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The 2012 Algorithms predict therapy outcomes based on LOS (short term v. longer term encounters), thereby addressing the needs of both clients who attend more sessions and clinicians not working from a brief therapy perspective—covering 97% of those seeking services. Previous trajectories only accounting for 8 sessions of therapy only covered 62-77% of clients but now, using the latest in statistical methodology, the new algorithms extend to 18 sessions and cover the 1 in 4 to 1 in 3 clients who attend more than 8 sessions and change more slowly.

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  1. 1. www.heartandsoulofchange.com March, 2013 2012 Algorithms & Feedback Messages: Fitting More Clients & Therapists 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 Love this Quote Ralph Waldo Emerson  “If a man (sic) will kick a fact ( ) out of the window, when he comes back he finds it again in the chimney corner.”  Let’s look at the facts about early change and the usual course or trajectory of change in psychotherapy. Time and Time Again  From the pioneering work of the late Ken H th l t K Howard t current d to t sophisticated investigations using the latest statisitical methods, studies reveal that the majority of clients experience the majority of change in the first eight visits. This is a surprisingly resilient finding.barrylduncan@comcast.net 2
  3. 3. www.heartandsoulofchange.com March, 2013 Sooner Rather Than Later 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. It’s A Fact Early Change is The Rule Cannabis Youth Treatment Project Early change in y g treatment is a robust predictor of outcome and retention in Project MATCH treatment. treatment Gotta measure outcome! http://www.chestnut.org/LI/Posters/CYT_%20MF_APA.pdf Babor, T.F., & DelBoca, F.K. (eds.) (2003). Treatment Matching in Alcoholism. United Kingdom: Cambridge, 113.barrylduncan@comcast.net 3
  4. 4. www.heartandsoulofchange.com March, 2013 The Rule: Treatment of Depression Collaborative Research Program TDCRP Conclusions: Early change is an important factor for the prediction of short- and long-term outcome. 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. The Research about Early Change Is a Gift This means that clients who report little or no progress early on will likely show no improvement over the entire course of therapy, or will end up on the drop-out list—early change p g predicts engagement in g g therapy and a good outcome at termination. Provides a tangible way for us to identify folks who are not responding so that we can chart a new course.barrylduncan@comcast.net 4
  5. 5. www.heartandsoulofchange.com March, 2013 Regardless of How Many Times It Reappears in the Chimney Corner  Rubs people the wrong way. Some think that the research about early change predicting outcome is an indictment against long term work. Simply not true. Long term work with clients is perfectly fine as long as they are benefiting. Early Change Doesn’t Fit My Clients! Some Clients Take Longer  Itis true that some u a o clients take longer than others, but importantly not for change to start, b t h t t t but rather for change to plateaubarrylduncan@comcast.net 5
  6. 6. www.heartandsoulofchange.com March, 2013 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 (last curve bottom right) right), 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. Sudden Epiphany? NOT Myth: Clients flat-line & then ik S th spike. Some clientsli t do take longer but change starts right away. So the question remains: When do you start getting worried when clients are not responding? I vote for sooner rather than later.barrylduncan@comcast.net 6
  7. 7. www.heartandsoulofchange.com March, 2013 More Evidence: University Counseling Clinic (UCC) V. Public Behavioral Health (PBH) Ave. LOS: UCC—6.5 v. 8.9 for PBH; 77% at UCC came < 8 while it took 12 at PHB to reach 77%. 62% < 8 at PBH. Most attended < 8 & only 1 in 4 go > 8 at UCC & 12 at PBH PBH. Trajectories, then, have a pretty good track record of fitting most clients. Trajectories The Long and Short of It But, many who saw , y clients for longer periods were not satisfied; Some even put off by overall trajectories showing most change happening in first 8barrylduncan@comcast.net 7
  8. 8. www.heartandsoulofchange.com March, 2013 So Many Killed the Messenger And worse, killed the message (not an indictment of long term work but a way to identify at risk clients) Finally, a solution came to me that had never been done: trajectories based in LOS as therapy and py change unfolded. So with Michael Toland & Bill Wiggin, we looked at 427K sessions & developed expected treatment response (ETR) for < 8 & < 18 sessions Because 18 Sessions Represented 97% of the Data  Compared algorithms w/ means of each intake score across sessions (the smell test), & the new ones were born.  The old ones covered 60 60- 75% of clients while the new ones cover 97%--now including that 1 in 4 clients who take a bit longer.barrylduncan@comcast.net 8
  9. 9. www.heartandsoulofchange.com March, 2013 Using the Latest Statistical Methodology, the 2012 Algorithms  Predict therapy outcomes based on LOS (short term v. longer term encounters), thereby addressing the needs of both clients who attend more sessions and clinicians not working from a brief therapy perspective—covering 97% of those seeking services. 2012 Algorithms Also Create New Feedback Messages  That consider how the client is doing relative to the last session & in the context of how he or she is doing since intake. Combined with old fashioned clinical judgment that doesn’t j g denigrate slower change, the new messages bring clinical nuance and common sense in addition to the new algorithms.barrylduncan@comcast.net 9
  10. 10. www.heartandsoulofchange.com March, 2013 Consumer Privilege, Partnership, & Outcome Accountability Score a Victory  The Partners for Change Outcome Management System (PCOMS), as disseminated by the Heart and Soul of Change Project, is now included in the Substance Abuse and Mental Health Services Administration’s (SAMHSA) National Registry of Evidence Based Programs and Practices (NREPP)  PCOMS incorporates the most robust predictors of therapeutic success into an outcome management system that th t partners with t ith clients while honoring the daily pressures of front-line clinicians.barrylduncan@comcast.net 10
  11. 11. www.heartandsoulofchange.com March, 2013 Partners  The NREPP process is an arduous one that includes both a research and dissemination review. All 3 RCTs that enabled our application for evidence pp based practice status were conducted by Partners of the Heart and Soul of Change Project. The 3 RCTs Resulting in SAMHSA EBP Statusbarrylduncan@comcast.net 11
  12. 12. www.heartandsoulofchange.com March, 2013barrylduncan@comcast.net 12