Published on

This webinar was conducted for the Community Behavioral Health (in Philadelphia) implementation of PCOMS in their CIRC agencies and is targeted to both consumers (called “participants” at CBH) and providers. Barry discusses the factors that make any therapeutic service effective as well as how true consumer partnerships via PCOMS improves both the effectiveness and efficiency of mental health services. This slide presentation accompanies a free webinar available on the “Resource” page at https://heartandsoulofchange.com.

Published in: Education, Business, Technology
1 Like
  • Be the first to comment

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide


  1. 1. https://heartandsoulofchange.com December, 2013 The Partners for Change Outcome Management System Barry Duncan, Psy.D. https://heartandsoulofchange.com Psy.D. 561.239.3640 barrylduncan@comcast.net barrylduncan@comcast.net 1
  2. 2. https://heartandsoulofchange.com December, 2013 What’s Up: Partners for Change Outcome Management System  First: A Few Words to the Participants about How Change Really Happens  Then I Want to Talk about the Good, Bad, & Ugly of MH Services and how PCOMS Can Help The History of Mental Health •The quintessential question: •What’s Wrong With You?! barrylduncan@comcast.net 2
  3. 3. https://heartandsoulofchange.com December, 2013 The Killer D’s Dysfunction Dysfunction Disorder Disability Disease Deficit Damaged None ever related to outcome Bottom Line Approaching problems with the assumption that we are b k ti th t broken, incomplete, scarred, or sick predisposes us to failure, making invisible our natural propensities for growth & recovery. In truth, change is inevitable and decidedly human, and primarily comes through the mobilization of one's strengths and abilities. barrylduncan@comcast.net 3
  4. 4. https://heartandsoulofchange.com December, 2013 The Wheel of Change: Factors Accounting for Successful Outcome 40.0% Your Resources & Resiliencies Your Approach to Change Your Relationships 30.0% 15.0% Hope/Expectancy 15.0% Think of Change as Your Favorite Pie   barrylduncan@comcast.net Eating a pie w/o filling is like trying to change without your involvement, resources, and ideas. d id  Your Strengths, Resources and Resiliencies 40% 40% of how change pp y happens is about you. You are the filling. The main ingredient is the filling. Change is about rallying these inherent strengths, what’s right with you, to defeat problems. 4
  5. 5. https://heartandsoulofchange.com December, 2013 Your Relationships The Crust Relational support, 30% of change, is the crust or h i th t container for the filling. A supportive relationship holds you comfortably while your resources take center stage. The crust allows the filling to be appreciated. Therapy provides a support for change, but so can others. Your Relationships 30% Your Hopes and Expectations   15%  barrylduncan@comcast.net The pie's mouthwatering visual presentation, presentation enticing aroma, and aroma aroused hopes for culinary delight illustrate expectancy— contributing 15%. Change tantalizes you with a delicious future, a helping of hope. , p g p Key here is a plan that resonates with your own ideas and fits your views about how you can change. Hope is ALWAYS there 5
  6. 6. https://heartandsoulofchange.com December, 2013 Your Approach to Change Your Involvement Is Key The actual approach is the meringue. Enhances i E h appearance & embellishes taste, cannot stand on own W/O the rest of pie to give it substance, meringue is nothing but fluff. Approach fluff provides means to an end, but is useless w/o you. Nothing but fluff if it does not deliver results.… Your Approach To Change—15% Change— The Secret Is Out Like Dorothy in The Wizard of Oz, you have always had the power to get back to Kansas. Research shows that change does not come about from the special powers or authority of any particular helper or model. model Change principally results from empowering your preexisting abilities and restoring hope. barrylduncan@comcast.net 6
  7. 7. https://heartandsoulofchange.com December, 2013 Consumers Are the Lions of Change Until lions have their historians, tales of hunting will always glorify the hunter. hunter African Proverb Empower Yourself: Monitor, Adjust, and Celebrate You are the engine of change. If you are going to h i t arrive at your destination, you have to know if your are on the right track.  If you are not on the right track—the change you desire is not happening— then it is time to consider switching tracks.  barrylduncan@comcast.net 7
  8. 8. https://heartandsoulofchange.com December, 2013 The Proof of the Pudding Is in the Eating In the late 70s, Alka Seltzer surprised everybody by firing i d b d b fi i the co. that created “I can't believe I ate the whole thing.”  Shock since the clever commercials had so quickly become a household b h h ld expression  Alka Seltzer had one big problem with it—they didn't sell more Alka Seltzer.  The Proof Adopt the same attitude as Alka Seltzer Seltzer.  No matter how clever, if your change plan isn’t producing results, it’s time to fire that plan.  St di Studies show that change, h th t h if it is going to occur, usually happens early on after implementation of a strategy or method.  barrylduncan@comcast.net 8
  9. 9. https://heartandsoulofchange.com December, 2013 Bottom Line Monitoring your progress is essential & dramatically ti l d ti ll improves chances of success. Don’t need to have the perfect approach as much as knowing whether your plan is working—and if it is not, to quickly adjust your strategy to maximize the possibility of your improvement Acknowledge Where You Are Now   Allows you to validate where you have been and reflect about where you are going. b h i  barrylduncan@comcast.net Looking at a map at the mall g y and finding the “you are here” spot. This must happen first, before you identify where you are going or how to get there. Provides a point of comparison to know whether you are progressing in your change efforts. 9
  10. 10. https://heartandsoulofchange.com December, 2013 Outcome Rating Scale (ORS) Individually: (Personal well-being) Looking back over the last week (or since your last visit), g ( y ), ╠═════════════════════════════╣ ╠ ╣ including today, help us understand how you have been doing in the following areas of your life, where marks to Interpersonally : the left represent low levels and marks to the right indicate (Family, close relationships) ╠═════════════════════════════╣ high levels. Socially: ( (Work, School, Friendships) , , p ) ╠═════════════════════════════╣ ╠ ╣ Overall: (General sense of well-being) ╠═════════════════════════════╣ X barrylduncan@comcast.net X X X 10
  11. 11. https://heartandsoulofchange.com December, 2013 Consumers 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 of change Cautionary Tale: The Death of George Washington In December 1799, our first president develops a minor sore throat. By morning the next day, he is dead. Reference: Flexner, J.T. (1974). Washington: The Indispensable Man. New York: Little, Brown and Company. barrylduncan@comcast.net 11
  12. 12. https://heartandsoulofchange.com December, 2013 Lessons of George Washington  The very same forces…continue to guide not only therapy, but also therapy many attempts at self change.  People get hung up on apparent rightness of a solution instead of its success. Washington illustrates: the “rightness” i no guarantee. “ i ht ” is t  Not monitoring benefit may encourage you to continue what is not working until like George… Therapeutic Services The Good… Study after study study, and studies of studies show the average treated client is better off than 80% of the untreated sample. barrylduncan@comcast.net 12
  13. 13. https://heartandsoulofchange.com December, 2013 Psychotherapy The Bad… Drop out rates average 47%, 60% with adol. adol. & SA clients Therapists vary… a lot Therapist Differences Incredible Variation Among Providers TDCRP: top third psychiatrists giving placebo bested bottom third giving meds; clients of best counselors improve imp o e 50% more & mo e dropped out 50% less; What accounts for the difference? barrylduncan@comcast.net Kim, D. , Wampold, B. , & Bolt, D. M. (2006). Therapist effects in psychotherapy: A random effects modeling of the NIMH TDCRP data. Psychotherapy Research, 16, 161– 172. 13
  14. 14. https://heartandsoulofchange.com December, 2013 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….  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, 1-11. Therapist Variables that Predict Change Baldwin et al. (2007). Untangling the alliance-outcome correlation. Journal of Consulting and Clinical Psychology, 75(6), 842-852.; Owen, Duncan, Anker, & Sparks (in press). Therapist effects in couple therapy. Journal of Sex and Marital Therapy. barrylduncan@comcast.net Therapists with the best results:  Are better at the alliance across clients; alliance ability accounts for therapist differences 14
  15. 15. https://heartandsoulofchange.com December, 2013 And the Ugly Providers Don’t Know  20-70% 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 of Clinical Psychology: In Session, 61, 145-153 range g  Graded their effectiveness, A+ to F— 67% said A or better; none rated below average.  Providers don’t know how effective they are PCOMS Outcome and Alliance Feedback The ORS The SRS Download free working copies at: http://heartandsoulofchange.com http://heartandsoulofchange.com barrylduncan@comcast.net 15
  16. 16. https://heartandsoulofchange.com December, 2013 Improving or Not Two Choices: Not Rocket Science  PCOMS simply identifies clients who are not responding so that the lack of progress can be addressed in a positive, proactive way that keeps clients engaged while therapists collaboratively seek new directions 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 sep./divorce rate Anker, M., Duncan, B., & Sparks, J. (2009). Using client feedback to improve couple therapy outcomes: A randomized clinical trial in a naturalistic setting. Journal of Consulting and Clinical Psychology, 77(4), 693-704. barrylduncan@comcast.net 16
  17. 17. https://heartandsoulofchange.com December, 2013 Barry Finds the Spot in the Norway Picture Reese, Norsworthy, & Rowlands (2009) Reese, Toland, Slone, & Norsworthy, 2010 Reese, R., Norsworthy, L., & Rowlands, S. (2009) Ro lands S (2009). Does a continuous feedback model improve psychotherapy outcomes? Psychotherapy,46, 418-431. Reese, R., Toland, M., Slone, N., & Norsworthy, L. (2010). Effect of client feedback on couple psychotherapy outcomes. Psychotherapy, 47, 616-630. barrylduncan@comcast.net  N=148: Feedback group doubled d bl d controls (10.4 t l (10 4 vs. 5.1 pts); ES: .48  Like Norway study, clients, regardless of risk status, b t t benefit f fit from continuous feedback  2010 study is replication of Norway Trial 17
  18. 18. https://heartandsoulofchange.com December, 2013 Cooper, Stewart, Sparks, & Bunting, 2012  Benchmark study of 288 7-11 7 11 yr olds; caretakerld t k 228; teacher-249; 11 counselors; 28 schools 2 Cooper, M., Stewart, D., Sparks, J., Bunting, L. (2013). Schoolbased counseling using systematic feedback: A cohort study evaluating outcomes and predictors of change. Psychotherapy Research, 23, 474-488. fold advantage over children not using feedback as measured on the SDQ Southwest Behavioral Health Public Behavioral Health Reese, Duncan, Bohanske, O B h k Owen, & Minami, 2013: PBH achieved outcomes comparable to RCTs of depression and feedback. How? PCOMS barrylduncan@comcast.net 18
  19. 19. https://heartandsoulofchange.com December, 2013 Three More in the Works Veterans, Group, and Youth Submitted: Returning vets in group tx for substance abuse; improved outcomes on the ORS, clinician & commander ratings; & reduced drop outs Submitted: Group psychotherapy: improved outcomes and improved p p retention Completed: RCT of intervention in the schools with children and adolescents with behavioral problems Schuman, D., Slone, N., Reese, J., & Duncan, B. (2013). Using feedback to improve outcomes with Iraq/Afghanistan veterans. Slone, N., Reese, J., MatthewsDuvall, S. & Kodet, J. (2013). Using feedback to improve group psychotherapy outcomes. Murphy, J., & Duncan, B., Gillaspy, A., Bohankse R., & Zatoga, A. (in process). Using client feedback to improve school intervention i h li t ti outcomes. 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 long term null cases diminished by 80% (10% to 2%).  An estimated savings of $489,600. barrylduncan@comcast.net Bohanske, R., & Franczak, M. (2010). Transforming public behavioral healthcare: A case example of consumer directed services, 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 Psychological Association. 19
  20. 20. https://heartandsoulofchange.com December, 2013 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  : A SAMHSA EBP But Different a-theoretical & additive to any orientation; applies to clients of all diagnostic categories; & is EBP one c e a s o e client at a time—whether this therapist w/this treatment is benefiting this client barrylduncan@comcast.net 20
  21. 21. https://heartandsoulofchange.com December, 2013 PCOMS Implemented in Every State and 20 Countries (translated to 24 languages); 30,000 30 000 Registered Providers, 100,000 Consumers, over 427,000 Administrations in Our Data Base Now Implemented Here at CBH via the CIRCs 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 pairing. barrylduncan@comcast.net 21
  22. 22. https://heartandsoulofchange.com December, 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. The Outcome Rating Scale Measuring Change •Give at the beginning of the visit; Client places a mark on the line. •Each line 10 cm (100 mm) i ) in length. •Scored to the nearest millimeter. •Add the four scales together for the total score. •Reliable, valid, feasible barrylduncan@comcast.net 22
  23. 23. https://heartandsoulofchange.com December, 2013 Starting With the Predictors Change and the Alliance •Client’s rating of th Cli t’ ti f 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. barrylduncan@comcast.net 23
  24. 24. https://heartandsoulofchange.com December, 2013 The Alliance: Over 1000 Research Findings  Quality of the alliance more potent predictor of outcome than orientation, experience, or professional discipline– across all modalities. d liti  Clients rarely report negative reactions before deciding to terminate. But Perpetually Minimized in Difficulty and Importance •It gets such little press compared to models and t h i d l d techniques and i often d is ft relegated to statements like “first gain rapport and then…” or “form a relationship and then…” as if it is something we effortlessly do before the real intervention starts The starts. alliance is not the anesthesia to surgery. •The alliance deserves far more RESPECT… barrylduncan@comcast.net 24
  25. 25. https://heartandsoulofchange.com December, 2013 The Session Rating Scale Measuring the Alliance •Give at the end of session; •Score in cm to the nearest mm; •Each line 10 cm in length; •Discuss with client anytime total score falls below 36 •Reliable, valid, feasible barrylduncan@comcast.net 25
  26. 26. https://heartandsoulofchange.com December, 2013 The Alliance The of Change Alliance feedback enables a fit between client expectations, preferences, and services Does not leave the alliance to chance—applying over 1000 studies showing the relationship of the alliance to positive outcomes 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 Alliance  barrylduncan@comcast.net 26