Published on sponsored webinar about the nuances of using the Session Rating Scale

Published in: Education
  • Be the first to comment

  • Be the first to like this

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide


  1. 1. November, 2012 The Nuances of the Session Rating Scale Barry Duncan, Psy.D. Psy.D. 561.561.3640 1
  2. 2. November, 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. 3. November, 2012 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 g 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. Project MATCH The Alliance •CBT, 12-step, & Motivational , 12- p, Interviewing •NO difference in outcome •The client’s rating of the alliance the best predictor of: Treatment participation; Drinking b h i d i D i ki behavior during 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. 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), 3
  4. 4. November, 2012 The Dodo Also Rules Family Work Cannabis Youth Treatment Project •600 Adolescents marijuana users: •Significant co-morbidity (3-12 problems). co- (3- problems) •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- Helper Variables that Predict Change Counselors with the best results:  Are better at the alliance across clients; alliance Baldwin et al. (2007). Untangling the alliance-outcome correlation. Journal of Consulting and Clinical Psychology, ability accounts for 75(6), 842-852.; Anker, Owen, Duncan, & Sparks (2010). The alliance in couple therapy. Journal of Consulting and Clinical helper differences Psychology, 78(5), 4
  5. 5. November, 2012 Client/Extratherapeutic Factors (87%) Feedback Effects 15‐31% Alliance Effects ll ff Treatment Effects 38‐54% 13% Model/Technique 8% Model/Technique Delivered: Helper Effects Expectancy/Allegiance 46‐69% Rationale/Ritual (General  Effects) 30‐?% Relationship Factors The Alliance: • Relational Bond • Agreement on goals 38-54% • Agreement on tasks Seven Times th I S Ti the Impact of t f Model/Technique…Accounts for Most of Counselor Variance Duncan, B. (2010). On Becoming a Better Therapist. Washington, DC: 5
  6. 6. November, 2012 The Therapeutic Alliance The Alli Th Alliance Goals, Means or Meaning Methods: or Theory of Purpose P Change Ch 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 6
  7. 7. November, 2012 Research into Practice The Alliance •Increasingly, the relationship is gy p 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 face but the data say: •The alliance deserves far more RESPECT… Norcross, J. (2010). The Therapeutic Relationship. In B. Duncan et al. (eds.). The Heart and Soul of Change. Washington, D.C.: APA. 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 7
  8. 8. November, 2012 When the alliance is in trouble… 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 8
  9. 9. November, 2012 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 Reliance on the Alliance The Alliance is the Best Friend We Have in the Therapy 9
  10. 10. November, 2012 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. Quickest Way Prevent Drop Out Clients drop out for 2 reasons: counseling 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 10
  11. 11. November, 2012 The Session Rating Scale Measuring the Alliance •Give at the end •Score in cm to of session; the nearest mm; •Each line 10 cm •Discuss with in length; client anytime total score falls •Reliable, valid, below 36 feasible The Session Rating Scale Traditionally  Told us with their feet  Will let us kno on SRS s know before telling/bolting.  Takes work for candor. Not about trying to please, social desirability, demand characteristics! d d h t i ti !  Disparity in power & socio- economic, ethnic, or racial diff., can make it 11
  12. 12. November, 2012 Becoming Better A Culture of Feedback with the SRS •When scheduling a first appointment, p pp 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 12
  13. 13. November, 2012 Make My 13
  14. 14. November, 2012 The Session Rating Scale An Introduction in Your Own Words  Let’s take a minute and have you fill out the other f th form th t asks your opinion about our that k i i b t 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 f th forms i t make every possible effort is to k ibl ff t 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 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 14
  15. 15. November, 2012 With High Scores Find Out What Went Well  What went well today for f you th t l d t your that led to high score?  What do you want to make sure that I keep doing d i next time? t ti ?  What did you like about how things went today? The Session Rating Scale What About Below 36 or 9cm?  Don’t expect specifics or e elations an o 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? 15
  16. 16. November, 2012 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. But Don’t Stress It’s Okay  Keep encouraging client to let you know 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 th t h l you to b better. t be b tt  Unless you really want it, you are unlikely to get it.  You won’t get it from 16
  17. 17. November, 2012 The SRS Graceful Acceptance  A willingness to be flexible usually turn things around. ll t thi d  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. What Separates The Best? Barry’s Recipe  1. Client Feedback Improves Outcomes More than Anything since the Beginning of Psychotherapy  2. Clients Account for Most of the Variance: Rally, Recruit Rally Harvest Resources for Change  3. Rely on the Tried & True Old Friend, the 17