When I'm Good, I'm Very Good...

‘When I’m good, I’m very good, but when I’m bad I’m better’: a new mantra for psychotherapists BARRY DUNCAN and SCOTT D. MILLER Current estimates suggest that nearly 50 per cent of therapy clients drop out and at least one- third, and up to two-thirds, do not benefit from our usual strategies. Following on from the ‘Supershrinks’ article in the previous issue, BARRY DUNCAN and SCOTT MILLER provide a comprehensive summary of the Outcome-Informed, Client-Directed approach and a detailed, practical overview of its application in clinical practice. Through case examples they demonstrate how most practitioners can increase their therapeutic effectiveness substantially through accurate identification of those clients who are not responding, and addressing the lack of change in a way that keeps clients engaged in treatment and forges new directions. A t first blush, Mae West’s famous words ‘When I’m good, I’m very good, but when I’m bad I’m better’ hardly frequently to trouble-shoot customer problems. Matt loved his job but travelling was an ordeal—not because next trip, but still no ‘go’. The problem continued to get worse. Now three sessions in, Matt was at significant seem like a guide for therapists to live of flying but because of another, far risk for a negative outcome—either by—but, as it turns out, they could be. more embarrassing problem. Matt dropping out or continuing in therapy Research demonstrates consistently was long past feeling frustrated about without benefit. that who the therapist is accounts for far standing and standing in public We have all encountered more of the variance of change (6–9 restrooms trying to ‘go’. What started clients unmoved by treatment. per cent) than the model or technique as a mild discomfort and inconvenience Therapists often blame themselves. administered (1 per cent). In fact, easily solved by repeated restroom visits The overwhelming majority of therapist effectiveness ranges from a had progressed to full blown anxiety psychotherapists, as cliched as it paltry 20 per cent to an impressive 70 attacks, an excruciating pressure, and sounds, want to be helpful. Many of per cent. A small group of clinicians— an intense dread before each trip. us answered “I want to help people” on sometimes called ‘supershrinks’—obtain Feeling hopeless and demoralized, graduate school applications as the demonstrably superior outcomes in Matt considered changing jobs but as reason we chose to be therapists. Often, most of their cases, while others fall a last resort decided instead to see a some well-meaning person dissuaded predictably on the less exalted sections therapist. us from that answer because it didn’t of the bell-shaped curve. However, Matt liked the therapist and it felt sound sophisticated or appeared too most practitioners can join the ranks of good finally to tell someone about the ‘co-dependent’. Such aspirations, we supershrinks, or at least increase their problem. The therapist worked with now believe, are not only noble but can therapeutic effectiveness substantially. Matt to implement relaxation and provide just what is needed to improve Consider Matt, a twenty-something self-talk strategies. Matt practiced in clinical effectiveness. After all, there is software whiz who was on the road session and tried to use the ideas on his not much financial incentive for doing 62 PSYCHOTHERAPY IN AUSTRALIA • VOL 15 NO 1 • NOVEMBER 2008

better therapy—we don’t do this work embrace what is known about change: Next we need to measure those because we thought we would acquire Many studies reveal that the majority known predictors in a systematic way the lifestyles of the rich and famous. of clients experience change in the with reliable and valid instruments. Unfortunately, the altruistic desire first six visits—clients reporting little So instead of regarding the first to be helpful sometimes leads us to or no change early on tend to show no few therapy sessions as a ‘warm-up’ believe that if we were just smart improvement over the entire course period or a chance to try out the latest enough or trained correctly, clients would not remain inured to our best efforts—if we found the Holy Grail, that special model or technique, Amid explanations and remedies aplenty, we could once and for all defeat the psychic dragons that terrorize clients. therapists search courageously for designer Amid explanations and remedies aplenty, therapists search courageously explanations and brand name miracles, but for designer explanations and brand name miracles, but continue to observe continue to observe that clients drop out, that clients drop out, or even worse, or even worse, continue without benefit. continue without benefit. Current estimates suggest that nearly 50 per cent of our clients drop out and at least one-third, and up to two-thirds, do not of therapy, or wind up dropping out. technique, we engage the client in benefit from our usual strategies. Early change, in other words, predicts helping us judge whether therapy is So what can we do to channel engagement in therapy and ongoing providing benefit. Obtaining feedback our healthy desire to be helpful? If benefit. This doesn’t mean that a client on standardized measures about success we listen to the lessons of the top is ‘cured’ or the problem is totally or failure during those initial meetings performers, the first thing we should resolved, but rather that the client provides invaluable information about do is step outside of our comfort zones has a subjective sense that things are the match between ourselves, our and push the limits of our current getting better. And second, a mountain approach, and the client—enabling performance—to identify accurately of studies have long demonstrated us to know when we are bad, so we those clients not responding to our another robust predictor—that reliable, can be even better. The only way we therapeutic business as usual, and tried and true but taken for granted can improve our outcomes is to know, address the lack of change in a way that old friend—the therapeutic alliance. very early on, when the client is not keeps clients engaged in treatment and Clients who highly rate the relationship benefiting—we need something akin to forges new directions. with their therapist tend to be those an early warning signal. To recapture those clients who clients who stick around in therapy and Using standardized measures to slip through the cracks, we need to benefit from it. monitor outcome may make your skin © Alberto Ruggieri, Illustration Works, Getty Images. PSYCHOTHERAPY IN AUSTRALIA • VOL 15 NO 1 • NOVEMBER 2008 63

crawl and bring to mind torture devices delivered. Rated at an eighth-grade ‘pissed off’, and amused. And he like the Rorschach or MMPI. But the reading level, the ORS is understood started to go. forms for these measures are not used easily and clients have little difficulty This process, the delightful to pass judgment, diagnose or unravel connecting it their day-to-day lived creative energy that emerges from the mysteries of the human psyche. experience. the wonderful interpersonal event Rather, these measures invite clients Matt completed the ORS before we call therapy could have happened into the inner circle of mental health each session. He entered therapy with to any therapist working with Matt. and substance abuse services—they a score of 18, about average for those The difference is that the use of the involve clients collaboratively in attending outpatient settings, but outcome measure spotlighted the lack monitoring progress toward their goals continued to hover at that score. At the of change and made it impossible to and the fit of the services they are third session, when the ORS reflected ignore. The ORS brought the risk of receiving, and amplify their voices in no change, it was not front page news a negative outcome front and center any decisions about their care. to Matt. But a different process ensued. and allowed the therapist to enact the You might also think that the In the same spirit of collaboration second characteristic of supershrinks, last thing you need is to add more paperwork to your practice. But finding out who is and isn’t responding to therapy need not be cumbersome. In fact, it only takes a minute. Dissatisfied Research shows repeatedly that clients’ ratings with the complexity, length, and user- unfriendliness of existing outcome of the alliance are far more predictive of measures, we developed the Outcome Rating Scale (ORS) as a brief clinical improvement than the type of intervention alternative. The ORS (child measures or the therapist’s ratings of the alliance. also available) and all the measures discussed here are available for free download at www.talkingcure.com). The ORS assesses three dimensions: as the assessment process, Matt and to be exceptionally alert to the risk of 1. personal or symptomatic his therapist brainstormed ideas, a drop out and treatment failure. In the distress (measuring individual free-for-all of unedited speculations past, we might have continued with well-being), and suggestions of alternatives, from the same treatment for several more 2. interpersonal well-being changing nothing about the therapy to sessions unaware of its ineffectiveness (measuring how well the client taking medication to shifting treatment or believing (hoping even praying) that is getting along in intimate approaches. During this open exchange our usual strategies would eventually relationships), and Matt intimated that he was beginning take hold, but the reliable outcome 3. social role (measuring to feel angry about the whole thing— data pushed us to explore different satisfaction with work/school real angry. The therapist noticed that treatment options by the end of the and relationships outside of the when Matt worked himself up to a third visit. home). good anger—about how his problem Pushing the limits of one’s Changes in these three areas are interfered with his work and added a performance requires monitoring the considered widely to be valid indicators huge hassle in any extended situation fit of your service with the client’s of successful outcome. The ORS away from his own bathroom—that expectations about the alliance. The simply translates these three areas he became quite animated, a stark ongoing assessment of the alliance and an overall rating into a visual contrast to the passively resigned enables therapists to identify and analog format of four 10-cm lines, person that had characterized their correct areas of weakness in the with instructions to place a mark on previous sessions. One of them, which delivery of services before they exert a each line with low estimates to the one remains a mystery, mentioned the negative effect on outcome. left and high to the right. The four words ‘pissed off’ and both broke into Research shows repeatedly that 10-cm lines add to a total score of 40. a raucous laughter. Subsequently, the clients’ ratings of the alliance are The score is simply the summation of therapist suggested that instead of far more predictive of improvement the marks made by the client to the responding with hopelessness when than the type of intervention or the nearest millimeter on each of the four the problem occurred, that Matt work therapist’s ratings of the alliance. lines, measured by a centimeter ruler or himself up to a good anger—about how Recognizing these much replicated available template. A score of 25, the this problem made his life miserable. findings, we developed the Session clinical cutoff, differentiates those who Matt added (he was a rock and roll Rating Scale (SRS) as a brief clinical are experiencing enough distress to be buff) that he could also sing the Tom alternative to longer research-based in a helping relationship from those Petty song “Won’t Back Down” during alliance measures to encourage routine who are not. Because of its simplicity, his tirade at the toilet. Matt allowed conversations with clients about the ORS feedback is available immediately himself, when standing in front of the alliance. The SRS also contains four for use at the time the service is urinal to become incensed—downright items. First, a relationship scale rates 64 PSYCHOTHERAPY IN AUSTRALIA • VOL 15 NO 1 • NOVEMBER 2008

the meeting on a continuum from “I did not feel heard, understood, and respected” to “I felt heard, understood, and respected.” Second is a goals and topics scale that rates the conversation on a continuum from “We did not work on or talk about what I wanted to work on or talk about” to “We worked on or talked about what I wanted to work on or talk about.” Third is an approach or method scale (an indication of a match with the client’s theory of change) requiring the client to rate the meeting on a continuum from “The approach is not a good fit for me” to “The approach is a good fit for me.” Finally, the fourth scale looks at how the client perceives the encounter in total along the continuum: “There was something missing in the session today” to “Overall, today’s session was right for me.” The SRS simply translates what is known about the alliance into four visual analog scales, with instructions to place a mark on a line with negative responses depicted on the left and positive responses indicated on Consider nineteen-year-old Sarah, develop a culture of feedback in the the right. The SRS allows alliance who lived in a group home and room. The power disparity combined feedback in real time so that problems received social security disability for with any socioeconomic, ethnic, or may be addressed. Like the ORS, the mental illness. Sarah was referred racial differences make it difficult to instrument takes less than a minute for counselling because others were tell authority figures that they are on to administer and score. The SRS is concerned that she was socially the wrong track. Think about the last scored similarly to the ORS, by adding withdrawn. Everyone was also worried time you told your doctor that he or the total of the client’s marks on the about Sarah’s health because she was she was not performing well. Clients, four 10-cm lines. The total score falls overweight and spent much of her time however, will let us know subtly on into three categories: watching TV and eating snack foods. alliance measures far before they will • SRS score between 0–34 In therapy Sarah agreed that she confront us directly. reflects a poor alliance, was lonely, but expressed a desire At the end of the third session, • SRS Score between 35–38 to be a Miami Heat cheerleader. the therapist and Sarah reviewed her reflects a fair alliance, Perhaps understandably, that goal was responses on the SRS. Did she truly • SRS Score between 39–40 not taken seriously. After all, Sarah feel understood? Was the therapy reflects a good alliance. had never been a cheerleader, was focused on her goals? Did the approach The SRS allows the implementation ‘schizophrenic’, and was not exactly in make sense to her? Such reviews are of the final lesson of the the best of shape. So no one listened, helpful in fine tuning the therapy or supershrinks—seek, obtain, and or even knew why Sarah had such an addressing problems in the therapeutic maintain more consumer engagement. interesting goal. And the work with relationship that have been missed Clients drop out of therapy for two Sarah floundered. She spoke rarely and or gone unreported. Sarah, when reasons: one is that therapy is not gave minimal answers to questions. asked the question about goals, all the helping (hence monitoring outcome) In short, Sarah was not engaged and while avoiding eye contact and nearly and the other is alliance problems— was at risk for drop out or a negative whispering, repeated her desire to be a they are not engaged or turned on by outcome. Miami Heat cheerleader. the process. The most direct way to The therapist routinely gave Sarah The therapist looked at the SRS improve your effectiveness is simply to the SRS and she had reported that and the lights came on. The slight keep people engaged in therapy. everything was going swimmingly, difference on the goals scale told the An alliance problem that occurs although the goals scale was a 8.7 out tale. When the therapist finally asked frequently emerges when client’s of 10 instead of a 9 or above out of 10 Sarah about her goal, she told the story goals do not fit our own sensibilities like the rest. of growing up watching Miami Heat about what they need. This may be Sometimes it takes a bit more work basketball with her dad who delighted particularly true if clients carry certain to create the conditions that allow in Sarah’s performance of the cheers. diagnoses or problem scenarios. clients to be forthright with us, to Sarah sparkled when she talked of PSYCHOTHERAPY IN AUSTRALIA • VOL 15 NO 1 • NOVEMBER 2008 65

her father, who passed away several that you can recover a substantial But unlike much of what is years previously, and the therapist portion of those who don’t benefit by passed off as research, the systematic noted that it was the most he had first identifying who they are, keeping collection of outcome data in your ever heard her speak. He took this them engaged, and tailoring your practice is not worthless to your experience to heart and often asked services accordingly. predicament. It allows you the luxury Sarah about her father. The therapist of being useful to clients who would The nuts and bolts also put the brakes on his efforts to otherwise not be helped. And it get Sarah to socialize or exercise (his Collecting data on standardized helps you to get out of the way of goals), and instead leaned more toward measures and using what we call those clients you are not helping, Sarah’s interest in cheerleading. Sarah ‘practice based evidence’ can improve and connecting them to more likely watched cheerleading contests regularly your effectiveness substantially. “Wait opportunities for change. on ESPN and enjoyed sharing her a minute” you say, “this sounds a lot First, collaboration with clients to expertise. She also knew a lot about like research!” Given the legionary monitor outcome and fit actually starts basketball. schism between research and practice, before formal therapy. This means that Sarah’s SRS score improved on sometimes getting therapists to do the they are informed when scheduling the goal scale and her ORS score measures is indeed a tall order because the first contact about the nature of increased dramatically. After a while, it does sound a lot like the ‘R’ word. the partnership and the creation of a Sarah organized a cheerleading squad A story illustrates the sentiments ‘culture of feedback’ in which their for her agency’s basketball team who that many practitioners feel about voice is essential. played local civic organizations to raise research. Two researchers were “I want to help you reach your goals. money for the group home. Sarah’s attending an annual conference. I have found it important to monitor involvement with the team ultimately Although enjoying the proceedings, progress from meeting to meeting using addressed the referral concerns about they decided to find some diversion two very short forms. Your ongoing her social withdrawal and lack of to combat the tedium of sitting all feedback will tell us if we are on track, activity. The SRS helps us take clients, day and absorbing vast amounts of or need to change something about our and their engagement more seriously, information. They settled on a hot air approach, or include other resources or like the supershrinks do. Walking the balloon ride and were quite enjoying referrals to help you get what you want. I path cut by client goals often reveals themselves until a mysterious fog want to know this sooner rather than later alternative routes that would have rolled in. Hopelessly lost, they drifted but because if I am not the person for you never been discovered otherwise. for hours until a clearing in the fog I want to move you on quickly and not be Providing feedback to clinicians on appeared finally and they saw a man an obstacle to you getting what you want. the clients’ experience of the alliance standing in an open field. Joyfully, Is that something you can help me with?” and progress has been shown to result they yelled down at the man, “Where We have never had anyone tell us in significant improvements in both are we?” The man looked at them, that keeping track of progress is a client retention and outcome. We and then down at the ground, before bad idea. There are five steps to using found that clients of therapists who turning a full 360 degrees to survey his practice based evidence to improve opted out of completing the SRS surroundings. Finally, after scratching your effectiveness. were twice as likely to drop out and his beard and what seemed to be several moments of facial contortions Step one: introducing the three times more likely to have a reflecting deep concentration, the man ORS in the first session negative outcome. In the same study of over 6000 clients, effectiveness looked up and said, “You are above my The ORS is administered prior to rates doubled. As incredible as the farm.” each meeting and the SRS toward the results appear, they are consistent with The first researcher looked at the end. In the first meeting, the culture findings from other researchers. second researcher and said, “That man of feedback is continually reinforced. In a 2003 meta-analysis of three is a researcher—he is a scientist!” To It is important to avoid technical studies, Michael Lambert, a pioneer which the second researcher replied, jargon, and instead explain the purpose of using client feedback, reported “Are you crazy, man? He is a simple of the measures and their rationale that those helping relationships at farmer!” “No,” answered the first in a natural commonsense way. Just risk for a negative outcome which researcher emphatically, “that man is make it part of a relaxed and ordinary received formal feedback were, at the a researcher and there are three facts that way of having conversations and conclusion of therapy, better off than support my assertion: First, what he said working. The specific words are not 65% of those without information was absolutely 100% accurate; second, important—there is no protocol that regarding progress. Think about this he addressed our question systematically must be followed. This is a clinical tool! for a minute. Even if you are one of through an examination of all of the Your interest in the client’s desired the most effective therapists, for every empirical evidence at his disposal, and outcome speaks volumes about your cycle of ten clients you see, three will then deliberated carefully on the data commitment to the client and the go home without benefit. Over the before delivering his conclusion; and quality of service you provide. course of a year, for a therapist with a finally, the third reason I know he is “Remember our earlier conversation? full caseload, this amounts to a lot of a researcher is that what he told us is During the course of our work together, I unhappy clients. This research shows absolutely useless to our predicament.” will be giving you two very short forms 66 PSYCHOTHERAPY IN AUSTRALIA • VOL 15 NO 1 • NOVEMBER 2008

that ask how you think things are going he was describing his problem in public way of working. The use of the SRS and whether you think things are on track. restrooms, he pointed to the ORS and continues the culture of client privilege To make the most of our time together and explained that this problem accounted and feedback, and opens space for the get the best outcome, it is important to for his mark. Other times, the therapist client’s voice about the alliance. The make sure we are on the same page with needs to clarify the connection SRS is given at the end of the meeting, one another about how you are doing, how between the client’s descriptions of but leaving enough time to discuss the we are doing, and where we are going. We the reasons for services and the client’s client’s responses. will be using your answers to keep us on scores. The ORS makes no sense “Let’s take a minute and have you fill track. Will that be okay with you?” unless it is connected to the described out the form that asks for your opinion Step two: incorporating the ORS in the first session The ORS pinpoints where the client We found that clients of therapists who is and allows a comparison for later sessions. Incorporating the ORS entails opted out of completing the SRS were simply bringing the client’s initial and subsequent results into the conversation twice as likely to drop out and three times for discussion, clarification and problem solving. The client’s initial more likely to have a negative outcome. score on the ORS is either above or below the clinical cutoff. You need only to mention the client scores as it relates experience of the client’s life. This is about our work together. It’s like taking to the cutoff. Keep in mind that the use a critical point because clinician and the temperature of our relationship today. of the measures is 100% transparent. client must know what the mark on the Are we too hot or too cold? Do I need to There is nothing that they tell you that line represents to the client and what adjust the thermostat? This information you cannot share with the client. It will need to happen for the client to helps me stay on track. The ultimate is their interpretation that ultimately both realize a change and indicate that purpose of using these forms is to make counts. change on the ORS. every possible effort to make our work “From your ORS it looks like you’re At some point in the meeting, the together beneficial. Is that okay with you?” experiencing some real problems.” Or: therapist needs only to pick up on the “From your score, it looks like you’re feeling Step four: incorporating the SRS client’s comments and connect them to okay.” “What brings you here today?” Or: the ORS: Because the SRS is easy to score “Your total score is 15—that’s pretty low. “Oh, okay, it sounds like dealing with and interpret, you can do a quick A score under 25 indicates people who are the loss of your brother (or relationship visual check and integrate it into the in enough distress to seek help. Things must with wife, sister’s drinking, or anxiety conversation. If the SRS looks good be pretty tough for you. Does that fit your attacks, etc.), is an important part of what (score more than 9 cm on any scale), experience? What’s going on?” we are doing here. Does the distress from you need only comment on that fact “The way this ORS works is that scores that situation account for your mark here and invite any other comments or under 25 indicate that things are hard on the individual (or other) scale on the suggestions. If the client marks any for you now or you are hurting enough ORS? Okay, so what do you think will scales lower than 9 cm, you should to bring you to see me. Your score on the need to happen for that mark to move just definitely follow up. Clients tend to individual scale indicates that you are one centimeter to the right?” score all alliance measures highly, really having a hard time. Would you like The ORS, by design, is a general so the practitioner should address to tell me about it?” outcome instrument and provides no any hint of a problem. Anything less Or if the ORS is above 25: specific content other than the three than a total score of 36 might signal “Generally when people score above 25, domains. The ORS offers only a bare a concern, and therefore it is prudent it is an indication that things are going skeleton to which clients must add the to invite clients to comment. Keep pretty well for them. Does that fit your flesh and blood of their experiences, in mind that a high rating is a good experience? It would be really helpful for into which they breathe life with their thing, but it doesn’t tell you very me to get an understanding of what it is ideas and perceptions. At the moment much. Always thank the client for the that brought you here now?” in which clients connect the marks feedback and continue to encourage Because the ORS has face validity, on the ORS with the situations that their open feedback. Remember that clients usually mark the scale the are distressing, the ORS becomes a unless you convey you really want it, lowest that represents the reason meaningful measure of their progress you are unlikely to get it. they are seeking therapy, and often and potent clinical tool. And know for sure that there is connect that reason to the mark they’ve no ‘bad news’ on these forms. Your made without prompting from the Step three: introducing the SRS appreciation of any negative feedback therapist. For example, Matt marked The SRS, like the ORS, is best is a powerful alliance builder. In fact, the Individual scale the lowest with the presented in a relaxed way that is alliances that start off negatively but Social scale coming in a close second. As integrated seamlessly into your typical result in your flexibility to client input PSYCHOTHERAPY IN AUSTRALIA • VOL 15 NO 1 • NOVEMBER 2008 67

tend to be very predictive of a positive SRS, therefore, are good news and that off? Where do you think we should go outcome. When you are bad, you are should be celebrated. Practitioners from here?” even better! In general, a score: who elicit negative feedback tend to be If no change has occurred, the • that is poor and remains poor those with the best effectiveness rates. scores invite an even more important predicts a negative outcome, Think about it—it makes sense that if conversation. • that is good and remains good clients are comfortable enough with “Okay, so things haven’t changed since predicts a positive outcome, you to express that something isn’t the last time we talked. How do you • that is poor or fair and improves right, then you are doing something make sense of that? Should we be doing predicts a positive outcome even very right in creating the conditions for something different here, or should we more, therapeutic change. continue on course steady as we go? If we • that is good and decreases are going to stay on the same track, how Step five: checking for change is predictive of a negative long should we go before getting worried? in subsequent sessions outcome. When will we know when to say ‘when?’ ” The SRS allows the opportunity With the feedback culture set, the The idea is to involve the client in to fix any alliance problems that are business of practice based evidence monitoring progress and the decision developing and shows that you do more can begin, with the client’s view of about what to do next. The discussion prompted by the ORS is repeated in all meetings, but later ones gain increasing significance and warrant additional Where in the past we might have felt like action. We call these later interactions either checkpoint conversations or failures when we weren’t being effective last-chance discussions. In a typical outpatient setting, checkpoint with a client, we now view such times as conversations are conducted usually at the third meeting and last-chance opportunities to stop being an impediment discussions are initiated in the sixth session. This is simply saying that based to the client and their change process. in over 300,000 administrations of the measures, that by the third encounter, most clients who do receive benefit from services usually show some benefit than give lip service to honoring the progress and fit really influencing what on the ORS; and if change is not noted client’s perspectives. happens. Each subsequent meeting by meeting three, then the client is at “Let me just take a look at this compares the current ORS with the a risk for a negative outcome. Ditto SRS—it’s like a thermometer that takes previous one and looks for any changes. for session six except that everything the temperature of our meeting here today. The ORS can be made available in just mentioned has an exclamation Great, looks like we are on the same page, the waiting room or via electronic mark. Different settings could have that we are talking about what you think software (ASIST) and web systems different checkpoints and last- is important and you believe today’s (MyOutcomes.com). Many clients will chance numbers. Determining these meeting was right for you. Please let me complete the ORS (some will even plot highlighted points of conversation know if I get off track, because letting me their scores on provided graphs) and requires only that you collect the know would be the biggest favor you could greet the therapist already discussing data. The calculations are simple and do for me.” the implications. Using a scale that is directions can be found in our book, “Let me quickly look at this other form simple to score and interpret increases The Heroic Client. Establishing these here that lets me know how you think we client engagement in the evaluation of two points helps evaluate whether a are doing. Okay, seems like I am missing the services. Anything that increases client needs a referral or other change the boat here. Thanks very much for your participation is likely to have a based on a typical successful client in honesty and giving me a chance to address beneficial impact on outcome. your specific setting. The same thing what I can do differently. Was there The therapist discusses if there is an can be accomplished more precisely something else I should have asked you improvement (an increase in score), a by available software or web-based about or should have done to make this slide (a decrease in score), or no change systems that calculate the expected meeting work better for you? What was at all. The scores are used to engage the trajectory or pattern of change based on missing here?” client in a discussion about progress, our data base of ORS administrations. Graceful acceptance of any problems and more importantly, what should be These programs compare a graph of the and responding with flexibility usually done differently if there isn’t any. client’s session-by-session ORS results turns things around. Again, clients “Your marks on the personal well-being to the expected amount of change for reporting alliance problems that are and overall lines really moved—about 4 clients in the data base with the same addressed are far more likely to achieve cm to the right each! Your total increased intake score, serving as a catalyst for a successful outcome, up to seven times by 8 points to 29 points. That’s quite a conversation about the next step in more likely! Negative scores on the jump! What happened? How did you pull therapy. 68 PSYCHOTHERAPY IN AUSTRALIA • VOL 15 NO 1 • NOVEMBER 2008

If change has not occurred by the majority of clients seen by a particular or no improvement is forthcoming, checkpoint conversation, the therapist practitioner or setting. however, this same data indicates responds by going through the SRS Why? Because research shows no that therapy should, indeed, be as item by item. Alliance problems are correlation between a therapy with brief as possible. Over time, we have a significant contributor to a lack of a poor outcome and the likelihood learned that explaining our way of progress. Sometimes it is useful to say of success in the next encounter. working and our beliefs about therapy something like, “It doesn’t seem like we Although we’ve found that talking outcomes to clients avoids problems if are getting anywhere. Let me go over about a lack of progress turns most therapy is unsuccessful and needs to be the items on this SRS to make sure you cases around, we are not always able to terminated. are getting exactly what you are looking find a helpful alternative. Barry Duncan writes: But it can be for from me and our time together.” Where in the past we might have hard to believe that stopping a great Going through the SRS and eliciting felt like failures when we weren’t being relationship is the right thing to do. client responses in detail can help the effective with a client, we now view Alina sought services because she practitioner and client get a better such times as opportunities to stop was devastated and felt like everything sense of what may not be working. being an impediment to the client and important to her had been savagely Sarah, the woman who aspired to be a their change process. Now our work ripped apart—because it had. She Miami Heat cheerleader, exemplifies is successful when the client achieves worked her whole life for but one goal, this process. change and when, in the absence of to earn a scholarship to a prestigious Next, a lack of progress at this change, we get out of their way. We ivy-league university. She was captain stage may indicate that the therapist reiterate our commitment to help of the volley team, commanded the needs to try something different. them achieve the outcome they desire, first position on the debating team, This can take as many forms as there whether by us or by someone else. and was valedictorian of her class. are clients: inviting others from the When we discuss the lack of progress Alina was the pride of her Guatemalan client’s support system, using a team with clients, we stress that failure says community—proof positive of the or another professional, a different nothing about them personally or their possibilities her parents always approach; referring to another potential for change. Some clients envisioned in the land of opportunity. therapist, religious advisor, or self-help terminate and others ask for a referral to Alina was awarded a full ride in group—whatever seems to be of value another therapist or treatment setting. minority studies at Yale University. to the client. Any ideas that surface If the client chooses, we will meet with But this Hollywood caliber story hit are then implemented, and progress is monitored via the ORS. Matt and the idea of encouraging his anger illustrate this kind of discussion. If the therapist and client have …findings of virtually every study of change implemented different possibilities and the client is still without benefit, it is in therapy over the last 40 years provide time for the last-chance discussion. As the name implies, there is some substantial evidence that more therapy is urgency for something different better than less therapy for those clients because most clients who benefit have already achieved change by this point, who make progress early in treatment. and the client is at significant risk for a negative conclusion. A metaphor we like is that of the therapist and client driving into a vast desert and running her or him in a supportive fashion until a glitch. Attending her first semester on empty, when a sign appears on the other arrangements are made. Rarely away from home and the insulated road that says ‘last chance for gas’. do we continue with clients whose ORS environment in which she excelled, The metaphor depicts the necessity scores show little or no improvement by Alina began hearing voices. of stopping and discussing the the sixth or seventh visit. She told a therapist at the implications of continuing without the Ending with clients who are not university counseling center and client reaching a desired change. making progress does not mean before she knew it she was whisked This is the time for a frank that all therapy should be brief. On away to a psychiatric unit and given discussion about referral and other the contrary, our research and the antipsychotic medications. Despondent available resources. If the therapist has findings of virtually every study of about the implications of this turn created a feedback culture from the change in therapy over the last 40 of events, Alina threw herself down beginning, then this conversation will years provide substantial evidence a stairwell, prompting her parents not be a surprise to the client. There is that more therapy is better than less to bring her home. Alina returned rarely justification for continuing work therapy for those clients who make home in utter confusion, still hearing with clients who have not achieved progress early in treatment and are voices, and with a belief that she was change in a period typical for the interested in continuing. When little an unequivocal failure to herself, her PSYCHOTHERAPY IN AUSTRALIA • VOL 15 NO 1 • NOVEMBER 2008 69

family, and everyone else in her tightly- brought up the topic of referral but eternity, including Alina’s assertion knit community whose aspirations rode we settled instead on a consult from a that she wanted to keep seeing me, we on her shoulders. team (led by Jacqueline Sparks). Alina, started to talk about who she might Serendipity landed Alina in my again, responded well, and seemed see. She mentioned she liked someone office. I was the 20th therapist the more engaged than I had noticed from the team, and began seeing our family called and the first who agreed with me—she rated the session the colleague Jacqueline Sparks. to see Alina without medication. highest possible on the SRS. The team By session four, Alina had an ORS Alina’s parents were committed to addressed topics I hadn’t including score of 19 and enrolled to take a honor her preference to not take differentiation from her family, as well class at a local university. Moreover, medication. We were made for each as gender and ethnic issues. Alina and she continued those changes and re- other and hit it off famously. I loved I pursued the ideas from the team for enrolled at Yale the following year with this kid. I admired her intelligence and a couple more sessions. But her ORS her scholarship intact! When I wrote spunk in standing up to psychiatric score was still a 4. a required recommendation letter for discourse and the broken record of Now what? We were in session the Dean, I administered the ORS to medication. I couldn’t wait to be useful nine, well beyond how clients typically Alina and she scored a 29. By getting to Alina and get her back on track. change in my practice. After collecting out of her way and allowing her and I When I administered the ORS, Alina data for several years, I know that 75 to ‘fail successfully’, Alina was given scored a 4, the lowest score I ever had. per cent of clients who benefit from another opportunity to get her life We discussed her total their work with me show it by the third back on track—and she did. Alina and demoralization and how her episodes session; a full 98 per cent of my clients Jacqueline, for reasons that escape us of hearing voices and confusion led who benefit do it by the sixth session. even after pouring over the video, just to the events that took everything she So is it right that I continue with had the right chemistry for change. had always dreamed of from her—the Alina? Is it even ethical? This was a watershed client for life she had worked so hard to prepare Despite our mutual admiration me. Although I believed in practice for. I did what I usually did that is society, it wasn’t right to continue. based evidence, especially how it puts helpful—I listened, I commiserated, I A good relationship in the absence clients center stage and pushes me to validated, and I worked hard to recruit of benefit is a good definition of do something different when clients Alina’s resilience to begin anew. But dependence. So I shared my concern didn’t benefit, I always struggled with nothing happened. that her dream would be in jeopardy if those clients who did not benefit, By session three, Alina remained she continued seeing me. I emphasized but who wanted to continue with me unchanged in the face of my best that the lack of change had nothing to nevertheless. This was more difficult efforts. Therapy was going nowhere do with either of us, that we had both when I really liked the client and and I knew it because the ORS makes tried our best, and for whatever reason, had become personally invested in it hard to ignore—that score of 4 was a it just wasn’t the right mix for change. them benefiting. Alina awakened me rude reminder of just how badly things We discussed the possibility that Alina to the pitfalls of such situations and were going. see someone else. If you watch the showed a true value added dimension At the checkpoint session, I went video, you would be struck, as many to monitoring outcome—namely the over the SRS with her, and unlike are, by the decided lack of fun Alina ability to fail successfully with our many clients, Alina was specific about and I have during this discussion. clients. Alina was the kind of client what was missing and revealed that she Finally, after what seemed like an I would have seen forever. I cared wanted me to be more active, so I was. She wanted ideas about what to do about the voices, so I provided them— thought stopping, guided imagery, AUTHOR NOTES content analysis. But, no change ensued and she was increasingly at risk for a negative outcome. Alina told me BARRY L. DUNCAN, Psy.D. and SCOTT D. MILLER, Ph.D. are she had read about hypnosis on the co-founders of the Institute for the Study of Therapeutic Change. internet and thought that might help. Together, they have authored and edited numerous professional Since I had been around in the 80’s articles and books, including The Heart and Soul of Change: and couldn’t escape that time without What Works in Therapy, Escape from Babel, Psychotherapy with hypnosis training, I approached Alina from a couple of different hypnotic Impossible Cases, and The Heroic Client. Recently, they released angles—offering both embedded self-help books, Staying on Top and Keeping the Sand Out of Your suggestions as well as stories intended Pants: A Surfer’s Guide to the Good Life, written by Scott and to build her immunity to the voices. Barry published, What’s Right with You: Debunking Dysfunction and She responded with deep trances and Changing Your Life. gave high ratings on the SRS. But the ORS remained a paltry 4. Comments: trainers@talkingcure.com At the last chance conversation, I 70 PSYCHOTHERAPY IN AUSTRALIA • VOL 15 NO 1 • NOVEMBER 2008

deeply about her and believed that surely I could figure out something eventually. But such is the thinking that makes ‘chronic’ clients—an inattention to the iatrongenic effects of the continuation of therapy in the absence of benefit. Therapists, no matter how competent or trained or experienced, cannot be effective with everyone, and other relational fits may work out better for the client. Although some clients want to continue in the absence of change, far more do not want to continue when given a graceful way to exit. The ORS allows us to ask ourselves the hard questions when clients are not, by their own ratings, seeing benefit from services. The benefits of increased effectiveness of my work, and feeling better about the clients that I am not helping, has allowed me to leave any squeamishness about forms far behind. Practice based evidence will not help you with the clients you are already effective with; rather, it will help you with those who are not benefiting by enabling an open discussion of other options and, in the absence of change, the ability to honorably end and move the client on to a more productive relationship. The basic principle behind this way of working is that our day-to-day clinical actions are guided by reliable, valid feedback about the factors that account for how people change in therapy. These factors are the client’s engagement and view of the therapeutic relationship, and—the gold standard—the client’s report of whether change occurs. Monitoring the outcome and the fit of our services helps us know that when we are good, we are very good, and when we are bad, we can be even better. PSYCHOTHERAPY IN AUSTRALIA • VOL 15 NO 1 • NOVEMBER 2008 71

When I'm Good, I'm Very Good...

by Barry Duncan on Feb 01, 2010

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When I’m Good, I’m Very Good... — Document Transcript