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Morten Anker, the first investigator on the Norway Feedback Trial discusses the project and the findings.

Morten Anker, the first investigator on the Norway Feedback Trial discusses the project and the findings.

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  • 1. 11/6/2009 The Norway Feedback Study Anker, Duncan, & Sparks (2009) Using Client Feedback to Improve Couple Therapy Outcomes: A Randomized Clinical Trial in a Naturalistic Setting. Anker, Duncan & Sparks Journal of Consulting and Clinical Psychology, 77, 696-704. Psykolog Morten AnkerReasons & Research Questions Feedback shown to improve outcomes in individual therapy (Lambert; Duncan & Miller). No feedback studies on couple therapy. Dodo verdict rules also in couple therapy: Implying that searching for different directions in improving therapy is neccesary. Psykolog Morten Anker 1
  • 2. 11/6/2009Reasons & Research Questions 1) The study seeks to answer how outcome for couples and therapists receiving systematic feedback on progress and alliance differs from those not receiving feedback at post-treatment. Are there any beneficial post- effects of feedback? 2) Do potential differential treatment gains between feedback and non feedback remain significant at six- six- month follow-up? follow- 3) If there is a differential feedback effect, is this effect limited to couples identified as not-on-track, and likely to not-on- deteriorate, or is there a more general beneficial effect for the feedback condition? 4) In addition, the study seeks to examine the variability in the effects of feedback across therapists, how feedback and therapist variables interact, and their relative interdependence. Psykolog Morten Anker Design Issues: Questions Therapist effects. Bleeding effect between Feedback and TAU conditions. Naturalistic setting. Feasibility of measures. ORS/SRS are measures and dialogical tools. Could be sensitive to demand characteristics and expectancy factors. How to measuse change in couple therapy? both, one, or none changes. Psykolog Morten Anker 2
  • 3. 11/6/2009 Design Issues: Some Controls  Therapist effects: Therapists served as own control.  Bleeding effect between Feedback and TAU conditions: We could find an existing feedback effect that in spite of the potential bleeding.  ORS/SRS are measures and dialogical tools. Could be sensitive to demand characteristics and expectancy factors: Follow-up could control Follow- for this.  How to measure change in couple therapy? Both changes. Psykolog Morten Anker 224 couples Therapists get 235 couples education in using and Office: A integrating ORS/SRS Office: B feedback Randomly assigned CDOI. Office A. CDOI. Office B. Treatment As 10 therapists who Usual. Office B.10 therapists who systematically 1.session: 1.Session: systematically integratesintegrates feedbacktheir goal. Couples mark about Couples mark their goal. feedback about alliance Same 10 therapists doalliance Lockeoutcome (SRS/ORS) and Wallace Marital Locke Wallace Marital and outcome (SRS/ORS) treatment as usual.in couple therapy.test. adjustment Therapists get in couple therapy. adjustment test.Outcome isoutcome and alliance feedback in ORS/SRS.all sessions. Carried get outcome Therapists ORS/SRS and alliance feedback in registered in all sessions but through all sessions. therapists have no access to the scores. 2½ years Follow-up after 6 months. Questions about change. up ORS Psykolog Morten Anker Lock Wallace Marital Adjustment Test. 3
  • 4. 11/6/2009ORS-ORS-change scores, do they reveal the future? Both ETR One ETR None ETR Follow- Follow-up ½ year ORS ORS ORS Follow- Follow-up: Development of the problems you sought help for. 56% 45.8% 33% N=167 N=107 N=68 Better/Much better Mean ORS Follow- Follow-up 30.12 25.37 23.82 SD=7.36 SD=10.3 SD=7.09 N=165 N=103 N=68 Follow- Follow-up: Percentage of couples where both score 25 65.8% 38.1% 30.8% (cut- (cut-of) or above. N=73 N=42 N=26 couples couples couples Mean LW Follow- Follow-up 91.28 86.24 81.12 SD=26.6 SD=28.38 SD=29.9 N=166 N=106 N=67 Relationship status: Separated at follow-up follow- 15% 29.9% 40% N=109 couples N=87 couples N=70 couples Psykolog Morten Anker Feedback Effect in Couple Therapy.Different ways at looking at the data:The predicted score of an individual in a couple with atherapist who recieved feedback was almost 5 (4.89 p<0.001)higher on ORS than one who did not.The difference between the groups nearly consituted a reliablechange and transcended the clinical cut off.Effect size: 0.50 Psykolog Morten Anker 4
  • 5. 11/6/2009 CHANGE ORS 69,1% score 30 above 25ORS 25 50,0% score 20 FEEDBACK above 25 N=84 15 TAU N=64 10 Pre-post N=410, Follow-up N=148 (intact 5 couples, with LW ORS pre-post-follow-up, biased toward TAU differential numbers of separated that is not in the follow-up) 0 First session Last session Follow-up Psykolog Morten Anker Results Pre-post Pre- ORS TAU Feedback Clinical significant change+ reliable change. 22.6% 50.5% Both in couple change 5 points or more. p<.001 Clinical significant change: Ends over cut of 10.8% 40.8% (25) and both have at least 5 points change. Either one or both at risk compared to their ETR. 74.5% 54.4% p<.001 Sub- Sub-group: At risk couples. Clinical significant change for 9.2% 28.6% both. p<.01 Psykolog Morten Anker 5
  • 6. 11/6/2009 Results Follow-up Follow-ORS TAU FeedbackClinical significantchange+ reliable change.Both in couple change 5 18.8 % 47.6 %points or more. p=.01Clinical significantchange: Ends over cut of(25) and both have at 12.5 % 35.7 %least 5 points change. Psykolog Morten Anker Results Follow-up Follow-ORS/LW/ TAU Feedbackseparation At least two sessions 24,6 28,28for both. Mean ORS.Subgroup: stil in the 83.06 (27.42) 91.16 (28.48)relationship. LockWallace 0.21 0.52ESSeparation 34.25 % 18.41 % A difference of 46.25 % P=0.014 Psykolog Morten Anker 6
  • 7. 11/6/2009 Non- Non-responders at follow-up follow-Any differences during therapy? Figure 2 35 30 Feedback responded 25 follow up N=84 TAU responded follow 20 up N=64 Feedback not 15 responded follow up N=122 Tau not responded follow up N=140 10 5 0 Pre Post Follow up Psykolog Morten Anker Variability in the Effects of Feedback across Therapists  Nine out of ten therapists benefited from feedback.  The effect of feedback varied significantly across therapists; less effective therapists (without feedback) benefited more from feedback than the most effective therapists. Psykolog Morten Anker 7
  • 8. 11/6/2009 Conclusions Feedback has a general positive effect on outcome. Feedback has a preventive effect on at risk cases. Feedback has a positive effect in at risk cases. Better therapies with Feedback has a positive long term effect. feedback !!! Psykolog Morten AnkerBufdir (Norwegian Directorate for Children, Youth and Family Affairs) has taken the consequences of this research: Bufdir (Norwegian Directorate (2008- Royal Proposition (St.prp. nr. 1for Children, Youth (p.44-45) (translated) : Consumer 2009) and Family Affairs), has "decided to use and quality development: for Change directed integrate the PartnersBufdir has Outcome the task of developing a model continuedManagement System (PCOMS) (Duncan, et al., 2004; quality development for consumer directed Miller, et al., 2005) witch family the ORS and SRS, in their in the utilizescounseling offices, in this way computer progress note system for the it can be utilized in the task to improve the family counseling offices. service systematically. To ensure high quality services for the consumers, it is under development a system for consumer inquiries and guidelines for systematic use of feedback from the clients." Psykolog Morten Anker 8
  • 9. 11/6/2009There will soon be more…. Psykolog Morten AnkerDisentangeling the Alliance-Outcome Correlation Alliance is more than Alliance mirroring change. Clients’ alliance score at sesion 3 predicts therapy outcomes over and above the effects of early symptom change. Psykolog Morten Anker 9
  • 10. 11/6/2009And there will soon be more…..  First session alliance score did not predict outcome, but last session score did.  Improvement in alliance during therapy important Psykolog Morten AnkerAnd there will soon be more…..  9% of the outcome variance could be explained by the therapist. Psykolog Morten Anker 10
  • 11. 11/6/2009 Footprints of couple therapy: Client reflections at follow up. 120 100 80 Satisfied 60 Problematic 40 20 0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Psykolog Morten AnkerThe principle researcher:WHEN ARE YOU GOING TO INTEGRATE FEEDBACK IN YOUR THERAPIES? Psykolog Morten Anker 11
  • 12. 11/6/2009www.heartandsoulofchange.com Psykolog Morten Anker 12