WhatInTheHeckIsCDOI?

12/7/2009 The Heart and Soul of Change: Becoming Better At What We Do June 17-19 New Orleans Featuring: Barry Duncan, Jacqueline Sparks, Makungu Akinyela, Michael Lambert, Lori Ashcraft, Bob Bohanske, John Murphy Learn: What Works and How to Deliver It How to Improve Your Outcomes and Accelerate Your Development How to “Level” the Counseling Process How to Join Forces with the Recovery and Social Justice Movements Sponsored by the Louisiana Counseling Association Save the dates! Registration information forthcoming at www.lacounseling.org and www.heartandsoulofchange.com What in the Heck Is CDOI Client Directed, Outcome Informed Ideas and Practices Barry Duncan, Psy.D. www.heartandsoulofchange.com 954.721.2981 www.whatsrighwithyou.com barrylduncan@comcast.net 1

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12/7/2009 Client Directed, Outcome Informed (CDOI) Ideas and Practices Contains no fixed techniques or causal theories regarding the concerns that bring people to treatment. Any interaction can be client-directed and outcome- informed when the consumer’s voice is privileged, social justice is embraced, recovery is expected, and helpers purposefully form strong partnerships to: (1) enhance the factors across theories that account for success; (2) use client’s ideas and preferences to guide choice of technique and model; and (3) inform the work with reliable and valid measures of the consumer’s experience of the alliance and outcome What in the Heck Is CDOI? Not Just Another Pretty Face  CDOI contains no fixed techniques or causal theories regarding the concerns that bring people to treatment  Not another model of practice 4

12/7/2009 •Since the 60’s, the # of models has grown from 60 to over 400… •Each claims superiority in conceptualization and outcome The result is fragmentation along theoretical and disciplinary lines Now over 100 so called evidence based treatments--effectiveness treatments--effectiveness not increased in 40 years… The Dodo Verdict •With few exceptions, partisan studies designed to prove the unique effects of a given model have found no differences— differences—nor has recent meta- meta- analyses…The analyses…The Dodo Verdict—the Verdict— most replicated finding in the psychological literature “Everybody has won and all must have prizes.” Rosenzweig, S. (1936). Some implicit common factors in diverse methods in psychotherapy. Journal of Orthopsychiatry, 6, 412-15. Wampold, B.E. et al. (1997). A meta-analysis of outcome studies comparing bona fide psychotherapies: Empirically, "All must have prizes." Psychological Bulletin, 122(3), 203-215. 5

12/7/2009 What in the Heck Is CDOI Dead White Guys •How Widely Applicable Can They Be?! What in the Heck Is CDOI? CDOI Values Pluralism  All approaches are valid & are potentially helpful for clients  All offer an explanation & a remedy; rationale and ritual  CDOI values plurality of perspectives  While there is not differential efficacy among models, likely there is for the client in your office now 6

12/7/2009 What in the Heck Is CDOI? Any Interaction Can Be CDOI Any interaction can be client-directed and outcome-informed when the consumer’s voice is privileged, social justice is embraced, recovery is expected… When the Consumers Voice is Privileged The Story of Dan Ariely  Clients are the ultimate authority of their own experience…  Many say they privilege the client, but…Dan Ariely  http://www.youtube.com/watch? v=_K0m3Bq- L5Y&feature=PlayList&p=B24 24C40DE1C0D14&index=0&pl aynext=1 7

12/7/2009 When the Consumer’s Voice Is Privileged Cardboard Cutouts  Nurses loved him, but discounted his experience about his own pain…they knew best  Without connection to those receiving services, clients become object of our professional whims. When Social Justice Is Embraced Clients Have Been Missing Persons Despite well-intentioned efforts, the infrastructure of therapy (paperwork, policies, procedures, and professional language) can reify non-contextualized descriptions of client problems and silence client views, goals, and preferences. 8

12/7/2009 When Social Justice Is Embraced “Leveling” the Counseling Process  Transparency & true partnership  Invites clients into inner circle of decision making  In multiple languages; Voice to diversity & the disenfranchised  Local culture and context over privileged knowledge When Recovery Is Expected Consumer-Centered, Recovery-Based  New Freedom Commission: Care is consumer-centered, with providers working in full partnership to develop individualized plans of care.  SAHMSA: National Consensus Statement on Mental Health Recovery 9

12/7/2009 When Recovery Is Expected SAMHSA Consensus Statement  Recovery is a journey of healing & transformation enabling a person with a MH problem to live a meaningful life in the community while striving to achieve full potential.  “Recovery” rejects “illness management” & prof.-directed services based on dx labels & prescriptive tx in favor of indv. tailored, strength-based, consumer-authored plans. The Killer D’s of Client Diminishment Dysfunction Disorder Disability Disease Deficit Damaged Not Reliable or Valid None ever related to outcome 10

12/7/2009 Diagnosis “I have found little that is good about human beings. In my experience, most of them are trash.” --Sigmund Freud, M.D. When Recovery Is Expected Clients Are the Lions of Change Until lions have their historians, tales of hunting will always glorify the hunter. African Proverb 11

12/7/2009 What in the Heck Is CDOI? And Helpers purposely form strong partnerships to: (1) enhance the factors across theories that account for success;  Purposely means that it’s proactive and conscience  http://mentalhealth.samhsa.gov/publications/all pubs/sma05-4129/ Implication of the Dodo Bird Verdict All 400 approaches work because: Of factors common to all therapies So what are the factors? 12

12/7/2009 The Treatment of Depression Collaborative Research Project (TDCRP) •Considered to be the most sophisticated comparative clinical trial ever conducted: •Four approaches (CBT, IPT, Drug, Placebo). •No difference in outcome between approaches •The client’s rating of the alliance at the second session the best predictor of outcome across conditions. •Tx model accounted for 0-2% of the variance… 0- Elkin, I. Et al. (1989). The NIMH TDCRP: General effectiveness of treatments. Archives of General Psychiatry, 46, 971-82. Client/Extratherapeutic Factors (87%) Feedback Effects 15-31% Alliance Effects Treatment Effects 38-54% 13% Model/Technique 8% Model/Technique Delivered: Therapist Effects Expectancy/Allegiance 46-69% Rationale/Ritual (General Effects) 30-?% 13

12/7/2009 Enhancing Factors Across Theories Bottom Line “The quality of the patient's  Privilege clients’ participation . . . experience & rally [emerges] as their resources to the most important the cause….what determinant of ORS is all about outcome." Orlinsky, D. E., Rønnestad, M. H., & Willutzki, U. (2004). Fifty years of process -outcome research: In M. J. Lambert (Ed.), Bergin and Garfield’s handbook of psychotherapy and behavior change (5th ed., pp. 307-390). New York: Wiley. The Alliance Bottom Line  The Alliance Matters—Big Time  TDCRP: alliance accounted for up to 21% of the variance…what the SRS is all about 14

12/7/2009 What in the Heck Is CDOI And Helpers purposely form strong partnerships (2) useclient’s ideas and preferences (theories) to guide choice of technique and model;  Application of this idea (and the common factors) is where client directed got its start,  Doesn’t de-value or limit your ideas, just points to the power of local knowledge, the client’s cultural vantage point in service of change The Client’s Theory of Change Pre- Pre-existing beliefs about the problem and change Source: Duncan, B., Solovey, A., & Rusk, G. (1992). Changing the Rules. New York: Guilford. 15

12/7/2009 The Client’s Theory of Change: Empirical Findings In the TDCRP, congruence between the clients TOC and tx resulted in: Stronger therapeutic alliances; Longer duration in treatment; and Improved treatment outcomes. Elkin, I. (1999). “Patient-treatment fit" and early engagement in therapy. Psychotherapy Research. 9(4) 437-451. Plurality Pays Off Differential Efficacy with Current Client  Q: does it resonate; does it fit client preferences; can both get behind it?  Alliance skills: explore client ideas, discuss options, collaboratively plan, and negotiate changes if benefit not forthcoming.  Application: alliance in action. The litmus test: whether or not it engages client in purposive work. 16

12/7/2009 What in the Heck Is CDOI And Helpers purposely form strong partnerships 3.To inform the work with reliable and valid measures of the consumer’s experience of the alliance and outcome  Is it working and are our services a good fit with what the client is wanting and sees as helpful? Bottom Line  Do not need to know what tx to use for a given dx as much as whether the relationship is a good fit and providing benefit…and when you do 17

12/7/2009 Feedback and Outcome Lambert’s Five Trials  All 5 sig. gains for feedback  22% of TAU at-risk cases improved compared with 33% for feedback to therapists, 39% for feedback to therapists & clients, & 45% when supplemented with support tools  A strong case for routine measurement of outcome in everyday clinical practice Becoming Better Isn’t It Good, Norwegian Wood  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. 18

12/7/2009 How Does Practice Based Evidence Work? Change and the Alliance •Client’s rating of the 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 pairing. 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. 19

12/7/2009 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 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), 203-211. Early Change is the Rule TDCRP Conclusions: Early change is an important factor for the prediction of short- and long-term outcome in therapy. Lutz, W., Stulz, N., & Köck, K. (2009). Patterns of early change and their relationship to outcome and follow-up among patients with major depressive disorders. Journal of Affective Disorders 118(1), 60-68. 20

12/7/2009 Becoming Better Measuring Outcome •Give at the beginning of the •Scored to the visit; nearest millimeter. •Client places a •Add the four mark on the line. scales together •Each line 10 for the total score. cm (100 mm) in length. CORS 21

12/7/2009 •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 score A.S.I.S.T: Automated Scoring, Interpretation, and data Storage Tool 22

12/7/2009 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: therapy 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 alliance 23

12/7/2009 The Session Rating Scale Measuring the Alliance •Score in cm to •Give at the end the nearest mm; of session; •Discuss with •Each line 10 cm client anytime in length; total score falls below 36 24

12/7/2009 SRS •Scored to the nearest mm •Give at the end of •Discuss each with session; client anytime •Each line total 10 cm in score length; falls below 36 A.S.I.S.T: Automated Scoring, Interpretation, and data Storage Tool 25

12/7/2009 Informing the Work Sage Psychotherapy Scholar, May West? Granted, at first When I’m blush, these good, hardly seem like I’m very words for good, but when therapists to live I’m bad, by—but, as it I’m better. turns out, they are. Informing the Work When I’m Good, I’m Very Good  When ORS scores increase, when you’re good, a crucial step to be very good is help clients see gains as a consequence of their own efforts and make sense of its meaning so repeat in the future. 26

12/7/2009 Informing the Work When I’m Bad, I’m Better  When outcome is bad in other words, you can make it better by changing something about the therapy to turns things around; and if things don’t turn around, by moving the client on to a different provider or service Being CD Is Being OI Feedback Is My Compass  Not an uninhabited terrain of technical procedures, nor the predictable path of diagnosis, prescription, & cure. Cannot be described w/o the client & therapist, co-adventurers in a journey across uncharted territory. Common factors provide landmarks for this interpersonal & idiosyncratic trip, & specific models provide well- traveled directions to consider, but feedback provides the compass, showing the way to the desired destination. 27

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WhatInTheHeckIsCDOI?

by Barry Duncan

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