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  1. 1. How Being Bad Can Make You Better Helping Every Single Client Barry Duncan, Psy.D. Psy.D. 954.721.2981 1
  2. 2. Winter Getaway! Training of Trainers  HSCP Training of Trainers (TOT): Jan. 31- Feb. 4, 2011 (24 hours of CEs) This intensive training experience gives you all you need to train others and implement CDOI. And it provides the first step in becoming an HSCP Certified Trainer of CDOI. 2
  3. 3. Skill Building/Deliberate Practice 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 Feedback Consumer Participation Critical Not a Perfunctory Piece of Paper  Administering, But Don’t Get It. Clients must understand purpose (monitoring outcome, privileging their perspective); Therapists must understand same + make them meaningful  Administering, Using Some. But not the clinical cutoff or numbers…Heuristic clinical use but no continuity or coherence  Administering, Using Some. But not connecting to the client’s experience or reasons for service  Administering the SRS. But seeing it as reflective of competence rather than an alliance building tool 3
  4. 4. Helping Every Client—Marcia It’s Addictive  She told me that focusing on outcome had sensitized her to the possibility of clients not being helped & that wasn’t acceptable. So when things were not changing, she ramped up thinking of options, incl. moving the client on.  That’s what I’m talking about. On Becoming A Better Therapist Graphing: A Helpful Visual  Adds a visual component— another way to focus tx  At a glance tells the story of the client’s progress.  Allows you to dispense of the previous session measures.  Indispensable with couples & families, helps discuss multiple viewpoints 4
  5. 5. Reviewing Graphs First Things First  Squeamishness  Percentiles and Trajectories  Clinical Cut Off  Session and Service Targets 5
  6. 6. On Becoming A Better Therapist ORS and Graphs in the Waiting Room  Many will complete the ORS, some will plot scores & greet you discussing implications.  A scale that is simple to score & interpret invites clients into the process of monitoring outcome.  Increasing participation is likely to have a beneficial impact on outcome. X X X X Now we’re ready to be better therapists, but first we must heed the words of a noted psychotherapy scholar 6
  7. 7. Sage Psychotherapy Scholar: Mae West? Granted, at first When I’m blush, these good, hardly seem like I’m very words for good, but when therapists to live I’m bad, by—but, as it I’m better. turns out, they are. Becoming Better Helping Every Single Client  When clients are not benefiting provides the opportunity to do your best work—gives you the possibility of being helpful to everyone you see. Sound too good to be true? It’s not. 7
  8. 8. Becoming Better Identifying Clients Not Responding  When outcome is bad in other words, you can 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, 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 planned. 8
  9. 9. 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. On Becoming A Better Therapist Client Improving  Wow, your marks on the personal well-being and overall lines really moved—about 3 cm to the right each! Your total increased by 6 points to 26 points. That’s quite a jump! What happened? How did you pull that off? 9
  10. 10. Becoming Better Linking Outcome to Treatment •See clients more frequently when the slope of change is steep. •Begin to space the visits as the rate of change lessens. •See clients as long as there is meaningful change & they desire to continue. Becoming Better Doesn’t Mean All Therapy Should Be Brief  Au contraire, research suggests that more is better than less for clients who progress early & want to continue.  When little or change, however, same data indicates that therapy should, indeed, be as brief as possible. 10
  11. 11. 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 struggle with continuing a process that is yielding little or no benefit.  To support what is working & challenge what is not. Urgency increases over time 11
  12. 12. Checkpoint Session: An Opportunity to Be Better  Be transparent— comment about the lack of progress and seek feedback from the client about what he/she thinks it means On Becoming A Better Therapist Client Not Improving  Okay, so things haven’t changed since the last time we talked. How do you make sense of that? Should we be doing something different here, or should we continue on course steady as we go? If we are going to stay on the same track, how long should we go before getting worried? When will we know when to say “when?” 12
  13. 13. 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 client responses in detail can help you & the client get a better sense of what may not be working. Checkpoint Conversation Further Considerations  Worth exploring fit of your approach with client’s sensibilities about what needs to happen—the client’s theory of change.  Ringing true with the client will increase expectation for change as well as participation.  Client’s TOC unfolds from a conversation structured by your curiosity about the client’s ideas, attitudes, and speculations about change. 13
  14. 14. Checkpoint Conversation Do Something Different  Nothing may come out of talk re alliance. Don’t worry. Making effort helps.  Invite others from support system, use a team or co- therapist, a different approach; referral to another therapist, religious advisor, self-help group—whatever!  Any ideas are implemented, and progress is monitored. Matt On Becoming A Better Therapist Precipitous Drops  First, get explanation: Is the drop related to the reason for service—a deterioration—or is a recent event holding sway over the client’s rating?  If deterioration, then a red flag, signals the necessity to have a heart to heart about what needs to happen different to quickly turn things around. 14
  15. 15. On Becoming A Better Therapist Potholes Are Different  The client hit a pot hole on the way, etc. The events hold sway over rating.  If pothole, then ask to redo looking at the whole week, related to reasons for tx.  If the pothole trumps the original reasons for tx, then go with it. Reconnect issues at hand to the open spaces on the ORS. But don’t turn everyday life events into therapy issues. On Becoming A Better Therapist Zigzag  Sometimes scores, even when connected to the client’s problems go up and down over time—a zigzag pattern.  Of primary interest is whether there is an upward or downward trend—back to the basic question: Are things getting better or not? 15
  16. 16. Becoming Better The Last Chance Discussion  Driving into desert running on empty, “last chance for gas.”  Depicts the necessity of stopping and discussing the implications of continuing w/o change. Becoming Better Never the LAST CHANCE  Doesn’t mean the “last chance” for your client—but rather the last chance of a change plan or pairing. No last chance for your client—referral can make the difference! 16
  17. 17. 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 other resources can be rallied? 5.Is it time to Fail Successfully? Becoming Better Helping Every Single Client  All clients can’t benefit. Still a way to be helpful.  Might have felt like a failure. But when I’m bad, I’m better. Now successful when client achieves change & when, in the absence of change, I get out of the way. 17
  18. 18. Becoming Better The Last Chance Discussion  At the least, consultation  Referral seriously discussed.  Rarely justified to continue past typical period.  Rarely is not never. Highly idiosyncratic & uniquely negotiated. Keeps us honest, addresses the lack of change transparently—new for me. Becoming Better Guard Against Finger Pointing  Guard against explaining client response thru theoretical filters & folklore— puts us right back where we have traditionally been— attributing lack of change to the client. Client non- response means something else should be done. 18
  19. 19. When I’m Bad, I’m Better Failing Successfully  Repeat commitment to help them achieve goals.  Failure says nothing about them or their potential.  If client wants, meet until arrangements are made.  But rarely continue with clients who show no improvement. 19
  20. 20. My Data 100 90 Percent reaching target 80 70 60 50 98% 40 30 75% 20 10 0 1 2 3 4 5 6 7 Failing Successfully Change of Therapist 20
  21. 21. 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. 21
  22. 22. Where You Are Headed MyOutcomes & ASIST  Web-based systems for therapists and agencies to track outcome and provide real time feedback   Being Bad Can Make You Better  Helps clients you are already effective with by empowering 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. 22