folklore— puts us right back where we have traditionally been— attributing lack of change to the client. Client non- response means something else should be done. When I’m Bad, I’m Better Failing Successfully  Repeat commitment to help them achieve goals.  Failure says nothing about them or their potential.  If client wants, meet until arrangements are made.  But rarely continue with clients who show no improvement. 70

www.heartandsoulofchange.com 2011 Failing Successfully Change of Therapist Watershed Client Failing Successfully I wish my helper had  I believed in PBE, but… failed successfully  Awakened me to the pitfalls; taught me to fail successfully.  Avoid a “chronic” client— the iatrongenic effects of continuing therapy w/o benefit.  ORS allows us to ask ourselves hard questions. 71

www.heartandsoulofchange.com 2011 Becoming Better Feedback Is My Compass  Not an uninhabited terrain of technical procedures, nor the predictable path of diagnosis, prescription, & cure. Cannot be described w/o the client & therapist, co-adventurers in a journey across uncharted territory. Common factors provide landmarks for this interpersonal & idiosyncratic trip, & specific models provide well- traveled directions to consider, but feedback provides the compass, showing the way to the desired destination. Being Bad Can Make You Better  Helps clients you are already effective with by empowering change—helps those not benefiting by enabling other options and, in absence of change, the ability to move the client on.  When we’re good, we’re very good, but when we’re bad, we can be even better. 72

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HeartandSoulofChange

by Barry Duncan

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