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  1. 1. November, 2012 On Becoming a Better Therapist Skills to Become the Best You Can Be Barry Duncan, Psy.D. Psy.D. 561.561.3640 1
  2. 2. November, 2012 Winter Getaway! Training of Trainers  HSCP Training of Trainers Conference: January 28- Feb. 1, 2013 (27 CEUs) This intensive training experience gives you all you need to train others and implement CDOI and PCOMS. And it provides the first step in becoming an HSCP Certified 2
  3. 3. November, 2012 Psychotherapy The Good… Study after study study, and studies of studies show the average treated client is better off than 80% of the untreated sample. Psychotherapy The Bad… Drop out rates average 47%, 60% with adol. adol. & SA clients Therapists vary… a 3
  4. 4. November, 2012 Therapist Differences Incredible Variation Among Providers TDCRP: top third psychiatrists giving placebo h l b bested bottom third giving meds; clients of best counselors improve 50% more & dropped out 50% pp less; meds useful for clients of more effective, not for less--What accounts for the Wampold, B., & Brown, J. (2006). Estimating variability in variability? outcomes attributable to therapists: A naturalistic study of outcomes in managed care. Journal of Consulting and Clinical Psychology, 73 (5), 914-923. Successful V. Unsuccessful Counselors Focus on Strengths Studied videos of 120 sessions of 30 clients.  Unsuccessful helpers focused on problems, neglected strengths.  Successful helpers focused on recruiting strengths to address problems….but is this what we do? Gassman, D. & Grawe, K. (2006). General change mechanisms: The relation between problem activation and resource activation in successful and unsuccessful therapeutic interactions. Clinical Psychology and Psychotherapy, 13, 4
  5. 5. November, 2012 The Killer D’s of Client Diminishment Dysfunction Disorder Disability Disease Deficit Damaged D d Not Reliable or Valid None ever related to outcome Helper Variables that Predict Change Counselors with the best results:  Are better at the alliance across clients; alliance ability accounts for helper differences Baldwin et al. (2007). Untangling the alliance-outcome correlation. Journal of Consulting and Clinical Psychology, 75(6), 842-852.; Anker, Owen, Duncan, & Sparks (2010). The alliance in couple therapy. Journal of Consulting and Clinical Psychology, 78(5), 5
  6. 6. November, 2012 1000 Studies about The Alliance and Outcome •Increasingly, the relationship is gy p viewed as merely “setting the stage” for the “real” treatment: •Confronting distorted thoughts; •Recovering forgotten memories; •Asking special questions; •Tapping on or waving fingers in front of the face…but face but the data say: •The alliance deserves far more RESPECT… Norcross, J. (2010). The Therapeutic Relationship. In B. Duncan et al. (eds.). The Heart and Soul of Change. Washington, D.C.: APA. And the Ugly Providers Don’t Know  20-70% range g  Graded their effectiveness, A+ to F— 67% said A or better; none rated below average.  Providers don’t know Hansen, N., Lambert, M., Forman, E. (2002). The psychotherapy dose-response effect and its implications for treatment delivery services. Clinical Psychology: Science and Practice, 9, 329-343. Sapyta, J., Riemer, M., & Bickman, L. Feedback to clinicians: Theory, research, and practice. Journal how effective they are of Clinical Psychology: In Session, 61, 6
  7. 7. November, 2012 To The Rescue Consumer Driven Outcomes Management  Howard et al. (1996) advocated for the f th systematic eval. of client t ti l f li t response during treatment to “determine the appropriateness of the current tx…the need for further tx…[and] prompt a clinical consultation for patients who [were] not progressing at expected rates” Feedback and Outcome Lambert’s Six Trials  All 6 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 h l t d ith support tools  A strong case for routine measurement of outcome in everyday clinical 7
  8. 8. November, 2012 Outcome and Alliance Feedback The O.R.S The S.R.S Download free working copies at: 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), 8
  9. 9. November, 2012 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 published 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, 9
  10. 10. November, 2012 In Fact, Client Based Outcome Feedback  Improves outcomes more than anything since the i th beginning of therapy Effects on Efficiency Cancellations, No Shows, LOS  Claud (reported in Bohanske & Franczak) compared ave. # of sessions, canc., no shows, and % of long-term cases before and after OM in 2130 closed cases in a CMHC.  Ave. # of sessions dropped 40% (10 to 6) while outcomes improved by 7%; 7% canc. and no show rates were d h t reduced by 40% and 25%; and % of Bohanske, R., & Franczak, M. (2010). long term null cases diminished by Transforming public behavioral healthcare: A case example of consumer directed services, 80% (10% to 2%). recovery, and the common factors. In B. Duncan et al. (Eds.) The Heart and Soul of Change: Delivering What Works, 2nd Ed. Washington, DC: American  An estimated savings of $489,600. Psychological 10
  11. 11. November, 2012 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 First Things First Why You Might Be Reluctant  Finding out is risky  What if you find out that you are not so good? What if you are in the wrong profession?  The only way we improve is thru feedback. It takes courage. But so does walking in a room with someone in 11
  12. 12. November, 2012 Regarding Counselor Variability Feedback Improves Outcomes  Norway: 9 of 10 got better o tcomes bette outcomes  Feedback raised effectiveness of the lower ones to their more successful colleagues colleagues.  Helper in low effectiveness group became the BEST with feedback! Many Believe They Already Know  The info the measures reveal—that reveal that are attuned to client’s experience & the forms superfluous.  Norway study: all believed they already acquired outcome & alliance info—that info that formal feedback wouldn’t improve their effectiveness.  9 of 10 improved; only 1 12
  13. 13. November, 2012 First Things First Why You Might Be Reluctant  You might be thinking that you need more paperwork like a hole in the head. Helpers can get really worked up over anything that adds paperwork, especially when they don’t see it as clinically useful. First Things First Why You Might Be Reluctant  Feedback about the benefit & fit need not b d t be cumbersome or intrusive. Only a couple of minutes & no intrusive questions.  Feedback the best hope to improve, clients appreciate your dedication to getting it right, & it is painless and can fit your natural 13
  14. 14. November, 2012 Getting the Max Out of the Measures Just the Facts Ma’am  The nuts & bolts & bolts, the nuances, more to it, clinically, than it looks  Feedback i h F db k is the way to transcend average. The First Session All Aboard  Have to be on board with two things: have to think privileging the c e s client is a good idea; dea; and have to want to be 14
  15. 15. November, 2012 The Measures and Social Justice “Leveling” the Counseling Process  Invites clients into inner circle of decision making  Available in multiple languages  Voice to diversity and the y disenfranchised  Local culture and context over privileged knowledge 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 15
  16. 16. November, 2012 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. 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 early…just 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), 16
  17. 17. November, 2012 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, feasible The ORS Is Not 17
  18. 18. November, 2012 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 application Becoming Better Creating A Culture of Feedback •When scheduling, provide rationale for seeking feedback; convey commitment to their goals and highest quality of service…in your own words •Work a little differently; •If we are going to be helpful should see signs sooner rather than later; If not helpful, we’ll seek consultation & consider a referral. •No one has ever said: Bad idea! 18
  19. 19. November, 2012 The Outcome Rating Scale An Introduction in Your Own Words  The ORS is an outcome measure that allows us to track where you’re at, how you’re 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 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 19
  20. 20. November, 2012 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 20
  21. 21. November, 2012 Initial Information… 40 •Client’s score is within the 30 clinical range. s c o re ORS 20 •Scoring more 10 like people in therapy and 0 wanting 1 2 3 4 5 6 7 8 9 10 Session number something to change Projected change 75th percentile ORS Scores 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 = 21
  22. 22. November, 2012 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 Take Clients at Face Value  Please don’t interpret high scores as a misrepresentation  It is the way the client sees him or herself  They don’t have to see a problem for therapy to help  Other’s ratings important too  Just because it’s high doesn’t mean they won’t 22
  23. 23. November, 2012 First Session: Connect ORS to the Client’s Described Experience  Atsome point, connect the client’s described experience of their lives to the marks on the scales 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 23
  24. 24. November, 2012 Integrating the Measures Problems and Challenges?  Has to be Relevant to the R l h Work  Or Becomes an Emotional Thermometer  And You Have to Get a Good Rating 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 24
  25. 25. November, 2012 Quickest Way Prevent Drop Out Clients drop out for 2 reasons: counseling 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 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 25
  26. 26. November, 2012 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? 26
  27. 27. November, 2012 The Session Rating Scale Traditionally  Told us with their feet  Will let us kno on SRS s know before telling/bolting.  Takes work for candor.  Disparity in power & socio- economic, ethnic, , , or racial diff., can make it tough. When was the last time you told your physician, “Youre making a big mistake"? But Don’t Stress It’s Okay  Keep encouraging client to let you know know…  Have to KNOW: No bad news. Not a measure of competence or anything negative about you or the client. Gift from the client that helps th t h l you to b better. t be b tt  Unless you really want it, you are unlikely to get it.  You won’t get it from 27
  28. 28. November, 2012 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 28
  29. 29. November, 2012 X X X X Now we’re ready to be better at what we do y but first we must heed the words of a noted psychotherapy scholar Sage Psychotherapy Scholar: Mae West? Granted, Granted at first When I’m blush, these good, hardly seem like I’m very words for us to good, but hen b t when live by but, as by—but, I’m bad, it turns out, they I’m better. 29
  30. 30. November, 2012 Becoming Better Identifying Clients Not Responding  When outcome is bad in other words, you can h d 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 Becoming Better Two Choices: Not Rocket Science  Either the client is improving or not. If not, i i t t the client is at risk.  Engage client in discussion about progress, and what should be done differently if there isn’t any.  Keeps clients engaged so that a new direction can be 30
  31. 31. November, 2012 Becoming Better 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. Becoming Better Linking Outcome to LOS •See clients more frequently when the slope of change is steep. •Begin to space the visits as the rate of change lessens. g •See clients as long as there is meaningful change & they desire to 31
  32. 32. November, 2012 Becoming Better What to Do Next  Involve the client in monitoring progress & the decision about what to do next, to elicit his or her ideas & formulate a plan.  The discussion repeated in all meetings, but later ones gain significance and warrant additional action: Checkpoint and Last Chance Discussions. Becoming Better When to Say When  Stimulates both client and therapist to d th i tt struggle with continuing a process that is yielding little or no benefit.  To support what is working & challenge what is not. Urgency increases over 32
  33. 33. November, 2012 Checkpoint Session: An Opportunity to Be Better B Be t transparent— t comment about the lack of progress and seek feedback from the client about what he/she thinks it means Becoming Better First, the Alliance  “It doesn’t look like we are getting anywhere. Let’s go over the SRS to make sure you are getting exactly what you are looking for.” Going thru SRS and eliciting g g client responses in detail can help you & the client get a better sense of what may not be 33
  34. 34. November, 2012 Checkpoint Conversation Do Something Different  Nothing may come of talk about the alliance Don t alliance. Don’t worry. Making effort helps.  Invite others from support system, use a team or co- therapist, a different approach; referral to another pp helper, religious advisor, or self-help group—whatever seems of value.  Any ideas are implemented, and progress is monitored. Becoming Better The Last Chance Discussion  Driving g into desert running on empty, “last chance for gas.”  Depicts the necessity of stopping and discussing the implications of continuing w/o 34
  35. 35. November, 2012 Becoming Better Never the LAST CHANCE  Doesn’t mean the “last chance” for fo your client—but rather the last chance of a change p plan or pairing. No p g last chance for your client—referral can make the difference! Last Chance Thoughts The Longer w/o Change, the Quicker to #5 1.What does the client say? 2.What have you done differently? 3.What can be done differently now? 4.What th 4 Wh t other resources can be rallied? 5.Is it time to fail successfully? 35
  36. 36. November, 2012 When I’m Bad, I’m Better Failing Successfully  Repeat commitment to help them achieve goals. goals  Failure says nothing about them or their potential.  If client wants, meet until arrangements are made. t d  But rarely continue with clients who show no improvement. My Data 100 90 Percent reaching target 80 70 60 50 98% 40 30 75% % 20 10 0 1 2 3 4 5 6 36
  37. 37. November, 2012 Last Chance Breaking Up Is Hard to Do  First three, BAU, no change  SRS, wanted help with voices  Did that for 3, no change  Team consult revealed new issues, and more ,  Followed up those new issues, nothing happened  Time to Fail Successfully Failing Successfully Change of 37
  38. 38. November, 2012 Watershed Client Failing Successfully I wish my helper had  I believed in PBE, but… failed successfully  Awakened me to the pitfalls; taught me to fail successfully.  Avoid a “chronic” client— the iatrongenic effects of continuing therapy w/o benefit.  ORS allows us to ask ourselves hard questions. Becoming Better Feedback Is My Compass  Not an uninhabited terrain of technical procedures, nor the p , 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 38
  39. 39. November, 2012 Being Bad Can Make You Better  Helps clients you are already effective with by empowering ff ti ith b i change—helps those not benefiting by enabling other options and, in absence of change, the ability to move the client on.  When we’re good, we’re very good, but when we’re bad, we can be even better. What Separates The Best? Barry’s Recipe  1. Client Feedback Improves Outcomes More than Anything since the Beginning of Psychotherapy  2. Clients Account for Most of the Variance: Rally, Recruit Rally Harvest Resources for Change  3. Rely on the Tried & True Old Friend, the 39