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Barry presents the three responsibilities of supervision (protecting client welfare, agency liability, and therapist development) as well as the four steps of outcome informed supervision; a supervision based on outcome data not theory or pontification that is aimed at early identification of clients at risk as well as training and encouragement of therapist growth.

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  1. 1. 6/30/2011 Supervision Matters Tapping into Therapist Aspirations to Get Better Barry Duncan, Psy.D. Psy.D. 561.239.3640 1
  2. 2. 6/30/2011 How Do We Get Better Pop Quiz Question #1: False Finding the right Study after study, and approach or studies of studies selecting evidence show that all based treatments treatments are the will improve right treatment—for treatment— outcomes some clients. How Do We Get Better Pop Quiz Question #2: False Personal therapy and While therapists find increasing our self personal therapy awareness makes us a invaluable, it neither better person and helps nor hinders improves our outcomes outcomes. Geller, J., Norcorss, J.,& Orlinksky D. (2005). The Norcorss, psychotherapist’s Own Psychotherapy. New York: Oxford Univ. Press. 2
  3. 3. 6/30/2011 How Do We Get Better Pop Quiz Question #3: FALSE Professional No difference in Training and outcomes between Continuing disciplines, training Education have a models, and not one direct impact on study supports CE as outcomes. outcomes. helping outcomes How Do We Get Better? Pop Quiz Question #4: FALSE The accrued The cold hard reality wisdom of clinical is that experience experience, years of seems to make little seasoning, difference. improves outcomes 3
  4. 4. 6/30/2011 There Is No Roadmap! And… How Do We Keep On Keeping On? Let’s face it… sometimes being a therapist feels like the worst job on earth Worse that Tarring Roofs and Draining Septic Tanks 4
  5. 5. 6/30/2011 Or Being the New Crewmember Who  Just beamed down to a hostile planet with Kirk, Bones, and Spock. Media Depictions Cast Us as Kooks & Crackpots  Often blamed for creating a nation of wimps or otherwise causing the decline of western civilization with our encouragement of self indulgence, preoccupation with feelings, and Stuart Smalley daily affirmations. 5
  6. 6. 6/30/2011 Then There Is the Economic Situation  The typical agency therapist faces many hardships—seemingly unattainable productivity, insurmountable paperwork, more funder oversight, threat of layoff And Does Not Even Speak To  The emotional downsides, the sometimes overwhelming tragedy of the human condition that seems inured to our best efforts—the stories of suffering that are hard to shake. 6
  7. 7. 6/30/2011 Becoming Better But We don’t do this work because we thought we would acquire the lifestyles of the rich and famous. And We Knew • at the outset that mixing it up in the morass of human misery would not be a walk in the park. 7
  8. 8. 6/30/2011 Being a Therapist Is More of a Calling • That smart, creative indvs make the sacrifices only to earn far less than others says something • Only makes sense b/c it is more of a calling than a job—a quest for meaning & fulfillment • And therapists want to get better at it We Never Lose the Desire Cumulative Career Development • Even in the arguable decline, we have an inextinguishable passion to get better • 86% “highly motivated” to pursue prof. dev. • No profession more committed—Therapists want to continue to get better over their careers 8
  9. 9. 6/30/2011 How Do We Get Better? Client Feedback and CDOI/PCOMS  Feedback v TAU; Both persons reliable or sig. change— 50.5% v. 22.6%; ES: .50; 4 xs # of clin. sig. change  FU: TAU-34.2% v. 18.4% Feedback Anker, M., Duncan, B., & Sparks, J. (2009). Using client feedback to 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. Clients Do Benefit But So Do We  Norway: 9 of 10 got better outcomes  Feedback raised effectiveness of the lower ones to their more successful colleagues.  Therapist in low effectiveness group became the BEST with feedback! 9
  10. 10. 6/30/2011 But Most Therapists Won’t Do It Despite the Evidence The Fact: Only 25-33% Implement on Their Own The Rest Have to Be Dragged Kicking and Screaming It Takes Ongoing Support via Supervision Supervisors Are the Key • Protect Client Welfare • Protect Agency from Risk/Liability • Promoting Therapist Growth • CDOI Supervision Covers All Three 10
  11. 11. 6/30/2011 Becoming Better Recapture Your At Risk Clients • Feedback tailors services based on response, provides an early warning system to prevent negative outcomes, & solves helper variability—feedback improves performance and quickens development… 2 ways Cumulative Career Development • Therapists want to think of themselves as learning more and getting better at what they do over time. As we accrue the hard earned lessons offered by different settings, modalities, orientations, and populations, we want to come out on the positive end of any agonizing reappraisal of our experience. • 11
  12. 12. 6/30/2011 But the Most Powerful Influence Currently Experienced Growth • or what we are learning from our real time, day to day clinical work. We like to think of ourselves as developing now. CEG translates to positive work morale and energizes therapists to apply their skills on behalf of clients. Translating Therapist Development to Supervision • Client feedback monitors outcome & plots cumulative career development. • Securing client feedback places therapists in accelerated courses of development in the front of the class to see and hear the lessons of the day—to experience currently experienced growth. 12
  13. 13. 6/30/2011 The Three Sources Isomorphic (Parallel) to CDOI Supervision • Tracking CCD like tracking client progress. Working w/therapists re plans to enhance dev. akin to collaboration re the tasks of tx • Feedback enables experience of CEG. Your curiosity about these experiences will enhance their curiosity to learn from clients. Isomorphic Supervision Just the Facts Ma’am • The nuts & bolts of isomorphic, client directed, outcome informed supervision. 13
  14. 14. 6/30/2011 Client-Directed, Outcome- Informed Supervision • Red Flags: • Helper not using language of CDOI or measures. • Helper not able to describe how measures are used; data integrity questionable • No show or drop-out rates are high; productivity low • Long-term service w/o progress • SRS scores reflect problems in joining or are perfunctory • Helper views process as just more paperwork Client-Directed, Outcome- Informed Supervision • Review ORS • Completed? • Good Intake Scores • Is ORS information used? • Do ORS scores indicate progress? • If not, is helper addressing this with client? • Review SRS • Completed? • Is SRS information used? • Are SRS scores ascending? • If not, review purpose and helper actions 14
  15. 15. 6/30/2011 Client-Directed, Outcome- Informed Supervision • Strategies: • Compliment attempts to use CDOI ideas • Encourage consultation when stuck • Validate concerns • Acknowledge learning curve • Be available for support • Challenge helper to learn new skills • Questions: • What are program specific obstacles? • What training does your staff need to implement CDOI work? • What training or supports do you need to implement CDOI supervision? Client-Directed, Outcome- Informed Supervision • Reminders: • Use the measures to support what is working and challenge what is not. • The measures allow clients to have a strong voice. • The majority of clients feel positive and hopeful that helpers ask them to formally rate their progress. • Helpers discomfort with the measures interferes with the relationship and with progress. 15
  16. 16. 6/30/2011 CDOI Supervision: Key to Client Benefit & Helper Growth • Based on outcome data not theory or pontification. • Oriented to common factors of change and the skills of outcome-informed services. • Aimed at early identification of clients at risk so services can be modified. • Offers feedback, support, training for those who aspire to become better Supervision: Four Steps • Start with graphs of all clients not reflecting benefit • Supervisor looks for use of measures, over/under utilization, data integrity, spends time on at risk clients, brainstorms options • Supervisor reviews stats & discusses ways to improve • Skill building, theoretical breadth, focus on client teachings, helper identity 16
  17. 17. 6/30/2011 Reviewing Graphs First Things First • Squeamishness • Percentiles and Trajectories • Clinical Cut Off Supervision: Four Steps • Start with graphs of all clients not reflecting benefit • Supervisor looks for use of measures, over/under utilization, data integrity, spends time on at risk clients, brainstorms options • Supervisor reviews stats & discusses ways to improve • Skill building, theoretical breadth, focus on client teachings, helper identity 17
  18. 18. 6/30/2011 Reviewing Graphs Over Utilization Creates wait lists, iatrogenic effects. First way is when the client continues in service in the absence of benefit. Reviewing Graphs Over Utilization • When max benefit reached, talk about stepping down; not 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 • ORS represents life in general instead of clients perceptions connected to the purpose of the service. 18
  19. 19. 6/30/2011 Review Checkpoint Or Last Chance Discussions X X X X 19
  20. 20. 6/30/2011 First order of business: What does the client say about this? CDOI Supervision General Considerations • What does the client want? • What are the client’s ideas about change • What are the client’s expectations about our role? • What are the client’s strengths? 20
  21. 21. 6/30/2011 Brainstorming Options Don’t Forget the Client • Consider client resources, ideas, and basic needs; 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? 21
  22. 22. 6/30/2011 Supervision: Four Steps • Start with graphs of all clients not reflecting benefit • Supervisor looks for use of measures, over/under utilization, data integrity, spends time on at risk clients, brainstorms options • Supervisor reviews stats & discusses ways to improve • Skill building, theoretical breadth, focus on client teachings, helper identity Reviewing the Stats: What the Heck Do They Mean? • Average Raw Change is converted to an effect size (ES). The ES offers a quick look at how things are going with clients compared to a normative data base. An ES of 1 means progressing better than 1 SD above the average. 22
  23. 23. 6/30/2011 Sadistics • It is just a measure of progress compared with clients with the same intake score. A positive number indicates that progress has exceeded expectations Cumulative Development Tracking Doesn’t have to be Complicated Start by entering data into Excel, & tracking outcome with simple calculations: ave. intake & final session scores, # of sessions, & ave. change score (diff. b/w ave. intake & final session scores), & ultimately the % of clients who reach reliable or clin. significant change. 23
  24. 24. 6/30/2011 Cumulative Career Development ASIST and • The single bit of information that tells you the most is the % of who reach target—the % who reach the 50th percentile trajectory for clients entering services with the same intake score. A.S.I.S.T. for Agencies: Changing Colors Identify Cases at Risk 24
  25. 25. 6/30/2011 A.S.I.S.T. A.S.I.S.T. Graphic Display of Outcome and Alliance Information Able to track and chart multiple clients at once 25
  26. 26. 6/30/2011 Cumulative Career Development • The single bit of information that tells you the most is the % who reach target—the 50th percentile trajectory for clients entering services with the same intake score. Collaboratively Form a Plan Improve/Foster Development • Discuss stats openly and ask for supervisee’s ideas • Co-develop a plan and implement; evaluate quarter by quarter; modify if outcomes not improving • Foster continued professional reflection 26
  27. 27. 6/30/2011 Becoming Better Consider Benefits of Tracking Outcome • Allows a systematic trial and error application of new learning as well as the refinement of the tried and true mechanisms that we know enhance outcomes. • Tracking cumulative career development enables reflection and action about effectiveness. Becoming Better Take Charge • Track effectiveness by active/inactive differences; 30 client block a good est. • Keep dev. front & center; implement ideas, practices, & models, as well as building skills. • Will readily see whether efforts are paying off, if chosen methods of increasing effectiveness need to be tweaked or changed outright. 27
  28. 28. 6/30/2011 A.S.I.S.T. for Agencies: ES Comparisons for Providers & Programs 28
  29. 29. 6/30/2011 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 29
  30. 30. 6/30/2011 Supervision: Four Steps • Start with graphs of all clients not reflecting benefit • Supervisor looks for use of measures, over/under utilization of services, spends time on at risk clients, brainstorms options • Supervisor reviews stats & discusses ways to improve • Skill building, theoretical breadth, focus on client teachings Learning from Clients Ongoing Reflection • Separate graphs: clients changing and not • Articulate changes and lessons • Note how it was done • Make before/after distinctions • Reflect about the new chapter in his/her dev as well as helper identity 30
  31. 31. 6/30/2011 Learning from Clients Our Norwegian Colleague • I became more transparent, more courageous. I felt more secure and conveyed it. • Clients and I got more concrete about change, how it started, and what else would be helpful. • Feedback sharpened my focus—pinpointed that we have a common purpose. Our Norwegian Colleague (cont) Be Proactive • Feedback helped me take risks and invite negative comments. • Made me more secure, I am far more daring. I am now more collaborative and allow things to emerge rather than following a set way to work. 31
  32. 32. 6/30/2011 Leave Time in Each Meeting Continual Professional Reflection • Skill Building: Practice well the skill of the craft— the alliance, for the sake of the craft itself. • Expanding Theoretical Breadth by playing “On the other hand…” • Learn from Clients: Tease out what is working and what is not using client outcome as a guide. Skill Building/Deliberate Practice Becoming Client Directed 3 Skills of Client Directed or Common Factors Practice 1. Recruiting Client Resources *Telling Heroic Stories *Listening for a Change 2. Reliance on the Alliance *Close to the Client’s Exp. *Validation *Work on the Client’s Goals 3. Client’s Theory of Change 32
  33. 33. 6/30/2011 Skill Building Becoming Outcome Informed 3 Skills of Outcome Informed Practice (The Three I’s) • Introducing the Measures • Integrating Client Feedback into Practice • Informing and Tailoring Services Based on Client Feedback Not a Perfunctory Piece of Paper • Administering, But Don’t Get It. Clients must understand purpose (monitoring outcome, privileging their perspective); Helpers must understand same + make them meaningful • Administering, Using Some. But not the clinical cutoff or numbers…Heuristic clinical use but no continuity or coherence • Administering, Using Some. But not connecting to the client’s experience or reasons for service; got to get a “good” score; agency needs data with integrity • Administering the SRS. But seeing it as reflective of competence rather than an alliance building tool 33
  34. 34. 6/30/2011 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 essence of your identity, illustrating what you embrace most about your work? 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 ended negatively • They learn from clients and experience their current growth…they learn from you 34
  35. 35. 6/30/2011 Everything You Need… This is your all-in-one reference for everything CDOI 35