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These are the slides from a one day workshop that covers both what works in therapy and how to deliver what works via the Partners for Change Outcome Mangement System (PCOMS)

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  1. 1. www.heartandsoulofchange.com October, 2012 The Heart and Soul of Change Delivering What Works In Therapy via PCOMS Barry Duncan, Psy.D. Psy.D. www.heartandsoulofchange.com 561.561.3640 barrylduncan@comcast.net Winter Getaway! Training of Trainers  HSCP Training of Trainers Conference: January 28- Feb. 1, 2013 (27 CEUs) This i t Thi intensive training i t i i experience gives you all you need to train others and implement CDOI and PCOMS. And it provides the first step in becoming an HSCP Certified Trainer. •Since the 60’s, the # of models has grown from 60 to over 400… The Dodo Verdict •Each claims superiority in •With few exceptions, partisan studies conceptualization and outcome designed to prove the unique effects of a given model have found no differences— differences—nor have recent meta- meta- analyses…The Dodo Verdict—the The result is fragmentation along most replicated finding in the theoretical and disciplinary lines psychological literature “Everybody has won and all Now over 150 so called evidence must have prizes.” based treatments, but Rosenzweig, S. (1936). Some implicit common factors in diverse methods in psychotherapy. Journal of Orthopsychiatry, 6, 412-15. ironically… 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.barrylduncan@comcast.net 1
  2. 2. www.heartandsoulofchange.com October, 2012 TDCRP Project MATCH The Alliance The Alliance •CBT, 12-step, & Motivational 12- •Considered most sophisticated Interviewing comparative clinical trial ever: •NO difference in outcome •CBT, IPT, Drug, Placebo , , g, •The client s rating of the alliance client’s •No difference in outcome the best predictor of: Treatment participation; •The client’s rating of the alliance at the second session the best predictor Drinking behavior during of outcome across conditions. treatment; Drinking at 12-month FU 12- 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. Elkin, I. Et al. (1989). The NIMH TDCRP: General effectiveness of treatments. Archives of General Connors, G.J., & Carroll, K.M. (1997). The therapeutic alliance and its relationship to alcoholism treatment participation and outcome. Journal Psychiatry, 46, 971-82. of Consulting and Clinical Psychology, 65(4), 588-98. The Dodo Also Rules Family Work The Search for the Holy Grail Cannabis Youth Treatment Project Doesn’t Do Much for Us  Helping is no more •600 Adolescents marijuana users: •Significant co-morbidity (3-12 problems). co- (3- •Two arms (dose, type) and one of effective now with all three types of treatment in each arm: our treatment •Dose arm: MET+CBT (5 wks), MET+CBT (12 wks), Family Support technologies (400 of Network (12 wks)+MET+CBT; them) and empirically •Type arm: MET/CBT (5 wks), ACRT (12 weeks), MDFT (12 wks). supported treatments No Difference! Approach accounted for 0% of the variance in outcome. (almost 150 of them) Alliance predicted: Premature drop-out; Substance abuse symptoms post- drop- treatment, and cannabis use at 3 and 6 month follow-up. follow- post- than 40 years ago. Evidenced Based Treatment APA Definition of EBP None Have Shown Superiority •Nothing wrong with EBTs but Dodo Evidence-based highlights fatal flaw: Being better practice is the than placebo/TAU is not saying much— much—if a friend went out on a integration of the best date, you asked about the guy, your available research with friend replied, “He was better than clinical expertise in the nothing—he was unequivocally context of client better than watching TV or washing characteristics, culture, my hair.” How impressed? and preferences (American Psychologist, •And the conclusion… conclusion… May 2006). Rosenzweig, S. (1936). Some implicit common factors in diverse methods in psychotherapy. Journal of Orthopsychiatry, 6, 412-15. 6, 412-barrylduncan@comcast.net 2
  3. 3. www.heartandsoulofchange.com October, 2012 APA Recommendations Implication of the Dodo Bird Verdict  Decisions should be made in collaboration with the client, All 400 approaches work based on the best evidence because:  Most effective when responsive to the client’s Of factors common to all strengths, cultural context, and preferences.  Responses are variable. So what are the factors? Therefore, ongoing monitoring of client progress and adjusting as needed is essential Factors Accounting for Client/Extratherapeutic Factors (87%) Successful Outcome Feedback Effects 15‐31% 40.0% Alliance Effects Spontaneous Remission Treatment Effects 38‐54% Client/Extratherapeutic 13% Model/Technique Common Factors 8% Relationship Models/Techniques 30.0% 15.0% Placebo/Hope/Expectancy Model/Technique Delivered: Helper Effects Expectancy/Allegiance 15.0% 46‐69% Rationale/Ritual (General  Effects) Lambert, M. (1986). Implications of Psychotherapy Outcome Research for Eclectic Psychotherapy. Duncan, B. (2010). On becoming a better therapist. 30‐?% In J. Norcross (Ed.) Handbook of Eclectic Psychotherapy. New York: Brunner/Mazel. Washington DC: American Psychological Association On Becoming Better The Killer D’s of Bottom Line Client Diminishment “The quality of Dysfunction the patients  Privilege clients’ Disorder participation . . . experience & rally p y Disability [emerges] as [ ] their resources to Disease  the most the cause. Deficit important Damaged determinant of  But nooooooooooo! Not Reliable or Valid outcome." None ever related to 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., outcome pp. 307-390). New York: Wiley.barrylduncan@comcast.net 3
  4. 4. www.heartandsoulofchange.com October, 2012 Change Is Afoot More Quotable Quotes about Diagnosis A Substantial Protest the DSM V “Psychotherapy is the only form of treatment which, at least to some extent, appears to create Society for Humanistic the illness it treats” Jerome Frank (Frank, 1961, p. 7). Psychology in alliance with Reliability: “To say that weve solved the other APA Div. & professional reliability problem is just not true…It s been true…Its orgs from around the world has Get O G Over it! i! 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 editor of DSM III (Spiegel, 2005, p. 63). •Creates the Illness •Reliability not good a petition entitled “An Open Letter to the DSM-5” Visit: •It’s BS http://www.ipetitions.com/petitio Validity: “There is no definition of a mental disorder. It’s bullshit. I mean, you just can’t n/dsm5/?utm_medium=email&u define it… these concepts are virtually impossible to define precisely with bright lines at tm_source=system&utm_camp the boundaries.” Allen Francis, lead editor of aign=Send%2Bto%2BFriend DSM IV (Greenberg, 2010, p. 1). Clients Are the Lions of Change Casting the Client in Heroic Roles  No formula here, more of an attitude requiring a balance between Until lions have their listening empathically with historians, tales of , mindfulness toward resources that you know are there. hunting will always glorify the hunter.  Identify not what clients need, but what they already have in their world African Proverb that can be put to use in reaching their goals Finding the Heroic Client Finding the Heroic Client What are the qualities that describe you when  Who was the first person to tell you that they you are your very best? What were you doing noticed the best of you in action? What were when these aspects became apparent to you? you doing when they noticed these aspects? What kind of person do these aspects describe?  Who was the last person to tell you that they noticed the best of you in action? What were Or, Wh t ki d f O What kind of person do these aspects show an d th t h you doing when they noticed these aspects? aspiration toward?  Who in your life wouldn’t be surprised to see What are the qualities that others would describe you stand up to these situations and prevail? In you when you are at your very best? What What experiences would they draw upon to were you doing when they noticed these aspects? make these conclusions about you? What “quintessentially you” stories would they tell?...Kim What kind of person do these aspects describe? Or, what kind of person do these aspects show an  When I am at my very best, I am aspiration toward? _____________.barrylduncan@comcast.net 4
  5. 5. www.heartandsoulofchange.com October, 2012 Telling Heroic Stories The Heroic Client  What are the obvious and hidden strengths, resources, resiliencies, • The Client: and competences contained in the • Change is a potent client factor, client’s story? weaving in and out clients’ lives creating many therapeutic  What are the competing stories—the opportunities. stories of clarity, coping, endurance, and desire that exist simultaneously with the confusion, pain, suffering, • Chance events: and desperation? • Things that simply happen while the person happens to be  What is already there to be recruited in therapy… for change? The Heroic Client Change Happens 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 p g p 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 Source: H oward, et al (1986). The dose effect response in psycho therapy. Am erican Psycholog ist, effective psychotherapy. New York: Brunner Mazel. 41(2), 159-164. Encourage Before Becoming Change Focused and After Distinctions  Listen for a change! Ask  How did you decide that now was the about and be curious about time for action? change: How did you do  What insights have you gained that you that? Where did that idea were finally able to put into action? come from?  What insights have you gained from this change that will help you in the future?  What does this say about you, the kind  Validate the clients of person that took the bull by the horns contribution to change. at this time? How is (drug/tx program) (drug/tx  How did you do it? How will you helping access strengths and maintain the gains you have made? resources that have always  How are you different now that you been there but were just have realized this change? beyond your grasp?  Ponder the difference in your self-image before you changed and now.barrylduncan@comcast.net 5
  6. 6. www.heartandsoulofchange.com October, 2012 Clients Client is the of Change The Heart of Change  Client’s Resources, Resiliencies, and Client outcome feedback Relational Support makes consumers the  Client’s View of the historians of their own hi t i f th i change Alliance  Client’s View of Partnering w/clients to Progress monitor outcome engages &Expectation of most the potent factor of Success change Therapist Differences Successful V. Unsuccessful Counselors Incredible Variation Among Providers Focus on Strengths TDCRP: top third Studied videos of 120 psychiatrists giving placebo sessions of 30 clients. bested bottom third giving meds; clients of best  Unsuccessful helpers focused p counselors improve 50% on problems, neglected more & dropped out 50% strengths. less; meds useful for clients  Successful helpers focused on of more effective, not for recruiting strengths to address less--What accounts for the problems…. 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. 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. Helper Variables that Relationship Factors Predict Change The Alliance: Counselors with the best results: • Relational Bond • Agreement on goals  Are bbetter at the h 38-54% • Agreement on tasks alliance across Baldwin et al. (2007). Untangling the alliance-outcome clients; alliance Seven Times the Impact of Model/Technique…Accounts correlation. Journal of Consulting and Clinical Psychology, 75(6), 842-852.; Anker, Owen, Duncan, & Sparks (2010). The alliance in ability accounts for for Most of Counselor helper differences Variance couple therapy. Journal of Consulting and Clinical Psychology, 78(5), 635-645. Owen, Duncan, Anker, & Sparks (2010). Therapist variability in couple therapy. Manuscript submitted for publication. Duncan, B., Miller, S., & Sparks, J. (2004). The Heroic Client. San Francisco: Jossey-Bassbarrylduncan@comcast.net 6
  7. 7. www.heartandsoulofchange.com October, 2012 The Alliance: The Therapeutic Alliance Over 1000 Research Findings  Quality of the alliance more The Alliance potent predictor of outcome than Goals, orientation, experience, or Means or professional discipline-- recall discipline Meaning M i Methods: TDCRP, MATCH, CYT. or Theory of  Clients rarely report negative Purpose Change reactions before deciding to terminate.  Same holds true for youth and Client’s View of the family services Relationship Research into Practice Reliance on the Alliance The Alliance • Be friendly, responsive, and •Increasingly, the relationship is flexible (like a first date); stay viewed as merely “setting the stage” close to client’s experience. for the “real” treatment: •Confronting distorted thoughts; g g ; •Recovering forgotten memories; • E Empathy and P iti Regard: th d Positive R d •Asking special questions; Validate. Legitimize the client’s •Tapping on or waving fingers in front of the face…but the data say: concerns/basic worth and the importance of their struggle. •The alliance deserves far more RESPECT… • Work on client’s goals period. Norcross, J. (2010). The Therapeutic Relationship. In B. Duncan et al. (eds.). The Heart and Soul of Change. Washington, D.C.: APA. • Fit the client’s theory of change. Empathy Empathy Plus Positive Regard Carl Rogers Was On To Something Equals Validation  Empathy. A meta-analysis of  Positive Regard: warm acceptance 47 studies: r of .26 between of client w/o conditions. therapist empathy and  When outcome & positive regard psychotherapy outcome, outcome were both rated by clients 88% clients, translating to ES of .32. of studies found sig. relationship. Critical that clients think we view  ES of model and technique them positively. differences is but .20; Client’s  Appreciation: appreciation of perception of empathy more people in general, their struggles, powerful than any technique and of their humanity and innate you can ever wield. goodness…Lizbethbarrylduncan@comcast.net 7
  8. 8. www.heartandsoulofchange.com October, 2012 The Rubber Hose of Doubt When the alliance is in trouble… 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 ; Consider… C id 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…Cheyenne Reliance on the Alliance The Client’s Theory of Change • Be friendly, responsive, and flexible (like a first date); stay close to client’s experience. Pre- Pre-existing beliefs • E Empathy and P iti Regard: th d Positive R d about the problem Validate. Legitimize the client’s concerns/basic worth and the and change importance of their struggle. • Work on client’s goals period. Source: Duncan, B., Solovey, A., & Rusk, G. (1992). Changing the Rules. New • Fit the client’s theory of change. York: Guilford. The Client’s Theory of Change: Plurality Pays Off Empirical Findings Differential Efficacy with Current Client  Q: Does it resonate? does it In the TDCRP, congruence between fit client preferences; can both get behind it? the clients TOC and tx resulted in: e c e s OC d esu ed :  Alliance skills: explore client Stronger therapeutic alliances; ideas, discuss options, collaboratively plan, and Longer duration in treatment; and negotiate changes if benefit Improved treatment outcomes. not forthcoming.  Alliance in action. Litmus test: whether it engages client in purposive work. Elkin, I. (1999). “Patient-treatment fit" and early engagement in therapy. Psychotherapy Research. 9(4) 437-451.barrylduncan@comcast.net 8
  9. 9. www.heartandsoulofchange.com October, 2012 Attitude Important Alliance As An Overarching Framework Alliance is Central Filter The Alliance is the Soul  Is what I am doing and  Transcends any beh & is saying now building or a property of all—from risking the alliance? tech. to scheduling appt  Doesn’t mean you can’t  Purpose is to engage in challenge but rather purposive work that you have to earn  Have to earn it each & the right and, consider every time; alliance is the alliance our craft; practice consequences elevates to art The Alliance Reliance on the Alliance The of Change Alliance feedback enables a fit between client expectations, preferences, preferences and services The Alliance is the Best Friend Does not leave the alliance to We Have in the chance—applying over 1000 studies showing the Therapy Room relationship of the alliance to positive outcomes Psychotherapy Psychotherapy The Good… The Bad… Study after study, Drop out rates and studies of average 47%, studies show the t di h th 60% with adol. ith adol. d l average treated client is better off & SA clients than 80% of the Therapists vary… untreated sample. a lotbarrylduncan@comcast.net 9
  10. 10. www.heartandsoulofchange.com October, 2012 And the Ugly To The Rescue Providers Don’t Know Consumer Driven Outcomes Management  20-70% range  Howard et al. (1996) advocated  Graded their for the systematic eval. of client response during treatment to effectiveness, A+ to F— “determine the appropriateness determine 67% said A or better; of the current tx…the need for none rated below further tx…[and] prompt a average. clinical consultation for patients Hansen, N., Lambert, M., Forman, E. (2002). The  Providers don’t know who [were] not progressing at expected rates” 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 Feedback and Outcome Outcome and Alliance Feedback Lambert’s Six Trials  All 6 sig. gains for feedback  22% of TAU at-risk cases improved compared with 33% for feedback to therapists therapists, 39% for feedback to therapists & clients, & 45% when supplemented with support tools  A strong case for routine The O.R.S The S.R.S measurement of outcome in Download free working copies at: everyday clinical practice http://www.heartandsoulofchange.com Skill Building Becoming Better Becoming Outcome Informed Isn’t It Good, Norwegian Wood 3 Skills of Outcome  Feedback v TAU; Informed Practice (The Both persons reliable Three I’s) or sig. change—  Introducing the d i h 50.5% 22 6% 50 5% v. 22.6%; Measures ES: .50; 4 xs # of  Integrating Client clin. sig. change Feedback into Practice  FU: TAU-34.2% v.  Informing and Tailoring Services Based on Client 18.4% Feedback Anker, M., Duncan, B., & Sparks, J. (2009). Using client feedback to Feedback 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 10
  11. 11. www.heartandsoulofchange.com October, 2012 Reese, Norsworthy, & Rowlands (2009) Meta-analysis by Lambert & Shimokawa (2011) First Independent Study of PCOMS (the ORS and SRS) Reese, R., Norsworthy, L., &  N=148: Feedback group Those in feedback group had Rowlands, S. (2009). Does a continuous feedback model doubled controls (10.4 3.5 higher odds of experiencing vs. 5.1 pts); ES: .48 improve psychotherapy outcomes? Psychotherapy,46, reliable change 418-431. Reese, R., Toland, M., Slone, N.,  Like Norway study, Those in feedback group had less clients, regardless of risk & Norsworthy, L. (2010). Effect of client feedback on couple than half the odds of experiencing status, benefit from psychotherapy outcomes. Psychotherapy, 47, 616-630. deterioration continuous feedback Feedback attained .48 ES  And also a replication study published Lambert, M. J., & Shimokawa, K. (2011). Collecting client feedback. Psychotherapy, 48, 72-79. Two More in the Works Effects on Efficiency Veterans and Youth Cancellations, No Shows, LOS Schuman, D., Duncan, B., &  Claud (reported in Bohanske & Completed: RCT Comparison of Reese, J. (in preparation). Franczak) compared ave. # of Using client feedback to returning Afghanistan and Iraq improve outcomes with sessions, canc., no shows, and % of Vets In group treatment setting, Iraq/Afghanistan veterans. long-term cases before and after OM in 2130 closed cases in a CMHC. improved outcomes and reduced Gillaspy, A. Murphy, J., Gillaspy A Murphy J & Duncan, B., et al (in process drop outs clinical trial). Using client  Ave. # of sessions dropped 40% (10 feedback to improve school intervention outcomes. to 6) while outcomes improved by Completes in December: RCT 7%; canc. and no show rates were of intervention in the schools with reduced by 40% and 25%; and % of Bohanske, R., & Franczak, M. (2010). long term null cases diminished by Transforming public behavioral healthcare: A children and adolescents with 80% (10% to 2%). case example of consumer directed services, recovery, and the common factors. In B. behavioral problems 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. In Fact, Client Based Feedback As A Common Factor Outcome Feedback  Overlaps with & affects all  Improves factors—tie that binds outcomes  Soliciting feedback is a more than living, living process that engages clients in monitoring anything outcome, heightens hope, since the fits client preferences, beginning of maximizes therapist-client therapy fit, and is itself a core feature of change.barrylduncan@comcast.net 11
  12. 12. www.heartandsoulofchange.com October, 2012 And…Finally First Things First Why You Might Be Reluctant  Puts the client’s voice  Finding out is risky center stage  What if you find out that  Allows services to be you are not so good? What client and family driven if you are in the wrong  Brings consumers into profession? the inner circle of  The only way we improve decisions is thru feedback. It takes  Partners in monitoring courage. But so does the benefit and fit of walking in a room with services someone in distress. Regarding Counselor Variability Provider Variation Feedback Improves Outcomes Feedback Improves Effectiveness  Norway: 9 of 10 got better outcomes C ounselors O utcom es (n = 30 o r mo re case s)  Feedback raised 1 .8 M ean E ffec t S iz e for all Cas es 1 .6 effectiveness of the lower 1 .4 Effect size e 1 .2 1 ones to their more 0 .8 0 .6 successful colleagues. 0 .4 0 .2 0  Helper in low effectiveness (n ) (n ) (n ) (n ) (n ) (n ) (n ) (n ) (n ) (n ) (n ) (n ) (n ) (n ) (n ) (n ) (n ) (n ) (n ) (n ) (n ) 0) 94 4 7 5 9 8 5 0 10 =48 8 12 47 7 14 41 1 16 40 9 18 37 5 20 34 1 22 31 =7 =6 =6 =5 =5 =5 =5 =4 =4 =4 =3 =3 =3 =3 = = = = = = = (n group became the BEST 1 2 3 4 5 6 7 8 9 11 13 15 17 19 21 C ounselor with feedback! 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 First Things First They Already Know Why You Might Be Reluctant  The info the measures  You might be thinking reveal—that are attuned to client’s experience & the that you need more forms superfluous. paperwork like a hole in  Norway study: all believed the head. Helpers can they already acquired get really worked up outcome & alliance info—that formal feedback wouldn’t over anything that adds improve their effectiveness. paperwork, especially  9 of 10 improved; only 1 when they don’t see it correct. as clinically useful.barrylduncan@comcast.net 12
  13. 13. www.heartandsoulofchange.com October, 2012 First Things First Getting the Max Out of the Measures Why You Might Be Reluctant Just the Facts Ma’am  Feedback about the benefit & fit need not be  The nuts & bolts, & cumbersome or intrusive. the nuances, more to Only a couple of minutes & it, clinically it clinically, than it no intrusive questions. looks  Feedback the best hope to improve, clients appreciate  Feedback is the way your dedication to getting it to transcend right, & it is painless and average. can fit your natural way. The First Session The Measures and Social Justice All Aboard “Leveling” the Counseling Process  Invites clients into inner  Have to be on board circle of decision making with two things: have g  Available in multiple p to think privileging the languages client is a good idea;  Voice to diversity and the and have to want to disenfranchised be accountable.  Local culture and context over privileged knowledge Starting With the Predictors Sooner Rather Than Later Change and the Alliance Who drops out? •Client’s rating of the alliance the best predictor of B engagement and outcome. •The bulk of e bu o change •Client’s subjective A occurs sooner experience of change early rather than in the process the best latter predictor of success for any particular pairing. Howard, K. et al. (1986). The dose-effect response in psychotherapy. American Psychologist, 41, 159-164.barrylduncan@comcast.net 13