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Nuances of the Outcome Rating Scale


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This is a webinar hosted by about the nuance of using the ORS. It covers how to introduce the measures, how to validate the client with the cutoff, how to connect the client's …

This is a webinar hosted by about the nuance of using the ORS. It covers how to introduce the measures, how to validate the client with the cutoff, how to connect the client's experience to the marks on the ORS, and how to ensure a good rating.

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  • 1. September 14, 2012 The Art & Science of Becoming a Better Therapist The Nuances of the Outcome Rating Scale Barry Duncan, Psy.D. Psy.D. 561.239.3640 1
  • 2. September 14, 2012 Winter Getaway! Training of Trainers  HSCP Training of Trainers Conference: January 28- Feb. 1, 2013 (27 CEUs) This intensive training 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 2
  • 3. September 14, 2012 What’s Up Nuances of Using the ORS  How to introduce the Outcome Rating Scale, to validate the client via the clinical cutoff, to connect the client s marks to his or client’s her described experience/ reasons for service, and to ensure a good rating. Getting the Max Out of the Measures Just the Facts Ma’am  The nuts & bolts & bolts, the nuances, more to it, clinically, than it looks  Feedback i h F db k is the way to transcend 3
  • 4. September 14, 2012 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 y disenfranchised  Local culture and context over privileged knowledge Starting With the Predictors Change and the Alliance •Client’s rating of the Cli t’ ti f th 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 4
  • 5. September 14, 2012 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. 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 early…just 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), 5
  • 6. September 14, 2012 It’s A Fact Early Change is The Rule Cannabis Youth Treatment Project Early change in y g treatment is a robust predictor of outcome and retention in Project MATCH treatment. treatment Gotta measure outcome! Babor, T.F., & DelBoca, F.K. (eds.) (2003). Treatment Matching in Alcoholism. United Kingdom: Cambridge, 113. •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 6
  • 7. September 14, 2012 The ORS Is Not This The ORS Is Different Than Other Outcome Measures  Co-constructed with client  Goes from general look at client distress to specific representation of p client’s experience & reason for service  Requires nuance & skill in 7
  • 8. September 14, 2012 Co-Constructed With Client  To Be Relevant to Therapeutic Process  To Have Meaning from the Client’s Understanding of His or Her Life 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! 8
  • 9. September 14, 2012 The Outcome Rating Scale An Introduction  The ORS is an outcome measure that allows us t t k where you’re at, h to track h ’ t how you’re d i ’ doing, how things are changing or if they are not. It allows us to determine whether the counseling is being helpful so we can do something different if it’s not helping. It also is way to make sure that your perspective stays central here, that we are addressing what you think is h th t dd i h t thi k i most important. It only takes a minute to fill out and most clients find it to be very helpful. Would you like to give it a try? Introducing the ORS: Clip 1 In Your Own Words Convey the notion of monitoring outcome and ensuring client voice is 9
  • 10. September 14, 2012 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? well?” or “Like 1 to 10? Like 10?”  It’s their subjective experience that matters so their understanding of the measure is paramount. Idiosyncratic Responses No Worries  Sometimes ? re scales, or how they t th rate 2 aspects of same t f scale: “Doing great with my kids, but my marriage stinks.”  “Rate what is relevant: “Are either of the topics related to why you are here? (Client says here b/c of relationship with partner…Okay, rate the Interpersonally scale to reflect your concerns 10
  • 11. September 14, 2012 The First Meeting The “Clinical Cutoff” •The dividing line 40 35 between a clinical & O u tc o m e S c o r e 30 25 “non- “non-clinical” 20 population (25). For 15 10 kids (32) & adolescents 5 0 (28); (28) caretakers (28) t k 1st 2nd 3rd 4th •Between 25-33% 25- Session Number score in the “non- “non- Actual Score Line 2 25th % 75th % clinical” range. The Clinical Cutoff Only 2 Choices  Either above or below.  M ti Mention client score as it li t 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 11
  • 12. September 14, 2012 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 Projected change 75th percentile ORS Scores Estimated Clinical Cutoff 25th percentile The Clinical Cutoff: Clip 2 Validating the Client’s Experience •Everything is 100% transparent •If really low score, say so and validate how hard things must be •Start with the scale you marked the lowest or start wherever you would like •Always a light touch—never touch— heavy- 12
  • 13. September 14, 2012 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 The First Meeting Over the Clinical Cutoff •Explore why the client entered xplo e ente ed therapy; circumscribed problem or mandated/coerced •If mandated, ask for the referral’s rating as a catalyst for conversation; doesn’t mean they are doesn t lying •Avoid stirring the 13
  • 14. September 14, 2012 Take Clients at Face Value  Please don’t interpret high scores as a misrepresentation  It is the way the client sees him or herself  They don’t have to see a problem for therapy to help  Other’s ratings important too  Just because it’s high doesn’t mean they won’t engage 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 14
  • 15. September 14, 2012 The ORS The Bare Bones  No specific content other than domains—a skeleton t th d i k l t 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. Integrating the Measures Problems and Challenges?  Has to be Relevant to the R l h Work  OrBecomes an Emotional Thermometer of Day to Day 15
  • 16. September 14, 2012 Get A Good Rating Make Sure  Transparency the rule, not confrontation/ judgment  Darrell and Angelina 16