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Handouts from webinar for George Braucht and CARES Academy for peers covering PCOMS and What's Right With You

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  1. 1. www.heartandsoulofchange.com March, 2013 What’s Right With You 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 The History of Mental Health and Substance Abuse Services •The quintessential question: •What s •What’s Wrong With You?!barrylduncan@comcast.net 2
  3. 3. www.heartandsoulofchange.com March, 2013 There Is Something Wrong With Us 24/7 bombardment that we are not resourceful or heroic, but rather that we are sick and getting sicker—the f i k th focus iis on what’s wrong with us…the killer Ds The Killer D’s Dysfunction Dysfunction Disorder Disability Disease Deficit Damaged None ever related to outcomebarrylduncan@comcast.net 3
  4. 4. www.heartandsoulofchange.com March, 2013 Bottom Line Approaching problems with the assumption that we are broken, incomplete, scarred, or sick predisposes us to failure, making invisible our own natural propensities for growth and recovery. In truth, change is inevitable and decidedly human, and primarily comes through the mobilization of ones strengths and abilities. Six Steps to C*H*A*N*G*E C: Challenge the Killer Ds: Debunk Dysfunction and Change Your Life H: Honor Your Heroic Self: Validate Your Struggles and Your Strengths A: Add a Helper: Recruit a Change Partner N: Never Underestimate Your Own Ideas: Value Your View of Change G: Give Yourself a Chance: Do Something—Implement a Plan E: Empower Yourself: Monitor, Adjust, and Celebratebarrylduncan@comcast.net 4
  5. 5. www.heartandsoulofchange.com March, 2013 C—Challenge the Killer Ds: Factors Accounting for Successful Outcome 40.0% Your Resources & Resiliencies Your Relationships Your Approach to Change 30.0% 30 0% 15.0% Hope/Expectancy 15.0% Think of Change as Your Favorite Pie  40% of how change happens is about you. You pp y are the filling. The main ingredient is the filling.  Eating a pie w/o filling is like trying to change without your involvement, resources, and ideas. d id  Change is about rallying Your Strengths, Resources these inherent strengths, and Resiliencies what’s right with you, to 40% defeat problems.barrylduncan@comcast.net 5
  6. 6. www.heartandsoulofchange.com March, 2013 Your Relationships The Crust Relational support, 30% of change, is the crust or h i th t container for the filling. A supportive relationship holds you comfortably while your resources take center stage. The crust allows the filling to be appreciated. Therapy provides a support for change, but so can others. Your Relationships 30% Your Hopes and Expectations  The pies mouthwatering visual presentation, presentation enticing aroma, and aroma aroused hopes for culinary delight illustrate expectancy— contributing 15%. Change tantalizes you with a delicious future, a helping of hope. , p g p  Key here is a plan that resonates with your own ideas and fits your 15% views about how you can change.  Hope is ALWAYS therebarrylduncan@comcast.net 6
  7. 7. www.heartandsoulofchange.com March, 2013 Your Approach to Change Your Involvement Is Key The actual approach is the meringue. meringue Enhances appearance & embellishes taste, cannot stand on own W/O the rest of pie to give it substance, meringue is nothing but fluff. Approach ot g u pp oac provides means to an end, but is useless w/o you. Nothing but fluff if it does not deliver Your Approach results.…over 400 models and To Change—15% Change— techniques •Since the 60’s, the # of models has grown from 60 to over 400, multiplying like… •Each claims superiority in p y conceptualization and outcome But the truth is that no one approach, either med or therapy is reliably better py y than any other… The Implication: Your resources transcend any approach usedbarrylduncan@comcast.net 7
  8. 8. www.heartandsoulofchange.com March, 2013 The Secret Is Out Like Dorothy in The Wizard of Oz, you have always had the power to get back to Kansas. Research shows that change does not come about from the special powers or authority of any particular helper or model. model Change principally results from empowering your preexisting abilities and restoring hope. You Are the Lion of Change Until lions have their historians, tales of hunting will always glorify the hunter. hunter African Proverbbarrylduncan@comcast.net 8
  9. 9. www.heartandsoulofchange.com March, 2013 H—Honor Your Heroic Self: Validate Your Strengths  Making changes in your life requires an appreciation of your strengths, the more heroic aspects of who you are— growth is achieved by marshalling your inherent resources against the obstacles before you. Telling Heroic Stories  Many different stories…taught to focus on only one story as if it is the best explanation  What are the obvious and hidden strengths, resources, resiliencies, and competences contained in my story?  What are the competing stories that can be told—the stories of clarity, coping, endurance, and desire that exist simultaneously with the stories of Your Heroic Self confusion, pain, suffering, and desperation?barrylduncan@comcast.net 9
  10. 10. www.heartandsoulofchange.com March, 2013 Think of a Time in Your Life  Think of a time in your life that was very difficult.  What problems did this situation create for your personal mental health as well as your family?  Did you use drugs or alcohol to get you through?  What pattern in your life does this story represent?  Who else knows this story about you?  What do you think they say this story says about what destructive patterns that you need to change?  Who wouldn’t be surprised that you are repeating this pattern now? Telling Heroic Stories…Imagine  Think of a time in your life that was very difficult, but you managed to get through it.  What personal resources did you draw on to get through this difficulty?  What family, spiritual, friend, or community support did you draw on to get through?  What does this story tell you about who you are and what you can do?  Who else knows this story about you?  What do you think they say this story says about who you are and what you are capable of?  Who wouldn’t be surprised to see you stand up to this problem and prevail?barrylduncan@comcast.net 10
  11. 11. www.heartandsoulofchange.com March, 2013 A—Add a Helper: Recruit a Change Partner  Relationships are the essence of humanity; we are social creatures who thrive in connection with others.  A supportive and caring relationship sustains us in tough times and encourages us to b i ti d t bring out our best. While it is possible to be the “Lone Changer,” it is a lot easier to have a faithful companion in our ride into the sunset of transformation. Bottom Line  Good relationships mobilize people’s inherent bili l ’ i h t resources and resiliencies. Don’t underestimate the power for change that resides in your relationships. relationships Human relationships are there for a reason. People need people…AA is on to something!barrylduncan@comcast.net 11
  12. 12. www.heartandsoulofchange.com March, 2013 The Relationship: Over 1000 Research Findings  Quality of the alliance more potent predictor of outcome than orientation, experience, or professional discipline.  Client perception of the alliance a better predictor than therapist’s.  The Power of Partnership deserves far more respect! N—Never Underestimate Your Own Ideas: Value Your View of Change  The resonance o you ideas with e eso a ce of your deas t any change plan is critically important. Your map is most important  A major reason for unsuccessful therapy, regardless of the severity or duration of the problem was because the client’s own ideas were ignored…barrylduncan@comcast.net 12
  13. 13. www.heartandsoulofchange.com March, 2013 Valuing Your View of Change Your Map of the Territory  Most of us have been persuaded to discount our own views, insights, and wisdom & instead, defer to the experts. The doctor knows best?  You have untapped wisdom about what it will take to transform your life. When enlisted, or when methods fit these core beliefs, more likely for change to occur  So rather than changing your own ideas to fit what is offered to you, elevate your perceptions above all others and allow your own view of change to direct your choices G—Give Yourself a Chance: Do Something—Implement a Plan  Th The key is to do k i t d something different about the problem  Many possibilities…always know that there is something else you can do!barrylduncan@comcast.net 13
  14. 14. www.heartandsoulofchange.com March, 2013 Do Something  Doing anything rallies your g y g y resources and creates an opportunity for good things to happen. Any approach is like a magnifying glass on sunny day—it brings together, focuses, and concentrates your , y strengths, resources, and ideas, narrows them to a point in space and time, and ignites into action E—Empower Yourself: Monitor, Adjust, and Celebrate  You are the engine of change. If you are going to h i t arrive at your destination, you have to know if the engine is on the right track.  If you are not on th right t the i ht track—the change you desire is not happening—then it is time to consider switching tracks.barrylduncan@comcast.net 14
  15. 15. www.heartandsoulofchange.com March, 2013 The Death of George Washington In December 1799, our first president develops a minor sore throat. By morning the next day, day he is dead. Reference: Flexner, J.T. (1974). Washington: The Indispensable Man. New York: Little, Brown and Company. Lessons of George Washington  The very same forces…continue to guide not only therapy, but also many attempts at self change.  People get hung up on the apparent rightness of the solution instead of its success. As Washington illustrates, the “rightness” of a method is no guarantee. t  Having no way to monitor benefit may encourage you to continue what is not working until, as in the case of George, drain the life right out of you.barrylduncan@comcast.net 15
  16. 16. www.heartandsoulofchange.com March, 2013 OOPS! Rightness Ri ht = Effectiveness Eff ti Bottom Line Monitoring your progress is essential and dramatically ti l d d ti ll improves your chances of success. You don’t really need to have the perfect approach as much as you need to know whether your plan is working—and if it is l i ki d i not, how to quickly adjust your strategy to maximize the possibility of your improvementbarrylduncan@comcast.net 16
  17. 17. www.heartandsoulofchange.com March, 2013 Outcome and Alliance Feedback The O.R.S The S.R.S Download free working copies at: http://www.heartandsoulofchange.com : A SAMHSA EBP But Different PCOMS is a a- theoretical & therefore additive to any therapeutic orientation including other EBPs, and, PCOMS applies to clients of all diagnostic categories: Much more bang for the buck!barrylduncan@comcast.net 17
  18. 18. www.heartandsoulofchange.com March, 2013 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 li i h  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. Reese, Norsworthy, & Rowlands (2009) First Independent Study Reese, R., Norsworthy, L., &  N=148: Feedback group Rowlands, S. (2009) Ro lands S (2009). Does a continuous feedback model doubled d bl d controls (10.4 t l (10 4 vs. 5.1 pts); ES: .48 improve psychotherapy outcomes? Psychotherapy,46, 418-431. Reese, R., Toland, M., Slone, N.,  Like Norway study, clients, regardless of risk & Norsworthy, L. (2010). Effect of client feedback on couple status, b t t benefit f fit from psychotherapy outcomes. Psychotherapy, 47, 616-630. continuous feedback  And also a replication study publishedbarrylduncan@comcast.net 18
  19. 19. www.heartandsoulofchange.com March, 2013 Meta-analysis by Lambert & Shimokawa (2011) of PCOMS (the ORS and SRS) Those in feedback group had 3.5 higher odds of experiencing reliable change Those in feedback group had less than half the odds of experiencing deterioration Feedback attained .48 ES Lambert, M. J., & Shimokawa, K. (2011). Collecting client feedback. Psychotherapy, 48, 72-79. Two More in the Works Veterans and Youth Schuman, D., Slone, N., Completed: RCT Comparison of p p Duncan, B., & Reese, J. (in preparation). Using client returning Afghanistan and Iraq feedback to improve outcomes with Iraq/Afghanistan veterans. Vets In group treatment setting, improved outcomes and reduced Gillaspy, A. Murphy, J., & Duncan, B., Bohankse, & drop outs Zatoga, A. (in process clinical trial). Using client feedback to improve school intervention outcomes. o tcomes Completes in March: RCT of C l t i M h f intervention in the schools with children and adolescents with behavioral problemsbarrylduncan@comcast.net 19
  20. 20. www.heartandsoulofchange.com March, 2013 And…Finally  Puts the client’s voice center stage t t  Allows services to be client and family driven  Brings consumers into the inner circle of decisions  Partners in monitoring the benefit and fit of services 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 Feedbackbarrylduncan@comcast.net 20
  21. 21. www.heartandsoulofchange.com March, 2013 Starting With the Predictors Change and the Alliance •Client’s rating of the Cli t’ ti f th 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. Becoming Better Measuring Outcome •Give at the beginning of the visit; Client •Scored to the places a mark nearest millimeter. on the line. •Add the four •Each line 10 scales together cm (100 mm) i ) in for the total score. length. •Reliable, valid, feasiblebarrylduncan@comcast.net 21
  22. 22. www.heartandsoulofchange.com March, 2013 The ORS Is Not This The ORS Is Different Than Other Outcome Measures  Co-constructed with client  Goes from general look at client distress to specific representation of p client’s experience & reason for service  Requires nuance & skill in applicationbarrylduncan@comcast.net 22
  23. 23. www.heartandsoulofchange.com March, 2013 The Outcome Rating Scale An Introduction in Your Own Words  The ORS is an outcome measure that allows us t t k where you’re at, h to track h ’ t how you’re d i ’ doing, how things are changing or if they are not. It allows us to determine whether the counseling is being helpful so we can do something different if it’s not helping. It also is way to make sure that your perspective stays central here, that we are addressing what you think is h th t dd i h t thi k i most important. It only takes a minute to fill out and most clients find it to be very helpful. Would you like to give it a try? The First Session Whatever It Takes  You can’t over-explain…  Clients get this. Face validity.  Whatever explanation the client gives is ok. Some will say: “You mean like poor to well? well?” or “Like 1 to 10? Like 10?”  It’s their subjective experience that matters so their understanding of the measure is paramount.barrylduncan@comcast.net 23
  24. 24. www.heartandsoulofchange.com March, 2013 The First Meeting The “Clinical Cutoff” •The dividing line 40 35 between a clinical & O u tc o m e S c o r e 30 25 “non- “non-clinical” 20 population (25). For 15 10 children (32); adols (32); 5 0 (28); (28) caretakers (28) t k 1st 2nd 3rd 4th •Between 20-30% 20- Session Number score in the “non- “non- Actual Score Line 2 25th % 75th % clinical” range. The Clinical Cutoff Only 2 Choices  Either above or below.  M ti Mention client score as it li t relates to the cutoff & have the client make sense of it.  Scores under cutoff may seem more straightforward  Reporting distress similar to others seeking services— the lower the score, the higher the distress. Looking for a change.barrylduncan@comcast.net 24
  25. 25. www.heartandsoulofchange.com March, 2013 Initial Information… 40 •Client’s score Client s 30 is within the clinical range. s c o re ORS 20 •Scoring more 10 like people in 0 therapy and 1 2 3 4 5 6 7 8 9 10 wanting Session number something to Projected change 75th percentile ORS Scores change Estimated Clinical Cutoff 25th percentile ORS: An Example •What can we glean 7.6 clinically from this client’s scores in 5.7 addition to being above the clinical cut off? 8.0 •How could we use this information to begin or 7.5 focus the session? Total = 28.8barrylduncan@comcast.net 25
  26. 26. www.heartandsoulofchange.com March, 2013 The First Meeting Over the Clinical Cutoff •Explore why the client entered therapy; circumscribed problem or mandated/coerced •If mandated, ask for the referral’s rating as a catalyst for conversation; doesn’t mean they are doesn t lying •Avoid stirring the cauldron First Session: Connect ORS to the Client’s Described Experience  At some point, connect the client’s described experience of their lives to the marks on the scalesbarrylduncan@comcast.net 26
  27. 27. www.heartandsoulofchange.com March, 2013 The ORS The Bare Bones  No specific content other than domains—a skeleton t th d i k l t to which clients add the flesh & blood of their experiences.  At the moment clients connect the marks with what they find distressing, the ORS becomes a meaningful measure of their progress and potent clinical tool. 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 27
  28. 28. www.heartandsoulofchange.com March, 2013 Get A Good Rating Make Sure T Transparency the th rule, not confrontation/ judgment  Darrell and Angelina Jolie Using the ORS with Groups  Feasible: 1 per week at the beginning  Alternate with GSRS  Member responsibility  Complete ORS, graph score, score and ready to discuss  Leader uses group process to support changes and problem solve what can be done if there is no changebarrylduncan@comcast.net 28
  29. 29. www.heartandsoulofchange.com March, 2013 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. 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 feasiblebarrylduncan@comcast.net 29
  30. 30. www.heartandsoulofchange.com March, 2013 Relationship Rating Scale Group Session Rating Scale Alliance and Cohesion •Give at the end of the th week or k alternate with ORS •Each line 10 cm in length; •Reliable, valid •Reliable valid, feasible •Discuss anything under 32barrylduncan@comcast.net 30
  31. 31. www.heartandsoulofchange.com March, 2013 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 SRS 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?barrylduncan@comcast.net 31
  32. 32. www.heartandsoulofchange.com March, 2013 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 Alliance The SRS Graceful Acceptance  And 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.barrylduncan@comcast.net 32
  33. 33. www.heartandsoulofchange.com March, 2013 GSRS  Feasible: 1 time per week at th end of th k t the d f the week  If only 1 group per week, alternate w/ORS  Remember that cohesion is even a better predictor of outcome than the alliance in group therapy Clinical Nuances Not a Perfunctory Piece of Paper  Administering, But Don’t Get It. Clients must understand purpose (monitoring outcome outcome, privileging their perspective); Helpers must understand same + make them meaningful  Administering, Using Some. But not the clinical cutoff or numbers…Use but no continuity; questionable data integrity  Administering, Administering Using Some. But not Some connecting to the client’s experience or reasons for service; no data integrity  Administering the SRS. But seeing it as reflective of competence rather than an alliance building toolbarrylduncan@comcast.net 33