PCOMCS as an Alternative to Diagnosis

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Presentation at the Global Summit for Alternatives to Diagnosis: This Summit doesn’t need to be reminded of the pitfalls and shortcomings of psychiatric diagnoses. But let’s not replace one expert-driven assessment of clients with another. Rather, I propose a system based on privileging the consumer’s voice about the nature of the concern and what is hoped to be changed derived from the client’s assessment of his or her major domains of life: personal well-being, interpersonal relationships, and social role functioning. With this as a starting point and continued client self-assessment, the consumer and the therapist collaboratively monitor progress, identifying when services are not working, and proactively seeking new directions when necessary. This system involves clients as full partners in all decisions that affect their care.

Client views of their progress is the foundation of therapeutic conversations, and their assessments of the alliance punctuate the discussion. With this transparency, PCOMS provides a mutually understood reference point for reasons for seeking service, progress, and engagement. Importantly, utilization of client feedback privileges the voices of clients over manuals and theories as well as other expert driven protocols, promoting idiosyncratic and culturally responsive intervention with diverse clientele. Client perspectives and perceptions, therefore, form the basis for service delivery including reimbursement.

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PCOMCS as an Alternative to Diagnosis

  1. 1. https://heartandsoulofchange.com August, 2014 barrylduncan@comcast.net 1 Partners for Change Outcome Management System An Empirical, Client Driven Alterative to Diagnosis Barry Duncan, Psy.D. heartandsoulofchange.com 561.239.3640 barrylduncan@comcast.net
  2. 2. https://heartandsoulofchange.com August, 2014 barrylduncan@comcast.net 2 No Need to Remind This Group of the Pitfalls of Psychiatric Diagnosis No Need to Remind This Group of the Pitfalls of Psychiatric Diagnosis  Not Reliable or Valid  Not Related to Outcome  Does Not Help Select Treatment  Colonizes Diversity  And Perhaps the Worst…the Killer Ds  Not Reliable or Valid  Not Related to Outcome  Does Not Help Select Treatment  Colonizes Diversity  And Perhaps the Worst…the Killer Ds Dysfunction Disorder Disability Disease Deficit Damaged The Killer D’s of Client Diminishment
  3. 3. https://heartandsoulofchange.com August, 2014 barrylduncan@comcast.net 3 But… Let’s Not Replace But… Let’s Not Replace  One Expert Driven System with Another  Instead, Partner with Clients Using Their Assessment of Their Lives and What They Want to Change in Their Personal Well Being, Relationships, and Social Functioning  One Expert Driven System with Another  Instead, Partner with Clients Using Their Assessment of Their Lives and What They Want to Change in Their Personal Well Being, Relationships, and Social Functioning Clients Are the Lions of Change Account for Most of Variance Until lions have their historians, tales of hunting will always glorify the hunter. African Proverb
  4. 4. https://heartandsoulofchange.com August, 2014 barrylduncan@comcast.net 4 •Client’s rating of the 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 pairing. Empirical, Client Driven Alternative Based on Predictors of Outcome 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. 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 flatter
  5. 5. https://heartandsoulofchange.com August, 2014 barrylduncan@comcast.net 5 •Add the four scales together for the total score. •Clients indicate where the problem lies and where benefit will be recognized •Give at the beginning of the visit; Client places a mark on the line. •Each line 10 cm (100 mm) in length. •Reliable, valid, feasible Becoming Better Measuring Outcome Becoming Better Measuring Outcome Clients The Heart of Change Clients The Heart of Change Client outcome feedback makes consumers the historians of their own change Partnering w/clients to monitor outcome engages most the potent factor (the heart) of change Client outcome feedback makes consumers the historians of their own change Partnering w/clients to monitor outcome engages most the potent factor (the heart) of change
  6. 6. https://heartandsoulofchange.com August, 2014 barrylduncan@comcast.net 6 •Client’s rating of the alliance the best predictor of engagement and outcome. 40 Years of Data say… •Client’s subjective experience of change early in the process the best predictor of success for any particular pairing. The Alliance: Over 1000 Research Findings  Quality of the alliance more potent predictor of outcome than orientation, experience, or professional discipline  Empathy, Positive Regard, and Authenticity each more powerful than any technique one could ever yield Carl Rogers was on to something!
  7. 7. https://heartandsoulofchange.com August, 2014 barrylduncan@comcast.net 7 The Session Rating Scale Measuring the Alliance The Session Rating Scale Measuring the Alliance •Give at the end of session; •Centers Client Voice about the Alliance •Reliable, valid, feasible Translates Bordin’s Classic Definition of the Alliance The Alliance The Soul of Change The Alliance The Soul of Change Alliance feedback enables a fit between client expectations, preferences, and services Alliance deserves far more respect—applying over 1000 studies showing the relationship of the alliance to positive outcomes
  8. 8. https://heartandsoulofchange.com August, 2014 barrylduncan@comcast.net 8 PCOMS: Operationalizes Client Privilege PCOMS: Operationalizes Client Privilege  Problems & paths for solution (dx & tx selection) defined by the client in conversation w/therapist.  Identifies non-responding clients so that the lack of progress is addressed & new directions collaboratively sought  Meta-analysis: PCOMS group had 3.5 higher odds of experiencing reliable change (now 4 RCTs)  Problems & paths for solution (dx & tx selection) defined by the client in conversation w/therapist.  Identifies non-responding clients so that the lack of progress is addressed & new directions collaboratively sought  Meta-analysis: PCOMS group had 3.5 higher odds of experiencing reliable change (now 4 RCTs) Lambert, M. J., & Shimokawa, K. (2011). Collecting client feedback. Psychotherapy, 48, 72-79. Also Can Be Linked to Reimbursement When Things Are Changing •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.
  9. 9. https://heartandsoulofchange.com August, 2014 barrylduncan@comcast.net 9 X X X X Instead of pathologizing clients when change isn’t happening, discuss alternatives, and ultimately, move on to different provider or service if no change persists When Change Isn’t Happening with a consumer-driven, culturally-responsive process that privileges and empowers the voices of diverse clientele. And finally, PCOMS Provides a Way to Replace the Empirically And Morally Bankrupt DSM Brings consumers into the inner circle, partners in defining services & monitoring its benefit

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