Monitoring in family therapyHow to stay loyal to our dialogical values? Karine Van Tricht, Peter Rober & Rolf Sundet 2nd Congress of the Open Network for Dialogical Practices 7-9 March 2013 Leuven, Belgium
Measure of process and outcome asconversational tools: Pathways to a dialogicaloriented practice of service user and therapist collaboration. Rolf Sundet Leuven, 2013 firstname.lastname@example.org University College of Buskerud, Institute for Research in Mental Health and Substance Abuse & The Ambulant Family Section, Dept of Mental Health for Children and Adolescents, Hospital of Drammen, Vestre Viken HF.
Mental Health Care anno 2013• Neoliberal society – Market economy• Economic product• Profitability o Money o Results o Social benefit• Psychotherapy o Evidence based o Effective o Efficient• ‘To measure is to know’ atmosphere• Quality Control Systems
From Evidence Based Practice to Practice Based Evidence• RCT’s & Psychotherapy o Specificity & complexity o Generalizability? o External validity? o Creativity?• RCT’s & Family Therapy = trouble in paradise o What is the diagnosis? o Complexity and specificity of treatment o Who/what is responsible for change?
Monitoring: bridging the gap between research and practice• Terminology o Outcome management o Routine Outcome Monitoring o Routine Outcome Measurement o Feedback Oriented therapy o Client Directed Outcome Informed Therapy o Tracking o Monitoring o ROMMEN o QITTEN
Evidence• Outcome improvement o Duncan & Sparks, 2009; 2010 o Reese et al., 2010 o Anker, Duncan & Sparks, 2009 o Duncan & Miller, 2000• Drop-out prevention & better dose/effect ratio o Lambert, 2007; 2010• Experienced as useful and helpful o Anker et al., 2011• Leading to a better working alliance o Sundet 2010; 2011; 2012
Monitoring as a way of working together Creating Feedback Dialogical Go with space / Integrating the flow Culture of feedback feedback New way of understan dingVan Tricht & Rober
Sources of inspiration (1) Client Therapist System System Socially, cultural, religious, spiritual Social (work, education, social contacts)The room of thetherapist as a Family, close friendsdialogical space inwhich a multitude ofstories, opinions, emotions andperspectives come Therapist(s), couple, parents, childrentogetherVan Tricht, Van denBroeck, Rober, 2011; Rober 2012
Sources of inspiration (2)• QIT online (Quality Improvement in Therapy) Basic Principles Characteristics Instruments Practice based Multidimensional Psychometrics Process oriented Multimodal A-theoretical Feedback driven Flexibel Change sensitive Broad spectrum Internetbased Clinically relevant User friendly Easily available Stinckens, Smits, Rober & Claes, 2012
A qualitative study of a locally developed family based practice within Mental Health for Children and AdolescentsConclusions: Two measures, the Outcome Rating Scale (ORS) and the Session Rating Scale (SRS):• They function as intended, that is; as tools of feedback.• A surplus: They function as conversational tools, that is; they give rise and opportunity to conservational types and processes
Repairing an alliance burst by means of discussing feedback
Clinical conclusionThe ORS and the SRS do not giveanswers, they are opportunities for questions
The family perspective:The function of ORS &SRS as conversational tools
To To To Tocommunicate focus structure exploreTo tell and To visualize To give To discoverexpress direction to the workTo state areas of To make To state To deepenacceptance and distinct thematicchange content
The Therapist Perspective:The Function of ORS and SRS as conversational tools
The scales as openings...for conversations about feedback, progression andchange...for conversations that express experiences, meanings,and perspectives about the therapeutic work...for conversations that create routine and structure...for conversations characterized by the not-knowingposition...for externalizing conversations...for conversations that bring forth a product or result
Specificity of integrating monitoring in Family Therapy• Instrumental level o Adult & child versions o Outcome & process• Implementational level o Clear introduction o In session: Apart / together o Home work: Apart / together o On paper or electronic• Dialogical level o Open, curious, interested and non-judgmental T attitude o Feedbackloops: how, what, when o Enactment
Feedback CULTUREIn the relationship between service user andtherapist, the therapist perspective must be transparentand the service users perspective is givenpriority, especially in situations of no change ordetrimental developmentIn the relationship between management and therapiststhe perspective of managers must be transparent andthe therapist perspective must be given priority in eachactual case.The function of feedback is dependent upon allowingthe therapists clinical autonomy in order to respond in atailored manner to the feedback from the service users.These measures are in danger of being ruined asfeedback and conversational tools if they are includedin a culture of competition and control
Alliances in Couple Therapy• How to define the alliance in systemic therapies?• Dyadic relations / additional information?• Clinical relevance when there’s so much confusion?• Overall conclusion: o Positive correlation between working alliance and successful outcome o Adding one more person adds multiple relationships Muran & Barber, 2010
Alliances in Couple Therapy• Individual model of the alliance + relational dynamics (Couple Alliance Scale, Pinsof & Catherall, 1984) o Alliances between each client and the therapist • Direct self-reported alliance • Inferred alliance (guesses of the qual. & strenght of the partners’ rel. T) o Alliance between ‘clients-as-a-couple’ and the therapist o Relational (im)balances • split alliances/siding/moving toward equilibrium Muran & Barber, 2010
“An emerging quality of collaboration in relation to the necessary accomplishments, arising from a web of interacting relational dynamics”Muran & Barber, 2010
A Dialogically ORIENTED PRACTICE• including the voice, perspective, idea of the other, that is; difference is included in the dialogical.• to respond to the other and be responded by the other.• to be embodied and embedded in social practices, that is; working with and in emotional transport and relational action
The practice• The use of conversational tools and the weight on dialogue gives rise to a practice where reflection and meaning making are intertwined with emotional and experiential participation of the therapist• The centrality of collaboration
Collaboration Collaboration is characterized by; Mutualism (turn-taking, jointly responding to the other’s response, dialogue, conversation) Common goal Putting difference to work
Family based practice”The helpful ”The helpful ”The helpfulrelationship” participation” conversation”Generating Using professional Asking questions,collaboration (Alliance knowledge giving time andand to listen, take structure the workseriously and believe)Giving of oneself Understanding Reformulation through participationFighting violation, Having many Giving and receivingdisparagement and possibilities feedbackdegradation
PublicationsSundet, R. (2010). Therapeutic collaboration and formalized feedback: Using perspectives from Vygotsky and Bakhtin to shed light on practices in a family therapy unit, Clinical Child Psychology and Psychiatry, 15(1), 81-95Sundet, R. (2011). Collaboration: Family and therapists perspectives of helpful therapy. Journal of Marital and Family Therapy, 37(2), 236-249Sundet, R. (2012). Therapist perspectives on the use of feedback on process and outcome: Patient focused research in practice. Canadian Psychology, 53(2), 122-130Sundet, R (2012). Patient focused research supported practices in an intensive family therapy unit: What happens? Journal of Family Therapy, (Accepted for publication).Sundet, R. (2012). Postmodern-oriented practices and implementation of patient-focused research: Possibilities and hazards. Australian and New Zealand Journal of Family Therapy (In review).
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