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  1. 1. 7/28/2011 Jacqueline Sparks, Ph.D. Associate Professor University of Rhode Island TEACHING OUTCOME- INFORMED PRACTICEjsparks@uri.edu Integrating CDOI &University Graduate Training Colleagues  Department of Human Development & Family Studies – University of Rhode Island  Couple & Family Therapy Program Jerome Adams Tiffani Kisler Jacqueline Sparks Dale Blumen 1
  2. 2. 7/28/2011 Our Program Students accrue 500 direct client contact S d Students intern 1 year at local agencies, schools, i l l i h l residential treatment, or hospital Students carry a caseload at on-campus clinic  AAMFT Accredited  2-year, full-time, 60 credits  Supervision provided by approved supervisors Where We’re Headed  Identifying and connecting with stakeholder interests  Cultivating allies  First steps  Integration (curricula, clinical training & supervision, evaluation)  Tools  Results  Maintaining & Building 2
  3. 3. 7/28/2011 Stakeholders Program (faculty & students) Clients (served by our clinic) Department & University Community y Professional Field Program Interests Train effective practitioners Create a unifying training model that conforms with core program philosophy Provide optimum service to clients Provide practice-based research opportunities Offer new options for community network providers Develop a competitive profile as a forward leaning, innovative program Align with University and the field’s interests in outcome- based learning. 3
  4. 4. 7/28/2011 Train Effective Practitioners  Clients have largely been overlooked as teachers  Th f l h h Therapists performing poorly can improve when they routinely integrate client feedback into their work  A feedback system would give us a field- tested method for helping trainees with poorer outcomes improve. CDOI Fit with Program Philosophy Collaborative & Strengths-based – Teaching students to routinely ask for and respond to client feedback embodies core values related to collaboration and a strengths focus Integrative – CDOI as a centerpiece for student integration of diverse treatment models  Commitment to diversity – With client voices guiding clinical work, trainees could learn from and better assist persons whose social and cultural locations differed from their own 4
  5. 5. 7/28/2011 Improve Clinic Services  Drop outs are a significant problem in the delivery of mental health services, averaging at least 47% (Wierzbicki & Pekarik, 1993)  Training clinics have more premature terminations and fewer successful outcomes than in other outpatient settings (Callahan et al., 2009)  Our clinic serves financially disadvantaged clients – provision of quality care of ii f li f particular concern  CDOI could serve as a vehicle for improving the effectiveness of our clinic services Practice-Based Research Opportunities MFT research and practice historically have been disconnected, disconnected if not viewed as in opposition iewed Clinics operate “in the dark,” and students absorb the message that continuous assessment of services is not important CDOI would instill in students a sense of the ethics and utility of a client – service system loop CDOI would supplement our ongoing research and client satisfaction protocols 5
  6. 6. 7/28/2011 Creating a Competitive Profile Interested in attracting and recruiting top students from across the WELCOME To the University of Rhode Island country and abroad. Couple and Family Therapy CDOI offered an Program Information Interview opportunity to i showcase our program as unique and exceptional. Community Interests  Larger systems of care serving children and families in our area moving to measurably identify treatment success or failure  Desire for University collaborative service ll b i i partnerships that introduce innovative, effective, and efficient new models 6
  7. 7. 7/28/2011 Department & University Interests Desire for exceptional, empirically-based scholarship Interest in objective, outcome-based models of evaluating student learning Interest in meaningful service and connection with local communities, state agencies, and statewide initiatives Emphasis on attracting a diverse student body and faculty and offering a diversity-infused curriculum Interest in global engagement and partnership Interests of the Field Calls for the provision of “safe, effective, patient-centered, timely, ffi i t d ti l efficient, and equitable” h lth care, i l di it bl ” health including mental health (Committee on Quality of Health Care in America, 2001, pp. 7-8; President’s New Freedom Commission on Mental Health, 2003) Mental and behavioral health organizations attempt to define effective, safe care (e.g., see APA Presidential Task Force on Evidence-Based Practice, 2006) The AAMFT defines core competencies and calls for shift from input-oriented to outcome-based education. 7
  8. 8. 7/28/2011Fit with Core Competencies Domain 4: Therapeutic Interventions  Match treatment modalities and techniques to clients needs, clients’ needs goals, and values. 4.3.1  Facilitate clients developing and integrating solutions to problems. 4.3.16  Modify interventions that are not working to better fit treatment goals. 4.3.10  Evaluate treatment outcomes as treatment progresses. 4.4.3  Evaluate clients’ reactions or responses to interventions. 4.4.4  Evaluate clients’ outcomes for the need to continue, refer, or terminate therapy. 4.4.5Input-Oriented Clinical Training Training in model h i techniques Emphasis on use of EBT without client input Skills training Emphasis on accrued clinical hours Intensive supervision (often self-report) 8
  9. 9. 7/28/2011 Competence = EffectivenessInput to Outcome-Based TrainingNot Related to Outcome Related to Outcome Skills training  Feedback protocols for Supervision improving counselor efficacy Hours of experienceReese, R. J., Usher, E. L., Bowman, D., Norsworthy, L., Halstead, J., Rowlands, S. etal. (2009). Using client feedback in psychotherapy training: An analysis of itsinfluence on supervision and counselor self-efficacy. Training and Education inProfessional Psychology, 3(3), 157-168.Whorthen, V. E.. & Lambert, M. J. (2007). Outcome oriented supervision:Advantages of adding systematic client tracking to supportive consultations.Counseling and Psychotherapy Research, 7(1), 48-53. 9
  10. 10. 7/28/2011 Recruiting the TeamOnce CDOI-based training is connectedto the varying interests and the empiricalliterature, supportfollows. . . Cultivate the CDOI Garden Explain th t E l i that CDOI does not d t replace a preferred view or treatment approach Work collaboratively to create a team that has a shared mission of i l f implementation t ti Identify projects and responsibilities 10
  11. 11. 7/28/2011Choose Measures We h W chose (ORS) (CORS) (SRS) (CSRS) Met standards of practicality for everyday clinical use without sacrificing validity and reliability. li bilit Brevity and face validity of the instruments facilitate administration Choose Tracking System We are using ASIST Data is entered into ASIST (either in the room on a laptop or after the session) ASIST automatically calculates and graphically depicts a trajectory of change and target benchmark 11
  12. 12. 7/28/2011 Integration Begin at applicant interview How URI CFT Training Is Unique Summer reading for S di f Students systematically gather formal feedback from clients at each session to guide treatment incoming students (Outcome Management [OM]).Duncan, B. (2011). What therapists want: It’scertainly not money or fame. PsychotherapyNetworker, May/June, 40-43, 47, 62. 40-Duncan, B. (2011). Opening a path: From what isto what can be. Psychotherapy Networker,May/June 46-47 46- Pre-Practicum  The Heroic Clients, Heroic Agencies Manual serves as a basic text  Students receive hands on training in CDOI  Students role play introducing, p y g, integrating the measures and being informed by client feedback Available for download at www.heartandsoulofchange.com 12
  13. 13. 7/28/2011 Theory Course Second course focuses on postmodern to present Heroic Client is incorporated d i the second half of the H i Cli t i i t d during th d h lf f th second course Students learn current evidence for feedback, common factors, and understand evidence based practice as currently defined by APALearn and evaluate the principles and applicationof practice-based evidence with an emphasis oncurrent research and debates in the field and asan integrative theory in family therapy. Practicum  CDOI provides a ready- made structure  S d l h f ll i l Students learn how to respectfully, yet persistently, request and respond to client feedback  Students learn to identify problems and address them before clients drop out  Clients come to trust not therapist s only their therapist’s desire to learn their views, but the significance of their own perspectives to treatment success. 13
  14. 14. 7/28/2011 Supervision Therapists are required to bring graphs, measures, d i l f ll ii and ASIST signals for all supervision Supervisors use information from the measures to structure p the supervisoryy conversation, including requests for specific video data Supervision Decision Points Supervisors can prioritize at- at risk cases that need immediate attention Helps to generate conversations about different approaches that may better fit a given client’s preferences and expectations. 14
  15. 15. 7/28/2011 Identifying and Amplifying Change Visual trajectories help trainees, supervisors, and clients demarcate change and plan for termination Supervisors have a tool for privileging the client’s unique lived experience over theory Shorter lengths of stay with fewer cases extending beyond 4 months where no measurable change has occurred. Including the Client in Supervision  Supervisor/supervisee conversations are now more intimately connected to client experiences  Clients’ voices become the central focus of supervision conversations and planning. 15
  16. 16. 7/28/2011 Live Supervision  Live supervision using one- p g way mirror gives supervisor real time information  Supervisor can make more targeted suggestions for in- session process and homework  Live supervision using CDOI has resulted in more productive supervisory focus and more efficient and successful sessions Evaluation Students conduct a self-assessment at the end of each semester of practicum The Student Clinical Self-Assessment Report requires students to analyze their outcome data for % of clients reaching benchmark, average alliance score, length of stay, and % of cases defined as drop-out From this assessment and supervisor evaluation, students set goals for their next practicum Evaluations are directly connected to outcomes identified by clients. 16
  17. 17. 7/28/2011 Evaluation  Student caseload ratings of outcome and alliance should not b sources of grading or promotion h ld be f di i  Grading reflects students’ engagement in the process and willingness to learn from clients  Our mantra is: “There is no There negative feedback, only negative responses to it.” Expanding the Learning Cultivate knowledge and appreciation of CDOI at community internship sites Encourage students to conduct CDOI-based research at sites Connect CDOI to site needs related to outcome evaluation Invite site staff and supervisors to trainings and roundtable discussions Introduce the goal of requiring students to track all outcomes as part of their training and evaluation 17
  18. 18. 7/28/2011School-based Site Research ORS/CORS assessments of 72 students, aged 6-18 Students referred to Ledyard Youth Services by f guidance counselors, school psychologists, teachers, and parents between 2009 and 2011 Anger, poor communication with family members, interpersonal difficulties with peers, bullying, depression, poor academic performance, and substance abuse ORS, 38 youth; CORS 34 childrenResults – Ledyard Youth Services Youth and children experienced significant gains in pre post pre-post analysis (average mean increased 7.3 points 73 ORS and 5.0 on CORS) At or above clinical cutoff scores for ORS increased from 39.5% to 81.6%; CORS, 50% to 79.4% Combined ORS and CORS sample 93% p % reached benchmark 18
  19. 19. 7/28/2011 Additional Sites Adopting Large multiple service agency for at- g p g y risk children and families integrating CDOI throughout Regional modified wrap-around program instituting CDOI into service delivery in the community Office-based community mental health agency and residential treatment program open to training; several CDOI practitioners on staff and interning 19
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  22. 22. 7/28/2011Client Feedback on ORS Use Sample: 9 adults and 2 16-year old boys 1 family, 3 individuals, 2 unmarried couples Caucasian, African American, mixed race 7, somewhat helpful; 2 extremely helpful; , p ; y p ; 1, unhelpful; 1, neither helpful nor unhelpful 81.8% somewhat or extremely helpful 22
  23. 23. 7/28/2011 Qualitative Responses ORS Extremely helpful: “it gave a good basis of how the week had gone and how I f l about it,” and “a h kh d dh felt b ” d“ tool for better family living” Somewhat helpful: “feeling good,” “fairly and consistently positive,” “good visual tool,” “good jumping off point for the session,” “I don’t always recall where we are or how we progressed” Neither helpful nor unhelpful: “it was nice to learn about my personal progress but charting us against what is ‘normal’ feels counter-intuitive” Client Feedback on SRS  6 of 11 responses (54.6%), somewhat helpful  f 3 of 11, extremely helpfulf  1, unhelpful; 1, neither helpful nor unhelpful  81.9%, somewhat or extremely helpful 23
  24. 24. 7/28/2011Qualitative Responses SRS Somewhat or Extremely Helpful: Importance of letting the therapist know how they are feeling the about the session; “made me consider the things we went over in a bit more depth” Neither Helpful nor Unhelpful: “trying to rate on the spot gave me no time to reflect on the session. For F example, sometimes one d l ti does not agree with t ith what a therapist might say or advice until on can process it”3 and 6-Month Follow-Up 69 clients contacted 3 and/or 6 months post therapy 25 male, 44 f l female; aged 5 to 67 mean LOS 9.07 l d 67; 9 07 sessions 69 completed ORS last session; 36, 3 months; 38, 6 months ORS was administered telephonically 24
  25. 25. 7/28/20113 and 6-Month Follow-up (n = 69) ORS1: 22.33 ORS2 31.00 ORS3 31.01 ORS4 30.12Clinical Outcomes (208 cases) Therapist n = 31 4 ½ -year period Av. # of sessions: 7 Av. LOS 3 mos. % of clients reaching benchmark 71% 25
  26. 26. 7/28/2011 Student FeedbackCDOI :  Gives a conceptual and practical framework to establish early comfort and confidence t bli h l f t d fid  Provides practical guidance for structuring the session  Provides a format for clients to guide treatment  Provides an incentive for expanding beyond one s one’s comfort zone and for learning new skills  Helps to minimize guesswork regarding whether progress is being made or a case may be at risk  Provides a format for learning about children’s views Expanding One’s Comfort Zone 26
  27. 27. 7/28/2011 Counselor Education at a Crossroad  I found the paper compelling (JMFT Associate Ed.)  I believe this is a watershed article that will have a lasting impact on how supervision is done in the future—both in mft and in other mental health professions. (JMFT Reviewer)  The authors have done a stellar job on an important piece that I believe will have a lasting impact on the field (JMFT Reviewer)Sparks, J. A., Kisler, T. A., Adams, J. F., & Blumen, D. G. (in press). Teaching accountability: Using client feedback to train family therapists. Journal of Marital and Family Therapy. 27