SupervisionforAChange

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Barry presents the fourth, and likely the most important secret of successful implementation of PCOMS: Supervision for a change. Without a supervisory infrastructure that supports therapists on the front lines, ensures the integrity of the data, and proactively addresses clients not responding to treatment, then implementation will fall flat and outcomes will not be improved. Barry will discuss the purposes of supervision and present the four steps: 1) Start with the graphs of clients not responding and all intake scores; 2) Look for data integrity and develop plans for clients at risk; 3) Review therapist stats and develop plan for improvement; 4) Mentor and encourage continual professional reflection.

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SupervisionforAChange

  1. 1. www.heartandsoulofchange.com March, 2013 4 Secrets of Implementation Supervision for a Change Barry Duncan, Psy.D. Psy.D. www.heartandsoulofchange.com 561.239.3640 barrylduncan@comcast.netbarrylduncan@comcast.net 1
  2. 2. www.heartandsoulofchange.com March, 2013 PCOMS Implementation 4 Secrets 1) In It for the Long Haul— organizational commitment at all i ti l it t t ll levels; 2) Love Your Data—collection and use of data right out of the gate; 3) Inspire the Front-Line Clinician— connecting PCOMS to therapist’s ti t th i t’ desire to do good work & improve over their careers; 4) Supervision for a Change--in both clients and therapists What is Supervision About? 1. Protect Client Welfare 2. Protect Agency from Risk/Liability 3. Helping Therapists Get Better— Better Promoting Growth  CDOI/PCOMS Sup. Covers Allbarrylduncan@comcast.net 2
  3. 3. www.heartandsoulofchange.com March, 2013 How Is Supervision Done Now? Individual Group Peer We don’t need supervision To Be a Supervisor: Need to Know 2 Things  How to Collect and Understand Data  How Therapists Perceive Their Developmentbarrylduncan@comcast.net 3
  4. 4. www.heartandsoulofchange.com March, 2013 Getting Better & Growth Are Part & Parcel of Therapist Identity  A continual retrospective evaluation of where we are versus where we have been, looking for evidence of our mastery of the work, & an ongoing filtering of our here and now clinical experiences, mining for the golden moments that replenishes us. Translating Therapist Development to Supervision  Client feedback monitors outcome & plots cumulative t l t l ti career development.  Securing client feedback places therapists in accelerated courses of development in the front of d l t i th f t f the class to see and hear the lessons of the day—to experience currently experienced growth.barrylduncan@comcast.net 4
  5. 5. www.heartandsoulofchange.com March, 2013 Isomorphic Supervision Just the Facts Ma’am  The nuts & bolts of isomorphic, CDOI/PCOMS supervision. CDOI/PCOMS Supervision: Key to Client Benefit & Helper Growth  Based on outcome data not theory or pontification.  Aimed at early identification of clients at risk so services can be modified.  Offers feedback, support, training for those who aspire to become betterbarrylduncan@comcast.net 5
  6. 6. www.heartandsoulofchange.com March, 2013 Supervision: Four Steps 1. Start with graphs of all clients not reflecting benefit; Also include scores in general. Ensure use of measures & data integrity. 2. Look for over-utilization; Spend most time on at risk clients: shape discussion and brainstorms options 3. Review stats & discuss ways to improve; Encourage action 4. Mentor via skill building, client teachings, & ongoing reflection CDOI/PCOMS Supervision Data Integrity: What to Look For • 30% of Intakes over the Cutoff: • Cli t or therapist does not understand Client th i td t d t d ORS –Role play introducing the ORS • ORS Scores between 35-40: • Client or therapist does not understand the measures; Rarely a good score; even mandated clients don’t score this high. Role play introducing the ORS, discussing score when it doesn’t match doesn t client description of experience • ORS Scores Look Like a Saw • An emotional thermometer: Client or Therapist does not understand ORS— Role play connecting the client’s reason for service to the marks on the ORS.barrylduncan@comcast.net 6
  7. 7. www.heartandsoulofchange.com March, 2013 30% of Intakes over the Cutoff Intake ORS Scores 1.28.7 1 28 7 • Client or 2.17.5 3.31.7 therapist likely 4.18.9 does not 5.12.4 6.29.6 6 29 6 understand 7.33.6 ORS –Role play 8.7.6 introducing the 9.13.7 ORS 10.30.6 The First Meeting Introducing the ORS  Introduce the ORS using your own i words—convey the notion of monitoring outcome and ensuring client voice is heard  Measure the marks and add the scoresbarrylduncan@comcast.net 7
  8. 8. www.heartandsoulofchange.com March, 2013 ORS Scores between 35-40 Intake ORS Scores • Client or therapist does 1.28.7 1 28 7 not understand the d d h 2.17.5 measures; Rarely a good 3.36.7 score; even mandated 4.18.9 clients don’t score this 5.12.4 high. Role p y g play 6.29.6 6 29 6 introducing the ORS, 7.38.6 discussing score when it 8.7.6 doesn’t match client 9.13.7 description of life 10.38.6 The First Meeting Getting A Good Rating 1 1. Score ORS & give feedback re score & cutoff; 2. Client describes situation inconsistent w/score; 3. Practice checking it out with the clientbarrylduncan@comcast.net 8
  9. 9. www.heartandsoulofchange.com March, 2013 ORS Scores Look Like a Saw The Emotional Thermometer ORS Scores Client or Therapist 1. 28.7, 17.1, 26.4, 12.7, 29.9 2. 17.5, 19.6, 22.4 does not 3. 31.7, 12.2, 28.4, 6.7, understand ORS— 4. 18.9, 19.2, 19.7 Role play 5. 12.4, 18.3, 9.9, 21.1, 11.8 6. 29.6, 31.3 6 29 6 31 3 connecting the 7. 33,6, 9.3, 8.6, 34.9, 31.6, 3.4 client’s reason for 8. 7.6, 8.5, 9.5 9. 13.7, 14.5, 17.5, 20.8 service to the 10.30.6 marks on the ORS Integrating the Measures Problems and Challenges?  Has to be Relevant to the R l h Work  OrBecomes an Emotional Thermometer of Day to Day Lifebarrylduncan@comcast.net 9
  10. 10. www.heartandsoulofchange.com March, 2013 The First Meeting Integrating the Measures  1. Score ORS & give feedback re score & cutoff; 2. Connect marks to client description & reason for service; 3.Use examples from work & report Fidelity Monitoring Tool  Administer and score the Outcome Rating Scale (ORS) each visit or “unit of service ” unit service.  Ensure that the client understands that the ORS is intended to bring his or her voice into the decision-making process and will be collaboratively used to monitor progress.  Ensure that client gives a good rating; i.e., a rating that matches the client’s description.  Ensure that the client’s marks on the ORS are connected to the described reasons for service.barrylduncan@comcast.net 10
  11. 11. www.heartandsoulofchange.com March, 2013  Use outcome (ORS) data to develop and graph individualized trajectories of change.  Plot client progress (ORS scores) on individualized trajectories from session to session to determine which clients are making progress and which are at risk for a negative or null outcome.  Use ORS scores to engage clients in a discussion in every session about how to y continue to empower change if it is happening and change, augment, or end tx if it is not.  Administer and score the Session Rating Scale (SRS) each visit or “unit of service.”  Ensure that the client understands that the SRS is intended to create a dialogue between therapist and client that more tailors the service to the client and that there is no bad news on client--and the measure.  Use the SRS to discuss whether the client feels heard, understood, and respected.  Use the SRS to discuss whether the service is addressing the client’s goals for treatment.  Use the SRS to discuss whether the service approach matches the client’s culture or worldview, or theory of change.barrylduncan@comcast.net 11
  12. 12. www.heartandsoulofchange.com March, 2013 PCOMS Therapist Adherence Scale  Never Sometimes Often Regularly Always g y y  1 2 3 4 5  Out of a total possible 60 points, adherence is considered acceptable at 48 or above at the 6 month mark and 54 or above at the one year after implementation. High adherence is insured by the PCOMS supervisory process. Supervision: Four Steps 1. Start with graphs of all clients not reflecting benefit; Also include scores in general. Ensure use of measures & data integrity. 2. Look for over-utilization; Spend most time on at risk clients: shape discussion and brainstorms options 3. Review stats & discuss ways to improve; Encourage action 4. Mentor via skill building, client teachings, & ongoing reflectionbarrylduncan@comcast.net 12
  13. 13. www.heartandsoulofchange.com March, 2013 Reviewing Graphs Over Utilization Creates wait lists, iatrogenic effects. First way is when the client continues contin es in service in the absence of benefit. Review Checkpoint Or Last Chance Discussions X X X Xbarrylduncan@comcast.net 13
  14. 14. www.heartandsoulofchange.com March, 2013 Reviewing Graphs Over Utilization  When max benefit reached, talk about stepping down; not pp g ; discharge, but planning for continued recovery out of tx.  If not stepped down, graphs look like a saw, rising and falling with everyday life; clients are disempowered li t di d  ORS represents life in general instead of clients perceptions connected to the purpose of the service. First order of business: What does the client say about this?barrylduncan@comcast.net 14
  15. 15. www.heartandsoulofchange.com March, 2013 Brainstorming Options Don’t Forget the Client  Consider client resources, ideas, and basic needs; id db i d what about the alliance— is client engaged?  People, places, things: Colleague or sup. consult; someone else from client support network; community support; faith based; peer recovery; or different provider… Supervisory Conversation The Longer w/o Change, the Quicker to #6 1. What does the client say? 2. Is the client engaged? SRS? 3. What has the helper done differently? 4. What can be done differently now? ? 5. What other resources can be rallied? 6. Is it time to fail successfully?barrylduncan@comcast.net 15
  16. 16. www.heartandsoulofchange.com March, 2013 Supervision: Four Steps 1. Start with graphs of all clients not reflecting benefit; Also include scores in general. Ensure use of measures & data integrity. 2. Look for over-utilization; Spend most time on at risk clients: shape discussion and brainstorms options 3. Review stats & discuss ways to improve; Encourage action 4. Mentor via skill building, client teachings, & ongoing reflection Cummulative Career Tracking Start However You Can Start by entering data into Excel, & tracking outcome l k with simple calculations: ave. intake & final session scores, # of sessions, & ave. change score (diff. b/w ave intake & final ave. session scores), & ultimately the % of clients who reach reliable or clin. significant change.barrylduncan@comcast.net 16
  17. 17. www.heartandsoulofchange.com March, 2013 Love Your Data Key Performance Indicators 1. Average Change: ag a g Is it above 6? 2. % reaching reliable and significant change 3. Effect Sizebarrylduncan@comcast.net 17
  18. 18. www.heartandsoulofchange.com March, 2013 Love Your Data MyOutcomes.com  The single bit of information that tells you the most is the % who reach target—the mean trajectory for clients entering services with the same intake score. Collaboratively Form a Plan Improve/Foster Development  Discuss stats openly and ask f supervisee’s ideas k for i ’ id  Co-develop a plan and implement; evaluate quarter by quarter; modify if outcomes not dif t t improving  Foster continued professional reflectionbarrylduncan@comcast.net 18
  19. 19. www.heartandsoulofchange.com March, 2013 Supervision: Four Steps 1. Start with graphs of all clients not reflecting benefit; Also include scores in general. Ensure use of measures & data integrity. 2. Look for over-utilization; Spend most time on at risk clients: shape discussion and brainstorms options 3. Review stats & discuss ways to improve; Encourage action 4. Mentor via skill building, client teachings, & ongoing reflectionbarrylduncan@comcast.net 19
  20. 20. www.heartandsoulofchange.com March, 2013 Cumulative Career Development Start with the Common Factors  Models/techniques, but…  Focus on the common factors.  Practice well the skills of the craft—the alliance. At some point, craft becomes art. Relational repertoire likely parallels your development Leave Time in Each Meeting Continual Professional Reflection  Skill Building, Role-plays: Practice the kill f th P ti th skills of the craft; learn new techniques  Learn from Clients: Tease out what is working and what is not using client outcome as a guide.  Talk about therapist identity and encourage an evolving description of the workbarrylduncan@comcast.net 20
  21. 21. www.heartandsoulofchange.com March, 2013 Helping Supervisees Learn from Clients  Provider experiences of thei c ent their current development are influenced mainly by the quality of their clinical experiences p w/clients.  Supervision can help helpers make the best of it. Reviewing Your Currently Experienced Growth • Review current clients, consider lessons Did you lessons. experience anything different? Did you do something you have never done when clients were changing, when they weren’t? H thi changed ’t? Has this h d your work? What does this mean in terms of how you think about your work and your identity as a therapist?barrylduncan@comcast.net 21
  22. 22. www.heartandsoulofchange.com March, 2013 You Do What? What is Your Identity?  How do you describe what you do? At your very best, what role do you play with your clients? What recent client represents the p essence of your identity, illustrating what you embrace most about your work?barrylduncan@comcast.net 22
  23. 23. www.heartandsoulofchange.com March, 2013 You Do What Labor or Art What we do is a measure of who we are. If we imagine our work as labor, we become laborers. If we imagine our work as art, we b t become artists. Jeffrey Patnaude You’ll Have Them When… CEG Kicks In  They have conversations with clients in ways not seemed possible before  They experience that first client who benefits  They recapture success with clients who would have li t h ld h ended negatively  They learn from clients and experience their current growth…they learn from youbarrylduncan@comcast.net 23

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